Wednesday, December 29, 2010

Homebirths 2008 in Victoria

For summary and comment go to the APMA blog.

Tuesday, December 21, 2010

"a goodly child"

Christmas greetings, as we celebrate the birth of the Child.

As the Christmas season approaches each year, it is usual in our family to not only send our greetings but to briefly summarise the highlights of the previous year.

I have always found this a challenge, wanting to say something worth hearing, without being tedious. The recipients of our letter include our families and close friends, with whom we communicate by phone, email, and in person as often as we can; and other friends, some of whom we have not seen for many years, and with whom we communicate only once a year.

I have been reflecting on the highs (and lows) of this year 2010, and my mind has returned consistently to the two new babies, James and Eve, who were born into our family in May, and who are thriving in mind and body. The wonder and beauty of new life is powerful enough to keep me going for as long as I have energy to think and write.

Like ripples in a pond, my thoughts have then moved to our precious grand-daughter Poppy, and beyond her to our own four children.  I have remembered my own mother, and the generations of mothers before her.

Grand-parents are allowed to dote, quite openly, on their grand-children. Parents are often more cautious. Parents carry the weight of many responsibilities, and often struggle to achieve what they consider basic, such as feeding, clothing, educating, teaching manners, and getting the children to bed on time.


In my musings about our grand-children, and our children, my thoughts moved to the story of a baby, in Exodus 2.
"The woman conceived and bore a son; and when she saw that he was a fine baby, she hid him three months." (verse 2)

Another version says he was "a goodly child". 

The story is well known.  After three months the mother made a little basket of papyrus, and plastered it with bitumen and pitch to make it water-proof, and set in in the shallow reedy part of the Nile river where the princess would come to wash.  She set her daughter Miriam as the onlooker, ready to offer practical assistance of a Hebrew 'wet nurse', the baby's own loving mother, when the princess also saw that he was a fine baby, and decided to keep him.  This decision saved the life of that baby boy.


When the birth of a child is welcomed by a mother who sees that this is "a goodly child", and that mother does all in her power to protect and nurture the child, even in the most adverse circumstances, there is hope for the future.  It was no miracle that the mother of the child saw that he was "a goodly child", and defied the government of the day in the most strategic way in looking after him.  The miracle was that the princess shared in the vision of "a goodly child".  She knew exactly what the mother intended, and she agreed with the mother's plan to save that child's life.

When a child is born there is a flooding of the love hormone, oxytocin, throughout the mother's body, in a way that she can only experience at such a time.  This outpouring continues with each touch, look, and suckle from the infant.  It is right for a mother to look at her child and see "a goodly child".  It is right and normal for a mother to use every strategy at her disposal to ensure the safety and nurture of that child, while maintaining the closeness of the exclusive mothering bond during the infant's first years.

I want to encourage every parent who reads this blog, to take a moment to look at your child, and see that she or he is wonderfully special, a child with great potential.  See that your child is "a goodly child".  Whatever the challenges you face in ensuring the safety and care of that child, so that she or he can grow to unhindered maturity emotionally and physically, keep your vision clear, and remember the mother whose child was wonderfully saved in infancy, and later became a great leader.

I also want to encourage midwives who read my writings to see each child as carrying immense and unmeasurable potential.  We midwives are the guardians of the next generation, protecting the mothers in their ability to not only give birth, but also to see their children for what they are.

May God's blessing be on you as we celebrate the birth of the Christ child.
Joy

Sunday, December 05, 2010

Loving

From time to time in this blog I attempt to write a personal letter to my readers. Many readers have never met me in person, and I don't know you. However, our common interest in midwifery and anything that touches on women's reproductive lives gives me the opportunity to use a broad range of topics in writing to you.


The wonder and beauty of human love shared by a woman and her man, are in my mind, founded on the creation story in Genesis 1. God created human kind “in our image, according to our likeness”; “in the image of God he created them, male and female he created them. God blessed them ... God saw everything that he had made, and indeed, it was very good.”

"Indeed, it was very good" the way our bodies, male and female, were created. The workings of the male-female creature, made wonderfully in God’s image and likeness, are indeed very good.

It [the way our bodies work together as woman and man] is very good whether we [intellectually] understand the processes or not. It is very good because it has been very good from the start, and we have a deep intuitive knowing that it is very good. 

This separation of intuitive ‘knowing’ from intellectual ‘learning’ fits with my understanding of normal, physiological childbirth and nurture of a baby. (I use the word ‘physiological’, to differentiate from normal meaning ‘usual’, which is often very far from the normal, natural process.)

Intuitive, or maieutic, knowing is influenced by the amazingly sensitive hormonal states within our bodies, and is not dependent on theoretical understanding of what's going on at the time. The intellectual ‘learning’, achieved through more didactic processes involving teachers/writers and students/readers, is a particularly human characteristic. Other creatures who share similar physiology do not seem to share our need, or capacity, to understand why, and how.

Although there are aspects of the whole loving – childbearing – child nurture spectrum that our minds are able to investigate and delve into, I believe that the unique opportunity that the creator has given us is that we can experience something that is VERY good best without seeking to manage, control, or even understand it.

I see this principle being worked out many times when a mother who has given birth to her child is transported into a relationship of deep love for that child.  Science calls it maternal instinct, and tells us that the primal parts of the mother’s brain are able to assert themselves, while the neocortex, or ‘new’ brain, is unstimulated.

That makes sense, and it reminds me that “indeed, it was very good.” The hormonal interactions of the normal loving – childbearing – nurture activities are “very good”. And when, as happens in these activities, there is a climax – a peak of the loving hormones, and we experience an altered state of consciousness with a huge rush of excitement, pain, wonder and amazement that we had not expected and that floods our being: indeed, that’s very good.

I don’t know if there is an ideal way for a couple to enjoy their oneness. I think it’s best not to seek that knowledge from an intellectual perspective. Each couple has the opportunity, in the privacy of their own relationship, to seek deeper and more enjoyable sexual intimacy. There is something reflecting the image and likeness of God in each of us that is, indeed, very good.

Thursday, December 02, 2010

Notation on the Register

I have now completed my application for 'notation' on the midwives register, as a midwife eligible for Medicare. My CV has been adapted to comply with the AHPRA standard, and copies of documents need to be certified as correct, also in compliance with the required standard.
This process has been a challenging one for me. A few of my trusted colleagues and friends wonder why I would even try to become 'eligible'. By accepting a terribly flawed process, am I not supporting our society's attempts to medicalise women's lives, and to give a veto power to the medical profession over midwifery and women's choice of physiological birth?
Readers who have followed this process will understand that the decisions midwives must make are complex.

I have come to a pragmatic point of acceptance:
... that the government has enacted a process for certain midwives to be eligible for Medicare.

The person who will benefit from my being eligible for Medicare is the woman, not me. The woman will be able to claim back some of the fee I charge - possibly one third for planned home births, and more if and when I am able to attend a woman privately for hospital birth.
I will seek to do all in my power to prevent this process from taking away a woman's freedom, or working under medical supervision in primary maternity care.

There are several hoops to jump through yet, and it may be a couple of months before I hear back from the Nursing and Midwifery Board of Australia if my application is successful.

Tuesday, November 23, 2010

Update on Medicare

Bec and James
For an update on Midwives with Medicare provider numbers, go to the midwivesVictoria blog

Sunday, November 14, 2010

Midwifery - much more than a job

Midwifery is the calling, the profession, the vocation that has claimed my attention and inspired me throughout most of my adult life. During the past two decades I have learnt to apply the basic knowledge and skill that I had when employed in a maternity hospital to the individual women whom I have been privileged to attend.



Midwifery is much more than a job.

When I was employed by the Women's in the 1980s, working a couple of night shifts each week, I used to feel as though I was having one night stands with women, being close to them at such significant moments in their lives, and walking away from them at the end of the shift. This was before I had noticed any professional discussion about caseloads, or continuity of care. I now see this feeling as evidence of my developing *midwife identity*. For twelve years I had a job as a midwife in a public hospital. A job that I could walk away from when the time came, and return home to my young children and my husband.

When the time came for me to move away from that *job* and set up my own *practice*, I experienced a sense of freedom that I had not previously imagined. I went into private practice like a duck to water. I could not have been in a better place, and my emerging identity as a midwife was sealed and flourished. I found that I could write and teach, sharing the knowledge I had acquired from study and from giving birth and nurturing my own children, and the principles upon which that knowledge was based.

I accepted that, in order for a private midwifery practice to be viable in this country, I needed to charge a fee that reflected the commitment I was making. When I was employed in midwifery there was always a pay packet at regular intervals. Now I would not be paid unless women paid me. All I can say is that I have not missed the regular salary one bit. Even as the main breadwinner for our household, the steady stream of clients who employ me to be 'with woman' have provided sufficient income for my needs.

The terrain of private midwifery practice in Australia is changing now. Midwives are now able to demonstrate to the regulatory authority that we are suitably competent in all aspects of basic midwifery, and through that process become eligible for private clients to claim Medicare rebates. The legislation around Medicare, particularly the requirements for collaborative arrangements, has been criticised by me and many others who have read it. The process to provide Medicare rebates is potentially arduous, and there are questions that are still unanswered.  But there is a process, and it is there for midwives to apply.

I know of a small group of midwives who are progressing towards the Medicare eligibility goal - some may already have achieved it.

I have stood back a little, attempting to line up options for collaboration with public hospitals. This is not to focus only on what I need, but to establish pathways for other midwives.

Some of my colleagues have become concerned that midwives who accept Medicare eligibility will be compromising midwifery standards, and women's rights to informed consent or refusal.   I will be watching closely to see that this does not happen.

Monday, November 08, 2010

Global forum: optimising the effecctiveness of Health Workers to achieve MDG's 1 and 5

I would encourage readers to follow, and to consider making a contribution to this global forum.
My responses to the forum questions will be posted at my 'private midwifery' blog, as well as at the forum site

Friday, November 05, 2010

I wonder what this one will teach me?

Mothers wonder ...
Midwives wonder.

I wonder what this one will teach me?

As each decision point is reached and the choice is made, this way or that, the course of events is shaped and cannot be undone. As each baby is born, and the cycle of life moves on, the mother learns something about herself, and something new about life. The midwife, in her interwoven world, also learns something about herself, and reinforces or renews her understanding of the wonder of life.

Dear reader, do you know what I am saying?

Do you understand the flow of life, and the decisions that are made - especially in the context of that basic and primal event of giving birth? Do you recognise a decision as a fork in life's journey. You choose one and you consequently reject the other. You can never come back to this decision, this bifurcation in the path.

The mothers who have had larger numbers of children; five, six, or more, are usually the ones who marvel at the uniqueness of each experience. When these mothers come to see me for a prenatal checkup I love to listen to what they have to say. I don't need to teach them about childbirth. We spend an hour or so in my little office, surrounded by my messy shelves of books and folders, and the cork boards filled with wonderful photos, and some artworks that are particularly dear to me, and my wall calendar with the names of the women to whom I am committed. I usually start with the question, "Did you have anything that you wanted to talk with me about today?" Then we pass the time in an easy, unstructured exchange. At some point I do the basic checks - blood pressure, palpation of the womb and auscultation of the baby's heart sounds. The information is noted down.

But the building of a relationship is what takes most of the hour's visit. There is no box in my paperwork to tick about trust. There is no place to note the unique sharing of lives: a woman and her midwife.


One particular day I was feeling very weary. The pressures of my personal life, and professional stuff including all the campaigning for better maternity services had left me feeling emotionally and physically low. Depressed? Yes, I was. I had become unexpectedly teary when some friends started talking about their plans for holidays. I told my sister about my feelings, and that I had not had a holiday for a long time, and she informed me that was not good work practice. Dear reader, I'm sure she didn't mean to hurt me. We love each other, and talk about things that are important to us.

Anyway, on that particular day, the phone rang. A mother told me she thought her labour was starting. She needed to contact her husband so that he would be at home to look after the children. Soon she rang again. Husband was on the way, and she asked me to come.

As I moved quickly from my introspective mood to a more organised, directed persona, I prayed for strength and wisdom. It's late afternoon. I may be out through the night. I need alertness of mind and strength of body. I may need special courage and wisdom as decision points are reached. I pray for God's special protection and blessing on the mother and child in my care.

On that particular day the labour progressed quickly. A baby was born without complication or incident. The mother sat quietly in an arm chair and focused on her little son as he worked his way to her breast and began to take his first feed. She had a couple of contractions, and I reminded her about the birth of the placenta.

Then the mother lifted the towel from her belly, and said "Joy, there's a lump here still. Could this be another baby?"

Yes, it could ... and it was.

As I put on a sterile glove to check how this baby intended to be born, there was one push, a gush of fluid, and the little sister made her entrance - beautifully.

I will never forget the mother's ecstatic face as she said "I've got TWO babies!"

That night as I returned home I reflected on not just the birth - amazing as it was - but also my physical, emotional, and spiritual journey that day. What did this one teach me? Quite a lot.

Friday, October 29, 2010

Midwives with Medicare 2

During this past week there has been an increse in activity in preparation for the advent of the medicare-midwife next Monday 1 November.

Midwives seem to be positioning themselves in two main camps: pragmatism, making the best of the situation, on one hand, and resistance to what is seen as removing the midwife's right to autonomy in practice as well as threatening the woman's right to informed consent. Much of the disagreement centres around legislation requiring a collaborative agreement between a midwife and a named doctor in order for the midwife to be able to access Medicare funding, and visiting access in hospitals for intrapartum care.

The Australian Private Midwives Association (APMA) position statement on Collaborative arrangements [click here] opposes the Determination, contending that:
"Private practice midwifery will become known as the model whereby midwives are working in private medical practices, with little regard for those self employed midwives who currently provide true midwifery care at this current time."

A recent meeting between the Health Minister Nicola Roxon and four independent candidates who stood in extremely marginal seats in this year's federal election, and maternity activist Justine Caines, has given rise to an interesting report published anonymously at the APMA blog. The writer indicates that
"It is possible that the Gillard Government is contravening its responsibilities under the Convention of the Elimination of all forms of Discrimination Against Women (CEDAW)."... and
"The political cost has been high with Minister Roxon embarrassed by poor advice."
 The Australian College of Midwives (ACM) has promoted the pragmatist position, with statements such as:
"The College maintains the view that while this Determination is a poor piece of legislation we need to continue working with the Minister’s Office and the Department of Health and Ageing to provide evidence that will support the Minister in making any necessary changes. The College is dedicated to ensuring that midwives and women are not disadvantaged by this legislation." (e-Bulletin 29/10/2010)
 Leaders in ACM have encouraged members to accept the Determination, indicating a fear that the whole maternity reform process could be derailed if there were to be a motion to disallow the Determination, and that motion were passed.  The reforms that enable midwives to claim Medicare funding, and have limited prescribing rights, and the right to order basic tests and investigations are seen as being of great value to the profession as a whole, while the potential disadvantage that comes with a return to medical supervision of a midwife's practice, sold under the guise of team work/collaboration, is seen as an acceptable trade off.

Midwives continue to work through these issues.

I hope to be able to keep readers informed of progress.

Monday, October 25, 2010

Midwives with Medicare

sisters Anna and Jenni, and their beautiful babies


Today I have checked through the application form that midwives are required to complete in order to obtain a Medicare provider number.

I would love to be able to say to my clients that from 1 November they will be able to claim Medicare rebates on my fees. However, as I do not yet have a doctor who will meet the legal requirements of the Midwives Collaborative Arrangements Determination I cannot proceed with any such application.

If you want to check the full detail of the Medicare fee schedule, go to the Federal Register of Legislative Instruments F2010L02640. [I can't find the link, but I have the document saved as a .pdf]

Here are a few examples of the Medicare fee schedule for a participating midwife's services:
Item 82100
Initial antenatal professional attendance by a participating midwife,
lasting at least 40 minutes, including all of the following:
(a) taking a detailed patient history;
(b) performing a comprehensive examination;
(c) performing a risk assessment;
(d) based on the risk assessment — arranging referral or transfer of the patient’s care to an obstetrician;
(e) requesting pathology and diagnostic imaging services, when necessary;
(f) discussing with the patient the collaborative arrangements for her maternity care and recording the arrangements in the midwife’s written records in accordance with section 2E of the Health Insurance Regulations 1975
Payable only once for any pregnancy
$51.35

Item 82120
Management of confinement for up to 12 hours, including delivery (if undertaken), if:
(a) the patient is an admitted patient of a hospital; and
(b) the attendance is by a participating midwife who:
(i) provided the patient’s antenatal care; or
(ii) is a member of a practice that provided the patient’s antenatal care
(Includes all attendances related to the confinement by the participating midwife)
Payable once only for any pregnancy (H)
$724.75

Item 82130
Short postnatal professional attendance by a participating midwife, lasting up to 40 minutes, within 6 weeks after delivery
$51.35


Clearly it would be in the intersts of both the woman and the midwife for this funding to be accessible. Midwives practising in homebirth would at least be able to give their clients the benefit of rebates for prenatal and post natal visits. Once midwives have visiting access at public hospitals (this is still theoretical), women who choose to have their own midwife attend them at a hospital would be able to claim a substantial rebate for the fee.


As I have considered how I could possibly comply with these requirements, without giving up my integrity as a midwife, the only pathway I can see is if I can obtain a collaborative arrangement with a public hospital. In effect, that's the way I have collaborated with the medical profession for many years. My clients have homebirth backup bookings at (usually) the Women's, Monash Clayton, or Box Hill. If medical referral is needed at any time through the episode of care, the medical team on duty at the time accepts the referral.

I will keep readers informed as we progress down this pathway.
A quick calculation of the fees payable by Medicare for:
  • an uncomplicated hospital birth (1 midwife) $1504.65
  • antenatal and postnatal care for planned home birth $779.90
[These amounts are calculated assuming that the mother has 3 long and 2 short prenatal checks; and two long and 3 short postnatal checks.  Other once only consultations as described in the legislation.] 

Saturday, October 16, 2010

Reflecting on progress in midwifery

Hello Grandpa!



When I studied midwifery (in the early 1970s) we learnt about the hormones in the menstrual cycle and the physiology of conception. We learnt about FSH and LH and oestrogen and progesterone and testosterone. We knew that oxytocin existed, but it was just the hormone the caused contractions of the uterus. The synthetic copy of oxytocin, Syntocinon, was used liberally as it could be measured and given in a 'scientific' way. I don't know if oxytocin crucial role in milk let down and love making was mentioned. The action of endorphins as natural opiates, and adrenaline and nor-adrenaline were part of that complex mystery waiting to be better understood. I don't remember any mention of bonding or maternal behavioural adjustments.

When Noel (my husband for the past 37 years) studied veterinary medicine in the late 1960s he learnt the same physiology. Vets became fascinated with the world of artificially managed conception, ovum transfer, and surrogacy in the world of producing the fittest and most highly desired offspring.

Noel's Masters and PhD research explored the protective effect of colostrum in the newborn calf. He showed that colostrum protects the calf against diarrhoea (scours) and septicaemia (blood poisoning) in the early days after birth. This result sounded obvious to me, but was important scientific knowledge at the time. My journying with him through academic processes, including the literature review and carrying out the research, informed me a great deal and opened my mind to critical thinking.

... move through time to today.

Noel and I are now doting grandparents. We have seen huge changes in our own understanding of the physiology of all things to do with childbearing, reproduction, and a human mother's ability to love and care for her child.

Acquiring knowledge of natural physiological processes in childbearing and nurture of the infant has been a fascinating journey that has, for me, absorbed my mind over most of the past three or four decades. It's an incomplete process.

As long as I am able to call myself a midwife I will have a duty of care to promote normal birth. I hope that midwives around the world will also claim that purpose.

Wednesday, October 06, 2010

Looking at the big picture

A lovely young woman in my care came for a prenatal checkup, beaming. After the usual hello she told me of her sister's birth a few days ago. Her sister gave birth to her first baby at a big public hospital, without any assistance, without any drugs! The wonder of physiological birth - the miracle of birth - has left its mark on this woman's mind. I was pleased to hear the story. Normal birth is worth protecting.

We know that birth is not an illness, yet a normal birth is often something that is a surprise rather than the expected pathway.

Medical dominance in birth has, for many people, extinguished this amazing knowledge. Midwives and doctors often see birth as a minefield, expecting disaster at any moment. Then they proceed to interfere, interrupt, intervene ... and hey presto ... they were right!

Years ago we midwives who were budding activists for promoting normal birth used the Fortelesa Declaration (WHO 1985) to get the message out that ‘Birth is not an illness’.

In the early 1990s we used the Innocenti Declaration (UNICEF and WHO) on the rights of the newborn to put pressure on maternity services in relation to breastfeeding and bonding.

In the mid-90s we promoted the ICM Definition of the Midwife, which is now incorporated into national codes of midwifery practice and educational standards.

We still have a long way to go. We need to constantly go back to this ‘big picture’ stuff, and hold it up as our standard.


The current state of play in the government's efforts at legislative reform (see another blog) is simply unacceptable to midwives under international and national midwifery standards.

Midwives have to just say NO! It’s not good enough to say we will take baby steps to Medicare funding. Compromise that is wrong is simply wrong, and will be regretted in the long run.

Friday, October 01, 2010

the safety of sharing a bed with a baby

Newspaper and other public media outlets are declaring that "Sharing bed raises infant death risks"

I have, for many years, encouraged mothers to consider co-sleeping. I was part of a group who prepared a co-sleeping brochure "Is your baby sleeping safely?" [2004 BFHI Australia]


Sue Cox explores the complex issue of safe co-sleeping and breastfeeding [see full article], with reference to James McKenna who has written and spoken extensively on the matter:
Professor McKenna defined co-sleeping as not about sharing a physical area, ie a bed, but having the baby within arm's length. He continued on by saying that breastfeeding and co-sleeping are the same adaptive complex designed by natural selection to maximise infant survival and parental reproductive success; there is no documented scientific study to show deleterious consequences of co-sleeping in safe environments; we have come to think of the abnormal as normal; and we are mistaking parental best interests for the infant's best interest. He suggested that current Western beliefs are based on Western European cultural history in which infanticide by 'overlying' existed and was so commonplace that same-bed co-sleeping was outlawed. This cultural history also favoured the notion of romantic love, patriarchal household authority and sanctity of parental privacy.


The claim that bedsharing raises infant death risks originates from the South Australian Coroner's review of the deaths of five babies, aged 3 weeks to 10 months. [full report]

The forensic pathologist has been reported to say that "Western culture had turned co-sleeping into something dangerous. ... in some cultures babies traditionally slept with their parents, but usually on firm bedding or on the floor without the weight of heavy covering."


Rather than a *blanket* outlawing of all co-sleeping, parents need to know where the danger lies. The same principles apply whether the mother is co-sleeping with her baby or placing her baby in another location such as a cot.

Avoid unsafe physical situations:
One of the five babies who died was suffocated when she became entrapped in the cushions at the back of a couch after falling asleep with her father.
Any parent knows about the exhaustion that we all face with the changes in the early days of parenting. It is not safe for anyone to lie on a couch with a baby. It is not safe for a baby to be sleeping in any environment where she can become trapped under or between cushions, pillows or other bedding. It is not safe for a baby to go to sleep lying on a parent who is also falling asleep, or even to let a baby sleep with other children.

Avoid unsafe temperature rise
A baby who is over-dressed, or over heated is placed at danger. Never use an electric blanket or other bed heaters with a baby. When sleeping with a baby, use cotton sheets and wool blankets, which allow air flow and moisture balance, rather than synthetic blankets and quilts/doonas. It is not safe to have pets in a room with a baby.

Avoid unsafe parental situations
Parents who have taken substances that may suppress their ability to respond (eg alcohol, cold medication, sleeping pills), or parents who smoke, should not co-sleep with their babies.

A breastfeeding mother who sleeps with her baby is intentionally responsive to the baby, and will usually form a C-shape with her own body around her child. In this way she will be responsive and alerted by any unusual movement by the child.

Sleep studies have shown mothers and babies interacting significantly while both appear to be sleeping. Mothers who follow intuitive patterns of mothering are able to learn safe sleeping with their infant, as well as being able to put their baby down in a safe place such as a cot for sleep.



Reference [quoted in Sue Cox's article linked above]:
McKenna JJ 1998 Breastfeeding and Mother-Infant Co-sleeping as an Adaptive System: Historical and Biocultural Perspectives. "Breastfeeding The Best Investment," CAPERS August Seminar, Melbourne, Australia.

Sunday, September 26, 2010

Medicare funding: carrot or poisoned chalice?



Australian maternity activists have for many years fought for public funding to be made available to women who choose a midwife as their primary maternity carer. The little group in the picture above in 2003 walked in a rally in Melbourne, wearing T-shirts with the message 'Push for better birth'. (you may recognise some of the faces!)



This front cover of Birth Matters, the quarterly journal of Maternity Coalition (I was editor at the time) comes with discussion:
"We'll have voting rights soon."
"How long until we have rights in childbirth?"


Maternity Coalition had facilitated the writing and promotion of the National Maternity Action Plan (NMAP 2001) The key elements of NMAP were choice for women of primary care provider, and place of birth. NMAP called for public funding for basic maternity services to be linked to the individual woman/baby/birth, rather than the complex and fragmented system of item numbers for out of hospital care under Medicare, and all acute maternity care being provided in hospitals. Medical items required in pregnancy and birth would continue. The change that we sought was that midwives would be recognised as primary care providers, and women would have choice without financial disadvantage when they chose a midwife.


The culmination of political and professional efforts to 'reform' maternity services, over these past couple of years, are coming to a head. The Labor government declared that it had a mandate to reform health. The Minister, under direction of the Australian Medical Association, held out a conditional offer of Medicare to midwives - a golden carrot in her hand. Consumer and midwife groups applauded - they saw an end to privately funding their maternity care. Many midwives are still holding on to a hope that they will be eligible for a Medicare provider number.

The condition is HUGE: supervision of midwifery practice by a doctor.

But what looked enticing is now being recognised as a poisoned chalice. Take a sip, midwife, and you're finished. There is no sign yet of an answer to the question 'How long until we have rights in childbirth?'

For most of the past 20 years I have been working to achieve equity of public funding for those women who choose a midwife as their primary maternity carer, and recognition of the midwife as a provider of basic maternity services. Equity means even-handedness, fair play: that services provided by a midwife are entitled to the same public funding as the same services provided by any other maternity care professional. As it happens, the only other professional with the authority to provide professional services in pregnancy and birth is a doctor. The inequity, or lack of fairness in maternity, is that although the midwife is as capapble as the doctor of providing basic maternity services, only the doctor is entitled to public funding for her/his services. And this is in a country that has legislation protecting competition in trade (Trade Practices Act).

This Medicare reform package will not deliver even a pathway to those goals of equity and choice. It will set midwifery back, and I expect it will feed the ever-increasing caesarean and birth trauma rates.

For more reading on this topic:

MIPP - Midwives Victoria
Homebirth Australia
Maternity Coalition
NEW Maternity Coaliton blog

Thursday, September 16, 2010

UNASKED QUESTIONS ABOUT SYNTHETIC OXYTOCIN

[This newsletter has been reproduced unaltered, with permission. If you would like to subscribe to it, please contact wombecology@aol.com]

PRIMAL HEALTH RESEARCH
A NEW ERA IN HEALTH RESEARCH
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road, London NW3 2JR
michelodent@googlemail.com
Summer 2010 Vol 18. No1
**************************
www.primalhealthresearch.com
(Free access to the Primal Health Research Data Bank)
www.wombecology.com
(The importance of pre- and perinatal ecology)
BETWEEN THE MIDATLANTIC AND THE MIDPACIFIC CONFERENCES
(Topics for the future: see below)


UNASKED QUESTIONS ABOUT SYNTHETIC OXYTOCIN
A labouring woman was puzzled and even anxious when she received a drip of synthetic oxytocin, The midwife immediately reassured her that oxytocin is not like a drug: it is “natural”. Perhaps this is why we ignore many questions regarding what is undoubtedly the most common medical intervention in childbirth on all five continents. Today, all over the world, most women giving birth vaginally get such a drip (called Syntocinon or Pitocin) including those with an eventual operative delivery by forceps or ventouse. Most women who undergo a caesarean section during labour have had such a drip before the decision to operate, and this drip is usually continued for some hours after the surgery. Even during and after a pre-labour c-section, synthetic oxytocin is included in many hospital protocols to facilitate uterine retraction. Furthermore, the rates of labour inductions are currently high, and induction almost always involves the use of synthetic oxytocin.

Preliminary questions
This new situation raises important questions. We must first wonder why modern women need substitutes for the hormone that is naturally released by the posterior pituitary gland. Is it because their oxytocin system is disturbed? Is the capacity to effectively release oxytocin depleted from generation to generation, as a result of several aspects of modern life, particularly medicalised birth? This is a vital question for the future of civilisation, since the oxytocin system is involved in sociability, capacity to love, and potential for aggression. Is it mostly cultural conditioning in a context of industrialised childbirth? In this latter case the current situation might be reversible. If it is simply a matter of environment at birth, we need to improve our understanding of the birth process. In fact, we must explore the possible contribution of multiple factors.

Other questions address the substances that might cross the placenta and reach the unborn baby. For example, the kind of fluid used to transport synthetic oxytocin. In earlier times, glucose drips were routine during labour. These infusions were not benign because simple sugar molecules rapidly cross the placenta while the mother’s insulin—released in response—fails to reach the fetal bloodstream. There is thus a risk of excessive insulin production generated by the baby's pancreas in response to these circulating high blood sugar levels. Extensive research has confirmed the risks of neonatal hypoglycemia.(1 to 7) These studies led to the replacement of glucose drips during labour by other liquids, such as Ringer’s solution. The results of such studies also apply to labouring women without a drip of synthetic oxytocin if they are encouraged to consume sugar or soft drinks. This is not always understood by the natural childbirth groups. Furthermore, if labour progresses spontaneously, adrenaline type hormone levels are low, voluntary muscles are at rest, and these women don’t need added energy.8

Can synthetic oxytocin cross the placenta?

When we finally acknowledge that all over the world most women receive synthetic oxytocin while giving birth, we can no longer deny problems arising from the possible transfer of oxytocin via the placenta. One can wonder why it remains an unexplored issue. The main reason, as we have suggested, might be that oxytocin is not considered a “real” medication because chemically the synthetic form is no different from the natural hormone: it is a simple molecule (a nonapeptide). However, the problem is not simple because the amount of oxytocin reaching the maternal blood stream via an intravenous drip is enormous compared with the amount of natural oxytocin the posterior pituitary gland can release. Furthermore, natural oxytocin is released through pulsations, while synthetic oxytocin is delivered continuously. Another reason for ignoring this issue might be the discovery of enzymes that metabolize oxytocin (oxytocinases) in the placenta. This finding might have led to a hasty, tacit conclusion that synthetic oxytocin does not reach the baby.

Until now, there has been only one serious article published on this subject.9 A team from Arkansas concluded that oxytocin crosses the placenta in both directions—after measuring concentrations of oxytocin in maternal blood, in the blood of the umbilical vein and umbilical arteries, and also after perfusions of placental cotyledons. More precisely, the permeability is higher in the maternal-to-fetal direction than in the reverse. Eighty percent of the blood reaching the fetus via the umbilical vein goes directly to the inferior vena cava via the ductus venosus, bypassing the liver, and therefore reaching the fetal brain immediately: it is all the more direct since the shunts (foramen ovale and ductus arteriosus) are not yet closed.

Since there is a high probability that a significant amount of synthetic oxytocin can reach the fetal brain, we must investigate the permeability of the so-called blood brain barrier at this phase of human development. This “barrier” implies a separation of circulating blood from cerebrospinal fluid in the central nervous system. It restricts the diffusion of microscopic particles, including bacteria, and molecules such as oxytocin. However, Australian researchers presented evidence that the developing brain is more permeable to small lipid-insoluble molecules and that specific mechanisms, such as those involved in transfer of amino acids, develop gradually as the brain grows.10 Furthermore, it appears that the permeability of the blood-brain barrier can increase under the influence of oxidative stress11,12,13, that commonly results when a synthetic oxytocin drip is administered during labor.14 Therefore, we have serious reasons to be concerned if we consider the widely-documented concept of “oxytocin-induced desensitization of oxytocin receptors”.15,16,17,18 It is probable that, at a quasi-global level, we routinely interfere with the development of the oxytocin system of human beings at a critical phase for gene-environment interaction. Within the framework of accepted scientific knowledge, we must acknowledge the important role of oxytocin, particularly in sociability, the capacity to love (of others and love of oneself) as well as the potential for aggression (aggression towards oneself and towards others).19 Interfering in normal reproductive physiology raises critical issues. For example: “Is there a link between the increased incidence of disorders associated with documented alterations of the oxytocin system (such as autism20,21 and anorexia nervosa22,23) and the widespread use of intravenous drips during labour?” “What will be the impact on the evolution of our civilizations?” We may even wonder if the widespread use of synthetic oxytocin can induce an unprecedented cultural revolution.

Such questions should inspire a new generation of research.

Plastic related substances

Of course, one cannot ignore the toxic effects of phtalates, which are added to plastics such as polyvinyl chloride (PVC) to increase their flexibility, transparency, and longevity. The National Institute of Environmental Health Sciences and the National Toxicology Program began studying phthalates following a discovery that blood stored in PVC plastic bags for transfusions contained significant concentrations of phthalates.24 The most common phthalate is di-ethylhexyl phthalate, or DEHP. In bags for intravenous drips and tubing, additives like DEHP can make up 40 or 50 percent of the product.

There are several reasons why this issue is critical. The first is that the effects of phtalates on intellectual development have already been demonstrated, in particular by an authoritative South Korean study.25 The authors found that high urinary concentrations of phthalate metabolites were associated with lower intellectual quotients (IQ) among 667 children at nine elementary schools. Another reason for serious concern is that today most women spend hours with an intravenous drip while giving birth. There is an accumulation of data confirming the transplacental transfer of phtalates among mammals in general26,27 and humans in particular.28 Most babies probably receive some amount of phtalates during the critical period surrounding birth. Is this amount negligible or dangerous? What are the possible long-term consequences? It is essential to emphasize that these phtalates pass directly into the fetal bloodstream, with no possibility of degradation in the digestive tract. Very sensitive tests today can find a millionth of a gram, or even less, of certain substances in blood or urine. This measurement process is called biomonitoring. In July 2006, an expert committee of the National Academy of Sciences (NAS) published the results of a comprehensive study of biomonitoring. The committee stated that, “In spite of its potential, tremendous challenges surround the use of biomonitoring, and our ability to generate biomonitoring data has exceeded our ability to interpret what the data mean to public health.”

Today, even the experts confess that they are in the dark.

References
1 - Mendiola J, Grylack LJ, Scanlon JW. Effects of intrapartum maternal glucose infusion on the normal fetus and newborn. Anesth Analg. 1982 Jan;61(1):32-5
2 - Lucas A, Adrian TE, Aynsley-Green A, Bloom SR. Iatrogenic hyperinsulinism at birth. Lancet. 1980 Jan 19;1(8160):144-5.
3 - Kenepp NB, Kumar S, Shelley WC, Stanley CA, Gabbe SG, Gutsche BB. Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. 1982 May 22;1(8282):1150-2.
4 - Carmen S. Neonatal hypoglycemia in response to maternal glucose infusion before delivery. J Obstet Gynecol Neonatal Nurs. 1986 Jul-Aug;15(4):319-23
5 - Grylack LJ, Chu SS, Scanlon JW. Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis. Obstet Gynecol. 1984 May;63(5):654-8.
6 - Kenepp NB, Shelley WC, Kumar S, Gutsche BB, Gabbe S, Delivoria-Papadopoulos M. Effects of newborn of hydration with glucose in patients undergoing caesarean section with regional anaesthesia. Lancet. 1980 Mar 22;1(8169):645.
7 - Singhi S, Sharma S. Neonatal hypoglycemia following maternal glucose infusion prior to delivery. Indian J Pediatr. 1991 Jan-Feb;58(1):43-9.
8 - Odent M. Laboring women are not marathon runners. Midwiferytoday
9 - Malek A, Blann E, Mattison DR. Human placental transport of oxytocin. J Matern Fetal Med. 1996 Sep-Oct;5(5):245-55.
10 - Saunders NR, Habgood MD, Dziegielewska KM. Barrier mechanisms in the brain, II. immature brain. Clin. Exp. Pharmacol. Physiol. 1999;26(2):85–91
11 - Noseworthy M, Bray T. Effect of oxidative stress on brain damage detected by MRI and in vivo 31P-NMR. Free Rad. Biol. Med. 1998;24:942–951
12 - Agnagnostakis D, Messaritakis J, Damianos D, Mandyla H. Blood-brain barrier permeability in healthy infected and stressed neonates. J. Pediatr. 1992;121:291–294.
13 - Noseworthy M, Bray T. Zinc deficiency execerbates loss in blood–brain barrier integrity induced by hyperoxia measured by dynamic MRI. PSEBM. 2000;231:175–182.
14 - Schneid-Kofman N, Silberstein T, Saphier O, Shai I, Tavor D, Burg A. Labor augmentation with oxytocin decreases glutathione level. Obstet Gynecol Int. 2009;2009:807659. Epub 2009 Apr 16.
15 - Robinson C, Schumann R, Zhang P, Young R. Oxytocin-induced desensitization of the oxytocin receptor. Am. J. Obstet. Gynaecol. 2003;188:497–502.
16- Gimpl G, Fahrenholz F. The oxytocin receptor system: structure, function and regulation. Physiol. Rev. 2001;81:642–643.
17 - Phaneuf S, Rodríguez Liñares B, TambyRaja RL, MacKenzie IZ, López Bernal A. Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour. J Reprod Fertil. 2000 Sep;120(1):91-7.
18 - Phaneuf S, Asboth G, Carrasco M, Lineares B, Kimura T, Harris A, et al. Desensitization of oxytocin receptors in human myometrium. Hum. Reprod. Update. 1998;4:625–633.
19 - Odent M. The Scientification of Love. Free Association Books. London 1999.
20 - Modahl C, Green L, et al. Plasma oxytocin levels in autistic children. Biol Psychiatry 1998; 43 (4): 270-7.
21- Green L, Fein D, et al. Oxytocin and autistic disorder: alterations in peptides forms. Biol Psychiatry 2001; 50 (8): 609-13.
22 - Demitrack MA, Lesem MD, Listwak SJ, et al. CSF oxytocin in anorexia.nervosa and bulimia nervosa: clinical and pathophysiologic considerations. Am J Psychiatry 1990 Jul;147(7):882-86
23 – Odent. Autism and anorexia nervosa: two facets of the same disease? Med Hypotheses 2010. doi:10.1016/j.mehy.2010.01.039
24 - Baker RW. Diethylhexyl phthalate as a factor in blood transfusion and haemodialysis. Toxicology.1978 Apr;9(4):319-29.
25 - Cho SC, Bhang SY, Hong YC, et al.. Relationship Between Environmental Phthalate Exposure and the Intelligence of School-Aged Children. Environ Health Perspect. 2010 Mar 1. [Epub ahead of print]
26 - Saillenfait AM, Payan JP, Fabry JP, et al. Assessment of the developmental toxicity, metabolism, and placental transfer of Di-n-butyl phthalate administered to pregnant rats. Toxicol Sci. 1998 Oct;45(2):212-24.
27- Kihlström I, Placental transfer of diethylhexyl phthalate in the guinea-pig placenta perfused in situ. Acta Pharmacol Toxicol (Copenh) 1983 Jul;53(1):23-7.
28 - Mose T, Knudsen LE, Hedegaard M, et al. Transplacental Transfer of Monomethyl Phthalate and Mono(2-ethylhexyl) Phthalate in a Human Placenta Perfusion System.0. International Journal of Toxicology 2007; 26(3): 221-229.

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BETWEEN THE MID-ATLANTIC AND THE MID-PACIFIC CONFERENCES
The Mid-Atlantic Conference on Birth and Primal Health Research – which attracted 1250 participants from 39 countries – has been a successful rehearsal before the Mid-Pacific Conference.
The Mid-Pacific Conference will occur on October 26-28, 2012, in Honolulu. The venue will be the prestigious Hawaii Convention Center, as the meeting point between Western and Eastern cultures.
Once more, the main objective of the conference will be to phrase new questions after presenting an overview of technical and scientific advances that will influence the history of childbirth. As in Las Palmas, the participation of Pr. Michael Stark, the “father” of the new simplified technique of cesarean, will symbolize technical advances, while the participation of Pr Kerstin Uvnas-Moberg, as an expert in behavioural effects of oxytocin, will symbolize scientific advances. The need to think globally will be emphasized by the participation of Dr Mario Merialdi, coordinator for maternal and perinatal health at WHO.
The Mid-Pacific conference will be characterized by the emergence of new important themes, such as the transgenerational effects of early experiences (during the “primal period”), the expected importance of economical factors in the evolution of medicine in general and obstetrics in particular, and also by the great diversity of renewed practical topics presented during the thirty concurrent sessions and through posters.
During these three days, inspired by our logo and surrounded by the foams of the oceanic waves, we’ll be in an ideal place to dream of and to work for the Rebirth of the Goddess of Love.
Aloha means Love!
Michel Odent and Heloisa Lessa

Friday, September 10, 2010

Bertha finds a midwife

"If you can type you can make movies"

.
That challenge was too much for me, so I have made this little 2-minute animation movie, in response to the one I posted below thismorning. Enjoy! JJ




NEW 17 Sept 2010 Bertha's first birth







BERTHA'S VBAC

midwife 'humor'



If you are able to think critically about midwifery, natural birth, women's choice in health care, advocacy, pain relief, ..., this quirky video clip is worth watching.

Yes, it's American, and we're different, aren't we?

Here's a thumbnail sketch of the clip:

The midwife talks with the anaesthetist and says the labouring woman needs an epidural.
The anaesthetist asks the usual medical questions.
The midwife says the woman feels fine - but no objective measurements of the woman's condition have been made.  The epidural is being ordered so that the cervix can be checked.  But the woman wants a natural birth, so she doesn't want all that medical stuff done, and the midwife is advocating for the woman's choice.
[Thanks to Caroline Hastie for this video clip]

Sunday, September 05, 2010

Fathers

Happy Father's Day, from Poppy

Fathers are an integral part of a midwife's life, yet they don't often find themselves being the focus of my writings.

Today we have celebrated father's day, with a nice breakfast of pancakes, bacon and eggs, and a few little gifts including the standard 'sox-n-jocks'. Poppy has given me permission to use her drawing of herself, her daddy, and grandpa and granny.


Our society has changed in the past couple of generations, from excluding fathers from any involvement in birth to an expectation that they will be present and accounted for throughout the labour and birth.

Today the father's ritual of cutting the cord is almost comic relief after a highly medicalised birth. Occasionally a father says "no, thank you" when the scissors are being thrust in his direction, and someone else has to step up to the task.

What is a father's chief role in birth and early parenting?

Many aspects of a role come to mind, including encouragement, support, caring, looking after household chores, preparing meals, making cups of tea, ... These are like pieces of a puzzle - each one incomplete in itself. They only make sense when they fit together perfectly.

Looking beyond the individual pieces of the puzzle, the role of the father can be summarised as "to love the mother".

There are enormous adjustments that have to be made when a new baby is brought into a family. The father who loves the mother, in a gentle and unconditional way, is providing the strong cement that will hold that family together through sleep deprivation, and feeding challenges, and the many other unexpected journeys that come up in ordinary life.

Father's Day is to a great extent a product of materialism, and a great marketing opportunity. Today I encourage each father to truly love the mother of your children, and in that way you will be establishing strong bonds within your family, and protecting your children as well as their mother.

Unfortunately there is no plan that will guarantee that you will live 'happily ever after'. I simply encourage parents to commit yourselves to the work of parenting, to the best of your ability, and you will not regret the investment you make.

Monday, August 30, 2010

Families


In the past week or so my mind has been drawn into a family-related project that I call 'Pictures and memories from long ago'.

With a strong sense of purpose, I have scanned pictures and documents, and copied accounts of the lives of some of my forebears. These fragments of memories have been drawn together, as I have remembered people and stories from the past.

The two women pictured in this post are truly wonderful women, from whom I have learnt values and been inspired to follow their guidance. The stately old lady is Jane Eliza Harriet White, aged 95 when this picture was taken, I think. My Grandma lived in the old homestead overlooking the bay at Redland Bay, Queensland. The tall palm trees made the house visible from a mile or so away as we headed towards School of Arts Road. Grandma had given birth to, and cared for her eight children, through terrible times or war and the Great Depression.

The beautiful younger woman, with two little girls, is my mother, Ella White. Mum's story includes missionary work in China, where she met and married my father. She gave birth to, and cared for her seven children, through the 50s and 60s. I have written about my mother in this blog in the past, especially as I waited for my own daughter to give birth.

Both Mum and Grandma included twins amongst their children. Mum had trained as a triple certificate nurse: nurse, midwife, and infant welfare sister. Grandma had done lady-like preparation for life in the early 20th century, including learning to paint landscapes. These two women have given me my two passions that go beyond family: midwifery and art.

My work of collecting and collating pictures and stories has been inspired by my enjoyment of digital technology. A simple e-book format that I used for my first book, Midwifery from my heart, has been readily adapted to the job at hand. I am bringing out the old albums, scanning the pictures, and presenting them in a way that tells a very special story.

My children and grandchildren are not very interested in their heritage at present. They have busy lives. But one day they may find, as I have, great pleasure in remembering and adding to my memories.

Monday, August 23, 2010

IS HOMEBIRTH SAFE?

and,

IS THAT A VALID QUESTION?

I am not wanting to write at length about this very significant question today, but would like to direct readers to Amy Romano's comment and debate at the Lamaze blog.

In what appears to be a global race to discredit homebirth, people who should know better have shamelessly manipulated retrospective data from planned homebirth, and come up with conflicting and often confusing results that have been published in peer-reviewed literature.

Note in this context the critiques of the Australian Medical Association's publication of the Kennare et al (2010) Planned home and hospital births in South Australia, 1991-2006: differences in outcomes. The wild claims of increased risk of perinatal death or morbidity are just that: wild claims made on deeply flawed research.

Amy Romano writes:
The (in)famous Wax home birth meta-analysis hit the scene over a month ago. But the buzz doesn’t seem to be dying down. In the weeks since the original pre-publication and press release, editors at The Lancet and BMJ have both weighed in, and there’s a steady stream of media attention. While all of the media have dutifully quoted midwives in leadership positions saying the meta-analysis is flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier post – did we need a meta-analysis to establish the neonatal outcomes of planned home birth? We had, after all, a very large, methodologically rigorous study on home birth safety involving over a half million women that was published less than 2 years ago. Won’t that suffice? ... (continued)

Thursday, August 12, 2010

Collaborative arrangements for midwives

photo: Mizz with Josh
Readers who have been following the political developments in the world of midwifery will know that the Australian government has signed into law a requirement for midwives to have 'collaborative arrangements' in order to entitle their clients to claim Medicare rebates on their charges. Midwives may become eligible for Medicare provider numbers after 1 November this year, if all goes to plan.

Midwives have known since early in the maternity reform process that the Health Minister is committed to collaborative arrangements. Midwives and childbirth advocates have repeatedly lobbied the Health Minister and her bureaucrats about the fact that the requirement for collaborative arrangements for midwives, without any matching requirement that doctors should engage in such arrangements, was an effective veto of private midwifery practice. There is no incentive, no reason why any doctor would consider signing a collaborative arrangement with a midwife in private practice, who is, in a small way, competing with the doctor for business.

Press releases and discussion about the Gillard government's action in progressing the small piece of legislation, 'National Health (Collaborative arrangements for midwives) Determination 2010' under subsection 84(1) of the National Helath Act 1953 can be reviewed at recent posts to the MiPP blog.

My intention in commenting here on this matter is to work through a scenario that I, and a woman who sought my services, would encounter if we tried to comply with the requirement for collaborative arrangements as laid down in this piece of legislation.

Section 7 requires that (1) an eligible midwife must record the following for a patient in the midwife's written records:
(a) the name of at least 1 specified medical practitioner who is, or will be, collaborating with the midwife in the patient's care (a named medical practitioner);
(b) that the midwife has told the patient that the midwife will be providing midwifery services to the patient in collaboration with 1 or more specified medical practitioners in accordance with this section;
(c) acknowledgment by a named medical practitioner that the practitioner will be collaborating in the patient's care;
(d) plans for the circumstances in which the midwife will do any of the following:
(i) consult with an obstetric specified medical practitioner
(ii) refer the patient to a specified medical practitioner;
(iii) transfer the patient's care to an obstetric specified medical practitioner.

Under this section, the woman who is my 'patient' requires a named medical practitioner (a) of whom the woman has been informed (b), and who agrees in writing to be the collaborating doctor (c).

I don't know where to start looking for this doctor (or doctors). My clients at present come from as far away as Epping in the North, Point Cook in the S-W, and the Yarra Ranges in the East - from 20-50K in each direction. I do not know the local doctors. Most of my clients are healthy women who take good care of their bodies and their families, and who don't have much need for doctors.

I have no idea how the named medical practitioner of this section is going to make him/herself available 24/7. Midwives take small caseloads so that we can respond at any time, day or night. Critical decision making in maternity care, particularly when the midwife is committed to protecting, promoting and supporting the natural physiological processes, is not something that happens in office hours. Most doctors have work hours; many medical practices are closed out of hours. Is this doctor going to give me his/her private contact details, and engage with the midwife at any time, under this collaborative arrangement?

I can only imagine how the insurance company of the named medical practitioner of this section will respond to any potential claims. The indemnity issue alone will probably be off-putting enough for even those most supportive of midwifery practice.

The requrement (d), plans for consultation and referral and transfer of care are not a problem at present. A midwife, by definition, arranges medical referral when and if required.


The legislation continues:
(2) The midwife must also record the following in the midwife's written records:
(a) any consultations or other communications ...
(b) any referral ...
(c) any transfer ...
(d) when the midwife gives a copy of the hospital booking letter for the patient to the named medical practitioner - acknowledgment [signed -received]
(e) when the midwife gives a copy of the patient's maternity care plan to the named medical practitioner - acknowledgment [signed - received]
(f) if the midwife requests diagnostic imaging &c for the patient - when the midwife gives the results to the named medical practitioner - acknowledgment [signed - received]
(g) that the midwife has given a discharge summary to the named medical practitioner and the GP - acknowledgment [signed - received]


Reading this section makes me wonder how I would be able to comply with all the complexities of this system.  I don't have a secretary sitting at a desk and organising my letters and paperwork. I wonder if this doctor is going to be happy with faxes, or with results sent by mail from the pathology lab?

My conclusion is that the future looks unpromising for midwives who are hoping to set up Medicare - supported practices.



In the Radio National's Life Matters program today, midwife Liz Wilkes and obstetrician Ted Weaver spoke on "collaborative arrangements".

For those who'd like to hear the online audio, download the podcast, or make comment, the website is:
http://www.abc.net.au/rn/lifematters/

Liz spoke well. Ted Weaver has his head in the sand. He reckons doctors haven’t been asked if they would sign a collaborative arrangement so that a midwife’s clients can access Medicare. He suggested obstetricians will agree to increase their clinical load without being paid – he used the term altruism!

Midwives are regulated practitioners in our own right.  Yet the Medicare reforms put us not only at the mercy of the medical profession, but also asking for their generosity.  There is really no sense, from a doctor's point of view, in supporting someone in competition for business.

Sunday, August 01, 2010

RANZCOG on trial

The new Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) C-Obs 38, issued July 2010 by the College of Obstetricians and Gynaecologists, RANZCOG, requires critical review.

Yesterday I commented in another blog on the 'risk' picture presented in this Statement.

The ultimate statistic:
RANZCOG notes an "extremely low but clinically important frequency of adverse outcomes", notably maternal death, for women who have elective repeat caesarean surgery (ERCS). However, RANZCOG deftly attributes the reason for the "apparent association" to "women with complex medical and obstetric problems [who] are much more likely to feature in the ERCS". This statement is dishonest and misleading. Women with no medical or obstetric problems have added to maternal mortality and serious morbidity statistics after caesarean surgery that has been undertaken for non-medical reasons, or after a cascade of interventions that began with medical interference in an otherwise uncomplicated pregnancy.

Homebirth for VBAC
While the 'H' word is not prominent in the RANZCOG statement on VBAC, it is understood from a previous College Statement (C-Obs 2) that RANZCOG "does not endorse home birth". This position has been clear since 1987, and has effectively prevented any useful dialogue on home birth between midwives and most obstetricians.  It's a matter of joining the dots.

Having declared its standard for antenatal preparation; intrapartum care; contraindications to Trial of Labour (TOL), and TOL in risk-prone circumstances, the RANZCOG statement on VBAC has defined the option of "TOL" in "risk-prone circumstances" as "sub-standard care" [emphasis added].
"A TOL may become particularly risk-prone where: there is a lack of services for safe provision of emergency care (eg a TOL conducted at home, birth centre or centre without ready access to obstetric, anaesthetic and paediatric support); there is a failure to provide or accept adequate intrapartum maternal and fetal surveillance; and there are clinical circumstances such as outlined above (eg more than one previous caesarean section)"

It is pretty clear to me that RANZCOG's TOL is unlikely to proceed to a spontaneous vaginal birth, with a healthy mother and baby. This statement exposes the lack of recognition of childbirth as a physiological process that is normal and good; a process that is in delicate hormonal balance. Throughout the document the reader is reminded repeatedly of the risk of rupture. It comes up like an advertisement: "remember you might need an obstetrician".

How often is the risk of rupture likely to result in catastrophic outcomes?

About 1 in 2000 labours for planned vbac.

*****

There are many factors to be considered by women who have had one or more previous caesarean births. The Births after Caesarean INFOSHEET, available at the Maternity Coalition website, summarises the choices that these women may face.

Midwives who agree to provide primary care for women planning VBAC, whether the birth is planned for home or hospital, face potential criticism based on the RANZCOG Statement. The Statement advises that before a midwife agrees to "administer care in risk-prone circumstances, that the women agree to counselling by a senior obstetrician who should ... [read on, there's a real sting in the tail of this one! That selfish woman needs to know that she is potentially imposing "considerable demands on the limited resources of the health team, with potential adverse consequences not just for her and her baby, but also for other women and their babies"]

Feeling guilty now?

Why don't you just roll over?

*****

In this RANZCOG Statement on Planned Vaginal Birth after Caesarean Section I have found material for all the bullying and manipulation that is needed to force women into submission to the medical system. While acknowledging a woman's right to make choices, the Statement sets the stage to shackle those who have the ability and skill to recognise and address complications early if they occur, while working in harmony with the natural physiological processes that lead to safe and joyous birthing.  Under this Statement the rate of Caesarean births, and all the related complications, is likely to continue to rise in Australia and New Zealand.

Wednesday, July 28, 2010

Notes from my practice

A baby has been born, at home. After a couple of days of pre-labour, frustratingly coupled with winter colds being suffered by the whole family, the labour began. I was called at about 3 am, and headed out into the country, driving through towns, and past vineyards and farms.

The midwifery student arrived just after me, and we went into the home together.

The student has kindly shared her reflections with me:

"When we arrived the woman was upright, pacing with her ipod on and using lots of heat packs. The room was lit by candles and the fire was burning.
"Suprisingly we did not do an assessment on arrival but instead proceded to unpack things. I helped to test and check the emergency equipment and positioned everything in unobtrusive but accessible places in case they were needed (they weren't). After about 20mins of setting up we were ready to do an assessment. It the very first of many stark contrasts to hospital midwifery in that this only included a temperature and fetal heart rate. The midwife explained that as the woman's BP had been stable all along there was no evidence to support it being unstable in labour, in addition we already knew the baby was cephalic and well engaged (from our previous appointments) so a palpation was unnessessary. A VE [vaginal exam] was also unnessessary as it wouldn't change the course of action/treatment at that time. No timings either, as there is no syntocinon to put up. All in all our assessment was about observing behaviours."


It has been an interesting exercise for me to see this birth through the eyes of someone who is new to the profession. Someone who recorded, after the birth, 
"It was the first time I have seen:
  • An upright first stage
  • Labouring in water
  • Birthing in water
  • No meds to hurry labour
  • No analgesia in labour
  • A physiological 3rd stage
  • A woman taking cues from her body, not from hospital staff
  • Family and friends with active labour involvement
  • A woman eating and drinking freely in labour
  • Waters breaking without someone breaking them
  • Kids in labour
  • Video camera in labour
  • A baby being swadled in sheets etc that the family had been using prior so it had their scent on it
  • True woman-centre care"


My enduring memories from this birth centre on the normality of everything that happened, contrasting with the potential threat of illness. The illness that this mother, father, and family faced at the time was that they all had colds - common garden variety upper respiratory viral infections. Coughing, congestion, chills, sleeplessness ... they had it all.

By the time labour was established the mother was weary.
As the time for birth drew closer, and the mother became frustrated by her physical weakness, I asked her to rest quietly in the womb of warm water. Some would call it transition. The light from candels was dimmed. The support crew withdrew to the kitchen, and had cups of tea and pieces of toast.

The miracle of birth unfolded and a beautiful pink baby boy, with a shock of black hair, was lifted out of the water by his mother and taken into her arms.

The miracle of birth continued as the child transitioned from placental circulation to strong, normal breathing, and began his lifelong search for good food.

The miracle of birth continued as the mother stood and released her baby's placenta, with only minimal blood loss.

Mother and baby are well and happy.


Another mother is waiting for her baby to be born.

She is a mother who has experienced the cascade of interventions in her previous pregnancy, with induction of labour, epidural, caesarean birth, separation from her baby, the baby being given formula feeds, and weeks of distress, pain, bonding and breastfeeding difficulties.

She is a mother who is longing to give birth to her baby, and who is learning to face her fears and work with a simple decision making process as each day passes.

Sunday, July 11, 2010

ANNOUNCING: Midwifery from my heart

Midwifery from my heart is the first in a new e-book series.

If you would like a copy of Midwifery from my heart, simply send a small donation of at least $10 to a charity providing services or relief for needy mothers and families, and let me know that you have done so when you request Midwifery from my heart. [email: joy@aitex.com.au ]

Charities to consider include
TEAR Australia
World Vision
CP Australia
ACM Scholarship fund for Aboriginal and Torres Strait Islander midwives


Introduction to the Villagemidwife e-book series

I am writing
To record my knowledge
To tell my stories
To teach others

I am a midwife. My words, thoughts and actions have been formed over many years and a unique set of experiences: the world into which I was born; the mother who bore me; the family that nurtured me; the towns and communities that have allowed me to be me, and this wide open land and its people.

I like to think that these are my thoughts, yet I know that much of what I say is my own filtering and organising of what I have absorbed from those around me. Although I am the speaker, I am not the source.

Midwifery belongs to women. The midwife is ‘with woman’, a companion for a distinct and definable childbearing event, in a special partnership. Midwifery does not belong to theorists, although the clear expression of the ‘with woman’ partnership by thinkers has helped set great value on this simple phrase.

Midwifery is women’s business, evolving and moving with women, in our own time and space, along with our joys and sadnesses, our changing bodies, our children who are sometimes wonderful, and sometimes bring us near despair, and our hopes always for a better future.

Midwifery from my heart
is about the life I know and love. It’s from my heart because I have learnt it, deep in my own life, and in the homes and lives of the women who have taken me with them. It’s midwifery because it’s ‘with woman’.

...

Friday, July 02, 2010

The unexpected journey

"By choice, in our adult years, many of us choose to travel away from our home base, to go on journeys of various lengths, from the small to the epic. We seek adventure, novelty, change. We launch ourselves on ventures near and far, with the comfort of both a phone card and a return ticket in our hip pocket. From a secure base, we revel in being on the move, delight in the foreignness of our encounters and welcome the rejuvenation of self that accompanies these departures from our norm.
...
"When a journey is not of your choice, if you are ill prepared for the road, if you have little idea where you are going, how long you will stay, where or when you might find a place to rest, how to speak the language, the allure of travel fades." [Quoted from a paper 'The inside journey through care', given by Jennifer McIntosh, PhD, Clinical Psychologist, Family Therapist, Researcher, 2001]


The universal expectation of pregnancy is the birth of a baby. The 'knowledge' is not only knowing in our minds; it's also known and prepared for hormonally in every cell of the mother's body. Even the father's body may experience hormonal changes that are likely to prepare him for the anticipated change.

Just as the fact of a baby is hormonally heralded, the normal physiological process of childbirth anticipates a specific journey for the mother and her child. We know there is an intense (internal as well as external) period of nesting; then the onset of spontaneous labour which builds as oxytocin pulses, and uterine muscles contract and retract, and opioid-like substances surge, and the cervix is drawn up and opened to release the child. The peak of adrenaline just prior to the expulsive phase prepares the child for the huge transition he must make in leaving one world and entering another.

The journey that is physiologically anticipated includes the mother's recognition of newborn's cry; a babe in her arms; a babe with all the sounds and smells and movements that stimulate further surges of the love hormone; a babe who soon begins his life-long quest for food and proceeds to draw milk from her breast.


The unexpected journey shocks and confuses the mother in this finely balanced hormonal state.

Hours later she is numbly aware that her arms are empty; that her breasts have not been touched. Her mind searches for explanations; for a map to guide this journey that she did not choose.

Wednesday, June 30, 2010

Preterm labour



This document, Neuro-endocrinology Briefing 35: Preterm labour is available online at the British Society for Neuroendocrinology.

The briefing was sent to me by my friend and mentor, Wolfgang Jochle, who lives in New Jersey, USA. Wolfgang's life work has focused on understanding the physiology of animal reproduction. A conversation with Wolfgang always extends my thinking, even though my education in the biological sciences is very limited.

My interest in the topic of preterm labour was heightened just this morning, as a colleague and I discussed a recent experience of working with a woman in spontaneous labour at 35 weeks' gestation. The timely arrival (by air-snail-mail) of this document in today's mail was just one of life's interesting coincidences.

Here's a brief excerpt ...
"But why is birth difficult to delay long enough to reach term? The answer may lie in the recruitment of the oxytocin neurones which, once primed by the initial signals, then respond to any small trigger (including uterine factors/contraction and or psychological situations such as stress that activate parallel brain pathways). This results in an ever-increasing positive feedback that promotes oxytocin secretion in larger pulses which inevitably precipitate further uterine contraction and birth. So, far from uterine mechanisms sustaining labour, brain activity is crucial, and drugs targeting oxytocin neurone priming mechanisms may be an appropriate way forward for therapeutic intervention in preterm labour." (Author: Dr Alison J Douglas, Edinburgh, UK)


A midwife working with healthy, socially well supported, well nourished women planning homebirth does not see much preterm labour. In fact we worry more about pregnancies that extend beyond 42 weeks. (I wonder if the science of neuroendocrinology has a physiological explanation for prolonged pregnancy?)

The time, and nature, of the onset of labour hold many mysteries. The image of "ever-increasing positive feedback that promotes oxytocin secretion in larger pulses" fits well with my understanding of the vastly varied experiences women have as they approach that tipping point, which means their baby will soon be born.

A midwife is conscious of this intricate balance of physical and psychological factors in birthing.