Saturday, March 29, 2014

the myth of choice

1983 - working night shifts a the Women's
For a couple of decades now, *choice* has been a pillar of the natural birth movement.

An organisation that I am a member of has the vision, that
"Every woman can choose how, where and with whom she births."

This vision has troubled me for some time.  Today I am attempting to critically explore the notion of choice, and whether it is desirable or imaginable that every woman choose "how, where and with whom she births."

Firstly, some historical considerations:
  • The Fortelesa (Fortaleza) Declaration (1985) on appropriate use of technology in birth challenged interventions, from shaves and enemas, to inductions of labour.  This seminal document also declared that "The whole community should be informed about the various procedures in birth care, enable each woman to choose the type of birth care she prefers".  *CHOICE!*
  • Changing Childbirth in the UK (early 1990s) declared that women want the 3C's: *choice*, control, and continuity of care.
  • A call for *choice* of place of birth (home/hospital) and care provider (such as individual midwife or the maternity system) was clear in the Australian National Maternity Action Plan (2002).

At the same time,  twenty years ago,
  • emerging trends in medical research led to the Cochrane Collaboration, defining the reliability of evidence;
  •  UNICEF and World Health Organisation introduced the Baby Friendly Hospital Initiative, with a key document being the Innocenti Declaration  of 1990. 
  •  various state and territory governments around this country were conducting broad reviews into birthing services, and producing their reports. (eg Having a baby in Victoria 1990)  These reviews sought consumer comment as well as professional.
  •  WHO prepared a series of basic publications on maternity care, including Care in Normal Birth: a practical guide (1996).  This document brought a consensus statement that "In normal birth there should be a valid reason to interfere with the natural process"

During the past two decades the world has experienced the digital revolution.  Twenty years ago, in 1994, few households had computers: the world wide web and email had only just been invented.   This phenomenon exploded communication and access to reliable information.  Our home went 'on line' in the early 90s, with a (very slow, and unreliable) dial up connection, and we were leaders in the field.   Prior to that, if I needed to send an email, I would ask my husband Noel to send it from his office at the university.  He kept up with the expansion of knowledge via inservice education, and a very helpful secretary, Jean.  He became the 'IT' expert in our home, until our children absorbed the knowledge and quickly spoke the language, as children do.  (but I have digressed from my topic!)

Twenty years ago, professional peer reviewed scientific publications were held in libraries, and accessed by scholars and the intelligencia.  Today, there is an inexhaustible wealth of knowledge at the tip of our fingers, from our computers, tablets, and phones.

Twenty years ago, information about natural childbirth was passed from teacher to student couples in highly motivated childbirth education.  Today women join social media groups where they share everything from their nausea and indigestion, to ultrasound pictures.  These groups, as well as personal blogs and microblogging, have introduced a degree of sharing of opinions, and introspection ('navel gazing'), that would have been unimaginable when person to person communication was limited to a telephone or over the back fence or a tea room at work.

So, what about choice?

In discussing choice in childbirth with colleagues and other interested folk, I have been a little surprised to observe that the woman's right to decline (a treatment/intervention) is often perceived to be the same as a choice in maternity care.  A woman's autonomy in any care situation (whether it's her toe nails or the birth of her child) is often limited to the little word "No!"

By way of example:
Jill is in hospital, in labour with her first baby.  Jill has been told she needs a Caesarean, because she has been labouring without adequate progress, and the doctor is concerned that her labour is obstructed and her baby is becoming distressed.

Jill does not want a caesarean birth, but she has no other options at this time, other than to do nothing, and that may lead to injury/death to her baby.  She has planned for a natural birth, because she believes that's the best way for her and her baby.  Jill has written in her birth plan/preferences document that if she truly needs a caesarean birth, she wants her baby's umbilical cord to remain uncut, and the placenta delivered intact (known as 'lotus' placenta).  She wants her baby to be placed skin to skin on her chest, and to remain with her in the operating room and in recovery so that breastfeeding can be initiated without delay.  She is aware of 'natural' caesarean births, discussed on her social media forum, and likes the idea. 

Jill communicates her wishes to her doctor.  If that doctor has previously supported women's choices in this way, he/she might be willing to agree.  But Jill is a patient in a public hospital.  The doctor who is performing the surgery is being supervised by the consultant obstetrician, and does not feel able to accommodate such a radical plan.  The hospital's policy is to send the baby and the father to the nursery while mother is in recovery, and Jill is told that the hospital is not able to provide suitable staff to accommodate her choices.  Jill has run out of options.  She needs the help of the hospital to get her baby safely born, and she finds to her surprise that the notion of choice doesn't work in this situation.
 Jill thought, prior to coming into labour, that she had chosen:
how: a natural birth 
where: in the local public hospital
with whom: the hospital staff at the time
'how' Jill gives birth is something that cannot be predicted, whether she chooses a private hospital with the most popular obstetrician according to the online rating system, or the guru homebirth midwife who has amazing skill and, according to social media, can do all sorts of things to make birth work as it's supposed to.  The best Jill can find out when she is choosing her care provider is an approximate rate of spontaneous unmedicated births that person reports for woman in their care.

I (frequently) remind women that they have only one choice in childbirth - to do it themselves, or to ask someone else to take over. This is the case, whether it's avoiding induction, having a vaginal breech birth (vbb), a vaginal birth after caesarean (vbac), a physiological 1st, 2nd or 3rd stage. (Haemorrhage and death are also physiological). 

There's an obvious rationale for the skilled midwife in these equations. A primigravida who wants to have a natural unmedicated birth, booked at Caesar's Palace, in the care of a knife happy OB, may have chosen where and with whom she births, but doesn't have much chance of achieving the 'how'.  

Choice is also dependent on money $$$.

The woman who chooses a caesarean for her own (not clinically indicated) reason can get a private doctor to deliver her baby if she can pay the doctor's fee (Medicare + out of pocket) and the hospital fee. But she has very little say about who else is in the room - her partner is likely to be welcome but may be asked to step outside. 

If we have a vision that every woman should be able to choose how - including elective C/S - do we think our public health $ should be supporting that so that women who can't afford the co-payment are also able to rock up and *choose*?

I am very concerned about over-spending of health $.  

The only sustainable policy direction in maternity care is to protect, promote and support the natural processes in birth wherever that is reasonable. The workforce needed as experts in achieving this goal is midwives whose duty of care by definition includes "promote normal birth". This does not remove the woman's right to make an informed decision to decline or accept the plan. Medical and surgical options should of course be available to those for whom they are likely to lead to better outcomes, but that's not a matter of the woman's *choice*.

Your comments are welcome.

Sunday, March 16, 2014


For several years now there has been a growing movement of consumer and professional opinion about the 'best' way to give birth to babies presenting breech. [See Breech Birth ANZ website]  This has come as a small pendulum swing away from the prevailing policy of elective caesarean for breech babies, which was quickly adopted after the Hannah et al (2000) paper on the Term Breech Trial, published in the Lancett.

Another historical grab, before I tell my breech story.

Please see the attached picture of the midwifery exam which I undertook in 1973.   Midwives then were required to have a basic understanding of breech presentations.   I don't want readers to imagine that the work of a midwife (or mother giving birth) was somehow ideal back then - in fact the medicalisation of childbirth, and the dominance of medical 'men' over the more subservient female nursing profession (which included midwifery) was entrenched, as can be seen in the previous post I wrote about this midwifery exam.
click to enlarge

I have always held that if for no other reason than the surprise breech, a midwife attending births needs to be competent in vaginal breech birth (vbb).   My involvement in workshops and education about vaginal breech births, and in the few vbbs I have attended, there has been an emphasis on having obstetricians who lead the cause of promoting vbb.  I have felt uncomfortable with this.  Obstetricians are surgeons.  Midwives need to claim breech births as being well within their scope of practice, as well as the identification of those for whom a vaginal birth is not likely to lead to good outcomes, and being able to refer to and collaborate with obstetricians.

Recently I have had the privilege of attending a birth at home, which turned out to be a surprise (undiagnosed) breech.  As the mother rested with her baby in her arms, she asked me to be sure to write a story about this birth.

Without identifying her, I am pleased to record the birth - through a midwife's eyes, with a midwife's knowledge and decision-making.  I don't consider myself an expert in breech or any other type of birth.  In fact, the only births that I take professional responsibility for are the ones that are very likely to proceed under the mother's and baby's own power, driven by an amazing natural physiological process.  My job is to work in harmony with those natural processes, and to protect, promote and support the natural processes, with the intention to intervene only if illness or complication arise in the birth and nurture of the baby.   In the case of breech births, the most critical period can be the birth of the baby's arms and head, and it is important that all midwives and doctors who take professional responsibility for birth are skilled in the decision making and simple manoeuvers. 

Working as I do, attending births privately usually in the home of the woman giving birth, I have a background knowledge of a mother before she tells me her labour has started.  In this case, I had been midwife for the birth of another child in this family, five years ago, also at home.  Reflections on the previous birth had also been tenderly preserved in my blog.

The first clear indication that this baby was presenting breech was the information that the waters had broken, and were "clear, with a bit of blood, and a black blob."  Labour was strong when I arrived.

I quickly set up my gear: the baby resuscitation box, and oxytocic, syringe and needle, and procedure gloves within reach; the oxygen cylinder connected up and ready if needed; a few clean bath towels to keep baby warm after the birth.   The 'nest' had been prepared - the couch draped with a waterproof cloth, so that the mother could kneel on the couch, facing away from me: an ideal upright position for a breech birth! (and a very reasonable position for an older midwife)

I saw more meconium, and asked the mother if I could examine her internally to confirm the presenting part.  The baby's bottom was 'at spines' - well on the way to being birthed.

I had a decision to make: I spoke simply to the mother and the father.  "The baby is coming, and it will be born bottom first."  I advised them that I did not expect any problems with the birth, but as an extra precaution I would like an ambulance to be called, in case we needed to transfer to hospital.

I would now like to describe each part of the birth as it proceeded.  Contractions were approximately every five minutes. 

As the baby's rump came on view a purple, swollen scrotum also appeared, and a stream of urine was passed from a swollen little penis.  I didn't mention these facts - the mother had work to do, and she would be able to discover her baby's gender in her own time.  From that moment it must have been 10-15 minutes until the birth was completed.  At some stage the 'first response' paramedic arrived, and I confirmed that the birth was going well.  He stood back.

  • Next contraction: a big push and one leg plopped out.
  • Next contraction: a slight rotation of the baby's bottom, and the second leg came down, and a little 'cycling' action of the legs (as though he said, "Thanks Mum, that feels better! Now, what should I do?")
  • Next contraction: the baby's body was born past the navel, then to the nipples, and a large, full blue and white umbilical cord was central.  The body hanging was unsupported - I had not touched him to this point (Hands off the breech!).  I was delighted to see the cord positioned beautifully in the little protected channel between the baby's two breasts that were squeezed together in the tightly stretched vaginal opening.  I gently checked the pulse - about 120, which is good.
  • Next contraction: first arm popped out, a little rotation, then second arm.  Baby's colour reasonable.
  • Next contraction: no progress.  I placed my thumb and fingers over the cord, close to its insertion.  Pulsing had slowed to about 80.  Time to get this little one out and breathing! 
  • With mother in the kneeling position, I placed my right hand in over the baby's chin, and a finger into his mouth.  The left hand went behind the baby 's head to flex it, and the head was born with minimal effort on my part.
  • Baby was initially pale as he lay on the birthing mat under his mother, with his cord intact, as mother turned to look at him, and ask how he was.  I dried him, checked the pulsing of the cord, blew on his face, and before the first minute was up, he had taken a gasp of air.  His colour began to improve.  A few more minutes before he was ready to cry, but all the time he was making the transition from womb to the outside world, there was no reason for me to interfere.
  • By 5 minutes, he was in his mother's arms, pink and strong. 
  • By the next day when I visited them, he had been breastfeeding strongly and effectively, and doing all the things newborn babies are expected to do. He weighed just over 4 kilograms.

Wednesday, March 12, 2014

midwifery: protecting health across generations

Maria Lactans (17th Century) Antwerp
One of the truly compelling reasons that I have for practising midwifery the way I do is the knowledge that there is no safer, no better way for a baby to be born and nurtured than the way our bodies have been wonderfully created to do it.  The marvels of science and medicine have not come up with a better process.  

I'll call it NORMAL birth: normal from a biological, physiological perspective in ideal conditions.
Not what *normally* happens today.
Not what is most common in birth today, or 100 years ago, or in a primitive society .... 

NORMAL birth requires a strong healthy woman who carries her pregnancy to term, and comes into spontaneous labour.  It requires the mother to accept and work with her body in labour, and to progress, without medication, to the climax of birth.  It requires the mother and baby to work together in establishing breastfeeding, within a nurturing family-community setting that supports the mother in these challenges.

This 'ideal' is what a midwife seeks to facilitate. "In NORMAL birth there should be a valid reason to interfere with the natural process." (WHO 1996)

At any point in the process we can face challenges, complication, illness, and the need to intervene.  That's when science, medicine, obstetrics ... become life-saving.

There are obvious and unquestioned benefits to a mother and her baby when the NORMAL processes are protected, promoted and supported.
  • A mother's body and mind respond in unison to the changes in hormones in her blood, as she prepares, and progresses.  
  • The mother's thinking brain is suppressed, in a quiet and unstimulating environment where she does not feel that she is being observed, so that her instinctive mind is free to proceed with the final nesting, and the surrender that accompanies strong labour.  
  • The baby is born alert and healthy, ready to engage in the instinctive breast crawl as breastfeeding is initiated.   
  • Early and effective suckling at the breast, together with the physical pressure of the baby's weight against the mother's uterine fundus, lead to strong contractions and completion of the third stage.  
  • Once the placenta and membranes are completely expelled the risk of haemorrhage is minimised, and continuing breastfeeding supports the involution of the uterus.  
  • Close physical contact from the time of birth supports the development of normal bacterial flora on the baby's skin and digestive organs, preparing the baby's immunological processes for ongoing function.  
  • Bonding between a mother and her newborn proceed as they make eye contact, with uninterrupted close contact, and the mother's body is awash with love hormones.

I have not mentioned the midwife.  Yes, the midwife is present, working in harmony with the NORMAL processes, and guiding and supporting when things get difficult, but staying quietly and unobtrusively out of the limelight.  The midwife is guardian - protecting the mother and her child, and providing a safe space for them in NORMAL birth.

When there is a valid reason to interfere with the natural process, the midwife guides the woman, and provides appropriate explanations.  The midwife seeks only the health and wellbeing of mother and child.

Today I am looking further than the primary episode of care, spanning the nine months of the pregnancy, and the six weeks of the postnatal period.

I am looking at future generations.

The study of epigenetics: "the study of heritable changes in gene activity that are not caused by changes in the DNA sequence" offers huge challenges in health care, and particularly at the beginning of it all; conception, pregnancy and birth.  Emerging within this field of science is a new respect, for example, for the effect of nutrition during a woman's pregnancy on the health of her grand-children - the children of the child forming in her womb.

I have no claim to expert knowledge in biology, but would encourage readers to keep exploring this field.

Our bodies are wonderfully made.

I have recently become aware of a new film project,
micro birth

"MICROBIRTH" is a feature-length documentary looking at birth in a whole new way, through the lens of a microscope.
The film explores the latest scientific research into the microscopic events that occur during and immediately after birth.
This compelling, brand new science is starting to indicate that if the natural processes of childbirth are interfered with or bypassed completely, this could have devastating consequences for the long-term health of our children.
Just to be clear, this film is not calling for an end to interventions as many times they are essential and they can be life-saving.
But as this new science is starting to indicate, the use of synthetic oxytocin to induce or speed up labour (Pitocin / Syntocinon), antibiotics, C-section, the routine separation of mother and baby immediately after birth and formula feeding, could significantly raise the risk of our children developing serious disease later in life.
And as the film shows, the medicalisation of childbirth could even be contributing to a potential global human catastrophe predicted to happen by the year 2030.

Tuesday, March 04, 2014

Birth statistics

Source: Victorian Health Department 2009
I expect readers will find the trend in the number of women achieving planned home birth (Table 33)  interesting.  (click on picture to enlarge)

To access the full Victorian Consultative Council on Obstetric and Paediatric Mortality & Morbidity (CCOPMM) Annual Report for the year 2009, click here.
[This is the most recent of the annual reports]

Midwives are the only professionals who attend women for planned home birth these days.  In years past there were a few GPs, but time and cost of insurance has caught up with them.  Midwives are attending homebirths privately without professional indemnity insurance, under a special exemption that is in place until June 2015.

I note:
  • the gradual increase in homebirths as a percentage of all confinements*, from 0.2 in 1985, to 0.4 in 2009 (Table 33).
  • Table 34 indicates the type of birth for all women who were recorded at the onset of labour as 'planned' homebirth.  Women planning homebirth in 2009 had 90% 'unassisted vaginal' birth (the overwhelming majority of these being spontaneous, unmedicated); 6% caesarean birth, and the rest forceps, vacuum, or unknown.  
  • This compares with only 38.6% of all women in 2009 coming into spontaneous labour without augmentation (same report, p61), and 54.6% having unassisted vaginal births (p64).

AIHW 2010 - click to enlarge
We do not yet have a 'Births in Victoria' report for 2010 or subsequent years.
This 2010 national report is from the Australian government's Mothers and Babies publications site.

I note:
  • In Table 3.18 (shown here), the number of babies born at home in Victoria has increased from 300 in 2009 (PDCU) to 567 in 2010. 
  • This is the actual place of birth, including those who planned to give birth in hospital, and the baby beat them to it, and those who intentionally gave birth unattended ('free birth')
  • The AIHW 2010 data does not report on home birth by intended place of birth in Victoria (Table 3.19, p29)
  • 2010 was the year that the two public hospital homebirth trials commenced at Sunshine and Casey.  The number of homebirths births through those hospitals was small (40)
  • 2010 was also the year that the federal government's maternity reform package was implemented, with midwives becoming eligible to provide Medicare-rebated antenatal and postnatal services from November 2010.

AIHW 2011 click to enlarge
 The 2011 national report from AIHW provides more information on home births in Victoria, as it includes the breakdown of those women who gave birth at home, having planned (intended to) give birth at home.

I note:
  • The number of planned homebirths in 2011, in Victoria,  was 432, accounting for 0.6% of the State's births.  
  • Looking back at Table 33 (above), the increase from 300 in 2009, 0.4%, is substantial.
  • Midwives in Victoria quickly accessed eligibility for Medicare, and promoted primary maternity care options for women.
  • The only place in Victoria where a midwife can practise privately is in the community, for planned homebirth.
  • No Victorian hospital has yet established processes whereby midwives can apply for clinical privileges and attend their clients in the hospital
  • Since 2010, a number of experienced midwives have resigned from mainstream Victorian hospital and birth centre employment and joined the ranks of midwives offering homebirth.
The following excerpt from AIHW 2011 provides interesting comment:
In 2011, there were 1,267 women who gave birth at home, representing 0.4% of all women who gave birth. The highest proportions were in Victoria and Western Australia (0.8%) (Table 3.18). It is probable that not all homebirths are reported to the perinatal data collections.
The mean age of mothers who gave birth at home was 31.7 years (Table 3.49). The proportion of mothers younger than 20 was 1.3%, and the proportion aged 35 and over was 29.8%.
The proportion of mothers who gave birth at home who identified as being of Aboriginal and Torres Strait Islander origin was 1.1%.
Most women who gave birth at home were living in Major cities (70.8%) (Table 3.49). Of mothers who gave birth at home, about one-quarter had their first baby (22.3%), and 77.4% were multiparous.
The predominant method of birth for 99.3% of women who gave birth at home was non-instrumental vaginal (Table 3.49). The presentation was vertex for 97.6% of women who gave birth at home.
Of babies born at home in 2011, 99.2% were liveborn. The mean birthweight of these liveborn babies was 3,614 grams (Table 3.49). The proportion of liveborn babies of low birthweight born at home was 1.6%, and the proportion of preterm babies born at home was 1.3%. (AIHW 2011, pages 65-66)

I note:
  • There were 10 babies of the 1,301 homebirths in 2011 recorded as fetal deaths.  These data do not provide detail as to how or why those deaths occurred.
  • The midwife is duty bound to promote the wellbeing and safety of the mother and baby in her care, above preference for place of birth, or other factors.

*The word 'confinements' is used in these reports, as a tally of the number of women who have given birth, rather than the number of births, which includes multiples.  Readers might like to suggest a better word!