Friday, February 27, 2009

Home birth: the unheard horrors

Thankyou everyone who has sent messages of support and concern for the midwives who face loss of our livelihood because we are unable to access professional indemnity insurance.

If you have been following this blog I hope you will see that I have attempted to present issues in independent practice, and homebirth which is the main practice terrain for independent midwives, in an unbiased way.
Yes, I am outraged.
Yes, I am wondering how I will make a living next year.
I'm not really old enough to retire; my superannuation savings have been disappearing at an alarming rate; and I don't think I would be strong enough to work shifts in hospitals.
My heart would break anyway, even if the arthritis in my knees and back could be managed.

But today a letter in The Age has brought the debate to a new low level. It's such an outrageous letter that I will take the trouble to copy it into this blog, and I will place my comments in [BOLD - AND YES, I AM SHOUTING!]:

Home birth: the unheard horrors
I WISH to object to Alison Leemen's criticism of the Federal Government's maternity review (Letters, 25/2) and her claim that the Government is "criminalising home birth". The Government is sensibly responding to the overwhelming data that in Australia, home birth is three times as risky for both the mother and her baby. [THIS IS SIMPLY NOT TRUE. THERE IS NO SUCH DATA. ALL MIDWIVES ATTENDING HOMEBIRTHS SEND THE DATA TO THEIR STATE OR TERRITORY'S PERINATAL DATA COLLECTION UNIT, AND WOMEN WHO TRANSFER FROM PLANNED HOME BIRTH TO HOSPITAL ARE ALSO REPORTED ON.]


A woman has the right to give birth at home, but she takes an increased risk and legally she must be advised about this. We see the avoidable disasters after attempted home birth daily in hospitals [I THINK THIS IS A GROSS EXAGGERATION AND WOULD LIKE TO SEE THE ACTUAL FIGURES FOR THE ALBURY-WODONGA HOSPITALS. THE MIDWIVES I KNOW IN THAT AREA ARE RESPECTED MIDWIVES, AND SINCE THERE ARE ONLY ABOUT 200 HOMEBIRTHS IN VICTORIA ANNUALLY, AND ONLY ABOUT 20% OF PLANNED HOMEBIRTH WOMEN GO TO HOSPITAL, I DON'T KNOW HOW DR MOURIK SEES WOMEN DAILY. WE KNOW THAT THERE ARE NO GURARNTEES EVER IN BIRTH. WE SEE AVOIDABLE DISASTSERS AFTER ATTEMPTED HOSPITAL BIRTH TOO]. These women do not go to the media with their horror stories to warn other women; we only hear if it goes well.”

Dr Pieter Mourik, obstetrician, Wodonga


It is likely that some of the misinformation about risk in Australian homebirth relates to a publication in 1998 in a respected journal by Bastian, Keirse and Lancaster (reference given below). Methodological criticism of the study by Wagner (1999) illustrates that less than three quarters of the data was collected by an ‘orthodox and acceptable’ method, giving a perinatal mortality rate of 3.8 per 1000 births, comparing favourably with other homebirth studies and the general Australian rate at the time. The remainder of the data was derived from ‘unorthodox and unacceptable’ methods, which Wagner considers unreliable. The latter group had an inflated perinatal mortality rate of 20.8. Wagner suggests that conclusions drawn about unacceptable death rates from unreliable sources are not valid.

Bastian H, Keirse MJNC, and Lancaster PAL 1998. Perinatal death associated with planned homebirth in Australia: population based study. British Medical Journal 317(7155):384-388.
Wagner M, 1999. Critique of BMJ Article. Homebirth Australia Newsletter No 52, 53 April p.18.

Thursday, February 26, 2009

What does the Report of the Maternity Services Review mean?

Having read the Report and its Recommendations, I understand that Australia could very well be looking at the end of private midwifery practice.

For those who aren't aware of the expected changes in regulation of midwives, and other health professionals, the new system of national registration is to be implemented 1 July 2010. Without insurance, self employed midwives will be unable to register. The hope within professional circles was that the federal government would provide the means by which indemnity insurance could be available, just as they did for the obstetricians when their medical defence organisations were in strife a few years ago.

The mention in the recommendations of 'consideration' of insurance for midwives (and privately practising midwives are the only ones who need it) is so couched in provisions and escape clauses that I for one feel it's a very remote possibility.

The 'consideration' of an indemnity arrangement would [only] be for "appropriately qualified and skilled midwives, within collaborative team-based models". What does the reviewer think a midwife is? Our qualification is obtained and kept within a standard process of education and annual renewal - just as is the case for other professionals. A midwife who provides primary maternity care, the most basic level of care there is, has skill working in harmony with the natural processes in pregnancy, birth, and care and nurture of a newborn baby. The definition of the midwife (ICM 2005)
requires a midwife to promote normal birth, and to work in partnership with women - amongst other things. Curiously missing from the government's Report is any notion of the midwife's duty of care to promote normal birth, and partnership with women ????

The use of the term 'midwife' throughout the document is incongruous with the international definition of a midwife. When you read 'midwife' in the report, it may make more sense if you substitute the term 'maternity nurse' or even 'obstetric assistant'.

By the end of this year, without a professional rescue arrangement, independent midwives throughout Australia will have to stop making bookings for births after 1 July 2010.

The report recommends providing indemnity for midwives in “collaborative team-based models”. What does that mean? Collaborative models usually have doctors and midwives working together – even though midwives do midwifery and doctors do obstetrics which is a different job. Even the privately operated midwifery group practices would not, I fear, be considered collaborative models.

Independent midwives do work in collaborative models. We make bookings at public hospitals for women planning homebirth - in Melbourne the Women's and Monash Medical Centre accept these bookings on the authority of the midwife's referral. If we consider a medical review is advisable we can write a letter of referral, and ask the hospital to advise on further action. That's collaboration, and it's consistent with common sense and the ACM national midwifery guidelines for consultation and referral. But I don't need to convince readers of this blog about that - it's obvious to anyone with their eyes open.

I don't understand the need of the Review to sacrifice the independent midwife - to use us as a scapegoat. We offer a service (one to one primary care midwifery with the option of homebirth) that is not available under other maternity models of care. Our outcomes are excellent.

What should the 250 or so women who plan homebirth each year in Victoria do? What should the 30 or so midwives in Victoria, who currently provide homebirth services, do?

Many of the submissions to the Review asked for consideration of homebirth as a publicly funded option. The Review has come back with a strong NO on that one. Why? Here are a couple of quotes ...

"Many of the consumers who participated in the Review consultation process had strongly held views about government funding for models of care that included birthing in a home setting. A number of submissions to the Review referred to the evidence of positive outcomes for homebirths for low-risk pregnancies. The Review concluded that, while homebirth is the preferred choice for some women, they represent a very small proportion of the total." (p20)

Excuse me! Didn't you notice that it's very difficult and costly to organise homebirth - surely the consistent small number says something about how important homebirth is?
"In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term)." (p21)

Sooo ... the midwives and women don't count - it's all about maternity health care professionals. Peace and harmony in the home is more important than equity and fairness. Homebirth does not require a bunch of experts - it's about well women giving birth with a midwife or 2 in attendance. It's not rocket science! But it gets better ...

"The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing
the expansion of collaborative approaches to improving choice and services for Australian women and their babies."

So the Review, in its wisdom, has decided that, rather than "polarising the professions" it will shut down the choice of homebirth.

Homebirth women, a minority group within the Australian birthing community, can be dismissed. They don't matter. Homebirth midwives, a minority group within Australian midwifery, can be deregistered. Our professional commitment, our livelihoods, don't matter.

And do you know what's a real worry? It's the silence of midwives - my colleagues in both private practice, and in employed midwifery. There has been very little discussion or comment on any of the forums, email lists, or blogs that I have checked out. Keep your heads down ladies. Perhaps it's just a bad dream?

Sunday, February 22, 2009

Recommendations 17 and 18

Blog readers will have noticed the information on the Maternity Services Review, and the Report which was published yesterday.

If you are wondering why this is important, the big question that looms, and that there was a widespread hope for a lifeline through the recommendations of the review, is the future of independent midwifery in Australia. Next year, from 1 July 2010, new legislation will be enforced requiring all health professionals to demonstrate suitable indemnity insurance arrangements for their private practices, in order to be registered. Every health profession, EXCEPT midwifery, is able to buy indemnity. The Australian government provides special indemnity arrangements for obstetricians and procedural GPs so that they can afford insurance.

The recommendations of the review are a long way from structural reform that will in any way change the status quo. The last two recommendations, #s 17 and 18, are of interest to midwives who provide primary care through the birthing continuum.

Recommendation 17:
That, noting the potential issues to be resolved including the potential interaction with Private Health Insurance arrangements, the Australian Government gives consideration to arrangements, including MBS and PBS access, that could support an expanded role for appropriately qualified and skilled midwives, within collaborative team-based models.

Recommendation 18:

That, in the interim, while a risk profile for midwife professional indemnity insurance premiums is being developed, consideration be given to Commonwealth support to ensure that suitable professional indemnity insurance is available for appropriately qualified and skilled midwives operating in collaborative team-based models. Consideration would include both period and quantum of funding.

Recommendations 17 and 18 give me no indication that any self-employed midwife – even those in privately operated group practices – will have any future under these proposed reforms.

Although we (self employed/private/independent midwives) collaborate constantly, using the ACM Guidelines (and basic common sense and knowledge of a midwife’s scope of practice), it would be difficult to argue that we practise in “collaborative team-based models” that would satisfy our colleagues. I wonder where the evidence supporting whatever is meant by that phrase comes from.

It was clear from the RANZCOG responses to the review and statements to the press that ‘independent’ midwives are not acceptable, and I am not in the least surprised by the lack of support for the midwife’s right to be employed directly by the woman, or the woman’s right to employ her own midwife/ves.

So ...
Although there is talk in the recommendations of indemnity insurance, there is no commitment to providing it so that midwives can continue our private practices. The next 16 months, leading up to 1 July 2010, will provide interesting subject material for this blogger.

Tuesday, February 17, 2009

Public and private maternity hospital outcomes

A new research paper, 'Adverse outcomes of labour in public and private hospitals in Australia: a population-based descriptive study' (authors: Stephen J Robson, Paula Laws and Elizabeth A Sullivan) has been published in the Medical Journal of Australia, and is available online.

It’s interesting that the publication of this paper coincides with the release of the report of the National Health and Hospitals Reform Commission, the federal government’s main advisory body on health reform – a report which seeks to send 14% of wages to private health funds!!!. See the article in today's Age.

I think the paper itself fails to identify the most important issue in private maternity care - that in private care the woman has a known primary or leading carer who is committed to overseeing all professional decisions, whereas in most public care the woman has no such trusted primary carer. We know that women have higher levels of satisfaction with private care when compared with fragmented public options. It’s a no-brainer!

Some years ago I spoke on Jon Faine’s ABC radio program, and Christine Tippett was also there. Dr Tippett said that she loves to do midwifery, indicating that she gets quite a buzz out of an uncomplicated spontaneous birth. I think this is a widely held view in obstetrics, and although I was firstly puzzled then outraged, I have realised that it’s probably true. Doctors who are providing primary care for well women who require no ‘help’ to get their babies out are doing the work of the midwife, in having a sort of partnership with the woman, who trusts them. The person in the room who actually has the qualification of ‘midwife’ is functioning as an assistant to the primary carer who actually happens to be a specialist obstetrician. And please note that that midwife could not provide a similar service as the doctor, because the woman trusts the doctor, not the midwife.

There is no sense at all in supporting ‘public’ over ‘private’ maternity services as they are currently offered in the Australian context. All women giving birth need to be able to trust the person who is making professional decisions, and 'public' women ought to be able to access that option too. We know that the midwife is able to provide this service, and collaborate with specialist doctors and services when complications arise. This is the point that midwifery and consumer advocates need to make loudly and clearly.

Saturday, February 14, 2009

Mirrors, stools and other birth gadgetry

As I have read blogs of other midwives, I have found that some of the issues they are writing about remind me of what we used to do years ago, that I have dropped from my midwifery practice.

Today I want to reflect on mirrors, and birth stools. Another such topic, for another day, is psychoprophylaxis breathing routines, and other strategies that I was introduced to in the early 1970s; firstly as a midwifery student and then as a mother to be in the Lamaze childbirth classes.

I don't use mirrors at all. I don’t have one in my kit, and a mirror is not on the list I ask mothers to look at in preparation for birth. I think they are one of those active childbirth gadgets from the 70s and 80s that we should move on from.

My reason for this belief is very personal - I found the mirror a hinderance rather than a help, and I think I now know why. When I was giving birth to my first 3 children (in 73,75,&77), I lived in Michigan USA. As the birth became imminent I was put on a 'delivery table' in an operating room; my hands were strapped down with velcro so that I wouldn't contaminate a sterile field (as if there was one!), and someone held a *mirror* so that I could see how I was going once the head was on view. And, doing as instructed, I pushed with all my (considerable) might, got petichial haemorrhages in my eyes and on my chest, and tore my perineum - as you do.

It was not until years later, as I began to assimilate the knowledge of brain activity and intuitive processes, that I remembered the mirror. This was a shock to me at the time (I had recently graduated as a midwife, so of course I had held mirrors too). Using a mirror requires complex neocortical brain activity, as you become aware of the reverse image a mirror gives. The very part of the brain that needs to be kept quiet is stimulated. I have come to the conclusion that if people really want to use mirrors they should try using them for practice while the engage in other activities in the generative region, and see what happens.

I now encourage mothers, if they are unsure, to put their hand on their baby to gauge how much head is there, and just how much push they need to keep the baby moving. The touch sensation, by which we feel our own labia, and we feel that ‘other’ (ie not self) is a profound sensation. I don’t understand brain physiology very well, but I think the link formed in our minds by that sort of touch is very different from the link initiated by sight that is reversed.

Why did our Creator make our bodies to give birth out of sight? Perhaps we don’t need the help of vision for the job we need to do. I think if we were meant to see our births we would have been made with extendable eyes or much more flexible backs or something like that.

I came across discussion about birth stools at This midwife is setting up her practice, and she notes “I'm having a hard time deciding which birth stool to purchase. I want one that doesn't inhibit the sacrum, which is harder to find than you'd think.”
There are a number of comments to the blog; mostly giving their opinions about the best type of birth stool. One respondent, a midwife educator Sarah Stewart from New Zealand wrote “I have had women who had had nasty anterior tears using birth stools so I tend to encourage women into other positions like kneeling. Is that a general trend or just peculiar to me?”

I haven't used birth stools for years now. The idea of the birth stool seems to be linked to closely managed second stage, with the midwife pondering the perineum and directing the pushing. I have also seen tearing and bruising and nasty haemorrhoids after birth stool second stages. Like Sarah, I think kneeling is often preferable to sitting, and many women like waterbirth so no other support needed (and it's likely that noone sees the birth). I encourage the mother to guide her baby's birth by keeping her hand on the head as it emerges, so that her pushing is appropriate to the baby's movement. Occasionally a couple of good pushes sitting on the toilet gets the baby moving in the right direction.

I remember the days (and nights), in the late 80s and early 90s, when I was working in hospital birth suites – St Georges first, then Mitcham Private. Birth stools were in use, and as I read current literature and reflected on my midwifery experiences I developed a practice of encouraging the mother to move from one position to another in second stage. I felt that by changing from sitting to kneeling; by intentionally moving the pelvis as a belly dancer does; the mother is able to rock the baby’s head slightly, and release any muscle tension, which can achieve progress. When I was with a mother who was struggling with progress in second stage, I looked for several positions that she was willing to use, in sequence. The birth stool may have been one of those positions, used for only 2 or 3 contractions at a time.

The birth stool has been in various cultures for many years. But is it not just another way of containing or ‘confining’ the birthing woman? The freedom to find a position when the birth becomes imminent is a key to active birthing. Does the presence of a birth stool not subtly suggest to the labouring woman that she ought to use it?

Thursday, February 12, 2009

A safe place to give birth

A baby girl is sleeping, safe and sound, in her home in the hills to the East of Melbourne. She was born on Monday morning, just as the early assessments of the extent of the devastation caused by unimaginably powerful firestorms on Saturday was coming through in the news.

The forest all around is dry - there has been precious little rain for a long time. The magnificent eucalypts surround the little timber houses: tall mountain ash, with huge slabs of bark hanging and flapping carelessly against their trunks. It's these loosely draped bark sheets, and other dry bits and pieces, that ignite quickly and are caught up, becoming burning missiles in the strong dry winds.

On Monday morning I was not listening to the radio, although it was on. I was focused on being 'with woman'. It was only later that I heard about the number of people who had died; the number of homes that had been destroyed; and the communities that had been left as blackened piles of rubble. And the numbers have continued to grow, as the stories and pictures have circulated, and people try to come to terms with the worst bushfire on record. Our world has changed.

The mother mentioned to me, after her baby had been born, that she had had a dream the previous night. She had dreamt that her waters had broken, and for some reason she was on the back of a ute, in labour, being taken to my house. She woke up and found that her waters had indeed broken, and her bed was wet. She got up, had a shower, and called me to let me know about the waters - didn't mention the rest of the dream though.

When the labour became intense the mother knelt on the floor and gave birth in the front room of her home, with her husband and two little boys, and me, her midwife, nearby.

It was only the next day, as I returned for a postnatal visit, that I realised the meaning of the dream. Saturday had been the hottest day on record for most of Victoria. The sky was an eerie smoky brown colour. The wind was strong and menacing. I had stayed inside the house, and when I stepped outside it was like going into a fan forced oven. I realised that this was the environment in which this mother's body was preparing for its moment of release of the little one. In her sub-conscious mind the mother must have known she would need to find a safe place, should a fire start to threaten anywhere near her home. In her subconscious mind she must have seen my home, where she has been coming for prenatal checks, as a safe place. (I don't have an explanation for the ute!)

The mother told me her little boy had been unwell on Saturday - a high temperature, dehydrated. She had been cooling him down with wet cloths, and giving him extra drinks. He improved on Sunday, and the weather was mild. The mother was able to move on from caring for her sick child, to birthing her new baby. She felt safe enough, but in her subconscious mind there was the plan to get out if the fire situation should threaten once more.

Perhaps I am imagining things; making up a dramatic explanation to someone else's dream. I don't think so. The need for a safe place is one of the most basic factors in the nesting instinct of not only human mothers, but other animal mothers too. In the deep sadness that I and everyone who has been touched by last Saturday's fires feel, I am truly privileged to be a midwife, and to help in some way to provide a safe place where a woman can give birth.

Wednesday, February 04, 2009

SMH daddy blog 'Home deliveries'

Here's a good 'Home deliveries' article by blogger Sacha Molitorisz, with lots of comment - the good, the bad, and the pathetic. I guess that's what blogging is all about.

Later (Thurs 5 Feb)- Well there are now 84 comments, and the blog was written just 2 days ago! I reckon that's a clear indication of the eagerness people have to share their opinion on birth.