Friday, March 27, 2009

freedom in birthing

A true midwife will be 'with woman', while at the same time supporting her desire to be free. This is expressed beautifully in the ancient statement attributed to Tao Te Ching, about 2000 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".

Monday, March 23, 2009

When we attack one another rather than working together

19 March 2009
One of the advantages of keeping a blog is that I can write whatever I want to. In this particular blog I want to attempt to address a matter of great concern to me.

Today's topic has arisen out of a message I received this week. Apparently several people who attended the same workshop as I did last weekend have reported that I said certain things with relation to the Maternity Services Review and the actions of the College of Midwives.

I am proudly a member and fellow of the College, and have held positions on the Victoria branch executive.

I don’t know what I said that could have been construed in the way that has been presented to me. I believe everything I said was consistent with what I have been writing - very publicly - on this blog and the MIPP blog http://midwivesvictoria.blogspot.com/

I don't know who has complained about me, but I hope they will read this attempt at clarification, and I hope it is satisfactory. I am writing to ask those midwives who may have misunderstood me to please work with me and the others in Victoria who seek to protect the rights of women to employ a midwife, and the rights of midwives to practise our art in the setting of our choice. I am very concerned that some midwives attack one another rather than working together towards our common goal. This is the behaviour of an oppressed group, and we cannot afford to waste our energy on internal fighting. We need to stand tall, and proud, as midwives who have a skill that our community will always need.

It has been alleged that I indicated a belief that RANZCOG (the College of O&G's) and the College of Midwives have done a deal to ensure the demise of midwives providing homebirth services.

NO WAY! Let me tell you what I understand and have said publicly:
I have understood from their press releases since before the Report was published that RANZCOG is opposed to 'independent' midwifery. RANZCOG has a statement against homebirth at their website (no link provided). It looks as though RANZCOG have successfully sold this line to the Review team. I know of no arrangement between RANZCOG and ACM.

It has been alleged that I have said the College of Midwives is not supportive of privately practising midwives.
NOT QUITE! I have stated openly that I do have concerns that the College may be unable to do much on behalf of privately practising midwives. That is quite a different matter from the College's support. This opinion was further enforced when I listened to the Minister on Insight. See my comments at http://villagemidwife.blogspot.com/2009/03/lack-of-insight.html

For this reason I have encouraged everyone who is concerned to take action now, and not to leave the work to the College of Midwives, or Maternity Coalition, or any other group.

I have been encouraging people to contact their federal MPs about why they want to be able to employ a midwife privately, and why they want to be able to choose homebirth, or employ a known midwife to attend them in hospital.

At the study day I requested and was given a few minutes for Janie Nottingham (Materntiy Coalition Victorian Branch leader) and me to speak to the group. We asked people to take the handouts that I had brought. Anyone who would like copies of the handouts can request one - please tell me your email address. Many of the hospital midwives who spoke to me said they had no idea of the national registration.

The matter of the Report's attitude to the women who choose to employ a midwife privately for homebirth has been summarised by birthing activist Bruce Teakle at http://midwivesvictoria.blogspot.com/

"Women choosing homebirth are a trivial minority:
A strong point [in the Report] is made of the small number of homebirths which occur in Australia:
P16: shows a graph of declining numbers of homebirths in Australia from 1991 to 2006.
P16: “Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia, compared with 2.7 per cent in England and Wales, 2.5 per cent in New Zealand, and 0.6 per cent in the United States.”
P20: “New Zealand maternity data for 2004 found that, while 4.5 per cent of mothers had planned a homebirth, only 2.5 per cent actually experienced a homebirth.”

"The reasons for the small Australian numbers are not explored, in particular the great difficulty most Australian women have accessing information or care for homebirth.

"No comparison is made with other minority choices, such as caesarean section on request, and there is certainly no consideration of banning these choices.

"The Reviewers acknowledge the high number of individual submissions from women who desired greater access and funding for homebirth. Despite this, it appears the Reviewers have been more responsive to the input of those who want to control women’s choices."


Women (and a few men) who went to a lot of trouble to prepare submissions to the Review have been told that their views are not important because they are a minority. Would this be an acceptable response if it were an ethnic or religious minority? Not at all!

In conclusion, I hope midwives will stop and think before they attack one another in this or any other campaign. We may have different opinions. That's fine. We may think things should be done differently. That's healthy.

The fact is that the College of Midwives or any other organisation can only lobby the Minister for Health, who will make decisions about the actions that proceed from the Maternity Services Review. It's up to everyone who cares about the future of midwifery, and the maternity choices women have, to look at the Report and to listen to those who are writing about it, and form your own opinion. If you are not satisfied with the Recommendations made by the writers of the report, please make an effort to inform your local federal Member of Parliament. Together we can show that even a minority has the right to be heard in this country.

birthing alone

[The following is an edited version. This post was taken down for a few days out of respect for a family whose baby was stillborn.]


A major article 'Home deliveries' appeared in the Sunday Age yesterday.

The article focuses on the issue of 'free birth', and one proponent in particular. Comments by representatives of the College of Midwives, Homebirth Australia, a public hospital maternity service, a homebirth mother-lawyer, and an independent midwife are sandwiched between the sensationalist story about and comments by a woman who prefers to be an "autonomous care provider".

There are many points in this article that would be worth discussing further. The fear that home births are being pushed underground has been explored by midwife academic Jenny Cameron. The victims of restrictive government policies that force women into the care of unregulated and sometimes unscrupulous operators are women and their families. Midwives offer excellent primary maternity services in communities, working with women in complex ways to promote physiologically normal births, with the wellbeing of mother and baby being central to all professional guidance and advice.

The woman is reported to believe "that nothing bad happened quickly in labour and that there would be time to get to hospital if things went wrong." A person who believes that is simply uninformed.

The issue of birthing alone, by choice, is one that questions the very foundations of midwifery. What has brought women to the place where they believe it's best to DIY? Is this the ultimate adrenaline rush; the ultimate search for meaning?

I have been told that there are variations of the 'solo' birthing phenomenon. Often the woman's partner is present, having been instructed ahead of time as to what is expected. There may also be an unregistered birth attendant. That person may have been present for a number of births, and there may be an expectation that she would act to help if there was a need.

Someone suggested that the partner could do a first aid course in resuscitation of a baby. Resuscitation is only ever needed if a baby is unable to breathe unassisted, and this is a true emergency.

Most people would not like their tooth filled by someone who had gone along to an evening class to learn about dentistry. How much more important is the newborn child, than a tooth needing to be drilled and filled?

In many parts of Australia the only way to access midwifery services for homebirth is privately. The obvious pun on 'free' birthing is that you don't pay a midwife's fee - which may be from around $2000 for one midwife to around $5000 for two, who provide a package of professional services through the pregnancy, birth, and postnatal period. In fact, 'free' births may not be free. Lay birth attendants may charge around $1000 for a prenatal chat and the labour.

We do not know how many planned unattended home births there are. Of the planned homebirths, some are born before the midwife arrives. In my practice alone, I might see one or two a year. There are many more unplanned 'out of hospital' births - the babies that come quickly, before the mother has got to the hospital: in the bathroom at home; in the car; on the freeway ....

Some authorities claim that most planned unattended births are that way because the woman has no access to a midwife who is able to attend birth in the home. I don't think anyone really knows, but that has not been the case in the planned 'free' births I have heard about lately.

Midwife means 'with woman'. Since women began having babies, other women have been 'with' them, and out of this phenomenon the professional midwife has evolved. Something has gone very wrong when a woman believes she is better without any skilled professional attendant. I grieve for that woman. A true midwife will be with woman, while at the same time supporting her desire to be free. It is expressed beautifully in the ancient statement attributed to Tao Te Ching, about 2000 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".

Monday, March 16, 2009

choices that most don't know about

A couple of weeks ago I wrote on Choice with reference to an Opinion piece by Age Editor Lucy Beaumont, who had stated "Women don't have a choice when the health system can't deliver."

I responded with the claim "There is only one *choice*, that a woman either accept the work her body is doing, or accept the medical intervention." I stand by this statement, as far as the basic natural processes in that amazing childbearing continuum are concerned.

However ...

[Yes, life is complex. There are no simple answers]

... There are a whole lot of choices in childbearing that most women don't know much at all about. Most come under the banner of 'routine' or 'standard' actions by health professionals, and most are done with little discussion and not even a pretense of informed decision making. These include:
. group B Streptococcus screening and subsequent antibiotic treatment in labour
. the induction of labour
. assessment of size of an unborn baby
. assessment of fetal wellbeing
. antenatal prophylactic Anti-D immunoglobulin for Rhesus Negative women
. assessment of dilation of a cervix
. time taken and progress in labour
. 'management' in Third Stage, and blood loss
. measurement of blood loss
. Vitamin K for newborn babies
. Hepatitis B Vaccine for newborn babies

A woman who simply accepts the standard care in this set of issues, and many more, may find that she has, in reality, no choice. She gets swept up on a production line conveyor belt.

Learning how to take responsibility for your own decision making probably begins before conception. Reliance on the little blue line with pee-on-the-stick pregnancy diagnosis rather than quietly accepting changes that come with early pregnancy; imagining that bonding is enhanced via the blotchy grey image on a computer screen, while paying no attention to the timeless event of 'quickening'; ... these technological advances while being very useful for a few, are probably setting most women up so that they follow each other like sheep going down the shute towards their ultimate fate.

Saturday, March 14, 2009

Sara Wickham's study day

Today midwives had a good study day with Sarah Wickham, hosted by Capers.

Sara's topic was 'Women, midwives, risk and decisions'.

Many of Sara's articles, including discussions and references on Anti-D, vitamin K, Group B Strep, and post term pregnancy are available at her website www.withwoman.co.uk

Thursday, March 12, 2009

A blog worth reading

This blog is by a woman Lauredhel. I have added a link to my blog list, and have left a comment after the post Maternity Services Review: Medicare payments to OBs up from $77m to $211m since 2004.

Here's the comment:
I am one of the independent midwives in Victoria facing loss of my livelihood if the recommendations of the Review are implemented. Most of my colleagues are keeping quiet. Perhaps it will go away!

I find the Report wishy washy and lacking any direction other than backward. The Discussion Paper advised that: “Improving the delivery of maternity services in Australia is not the responsibility of any single party. While there are actions which could be undertaken by the Australian Government on its own, substantial change requires a combined approach.”

Let's get real. Most of the Recommendations could be done without the Australian Government's permission. The Minister has the opportunity to move the focus of maternity care from a broken system, and a financial monopoly privileging the medical profession, to the woman, by funding a woman to obtain the basic care she needs.

Yet from the Report, and the Minister's statements on the SBS Insight program on Tuesday night, she seems unaware that if she follows the advice of the Recomemndations she will be setting birth back into the doctor supervision era that most midwives remember. It was only 1996 when Victorian midwives were free of the old regulations (1985) that required us to have a doctor's permission to do a vaginal exam. Whose vagina, you may ask?

Wednesday, March 11, 2009

LACK OF INSIGHT

The SBS INSIGHT program that went to air last night had the title
'Why are more Australian women having Caesarean sections?'

Guest panelists included mothers, midwives, and obstetricians. The Health Minister, Hon Nicola Roxon, joined the discussion by video conferencing. The transcript and video are available at the website. You will also find at that site a growing number of comments (over 500 at the time of writing this blog) from interested people.

What was clear to me, while watching the program, is the serious lack of insight that Nicola Roxon has. She played the safety card – where does she get that information from? Where is the evidence? She followed the script of the Report almost to the word.

There was no sign of acknowledgment or understanding that by implementing the recommendations she will be ushering in a new era, more restrictive to midwifery practice and to women’s choice of care provider than we have ever known before. We need to ask serious questions about the quality of advice about midwifery the Minister has been given. It’s not just about homebirth. It’s about a midwife’s right to choose to practise midwifery in any setting, and about a woman's right to access midwifery care privately if she chooses.

The absolute arrogance and lack of insight by obstetricians Ted Weaver and David Molloy astonished me – and you would think I had been around long enough not to be astonished. Would they recommend specialist primary care in other areas of medicine and surgery?

I was proud of the efforts of midwives in the program, and the women who spoke of woman centred care.

We have a big job ahead of us. We have a health system that supports every medical/technological choice, and restricts those who want to give birth in harmony with their body’s physiologically normal processes; clearly the safest and most satisfying way for most women.


Jo Hunter from Homebirth Oz has sent out a message about a petition

Please also sign our online petition to keep homebirth legal.

http://www.ipetitions.com/petition/australianhomebirth

Tuesday, March 10, 2009

A BIG PUSH FROM WOMEN



If you would like to join in the 'BIG PUSH', please go to the MIPP blog

Please let me know how your MP responds when you contact her/his office to tell them why it is important that Australian women are able to access private midwifery services, and why it is essential Australian midwives are able to work in the full scope of midwifery practice, including homebirth.

Thankyou.
Joy

Monday, March 09, 2009

A response to the Maternity Services Review

"It appears that the Reviewers have conceded to fear of extreme medical voices, over the interests of women. Hopefully the Minister, who is directly accountable to women, will be braver." [Bruce Teakle, Maternity Coalition Queensland Branch]

As anyone who has read this or other Australian midwives' blogs will understand, the Report of the Maternity Services Review recommends that the Federal government should prevent midwives from practising as private practitioners, which also means, in most of Australia, an effective outlawing of homebirth.


In response to this very real threat I feel there is an urgent need in Victoria that we work for free homebirth options, and widespread caseload, with the option of homebirth, for midwives working in the public system. (If any of the private hospitals want to join in that’s fine, but I’m not holding my breath!)

I don’t think women should have to declare ‘home’ or ‘hospital’ until they are ready. The midwife should have competence and unrestricted practice to go with the woman wherever she wants to give birth. As we have often said, it’s not about the bricks and mortar, or the curtains. The Report's language of 'informed choice' and 'access' to 'evidence based' models of care is mere rhetoric, when the recommendations of the Report announce that the very model which many of its submissions promoted and backed with significant evidence is to be summarily withdrawn.



The Report draws attention to the fact that a very small proportion of Australian women choose homebirth; that many of the submissions were from mothers who were dissatisfied with the choices available to them, and in fact had chosen homebirth or other midwife led models; and that moving to a mainstream private model of care incorporating homebirth 'risks polarising the professions' (whatever that means!). As Bruce Teakle has observed, the Reviewers "have conceded to fear of extreme medical voices, over the interests of women."

As Allison Leemen said (ABC Unleashed) "Homebirth with an independent midwife is a great model of care for lots of reasons, key among them that it provides continuity of care with a known carer - something the Maternity Services Review says it wants to see in hospital -based models. So why is it killing off the only model that reliably delivers that care?”

We must insist to our professional associations as well as to the government that homebirth is not about the marginal minority of women or midwives. Internationally homebirth is recognised as normal midwifery practice and is a safe and reasonable option for many women.

We know that many more women would want homebirth if it was free, and this has been demonstrated in the Review by the rates of homebirth being highest in NT, WA and SA where publicly funded options are currently available for some women. People do not, without strong reason, ask for something that is not available. Those who are prepared to pay for homebirth are usually well informed. Other women are on a journey of discovery when they become pregnant, and if the system offers them a reliable care option, such as homebirth, they will think about it then. Shutting down homebirth options by shutting down independent midwifery makes no sense at all. Furthermore, midwives in Victoria will quickly lose competence and confidence in homebirth practice if we are forced to cease our practices. If, on the other hand, there were publicly funded homebirth models on offer, whether or not independent midwifery continues, many more midwives could be upskilled quickly by those who are currently experienced in homebirth.

Friday, March 06, 2009

Happy International Womens Day

Most who read this blog are women, and most are deeply interested in that amazing, demanding, sometimes overwhelming, but quintesential womanly time of life, when we bear and nurture our children.

The following message is from VICTORIAN WOMEN’S TRUST

Dear Friends of the Trust,

Wishing you a happy International Women’s Day this Sunday!

The Women’s Trust will have a stall tomorrow (Friday 6 March) at the Queen Victoria Women’s Centre market (just behind the QV building, 210 Lonsdale Street) from 11am-3pm. If you’re in the city and can drop by, come over to the Trust table, check out our publications and merchandise (including the Women’s Anthem CD) and say hello.

Also at the market will be the Brunswick Women’s Choir who will be singing the Women’s Anthem ‘Love & Justice’ during two 15 minute sets at approximately 12.05 and 12.45pm.

The Anthem ‘Love & Justice’, which we commissioned Kavisha Mazzella to write last year as part of the Centenary of Suffrage in Victoria, will also be getting some airtime this weekend as part of IWD celebrations.

A recording of the inaugural performance of the Anthem late last year (with a choir of over 450 women) will be played on:

*774 ABC Melbourne – Tracy Bartram, who led a verse of the Anthem at the inaugural performance, is filling in as host this weekend on the Saturday Morning program (7 March). She will interview Executive Director Mary Crooks after the 7am news bulletin, as well as play the live recording of the Anthem.

*ABC Radio National (Melbourne 621 AM) - Paul Petran of Music Deli will be playing the Anthem at the end of his program on Friday evening (6 March) (program starts @ 8.05pm), and on Saturday morning 7 March (program starts @ 4.05am (for insomniacs and shift workers!). It will be repeated at the end of the program on Sunday 8 March (program starts @ 4.05pm). The program goes for one hour - if you miss it you can listen in to the podcast for a month afterwards on www.abc.net.au/musicdeli


The Trust has in stock copies of a CD which includes (1) Mary Crooks’ introduction providing the historical context of the anthem, (2) the inaugural performance of the anthem, (3) Convenor Dur-e Dara’s gifting to the women of Victoria and beyond, and (4) practice tracks, with Kavisha Mazzella singing each part for you or your choir to learn from. Copies are available for $10, including postage. If you would like to obtain a copy of the CD, please email women@vwt.org.au or phone (03) 9642 0422.

Have a great long weekend!

Tuesday, March 03, 2009

IF

IF
the federal government provides an affordable indemnity arrangement for independent midwives, before 1 July 2010
THEN
midwives will be able to continue attending women who plan homebirth, and accompany women who go to hospital, as we do today.

IF
there is no indemnity provision for independent midwives
THEN
* the only homebirth options will be those provided under public funding
* the only midwives will be those who are employed by hospitals, health services etc
* midwives will not be able to provide any private fee for service consultations
* some women will engage unregistered attendants to attend them when giving birth at home (that is, go underground). This puts mothers and babies at risk, as there is no regulation or accountability of the attendants.



SINCE
there are no publicly funded homebirth programs in Victoria

AND
the refusal of the Maternity Services Review to do anything about funding homebirth nationally means that the buck has been passed from the federal health portfolio back to the state

THEREFORE
mothers and midwives and anyone else who considers midwife led models of care with the option of homebirth a reasonable choice need to make a concerted effort to approach the State Health Minister, and their local state government MPs, to urgently request action in the public interest.

Monday, March 02, 2009

CHOICE?

A birth made to order? What a joke

Author: Lucy Beaumont
The Age Opinion March 2, 2009

"Women don't have a choice when the health system can't deliver."

Journalist Lucy Beaumont has written about her own devastating experience of birth. And she seems to have concluded that she was hoodwinked into believing that "this labour thing was going to be tough, but "good tough". More intense than anything I'd ever physically known before but essentially positive. And for some reason I felt entirely up to the challenge, supremely confident after a fairly stress-free pregnancy."

The memory of lapsing into unconsciousness as she haemorrhaged; of the doctor at the business end, and the midwife next to her giving her face a slap in an effort to bring her back - that memory will be with her as she approaches the birth of her next child.

I value the opportunity to reflect on this account, and am writing for those readers who are wondering how might this experience have been different.

Beaumont is right, "Women don't have a choice when the health system can't deliver."

But I would like to take that statement a step further. "Choice" in childbirth is one of the hugely misunderstood concepts. There is only one *choice*, that a woman either accept the work her body is doing, or accept the medical intervention. The only choice that this woman had, after experiencing prelabour for 48 or so hours, and the 'postmature' stamp, was to agree to induction of labour or to continue waiting for spontaneous labour to establish. Once you step over the line, into 'Plan B' I call it, you have very little choice. In fact, the idea of choice becomes a bit of a sadistic game: "Have you had enough of natural birth now? See, you can't do it yourself. Let's get this epidural in and move into the 21st century!"

We can all be wise with the help of hindsight. If I had been advising this woman at that time of her critical *choice*, would I have had the confidence that I now have in writing about choice?

The difference in my role is that usually I would only be involved in that *choice* if that woman had asked me, personally, to advise her as her primary carer. And that arrangement is usually set up in early pregnancy, giving us the opportunity over the months of the pregnancy to build confidence and trust in our shared decision making. It's called midwife led continuity of carer. It's the sort of maternity care that is based on good evidence! The Cochrane Review (Hatem 2008) not only confirmed the safety of midwife led care, but concluded that “All women should be offered midwife-led models of care and women should be encouraged to ask for this option.”

"All women ..." What a paradox we face at present in Austrlia today that the very providers (self employed midwives) of such a care option are facing deregistration because our government's reviewers of maternity services don't consider the women who employ us, or the midwives who work this way, worth protecting.

So if Lucy had been in my care (or any other midwife who accepts the 'caseload' primary carer role seriously, whether employed or independent), we would have been able to explore what was important to her. I could have encouraged her with words like, "You and your baby are well. You are obviously getting ready for labour. There is no valid reason for us to interfere with your body's preparation for spontaneous labour."

I know these things are true, because any mother or baby who were not in good shape at the beginning of the induction process would not have proceeded to a vaginal birth.

There are times when a woman in a midwife's care decides that her best choice is to step out of 'Plan A' into 'Plan B'. The known and trusted midwife continues working with her, using her knowledge and skill to promote normal birth. The partnership between the woman and her midwife is often the key to maintaining good progress, or alternatively, to moving into further appropriate medical or surgical management.