Sunday, September 23, 2012

Women's rights in childbearing

I took a consultation paper on birth registration, and the latest issue of MIDIRS with me in the plane yesterday.  The flight from Melbourne to Brisbane takes about two hours, which fits well with my capacity to stay focused on a topic. 






The issues around women's rights in childbearing have been promoted by many writers and film makers.  A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to  criminal proceedings against doctor-midwife Agnes Gereb.

Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.
Who decides how and where a baby is born? Who bears the risks of childbirth? What legal rights do women have to choose how they give birth? These are just a few of the issues that will be discussed at the upcoming Childbirth and Law Forum on Friday 12 October 2012 at Riverside Theatre, Parramatta.


The Childbirth and Law Forum will begin at 2pm with presentations from  two speakers who will discuss the legal issues facing childbirth today in Australia. (Homebirth Australia press release)


It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system.  Barrister Elizabeth Prochaska wrote:

A recent case of mine shows that it is worth fighting decisions to refuse to provide a home birth (even at a late stage in pregnancy).  A large London hospital suspended its home birth service for a month due to staff shortages and informed women who had planned home births that they would be transferred to hospital by ambulance regardless of whether or not they consented to transfer.  AIMS put a coupe in contact with me who had been promised a home birth by the hospital.  With only a few weeks before their baby was due, they decided to threaten legal action, relying on a legitimate expectation and the Ternovsky case. The hospital rapidly backed down and agreed to provide independent midwives to attend all the affected women at home. (Prochaska E. AIMS Journal, vol 24, no2, 2012, pp6-7.)

The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care.  Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth.  For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth.  Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.

In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them.  They are no longer 'low risk'.

Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate.  A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance.  The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be). 


Midwifery services today use the term 'evidence based' without challenge.  The exclusion of women from birth centres and homebirth programs is considered 'evidence based'.  Rarely does anyone ask, "what evidence is that?"


A recent update of the Cochrane review , the centre of excellence in medical evidence, states:

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. ...

Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women

Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. [emphasis added] In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. 

An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards.  Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.

In 'Women's rights in childbearing'  (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth.  The article reports that  UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."

Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present.  The limits of responsibility in such a situation are in no way defined or clear.  It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife.  Unfortunately it will take adverse outcomes to test the limits of women's rights.

Tuesday, September 11, 2012

Social Media and midwives

Two of my precious grand-daughters, Poppy and Amelie
I want to declare my interest in the use of social media by midwives.

This blog site provides ample evidence of my commitment to and fascination with openly available websites. This blog is a notice board; a library; a magazine; an ongoing journal of my opinions and comments about midwifery and about life.   It is also an ongoing record of special people in my life, such as the two precious little girls pictured today.

I began this blog in 2006, and it sat, unused and dormant, until mid-2007. At that time I felt a strong need to communicate with young women, particularly those who searched the internet for information in preparation for the births of their babies, and I realised I could do this as a blogger. From time to time over the years I had received emails, usually from women in other countries, thanking me for The Midwife's Journal, which they had found on my old website. A woman from Holland referred to The Midwife's Journal, which had been written at least 10 years prior (ie before the word blog existed in my vocabulary, at least), as a 'blog'.

It occurred to me then that I could continue The Midwife's Journal as villagemidwife, the blogger.

These are the headings from that new beginning [link]:
  • Natural birthing in Australia today 
  • The culture of birthing 
  • Vaginal breech birth 
  • Who let the dads in? 
  • Nurture and nourishment of the newborn baby 
  • Paternal behaviours 
  • Mother-infant bonding, and maternal instincts 
  • Giving birth 
  • The life of the unborn child in the womb, and imprinting at birth 
  • Commenting on some of life's big moments 
  • Midwife for Christ’s birth 
  • You are free, my dove 
  • The homeborn newborn: how do mothers manage breastfeeding when there's noone to show them what to do? 
  • Protecting normal birth 
  • Why protect normal birth? 
  • Birth Trauma 


The regulator for health professionals in this country has announced a review of its social media policy:

The National Boards will consult publicly on social media policy in coming months The National Boards in the National Registration and Accreditation Scheme (National Scheme) will release a consultation paper on a social media policy in October/November 2012.

A draft of the social media policy has been released as a preliminary consultation paper to targeted stakeholders for initial feedback, ahead of a wider public release. The preliminary consultation process aims to ‘road test’ the initial draft to weigh operational impact, issues or initial concerns. We are pleased that this early draft is generating a lot of interest, especially on social media. National Boards are monitoring feedback closely and will take the issues raised into account when refining the draft social media policy before it is released for public consultation on the National Boards’ websites.

If you would like to contribute feedback on the preliminary draft social media policy, please email your considerations to socialmediaconsult@ahpra.gov.au by close of business 14 September 2012. When the formal public consultation process opens, the National Boards encourage feedback from registered health practitioners and members of the community on the draft social media policy. The National Boards will publish the public consultation document on their websites, and will encourage wider distribution to seek extensive feedback.

Until then, visit the News section of the National Board websites (via www.ahpra.gov.au) for updates on past and current consultations, general communiqu├ęs from National Boards, media releases and more.

I have read the draft policy, which reminds health practitioners that in using social media, we must comply with the National Law, Advertising Guidelines and the code of conduct.


Midwives who in recent years had published testimonials at their websites have found themselves being directed to the law that prohibits the use of testimonials.  Birth Stories, on the other hand, seem to be permitted.

There will be times when I have used experience from real life in my writings, and it is possible that some of those who read my accounts may at times recognise the woman, even if I have been careful not to identify her. Whether this could, in a narrowly defined mindset, be seen as a breach of privacy, is yet to be seen.

There is nothing sinister about blogging, or any other aspect of social media, per se.  The medium is neither good nor bad: it's simply a medium.  The content is what can be anything from wholesome and useful, to trivial navel gazing self absorption, to defamatory and destructive.   The author has the ability to communicate in a way that is useful, or not.  I hope to continue writing in this medium, and I hope there are readers who value the material posted and thoughts expressed.


Your comments are, as always, welcome.


Friday, September 07, 2012

availability of midwives for homebirths

Today I would like to explore a few issues around the availability of midwives to provide professional services for homebirth, and suggest what I see as a way forward.

These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.

'Risk' - however defined - is a major obstacle.  The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital.  This narrow mindedness is not informed by evidence or by logic.

The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.

With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded.  A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program.  Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.

Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.

These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes.  Yet midwives say very little. 

These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder.  An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care.  Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth.  Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access.  When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.

$$ Cost is significant in private homebirth.  While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives.  Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging.  For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate.  The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.

The other factor in cost of private homebirth is the number of midwives.  Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more.  A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth.  I disagree.  Strongly!

I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives.  I cannot support this option - it scares me.  I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula?  A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".

Practical matters: the main one that comes to mind is the distance across this wide brown land.  Gone are the days of the village midwife on her bike.  Each time I visit a client, I am using precious fuel.  Likewise, each time a woman comes to me.  If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife.  (An exception is a few special women who I have attended on several occasions over the years.  I have become a part of those families, and it's lovely to return for the birth of the next baby.)

Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home.  Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.

Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.   

What am I saying?

I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth. 
  • midwives need to think critically about risk
  • midwives need to work to make primary maternity care by a known midwife affordable
  • midwives need to wake up to their capacity to provide midwifery services in homes and hospitals, for all women.