possibly postmature

Possibly postmature
and
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 

• the date of the first day of the last period
• the normality of the last period
• the date of quickening

And, if ultrasound is used, there are additional pieces to add to the puzzle.


Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.


A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.


A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?

Why?

          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?


With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 



There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.

No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable. 

Obstetric violence in Australia today?

This is the definition of obstetric violence, presented by UK obstetrician Dr Amali Lokugamage at RCOG World Congress 2014 in India:

"Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
"It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
"It is also the act of disregarding the emotional needs of mother and baby throughout the whole [childbearing] process" 
Jesusa Ricoy-Olariaga 2014

Today I want to carefully reflect on a couple of births and other maternity experiences that are very close to home.  
I want to carefully measure the maternity culture that I know and participate in, in and around Melbourne today.  
I want to ask in what way I am contributing to obstetric violence.
I want to seek ways by which adverse aspects of a culture can be changed.

[Please note that names and some of the details in the cases have been changed for anonymity]

Case study 1
Bess was a 30 year-old, carrying her third child, planning homebirth.  I have been her midwife for each of her births, and her first and second baby were born at home in my care.

At about 36 weeks, Bess visited her GP, who looked at her abdomen, and said her baby was too small - growth restricted (IUGR).  The GP quickly arranged an ultrasound scan, which appeared to support the diagnosis, and an appointment for Bess at the tertiary hospital.  The GP spoke to me about her concerns, and I wondered if I had missed something.  

.... fast forward to 38 weeks
Bess was advised to go to hospital to have an induction of labour.  She asked me if I thought her baby was too small.  I did not.  However, I told her "If I'm wrong, and there is a valid reason to get this baby born (as she had been advised by the hospital and the GP), you have more to lose than if I'm right."

... fast forward to a couple of days after the birth of her baby (whose weight was well within the normal range).
Bess told me she did not feel traumatised by the experience: rather, she had faced the challenge head on, and accepted the intervention of induction of labour by artificial rupture of the membranes (ARM).  She had progressed unmedicated, and gave birth without assistance to a healthy baby boy.   When she was told, a couple of hours after the ARM, that it was time to commence IV Syntocinon, she declined and was quite definite about not needing further intervention.  She knew from the tone of the contractions she had experienced that her baby was on his way. 

Obstetric violence monitor (using the above definition):
-1  Bess was pressured by (albeit well-meaning) doctors and maternity care system that introduced fear of harm to her baby, when in fact her pregnancy was progressing normally
-1  Spontaneous onset of labour was denied
+1 Bess was able to decline further intervention after the ARM
+1 Bess considered that, despite experiencing pressure to comply with medical plan, her decisions had been respected, and she felt emotionally supported

Score: Pass - Case 1 is not an example of obstetric violence

Comment:  There are many contributing factors in any decision-making.  The choices that a woman has around her maternity care, and the decisions she makes at any time, are not equally weighted.  The support she has, both professional (eg from a known and trusted midwife) and personal (eg from partner, family, friends) will probably influence outcomes, especially if the decision-making pathway is not clear.

Case Study 2.
Deb was a 38-year old mother who had had two caesarean births, both prior to labour.  Deb wanted a VBA2C (vaginal birth after 2 caesareans) for this birth.  She considered herself well informed about making this plan, and made sure that her written birth plan was included in her hospital record.  She had felt cheated in her previous caesareans, and longed for the spontaneity and bonding between mother and baby in normal birth.

Prior to the onset of labour, Deb had some bright bleeding from her vagina.  She went to the hospital, and had some electronic fetal monitoring and other investigations.  The doctor told Deb that her baby did not seem to be distressed, but that he strongly recommended a repeat caesarean immediately.  Deb explained to him that she would accept a caesarean birth, even though it was not what she had so much hoped and planned for, if the hospital would permit her to keep her baby with her, skin to skin, in the operating theatre, in the recovery room, and when they had returned to the postnatal bed.  The doctor went away to make this arrangement, but was told the hospital did not provide staff for that option: that the baby and his/her father would be taken to the postnatal ward, and the mother reunited with them as soon as she was released from the recovery room.

Deb then refused the emergency caesarean.  Deb's baby was, a couple of days later, still born.

Obstetric violence monitor (using the above definition):
-1  The emotional needs of the mother were disregarded
-1  The emotional needs of the baby, as understood by the mother, were disregarded

Score: FAIL - Case 2 IS an example of obstetric violence

Comment:  Deb's case is clearly complex from an obstetric/medical point of view, and I have cherry picked a few facts in coming to my conclusion that this is an example of obstetric violence.  The hospital disregarded the clearly expressed emotional need of this mother, and used inflexible staffing arrangements as the reason for denying her request.



In what ways am I contributing to obstetric violence?
There is no simple tick-box for obstetric violence in maternity care today.  As evidence emerges about the finely orchestrated hormonal processes in birth and nurture of the new born child, the expectations of women will change.  The providers of professional maternity services must also integrate the contemporary knowledge into our care.




One of my own babies was born with a fractured clavicle, and aspirated mucus, as a result of rather rough handling by the doctor.  The mucus was cleared from her lungs using suction and percussion, and the clavicle healed as expected.  But that child became fearful and anxious when ever her throat became inflamed.  She had a definite memory of pain that had been caused by the failure of my accoucheur to permit me to give birth to her spontaneously.  She had experienced obstetric violence.  I did not feel or know that I had been traumatised - the requirement for me to be lying on my back with my feet in stirrups was standard at that time.

At about that same time, in the 1970s, there were dark and horrible secrets in many facilities where children received care.  Predatory sexual activity, and physical and emotional abuse, were tolerated within the system.  A blind eye was turned.  It has taken several decades for the light of public scrutiny to be directed towards those institutions, and for the people who experienced such abuse as children to have an opportunity to tell what they can of their stories.  

In reviewing birth as I know it in Melbourne today, I want to ensure that I and my colleagues are not tolerating - turning the blind eye - situations of abuse and violence against women and babies.


The maternity system as we know it today does not protect, promote and support natural physiological processes in birth and nurture of babies.  It does not follow the standard, that "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

It is possible that future generations will look, aghast, at the way mothers and babies are being treated in the early 21st century, in the same way that we are shocked by revelations of institutional abuse of children in the C20. 

the myth of choice

1983 - working night shifts a the Women's

For a couple of decades now, *choice* has been a pillar of the natural birth movement.

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

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


Firstly, some historical considerations:

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

At the same time,  twenty years ago,

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

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

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

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

So, what about choice?

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

By way of example:

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

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

Jill communicates her wishes to her doctor.  If that doctor has previously supported women's choices in this way, he/she might be willing to agree.  But Jill is a patient in a public hospital.  The doctor who is performing the surgery is being supervised by the consultant obstetrician, and does not feel able to accommodate such a radical plan.  The hospital's policy is to send the baby and the father to the nursery while mother is in recovery, and Jill is told that the hospital is not able to provide suitable staff to accommodate her choices.  Jill has run out of options.  She needs the help of the hospital to get her baby safely born, and she finds to her surprise that the notion of choice doesn't work in this situation.

 Jill thought, prior to coming into labour, that she had chosen:

how: a natural birth 
where: in the local public hospital
with whom: the hospital staff at the time

'how' Jill gives birth is something that cannot be predicted, whether she chooses a private hospital with the most popular obstetrician according to the online rating system, or the guru homebirth midwife who has amazing skill and, according to social media, can do all sorts of things to make birth work as it's supposed to.  The best Jill can find out when she is choosing her care provider is an approximate rate of spontaneous unmedicated births that person reports for woman in their care.

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

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

Choice is also dependent on money $$$.

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

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

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


Your comments are welcome.

collaboration, coercion, and concocted evidence

Today I would like to write about an experience that I have found very difficult, and I know the parents of the baby shared my concerns.

It is not easy for me to write about this.  I'm usually a peace maker.  I'm usually more pragmatic; I don't like being idealistic about birth issues, simply because life is not perfect.

This post follows the previous one, in which I have written about some of the 'carrot and stick' aspects of maternity reform.   One 'stick' is the cost of midwifery services.  While one-to-one primary maternity care by a midwife, and use of hospital facilities only when indicated - the basic best practice model - describes pretty much the scope of private midwifery services, and thousands of dollars are 'saved' by the state for each woman who does not require hospitalisation for birth, the women who choose care from a midwife pay for the privilege.   

The second 'stick' that I want to consider is collaboration. 

Collaboration, which in theory means that professionals work together so that the consumer/patient receives optimal care, is a requirement for eligible midwives who wish to enable women in our care to claim Medicare rebates (See Collaboration Determination 2010).   I have no problem with collaboration.  BUT, I have a big problem when, instead of collaboration a woman in my care is subjected to coercion, bullying, and fear-mongering with concocted data being presented as evidence.  I have a big problem when a bureautically-defined process that's called collaboration is a requirement for midwives, but no doctor, and no hospital is required to reciprocate.

From time to time as I write at this blog I include stories from my experience.  Today's story of (non-) collaboration, coercion, and concocted evidence goes like this:

Background:

Jill and her husband Jack (for want of better names) were expecting their third baby.  Jill is a healthy young woman, and she gave birth without incident to her other two children at home in my care. 
When Jill spoke to me about maternity care for the birth of this baby, I explained that we needed to find a suitable doctor to provide a referral to me for antenatal and postnatal midwifery services, in order to comply with the medicare collaboration rules. 
The local GP who Jill had seen previously agreed to collaborate, and it all looked good.  Jill was happy to see the GP and had routine tests and investigations arranged.  The doctor asked Jill to come back for some checkups during her pregnancy.

>>> fast forward to 36 weeks
I visited Jill and Jack and the children in their home.  I noted that Jill had found the summer heat rather taxing!  We had had a run of four or five very hot days, which is taxing for everyone.  I palpated her abdomen, and thought the baby was not very big.  I remembered that neither of the other two children had been large.  OK, I thought, let's see how this baby looks in a couple of weeks' time.  Jill had been having some troublesome pre-labour contractions, especially in the evening.  I encouraged her to rest, to eat nourishing food, and to keep her baby growing in her womb for a couple more weeks.
A couple of days later Jill's GP saw her, and told her there was a problem: the baby was too small.  An ultrasound to estimate the size of the baby was arranged.  Jill was told her baby was small, and she had too little amniotic fluid.  Jill's GP told her she was to go to the tertiary referral hospital for review.  Jill is a logical thinker, and she tried to discuss her options.  No discussion!  And you had better rethink the plan for homebirth too!
Jill phoned me and told me she was feeling bullied.  She respected the doctor's opinion, and was prepared to accept investigations, but she felt she was being pushed up against a wall.
The next couple of weeks were busy, with visits to the GP, visits to the fetal monitoring unit at the big hospital, arranging family members to care for the children, and arranging time off work for Jack.

>> 38 weeks
Time for another ultrasound growth scan. 
Would you believe it, the baby's not growing as well as we would like!  Estimated weight 2.4 Kilos.
Baby's placenta is fine, but it might not continue to function well.
Advised to have an induction of labour tomorrow.
Jill talked it over with me. 

[I could not help but ask myself, would I have raised the alert about this baby; about this pregnancy?  No, I don't think so.  Had I missed something important?]

Jill was finding the pressure overwhelming.  I reassured her, that she could choose the pathway.  I encouraged her to make the best decision that she could in the situation; that I would work with her at the hospital or at home.
Jill decided to accept the hospital's offer of induction of labour by artificial rupture of membranes.

 ...

The labour and birth progressed normally, and five hours after arriving at hospital, Jill gave birth without incident to her healthy baby boy.   I looked down at him and thought, "he's not too little!"  He later weighed in at a healthy 2.8 kilos.

Later that evening, Jack and Jill wanted to take their new baby home.  The doctor from the paediatric department arrived in their room, and told them the hospital required Jill to remain in hospital for 24-48 hours, so that the baby could be observed for the symptoms of early onset group B streptococcus (EOGBS). 
Jill had received an antibiotic in labour to prevent EOGBS, and argued that she was an experienced mother, and would recognise if her baby became ill.  The doctor then presented some concoction of evidence - who knows what she actually said!  What Jack and Jill heard, and told me, was that they were told that 50% of the babies of mothers with positive GBS swabs will die from the disease.  That's scarry!  Jack phoned me and asked me to talk through EOGBS with them, which I did.  They went home.  Baby continued to feed from Jill's breast and thrived.

[For those who are interested, I would like to note here that GBS is a serious infection.  There is a high mortality statistic related to GBS, but it did not apply in any way to Jill's baby.  A baby who develops GBS and is not treated, either in labour or after birth, would have approximately a 50-50 risk of dying from the infection.  That's why we treat infection in labour or after birth so seriously.]

The coercion and concoction of evidence that Jill has experienced in this episode of care is a very distressing phenomenon.  I wish it was an isolated event.  Sadly it's not.  And I regret that Jill and Jack experienced the coercion and bullying as a result of my collaboration.

a pot of tea

my new enamel teapot

I am delighted with my new enamel teapot which my daughter found for me.

Today I would like to make a pot of tea, and talk with you about one of the challenging topics in maternity care: decision-making.

here are some of my questions:

• Who is the decider?
• What choices does a woman have?
• Are there limits to personal autonomy?
• How much information does a midwife (or obstetrician) need to give a woman when a decision needs to be made? 

You:  That's easy, it's my body, my baby, my birth.  I'm the decider.

Me:  Yes, but your decision can only be made from what is on offer at the time, can't it?

You:  What do you mean?

Me:  Let's take a very common decision that has big implications for subsequent events in birth, induction of labour.  Let's assume that you and your baby are well, that your pregnancy has continued a few days past the due date, and you are getting tired of being pregnant, of all the phone calls: "Are you still in one piece?" and waking up in the night with a half-full bladder, and half strength contractions that don't go anywhere.  Someone suggests that you ought to have induction of labour.  How would you decide?

You:  I would ask you as my midwife to tell me the pros and the cons, and I would make my mind up.

Me:  I need to declare a certain bias here.  As a midwife, by definition, I am committed to protecting and promoting the natural process unless there is a valid reason for interruption.  It sounds to me as though you are likely to come into spontaneous labour very soon, with all those runs of pre-labour contractions, and I see no clinical reason to induce labour at present, so I cannot encourage you to consider induction of labour.  I will list off some of the risks that are inherent in this procedure: a cascade of interventions, use of artificial stimulants that can lead to hyperstimulation of your uterus, and reduced blood flow to your baby; to increased perception of pain, and need for medical forms of pain management, possibly increasing the likelihood of assisted vaginal birth or even caesarean; separation of mother and baby at birth; difficulties with bonding and breastfeeding ... do you want more? 

You:  So, my decision is no.  I don't want induction of labour.

Me:  When I check you again in a week's time and you still haven't had your baby, I may want to encourage you to re-consider induction of labour.

You:  But you have convinced me that it's not a good idea.

Me:  That was last week.  We are now 10 days past your due date, and the guideline I am required to follow leads me to advise you to carefully consider induction of labour if you are past 40 weeks + 10 days.  There are pros and cons which you need to consider - some the same and some different from what we discussed last week -  as you make your decision. 

You:  I do want to have my baby, but I don't want to do anything that would hurt my baby.  How can I be sure?

Me:  There are no guarantees.  Each decision point is like a fork in the road: you must take one or the other, and there is no turning back.  I would encourage you to be reviewed at the hospital, where they can use ultrasound to check fluid levels around the baby, and the function of your baby's placenta, and do some monitoring.   If any of these tests result in non-reassuring features, there will be more 'encouragement' to proceed to the birth without delay, which could include surgical induction (breaking the waters - the membrane holding amniotic fluid around the baby), and possibly medical induction (IV syntocinon).  If all the tests are reassuring, I will encourage you to consider waiting for spontaneous onset of labour.

You:  So, although I get to make the decision, I need to trust the information and trust the person who is giving it to me.

Me:  That's right.


Another possible pathway in this scenario is that you, the woman, have made an effort to inform yourself, and decided that under no circumstances will you accept induction of labour.  You want to have your baby naturally, in your home.  You know your rights, and you decline any offer of investigations because you have no intention of being spooked by the medical system.  How much information am I required to give you?  Should I discuss all the possibilities, or should I give you my professional assessment based on my palpation of your abdomen, and my (limited) ability to auscultate and assess?

If there is an adverse outcome, am I culpable because I did not give you enough information?

Decision making is not a one-off choice; it constantly evolves as we move through a childbearing episode. The trump card that a woman has is 'Plan A' - her capacity to do it without assistance or education or coaching or therapies or any outside help. But it's the fine line between Plan A and Plan B, when intervention is likely to lead to better outcomes - that may call for expert and timely professional action.

My concern about naming a 'decider' relates to situations in which I have seen the professional treat decision making as a sort of lottery - "I can do this or I can do that - your choice" without giving sufficient information to help the person understand the choice they are making. It's an ongoing process that demands trust and reciprocity between the woman and the midwife.

Even if 95% of women who come into spontaneous labour could stay in 'Plan A', and go on to an unassisted birth, what happens to the 5%? How does a woman know? 

I hope you have enjoyed your cup of tea.
Your comments and further discussion are welcome.

Millennium Development Goals: How are we progressing with the maternity goals?

Millennium Declaration

In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. In September 2010, the world recommitted itself to accelerate progress towards these goals.

The 8 Millennium Development Goals are:

1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women

4 Reduce child mortality

5 Improve maternal health

6 Combat HIV/AIDS, malaria and other diseases
7 Ensure environmental sustainability
8 Develop a global partnership for development

Each of these goals has a potential to improve maternity outcomes in the world's poorest countries.  Goals 4 and 5 give direct measures of maternity care.
If you would like to see the UN 2011 table summarising progress, click here.


Readers may wonder what significance the MDGs have in the context in which I practise midwifery.  Private midwifery in and around Melbourne is, surely, for a privileged minority, who are usually healthy, well educated women, and able to pay for the maternity care they choose.

This is true.

Women who plan homebirth in my practice understand that my role includes arranging transfer to hospital if complications are detected.  Well staffed and equipped maternity hospitals are within easy reach by car or ambulance, in most instances.  Availability of appropriate referral services is a key to safe and optimal outcomes, whether the referral is from planned homebirth, or from small primary maternity care units in rural towns.

Women in places where maternal mortality is high may not be within reasonable reach of emergency obstetric services; may face prohibitive costs if they do go to hospital; and often delay in seeking medical intervention.  Their bodies are often weakened by anaemia, malaria, HIV/AIDS, intestinal parasites, and other preventable conditions.  Mothers and babies die from Tetanus, because the mothers have never been vaccinated against Tetanus.   Women do not have access to acceptable family planning measures; child-brides are pregnant before their bodies are fully developed; too many women develop obstetric fistula; and the list goes on.

The challenge that I see in comparing maternity care here in Melbourne, with maternity care in some of the world's most disadvantaged settings, such as Sub-Saharan Africa, or the highlands of Papua New Guinea, is the continuing and increasing reliance on medical and surgical management of birth in the West.  This logically equates to a loss of knowledge, a loss of expertise, in working with natural processes in the childbearing continuum.  The excessive and unnecessary medicalisation of birth and everything related to maternity care, as is seen in mainstream maternity care in Melbourne, will not improve maternal or infant health in less developed countries. Melbourne hospitals are teaching doctors and midwives who will pass contemporary practices on to their students in all parts of the globe.  Melbourne, which has world-best facilities for those who need them, must set an example of best practice in protecting each woman's ability to give birth under her own amazing power - 'Plan A', unless there is a valid reason for 'Plan B'.

For decades we have seen the global impact on the lives of babies of the loss of collective confidence in breastfeeding.  Efforts to protect, promote, and support breastfeeding are required in the rich world if we want to have any impact in poorer countries.  The Baby Friendly Hospital Initiative (BFHI), which in Australia is known as the Baby Friendly Health Initiative, has the expectation of the same high standards in each of the '10 Steps to successful breastfeeding', whether the hospital provides care for those who pay big money, or those who are in low socio-economic settings.

Childbirth is not very different from breastfeeding.  The loss of confidence in natural physiological processes in childbirth, including the spontaneous onset of labour, progress in labour, giving birth without medical pain relief or physical assistance, expelling the placenta, and establishing breastfeeding, to name a few key points, needs to be recognised and rectified in Australian mainstream maternity care.  There is no safer or more reasonable way to proceed with childbirth, for most women, than to do so under the natural, hormonally-driven processes within each woman's body.  Only those for whom a valid reason to interrupt the natural processes will be better off with such intervention.

I expect any readers are likely to be already convinced of these facts, so I won't press on.   

Midwives, we carry the knowledge of normal birth!  We must value that knowledge, and hold on to the skills of working in harmony with women's natural physiological processes, whether in early labour, breastfeeding, birth, or the third stage. 

The 1996 'Care in normal birth' instruction from World Health Organisation, that
"In normal birth there should be a valid reason to interfere with the natural process" is as relevant when applied to the Millennium Development Goals, as it is in a Birth Centre in the rich world.