Saturday, October 24, 2009

More on caesareans and delayed childbirth - commentary by Judy Cohain

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.


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
04111 90448

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.

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]