Monday, March 22, 2010

There's no milk like mum's milk - part 2

It was the third day after a caesarean birth in Melbourne's tertiary hospital which is also accredited as 'Baby Friendly'.

[For the first part of this discussion, click here]

Mother had received excellent midwifery support and care during and after the birth, and the midwife on duty had arranged to stay with the little family in the Recovery room so that baby could initiate breastfeeding immediately.

Baby breastfed well in the hour or so after the birth.

In the next 24 hours, baby made some effort at breastfeeding, without attaching and sucking. Midwives helped the mother massage her breasts, express colostrum and give it to baby. I visited them in hospital and encouraged mother in this plan.

The following day I was unable to visit, as I had come down with a nasty head cold which I did not want to share. I spoke to the mother on the phone. Baby was only about 30 hours old, and had had limited success at the breast. Mother was happy giving her expressed colostrum.

The next morning - the third day - the midwife announced that baby looked jaundiced, and was dehydrated. Baby was weighed, and of course had lost weight. Although the loss was not excessive, that did not seem to be taken into account in the new care plan. Without making any effort to support breastfeeding, the midwife announced that the baby needed a blood test for jaundice. This recorded jaundice at the lower limit of the range requiring phototherapy. The mother was informed that baby needed to go 'under the lights' and would be given formula milk to complement the expressed breast milk.

The parents reluctantly agreed to the formula - there was really no alternative. They asked that they be able to give it via a cup or syringe, to avoid using a teat. The nurse's response was that that takes too long, and there's no problem with a teat anyway!

...

That nurse undermined the good work by midwives and the medical team in the preceding days, who had worked to promote, support and PROTECT breastfeeding.

Not only did the mother receive conflicting advice; she had reached a point where she was no longer able to trust the guidance of the midwives and other hospital staff. Breastfeeding was compromised by the formula, which took away the baby's appetite and interest in the breast, the enforced separation that came about with phototherapy, and the use of a teat.

...

Someone may be asking, "What alternative plan was there?" "What would a truly 'baby friendly' maternity service have done in this instance?"

At the very least, giving the supplement by cup or syringe, as requested by the parents, would have minimised the risk of nipple confusion.

Secondly, there was scope for more effort to help the mother with breastfeeding, while continuing to observe the baby for any medical problems such as jaundice and dehydration. In this case there was no cause for concern: the baby was at term, and would not be harmed by a more conservative approach than was taken.

And finally, I need to challenge the acceptance of artificial formula as a suitable alternative to a mother's own milk. The first alternative is human milk from another mother - yet Australian health authorities have put their collective heads in the metaphorical sand. Human milk banking, providing donated and pasteurised human milk for human infants, is the best supplement when a mother's own milk is unavailable.

Yet babies are routinely exposed to the bovine milk, and all the other micronutrients derived from plant oils and any number of foreign and potentially allergy-forming sources, when donated human milk would be far more suitable.

"There's no milk like mum's milk!"

Wednesday, March 17, 2010

A landmark day for midwifery in Australia?

Yesterday the federal government's spin doctors announced that the passing of legislation through the Senate "provides long deserved recognition of Australia's highly skilled midwives.
... giving "midwives access to the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for the first time."
... improving the "choices for Australian women to access high quality, safe maternity care as well as providing support for our talented midwives."
... establishing "a new Government-supported professional indemnity scheme for eligible midwives."

"Today marks a new era for our health workforce - ensuring smarter use of our skilled workforce, and more encouragement to work in multi-disciplinary teams.
This will help deliver better health and better results for patients.
"As a Government, we are extremely proud to be delivering these changes - providing new and innovative options for thousands of women and the community."

The Health Minister's press release makes it all sound great. BUT?

The Australian College of Midwives also welcomes the legislation.
"From 1 November this year, women will be able to choose to see a community midwife, and receive Medicare rebates for their visits to the midwife. The midwives will provide pregnancy and postnatal care in the community, and women may have the option of birth care in hospital from their chosen midwife.
“We welcome Nicola Roxon’s support for women to receive Medicare rebates when they choose the care of a midwife’ Dr Gamble said.
... ‘But we remain concerned to see that access to professional indemnity insurance becomes available for all midwives, including those providing professional care for women who choose to labour and birth at home.”

It's POSSIBLY a landmark day for SOME midwifery. But for miwives like me, who have chosen to be employed privately by women for homebirth or for other private midwifery services, the legislation gives us little to cheer about. Even the promise of Medicare and prescribing rights, to be implemented by November this year, appears to be so wound up in bureaucratic micro-management that we wonder if we will ever be able to meet the criteria. We are doubtful that the Medicare-funded midwife will be able to provide any service that is acceptable to clients, at the same time as providing a reasonable livelihood for the midwife.

The Greens Senator Rachel Siewert spoke up about the systematic discrimination against a small group of midwives and the women who employ us, declaring that "Major parties unite against midwives and homebirths.

"The Federal Government and Coalition have united to ensure that homebirth in Australia will be further marginalised by rejecting amendments to provide midwives with access to indemnity insurance irrespective of the location or venue of the births that they attend
...
"In addition the government chose to reject Greens amendments that would have taken away the power of doctors to veto aspects of midwifery practice, such as homebirth, that they are philosophically opposed to, despite the near universal evidence that safe low risk homebirth has positive outcomes for mother and child.

"We have consistently said that the Government amendments to their Midwives legislation give doctors too much control over midwives practice," said Greens health spokesperson Senator Rachel Siewert.

"It is extremely disappointing to see the major parties side together against the interests of midwives in refusing a Greens suggestion to broaden the scope of collaborative arrangements between midwives and medical practitioners to include health services, thereby ensuring that doctors can't veto homebirths."


Time will tell whether these legislative 'reforms' actually do what the government is claiming they will do, or if the culture of medical dominance is further strengthened.

Thursday, March 11, 2010

There's no milk like mum's milk

You might have overheard a conversation in a playground in Melbourne's leafy Eastern suburbs.
"These are amazing pesticide-free organic bamboo nappies," said Jenny.
"All my baby's clothes are organic cotton with no artificial colours," replied her friend Jacqui.
"This baby sling is really the BEST"
...

Variations on this converstation are being played out across our land. The baby industry relies on youthful idealism when hawking its stuff to our new parents and parents to be. A new baby is the essence of newness and hope. Who would not want all that is good and pure and right for that little one?

Fabulous baby clothes, maternity fashions, prams, toys, books, and other consumables flood shops as well as the online market. Providers of products and services advertise their stuff by every possible means, lining up in booths at a baby expo, with glossy handouts and trivial gifts that will entice market share.


There is one product that cannot be bought or sold, yet its value to both mother and baby is beyond any dollar estimation.

There's no milk like mum's milk.

There's nothing in the market that comes within cooee of a mother's own milk, in terms of nutritional correctness for the individual child, disease prevention through antibodies and other unique biological substances, protection of the psychological bond between mother and child, optimal physical support of the growing child, protecting the mother's health, and much more.

There's no milk like mum's milk.

A couple expecting their first baby will have an impressive array of items ready to welcome their child. Family members and friends will contribute. The mother-2-B will lovingly wash and fold beautiful clothes and wraps in preparation for the birth.

They know breastfeeding is 'best', so they will plan that too.

Yet breastfeeding is an incredibly vulnerable entity, easily lost.

There is a discrete window of opportunity, around the time of birth, when breastfeeding is initiated and established. We have substantial relable evidence as to the maternity practices that either support or interfere with the establishment of breastfeeding. In simple terms, breastfeeding will be threatened when new mothers experience anything that interferes with their learning to breastfeed, such as:
  • receiving conflicting advice
  • not being able trust the guidance of the midwives and other hospital staff
  • being unnecessarily separated from their newborn babies

Breastfeeding is a 2-way activity: a baby breastfeeds, and a mother breastfeeds, simultaneously.

Breastfeeding will be threatened when newborn babies experience anything that interferes with their learning to breastfeed, including:
  • being given anything to suck that is not mother's breast (including teats, dummies, and fingers)
  • not being able to satisfy their need for mother's milk when they feel hungry

Many maternity hospitals have, over the past 20 years attempted to change the way breastfeeding is supported and promoted and protected, for the wellbeing of babies and their mothers. The global Baby Friendly Hospital Initiative was established by World Health Organisation and UNICEF in response to the global threat to health that had arisen with the world-wide promotion of artificial milk formulas that are used as a substitute for mothers own milk.

Many Australian maternity hospitals have implemented the Baby Friendly Health Initiative (BFHI), and undergo periodic external audits by assessors appointed by the BFHI.

In my next post I will outline a case in which staff of a 'Baby Friendly' hospital failed to maintain the expected standard, and the impact that failure has on the mother and baby.

Friday, March 05, 2010

Maternity reform hijacked 2

Consumer choice
The women who employ midwives privately do so for many reasons. In most instances a midwife is employed with the intention of promoting and supporting physiologically normal processes in birth. Since midwives do not have visiting access/ practising rights at hospitals, planned homebirth is the main setting in which Victorian midwives practise. Some women employ midwives privately to accompany them to hospital for the birth. The main reason is that with a private midwife a degree of partnership and trust are able to be formed, and the woman's preference for continuity of carer. While no-one can predict the course of events, the process of making informed decisions in labour and birth can be enhanced.

Evidence from Victorian and other Australian data collections, and international peer reviewed publications supports the effectiveness and safety of planned home birth in the care of a midwife, with access to specialist medical services when the need arises.

Normal midwifery practice includes the ability to refer and make timely decisions about the need to transfer care from home to hospital, or from a primary care facility such as a birth centre or hospital that does not provide emergency obstetric surgery to a higher level hospital. Victorian independent midwives, who have demonstrated accountability and transparency in their private midwifery practice over many years, have exemplary statistics, as recorded by the Health Department's Perinatal Data Collection Unit (PDCU). Planned homebirth, with a midwife as the responsible professional in attendance, is at least as safe a choice in Victoria as planned hospital birth, and the rate of interventions such as caesarean or other operative birth is very low. For example, the PDCU Performance Indicator analysis for standard first-time mothers who planned homebirth showed that 6.5% have caesarean births (DoH Letter dated 15 October 2009) which compares favourably with the statewide public hospital rate of approximately 15%, and the statewide private hospital rate of approximately 27% for standard primiparae in 2007-08 [Source: Victorian Maternity Service Performance Indicators, 2009].

The end result of this reform is likely to be that private midwifery practice will be further marginalised, forced into a grey zone, on the edge of legal practice, or even underground. The outcome of unrealistic restriction to private midwifery practice is that women who plan homebirth may look to unregulated maternity care providers, who are prepared to work outside the law. This cannot be considered safe or acceptable.

Who will be held accountable for adverse outcomes that could have been prevented, with a little bit of a sense of fairness in protecting the choice of consumers who wish to plan to give birth at home?


Competition considerations
Under the Trade Practices Act, government is required to promote competition in health policy, to ensure reasonable choice for consumers and defensible cost for government; that regulations stand or fall on whether benefits can be shown to be greater than costs.

The privileged monopoly that has been granted by successive Australian governments to the medical profession is indefensible in maternity services. While midwives are quite capable of providing primary maternity services for the majority of pregnant women, continuing as the responsible professional carer throughout the labour, birth, and postnatal period, this model of care is largely unavailable in our communities.
There is no public funding for private midwifery care.
Funding arrangements between federal and state health departments fragment maternity care, which is not good practice.
Medicare rebates apply to services provided by GPs or specialist obstetricians, while there is no broad access to midwife led models of care.
The Medicare safety net uses public funds to further privilege the private obstetric market.
Tax rebates on private health insurance also privilege the private obstetric market.

Despite repeated calls by midwives' associations, there has been no serious attempt to apply a public benefit test to maternity-related policies which provide a monopoly for the medical profession, and stifle competition by midwives.

Competition considerations include the need for public funding for consumers who choose maternity services provided by a private midwife, equity and parity with doctors in access for midwives to public funding support for private indemnity insurance, which would likely lead to visiting access for midwives to practise in public hospitals.

Policies for which a public benefit cannot be demonstrated must be repealed or modified so that they do not reduce competition.

For more comment on this topic, go to
Part 1 Background
Part 3, Professional Indemnity Insurance, and Collaborative Arrangements