Wednesday, June 25, 2008


Or, Why continuity choice and control are not enough

Sue, whose life-changing experience of giving birth to Jack last year, wrote: “
And also for me, what is missing, is the focus on the heart. There is birth education out there, but too much of it misses the heart, getting women back in touch with themselves, their inner voice, and waking that up.”

Sue, I totally agree.

The message that women want the three C’s, continuity choice and control, emerged in the UK with the publication of the House of Commons Health Committee’s Report on Maternity Services (1992). Together with the Changing Childbirth Report (1993), these documents set out an agenda to make maternity care more woman centred, to facilitate midwifery care for homebirth as a standard option for well women, and to normalise childbirth in the UK. Caroline Flint (1993) published the book ‘Midwifery teams and caseloads’, with the frequently repeated mantra in words and pictures “get to know her”. Continuity of carer – a caseload - became a goal for many midwives.

Women told the Health Committee that they want *choice* of care and place of birth. I and many other midwives and birthing activists have chorused ‘choice’ since that time. Yet choice is a slippery entity that easily moves out of reach when in reality the availability of a particular model of care, or a place in a birth centre or even birth at home is easily overruled by other factors. Furthermore, I am sad to acknowledge that in recent years the pendulum has swung in the other direction, with women ‘choosing’ elective caesarean surgery.

Women expressed the desire to have *control* over their own bodies at all stages of pregnancy and birth. Of course, this element is readily agreed to by the midwifery profession, and supportive theories of partnership and cultural safety have emerged. Yet midwives know that the natural processes in giving birth demand a surrender or relinquishing of mind control so that the deeper hormonally mediated forces in a labouring woman can act unhindered. French obstetrician Michel Odent has written books and papers, and taught the midwifery profession about the importance of subtle hormonal influences at all times through the childbearing continuum, and the first year of a child’s life. The term ‘undisturbed birth’ is now used for a birth in which the mother is able to progress without interruption. But a mother in advanced labour, in a quiet, familiar, unstimulating space, cannot give any attention to control. The mother who feels a strong need to control may instead choose regional anaesthesia or even surgery, rather than allowing herself to go “out of control” in a powerful hormonally driven state.

With my mind juggling these thoughts I read the new issue of Women and Birth, the journal of the Australian College of Midwives (Vol 21:2, June 2008). New Zealand midwife Joan Skinner’s Editorial titled ‘Risk: Let’s look at the bigger picture’ is a critical look at what more is needed to achieve better maternity care. “…we [midwives] in New Zealand, where the midwifery-led model of care is now the norm, are learning that autonomy and continuity of midwifery care are not, of themselves, the solution to the rising intervention rates in birth. Despite having developed a strong and autonomous midwifery profession, which now provides most primary maternity care, we have not succeeded in making a significant dent in our risk framework. Our intervention rates and our medico-legal environment attest to this. …we need to FIRST attend to changing hearts and minds, not JUST the model of care. We need to open up to possibilities of collaboration with others, rather than focusing on professional autonomy.” The writer suggests that midwives, in seeking to turn the tide of maternity care from a techno-rationalist to a truly woman centred care, need to engage with other knowledge frameworks, including biosciences, human geography, and architecture.

While midwives can strongly assert our role as guardians of normal birth, and can seek to effect this through primary care caseload midwifery, we do not have ‘ownership’ of the birthing terrain. Neither, for that matter, does the mother, although her ownership of her own body and her experiences is supremely important in a functional society. The whole society has an interest in the next generation, and whether a person is looking from the perspective of a sociologist, an architect, or a farmer, their knowledge is valuable to the society’s provision of services around birthing of children.

Without changing hearts and minds of pregnant women, future parents, fathers, grandparents, hair dressers, shop keepers, and people in all ages and stages and walks of life, the midwife’s skill in promoting and protecting normal birth will not be valued.

Sunday, June 22, 2008

HOMEOPATHY in midwifery

Joy Johnston

[This original article was first printed in MIDIRS Midwifery Digest, vol 18, no 2, June 2008, pp 185–187]


Complementary therapies which offer treatment alternatives in pregnancy and birth have been welcomed by many midwives and by women in our care (Tiran 2000). This is particularly so for those who seek to work with and protect the healthy natural processes in birth.

The increasing interest in, and availability of complementary therapies has led to Governments in many countries increasing the statutory regulation of alternative health practitioners (Williams et al 2004). This includes implementing systems which seek to protect public interest by registration of members of the professional group, accrediting courses of education, regulating products, and investigating and acting on claims of professional misconduct.

This article will focus on the use of homeopathy within the current maternity care system and will debate some of the issues that should be of concern to midwives who need to look objectively at the claims of homeopathy, and be conversant with the current, reliable advice and interventions as part of their recognised professional practice and accountability.

A brief history of homeopathy

Homeopathy was first developed and promoted by German physician, Dr Samuel Hahnemann (1755-1843). Both proponents and opponents today agree that, regardless of their ability to cure illness, homeopathic treatments were and are likely to do less damage to ill people than many of the practices carried out in the name of conventional medicine at that time. These practices included bloodletting, purging, and blistering. Homeopathy has been called, with good reason, a ‘kinder, gentler medicine’ (Stehlin 1996).

To give context to Hahnemann’s revolutionary theories, he lived prior to the emergence of knowledge about bacteria, viruses and infection. In 1847 Semmelweis identified surgeons’ hands as the route of spread of puerperal infection, and in 1865 Lister developed his system of hand washing and asepsis. (Parker 2008) It is likely that patients of Dr Hahnemann and his followers fared significantly better than those who received the other treatments on offer at that time, and it would not have taken modern statistical methods to observe the difference!

Homeopathy today uses language and concepts that may have been more familiar to the European world of the late 18th and early 19th century, than contemporary concepts and languages. Words such as ‘remedy’, ‘proving’, ‘potency’, and ‘potentisation’ have special meanings in homeopathy (Jones 2007). ‘Repertories’ and ‘rubrics’ list illnesses, symptoms, and treatments. This use of language may be seen as quaint and distinctive, alternatively the same impression may lead one to question the currency, in terms of effectiveness, of homeopathic theory.

[Readers who would like the .pdf version of this complete paper may request it]

Wednesday, June 18, 2008

Emma Flaim's Mother Series - Lino prints 1&2

These lovely lino prints have been added to my collection of birthing art and photos. Anyone who knows me may even see me in one of them! Thankyou Emma for your work. Joy
Emma Flaim's Mother Series - Lino prints 3 and 4

Saturday, June 14, 2008

Fair go!

I met with Jackie, who is having her first baby in a few weeks’ time, and she expressed frustration and dismay. How is it, she asked, that noone had told her she could have a midwife working solely with her when her time to give birth comes? All these months, visiting the obstetrician, booking in at the hospital, and going to the hospital for prenatal classes, and the idea was not once discussed. Last week she was told that the hospital midwives would come and go when she was in labour – their shifts might change, and they would have to help out the other midwives in the birthing suite. Fair enough, she said, but what about me? Then she talked to Margie, the midwife who works for her obstetrician, who suggested she find an independent midwife.

The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services. A caesarean rate of over 30% is unreasonable (see blog entry Sunday, May 18, 2008 IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS? for discussion). Caesareans that are performed without a valid reason, or because the service has failed to provide appropriate care, leave too many mothers and babies distressed and separated at a time when they need to establish strong attachments; placing many mothers and babies at higher risk of serious illness or death than they would have had in giving birth naturally; increasing the pain and depression experienced by mothers postnatally and restricting their ability to move. It wastes precious resources in hospitals – resources of staff and facilities that should be available for those who truly need specialist doctors and surgery.

During the past couple of decades I have worked hard to address the inequities in maternity care. I am seeing some progress – ever so slowly. Perhaps a reasonable benchmark for progress would be when every pregnant woman, regardless of risk status or wealth or expected place of birth, is given the opportunity to choose a midwife who will be with her as the primary maternity caregiver. After all, a midwife is with virtually every woman giving birth: why should the system not cater for the woman who wants to know that midwife?

In the late 1990s I was working part time for the Victorian branch of the Australian College of Midwives, and we encouraged midwives to be active in lobbying the Nurses Board for a Code of Practice for midwives, which was introduced in 1996 with the sunsetting of the Midwives Regulations. That Code acknowledged the International Confederation of Midwives’ Definition of the midwife for the first time in this State, a definition that clearly declared the professional scope of practice of the midwife, working in partnership with the woman, providing woman centred care, collaborating with other professionals when appropriate, and being competent in provision of primary maternity care that protects the wellbeing of mother and child.

The Australian government had brought legislative reform to prevent anti-competitive monopolies, and within this reform agenda called for various reviews of legislation, including the laws regulating provision of health services. I prepared several responses for the College of Midwives, arguing that government funding for maternity services, through Medicare and hospital funding, unfairly excludes midwives from acting as midwives and providing maternity care. The medical monopoly of funding forces women into models of care that are likely to result in medical and surgical management, without improving outcomes for mothers or babies. There was good evidence then, and much more now, demonstrating the effectiveness of midwives working at the basic or primary care level throughout the pregnancy-birthing continuum, and referring women to specialists if and when the need arises. There is no evidence supporting specialist obstetricians as primary carers.

Our arguments were sound. New Zealand maternity services had, in the early 1990s, undergone major reform, and our colleagues across the Tasman were moving into independence and autonomy, with equal pay for midwives and doctors who provided the same service, that we only dreamed of. But although our arguments made sense, the political ‘buck passing’ from State to Federal health departments, and back again, seemed to extinguish any hope for reform as soon as it appeared.

In 1985 the World Health Organisation (WHO) had published the Fortelesa Declaration, addressing appropriate technology in birth. This document became the launching pad for activity by WHO and international professional bodies to address the evidence supporting practices in maternity care. The Cochrane Collaboration ( ) was established in 1993, looking initially at evidence based practices in obstetrics, and moving quickly to all health care interventions. Early research demonstrated the beneficial effect of continuity of care by a known midwife, and other aspects of midwife primary care.

The College of Midwives had, in the mid 1990s, formed a partnership with the emerging political lobby group Maternity Coalition. Our projects included a Midwifery Campaign, demanding ‘choice’ and ‘access’ for all women: choice of caregiver and place of birth, and access to models of care that enabled this choice. Soon after the turn of the century a group of consumer activists and midwives in Maternity Coalition, under the leadership of Barb Vernon from ACT and Tracy Reibel from Perth, prepared the National Maternity Action Plan (NMAP) as a framework for maternity reform. This document received widespread support, and not a little criticism, and put pressure on government health departments to address the inequity in maternity service provision, particularly for women who wanted to give birth naturally.

In the early 1990s the Baby Friendly Hospital Initiative (BFHI) was born, with its goal, the protection, promotion and support of breastfeeding. The essence of the BFHI was a world-wide program auditing maternity hospitals, using the ‘Ten Steps to successful breastfeeding’, on their practices which either supported or hindered the establishment of breastfeeding by mothers and their newborn babies. The BFHI is a major health promotion activity, which restores for women their natural authority for breastfeeding and protecting the health of their children.

When addressing breastfeeding it is logical that mothers, and midwives, will see the obvious connections between pregnancy, birth, and the nourishment and nurture of the infant. Why enable mothers to take responsibility and authority for their breastfeeding, and not their birthing? Midwives, being ‘with woman’, are able to do just that.

Internationally there was an awakening of midwifery, with midwives and women calling for reform, a ‘fair go!’. In the USA, the Coalition for Improving Maternity Services (CIMS) ( developed the Ten Steps of Mother-Friendly Care, in many ways projecting the BFHI into the fuller context of maternity care. In the UK maternity activists and midwives were promoting normal birth; and home birth received support at government report levels. Everywhere in the developed world caesarean rates were on the rise, while mortality rates in developing countries were shockingly high. That is still the case today. There is still much to be done. The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services.

A new and troubling element has asserted itself in the modern maternity terrain. The ‘choice’ of Caesarean birth: “too posh to push”; “honeymoon vagina”; and “I don’t want to sag down there and spoil my sex life” are a few of the reasons given. It seems that in this topsy-turvey world we live in, the consumer’s choice of major abdominal surgery is more readily provided for than the choice of the mother who simply wants to give birth naturally. A booking can be made in the hospital; all the needed personnel and gear assembled; and ‘bob’syouruncle!’. Well organised and delivered on time. Much more reliable than the mystery journey of natural birth, when labour comes like the thief in the night, and progresses according to mysterious rules and secret forces that cannot be controlled.

In promoting consumer choice, have we encouraged women to short-change themselves by opting out of one of life’s most amazing and healthy processes?

When women 'choose' models of care and interventions (such as induction, drugs, epidural, or surgery) the hospital is able to give that, and has a satisfied customer. I think this is the down side of the 'consumer choice' message. I believe there is an ethical argument that in maternity care the service providers are bound by the 'no harm' imperative to support and protect normal birth, and NOT to interfere without a valid reason. I believe caesarean should not be done on demand.

The core rationale behind the CIMS 10 steps is enabling women to give birth safely and naturally without medical help unless there is a valid reason. This is good, but can't happen unless women actually accept it, and are then able to progress undisturbed (allowing their bodies to do the work) with trust in the care provider who is leading the professional care decisions. That's where the primary carer's role becomes critical. Without models of care where the midwife and woman are able to work in partnership and protect normal birth, it’s unlikely that the increasing tide of caesareans will turn. We have plenty of proof that the status quo is not achieving the protection of normal birth.

I want to see a fair go for all concerned - the service providers, midwives, doctors, the consumers (mother and baby), the family and society, and policy makers. We will only achieve this when the consumers and the professionals work together to provide maternity care that values the wonderful natural processes in birthing, and uses technology appropriately for all who need it, not just for those who can afford to buy it.

Tuesday, June 10, 2008


I remember my first meeting with the obstetrician in his rooms in Melbourne, when I was pregnant for the first time. I came dressed nicely, and my husband Noel accompanied me. Noel was asked politely to wait – he would be invited in to meet the doctor after he had performed his examination. I was instructed to take my clothes off, to don the white examination gown, and lie on the firm narrow couch. My abdomen and breasts were palpated, and my vagina pried by a man in a grey pin-stripe suit, a crisp white shirt and a bow tie, which was the standard attire for men of such professions at the time. I was then asked to dress, and the doctor would come back and speak to me.

Innocently I informed the doctor that I was a midwife, and that I wanted a natural birth. He gave a reply that I understood as ‘we shall see’. At some pre-determined moment Noel was invited into the interview, sat on a chair next to me, and he asked some question.

“Mrs Johnston and I have already discussed that” was the reply, in a dismissive tone that indicated that the deal had already been done, so he need not exercise his mind on it.

My ‘choice’ to plan to have a natural birth was, I thought, simple. Young people today would call it a ‘no brainer’. Many of those same young women today go into maternity care with the same degree of innocent trust that I had. And many experience the authoritarian conquering power of the obstetrician who looks over her glasses and says “We shall see!”

If we stopped to assess the quality of the offered service by asking questions such as “How many first time mothers in your practice last year experienced uncomplicated, unmedicated, spontaneous birth?”, we may discover that this person is not skilled at protecting normal birth. And why should they be? They are surgeons whose education and registration prepare them as specialists, most with very little knowledge of working in harmony with and supporting natural female rhythms.

It’s as though we have blinkers on our eyes. We wouldn’t go into buying a house or a car or even a pair of shoes with the same lack of critical thinking that we seem to easily adopt when it comes to having a baby, which is surely the most significant investment of time, energy, and every other resource at our disposal that we will ever experience.

This past Sunday evening there was a segment called ‘Birth Choice’ on Chanel 9’s 60 Minutes. I watched it and became increasingly more distressed as time went by. The show presented two extremes, DIY homebirth, without a midwife, compared with the ‘too posh to push’ caesarean birth on demand. It was sensationalist and misleading not a rational or responsible presentation of the choices a woman faces in birth. Presenting the opinion of an obstetrician on homebirth is similar to asking the manager of a nursing home about parenting issues. Uninformed!

I want to be fair in my criticisms – the filming of the homebirth was done in a respectful and delicate way. It was a spontaneous, uncomplicated, unmedicated birth in water, and the baby was in excellent condition, which is what I would have expected. Yet I felt sympathy for the un-midwifed mother, who was under the prying eye of the video camera, and had noone who had the knowledge or skill to say "You are well; your baby is well. Take this beautiful little girl into your arms and love her." The mother was concerned about her blood loss after the birth, and went to the hospital. I hope she was midwifed well there.

I cannot understand the woman who chooses major surgery - surely she has been sold a lie? The notion of keeping things tight "down there". Oh dear!

There are some mothers and babies who have needed and accepted surgical births, and who are thankful for the 'good' outcomes. I am also thankful for good outcomes. This is also a 'no brainer'. But I have also seen the women who have suffered surgical complications - infections, retained swabs, drug errors, haemorrhage, impaired clotting, pain, and a great deal of psychological trauma of separation and disturbed bonding. These are not good outcomes.

It is with this knowledge that I will continue to work to protect and promote healthy natural processes, and support normal birthing when ever I can. I believe we have only one real choice - that is, to either work in harmony with our healthy natural processes in pregnancy, birth, and parenting, or to ignore them. Medical options at present in developed countries like Australia offer surgical options which come at a cost. It is important, I believe, that the cost as well as the potential benefit of avoidance of natural birthing be understood before choices are made.