Sunday, August 30, 2009

a baby born


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

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

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

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

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

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

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

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

Thursday, August 27, 2009

why midwives promote normal birth

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

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

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

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

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

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

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

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

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

Tuesday, August 25, 2009

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

Why indeed!

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

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


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

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

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


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

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

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

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

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


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

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

Monday, August 24, 2009

A change of focus in this blog

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

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


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

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

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

Thursday, August 20, 2009

mother-child art


Today's art by Poppy and Granny

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

Tuesday, August 18, 2009

Indemnity insurance: the great obstacle

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

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

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

[Yes, it is personal!]

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

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

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

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

The Senate committee takes the easy option

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

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

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

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

That's politics.

That's political buck passing.

It's a hot potato.

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

Watch the midwives' blogs for comment.

Sunday, August 16, 2009

A new private midwifery blog

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

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

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

Friday, August 14, 2009

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

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

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

The Department representative agreed.

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

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

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

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

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

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

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



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

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



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


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

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

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

Wednesday, August 12, 2009

Midwifery framework

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

What exactly is meant by this term 'framework'?

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

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

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

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

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

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

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

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

Monday, August 10, 2009

a new business model for private midwifery services

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

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

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


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

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

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

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

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

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



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

Thursday, August 06, 2009

Streaming from the Senate committee hearing

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


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

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


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

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

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

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

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



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


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

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

Wednesday, August 05, 2009

video footage from the rally



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

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

Tuesday, August 04, 2009

THE RALLY





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

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

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

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

















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

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