Friday, March 06, 2015

in two minds: why 'choice' is often a mirage

Today I am looking at (the woman's) choice, decision-making (whether it can be called 'informed' or not), and the midwife's challenge which, by definition, includes the protection, promotion and support of healthy natural processes in birth and nurture of the baby. 

From time to time a book or an article promoting women's *rights* in pregnancy and childbirth comes to my attention.  A recent feminist blog is headed with a big question "Why is it still controversial to say that women should make the decisions about childbirth?"

The group Maternity Choices Australia, which emerged out of Maternity Coalition (an organisation in which I was active for a couple of decades) has placed strong emphasis on a woman's own choices in the maternity terrain.

Who is *in two minds*?  
The woman herself. 

What are the two minds?
The woman's intellectual mind and the intuitive mind.  The same brain has separate parts that are used differently.

Why is 'choice' often a mirage?
Choices that are made (using the intellectual mind) prior to the time at which the intuitive mind takes the lead (particularly in labour and bonding) can be irrelevant, but can trap the woman. 

Although I am critical of a great deal of the maternity choice campaign as I see it today, my criticism is based on my understanding of the physiology of birth, which describes the two minds and their interaction with each other; not on feminist arguments of women's rights or fetal personhood.

The person missing from the current arguments about a woman's own choice is the midwife.  Not the generic midwife, whoever is given the task of providing midwifery services at a given moment; the one midwife who is acting as the unique professional, dedicated to working alongside and in partnership with that individual woman through the pregnancy, birth, and postnatal.

I am ready here for someone to tell me that I am being idealistic.  How can health services provide a one-to-one partnership between each woman and a committed midwife whose skill and knowledge the woman is able to trust at any decision-point?

Yes, I know it's not easy.  I have recently ceased providing this level of midwifery care, because I have become too old; too weary.  I can no longer offer to stay awake past my bedtime, or get up in the wee hours; to put aside my own needs hour after hour for the sake of what I believe to be optimal care in birth.   I still see that as optimal, even though I can no longer offer it. 

The only way I can see a maternity world that protects women's ability to make decisions about childbirth is when systematic changes are made so that midwives and women can honestly explore any choices that are presented as time progresses.  When the woman, using her intellectual mind, can explore and grasp the complexity of decision-making in labour, and can trust her midwife-partner to interrupt her from her intuitive state only if she needs to bring a matter of importance to her (intellectual) attention.  

I want to caution here, that without effective partnership, midwives and maternity services, as well as mothers, can err in over-reliance on 'natural' birth.  A UK report highlights the need for caution.  Anecdotes are common and some lead tragically to coroner's reports.

A midwife who delegates decision-making completely to the woman is foolish, lazy, incompetent, unprofessional!
For example:
Midwife A says she believes the woman is free to make any choice she wants about how long to stay in a birth pool after giving birth. 

The woman B has progressed in harmony with amazing natural, physiological forces in her body to give birth unmedicated and unassisted to her baby.  This was just what the new mother B had wanted, and she had (in her intellectual mind) chosen this pathway as having real advantages for herself and her baby.   Midwife A had supported B's plan. 

In the minutes after the birth, B stayed in the birth pool, hormonally awash in the beauty of her newborn and the afterglow of her ecstatic experience.  Midwife A was confident that all was well, and said nothing about getting out of the water.  Baby C did what healthy unmedicated babies do: she found her mother's breast.

Mother B experienced painful uterine contractions, and about 30 minutes after the birth B experienced a gush of blood, and midwife A reassured her that her placenta was about to be born.  Nothing was said about getting out of the water.

More minutes passed, with further after-pains, further bleeding, but no expulsion of the placenta.  Nothing was said about getting out of the water.


Because Midwife A believed B would know when she needed to get out of the water.

Midwife A was wrong.  Mother B was using her intuitive mind as she nurtured and bonded with her baby C.  She had no idea of time, or any other aspect of expected progress that her intellectual mind had considered prior to the birth.  The only intuition about moving out of the birth pool came much later, when B became faint.  I don't need to spell out the consequences of this error in delegation of 'choice'.

In conclusion, I can say that it is still controversial to say that women should make decisions in childbirth.  The big challenge is that midwives and women are enabled to work together, in deep respect, and with freedom to find the best course as time passes.  Neither can do it alone.

Monday, January 05, 2015

A question


Having moved from our home of 30 years in Melbourne's leafy Eastern suburbs to a beautiful semi-rural 'lifestyle' block in central Victoria (link), Noel and I are getting used to our new way of life.  For most of the past month we have not had a reliable internet connection to our home, so have been using the free service at the Kyneton library, and other processes in an attempt to keep in touch with the outside world.

We now have the new year 2015, and an old challenge.  I have been thinking about this question, and hope I can record here something of the current situation in Australian maternity care.  This question was posted by a midwife, to a large international group that discusses human rights in childbirth.  

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have safe cesareans if they need one? 

I am quite disturbed and shocked at this question.  Why, I ask, would there be a need for passion and activism to advocate for the right of women and their babies to have safe maternity care?   

Perhaps the question is irrelevant to Australia?  Perhaps this is an issue in developing countries, or somewhere else?  

Yes, women can get relatively safe caesarean births here if they have a valid reason.  Those who can afford it, or who work out how to manipulate the public health system, can also get caesareans without needing it.  This surgery might meet all the required hospital safety protocols, but the risks of major abdominal surgery add a new dimension to the safety equation.  Infection, haemorrhage, drug errors, adverse drug interactions, issues of pain management, separation of mother and baby, interference with bonding and establishment of breastfeeding, and additional risks of catastrophic birth outcomes in a subsequent pregnancy are just a few of the additional risk factors in surgical birth when compared with spontaneous, unmedicated uncomplicated vaginal birth.

I would suggest that the big question in a modern Western society such as Australia is 

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have skilled professional services that will protect the mother's capacity to give birth to a healthy baby spontaneously?

Indeed, do we as a society value a mother's ability to give birth?  Do we value the midwife's duty of care which includes the protection of normal birth?   

No, we don't.

Maternity care in Australia is a dog's breakfast that pays more attention to a woman's ability to pay a fee for service than anything else.  It includes obstetrician-managed 'private' care for women who have no clinical need for a specialist; it includes public hospital maternity services that fail to communicate plans and tests done antenatally with the staff who provide intrapartum care; it includes midwife-led private care for planned homebirth, with no provision for the midwife to continue as the responsible professional if the decision is made to go to hospital for the birth; and it includes a fringe of women who proceed with free-birth, with what care there is directed by doulas and unregulated birth workers.

Advocacy in this country around birth is more focused on the woman's right to 'choose' than protecting and promoting natural healthy processes.  Yes, some women 'choose' just that, and make choices about their care that they believe will enhance the process.  But much 'choice' focuses more on whether or not to use painkilling drugs in labour; whether or not to induce or augment labour; planning a waterbirth, or delayed cord clamping, or vaginal breech birth, or some other aspect of care which may be very important in itself but which cannot be addressed separately from the bigger picture. 

Midwives are the only group who have (or should have) the skill and capacity to improve birth outcomes working in harmony with natural processes.  Mothers can't do it on their own.  Physiological birth requires a woman to minimise neocortical activity - thinking.  Childbirth educators, doulas, or well meaning family or friends can't do it.  They don't have the midwife's unique skill. There is plenty of evidence supporting this contention, which requires a care-partnership between woman and her trusted midwife, who is present as the leading or primary professional carer at the time when decisions are being made.  Yet many Australian midwives approach pregnancy and birth as though their role is inconsequential.  They work from an obstetric-managed philosophy of care, relying more on tests and investigations that detect abnormalities than any authentic midwifery philosophy of firstly protecting, promoting and supporting physiological processes in birth, balanced with a commitment to accessing appropriate emergency obstetric services when indicated.

So, is there a place for ' passion and activism in the middle ground, ...'?

I hope so!

That middle ground where women are valued and respected for their capacity as birth-givers; where we seek first to achieve unmedicated, healthy mothers and babies, and place restrictions on the professionals and the consumers as far as frivolous or unfounded interventions are concerned; where midwives are valued for their ability to protect and support the natural processes. 

This is worth being passionate about.

Friday, October 17, 2014


Dear reader

Over many years I have enjoyed writing as villagemidwife, and I know that there are many people who read my posts.  Much of my writing is an outpouring of thought and emotion that has been directly linked to my practice.  I am hoping to continue writing for a long time, but it's likely that that will change, as my life's pathway moves on.

I have attended the last birth in my caseload.  I am continuing to practise, particularly in sorting out breastfeeding problems and other postnatal care, but I have decided to act my age, and to leave the births to the younger midwives.  My decision to cease attending births was supported by the fact that in the past 3+ years, since the government's maternity reforms, the number of privately practising midwives in and around Melbourne has increased exponentially, while the number of women who wish to engage a midwife for homebirth, or hospital support, is increasing only steadily.  That means many midwives are under-employed, and there is huge competition for 'business'.

[aside] This sort of language may be unpalatable to some readers.  Birthing is about women and their beautiful babies.  Yes!  Surely midwives who practise independently do so because we have made personal commitments to the protection, promotion and support of natural birthing in a way that we are not likely to be able to practise in mainstream maternity services?  Yes!
But these wonderful possibilities can only be sustained if the midwife is free to focus on the woman and her child, and that means maintaining a reasonable caseload and being paid a reasonable amount of money. 

We have sold our house in the leafy Eastern suburbs, and bought a beautiful (smaller) house on five acres in Kyneton.  If you want to search, the address is 121 Rosa Court, Kyneton Victoria 3444.

If you enjoy reading this blog, you may also enjoy OLD midWIVES' TALES.
Also a fac_book site of the same name.  You are welcome there too - just go to the site and send me a membership request.
So far I am the only writer, but I would love to have other midwives record something of their wisdom, experiences, and learnings.

With best wishes
Joy Johnston

Thursday, September 25, 2014


(by Poppy)
Several years ago, in 2010, I posted Dangerous Drugs, in which I explored my thoughts and concerns about the adverse effect of opiate drugs on a baby's ability to function normally in the first few days of life.  In that post the narcotic (opiate) drug endone came under the spotlight, as it was being (and still is) used liberally in early postnatal settings, particularly after caesarean births or when women complain of perineal pain.

[Note to readers:  If you would like to check the information about any drug, you can search the myDr medicines site.  For example, Endone tablets. ]

In 2012 I completed an accredited course in Pharmacology, the Graduate Certificate in Midwifery at Flinders University, and subsequently received endorsement of my registration as a midwife prescriber, and obtained my own prescription pads.  I and many other Australian midwives have used social media for discussion of prescribing issues, in the Midwife Prescriber group.

Any medicine that contains opiates (including over the counter medicines such as panadeine [paracetamol+codeine]) is metabolised into morphine as well as other substances, and has a similar analgesic action to endone for the mother, and is transmitted via breast milk to the baby.  There is a great deal of variability in the way an individual metabolises opiate medicines, transferring the substances from the stomach, via the liver, to the blood stream, and to pain receptor sites.  The existence of ultra-rapid metabolizers of codeine should be noted by any midwife or doctor or pharmacist who prescribes or recommends oral opiates for women who are breastfeeding, and the medicine should not be used if the baby appears affected (excessively sleepy/lethargic) after being fed with mother's milk.  (??? aren't babies supposed to be sleepy after breastfeeding?  Yes - not lethargic though.)

Pethidine (meperidine)
After that rather lengthy introduction, today I would like to focus on another opiate, pethidine, or meperidine (Demarol) in some countries.

Peer reviewed medical literature has for more than a decade drawn attention to the neurotoxic effect of metabolites of pethidine, in both the adult and in the breastfed infant.  In 2006, the New Zealand Medical Journal published a paper by Shipton, stating that "Pethidine is no longer considered a first-line analgesic. ... Clinicians around the World recommend its removal from health systems
or restriction of its use." (p1)

Anderson published A Review of Systemic Opioids Commonly Used for Labor Pain Relief (Journal of Midwifery and Women's Health, 2011), and stated that,
"Meperidine [Pethidine] and its metabolites accumulate in colostrum and breast milk and may be associated with newborn neurobehavioral alterations and unfavorable effects on developing breastfeeding behaviors. Wittels et al43 conducted a prospective, randomized study of breastfeeding women who underwent cesarean births and compared intravenous PCA administration of meperidine to intravenous PCA administration of morphine. Meperidine was associated with significantly more neurobehavioral depression in breastfeeding newborns on the third and fourth days of life when compared with the behavior of the newborns in the morphine cohort (P .05), despite similar overall doses of morphine and meperidine." (page 227)

A question posted at the Midwife Prescriber site a week ago indicated that pethidine is currently used liberally in labour and postnatally, except in public hospitals in New South Wales, where I understand its use has been restricted.  Old habits die hard!

Here's a recent case (true story) -
A woman who is a well informed registered professional, having her second baby by elective caesarean for transverse lie, at a public teaching hospital in Melbourne:
  • requested that the IV be inserted in a vein on her left arm rather than the back of her hand, because she wanted freedom to hold and feed her baby after the birth.
  • was surprised that the young anaesthetic doctor was very reluctant to do this - had to insist - and eventually got what she requested
  • asked not to be given pethidine which is the standard in that hospital, preferred morphine via a PCA, as she was aware of concerns about metabolisation of pethidine, and transfer to colostrum, and felt she could have more control over the amount of drug in her system this way
  • once again found that she had to argue with the anaesthetic doctor in order to achieve this preference. No valid reason was given for the hospital's preference of pethidine. The doctor said that "the midwives don't like PCA and don't know how to manage it" (which I think is nonsense)
  • and after this doctor had (albeit reluctantly) complied with the woman's wishes, said to the woman. "You're right you know, we don't like using pethidine. It's a 'dirty drug'. And not siting the IV on the back of your hand is a no brainer."

This story illustrates unprofessional behaviours, particularly by the anaesthetic doctor, who was probably doing exactly what she or he had been told to do.  As a teaching hospital, one would expect evidence to be critically examined and applied.  If pethidine is not the best available medicine, it should not be used.  Passing the blame to the midwives is outrageous.  Most of the midwives working in hospitals have not studied pharmacology, and do not have authorisation to prescribe.  The person who signs the medications chart is the person who takes responsibility for the prescription.  If there are problems with the equipment, sort that out.

Drugs such as pethidine, morphine, endone, OxyContin, and others are DANGEROUS DRUGS.  They are kept in the DANGEROUS DRUG cupboard in hospital wards, and protocols must be followed to ensure that these medicines are signed out and administered correctly.  They are called DANGEROUS DRUGS because they are DANGEROUS!

The challenge is that when a dangerous drug is required, such as after major surgery, what is the least dangerous option for the mother and her new baby?

Sunday, September 21, 2014

possibly postmature

Possibly postmature
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 
  • the date of the first day of the last period
  • the normality of the last period
  • the date of quickening
And, if ultrasound is used, there are additional pieces to add to the puzzle.

Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.

A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.

A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?


          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?

With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 

There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.

No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable. 

Wednesday, August 20, 2014

Risk and maternity care

Discussion about risk in maternity care may be met with the full range of responses, from the hands over the ears "hear no evil", through to scary stories about the "disaster waiting to happen".  A midwife needs to understand risk, recognise progression into complications, and appropriate response to change in a woman's or baby's status, without being fearful.  A midwife is guided by principles such as
"In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: A practical guide.)

The usual model of care offered by midwives who practise privately is primary maternity care, with a strong emphasis on continuity of carer and the promotion, protection and support of the natural physiological processes in childbearing: spontaneous unmedicated birth, facilitating strong mother-baby bonding, and exclusive breastfeeding. This emphasis is consistent with best standards of midwifery practice and health promotion globally, and is to be applauded and supported in the interests of public wellbeing and safety. 

Today I want to look at practice issues for midwives in private practice, from a risk based approach.  Not just risk of complications or illness in the mother or baby, but also the risk that a midwife's practice may not be of the standard expected by the profession or the community.

The statutory regulator for health professionals, AHPRA, has established a set of regulatory principles which require the Boards to establish a responsive, risk based approach to addressing practice issues. ( )

It has been recognised for many years that systems of maternity care which rely on risk assessment will place a disproportionately high number of women in the "at risk" categories, leading to an increased likelihood that these women will be subjected to a higher level of intervention in the birth.  This process might be seen as necessary, in ensuring the best outcomes, but it often fails to do that!  No amount of bureaucratic micromanagement through laws or practice guidelines will ensure safety.  Many women for whom no risk categories apply will develop complications that require expert obstetric intervention, while many of the women in the "at risk" categories will, with appropriate care, proceed to an uncomplicated, spontaneous birth of a healthy baby.

Within the broad scope of midwifery, issues of special note in private practice, when there may well be an increased risk to women and babies in the care of midwives include:
• Education of midwives, registration, and transition to private practice
• Notifications, investigations, and hearings into professional conduct
• Lack of professional indemnity insurance for homebirth
• Notation as an eligible midwife [including Medicare, endorsement for prescribing, hospital visiting access]

Here are a few of the risks, all of which could contribute to poor outcomes for the mother and baby:

  1. Risk of unrealistic, idealistic notions of midwifery practice and natural birth, 
  2. Risk of inexperience, and lack of appropriate education and preparation for autonomous practice.
  3. Risk of professional isolation, and stunted growth of a midwife's professional identity.
  4. Risk of bias in the regulatory body against private midwifery practice.
  5. Risk of bias in mainstream hospital maternity services against private midwifery practice. 
  6. Risk of discouraged, disheartened midwives leaving the profession and being unable to find suitable employment.
  7. Risk to the public of being prevented from accessing the options for midwife-led maternity care, introduced through legislative reform in 2010. 
  8. Risk that women are being prevented from accessing the potential for excellent outcomes that are seen in midwife-led care.
  9. Risk of obstruction of trade for midwives.
  10. Risk of the rise of 'free birth' and births attended by unqualified or lay midwives.

There is a separate, and different category of risk that needs to be included in any discussion about private midwifery practice in Australia.  Midwives are unable to purchase professional indemnity insurance (PII) for homebirth - the core ingredient of most midwives practices.

It is unreasonable that Australian midwives' homebirth practices should continue to be excluded from the PII that is currently available.  Eligible midwives are able to buy insurance for every aspect of their practice, except homebirth.  This needs to be changed.  Insurance, per se, does not make birth safer or less safe; does not ensure good outcomes.  Insurance seeks to protect the financial interest of the players, rather than the health interests.

Tomorrow I am meeting with other representatives of professional organisations, and the NMBA, to discuss midwifery practice issues and regulation.  The points I have noted in this blog are contained in a discussion paper that I have written for this meeting.

Your comments are welcome.

Monday, July 21, 2014


The mother of a two-and-a-bit year old commented wistfully, "I had no idea of what I was committing to when I became a mummy."

That's so true.

In fact, I don't think it's possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.
Thanks to Miriam and Amelie

This mother who, for whatever reasons, started her family in her mid- to late-thirties has probably experienced a great deal of freedom and responsibility in her personal and professional life.  She has experienced leaving home, and becoming independent of parental influences.  She has possibly experienced promotions and increases in her work earnings.  She may have enjoyed overseas travel or achieved success in the personal pursuits that she has chosen.


And now, at about 40 years of age, she has her two-year old constantly in her care, and is preparing for the arrival of a sister or brother.

The day begins with "I very hungry now mummy", and continues as she seeks to meet each of the needs of the child. Multiple meals and snacks, nappy changes, library, play group, walks to the playground, playing hide-and-seek, art work at the kitchen table, music, visits to friends, daytime sleeps, melt downs because the little one didn't get all the sleep she needed, sweeping up crumbs and food scraps under the table for the n-th time, and thinking about upping her dinner menu to something special tonight.  These are just a few of the day's challenges, along with shopping for groceries, mountains of washing, drying, folding and putting away the clothes, getting to appointments on time, and much more.

There is no suggestion of complaint in this mother's musings.  Most of the time she patiently accepts the work of caring for one small person; valuing her own role as mother above all other options at this time of her life.  University education and professional standing cannot compete with the status that is simply and profoundly accessed under the title 'mother'. 

Am I being idealistic?   Am I seeing only what I choose, through the filter of many years; forgetting the reality of sleep-deprivation, and the constant and unrelenting need of the little one for attention? 

I don't think so.  I see a great mystery, something timeless and inexplicable, in the ability of a mother to care for her children.  I accept that many aspects of mothering call for a commitment that goes far beyond our usual limits, and that it's not possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.

The mystery of the mother is our birth-right; contained within the wonderous bodies that God created in his own image, and that God said "is good".  Mothering is part of the natural physiological process that can happen automatically in a woman's person during pregnancy and after the birth of her baby.  It's the same normal physiological process that I as a midwife have sought to protect, promote and support, unless there is a valid reason to take another, more medical, pathway.

Yet the ability of a mother to give, and give again, is not to be taken lightly.  The presence or absence of loving support and encouragement from husband, family, friends and within the community can make a huge difference.

I recognise that mothers today are expected to return to paid employment after their babies have reached one year, or even six months, with children being placed in day care.  I cannot accept this as being in the child's or the family's interests.  In the end Australian families will be paying a high price for this social experiment that interferes with the basic building blocks of love and attachment between mothers and their babies. 

Mothers who are willing and able to nurture their own babies should be supported to do so.