Thursday, April 17, 2014

indemnity insurance: who benefits?

It's a simple question.  Who benefits from indemnity insurance?

We're all familiar with insurance: home and contents insurance, vehicle and third party property insurance, health insurance, travel insurance ...  Some are mandatory; some are not.  

Narrowing the field a little ...
... to mandatory indemnity insurance for midwives as regulated health professionals.  Who benefits from that?

The obvious answer is that the consumer - the mother+baby who receive professional care from the midwife - are potential beneficiaries.  When/if a mother or her baby experience adverse outcomes that may have been avoided under professional care that may have been done differently, that mother or baby are able to sue the midwife for the loss they claim to have suffered.

An eye for an eye!

The matter is placed in the hands of lawyers.
If the midwife has indemnity insurance, the insurer advises and supports the midwife.  The insurance policy may have exemptions and limits that are taken into consideration.
Sometimes a settlement is reached without going to court.  Money is paid to the person who suffered loss, and that's the end of it.
Or the case is scheduled to be heard in the appropriate law court.
If the court agrees that the midwife was culpable, an order is made that a sum of money be paid to the person who suffered loss in the care of the midwife.
Who benefits?
The person who was harmed.

The complication is the availability/affordability of indemnity insurance.  This is a global problem.  No-where in the world is there an indemnity insurance product for individual midwives that provides assurance of sufficient funds to pay out for the life-long health needs of a baby who is severely disabled by hypoxia at the time of birth. 

It's not a new problem.  I have been attending births without indemnity insurance since it became unavailable in 2001.   I (and others in this country) have been permitted to continue practising without insurance for births, while our government agencies attempt to solve the problem.  Midwives in oz are at present exempt from having indemnity insurance for privately attended homebirth, because it's not available. This exemption will be reviewed by June 2015.

Australia's national regulatory board published a research report on professional indemnity insurance for midwives in December 2013.

The UK Department of Health has rejected a proposal by Independent Midwives UK, concluding that government funding of midwives' insurance will not give patients protection (DoH News story 6 March 2014).

German midwives and mothers have been holding huge public rallies - see hebammenblog and scroll down to 13 March (and use translation if, like me, you don't understand German)

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defence schemes which cost more than some midwives earn.

I am considering this threat to private midwifery practice from as many perspectives as I can.  Readers may consider my concerns to be tainted by self-interest, because I practise midwifery privately.  But, as I am close to retirement from attending births, I see myself as a commentator who knows the terrain well.

From a professional perspective, the cost of indemnity insurance demands consideration.  Midwives who are taking a full caseload (40+ births per year as primary carer, as well as other midwifery services) are paying between approximately $2,000 to $7,500 annually.  Neither of the policies on offer covers homebirth; the more expensive policy covers birth attendance in a public hospital at which the midwife has been credentialed and awarded clinical privileges.  The number of women planning homebirth with a privately practising midwife is small - less than 0.5% of the birthing population.  Midwives who take too many bookings burn out quickly, and women lose faith with their private one-to-one midwife if she is not available to attend their births. 

That's the top end of the scale. 

Midwives who have a very small caseload; perhaps only a few bookings for primary care per year, are also required to have indemnity insurance, and the minimal cost is approximately $2,000.  Those midwives, possibly living in rural towns or properties, may work part time as employees in the local hospital, and see their small 'private practice' as an expensive hobby.   

From a professional business perspective, there is clearly a point at which the cost of private practice outweighs any perceived benefit.   

As fees for indemnity insurance increase, and the cost is passed on to the client, some midwives will not be able to earn enough to afford meaningful PII, unless they charge high fees that make their services unaffordable to the majority of women.

It's a self-defeating cycle.

costs progressively rise - 
midwives burn out or fail to attract enough business to continue offering their professional services - 
reduced access to private midwifery services for women

However, the bigger issue (imho) is the myth that mandatory indemnity insurance is somehow in the public interest, when the vast majority of cases of cerebral palsy, for example, cannot be linked to an action or omission by any professional care provider (hospital or home), and there's no claim on anyone's insurance.

From a social perspective, does our society think that midwives should be free to provide services privately (independently) to women, in a way that is affordable and accessible? 

Or the other side of the same coin, that women should be free to engage a midwife privately? 

Most women in our society like to be able to control who provides other personal, intimate services such as hair cutting, or beauty services for removal of unwanted hair, so why would they not want to have a say in who attends them for the most intimate of professional services?

But most women in our society have no idea of the scope of a midwife's practice, or indeed of their own birth-right: to give birth safely and triumphantly under amazing natural forces.
The midwife's ability to protect, promote and support normal birth is limited by the professional/regulatory control: a state's duty to protect the public through the regulation of the profession.

The UK government article that I referenced above suggests that midwives should be able to form 'social enterprise' businesses that purchase insurance for members. To me (I do enjoy the one-to-one relationship between me and the woman for whom I provide primary maternity care) this sounds like layers of unhelpful nanny state control that provides only a mirage of safety.

The indemnity insurance situation for midwives in Germany is different from that in Australia or UK.  A German midwife informed me that "Our "independent" midwives do not practice "privately" or "outside" the system.  Here their service are still covered by national healthcare and their "extinction date" has just been pushed back another year as the insurers will offer indemnity insurance for another year to come (with another raise of 20% and limited for another 12 months and the sum covered cut down to half of what it covered before…)

Back to the initial question:
Who benefits? 

  • when a midwife's indemnity insurance does not cover what midwives do?
  • when the increasing costs of providing midwifery services prevents some midwives from offering their professional services, thereby reducing access of women in the community to midwives?
  • when the increasing pressures associated with providing midwifery services lead to burn-out and break-down and unsustainable commitments being made
  • when the increasing costs of providing midwifery services leads to business models that focus on risk management and the bottom line $$ rather than the woman-midwife partnership?

Who benefits?
  • Not the consumer/client/woman+baby
  • Not the midwife
  • Not the community
someone else!

Dear reader, today I have only touched on these matters.  What solutions can we propose?
In the present climate I see reports of cases before the coroner that are likely to have had good outcomes if they had been managed differently.  I read reports of midwives taking extreme positions on management of women with known risk. 

I have phone calls from women who think they would like homebirth because they don't like hospital.   

The solution is not to be found in ever-tightening rules being imposed on midwives.

The solution is not to be found in governments throwing money at the insurance industry.

One aspect of the solution, as I understand birth, must be that a midwife can arrange to provide care for women in hospital as well as home.  

I would like to see the 'villagemidwife' concept available in any town or community where a midwife chooses to work in a professional capacity, providing primary maternity care for individual women.  The setting for births in this midwife's practice must be determined by the woman's and baby's needs at the time of birth.

A society that provides regulation of midwifery must also ensure the ability of the midwife to practise midwifery.  That is the only way to protect the public.  A society that makes midwifery unaffordable, inaccessible, or restricted to homebirth, is depriving its mothers and babies of one of the most basic health promotion services that human existence has ever known.

Monday, April 07, 2014

A midwifery half-truth: doing nothing

A couple of weeks ago I wrote about the myth of choice.

The midwife 'doing nothing' is a similarly misleading notion: not quite a myth, but definitely a half-truth. It's only one side of the coin.  It sets a potentially dangerous precedent, devaluing the expert professional activity of the midwife, being actively 'with woman' in the interest of safety and wellbeing of mother and child, to the point we have today: an epidemic of unattended births ("free births") in the community.  The rationale is like this: "If the midwife does nothing, then we don't need a midwife."

Today I want to critically explore what midwives are doing when we may appear to be 'doing nothing': what happens when I spend time on the couch in an almost dark room in the wee hours, with my eyes closed; what I am doing when I take up some simple knitting or crochet project as I wait for a baby to be born.

Let's consider the pregnant_woman/mother+baby to be central in this discussion.  What does that woman hear from her own intuition, from midwives, from other professional maternity care providers, from family, and from other sources?

There are many voices, and the value that the woman places on each of those messages varies from one to another.  Social media has, for at least the past decade, played an increasingly powerful role, as indeed this blog site offers information and discussion.  The current generation of mothers is the generation who uses online searches to 'research' a question, who follows multiple social media sites, who is prepared to ask questions.  Whereas previous generations had the 'disease of the month' prompted by an article in a publication (such as Reader's Digest), today's generation can search and often self-diagnose - with dubious effectiveness.  Gadgets can be bought: a pregnant woman can set herself up with a fetal heart rate monitoring device, a blood pressure machine, digital scales for the baby, and any number of other potentially useful, potentially useless pieces of equipment.

But I digress.

Back to the assertion I have made, that 'doing nothing' is a half-truth.  Further, I suggest the notion that the midwife does nothing, without taking into consideration the enormous and life promoting role of the midwife in any professional setting, could have negative consequences for idealistic, impressionable, inexperienced midwives, and for women in their care.

A woman who is labouring strongly, who has invited me into her home to attend her for birth, will have spent time with me during the pregnancy, discussing and planning and preparing for this climactic time.

I am in her home; I have moved quietly into her intimate space, and
  • I assure myself that mother and baby are well, through observation, active listening, and auscultation of baby's heart sounds after a uterine contraction
  • I communicate my assessment and any concerns to the mother, and support her, reassure her if appropriate 
  • I prepare the space so that I can maintain my written record 
  • I prepare equipment that may be needed, such as the newborn 'bag and mask', and oxytocic for mother
  • I recognise any idiosyncratic matters or instructions that are given, such as "don't open the door because the cat might escape"
  • I make a mental note of this woman's progress up to this point in time, how she is responding, what professional observations are reasonable, and what I expect to see happening
  • I assume a protective role of the space, knowing that interruptions and intrusions and interventions can be disruptive: for example, telephones are not welcome in the birthing room.
  • I may sit on a chair or rest on the couch in an almost dark room in the wee hours, with my eyes closed
  • I may take up some simple knitting or crochet project as I wait for a baby to be born.
Doing nothing?  No way!

Even if the labour and birth are 'uneventful', even if the baby is born quickly and easily (from an observer's point of view), without any instructions from me, my presence is the essence of my professional action.  I bring the capacity to intervene, when there is a valid reason.  I bring the ability to minimise interruption that may increase anxiety in the labouring woman, so that the woman is free to progress, unaware of what's going on in my mind or in the outside world.

Dear reader, if you know the ICM Definition of the Midwife, and other foundational statements and codes in our profession, you will understand what I am saying. 
"... This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures." (ICM 2011 - emphasis added)

Those who understand the promotion and support of normal, physiological processes in birth will know the masterly inaction of authentic midwifery.  This is not 'doing nothing'!

Midwives need to protect women from an idealistic message that tells only part of the midwifery story, and may confuse those who genuinely need the midwife to act in the interest of wellbeing and safety of mother and/or baby.  If that were not the case there would be no need for a midwife.

Your comments are welcome.

Tuesday, April 01, 2014

Obstetric violence in Australia today?

This is the definition of obstetric violence, presented by UK obstetrician Dr Amali Lokugamage at RCOG World Congress 2014 in India:

"Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
"It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
"It is also the act of disregarding the emotional needs of mother and baby throughout the whole [childbearing] process" 

Jesusa Ricoy-Olariaga 2014

Today I want to carefully reflect on a couple of births and other maternity experiences that are very close to home.  
I want to carefully measure the maternity culture that I know and participate in, in and around Melbourne today.  
I want to ask in what way I am contributing to obstetric violence.
I want to seek ways by which adverse aspects of a culture can be changed.

[Please note that names and some of the details in the cases have been changed for anonymity]

Case study 1
Bess was a 30 year-old, carrying her third child, planning homebirth.  I have been her midwife for each of her births, and her first and second baby were born at home in my care.

At about 36 weeks, Bess visited her GP, who looked at her abdomen, and said her baby was too small - growth restricted (IUGR).  The GP quickly arranged an ultrasound scan, which appeared to support the diagnosis, and an appointment for Bess at the tertiary hospital.  The GP spoke to me about her concerns, and I wondered if I had missed something.  

.... fast forward to 38 weeks
Bess was advised to go to hospital to have an induction of labour.  She asked me if I thought her baby was too small.  I did not.  However, I told her "If I'm wrong, and there is a valid reason to get this baby born (as she had been advised by the hospital and the GP), you have more to lose than if I'm right."

... fast forward to a couple of days after the birth of her baby (whose weight was well within the normal range).
Bess told me she did not feel traumatised by the experience: rather, she had faced the challenge head on, and accepted the intervention of induction of labour by artificial rupture of the membranes (ARM).  She had progressed unmedicated, and gave birth without assistance to a healthy baby boy.   When she was told, a couple of hours after the ARM, that it was time to commence IV Syntocinon, she declined and was quite definite about not needing further intervention.  She knew from the tone of the contractions she had experienced that her baby was on his way. 

Obstetric violence monitor (using the above definition):
-1  Bess was pressured by (albeit well-meaning) doctors and maternity care system that introduced fear of harm to her baby, when in fact her pregnancy was progressing normally
-1  Spontaneous onset of labour was denied
+1 Bess was able to decline further intervention after the ARM
+1 Bess considered that, despite experiencing pressure to comply with medical plan, her decisions had been respected, and she felt emotionally supported

Score: Pass - Case 1 is not an example of obstetric violence

Comment:  There are many contributing factors in any decision-making.  The choices that a woman has around her maternity care, and the decisions she makes at any time, are not equally weighted.  The support she has, both professional (eg from a known and trusted midwife) and personal (eg from partner, family, friends) will probably influence outcomes, especially if the decision-making pathway is not clear.

Case Study 2.
Deb was a 38-year old mother who had had two caesarean births, both prior to labour.  Deb wanted a VBA2C (vaginal birth after 2 caesareans) for this birth.  She considered herself well informed about making this plan, and made sure that her written birth plan was included in her hospital record.  She had felt cheated in her previous caesareans, and longed for the spontaneity and bonding between mother and baby in normal birth.

Prior to the onset of labour, Deb had some bright bleeding from her vagina.  She went to the hospital, and had some electronic fetal monitoring and other investigations.  The doctor told Deb that her baby did not seem to be distressed, but that he strongly recommended a repeat caesarean immediately.  Deb explained to him that she would accept a caesarean birth, even though it was not what she had so much hoped and planned for, if the hospital would permit her to keep her baby with her, skin to skin, in the operating theatre, in the recovery room, and when they had returned to the postnatal bed.  The doctor went away to make this arrangement, but was told the hospital did not provide staff for that option: that the baby and his/her father would be taken to the postnatal ward, and the mother reunited with them as soon as she was released from the recovery room.

Deb then refused the emergency caesarean.  Deb's baby was, a couple of days later, still born.

Obstetric violence monitor (using the above definition):
-1  The emotional needs of the mother were disregarded
-1  The emotional needs of the baby, as understood by the mother, were disregarded

Score: FAIL - Case 2 IS an example of obstetric violence

Comment:  Deb's case is clearly complex from an obstetric/medical point of view, and I have cherry picked a few facts in coming to my conclusion that this is an example of obstetric violence.  The hospital disregarded the clearly expressed emotional need of this mother, and used inflexible staffing arrangements as the reason for denying her request.

In what ways am I contributing to obstetric violence?
There is no simple tick-box for obstetric violence in maternity care today.  As evidence emerges about the finely orchestrated hormonal processes in birth and nurture of the new born child, the expectations of women will change.  The providers of professional maternity services must also integrate the contemporary knowledge into our care.

One of my own babies was born with a fractured clavicle, and aspirated mucus, as a result of rather rough handling by the doctor.  The mucus was cleared from her lungs using suction and percussion, and the clavicle healed as expected.  But that child became fearful and anxious when ever her throat became inflamed.  She had a definite memory of pain that had been caused by the failure of my accoucheur to permit me to give birth to her spontaneously.  She had experienced obstetric violence.  I did not feel or know that I had been traumatised - the requirement for me to be lying on my back with my feet in stirrups was standard at that time.

At about that same time, in the 1970s, there were dark and horrible secrets in many facilities where children received care.  Predatory sexual activity, and physical and emotional abuse, were tolerated within the system.  A blind eye was turned.  It has taken several decades for the light of public scrutiny to be directed towards those institutions, and for the people who experienced such abuse as children to have an opportunity to tell what they can of their stories.  

In reviewing birth as I know it in Melbourne today, I want to ensure that I and my colleagues are not tolerating - turning the blind eye - situations of abuse and violence against women and babies.

The maternity system as we know it today does not protect, promote and support natural physiological processes in birth and nurture of babies.  It does not follow the standard, that "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

It is possible that future generations will look, aghast, at the way mothers and babies are being treated in the early 21st century, in the same way that we are shocked by revelations of institutional abuse of children in the C20. 

Saturday, March 29, 2014

the myth of choice

1983 - working night shifts a the Women's
For a couple of decades now, *choice* has been a pillar of the natural birth movement.

An organisation that I am a member of has the vision, that
"Every woman can choose how, where and with whom she births."

This vision has troubled me for some time.  Today I am attempting to critically explore the notion of choice, and whether it is desirable or imaginable that every woman choose "how, where and with whom she births."

Firstly, some historical considerations:
  • The Fortelesa (Fortaleza) Declaration (1985) on appropriate use of technology in birth challenged interventions, from shaves and enemas, to inductions of labour.  This seminal document also declared that "The whole community should be informed about the various procedures in birth care, enable each woman to choose the type of birth care she prefers".  *CHOICE!*
  • Changing Childbirth in the UK (early 1990s) declared that women want the 3C's: *choice*, control, and continuity of care.
  • A call for *choice* of place of birth (home/hospital) and care provider (such as individual midwife or the maternity system) was clear in the Australian National Maternity Action Plan (2002).

At the same time,  twenty years ago,
  • emerging trends in medical research led to the Cochrane Collaboration, defining the reliability of evidence;
  •  UNICEF and World Health Organisation introduced the Baby Friendly Hospital Initiative, with a key document being the Innocenti Declaration  of 1990. 
  •  various state and territory governments around this country were conducting broad reviews into birthing services, and producing their reports. (eg Having a baby in Victoria 1990)  These reviews sought consumer comment as well as professional.
  •  WHO prepared a series of basic publications on maternity care, including Care in Normal Birth: a practical guide (1996).  This document brought a consensus statement that "In normal birth there should be a valid reason to interfere with the natural process"

During the past two decades the world has experienced the digital revolution.  Twenty years ago, in 1994, few households had computers: the world wide web and email had only just been invented.   This phenomenon exploded communication and access to reliable information.  Our home went 'on line' in the early 90s, with a (very slow, and unreliable) dial up connection, and we were leaders in the field.   Prior to that, if I needed to send an email, I would ask my husband Noel to send it from his office at the university.  He kept up with the expansion of knowledge via inservice education, and a very helpful secretary, Jean.  He became the 'IT' expert in our home, until our children absorbed the knowledge and quickly spoke the language, as children do.  (but I have digressed from my topic!)

Twenty years ago, professional peer reviewed scientific publications were held in libraries, and accessed by scholars and the intelligencia.  Today, there is an inexhaustible wealth of knowledge at the tip of our fingers, from our computers, tablets, and phones.

Twenty years ago, information about natural childbirth was passed from teacher to student couples in highly motivated childbirth education.  Today women join social media groups where they share everything from their nausea and indigestion, to ultrasound pictures.  These groups, as well as personal blogs and microblogging, have introduced a degree of sharing of opinions, and introspection ('navel gazing'), that would have been unimaginable when person to person communication was limited to a telephone or over the back fence or a tea room at work.

So, what about choice?

In discussing choice in childbirth with colleagues and other interested folk, I have been a little surprised to observe that the woman's right to decline (a treatment/intervention) is often perceived to be the same as a choice in maternity care.  A woman's autonomy in any care situation (whether it's her toe nails or the birth of her child) is often limited to the little word "No!"

By way of example:
Jill is in hospital, in labour with her first baby.  Jill has been told she needs a Caesarean, because she has been labouring without adequate progress, and the doctor is concerned that her labour is obstructed and her baby is becoming distressed.

Jill does not want a caesarean birth, but she has no other options at this time, other than to do nothing, and that may lead to injury/death to her baby.  She has planned for a natural birth, because she believes that's the best way for her and her baby.  Jill has written in her birth plan/preferences document that if she truly needs a caesarean birth, she wants her baby's umbilical cord to remain uncut, and the placenta delivered intact (known as 'lotus' placenta).  She wants her baby to be placed skin to skin on her chest, and to remain with her in the operating room and in recovery so that breastfeeding can be initiated without delay.  She is aware of 'natural' caesarean births, discussed on her social media forum, and likes the idea. 

Jill communicates her wishes to her doctor.  If that doctor has previously supported women's choices in this way, he/she might be willing to agree.  But Jill is a patient in a public hospital.  The doctor who is performing the surgery is being supervised by the consultant obstetrician, and does not feel able to accommodate such a radical plan.  The hospital's policy is to send the baby and the father to the nursery while mother is in recovery, and Jill is told that the hospital is not able to provide suitable staff to accommodate her choices.  Jill has run out of options.  She needs the help of the hospital to get her baby safely born, and she finds to her surprise that the notion of choice doesn't work in this situation.
 Jill thought, prior to coming into labour, that she had chosen:
how: a natural birth 
where: in the local public hospital
with whom: the hospital staff at the time
'how' Jill gives birth is something that cannot be predicted, whether she chooses a private hospital with the most popular obstetrician according to the online rating system, or the guru homebirth midwife who has amazing skill and, according to social media, can do all sorts of things to make birth work as it's supposed to.  The best Jill can find out when she is choosing her care provider is an approximate rate of spontaneous unmedicated births that person reports for woman in their care.

I (frequently) remind women that they have only one choice in childbirth - to do it themselves, or to ask someone else to take over. This is the case, whether it's avoiding induction, having a vaginal breech birth (vbb), a vaginal birth after caesarean (vbac), a physiological 1st, 2nd or 3rd stage. (Haemorrhage and death are also physiological). 

There's an obvious rationale for the skilled midwife in these equations. A primigravida who wants to have a natural unmedicated birth, booked at Caesar's Palace, in the care of a knife happy OB, may have chosen where and with whom she births, but doesn't have much chance of achieving the 'how'.  

Choice is also dependent on money $$$.

The woman who chooses a caesarean for her own (not clinically indicated) reason can get a private doctor to deliver her baby if she can pay the doctor's fee (Medicare + out of pocket) and the hospital fee. But she has very little say about who else is in the room - her partner is likely to be welcome but may be asked to step outside. 

If we have a vision that every woman should be able to choose how - including elective C/S - do we think our public health $ should be supporting that so that women who can't afford the co-payment are also able to rock up and *choose*?

I am very concerned about over-spending of health $.  

The only sustainable policy direction in maternity care is to protect, promote and support the natural processes in birth wherever that is reasonable. The workforce needed as experts in achieving this goal is midwives whose duty of care by definition includes "promote normal birth". This does not remove the woman's right to make an informed decision to decline or accept the plan. Medical and surgical options should of course be available to those for whom they are likely to lead to better outcomes, but that's not a matter of the woman's *choice*.

Your comments are welcome.

Sunday, March 16, 2014


For several years now there has been a growing movement of consumer and professional opinion about the 'best' way to give birth to babies presenting breech. [See Breech Birth ANZ website]  This has come as a small pendulum swing away from the prevailing policy of elective caesarean for breech babies, which was quickly adopted after the Hannah et al (2000) paper on the Term Breech Trial, published in the Lancett.

Another historical grab, before I tell my breech story.

Please see the attached picture of the midwifery exam which I undertook in 1973.   Midwives then were required to have a basic understanding of breech presentations.   I don't want readers to imagine that the work of a midwife (or mother giving birth) was somehow ideal back then - in fact the medicalisation of childbirth, and the dominance of medical 'men' over the more subservient female nursing profession (which included midwifery) was entrenched, as can be seen in the previous post I wrote about this midwifery exam.
click to enlarge

I have always held that if for no other reason than the surprise breech, a midwife attending births needs to be competent in vaginal breech birth (vbb).   My involvement in workshops and education about vaginal breech births, and in the few vbbs I have attended, there has been an emphasis on having obstetricians who lead the cause of promoting vbb.  I have felt uncomfortable with this.  Obstetricians are surgeons.  Midwives need to claim breech births as being well within their scope of practice, as well as the identification of those for whom a vaginal birth is not likely to lead to good outcomes, and being able to refer to and collaborate with obstetricians.

Recently I have had the privilege of attending a birth at home, which turned out to be a surprise (undiagnosed) breech.  As the mother rested with her baby in her arms, she asked me to be sure to write a story about this birth.

Without identifying her, I am pleased to record the birth - through a midwife's eyes, with a midwife's knowledge and decision-making.  I don't consider myself an expert in breech or any other type of birth.  In fact, the only births that I take professional responsibility for are the ones that are very likely to proceed under the mother's and baby's own power, driven by an amazing natural physiological process.  My job is to work in harmony with those natural processes, and to protect, promote and support the natural processes, with the intention to intervene only if illness or complication arise in the birth and nurture of the baby.   In the case of breech births, the most critical period can be the birth of the baby's arms and head, and it is important that all midwives and doctors who take professional responsibility for birth are skilled in the decision making and simple manoeuvers. 

Working as I do, attending births privately usually in the home of the woman giving birth, I have a background knowledge of a mother before she tells me her labour has started.  In this case, I had been midwife for the birth of another child in this family, five years ago, also at home.  Reflections on the previous birth had also been tenderly preserved in my blog.

The first clear indication that this baby was presenting breech was the information that the waters had broken, and were "clear, with a bit of blood, and a black blob."  Labour was strong when I arrived.

I quickly set up my gear: the baby resuscitation box, and oxytocic, syringe and needle, and procedure gloves within reach; the oxygen cylinder connected up and ready if needed; a few clean bath towels to keep baby warm after the birth.   The 'nest' had been prepared - the couch draped with a waterproof cloth, so that the mother could kneel on the couch, facing away from me: an ideal upright position for a breech birth! (and a very reasonable position for an older midwife)

I saw more meconium, and asked the mother if I could examine her internally to confirm the presenting part.  The baby's bottom was 'at spines' - well on the way to being birthed.

I had a decision to make: I spoke simply to the mother and the father.  "The baby is coming, and it will be born bottom first."  I advised them that I did not expect any problems with the birth, but as an extra precaution I would like an ambulance to be called, in case we needed to transfer to hospital.

I would now like to describe each part of the birth as it proceeded.  Contractions were approximately every five minutes. 

As the baby's rump came on view a purple, swollen scrotum also appeared, and a stream of urine was passed from a swollen little penis.  I didn't mention these facts - the mother had work to do, and she would be able to discover her baby's gender in her own time.  From that moment it must have been 10-15 minutes until the birth was completed.  At some stage the 'first response' paramedic arrived, and I confirmed that the birth was going well.  He stood back.

  • Next contraction: a big push and one leg plopped out.
  • Next contraction: a slight rotation of the baby's bottom, and the second leg came down, and a little 'cycling' action of the legs (as though he said, "Thanks Mum, that feels better! Now, what should I do?")
  • Next contraction: the baby's body was born past the navel, then to the nipples, and a large, full blue and white umbilical cord was central.  The body hanging was unsupported - I had not touched him to this point (Hands off the breech!).  I was delighted to see the cord positioned beautifully in the little protected channel between the baby's two breasts that were squeezed together in the tightly stretched vaginal opening.  I gently checked the pulse - about 120, which is good.
  • Next contraction: first arm popped out, a little rotation, then second arm.  Baby's colour reasonable.
  • Next contraction: no progress.  I placed my thumb and fingers over the cord, close to its insertion.  Pulsing had slowed to about 80.  Time to get this little one out and breathing! 
  • With mother in the kneeling position, I placed my right hand in over the baby's chin, and a finger into his mouth.  The left hand went behind the baby 's head to flex it, and the head was born with minimal effort on my part.
  • Baby was initially pale as he lay on the birthing mat under his mother, with his cord intact, as mother turned to look at him, and ask how he was.  I dried him, checked the pulsing of the cord, blew on his face, and before the first minute was up, he had taken a gasp of air.  His colour began to improve.  A few more minutes before he was ready to cry, but all the time he was making the transition from womb to the outside world, there was no reason for me to interfere.
  • By 5 minutes, he was in his mother's arms, pink and strong. 
  • By the next day when I visited them, he had been breastfeeding strongly and effectively, and doing all the things newborn babies are expected to do. He weighed just over 4 kilograms.

Wednesday, March 12, 2014

midwifery: protecting health across generations

Maria Lactans (17th Century) Antwerp
One of the truly compelling reasons that I have for practising midwifery the way I do is the knowledge that there is no safer, no better way for a baby to be born and nurtured than the way our bodies have been wonderfully created to do it.  The marvels of science and medicine have not come up with a better process.  

I'll call it NORMAL birth: normal from a biological, physiological perspective in ideal conditions.
Not what *normally* happens today.
Not what is most common in birth today, or 100 years ago, or in a primitive society .... 

NORMAL birth requires a strong healthy woman who carries her pregnancy to term, and comes into spontaneous labour.  It requires the mother to accept and work with her body in labour, and to progress, without medication, to the climax of birth.  It requires the mother and baby to work together in establishing breastfeeding, within a nurturing family-community setting that supports the mother in these challenges.

This 'ideal' is what a midwife seeks to facilitate. "In NORMAL birth there should be a valid reason to interfere with the natural process." (WHO 1996)

At any point in the process we can face challenges, complication, illness, and the need to intervene.  That's when science, medicine, obstetrics ... become life-saving.

There are obvious and unquestioned benefits to a mother and her baby when the NORMAL processes are protected, promoted and supported.
  • A mother's body and mind respond in unison to the changes in hormones in her blood, as she prepares, and progresses.  
  • The mother's thinking brain is suppressed, in a quiet and unstimulating environment where she does not feel that she is being observed, so that her instinctive mind is free to proceed with the final nesting, and the surrender that accompanies strong labour.  
  • The baby is born alert and healthy, ready to engage in the instinctive breast crawl as breastfeeding is initiated.   
  • Early and effective suckling at the breast, together with the physical pressure of the baby's weight against the mother's uterine fundus, lead to strong contractions and completion of the third stage.  
  • Once the placenta and membranes are completely expelled the risk of haemorrhage is minimised, and continuing breastfeeding supports the involution of the uterus.  
  • Close physical contact from the time of birth supports the development of normal bacterial flora on the baby's skin and digestive organs, preparing the baby's immunological processes for ongoing function.  
  • Bonding between a mother and her newborn proceed as they make eye contact, with uninterrupted close contact, and the mother's body is awash with love hormones.

I have not mentioned the midwife.  Yes, the midwife is present, working in harmony with the NORMAL processes, and guiding and supporting when things get difficult, but staying quietly and unobtrusively out of the limelight.  The midwife is guardian - protecting the mother and her child, and providing a safe space for them in NORMAL birth.

When there is a valid reason to interfere with the natural process, the midwife guides the woman, and provides appropriate explanations.  The midwife seeks only the health and wellbeing of mother and child.

Today I am looking further than the primary episode of care, spanning the nine months of the pregnancy, and the six weeks of the postnatal period.

I am looking at future generations.

The study of epigenetics: "the study of heritable changes in gene activity that are not caused by changes in the DNA sequence" offers huge challenges in health care, and particularly at the beginning of it all; conception, pregnancy and birth.  Emerging within this field of science is a new respect, for example, for the effect of nutrition during a woman's pregnancy on the health of her grand-children - the children of the child forming in her womb.

I have no claim to expert knowledge in biology, but would encourage readers to keep exploring this field.

Our bodies are wonderfully made.

I have recently become aware of a new film project,
micro birth

"MICROBIRTH" is a feature-length documentary looking at birth in a whole new way, through the lens of a microscope.
The film explores the latest scientific research into the microscopic events that occur during and immediately after birth.
This compelling, brand new science is starting to indicate that if the natural processes of childbirth are interfered with or bypassed completely, this could have devastating consequences for the long-term health of our children.
Just to be clear, this film is not calling for an end to interventions as many times they are essential and they can be life-saving.
But as this new science is starting to indicate, the use of synthetic oxytocin to induce or speed up labour (Pitocin / Syntocinon), antibiotics, C-section, the routine separation of mother and baby immediately after birth and formula feeding, could significantly raise the risk of our children developing serious disease later in life.
And as the film shows, the medicalisation of childbirth could even be contributing to a potential global human catastrophe predicted to happen by the year 2030.

Tuesday, March 04, 2014

Birth statistics

Source: Victorian Health Department 2009
I expect readers will find the trend in the number of women achieving planned home birth (Table 33)  interesting.  (click on picture to enlarge)

To access the full Victorian Consultative Council on Obstetric and Paediatric Mortality & Morbidity (CCOPMM) Annual Report for the year 2009, click here.
[This is the most recent of the annual reports]

Midwives are the only professionals who attend women for planned home birth these days.  In years past there were a few GPs, but time and cost of insurance has caught up with them.  Midwives are attending homebirths privately without professional indemnity insurance, under a special exemption that is in place until June 2015.

I note:
  • the gradual increase in homebirths as a percentage of all confinements*, from 0.2 in 1985, to 0.4 in 2009 (Table 33).
  • Table 34 indicates the type of birth for all women who were recorded at the onset of labour as 'planned' homebirth.  Women planning homebirth in 2009 had 90% 'unassisted vaginal' birth (the overwhelming majority of these being spontaneous, unmedicated); 6% caesarean birth, and the rest forceps, vacuum, or unknown.  
  • This compares with only 38.6% of all women in 2009 coming into spontaneous labour without augmentation (same report, p61), and 54.6% having unassisted vaginal births (p64).

AIHW 2010 - click to enlarge
We do not yet have a 'Births in Victoria' report for 2010 or subsequent years.
This 2010 national report is from the Australian government's Mothers and Babies publications site.

I note:
  • In Table 3.18 (shown here), the number of babies born at home in Victoria has increased from 300 in 2009 (PDCU) to 567 in 2010. 
  • This is the actual place of birth, including those who planned to give birth in hospital, and the baby beat them to it, and those who intentionally gave birth unattended ('free birth')
  • The AIHW 2010 data does not report on home birth by intended place of birth in Victoria (Table 3.19, p29)
  • 2010 was the year that the two public hospital homebirth trials commenced at Sunshine and Casey.  The number of homebirths births through those hospitals was small (40)
  • 2010 was also the year that the federal government's maternity reform package was implemented, with midwives becoming eligible to provide Medicare-rebated antenatal and postnatal services from November 2010.

AIHW 2011 click to enlarge
 The 2011 national report from AIHW provides more information on home births in Victoria, as it includes the breakdown of those women who gave birth at home, having planned (intended to) give birth at home.

I note:
  • The number of planned homebirths in 2011, in Victoria,  was 432, accounting for 0.6% of the State's births.  
  • Looking back at Table 33 (above), the increase from 300 in 2009, 0.4%, is substantial.
  • Midwives in Victoria quickly accessed eligibility for Medicare, and promoted primary maternity care options for women.
  • The only place in Victoria where a midwife can practise privately is in the community, for planned homebirth.
  • No Victorian hospital has yet established processes whereby midwives can apply for clinical privileges and attend their clients in the hospital
  • Since 2010, a number of experienced midwives have resigned from mainstream Victorian hospital and birth centre employment and joined the ranks of midwives offering homebirth.
The following excerpt from AIHW 2011 provides interesting comment:
In 2011, there were 1,267 women who gave birth at home, representing 0.4% of all women who gave birth. The highest proportions were in Victoria and Western Australia (0.8%) (Table 3.18). It is probable that not all homebirths are reported to the perinatal data collections.
The mean age of mothers who gave birth at home was 31.7 years (Table 3.49). The proportion of mothers younger than 20 was 1.3%, and the proportion aged 35 and over was 29.8%.
The proportion of mothers who gave birth at home who identified as being of Aboriginal and Torres Strait Islander origin was 1.1%.
Most women who gave birth at home were living in Major cities (70.8%) (Table 3.49). Of mothers who gave birth at home, about one-quarter had their first baby (22.3%), and 77.4% were multiparous.
The predominant method of birth for 99.3% of women who gave birth at home was non-instrumental vaginal (Table 3.49). The presentation was vertex for 97.6% of women who gave birth at home.
Of babies born at home in 2011, 99.2% were liveborn. The mean birthweight of these liveborn babies was 3,614 grams (Table 3.49). The proportion of liveborn babies of low birthweight born at home was 1.6%, and the proportion of preterm babies born at home was 1.3%. (AIHW 2011, pages 65-66)

I note:
  • There were 10 babies of the 1,301 homebirths in 2011 recorded as fetal deaths.  These data do not provide detail as to how or why those deaths occurred.
  • The midwife is duty bound to promote the wellbeing and safety of the mother and baby in her care, above preference for place of birth, or other factors.

*The word 'confinements' is used in these reports, as a tally of the number of women who have given birth, rather than the number of births, which includes multiples.  Readers might like to suggest a better word!