 And now it's my pleasure to introduce to you Sally Ferguson. Sally Ferguson is an assistant professor of midwifery at the University of Canberra in Australia. She has been in midwife since 1986 and was part of the original midwifery team at the birth center of the Canberra hospital. Her passion for midwifery is obvious as you go, as you will see. And she's speaking to us today about salutogenesis in midwifery. So no further ado, I turn it over to you, Sally. Thank you, Lorraine. And thank you everyone for having me. You may want to turn up your microphone just a little bit, Sally. You can just adjust. Click on the little icon, the little down arrow next to your microphone and adjust your microphone volume. Is that better? They're much better. There you go. Okay, okay. All right, so just tell me throughout if I need to raise my voice a bit. All right, the aim of my presentation is to explain salutogenesis to those of you who aren't familiar with the idea and continue to establish its relevance for midwifery because salutogenesis and midwifery fit beautifully together. I'm doing a PhD on salutogenesis and childbearing, so I'm absolutely immersed in it and I'm beginning to... So I hope that I can help you to understand and motivate you to think about salutogenesis in your midwifery. So to help us to understand salutogenesis, I'd like to introduce you to Aaron Antonofsky. Aaron Antonofsky is an Israeli medical sociologist who created the concept. And Antonofsky would tell you that salutogenesis is a concept focusing on discovering the causes of health rather than the causes of illness. So as a medical sociologist, it annoyed Antonofsky that pathogenesis was used to frame health promotion. He did not understand, as we don't understand, why that would be the case, as we all know that health is not just... So he, Antonofsky, wanted to create a health promotion framework, something that would rival pathogenesis. And he started his work with Holocaust survivors and thought that he would find a lot of pathology when he looked at these people and that there was a particular bunch of people he found who not only survived the Holocaust, but they thrived. So he decided that they must have had that promotion. So that started him thinking of this group fascinated him and he did 51 interviews with them to try and work out what exactly it was that they could say well. And in the end, years and years later, in the end, he came up with the concept of sense of coherence. So Antonofsky would say that those people who thrived in that setting had strong sense of coherence. And sense of coherence is the working unit of salutogenesis. So they go together. And we'll talk about salutogenesis in it. But before we do that, let's create the relevant free. So as you know, as I know, and he is sued down, tells us that maternity services are currently rooted in pathology. You know that, the tertiary service. In tertiary maternity services, we love to focus on risk, don't we? We love to categorize women in relation to their risk. And even though we know this has died for their child. Down says, and Antonofsky said, if risk is emphasised and health is the emphasised, then you end up with a risk-focused maternity service where you have soaring labour intervention rates and soaring therapy. Down says, and Antonofsky say, and other people know from psychology that... Sally, if I could just interrupt you for a moment. Do you have your microphone nice and close to your mouth because your voice is fading in and out a little bit? Is it? How is that? That's much better. Just keep your microphone whatever that is. Alright. And interrupt me again if it goes away. So what we're talking about is that you get what you emphasise in life and in maternity services. So if you're going to emphasise risk, then that's exactly what you're going to get. And in normal childbirth, down tells us that our...in soaring labour intervention rates and our soaring caesarean section rates are related to the fact that we are driven by pathogenesis and we are emphasising risk. You might not know that Australian caesarean section rates are increasing a percentage point a year and spontaneous vaginal birth rates are going down a percentage point a year. So if we keep going like this, in 12 years we cross over and we have more caesarean section in Australia than normal birth. So that's such a scary idea. Pathogenesis is not working for our maternity services and we need another way to look at the world where we emphasise and create the normal. And that's why midwives do so beautifully. They create the normal and that's what we're meant to be doing. Salyutogenesis offers the midwife so much. And Antonoski would say, why not look at a person's health factors rather than their risk factors? And that's what Salyutogenesis invites us to do. It invites us to look at a woman's health factors. If we get what we emphasise then that's what we need to be doing. That doesn't mean we ignore Margot's polyhydramidias, that would be stupid. But what it does mean is that in the equation you have the fact that she is a well woman having a well baby. She's supported by a midwife that she knows and loves, that she has a doula, that she has a lovely partner, that she will have continuous support in labour, that she's spectacularly birthed her four kilo baby girl two years ago. These are all things that need to be in that equation when we're providing care to Margot so that we balance risk, health and all the factors. Francis Day-Sturk who we've just heard from so eloquently now and Louise Palmer talk about Salyutogenic birth. There are two of only a few authors that are talking about Salyutogenesis in relation to childbearing and they emphasise the midwife's role in increasing a woman's sense of coherence and ultimately their childbearing health. Sinclair and Stockdale do the same. They say that Salyutogenesis offers midwives an opportunity to positively influence public health by empowering and motivating women to confidently take control of their childbearing. Isn't that beautiful? Salyutogenesis offers midwives an opportunity to positively influence public health by empowering and motivating women to confidently take control of their childbearing. And so this would occur through the enhancement of the Salyuto concept of sense of coherence. That's the essence that Antonofsky found with the Holocaust survivors. So let's talk about Sinclair. So this woman is driving my PhD and she's a hard task master. She represents all the women that I've ever cared for as a midwife who are easily able to tap into their birthing zone and they just go on to birth in the most spectacular way. You know this woman who fills her room up with beautiful endorphins and you know that you should have brought your knitting because you're not going to be doing anything. You're just going to be being with her. So remember Antonofsky's Holocaust survivors. Well this woman represents them for me. So this woman I knew had the essence that health promoting that I wanted to think about in relation to those dreadful. What is it that this woman knows that other women don't know? What can she teach other women? What can she teach midwives? So if you have strong sense of coherence and I believe that that's what this woman has then you see your world or the hard thing that you're doing as comprehensive. So this woman for childbearing makes sense. She understands what she's doing that there is a manageability component so she believes that she can do this hard thing. She believes that she either has the resources or can realise the resource with their potential. She can go and seek out midwifery care. She can go and do all the things she needs to do to get the support that she needs to manage these hard things. And the best bit is the meaningfulness. Because that is what Stockdale and Sinclair are talking about. That's the active component. That's the motivational aspect. So this woman clearly childbearing has meaning for her and value for her. She's motivated if she to be able to tackle her hard things. So it creates a sort of... So she's motivated enough. She understands the concept. She can rally her existing essential resources but what that creates is a sort of optimist. Which is just lovely. So a lovely optimist which to work and think about your work. So Salute Genesis Literature Review. So as we just said, Sensor Coherence is the working unit of Salute Genesis. So let's just go back and see what they say about Salute Genesis in the literature. So Salute Genesis has become an important health promoting concept in Europe and especially in Scandinavia. And there's thousands of studies on Salute Genesis and sense of coherence. And generally speaking, if you have strong sense of coherence, you have better physical health. That is you have less chronic disease, less diabetes, less cancer. You have better emotional health. That is you have less depression, less anxiety and less post-traumatic stress disorder amongst us. You have better health behaviors. That is you clean your teeth the longer you eat better, you drink less alcohol, you smoke less cigarettes and you do more physical exercise. And a systematic review by Ericsson and Lindstrom in 2006 concluded that strong sense of coherence leads to better health, especially emotional health. So there's thousands of articles on Salute Genesis and sense of coherence on general health, but only I could only find 17 on childbearing. Let me tell you about that. I'm just about to publish this literature review on sense of coherence and childbearing. And what I found was women with low sense of coherence, and this gets measured on Antonovsky's Orientation to Life questionnaire. He devised a 29.113. Most people use the 13.113. So women with low sense of coherence. Can you hear me? That all right? Your microphone nice and stable, please. Okay, sorry, sorry. So women with low sense of coherence experience more premature labour. They smoke, they're more likely to smoke in a pregnancy and beyond. They claim to be dissatisfied with their partners. They rate their baby as more fractious. They experience low emotional and physical well-being and more major life worry. They have more stress and depressive symptoms and if you ask them in a pregnancy they would say that they want to have a caesarean section for their birth. Women with high sense of coherence have more uncomplicated birth. They choose more home birth. They have greater well-being in pregnancy. They have less post-traumatic stress disorder and less depression after miscarriage. And if you ask them in a pregnancy they would say that they want more, they would like to have a normal birth. So that's what the research says about sense of coherence in relation to childbearing. And the best bit, otherwise all of this would be a waste of time, there's also research that says that we can grow someone's sense of coherence and improve their health. So we don't know too much about it but what we do know from the literature is music therapy increases sense of coherence. Support, education and Marilyn Ferreur has just told us that mindfulness increases sense of coherence in a childbearing woman. They're very exciting ideas about the way that we could improve people's health by increasing their sense of coherence. So let's relate this back to salutogenic midwifery. So I think it's safe to say that good midwifery is already using a salutogenic perspective. Good midwifery probably does emphasise health as well as risk. And good midwifery probably is increasing a woman's sense of coherence. By increasing her comprehension of her childbearing, we're probably quite good at that, helping women to understand their childbearing. Increasing the manageability of her childbearing, good midwifery is good at that. Enabling women actually being a resource for her and helping her to find the other resources that are going to make for healthy childbearing. And I think the most important one is the meaningfulness. So I think good midwifery is motivational and it is creating energy and it is persuasive. And, you know, I talk about providing women with information and then standing back while they make a choice. Well, I think we could probably be a bit more persuasive than that, especially around normal birth, around breastfeeding, around immunisation. There are things that women could be persuaded. Birth is certainly good. Good midwifery is energising motivate. So using this approach, women would be encouraged to activate, emancipate and increase their perception of their existing and potential resources. Rogers says that. So isn't that beautiful? Using this approach, women would be encouraged to activate, emancipate and increase their perception of their existing potential resources. Good midwifery is probably. So one of the few salutogenic midwifery examples that are around is some work done by Stockdale and her friends in 2008. And Stockdale and others did salutogenic breastfeeding classes. So they did a randomised control trial where they compared the outcomes of the women who attended the salutogenic breastfeeding classes and compared them with women attending routine breastfeeding classes. They developed the salutopressfeeding classes to increase the comprehension, so to increase the women's sense of coherence by increasing her understanding of her breastfeeding, to increase her manageability of all her meaningfulness of her breastfeeding. So that is motivating her to want to breastfeed, and in that research they provide some beautiful motivational theory that it was really lovely and simple and easy to understand. And they explained that you can motivate someone by increasing the value of the thing as well as increasing the woman's expectancy of success. So if you want to motivate someone to breastfeed, what you do is increase the value of it for them but also increase their expectancy of success. So that's what the salutogenic breastfeeding classes, that's the way they were designed. Let me briefly tell you what they did. So the salutogenic concept was, one of them anyway, was presenting the most common breastfeeding challenges as normal. And so they called them normal challenges. They provided a booklet for not if but when challenges. So if a woman did end up with sore nipples, they didn't even talk about it too much in the class. They just said, if you do end up, and when you do end up with your sore nipples, go and have a read of page 9 and it'll explain to you. So it didn't undermine women's confidence when they did come up against challenges of breastfeeding and the findings of that study were that it increased the maternal confidence, it increased their sense of support, so they felt more supported and it increased breastfeeding duration. So that's a beautiful example of salutogenic midwifery. So what we need is more research around sense of coherence and childbearing. I could only find 17 studies that related to that, but it does look promising. It looks really promising for healthy childbearing, especially in relation to our birthing statistics, those dreadful statistics that we're going back with in terms of our normal birth rates. But we need more research. My PhD research asks the question, how does a woman's sense of coherence affect her birth choices and outcomes? And I'm about halfway through collecting the data for that. And I don't know if you're allowed to hope when you are doing a PhD, but I do, and I am hoping that a woman with strong sense of coherence does make different birth choices and she does have more straightforward birth. And if we know that, then we can take the next steps, which are having salutogenic midwifery that raises women's sense of coherence and hopefully improves their childbearing, their ability to have straightforward childbearing. So there's more research needed in every area. So to close, I would just like to talk to you about my hopes. That is that salutogenesis and the raising of a woman's sense of coherence could become core business for midwifery business. Imagine if antinatal education was framed in salutogenesis. Imagine if every woman going through routine antinatal education came out the other side, empowered and motivated to confidently take control of their childbearing. I think we would see that that would make the world of difference and that we could make some inroads into those dreadful statistics. So that's the list of my references. Thank you very much. Thank you very much for listening to me. Does anybody have any questions for me? Are you there, Lorraine? Hi, it's Deborah. I think we might be having a technical difficulty with Lorraine. So I'll just facilitate the questions for Sally. And I'm using Sally's mic, so it looks like Sally's talking here. So thank you, Sally. I always, always really enjoy Sally's presentations that just, you know, midwifery so well. And I think she's, you know, touching on a subject that can be useful to all of us. So I'll take the questions and I'll hand over to Sally for some answers. Oh hi, Lorraine. Do you want to step back in? Sure thing, no problem. There's some great questions popping in here. Sorry about that, everyone. I live in rural Nova Scotia and sometimes it doesn't like the internet. So here's the first question from Mel. Mel asks, would midwives picking up poor sense of coherence in women in early pregnancy indicate, highlight possible mental health needs in late pregnancy or after birth? That's a very good question. Yes. There certainly is a correlation between low sense of coherence and scoring high on depression scoring. So women with low sense of coherence do experience more depression anxiety. So there is definitely a connection. We were to provide the sense of coherence scale to women like we do the depression scale. Okay, never mind, fine. Can you hear me? So it may be possible, it may be possible to, I mean one of my hopes would be that we use the sense of coherence now during pregnancy. So we do locate that woman who is likely to experience less straightforward birth and perhaps more emotional health needs. And we can locate her and we can add support and love and we can maybe raise her sense of coherence and improve her outcome by doing that. Thank you. Now we have a question from Cecilia. And Cecilia, do you have any idea or do you have an idea of ways to work practice with salutagenesis thought and action into the student experience? Yes, I don't think that would be very different to how you incorporated into any experience. So the student experience would really just be understanding salutagenesis, the concept, understanding what sense of coherence means and being clear about wanting to raise it with women and with people. So wanting to increase the woman's comprehension, wanting to increase her manageability, and that's what you're doing as a student as well, you're increasing her manageability, adding another resource. And motivating her to want normal birth, straightforward birth, increasing the value of it and increasing her obstacles. So every time you tell her that she's designed to birth, that she's grown the most beautiful baby and she's going to birth the most beautiful baby, all those things we say, that's all about increasing acceptance. So it's actually stuff that we are, or good midwifery is doing. Great, thank you. Now, let me see here. So Tammy asks if you're able to offer us where you can find the breastfeeding booklet. Is that in your references here? It is, yes. So it's the 2008. So the Feasibility Study to Test Design of Breastfeeding, the reference book is there. Great, thank you. I'm not sure the booklet is there, but you could contact the... Good, okay. And lots of really good comments in here about taking that positive perspective. Are there any other questions that people would like to put into chat? Checking to make sure I haven't missed any. I see typing. You never know. Maybe there's some more questions coming. We still have a bit of time, so there's lots of time for questions if you have any. There, Deb has shared a link to a self-test on coherence. That sounds like a good one. There we go. Chris has asked a question. Is there a way to do a crash course on cellutogenic principles? I have only one day to do our whole childbirth ed course and the time is so limited. Well, the place that I started was... Bergstrom and Lindstrom have written a little booklet called The Hitchhiker's Guide to Cellutogenic. So I suggest that you start there. It's about 100 pages. It's really easy to read and it just has the basic principles. And so it's pulled together. Most of Antonoski's work into this booklet. So The Hitchhiker's Guide to Cellutogenesis, it's called, and the author is Bergstrom and Lindstrom. I hope that helps. Good luck with doing that. Does anyone else have any questions? There's one from Allie. She asks, you mentioned the Maryland four-year paper. Which one were you talking about? It's the latest one, Allie. So the 2014 one. I can't remember what it's called, but there's some work in there on sensor coherence and mindfulness. Sorry, I shouldn't know. Anything, so you never know. There might be some more there. And Denise asks if you could add it to your reference. I will. Yes, of course. Deb asks, are you familiar with the concepts of centering pregnancy or prenatal pregnancy? I am, yes. And I would imagine that centering pregnancy, even though they may not know, it's based that work on cellutogenesis. So I think compared to routine antinatal education that centering probably does use the cellutogenic. Deb Davis has added a link to Sally's article that has a structured literature review for anyone who's interested. That's what that link is there. And Deb Pudderborough asks, do you feel that this system helps promote these concepts? Which concepts, so the centering pregnancy, do they promote the concepts? Absolutely. I think that's exactly what centering does and that's why it makes a difference. I think that it provides good information. I think it does motivate women and I think that it does increase their manageability. And I think it's being in those lovely small groups where the women drive the business that makes for much more effective learning and probably better. And I know centering has really good outcomes compared. Yes, I think Deb, the locus of control, that's a really interesting point. There's not much about on relating locus of control to cellutogenesis, but there should be. So I agree. I think probably what would cellutogenic midwifery would be doing would be moving someone from extrinsic to intrinsic locus of control. I think that's exactly right because that takes a motivational leap to do that, to move from taking control of things. That's a real... More links from Deb Davis. Thank you, Deb. Denise Hind asks, when you talked about support, would you see the need for first-time women to mix with others who've had a positive birth experience rather than only be with other women? I think that's a really good point that we need to be careful about the way that we design with the care in it. Women are supported by other women. I think probably they're better supported by other women sometimes than they are by midwifery. So really harnessing those women with birth experience and using the support of other women. That's a cellutogenic idea and could be well incorporated into any aspect of midwifery, midwifery, anti-natal edgy. Perfect. Yes, I'm surprised too, Kate, but there are lots of people... There are some people talking about it, but we need more people to talk about it because it has so much to offer the profession. Allie asks, Denise is just commenting on something that Denise said about the benefit of centering pregnancy. So Allie's saying that Denise is... that is the benefit of centering pregnancy. We're both multi-climate, share and learn together, and I completely agree with that. That's a wonderful model. We've got about three more minutes for questions, everyone. So if you've been putting off, putting one in the chat, do it now. But Denise says, here in New Zealand, the government has been funding only classes for primates, and generally only they seek classes. Yes, I think that is... Generally speaking, it is the primate that attends the anti-natal classes. But we could... I know in Australia that women... Multis might do just a one-off, a fresher sort of a class, but no matter who the classes are designed for, I think we could use these primates so easily, and in good midwifery work, they probably already are. The Tabbathas saying, doula and maternity consumer representatives often do well at supporting and engaging with women, particularly with regards to informed decision making. And I agree with that, and I think we could probably argue that there's a cell-utogenic component of that that doula and maternity consumer representatives are there for the woman, employed by the woman, for the woman to provide her with information to increase her manageability at exactly what they were doing. And it clearly already has meaning for the woman to be employing these people, and that they would still come on a national level. The Janine is saying, it is often mulled tips who seek out classes such as hypnobirthing, which aligns very well with this. And I think that's right, Janine. I think that I know a lot about hypnobirthing, but I imagine it's about motivating people and enabling and encouraging self-belief in their abilities, and exactly what Stockdale says, encourage people to confidently take control of their childbearing. That's all being able to tap into their ability. Deb's put up the original questionnaire by Antonos Kic. That's a wonderful point by Denise. That BFHI's 10 steps encourages promotion of breastfeeding support groups. So midwives need to encourage women to attend local home birth groups and hear about non-medical experience. That's a good... I think we could have, you know, normal birth hospital initiative or some sort of initiative where we promote normal birth and promote breastfeeding. That could use itself. Last question to Hiromi. I'm just letting you know that there's women getting together and giving birth without doctors, but doctors do not like the idea. But is that part of women's rights issues or not? I'm not sure that's a question for me, but I'll have a go at answering it anyway. So let me just read the question again. I'm just letting you know that there are women getting together and giving birth without doctors. Doctors do not like the idea. But is that part of women's rights issues or not? So of course, you know, women can make choices about the way that they have their babies. We know that if women have their babies with midwives, then they are going to have a better outcome, especially if they know and love their midwives. So it's definitely a woman's right to choose where she... who is with her when she has her baby and where she is. And on that note, I just want to say thank you very much, Sally. It was a really, really interesting and informative presentation. So could we all give Sally a big round of applause, and then we're going to be setting up for our next presentation. So thank you, thank you, thank you. Thank you, Lorraine, and thank you, everybody. Lots of applause coming in for you. And our next speaker is Sarah Ward. So we'll take us about a 10-minute break.