Saturday, June 14, 2008

Fair go!

I met with Jackie, who is having her first baby in a few weeks’ time, and she expressed frustration and dismay. How is it, she asked, that noone had told her she could have a midwife working solely with her when her time to give birth comes? All these months, visiting the obstetrician, booking in at the hospital, and going to the hospital for prenatal classes, and the idea was not once discussed. Last week she was told that the hospital midwives would come and go when she was in labour – their shifts might change, and they would have to help out the other midwives in the birthing suite. Fair enough, she said, but what about me? Then she talked to Margie, the midwife who works for her obstetrician, who suggested she find an independent midwife.

The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services. A caesarean rate of over 30% is unreasonable (see blog entry Sunday, May 18, 2008 IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS? for discussion). Caesareans that are performed without a valid reason, or because the service has failed to provide appropriate care, leave too many mothers and babies distressed and separated at a time when they need to establish strong attachments; placing many mothers and babies at higher risk of serious illness or death than they would have had in giving birth naturally; increasing the pain and depression experienced by mothers postnatally and restricting their ability to move. It wastes precious resources in hospitals – resources of staff and facilities that should be available for those who truly need specialist doctors and surgery.

During the past couple of decades I have worked hard to address the inequities in maternity care. I am seeing some progress – ever so slowly. Perhaps a reasonable benchmark for progress would be when every pregnant woman, regardless of risk status or wealth or expected place of birth, is given the opportunity to choose a midwife who will be with her as the primary maternity caregiver. After all, a midwife is with virtually every woman giving birth: why should the system not cater for the woman who wants to know that midwife?

In the late 1990s I was working part time for the Victorian branch of the Australian College of Midwives, and we encouraged midwives to be active in lobbying the Nurses Board for a Code of Practice for midwives, which was introduced in 1996 with the sunsetting of the Midwives Regulations. That Code acknowledged the International Confederation of Midwives’ Definition of the midwife for the first time in this State, a definition that clearly declared the professional scope of practice of the midwife, working in partnership with the woman, providing woman centred care, collaborating with other professionals when appropriate, and being competent in provision of primary maternity care that protects the wellbeing of mother and child.

The Australian government had brought legislative reform to prevent anti-competitive monopolies, and within this reform agenda called for various reviews of legislation, including the laws regulating provision of health services. I prepared several responses for the College of Midwives, arguing that government funding for maternity services, through Medicare and hospital funding, unfairly excludes midwives from acting as midwives and providing maternity care. The medical monopoly of funding forces women into models of care that are likely to result in medical and surgical management, without improving outcomes for mothers or babies. There was good evidence then, and much more now, demonstrating the effectiveness of midwives working at the basic or primary care level throughout the pregnancy-birthing continuum, and referring women to specialists if and when the need arises. There is no evidence supporting specialist obstetricians as primary carers.

Our arguments were sound. New Zealand maternity services had, in the early 1990s, undergone major reform, and our colleagues across the Tasman were moving into independence and autonomy, with equal pay for midwives and doctors who provided the same service, that we only dreamed of. But although our arguments made sense, the political ‘buck passing’ from State to Federal health departments, and back again, seemed to extinguish any hope for reform as soon as it appeared.

In 1985 the World Health Organisation (WHO) had published the Fortelesa Declaration, addressing appropriate technology in birth. This document became the launching pad for activity by WHO and international professional bodies to address the evidence supporting practices in maternity care. The Cochrane Collaboration ( ) was established in 1993, looking initially at evidence based practices in obstetrics, and moving quickly to all health care interventions. Early research demonstrated the beneficial effect of continuity of care by a known midwife, and other aspects of midwife primary care.

The College of Midwives had, in the mid 1990s, formed a partnership with the emerging political lobby group Maternity Coalition. Our projects included a Midwifery Campaign, demanding ‘choice’ and ‘access’ for all women: choice of caregiver and place of birth, and access to models of care that enabled this choice. Soon after the turn of the century a group of consumer activists and midwives in Maternity Coalition, under the leadership of Barb Vernon from ACT and Tracy Reibel from Perth, prepared the National Maternity Action Plan (NMAP) as a framework for maternity reform. This document received widespread support, and not a little criticism, and put pressure on government health departments to address the inequity in maternity service provision, particularly for women who wanted to give birth naturally.

In the early 1990s the Baby Friendly Hospital Initiative (BFHI) was born, with its goal, the protection, promotion and support of breastfeeding. The essence of the BFHI was a world-wide program auditing maternity hospitals, using the ‘Ten Steps to successful breastfeeding’, on their practices which either supported or hindered the establishment of breastfeeding by mothers and their newborn babies. The BFHI is a major health promotion activity, which restores for women their natural authority for breastfeeding and protecting the health of their children.

When addressing breastfeeding it is logical that mothers, and midwives, will see the obvious connections between pregnancy, birth, and the nourishment and nurture of the infant. Why enable mothers to take responsibility and authority for their breastfeeding, and not their birthing? Midwives, being ‘with woman’, are able to do just that.

Internationally there was an awakening of midwifery, with midwives and women calling for reform, a ‘fair go!’. In the USA, the Coalition for Improving Maternity Services (CIMS) ( developed the Ten Steps of Mother-Friendly Care, in many ways projecting the BFHI into the fuller context of maternity care. In the UK maternity activists and midwives were promoting normal birth; and home birth received support at government report levels. Everywhere in the developed world caesarean rates were on the rise, while mortality rates in developing countries were shockingly high. That is still the case today. There is still much to be done. The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services.

A new and troubling element has asserted itself in the modern maternity terrain. The ‘choice’ of Caesarean birth: “too posh to push”; “honeymoon vagina”; and “I don’t want to sag down there and spoil my sex life” are a few of the reasons given. It seems that in this topsy-turvey world we live in, the consumer’s choice of major abdominal surgery is more readily provided for than the choice of the mother who simply wants to give birth naturally. A booking can be made in the hospital; all the needed personnel and gear assembled; and ‘bob’syouruncle!’. Well organised and delivered on time. Much more reliable than the mystery journey of natural birth, when labour comes like the thief in the night, and progresses according to mysterious rules and secret forces that cannot be controlled.

In promoting consumer choice, have we encouraged women to short-change themselves by opting out of one of life’s most amazing and healthy processes?

When women 'choose' models of care and interventions (such as induction, drugs, epidural, or surgery) the hospital is able to give that, and has a satisfied customer. I think this is the down side of the 'consumer choice' message. I believe there is an ethical argument that in maternity care the service providers are bound by the 'no harm' imperative to support and protect normal birth, and NOT to interfere without a valid reason. I believe caesarean should not be done on demand.

The core rationale behind the CIMS 10 steps is enabling women to give birth safely and naturally without medical help unless there is a valid reason. This is good, but can't happen unless women actually accept it, and are then able to progress undisturbed (allowing their bodies to do the work) with trust in the care provider who is leading the professional care decisions. That's where the primary carer's role becomes critical. Without models of care where the midwife and woman are able to work in partnership and protect normal birth, it’s unlikely that the increasing tide of caesareans will turn. We have plenty of proof that the status quo is not achieving the protection of normal birth.

I want to see a fair go for all concerned - the service providers, midwives, doctors, the consumers (mother and baby), the family and society, and policy makers. We will only achieve this when the consumers and the professionals work together to provide maternity care that values the wonderful natural processes in birthing, and uses technology appropriately for all who need it, not just for those who can afford to buy it.

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