In Jewish tradition a blessing is recited for surviving a period of danger:
Blessed are You, Adonai, our God, Ruler of the Universe, Who bestows good things on the unworthy, and has bestowed on me every goodness.
The response from the minyan is May the One who has granted you all kindness always grant kindness to you, selah. It sounds less stilted in Hebrew!
The postpartum period is a key moment when this blessing is made, and Jewish tradition has always regarded childbirth as a dangerous passage. Indeed, the danger associated with childbirth explains the willingness to break Shabbat for the purpose of assisting the labouring woman. Looking at the complications of pregnancy and childbirth, it is clear that there are dangers intrinsic to the process - both for the mother and the fetus. Now, in Jewish tradition the fetus is not "nefesh" - but for most women continuing a pregnant the well-being of the fetus and a good outcome to that pregnancy is intimately connected with their own well-being. There are a myriad of dangers that threaten the childbearing woman: from ectopic pregnancy and miscarriage, through haemorrhage, hypertensive disorders, infection, obstructed labour and trauma.
Of course, the dangers of childbirth have long been recognised (hence the Birkhat HaGomel). When we recognise a danger is it natural to want to DO something about it. In the past, this "doing" has consisted of amulets and talismans, avoidance of the evil eye, acts of virtue and prayer - all attempts to avert disaster. With the advent of modern medicine the "doing" has shifted to screening, diagnostics, therapies, 'management' and well-intended interventions of all kinds.
There is something of a war about the risks of childbirth in the blogosphere. On one side are those who argue that "The dangers of childbirth justify medical interventions" and on the other side those who argue that we should simply "Trust Birth" and that "Birth is as safe as life gets" (and similar formulations). In fact, there is ample evidence from nature that we should be wary of childbearing and that it is a dangerous state.
It should, however, be obvious that recognising a danger is not the same as knowing what to do about it. If we do not approach medicine with a rigorous demand for evidence of benefit, then our interventions are little more than talismanic rituals designed to avert a danger. That is the task of evidence-based healthcare: to help us understand when interventions can reduce risks, where they make no difference, and where they increase risks or introduce new risks.
Friday, 26 June 2009
Saturday, 28 February 2009
Stop Press! Shabbat Midwifery has Talmudic approval
Well, that will teach me to try my hand at Jewish learning! I spent absolutely ages, working through the various contortions of Pikuach Nefesh and what they might mean for working in maternity services on Shabbat. I pondered the distinctions between 'doing' and 'being'; between (life-saving) therapeutic and (potentially life-saving) prophylactic interventions. And then I discovered that the Rabbis of the Babylonian Talmud had already set their minds to this. Not very 'stop press' either - since the Talmud has been around for about 2,000 years. [And it's taken me a good 12 months to get around to posting my correction! Some blogger I am....]
So, let me revise my previous opinion, and share with you my latest findings on what Jewish tradition has to say about about breaking Shabbat to assist a labouring woman.
The Mishneh (an early commentary on the Hebrew Bible) reads: We may deliver a Woman on Shabbat, Summon a Midwife for her from Place to Place, desecrate Shabbat on her account, and tie up the navel-string. R. Jose said: One may cut [the navel-string] too.
Other scholars of a more woman-centred dispostion took a different view
Mar Zutra recited it thus: Rab Judah said in Samuel's name: If a woman is in confinement, as long as the uterus is open, whether she says, ‘I need it’ or ‘I do not need it,’ we desecrate the Sabbath for her. If the uterus is closed, if she says, ‘I need it,’ we desecrate the Sabbath for her; if she does not say, ‘I need it,’ we do not desecrate the Sabbath for her.
This is perhaps closer to the NICE intrapartum care guidelines that suggests, since pain is subjective, consideration should be given to women's requests in latent labour even including requests for epidural.
The basis for the ruling is that labour is always regarded as a potentially life-threatening event in Jewish law - something I want to blog about [expect another post sometime in 2010 if current blogging activity keeps up!]
So, let me revise my previous opinion, and share with you my latest findings on what Jewish tradition has to say about about breaking Shabbat to assist a labouring woman.
The Mishneh (an early commentary on the Hebrew Bible) reads: We may deliver a Woman on Shabbat, Summon a Midwife for her from Place to Place, desecrate Shabbat on her account, and tie up the navel-string. R. Jose said: One may cut [the navel-string] too.
So, there goes my theory that lotus births might be biblically mandated on Shabbat. In fact, it seems that everything is permitted to assist the labouring woman.
Rab Judah said in Samuel's name: If a woman is in confinement, as long as the uterus is open, whether she states, ‘I need it,’ or ‘I do not need it,’ we must desecrate the Sabbath on her account. If the uterus is closed, whether she says,‘I need it’ or ‘I do not need it,’ we may not desecrate the Sabbath for her.
This ruling gives opinion to a further question: when can we tell whether the woman is in labour ('her uterus is open'). The Talmudists’ argument echo current debates about the differentiation of the latent and active labour. Despite referring to the uterus being open, no explicit mention is made of dilatation. Rather, the methods used to define active labour focus on demeanour and external signs. And the attitude of many midwives and labour ward managers is similar to that of Rab Judah. If she is in active labour anything can be done. If she is not in active labour then nothing can be done.
Rab Judah said in Samuel's name: If a woman is in confinement, as long as the uterus is open, whether she states, ‘I need it,’ or ‘I do not need it,’ we must desecrate the Sabbath on her account. If the uterus is closed, whether she says,‘I need it’ or ‘I do not need it,’ we may not desecrate the Sabbath for her.
This ruling gives opinion to a further question: when can we tell whether the woman is in labour ('her uterus is open'). The Talmudists’ argument echo current debates about the differentiation of the latent and active labour. Despite referring to the uterus being open, no explicit mention is made of dilatation. Rather, the methods used to define active labour focus on demeanour and external signs. And the attitude of many midwives and labour ward managers is similar to that of Rab Judah. If she is in active labour anything can be done. If she is not in active labour then nothing can be done.
Other scholars of a more woman-centred dispostion took a different view
Mar Zutra recited it thus: Rab Judah said in Samuel's name: If a woman is in confinement, as long as the uterus is open, whether she says, ‘I need it’ or ‘I do not need it,’ we desecrate the Sabbath for her. If the uterus is closed, if she says, ‘I need it,’ we desecrate the Sabbath for her; if she does not say, ‘I need it,’ we do not desecrate the Sabbath for her.
This is perhaps closer to the NICE intrapartum care guidelines that suggests, since pain is subjective, consideration should be given to women's requests in latent labour even including requests for epidural.
The basis for the ruling is that labour is always regarded as a potentially life-threatening event in Jewish law - something I want to blog about [expect another post sometime in 2010 if current blogging activity keeps up!]
Rabina asked Meremar: Mar Zutra recited it in the direction of leniency, [while] R. Ashi recited it in the direction of stringency; which is the law? — The law is as Mar Zutra, replied he: where [a matter of] life is in doubt we are lenient.
I also hope to tackle the vexed question of the differentiation between Jew and non-Jew in Rabbinic discussion of midwifery, especially where it entails the breaking of Shabbat. [that post may have to wait until 2011!]
Saturday, 22 March 2008
Biblical Women: Queen Vashti
This is the first of what might become a series on women in the Hebrew bible. Future posts could include musings on Dinah, whom Anita Diamant imagines as a midwife in The Red Tent (as I was recently reminded by midwifemuse) or Miriam, whom Rashi identifies as the midwife Pu'ah. I've already talked a little about Lilith, but perhaps I will turn to her again in this series, for she is a huge figure in Jewish childbirth experience.
For my first post though, I focus on Queen Vashti, a character in the Purim festival, which we have just celebrated. Purim celebrates the events told in the Book of Esther, with Vashti a relatively minor but intriguing figure. Her story takes me away from the childbirth topic for a moment to reflect on women and body image.
On the seventh day of feasting, when the king was merry with wine, he ordered Mehuman, Bizzetha, Harbona, Bigtha, Abagtha, Zether and Carcas, the seven eunachs in attendance on King Ahasuerus to bring Queen Vashti before the king wearing a royal diadem, to display her beauty to the peoples and the officials; for she was a beautiful woman. But Queen Vashti refused to come at the king’s command conveyed by the eunuchs….(Esther 1:10) Memucan declared in the presence of the King and the ministers “Queen Vashti has committed an offense not only against your Majesty but also against all the officials and against all the peoples in the provinces of King Ahasuerus. For the queen’s behaviour will make all wives despise their husbands, as they reflect that King Ahasuerus himself ordered Quen Vashti to be brought before him, but she would not come. This very day the ladies of Persia and Media, who have heard the queen’s behaviour, will cite it to all Your majesty’s officials, and there will be no end of scorn and provocation!” (Esther 1:16-18) Let a royal edict be issued “All wives will treat their husbands with respect, high and low alike”. (Esther 1:19)
For some, Vashti is the archetypal feminist. Since the women’s liberation movement of the 1960s and 70s, Vashti has been for many Jews a symbol of female emancipation. She is a woman who refuses to parade herself for the pleasure of men, and in doing so disobeys her husband. The biblical text says that King Ahasuerus ordered Vashti to display her beauty “wearing a royal diadem”. But midrash spins this to mean “wearing only a royal diadem”. In other words, naked except for a crown. For feminism of the 1970s, protesting the objectification and sexual exploitation of women was central, and Vashti proved an inspiring symbol. Vashti refuses to be just another object to be displayed alongside the rest of King Ahasuerus’s material riches. Where Vashti openly defies King Ahasuerus, Esther achieves her goal through more stereotypically-feminine attributes of manipulation and subterfuge.
But the vignette in which Vashti disobeys the command to display her beauty can be read differently. Rather than being a story designed to elevate feisty Queen Vashti , it could be read as primarily about the weakness of King Ahasuerus. We are told not only of his immodesty and corrupt sexual mortality, but also about his lack of power in relation to his own wife. The purpose of Vashti’s defiance is not to make her the heroine of the story, but to mock Ahasuerus. The impotence of his commands set the scene for the unfolding story of the whole Book of Esther. First, he carries out the instruction of Memucan in issuing the edict that wives must treat husbands with respect. Even the proposal for bringing all the young women of the kingdom to the palace to find a replacement for Queen Vashti was originally made by the King’s servants, and only then acted upon by the King, as it is written “The proposal pleased the King, and he acted upon it”. The plot to kill the Jews of Persia is then pursued without the King’s knowledge or permission, by Haman. Later the King arranges that feasts be held, as he has been asked to do by Esther. He impales Haman on the stake intended for Mordechai, not as his own inspiration but on the suggestion of Harbona the eunuch. The closing and bloody events of the Purim story are done at Mordechai’s bidding, writing edicts in the name of the King. This is a King that is barely a King at all, acting on the instructions of his officials: Haman and then Mordechai, his eunuchs, Mehuman/Memucan and Harbonah and his wives: Vashti and then Esther.
The book of Esther is a bawdy and comic story, and so it may be fitting that God does not appear – at least directly. However, the metaphor of kingship is one of our most frequent ways of thinking about God and I think we can see in the character of Ahasuerus a subtle allusion to that metaphor, but as God’s opposite. Purim is a festival of reversals, and where HaMelech HaOlam is omnipotent and omniscient, Ahasuerus is impotent and doesn’t have a clue what’s going on. Thus Vashti’s rebellion is part of a pattern revealing the King’s weakness, but not necessarily to be interpreted as evidence of her courage. Although Vashti has been interpreted as an admirable figure over the past thirty or forty years, she gets a much harsher press from traditional Jewish sources.
Some talmudic voices suggest that Vashti’s refusal to display herself was not motivated by modesty at all, but rather by vanity. Midrashim tell that she was afflicted by leprosy, or that she had grown a tail, and this is why she disobeyed the King’s commands. In these commentaries, Vashti would normally have no qualms at parading herself at the King’s banquet, but only when she is looking at her best.
Vashti refuses to display herself, not out of principle, but because she is ashamed of her body. Of course, this sort of thinking brings us right to the present day. When objections to the way women are judged according to narrow conventions of physical beauty are raised, these are often dismissed as the bleating of the less attractive who lose out in this contest. “Feminists object to beauty contests because feminists are ugly losers” is the simplistic charge.
A lot has changed in gender politics, mostly for the good, since Vashti was first rehabilitated by some Jewish communities in the 1970s. But on this question of objectification of women’s bodies, it may be that we have taken very significant steps backwards in the past decade or so. As Ariel Levy writes in Female Chauvanist Pigs: Women and the Rise of Raunch Culture, we are more surrounded by images of women’s bodies as commodities than ever before. But more than that, women, especially young women, are encouraged to see active participation in this culture as a form of liberation. In this context, the only reason not to display yourself for the judgment of others would be shame in not measuring up. For Vashti the problem was leprosy, or her curious tail. Today it is excessive body hair that needs defoliation or flab that needs sucking in with cast iron underwear. These are the reasons to resist exposure, rather than objecting to being a ‘thing’ or object to someone else. And of course, in this battle with our bodies, we risk becoming a ‘thing’ or object to ourselves.
Feminists have become a little afraid of criticising that shift in the culture, not wanting to be mistaken for moralists, or killjoys, not wanting to be accused of having no sense of fun, or lacking a sense of humour. Let’s face it, we also care about how we are perceived and want to be liked, want to be valued in society’s terms. The charge that feminists might object to the depiction of women in the media because we are no glamour models ourselves should be seen for what it is. But at the same time there is a part of us that is wounded by that charge.
In other words, our current cultural context is now perhaps more in tune with the cruelest talmudic assessments of Vashti. But Purim is a topsy-turvy festival, a time for turning things on their head. And perhaps this is a good time to think about what the celebration of Vashti might mean, not as a historical legacy of the women’s liberation movement of of past decades, but as a pressing issue for women today.
For my first post though, I focus on Queen Vashti, a character in the Purim festival, which we have just celebrated. Purim celebrates the events told in the Book of Esther, with Vashti a relatively minor but intriguing figure. Her story takes me away from the childbirth topic for a moment to reflect on women and body image.
On the seventh day of feasting, when the king was merry with wine, he ordered Mehuman, Bizzetha, Harbona, Bigtha, Abagtha, Zether and Carcas, the seven eunachs in attendance on King Ahasuerus to bring Queen Vashti before the king wearing a royal diadem, to display her beauty to the peoples and the officials; for she was a beautiful woman. But Queen Vashti refused to come at the king’s command conveyed by the eunuchs….(Esther 1:10) Memucan declared in the presence of the King and the ministers “Queen Vashti has committed an offense not only against your Majesty but also against all the officials and against all the peoples in the provinces of King Ahasuerus. For the queen’s behaviour will make all wives despise their husbands, as they reflect that King Ahasuerus himself ordered Quen Vashti to be brought before him, but she would not come. This very day the ladies of Persia and Media, who have heard the queen’s behaviour, will cite it to all Your majesty’s officials, and there will be no end of scorn and provocation!” (Esther 1:16-18) Let a royal edict be issued “All wives will treat their husbands with respect, high and low alike”. (Esther 1:19)
For some, Vashti is the archetypal feminist. Since the women’s liberation movement of the 1960s and 70s, Vashti has been for many Jews a symbol of female emancipation. She is a woman who refuses to parade herself for the pleasure of men, and in doing so disobeys her husband. The biblical text says that King Ahasuerus ordered Vashti to display her beauty “wearing a royal diadem”. But midrash spins this to mean “wearing only a royal diadem”. In other words, naked except for a crown. For feminism of the 1970s, protesting the objectification and sexual exploitation of women was central, and Vashti proved an inspiring symbol. Vashti refuses to be just another object to be displayed alongside the rest of King Ahasuerus’s material riches. Where Vashti openly defies King Ahasuerus, Esther achieves her goal through more stereotypically-feminine attributes of manipulation and subterfuge.
But the vignette in which Vashti disobeys the command to display her beauty can be read differently. Rather than being a story designed to elevate feisty Queen Vashti , it could be read as primarily about the weakness of King Ahasuerus. We are told not only of his immodesty and corrupt sexual mortality, but also about his lack of power in relation to his own wife. The purpose of Vashti’s defiance is not to make her the heroine of the story, but to mock Ahasuerus. The impotence of his commands set the scene for the unfolding story of the whole Book of Esther. First, he carries out the instruction of Memucan in issuing the edict that wives must treat husbands with respect. Even the proposal for bringing all the young women of the kingdom to the palace to find a replacement for Queen Vashti was originally made by the King’s servants, and only then acted upon by the King, as it is written “The proposal pleased the King, and he acted upon it”. The plot to kill the Jews of Persia is then pursued without the King’s knowledge or permission, by Haman. Later the King arranges that feasts be held, as he has been asked to do by Esther. He impales Haman on the stake intended for Mordechai, not as his own inspiration but on the suggestion of Harbona the eunuch. The closing and bloody events of the Purim story are done at Mordechai’s bidding, writing edicts in the name of the King. This is a King that is barely a King at all, acting on the instructions of his officials: Haman and then Mordechai, his eunuchs, Mehuman/Memucan and Harbonah and his wives: Vashti and then Esther.
The book of Esther is a bawdy and comic story, and so it may be fitting that God does not appear – at least directly. However, the metaphor of kingship is one of our most frequent ways of thinking about God and I think we can see in the character of Ahasuerus a subtle allusion to that metaphor, but as God’s opposite. Purim is a festival of reversals, and where HaMelech HaOlam is omnipotent and omniscient, Ahasuerus is impotent and doesn’t have a clue what’s going on. Thus Vashti’s rebellion is part of a pattern revealing the King’s weakness, but not necessarily to be interpreted as evidence of her courage. Although Vashti has been interpreted as an admirable figure over the past thirty or forty years, she gets a much harsher press from traditional Jewish sources.
Some talmudic voices suggest that Vashti’s refusal to display herself was not motivated by modesty at all, but rather by vanity. Midrashim tell that she was afflicted by leprosy, or that she had grown a tail, and this is why she disobeyed the King’s commands. In these commentaries, Vashti would normally have no qualms at parading herself at the King’s banquet, but only when she is looking at her best.
Vashti refuses to display herself, not out of principle, but because she is ashamed of her body. Of course, this sort of thinking brings us right to the present day. When objections to the way women are judged according to narrow conventions of physical beauty are raised, these are often dismissed as the bleating of the less attractive who lose out in this contest. “Feminists object to beauty contests because feminists are ugly losers” is the simplistic charge.
A lot has changed in gender politics, mostly for the good, since Vashti was first rehabilitated by some Jewish communities in the 1970s. But on this question of objectification of women’s bodies, it may be that we have taken very significant steps backwards in the past decade or so. As Ariel Levy writes in Female Chauvanist Pigs: Women and the Rise of Raunch Culture, we are more surrounded by images of women’s bodies as commodities than ever before. But more than that, women, especially young women, are encouraged to see active participation in this culture as a form of liberation. In this context, the only reason not to display yourself for the judgment of others would be shame in not measuring up. For Vashti the problem was leprosy, or her curious tail. Today it is excessive body hair that needs defoliation or flab that needs sucking in with cast iron underwear. These are the reasons to resist exposure, rather than objecting to being a ‘thing’ or object to someone else. And of course, in this battle with our bodies, we risk becoming a ‘thing’ or object to ourselves.
Feminists have become a little afraid of criticising that shift in the culture, not wanting to be mistaken for moralists, or killjoys, not wanting to be accused of having no sense of fun, or lacking a sense of humour. Let’s face it, we also care about how we are perceived and want to be liked, want to be valued in society’s terms. The charge that feminists might object to the depiction of women in the media because we are no glamour models ourselves should be seen for what it is. But at the same time there is a part of us that is wounded by that charge.
In other words, our current cultural context is now perhaps more in tune with the cruelest talmudic assessments of Vashti. But Purim is a topsy-turvy festival, a time for turning things on their head. And perhaps this is a good time to think about what the celebration of Vashti might mean, not as a historical legacy of the women’s liberation movement of of past decades, but as a pressing issue for women today.
Thursday, 21 February 2008
Advanced Kashrut for Midwives
Sometimes I use a clever web-based tool called google analytics to tell me a little bit about the audience of this blog: where you come from geographically, and what brings you here. The search terms "placenta+kosher" come up suprisingly frequently, and I still haven't answered this burning question: Is placenta kosher?
So, today is the day.
Let's recap two relevant points in Beginners Kashrut for Midwives:
On this basis, you would think that human placenta is not kosher, because human beings do not chew the cud, and have five toes on each foot. Therefore human being are not kosher, and anything derived from them cannot be kosher.
However, if we return to Intermediate Kashrut for Midwives on the subject of breastmilk you will remember that the products of human beings should be considered outside of the kashrut/trayf dichotomy. Human beings are not regarded as 'animals' in Jewish law. Indeed, some authorities rule that the amino acid l-cysteine, derived from human hair, is kosher - as long as the hair comes from the living and has not been involved in idol worship. On that basis it would seem that eating placenta could be permissable. However, there are some other relevant laws of kashrut to take into account.
So: tentatively, one might rule that placenta is permissable by analogy with breastmilk.
However, in most human cultures the placenta is not eaten, and most would regard the act of eating this organ as disgusting. This is in contrast with breastfeeding, which is regarded wholly positively in Jewish tradition. There is a Jewish law against doing disgusting things and many people would feel that placentophgy contravened this law, even if it were not subject to the normal food laws of kashrut.
On the other hand, there are arguments that postpartum consumption of placenta can protect the new mother against postpartum haemorrhage and postnatal depression. Jewish law holds that almost any commandment can be broken for the purpose of saving a life. Both postpartum haemorrhage and postnatal depression can be lifethreatening . In the industrialised world where oxytocic drugs and blood transfusions are readily available to treat postpartum haemorrahge, it is arguable that mental health conditions following birth represents a great risk of maternal mortality. If the placenta plays a protective role against these, there are strong arguments in Jewish law for making consumption of placenta not only permissible but mandatory, for the women particularly at risk.
So, there you have it:
Q. Is placenta a kosher food?
A. Possibly, on analogy with brestmilk.
Q. Is is halachic (legal) to eat placenta for any purpose?
A. Probably not, on grounds of being disgusting.
Q. Is is halachic (legal) to eat placenta for a medical purpose?
A. Probably, and probably mandatory for a life-saving medical purpose.
I welcome comments from those who know their talmud. I would be esepecially interested to learn of any Rabbinic rulings on the above.
So, today is the day.
Let's recap two relevant points in Beginners Kashrut for Midwives:
- Only animals which chew the cud (ruminate) and have cloven feet are kosher.
- Only animal products derived from kosher animals are kosher.
On this basis, you would think that human placenta is not kosher, because human beings do not chew the cud, and have five toes on each foot. Therefore human being are not kosher, and anything derived from them cannot be kosher.
However, if we return to Intermediate Kashrut for Midwives on the subject of breastmilk you will remember that the products of human beings should be considered outside of the kashrut/trayf dichotomy. Human beings are not regarded as 'animals' in Jewish law. Indeed, some authorities rule that the amino acid l-cysteine, derived from human hair, is kosher - as long as the hair comes from the living and has not been involved in idol worship. On that basis it would seem that eating placenta could be permissable. However, there are some other relevant laws of kashrut to take into account.
- Eating of blood is not kosher, and animals are killed and their meat processed so as to drain as much blood as possible.
- Meat cannot be mixed with milk
So: tentatively, one might rule that placenta is permissable by analogy with breastmilk.
However, in most human cultures the placenta is not eaten, and most would regard the act of eating this organ as disgusting. This is in contrast with breastfeeding, which is regarded wholly positively in Jewish tradition. There is a Jewish law against doing disgusting things and many people would feel that placentophgy contravened this law, even if it were not subject to the normal food laws of kashrut.
On the other hand, there are arguments that postpartum consumption of placenta can protect the new mother against postpartum haemorrhage and postnatal depression. Jewish law holds that almost any commandment can be broken for the purpose of saving a life. Both postpartum haemorrhage and postnatal depression can be lifethreatening . In the industrialised world where oxytocic drugs and blood transfusions are readily available to treat postpartum haemorrahge, it is arguable that mental health conditions following birth represents a great risk of maternal mortality. If the placenta plays a protective role against these, there are strong arguments in Jewish law for making consumption of placenta not only permissible but mandatory, for the women particularly at risk.
So, there you have it:
Q. Is placenta a kosher food?
A. Possibly, on analogy with brestmilk.
Q. Is is halachic (legal) to eat placenta for any purpose?
A. Probably not, on grounds of being disgusting.
Q. Is is halachic (legal) to eat placenta for a medical purpose?
A. Probably, and probably mandatory for a life-saving medical purpose.
I welcome comments from those who know their talmud. I would be esepecially interested to learn of any Rabbinic rulings on the above.
Wednesday, 20 February 2008
Obstructed Labour: Birth at the Checkpoints
Life is very busy, and it's been a while since I've blogged. There are so many entries I've intended to write: the last installment of kashrut for midwives (in which the question "Is placenta kosher?" will finally be answered), Jewish perspectives on risk in childbirth, and some corrections to my post on pikuach nefesh and shabbat. I promise I will get to them. But none of these subjects has brought me back to the blog. What has demanded my attention is hearing yet again about Palestinian women giving birth at checkpoints on Israel's borders.
It's hard even to imagine living the life of Afaf Hilmiyeh, a twenty-year old woman living in Abu Dis. Abu Dis is effectively a suburb of Jerusalem, but cut off from Jerusalem's facilities by the separation wall/fence/barrier. Afaf was nine-months pregnant and planned to give birth at Al-Makassed Islamic Charitable Society Hosptial in Jersualem, which is a local obstetric unit for her. In order to get to Al-Makassed Hospital, Afaf had to apply for a permit to enter Jerusalem. Her mother queued for two days, and Afaf was granted a permit for a period of 12 hours on her due date. The WHO defines "term" pregnancy as between 38 and 42 weeks gestation. Only a small percentage of babies actually arrive on the "expected date of delivery."
Predictably, Afaf did not go into labour on her due date. While her mother queued again, with Afaf's identity card, to get a second permit, Afaf's labour started. Afaf set out with her mother-in-law, but without identity card or permit, to Al-Makassed Hospital. They were turned back at Ras Kubsa Gate. She then proceeded to the checkpoint at a-Za'ayem, where Afaf's mother was waiting to be issued a permit for her. As Afaf had no identity card, she was at first prevented from going to the hall where permits are issued. Eventually Afaf was allowed to join her mother, but no permit had yet been issued and even if it had, there was no time to get to the hospital. Afaf gave birth to a baby girl lying on the floor of a corridor off the permit hall, with a handbag for a pillow and surrounded by soldiers.
Sometimes women in the UK give birth in a hospital corridor, in the entrace foyer or the hospital car park. This is usually because labour is unexpectedly quick. Mothers and babies are normally physically well after such an experience. Indeed these can be 'better births', from a purely physiological point of view, than long-drawn out labours which are subject to successive interventions. However, the experience of giving birth in public, without profesional support and feeling unsafe is likely to be very shocking to the mother and the people she is with. Midwives who have attended births in hospital car parks, corridors and entrance foyers talk movingly about how exposed the mother is in that situation, about the inevitable gawpers and about using their own bodies as a screen to give the woman as much privacy as possible. How much worse must it be to give birth in public, under the hostile gaze of the very people who have obstructed your journey to hospital?
It can also be dangerous. A planned homebirth, with the possibility of transfer to hospital, is one thing. Birth at the checkpoint, in transit to hosptial, is a different thing entirely. According to B'tselem, an Israeli human rights organization, there have been fifty-three deaths of Palestinians following an infringement of their right to medical treatment since 2000, often through delay at the checkpoints. Of these, nine were perinatal deaths, and one was a maternal death. The UN puts the figure even higher.
Watch this fantastic short film by Alia Arasoughly.
It's hard even to imagine living the life of Afaf Hilmiyeh, a twenty-year old woman living in Abu Dis. Abu Dis is effectively a suburb of Jerusalem, but cut off from Jerusalem's facilities by the separation wall/fence/barrier. Afaf was nine-months pregnant and planned to give birth at Al-Makassed Islamic Charitable Society Hosptial in Jersualem, which is a local obstetric unit for her. In order to get to Al-Makassed Hospital, Afaf had to apply for a permit to enter Jerusalem. Her mother queued for two days, and Afaf was granted a permit for a period of 12 hours on her due date. The WHO defines "term" pregnancy as between 38 and 42 weeks gestation. Only a small percentage of babies actually arrive on the "expected date of delivery."
Predictably, Afaf did not go into labour on her due date. While her mother queued again, with Afaf's identity card, to get a second permit, Afaf's labour started. Afaf set out with her mother-in-law, but without identity card or permit, to Al-Makassed Hospital. They were turned back at Ras Kubsa Gate. She then proceeded to the checkpoint at a-Za'ayem, where Afaf's mother was waiting to be issued a permit for her. As Afaf had no identity card, she was at first prevented from going to the hall where permits are issued. Eventually Afaf was allowed to join her mother, but no permit had yet been issued and even if it had, there was no time to get to the hospital. Afaf gave birth to a baby girl lying on the floor of a corridor off the permit hall, with a handbag for a pillow and surrounded by soldiers.
Sometimes women in the UK give birth in a hospital corridor, in the entrace foyer or the hospital car park. This is usually because labour is unexpectedly quick. Mothers and babies are normally physically well after such an experience. Indeed these can be 'better births', from a purely physiological point of view, than long-drawn out labours which are subject to successive interventions. However, the experience of giving birth in public, without profesional support and feeling unsafe is likely to be very shocking to the mother and the people she is with. Midwives who have attended births in hospital car parks, corridors and entrance foyers talk movingly about how exposed the mother is in that situation, about the inevitable gawpers and about using their own bodies as a screen to give the woman as much privacy as possible. How much worse must it be to give birth in public, under the hostile gaze of the very people who have obstructed your journey to hospital?
It can also be dangerous. A planned homebirth, with the possibility of transfer to hospital, is one thing. Birth at the checkpoint, in transit to hosptial, is a different thing entirely. According to B'tselem, an Israeli human rights organization, there have been fifty-three deaths of Palestinians following an infringement of their right to medical treatment since 2000, often through delay at the checkpoints. Of these, nine were perinatal deaths, and one was a maternal death. The UN puts the figure even higher.
Watch this fantastic short film by Alia Arasoughly.
Friday, 7 December 2007
chaplainbook
If you've been following this blog, you know that hospital chaplaincy worries me. How often does the chaplain fill a void that exists because we don't allow the time or space for clinicians to practice holistically and with compassion. I wonder what we risk by creating a specialised 'compassion service.' Despite my scepticism about the role of chaplains in the NHS, I was delighted today to receive Rachel Barenblat's slim volume of poetry, chaplainbook in the post. Rachel is training for the Rabbinate and is better known, to me at least, as the velveteen rabbi. Her blog is inspiring, and so are the poems she wrote over a period of nine months chaplaincy work in the US.
On-Call Prayer
Help me be present tonight
without fear or expectation.
Help me release the baggage
of my week, freeing
my shoulders.
Help me fold my ego gently
and tuck it in a drawer
where it will be safe
and unobstrusive
and not in the way.
Don't give me more
than I can handle. Don't
take it personally when I
crave excitement, then
change my mind.
Shelter this ship
through the longest night.
Remove the sorrows
of sailors and passengers.
Help us reach the dawn.
Rachel Barenblat
Not letting the ego get in the way is the essence of midwifery. It is what midwives mean when they talk about taking pleasure in women feeling that whatever they have done they have done themselves, as opposed to feeling "I couldn't have done it without you". It is too easy to let the ego be pumped up by gratitude (and conversely, to be diminished by seeming ingratitude).
Help me fold my ego gently
and tuck it in a drawer
where it will be safe
and unobstrusive
and not in the way.
On-Call Prayer
Help me be present tonight
without fear or expectation.
Help me release the baggage
of my week, freeing
my shoulders.
Help me fold my ego gently
and tuck it in a drawer
where it will be safe
and unobstrusive
and not in the way.
Don't give me more
than I can handle. Don't
take it personally when I
crave excitement, then
change my mind.
Shelter this ship
through the longest night.
Remove the sorrows
of sailors and passengers.
Help us reach the dawn.
Rachel Barenblat
Not letting the ego get in the way is the essence of midwifery. It is what midwives mean when they talk about taking pleasure in women feeling that whatever they have done they have done themselves, as opposed to feeling "I couldn't have done it without you". It is too easy to let the ego be pumped up by gratitude (and conversely, to be diminished by seeming ingratitude).
Help me fold my ego gently
and tuck it in a drawer
where it will be safe
and unobstrusive
and not in the way.
Tuesday, 20 November 2007
Intermediate Kashrut for Midwives
As I have previously posted, breastfeeding is positively regarded in Jewish tradition and sources. It is presumed that human babies feed from their mother’s milk, or the milk of a wet nurse. But careful readers of my recent blog, basic kashrut for midwives, may well have come to the conclusion that human milk is not kosher.
Let us recap:
In order to be kosher, milk must come from a kosher mammal. The milk of horses and camels is certainly not kosher.
Yet human beings do not have cloven hooves, nor do we chew the cud. Therefore, it would seem, the human being is not a kosher animal.
On this basis, it would seem that human milk cannot be kosher.
But worry not: kashrut refers to food sources, or potential food sources. Thus animals are divided into those which are kosher and those which are trayf (non-kosher). Humans are not a source of food. You may not in Jewish law kill a human for the purpose of eating him or her, nor may you desecrate the dead human body for that purpose. Humans are therefore neither kosher nor trayf, but are a completely different category altogether. Thus the milk that women produce for their babies is not subject to the rule that kosher milk must come from a kosher mammal.
In fact, from the point of view of kashrut, human milk isn’t categorised as ‘milk’ at all. Going back to Basic Kashrut for Midwives, you will remember that milk and meat are not eaten together, and that separate vessels are used in preparing and serving milk and meat dishes. Human milk, however, is regarded as pareve, or ‘neutral’ and thus the child who is eating solids and breastmilk may consume both at the same ‘meal’. From the point of kashrut, expressed breastmilk may pose a problem because it can be confused with the milk of other animals, and therefore lead to inadvertantly setting a bad example (if someone believes that you have mixed milk and meat). To conform to the strictest observence of kashrut, one must therefore take special care that expressed breastmilk is not mixed with meat. However, expressed breast milk in a bottle with a teat, with no risk of mixing with meat, and which is clearly distinct from the milk of kosher animals does not pose a problem from the point of view of even strict observence of kashrut.
However, the Talmud does seem to take a fairly dim view of expressed breastmilk from the point of view of niddah (ritual impurity), rather than kashrut. Breastfeeding is positively encouraged, but milk which is ‘outside the breast’ is not so welcome. In truth, Judaism has traditionally had a problem with bodily fluids: and breast milk, alongside tears and blood are felt to contaminate other food or liquids. So lactating women should be very careful not to leak milk or cut themselves while chopping onions – if they are not to commit a triple transgression of getting blood, milk and tears into the pot.
Let us recap:
In order to be kosher, milk must come from a kosher mammal. The milk of horses and camels is certainly not kosher.
Yet human beings do not have cloven hooves, nor do we chew the cud. Therefore, it would seem, the human being is not a kosher animal.
On this basis, it would seem that human milk cannot be kosher.
But worry not: kashrut refers to food sources, or potential food sources. Thus animals are divided into those which are kosher and those which are trayf (non-kosher). Humans are not a source of food. You may not in Jewish law kill a human for the purpose of eating him or her, nor may you desecrate the dead human body for that purpose. Humans are therefore neither kosher nor trayf, but are a completely different category altogether. Thus the milk that women produce for their babies is not subject to the rule that kosher milk must come from a kosher mammal.
In fact, from the point of view of kashrut, human milk isn’t categorised as ‘milk’ at all. Going back to Basic Kashrut for Midwives, you will remember that milk and meat are not eaten together, and that separate vessels are used in preparing and serving milk and meat dishes. Human milk, however, is regarded as pareve, or ‘neutral’ and thus the child who is eating solids and breastmilk may consume both at the same ‘meal’. From the point of kashrut, expressed breastmilk may pose a problem because it can be confused with the milk of other animals, and therefore lead to inadvertantly setting a bad example (if someone believes that you have mixed milk and meat). To conform to the strictest observence of kashrut, one must therefore take special care that expressed breastmilk is not mixed with meat. However, expressed breast milk in a bottle with a teat, with no risk of mixing with meat, and which is clearly distinct from the milk of kosher animals does not pose a problem from the point of view of even strict observence of kashrut.
However, the Talmud does seem to take a fairly dim view of expressed breastmilk from the point of view of niddah (ritual impurity), rather than kashrut. Breastfeeding is positively encouraged, but milk which is ‘outside the breast’ is not so welcome. In truth, Judaism has traditionally had a problem with bodily fluids: and breast milk, alongside tears and blood are felt to contaminate other food or liquids. So lactating women should be very careful not to leak milk or cut themselves while chopping onions – if they are not to commit a triple transgression of getting blood, milk and tears into the pot.
