Today on Science & Sensibility, Australian childbirth educator Tanya Strusberg, LCCE, FACCE reviews Birth with Confidence: Savvy Choices for Normal Birth by longtime Australian birth professional Rhea Dempsey. Tanya also had an opportunity to interview Rhea about her 4 plus decades of being involved in the birth community, internationally and at home in Australia. Have you read Rhea's book? Share your thoughts and feedback in our comments section. - Sharon Muza, Science & Sensibility Community Manager.

If I had met Rhea Dempsey 30 years ago, I think I would have considered her to be my arch nemesis. 30 years ago, I was a plump, decidedly unfit 13-year old girl who loathed and detested physical education with a passion. Rhea, back then was a physical education teacher. Oh boy, would we have clashed.

I am very glad that Rhea and I did not meet back then. Instead, we met each other a couple of years ago in Melbourne, Australia at the screening of a wonderful Australian birth documentary called The Face of Birth, directed by Kate Gorman and Gavin Banks. Rhea was among the stellar list of experts interviewed in the documentary and even though I had only recently returned to Melbourne after living overseas for many years, it did not take me long to work out that Rhea was widely considered to be one of Australia's most respected birth professionals.

Rhea's understanding and experience of birth has been gained over almost forty years of birth work; supporting birthing women, their partners and families at over one thousand births in home and hospital settings. She is respected as one of Australia's foremost thinkers on the topic of working with pain in childbirth and its connection to normal physiological birth.

With all those years of experience, it seemed obvious that Rhea should one day share her knowledge with a wider audience. Her long-awaited book, Birth with Confidence: Savvy choices for normal birth (Boathouse Press, 2013) is a tremendous resource not only for pregnant women, but also for birth professionals. Over the decades, Rhea, like many of us working in the field, has observed a dramatic shift away from normal physiological birth towards an increasingly medicalised, highly interventionist labor and birth setting. The likelihood of a woman achieving an intervention-free, normal vaginal birth complete with the natural flow of birthing hormones is pretty rare in most modern hospital settings today.

Rhea talks about what she calls the "labor-bypass era".

"Birthing women no longer need to engage with their straining, striving, laboring, birthing bodies. You can have your baby without actually having to labor and birth at all, if you don't want to. Babies can be delivered by cesarean and bypass labour entirely, or because of the epidural option, women can labor but bypass feeling it - you can read the Sunday paper, update your Facebook status or sleep through it."

"The messages reaching women from this labor-bypass birthing culture are: healthy mother and baby are all that matter, and efficient, cut and dried, convenient birthing is possible and it's your right. In fact, you definitely should be comfortable and pain-free."

Some readers may find Rhea's approach to be somewhat blunt and to the point. She makes no apology for this, and in fact even warns her readers up front about her somewhat frequent use of the "F" word. I can imagine that if she had been my physical education teacher all those years ago, she would have been utterly unforgiving. However, those who know Rhea personally will attest to her incredible warmth and gentle, nurturing spirit.

Rhea's razor-sharp perception and innate understanding of the inner workings of a labouring woman's mind are extraordinary. Her deep understanding of the physiology of labor and birth and particularly her knowledge of the process of pain in labor are what puts Rhea on a level all of her own.

In Chapter Four, Rhea begins by describing a woman's 'circles of influence' - from friends to family to wider culture and in so doing, helps women to understand how these can support or sabotage her birthing potential. She also skillfully categorises women according to what "pain type" they identify with. According to Rhea, understanding your attitude towards pain in labor can help to predict what will happen when pain dynamics get going. Spread across a continuum they are a 'pain-avoiding' group, a 'status-quo' group, a 'wait and see' group, an 'aspirational but naïve' group and, finally, a 'pain embracing' group.

As a Lamaze certified childbirth educator, I have found Rhea's extensive analysis of pain in labour to be tremendously helpful as I discuss the topic of pain in my classes and try to help women to reframe the concept of pain altogether. At the end of each chapter, Rhea gives her readers the opportunity to write down their own personal reflections and these could easily be adapted for a wonderful class activity or homework assignment.

While Rhea writes with Australian women in mind, Birthing with Confidence is a book ALL pregnant women should read. I also think it should be an essential addition to every birth professional's personal library. Australia and the United States in particular share much in common in terms of our perinatal statistics. We are basically on a par with our cesarean rates (currently 33%, although some private hospitals are as high as 50%), induction rates (26%), augmentation rates (19%) - particularly through the use of synthetic oxytocin - even though we have a strong tradition of midwifery led care. 77% of all women who birthed in Australia in 2013 used some form of pharmacological pain relief (analgesia or anesthesia, or a combination of both).

In this accessible, straightforward book, Rhea Dempsey explains how a woman's choice of caregivers, support team and birthplace, as well as her life experience and personal attitudes to pain, will affect her birth outcomes. Featuring real-life stories, the latest Australian statistics and opportunities for guided personal reflection, Birth with Confidence provides the knowledge and practical advice that women need for the best chance of normal birth in today's birth culture.

I was fortunate enough to catch up with Rhea recently to ask her some of my most burning questions!

Tanya Strusburg: Can you tell the readers a little bit about how you originally came to be involved in birth work?

Rhea Dempsey: My involvement in birth work has unfolded organically. The birth of my first child in London in the 1970s awakened me to birth activism. According to the birth culture at the time, it was a routine birth, but it was certainly not the natural birth experience I had envisaged for my daughter. I was left with the question - what happened? Searching for the answer to this question led me to birth activism and the following almost 40 years of working in birth - birth activism, attending births, birth education, counselling, training and writing.

I've written more about the births of my babies and my awakening to birth work in the introduction to my book.

TS: What are some of the biggest changes in the Australian maternity system that you have observed in the time that you have worked as a childbirth educator and birth advocate?

RD: Changes I've observed in the Australian maternity system during my years of birth work include;

• The presence of fathers at the birth of their children.
• The rise in technological surveillance and routine screening of mothers and babies.
• Attitudes about birth have changed dramatically we are now in what I call the 'labor bypass era', where the three C's dominate the cultural message - Comfort, Convenience and Control. This has created a shift from interventions not only being used for medical need, but also as routine procedures, as well as accessed on the basis of social choice and social expectation.
• The seduction of the epidural, with the consequent rise in the cascade of interventions and the demonising of pain in labor.
• Also more recently, in the face of ever rising intervention rates, the growing urgency to champion normal physiological birth.

TS: Why do you think Australia has such similar statistics to the United States in terms of our Cesarean rate and other obstetric interventions, given we have a strong tradition of midwifery-led care?

RD: Although Australia has a history of midwifery care, midwives in the main have not practiced autonomously, but are constrained by the medical-obstetric hierarchy, which dominates birth culture, resulting in high levels of medical interventions.

TS: You've been training birth attendants (or doulas) for a number of years now. When you started, was this a known profession? Have you seen an increase in awareness and acceptance in Australia of the benefits of doula support?

RD: After my first daughter's birth, I returned to Australia and joined the unfolding homebirth scene. The reclaiming of homebirth by lay midwives supported by General Practice medical practitioners happened in Australia in a similar way to U.S., although it was more fully documented in the U.S. through the works of Ina May Gaskin, Elizabeth Davis and others.
Over time, medically trained midwives came to work in homebirth and the early lay midwives, like myself, supported birth in ways now recognized as the work of a doula, although the title doula wasn't used in Australia at the time. I have been training doulas for 15 years and during that time there has been a great increase in awareness and acceptance of the role of a doula.

TS: What led you to write a book? Did you have a strong idea from the outset about what you wanted to write about, or was it more of an organic process?

RD: Writing my book was part of the organic unfolding of my birth work. I started my book with a clear intention to speak to women who still have a yearning for normal physiological birth. I saw the need to particularly address the 'pain' issue and normalize the challenge of functional physiological pain in birth in order to support and inspire birthing women for this wondrous rite of passage.

TS: What do you believe are the biggest obstacles for women giving birth today, wanting to achieve a normal physiologic birth, and what advice would you give a woman who wants to have a low intervention hospital birth?

RD: Women wanting a normal physiological birth need to be savvy rather than naïve about their choices:

• Access caregivers who have a philosophical match with their intentions
• Access continuity of care with a known midwife
• Embrace and prepare for the challenge of functional exertion pain and ensure they have the experienced support of a 'facilitating holding circle' to back their intentions.
• Boost their 'informed refusal' capacity.

TS: You also work as a pregnancy and birth counsellor. What drew you to this area of work?

RD: Being present to women's stories goes with the territory of birth work, so gaining professional qualifications in counselling and psychology was a natural development. In recent years, sadly much of my counselling work involves birth trauma debriefing.

TS: I believe you have started working on a new book. Can you tell our readers a little bit about it?

RD: My next book will go deeper into the rite of passage of birth and motherhood by exploring 'wild cards' - the life and psychological issues that can impact a woman's birthing and postnatal experience.

About Tanya Strusberg

Tanya Strusberg is a Lamaze Certified Childbirth Educator (LCCE) and founder of birthwell birthright, an independent childbirth education practice based in Melbourne. In 2015, Tanya was inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to childbirth education. Through her internationally-accredited Lamaze Educator Training program, she is very excited to be training a new generation of Australian Lamaze educators. Last, but absolutely not least, she is also the mother of two beautiful children, her son Liev and daughter Amalia.

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