Control

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Even the heading of their case studies implies it and denies it. CONTROL. This is the key to people's lives, minds and capabilities. This is the one thing women lose, or more specifically feel they lose, during their pregnancy, labour and early stages of parenting.

I have control over their notes for this case study, the doctors and midwives have control over their medical records and in some cases even control over the kind of labour and birth these women will experience, and the yet the greatest loss of control is to something that starts so small it's barely visible to the human eye: the Baby.

Over the past six months I have got to know and learned to listen to four women and their partners. Two couples were experiencing the joys of parenthood for the first time and two were dab hands. Well they both had one child each! Despite the fact that two of my couples were already "families" they had both had a very hard time and so were in some ways as new to the game as the ones who were starting out. One lady had had very bad Postnatal Depression with her first son and it was actually talking to her and my sister that gave me the idea for this piece. The other had sadly experienced a stillbirth with her first son and which resulted in an extremely medically controlled second birth with her next son.

For an experience, or pre-ordained function that we as women are genetically designed to fulfill, pregnancy and childbirth is often accompanied by an alien illness that even in today's society we seem ill-prepared to cope with. All my ladies had planned their little packages, yet even during the six months I was working with them two other ladies enlisted my services for pregnancy massage for pregnancies that hadn't been planned (and in one case was definitely not wanted).

What is control and why do we need it or so much of it? Is it because we, as women, are determined to make decisions about our lives for ourselves now that we have tasted liberation courtesy of the Suffragettes in 1918 and the Contraceptive Pill in 1961? Or is it a human instinct that is inbuilt as a survival mechanism?

The aspects of control I encountered during this period were all very real and to each person very important. Some where more worried than others about how having a Baby would affect their lives and I found generally the fathers to be more blasé than the women despite actually vocalising some very real concerns and fears.

My first lady put her feelings to me in a nutshell, "You spend nine months, most of that time completely out of control of your own body, with no guarantees that you'll end up with anything at the end of it … You're unconsciously and subconsciously physically and mentally preparing for this Baby whether you like it or not."

First Loss

Something that has been done since the birth of humankind, something that society takes for granted has until recently been an all woman's arena. With the birth of modern medicine and increased access to information about childbirth for expectant mothers, all this has changed. As scientific knowledge has developed over the centuries and the age of information technology was born, we as women seem to have slowly lost or rather lost faith in our natural instincts. The more we learn through research, communication and education, (which I am not dismissing) the further away in many ways we become from ourselves. I think society is beginning to acknowledge and question this loss especially spiritually and I think with the current trend towards alternative therapies, people are slowly beginning to listen to themselves again.

The last forty years especially have seen women take control of their lives and bodies in a revolutionary way. The arrival of the Pill (by Carl Djerassi 1961) means that we are now 99.83% in control of our ovaries. The rise of women in the work place means we are in much greater control of our own careers and finance. So is this the problem? Is the one thing that women have spent centuries fighting for, the fundamental right to control our own lives, has this right been our undoing?

The amazingly complex process of pregnancy, once sperm meets egg, is something that we have no control over either intellectually or physically. Slowly it grows and develops, this tiny life form using you simply as a carrier. The women I have spoken to vary on when they actually knew they were pregnant. Some knew at conception, some not for several months. They then all had to trot to the doctor to have it confirmed. But before the birth of modern medicine confirmation of conception was a privileged gift that only the woman would know about and was called "The Quickening." It was the first time she felt her Baby move!

The intricate changes that occur everyday are so small that you don't even notice. Baby's spinal development begins at 5 weeks, by 7 weeks arms and legs have begun to develop, at 12 weeks the Baby is moving vigorously, at 13 weeks fingers and toes have taken shape, and it's not until week 16 that the mother may become aware of movement. To have another human being moving vigorously inside you and not even know it is simply weird!

All my ladies had very high-powered jobs but even friends who didn't work said the same: the feeling of total lack of control was surreal. Thanks to medicine we know what to do to protect and assist in the development of an unborn child, but despite that knowledge it isn't always enough to ensure a successful pregnancy. Many of these were women who made cut and thrust decisions, managed teams and organised companies, yet they couldn't control their own bodies or guarantee the survival of their Baby. One lady said that at 14 weeks she wasn't consciously thinking about being pregnant but realised subconsciously everything she was now doing revolved around the Baby. She also said that until she had had her first scan she couldn't really believe it was true. Later she said she'd felt stupid lying waiting for the scan as though she was imagining it all and they would tell her off for wasting their time. With the symptoms of pregnancy developing, heart burn, constipation and fatigue to name but a few, the outside world became aware of my ladies' altered state and to some extent they began to relax into things.

Although most of us having a basic understanding of our hormones and how our Endocrine, Hypothalamus and Pituitary glands work, many women are still significantly affected and sometimes caught out by their hormonal changes each menstrual cycle. Becoming pregnant is the result of a chain reaction created by our hormones. The successful result of becoming pregnant then triggers a catalogue of new hormonal discharges that can be very hard to cope with. Your body suddenly turning into its own self-dispensing drug cabinet. Levels of progesterone and oestrogen continue to rise instead of fall, as they do for menstruation, and the production of these hormones is eventually taken over by the placenta. Levels of progesterone rise some 50 to 100 times higher than in a non-pregnant woman and even with the rise of oestrogen they are still 50 times higher than oestrogen. To sum up, during our menstrual cycle progesterone is barely measurable until ovulation when it reaches a peak, then disappears at menstruation. Oestrogen, on the other hand, is present and measurable in fluctuating quantities throughout. So the shift in hormones in general and in relation to each other is massive. In addition to this Relaxin is produced in the first month of pregnancy and stays in the blood for up to five months postnatally and softens the body's ligaments and connective tissue.

All hormonal changes have an effect on our mood, directly or indirectly. It may not be a specific change in our levels of Serotonin and therefore chemically effecting us, but it may be the over-production of Relaxin causing symptoms of Symphysis Pubis. This results in pain and the restriction of movement and in severe cases total bed rest may understandably cause the pregnant lady get distress and unhappiness.

Most of my ladies had at some stage during their early pregnancy passed through a stage of tearfulness and emotional uncertainty. They found they were short-tempered and critical of other people's actions, including their partner's. While their partners rallied round trying to reassure and encourage them, it only seemed to aggravate and irritate them more despite the fact they knew they were being unreasonable. Once this rite of passage had taken place, the pregnancies confirmed, their bellies swelling and those first breathtaking flutters felt my ladies were able to relax. Ironically then it seemed, that it was at this stage or slightly later that some of the expectant fathers began to self-doubt. They were concerned about supporting their partners emotionally, their new family financially and of simply being able to cope. Their lack of knowledge of what to do either during labour or in the early days of fatherhood also caused anxiety as did the idea that they might unwittingly harm the unborn Baby either during sex or through massage and they weren't sure whether the Baby would really like being massaged by them once born. They seemed to share an overall feeling of uselessness or incompetence and felt that it was somehow women's work simply because we are more maternal and in tune with these things instinctively. The sad thing is that probably their fathers and fathers before them went through these same swings of emotion alongside the all-encompassing joy of impending parenthood. These dips of self-confidence especially during the first few months of pregnancy are normal.

Last Stages

The last few months of my ladies' pregnancies passed with out major hiccups, but the feeling of control they had gained through the on-going months wobbled as their impending labours approached and with them the fear of pain, intervention, the unknown or Post Natal Depression (PND).

Control of one's labour seems to be the most important and also most devastating aspect of the whole pregnancy. I was horrified to learn of a friend giving birth in Italy and the standard practice in hospitals to "not allow the Baby to go over ten days from its due date". My friend was nine days late and so had to be induced. I was also surprised to learn that women have to be shaved and to lie flat on their backs with their legs in stirrups to give birth. The mad thing is that Italy has excellent ante and postnatal medical care and extremely clean hospitals.

"I had to have an emergency caesarean at 35 weeks due to pre-eclampsia and I've been consoled not only on the poor health of my Baby but on the fact I was unable to do it properly." This was a remark a friend made to me a few days after her daughter was born five weeks premature and with both of them having nearly died. "Doing it properly" confused me so I asked her to clarify. The lady who made the remark was commenting on my friend's non-vaginal birth. All my ladies were told to make birth plans and we discussed what they wanted, expected and feared from the experience, what they wanted their partners to be doing or if they were to be present at all. Three ladies had a fear of caesareans, one had a fear of the possible length of labour, one feared the possibility of induction, none of them was impressed with the pain aspect and in some ways my lady having a home birth was more worried about this as her options were so limited. My only experience in the past of a home birth resulted in the most pain-free, exhilarating experience of any of my friends or clients.

I understand the need for a birth plan and my ladies certainly felt that armed with their plan they were truly in control of proceedings, their body and the Baby, even though everyone was warned of unexpected complications. My concerns about labour and birth plans for my ladies and women in general lie with our nature, society and maybe that survival instinct. We are so not happy or secure with relinquishing ourselves to the power of labour itself. Subsequently we fight what our bodies are trying to do, place 19th century fashion criteria on ourselves and obstetricians or gynaecologists, and seek convenience before what is natural, normal and beneficial in terms of speed and pain relief. Thus when the birth plan flies out the window at the doctors' will we are left devastated, traumatised and often with a feeling of being violated. This is your perception of proceedings though because it didn't go the way you planned. The important fact is that you and Baby are alive and hopefully well. Doctors do need to be very aware of the need for control that women have surrounding their labours and should not dismiss it because, as a professional, they feel that a certain procedure or position would be more favourable. But equally as much, women need to stop being so critical of themselves if things don't go as planned. Through using massage, visualization and breathing during pregnancy and labour a woman can learn the enormous powers her body has as well as learning to accept her limitations.

Not What You Expected

"I found myself standing on the front door step with the Baby screaming inside, completely paralysed and unable to go back in."

"The first few weeks were hell, my nipples were cracked, bleeding and in one section severed from the areola. Every time I tried to stop feeding she just screamed. I stopped breastfeeding after seven weeks."

"I felt so completely useless it just filled me. Everybody else's babies slept or fed normally. I just couldn't do anything to console her."

"At one stage I contemplated suicide."

"I had to have an emergency caesarean at 35 weeks due to pre-eclampsia and I've been consoled not only on the poor health of my Baby but on the fact I was unable to do it properly."

"I thought I'd gone mad."

"It was only a Baby, why couldn't I cope?"

"I hated him and as I knew this was wrong I hated him even more for making me a bad person."

These are quotes or comments friends, family and clients have made to me over the last six months. Two different women made the contemplated suicide comment.

There are different schools of thought on PND. One is that it is a hormonal disease caused by the severe drop in progesterone during labour and puerperium the first days after birth. The other general one is that it is a combination of hormonal levels changing; sleep deprivation due to Baby crying and feeding, the stress of new motherhood and a sense of isolation due to the breakdown of communities and lack of support networks. I was certainly amazed at how many women felt new motherhood was an experience or path they had to take on their own, that somehow asking for help or advice with their new Baby was the ultimate admittance of failure. It seems to me that it is especially during labour and early parenthood that women's feelings of loss of control coupled with the desperate need to be in control is the most damaging.

During the six months of my pregnancy case histories I started a Baby Massage Instructors' Course as I felt this was a natural progression from pregnancy. I found a very heavy influence on the inclusion of fathers and that this could be their role in the new Baby's life. I spoke to my expectant parents and they all agreed that this would be a wonderful bonding experience for their partners. One lady told me that her husband was already doing massage with their first son. What she also told me was that this had certainly created a bonding between father and son, so much so that her son, now two, would not accept massages from her, physically rebuking her if she tried. She was happy and pleased about the relationship that had developed between father and son, but it had also had an alienating effect on her, no doubt felt more acutely because of the post natal depression she had suffered. Nevertheless, she simply felt it was one more thing she was no good at and one more fun activity her husband and son were experiencing together. Yet reading the research below, it was in fact her as his mother who needed this bonding experience and I think we as therapists need to remember, as much as we need to include fathers through the journey and beyond, the ability to breastfeed or the mother's intuition isn't always enough to create the bond between mother and Baby. We should not forget that mothers need fun bonding experiences as well as biological ones so the emphasis should be on family groups with dual or mirroring massage.

During my research generally, and into PND for this piece, I came across very few Internet sites relating to pregnancy massage, but found several for infant massage, some with medical research into the effects of mothers suffering with PND learning baby massage. The following quote is from the Fetal and Neonatal Stress Research Group:

Massage and mother baby interaction with depressed mothers
"Mothers with postnatal depression are known to have a worse relationship with their babies. The aim of this study was to find whether a program of attending mother baby massage classes which are on offer at Queen Charlotte's would be beneficial. A group who attended 5 massage classes were compared with a similar group who attended a support group. At the end of the test period the massage group had significantly less depression and very significantly better interaction with their babies, than the control group. This is the first time that such a method has been found for improving the relationship between a depressed mother and her baby." (Institute of Reproductive and Developmental Biology, Fetal and Neonatal Stress Research Group)

I found this research referred to in another article stating that this study was conducted in 1996 with a quote by Dr Vivette Glover of Queen Charlotte's and Chelsea Hospital London, "Baby massage is likely to have a very important role in helping postnatal depression." (Post Natal Depression. Infant Massage Information Service) Perhaps as the research results are so positive regarding the benefits of massage on Baby and mother physiologically and psychologically, the study might be extended somehow to using massage as preventative care for PND as well as curative or alleviating care.

Choices

The main aim in working with my ladies and their partners over the last six months was to make them feel good. Good, but good how? I felt having watched many friends and family members that there was, and is, a fundamental gap in antenatal and postnatal care. The doctors and midwives follow the medical procedures list and a very good standard of care is usually provided, as long as you haven't got too many questions, too many concerns, or heaven forbid take up too much time! I believe that massage can bridge that gap.

To start with, the opportunity of an extra pair of ears to bend is always indispensable and secondly many hands make light work! When trying to find case studies, I contacted my doctor's surgery and told them what I was doing. I explained that I needed four ladies to massage for free, reassuring them that I was qualified in A&P, etc. I was told they couldn't possibly help me but to try the local midwives. I did so and spoke to a midwife who asked if I could treat one of her postnatal ladies as she felt "it would really do her good". I explained that I actually needed pregnant ladies for my studies, but I was sure that something could be arranged for the other lady. The midwife explained that my request had to be put before her colleagues at the next meeting and that she would call me back as soon as possible. Seven months later I'm still waiting. Either they rejected the idea or they were just so busy they forgot to get back to me. Unfortunately though, a woman who needed help has missed out and the ladies of Forest Hill have missed a golden opportunity! The midwives are obviously very busy so where does that leave the slightly anxious, "Oh I'm just making a fuss, but I have lower back pain," expectant mum?

I'm not qualified in paediatrics, gynaecology, obstetrics or midwifery but nobody can deny that massage is very effective, eases and relieves numerous complaints physiological and psychological and for centuries was used in pregnancy and labour! Why then is it categorically listed as a contra indication? And why does the health profession still shun anyone trying to help lighten their load or ease their time restrictions? Is it not logical that if "Mum to be" is stress free and pain free she and Baby will be healthier? With "Mum to be" happy in the knowledge that she is having a massage tomorrow, or that maybe when she gets home from work her partner can spend some time feeling Baby, using visualization or breathing exercises with them both or even better he has the knowledge and confidence to massage her lower back and shoulders and remind her what to do about those ankles, she will as a result take up less medical time

Massage gives back a snippet of control that has been lost over the previous weeks or months. While a woman is being massaged she is relaxing, having a rare half hour or so for herself. She is in a calm, safe and balanced environment providing her, her body and Baby with unconditional permission to be. I found that my ladies could either choose to tune in with Baby or tune out. Baby would regularly become quite active even if mum seemed fast asleep and then eventually Baby himself would decide that this was also an ideal opportunity to chill.

Whilst being massaged you begin to listen to your body, you take on board those aches and pains you hadn't acknowledged before. You listen to the rhythm of your heart and the blood being pumped around your body. You begin to loosen your stomach muscles and loud gurgling may occur. You have time to clear your mind or make that mental list of "been meaning to dos". The control is that it's your choice, "Do I feel like having a treatment," how far will you slip into unconsciousness, will you really let that arm go floppy and all the time you are learning about your body and the Baby. With this new knowledge comes a greater understanding, "Oh that was cramp maybe I've got wind," or "My glands shouldn't swell like that. My lymph is obviously working hard. I must be fighting something." You are given choices of alternative ways to alleviate yours or Baby's symptoms, "My lower back hurts so I'll do some all four or cat stretching to move Baby off my spine." "Baby's restless so I'll rub my tummy and do some breathing." Your partner can be involved and it gives the three of you an opportunity to explore the physical changes occurring around you. Many women worry that their partners will at some stage of their pregnancy stop fancying them or that a massage from their partner equals sex due to its connotations or use before the pregnancy. Either way if your partner works on you during your various trimesters he will develop a greater understanding of you as a woman physically (explore alternatives to penetrative intercourse) and mentally (massaging is unconditional) whilst watching in awe as your body grows and changes incorporating and encompassing his unborn child. Through massage and, if he is interested, using visualization, he can learn, feel and therefore bond with Baby long before the child is born. (Anybody talking to Baby before birth is already using some form of visualization.)

Due to the hormonal changes that occur during massage and the release of endorphins, it is a very good form of pain relief and therefore very useful during labour. And who better to administer reassurance support and pain relief than the one person you trust and whose fingers you are trying to crush! The added bonus is that it is fun and makes you both feel good.

Answers

I feel that if more women were to have massages during their pregnancy then there simply would be fewer problems occurring during and after the birth. Nearly every woman has or knows of a bad labour story and it is human nature to mull over the morbid or macabre rather than focus or recite the positive empowering experiences that do take place. If we somehow learn to find a space where we can simply be, where we can regain our fundamental right to know our bodies and be at one with ourselves, we will be able to stand up for ourselves and win back our natural instincts as women and mothers. With a genuine respect for our instincts and a strong support network, depression in whichever form can be either eradicated through physiological and psychological rebalance or at least identified and medically treated at an earlier opportunity.

Everyone is different and every child is created in different circumstances. However, if we can gain a greater understanding of our bodies, minds and accept our limitations, and admit to the negative effects our self-destructive necessity to be perfect and in control at all times has, then many women would be less inclined to self-criticism. We are our own worst enemies and our own biggest critics, but I've yet to find a client or friend who isn't a good mother.