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?