Wednesday, December 30, 2009

What does the new year have on offer for midwives?

And the linked question is, what does the new year have in store for women and families who want to access professional midwifery services?

I don't have time today, on the eve of the new year, to explore these questions at any depth. But I do want to encourage anyone who is contemplating the birth of a baby to be strong and value your knowledge of pregnancy and birth as quintessential events in a woman's life; a series of events that have powerful social and personal implications in your family and community.


What does the new year have on offer for midwives?

For me, I am looking forward to:

* being 'with woman', learning to work with and share trust with the women and their families, as we prepare for birth, work in harmony with and engage with the amazing God-given natural ability of a woman to give birth and nurture her infant.

* being a part of a complex professional team that provides expert maternity care for mothers and babies who experience complication and illness in their pregnancy-birth continuum.

* being a teacher and mentor to other midwives and women who seek to understand authentic midwifery.

* being a part of the midwifery profession, working through challenges as they arise in a time of major reform by both federal and state government in the regulation of midwives.

* being a life-long learner, willing to reflect on each experience, and apply the learning to my life.

* giving love to, and receiving love from, those around me.


And, what does the new year have in store for women and families who want to access professional midwifery services?


This will be dependent on where those women live, and what they are able to access. The standard options accessible to women in most Australian cities and large towns may provide maternity services, prenatal checks, hospital bookings and medically managed births, without any understanding of promotion of health through working in harmony with the woman's own healthy natural processes.

Basic midwifery care that is matched to each woman, with the midwife being committed to being the coordinator of the whole episode of care, and personally in attendance for birth, is not widely available.

My New Year's resolution is to continue working to improve access for women to basic midwifery services that promote and protect physiologically normal birth, and support women in making appropriate decisions when the natural process may not be likely to lead to good outcomes.

Saturday, December 19, 2009

Christmas greetings


Our loving greetings this Christmas, and with a prayer for God’s blessing on you in the coming year.

Joy and Noel

[Photo: These painted plaster figures have provided our family's Christmas montage for many years now. Joseph now wears a blu-tak collar to keep his head on. The 'hay' is sugar cane mulch. This year we have added three 'Kaper Kidz' dolls, representing Granny, Grandpa, and our Poppy.]

Tuesday, December 08, 2009

NEWS FROM AIMS

ASSOCIATION FOR IMPROVEMENTS IN THE MATERNITY SERVICES
5 Ann’s Court, Grove Road, Surbiton, Surrey, KT6 4BE
Tel: 020 8390 9534 email: chair@aims.org.uk
www.aims.org.uk

PRESS RELEASE


Immediate Release - 7th December 2009


SAFETY OF DISADVANTAGED WOMEN AND BABIES IS THREATENED BY KING’S CLOSURE OF THE ALBANY MIDWIFERY PRACTICE

King’s College Hospital has abruptly severed its contract with the Albany Midwifery Practice with no prior consultation with women – and without proper provision in place to replace the service – leaving expectant and new mothers in the lurch and anxious about receiving appropriate care.

The Albany Midwifery Practice has been shown to offer the Gold Standard of care to around 200 women in Peckham each year. It provides an outstanding service which enables women to be cared for by a midwife they know. Women who use this service are enabled to make their own decisions about the place to birth. It is unacceptable to withdraw such a safe and much needed service from the poorest women in society.

The Albany Midwives’ care has provided women-centred care for women from deeply disadvantaged backgrounds for twelve years. Peckham ranks as the fourteenth most deprived district of 354 districts in England.

The statistics speak for themselves:
Albany Midwifery Practice [King’s College Hospital]

Caesarean section rate 14.4% [24.1%]
Breastfeeding rates 80% at 28 days [35% at 7 days]

Perinatal Mortality 4.9 per 1000 (1997-2007) [7.9 per 1000] (England and Wales 2006) 11.4 per 1000 (Southwark 2003-2005)


The Practice offers women a chance to have care from a midwife they know and to have their full attention throughout labour. Between 40% and 50% of these women choose to have their babies at home.

‘I feel blessed and truly privileged to have had the Albany midwives care for me during my pregnancy. They are an amazing group who go out of their way to treat their women (and our families) with the care and consideration we deserve during our pregnancies. I know for a fact that I wouldn’t have had the confidence to resist an instrumental delivery if I had not been so well informed and supported during my pregnancy and labour. I also know that I wouldn’t be the confident mother I am today if I had not met the Albany midwives. They have made a profound impact on my life and if I am blessed with a further pregnancy I wouldn’t hesitate in trusting them again with my care. ‘(Serra)

The Association for Improvements in the Maternity Services (AIMS) is concerned that these women may well find themselves in hospital where one-to-one care in labour is not offered. The Health Care Commission Report showed that over a third of women in King’s were left alone in labour or shortly after birth and were frightened. Already the UK maternal death statistics show that women in these disadvantaged groups are more than six times more likely to die in childbirth. All these deaths took place in hospital.

In order to justify the suspension of the service King’s College Hospital appears to be trying to make the case that the service is unsafe. They have looked at a selected number of Albany cases admitted to their Special Care Baby Unit and asked the Centre for Maternal and Child Enquiries (CMACE) to investigate.

We understand, however, that they have not examined the deaths of babies that have occurred in the King’s unit nor the babies from there who were also admitted to the Special Care Baby Unit. Nor do we have what AIMS believes is crucial data – comparative rates of mental illness after childbirth, where we believe the Albany is likely to have far better results.

This action mirrors the attempt, in 1985, by obstetricians at The London Hospital to strike off Wendy Savage, a consultant obstetrician, who provided the kind of care that women wanted and who also had a far lower caesarean section rate than her colleagues.

‘The suspension of one of the Albany Midwives and cessation of their practice reminds me of my own suspension in 1985. The same intolerance to alternative ways of providing maternity care, despite comparable outcomes for the babies and lower Caesarean section rates, the same technique of selecting cases with adverse outcomes without looking at the overall care, and the same refusal to look at what the women themselves want. I hope that King’s will listen to those who consider this suspension an outrage and reinstate the midwife and the service immediately.’
Wendy Savage MBBCh MSc HonDSc FRCOG


King’s has claimed that it has suspended the service because it has the safety of the mothers and babies at heart. The Albany Midwifery Practice has long been acknowledged as a centre of excellence, yet King’s management is unwilling to provide this standard of care for more women, and instead is trying to remove it so that women have no choice but to accept medicalised care.

The reality is that King’s College Hospital’s action in withdrawing the Albany Contract has put women and babies at increased risk.

AIMS demands that King’s College Hospital releases the CMACE Report and the comparable statistics for its own consultant unit so that data from both services can be examined objectively.

Contact: Beverley Beech, Email: Chair@aims.org.uk
Phone: 020-8390-9534 Mobile: 07790-312297
Debbie Chippington-Derrick Phone: 01276 510575

www.savethealbany.org.uk
AlbanyMums on Facebook
www.gopetition.co.uk/online/32641.html

Saturday, December 05, 2009

postnatal complexities

I drove to the home for the postnatal visit in the late morning. The baby had been born at home two nights previous. It had been a quick, powerful birth. The mother told me she knew her labour had commenced when she was putting her children to bed because she felt the urgency to settle them, and get on with her work of birth without distraction. She asked me to come without delay. I arrived at about 10pm. Labour was strong. The baby was born at 10.30, and welcomed lovingly into his mother's arms. The placenta came away soon after.

The mother greeted me at the door. She had obviously been crying.
"Are you alright?" I asked.
"The rabbit has died", she explained, "and I think I am having my third day blues."

We sat down together, had a cup of tea, and chatted. The baby was perfect. He was sleeping in his bassinet in his parents' bedroom. Feeding well at his mother's breast, skin colour good, passing urine and meconium - what more could a midwife want? Mother was strong, and her physical recovery from birth was progressing normally.

Our chat was interrupted by an urgent cry of pain from the toddler. Her little toe had been jammed in the door accidentally by her older brother. The mother's attention was diverted as she soothed her little one, the way mothers do.

A mother expects these minor crises to present unexpectedly, and she deals with them. It's part of being a mother. Mothers who choose homebirth, and who intentionally maintain their strong attachments with older babies in the early postnatal days demonstrate strength and courage in their mothering. Complexities of life don't somehow disappear because a new baby has been welcomed into a family.

I have been priviliged to attend this family for the births of several of their children. That continuity of care, not only through a pregnancy, but also in the continuum of a family's development, is precious. This is 'village' midwifery.

Wednesday, November 25, 2009

Medical dominance in birth

Society and cultural beliefs may not always agree with or understand the ‘promotion of normal birth’ which is, by definition, the duty of every midwife (ICM 2005). Many midwives who may have only practised under medical supervision, may not understand or have any skill in the promotion of normal birth. Regardless of the fashion of the day, and a midwife who does not possess skill in promoting normal birth should be challenged and supported in achieving competence, in the same way as a midwife is required to have competence in newborn resuscitation or any other basic midwifery skill. [Continued]

Wednesday, November 18, 2009

Learning from Dr Michel Odent

An excerpt from Michel Odent's Primal Health Research Newsletter Vol17 no3. The obstetrical implications of waterside hypotheses
WWW.WOMBECOLOGY.COM

Learning from birthing pools
In the early 1990s, when we became more familiar with the concept of antagonism between hormones of the adrenaline family (stress hormones) and oxytocin (the key hormone in parturition), I started to investigate the management of a common pathological situation in midwifery and obstetrics. It is the ‘failure to progress’ in the middle of cervical dilation, associated with intense lumbar pain. In this case, the pain appears as an obstacle to cervical dilation. I was considering non-pharmacological methods of pain relief. This is how I introduced the concept of ‘lumbar reflexotherapy’, based on the ‘gate control theory of pain’. Intracutaneous injections of sterile water in a precise zone of the lumbar region innervated by the posterior branch of the twelve dorsal nerve can block the visceral pain coming from the contracting uterus.32 I also proposed immersion in water at body temperature as a way to relieve pain, to reduce the level of stress hormones, and thus achieve more effective uterine contractions.

Taking into account the physiological perspective, and also the strong attraction to water expressed by many labouring women, I eventually bought a blue inflatable garden wading pool. Thus began the history of birthing pools in hospitals.33 As soon as the birthing pool was installed new strategies became possible. When a woman in hard labour was demanding painkillers, we had something else to offer than the injection of an analgesic drug (this was before the age of epidural analgesia). We could introduce the mother-to-be to the aquatic birthing room, so that she could observe and hear beautiful blue water filling the pool. The room was painted blue, with dolphins on the walls. From that time the question was no longer: "When will you give me a pain killer?" It was more often than not: "How long does it take to fill the pool?" The first lesson concerned the importance of the time when the woman in labour is anticipating the bath: the dilation of the cervix can already progress dramatically before water immersion—if the aquatic environment is associated with privacy. It is like the sudden release of brakes . We witnessed one of the many magic effects of water on human beings...a profound power that cannot be easily explained with the language of physiologists.34 At the time of the plastic pool (before we installed a solid pool), women were not influenced by the media or by what they read in books about childbirth. Their behaviour was spontaneous and thus we learned about the genuine effects of a water environment. A the typical scenario (with many possible variations) was the case of a woman entering the pool in hard labour around 5 cm, spending an hour or two in water and then feeling the need to get out of the pool when the contractions were becoming less and less effective. This going back to the dry land often induced a short series of irresistible and powerful contractions so that the baby was born within several minutes.

One day, a mother-to-be had not been in water for long when suddenly she had two irresistible contractions and the baby was born before she felt any need to get out of the pool. While giving birth, this woman was really "on another planet". Clearly, in that altered state of consciousness associated with hard labour, she intuitively knew that her baby could be born safely under water. There was no panic. It is as if a deep-rooted knowing could express itself as soon as the intellect and its knowledge was set aside. Such births happened again.34 From that time many journalists, reporters,and photographers were fascinated by babies being born in water. They were indifferent all other aspects of our unconventional practices. After a short period of surprise and even frustration, I concluded that good journalists are experts in Human Nature. They know how to attract the attention of their readers or their viewers. They have this intuitive knowledge that there is a special relationship between human beings and water. By referring to this historical phase of the use of birthing pools, we offer food for thought in the age of Waterside Hypotheses.

Monday, November 09, 2009

Not happy, Julia!


[Pic: Melissa and I hand over some calling cards to the chap who was manning the front desk at Julia Gillard's office thismorning.]

An estimated 350 ordinary people, predominantly mothers and babies and little children, rallied in the heat thismorning outside Julia Gillard's Werribee office.

The message was clear - SHAME on you, Julia! Australia's first female Deputy Prime Minister, and you are allowing medical dominance over childbirth to be written into the laws of this country in an unprecedented way.

A couple of young police persons were in visible attendance from an hour before the rally commenced. I had a chat with them, and gave them some information about the rally and a link to this blog, and thanked them for looking after us. We also noticed an Australian Federal Police car parked near the rally. Two large men (not in uniform) who were standing on the footpath also kept an eye on us. These two men entered Julia's office after the crowd had left.

There was no melee. By midday there were a few crying children - little ones who are not accustomed to being out in the sun, listening to their mummies talking into loud speakers. They were probably wanting some mummy time, snuggled in her lap, and suckling at her breast.

As a member of this community I am outraged that Australian parents and children and midwives should even consider gathering on a public street to voice our concerns. Yet we have been driven to that extreme by a government that is being directed by the powerful medical union, the AMA, who has proudly claimed responsibility for the latest amendment to legislation.

Julia Gillard spoke to midwives in 2005, when she was the shadow health minister, in election mode. In that speech she said:

there are “limited opportunities [for midwives] to practise as primary carers and provide continuity of care to women”
and
“Unless and until the Government is shocked and shamed into realising that Australian women …"
and
“I believe that midwives … are key heath care professionals whose role in the care of women and their babies has yet to be fully realised in the Australian health care system”

Today we have reminded Julia of what she said before the Australian people voted Labor into office.


ps.
We have heard that about 400 rallied outside Kevin Rudd's Morningside (Qld) office, and 200+ outside Tanya Plibersek’s Surry Hills (NSW) office. The WA rally will be held outside Stephen Smith's office at 11.10 am local time.
pps. Perth had about 100 people. Rachel Siewert, Danielle Senini and Sally Westbury addressed the crowd. Very polite federal police attended. Channel 7 and 10 had news crews there. West Australian and Local papers interviewed and photographed the crowd.

For more pictures, please go to the MIPP blog.

Saturday, November 07, 2009

REMINDER: RALLY ON MONDAY

Monday 9 November 2009 from 10.30am (local time)


Rally points:

Brisbane:
Prime Minister
Kevin Rudd’s office
630 Wynnum Road
Morningside Qld 4170

Werribee:
Deputy Prime Minister
Julia Gillard’s office
Shop 2, 36 Synnot Street
Werribee Vic 3030

Sydney:
Minister for the Status of Women
Tanya Plibersek’s office
111-117 Devonshire Street
Surry Hills NSW 2010

Perth: at 11.10am Perth Only
Office of Stephen Smith (most senior Gov member in WA)
953A Beaufort Street
Inglewood WA 6932




[Our calling cards]

If you are unable to attend, please prepare your 'calling card' - a letter to Kevin, Julia, Tanya, or Stephen (or another member of the government), telling them who you are and why you can not accept maternity reform which prevents midwives from practising midwifery in their own right, and prevents women from giving birth in their homes with their chosen midwife attending them. Please email your letter to your midwife or someone else who is going to the rally, and ask them to give it to the MP concerned.

Anyone who would like their calling card to appear on this blog, please email it to joy@aitex.com.au

Friday, November 06, 2009

Thinking about vaginal breech births

I have put a comment about the screening of this video at the MIPP blog.

A point that was only touched on in the discussion after the showing was the disenfranchising and deskilling of midwives in breech births. It has become an obstetric consultant ‘act’, even though every midwife should be ready and competent in spontaneous breech births. Midwife Fiona Hallinan mentioned that Box Hill hospital is setting up consultant cover for breeches – it’s all about defensive medicine. RWH refuses to support a woman’s choice, and staff will bully her into compliance with their wishes to do an elective Caesar. I was told that this is because they can’t be sure someone is competent at all times. And as Lionel Steinberg pointed out, an obstetrician goes against the current ‘gold standard’ at his own risk. The insurance will pay out for a baby’s brain damage in an undiagnosed breech birth where the midwives haven’t got a clue what to do, but won’t support the obstetrician who goes against the rules.

The video ‘A breech in the system’ made the point that the woman was lucky that the obstetrician on call at the time was competent – had learnt about breeches in India and PNG. There was great rejoicing around that fact. It’s tragic that an obstetrician needs to be given ownership of a spontaneous birth that a midwife could just as well have attended.

There was a lot of padding in ‘A breech in the system’. Beautiful underwater footage, lots of Byron Bay alternative hocus pocus – none of which seemed to make any difference. ECV (external cephalic version) got some bad publicity, and it ‘didn’t work’ either!

In the current climate of serious threat to all midwives’ right to practise on our own authority, breech births are a bit of a distraction. This video is good in that it demonstrates spontaneous birth – something we need to value and hold on to.

Wednesday, November 04, 2009

MOTHERBABY FUND 2009



This page will provide an ongoing tally of gifts that are made to global relief and development charities that assist needy women and their children.

I encourage all readers of this blog to join me in this special venture.

Donations are made directly to the chosen charity, and reported here, without identifying the donor. Please choose a charity that you believe is reputable, minimising overhead costs, and transparent in its reporting to donors. I encourage you to consider donations to the charities listed below. This list will be added to as information is provided to me, Joy Johnston begin_of_the_skype_highlighting     end_of_the_skype_highlighting [joy@aitex.com.au].

The person(s) who donate money will receive a receipt from the charity, and the gift may be tax deductible. Please send me the information if you want your donation to be included in the MOTHERBABY FUND 2009.


MOTHERBABY FUND 2009
$895.00


Donations since 4 November
$200.00 to TEAR for establishing a women's self-help group
$60.00 to TEAR for training a village health worker/birth attendant
$85.00 to TEAR for HIV care and eduction
$35.00 to TEAR for Literacy Skills
$550.00 to TEAR for community school
$20.00 to TEAR
$20.00 to a local women's refuge


Other charities to consider:
Aboriginal Midwives Trust
World Vision
Christmas Child
Oxfam

Sunday, November 01, 2009

discovering enjoyment in breastfeeding

Of all God's wonderful provisions for a healthy relationship between a mother and her child, breastfeeding is enduring and powerful. It's part of the natural physiological continuum. I have a window sticker on my car that sums it up:
"There's no milk like mum's milk."

Breastfeeding, like normal birth, is by no means an easy option - especially in the early days and weeks of a baby's life.

Recently I visited a new mother who was having difficulies feeding her baby, who was about two weeks old. She was expressing her milk, putting it into a bottle, and giving it as well as some of the artificial powdered stuff to the little bloke.

Today I received an email from that mother.

"I just wanted to write and say a huge THANK YOU for teaching me how to enjoy breast-feeding : )

"I no longer see it as a burden or as a scary thing, but something completely natural and wonderful. I've grown more confident with feeding [BABY] in public and am now keen to take him places with me so that he can explore the world outside! Thank you!

"I'm also looking forward to being able to help other mums in future breastfeed their babies."


In a few simple sentences this mother has told me everything I want to know about their progress. I don't know how often the feeds are, or how many times the new parents get up at night. But I do know that this mother-baby pair have discovered enjoyment in breastfeeding. What's more, the mother is looking forward to sharing this wonderful gift with her peers.

I feel priviliged to have had a small part in this new mother's beautiful transformation.

Saturday, October 24, 2009

More on caesareans and delayed childbirth - commentary by Judy Cohain

Regarding:
Smith GCS, Cordeaux Y, White IR et al (2008). The effect of delaying childbirth on primary cesarean section rates. PLoS Med 5(7): e144. doi:10.1371/journal.pmed.0050144.

Smith et al goes so far as to use dystocia, undefined by American College of Obstetrics and Gynecology (ACOG) or anyone else except as delayed labor, to make women feel guilty for delaying first childbirth. The authors found that at age 16, women have an average labour of 9.1 hours which rises slowly peaking at 10.4 hours from age 33 and above. The authors sampled myometrial strips obtained from 62 women and claim to have found a reduced degree of spontaneous contraction in older women. They used this supposed difference to define older women as having ‘impaired’ uterine function. This ‘impaired uterine function’ is then theorised to explain why women over 16 have labours that on average last up to 1.3 hours longer, explaining their increased rate of caesarean surgery. The authors did not analyse the reasons women in this study underwent caesarean surgery although as previously stated, the vast majority of caesareans are known to be due to ‘dystocia’. No one knows what would have been the outcomes if women were allowed to labour longer. Instead of the authors defining the arbitrary definition of dystocia as the problem, they blame the extra 1.3 hours that older women take to give birth and define the older uterus as dysfunctional rather than slower. Without evidence that a 1.3 hour longer average labour results in poorer outcomes, the term they use to describe older women as having a ‘dysfunctional’ uterus is, in polite terms, inaccurate. This surely is action bias in its most ageist/sexist form.



from:

Is Action bias one of the Numerous Causes of UnneCesareans? by JS Cohain, in press, MIDIRS Midwifery Digest Dec 2009

N.B. why would women who are in normal shape and state of mind, volunteer to let 'scientists' take strips of muscle from their uterus? Would you?

[Judy Cohain is a midwife in Israel]

Thursday, October 22, 2009

Melbourne Midwives' Family Picnic

Saturday 28 November, at Elgar Park, Mont Albert (just off the Eastern Fwy – cnr Elgar Rd and Belmore Rd), 11am-4pm. [See Map of Melbourne]

Please check MIPP blog by 9am that day for alternate plan if weather is unsuitable.



Midwives and our families invite the families we know and serve to join us for a picnic lunch, to celebrate life, and birth, and mothering, and midwifery.



BYO everything – food, picnic rugs, hats, chairs &tables (if you want them), games, and your musical instrument and a song if you like.



Elgar Park has toilets, playground, lots of open space, bush areas, wetlands with boardwalk, walking tracks …



Please pass this message on to others who may be interested.

Joy Johnston
joy@aitex.com.au
04111 90448

PLEASE JOIN WITH ME IN MAKING A GIFT OF THANKS TO GOD FOR OUR CHILDREN
Anyone who would like to contribute to a group gift from TEAR Australia’s catalogue to help some of the world’s poor, such as tree seedlings ($10), or family health care ($40) or training a village health worker/ birth attendant ($60), or setting up a women’s self help group ($200), please contact me. The collection currently stands at $200. I will report back to all who donate to this project. Joy

Wednesday, October 14, 2009

Is the increasing rate of caesarean birth linked to the age of mothers?

An interesting discussion into the rise in caesareans took place on ABC Radio National's Health Report, 12 October. The transcript and the audio are available online.


The research team analysed data collected from all births in Scotland over a period of time, and identified women having an uncomplicated first pregnancy.

Here's a brief excerpt of concluding remarks in the interview:
Gordon Smith: There are a whole number of issues about caesarean section, and I think one of the things I would say it's about like the issues around hysterectomy 20 years ago, for a proportion of women a caesarean section is an extremely helpful and valuable intervention, but I think there is a general concern about it in terms of say health economics, that it's much more expensive to provide a caesarean delivery compared with normal delivery, from a philosophical approach that we should try to encourage normality and for many women we attach quite rightly a real importance to achieving a normal birth, and then there's also concerns about the long-term effects of caesarean section, effects on subsequent pregnancy, where there's certainly increased rates of complications. And particularly one of the things we're seeing now is women who've had high numbers of previous caesarean sections. They are a group of particular concern, because some of the most serious and life-threatening consequences that we see in obstetrics are occurring to women who are coming back with four and five previous caesarean sections where there can be real problems.

Norman Swan: The risk of rupture.

Gordon Smith: Risk of rupture, but also the risk of abnormal insertion of the placenta, particularly what we call placenta praevia where the placenta is in the lower part of the uterus and also what we call morbid adherence of the placenta, where the normal relationship, the way the placenta invades into the muscle is affected by the presence of scar tissue and in fact the placenta over-invades into the wall of the womb which can lead to life-threatening bleeding, which can be difficult to control even under optimal circumstances. So I think caesarean section has many advantages in a certain context, and particularly for those women who aren't planning many, many future births, but I think there's going to be an ultimate long-term consequence of increased rates of caesarean section which will become increasingly apparent over the next few decades.


Reference:
Smith GCS et al. The effect of delaying childbirth on primary caesarean section rates. PLoS Medicine 2008;5(7):e144
[Gordon Smith is Professor of Obstetrics and Gynaecology at the University of Cambridge.]


How does this sort of discussion inform a midwife, or a mother anticipating birth?

"Think globally"

Epidemiological research seeks to tease out information from large sources of data. The information we glean from this sort of research helps us to understand the big picture, but it does not influence the way we approach the maternity care of an individual woman. The big picture concern that Professor Smith has identified is that the women today who are having caesarean births will, in future births, face an increased risk of life-threatening haemorrhage.

The obvious conclusion that I draw is that regardless of the age of a woman, or the 'risk' of needing caesarean, the maternity service has a duty of care to do all it can to promote and support normal birth, and to use caesarean surgery judiciously.


"Act locally"

The midwife's professional advice to a woman in her care is finely tuned to that individual woman. The midwife takes into account the woman's whole self - physical, social, psychological, spiritual ... wellbeing, as well as outside factors such as the weather conditions that may have an impact on events. The woman who is working in partnership with a trusted midwife also has knowledge about herself that she shares with her midwife as her time to give birth approaches.

Every woman giving birth has elements of her situation that may enhance or detract from her chances of proceeding with physiologically normal birth. The skilled midwife acts to promote normal birth, taking into account the realities and risks, as well as the advantages that apply to an individual mother.

Monday, October 12, 2009

who to trust?

"You need to decide now who to trust, Jenny. Me, or the hospital. I am going to offer you an alternative plan, which is quite different from the plan that has been offered by the hospital."
A case study.

Friday, October 09, 2009

Thinking about the midwife

This past week I have been privileged to be midwife for two primiparous mothers who have given birth in their own homes. In attending these births I have worked alongside two younger midwives whose employment has been facilitated under my new private midwifery service model.

I won't tell the stories of these two beautiful births here. The focus of my reflections today is the midwives. Women who commit themselves to other women, and whose personal lives, families, and plans are interrupted from time to time, unpredictably, so that a baby can be born.

We midwives could not do what we do if it weren't for other members of our community, sometimes husband, or sister in law, or parent, or good friend, who is delighted to be the backup parent so that a midwife can go out for a birth. Midwives who are also mothers can only provide this level of full commitment to another mother when we know that our own children are safe and happy.

A midwife has a sister in law, who is a wonderfully energetic person who embraces her young nieces and nephews, so that their mother is happy to go out to a birth. The sister in law goes out of her way to give the children an especially happy time. When mummy comes home they are full of stories, and they have plenty to show, including the poster paint on their clothes as well as the pictures they have painted.

A midwife has a husband, who is deeply in tune with the moment by monent unpredictability that his life partner faces. He provides a cheerful and positive tone when answering the phone, and welcomes each new life as if the little one were a member of his own family. He recognises his mate's need for sleep after a night out, and makes the home a quiet and nurturing space for her. He knows when she would like a coffee, or when a relaxing cup of chamomile tea would be better.

A midwife has children, whom she nursed at her breast and nurtured throughout infancy. She has learnt a great deal of her midwifery from her own mothering experience, learning how to recognise a baby's cues, and how to encourage the little one to achieve. As the children grow, the emerging adult within the young child sees mummy in a different light. She is a midwife, who cares about others while planning and providing for her own. She has ambition to develop professionally. The emerging adult within the young child learns to admire the woman who previously was the personification of comfort and safety. From time to time the child needs that comfort and safety from mummy, and is reassured that those arms are as ready to embrace, and that the midwife is also in every aspect a mother. At times the child will be heard repeating advice about health promotion in pregnancy, or caring for a baby, or breastfeeding - and the mother recognises her own voice in those words of wisdom.

A midwife has friends, who respect her need to miss a tennis morning from time to time, or to be excused from another commitment at the last moment.

The whole community around a midwife supports and affirms her, enabling her to carry out the primally simple yet profound role of being 'with woman'. It's as though there is something of midwifery deep within the heart of each one, valuing the birth of a child above the small and relatively insignificant detail of their own plans at that time.

It takes a whole community - a village - to support a midwife, who in turn enables a mother to give birth to her child with confidence and strength. And the cycle continues, as a community moves in to support that family as they nurture that child.

Thankyou to the communities who support the midwives who are 'with woman' today.

Sunday, October 04, 2009

*Framework* - the latest buzzword

There has been a lot of talk in midwifery circles lately about a *framework* that will enable eligible midwives to practise privately within the new environment promised under the government's package of midwifery reform. We have been informed that an "advanced midwifery credentialing framework" will be required for eligible midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors". [continued]

Wednesday, September 30, 2009

The safety of home birth: Is the evidence good enough?

There have been three recent papers published, giving strong evidence of the safety and acceptability of homebirth: a large study from the Netherlands (deJonge et al 2009), and two Canadian studies (from Ontario, Hutton et al 2009 and from British Columbia, Janssen et al 2009).

The paper by Patricia Janssen PHD and colleagues (link above) reports on Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. The study included all planned homebirths attended by registered midwives from 1 Jan 2000 to 31 Dec 2004 in British Columbia, Canada. The interpretation of the data is that "Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared withplanned hospital birth attended by a midwife or physician." (p337)

Similar findings have been reported in the other 2009 studies.

A Commentary by two Melbourne midwife academics, Helen McLachlan PhD and Della Forster PhD, titled The safety of home birth: Is the evidence good enough? was published in the same journal. My curiosity was sparked. Helen and Della have been active researchers on the local maternity scene, and from memory their work has included randomised controlled trials of breastfeeding interventions, and some on team midwifery. But I haven't seen anything from either of them about homebirth in the past.

The commentary gives wise, predictable thoughts about the debate surrounding homebirth. It gives a good listing of current references on homebirth.

The fashionable refrain from a section of the health/medical research community is that the evidence is not good enough unless it was obtained after randomisation of subjects. An interesting discussion is entered into, and the authors come up with the conclusion that "Better evidence on the safety of home birth is needed, ideally from randomized controlled trials".


The paper quotes professional discussion around the reported finding that an attempt in the Netherlands to conduct a randomised controlled trial was aborted, because women "were not willing to be randomly assigned to home versus hospital birth and declined participation because they had already chosen their place of birth."

This is a no-brainer (imho)! Of course. Yet the authors go on to discuss the importance of high quality evidence, as if another group of women - possibly those in public maternity care in Melbourne - will think differently. Why would they? How much evidence do we need in order to give a tick to spontaneous, unmedicated, un-interfered-with birth?

I can imagine the outcry if someone suggested seriously that we really don't know if conception of babies is safer in the hospital laboratory or in the home. Therefore a randomised controlled trial needs to be conducted. All eligible potential parents are to be randomly allocated to either treatment or control.

It might be difficult to enlist participants in this reseach, might it not?

Some of those who read this blog will have given birth at home; some are midwives who attend homebirths; while others are interested onlookers. If you have any knowledge of the terrain of physiologically normal birth, either in hospital or in the home, you will probably agree with me that the mother and all her support team need to be intentional about protecting normal birth. There is the intention to actively choose to work in harmony with your body; to be ready for and accept the work your body and mind must do; and to actively make decisions as events unfold. This is not the stuff of managed care and research protocols. It requires the deep and intuitive knowledge that a woman has because she is a woman, and it is best facilitated when the labouring woman knows and trusts the midwife who is responsible for professional decision making at the time.

Tuesday, September 29, 2009

my summary of active labour and birthing



Labour and birthing is as individual as we are ourselves. I have made this simple summary to assist with discussion and planning, especially for a first birth. You can click on the picture to enlarge it, and if you Right-click you will be able to save it to your computer and print it out.

Please contact me if you have any questions. joy@aitex.com.au

Thursday, September 17, 2009

'Drive-through' birthing

Several followers of this blog have asked me how the mother and her twins are progressing, since their story was shared a few weeks ago.

I have the mother's permission to share with you the news of spontaneous labour and birth of these two babies. Our hearts are full of praise to God the giver and sustainer of life.

Labour commenced at about 7am, and was stronger than what the mother was used to for any of her previous births. We went to Box Hill hospital, and the obstetrician who had supported the plan for vaginal birth (twins, first breech) came in and worked with us.

Membranes ruptured spontaneously for Twin A, who progressed quickly to breech vaginal birth. Baby experienced some respiratory distress for most of the following hour, and we are thankful that the paediatrician kept the baby in the birth room after special request.

Twin B had turned to cephalic. Mother gave birth to the second baby about an hour after the first.

The family went home a few hours after the birth. Mother called it 'Drive through' birthing.


I have told this story as an example of a complex decision making process between woman, midwife, and hospital - without bullying or coercion, even though the 'hospital' advised elective caesarean surgery. I am glad I was able to work with the hospital in this birth, disagreeing with expert advice at times, and supporting the woman in her desire to give birth when her time was accomplished.

There is no 'one size fits all' in birthing. These births included some features which are categorised 'high risk'. Those risks were present, in slightly different ways, regardless of the birth plan. The plan to proceed under natural physiological systems was made after considering the risks and benefits of spontaneous birthing, and the alternative - planned, elective surgery. Another alternative was to change the plan at some stage in the labour, but that option was not needed.

With the benefit of hindsight I am sure that there was no better way to negotiate the uncharted and unpredictable journey of these births. In fact I think if there had been delays – such as epidural, stirrups, or a trip to operating theatre, the story could have been very different. The mother knew her babies needed to be born, and she just got down to the job of birthing – something she is very good at.

[For the birth plan, click here.]

Tuesday, September 15, 2009

thoughts on the afterbirth

The birth of the placenta or 'afterbirth' is known as the Third Stage or S3.


Midwives who promote normal birth are usually confident to proceed under physiological conditions through the third stage, working in harmony with the mother's natural birthing processes. The elements of physiological S3 include trust between the woman and her known midwife who is professionally responsible for conducting the birth, attention to a safe, non-stimulating birthing environment, cord not clamped prior to cessation of all pulsation, uninterrupted skin to skin contact between baby and mother - all following the spontaneous unmedicated birthing of a healthy baby by a healthy mother. The baby's instinctive movements in seeking the breast enhance the natural production of oxytocin, and the baby's pressure on the mother's abdomen encourages contraction of the mother's womb, ensuring the functioning of living ligatures within the uterine muscle wall at the placental site.

Midwives attending homebirths use oxytocics when clinically indicated.

[The attached tables show the rate of pph for homebirth mothers in Victoria each year 2002-2007. These tables do not indicate severity or degree of morbidity.]


Hospitals in Australia strongly promote active management of S3. This involves injection of a synthetic oxytocic, with or without an ergot alkaloid, soon after the birth of the baby, causing strong contraction of the uterine muscle. When there are signs of placental separation (cessation of pulsation and lengthening of the cord, and sometimes blood loss), the midwife or doctor exerts controlled traction on the cord while guarding suprapubically with the other hand, until the placenta and membranes have been delivered.


Postpartum haemorrhage (pph) is a serious and life threatening condition, which is one of the main causes of preventable maternal death globally. The International Confederation of Midwives statement on pph includes instructions for active management of S3.


[Click on the picture to enlarge - Summary of a paper by Carolyn Hastie and Kathleen Fahy, 'Optimising psychophysiology in third stage of labour: Theory applied to practice'. Women and Birth (2009) 22, 89-96. Australian College of Midwives.]

Efforts by midwives to describe a physiological approach to S3 underline the need for research into the effectiveness of such midwifery care. A recent paper by Hastie and Fahy (2009) [first page scanned above] reviews literature, defines key terms, and presents a theoretical framework of Midwifery Guardianship applied to the third stage. This paper adds to the writings of Michel Odent and others in the past couple of decades, exploring and explaining the neurophysiology of unmedicated, normal birth.

There is no 'one size fits all' in maternity. Each woman and each baby are individual, and decision making is an active process that continues throughout the episode of care. The midwife's toolkit includes the skill and knowledge to promote normal birth, and to work in harmony with the natural processes, when that is likely to lead to the best possible outcomes. The midwife is also able to intervene in a timely and appropriate manner, using current strategies that are supported by contemporary evidence, and critically reflecting on practice in an effort to continually learn and improve maternity care for mothers and babies.

Monday, September 14, 2009

monthly review

Thismorning I have written my 'Monthly review' in the countdown to 1 July 2010.

I am not trying to sugar-coat anything - the future still looks bleak for independent midwives and for the women who we care for. I hope that by tracking the progress of the so called 'reforms', we will have hope that solutions can be found. Australians do have a belief in fairness and equality.


[Photo: That's me and Noel, with our first baby, the beautiful Miriam. If you look through her FB photos, you might even see the 70's kaftan on her!]

Friday, September 11, 2009

What will Medicare rebates mean?

A guest editorial 'Medicare rebates for midwives: An analysis of the 2009/2010 Federal Budget' appears in the September issue of the Journal of the Australian College of Midwives [to read more, click here]

...
Medicare fragments care into 'items' - fragments a woman into prenatal, intrapartum, and postnatal care, as most Australian women today experience. Medicare causes buck-passing between federal and state health departments.

...
Holistic primary maternity care by comparison is woman-centred, meaning that the pregnant woman/mother-baby dyad are central throughout the continuum of care. Midwives providing woman-centred care work with caseloads, or at the very least in small group practices. Notions of partnership between a woman and her known midwife, promotion of normal birth, and preventative measures - all of which are fundamental elements in the international definition of the midwife (ICM 2005), are nigh impossible in fragmented models of MEDI-care.

...

BTW
Privately practising midwives have been told that the Minister is concerned at the lack of support (from us) for the maternity reform process.

I have to say from my persptective the feeling's mutual.

We're back to Alice's adventures in Wonderland - "curiouser and curiouser!"

Thursday, September 10, 2009

waiting

Waiting is one of those basic requirements for normal physiological birth.
A mother who wants normal birth has to accept it, and a midwife who attends normal birth has to also.

In our organised world, with clocks and appointments and deadlines, waiting for the right time can be a challenge. You are feeling full and heavy. You go for a walk in the evening, and your womb is becoming very tight. You wonder if the baby will come tonight? You wake up in the morning - nothing happened! "Don't be disappointed," you say to yourself. "Baby will come at the right time." Then one morning you wake up and wipe away a bit of blood stained show. Aha! You know something is happening in there. Trying not to be too eager, you do those few last minute jobs that need to be done. You notice that the air feels different today. What a wonderful day to give birth to this precious little one.

I remember these beautifully deep feelings as I wait, this time as the midwife, the older woman, for a young woman to tell me she is ready to give birth.


The phenomenon of waiting for a baby to be born is as old as human existence. Many times as a child I heard the old language of the King James translation of the Bible, in the Christmas story. "Elizabeth's full time came that she should be delivered; and she brought forth a son." (Luke 1:57) "And so it was, that, while they were there, the days were accomplished that she [Mary] should be delivered. And she brought forth her firstborn son ..." (Luke 2:6,7)

Elizabeth's 'full time' came; Mary's 'days were accomplished': and they both 'brought forth' their children. Waiting for the time is in a sense passive, then the time comes for actively doing the job of 'bringing forth'. The women's knowledge passed down over millenia in these simple stories has informed my birth-giving, and my midwifery practice.

When anticipating physiological birth we experience the waiting as part of our nesting. I make the distinction here, because the only person who can do the physiological work of nesting, waiting, labouring, and birthing, is THE woman. Just as nesting can be interrupted by a sense of handing over to the 'expert', the waiting is also interfered with, deep in the mind of the woman who is unwilling to work with her body in birthing, who has given up her ability to reach her full time, to accomplish her days.

It is no wonder that this one may also experience difficulty in 'bringing forth' the child.

Friday, September 04, 2009

Two-year exemption from indemnity insurance announced today


a brief reprieve at least.

[If you don't know the siginficance of the Bilby, check this post for the introduction of this little endangered marsupial into the midwifery reform story.]

Sunday, August 30, 2009

a baby born


Normal birth does not belong to any particular group of people, any special lifestyle, or set of beliefs. Normal birth does not happen as a result of any particular course of childbirth education, reading any book, or getting instruction from any birthing teacher.

A beautiful young woman gave birth to her first child on Friday, in a fashionable suburban unit in a medium-density housing estate. The home has very little 'garden', and no shovel or other tool to dig a hole in the earth to bury the placenta, so I brought the placenta home to my garden.

The significant features in the labour and birth of this baby girl were, from a midwife's point of view, as near to ideal as I could hope for:

• A healthy mother
• Baby in an optimal position, back on the Left, head engaged from about 36 weeks
• Spontaneous onset of labour at 40 weeks +11 days in the early morning
• Labour became strong, and mother felt an urge to push by about midday
• Baby was born through water before 2pm in good condition
• Mother sat on the couch, with baby skin-to-skin, cord uncut, for the next hour or so, while baby searched for and took the breast.
• The placenta was birthed spontaneously about an hour after the birth. Mother’s blood group was Rhesus negative, so cord blood was collected from the vessels on the placenta. The pathology company’s courier came to the home and took the cord and maternal blood to the laboratory.
• There was minimal blood loss.
• There was a small first degree perineal tear which was not sutured.

This birth will be recorded in the Victorian government health department's perinatal data for 2009 as an unassisted vaginal birth, a homebirth attended privately by a midwife as the primary professional care provider, a water birth, and all the detail specific to this mother and child. I have chosen to put this birth on the record because the uncomplicated, normal, physiological birth often goes unnoticed.

The second midwife who assisted me in this birth is a recent graduate from one of the Bachelor of Midwifery programs in Melbourne. This is a midwife who will be able to carry authentic midwifery knowledge and skill into future decades.

A midwife's skill, working in harmony with each birthing woman, is like a dance. Most of the time the woman leads, and the midwife accompanies. There are moments when the woman experiences huge challenges that threaten to overwhelm her, when the midwife takes the lead. This truth was recorded many years ago:

You are a midwife.
You are assisting at someone else’s birth.
Do good without show or fuss.
Facilitate what is happening
rather than what you think ought to be happening.
If you must, take the lead.
Lead so that the mother is helped,
yet still free and in charge.
When the babe is born the mother will rightly say
“We did it ourselves”.
Attributed to Tao Te Ching, about 2000 years ago.

Thursday, August 27, 2009

why midwives promote normal birth

The promotion of normal birth, within a framework of watchful readiness to intervene if needed, is a fundamental duty of care of all midwives. The Definition of the midwife, a core document of the International Confederation of Midwives, states that the midwife's care "includes preventative measures, the promotion of normal birth, the detection of complications ..." (ICM 2005, emphasis added)

In this respect, a midwife is not free to support the 'every woman, every choice' slogan of our leading consumer and midwife advocacy organisation, Maternity Coalition. Every 'choice' includes caesarean, induction, epidural ... the works ... on demand. The midwife who is practising authentic midwifery will act in such a way that enables a woman to accept and embrace her birthing strength, rather than cower and demand that her body be numbed and her baby removed like an unwanted growth.

Wishy-washy notions of choice in maternity care abound in our society. Paradoxically the one choice that is difficult to access in the developed world, including our land of Oz, is normal birth. I think there are many reasons for this, including de-skilling of the midwifery workforce, medical control of the birthing continuum, and medical oversight of all things maternity. It is unusual today to find a midwife in mainstream care, or medical practitioner who has a commitment to promoting normal birth, coupled with the skill to work in harmony with hormonally mediated natural processes. Instead, the reliance is on machines, drugs, and surgery.

A woman phoned me the other day to talk about engaging a midwife who would accompany her for birth in a private hospital.
First baby,
well prepared as far as all the standard childbirth education classes are concerned,
healthy,
and pretty excited about having a baby.
BTW, hubby is petrified! Not likely to be much support ...

I willingly launched into an explanation of what I or another independent midwife could offer in such a situation. I explained why it's important to trust your baby and your body ... and why we encourage women to use water and position and massage ... in learning to work with the pain of labour.

"I'm not really concerned about drugs. But a friend of mine had a baby recently and her doctor put her legs in stirrups, and I would prefer not to have that. I want someone who can tell me I don't need to have stirrups."

[OK! How to answer that one? Stirrups may have been a good idea in that particular birth.]

But, if you have the drugs, you may not be able to be active. You know narcotics are dangerous drugs, don't you? You know epidural anaesthesia is a pretty major medical procedure, with real risks, don't you? And the narcotics and anaesthetics pass to your baby ...

I do hope this woman has found someone who will help her to avoid the indignity of stirrups - to have the birth of her choosing. I don't think she is looking for a midwife.

Tuesday, August 25, 2009

"Why bother coming here if you won't let us manage you the way we think is best?"

Why indeed!

This is the question that a mother was asked by a doctor. Not a junior, down the line doctor, in a small under-resourced hospital. It was the senior obstetrician in one of Melbourne's three tertiary, state-of-the art, well resourced referral hospitals.

I am writing about this case because I am witnessing a more intense effort by hospital staff at coercion and bullying to make this woman comply than I had anticipated or experienced in the past.


The mother's problem is that she is carrying twins, AND 'Twin A' is presenting breech, AND she wants to give birth spontaneously, rather than agree to elective caesarean surgery.

In good faith the mother accepted my advice to attend the hospital for review after her twin pregnancy had been confirmed.

The hospital's reason for insisting on surgery: they can't be sure there will be a doctor who is competent for a vaginal breech birth, let alone twin breech, when the time for birth comes. Even in a tertiary level hospital, funded to provide competent staff round the clock to provide appropriate obstetric and midwifery services for any woman, the pressure is on to manage a slightly complex case in the day shift.


The midwifery profession has clear guidelines for consultation and referral, and I find these guidelines reasonable. In a situation such as this one, when a woman planning homebirth in my care is found to have twins, I encourage her to obtain information from the back-up hospital, and make an informed decision about her birthing. I do not push vaginal birth at any cost. The safety and wellbeing of mother and child(ren) is my primary concern.

Although I have no visiting access in hospitals, I don't need that to practise my skill as a midwife. All I need is the partnership of trust with the woman. As long as she is confident to proceed in harmony with her body through the birthing process, I can reassure her, and guide her professionally if decisons need to be made.

I have not shut the door to homebirth with twins. It is not my door to shut. The woman needs to make her choice, and I am committed to being with her as her midwife in the setting she chooses.

I know this woman has a good chance of giving birth safely and spontaneously to her two babies. I know this from my knowledge of the woman, and her previous births, and her wisdom and deep faith in God, the giver of life.

I also know the decision points that may be reached in vaginal birthing of twins.


The question, "Why bother coming here if you won't let us manage you the way we think is best?" offers a clue as to the real problem. The mother does not want to be 'managed' in the first instance by anyone - doctor or midwife. She wants to proceed in her birthing under her own natural process. If the baby or babies became distressed, or if her labour failed to progress, the hospital is able to offer specific remedial action - surgery. But that's a decision point that has not yet been reached yet.

I fully support the woman in her desire to hold off that decision until, if, and when it needs to be made.

Monday, August 24, 2009

A change of focus in this blog

The topics that I have explored in this blog in the past six+ months have been dominated by the cloud on the birthing horizon: the knowledge that Australian midwives face a future of being unlawful if we continue practising privately without indemnity insurance after 1 July next year.

As time has passed, the cloud has become blacker, as the extent of the midwife extermination campaign becomes clearer. The threat to our professional livelihoods, and to the options available to women who employ us, has become more ominous than I had imagined would be possible.


NINE MONTHS
In the remaining nine months that I have as a midwife able to practise my profession openly, I plan to use this blog to record midwifery knowledge. I hope to identify issues as they occur in my practice, briefly exploring some of the complexities of woman centred midwifery care, and decision making that promotes and protects normality in birth.

I hope that readers will understand the urgency that I feel in recording this professional body of knowledge that I have accumulated and developed over the past 35 or so years. I know that women giving birth in harmony with their own God-given physiological power will not change, regardless of restrictive laws and regulations set up by governments. Authentic midwifery that is deeply protected in the intuitive minds of women will also survive the outrageous attempts of authorities to make birth a process that is managed with production line precision by people whose job it is to enforce compliance.

Readers who are interested in the ongoing negotiations and activism around private midwifery and homebirth, please keep an eye on blogs linked to this one, including Midwives in Private Practice, and Private Midwifery Services.

Thursday, August 20, 2009

mother-child art


Today's art by Poppy and Granny

Dear reader
If you have mother-child art that you and or your children have made, please send me a pic to include here, or a link.
In all the stress of political lobbying and the fears about loss of private midwifery in the future, remember that our bodies are wonderfully made, and celebrate the wonder of motherhood and families.
jj

Tuesday, August 18, 2009

Indemnity insurance: the great obstacle

In past months, as the momentum in activism to protect private midwifery and homebirth has increased, the general agreement among midwives and consumer groups has been to accept that indemnity insurance is in the public interest. That it is somehow the right of the consumer/woman to sue the practitioner/midwife if something goes wrong.

[Pause for a moment and check the evidence of how many people who have adverse outcomes in health care have even a remote chance of winning such a case. The winners are the insurance companies and the legal representatives.]

The plan for mandatory indemnity insurance for all health professionals has been in government circles for years now – and I have been fighting it for many years. When midwives' indemnity insurance ceased about eight years ago, I was a member of the Nurses Board of Victoria, and mandatory insurance was being introduced into draft legislation. I stated that it was unreasonable for anything to be mandated if it was not accessible, and argued that, if required, the Board should provide it with registration. For my troubles I was declared to have a conflict of interest, and any time the issue of professional indemnity insurance was mentioned in Board minutes, my conflict of interest was noted.

[Yes, it is personal!]

I think we are being naïve to just lie down and accept this requirement, when what is being required is inaccessible. There’s no established ‘consumer right’ to anything about indemnity – it’s a market $$$ issue. I find it interesting (from Lisa’s blog) that the UK NMC (Nursing and Midwifery Council) said: "We do not have the legal power to impose indemnity insurance on nurses and midwives. It is extremely difficult to obtain indemnity insurance on the open market. Imposing such a requirement could place an unreasonable expectation on nurses and midwives because they may not be able to find the insurance. For these reasons we have reinforced the need for them to be honest with their clients about this situation."

So we shouldn’t argue that insurance for all health practitioners is a right, and we should not support its introduction unless it is accessible on equitable terms. If there’s no legal power for the UK NMC, there’s probably no legal power for the Australian health practitioners board. But as long as we believe there is, we will never challenge it.

The only real human right in birth and parenting is that basic ‘natural law’ right to do what our bodies were created to do. As it happens, that’s the terrain of homebirth midwifery. If a woman can’t or doesn’t want to act in concert with her own body’s physiological processes, she has to find the best on offer from the medical obstetric system – and that’s not a right, it’s a ‘privilege’ that we have in a wealthy developed society, that our sisters in many other countries do not have.

We midwives really have to think for ourselves in this, what’s ethical and moral. The Health Minister has two choices – either provide indemnity for ALL midwives in a way that is affordable and accessible, or don’t mandate it.

The Senate committee takes the easy option

A few days ago I commented on the Senate Inquiry's repeated question to the Department, "Is this [the refusal of the government to include homebirth in the indemnity package for private midwifery practice, thereby making it unlawful for a midwife to attend homebirth in a private professional capacity] an unintended consequence?"

I concluded from the Hansard that the Department was unable or unwilling to answer the Senators' direct question. In fact, their avoidance of the question suggested that the consequence was truly intended.

Yet, in the Report of the Senate committee, released yesterday, we are told that "an unintended consequence of this may be to drive homebirths underground unless an exemption is granted or an insurance product found."

The Senate Committee review has failed to recommend any amendments to this legislation, despite overwhelming public interest and response.

That's politics.

That's political buck passing.

It's a hot potato.

They are washing their hands. "Not my problem!"

Watch the midwives' blogs for comment.

Sunday, August 16, 2009

A new private midwifery blog

I am pleased to announce the 'birth' of a new private midwifery blog, PRIVATE MIDWIFERY SERVICES.

Access to private midwifery services in Australia is likely to change significantly in the year leading up to 1 July 2010. Through this blog I hope to support women and midwives who will be affected by the changes.

I would like to make a list of midwives' blogs at the new site, and invite Aussie midwives who are blog keepers to trade links. In this way anyone who is interested in following the unfolding events leading up to 1 July 2010 is able to find and follow the links. Please contact me by responding in the comments section, or by email.

Friday, August 14, 2009

The question that was not answered: "Is this an unintended consequence?"

In last week's Senate Community Affairs Committee Inquiry into the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills, the Senators questioned the representatives of the Department of Health and Ageing at length about the homebirth issue.

Senator Siewert asked: "Who looked at the risk to women and their children when women free-birth? There is an acknowledgement that home births will continue without a registered midwife. I find it incredible that we have done all this work but no-one has thought to deal with the risk to women and their children when women free-birth, because they will."

The Department representative agreed.

Senator Boyce asked: "Is this an unintended consequence?"

The response includes a curious batch of 'spin', strung together in 'Yes, Minister' style. For example:
"There are a number of players in this environment. ... under certain conditions and prescriptions ... talking about services they provide and how they fit into the matrix of birthing services ... also about a side-by-side national maternity services plan which is being developed ... a number of streams of activity occurring ... we are acutely aware of the issues ... have been having discussions around these issues ... the minister has been having discussions with stakeholders around those issues. ... I do not think we are at a stage of being able to say more than that."

Senator Boyce: "Most of us have not quite worked out whether we are talking about intended or unintended consequences."

Department again sidesteps the question, and mentions the benefit in the maternity package.

Senator Boyce: "Was the intention to deliberately frustrate the efforts of people to have a midwife attend a home birth or was it unintentional that this has occurred?"

Department again sidesteps the question, and mentions lack of indemnity.

Senator Boyce:
"Nevertheless, that [indemnity] could be actively be [sic] remediated by five o'clock this afternoon if there were a will to do so."



The inquiry continued to delve into what possible reasoning the Department may have had for this consequence - they never found out whether it was intended or unintended. It emerged that although 'qualified assistance' was not to be permitted for homebirth, unregistered persons who were in some way qualified (the meaning of 'qualified' was not defined) could somehow step into the gaping hole left by registered, experienced, qualified, independent midwives who currently attend homebirth.

As if that wasn't enough, the Department's expert on the Act stated: "There is nothing in the scheme that prevents someone from asssisting a person in a birth situation of any kind, whether it is in a clinical setting or in a home-birth situation."
EXCEPT,
if you are a "registered midwife without indemnity insurance."



It is clear from the discussion and context that this whole mess is not an unintended consequence. As has been documented in this and other blogs and contemporaty publications, the Report of the Maternity Services Review bowed to poweful medical lobbying, without acknowledging the clear conflict of interest, and de-railed the Government's early promise of true reform to maternity services.


Another quotable quote from the Department's spokesperson: "remember that it is draft legislation, not final legislation."

I reckon there's a lot more work to be done!

Post script:
The 1915 individual submissions to the Senate Inquiry are now available for review. Any blog readers who made submissions to the Inquiry, please feel free to tell other readers the number for your submission. Mine is 1592.

Wednesday, August 12, 2009

Midwifery framework

In my last blog entry I referred to the 'framework' under which midwives may be required to work after 1 July next year.

What exactly is meant by this term 'framework'?

I don't know if anyone has carefully defined 'framework' as it applies to contemporary midwifery practice, but from a simple understanding of the term, most people would understand 'framework' to mean the underlying principles that put shape and boundaries to our work, in the same way that the frame of a house defines the shape and boundaries of the house. The framework is not usually visible, but it is none the less essential.

Framework is not new. Midwifery already has a strong framework. For many years midwives in Australia have attempted to allign our framework with the international definition, codes, standards and competencies for midwifery. In many ways this constantly evolving, internationally agreed framework has supported our calls for reform of Australian maternity services, resisting medical dominance supported by anticompetitive government funding arrangements. The International Confederation of Midwives has dilligently collaborated with FIGO (Federation Internationale de Gynecologists et Obstetricians [pardon my anglicised French!]), WHO (World Health Organisation) and other key international bodies in defining and developing a strong midwifery profession.

Independent midwife Lisa Barrett has commented on the expected framework for midwifery in her blog: "In real terms this means restrictions. This is where it gets muddled. Are the restrictions to keep midwives safe or to limit the right of women to chose?"

This statement appears to me to indicate fear that some freedoms that exist at present will be lost. It suggests muddled thinking. Of course there will be restrictions: we already work under restrictions. BUT, the right of a woman to choose is a totally separate issue from the professional boundaries that the midwife works in.

A week ago a client who had booked me for homebirth asked me if I would attend her breech birth at home. Without hesitation I reassured her that it is her choice to give birth spontaneously, working in harmony with her own physical and physiological abilities, in the setting of her choice. And that as her midwife I would be with her. But I also recommended a path of action that included referral to obstetric services for consideration of external cephalic version. I work within a responsible midwifery framework. Had I ignored the need for collaboration when an abnormal presentation is detected I would have been denying this woman the right to an informed decision making process, and restricting her options to the non-intervention model under which a midwife primary carer practises.

Another woman phoned me to tell me she has just discovered that she has twins, and is looking for midwives who will support her choice of homebirth. I encouraged her to make choices that she knows are best for her babies and herself; choices that cannot be made months in advance of the birth. Her right to choose is apart from the midwife's professional framework. If, after having considered carefully all her options, this woman is labouring and intending to give birth at home, I will do all I can to provide whatever professional private midwifery services she wants from me.

The question Lisa asked is "Are the restrictions to keep midwives safe ...?" I don't think so. Any 'restrictions' we experience within a professional midwifery framework are really structure, shape, and boundaries to midwifery practice. Without integrity in the framework the whole structure will collapse. Framework does not keep midwives safe; the safety of midwifery practice is complexly and beautifully dependent on the awesome natural processes that God created, and authentic midwives know how to work in harmony with.

Framework does not conflict with a woman's right to choose between physiological and medical processes.

Monday, August 10, 2009

a new business model for private midwifery services

I would like to hear from midwives in and around Melbourne who are interested in employment opportunities in private midwifery practice.

A plan is being developed, under which midwives who wish to enter the world of private midwifery practice in a casual employment model*, may begin getting experience in coming months, with the plan to move into extended practice models that become available after 1 July next year. Under this new model, midwives will be paid a minimum of the award hourly rate for caseload practice, and work with an experienced private practice midwife.

[* Note that the usual models for private midwifery practice in Australia are either a self employed midwife, or a midwife who practises within a group.)


The future of private midwifery in Australia is at present in the hands of our law makers, and although some midwives are hopeful that solutions will be found and amendments made before the draft legislation becomes the law, we face the real possibility that private midwifery practice as we know it will be unlawful after 1 July next year.

This new business model for providing private midwifery services has potential to minimise transitional disturbances for women and midwives, as the reforms are introduced in 2010 and beyond, if indeed private midwifery survives. If not, employment options for these midwives will be severely limited.

From my personal perspective, being one of the elders of the private midwifery community, I would like to be able to continue practising independently until at least 2015. I am not opposed to change. A profession that can not critically reflect on what it does, and make changes in an effort to improve its standards and outcomes, is not in a good place.

However I will continue to oppose changes that unfairly restrict consumer access to private midwifery, and restrict midwives' ability to practise independently within the scope of midwifery, promoting and protecting normal birth. I will strenuously oppose any attempt by legislators, or by other professions with whom midwives collaborate, or even by consumer groups, to dictate the boundaries and terms of midwifery.

Does this sound like paranoia? Am I overstating the issue? I don't think so. There have been many examples of serious threats to midwifery in the sorry saga of midwifery reform 'Yes, Minister'-style in recent months, approaching a climax last week in the Senate inquiry.

I am not sure what forms of private midwifery services will survive the government's current reform process. I am aware of the expectation that midwives who are considered eligible for any government support in the form of indemnity and Medicare (the two will be linked), will be required to accept a framework that describes policies and processes. The South Australian government's Policy for Planned Birth at Home has been suggested as a starting point for the development of a national homebirth framework. The South Australia homebirth policy was never intended as a framework for private midwifery practice: it was designed as a framework for homebirth services provided through public hospitals in SA.



When I eventually put down my Pinnard for the last time, I would like to be sure that there are midwives who know and will pass on the principles of authentic midwifery to the next generation. When I started writing this blog a couple of years ago it was with the hope that I would be able to put my knowledge and passion for midwifery into a form that is accessible by other midwives and women interested in promoting normal birth. My fear is that midwives with this skill may be lost to the maternity service world in coming months.

Thursday, August 06, 2009

Streaming from the Senate committee hearing

Today I and many others who are concerned about the impact of the government's legislative reforms for midwifery watched and listened to the presentations, streamed direct from the Senate Community Affairs Committee's Inquiry into the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills. [If you follow the link you may note that only 34 of the reported 2000 submissions to the inquiry are available for public access today. My submission has not yet been posted at the site. I hope the Senators have read them.]


The people who appeared before the committee representing midwives and maternity consumer interests presented their arguments in a professional and exemplary way. Private midwifery practice and homebirth, the aspect of midwifery that has been presented as insignificant in the report of the Maternity Services Review, occupied a disproportionately large share of the time available.

I was able to listen to a few of the presentations and discussions. The Senators did seem to grasp the huge inequity in not only the proposed legislation, but also in the restrictions midwives in Australia face at present. Several speakers drew attention to the lurking shadow of unattended birth, and the expected increase in adverse outcomes as rates of unattended births rise.


I know several midwives who intend to continue as midwives for women planning homebirth after 1 July 2010; midwives who believe the moral and ethical duty of care to practise authentic midwifery for women who plan to give birth unassisted at home, outweighs the unreasonable and irrational attempts of this government to remove midwives from our private practices.

A newsletter from Homebirth Australia quotes feminist academic and homebirth mother, Monica Dux, who argued most eloquently that this struggle was simply not about homebirth, but more so that of a fundamental right for women. Her opinion piece appeared in The Age on 17 July

The assumption...that minority rights are unimportant and can be casually overridden - is both offensive and antithetical to the fundamental values of a liberal society... It is not only the rights of the minority who undertake home birth that are at stake here. This is an issue that impacts on all women.

In the past century we have seen a profound shift in the status of women, from being virtual chattels owned by husbands or fathers, to the attainment of full citizenship and (supposedly) equal rights with men. This hard-won legislative and cultural change has allowed women greater freedoms, but it has also given rise to an expectation of physical dignity, and of ownership over our own bodies, ...

The legislative squeezing-out of home birth represents a serious regression in this reform process. Given that the new laws will effectively make private midwife-assisted home birth illegal, the Federal Government is acting to deprive most women of the ability to make a fundamental choice about their own bodies; the choice to birth in a non-medicalised environment.



Giving birth under conditions that promote physiologically normal, healthy functioning of a mother's and baby's bodies is not like any other health issue. It does not require drugs or equipment or technique. The midwife's skill includes an ability to partner the birthing woman, in heart and mind and body, with the knowledge that together they can promote health.


We know that employees of legislators and health departments are reading the blogs that address the issues of maternity reform. That was stated in today's review. One Senator commented on the 'Bilby', a reference from this blog.

There is no simple way of ensuring that the needed amendments will be made before these legislative reforms become law. We must continue to draw attention to it, and demand that midwives be enabled to continue private practice, in the public interest.

Wednesday, August 05, 2009

video footage from the rally



You can access other related You-Tube videos, and this video , which is the excellent work of homebirth mum, journalist and editor extraordinaire Libby Chow.
Thanks Libby for documenting this awesome community effort.
In the name of choice, freedom and human rights - homebirth.

The speakers featured in this clip are Sally-Ann Brown, Robyn Thompson, Senator Steve Fielding, yours truly, Joy Johnston.

Tuesday, August 04, 2009

THE RALLY





A great crowd turned out thismorning, in Melbourne's cool winter weather, to tell Nicola Roxon that we want private midwifery.

People came from all around - Geelong and the Barwon coast, the Otways, Ballarat, Bendigo, Echuca, the Yarra Ranges, Gippsland, the Peninsula, and many Melbourne suburbs.

The youngest baby I saw was 6 days old, born at home.

Senator Steve Fielding came and promised his support. Thanks Steve, we need you to put families first, and protect our God-given right to give birth - to do what our bodies are so wonderfully able to do, in our own homes, with a known and trusted midwife in attendance.

















Blog readers, if you have a photo from the rally that you would like shared on this blog, please send it to me. More pics are going on the MiPP blog.

Thankyou everyone who demonstrated support today for a very worthy cause.