Monday, February 17, 2014

The bigger picture

Grand-daughter's photography - you can see that I love her!
I have a lull in my bookings at the moment, and have set myself the challenge to consider the bigger picture.

Questions of birth/maternity care/midwifery that comprise the bigger picture are along this line:
  • How well does Australia measure up against global midwifery?
  • What is being done in Australia to protect sustainability in the midwifery profession?
  • What can a woman in Australia anticipate as she carries, births, and nurtures a baby?

It would be easy for me personally to be dismissive about the bigger picture.  Leave that to the younger generation!  I have enjoyed my career, have had many incredibly beautiful experiences with women who have given me their trust, and have invited me into their lives at their most intimate moments.  I have written many of my stories down in journals and blogs and argued my point in articles and published papers.

How well does Australia measure up against global midwifery?
The home of global midwifery is the International Confederation of Midwives (ICM).  The Australian College of Midwives (ACM) is a member organisation of ICM, and Australian codes and standards are based on the ICM Definition of the Midwife (2011).

ICM lists the following key concepts.  I will use them as a basis for my assessment of Australian midwifery as I know it, and give each point a score out of 10. I will not attempt to justify or give references, since this is a statement of opinion.  However, my opinion is based on careful reading of midwifery literature, and careful reflection on a lifetime of midwifery practice.  If the reader considers that I have made a statement that is wrong, or unsupportable, please tell me why.

ICM Key midwifery concepts that define the unique role of midwives:

  • partnership with women to promote self-care and the health of mothers, infants, and families;
  • respect for human dignity and for women as persons with full human rights;
  • advocacy for women so that their voices are heard;
  • cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
  • a focus on health promotion and disease prevention that views pregnancy as a normal life event.
1. partnership with women to promote self-care and the health of mothers, infants, and families:
Promoting self-care and health of mothers, infants and families is a wonderful, big picture statement. 

I would suggest that we look at rates of spontaneous unmedicated birth as an initial measure of health promotion, self care, and wellness of mothers and babies.   Spontaneous unmedicated birth will be most likely to proceed when the midwife is practising as an authentic midwife, establishing a partnership with the woman based on reciprocity and trust.   WHO (1996) stated that "In normal birth there should be a valid reason to interfere with the natural process."  Achieving spontaneous unmedicated birth is a measure of the capability of the midwife as much as the mother.  There is no safer or better way, in most instances, than for the midwife and the woman to work in harmony with natural processes.  The midwife acts in a way that minimises disturbance, disruption, interference, interruption, while observing and assessing progress and wellness.  The woman learns to minimise neocortical activity, and access her amazing supply of natural opiates.  Her oxytocin and adrelanine peak as she gives birth, providing for her baby the ideal transition to life outside the womb, and giving herself the ability to contract her womb strongly and expel the secundines (an old fashioned word meaning the afterbirth) without excessive bleeding.

In Australia more than 30% of women have caesarean births, completely by-passing these physiological states. Only about 25% of women have no analgesia for birth.  Only a tiny minority of the women receiving maternity care in Australia are cared for in labour by a known midwife - one of the evidence-based measures by which we can anticipate improved outcomes for mother and baby.  There is much room for improvement!

SCORE 4/10

2. respect for human dignity and for women as persons with full human rights
What measure is there for respect of human dignity?  I don't know.
There are many cultures in Australia, and it's not possible to generalise.  The planned homebirth 'culture' is quite exceptional.  These women are  usually not wealthy, but find the money so that they can have private midwifery care.  They value their personal dignity, within their own homes.  They accept the work of childbearing, as their own job, and give it their best. 
On the other hand, I consider the educated, relatively wealthy segment of our population, whether they are cared for in private or public hospitals, there are many examples and anecdotes of a lack of respect, an expectation by the midwives and doctors in the hospitals that they will submit to the superior training and knowledge of the medical practitioner who is most senior at the time.
My conclusion is that in Australian mainstream maternity care, there is a lack of respect for the human dignity of women as persons with full human rights, and this is backed up by the Australian Medical Association Position Statement on maternal decision making  (2013)
  1. A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.
  2. A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.
  3. Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies. ...
There is, again, much room for improvement!
 SCORE: 5/10

3. advocacy for women so that their voices are heard
Australian women have for many years attempted to have their voices heard, and organisations such as Maternity Coalition have advocated on behalf of women.  I and many of my midwife colleagues have been in the thick of it.  Many of the stories since about 2007 can be found on this, and linked blogs.  Here are a couple of pictures that describe advocacy for women:
Mothers, babies, and midwives outside a politician's office in Melbourne

more than 2000 rallied in the rain, on the lawns of Parliament House in Canberra

In response to advocacy, the government of the day (2008) announced a Review of Maternity Services, and asked the public to tell them what they wanted.  Thousands of ordinary people, mostly childbearing women, sent submissions.  Many of them asked for choice - that they could choose where they had their babies, and with whom.  Many told their stories about wonderful empowerment in giving birth at home, with their own midwife. Yet, when the report of the Maternity Services Review was published, homebirth was excluded from the reform package.  

Midwives now have indemnity insurance, but not for homebirth!  We now have Medicare, but not for homebirth!  We now have the processes so that hospitals can award clinical privileges to midwives, but except for a few in the S-E corner of Queensland, this just is not happening.

There is, again, much room for improvement!
SCORE: 3/10

4.  cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies.
It would be politically correct for me to launch into discussion of the plight of Australia's aboriginal peoples in addressing this topic.  There is a great need for such work, and for improvement in all sorts of health outcomes and health promotion.  But I do not see many indigenous people, and in my years of practice have cared for only a handful.   Not many women with indigenous heritage will seek out the services of an independent midwife.
Painting by Odetta Moore (Copyright).  "This is our baby boy waiting to be born.  That's him in the middle.  The circles round him are me, holding him and protecting him.  The tortoises in the corners are his protectors."

There is another vulnerable cultural group that we midwives are seeing, and for whom we need to improve care.  Women who are in this country on work visas, either for themselves or their husbands.  Many come from India and Pakistan, some from Africa.

The visas that these women use do not entitle them to publicly funded health care under Medicare.  The visas require health insurance, but the insurance policy usually does not cover childbirth.  These women enquire at public hospitals, and are told that they will be required to pay $11,000-$15,000 upfront for maternity care.  Some have no prenatal maternity care, and present at a public hospital in labour.  Some are choosing homebirth, as the cheaper option.  Many are Moslem women, fully covered when outside the home, and it's common to see very low levels of Vitamin D, and iron deficiency anaemia.

What can we do to improve the health outcomes for these women and their babies?

SCORE: 5/10

5. a focus on health promotion and disease prevention that views pregnancy as a normal life event.
Health promotion in maternity care in Australia relates to initiatives such as smoking cessation, obesity, family violence, and baby sleeping arrangements.  There is little recognition of the fact that pregnancy is a normal life event; that health outcomes are best when technology and medicine and surgery are used sparingly; and that health outcomes are best when exclusive breastfeeding is initiated at birth.

Pregnancy is seen, in mainstream maternity care, as a minefield; a disaster waiting to happen.  Women are investigated, tested, and explored - in expectation of something awful.  Concepts of informed decision making are poorly understood, and even more poorly followed.  Women report being bullied if they question a plan of action, or try to decline an offered treatment.

Australian maternity services are medically driven, with obstetric hierarchy dominating most services and decisions.  The RANZCOG College Statement on Homebirths, while attempting to support personal autonomy and informed decision making, leaves little room for discussion, and a great deal of room for coercion:
"... While supportive of the principle of personal autonomy in decision making, RANZCOG cannot support the practice of planned homebirth due to its inherent risks and the ready availability of safer options for labour and delivery in Australia and New Zealand. Where a woman chooses to pursue planned homebirth, it is important that reasons for this are explored and that her decision represents an informed choice, considering all the possible benefits and potential adverse maternal and perinatal outcomes. ..."
There is, in my opinion, ample evidence supporting planned homebirth, with plans for transfer of care to hospital in a timely manner when indicated.

There is, again, much room for improvement!

SCORE: 3/10





Midwifedenise said...

The rising rates of intervention and low (3%) homebirth in NZ suggest that more is needed to address medicalised birth than being with a known midwife in labour!

Joy Johnston said...

I agree, Midwifedenise. There needs to be more than the 'known midwife'.