optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:

I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.

I don't want to be critical of the optimal birth space ideology.

HOWEVER ...

The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]


NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:

• a place that the woman has chosen to be in
• a place that the woman is happy to continue in, as labour progresses
• a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
• a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
• a place that allows the woman to feel private and unobserved
• a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 


Your comments are very welcome.

spontaneous birthing

There was no acceptable alternative; no short-cut or easy way.  The labour had established.
The young mother struggled with every surge of uterine activity.  "I can't do it!  I am too tired!", she cried in English, then lots more in another language.
If one of us had been able to step in as proxy; to labour and give birth, or even to do some of the work, and lessen her load, we would have.  Surely it's unfair that the woman has to do it all?

Each time I witness the massive effort that culminates in the unmedicated, unassisted birth of a baby - and particularly a first baby - I am in awe.   The journey that can have many unpredictable and unexpected turns in the path; many forks in the road.  At each decision point, only one way can be taken.  Is this the best way?

As midwife, I hear many voices.  The mother's body, the baby's body, my own mind, the voice of professional and scientific knowledge, and the words of others participating in the birthing journey.

When the mother's mind says "I can't do it! I'm too tired!" I can't just block my ears.

I ask, what does her body tell me?

There is power in these contractions, and I have seen progress over time.
There is strength in this young body.  Her pulse rate is steady and strong.
There is quietness in the moments of resting between contractions.
Is mother well?  At present, yes.

I know we can continue.

I ask, what does her baby's body tell me?

The baby's heart rate is strong and steady.
The contractions, although strong, do not bring any sign of distress in the baby.
The baby's station is progressing with time.
Is baby well?  At present, yes.

I know we can continue.

I ask, what does my own mind tell me?

It's the middle of the night, and my mind is also weary.
I hear the cries.  I know that she is sleep-deprived.
I seek to guide this girl who is being transformed into a mother through this rough terrain.

I will not interrupt or interfere with the amazing metamorphosis; the life-giving struggle that we are witnessing.

I ask, what does professional and scientific knowledge tell me?

Simply this: that there is no safer or more appropriate way for this baby to be brought into the world, than for the midwife to work in harmony with natural physiological processes in labour and birth.
That this woman's body is wonderfully made, that this baby's body is uniquely suited to this mother, and that the process of birth is so much more than delivery of a child from the womb to the outside world.
That the transitions which must take place shortly are best supported in strong, unmedicated birthing.

I know we can continue.

I ask, what do the others - the husband, the friend, the student - tell me?

We are working together, and I am responsible for so much.  These members of the team are looking to me for encouragement and strength.  They do not have the years of life experience that I have, and they are quietly learning to harmonise their actions with those of the labouring woman.

I know we can continue.



We moved to the birthing pool.  The pushing had been ineffective, and the voice "I can't do it, I'm too tired!" was becoming more persistent.

Then, as an expulsive urge was about to go, I saw some fine, thick black hair peep out between the labia, then disappear again.

"I can tell you what colour your baby's hair is" I said.  "Black."

We all laughed.  Babies from their people group all have black hair.


I don't know when the young mother realised that she actually could give birth, that she was giving birth.  But I know and hold onto the look of utter amazement and satisfaction as she took her child into her arms.

Thanksgiving

Me with my girls

From time to time as that special day passed I rubbed my belly, enjoying the sensation of tightening as the fundus became firm. I was as confident and ready as a 23-year-old entering motherhood for the first time could be.

For most of the week prior to this day we had gone for walks in the evening, and the tightenings had come for a while, then stopped. Each night as we went to bed I wondered, "Is this the night?" Each morning I awoke, rubbed the bump that protruded under my diaphragm, looked in the mirror at the enormity of my previously flat abdomen, and continued in waiting mode.

The special day was Thanksgiving Day in the USA. We had settled in to our home in Michigan; Noel had commenced his graduate studies in the Dairy Science department at Michigan State University; and we had been invited to join the Professor, Wayne Oxender DVM, and his partner, for our first American Thanksgiving meal.

Our hosts had prepared special food that had significance to the celebration of thanksgiving to God for preserving the lives of the Pilgrim fathers through the previous year, with food stored for the coming winter.

Decorations had been carefully made using corn husks and natural fibers. The turkey had been stuffed and was basted carefully as it roasted to perfection for many hours. I had never seen a turkey like that one. There was abundant sweet corn, sweet potatoes, and corn bread. Probably a dish of spinnach. I don't remember the details. A large bowl was set up with hot apple cider that had sticks of cinnamon floating in it. We dipped into it many times. It was sooo good!

This was a totally new culinary experience for a girl from sunny Queensland. Then pumpkin pie - who ever would have thought of using pumpkin, the staple vegetable, as a dessert? On top of the servings of pumpkin pie someone squirted fake cream out of a pressurised can - the fashion at that time. Who ever would have thought of putting cream into a pressure pac? The irony of using fake cream on this most basic of 'back to the simple life' feasts stuck in my mind, but I was too polite, too blown away, to say anything.

As I said at the start of this post, I was experiencing some tightenings which were preparatory for my labour with my first child, Miriam. That evening the labour became established, and I gave birth the following day.

The good company, good food, and totally new world that we experienced in late November 1973 prepared me for motherhood. Being surrounded by members of the veterinary profession, with their special interest in reproduction and raising of calves, was good for me. I have often reflected on that period in my life, and it has in many ways supported my efforts to work in harmony with natural physiological processes in the birth and nurture of babies in my care.

Uncertainties

bonsai Japanese Maple

Members of my family are at present dealing with major challenges as they progress along the pathway towards the birth of a child.

I am a midwife who seeks to promote, protect and support wellness and wholeness in pregnancy, birth and the nurture of a baby. This is the usual situation for most women.

I would like to especially acknowledge anyone who finds themself on an unexpected, and really unwanted (if they had been able to choose) pathway in the journey to a birth.

With this in mind, I am linking this post to the blog of my nephew Dave and his wife Petrina, whose unborn baby is being treated for heart failure. As I read through the posts at their blog I am confronted again and again with the uncertainties of this particular case. I am also thankful for the openness and clarity with which these young parents have attempted to share some of their feelings - not knowing where the journey will take them.

Most of you who read my blogs will be doing so out of your interest in midwifery.  The question to the midwife is, how can I be midwife, 'with woman', when the overwhelming focus of care and decisions that are being made are intensely medical; when the birth of this baby will almost certainly be surgical, and contact between mother and baby will almost certainly be minimal as a new team of specialists assumes care for him or her.

Any complicated pregnancy presents this challenge, to a greater or lesser degree.  Increasingly specialist medical knowledge and technology are pitting themselves against conditions that would previously have been incompatible with life - this phenomenon appears to be unstoppable from the perspective of science and medicine.  Where there is any hope of life, parents are likely to give permission for whatever is offered.

We say that every woman giving birth needs a midwife.  The midwife for a woman in a complex and challenging medical birth focuses on the woman as a whole person - not just as the carrier of a very special baby.  Many of the plans that are made by women approaching normal-physiological birth cannot be considered.  The baby's *condition*, or the *complication* take on leading roles in the story that is being played out in real time.   


If you have read this far, you might wonder why I have included a picture of a little bonsai tree from my garden.  The reason is, that in a special way, I learn lessons from tending these wonderful but fragile plants.  There is a sense of connection between a living thing and its carer, as I know that without daily care and special knowledge this tree will die.  There is such beauty in the changes that come with seasons - I had previously posted a picture of this tree in the winter, having lost its leaves.  These miniature trees offer me a special life focus, as I tend the creature, and seek to work in harmony with the Creator.

Becoming parents

The focus of the midwife is, without doubt, the woman.  Midwife means, literally, 'with woman'.

But the woman is much more than the bearer of a child.  The woman becomes a mother, in the context of a family, and the child is nurtured within her or his family.  The child grows physically, emotionally, and spiritually as food, shelter, and protection are provided by both mother and father, and values are taught from before birth.  Focus on becoming parents is included in the work of the midwife, and extends well beyond the scope of midwifery.

I have recently received a copy of a new book, "Becoming Us, The Essential Relationship Guide for Parents" by Elly Taylor.   I am looking forward to reading it.

It's available in all good book shops, ABC shops and on-line.

For more, see the linked website Parent Support Online.

what will the students do ...

... after graduation?

New graduate midwives in Victoria are facing great difficulties in securing employment.

A facebook site has been set up to support student midwives who do not have a 'graduate year' position available to them. The fb group lists 44 as students without a grad year, and a couple of hundred 'friends', all since the site was created a week or so ago.

what will the students think?

A few weeks ago I wrote about the interim Position Statement on Homebirth that appeared , with endorsement, on the website of the statutory body. The Position Statement and associated documents had been prepared by the College of Midwives.

Today I attended a meeting of members of the College, at which I and other members took the opportunity to speak about our concerns around these documents.

mother-midwife

 The midwifery I practise is inextricably linked to my being a mother, and being a mother to my family cannot be separated from midwifery as I know it.

Although I learnt the basics of midwifery in the classroom and wards of the Royal Women's Hospital, I consolidated my learning, and became convinced of my identity as a mother-midwife during the months and years of pregnancy, giving birth, breastfeeding, and nurturing my four children.

This precious picture shows our two girls, happily breastfeeding their dollies.  The year was 1977, when their brother was a baby. 

Further down the page is a pic taken this week, of Bec with her baby James at her breast, in that blissful milky dream-state.

This past week has been a very special one for our family, as we have experienced the inevitable separation that comes with death of a loved one.  Yesterday my husband's mother, Lily Johnston, was buried, surrounded by her loving family.    Grandma had her 99th birthday earlier this year.

Being mother-midwife to my family requires a special trust between me and the young women.  I cannot presume that any woman will accept the principles that I follow; I cannot expect, nor would I want, uncritical adherance to a professional care plan that is not widely understood in our community. 

The ability of a particular woman in bearing and nurturing a child is not a fixed or definable matter.  The 'power-passage-passenger-psyche' equation is tested as the mystery of labour proceeds.  A woman who is able to continue and make good progress does not need to consider other options.  'Plan A' is, for her, the only plan to be considered.

A woman whose progress is slow, or who is unable to accept the pain she experiences, or whose baby's heart sounds tell us that he is not receiving enough blood during the contractions - this woman is confronted with complex and often challenging choices and decisions: 'Plan B'.

Being mother-midwife often takes me into realms of uncertainty. 

Midwife Medicare Provider Number

The Department of Human Services Medicare Australia has allocated a Provider Number to Mrs Joyce Johnston [that's me, the villagemidwife], Aitex Private Midwifery Services, at 25 Eley Rd Blackburn South, Victoria 3130, effective 22/09/2011. The Provider Number is for the purpose of rendering accounts for approved Medicare services performed and for requesting certain diagnostic imaging and pathology services while working in a private capacity.

As a Medicare-authorised midwife, there is scheduled fee for each item, from which rebates are calculated [variation in amount payable depends on a person's safety net].  For example:

Living with uncertainty

I arrived at the home of a woman in labour, and everything I saw and knew about this woman and her baby told me that the birth was imminent. After greeting her - she was in the shower - I went through the routine setting out of my equipment in readiness and connecting the oxygen cylinder to the flow meter.

Three hours later, there was no baby. No apparent problem with either mother or baby. A rim of cervix, an undescended fetal head, ... Mother asked me if I had brought my knitting. No - I really didn't expect to be waiting around long enough. It's a second baby, after all.

Mums Matter!

The Australian Private Midwives Association (APMA) has just launched an on-line campaign, called Mums Matter!

Where is the woman?

Today's SMH and Age newspapers carry reports around the insurance debacle that has been unfolding this past week. I have written about it here and at the other blogs - you can click on the links at the right hand side of this page if you haven't already read them.

Where is the woman?
... the pregnant-labouring-childbearing woman in this whole dog's breakfast of red tape?

changes in my world

Today the sky is blue, there is a soft, warm breeze, and signs of Spring are everywhere. I haven't thrown open the doors and windows of the house yet, but I would love to be outside, enjoying the sunshine, allowing my skin to drink in that life-affirming warmth, going for a walk, or pottering in the garden.

But I need to work on supporting other midwives who are feeling threatened, and letting the world know what is happening here in Australia.

There is another change in my world, and only time will tell what it means to midwives and to the women who value our services.

Midwives have been told that a midwife colleague has been 'reported' to the regulatory authority for being with a woman in hospital, after transferring that woman to the hospital from planned home birth.

Under the new 'mandatory reporting' rules, a notification must be made if, in the course of professional practice, another regulated health professional "form[s] reasonable belief that a [midwife] has placed the public at risk of substantial harm due to practising their profession in a way tha constitutes a significant departure from accepted professional standards." (ANF Vic 2010)

In the case of an independent midwife transferring care of a woman from home birth to hospital, and continuing to support the woman in hospital: the standard practice of homebirth midwives for many years - that midwife is not covered by any professional indemnity insurance. The 'significant departure' from 'accepted professional standards' is that the midwife is 'practising' without insurance.

Until yesterday, midwives and hospitals accepted the presence of the midwife in a hospital birth suite in a non-clinical, non-decision-making role, as being outside the requirement for insurance. As recently as this past Saturday, I was with woman in a hospital birth suite. The woman had planned homebirth, in my care. I believe the 'risk of substantial harm' in that case would be greater if I abandoned that woman, rather than continuing with her in a supportive and caring role.  I am a midwife, with woman, and my practice must be centred on the woman, not on the setting or model of care, or even the availability of insurance.

However, a new, extremely narrow definition of 'Practice' has emerged, covering any situation in which a midwife uses her skills and knowledge as a midwife.

I will write about what this means as I get opportunities today.

Thankyou, readers, for your interest.

Refining and redefining a midwife's boundaries

The release by the Australian College of Midwives (ACM) of an Interim Homebirth Position Statement and guidance document has prompted discussion and debate amongst those of us who are interested in the boundaries of a midwife's practice. Of immediate concern is the statement in the guidance that:

"There are some contraindications to a planned homebirth which women should be informed of at booking. These are: • Multiple pregnancy • Abnormal presentation (including breech presentation) • Preterm labour prior to 37 completed weeks of pregnancy • Post term pregnancy of more than 42 completed weeks • Scarred uterus"

[I have written about the 'Scarred uterus' at the MIPP blog]

The word 'contraindication' means 'NO!'.

There is little room for movement in the word ‘contraindication’ which in any medical setting means that there is a reason to avoid using a particular treatment. For example, Penicillin is contraindicated when a person has an allergy to penicillin. Many specific drugs are contraindicated in pregnancy because they may adversely affect the fetus.

When I spoke about this concern to a respected colleague she told me not to worry, that it just means we have to initiate ‘Appendix A’ [in the ACM National Midwifery Guidelines for Consultation and Referral (ACM 2008)]. Appendix A gives a process for the midwife to follow 'When a woman chooses care outside the recommended ACM National Midwifery Guidelines ...' . My colleague argued that once a midwife has signed off on Appendix A for whatever reason, the midwife just continues to provide care, confident that the woman is making an informed decision. "Put it to the woman when she inquires about homebirth that her previous caesarean means that you are not able to support homebirth because the guidelines say so, but if she still wants homebirth she can sign a statement ..."

As has been pointed out by a consumer activist, the ACM has generously speculated in the guidance document on the possibility that “In the event of a woman making her own decision/s ...” This statement made me stop and think – a woman making her own decision/s – isn’t that what usually happens??? Oh dear!

What ever happened to all the notions of woman-centred care, informed decision making, partnership, cultural safety, reciprocity, trust? Is ACM trying to protect midwives from those women who make their own decisions? I think that's the only sort of woman I can provide midwifery for!

I have been a member of ACM continuously since the 1980's when it was the Midwives Association of Victoria Inc, and I proudly received Fellowship (FACM) from the College in 1997. Professional bodies attempt to describe and define boundaries of that profession, and members must either go with the change or resist it.  In this matter, I am resisting.

The ACM has been funded in this project by the federal government, which has initiated major reforms across health, to refine and redefine the midwife's boundaries, especially in the context of private practice. The Australian people elected a Labor government. We are now experiencing centrally controlled social health policy that restricts the individual (consumer and practitioner) while claiming to bring benefits for everyone? That's how a socialist health policy works.  Why are we surprised?

Enough from me.
Your comments are very welcome.
Joy

News for privately practising midwives and women planning homebirth

from
Australian Health Ministers’ Conference

COMMUNIQUÉ
5 August 2011

Professional Indemnity Insurance Exemption for Independent Privately Practising Midwives
"Ministers agreed to a further 12 month extension of the exemption to 1 July 2013 while further options are explored with a report back to the next Health Ministers meeting."

My comment:
I don't have time to write much today, as I have a primip in labour, and Saturday morning chores to do in the house. This extension to the Exemption is good news - we can continue planning homebirth until June 2013 at least!
Joy

Your commets are very welcome.

"Women have the right to ..."

What right or rights do women have? What special rights do childbearing women have? What rights do mothers and babies have?

This question has played in my mind recently. Readers who have read the previous post may have noticed the statement:

"Women have the right to self determination and to be supported and encouraged to get on with ..."

Do they? Really?

What does 'self determination' look like? How does it work when difficult decisions need to be made in maternity situations? How does it work when the woman is frightened by the power of her labour? What support and encouragement is appropriate ...? Isn't that the time when the "best laid plans" come undone?


We know that in modern societies all competent persons (female or male), in the context of health care, have the right of refusal. The woman in maternity care has this right, even when her refusal may result in what most would consider to be adverse consequences for herself and her baby.

'Refusal' is very different from 'self determination'.

Consider this scenario:

Midwife: "Jane, I am advising you to go to hospital and have an induction of labour, for the following reasons [eg post 42 weeks' gestation] ..."

Jane: "I understand that you advise induction of labour. Would you please tell me what is likely to happen if I refuse your advice."

Midwife: "As your midwife I would continue to check you and your baby, and tell you if I detect any changes. I would also advise obstetric review at XX hospital. The tests that are usually carried out at this time are fetal monitoring, ultrasound studies that check blood flow to your baby, and measurement of your baby's amniotic fluid level. These investigations, which can be repeated as time passes, may detect subtle changes in baby's condition, or may reassure us that your baby is well."

Jane: "I have always planned to wait for spontaneous onset of labour, unless there is a valid reason to interrupt my natural process. I don't think 42 weeks gestation alone is sufficient reason. Therefore I will refuse induction today, and wait for labour to begin. I am willing to make an appointment for specialist obstetric review."

This conversation, in which the midwife gives professional advice (for whatever reason), and the client/consumer makes a decision, based on her understanding of principles of appropriate maternity care, and the information given to her, to refuse that advice, is what I call 'informed refusal', or 'informed decision making'.

A very different conversation would be something like:

Midwife to Jane: "You're 42 weeks. What do you want to do now? Induction or wait for labour?" [ie self-determination]

Since the early 1990s, midwives and maternity consumers have quoted the reports of the British government's inquiries into maternity care, that women want the 'THREE C's' choice, control, and continuity of care. Since the early 1990s I have worked with Australian women and midwives, and have often used the THREE C's as a guide in the uncharted terrain of birth reform.  However, this little mantra should not be seen as a statement of women's birthing rights.

I have seen situations in which a woman's choice, or her sense of control [self determination], have led to what I see as disastrous outcomes - loss of life, and potentially preventable harm.  In these situations 'continuity of care' has been 'continuity' [same person] without the 'care' from a professionally skilled person who has the duty and ability to act in the interests of mother and baby at all times.  The care has been confused, fragmented, and ineffective.   A midwife or doctor who says "What would you like to do now?", when the only responsible statement is, for example, "I must advise you that your baby needs to be born now ..." is forgetting their professional duty to that woman.

When a woman has effective continuity of care, with a midwife who she (the woman) respects, and who respects her, there will be no doubt about the differences between a woman's rights, a woman's choices, and the midwife's duty of care. 

idealism in midwifery

with Karen, and her babies Simon and Hannah, about 12 years ago

This past week I have been engaging in a review of my professional practice. One of the tasks set down is to write a personal midwifery philosophy. I am a lover of writing - bringing together thoughts and knowledge into words that can be passed on to others. Writing a personal midwifery philosophy is, so to speak, 'right up my alley'.

Where do I start?

The word 'philosophy' is made of two words, 'love' and 'wisdom'. A personal philosophy of midwifery could be a statement of what I love in midwifery, and what wisdom I find in midwifery.


In considering this challenge I hit an unexpected obstacle. The material that was sent to me to use in preparation for this review contained an example:

"Personal midwifery philosophy
"I believe:
• Pregnancy, birth and mothering are a normal, privileged, life-affirming and glorious part of life.
• Women can do it even when it is difficult.
• Women have the right to self determination and to be supported and encouraged to get on with this (most) important aspect of their lives.
• Women have responsibilities to themselves and their babies to actively participate in their health care.
• Midwives work with women and women work with midwives in a flexible, (hopefully) nurturing and synergistic relationship."

Dear reader, did you see anything in that quote that set the red lights flashing, and bells ringing?

I can’t fully agree with any part of this philosophy. IMHO it’s idealistic, naive, and indicates a potentially unprofessional mind set. Here, briefly, are my reasons for rejecting such a statement:

1. Pregnancy, birth and mothering CAN BE normal/abnormal; privileged/nothing like privileged; life-affirming/soul destroying; glorious/terrifying, depressing. What does this statement have to do with midwifery?
2. Some women can; some can’t, won’t, or don’t do whatever it is, even when it’s difficult. What does this statement have to do with midwifery?
3. Women have the right to ... What does this statement have to do with midwifery?
4. Women have responsibilities ... What does this statement have to do with midwifery?
5. Midwives work with women and women work with midwives in a flexible, (hopefully) nurturing and synergistic relationship. This statement is starting to address midwifery, but what does it mean? Do midwives need to be nurtured by the women they attend?

I hope you don’t think I’m splitting hairs here. This is a serious critique. As I read the quoted sample 'philosophy', it’s as though midwifery has become lost in idealistic notions of women’s choices, rights, and responsibilities. Of course I would like women to have all these things, but they are not part of a philosophy of midwifery. They don't say anything about what's to love in the wisdom of midwifery. 


A woman who gave birth in my care to two of her children more than a decade ago wrote to me about her experience in supporting her son and daughter in law at the birth of her first grand child:

I am again full of extreme gratitude to you for what you gave me all those years ago.
I am realising afresh what a pivotal time in my life my homebirths were.

The philosophy of midwifery care that energised me fifteen or twenty years ago is the same one that I have today. While no words can adequately describe the breadth and depth of the wisdom of working in harmony with our amazing, wonderfully made bodies, I have written:

"As a midwife working in a special partnership with each woman as her professional care giver, I seek to practise in a way that harmonises with the woman’s natural physiological processes, and promotes health. There is no better or safer way for most women and babies than to proceed through their childbearing and nurture of the newborn in harmony with natural process, with a plan to give birth without relying on analgesics, stimulants, or other pharmacological or surgical intervention.

"As a midwife my duty and responsibility to each woman and baby is also to identify any complications that may arise or be likely to arise, and to take steps to obtain appropriate and timely interventions when indicated."

Your comments are welcome.

midwives in the making

(c) Picture used with permission

Yesterday I had the privilege of presenting a 1.5 hour talk on private midwifery practice to the midwifery students at Deakin University in Burwood. I love having the opportunity to inspire the next generation of midwives.

I know some visitors to this blog are studying midwifery, in many countries. In today's post I want to give you an outline of my presentation, and links to some of the key documents.

The parts of the presentation were:

• Overview and introduction: developing a strong 'midwife identity'
• Private midwifery practice, changes in legislation with Medicare rebates and other changes for eligible midwives. Go to Midwives Australia for more information and links
• Planning for birth: philosophy of birth based on the statement that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996); decision-making concepts of 'Plan A' and 'Plan B', birth preparation meeting handout
• DVD of a beautiful home/water birth [One picture used here with permission - the visual image is sooo powerful!]
• Highlighting aspects of midwifery practice that can apply only when the whole labour progresses under natural hormonal, unmedicated processes: physiological third stage, and baby's transition from the womb
• Questions

Please follow these links if you are interested in the topics mentioned. I intend to prepare a post on 'Planning for birth' at my private midwifery blog - will do that as soon as I can.

For the record, my relationship with the Deakin University School of Nursing and Midwifery is that I am employed as a casual lecturer, and as a tutor and marker for some of the midwifery Professional Development Unit Learning Packages. Several years ago I prepared one of the Learning Packages on the midwife in the community (PDU 323) and more recently I have written a Learning Package on Caseload and Homebirth midwifery, which is being processed in preparation for release.

Vitamin D

Melbourne is a bleak and chilly place at this time of year. My little deciduous Bonsai trees have dropped their leaves. Most days there's not much sunshine - not a lot of synthesising of precious Vitamin D going on in our bodies.

This past week I have been seeking an update of my knowledge of Vitamin D. My questions were prompted when a woman in my care, who gave birth in hospital, was instructed to give her baby Pentavite (R) daily in the first year, to ensure adequate Vitamin D intake. The Penta-vite Liquid Multi-vitamins for Infants (0-3 yrs) contains 10.1 mcg of Vit.D3, as well as Vitamins B1, B2, B3, B6 and C.

The hospital midwife indicated that this protocol was now being followed for breast feeding mothers whose Vitamin D levels tested low.

I inquired about current midwifery practice amongst colleagues, and some were quick to send links to sites and articles on the importance of adequate amounts of the 'sunlight vitamin' in pregnancy, lactation, and infancy.

I recommend a current update article in Medscape ObGyn and Womens Health. Vitamin D, Deciphered, Declassified, and Defined for Your Patients written by Sandra A. Fryhofer, MD.

"In the past, vitamin D worries were mainly about bone health. That's all changed. New studies now support an ever-increasing role of vitamin D in preventing all kinds of diseases: heart disease, diabetes mellitus, cancer, infection, autoimmune diseases (multiple sclerosis, rheumatoid arthritis), and the list goes on!"

Other Medscape articles that provide useful perspectives on this topic are
ACOG Says More Data Needed on Vitamin D During Pregnancy

"June 22, 2011 — More data are needed before physicians start routinely screening pregnant women for vitamin D deficiency, according to a statement from the American College of Obstetricians and Gynecologists (ACOG), published in the July issue of Obstetrics & Gynecology."

Also ...
Protean Manifestations of Vitamin D Deficiency, Part 1 The Epidemic of Deficiency

Protean Manifestations of Vitamin D Deficiency, Part 2
Deficiency and Its Association With Autoimmune Disease, Cancer, Infection, Asthma, Dermopathies, Insulin Resistance, and Type 2 Diabetes

Protean Manifestations of Vitamin D Deficiency, Part 3
Association With Cardiovascular Disease and Disorders of the Central and Peripheral Nervous Systems


One of my midwife colleagues wrote:

"It is so important to get enough in your diet and sunlight. Our society has become sun protective obsessed that we are not getting enough. I would suggest to your client buying the best quality organic butter and slapping it on everything. If she can get hold of raw milk from grass fed cows even better. Fish oil or grass fed free range chook eggs. 10-15 min in the sun (till the skin gets a light pink colour) is enough vitamin D Daily and make sure she doesn't wash her skin after a sun bake. How long to be in the sun depends on how far North or South you live and the time of year. Best time to get your vitamin D is between 10-3pm (the time everyone is shunning the sun). The problem with getting your vitamin D from the sun is knowing when to have enough, people work or lay in the sun for long periods of time are more at risk of skin cancer... but a daily dose of light pink skin is healthy."

Having looked at the evidence and debate I will now be more committed to not only checking Vitamin D levels, and promoting healthy diet and sensible daily sun exposure where possible. I recall advice that was given to mothers in the 1950s and 1960s, that they should give baby time each day in the sun with little or no clothes on, weather permitting. Perhaps we will reinstate this old advice.

PS

From Medscape Medical News: Vitamin D Found to Be Safe for Healthy Pregnant Women

July 6, 2011 — Vitamin D supplementation of 4000 IU/day is safe and effective for healthy pregnant women and their infants, according to the results of a large, double-blinded, randomized clinical trial published online June 27 in the Journal of Bone & Mineral Research.

[I checked the amount of Vitamin D in my daily multi-vitamin supplement, and it's 200 IU.  According to the lead author Bruce W. Hollis, PhD: "Surprisingly the scientific debate has made little progress since Dr. Gilbert Forbes made a recommendation of 200 IU (international units) per day in 1963, which was based on a hunch."]

Your comments are welcome.

"When there are two midwives ...

... the baby's head is crooked."

[This is a saying from Persia, quoted by Michel Odent, in Childbirth in the Age of Plastics (2011), p63]
Here's the context:

Learning from home births

...

One of the main obstacles for easy births - particularly easy home births - is the common overuse of language. I have countless anecdotes of useless questions, comments, and advices from well-intentioned birth attendants.
Another obstacle is a deep-rooted tendancy to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. ... Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or South America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: "When there are two midwives, the baby's head is crooked".

And of course a crooked head means a painful, difficult birth. The optimal position for the fetal head is flexed at the beginning of labour in the occiputo-transverse to occiputo-anterior plane, well applied (evenly) to the internal os of the cervix, with continuing flexion of the fetal head as labour progresses. A head that is presenting posterior, or asynclitic (tilted to one side) is not well applied to the cervix, and dilation of the cervix can be difficult, and labour incoordinate.

A reader may wonder why traditional wisdom would warn that "Where there are two midwives a baby's head will be crooked." Is that just an old wives' tale, to be discarded by the modern, intelligent mind? Is there any possibility that the presentation of a baby in the womb is in any way influenced by the presence of a second midwife?

Assuming that there is something of universal worth in this saying, how can it apply to women and midwives in Melbourne, Australia, today?

Just for the record, my midwifery practice includes births at which I am the only midwife, and births at which a second midwife has been invited, and births at which I am in attendance as the second midwife.

The key: being woman-centred
Midwives understand that the woman who is giving birth is the central, focal point of everything that is happening in chilbirth. Within that woman, in her womb, is the baby. Woman-centred care is also baby-centred, because the woman and baby are one.

Midwives also understand that the woman and her midwife form a special partnership, based on reciprocity and trust. A one-woman-one-midwife partnership.

In the real world, despite the best laid plans, a midwife can never guarantee that she will be in attendance for a particular woman. The only people who can be sure they will be at the birth are that woman and her baby. In the real world, a good midwife is able to meet a labouring woman and work with her in such a way that the woman is able to optimise her birthing potential, feel safe regardless of the setting (home/hospital), and experience great satisfaction with the care. No crooked heads here.

In any physiological birthing relationship, there is room for only one birthing woman, one midwife, and one baby (at a time, in the case of multiples). If others are present with midwifery (or 'wannabe') skills; and 'others' may include midwives, lay birth attendants, doctors, alternative health practitioners, relatives, or even the labouring woman herself; these people must either step back from their professional roles, or work in harmony with *the* midwife. There is no place for different philosophies of care - they will make the baby's head go crooked.


Many midwife colleagues of mine, practising in the real world in which we live, tell me they would never intentionally attend a birth without a second midwife. There are many good reasons for the second midwife, including:

• the possibility that mother and baby are both needing active midwifery interventions at the time of birth
• a known midwife present if the other one is unable to attend
• someone who will question or challenge practices if needed
• 'tag team' if everyone is tired
• a witness if something goes wrong

The first of these is perhaps the most compelling, and any midwife will need to address this possibility with the woman who is considering her choice of care providers for home birth.  What will be done if the baby is not breathing at birth, and the woman also requires attention?

In hospital births, and in some home births, the midwives have separate roles allocated - one for the woman, and the second for the baby.  If the baby needs resuscitation attempts to be made, the person who leads that is the second midwife.  The baby is often moved away from the mother to a resuscitation table in these situations.

When a midwife is working solo in the home, the woman knows that there is no second midwife.  If the baby needs resuscitation, this is done with the baby lying on his back on a towel on the floor, in front of the mother who kneels.  The umbilical cord is not cut.  The midwife also kneels, and has good access to the baby.  They work together, and the midwife is able to talk to the mother.  A baby who is born in a distressed state, not able to initiate normal breathing, may have a very slow, or absent pulse.  It's vital in this case that as the cardio-pulmonary resusciation proceeds, and the baby's pulse increases, the baby receives the full placental transfusion via the umbilical cord.  This will bring a proportionately large volume of blood, with the fetal haemoglobin that stores oxygen, perfusing the baby's central organs and brain, protecting the baby from hypoxia.  This, in my opinion, is a better model for initial resuscitation.

Women who plan to give birth under natural, physiological processes have access to natural, physiolocal support mechanisms.  The adrenal hormones that give the 'fight or flight' response are particularly valuable.  Not only does the mother experience a surge of adrenal hormones just prior to the birth; baby does also.  The mother gets a surge of energy, and her baby is ready to do what needs to be done.  Neither mother nor baby in the home birth situation have narcotics that would suppress their ability to respond, or to breathe.  Neither mother nor baby have synthetic oxytocics that would impede the mother's ability to expel the placenta safely without excess blood loss.

The safety and appropriateness of home birth is clearly demonstrable for women (and babies) who are well prior to the onset of spontaneous labour, and who progress without complications.

Midwives and the battle of the bulge

A new draft National Antenatal Care Guidelines has been released for public consultation. The consultation period ends on 27 June 2011. The guidelines can be found here.

Today's health care world relies heavily on guidelines, and this document is being developed with government funding under the AHMAC priority to "Ensure Australian maternity services provide high-quality, evidence-based maternity care."


If anyone has had an opportunity to read through these draft guidelines, you will find much that is accepted as good practice, presented clearly and referenced. However we need to read with our critical minds switched on: otherwise there's no point in reviewing the draft. Midwives and doctors who provide antenatal care need to ponder the impact on our practices that they might have when they are approved.

Routine weighing at each antenatal visit
Please take note of

Recommendation 4: Routinely weigh women at each antenatal visit. Excessive or inadequate weight gain may have negative effects on the woman and the baby. (p vii)

This recommendation is rated as Grade 'A', which means "Body of evidence can be trusted to guide practice."

I put a question out about this to colleagues, via a midwives' email list. "Do you routinely weigh women at each antenatal visit?" It appears that there is a general consensus in the group that midwives do not currently weigh women at each visit.


It’s clear that obesity in pregnancy is linked to poor outcomes, and the midwife’s duty of care is around promoting health through good diet and weight management. Obesity is the big current focus of health promotion. However it appears to require a great leap of faith to believe that routine weighing in pregnancy will result in better weight management, and better outcomes.

As I remember being pregnant in the ‘70s, when everyone was weighed at every visit, women were harming themselves in an attempt to control weight gain. Some women were restricting their intake to the point were they were nutritionally unbalanced, leading to a lot of fluid retention, and pre-eclampsia. The doctors (bless them) were prescribing a diuretic (Lasix) to get rid of the excess fluid, which did actually give ‘better’ weight gain, but at what cost? The routine weighing potentially led to adverse effects.


The Draft Guidelines Appendix D (p138) gives the UK National Institute for Clinical Excellence (NICE) recommendations, that Weight and height be measured at the first appointment, and BMI calculated. Then this second recommendation:
“Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]”


This second recommendation from NICE has been summarily dropped for the new Draft Australian guidelines, with some review discussion around ‘new evidence’ associated with a high or low pre-pregnancy BMI that has emerged since the NICE (2003).

It would seem wrong to impose routine weight monitoring on all women, when the new evidence, even if it is grade 'A' applies only to those at the ends of the spectrum.

It's good that maternity services seek to "provide high-quality, evidence-based maternity care." BUT, any guideline that claims to be evidence-based, with an A-grade "Body of evidence [that] can be trusted to guide practice." needs to be just that. In this case, there is no evidence that routine weighing of all women will do anything to address obesity and ill health, or under-nourishment for that matter, or improve maternity outcomes.

Comments from readers are welcome. If you refer to something in the Draft Guidelines, please quote the page.

ps
Readers will be interested in the Science and Sensibility blog entries and discussion on maternal obesity.  The writer, Pam Vireday's blog is Well Rounded Mama.

career in midwifery?

wet and happy after a job well done!
[Thanks Miranda for the pic.]
Click here for Miranda's comments Why I Chose Homebirth

A young woman is considering a career in midwifery.

She is drawn by the ideas midwives write about:

• forming a partnership based on reciprocity and trust with each woman; 
• learning how to work in harmony with the woman's own natural processes; 
• promoting health in a holistic way; protecting the woman's birthing potential; 
• and providing a smooth interface between primary maternity care and medical intervention when there is a valid reason to interrupt the natural process.

The young woman has some doubts, recognising a potential clash between her own views on western medicine and the mainstream health system. She likes the idea of working as a private midwife attending well women in their own homes, but she realises that there is a journey that has to be taken in achieving a midwifery qualification, with study and experience that includes the medical/hospital system. She writes:

I'm worried that the "system" wont change, if not become even worse. Do you think it's going to become easier or even harder to practice midwifery in the way that you promote? IE- do you think i'll always be paddling up stream or, is there light at the end of the tunnel?

I have brought this discussion through to the blog, because these are questions that many are asking.

A slogan from the International Confederation of Midwives is

"The world needs midwives now more than ever"

even though ...

• The system may become worse.
• It may become even harder to practise midwifery in a woman-centred way.
• We may feel as though we are always paddling up stream.
• We may not be conscious of light at the end of the tunnel.

It is idealistic and unhelpful for midwives to focus only on the strong, healthy women and babies: women who are able to give birth spontaneously and joyfully in their homes.

Midwives, and authentic midwifery practice are needed in mainstream health care, which in this country means hospitals. True midwifery is needed for the women and babies who can't afford a private service, for women and babies in developing countries where the rates of maternal and perinatal deaths are many times that in Australia. True midwifery is needed for women who know they will need caesarean surgery in order to have the best chance of being 'delivered' safely.

The current batch of challenges in Australian midwifery are the result of a socialist government's attempt to improve maternity care. Socialist policy does not value the individual's concerns or iterests in the way that many people in the free world understand to be important. Centralised government regulation of midwives and other health professionals is likely to lead to bureaucratic red tape that restricts some midwives and women in the way the want to give birth. It is likely that we midwives will feel that we are always paddling upstream.

Governments will change. Regulations and laws will change. Women continue to need midwives who are 'with woman', regardless of the laws, regulations, or philosophies of the government.

"The world needs midwives now more than ever"

Today I received by email the picture of Miranda, with her newborn baby, and permission to use it in blogs. What a beautiful reminder that, for each midwifery partnership, there is light at the end of the tunnel. There is new life at the end of the hard work. There is beauty, and hope. Thankyou, Miranda.


ps
If you are interested in the state of affairs for private midwifery in Australia, and links to search for a midwife online, please go to the APMA blog.

learning about breastfeeding

A young midwifery student who I will call 'B' wrote to me:

Today I had work on the postnatal ward, and I had one of my "What would Joy do?" moments, as I had a particularly hard case to deal with, well for me it was hard.

I was caring for a woman who had a baby girl at term. There was some concern about possible infection, so baby was admitted to the newborn nursery soon after birth. I found the mother in her bed crying. I found myself having to be 'with' her in a very human, tangible way that I find hard to put into words.

After having a talk and her calming down, I wanted to help her with breastfeeding. The issues I saw for this mother were:
a) separated from her child
b) bottles and formula
c) sick baby
d) the fact she had only expressed once since her baby had been moved to special care 24 hours before and had minimal skin to skin/ feeding attempts since.

I showed her how to hand express, showed her how to use a pump, and helped her attach her baby in the special care nursery.

It was just one of those cases where I especially wanted her to succeed in feeding, which was what she desperately wanted too, and I wonder if there is anything else I can do for her?

This is an all too common scenario that student midwives face. I congratulate 'B' on the way she has been working through her thoughts in this situation.

A key to supporting this mother and baby are to understand breastfeeding from the baby’s point of view, and to help the mother to see that perspective too. Babies want milk; they want it in abundance and from their mothers' breasts. Any artificial substitute is inferior in the baby's mind, as well as being inferior from a nutritional perspective.

A student midwife working in a hospital has very little authority or ability to change the culture within the unit. Did that baby really need to be separated from her mother? Were all the medical processes that followed the separation necessary and helpful? ...

The ideals of the Baby Friendly Health Initiative, or the Mother-Friendly Childbirth Initiative, empowering women as mothers and promoting bonding, breastfeeding and health are not very useful to a person like 'B' working a shift in a postnatal maternity ward. 'B' needs a strategy by which she can impart hope and encouragement to the new mother until her child is returned to her care.

As soon as baby is well enough she will be looking for her mother's milk. It is usually possible to revisit the unhurried, skin-to-skin experience as could have happened in those magical hours after birth, when a baby intuitively seeks and takes milk. The midwife who is confident in understanding a baby's approach to breast feeding will also be 'with woman' in that natural process.

A personal question

"How are you?"

Grandpa and his girls

Three simple words; a question: "How are you?"
A question to which I reply "I'm OK, how are you?" - or something else.

A caring tone; a sympathetic look; honest, open concern from one who knows the deep waters I must traverse.

It's a question that needs a voice - not txt or email or a Fb poke! A question for which communication technology can never surpass the value of the human voice.

"How are you?" is a question that invites a response.

"Thanks for asking."


Dear Reader
Today I am writing about life, and not specifically midwifery. My thoughts have been prompted by a deeply personal experience which has brought me to a new appreciation of the value of that personal question, "How are you?"

As I reflect on my own experience I feel ashamed at my own failure to be with others in their distress. As I receive messages through the various (impersonal/technological) means of communication, my heart longs for the personal word.

I don't think this need to use personal communication will ever be lost, even as generations of young people who have been nurtured at the bountiful breast of information technology move into adult life.  Their basic need for human interaction will be most keenly felt when they face life's challenges and difficulties; when they need a caring voice to ask, "How are you?"

My presentation at the Virtual International Day of the Midwife webinar

I am terribly disappointed that I was unable to properly participate in the webinar today. The facilitator Carole took over and read from my .ppt notes. Thanks Carole! I don't know why my microphone failed me, but I could not get a response, no matter what I tried.

I would like to share some of the presentation with my blog readers.
Two of the topics included in the presentation, Midwife-blogger, and Vernix can be found at another blog that I write, http://privatemidwiferyservices.blogspot.com/

There were some great messages sent to the classroom. Here are examples of comments (without names of the writers) on Vernix, followed by general discussion on blogging:

Baby ColdCream

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Super moisturizer! If only we could market it!

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something i did not expect to see on my baby! it was quite a shock but it truly is a miraculous substance!

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When I was working near Mexico ALL the women in the birth room would wipe it off the baby and on their own faces :) So sweet

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good for the crow's feet!
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My last bub had it allon his back, eww! :) I think they wiped it off my hosp babies. :)

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I am a student and other midwifery students are able to use it [a blog] for learning.

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Thirst for knowledge

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Lisa's blog is how I found out about true midwifery practice
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It is a way for those who aren't yet apprenticing to be exposed to information that they may not be able to have a hands-on to yet.

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comments are really mini conversations on a blog

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I'm not a midwife yet, just going to become...But already thinking about a blog that can really help in my future practice. I'm from Belarus and homebirth here is not legal and not that popular yet. Hope to change this situation.

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It creates a feeling of community to discover that someone somewhere else is interested in similar things

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i found blogs to be the only way to uncover the real effect of the new legislations

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I found it interesting to read overseas blogs by midwives who stated they would never work in Aus because of the ongoing battle between medical and midwives.

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As students, blogs from practising midwives are excellent sources of "unconventional" learning. Dont ever stop!!

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Thank you for the lovely comments on your slides, I'll be a reader from now on, if I can find you;-)

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I learn so much from blogs

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i have always been intimidated by blogging... but now it really doesn't seem so bad!

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me too

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You see, even though I wasn't able to do my talk, the audience took over and made the best of it! Thanks to all who participated.

The making of a midwife

I have recently finished reading Patricia Harman's memoir (pictured here), Arms wide open: a midwife's journey. I have enjoyed the journey.

As I progressed through the book I welcomed insight into the way Patsy, an idealistic hippy wild child in the early 1970s, learnt about life and in that learning, she found midwifery.

I welcomed insight into the realities of the American counter-culture, war resisters, commune life, living without what most of their peers would call the basic necessities of life.

I welcomed the honesty of statements by Patsy, now a grandmother with a nice home and a day job, no longer attending births, such as "You'd think by my age I'd have everything figured out, but I don't have a clue and I'm more confused than when I was thirty."  I concur.

I found to my surprise that Patsy's midwifery journey reminded me in many ways of my own. I was at the same time, learning about life, and discovering my midwife identity in a sort of mirror image journey.

Here's what I mean by a mirror image journey.

Patsy and I must be about the same age, and we gave birth to our babies at about the same time. I was living in Michigan in those formative years, the 1970s, in a little brick house with a basement, surrounded by tall oak trees that shed mountains of brown leaves each 'Fall'. I raked leaves in autumn, shovelled snow in the winter, planted spring gardens, and enjoyed home grown veges in the summer.

While Patsy learnt how to stay warm and well in an isolated primative log cabin, I, who had spent most of my life in the sub-tropics in Queensland, learnt how to live with central heating, and cook in a kitchen that had green carpet on the floor.

While Patsy and her companions had dropped out of education, I had already graduated as a midwife in my home country. Noel, my husband was a graduate student at Michigan State, working on the fascinating and previously unnoticed protective effect of colostrum in the newborn calf. I was absorbing scientific literature and knowledge as fast as I could, broadening my understanding of reproduction, and particularly the needs of mammalian newborns.

Like Patsy, I attended the local Lamaze birth preparation classes and learnt psychoprophylaxis and Lamaze breathing. Unlike Patsy, I did not discover homebirthing. I gave birth to my first three children in the local hospital, was moved in second stage to the delivery/operating room, positioned with legs in stirrups and hands held to boards by big pieces of velcro. I was told to "take a deep breath and push push push!"

While Patsy raised her children in a loosely knit 'family' of a commune, I was away from all my family, became a full-time mother, and was satisfied with that role. Apart from the help offered by a few neighbours and friends from our Church, I needed to be emotionally and physically self-sufficient.

While Patsy developed a sort of faith in the forces of nature, I continued in the Christian faith in which I had been nurtured.


My awakening in midwifery came later, in the early 1990s, when I thought that my four children no longer needed a parent to be at home for them all the time.

I was able to move without difficulty into homebirth, even though I had not given birth at home myself.  The knowledge that stood by me had been instilled in my mind over the years of my own childbearing, building on the foundation that I had learnt in my student days at the Royal Women's Hospital in Carlton.  The years of breastfeeding had given me insight into mother-baby bonding and nurture.  The years of parenting had given me an understanding of what it means to promote health, and work in harmony with natural processes.  The years of part time shift work, usually nights, in hospital maternity wards, had taught me that I wanted to be 'with woman' - that the 'one night stands' I was having in the hospitals were not optimal in any way.

Like a butterfly emerging from its quietness in the crysalis, I had metamorphosed, and came out of that space ready for action.

Enough from me for today.  Your comments are, as always, welcome.

ps Arms wide open is Hardcover, or eBook, 324 pages.  Publisher: Beacon Press. ISBN: 978-0807001387
http://www.patriciaharman.com

When birth is no longer normal

Midwives consider ourselves the guardians or keepers of normality in birth. We attend conferences and repeat slogans about keeping birth normal. We talk about sitting on our hands, about trusting the natural process, about protecting the woman's space so that she can give birth naturally and safely.

Our definition declares that our duty of care includes the promotion of normal birth.

Here is an excerpt from that definition of the midwife (ICM 2005):

"...
The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
..."

Australian midwives need to know this definition well. It has been adopted by our regulatory agency AHPRA, and the Australian Nursing and Midwifery Council, and is foundational to current midwifery education, codes and standards.

The big challenge for the midwife is to balance each aspect of our professional duty. Our desire to promote normal birth must not be allowed to over-ride our responsiblity to carry out preventative measures, or to detect complications in mother or child, access medical care and other appropriate assistance in a timely manner, and the carrying out of emergency measures.


I have reflected many times on what it means for a midwife to be a responsible and accountable professional. In recent submissions to government inquiries, I and other midwives have written about the processes by which midwives are required to give an account of what we do, and this is especially so when there is an adverse outcome. Our society has an expectation that professional care will be in the public interest; that the safety and wellbeing of mother and child are the primary concern of the midwife and any other person who provides professional maternity care.

A recent report by the Queensland Coroner on the death of a baby Samara Hoy has been distributed in midwifery circles.  It is a public document.  The Coroner's findings were critical of both midwifery and obstetric care (or the lack thereof) in this case. Reading the report has left me with many questions about the standard of care and culture of maternity services in that hospital.

If this woman had been planning homebirth, and her midwife had taken her to the local public hospital when meconium, fetal tachycardia, decelerations ... were observed, there would have been no question about continuous electronic fetal heart monitoring (EFM), or offering a theoretical set of options, one of which was waiting for nature to take its course.

That's the essence of midwifery: that if complications are detected, we have a process to follow, including "accessing of medical care or other appropriate assistance".

The tragedy in this story in my mind is that the woman was so alone. Although there was a person there with the role and title of midwife, there was no person with whom that mother had a partnership based on reciprocity and trust. There appears to have been no informed decision making by the woman. The decision by various midwives, and the collaborating doctor, to not even use the facilities available for checking the baby's response to the contractions suggests either a misplaced reliance on natural processes, or just plain incompetence. The physical findings of the Coroner of strangulation marks left by a tight umbilical cord around the baby's neck, and meconium aspiration, suggest that severe fetal distress would have been observable, particularly with EFM, for some time prior to the birth.

I can only surmise that the midwife was committed to a skewed idea of keeping birth normal, by sitting on her hands and keeping her head in the sand.

A young mother who has engaged me as her midwife for planned homebirth asked me under what circumstances would I think she would need a Caesarean birth.  I don't have an easy answer, but we chatted about how I know when birth is no longer normal, and what would happen in such a situation.

I know it's easy for me to be an armchair critic, but I have written this post with the hope that other midwives who read it will also reflect on what we do when birth is no longer normal.

Midwifery knowledge

click to enlarge

One of my current projects is to lead the review of the Maternity Coalition INFOSHEETs - see the APMA blog for more detail. I also headed the previous working group which put together these information sheets in about 2006. Our aim was, and is, to provide reliable information that supports informed decision making for women and midwives who seek to promote normal physiological birthing, and to work in harmony with the natural processes in pregnancy, birth the perinatal period.

It's a big project, and the working group is asked to consider current evidence and practice, and check the information provided on the INFOSHEET. Recently we completed the first to be reviewed, A Baby's Transition From the Womb to the Outside World, (see jpeg file above) and are now working on The Third Stage of labour. Unfortunately I do not know how to link a .pdf file to this blog, so if you would like a copy of the revised document emailed, please send a request to me joy[at]aitex.com.au

A midwife commented to me that "what we need to say loud and clear is that we use Midwifery Knowledge which is very different and definitely not less than obstetric and surgical belief."

Yes, I (sort of) agree – but remember that ‘midwifery knowledge’ is not well defined, as is also the case with some 'medical' practices, or 'alternative health' knowledge. If our knowledge embraces truth, it's true regardless of whose it is. Midwifery knowledge should not belong to midwives only - it should be common knowledge.

If 'midwifery knowledge' is to be accepted as reliable it has to be well articulated and put out to scrutiny. I believe that’s what these infosheets are trying to do.

Management (or non-management) of the Third Stage (S3) and the time interval from birth to clamping of the umbilical cord are two examples of what I would call 'midwifery knowledge', compared with rituals that have been widely accepted by modern obstetrics and midwifery, without any evidence to support them.

I am excited to see changes in the mainstream maternity attitudes to time of clamping the cord, and protocols for active management of S3. This has been in response to evidence, just as the virtual mandating of active management of S3 in hospitals was in response to flawed evidence.

We must continually engage in critical review of all that we do. Many hospital ‘guidelines’ require [that’s an oxymoron I know] immediate clamping of the cord, and none of them that I have seen have a reference linked to it.

Watch the APMA blog in the coming weeks for developments in the revision of this INFOSHEET. This is all voluntary work, and it is put out in the public domain to encourage involvement of anyone who is interested.

Today’s Age newspaper has an article about a research program for which ethics approval is being sought for a cord blood trial, and the relationship between a baby receiving its own placental transfusion and cerebral palsy. There are many questions that this research, if well done, may begin to provide answers to. The proliferation of private facilities that collect and store cord blood, without any reliable evidence that the baby will benefit from it - and without any evidence that the baby has not been harmed by the withholding of that placental blood at the time of birth - is evidence that many parents have taken a punt on this issue.

Your comments are welcome.

The birth of Richie Jack

It is with a deep sense of respect and privilege that I share this birth story link with my readers. You are invited to go to Ashley's blog and read her story.


As the midwife I experience a parallel journey. Together we negotiate the often unpredictable and challenging terrain that leads to birth. Our partnership requires trust that goes both ways - she needs to feel able to trust me, and I her.

As I read Ash's birth story, I was reminded of my own emotional journey, and the series of decisions that were made. I felt challenged as time passed - of course I would have loved to see it all happen spontaneously.

Today I visited Ash and little Richie, and as we had a cup of tea together we chatted about the birth, and all that has transpired since then. As we packed the deflated birth pool into its box, and put it in the car boot, there was no sense of loss in our minds. The birth pool had not been used, and Ash had given birth in the hospital. The hospital was the right place for this birth; the best place.

What more could we ask?

Midwives in Hungary

A report from Hungury, where homebirth midwives are being treated as criminals, prepared by Al Jazera


News [click here for link] has come that Agnes Gereb has been sentenced to two years in prison for malpractice, and banned from practicing both as an obstetrician and a midwife for five years.

The villagemidwife e-book series

I am writing
To record my knowledge
To tell my stories
To teach others

I am a midwife. My words, thoughts and actions have been formed over many years and a unique set of experiences: the world into which I was born; the mother who bore me; the family that nurtured me; the towns and communities that have allowed me to be me, and this wide open land and its people.

I like to think that these are my thoughts, yet I know that much of what I say is my own filtering and organising of what I have absorbed from those around me. Although I am the speaker, I am not the source.

Midwifery belongs to women. The midwife is ‘with woman’, a companion for a distinct and definable childbearing event, in a special partnership. Midwifery does not belong to theorists, although the clear expression of the ‘with woman’ partnership by thinkers has helped set great value on this simple phrase.

Normal birth for a breech baby

From time to time a presentation becomes available via this wonderful www that is really worth sharing.

Today I would like to direct my readers to the blogs of two colleagues, midwives who are committed, as I am, to sharing the knowledge and skill of authentic midwifery. I would encourage you to follow these two links, then come back and read my comments. Please feel free to make any comment here, or on the other blogs too. (You know that comments are very much appreciated by bloggers.)

Lisa Barrett has written about the Mechanisms of unassisted normal breech birth, with a superb set of photos.

Carolyn Hastie has presented this You-Tube video, which is in Spanish, with her own comments.