Friday, March 23, 2012

old-style midwifery

I have tried to capture the essence of the 'extraordinary'
The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.
[From APMA Blog]

Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

Monday, March 12, 2012

safer and better systems of care

with my first baby 1973
Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.

Thursday, March 01, 2012

maternity services survey

This is a high priority request to any readers who have had a baby in Australia since November 2010, or who hope/plan to have a baby in the near future. 

Please click HERE and follow the survey process. The survey will close midnight Sunday the 4th of March 2012. [The survey will accept one response only from an individual]

Please tell the survey why you want to have your own midwife, plan homebirth, promote normal birth, or whatever is important to you. Also, if you have friends who you think could spare 10 minutes to complete the survey, please pass it on to them.

In 2010 the Australian Government introduced a series of reforms to improve access and choice in maternity services for women in Australia. The Australian Government Department of Health and Ageing (DoHA) is now seeking feedback from women on what their experiences have been with recent maternity service arrangements and whether they are aware of the reforms that are in place. Your important feedback will help to shape the future of maternity services in Australia.
Healthcare Management Advisors (HMA) has been engaged by DoHA as an independent organisation to conduct and collate the results of this short survey (3-5 minutes). All your responses will come directly to HMA and will be summarised so as not to be identifiable in any reporting. A report will be provided to DoHA for consideration by the Minister for Health regarding future arrangements for maternity services in Australia.
This short survey can be accessed through the following link The survey will be open until Sunday the 4th of March 2012. Please contact Justine Irving at HMA on or (08) 8168 8000 if you have any questions or if you would like to complete the short survey over the phone or in hard copy. On completion of the online survey you will be directed to the Australian Government Maternity Services Reform website ( where you can find additional information on these reforms.