Wednesday, September 30, 2009

The safety of home birth: Is the evidence good enough?

There have been three recent papers published, giving strong evidence of the safety and acceptability of homebirth: a large study from the Netherlands (deJonge et al 2009), and two Canadian studies (from Ontario, Hutton et al 2009 and from British Columbia, Janssen et al 2009).

The paper by Patricia Janssen PHD and colleagues (link above) reports on Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. The study included all planned homebirths attended by registered midwives from 1 Jan 2000 to 31 Dec 2004 in British Columbia, Canada. The interpretation of the data is that "Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared withplanned hospital birth attended by a midwife or physician." (p337)

Similar findings have been reported in the other 2009 studies.

A Commentary by two Melbourne midwife academics, Helen McLachlan PhD and Della Forster PhD, titled The safety of home birth: Is the evidence good enough? was published in the same journal. My curiosity was sparked. Helen and Della have been active researchers on the local maternity scene, and from memory their work has included randomised controlled trials of breastfeeding interventions, and some on team midwifery. But I haven't seen anything from either of them about homebirth in the past.

The commentary gives wise, predictable thoughts about the debate surrounding homebirth. It gives a good listing of current references on homebirth.

The fashionable refrain from a section of the health/medical research community is that the evidence is not good enough unless it was obtained after randomisation of subjects. An interesting discussion is entered into, and the authors come up with the conclusion that "Better evidence on the safety of home birth is needed, ideally from randomized controlled trials".


The paper quotes professional discussion around the reported finding that an attempt in the Netherlands to conduct a randomised controlled trial was aborted, because women "were not willing to be randomly assigned to home versus hospital birth and declined participation because they had already chosen their place of birth."

This is a no-brainer (imho)! Of course. Yet the authors go on to discuss the importance of high quality evidence, as if another group of women - possibly those in public maternity care in Melbourne - will think differently. Why would they? How much evidence do we need in order to give a tick to spontaneous, unmedicated, un-interfered-with birth?

I can imagine the outcry if someone suggested seriously that we really don't know if conception of babies is safer in the hospital laboratory or in the home. Therefore a randomised controlled trial needs to be conducted. All eligible potential parents are to be randomly allocated to either treatment or control.

It might be difficult to enlist participants in this reseach, might it not?

Some of those who read this blog will have given birth at home; some are midwives who attend homebirths; while others are interested onlookers. If you have any knowledge of the terrain of physiologically normal birth, either in hospital or in the home, you will probably agree with me that the mother and all her support team need to be intentional about protecting normal birth. There is the intention to actively choose to work in harmony with your body; to be ready for and accept the work your body and mind must do; and to actively make decisions as events unfold. This is not the stuff of managed care and research protocols. It requires the deep and intuitive knowledge that a woman has because she is a woman, and it is best facilitated when the labouring woman knows and trusts the midwife who is responsible for professional decision making at the time.

Tuesday, September 29, 2009

my summary of active labour and birthing



Labour and birthing is as individual as we are ourselves. I have made this simple summary to assist with discussion and planning, especially for a first birth. You can click on the picture to enlarge it, and if you Right-click you will be able to save it to your computer and print it out.

Please contact me if you have any questions. joy@aitex.com.au

Thursday, September 17, 2009

'Drive-through' birthing

Several followers of this blog have asked me how the mother and her twins are progressing, since their story was shared a few weeks ago.

I have the mother's permission to share with you the news of spontaneous labour and birth of these two babies. Our hearts are full of praise to God the giver and sustainer of life.

Labour commenced at about 7am, and was stronger than what the mother was used to for any of her previous births. We went to Box Hill hospital, and the obstetrician who had supported the plan for vaginal birth (twins, first breech) came in and worked with us.

Membranes ruptured spontaneously for Twin A, who progressed quickly to breech vaginal birth. Baby experienced some respiratory distress for most of the following hour, and we are thankful that the paediatrician kept the baby in the birth room after special request.

Twin B had turned to cephalic. Mother gave birth to the second baby about an hour after the first.

The family went home a few hours after the birth. Mother called it 'Drive through' birthing.


I have told this story as an example of a complex decision making process between woman, midwife, and hospital - without bullying or coercion, even though the 'hospital' advised elective caesarean surgery. I am glad I was able to work with the hospital in this birth, disagreeing with expert advice at times, and supporting the woman in her desire to give birth when her time was accomplished.

There is no 'one size fits all' in birthing. These births included some features which are categorised 'high risk'. Those risks were present, in slightly different ways, regardless of the birth plan. The plan to proceed under natural physiological systems was made after considering the risks and benefits of spontaneous birthing, and the alternative - planned, elective surgery. Another alternative was to change the plan at some stage in the labour, but that option was not needed.

With the benefit of hindsight I am sure that there was no better way to negotiate the uncharted and unpredictable journey of these births. In fact I think if there had been delays – such as epidural, stirrups, or a trip to operating theatre, the story could have been very different. The mother knew her babies needed to be born, and she just got down to the job of birthing – something she is very good at.

[For the birth plan, click here.]

Tuesday, September 15, 2009

thoughts on the afterbirth

The birth of the placenta or 'afterbirth' is known as the Third Stage or S3.


Midwives who promote normal birth are usually confident to proceed under physiological conditions through the third stage, working in harmony with the mother's natural birthing processes. The elements of physiological S3 include trust between the woman and her known midwife who is professionally responsible for conducting the birth, attention to a safe, non-stimulating birthing environment, cord not clamped prior to cessation of all pulsation, uninterrupted skin to skin contact between baby and mother - all following the spontaneous unmedicated birthing of a healthy baby by a healthy mother. The baby's instinctive movements in seeking the breast enhance the natural production of oxytocin, and the baby's pressure on the mother's abdomen encourages contraction of the mother's womb, ensuring the functioning of living ligatures within the uterine muscle wall at the placental site.

Midwives attending homebirths use oxytocics when clinically indicated.

[The attached tables show the rate of pph for homebirth mothers in Victoria each year 2002-2007. These tables do not indicate severity or degree of morbidity.]


Hospitals in Australia strongly promote active management of S3. This involves injection of a synthetic oxytocic, with or without an ergot alkaloid, soon after the birth of the baby, causing strong contraction of the uterine muscle. When there are signs of placental separation (cessation of pulsation and lengthening of the cord, and sometimes blood loss), the midwife or doctor exerts controlled traction on the cord while guarding suprapubically with the other hand, until the placenta and membranes have been delivered.


Postpartum haemorrhage (pph) is a serious and life threatening condition, which is one of the main causes of preventable maternal death globally. The International Confederation of Midwives statement on pph includes instructions for active management of S3.


[Click on the picture to enlarge - Summary of a paper by Carolyn Hastie and Kathleen Fahy, 'Optimising psychophysiology in third stage of labour: Theory applied to practice'. Women and Birth (2009) 22, 89-96. Australian College of Midwives.]

Efforts by midwives to describe a physiological approach to S3 underline the need for research into the effectiveness of such midwifery care. A recent paper by Hastie and Fahy (2009) [first page scanned above] reviews literature, defines key terms, and presents a theoretical framework of Midwifery Guardianship applied to the third stage. This paper adds to the writings of Michel Odent and others in the past couple of decades, exploring and explaining the neurophysiology of unmedicated, normal birth.

There is no 'one size fits all' in maternity. Each woman and each baby are individual, and decision making is an active process that continues throughout the episode of care. The midwife's toolkit includes the skill and knowledge to promote normal birth, and to work in harmony with the natural processes, when that is likely to lead to the best possible outcomes. The midwife is also able to intervene in a timely and appropriate manner, using current strategies that are supported by contemporary evidence, and critically reflecting on practice in an effort to continually learn and improve maternity care for mothers and babies.

Monday, September 14, 2009

monthly review

Thismorning I have written my 'Monthly review' in the countdown to 1 July 2010.

I am not trying to sugar-coat anything - the future still looks bleak for independent midwives and for the women who we care for. I hope that by tracking the progress of the so called 'reforms', we will have hope that solutions can be found. Australians do have a belief in fairness and equality.


[Photo: That's me and Noel, with our first baby, the beautiful Miriam. If you look through her FB photos, you might even see the 70's kaftan on her!]

Friday, September 11, 2009

What will Medicare rebates mean?

A guest editorial 'Medicare rebates for midwives: An analysis of the 2009/2010 Federal Budget' appears in the September issue of the Journal of the Australian College of Midwives [to read more, click here]

...
Medicare fragments care into 'items' - fragments a woman into prenatal, intrapartum, and postnatal care, as most Australian women today experience. Medicare causes buck-passing between federal and state health departments.

...
Holistic primary maternity care by comparison is woman-centred, meaning that the pregnant woman/mother-baby dyad are central throughout the continuum of care. Midwives providing woman-centred care work with caseloads, or at the very least in small group practices. Notions of partnership between a woman and her known midwife, promotion of normal birth, and preventative measures - all of which are fundamental elements in the international definition of the midwife (ICM 2005), are nigh impossible in fragmented models of MEDI-care.

...

BTW
Privately practising midwives have been told that the Minister is concerned at the lack of support (from us) for the maternity reform process.

I have to say from my persptective the feeling's mutual.

We're back to Alice's adventures in Wonderland - "curiouser and curiouser!"

Thursday, September 10, 2009

waiting

Waiting is one of those basic requirements for normal physiological birth.
A mother who wants normal birth has to accept it, and a midwife who attends normal birth has to also.

In our organised world, with clocks and appointments and deadlines, waiting for the right time can be a challenge. You are feeling full and heavy. You go for a walk in the evening, and your womb is becoming very tight. You wonder if the baby will come tonight? You wake up in the morning - nothing happened! "Don't be disappointed," you say to yourself. "Baby will come at the right time." Then one morning you wake up and wipe away a bit of blood stained show. Aha! You know something is happening in there. Trying not to be too eager, you do those few last minute jobs that need to be done. You notice that the air feels different today. What a wonderful day to give birth to this precious little one.

I remember these beautifully deep feelings as I wait, this time as the midwife, the older woman, for a young woman to tell me she is ready to give birth.


The phenomenon of waiting for a baby to be born is as old as human existence. Many times as a child I heard the old language of the King James translation of the Bible, in the Christmas story. "Elizabeth's full time came that she should be delivered; and she brought forth a son." (Luke 1:57) "And so it was, that, while they were there, the days were accomplished that she [Mary] should be delivered. And she brought forth her firstborn son ..." (Luke 2:6,7)

Elizabeth's 'full time' came; Mary's 'days were accomplished': and they both 'brought forth' their children. Waiting for the time is in a sense passive, then the time comes for actively doing the job of 'bringing forth'. The women's knowledge passed down over millenia in these simple stories has informed my birth-giving, and my midwifery practice.

When anticipating physiological birth we experience the waiting as part of our nesting. I make the distinction here, because the only person who can do the physiological work of nesting, waiting, labouring, and birthing, is THE woman. Just as nesting can be interrupted by a sense of handing over to the 'expert', the waiting is also interfered with, deep in the mind of the woman who is unwilling to work with her body in birthing, who has given up her ability to reach her full time, to accomplish her days.

It is no wonder that this one may also experience difficulty in 'bringing forth' the child.

Friday, September 04, 2009

Two-year exemption from indemnity insurance announced today


a brief reprieve at least.

[If you don't know the siginficance of the Bilby, check this post for the introduction of this little endangered marsupial into the midwifery reform story.]