in two minds: why 'choice' is often a mirage

Today I am looking at (the woman's) choice, decision-making (whether it can be called 'informed' or not), and the midwife's challenge which, by definition, includes the protection, promotion and support of healthy natural processes in birth and nurture of the baby. 

From time to time a book or an article promoting women's *rights* in pregnancy and childbirth comes to my attention.  A recent feminist blog is headed with a big question "Why is it still controversial to say that women should make the decisions about childbirth?"

The group Maternity Choices Australia, which emerged out of Maternity Coalition (an organisation in which I was active for a couple of decades) has placed strong emphasis on a woman's own choices in the maternity terrain.


Who is *in two minds*?  
The woman herself. 

What are the two minds?
The woman's intellectual mind and the intuitive mind.  The same brain has separate parts that are used differently.

Why is 'choice' often a mirage?
Choices that are made (using the intellectual mind) prior to the time at which the intuitive mind takes the lead (particularly in labour and bonding) can be irrelevant, but can trap the woman. 


Although I am critical of a great deal of the maternity choice campaign as I see it today, my criticism is based on my understanding of the physiology of birth, which describes the two minds and their interaction with each other; not on feminist arguments of women's rights or fetal personhood.

The person missing from the current arguments about a woman's own choice is the midwife.  Not the generic midwife, whoever is given the task of providing midwifery services at a given moment; the one midwife who is acting as the unique professional, dedicated to working alongside and in partnership with that individual woman through the pregnancy, birth, and postnatal.

I am ready here for someone to tell me that I am being idealistic.  How can health services provide a one-to-one partnership between each woman and a committed midwife whose skill and knowledge the woman is able to trust at any decision-point?

Yes, I know it's not easy.  I have recently ceased providing this level of midwifery care, because I have become too old; too weary.  I can no longer offer to stay awake past my bedtime, or get up in the wee hours; to put aside my own needs hour after hour for the sake of what I believe to be optimal care in birth.   I still see that as optimal, even though I can no longer offer it. 

The only way I can see a maternity world that protects women's ability to make decisions about childbirth is when systematic changes are made so that midwives and women can honestly explore any choices that are presented as time progresses.  When the woman, using her intellectual mind, can explore and grasp the complexity of decision-making in labour, and can trust her midwife-partner to interrupt her from her intuitive state only if she needs to bring a matter of importance to her (intellectual) attention.  

I want to caution here, that without effective partnership, midwives and maternity services, as well as mothers, can err in over-reliance on 'natural' birth.  A UK report highlights the need for caution.  Anecdotes are common and some lead tragically to coroner's reports.


A midwife who delegates decision-making completely to the woman is foolish, lazy, incompetent, unprofessional!
For example:

Midwife A says she believes the woman is free to make any choice she wants about how long to stay in a birth pool after giving birth. 

The woman B has progressed in harmony with amazing natural, physiological forces in her body to give birth unmedicated and unassisted to her baby.  This was just what the new mother B had wanted, and she had (in her intellectual mind) chosen this pathway as having real advantages for herself and her baby.   Midwife A had supported B's plan. 

In the minutes after the birth, B stayed in the birth pool, hormonally awash in the beauty of her newborn and the afterglow of her ecstatic experience.  Midwife A was confident that all was well, and said nothing about getting out of the water.  Baby C did what healthy unmedicated babies do: she found her mother's breast.

Mother B experienced painful uterine contractions, and about 30 minutes after the birth B experienced a gush of blood, and midwife A reassured her that her placenta was about to be born.  Nothing was said about getting out of the water.

More minutes passed, with further after-pains, further bleeding, but no expulsion of the placenta.  Nothing was said about getting out of the water.

Why?

Because Midwife A believed B would know when she needed to get out of the water.

Midwife A was wrong.  Mother B was using her intuitive mind as she nurtured and bonded with her baby C.  She had no idea of time, or any other aspect of expected progress that her intellectual mind had considered prior to the birth.  The only intuition about moving out of the birth pool came much later, when B became faint.  I don't need to spell out the consequences of this error in delegation of 'choice'.



In conclusion, I can say that it is still controversial to say that women should make decisions in childbirth.  The big challenge is that midwives and women are enabled to work together, in deep respect, and with freedom to find the best course as time passes.  Neither can do it alone.

conversations on *choice*

I would like to bring some thoughts about maternity choices from the relative safety of a closed social media group to the openness and exposure of this blog, which does not restrict access.  This is not the first time I have written about choice.  A simple search of this blog brings up posts each year since 2007.

The current conversations have been prompted, in my mind at least, by my awareness of the movement that promotes a person's right to self-determination in health care, and particularly a woman's right to autonomy over her own body in the highly contested terrain of maternity care.

Here are a few real examples of that evasive entity, *choice*:

1. Jenny is pregnant with her sixth child.  She is a healthy 38-year old, who had a caesarean birth for her first, and has had uncomplicated births of her babies since then.  She would really like to give birth at home, in water, but the (free - publicly funded) homebirth program from a nearby public hospital will not agree to homebirth because she is considered high risk (previous caesarean, multiparity >5). 
   
   Jenny inquires about private homebirth services, and thinks that the cost of $5,000+ is prohibitive, even with Medicare rebate of approximately $1,000.  The midwives are also concerned that her risk status might put them at risk of mandatory notification to the regulatory Board.
   
   Jenny inquires at the local public hospital, where she could receive free maternity care.  She is told that she would not be permitted to use water immersion in labour, be managed as 'high risk', have continuous fetal monitoring in active labour, have IV access established in labour, and immediate active management of third stage after the baby was born.
   
   Jenny feels she has no real choice.  The system (public or private) simply does not support her choice to proceed naturally, and does not respect her desire to avoid what she considers to be unnecessary medical interference that could quickly lead to complications.
2. Jean is pregnant with her second child.  Her first baby was born three years ago, weighing 4 kilograms, and she had an epidural and forceps, and a large third degree perineal tear which took a long time to heal.  Jean feels traumatised by her experiences in her first birth, and she feels that her marriage relationship has suffered, because she does not enjoy intimate contact, and tries to avoid sexual intercourse.   She considers herself healthy, but she is over weight, and she has 'failed' the glucose tolerance test.  The hospital advises that she needs a series of ultrasound assessments of her baby's growth, and possible induction at 38 weeks if the baby seems large. 
   
   Jean is now 34 weeks along in this pregnancy.  Jean's preference is for natural birth, and she discusses this with the hospital midwife. 
   
   Jean feels that she has no real choice.  She could opt for an elective caesarean, or for an induction of labour, but the system does not have a pathway for her that supports and protects unmedicated natural birth. 
3. Jo is pregnant with her first child, and everything was 'normal' until the 35 week check when she was told that her baby was presenting breech - bottom first.  She was told by her (private) doctor that she would be booked for elective caesarean at 40 weeks, unless her baby turned. 
   Jo has quickly checked out websites that address breech births, and joined social media groups, got hold of moxa sticks, and started positioning herself crawling on the floor with her bum higher that her shoulders to help the baby turn.  She finds that there are a couple of obstetricians in town who are 'pro' vaginal breech birth, and a couple of public hospitals that support the option. 
   
   Jo feels that she has no real choice.  Decisions will need to be made as she progresses along the road to the birth of her baby.  Those decisions may be limited by the services available, the service providers, and the status of her baby as far as position, progress, and wellness are concerned.
4. Jazz is pregnant with her third child, and is planning homebirth with the publicly funded hospital homebirth program. 
   
   Jazz understands that she has one choice, 'plan A': to proceed naturally without medication or other medical intervention, at home.  If she needs to move to 'plan B' for any reason, her midwife will go with her to hospital, and Jazz will be able to make what she considers to be the best decisions from options available at the time.

A midwife has a clear duty, by definition and best practice, to support and protect normal physiological processes in birth, unless there is a valid reason to offer medical intervention(s).  This is the DEFAULT position, that protects the safety and wellbeing of mother and child. 

'Plan A' does not deny the woman's right to decline any treatment that is offered.  But that is the woman's prerogative; not the midwife's.  The pathway to good maternity services comes with respect for both the woman's voice, and the midwife's.  There is no partnership if either the woman, or the midwife, feels unable to contribute honestly to the decision-making.

The midwife who does not apply health promotion/ best practice principles to their advice and protect that *Plan A* default position will probably contribute to the society's loss of professional skill required to work in harmony with the unique natural physiological processes in pregnancy, birth, and nurture of the infant. Once that skill is diminished or lost, the mother will find her *choice* has been seriously restricted to the medical options. eg professional de-skilling in breech vaginal births.

I have seen midwives overwhelmed by their desire to support a woman's choice, and ignoring or missing signs that a potentially life-saving intervention needs to be taken.    

[A note to those who read this post.  If you think I am referring to you, it's possible that I am.]

supervision, part 2

Beautiful Brisbane, the city of my birth

continuing from yesterday's post, ...

[I have posted these comments on a social media site that might not be accessed by many of my readers, so have copied and expanded it here.]

A blog post by UK midwife-author-teacher Sarah Wickham, questioning the Australian regulation of midwives, provides comment on the UK model of supervision of midwives.

 
I share Sarah Wickham's concern, when midwives are subjected to "vexatious reporting and persecution in a number of ways, simply for supporting women’s choices."
 
Without pointing the finger at any person, and I wasn't at the recent homebirth conference in Brisbane, I think it's likely that Sarah has heard only a fraction of the story.  In my opinion there have been too many cases recently, some on public record, in which midwives have hidden behind a notion of the woman's choice, when in fact there was no discussion of escalation of care and appropriate intervention.  Midwifery partnership can only be achieved when the conversation between the midwife and the woman is ongoing, and informed *decisions* are made rather than choices.

An effective program of professional supervision of midwives could, theoretically at least, support the midwife in real time whose client is making an informed decision that does not follow usual professional advice.  This would apply whether the midwife was in private practice or employed in a hospital or other birthing facility.   The UK model of supervision of midwives is for all midwives.
 
A midwife can't afford to be a true believer, or to 'trust birth' in any idealistic way, even though we act to promote, protect and support normal birth and the physiological adaptation of the newborn to life out of the womb.
 
The setting/place of birth (home/hospital) has become an obstacle in this country to good midwifery practice, because privately practising midwives are restricted to homebirth.  The exclusion of PP midwives from mainstream hospital is not in the interests of wellbeing and safety of mother and baby, and probably contributes in complex (and unaccountable) ways to some adverse outcomes. The midwife's duty of care includes what we do in emergencies, and accessing medical (ie hospital) help in a timely manner. 
 
The introduction of the wonderful www, and social media, and digital communication ... has had a profound impact on some women's access to information about birth, and their choices. Anyone who remembers 20 years ago, when homes didn't have internet access, and mobile phones were great big clunky devices, will know what I mean. Now women tell me they have 'researched' their choices, as though it's done and dusted. The rise and rise of freebirthing is very much an internet phenomenon.
 
Please keep the conversation happening.

some of the carrots and sticks of maternity reform

A few weeks ago I wrote:

Regulatory pressures that have increased since the previous government's maternity reform package was implemented in 2010 are like the carrot and the stick.  The 'eligible midwife' carrot is that certain midwives earn special privileges:  Medicare rebates, clinical access to hospitals, and prescriber authority.  The 'eligible midwife' stick is the linked requirements and cost of professional indemnity insurance, collaborative arrangements with obstetricians, and getting over increased bureaucratic hurdles such as the midwifery practice review.  There is no reliable evidence that this approach will make birth safer for mothers and babies, or eliminate the fear of a rogue element in midwifery. ...

Today I would like to look closer at an example of what I mean by the 'stick'.

• One-to-one midwifery is accessible only to the relatively wealthy, who can afford to pay, and the lucky, who are accepted into public hospital caseload programs,

research

Picture this scene:
Part 1 - Plan A:
A woman having her first baby has laboured spontaneously through the day and the next night.  She has gone to the hospital, and spent a few hours in the water, staying upright and mobile.  At 08:00 hours her cervix has dilated to 4-5cm; her cervix is soft and baby's head is 'high'; and her contractions are less frequent than they were a few hours ago.  She is told that she needs her labour to be augmented: move to 'Plan B'.
[This is a major decision point for a labouring woman.  She can either continue working with her body's natural processes (hormonal, physical, and emotional), or give permission for medical processes to be commenced - all with the goal of a healthy woman giving birth to a healthy baby.]

Part 2 - decision to move to Plan B:
The woman agrees to augmentation of her labour, and after considering pain management options available, requests epidural anaesthesia. 
The hospital staff organise the intervention without delay: and IV line is sited, a pump with a second bag of IV fluids plus oxytocic is prepared, and the anaesthetics doctor introduces herself, asks questions about the woman's health, and explains what she is about to do.  The epidural is commenced, and after a couple of contractions the woman feels less pain and lies down quietly in the bed.  The electronic fetal monitor provides continuous information about the baby's condition, as well as charting the presence of uterine contractions.  After the doctor has checked the level of the anaesthetic block with ice, she goes out of the room.

Part 3 - invitation to participate in research
[and the reason for this post]
Soon after, a person comes into the room and introduces herself as a research midwife. She asks the woman if she would agree to being enlisted in a research trial.  She explains that the purpose of the trial is to reduce unnecessary caesareans.
She explains that, in this trial women who have already elected to have an epidural would be randomly allocated, if the question of whether or not to have a caesarean birth, to a particular test of the baby's blood (lactate), which would be accessed vaginally via a scratch on the baby's scalp.
[I won't tell you what the woman chose.  How would you respond?]

Comments on this research from a scientific, professional point of view:

1. Research is an integral part of professional health care today.  I accept that.  
2. The design of a particular trial - in this case to enlist women in labour after they have had an epidural, means that those who have spontaneous uncomplicated labours and births, or those who have elective surgical births, do not even think about the issues such as a decision to go to caesarean, or to continue in labour.
3. This research seeks to look at those for whom the intervention (intrapartum fetal blood sampling for lactate measurement as an assessment of fetal wellbeing, in the presence of non-reassuring fetal heart rate trace) could be critical in making a decision about the way a baby will be born.
4. The randomisation of all research subjects (labouring women who agree to being enlisted in the trial) into treatment or control groups seeks to prevent bias in decision-making. 
5. Research on human subjects can only be approved if the researchers are able to demonstrate the value of the information to the relevant discipline(s), and strategies that prevent harm (to the mother and/or baby, in this case). 
    
   Comments on this research from a woman's point of view:
6. If I agree to what you are asking, and my baby becomes distressed, do I have any say in what is done?  No - the decision is made according to the randomisation.
7. I feel exhausted after a couple of nights without sleep, and now I am being asked to make a decision about something which I have never thought about before.  How can I know what's going to be best for me and my baby?  That's why the research is being done.  Noone knows what is the best way to proceed.  
8. If I say no, I don't want to be in the research, and a decision needs to be made about whether or not to do a caesarean, how will that happen?   ...

I often argue that there is really only one real choice in childbirth: to do it yourself (Plan A), or to ask someone else to do it for you (Plan B). 

There are no guarantees in birth.  It's a journey, and decisions must be made as events unfold.

Midwives are bound, by definition, to promote normal birth.  A woman whose labour proceeds without complication is in the optimal position to give birth spontaneously, and with good outcomes for herself and her baby.   There will never be a safer or more appropriate way for these women to give birth, than to do it themselves.

Any intervention brings potential benefits and risks.  Augmentation of labour with oxytocic may, in many cases, bring about a more coordinated labour than what was being experienced before the augmentation, and a happy, healthy mother with a happy healthy baby in her arms a few hours later.  However, augmentation of labour can also lead to hyper-stimulation of the uterus, a distressed hypoxic baby, an emergency surgical birth, haemorrhage, ...

When a woman needs/chooses to move from Plan A to Plan B, the presence of a known and skilled midwife who can reassure her, and at times offer guidance, is essential.  Midwifery is not limited to promoting normal birth.  It's about being 'with woman' - a midwife with a woman, in a professional arrangement that enables sharing of information and support that is uniquely tailored to that woman and her baby.  The journey that leads to the birth is not predictable, but each woman's decision making is her own, without pressure or coercion.  This is, in my opinion, the pathway to safe birth through accessing appropriate interventions when indicated.

home midwifery in the (legal) spotlight

Melbourne in mid-winter is grey and damp and cold.  The tall concrete buildings block the weak, angled sunlight.

This week I have sat for two days in a tired meeting room in a city hotel that has passed its prime:  not old enough to be interesting; not fresh enough to be attractive.  The plate glass windows in the conference room revealed nothing more than the boarded up windows of a derelict multi-storey building on the other side of Little Collins Street.

The conference provided opportunities for comment on homebirth, and particularly homebirths that have gone wrong.  Lawyers presented papers on topics such as 'Managing the Risks inherent in Women's Choice in Obstetric Care', and 'Practical Obstetric Risk Management: defending your care'.  It sounded simple.    

Human rights in the childbirth process were eloquently discussed by other lawyers who drew from both their knowledge of the law and their personal experience.

'Open Disclosure' was discussed by two speakers, and I concluded that, in order to 'defend' oneself against potential legal or disciplinary action, an adverse event in a hospital is met with what seems to me to be a charade called 'open disclosure' that is not very open, and that doesn't disclose much.  Don't be too literal about the meaning of 'open' or the meaning of 'disclosure'.  A curious conundrum! 

A Coroner delivered, with barely an inflection in his voice, a keynote address on 'Lessons to be learned from the Home Birth Cases in Vic and SA.'  In this presentation, seven cases were reviewed, the common thread being that they had been planned homebirths, with either a registered midwife or a previously registered midwife in attendance.  When considering risk factors such as previous big babies, previous caesarean births, and a twin pregnancy, the conclusion was that most of these cases should not have been planned homebirths; that the midwife had a duty of care to transfer care to an obstetric unit.

In 6/7 cases, the baby deaths were declared by the Coroner to have been potentially preventable.  The Coroner does not attempt to apportion blame, merely to discover the facts, and to make recommendations.  The Coroner's filtering of the information presented at the inquest failed to notice any possible reason that a woman might have had for trying to avoid a medically managed birth; any mention of her desire to hold her baby to her breast within moments of birth; or even any recommendations that maternity hospitals provide pathways for women who want to have a known and trusted midwife providing continuity of care within the hospital.

I want to be perfectly clear here: I cannot speak for either the mothers or the midwives.  I am merely an onlooker, and I have read the Coroner's findings that have been put in the public domain.  I am also shocked at the tragedies that precipitated these cases into the Coroner's court.

The points made by those who spoke about women's rights were either ignored or not understood by those who spoke from the professional duty of care perspective.   The fact is that pregnant women have personal autonomy; that decisions do not have to be approved by, or even understood by, those who attend for birth.

***
The presentation following that by the Coroner was from the Victorian Perinatal Data Collection Unit.  I noted down a point that was briefly made, without any further comment, that, of the approximately 900 perinatal deaths in this State annually, 63% are found to have potentially avoidable factors.

The loss of a baby's life is, thankfully, uncommon in our world.  Yet it is one of the most heart-wrenching experiences imaginable.  Whether the death is linked to homebirth or not, everyone needs to take what lessons are available from the facts of the case.  I ask myself, what lessons have I taken from these seven tragic cases?

***
I believe the huge challenge that lies ahead for midwives and the whole maternity world is to find a balance between providing advice and care that protects the wellbeing and safety of the mother and child, while at the same time respecting the woman's decisions and choices.  This is not going to be easy.  It is an ongoing process, and demands trust and commitment between the midwife-woman, and the midwife-obstetric/hospital system. The paternalistic dictatorial style of hospitals has, in many instances, demanded submission to hospital policies and processes. This needs to change. The misunderstanding of risk in maternity care, as was clearly demonstrated in the cases reviewed, will likely continue to open the door for self-educated, internet-researched women to make the choice of birthing without a midwife in attendance.  This needs to change, to include intelligent dialogue and planning that is specific to the individual woman/pregnancy.  The misunderstood partnership between woman and midwife, as was also clearly demonstrated in the cases reviewed, may from time to time place unreasonable weight on the woman's choice, and devalue the midwife's skill and knowledge.  This also needs to change, enabling midwives to practise more autonomously and accountably.

Women who engage a midwife to attend them at home for birth, having an identified risk profile, such as a previous caesarean, a previous post partum haemorrhage, or multiparity, or any of the other features that are classified as risk - these women, and these midwives, need support rather than being driven underground.  The midwife who is ready to go with her client to the hospital, and continue supporting the woman's informed decision-making process within the hospital, will accompany that woman to the best birth that she can have.

And, we only want the best.



Your comments are welcome.

ps - this link to the story of a maternal death is, sadly, what we will see more of if we don't maintain a midwifery profession that is 'with woman'.

Informed decision making

As I take a few moments to reflect on the past couple of weeks, I am trying to pull together the issues in the world of maternity, and highlight anything that needs critical comment from yours truly. 

no explanation required!

The AMA's new Position Statement on Maternal Decision-Making is worth focusing on for a few moments.  My initial comments are at the MidwivesVictoria blog.

The topic of  'decision-making' in situations of known risk - particularly breech and twin births - is being discussed constantly by mothers, via social media.  One group, linked to BBANZ, that I belong to, often has messages from women who are torn between options that appear to be poles apart - the elective caesarean, or the unpredictable, un-knowable journey of spontaneous natural birth.  Another option comes up from time to time, especially for women who have financial reserves + private health insurance and can access a private maternity hospital and a sympathetic obstetrician (that's a big IF), that the doctor sets out the 'rules'.

"OK, here's the plan.  You come to hospital as soon as your labour starts and ..."

These few obstetricians, well known for pushing boundaries, set down what they believe is the safest course of action in the given situation.  They (understandably) want good outcomes, as do the women in their care.   They are able to achieve good outcomes if they recognise the time when it is best to depart from the spontaneous natural process, and take decisive action without delay.  This may mean delivering a baby with forceps or ventouse, or moving to the operating theatre for caesarean surgery.  The women understand the rules, as they have been discussed, and are expected to submit to them.

In many cases, this is an acceptable, and successful exchange.  Yet it is medical dominance, with a touch of class, Melbourne style. 

When the doctor enunciates the plan, and receives a compliant nod from the woman, there is a big exchange of trust.  There is not likely to be any subsequent *informed* decision-making by the woman, because she has entered a 'plan' with her doctor.

This phenomenon disturbs me as much as any other form of medical dominance, whether it is carried out in a private arrangement, or in the less refined tactics that we often experience in public hospitals.  The woman's ability to bear and nurture her child is a basic ability that requires huge respect.  I would like to suggest that the AMA position on maternal decision-making is not worth the paper it is written on, unless the protection of the woman's own natural processes in childbearing, including spontaneous onset of labour, giving birth, and breastfeeding, are held in high priority, and not by-passed without a valid reason.

Informed or mistaken?

Informed choice
Informed decision
Informed refusal
...

In my world the adjective 'informed' is often used in an attempt to declare that the person who is making the 'informed' choice/decision/refusal/whatever is intelligent, and has carefully considered options.  My question is, often, who's kidding whom?


A woman who wants to make an informed choice about who provides her care, and other aspects of the model of care, can only choose from what is available to her. 

A woman who wants to make an informed decision, particularly about an aspect of natural, physiological birth, may say she does not want to be treated as the next number on the production line.  She does not want standard care, whatever that is.  She wants to be treated as an individual.

A woman who wants to make an informed refusal of, for example, pre-labour caesarean surgery for a baby presenting breech, can find herself up against a system that does not support or understand her intentions.


In the often complex and demanding journey that a woman takes in giving birth to and nurturing her baby, the information available can be only marginally relevant to the individual situation: the choices and decisions can appear as shades of grey, rather than good and bad.  The constant juggling of the interests of the woman and her child, within the multiple contexts of a marriage, a family, a maternity service, and a community, can change the options for decisions in a moment.  In fact, a woman who considers herself well informed, and who is intentional about proceeding with an unmedicated physiological birth, has very little choice when some person with authority says "We need to get your baby delivered now."  A woman in labour who is confronted with even the suggestion that her baby's condition may be compromised, without whatever intervention is being offered, can suddenly find herself submitting to something that she would otherwise have avoided.


Health care, and especially maternity care, has changed in recent decades, from a "doctor-knows-best"-no-discussion model, with a hierarchical knowledge-based framework, to a system that attempts to include and respect the wishes and values of the patient/client.   This is, I believe, to be encouraged in principle.  But, in practice, I am often frustrated at the absence of an appropriate conversation about decisions or choices that need to be made.


At present the Melbourne Coroner's office is inquiring into the circumstances around the death of a baby whose mother intended to give birth at home.  Newspaper reports of this inquiry highlight the fact that the mother had refused caesarean surgery a few days before she came into labour.  In a news paper report of the proceedings, a medical specialist is reported to have said that: 

the "inadequate, incomplete and at times misleading information" available, particularly on the internet, made it difficult for women to make an informed decision about their birth plans.

There is little doubt from the reports that the mother believed she had made informed decisions.  Yet, in the tragedy of loss of the life of a baby, it's easy to argue that there were seriously mistaken decisions that led to the events of that day.


Women who have had previous caesarean birth(s) may make choices and decisions about their carers, and their planned place of birth, early in their pregnancies.  By way of contrast, women who find that their baby is presenting breech as they approach Term are suddenly confronted with a bewildering array of decisions.  As they obtain information they become aware that there is no right way (eg elective caesarean) and wrong way.  There is increased risk in breech birth, regardless of the actual method of birth. At each decision point, they can feel exposed and uninformed, even misled - but decisions must be made and there is no turning back.  Each decision places the participants in a new context, which may lead to more decision-making.

A woman who had planned to give birth naturally in a hospital birth centre found that her baby was frank breech a couple of days after her due date.  The special set of decision points that she encountered after the breech diagnosis were:

• attempt external cephalic version (ECV): the decision was made on Saturday that this baby was not suitable for ECV, and the mother was informed that she would be booked for a Caesarean on Monday.
• spontaneous onset of labour: Mother laboured at home Sunday night, and called her midwife for support around midnight.
• progress in labour: After several hours of established labour, the mother's cervix was dilated 6-7cm, and the presenting part was high.  The decision was made to go to hospital.  Labour continued strongly.  The obstetrics registrar at the hospital agreed that progress was good, but advised a caesarean birth.  The mother declined, and stated that she was intending to give birth vaginally.  All maternal and fetal observations were within normal range.
• review of progress in labour: After several more hours of labour, full dilation of the cervix was confirmed, but no progress of the presenting part.  Once again the mother was advised that she needed caesarean surgery, and this time she agreed.  Her baby was born in good condition, and the hospital staff facilitated early skin to skin contact and breastfeeding in the recovery area of the OT. 

In discussion a week after the birth, this woman commented to her midwife, "You know, it's a totally different outcome, having a caesarean birth after labour, knowing that I couldn't do any more myself, than if I had agreed to it the first or second time I was told I needed it."

The midwife agreed.  The decision making process included an ongoing review of the progress of mother and baby through uncharted terrain.  The decisions were made on the best information available.  There was ultimately only one *choice* - for the woman to do it herself, or not.  This is the only informed birth plan a woman can make, and follow through with.


related posts:
decision making for breech
breech vaginal birth
messages about breech births

hospital policy in the spotlight

Today as I write I have in mind a young midwife who is employed by a busy private hospital in Melbourne.  I hope that midwife comes to my blog, and reflects on the incident that I witnessed recently, and which I will briefly describe here.

The labouring woman had written a brief birth plan; the sort of plan that I call "Plan A".
Something like this:

I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.  At the time of birth, my baby’s cord should not be clamped or cut, and my baby must not be separated from me, except for clear medical reasons, and with my consent.  
I do not want any drugs to be administered to me or my baby without my consent. ...

"Yes, we do 'skin to skin', we do 'delayed cord clamping', and we keep babies with their mothers."
"But we can't do physiological third stage."
"The problem is," the young midwife said, "It's hospital policy that you have syntometrine.  I have checked with my manager, and we have to give you syntometrine for the placenta.  It's hospital policy."

The mother was labouring, wasn't saying much, so nothing was resolved.  The midwife brought the tray containing ampoules of the oxytocics into the room.

... fast forward  ...

A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss.


I am recording this brief account because I want to comment on it.

• A midwife became the pusher and enforcer of a hospital policy to administer a particular drug preparation.  This is not midwifery.  There was no professional discussion offered as to the implications of the use of this drug for mother or baby.  The midwife simply acted as an agent of her employer, demanding compliance with this policy.  
• A midwife failed to recognise or uphold a woman's right to informed decision making, and ultimately her right of refusal.

I feel very concerned for this midwife, who is at the beginning of her career.   It seemed clear to me that the midwife considered it her job to enforce the policy.  The midwife gave no indication of any understanding of or interest in the physiology of birth.  Rather, she seemed set on carrying out a series of tasks that were, apparently, the essence of her professional practice. 

The midwife appeared to be ready to ignore a written statement by the woman, that she intended to give birth spontaneously, without drugs.  There seemed to be an assumption by the midwife that the woman's choice of working in harmony with physiological processes and avoiding unnecessary medications was a choice that could carry no weight in that particular hospital.   There was no discussion of the potential benefits or risks of either course of action.  'Hospital policy' was the big flashing light that apparently barred the woman from attempting her plan of action.

The prophylactic use of oxytocics in the third stage of labour, 'active management of third stage', is a process of routine intervention that comes under the banner of the 'evidence based practice' movement.  The uncritical adoption of active management by most hospitals, with the belief that it reduces blood loss and thereby reduces maternal morbidity, is rarely questioned.

In this birth, the mother was ideally suited to unmedicated, safe, physiological third stage because the following requirements had been met:

• a woman in good health
• at term
• spontaneous onset of labour
• good progress in labour
• uncomplicated, unmedicated first and second stages of labour.

In contrast, there are good reasons why one might seek to avoid use of Syntometrine. 
Syntometrine is a preparation that combines synthetic oxytocin with ergometrine.
Syntometrine is an S4 drug - restricted to prescription by a doctor or an authorised midwife prescriber.  The idea that a hospital would make policy requiring the use of a restricted medicine is in itself suggestive of a breach of the basic rules of prescribing. 

Follow the link above to read consumer information about Syntometrine.  One small sentence stands out:  

Tell your doctor if you plan to breast-feed after being given Syntometrine. One of the ingredients in this medicine secretes into breast milk. Your doctor will discuss the potential risks and benefits involved.  (http://www.mydr.com.au/medicines/cmis/syntometrine-solution-for-injection )

Breastfeeding is an intrinsic part of physiological birth.
 
Further information on the use of Syntometrine in lactation comes from MIMS, the widely used medicines reference resource:

Use in lactation Of the two components, only ergometrine is known to pass into breast milk. The use of Syntometrine during lactation is not generally recommended.
Ergometrine is secreted into milk and the inhibitory effect of ergometrine on prolactin can cause a reduction in milk secretion. Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding at least 12 hours after the administration. Milk secreted during this period should be discarded.  ...

How many mothers are given this information prior to administration of Syntometrine?  Very few, I think.

I hope readers see the point I am making.  Today we are advocating a return to spontaneous breech birth, returing to the woman and her baby their right to unmedicated physiological birth.   Perhaps we also need a group of intelligent, well motivated consumers, to become activists for umnedicated, uninterrupted birth, from the onset of labour to the completion of the expulsion of the placenta and membranes and cessation of bleeding.


Your comments are welcome

Dueling Experts

This week, at the MIPP blog, I have recorded some of the questions asked in the course of a formal hearing into the conduct of a midwife.  The scene was a room in the County Court in Melbourne: formal, foreboding, and unfamiliar territory to the midwife whose actions in two particular cases were allegedly unprofessional.  The panel appointed to hear the case did not have anyone who could be called a peer.  Those three women also appeared to be in very unfamiliar territory.

Although formal hearings are open to the public, I have not identified the midwife or the witnesses who spoke for the Board or in the midwife's defense.  The name of the person who made the notifications (complaints) is suppressed by law, and the names of the women who received care from the midwife, leading to the complaints are also not allowed to be published.

In his opening address the lawyer acting for the Board ( Nursing and Midwifery Board of Australia ) commented that this case will probably come down to 'dueling experts'.  The second time he used that phrase it sounded more like 'drooling experts'!  Whether it was intended as a joke or not, it's difficult to see the funny side when a colleague is having to undergo such grueling questions about births that took place more than 6 years ago.

There were two experts called to answer the questions put to them by the two lawyers.  Both experts are Professors of midwifery: highly respected women who have impressive academic credentials.   The arguments become polarised between risk and the woman's choice.

Expert 1 told the panel hearing the case that the risk of a twin birth, or a postmature birth, was too great to be managed in the woman's home by midwives. 'Risk' and 'safety' appeared to be synonymous.
 
Expert 2 told the panel that safety can only be achieved when the woman's right to choose is upheld and supported - even if the woman is giving birth to twins, or the pregnancy is postmature.

Have you ever listened to dueling banjos?  Take a moment to listen to this one from Youtube, played by John O'Connell with James Meall.

That's the image that came to me when the barrister said we faced dueling experts.
They start out slowly, deliberately.
One makes a statement.
The second answers.
Another statement, slightly more complicated.
Another answer.
And it continues until they are in full swing, and I think one or both must surely be lost.  I do not understand how one or the other 'wins' the duel - I think banjo players must have some rules about that. 

And so it is for midwives.

Is a midwife *allowed* to agree to homebirth when one or more risk factors have been identified?
Is a woman *allowed* to plan homebirth when one or more risk factors have been identified?

This is the question, ultimately, that this panel are required to answer.  The NMBA has a two-fold statutory role, to protect the public and to guide the profession.  The protection of the public, in this case, is about putting limits on midwives, and thereby putting limits on the women who engage our professional services.  The guidance of the profession is, in this case, about attempting to define the boundaries of a midwife's practice.

I have come away from this episode of dueling experts without any solution.
I agree with the second expert, who strongly asserted that safety can only be achieved when a mother's right to informed decision making is protected and upheld.
Yet I know well that midwives will continue to be challenged if they agree to operate 'on the fringe'.

availability of midwives for homebirths

Today I would like to explore a few issues around the availability of midwives to provide professional services for homebirth, and suggest what I see as a way forward.

These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.

'Risk' - however defined - is a major obstacle.  The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital.  This narrow mindedness is not informed by evidence or by logic.

The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.

With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded.  A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program.  Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.

Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.

These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes.  Yet midwives say very little. 

These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder.  An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care.  Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth.  Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access.  When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.

$$ Cost is significant in private homebirth.  While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives.  Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging.  For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate.  The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.

The other factor in cost of private homebirth is the number of midwives.  Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more.  A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth.  I disagree.  Strongly!

I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives.  I cannot support this option - it scares me.  I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula?  A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".

Practical matters: the main one that comes to mind is the distance across this wide brown land.  Gone are the days of the village midwife on her bike.  Each time I visit a client, I am using precious fuel.  Likewise, each time a woman comes to me.  If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife.  (An exception is a few special women who I have attended on several occasions over the years.  I have become a part of those families, and it's lovely to return for the birth of the next baby.)

Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home.  Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.

Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.   

What am I saying?

I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth. 

• midwives need to think critically about risk
• midwives need to work to make primary maternity care by a known midwife affordable
• midwives need to wake up to their capacity to provide midwifery services in homes and hospitals, for all women.

Getting information

I have been pondering the question of how do women get the information they want in relation to their maternity decisions.

We have always talked, shared, and explored 'women's business' - in the past over the back fence, or over a cup of tea.  These days it's via social networking, via the iPhone or tablet.  The details of the horrible nausea, or the results of the most recent ultrasound scan, complete with picture, are updated for all one's 'friends' to see, and many check the 'like' button.  Questions are asked at internet forums, and there seems to be no shortage of guides who are willing to assist the inquirer with their tried and true remedies.  Women wanting to get pregnant can download their 'fertility tracker' free!  (How did we get pregnant before we had fertility trackers?)

Today I entered 'nausea and vomiting in pregnancy' in a search engine, and got more than 1.3 million hits.  Take your pick from ginger, vitamin B6, acupuncture, ...

The first site I went to told me that morning sickness is "generally considered to be the result of a combination of elevated oestrogen levels and low blood sugar" [that's news to me!]

So, how does someone get reliable information about a pregnancy issue?  How does one make informed choices?  How should a midwife advise a woman who is experiencing nausea, retching, and vomiting in early pregnancy?

Midwife academics Lisa McKenna and Meredith McIntyre published a literature review on the use of over-the-counter medicines by pregnant women.   The authors reported that ‘preparations used included cold cures, antihistamines, pain killers, herbal teas, antacids and laxatives – all of which are easy to obtain …  and are considered as low risk [of causing any harm to the developing fetus].’ (McKenna and McIntyre 2006, p637)  A Cochrane review by Matthews and colleagues (2010) reported a lack of high-quality evidence to support professional advice on complementary and alternative treatments for nausea and vomiting in early pregnancy.

I have found in practice that many women who seek primary care from a midwife, especially a midwife who attends homebirths, will have established patterns of alternative health care, including self-care, which the woman may not mention unless specific questions are asked.   The scientific paradigm that midwives and many other regulated health professionals follow in understanding evidence may not be accepted or understood by people who follow alternative health care systems.  To complicate matters even more, there are many midwives and doctors who have integrated alternative therapies into allopathic models of care.

In reviewing over the counter medicines for pregnant women, I came across the RANZCOG College Statement  (C-Obs25) on evidence supporting vitamin and mineral supplementation in pregnancy and lactation.  I recommend this statement for those who are seeking reliable information on folate, vitamin B12, B-group vitamins, vitamin D, vitamin K, and minerals such as Iron, Calcium, and Iodine.