thoughts on motherhood

Women contemplating motherhood face enormous challenges.  Pregnancy and childbirth are just the beginning.

Many Australian women tell me that they are angry when the 'system' dictates what they can and can't do.
"It's my body; my baby", they say.
"Surely I know what's best for myself and my baby!"
"Surely you're not allowed to not allow me?"

Women also tell me that they have deep sadness as they remember and reflect upon their experiences in birth.  "I know I needed a repeat caesarean.  But I felt like a piece of meat on a slab.  My baby was taken to the Nursery, while I was in Recovery.  I didn't see him for a couple of hours, and that still makes me sad.  I was afraid for him, and wanted him with me.  If I could have had a natural birth, I would have."

Natural birth has become the ultimate, longed-for experience in childbirth.

Unmedicated, physiological birth; uninterrupted, ecstatic, even orgasmic.
No clamping of the umbilical cord.  No separation of mother and baby - at all!  Not just the first hour, but as long as it takes.

Achieved by only a few.

Who wouldn't want to join that exclusive club?

Not only does the mother appreciate the physical, emotional and hormonal bonuses of working in harmony with amazing natural processes in birth, but the baby also joins in, without any prompting, in this unique primal dance.  


The point I am trying to make, and the main reason I am writing this post, is that there's a problem - women can't pick and choose their maternity journey.  My comments may seem predictable.  How many times have I written this sort of thing, since I started blogging in 2006?  

• The choices or decisions in maternity are quite simple - to intervene or not.  The biological processes in pregnancy, birth and lactation will continue as time passes.  
• Once interventions have occurred it may be difficult to return to the natural, healthy process.
• Undesired outcomes including death may occur, with or without medical or surgical interventions.

I have heard childbirth educators who teach that women who really want natural birth need to surround themselves with a team of supporters who will not waver in their support.  "The chain is only as strong as its weakest link," they say.  "If your supporters (including friends, husband, photographer, carer for children, doula, midwives) stop believing in you, they will cause you to give up just when you should be strong!"

This sort of advice is appalling.

Noone can predict a childbearing journey.  Natural birth is not something that can be ordered like a saleable commodity.  Women can't pick and choose.  A woman's pain in labour may be an indication of serious complication which, if nothing is done to relieve it, has catastrophic consequences.  A woman who shuts down her own responses to pain, and blocks the empathy and care of her supporters is ignoring natural processes at her peril.  A midwife who is disengaged, and sits on her hands rather than guide a woman on in labour, or, make the call to escalate care, is negligent or incompetent.  This might be as 'simple' as, without words, guiding a labouring woman to change her position, thereby moving from the transition to the second stage.  It may be as profound as telling the woman that you are now advising medical intervention, with all that that means.


Advice on childbirth has multiplied in recent years, with social media and internet communications.  A childbirth blog that has (literally) thousands of 'like's, tells us that "The legal authority in childbirth lies with the woman giving birth, not the providers ..." [link]

That's nonsense. 

There is a legal and ethical 'duty of care' that providers (midwife or doctor or other health care providers) are required to take very seriously.   It's an ongoing responsibility that the care provider carries as long as they are in attendance or other relationship such as in phone contact with the recipient of care.

This doesn't mean that all advice or decisions by providers are necessarily 'best practice' or acceptable to the woman.  Some providers maintain practices that are out of date, and believe they should intervene when others consider the progress to be uncomplicated and not requiring intervention.  Some providers (midwives and doctors) take large caseloads that result in cutting corners and burnout.  Human error is a constant threat.  These factors are balanced, to a degree, by the legal right of a competent woman to decline any intervention on herself (but not necessarily on her baby after birth).

We can talk about the legal and ethical standard for informed consent, but the hospitals/doctors/midwives know that they are much more likely to be defending their actions to their indemnity provider or the coroner or AHPRA.  


And there's the uneven playing field. The provider does *it* many times every day, while the woman is doing it for the first (or whatever) time - and takes the 'outcomes' (including pelvic floor damage, surgical wounds, infection, and many other types of morbidity, not to mention mortality) home.
 

Becoming a mother - bearing and nurturing a child - is an awesome and privileged position for any woman to be in.  Our bodies are wonderfully made.  

But, we can't pick and choose what happens in our maternity journeys.

The most healthy and 'low risk' pregnancy can suddenly and unpredictably be subject to life-threatening complications.  Alternatively, a woman with recognised risk factors can proceed without any complication.

Decision-making in the childbearing continuum is an ongoing process.  The woman who can trust her care provider enough to challenge or seek further discussion when any decision point has been reached is, I believe, in the best position.  The woman who believes she is alone, and has to be strong  and resist intervention or professional advice 'no matter what', is likely to be overwhelmed with fear and may make decisions that are not in her best interest.

legal rights in childbirth?

Bec and Lucinda

For some years I have been troubled by apparently common misunderstandings of a woman's *rights* in maternity care.   I have pondered these questions publicly on this and other blogs; questions of choice and informed decision making. 

Consider these statements:

You [a competent adult] have the *right* to bodily autonomy.  This means that noone is permitted to do anything to you without your permission.

In any health care situation, including maternity care, you [a competent adult] have the *right* to decline a treatment or intervention.

These legal rights are well established, and I am not going to spend time discussing them. 

Now consider the following statement, which appeared this week in a news article titled Risky underground homebirths: freebirths tipped to rise:

"Women have the legal *right* to birth how they want to"

A legal right? 


Surely not!

Even in the most ideal maternity care situations there will be some women who, in order to protect the life and wellbeing of the mother and her baby, will be advised to undergo surgery.   What happened to these women's legal rights to birth how they want to?

Maternity care in the developing world is often far from ideal.  Women whose health has been compromised by war, social exclusion, poverty, poor nutrition, disease, and other preventable conditions give birth to babies often in shocking conditions, with high rates of mortality and morbidity.  Do these women have a legal right to birth how they want to?  No!



Giving birth is a natural, spontaneous phenomenon, if a woman's body is left to its own devices.
Babies will be born naturally whether someone is monitoring progress or not.   
The sort of birth that the mother wants, which according to the quote above is her legal *right*, may be very different from the natural outcome.  

Giving birth spontaneously is, in my mind, a woman's *natural right* (not a legal right), just as we have a natural right to breathe, or walk, or perform any other natural function of our bodies.  Women do have a natural right to birth their babies.  Midwives are in the unique position to protect and work with that natural process, giving the mother confidence as she navigates the most challenging terrain.  The only way we can achieve our natural right to birth is if we stay on that natural pathway, and for the majority of women, this is a wonderful and rewarding phenomenon, working with the amazing hormonal cocktail that sets up powerful maternal instincts and bonding/attachment for mother and baby.
   
Those who have access to modern hospitals are not bound to use their natural right: they can obtain medical management and intervention, which is provided in modern societies along with other medical services.   We are privileged to have this access, and even a degree of choice in planning the way babies are born.  But, access to choice in the way a baby is born is not a simple matter.  It's not a legal right. 

I think it would be silly to argue that women have any legal right to a particular medically managed pathway in childbirth.
 
So, with great respect, I would like to suggest that midwives and maternity activists stop saying that women have a legal right to birth how they want to. It's nonsense.


Why am I so concerned about this question?

I have read coroner's findings, acted as an expert witness, and discussed cases with peers, and the recurrent theme has been this distorted belief, on the part of the midwives, that women should be able to choose the sort of birth they want, and that the midwife should facilitate this choice.  Midwives working under this belief have forgotten the harsh reality that preventable death and disability is often not far away.

The mother who wants an 'undisturbed' birth, and tells the midwife that she does not want any monitoring of her own vital signs or her baby's.  Yes, she gives birth, and usually the baby's condition is good.   ...

The mother who has various medical conditions including unmanaged gestational diabetes, wants a VBA2C, and who decides that there is too much negative energy in the hospital, so she finds an independent midwife who commits to homebirth.  ...

The mother who feels that she suffered trauma in her previous birth, in which labour was augmented, and a forceps birth resulted in severe perineal tearing which was repaired.  She does not know what she should do.  Should she request an elective caesarean birth? ...

These mothers may not be claiming any legal right to the sort of birth they want.  But they are looking for competent professional care.  A midwife can proceed on life's path with the woman, and provide information, support, expert advice, and sometimes guidance.

The midwife can support the woman's natural right to spontaneous birth, in the setting that is considered most appropriate at the time. 



Footnote:
In relation to human rights and birth at home, the judgment of the European Court of Human Rights in the case of Ternovski v Hungary (2010) is significant.

A midwifery half-truth: doing nothing

A couple of weeks ago I wrote about the myth of choice.

The midwife 'doing nothing' is a similarly misleading notion: not quite a myth, but definitely a half-truth. It's only one side of the coin.  It sets a potentially dangerous precedent, devaluing the expert professional activity of the midwife, being actively 'with woman' in the interest of safety and wellbeing of mother and child, to the point we have today: an epidemic of unattended births ("free births") in the community.  The rationale is like this: "If the midwife does nothing, then we don't need a midwife."



Today I want to critically explore what midwives are doing when we may appear to be 'doing nothing': what happens when I spend time on the couch in an almost dark room in the wee hours, with my eyes closed; what I am doing when I take up some simple knitting or crochet project as I wait for a baby to be born.

Let's consider the pregnant_woman/mother+baby to be central in this discussion.  What does that woman hear from her own intuition, from midwives, from other professional maternity care providers, from family, and from other sources?

There are many voices, and the value that the woman places on each of those messages varies from one to another.  Social media has, for at least the past decade, played an increasingly powerful role, as indeed this blog site offers information and discussion.  The current generation of mothers is the generation who uses online searches to 'research' a question, who follows multiple social media sites, who is prepared to ask questions.  Whereas previous generations had the 'disease of the month' prompted by an article in a publication (such as Reader's Digest), today's generation can search and often self-diagnose - with dubious effectiveness.  Gadgets can be bought: a pregnant woman can set herself up with a fetal heart rate monitoring device, a blood pressure machine, digital scales for the baby, and any number of other potentially useful, potentially useless pieces of equipment.

But I digress.

Back to the assertion I have made, that 'doing nothing' is a half-truth.  Further, I suggest the notion that the midwife does nothing, without taking into consideration the enormous and life promoting role of the midwife in any professional setting, could have negative consequences for idealistic, impressionable, inexperienced midwives, and for women in their care.

A woman who is labouring strongly, who has invited me into her home to attend her for birth, will have spent time with me during the pregnancy, discussing and planning and preparing for this climactic time.

I am in her home; I have moved quietly into her intimate space, and

• I assure myself that mother and baby are well, through observation, active listening, and auscultation of baby's heart sounds after a uterine contraction
• I communicate my assessment and any concerns to the mother, and support her, reassure her if appropriate 
• I prepare the space so that I can maintain my written record 
• I prepare equipment that may be needed, such as the newborn 'bag and mask', and oxytocic for mother
• I recognise any idiosyncratic matters or instructions that are given, such as "don't open the door because the cat might escape"
• I make a mental note of this woman's progress up to this point in time, how she is responding, what professional observations are reasonable, and what I expect to see happening
• I assume a protective role of the space, knowing that interruptions and intrusions and interventions can be disruptive: for example, telephones are not welcome in the birthing room.
• I may sit on a chair or rest on the couch in an almost dark room in the wee hours, with my eyes closed
• I may take up some simple knitting or crochet project as I wait for a baby to be born.

Doing nothing?  No way!

Even if the labour and birth are 'uneventful', even if the baby is born quickly and easily (from an observer's point of view), without any instructions from me, my presence is the essence of my professional action.  I bring the capacity to intervene, when there is a valid reason.  I bring the ability to minimise interruption that may increase anxiety in the labouring woman, so that the woman is free to progress, unaware of what's going on in my mind or in the outside world.

Dear reader, if you know the ICM Definition of the Midwife, and other foundational statements and codes in our profession, you will understand what I am saying. 

"... This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures." (ICM 2011 - emphasis added)

Those who understand the promotion and support of normal, physiological processes in birth will know the masterly inaction of authentic midwifery.  This is not 'doing nothing'!

Midwives need to protect women from an idealistic message that tells only part of the midwifery story, and may confuse those who genuinely need the midwife to act in the interest of wellbeing and safety of mother and/or baby.  If that were not the case there would be no need for a midwife.


Your comments are welcome.

breech

For several years now there has been a growing movement of consumer and professional opinion about the 'best' way to give birth to babies presenting breech. [See Breech Birth ANZ website]  This has come as a small pendulum swing away from the prevailing policy of elective caesarean for breech babies, which was quickly adopted after the Hannah et al (2000) paper on the Term Breech Trial, published in the Lancett.

Another historical grab, before I tell my breech story.

Please see the attached picture of the midwifery exam which I undertook in 1973.   Midwives then were required to have a basic understanding of breech presentations.   I don't want readers to imagine that the work of a midwife (or mother giving birth) was somehow ideal back then - in fact the medicalisation of childbirth, and the dominance of medical 'men' over the more subservient female nursing profession (which included midwifery) was entrenched, as can be seen in the previous post I wrote about this midwifery exam.

click to enlarge

I have always held that if for no other reason than the surprise breech, a midwife attending births needs to be competent in vaginal breech birth (vbb).   My involvement in workshops and education about vaginal breech births, and in the few vbbs I have attended, there has been an emphasis on having obstetricians who lead the cause of promoting vbb.  I have felt uncomfortable with this.  Obstetricians are surgeons.  Midwives need to claim breech births as being well within their scope of practice, as well as the identification of those for whom a vaginal birth is not likely to lead to good outcomes, and being able to refer to and collaborate with obstetricians.

Recently I have had the privilege of attending a birth at home, which turned out to be a surprise (undiagnosed) breech.  As the mother rested with her baby in her arms, she asked me to be sure to write a story about this birth.

Without identifying her, I am pleased to record the birth - through a midwife's eyes, with a midwife's knowledge and decision-making.  I don't consider myself an expert in breech or any other type of birth.  In fact, the only births that I take professional responsibility for are the ones that are very likely to proceed under the mother's and baby's own power, driven by an amazing natural physiological process.  My job is to work in harmony with those natural processes, and to protect, promote and support the natural processes, with the intention to intervene only if illness or complication arise in the birth and nurture of the baby.   In the case of breech births, the most critical period can be the birth of the baby's arms and head, and it is important that all midwives and doctors who take professional responsibility for birth are skilled in the decision making and simple manoeuvers. 

Working as I do, attending births privately usually in the home of the woman giving birth, I have a background knowledge of a mother before she tells me her labour has started.  In this case, I had been midwife for the birth of another child in this family, five years ago, also at home.  Reflections on the previous birth had also been tenderly preserved in my blog.

The first clear indication that this baby was presenting breech was the information that the waters had broken, and were "clear, with a bit of blood, and a black blob."  Labour was strong when I arrived.

I quickly set up my gear: the baby resuscitation box, and oxytocic, syringe and needle, and procedure gloves within reach; the oxygen cylinder connected up and ready if needed; a few clean bath towels to keep baby warm after the birth.   The 'nest' had been prepared - the couch draped with a waterproof cloth, so that the mother could kneel on the couch, facing away from me: an ideal upright position for a breech birth! (and a very reasonable position for an older midwife)

I saw more meconium, and asked the mother if I could examine her internally to confirm the presenting part.  The baby's bottom was 'at spines' - well on the way to being birthed.

I had a decision to make: I spoke simply to the mother and the father.  "The baby is coming, and it will be born bottom first."  I advised them that I did not expect any problems with the birth, but as an extra precaution I would like an ambulance to be called, in case we needed to transfer to hospital.

I would now like to describe each part of the birth as it proceeded.  Contractions were approximately every five minutes. 

As the baby's rump came on view a purple, swollen scrotum also appeared, and a stream of urine was passed from a swollen little penis.  I didn't mention these facts - the mother had work to do, and she would be able to discover her baby's gender in her own time.  From that moment it must have been 10-15 minutes until the birth was completed.  At some stage the 'first response' paramedic arrived, and I confirmed that the birth was going well.  He stood back.

• Next contraction: a big push and one leg plopped out.
• Next contraction: a slight rotation of the baby's bottom, and the second leg came down, and a little 'cycling' action of the legs (as though he said, "Thanks Mum, that feels better! Now, what should I do?")
• Next contraction: the baby's body was born past the navel, then to the nipples, and a large, full blue and white umbilical cord was central.  The body hanging was unsupported - I had not touched him to this point (Hands off the breech!).  I was delighted to see the cord positioned beautifully in the little protected channel between the baby's two breasts that were squeezed together in the tightly stretched vaginal opening.  I gently checked the pulse - about 120, which is good.
• Next contraction: first arm popped out, a little rotation, then second arm.  Baby's colour reasonable.
• Next contraction: no progress.  I placed my thumb and fingers over the cord, close to its insertion.  Pulsing had slowed to about 80.  Time to get this little one out and breathing! 
• With mother in the kneeling position, I placed my right hand in over the baby's chin, and a finger into his mouth.  The left hand went behind the baby 's head to flex it, and the head was born with minimal effort on my part.
• Baby was initially pale as he lay on the birthing mat under his mother, with his cord intact, as mother turned to look at him, and ask how he was.  I dried him, checked the pulsing of the cord, blew on his face, and before the first minute was up, he had taken a gasp of air.  His colour began to improve.  A few more minutes before he was ready to cry, but all the time he was making the transition from womb to the outside world, there was no reason for me to interfere.
• By 5 minutes, he was in his mother's arms, pink and strong. 
• By the next day when I visited them, he had been breastfeeding strongly and effectively, and doing all the things newborn babies are expected to do. He weighed just over 4 kilograms.

Birth statistics

Source: Victorian Health Department 2009

I expect readers will find the trend in the number of women achieving planned home birth (Table 33)  interesting.  (click on picture to enlarge)

To access the full Victorian Consultative Council on Obstetric and Paediatric Mortality & Morbidity (CCOPMM) Annual Report for the year 2009, click here.
[This is the most recent of the annual reports]

Midwives are the only professionals who attend women for planned home birth these days.  In years past there were a few GPs, but time and cost of insurance has caught up with them.  Midwives are attending homebirths privately without professional indemnity insurance, under a special exemption that is in place until June 2015.


I note:

• the gradual increase in homebirths as a percentage of all confinements*, from 0.2 in 1985, to 0.4 in 2009 (Table 33).
• Table 34 indicates the type of birth for all women who were recorded at the onset of labour as 'planned' homebirth.  Women planning homebirth in 2009 had 90% 'unassisted vaginal' birth (the overwhelming majority of these being spontaneous, unmedicated); 6% caesarean birth, and the rest forceps, vacuum, or unknown.  
• This compares with only 38.6% of all women in 2009 coming into spontaneous labour without augmentation (same report, p61), and 54.6% having unassisted vaginal births (p64).

AIHW 2010 - click to enlarge

We do not yet have a 'Births in Victoria' report for 2010 or subsequent years.
 
This 2010 national report is from the Australian government's Mothers and Babies publications site.

I note:

• In Table 3.18 (shown here), the number of babies born at home in Victoria has increased from 300 in 2009 (PDCU) to 567 in 2010. 
• This is the actual place of birth, including those who planned to give birth in hospital, and the baby beat them to it, and those who intentionally gave birth unattended ('free birth')
• The AIHW 2010 data does not report on home birth by intended place of birth in Victoria (Table 3.19, p29)
• 2010 was the year that the two public hospital homebirth trials commenced at Sunshine and Casey.  The number of homebirths births through those hospitals was small (40)
• 2010 was also the year that the federal government's maternity reform package was implemented, with midwives becoming eligible to provide Medicare-rebated antenatal and postnatal services from November 2010.

AIHW 2011 click to enlarge

 The 2011 national report from AIHW provides more information on home births in Victoria, as it includes the breakdown of those women who gave birth at home, having planned (intended to) give birth at home.

I note:

• The number of planned homebirths in 2011, in Victoria,  was 432, accounting for 0.6% of the State's births.  
• Looking back at Table 33 (above), the increase from 300 in 2009, 0.4%, is substantial.
• Midwives in Victoria quickly accessed eligibility for Medicare, and promoted primary maternity care options for women.
• The only place in Victoria where a midwife can practise privately is in the community, for planned homebirth.
• No Victorian hospital has yet established processes whereby midwives can apply for clinical privileges and attend their clients in the hospital
• Since 2010, a number of experienced midwives have resigned from mainstream Victorian hospital and birth centre employment and joined the ranks of midwives offering homebirth.

The following excerpt from AIHW 2011 provides interesting comment:

Homebirths 
In 2011, there were 1,267 women who gave birth at home, representing 0.4% of all women who gave birth. The highest proportions were in Victoria and Western Australia (0.8%) (Table 3.18). It is probable that not all homebirths are reported to the perinatal data collections.

The mean age of mothers who gave birth at home was 31.7 years (Table 3.49). The proportion of mothers younger than 20 was 1.3%, and the proportion aged 35 and over was 29.8%.

The proportion of mothers who gave birth at home who identified as being of Aboriginal and Torres Strait Islander origin was 1.1%.

Most women who gave birth at home were living in Major cities (70.8%) (Table 3.49). Of mothers who gave birth at home, about one-quarter had their first baby (22.3%), and 77.4% were multiparous.

The predominant method of birth for 99.3% of women who gave birth at home was non-instrumental vaginal (Table 3.49). The presentation was vertex for 97.6% of women who gave birth at home.

Of babies born at home in 2011, 99.2% were liveborn. The mean birthweight of these liveborn babies was 3,614 grams (Table 3.49). The proportion of liveborn babies of low birthweight born at home was 1.6%, and the proportion of preterm babies born at home was 1.3%. (AIHW 2011, pages 65-66)

I note:

• There were 10 babies of the 1,301 homebirths in 2011 recorded as fetal deaths.  These data do not provide detail as to how or why those deaths occurred.
• The midwife is duty bound to promote the wellbeing and safety of the mother and baby in her care, above preference for place of birth, or other factors.

*The word 'confinements' is used in these reports, as a tally of the number of women who have given birth, rather than the number of births, which includes multiples.  Readers might like to suggest a better word!

Birth stories: why are they important?

A few days ago I wrote a blog post about Birth Stories.  That article has attracted a large number of visitors to the site, about X10 the usual tally, and impassioned discussion on social media sites.

The problem that I have written about there is that a revised advertising guideline for midwives, to be in effect 17th March 2014, states that "the use of patient stories to promote a practitioner or regulated health service" is a testimonial, and prohibited under the Health Practitioner Regulation National Law.  The revised guideline has taken the word 'testimonial' to mean "a positive statement about a person or thing".  


In drawing attention to this matter I hope the regulatory Board (NMBA) will see that the writing and sharing of birth stories is an important part of social dialogue between women and midwives and the whole birthing community;  that birth stories are not written primarily to promote the midwife or her practice, and therefore should not be considered testimonials.  Birth stories help the mother to recall and record for all time the often amazing journey that she undertook in bringing new life into her family.  The midwife is a small part of the birth story.  The woman and her baby are the central focus.


Having used the word search function of this site, I found a 'birth story in pictures' that I wrote in February 2010.  At the end of that post I wrote: "Please note that midwives and other registered health professionals are not permitted to use testimonials to advertise our services."

In March 2011, I wrote about 'The birth of Richie Jack', and in that post linked to the birth story blog written by his mother, Ashley.  In my post I wrote:

...

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

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

I have always encouraged mothers in my care to write their birth stories, and will continue to do so, regardless of the revised guideline and its position on 'patient stories' that may mention me, the midwife, in a positive (or negative) way.  The internet and social networks are here to stay, and a mother who uses the internet as a means of sharing her story should be free to do so.


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.

conversations about breastfeeding

Two recent online Conversation articles, 'Breastfeeding improves IQ – now have we got your attention?' (Hayley Dickinson, 1 August 2013), and ‘Nipple Nazis’ vs overwrought mums: the breastfeeding debate' (Katie Attwell, 9 August 2013) have prompted a great deal of attention and sharing of strong opinions. 

I have read many of these comments with interest; and am surprised at the lack of comment from midwives.  We are the one profession that has more ability to protect, promote and support breastfeeding than any other - simply because we are with woman at the incredibly critical times for breastfeeding: the birth, the hours after the birth, and the early days.  If breastfeeding works for both mother and baby in the first week of life, most of the problems have been sorted.

If, on the other hand, after a couple of sleepless nights and days, both mother and baby exhausted and crying, the mother's nipples bleeding and incredibly painful, and someone tells her that her baby should have some formula because her baby will lose too much weight, and she should express her milk until her nipples heal  ...  It's all uphill, isn't it?

These discussions - they are all there for you to read, and come to your own conclusions.  I will make a few observations.

Having read the IQ article, and a quick succession of responses that questioned everything from the validity of the research conclusions, to the value of breastfeeding, I wrote:

There are many compelling reasons today for health professionals to promote, protect and support breastfeeding. We have a duty of care to do no harm. Promoting breastfeeding is, to my mind, a no-brainer. (and I don't really care if my IQ would have been higher if my mother had breastfed me longer)

Almost everyone in our society accepts that 'breast is best' for babies and their mothers.
The dilemma that midwives face in the brief period of birth and postnatal care in which we are directly responsible for mother and baby is that breastfeeding can be easily disrupted. Midwives, more than any other group of health professionals, can work with mothers and babies in through those early days, and guide and encourage mothers when the going gets tough.

When hospital maternity units work towards becoming 'Baby Friendly', implementing the BFHI global criteria, one of the most challenging steps is to demonstrate that a sufficient proportion of healthy breastfed babies were exclusively breast fed or breast milk fed from birth to discharge from the unit.

Mother-baby pairs who have used formula supplements, or milk from another mother, can be supported in optimising their reliance on mother's own milk, at the same time as being realistic about their particular situation.

Breastfeeding is one of life's big challenges. If it weren't so good, it probably would not be so contested.

 Many of those who posted comments supportive of breastfeeding were challenged by a doctor who claimed, repeatedly, that there was little difference between the health of breastfed and formula fed babies in our (wealthy) society, which has clean water and enough money to purchase formula.  For example:

why are you so resistant to discussion of what the data actually show about the effects of feeding type in our society? Is it because it threatens your ideology? And what, exactly, do you consider the ''risks of formula'' to be (in our wealthy society)?
Families should be encouraged to choose breast feeding and, if they choose it, the mother should be assisted to make it work - so long as the harms of continuing do not become greater than the benefts.

The self-appointed jury panel in this case included mothers, retired persons, university lecturers, a public hospital clinician, a PhD candidate, and others.  The strength and frequency of comment from one leader set the rules.  Nothing was protected, other than mothers who did not breastfeed.  How dare anyone make a connection between the harmful effects of smoking, and the (supposed) harmful effects of not breastfeeding (in a wealthy society)!


A point that I want to record in this context is that no matter how 'wealthy' our society is, no matter how difficult it is to demonstrate through research an advantage for a breastfed child over the non-breastfed child, breast feeding is the biological norm.  No technology or man-made substance has, or will, be developed to replace that norm.  Anything that is developed as a replacement for a mother's own milk, delivered directly to her suckling infant, can only be an inferior substance.

Another point that is clear to me is that, if it is truly dangerous (as we know it is) for a baby in the developing world to be denied his or her mother's milk, the onus is on us, the developed/wealthy world, to set the standard.  Statements that trivialise the life-giving properties of breastmilk in the wealthy world have overtones of colonialism and racism.  Australia is not uniformly wealthy.  Disadvantaged groups of people in Australia today have lower rates of breastfeeding than those in the better postcodes, and poorer health outcomes for babies as well as other age groups.

Here's a true story: A woman who came to Australia with her husband on a 457 work visa told me, with tears, of the birth of their first baby.  He had been born in a hospital in India, was healthy and hungry, and she was shown how to give him formula in a bottle.  She did not receive assistance with breastfeeding, which she tried, unsuccessfully, to initiate.  By the time he was three weeks of age he was refusing the breast, and essentially fully bottle fed.  He died at one month of age.  She asked me to help her give birth to her new baby, and breastfeed him - which she did.  



This brings me to the second article, headed 'Nipple Nazis'.

Again the correlation between social attitudes towards smoking, and not breastfeeding, was drawn.  Again, the cry from the stalls: how dare you!  That's not allowed!

It is true that the quantum of harm is greater with smoking than with not breast feeding.  But the harm of smoking is (usually) to the adult who smokes.  Even if there is only a small amount of harm with not breastfeeding - especially for premature babies who develop necrotising enterocolitis (NEC) and need surgery to remove large portions of dead bowel tissue, and for babies in poorer communities, and for those who receive contaminated feeds when someone in the big business making the formula makes a mistake ...  surely the onus is on the midwives, and the health system, to do all it can to promote, protect and support breastfeeding.  The baby is the innocent recipient of whatever the mother chooses to feed him or her.  I reject any notion that a wealthy society can accept a standard that would put poorer people groups at an increased risk of harm. 

So, dear reader, why are we looking at offensive headings such as 'Nipple Nazis', when considering breastfeeding?  Who is a 'Nipple Nazi'?  The term has been used in maternity and child health services for the midwives, nurses, lactation consultants, and doctors, who seek to promote, protect and support breastfeeding. How is it that the thought police have not stamped out that outrageous and offensive suggestion?  What is it about the work that we do that has ANY relation at all to that horrible and inhumane blot on history?

It seems to me that while our society - at least that section of it who reads the health section of The Conversation - is very protective of the feelings of any mother who finds herself unable to, or chooses to not breast feed for whatever reason - we don't see anything wrong with the implied derision of those who make it their business to work in harmony with the natural processes in breastfeeding.

Midwives and Medicare

For the past 2+ years I have been able to give clients Medicare rebates for antenatal and postnatal midwifery services.  I am looking forward to having a prescriber number in the near future.  This is part of the government's reform measure, More Choice for Women - Expanding Medicare Support for Midwives, introduced in November 2010.

The basic requirement that I must fulfill before a client can claim a Medicare rebate is that there is a collaborative arrangement in place: a letter or statement, signed by a suitable doctor.  As I have no 'agreement' to meet this need, I must seek out an arrangement for each woman.

There are a couple of doctors who have 'collaborated' with me on more than one occasion.  Most of the time it's a one-off.  Most of my clients live within a 1-hour drive radius of my home.  That's a huge metropolitan area, and some out in nearby towns.  In that area there are thousands of doctors.  Very few have met me.  Some have refused to collaborate, saying that they would thereby be liable for anything I did.

Several months ago a woman who has had three previous uncomplicated births in hospital contacted me.  She wants to have her next baby at home.  I explained Medicare and collaboration, and emailed a letter describing the need for a collaborative arrangement with a doctor, to her.  She took the letter to her local doctor.  In her own words, 

I am just writing to advise you of the trouble that I am having getting a GP to write a referral to your services.

After contracting you to get a letter for the referring doctor, I went to my local GP for confirmation of my pregnancy. They were happy to send me for tests and ultrasounds but when I explained that I didn't want to birth my fourth child in a hospital, but rather have midwifery care and plan a homebirth I was met with an almost hostile response. This GP who had seen me throughout 2 of my previous pregnancys pointed out that he would not write me a referral due to the use of the word "collaborative" . He failed to understand where his duty of care ended and the midwife's began. I tried to explain that I didn't need to see him throughout the pregnancy and that I only needed initial blood tests and this letter but he would not listen. He continued to explain that he would not put his reputation on the line for the sake of my Medicare rebate!

Feeling disheartened I searched for a doctor who had a similar outlook on the way birth should be. I felt positive that this woman would give me the referral I needed.

This time the doctor endorsed homebirth, was happy for me to see a private midwife and ordered the appropriate tests to be sent to my chosen care provider but once more would not write the letter. When I asked for an explanation once again there was talk of scaremongering from insurance companies who had advised her that if she wrote this letter and something went wrong at the birth, even if she was 200ks away she would be liable.

I find it extremely frustrating and disheartening that in order to get the birth that is right for me and my family, I am being financially penalised because my doctors of choice don't fully understand what is required of them.

With this woman's permission, I forwarded her letter to the Health Minister, Hon Tan Plibersek, MP.  The letter I have received from the Minister's office, in reply, gives me hope that the wrinkles may be ironed out.

Excerpts from the Minister's letter, dated 27 May 2013:

The More Choice for Women - Expanding Medicare Support for Midwives, introduced on 1 November 2010, expanded the Medicare arrangements to include midwifery care.  This was in recognition that women should have a range of birthing options available to them and be supported in their choice of practitioner.

Recognising midwives as primary maternity care providers under Medicare was also intended to assist in improving service delivery by enabling better use of the existing workforce ...

 ...

Since the measure was introduced, midwives have reported ongoing difficulties with establishing collaborative arrangements with individual medical practitioners.  This has hindered their ability to provide services under Medicare.

In recognition of this, at the Standing Committee on Health (SCoH) meeting of 10 August 2012, the Minister for Health ... agreed to vary the legislation on collaborative arrangements, to enable agreements between midwives and hospitals and health services.

The Department is currently in discussion with the medical, midwifery  and consumer groups to discuss the detail of the proposed changes.

The Minister recognises that the lack of hospital clinical privileging and admitting and practice rights is a fundamental issue for midwives.  This prevents privately practising eligible midwives from working to their full scope of practice, undermines continuity of care and reduces choice for women.  

As such, the Minister has asked Health Ministers to finalise consistent approaches to credentialing for midwives in public hospitals in line with States' and Territories' commitments under the Maternity Services Plan.

The Minister is committed to supporting increased participation by eligible midwives in the Medicare arrangements and to the proposed changes to the collaborative arrangement requirements that would facilitate this.

Thankyou for raising this important issue.  I trust this information is of assistance to you.
Yours sincerely
[&c]

My comment:
A letter like this to an ordinary inquirer like me does not give any new information.  However, I feel encouraged by the tone of the latter part of the letter.

Specifically:

• that midwives need practising rights in public hospitals 
• that the Minister has put pressure on the State and Territory Health Ministers, to get a move on 
• that public hospitals will be expected to support collaborative arrangements with midwives
• that the Minister is committed to this reform measure.

Readers may also share critical thought about the More Choice for Women ... reform measure, such as:

•  the inequity of signed collaborative arrangements, in that the midwife is required to obtain the arrangement, but no doctor is obliged to agree or to sign anything.  The loser, of course, is the woman.  AND the midwife looks pretty useless.
• the lengthy delays (such as since SCoH in August 2012) in making even the promised changes to the Collaboration Determination
• the obstruction by public hospitals throughout the country, with the exception of a few in S-E Qld, to any progress on practising rights for midwives
• with the above point in mind, surely it's unlikely that these hospitals will agree to collaborate with midwives, even after the legislation has been varied as promised 
• and finally, with an election, and probably a change of government in September, will we see ongoing support for More Choice for Women - Expanding Medicare Support for Midwives?

Your comments are welcome