Monday, January 05, 2015

A question


Having moved from our home of 30 years in Melbourne's leafy Eastern suburbs to a beautiful semi-rural 'lifestyle' block in central Victoria (link), Noel and I are getting used to our new way of life.  For most of the past month we have not had a reliable internet connection to our home, so have been using the free service at the Kyneton library, and other processes in an attempt to keep in touch with the outside world.

We now have the new year 2015, and an old challenge.  I have been thinking about this question, and hope I can record here something of the current situation in Australian maternity care.  This question was posted by a midwife, to a large international group that discusses human rights in childbirth.  

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have safe cesareans if they need one? 

I am quite disturbed and shocked at this question.  Why, I ask, would there be a need for passion and activism to advocate for the right of women and their babies to have safe maternity care?   

Perhaps the question is irrelevant to Australia?  Perhaps this is an issue in developing countries, or somewhere else?  

Yes, women can get relatively safe caesarean births here if they have a valid reason.  Those who can afford it, or who work out how to manipulate the public health system, can also get caesareans without needing it.  This surgery might meet all the required hospital safety protocols, but the risks of major abdominal surgery add a new dimension to the safety equation.  Infection, haemorrhage, drug errors, adverse drug interactions, issues of pain management, separation of mother and baby, interference with bonding and establishment of breastfeeding, and additional risks of catastrophic birth outcomes in a subsequent pregnancy are just a few of the additional risk factors in surgical birth when compared with spontaneous, unmedicated uncomplicated vaginal birth.

I would suggest that the big question in a modern Western society such as Australia is 

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have skilled professional services that will protect the mother's capacity to give birth to a healthy baby spontaneously?

Indeed, do we as a society value a mother's ability to give birth?  Do we value the midwife's duty of care which includes the protection of normal birth?   

No, we don't.

Maternity care in Australia is a dog's breakfast that pays more attention to a woman's ability to pay a fee for service than anything else.  It includes obstetrician-managed 'private' care for women who have no clinical need for a specialist; it includes public hospital maternity services that fail to communicate plans and tests done antenatally with the staff who provide intrapartum care; it includes midwife-led private care for planned homebirth, with no provision for the midwife to continue as the responsible professional if the decision is made to go to hospital for the birth; and it includes a fringe of women who proceed with free-birth, with what care there is directed by doulas and unregulated birth workers.

Advocacy in this country around birth is more focused on the woman's right to 'choose' than protecting and promoting natural healthy processes.  Yes, some women 'choose' just that, and make choices about their care that they believe will enhance the process.  But much 'choice' focuses more on whether or not to use painkilling drugs in labour; whether or not to induce or augment labour; planning a waterbirth, or delayed cord clamping, or vaginal breech birth, or some other aspect of care which may be very important in itself but which cannot be addressed separately from the bigger picture. 

Midwives are the only group who have (or should have) the skill and capacity to improve birth outcomes working in harmony with natural processes.  Mothers can't do it on their own.  Physiological birth requires a woman to minimise neocortical activity - thinking.  Childbirth educators, doulas, or well meaning family or friends can't do it.  They don't have the midwife's unique skill. There is plenty of evidence supporting this contention, which requires a care-partnership between woman and her trusted midwife, who is present as the leading or primary professional carer at the time when decisions are being made.  Yet many Australian midwives approach pregnancy and birth as though their role is inconsequential.  They work from an obstetric-managed philosophy of care, relying more on tests and investigations that detect abnormalities than any authentic midwifery philosophy of firstly protecting, promoting and supporting physiological processes in birth, balanced with a commitment to accessing appropriate emergency obstetric services when indicated.

So, is there a place for ' passion and activism in the middle ground, ...'?

I hope so!

That middle ground where women are valued and respected for their capacity as birth-givers; where we seek first to achieve unmedicated, healthy mothers and babies, and place restrictions on the professionals and the consumers as far as frivolous or unfounded interventions are concerned; where midwives are valued for their ability to protect and support the natural processes. 

This is worth being passionate about.