Tuesday, December 30, 2008

Old midwives' tales

I thought I had blogged my last entry for this year when I wrote yesterday about the 6-week postnatal consultation. However, an opinion piece in today's newspaper has, sadly, left me feeling that I need to defend my profession, yet again!

'Orgasmic birth and other old midwives' tales' has appeared in various Fairfax newspapers.

I have made a nice cup of tea, enjoyed a chocolate (there are too many sitting around after Christmas!), and am imagining how this article will impact on women who are considering the possibility of planning homebirth. As one of the 'old midwives' practising in and around Melbourne today, I need to reflect on the notion of orgasmic birth.

I don't have any comments on the film, Orgasmic birth - the best kept secret. I haven't seen it. I don't feel I need to defend Ina May Gaskin, the 'hippie guru'. I have met her once, and listened to her give an inspiring talk at a homebirth conference. But Ina May would agree with me, I am sure, that the work of a midwife is not about being a guru, or any other tag. It's all about a presence, being 'with woman'.

Natural, physiological birth does not belong to any cultural group, hippie or homeschooler, or even home birthing. Natural birth does not belong to any professional group; midwife, doctor or anyone else. The knowledge of natural birth is stored deep within each woman's intuitive mind, and this knowledge becomes available in the same way that other hormonally directed behaviours are awakened at certain times in our lives.

Midwives carry knowledge and skill that helps us to work in harmony with each woman's own natural processes in birthing and nurture of the newborn. We see some women giving birth quietly, with apparently minimal pain or distress, and we see other women struggling and roaring through the enormity of their labours. We watch the birthing of not just a child, but also of a mother, as she receives her child into her arms, and intuitively does what mothers do. We hear women from both ends of the experience spectrum, and from many points in between, tell of their satisfaction or their disappointment. Although the rates of normal birth are high for women whose primary carer is a midwife, we can not guarantee a particular outcome.

I don't know how many of the women I have attended for birth would jump on the 'orgasmic birth' bandwagon, and claim that they had 'it'. I don't care. My job in being 'with woman' includes being constantly mindful of the wellbeing of mother and baby. If they are both well, it doesn't matter if the mother smiles at her beloved, or moans or closes her eyes. It doesn't matter if she stands proudly to give birth, or curls up in a pool of water. The experience of birth is a deeply etched memory which the mother takes away from the birth, and she can interpret the experience as she pleases.

Childbearing women today are influenced by sales pitches and marketing of every aspect of the childbirth experience, including the experience itself. When 'good' is no longer good enough; when the length of labour, and the power of the contractions is just right, and the urge to push is as the person who gave the class said it would be, and the noise coming from deep in your throat is the most powerful birth song you have ever imagined, and whole experience of birth needs to be the most ecstatic ...

No! This is all wrong.

Let's not compete over birth, as if the bits that come together to make up the whole are items you can select from a supermarket shelf, or learn from watching a film. Birth is a new beginning, a new life, full of potential. Giving birth is one of the most complex and awesome acts that we will ever be privileged to participate in, either as the mother, or in a relationship with the birthing mother. Once we set out on the journey of birth we cannot know where we will end. But we do know that in birth journeys there is no safer path than the natural process, unless a decision point is reached in which a valid reason for interference is apparent.

Will it be agony or ecstasy? You can't know. But you will never know unless you choose to engage in one of life's most demanding and most rewarding journeys. Today you have a choice: either to seek to work in harmony with your body's natural ability, 'Plan A', or to ask a doctor to dull your senses and remove the baby from your body. A skilled midwife can be with you, but only you can achieve 'Plan A'.

May the year 2009 bring many women to a new knowledge of their amazing birthing ability, with happy and healthy birth days.

Monday, December 29, 2008

6 weeks after the birth

I was talking with a midwife colleague who has recently set up her own independent midwifery practice, and she asked me about the 6 week postnatal check. Is it important? What are we trying to achieve?

Since I began private practice I have invited women in my care to come back to my home office at about 6 weeks. I don't mind if one comes at 5 weeks, and another at 8 weeks - I see it as a milestone, in that the mother and her baby return to visit me, after I have completed the postnatal 'care'. It's a good time for 'show and tell', and marks the end, for most new mothers, of their post-birth healing period.

So what do I expect to talk about, and to achieve in that follow-up consultation?

A midwife and woman who have established a bond of trust and respect within the professional partnership appreciate the opportunity to meet again. The 6-week visit is a time to close the professional relationship, which can be renewed in the future if the mother asks me to be her midwife again.

I can't overstate the value of focused, face to face, un-rushed time spent together without distraction. A great deal is communicated in eye contact, body language, and subtle, non verbal means.

I try to give the mother an opportunity to tell me any concerns that she might have. If there are any questions about what happened in the labour or birth, or postnatally. It's an opportunity to go through my notes with her in detail, and to give her a copy, if I haven't already done so.

I have a little list to work through, and discuss further when indicated:
Mother's general condition: does she look well? are you sleeping enough? how much?
Mother's recovery from birth: is your fundus palpable? has the lochia ceased? when? is your perineum fully healed, if there was a tear? would you like me to look at your perineum? are you experiencing any incontinence?
Mother's family planing: have you resumed sexual intercourse? have you any concerns about contraception? do you understand LAM (Lactation amenorrhoea method)?
Baby: general appearance - colour, activity, hearing, tummy time, fontanelles, smiling, responding, include weight and full physical check if the mother wishes
Baby's feeding: this is an opportunity to discuss any concerns the mother has. Most babies will want a feed during the consultation, and I look for opportunities to guide and encourage
Support network: have you linked in with peer support groups, such as BaBs (Birthing and Babies Support) and ABA (Australian Breastfeeding Association), mother groups through the Maternal and Child Health centre, or local community groups and churches?

There are no specific questions in my list that are intended to explore mental health issues. However, if there are cues for exhaustion or postnatal depression, this is an opportunity to go further if the mother is willing.

If we identify any matter in which healing or recovery is incomplete at 6 weeks, we can make a plan for further review, considering appropriate medical consultation.


An independent midwife is working primarily with well women: women who are healthy through their pregnancies, who carry their babies to Term, come into spontaneous labour, choose to work in harmony with their bodies in labour, progress without needing drugs for pain relief, and give birth to their babies under their own power. This evidence of 'wellness' is in fact an awesome achievement, for which our bodies are wonderfully made.

Yet we cannot assume that every woman and every baby will be well, even those who return for the 6-week postnatal check. A midwife's skill, in working with wellness, is also to identify anything that is abnormal, and guide her client in making a plan to address that issue. The same active decision making process that we use in pregnancy and birthing applies postnatally.

Midwives with caseloads are especially privileged in the way we can work, one to one, with women. But with that privilege comes an increase in our responsibility to the individual woman. The 6-week postnatal consultation is an opportunity for me, the midwife, to review the episode of care, reflect on the way in which I have learnt from this experience, and effect closure without leaving any loose ends.

Sunday, December 21, 2008

Christmas Greetings




Wishing you a happy Christmas, and all the very best in the new year.

Thankyou for your comments both at this blog, and by email, and in person. You have encouraged me to do all I can to record my midwifery knowledge and make it available to others.

The Christmas season is a time when we celebrate the birth of THE child. My prayer is that mothers throughout the world will be enabled to value their amazing strength in birthing, and choose to give birth and nurture their children to the best of their ability; and that midwives will value our role in being 'with woman', in promoting and protecting normal birth.

My husband Noel and I would be honoured if you would care to read our annual letter to our relatives and friends.

Thursday, December 18, 2008

childbirth: a half-baked product of evolution?

Having made it clear that I am outraged by this suggestion last week (see previous post), I would like to spend a little time working through the idea.

My understanding is that birth is indeed "a normal function of life". This does not mean that birth is meant to be uneventful or without challenge, any more than breathing, or any other normal function, is. Breathing can, in certain situations, be linked to life-threatening situations, as can birth.

The writer loses my respect with the outlandishly simplistic assertion that "The belief that nature intended women to give birth in a certain way only holds if you believe intelligent design rather than science. If you believe in evolution, ..." The issues of childbirth are not about belief in theoretical frameworks that seek to explain life through evolution, intelligent design, or indeed, creation. Childbirth is a fact of life. Intelligent design is a concept that has been used in recent decades, particularly by educators in the US, in the creation-evolution debate. The observation that nature 'intended' women to give birth in a certain (natural, physiological) way has nothing at all to do with a belief system.

Regardless of how we happened to get here, one of the realities of modern human existence is that there is STILL no safer way, physically and emotionally, for most mothers to give birth to their babies than by working in harmony with natural processes. Only when a valid reason exists to interfere with the natural process does the possibility arise that the risks of intervening may be less than the risks of doing nothing. When a point is reached in the critical decision making for a particular mother-baby pair, the subsequent progress and outcomes will be irrevocably influenced by the decision that is made.

Darwinian principles of natural selection, when applied to human reproduction, would result in natural limitations to the individuals for whom natural conception, gestation and childbirth is difficult or dangerous. Natural selection also applies to other mammals that produce relatively large offspring. A small bitch who is carrying pups from a genetically larger dog will not have good rates of success, or reproductive fitness, under natural whelping conditions.

In Western cultures there is little natural selection in human reproduction today. Women who in previous generations would be unable to bear a child are assisted and supported. If we detect distress in the fetus, or failure to progress by a labouring woman, the decision to operate is quickly facilitated.

Instead of mourning the discomforts and potential reproductive hazzards associated with "fat brains and narrow hips" which apparently compromise "the ease of pushing out offspring", I would like to briefly mention a few of the features of the natural process in childbearing which can only be described as awesome. My list of marvels includes courtship and loving; the nesting instinct; spontaneous onset of labour at Term; the changes in a woman's behaviour in physiologically normal labour; the spontaneous adjustments made by a newborn baby at birth; the separation and expulsion of the placenta; the search by the baby for the mother's breast and the psychological attachment of mother and infant; and many more. Each of these natural processes, within physiological birthing, may be disturbed and inhibited by interference, with ongoing consequences to the mother and baby.

As far as I know these potentials have been part of the childbearing process for as long as any historical record exists. The changes we know of have been in our ability to intervene in the natural process. Whether we women reached our current physical and psychological makeup as a result of natural selection, survival of the fittest, and evolution, or whether our first parents had the same natural processes that we possess, is outside the realm of recorded history, and is therefore open to congecture.

For those who have read thus far, I am happy to put it on the record that I accept the Christian belief that our God is "creator of heaven and earth" (from the Apostles Creed). I do not claim to understand HOW God created. I think it reasonable that the creature (I) may not be able to fully comprehend the work of the creator (God).

Sunday, December 14, 2008

More maternity press

The federal government's maternity services review is providing journalists with a good deal of material.

This week SMH has a piece on informed choices, the Age has expressed concern over rising rates of caesareans, and a personal story of caesarean and vbac, and the Australian has Midwives push for Medicare.

I would like to look closer at a statement that caught my eye in the SMH 'informed choices' article:
"Many submissions referred to nature. As one woman wrote: "Give women back their rights to birth, the right that women have had taken from them due to a medicalised world. Reinstate BIRTH as a normal function of life!"

"Birth is a normal function of life but it is also dangerous. Women have been giving birth since the beginning of time but they have also regularly been maimed or killed in the process, and continue to be in countries where women cannot resort to modern medicine if things go wrong.

"The belief that nature intended women to give birth in a certain way only holds if you believe intelligent design rather than science. If you believe in evolution, you will understand that there are competing interests in the way a species develops over time and humans have evolved in ways which make childbirth particularly nasty: we have fat skulls to hold our fat brains and narrow hips so we can walk upright, compromising the ease of pushing out offspring. We use pain relief and surgery when faced with other half-baked products of evolution, such as wisdom teeth and burst appendixes, without feeling like failures, so why not childbirth?"

AMAZING!
PREPOSTEROUS!

What a ridiculous connection to make. So we are now to believe that childbirth is one of the "half baked products of evolution" that should be put in the hands of 'science' and taken care of!

When I was young I heard of women who had had all their teeth removed before they got married, so that there would be no dental bills. The 'science' of the day told them that a good pair of dentures would be much preferable to oral hygiene, and the teeth look much nicer than the natural sort. As those women got older their gums became progressively more degraded, and they reached a point where the dentures would not stay in place. Today's 'science' encourages us to protect the natural process, with day to day care of our teeth, and specialist care when disease or decay are present.

When I was young I knew children who underwent elective surgery to remove their tonsils and appendixes. The 'science' of the day told their parents that tonsils and appendices were vestigal parts of the anatomy that were not necessary, and that could become infected. Better to do a bit of housekeeping, and book all the children into hospital to have their useless bits removed. Today's 'science' encourages us, once again, to protect the natural processes, and to maintain healthy tonsils and bowels through healthy diets and lifestyles. Once again, there is specialist care available when disease occurs.

There is a very important reason why midwives are required, by definition, to promote and work in harmony with normal, or 'natural' birth, whenever that is possible. There is NO safer way of childbirth for most mothers and babies than following the complex, unpredictable, and often difficult process of spontaneous, unmedicated birth. If we want to talk science, this has to be the starting point. Every intervention, every drug, every procedure carries its own package of risk. Drugs and surgery can, and I hope will, be made safer over time. Risk management protocols in hospitals can, and I hope will, minimise the number of people harmed as a result of human error. If maternity care providers follow scientific and ethical thinking about safety and wellbeing of those in our care, we can not afford to lose our skill in working with the natural processes in birth and nurture of the newborn.

In addition, there is a deeply significant emotional process in birth. It's no wonder there were so many responses to the maternity services review.

Thinking people find birth important. I am outraged at the suggestion that childbirth should be treated as one of the "half baked products of evolution".

Tuesday, December 09, 2008

FEAR OF BIRTH

The headline on page 5 in today's Age is 'Fear of birth causes rise in caesareans'. This article is reporting on the newly-released Australian Institute of Health and Welfare (AIHW) report Australia's mothers and babies 2006.

The continuing rise in caesarean births, from 20% in 1997 to 31% in 2006, is an indicator of a maternity system in crisis. The AIHW report does not attempt to answer the question "why?"; it simply states the facts.

One reason for the increase in caesareans, according to Julia Medew, Health Reporter for the Age, is the 'fear of birth'. The non-medical reasons for caesarean include, according to Medew, psychosocial, patient choice, family history of vaginal prolapse or incontinence, the unpredictability of the birthing process itself, and the risk of an emergency caesarean.

I am sure the 'fear of birth' influences many of the medical decisions to proceed with casearean surgery. The 'fear of birth', an unpredictable natural process, that results in high rates of inductions, the cascade of interventions, and subsequent rescue of mother and baby by surgery. The 'fear of birth' that has robbed midwives of their skill in being 'with woman'; resulting in strong reliance on opiate pain killers, and epidurals, and thereby diminishing the ability of the mother-baby unit in achieving their natal journey. The 'fear of birth' that presents major abdominal surgery as a 'safe' option to the natural process.

I think it's true that many women experience a deeply significant 'fear of birth'. The way we manage that fear of birth is very complex, influenced by our knowledge about birth, our expectations, our belief system, our trust in our own bodies, the influence of family and professional carers, and many other factors.

Many women in my care have expressed their own 'fear of birth'. While I as a midwife use language such as 'working in harmony' with the natural processes, women write in their birth stories about reaching a place where they had to let go, to surrender to their bodies, come what may. Some speak of a very frightening place, a tunnel, a valley of the shadow of death. The 'fear of birth' is over-ridden by the 'fear of death'.

There can be no generalisations here: a woman's experience in natural birth is hers alone. While to one the letting go of conscious control becomes a powerfully thrilling journey into a new terrain, another might struggle to retain control, and be terrified, as a force she does not understand, and cannot accept, propels her child through her birth canal and out of her body.

A few days ago a mother told me that she has experienced what I understand as post traumatic memories since the birth of her first child, at home, in my care. This mother is now preparing for the birth of her second child. She told me she is afraid.

I do not remember anything about that birth that would have alerted me to this fear of birth. Labour progressed well, and a beautiful healthy baby was born through water. I am saying this to highlight the fact that the mother's lived experience may differ significantly from the professional assessment of the midwife or doctor who takes responsibility for the care. From my perspective, it was a good birth. From the mother's perspective, something was very wrong, and she fears it happening again.

I have reflected on this apparently enormous difference between the experience of the mother and the experience of the midwife. When I am 'with [labouring] woman', I find myself going through a physical and emotional partnering. I also experience transitions, and fears - not the same, but linked, to the woman I am with. I need to keep myself at the same time closely connected to the woman, yet objectively outside her experience, so that my professional assessments are clear. I do not know a woman's limits, but my duty is to know and hear her, and to hold a space that enables her to continue in her journey.

Theories of partnership and cultural safety in midiwfery place the woman at the centre of everything. The care I provide is culturally 'safe' if the woman, with her own culture and personal needs, feels that it is 'safe'. In partnership, there is an emotional 'safe' place - once again from the woman's perspective.

Returning to my initial claim, that the continuing rise in caesarean births is an indicator of a maternity system in crisis, I wonder if this reflection on the 'fear of birth' contributes in any way to addressing that crisis. Yes, I believe midwives hold the key. Midwives offering one to one partnerships with women hope that in doing so we can promote and protect normal birth, and enable wholeness and wellness in the majority of women in our care. Yet there will be some who, as discussed here, experience to a greater or lesser degree, ongoing 'fear of birth'. My strong belief is that, even though the 'fear of birth' is deeply ingrained in our psyche, and in our culture, there is no safer way to give birth than to proceed down the normal pathway. The natural process is 'Plan A'. Accepting the unpredictability of our bodies, and our lives, we are able to make the best choices from any that are available if 'Plan B' needs to be considered.

The mother who spoke to me about her fear is likely to read this entry. My heart goes out to her, and to others who experience that crippling fear, that you will be able to find new strength and enabling in the amazing gift of GIVING birth.
Joy

Sunday, December 07, 2008

Why is it important to support maternity organisations?

Last month I wrote down some thoughts on maternity organisations. Although I did not identify a particular organisation, it would have been easy to deduce that I was referring to Maternity Coalition. I have been a member of Maternity Coalition continuously since the mid '90s, and have held roles on the national management committee including Editor of the quarterly journal Birth Matters, and Treasurer.

Yesterday afternoon the annual general meeting of Maternity Coalition was convened. This is an AGM like no other, as members link up by telephone, using FreeConference telephone conference call technology. Four other members joined me in my home office, with the telephone on speaker, between 4 and 5.30pm. There were, we are told, 27 members in attendance, in several time zones across the country. Approximately 50 proxy votes had been received. I consider that evidence of widespread interest in and support of the organisation.

In Maternity Coalition, the purpose of the AGM is to confirm the minutes of the previous AGM, to receive from the committee reports upon the transactions of the Association during the previous financial year, to declare all positions vacant, and elect officers and committee members of the Association.

Yesterday's meeting gave strong support to a new president, and general members of the management committee. The job of chairing a large conference call meeting, together with the logistics of allocating votes to members present, and to the proxy voters, was managed very well.

Some readers may wonder what incentive there was for all these people to give up a Saturday afternoon, and to vote in a team of volunteers to manage the affairs of Maternity Coalition.

I believe we are reaching a critical point in reform of publicly funded maternity care in Australia. Quite a few of the articles I have written on this blog, as well as the MIPP and BaBs blogs in recent months have focused on the federal government's maternity service review. The time for reform has come. The monopoly of funding, which restricts the ability of a midwife to practise midwifery, while supporting the obstetric profession's control of maternity care, is not in the interest of public health. Our current government has shown clear signs that it is prepared to dismantle this unfair monopoly. Maternity Coalition needs to be a strong voice at this crucial time, bringing together the shared interests of mothers and midwives in improving maternity services for all mothers and their families.

Maternity Coalition has, over the past decade, been recognised as a peak body - a key stakeholder in maternity issues. The organisation has grown from 20 or so members in Melbourne in the early 90s, getting together on a Sunday afternoon, to a national body with branches in all States and Territories. It may be coincidental that the exponential growth of this organisation has come in the same decade when most homes have become connected to the internet; when websites and email have opened up communication in a way that we would not have imagined twenty years ago. The move from face to face meetings to telephone conference calls has been essential in supporting the growth of the organisation nationally.

The National Maternity Action Plan (Maternity Coalition 2002), which was written by mothers and midwives in Maternity Coalition, sets out the right of women to have the choice of a known midwife to care for them throughout pregnancy, birth and the first few weeks after the birth. That is, essentially, what is missing from most Australian maternity services. Although a person who has the midwife qualification will usually be attending a labouring-birthing woman in hospital, the woman does not know the midwife, and vice versa. Although midwives staff maternity wards they do not have an opportunity to develop a partnership with the women in their care. The care is service-centred, not woman-centred.

I feel as though I am just getting started on this theme, but I know I must be brief. I hope that all women of this country will soon be able to access authentic midwifery care: a partnership of a woman and her midwife through the pregnancy-birth-early parenting continuum. The midwife's duty of care, working in harmony with natural processes, includes promoting normal birth, and is balanced by a duty to collaborate with other health professionals when this is appropriate.

Monday, December 01, 2008

IN THE SUNDAY AGE

A major article 'In Safe Hands', and an Opinion piece 'Homework is the mother of prevention' with the sub-title 'Many pregnant women put more preparation into buying a new car than they do into the process of giving birth' caught my eye as I leafed through the paper while eating my porridge and enjoying a cup of tea thismorning.

I felt the need to comment critically on some of the points made in these articles. Years ago I would have invested energy into writing a letter to the editor. We know that about one in 10 such letters are published. Now I see the opportunity to write a blog, and perhaps send some of it off to letters@... The topics I have chosen to comment on are:
"what's best for the mothers"
"midwives who practise in isolation without the involvement of other medical staff"
"to defer to their doctor's opinion and to the institutional imperatives"

Dr Christine Tippett is the central topic of 'In Safe Hands'. Christine Tippett is an obstetrician who I respect in many ways. However, her comments on midwifery are misleading and ill informed. I do encourage my readers to read the article (linked above), and come to your own conclusions.

It's good to note that Dr Tippett is anticipating reform - federal funding for maternity services provided by midwives. Until midwives and doctors are able to achieve parity, equal pay for equal work; and until women are able to choose without financial or professional restriction a midwife to provide the basic maternity care, or primary care, the medical monopoly of public funding for maternity care will continue unchecked. And until the medical monopoly of public funding for maternity care is disbanded, the medicalisation of the pregnancy-birthing continuum for mothers and their babies will also continue unchecked.

As I read through 'In Safe Hands', I was pleased to see that Dr Tippett acknowledged "Doctors don't own the women, midwives don't own the women" - TRUE. However, the statement goes on " ... We have a responsibility to look not at what we want but at what's best for the mothers we look after." That where the arguments lost me. Who decides what's best for mothers? From the context, it appears that 'we' (the professionals) do.

Evidence based practice, as defined by statistics derived from randomised controlled clinical trials, has been for many years held up as the gold standard for all areas of health care. The whole evidence movement grew up from the work of an obstetrician, Archie Cochrane, who argued that much of what is done in maternity care had little evidence to support it, other than the lowest level which is opinion. The Cochrane Library has, for years, consistently supported midwife-led care as being safe and effective. A recently published review has added to the evidence, confirming that Midwife-led care confers benefits for pregnant women and their babies and is recommended. Surely, if 'we' (the maternity professionals) were committed to "what's best for the mothers we look after" we would have implemented midwife led care as an easy option for any woman to choose. But those who have actually tried to access midwife led care in any of its many forms and dilutions, will tell you that they are easily transferred out of the birth centre and passed on to a new midwife; that the 'Know your midwife' program was full; that noone told them about the midwife led option at the local hospital until it was too late; that they were directed down the private obstetrics pathway and midwife led care was not an option; and so on. Those who are well informed and understand the evidence of "what's best ..." will sometimes choose to give birth at home because that's the only option for such care.

Dr Tippett takes the opportunity to make some very damning statements about "midwives who practise in isolation without the involvement of other medical staff"
Midwives who, supposedly, don't understand collaboration, yet when a complication arises "the woman is often brought to the hospital to be treated by doctors she has never met ..." Excuse me! Isn't that what a medical specialist does? Isn't that what happens when complications arise with any other part of our bodies? Are we supposed to stay in touch with a brain surgeon in case our brains need operating on?

Dr Tippett goes on to explain that midwives committed to a home-birth model "do things in a homebirth setting that no maternity service around the developed world would think is a good idea", and are "engaged in dangerous practice." No mention is made of the women having any say in the choice to give birth at home after a caesarean, or of the very occasional plan a woman may make to give birth to twins at home.

I am one of those apparently reckless midwives who will plan homebirth after a previous birth by caesarean. This is not a simple choice. It is also not my choice. I am not giving birth. The one item that I can offer is continuous basic midwifery care through pregnancy, birth, and the early parenting continuum. That is the most evidence based option in maternity care.

If a woman has had a previous birth by caesarean, and chooses to work in harmony with her body's natural process in giving birth, there are several hurdles that apply to all normal birth. Spontaneous onset of labour at Term. Establishing strong labour without relying on uterine stimulants or pain killing drugs. Progressing within a reasonable time, and giving birth to a healthy baby under her own power. Completing the third stage (expelling the placenta) without excessive blood loss. This is the way to safe vbac - regardless of the place of birth. If complications arise at any point in the process, that's the time to collaborate, and have a discussion with a medical/obstetric team as to the best way to progress. These decisions can only be made in real time. It is not possible to make informed decisions until the decision point is reached.

After an article which completely avoided any understanding of the mother as having an interest in the decision making, it was heartening to read Monica Dux's opinion piece. The mother's role as the writer experienced is summed up in the statement "Despite all the rhetoric about the importance of consent and respecting the patient's wishes, my experience of giving birth in a big hospital is that women are encouraged to take a passive role, to defer to their doctor's opinion and to the institutional imperatives. If you argue, you are often told,'that's just the way we do things'." There is bluntly honest truth in this article. However there is also a complete absence of the midwife.

My conclusion is that Monica Dux has experienced birth as many do in Melbourne and other Australian cities today. She may have been aware of someone on the hospital staff who had the title 'midwife', but she never experienced the true role of midwife: with woman. She proceeded through her experience of birth alone, an individual who had to negotiate a system that cared little about her as an individual.

It is my hope that as the federal government's Maternity Services Review progresses, and as reforms are introduced, the number of women who experience birth without authentic midwifery will be quickly minimised.

IN SAFE HANDS?

With reference to the article “In Safe Hands’ in the Sunday Age.

I think Christine Tippett is actually giving a hint as to how RANZCOG is lobbying the federal government with reference to the Maternity Services Review. It’s OK to extend the ‘allowed’ practice of midwives in hospitals where we can keep an eye on them, BUT we can’t allow those maverick independents any freedom.
It’s the old strategy, divide and conquer. Divide the midwifery profession into the acceptable and the unacceptable …

The Victorian branch of RANZCOG (or was it RACOG then?) did the same thing in 1993 when the new Nurses Act was brought in. An 11th hour fax (everyone didn’t have email then) to the health minister claiming that it would be unsafe to remove the regulations (which required a doctor to supervise a midwife’s practice, amongst other items) resulted in the retention of the regulations until they sunsetted in 1996. Although the regulations have been dead and gone for more than a decade, many midwives in Victorian hospitals are still working under protocols that assume the historical restrictions that existed under the regulations.

I think the midwifery profession as a whole needs to strenuously object to the statement by Dr Tippett that “It’s important that there’s not federal funding for people who are engaged in dangerous practice”, in the context of the claim that some independent midwives attend vbac and twin births at home.

Our laws provide a means of regulating midwifery practice, as well as obstetric, dentistry, or any of the other health professions. Midwifery is not regulated by the obstetric profession. If Dr Tippett has information that leads her to believe a registered midwife has “engaged in dangerous practice”, surely the right thing to do would be to notify the regulatory body of the matter, rather than using the public media to set up a scare campaign against independent midwives. As with any other profession, the regulatory process is a carefully managed and is accountable. It’s not perfect (imho), but it’s what we have, and even midwives have a right to expect fairness in law.

Please tell me if I'm being paranoid here. If not, would everyone who cares about protecting the right of midwives to practise midwifery in any setting, whether they are employed by a health care provider or by the woman, please take this matter seriously. When a person of Dr Tippett's profile is willing to make a statement about midwives engaging in dangerous practice, we must conclude that midwifery is under threat from RANZCOG. And it's not about the twin births or vbacs at home. The issue is who chooses what's best for women?

Sunday, November 23, 2008

Is childbirth education possible?

I used to call myself a childbirth educator. I used to teach classes for expectant parents whose minds were as thirsty for the words and concepts of childbirth as the desert sand is for rain. I used to use the doll and pelvis, and speak with authority on optimal fetal positioning. I knew that to stand in front of a room full of eager, intelligent women and their men was a rewarding, satisfying event. I had what they wanted - the knowledge of childbirth.

As time has passed I have become progressively less interested in trying to explain the secrets of birth in a didactic, classroom setting. In fact, I ask myself the question in the title of this blog, "Is childbirth education possible?" A short course in obstetrics, or even midwifery, does not educate anyone to be able to give birth.

Of course you can be educated about what happens as labour gets established; about the colour of the amniotic fluid and normal progress in labour. "We" (those in the know) can educate "them" (those anticipating childbirth), using language passed down over hundreds of years of our civilisation - many of the words being Latin. Those being educated quickly learn that the labia are the lips; the cervix is the neck; the liquor is fluid; rubra means red, and alba means white.

Some forms of childbirth education have moved away from the medical language and call the uterus the womb; contractions are surges; the ilium is the hip bone and the ischium is the sit bone.

When teaching childbirth classes in a hospital I had access to wonderfully coloured charts and educational aids. A class in the series was about the options for pain relief in labour. There was a plastic model of the spine, with each vertabral bone sticking out from the plane, and an illustration of where the long needle was placed so that an epidural or spinal anaesthetic could be injected. Another class included a tour of the labour ward. Fathers-to-be were particularly impressed with the machinery of birth: the machine that goes 'ping', the electronic fetal monitor, being able to attract a crowd of curious onlookers. Classes like this are going on in maternity hospitals every week. Education about obstetrics; orientation to the maternity facility; preparing people for what will be done when the time comes for their babies to be born: yes. But education for childbirth? Not really.

I have listened to education that focuses on emotions experienced in labour. Dads-to-be are exhorted to support and encourage their partner in practical ways. Mums-to-be are prepared for their crisis of confidence. Supporters are told that the (support) chain is only as strong as the weakest link. You must hold faith. You must believe.

When I was pregnant with my first child in 1973, I was impressed with the Lamaze childbirth education, and attended a series of classes. The French doctor Lamaze, who taught breathing techniques and psychoprophylaxis and talked about Pavlov's dogs and conditioned reflexes, had eclipsed his English colleague, Dr Grantly Dick-Read, who taught that pain in childbirth could be minimised when the labouring woman understood what was happening, and thereby approached birth without fear. Dick-Read is considered by many to be the father of the childbirth education movement. Today I encourage mothers to learn in a maieutic way, intuitively.

Today many classes are available, and I cannot make comments on individual styles of education for childbirth. My observation is that education is about head knowledge. It's about understanding the processes, rather than enabling the fulfilment. As I said, a short course in obstetrics, or even midwifery, does not educate anyone to be able to give birth.

Giving birth is not an act of a conscious mind. It is not something that we can plan or organise or control. Giving birth is the climax of an amazing process in which physical, emotional, and hormonal systems are orchestrated within the bodies of the mother and child. Giving birth requires the mother and all who are close to her to firstly learn to work in harmony with her body, then when the time comes to yield to her birthing power. That learning is done on the job. The mother must willingly engage with her labour, without any distraction, and learn intuitively what will assist and what will hinder her progress. She must choose to be strong; not expecting to share her job with anyone. Her support team or even her midwife cannot do this for her. It is internal learning, and knowing.

A young mother had been labouring through the day, and her labour became strong as the night progressed. From palpation I knew that her baby was a good size. I estimated that she should be coming up to full dilatation by about 1am, and I prepared myself for a birth at home. Baby's heart beat was consistently good.

By 3am I was wondering where the baby was. I checked internally and found that the cervix was probably fully dilated, but the head was high - well above the ischial spines. It had barely entered the birth canal.

By about 7am, after doing all we could to encourage progress, we agreed to transfer to hospital and get some help. However, the traffic in Melbourne at that time of day is heavy, so I suggested we wait a while.

By 8am a major change had occurred. The young mother had found the way! With new strength that she could not have known existed, she brought her baby through her birth canal, and on view. Each effort was amazingly effective.

How did she do it? Childbirth education classes had not taught what she needed to know that morning. She learnt from within herself, using the God-given intuitive knowledge that mothers have to enable normal childbirth. It wasn't the encouraging words of "You can do this", or any instruction from me or anyone else. A woman gave birth to her first child.

Our hearts were overflowing with thankfulness to the giver of life as we welcomed that beautiful child.

Tuesday, November 18, 2008

MATERNITY SERVICES IN VICTORIA, AND THE FEDERAL GOVERNMENT’S MATERNITY SERVICES REVIEW




The Review by federal Health Minister Nicola Roxon has attracted an unprecedented number of responses. Maternity services are important to our society!

Victorian government’s policy Future Directions for Victoria’s Maternity Services (2004) is the framework that will guide developments over the ensuing 5-10 years. The policy seeks to “work towards quality birthing services where providers have a multidisciplinary approach and where women are informed and have choices.”

The current mix of federal and state funding for maternity care restricts a woman’s access to care by a known midwife of her choice, and protects a monopoly of doctors as the only providers of maternity care. Birth is not an illness, yet public funding for maternity care, as well as private health insurance, fragment the care into medical items within schedules.

What is the state of maternity services in Victoria today?

1. Choice of midwife led primary care is available to some women – see Attachment 1 ‘Having a baby in Victoria’ below.

2. Detailed information on hospitals and number of births is available from Vic Perinatal Data Collection Unit (PDCU) perinatal.data@dhs.vic.gov.au

Attached copies from the PDCU 2007 report Hospital Profile of Maternal and Perinatal Data (attached to this blog as photographs - not particularly good quality, but I can't see how to link a scanned page to this blog!)

• P20 Onset of labour for women who gave birth 2006, with comparison of data for public hospital, private hospital, and homebirth
• P21 Epidural/spinal analgesia in labour primiparae and multiparae- comparison of data for public hospital, private hospital, and homebirth
• P22 Intrapartum analgesia
• P22 Type of birth
• P23 spontaneous vaginal births, forceps births, vacuum births - comparison of data for public hospital, private hospital, and homebirth
• P42-43 graphs of public and private data for maternal age group, maternal postnatal length of stay, type of labour, and type of birth

3. Care options are dictated by private health insurance – approx 36% of women in Victoria give birth in private hospitals
• Bookings at private hospitals are made through specialist obstetricians – (very few general practitioners)
• Outcomes for private hospital intervention rates are consistently higher than public hospitals, even though women with complex medical needs are often referred to public hospitals
• Midwives, who by definition have a duty of care to promote normal birth, are not able to be primary care providers for any women in private obstetric care. The midwives in these hospitals are subservient to the obstetricians in all care decisions.
Maternity Service Performance Indicators are published giving detailed data for public hospitals, and only aggregate data for private hospitals.

Attachment 1.
Source: Janie Nottingham - used with permission
‘Having a baby in Victoria’
In 2006, 68 547 women utilised birthing services in Victoria, in 2007 this has grown to 72 000.

64.1% of Victorian women utilised public maternity services

200 women gave birth at home by choice

The Victorian State Government issued a paper on maternity services reform, Future Directions. This document supports the establishment of primary midwifery models of care, with particular emphasis on ‘caseload models’. Caseload midwifery is where one midwife cares for one woman. The benefits and cost savings of caseload or 1-2-1 midwifery are well documented. The World Health Organisation considers this care the most appropriate for the 75-80% of women that experience normal, healthy pregnancies.

Despite the cost savings and benefits there are few public funded ‘caseload models’

Sunshine Hospital has recently established a caseload service for 1000 women

Geelong offers a service for 470 women per year. They are turning away up to 25 women per month who want to access the service.

Royal Women’s is currently conducting a trial caseload service for 1000 women. It is well known that trials in innovative maternity care (despite positive outcomes) rarely transform into established services.

Box Hill has a Know Your Midwife service. Ironically this service does not include care in labour (the most critical time to have a known carer)

Since 1997 37 rural based obstetric units have closed, with Daylesford planned to close later this year. Only one has re-opened (Seymour). Women and their families are forced to travel for basic healthcare. The financial and emotional costs to families are considerable. There is a wealth of evidence outlining the safety and improved health outcomes of local maternity care (particularly primary midwifery care)

Rosebud Hospital closed its maternity service in 2007. Officially this was due to a loss of Obstetric cover. This decision contradicts current evidence, Victorian policy (via Future Directions) that demonstrates the safety and success of primary midwifery units.
The Angliss suspended its caseload midwifery service despite stunning outcomes in 2004. Ironically just before the release of future directions
The midwifery workforce, Australia-wide is not used to its capacity. Midwives are educated and registered to provide the entire care to healthy women.

Data sourced from the perinatal data collection unit stats

Wednesday, November 12, 2008

Maternity organisations - members

A maternity organisation may have begun with a small number of members who all worked together towards an agreed end. These people met and talked and each one learned how they could contribute to the work. They saw the need to formalise their structure, so they obtained a model constitution, adapted it to their needs, and became incorporated. Money was needed, so a membership fee established. A treasurer was chosen, and bank account set up. The rules required certain other office bearers, and before long it was time for annual reports and financial audits and an annual general meeting.

The decision making process in a maternity organisation has usually been, in my experience, based on consensus. While everyone is working together, this style has worked well. Members of the organisation's executive are likely to reach agreement quickly, with minimal debate, on proposed actions. The person who proposes a course of action is often the one who takes leadership of that project on behalf of the organisation. There does not seem to be a need for a parliamentary style of motions being seconded, discussion, amendments, more discussion, and voting.

Is consensus decision-making any less robust or reliable than the parliamentary style? I asked this question years ago when I was a beginner in voluntary associations. I was told that the consensus style is more feminist, while parliamentary style is more male. Female processing makes a lot of sense for anything maternity! For the time being I accepted that explanation.

Today I would say that although I still support the consensus style, this should not be confused with complacency. I see every member of a committee as having responsibility for the actions of people on behalf of that committee or board or group. It is important that proposed actions be agreed upon, and the notes of the meeting record the fact. It's also important that someone follow through and report progress until the action is completed. It's all too easy to sit back and expect someone else to do the work. It's also dangerous if the group becomes a rubber stamp committee, when one person dominates the meeting, and everyone else agrees without using their own minds to question or engage in critical review. As the complexity and cost of projects increases, so does the expectation of transparency and accountability.

As more members are signed up into the maternity organisation, and more money is brought into the organisation's bank account, there is an increasing amount of work for someone acting on behalf of the committee to process and manage memberships. As a volunteer organisation, the committee depends on volunteers whose skill or commitment may be more or less competent or available at particular times, for all sorts of reasons. A reliable process of managing membership subscriptions, so that membership lists are kept up to date, and financial accounting can be correct, becomes essential. It becomes increasingly expensive if paid professional services are engaged to do the work. Yet a point will be reached where the volume of work and the skill required exceeds that which can be reasonably expected of a volunteer.

Maternity organisations will always need volunteers who are elected by members to manage the work of the organisation. As the organisation grows, prudent planning by its office bearers can ensure succession planning for the various positions. An organisation that has annual elections for all office bearers is put at risk of losing corporate knowledge if there is a large turnover. The rules can be changed to protect the organisation from this, by having, for instance, three-year terms of office, and a requirement for only one-third of the office bearers' positions to be voted on each year. However the advantage of having one-year terms is that office bearers who are not performing well can potentially be voted out sooner rather than later.

Tuesday, November 11, 2008

Leadership styles

The style adopted by the leaders within an organisation can either support or inhibit the work. Organisations with a maternity focus draw most of their committee and members from the people most interested in maternity issues: mothers and midwives. Some volunteers come into both categories. Occasionally a person whose 'tag' is father, or granny, or something else, will put up their hand to work to achieve the purposes of the association.

The hormonally-driven behaviours common to mothering across many animal species encourage a mother to protect her own young. The bonding between a mother and her infant, resulting in focused attention of that mother to that baby without limit, is a natural phenomenon that no modern technology or systems can replace. Midwives encourage new mothers to listen to the intuitive promptings within their relationsips with their babies.

Mothers of babies and young children are unlikely to be able to devote vast periods of time to voluntary work. Most volunteer mothers and midwives have complex sets of commitments to their families, their paid jobs, and their personal interests. Most volunteer mothers find time when their children are asleep to go to their computers, read messages, write replies, make phone calls, and do the work they have committed themselves to.

A leader who encourages others to engage in the work they have committed to, and to give their best to the work is at the same time supporting the newer volunteers to improve their capacity in that work. A leader who undermines the work of a volunteer, or who takes a strongly authoritarian position (sometimes called micro management), will find a diminishing supply of voluntary workers.

A leader who recognises potential in a person who is showing some interest in the work, and who mentors and guides by example, will find others who take up the challenge of the work, and who develop new skills and new confidence over time.

I have found that there is usually far more work that could be possibly done within a voluntary association, than capacity within the people who are active at any time. We always face limitations, both personal and financial. Each group needs to prioritise, and the activities planned will usually be those that match the interests and abilities of the committee at the time. A leader or president who lacks trust in others' ability to act on behalf of the organisation is in fact limiting the work of the organisation to what she or he can perform. That leader can only continue if the committee is willing to 'rubber stamp' any plan suggested by their president. A leader who facilitates and enables others to take responsibile action multiplies the potential output of the group.

There is no place for carelessness in a voluntary association. There is no place for "I'm just a volunteer". An action that is agreed upon should be carried out to the best of the ability of the person who agrees to do it. All who take on roles in the organisation are expected to be accountable, and to act in the interests of the group.

In considering leadership style I recognise that I am seeing the issues from a midwife's perspective, not that of a business person. A midwife develops a relationship with each woman, and learns to work in harmony with the woman's own strengths and weaknesses to promote natural physiological processes. A business executive, on the other hand, has definite expectations of performance and outcomes.

An organisation that seeks to improve the maternity experience in some way for mothers and babies, or for families, does well to model itself on the mother-midwife partnership in promoting normal birth. I would encourage all who commit to such work to truly value each other, in whatever capacity you and other committee members are able to work. There are practical ways that each person can contribute to achieving an organisation's purposes and goals.

Thoughts about maternity organisations

Today I am beginning a new theme, maternity organisations, which I plan to write about over the coming weeks. I hope that these thoughts will be productive, in supporting those who generously volunteer their time, skill, and energy to improving maternity care for all women in a society. I am writing about issues, not individual people. If any reader wishes to suggest an issue or topic, for my comment, or to make a guest comment on this blog, please contact me.

Voluntary associations require a set of rules and a committee to manage the affairs. The rules are the constitution, and if an organisation has become incorporated in law, the rules and an annual statement are lodged with a statutory body, such as (in Victoria) the Office of Fair Trading and Business Affairs at the Department of Justice.

Anyone who is interested in understanding how organisations work can check websites such as Our Community, or read well respected text books such as N E Renton, Guide for Meetings and Organisations, volumes 1 and 2.


THE TATE FAMILY

The TATE family are members of our Club.
First of all, there is DICK TATE, who wants to run every activity.
Then there are his two brothers - RO TATE, who tries to change everything, and POTEN TATE, who wants to be the big shot.
Their sister, AGI TATE, likes to stir up trouble and her cousin IRA TATE, often helps her. Another cousin, IMI TATE, wants the Club to mimic everybody else.
The parents, HESI TATE and VEGE TATE, pour cold water on all proposals put forward by the committee.
The annual meeting always groans when another relative, DEVAS TATE, stands up to speak. But FACILI TATE often moves constructive amendments.
The most delightful member of this large family is FELICI TATE, while old ES TATE is always welcome for is generous donations to Club funds.
(Source: Renton, 6th edition (1994), Volume 1, page 306)

Monday, November 03, 2008

Normal Birth: the baby

What is normal for a baby?
What conditions are optimal for a newborn child as the transition from life in the womb to life out here takes place?
What does a baby expect, in a normal physiological sense, in those moments after birth?

Recently I watched a wildlife documentary from Africa, following the annual migration of wildebeest. As the birth of a wildebeest calf was documented, the point was made that the cow and calf needed to forge immediate bonds essential for survival of the young. Senses of smell, taste, and hearing become central in the attachment between mother and child.

I believe the human mother/infant bonding process is no less dependent upon these normal, physiological factors. I believe our 'advanced', medicalised birthing rituals have become so accepted that we as a society have all but forgotten the importance of natural, normal forces that are keys to normal birthing. Our babies deserve the best start that we can provide for them. That best start is, without a doubt, being born strong and energetic, free of mind-altering drugs, and being taken by the mother to her breast with no unwarranted interference from other people.

During pregnancy a baby gets to know one person - her or his mother. The way that woman moves and breathes and talks and reacts: this is all home ground for that developing fetus. After birth the baby is absolutely at home in the arms of the woman who has carried him or her through the past nine months. Her voice is familiar; her laugh brings a memory of the laugh inside that warm safe place, when the little one learnt that with the laugh, or the embrace of the loved one, comes a surge of good hormones.

Not only does the baby recognise her mother's movements and sounds; she is also prepared for the microbiological world of her own mother. Her blood stream is already primed with antibodies to any organisms that the mother's immune system has encountered. As the newborn child is held naked against her mother's naked breast; as the mother whispers words of welcome and kisses the little nose, the baby's skin, digestive and respiratory systems are quickly populated with the normal bacterial flora from the mother and her home.


As a mother enters the most demanding stage of normal labour, as she experiences that altered state of consciousness, she may feel extremely weary. A thought flashes through her mind "how much longer can I keep going?"

Then, with the birth of the baby, the tiredness leaves her. A surge of adrenaline and other stress hormones passes through her, and her baby, supporting the birthing effort. The baby's body is physiologically primed to respond, and make the amazing adjustments that are essential in normal birth. There are several simultaneous events: the cooling of the air on his face; the change from a warm, dark, uniformly fluid filled environment to the air, light, and sound of our world. As the baby's chest moves out of the birth canal, his arms passively move away from his body, free from the previous constraints. That physical action draws air into the lungs, and together with the other complex changes initiates normal breathing. Changes in blood flow from the heart to the lungs happens simultaneously, quickly reducing the blood flow to the placenta, as the newly opened lungs take over the job of providing essential oxygen. Baby's eyes are open; pupils dilated; all senses fully primed. Smell, sight, hearing, touch, taste - and the baby's mind is recording and processing every sensation.

This is a mere thumbnail sketch of the amazing transition that happens every time a baby is born in harmony with the natural birthing processes.

Saturday, November 01, 2008

normal birth

In this video I summarise the 'bare necessities' of normal birth.
If you would like a .pdf file to print out a page on this discussion, please contact me via the comments section, or by email joy@aitex.com.au
The video is very brief - it takes about a minute.

video

Thursday, October 30, 2008

NORMAL BIRTH: The bare necessities

Understanding that physiologically normal birth is a quintessential female act
• only women can give birth
• other people can greatly influence a woman’s ability to work in harmony with her natural processes.
Each woman chooses her professional care provider(s), as well as her own trusted team, which may include
• Partner
• Family members
• Friends
• Other supporters such as lay birth helper (doula)

Recognising the importance in physiologically normal birth that a mother is able to
• feel safe, personally respected, in a personal, intimate space
• be flexible – the mother can change what she wants/ doesn’t want
• move out of her thinking mind, and work in harmony with her intuitive brain
A mother who is able to take control of her environment, the space in which she labours, or the amount of light in the room, or personal touches such as her own music, or essential oils, can minimise feelings of alienation in labour, and enable her body to work effectively.

Minimising sensory stimulation in labour protects normal birth. Interference from anxiety, fear, higher brain activity, such as thinking about
• time between contractions,
• amount of dilatation, and other calculations that are in fact indicators of progress, which may inhibit normal birth
A woman may also be inhibited by the feeling of being observed, through photography, or strangers entering her labouring/birthing space. Any sensory stimulation may be unwelcome, and many mothers ask midwives to please refrain from using perfumes when attending births.

Being well. Healthy women usually give birth to healthy babies. Healthy diet, exercise, no exposure to smoking or other harmful substances in the environment, good social/emotional support in pregnancy and after the birth, access to professional care (eg dentist, physiotherapist, GP) as needed support wellness in pregnancy and birthing.

Knowing and trusting the midwife who can act with authority and take professional responsibility for primary maternity care. Being attended by a known midwife helps a woman to
• understand choices and make informed decisions
• have confidence in the knowledge base of her care provider
• be realistic about expectations


If a decision is made to accept medical intervention, the change of plan is made from the physiologically normal birth, to the best birth that can be achieved with the collaborative efforts of the maternity care providers in that situation.

Copyright: Joy Johnston 2008
[If you would like a .pdf of this document, to use as a handout without charge, please contact me joy@aitex.com.au)

Sunday, October 26, 2008

MIDWIFE Wordle




This word cloud was made by posting the url to this blog at the Wordle site.

Wordle - Beautiful Word Clouds

Wordle - Beautiful Word Clouds

Friday, October 24, 2008

normal breastfeeding

Recently I received an email message from someone named Nimal, who I do not know, in Sri Lanka, saying

"I was quite impressed by your website in which you talk to many mothers and mothers-to-be with your in depth experience. I feel a website like this helps many mothers who are looking forward to be mothers and those who are already mothers. I found there are so many useful articles in your website.
I feel you could add another valuable article to your website, thats about the crucial importance of breast feeding, the length of it etc etc."

Thankyou, Nimal, for this invitation to write more about breastfeeding.

Briefly, one cannot promote physiologically normal birth without also promoting physiologically normal nourishment and nurture of the newborn child. Breastfeeding is part of that natural continuum. In fact, if the woman is privileged to experience minimal disturbance in the crucial moments around the time of birth, it is unlikely that the midwife in attendance will need to do anything about breastfeeding. The mother and baby proceed on the intuitive journey, in skin to skin contact, making eye contact, and soon the baby searches for the breast.

Once the baby knows that food is found at the breast, and the mother has mastered a few basic skills such as holding the baby in a relaxed way, lovingly molding baby's body to her own, with baby's chest agaist her chest, baby's chin against her breast, baby's head slightly tilted back ... breastfeeding happens whenever baby is hungry or just needs mummy's special comfort*.

How long should this continue before weaning begins? That's easy. As long as it takes.

By this I mean, until baby starts putting pieces of suitable food into his or her own mouth, and tells mummy it's time to give me more than the breast milk. This is usually around 6 months of age. There should be no dairy or soy artificial alternatives to mother's own milk, except in situations so dire that an inferior substitute is truly all that's available.

This discussion leads me to an obvious line of comment: what about the mother and baby who do not experience physiologically normal birth and initiation of breastfeeding?

I have often used the principles of the breastcrawl for babies who have spent time away from their mothers, or whose experiences at learning to breastfeed have been less than satisfactory. Babies have an amazing capacity to learn, and it seems that the triggering of that instinctive ability to seek the breast and obtain mummy's milk is not well understood.

* The asterisk is on comfort. Breastfeeding is the essence of comfort, for both the mother and baby. Too often, in Melbourne the city where I live, where babies can be seen as accessories for the woman who has everything, the phrase 'comfort sucking' is used, usually in a negative way. What a shame!

Friday, October 17, 2008

Preventing and treating post partum haemorrhage

Since attending a study day last week, I have been reflecting on the way midwives and obstetricians 'manage' the third stage of labour, and the effect this has on the amount of blood loss a woman experiences.

Karen Moffatt, a senior midwife at the Women's, illustrated the unreliable nature of the estimates of blood loss recorded after birth. The test is to ask midwives, doctors, and students, to record their estimates after looking at fake blood that is poured and spread over sheets and pads, in a way that is meant to approximate what we see as we clean up after a birth. The results of these tests are usually that we are more correct on smaller amounts, such as 100-300 ml, and seriously less correct on the larger amounts, such as 1000ml. My guesses were, too. I underestimated the larger amount.

Blood loss in excess of 500 ml is recorded as a post partum haemorrhage. But if we are mis-recording the amounts, it's difficult to make any conclusions from what we record.

I would like to ask any blog readers who are interested in this topic to tell me what you think of it.

At the study day the presenters were unequivocal - they require midwives in the hospital to practise active management of third stage because it's supported by the evidence. The International Confederation of Midwives and FIGO, the international peak body for obstetricians, have written a joint statement, requiring all skilled birth attendants to carry out active management of third stage of labour.

Independent midwives attending homebirth in Australia carry the oxytocic drugs (Trade names Syntocinon and Syntometrine), and would usually use them as treatment rather than prophyllaxis. This means taking a 'wait and see' attitude, or as Michel Odent says, "don't manage the third stage".

I do not want to argue against the evidence, which applies to most women in hospital settings. But I do want to argue that women who are giving birth to the baby safely under optimal physiological conditions are more likely to ALSO safely complete the process by expelling their placentas without excessive blood loss and potential morbidity.

What are the optimal physiological conditions I speak of? This will be slightly different for each woman, because it will be her own space. The same undisturbed space in which she entered the deepest and most demanding stage of her labour. The personal, quiet space. There can be many 'non-medical' disturbances and disruptions, some of which are inadvertently brought on by the mother herself or her midwife. Photography, family congratulations, phones, showing the baby to the children - these are often enough to take the mother out of her birthing space, and interrupt the intense hormonal and physical process of receiving and bonding with a newborn baby.

Since establishing my private practice about 15 years ago, I have needed to learn from women how to work in harmony with the wonderful natural processes in birth. I did not know about physiologically normal third stage. I knew how to administer oxytocic, how to apply controlled cord traction, and how to record blood loss.

In my early years as a homebirth midwife I experienced one serious post partum haemorrhage, and transferred that mother to hospital for a manual removal of the placenta. It was a horrible experience for the mother, the father, the second midwife, and for me.

The promotion of normal birth includes protecting women from excessive blood loss. That's obvious. I am concerned, and have therefore written this blog, because the way to achieve the protection from excessive blood loss for well women seems to be so very different from the way it's done in mainstream maternity services. I look forward to hearing from anyone who has wisdom on this matter.

Joy

Sunday, October 12, 2008

A new law

This past week has seen the passage of a new law through the Victorian parliament - the Abortion Law Reform Bill 2008. In responding to this new law, I hope to present a brief summary of how I believe the decision to terminate the life of an unborn child impacts of our lives, and on our society. I do believe there is another higher law, that of God the creator and sustainer of life, to which we are all answerable. This principle is often referred to as the sanctity of human life.

Abortion has been available through medical referral in Victoria for the past 40 years or so. The 'new' law takes abortion out of the criminal code.

Most terminations of pregnancy are carried out prior to 22 weeks' gestation, and are performed on the grounds that the mother's physical or mental health would be compromised by continuing the pregnancy.

A case that received a great deal of publicity in 2000 and subsequently, when a group of doctors at a Melbourne public hospital performed a termination of pregnancy at 31 weeks for a baby with dwarfism has been, I believe, a driver for the new legislation. This case is discussed in a 2004 MJA article, Abortion: time to clarify Australia's confusing laws.


My purpose in writing this blog is to state that I am shocked and disturbed by our society's huge reliance on abortion. The rate quoted in the abovementioned article is "more than one for every three livebirths. Less than 2% of these abortions are for fetal abnormality." Most of the terminations of pregnancy are for social reasons.

In the 40-year period since abortion became not only legal but more commonplace, there has been a parallel loss of ability with normal birth. Women choose regional anaesthesia, taking away their ability to feel the passage of the baby through their highly sensitive birth canals. Women are ending up on the operating table for caesarean surgery at an alarming rate. The highest rates of interventions in birth occur not among the unhealthy, low socio-economic groups, but among healthy, well educated women with private health insurance, booked at private maternity hospitals.

Why is this so?

In recent generations women have been told we have an absolute right of control over our bodies, and the baby we carry. Modern technology has 'forced' us to make decisions about prenatal screening, and sometimes to consider terminating the pregnancy. We move quickly along the production line, with an early pregnancy blood test and ultrasound, giving risk ratios that predict the likelihood of Down Syndrome. If the risk is considered too high, we have to decide whether or not to have an amniocentesis. Then at 18 weeks or so we have the 'anomaly' ultrasound scan, checking all the organs and measuring the parts. Another decision point has been reached. Some women are shocked at this time to be told of 'ecogenic foci' or 'soft markers' for Down Syndrome. Words that they have never before encountered suddenly become a cruel refrain that plays over and over in their minds. "Is my baby alright?" Yet this deeply distressing decision process accounts for only a tiny minority of abortions. Most abortions are for babies who are conceived at a time that is inconvenient in the mother's life.

Our bodies are wonderfully made. The ability to conceive and give birth to our children is among the most life-affirming, intimate acts that we will experience. But something so precious is also very easily damaged.

One of the reasons some women are unable to tolerate the pain of even normal birth is the memory of previous sexual or reproductive experiences. This memory is deeply stored, and may even be hidden for many years. When labour is progressing the memory surfaces, and may overwhelm the mother, adding to her pain and distress.

I believe the progressive increase in surgical births - an indicator of women's inability to give birth safely under natural processes - is strongly linked to our society's teaching that women can terminate pregnancies that they don't want.

Although I believe there is a greater principle of sanctity of human life, I do believe the laws of the land need to be carefully written to provide for legal abortion. Even with the new law, abortion carries definite physical risks to the mother; infection and haemorrhage being the main ones. The alternative of backyard, septic abortions, is too terrible to allow.

When I have the opportunity to counsel a woman about prenatal screening, or about the possible detection of abnormalities in their babies, I try to encourage them to face the situation carefully and honestly. We cannot guarantee a 'normal' or 'healthy' child - whatever those words may mean. Life is not about perfection. A child is not a commodity - an accessory for the girl who has everything. Some of the most tragic disabilities that parents face as their children grow are conditions that cannot be detected prenatally.

Friday, October 10, 2008

When the penny drops


It was good to spend two days with other midwives this week, in a conference on 'emerging issues in pregnancy, birth and postnatal care' at the new Women's hospital There were many interesting presentations by midwives who are involved in research on topics including estimating the volume of blood loss at a particular time; urinary incontinence experienced by women who are pregnant with their first child; an audit of treatment of newborn babies with antibiotics; expressing breast milk; and 'New look' postnatal care in Barwon Health, where well women with healthy babies are 'cared for' in a way that is radically different from standard medically based postnatal care.

An outstanding presentation, in my opinion, was given by several midwives who are providing one-to-one primary care through the Cosmos Trial. These midwives told about the changes they have experienced since managing their own caseloads. They expressed pride, and satisfaction, and told of the positive responses of women who are enlisted in the trial, and who have been allocated to receive the 'intervention' - a known midwife.

It is interesting to note that a new Cochrane Review of Midwife-led versus other models of care for childbearing women has been released. This review recommends that "all women should be offered midwife-led models of care" - that is, primary maternity care by a known midwife who is committed to attending that woman as the responsible professional in pregnancy, labour and birth, and through the postnatal care. This is what the caseload midwives at the Women's, and at Sunshine, Geelong, and other places are offering. It's also what independent midwives do.

It is quite thrilling to me to see this 'evidence based' model of midwifery care being implemented and researched in the major, mainstream maternity services. The midwives who have stepped out of their previous shift work, hospital nurse mode, and embraced the full midwife identity are excited about what they are doing. That's what I mean by 'when the penny drops'. Midwifery becomes so much more meaningful. We ARE 'with woman'. It's real.

Some readers of this blog may remember how, several years ago, there was strong consumer outcry objecting to the closure of the Family Birth Centre at the Women's. Many women have used Birth Centres over the past 30 years. My fourth child, Josh, was born at the Women's Birth Centre.

The hospital is seeking now to enable normal birthing for any woman in its care; that the focus be on the woman rather than the facility. Having heard the presentations by the caseload midwives, I believe this is now beginning to happen.

Saturday, October 04, 2008

Thinking about choice

The maternity reform movement has for many years now used 'choice' as a key demand. Women want choice. My body, my baby, my choice!

Today, I encourage women to avoid what I call the supermarket attitude to choice in maternity care: "I want that, and I don't want that, and I'll have a pink one of that, and two of that ..." Choice is still a key demand, but it's a limited choice.

There is really only one choice at any time in maternity care: either you do it yourself, or you ask someone else to do it for you. While you can proceed under natural, intuitive processes, you are free to decline all other offers of help if you so choose. However, once you choose an unnatural pathway, whether it's speeding up the labour, or taking away the pain, or surgical birth, you relinquish your right to choice. How strange it would be if you were asked would you prefer a 14 or 16 gauge cannula in your vein! Or into which intervertebral space would you like the epidural anaesthetic to be administered?

The midwife's commitment is to work in a way the promotes normal birth. The partnership between a woman and her midwife supports the woman who chooses to work in harmony with her natural processes.

About seven years ago I worked with a group of committed consumers and midwives in Maternity to produce and publish the National Materntiy Action Plan (2002) which included the key demand that women have the right to choose a midwife as their leading or primary materntiy carer.

"The National Maternity Action Plan is a blueprint for reform of Australia's maternity services.
It has been put together by pregnant women and mothers who are committed to seeing women have the choice of a known midwife to care for them throughout pregnancy, birth and the first few weeks after the birth.
The right to choose a midwife as her lead carer is available to women in many other OECD countries, but not to women in Australia. It is based on scientific evidence that shows women and babies have very good outcomes from midwife-led care. The National Maternity Action Plan explains why reform of our maternity services is needed and how women and babies will benefit.
It calls on governments to respond as a matter of priority."

It is encouraging to note that the current national Review of Maternity Services quotes the National Maternity Action Plan in the call for "urgent reform to promote access to community midwives, including funding, legislation, standards of care, and indemnity arrangements." (from the Introduction)

I am thinking about choice, as it applies to maternity care today.

In the early 1970s I was amongst the outspoken young women who demanded that our husbands be allowed into the birth room. As a recently graduated midwife, and obviously pregnant, I proudly and somewhat naiively told the hospital matron about my choice. She looked icily at me as she said "Mark my words, Sister, there can only be trouble from that. Men don't belong in the delivery room." I quickly dismissed her warning - how could she understand my choice?

In the '80s the wonder of ultrasound became available, and I and many others presented in early pregnancy, holding on to a full bladder, and took home the grey polaroid image of a fetus. My choice, no questions asked.

In the early 90s there was a government report in the UK which identified 'choice, continuity and control' as what women want. At that time I was beginning to identify strongly with the birth reform movement, and I embraced those demands. Anything about midwifery in the UK, where midwives could be real midwives, had to be so much better than what we have. I bowed uncritically to a higher authority, and went about integrating the notion of 'choice' for women into my midwifery identity.

By the early years of this century, with the State and National caesarean birth rates rising by about 2% each year, word got out that women were increasingly choosing caesarean. These were said to be sensible, organised women, who wanted to be able to schedule the birth of a child into the other important matters of their lives, like work and maternity leave. These included women who were averse to the unpredictable nature of natural childbirth; who wanted to keep their "honeymoon vagina" and were "too posh to push". Their choice. And they found doctors who would respect their choice without question.


I do not want to suggest that choice should not continue to be a key demand of the birth reform movement. Yet when the 'choice' for costly and possibly harmful interventions into birthing is made for no reason other than preference, I object. I do not think it is reasonable for hospitals, doctors, and all the other staff to be distracted from their ongoing professionally valid work in order to provide a consumer items and interventions at public expense, unless those interventions are likely to improve the outcomes for the mother or her child. The items to which I refer come from a long list, including induction of labour, continuous electronic fetal monitoring, narcotic pain killers and epidural anaesthesia, and caesarean surgery.

A mother who was particularly anxious about her healthy newborn baby is not able to 'choose' to place the child in a high dependency special care nursery. That would be ridiculous. The mother does need help to develop skills and confidence in caring for the newborn, and that support can be provided by a midwife or sister or friend. Yet the 'choice' of epidural or caesarean on demand is not dissimilar. With good support that mother can learn how to work with her labour, and make truly informed decisions as the labour progresses. Having an epidural or a caesarean is not a failure, or in any way wrong in itself, when the decision is made carefully. But a system that allows women to choose such major and potentially harmful options, without first exploring less harmful alternatives, is failing in its duty of care to the woman and her child.

Someone might say that they are choosing carefully, and they choose an elective caesarean. At present that's not difficult to do, particularly in the private maternity system. The same public funding is applied through hospital funding arrangements, and Medicare, and the Medicare Safety Net, and the Private Health Insurance tax incentives, as would apply for caesarean surgery on medical grounds. That is, in my opinion, an abuse of public funding.

Midwives have choice too. We can choose to get alongside women, establish partnerships based on trust, and organise ourselves so that our services are available and we minimise the risk of burnout. Or we can choose to be obstetric technicians, managing the monitoring and surveillance of women in birth, and making sure that the paperwork is up to date.

I don't think many midwives can, in the present maternity terrain, choose to be self employed. The stresses of irregular bookings, and unreliable income, and unpredictable work hours are too much for many to take on. But changes are occurring throughout the public hospital materntiy system, particularly in places like Sunshine, Geelong, Casey, and the COSMOS trial at the Women's. I am watching these places, and others, with keen interest.

Thursday, September 25, 2008

Understanding pain

There is something unimaginable about the pain that another person experiences. It's never easy to witness. My response is to want to do something that will end the pain.

But surely, I am a midwife, I should be used to the intense pain of labour. I tell women to work with their pain; to accept and use it. I know both the mental haze of narcotic drugs, and the total differentness and mental alertness of spontaneous unmedicated birth for myself, and for many of the women I have been with, and the latter is the winner without a doubt. I haven't personally experienced the numbness of regional anaesthesia (such as epidurals and spinals), but I cannot imagine anyone would choose that over the physical achievement and mental exhilaration of normal birth.

Yesterday I was at the home of a mother who was looking forward to the birth of her second child. She was strong and well, and had prepared beautifully, and was now in labour. Her husband gave unconditional personal support, and her sisters and whole family all had their support roles. The bedroom was quiet and almost dark; she spent time on the exercise ball, and resting as the hours lengthened. The birth pool was set up in the bathroom, and soft candle light made the space all the more special as an intimate place to welcome the precious newcomer. Labour had begun in the morning - a lovely clear sunny day in Melbourne. As the afternoon sun set, and the sounds of labour became more regular and stronger, I expected that undefinable change to occur, as a woman surrenders to the enormous power within her body, and her baby is brought forth.

But that didn't happen. The sounds became more distressed. We waited. I withdrew for a while, not wanting the mother to feel pressured. She told me today she wondered if I didn't believe she was really in a lot of pain. I did, and I was concerned about what I was hearing and feeling. I was intuitively sensing what we refer to as 'failure to progress', although intellectually that didn't make sense. It doesn't usually happen with a second labour, when the first baby was born at term, vaginally.

The minutes passed into hours, and the mother became more tired, and vomited. I checked internally for progress. Cervix about 5cm dilated; bulging forewaters; and a very high head that could be easily pushed away. I was careful not to rupture the membranes. The only advice I could give was that we should go to hospital. I hoped we would see progress of this baby, and my intuition would be proved wrong.

It was about six hours later that this family welcomed their new baby, with the help of the midwifery and obstetrics and anaesthetics and paediatric teams at the Women's. The hoped-for progress did not eventuate, and gradually the little one became more distressed. A caesarean birth was the best birth possible, and I was grateful.

I called this post 'Understanding pain'. My understanding of pain in labour includes the belief that there is a pain that is OK, and there is another pain that is intolerable. The distinction between the two is not easy to make, either by the labouring woman or by others. I think a midwife develops an intuition, but I am always ready to question my intuition. The labouring woman is the only person who can say, "this is OK" or "this is not OK". Many women have said, in effect, "this is not OK", in transition, and then gone through the paroxysm of pain, into the wonder of new life and love. But when "this is not OK" continues, without relief, the message is a different one.

By reflecting on an experience such as this one, I am reminded that I must hear what the woman is telling me, whether it fits with my perceived knowledge base or not. I must approach the decision points carefully, with clear thinking and without fear.