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.