Thursday, June 28, 2012

CULTURAL HYSTERIA?

Readers of this blog are probably familiar with the historical roots of 'hysteria'; the Greek word ὑστέρα (hystera) meaning womb, the condition of the wandering womb, and recommended treatments.

"Galen, a prominent physician from the 2nd century, wrote that hysteria was a disease caused by sexual deprivation in particularly passionate women: hysteria was noted quite often in virgins, nuns, widows and, occasionally, married women. The prescription in medieval and renaissance medicine was intercourse if married, marriage if single, or vaginal massage (pelvic massage) by a midwife as a last recourse.[1]" [Wikipedia]
The Medical Dictionary that my computer's online dictionary led me to offers this information:
hysteria hys·ter·i·a (hĭ-stěr'ē-ə, -stēr'-) n.

A neurosis characterized by the presentation of a physical ailment without an organic cause, such as amnesia.

Excessive or uncontrollable emotion, such as fear.[Link]


I wish to contend here that there is a cultural hysteria in response to midwifery.  A cultural neurosis that leads to excessive and uncontrollable fear about that highly contested terrain, childbirth.

While midwives are recognised internationally as essential providers of primary maternity care, Australian midwives (and our sisters in many other developed countries) face exclusion and restriction when simply practising our profession.

Cultural hysteria with regard to midwifery depicts the midwife as someone who lacks skill in management of obstetric emergencies, events that are bound to happen, leading to a mass fear reaction.  Cultural hysteria sets up a fearful scenario, and uses that scenario to prove its point.

I don't have answers to every possible scenario, but I do know that in the State of Victoria, where I live and work, data from privately attended planned homebirth have been collected and reported on for many years, demonstrating the clinical effectiveness of planned homebirth in the care of a midwife.

The mothers who planned to give birth at home have not been uniformly 'low risk': they include births after Caesarean, mothers who are older, or who have had more births, or whose babies are bigger than average.  They are ordinary women, who just want to give birth to their babies.

The midwives have not undertaken any special courses of study: they are simply competent midwives, who seek to work in harmony with physiological processes, and who, generally, refer women appropriately when complications are suspected. 

The Victorian government’s Perinatal Data Collection (PDC) unit within the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) publishes an annual profile that captures all planned homebirths in the state, and puts the data alongside cumulative data from hospitals and statewide totals. These reports, although retrospective, carry a high degree of reliability.

The reports over the past 20+ years have shown planned homebirth in the care of a midwife as a safe option in terms of maternal and perinatal morbidity, with many features that are considered protective of the mother’s and baby’s wellbeing and safety. 

For example, in 2008, the most recent set of published data in this series:
• 91.5% of women planning homebirth had unassisted cephalic births, compared with 55.4% state-wide.
• Approximately 5% of women planning homebirth at the beginning of labour had caesareans, compared with 19% in small ‘low risk’ (<100 births) hospitals, and 31% statewide.

When looking at the baby outcomes for the same group (2008),
• 95.6% of babies born to mothers who planned homebirth at the beginning of labour did not require admission to a hospital nursery, which is approximately the same as the rate for small hospitals with less than 400 births per year.

These data support our contention that there is safety and protection of wellbeing for mother and baby when midwives attend women for planned homebirth.


I recognise that individual cases may be held up as examples of things going very wrong in birth, whether that birth takes place in a tertiary hospital, a private hospital, the woman's home, a birth centre, or in the back seat of the car. 

There are risks associated with birth, as there are particular risks linked to any life event.

I believe that the safety and wellbeing of mothers and babies in our community is enhanced by a strong midwifery profession that is recognised as essential in effective primary maternity care.


Saturday, June 23, 2012

WHY I DISAGREE WITH THE CORONER'S RECOMMENDATIONS

Having written last week about some of the complexities of the decisions made by women about their birth-giving, and the roles of midwives, I would like today to briefly explore why I disagree with (most of) the South Australian Coroner's recommendations in the recent case.

I have summarised the recommendations as:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

Rather than starting with #1 and plodding through this minefield, I will start with what I see as easier, and pick my way through the minefield, trying to state my opinions clearly. (And, dear reader, I must warn you that I often delete a great deal of what I write, so that you see the heavily edited version)



6) education for public distribution on homebirths and risks 
This is not a bad idea. My only hesitation relates to what sort of education, and who writes it, and who defines the risks, and ...

 5) "establishment of alternative birthing centres" 
Also not a bad idea - for the 1980s, that is. Midwifery theorists proposed that hospital rooms dressed as 'home-like' settings would help women to feel OK about birth.  Some women did well, while many were excluded by risk protocols, and moved into standard (the alternative to 'alternative') obstetric care.  I gave birth to my fourth child at the Women's Birth Centre in 1980, and that experience helped me come out of medically managed and dominated midwifery.  I know many other midwives who have learnt to work in harmony with physiology in unmedicated birth, and to trust their midwifery knowledge when detecting and acting upon complications, during their time working or giving birth in a birth centre.  Perhaps that's a good reason to establish birthing centres.

4) "establishment of a position known as the Supervisor of Midwives"
I need to sit on the fence for this one.  The role of Supervisor of Midwives is one that I don't fully understand.  How would these people be appointed?  What would their role entail?  Would all midwives be supervised, or only certain midwives?    The UK-style Supervisor of Midwives is different from the New Zealand system.  Psychologists work under a system of professional supervision.  I believe a thorough exploration of this proposal needs to be had by midwives, ethicists, psychologists, lawyers, and maternity consumer spokespeople, and some agreement reached, before yet another regulatory control be imposed on the profession.

1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
NO!
Australia does not need to outlaw unregulated midwifery services.
Australia needs to protect and support the midwifery profession, so that midwives can provide midwifery services in homes and hospitals; so that women will feel safe in the professional care of midwives as primary carers, who are able to work seamlessly with specialist services when indicated.
Modern societies, and the legislators and coroners and others in positions of authority need to recognise that spontaneous labour and birth is a fact of nature, not something that a midwife controls or gives permission for, and that women under natural law are able to use the professional services provided in their community, or not.  It's their choice.

2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
NO!
Midwives who understand the ethical and moral duties of our profession, who by definition work 'in partnership' with a woman, will REFUSE to report women on the grounds of a plan for homebirth.  My own practice for many years has been to encourage women to see the choice of place of birth as a decision they make as labour becomes established, and not before.  I believe this is best practice, as the midwife is committed to the woman, not to the planned setting for birth.

8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

HOW would this work?  Will that woman be arrested and forced to listen to 'appropriate advice' being delivered?

I have not tried to tease out which risk factors the Coroner thinks would be used to initiate reports or the giving of advice.  There are few absolutes in midwifery.  Regardless of what risk factors may be attending a particular situation, physiological birth always starts with spontaneous onset of labour, and spontaneous onset of labour happens in the woman's own time, in her own world, in her own body.  The woman has to make a decision to call a midwife, or not; to go to hospital, or not.  This decision cannot be taken from her.

This set of recommendations exhibits a shallow and linear view of life, risk, and decision-making.  The question that the Coroner seemed to avoid is:
"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and
"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"



Australia is a society which supports a wide range of freedoms for the individual.  I don't have the words to describe the legal and ethical framework that this is built upon, but I know that when a State (government-sanctioned authorities) is given power to control the most intimate relationships between a woman and her child, that comes with a great loss of basic freedom.

Civil disobedience by midwives has been recorded many times, when the midwives believed that the lives or wellbeing of the mother and/or her baby were at risk.  The Hebrew midwives, Shiphrah and Puah, who were prepared to disobey and deceive the autocratic, absolute authority of Pharoah, are our model.
The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, "When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.  But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live.  So the king of Egypt summoned the midwives and said to them, "Why have you done this, and allowed the boys to live?"  The midwives said to Pharoah, "Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwives come to them."  So God dealt well with the midwives; and the people multiplied and became very strong,.  And because the midwives feared God, he gave them families. (Exodus 1: 15-21, From the New Revised Standard Version (1989) of the Bible)

Sunday, June 10, 2012

Understanding what's behind an adverse outcome

Today I am recording a few of my personal thoughts in relation to the (lengthy) Coroner's report that was released this past week, in Adelaide.  I have written about it from the perspective of Australian Private Midwives Association (APMA) at the privatemidwives blog.

Principles of accountability and transparency must be applied to professional practice.  When something goes wrong in birth, our society wants to know, and has a right to know what happened.  It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear?  How must I act when a woman in my care understands her personal risk differently from the mainstream?

A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain.  The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity.  So, when I read in the SA Coroner's report that 

"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."
I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?

The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.

This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:
  • if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);  
  • if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean; 
  • if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean) 
That is a superficial, linear argument that fails to recognise the complexities of maternity care.  This suggested course of action ignores the increased risk that each caesarean places on the woman's reproductive future: a risk that does not really show up in the statistical reports.  It passes over the fact that many women who seek private midwifery care are consciously avoiding mainstream services.  It fails to notice that highly skilled, experienced midwives have been excluded from practising in any setting except the home.  And then there are all the issues of trust and continuity in providing optimal maternity care.

I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result.  The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation.  She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]

Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive.  The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives.  The emergency code had been rehearsed, prepared for, and was called into action.  Perhaps that group of midwives will be more ready and competent when it really is called for???

In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety.  I cannot control another person's actions.  I also cannot use these experiences as a reason to stay out of hospital in future situations.  The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.

I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
***********

The Coroner's recommendations are listed at the end of the 106-page report.  In this blog I am attempting to summarise the recommendations, for future reference:


1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

Saturday, June 02, 2012

TWO WHO ARE TWO

TOO good!

In this past month I have had many opportunities to enjoy the two little ones, James and Eve, who joined our family two years ago.

I have seen the two mothers go through amazing processes of learning to cope with the complexities of their lives, while mothering their babies.   I have seen two fathers adapt and learn how to love in a new way, and to become daddies.

I have reflected on the enormous investment of time, energy, money, and other entities that probably can't be described in a few words - investment by the child's parents, wider family, and community. Investment in a precious resource, a human life, and in the hope for a new generation.

Today I am posting a poem written my our beautiful daughter in law, Anna, celebrating Eve's second birthday. Anna has given me permission to share this tender love-poem with my readers. (Thankyou, Annie)

A Poem for Eve Dulcie - our La Dolce Vita (life is sweet), on your 2nd birthday..... 
I love your sense of humour-
Feeding breakfast to your toes
Declaring that it is "pickle day"
Or that you've lost your nose
I love your creativity, on paper (or on walls!)
The way you tell me stories
Or play dress-ups with scarves and shawls
You are my little encourager
Telling me that I'm good
At vacuuming or singing
Or playing Robin Hood
I love your little bird song
I could listen to your voice all day,
Singing songs in the bath
Or while you laugh and play
Your heart is so precious
Saying more than a love letter
You make me want to do my best
And as a mum, be better
The type of love you give is rare
So accepting and forgiving
An Evie filled life is one,
That is all the more worth living
I'm still learning to be your mum
I've made plenty of mistakes
But I'm head over heels for you kid
With every step we take
My curly headed rascal
My beautiful green eyed girl
Mummy's little hero, Daddy's little pearl
I love the way you love me
Always wanting to hold my hand
At breakfast or watching TV
Or playing in the sand
Your infectious belly chuckle
Your heart-warming grin
Your dainty royal wave
Your porridge covered chin
When I wake at morning
And when I sleep at night
I thank God for giving me you –
My Eve, my hearts delight."