Tuesday, April 28, 2009

Submission to the Senate Inquiry into National Registration and Accreditation Scheme for Doctors and Other Health Workers

Submissions are sent to:
The Secretary
Senate Community Affairs Committee
PO Box 6100, Parliament House
Canberra ACT 2600


I am writing to the Inquiry as a midwife. I have been a midwife since 1973, and working independently since 1993. Aged in my late 50s, I am nearing the end of a satisfying and productive professional career which includes practice, teaching, and other professional consulting and writing.

It is with great sadness that I prepare this submission, as I recognise the likelihood that the new laws governing registration and accreditation of my profession will also signal the termination of my right to practice, due to the fact that professional indemnity insurance is not available for midwives.

I am not opposed to national registration, or to the mandating of indemnity insurance as a condition for registration, but I am deeply concerned about the Government’s inequitable support for the medical profession over the midwifery profession in this instance.

In our submissions to the federal government’s recent Maternity Services Review I and many other midwives, consumers, and maternity organisations informed the Review of the urgent need midwives have for indemnity that will cover our private practices. The Report (Section 6.2) acknowledged the Government’s support for the medical profession, including the Premium Support Scheme, “which provided financial relief to specialists such as obstetricians so that their premium costs relative to other specialties became more affordable”, but failed to recommend that any similar support be available for midwives, or to offer any other lifeline to midwives.

My question to the Senate Inquiry is, “how can one professional group (midwives) be excluded from practice on the grounds of no insurance being available, when the group competing for the same work (obstetricians and proceduralist GPs) receive substantial government support to purchase their indemnity insurance?”

This anomaly appears to be in breach the intent of competition policy and monopolies supported by government funding. Yet it appears that under the Trade Practices Act, a case would need to be made under Section 45DD, that a Secondary Boycott situation existed (eg: “We found Obstetrician A colluding with Obstetrician B to prevent Midwife C from working.”) This scenario is most unlikely, as the Government’s financial support through Medicare provides the medical practitioners with an effective monopoly of prenatal (out of hospital) care, and the inability of midwives to obtain professional indemnity insurance excludes midwives from most opportunities to provide care privately in hospitals for women during the birth and post natally. Hence there is no case of ‘Secondary Boycott’ or collusion to exclude midwives from practice at a community level, as there is a systematic exclusion of midwives through Medicare and the funding of hospitals. I believe that the Government needs to remedy this situation in the public interest.

A paper 'The Trade Practices Act and the Health Sector' was presented by Professor Allan Fels, the then chair of the ACCC, in 1998. Prof Fels stated that the role of the ACCC includes "looking at health professionals' conduct to determine whether it promotes or hinders patients' interests in being able to choose among a variety of services and price options according to their needs", and "competition policy is based on the premise that consumer choice, rather than the collective judgment of the sellers, should determine the range and prices of goods and services that are available. Or in other words that the competitive suppliers should not pre-empt the working of the market by deciding themselves what their customers need, rather than allowing the market to respond to what consumers demand."

These principles have not been applied to Government funding for basic maternity care, which is the practice domain for which midwives are registered. Consumers who choose to employ a midwife as their primary carer do so, in most cases, without any government support. The medical profession’s monopoly of maternity funding and maternity care provision is not in the public interest. There is no evidence that excluding midwives from practice improves outcomes for mothers and babies.

The current restriction of the scope of practice of Australian midwives is regressive when compared with contemporary standards in developed nations. The Australian consumer ought to be free to choose the primary maternity care provider, either a midwife or a doctor, with consideration of the ability to each one to provide the service required by the individual woman and her child.

I therefore request that, in the implementation of the Government’s national registration and accreditation scheme for midwives, the Senate Community Affairs Committee ensure that midwives have equitable access to Government support for their purchasing of indemnity insurance, and for the provision of services. This is in the public interest and in the interest of free trade.


Joy Johnston
joy@aitex.com.au

Monday, April 27, 2009

emotion and fact

There are times in life when emotions threaten to overwhelm, when we fear what lies ahead, and feel unable to see a way through. This scenario can apply in times of stress or illness; it can also apply in pregnancy.

Sally's baby is due in a couple of weeks' time, and she is planning to give birth vbac (vaginal birth after caesarean) at home. It's her second baby, and she is experiencing an emotional roller coaster ride as that time approaches. Some of the anxiety and fear Sally is experiencing is related to her daughter's birth: a caesarean without labour. At the time Sally accepted that her baby needed to be taken from her, but as she has thought about it more, she has concluded that the caesarean was probably unnecessary. Someone in the 'system', for some reason, chose to give her surgery, and she agreed. She had been told that she had pre-eclampsia - a diagnosis that she now questions. Will it happen again? The fears that are surging, draining her emotionally, are difficult to put a name to; they just are.

Sally has booked at a public hospital near her home, and has also booked me to be her midwife. This means two bookings, as that hospital does not provide a homebirth backup service.

As we talk I am trying to help Sally differentiate between emotion and fact; her fears and her actual decisions.

I think every woman experiences, to some degree, an emotionally rough journey as we approach a birth. I know I did, with each baby. When embracing uncertainty we must try to hold onto instability and change. It's the same with a balloon filled with water, each movement at any point brings corresponding corrections to the whole unit. The birthing continuum has often been likened to physical experiences involving water and buoyancy: body surfing, when we are lifted and carried quickly on top of the wave, and sometimes dumped ingloriously in the turbulence; or a canoe ride down a river, with moments of quiet, as well as the rapids and the whirlpools. The principle we remember is to not panic, to wait until we come to the surface, to take in breath when it's safe to do so, and be ready for the next episode.

When a woman tells me of her emotion, anxiety, and fear, I encourage her to accept it. To own it as part of the awesome journey she has begun. It is not unusual or wrong for Sally to be anxious about the birth of this baby. The feelings she has experienced so far have led her to make certain plans for this birth. She has become well informed, and understands decision making better now than she did a few years ago.

Here are a few facts that Sally has reaffirmed today:
*that she is well, and that her baby is well
*that at present there is no safer or preferred way for her to give birth than naturally
*that natural birth requires spontaneous onset of labour
*that at any time Sally can review her plans, and make choices that she believes are best for herself and her baby

The hospital is able to provide the expert care if and when needed. But at present Sally is happy to wait for spontaneous onset of labour. The doctor who saw her last week said they needed to make a date for repeat caesarean. Sally declined the offer, and reminded the doctor that vbac requires spontaneous onset and progress in labour. The doctor, who was unwilling to accept that degree of uncertainty, attempted to convince her that at least she needed to make a date; that without that magical date she may have an emergency caesarean.

"Yes", Sally replied. Isn't that part of the usual birthing process? A midwife who heard the exchange nodded in approval and said "Yes! Good on you!"

Tuesday, April 21, 2009

freedom to make decisions

From time to time I receive emails from students, asking me to tell them about my midwifery practice. This week's student email had an attachment with about 20 questions under the heading 'Issues that affect midwifery practice'. Rather than spending a couple of hours completing this questionnaire, I have referred the inquirer to this blog, and others, where many of the questions have already been answered.

Today I have selected a question from the list:

"Do you believe pregnant women today have more freedom to make decisions about their birth than they have previously?"

My answer is No, and Yes.

Fence-sitting is probably not very helpful, but I will try to explore the question further. I don't want to sound like the old crone telling stories about the 'good old days' either.

I will link my comments to what I know now about:
1. the freedom that a pregnant woman has to make decisions today
2. the freedom I experienced about 30 years ago, when I was the pregnant woman
3. the freedom my mother, who was also a midwife, told me of her experience about 60 years ago, when she was the pregnant woman.

I say 'No' - that women today do not have more freedom to make decisions about their birth than we had either 30, or 60 years ago (or further back in time, for that matter). Today's mothers face information overload; so many choices that they can easily lose sight of the fact that bearing a child is as normal as life gets.

Many women today are captive to fashion and custom that are driven by capitalistic and humanistic ideologies that have developed in recent generations. There are so many products and gadgets and services that go with the baby business that the reality of the miracle of precious new life can easily be missed.

Today's mother is uncritical as she welcomes technology that invades the privacy of the womb, giving proof of a heart beat in the early weeks, and progressing on to amazing 3D pictures of an unborn child; and answer the question, is it pink or blue? She does not ask for proof that this is safe for the child, or for the next generation. She is encouraged to justify the experience as an opportunity for bonding.

Yet a darkness falls on her life when some small item, called an anomaly, is 'discovered' on the flickering screen. The longed-for child becomes a condition that has to be managed. Dreadful decisions have to be made.

Thirty years ago ultrasound was new technology, available to only a few. Sixty years ago it was beyond imagining. The mother carried her child in the secret place, and experienced meeting her child and discovering its features all in good time.

Thirty years ago the midwife learned to use the Pinnard stethoscope, and the labouring woman was 'managed' lying on a bed. For the birth the woman was often placed in the 'left lateral', the teaching position. The midwife, and a group of students, stood on the right side of the bed, watching and managing the (sterile - no touch) business of birthing, while another midwife stood on the left side of the bed and administered the gas.

Sixty years ago the movements in the womb, felt by the mother, were the primary indicators of wellbeing. A baby whose movement had ceased was stillborn. Still before birth, as well as still after birth.


AND I say 'Yes', women are more free today than in previous generations, to make decisions about their births, because today we try to protect human rights such as autonomy in decision making. Today noone can touch you, or take your pulse without your permission. Anyone expressing that idea 30 years ago would have been quickly put in their place. I felt extremely anxious in 1980, as a pregnant woman booked to give birth to my fourth child at the Royal Women's Hospital Family Birth Centre, when I declared to Dr John Neil that I did not wish to have a glucose tolerance test. He rubbed his chin and said "Well we do let birth centre patients have some say in these things", and generously gave his OK.

My generation of mothers fought for, and won the right to have our husbands at our side in the labour ward, while our parents had been separated at the fathers waiting room. Today I wonder if we have progressed. Although midwives today have learned to operate sophisticated pumps and monitors and beds that are like transformers, many have lost the skill that my mother had 60 years ago, being 'with woman'.

Monday, April 20, 2009

making sense of risk management and safety in maternity

In the past couple of months the Australian homebirth and independent midwifery world has been experiencing a new level of challenges and threats to our very existence. The precipitating event was the release of the report of the Maternity Services Review. I have attempted to keep a running record of the published articles and other media, at the MiPP blog.

The safety of homebirth is the key issue in the minds of those who support, and those who are seeking to outlaw homebirth. How can 'safety' be so contentious? Is one party so biased that they can't see what is clear to the other? Are these professional people, on both sides of the fence, not intelligent, well educated, and supposedly ethical people? And what about the parents - consumers who choose homebirth, even though they have to pay for the privilege of not using the hospital? Are these people blinkered, uninformed, even careless about the safety of women and their unborn children?

I know most of our regular blog watchers are aware of these and other related questions, but for those who are still unsure, here are a few recent links:

Largest study in the world confirms homebirth is safe

SMH reporter Miranda Devine, in A home birth is not a safe birth ...

Dr Pesce's comment [ABC Unleashed] on 6 baby deaths in WA in 4 years, which he considered to be proof of the danger of homebirth. "The WA health department said:
"... that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths."

Another statement in the same article reported "a three-fold increased risk of a full term, otherwise healthy baby dying during a planned home birth ..." The paper from which this information was sourced has come under strong criticism for its methodology. Internationally respected epidemiologist Marsden Wagner, in reviewing the paper, noted that conclusions drawn about unacceptable death rates from unreliable sources are not valid.

There are many more references - both in favour of, and against, homebirth. The use of numerical data (quantitative) in understanding evidence must also be balanced with the qualitative research that seeks to report on 'why', and 'how' a particular decision is made or outcome is reached, rather than just 'how many'.

Complicating the whole picture is the rise in the number of unattended home births. There are anecdotes of the tragic death of babies born at home, and 'near miss' experiences, in recent months. Within the stories I have heard about births that have gone wrong, I have been shocked at assumptions that people have made, in justifying choices and decisions.

For example:
A mother planning unattended birth was told to send her husband or a friend to a St John Ambulance resuscitation course, to learn how to resuscitate a baby that is born not breathing.
Another mother took that plan a step further by employing a midwife to be present at her birth, but did not allow that midwife to auscultate the baby's heart sounds prior to the birth.
A mother giving birth unattended experienced delay from the birth of the baby's head to the birth of the rest of the baby. It took many minutes - too long - and the baby did not survive. A midwife would have been expected to intervene in an attempt to protect the life of the child.

I feel that I'm stating the obvious, but it needs to be said. Resuscitation does not work if a baby is already dead.

Much of the risk management in maternity care - both midwifery and obstetric - is to identify babies or mothers 'at risk' of poor outcomes in birth, and to take steps to prevent damage or death. None of us have a crystal ball: it's all about drawing a line. Homebirth is safe because there are important features of homebirth that minimise risk: for example, the mother's own environment; the absence of dangerous drugs and uterine stimulants; the one-to-one focused attention of the midwife. The Dutch maternity system, in which about a third of all births are at home, and for which safety has been clearly demonstrated, requires the midwives to screen women for risk. Women are expected to be referred to specialist (hospital) care if they develop complications, or if they are not progressing well, or ...

I cannot make generalisations about the practices of independent midwives and homebirth in Australia. It is likely that some have their heads in the sand (or in the clouds?), and are ignoring risk. What about homebirth for babies in breech presentations, twins, failure to progress? VBAC? Post maturity? Grand multiparity?

These are not yes-no answers. As some of my clients know, I will attend homebirths for women who would not be acceptable under most risk management selection criteria that I am aware of. That's one of the benefits of being 'independent'. Each woman can be addressed as an individual; each decision can be made individually; the care is woman centred in a way that may not be carried through in service guidelines. My commitment is to be 'with woman' - not to homebirth. If the woman is well and progressing well in spontaneous labour, she is free to decide where is the best place for her to give birth.

Sunday, April 12, 2009

Birth of a calf


[Pic: Poppy and Uncle Al check the cow and the new calf]


I had a call from our daughter Bec on Friday morning. A cow who had begun labour had bulging membranes, but nothing had happened for a while. Was it alright? Should anything be done?

My response was that I thought it was best to leave the cow to give birth in her own time. And keep the puppy away. I thought that if there was a problem something could be done later in the day, as we were heading to the farm to visit them for lunch. Noel, my husband, did his Veterinary post graduate studies with dairy cattle when I was busy bearing and nurturing our own babies.

An hour or so later, as we headed up the Calder Hwy, we received the news that a calf had been born and all was well. At the farm we saw the cow and calf, separate from the rest of the herd, and unstressed. Membranes still hung from the cow's vagina. Later we noticed that the afterbirth had been passed. All part of the normal daily occurrences on a farm. My son in law Al says his cows are not too posh to push.

Normal birth of a human baby at home is not very different from normal birth of a calf in the paddock. The oversight that a midwife provides includes keeping the space free of disturbance so that the mother is able to progress in her own time. The midwife does not try to hurry things up, or manage the birth, and would only consider interference if the natural process had in some way become unsafe.

When the labour starts the cow withdraws from the herd, and finds a safe place, such as near a big tree, or rocks. She is patient.

The labouring woman also needs to withdraw. She needs unstimulating space around her, and her own home is often the ideal place. If her children are there, she needs to know that they are being cared for well so that she can move away from them. She will not labour well until she can do this.

A cow does not need to be taught how to give birth. It happens, under instinctive hormonally mediated processes. The human mind also has strong instinct and our bodies secrete powerful hormones, but we often suppress our instinctive thinking, and take over, or interrupt, with 'higher' brain activity - the activity of the neocortex. Anything that is specifically human is neocortical activity. Artificial lighting; managing progress; calculation of times and measurements. How many women think their main job in labour is to record the frequency and length of contractions? How many women become overwhelmed by labour, as they try to intellectually integrate the information give to them by their doctor or midwife? What does 5 cm dilated really mean?

The preparation and learning that a human mother needs to do, and that a cow does not need to do, is to learn how to accept her body's work and not to interrupt it. The secret to this, in most instances, is to withdraw - emotionally and physically - from anything else that might stimulate intellectual (neocortical) thinking or in other ways cause stress.

Wednesday, April 08, 2009

A fine line: undisturbed, unassisted, and unattended births

Midwives who are experienced in unmedicated spontaneous birth will often take a quiet, unobtrusive role when attending a labouring woman. By the time labour is established, the room is quiet and often lit only by a candle or other soft light source, and no interruptions are allowed. Any voices are hushed, and only when the woman is resting between contractions – not during contractions. If the woman has planned to use water immersion in labour, the tub has been set up and is ready for use. The midwife is constantly observing, expertly using her senses of hearing and sight and intuition (heart). The midwife experiences a parallel journey, as she intuitively harmonises her thoughts and actions with the woman’s. Any observations that require touch, such as listening to the baby’s heart tones, are done in a way to minimise disturbance to the woman. The midwife is not ‘assisting’ the birth; she is in attendance – with woman.

The term ‘undisturbed birth’ has been used by author Sarah Buckley (2005, p110), with reference to her own experience of giving birth to her fourth child, without a midwife in attendance. Other terms used for unattended birth, when it is intentional, are free birth, pure birth, self birth, and unassisted birth.

The fine line that the midwife sometimes walks is being able to be with woman, and yet enabling the woman to proceed without physical or emotional disturbance. Many women would consider that they were able to enter a special ecstatic place in which they remained undisturbed through their birth experience, with a trusted midwife present.

However, if a midwife identifies a complication or condition in the mother or baby, for which she recommends referral to specialist services, the act of disturbance may be in the interests of the wellbeing of her clients, both mother and baby. This is within the professional duty of care, and is the midwife’s skill. The midwife’s guiding principle, that “In normal birth there should be a valid reason to interfere with the natural process” (WHO 1996, p4) informs both the non-interference, and the alternative, in midwifery care.

Dr Buckley argues cogently that the complex natural hormonal mix, and particularly the role of oxytocin, that is the physiological norm in childbirth is also what we experience in loving, passionate sexual intercourse. This connection has previously been clearly described by Michel Odent in many of his writings and lectures. “[oxytocin] is the ‘hormone of love’. Whichever facet of love we consider, oxytocin is involved.” (Odent 2002, p72)

The connection that Dr Buckley makes, in describing and idealising an unattended birth as undisturbed, may encourage other mothers to give birth without professional attention. In Dr Buckley’s case, both she and her husband who was also present, had medical skill and knowledge that could have been used. This is a very different scenario to unattended birth where no person present has a foundational knowledge of progress in labour, normal birth, or normal transition of the newborn from the womb to the outside world.

Dr Buckley observes that “When a midwife’s intuitive skills and ways of knowing are increasingly sacrificed to technology, more and more invasive procedures will be needed to get information that, in other times, her heart and hands would have illuminated.” (p111) The fine line the midwife walks is to use technology appropriately, while valuing and enhancing her skills in promoting normal birth.

The midwife’s goal can and should be ‘undisturbed’ or ‘unassisted’ birth in any situation where there is no valid reason to interfere with the natural process. A midwife cannot ethically support planned ‘unattended’ birth, which is the antithesis of maternity ‘care’, as that situation removes the experienced critical eye and ear and heart of a midwife, and puts the responsibility on the labouring woman, and anyone else who is with her at the time.

Monday, April 06, 2009

evidence based maternity care

In the context of current discussion about birthing without a professional attendant (which is known as free birthing, pure birthing, self birthing, and probably others) a blogger-mother wrote,
"If evidence based care is the best antenatal and labour care, and some evidence based care leads to interventions, and intervention - any intervention - is perceived as a terrible thing, then if no one checks you or you baby, ..."

This statement has prompted me to explore the meaning of evidence based maternity care.

The statement suggests that some women are avoiding professional monitoring in pregnancy and birth because they don't want to know. Every investigation and test, no matter how seemingly trivial, is done so that action can be taken if it is deemed the best course of action. Knowledge brings responsibility. Every time I put my hands on a woman's abdomen to palpate the baby, I am responsible for my response to what I discover in that palpation.

Over the past few decades some basic maternity care rituals have changed in the light of evidence. Mothers 30+ years ago were given enemas and shaved - sometimes all visible pubic hair and everything as far back as the anus; sometimes just below the pubic ridge. Either way, the regrowth was unpleasantly itchy (speaking from experience), and the chance of cuts from razors was fairly high. Enemas were to empty the lower bowel. These measures were apparently to prevent germs from contaminating the birth, which was treated as an operation site, with green sterile drapes.

World Health Organisation declared in 1985 (Fortelesa Declaration) that there was no evidence supporting enemas and pubic shaving, and in 1996 (Care in Normal Birth: a practical guide) listed enemas and pubic shaving to be "practices which are clearly harmful or ineffective and should be eliminated".

The removal of enemas and shaves from standard maternity care was relatively successful (some people today 'choose' these procedures) but other 'non-evidence based' positions that have been promoted for decades are ignored by many professional maternity services. These include, for anticipated normal birth: continuous fetal monitoring, induction of labour, amniotomy, vbac, lithotomy position ...

Current discussion over the choice some women have made to give birth at home without a professional midwife in attendance focuses on the big issues of potentially avoidable death and damage to the mother or child. Today's news reports that Sydney Dr Andrew Pesce "said he was aware of at least four deaths and another four homebirth babies who sustained possible brain damage since last July." The report does not differentiate between planned homebirth in the professional care of a midwife, and the DIY unattended version. Evidence from Australian and other sources support planned homebirth in the professional care of a midwife for women who are low risk and come into spontaneous labour at term to be no more likely to experience adverse outcomes than those of similar status in hospital maternity care.

It's no good hiding behind a sweeping statement such as "babies die in hospital too". The decision making process that midwives use, regardless of our practice setting, is to try to identify babies and mothers for whom intervention is likely to improve outcomes. This is where midwives are constantly reviewing our practices, so that we can act quickly and decisively when we need to; but also so that we can understand the scope of normal birth, without unnecessary interferance. A woman who is well at term, in spontaneous labour, and progressing well without needing pain relief should expect a well baby. If the baby is not coping well with the stress of labour, the midwife is able to identify the problem when listening to a baby's heart sounds after a contraction. There may also be signs of potential problems in the colour or consistency of the amniotic fluid. A midwife will make professional judgments, and give advice, on what she sees.

There are aspects of the maternity care world today that are like the scary 'wonderland' world of Alice. Issues become enormous, or tiny, without warning or reason. The person with power makes nonsensical edicts. Alice is caught up in a wild stream of frightening experiences.

In my vision I have made Alice's sister her midwife, going with her in her journey towards birthing her child,
"Alice returned to the grassy bank in the golden afternoon light and decided not to go down that rabbit hole again. She stayed above ground and with her sister accompanying her, ..."

Sunday, April 05, 2009

Every Woman Every Choice ???

Every Woman Every Choice

It's a catchy slogan!

What does it mean?

Is it something we want in maternity care?

I found this slogan on a campaign letter from Maternity Coalition - an organisation that I have belonged to, and helped to build, for the past 15 or so years.

In today's world of fast electronic communication there are many statements and articles that come to my email inbox, that I read quickly and delete. It's not that they are unimportant - it's more likely that I don't see the need to engage with them at the time.

However this slogan caught my critical eye.

EVERY WOMAN?

Does this refer to every woman, regardless of her other health needs, her location, her wealth or personal circumstances?

EVERY CHOICE?


Which choices are these? Drugs to induce or stimulate labour, or to relieve pain? That's been an 'acceptable' choice in most maternity services for the past few decades. Elective caesarean - that seems like the easiest to organise these days.

How about care of a known midwife who will attend a birth at home or in a birth centre that's committed to promoting physiologically normal birth? Now that's a choice that is supported by solid research evidence. Let's organise that!

Anyone who has attempted to 'choose' the latter will know that it doesn't happen easily. Birth centres are booked out; many women booking in a birth centre are transferred out to 'standard' care at some time, under strict protocols; many midwives are reluctant to accept caseload midwifery; and so on. Homebirth is available with public funding in a few locations, and with independent midwives in a few others.

How many women who have had a previous caesarean birth, for whatever reason, are able to choose the sort of care that makes vaginal birth likely? Not many. Look at the statistics, such as the recent Victorian Maternity Performance Indicators.

The notion of 'Every Woman Every Choice' is NOT a goal that I can share. At best it's just a hollow slogan; at worst it's a sellout to medical and technological dominance of women's lives. And although it appeared in a Maternity Coalition (MC) statement, it's actually in conflict with the statement of purposes of that organisation.

The Statement of Purposes of MC, within its constitution, includes:
"iv To protect pregnancy and childbirth as a natural process"

Protecting pregnancy and childbirth as a natural process means that we argue AGAINST the 'every choice' trend. It means that we focus on learning how to work in harmony with our sensitive physiology, and that we promote care options that demonstrate excellent outcomes.

I would prefer that every woman has access to appropriate maternity services. Of course defining what is appropriate would not be easy. What is appropriate for a woman who lives in a city or rural area; whether she is 16 or 46 or somewhere in between; whether she is having her first baby or her 9th?

Every pregnant-birthing woman deserves access to maternity services that protect wellness in an equitable way. Midwives can provide that level of maternity services for the majority of women, and midwives working with medical, obstetric and anaesthetic hospital services can provide appropriate maternity services for those who experience complications or illness.

Should Every Woman have Every Choice?

Even if that were a realistic notion, I don't think it's something a government should be asked to provide within its package of funded and regulated health care.

Our society is not equitable. Money buys choice for the few.

Should Maternity Coalition, or any other ethical body support the notion of 'Every Woman Every Choice'?

NO!

The following comment has been received from Lisa Metcalfe, NSW President of Maternity Coaliton.
Joy
All of your points about the reality of choice are true, however we have taken this step to counter the current trend in intervention and lack of control or choice that you so clearly express. How can our maternity system support obstetric care and elective c/s but not a woman who chooses a midwife and only deep water for pain relief??

If the political, medical and social world will accept the choice for elective c/s then there must be equal acceptance of the the choice to birth with a known care provider in a location that is acceptable to the women. This campaign is specifically designed to highlight all of the issues that you raise and include the troublesome issue of the potential loss of the ability of midwives to have a private practice because of National Registration requirements.

MC is not walking away from any of its commitment to birth as a natural process, but by highlighting just how hard it is to achieve this we may still break through the discriminatory maternity service provision in this country.

Wednesday, April 01, 2009

more about choice

My thoughts have returned again to the issue of choice, and what are the limits or boundaries around the whole notion of choice for women giving birth.

A young mum-2-B told me she was shocked when the midwife at a suburban public hospital told the group of expectant parents that they were not to argue if the doctor wanted to put forceps on their baby's head to deliver it. Preparing for birth, in this situation, included an attempt by someone who is called a midwife to ensure submission by the woman to those who are in positions of authority.

I would like to work with this young woman so that she understands the broader context of consent; so that when the time comes for her to labour and give birth to her child she will be confident in her own decision-making; so that if indeed she needs to face the question of forceps or any other intervention, her acceptance or refusal will be based on a principle of her knowledge of her own body, and making the best choice she can make at the time; not on the bullying of someone who wants to ensure compliance with the dominant authority structures in the hospital.

I would like to work with this young woman so that she understands her own ability in birthing. The physiological processes that our bodies expect to engage in are profound and extremely sensitive. The physical and hormonal changes in labour and birth can be disturbed by seemingly small interruptions that may not be considered interferences or interventions. It's about being able to access that innate power to do whatever it is that women do in birthing. How can a woman actively *choose* to work in harmony with her body's natural processes, and *choose* to avoid situations that will interrupt those natural processes. That is the essence of choice in childbirth.

****
Another aspect of choice:
A midwife attending a planned homebirth was distressed when the labouring woman refused her requests to listen to the baby's heart beat. The labouring woman was exercising her autonomous right to refuse - her choice.

But it doesn't end there. The midwife's duty of care includes attending to the baby's wellbeing as well as the woman's. Listening to the baby's heart sounds from time to time in labour is a non-invasive and usually acceptable way midwives use to ascertain how the baby is responding to events (uterine activity and subsequent progress). The midwife is responsible not only to her client, the woman and baby, but to the society that gives her the right to practise midwifery. Midwives are required to answer to peer review of our practices from time to time; and particularly when there is an adverse outcome. Reviewers in this case would, I believe, encourage the midwife to reflect on how she might act if this situation happened again.

A reader of this blog recently wrote to me, in the context of discussion about women's choices "It really disappoints me to hear a midwife disrespecting womens choices in birth. Surely it should be for no-one but the woman to decide."
This is a good question. Should women expect to have absolute freedom to choose what happens when they give birth? Are there no boundaries?

There is no other 'freedom' that we exercise that is absolute, even in a free society. Think about travel. We can choose when we leave home and where we go for whatever reason, but we are required to act within certain limits. The way we drive our cars, or ride our bicycles, is regulated by law.

Once a child comes into our lives, our freedoms are further limited, as we have a responsibility towards that child. The midwife's duty to protect the child in its transition from the womb to the outside world is not in opposition to the mother's freedom or ability to choose. The partnership between a midwife and the woman should be harmonious, working together to achieve the very best outcomes for both.


Those who are thinking about the choice of unassisted childbirth, I would like to recommend that you read http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2009/3/25/freebirthing.html