The bigger picture

Grand-daughter's photography - you can see that I love her!

I have a lull in my bookings at the moment, and have set myself the challenge to consider the bigger picture.

Questions of birth/maternity care/midwifery that comprise the bigger picture are along this line:

• How well does Australia measure up against global midwifery?
• What is being done in Australia to protect sustainability in the midwifery profession?
• What can a woman in Australia anticipate as she carries, births, and nurtures a baby?

It would be easy for me personally to be dismissive about the bigger picture.  Leave that to the younger generation!  I have enjoyed my career, have had many incredibly beautiful experiences with women who have given me their trust, and have invited me into their lives at their most intimate moments.  I have written many of my stories down in journals and blogs and argued my point in articles and published papers.


How well does Australia measure up against global midwifery?
The home of global midwifery is the International Confederation of Midwives (ICM).  The Australian College of Midwives (ACM) is a member organisation of ICM, and Australian codes and standards are based on the ICM Definition of the Midwife (2011).

ICM lists the following key concepts.  I will use them as a basis for my assessment of Australian midwifery as I know it, and give each point a score out of 10. I will not attempt to justify or give references, since this is a statement of opinion.  However, my opinion is based on careful reading of midwifery literature, and careful reflection on a lifetime of midwifery practice.  If the reader considers that I have made a statement that is wrong, or unsupportable, please tell me why.

ICM Key midwifery concepts that define the unique role of midwives:

• partnership with women to promote self-care and the health of mothers, infants, and families;
• respect for human dignity and for women as persons with full human rights;
• advocacy for women so that their voices are heard;
• cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
• a focus on health promotion and disease prevention that views pregnancy as a normal life event.

1. partnership with women to promote self-care and the health of mothers, infants, and families:
Promoting self-care and health of mothers, infants and families is a wonderful, big picture statement. 

I would suggest that we look at rates of spontaneous unmedicated birth as an initial measure of health promotion, self care, and wellness of mothers and babies.   Spontaneous unmedicated birth will be most likely to proceed when the midwife is practising as an authentic midwife, establishing a partnership with the woman based on reciprocity and trust.   WHO (1996) stated that "In normal birth there should be a valid reason to interfere with the natural process."  Achieving spontaneous unmedicated birth is a measure of the capability of the midwife as much as the mother.  There is no safer or better way, in most instances, than for the midwife and the woman to work in harmony with natural processes.  The midwife acts in a way that minimises disturbance, disruption, interference, interruption, while observing and assessing progress and wellness.  The woman learns to minimise neocortical activity, and access her amazing supply of natural opiates.  Her oxytocin and adrelanine peak as she gives birth, providing for her baby the ideal transition to life outside the womb, and giving herself the ability to contract her womb strongly and expel the secundines (an old fashioned word meaning the afterbirth) without excessive bleeding.

In Australia more than 30% of women have caesarean births, completely by-passing these physiological states. Only about 25% of women have no analgesia for birth.  Only a tiny minority of the women receiving maternity care in Australia are cared for in labour by a known midwife - one of the evidence-based measures by which we can anticipate improved outcomes for mother and baby.  There is much room for improvement!

SCORE 4/10

2. respect for human dignity and for women as persons with full human rights
What measure is there for respect of human dignity?  I don't know.
There are many cultures in Australia, and it's not possible to generalise.  The planned homebirth 'culture' is quite exceptional.  These women are  usually not wealthy, but find the money so that they can have private midwifery care.  They value their personal dignity, within their own homes.  They accept the work of childbearing, as their own job, and give it their best. 
On the other hand, I consider the educated, relatively wealthy segment of our population, whether they are cared for in private or public hospitals, there are many examples and anecdotes of a lack of respect, an expectation by the midwives and doctors in the hospitals that they will submit to the superior training and knowledge of the medical practitioner who is most senior at the time.
My conclusion is that in Australian mainstream maternity care, there is a lack of respect for the human dignity of women as persons with full human rights, and this is backed up by the Australian Medical Association Position Statement on maternal decision making  (2013)

1. A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.
   
2. A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.
3. Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies. ...

There is, again, much room for improvement!

 SCORE: 5/10

 

3. advocacy for women so that their voices are heard

Australian women have for many years attempted to have their voices heard, and organisations such as Maternity Coalition have advocated on behalf of women.  I and many of my midwife colleagues have been in the thick of it.  Many of the stories since about 2007 can be found on this, and linked blogs.  Here are a couple of pictures that describe advocacy for women:

Mothers, babies, and midwives outside a politician's office in Melbourne

more than 2000 rallied in the rain, on the lawns of Parliament House in Canberra

In response to advocacy, the government of the day (2008) announced a Review of Maternity Services, and asked the public to tell them what they wanted.  Thousands of ordinary people, mostly childbearing women, sent submissions.  Many of them asked for choice - that they could choose where they had their babies, and with whom.  Many told their stories about wonderful empowerment in giving birth at home, with their own midwife. Yet, when the report of the Maternity Services Review was published, homebirth was excluded from the reform package.  

Midwives now have indemnity insurance, but not for homebirth!  We now have Medicare, but not for homebirth!  We now have the processes so that hospitals can award clinical privileges to midwives, but except for a few in the S-E corner of Queensland, this just is not happening.

There is, again, much room for improvement!

SCORE: 3/10

4.  cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies.
It would be politically correct for me to launch into discussion of the plight of Australia's aboriginal peoples in addressing this topic.  There is a great need for such work, and for improvement in all sorts of health outcomes and health promotion.  But I do not see many indigenous people, and in my years of practice have cared for only a handful.   Not many women with indigenous heritage will seek out the services of an independent midwife.

Painting by Odetta Moore (Copyright).  "This is our baby boy waiting to be born.  That's him in the middle.  The circles round him are me, holding him and protecting him.  The tortoises in the corners are his protectors."

There is another vulnerable cultural group that we midwives are seeing, and for whom we need to improve care.  Women who are in this country on work visas, either for themselves or their husbands.  Many come from India and Pakistan, some from Africa.

The visas that these women use do not entitle them to publicly funded health care under Medicare.  The visas require health insurance, but the insurance policy usually does not cover childbirth.  These women enquire at public hospitals, and are told that they will be required to pay $11,000-$15,000 upfront for maternity care.  Some have no prenatal maternity care, and present at a public hospital in labour.  Some are choosing homebirth, as the cheaper option.  Many are Moslem women, fully covered when outside the home, and it's common to see very low levels of Vitamin D, and iron deficiency anaemia.

What can we do to improve the health outcomes for these women and their babies?

SCORE: 5/10

5. a focus on health promotion and disease prevention that views pregnancy as a normal life event.
Health promotion in maternity care in Australia relates to initiatives such as smoking cessation, obesity, family violence, and baby sleeping arrangements.  There is little recognition of the fact that pregnancy is a normal life event; that health outcomes are best when technology and medicine and surgery are used sparingly; and that health outcomes are best when exclusive breastfeeding is initiated at birth.

Pregnancy is seen, in mainstream maternity care, as a minefield; a disaster waiting to happen.  Women are investigated, tested, and explored - in expectation of something awful.  Concepts of informed decision making are poorly understood, and even more poorly followed.  Women report being bullied if they question a plan of action, or try to decline an offered treatment.

Australian maternity services are medically driven, with obstetric hierarchy dominating most services and decisions.  The RANZCOG College Statement on Homebirths, while attempting to support personal autonomy and informed decision making, leaves little room for discussion, and a great deal of room for coercion:

"... While supportive of the principle of personal autonomy in decision making, RANZCOG cannot support the practice of planned homebirth due to its inherent risks and the ready availability of safer options for labour and delivery in Australia and New Zealand. Where a woman chooses to pursue planned homebirth, it is important that reasons for this are explored and that her decision represents an informed choice, considering all the possible benefits and potential adverse maternal and perinatal outcomes. ..."

There is, in my opinion, ample evidence supporting planned homebirth, with plans for transfer of care to hospital in a timely manner when indicated.

There is, again, much room for improvement!

SCORE: 3/10

TOTAL SCORE: 20/50

40%

FAIL!

What should I say to the students?

Over the years I have spoken to each new intake of midwifery students at Deakin University in Burwood about the midwife in private practice.   I feel privileged to be invited to give this lecture.  I stand before a room full of fresh and eager young women (usually), who want to become midwives.

Yesterday I asked Martina, a young midwife who asked me to mentor her in homebirth and private practice, who had been in that same lecture room a few years ago, what she thought I should focus on.  She was quick to reply: "normal unmedicated birth, physiological third stage, leaving the cord un-clamped - these are basic midwifery, but students may rarely experience them as they complete the practical requirements of the course."  

Yes Martina, I think you are right.  This truly is basic midwifery.  Students may find that their courses emphasise so strongly the complications and illnesses that can devastate a woman in pregnancy and birth, yet undervalue the body of scientific and clinical knowledge around protecting spontaneous normal birth, breastfeeding, and mothering.  Teachers may take it for granted that students will learn how to be 'with woman' when the woman is strong and well and intentional about working with her own body's natural power in childbirth, while they prepare the students for obstetric emergencies, neonatal and maternal resuscitation, and other potentially life-saving measures.

Working in harmony with natural processes in birthing is indeed a wonderful thing.  Midwives sometimes refer to ourselves as 'oxytocin junkies', and anyone who has spent time repeatedly in the zone of healthy spontaneous birthing will know what I mean by that phrase.  We come away from birth with a renewed sense of awe and wonder each time, and we never exhaust its potential. 

Yet I need to balance that fact against the reality that a midwife's place in birth is not a passive one.  If there were no serious professional role for the midwife in a 'natural', spontaneous birth, it would be reasonable for women to be attended by their sisters, friends, or a sub-professional group of birth attendants.  A midwife attending planned homebirth is watching the woman's response to her body's intuitive work, watching the baby's response to the labour, and assessing progress over time.  While an inexperienced midwife might become frustrated when progress is poor, the seasoned midwife seeks an understanding, weighing up what she observes against her knowledge of normal. 


Midwives entering the profession today face a distinct set of challenges:

• Basic midwifery

Mainstream maternity service providers in cities like Melbourne - the employers of the majority of midwives - are pretty good at dealing with the complicated aspects of birth.  They have educational and research arms that impress colleagues around the world.  But, in general, they do not do a good job at 'basic midwifery'.  There are few strategies that protect wellness.  The rates of various interventions, from induction of labour for non-medical reasons, to rates of caesarean, or rates of serious perineal trauma, or rates of admission of babies to neonatal intensive or special care nurseries - all performance indicators - could be improved. 

It is the job of midwives to insist on 'basic midwifery' improvements to the care of women.  We can't expect the obstetric services director - a medically trained specialist in surgery - to champion midwifery which is outside the scope of an obstetrician's expertise.  (Mind you, some obstetricians do understand, and champion, the work of the midwife) 

• increasing medicalisation of life events

This challenge point is linked to the previous one.  Our society has, to a great extent, lost its knowledge of and trust in wellness.   There is a point at which additional medical interventions fail to improve outcomes, and possibly increase the risk of poor outcomes.  Midwives today carry knowledge of protecting and supporting spontaneous birthing processes.  We must value our knowledge and skill.

• increasing bureaucratic red tape

Midwives have lobbied successive governments over many years for equity and fairness in access to public funding for midwifery services.  This challenge continues, even though we are now able to provide Medicare rebates for some midwifery services, and other extensions to practice such as requesting tests and investigations, and prescribing some medications.  There are many bureaucratic requirements attached to these new professional benefits, and only time will tell if we meet the expected standard.


**********
Private midwifery practice in Australia today focuses on homebirth.  Homebirth offers midwives an opportunity to experience 'basic midwifery', because the only way to access the obstetric component of maternity care is to transfer care to a hospital.  

Over the years of my midwifery practice I have become more and more committed to the protection, support, and promotion of the spontaneous natural processes in pregnancy, birth, and breastfeeding, and this has been predominantly through planned homebirth.   It makes sense.  It leads to better outcomes for mother and baby.  Over the years of my midwifery practice I have also valued greatly the appropriate use of medical and surgical interventions.  In situations where the natural process is not likely to lead to good outcomes, we have excellent processes for 'Plan B'.  This is good.

I am happy to encourage the new group of midwifery students to give all they can to this profession, and I believe they may discover that midwifery will satisfy and challenge the most critical mind.

Welcoming the newest member of the family

Thanks to Bec and Al for this picture

In the past few weeks, in writing this blog, I have delved into personal memories and thoughts, preparing for and anticipating a particular birth.   I expect this fact has been clear to many of my readers; many being women with whom I have shared that deep and wonderous journey.  Although I usually write in an impersonal way of 'the woman' and 'the midwife', so much of my knowledge of midwifery is inextricably linked to my own experiences in childbearing and mothering - intensely personal.  In many ways, I am the woman; I am the midwife; I am even the child.

Tonight as I sit at my computer, thinking of how I can express the wonder that is welling up in my heart, I hear the brief small cry of the wee one in another room of our home.  I know she will soon be transported back into that milky dream world, her little body being nourished by the abundant supply that is freely given.

I treasure the memory of the first view of her beautiful face, and the ecstatic glow on her mother's face, as we three - mother, child, and midwife - three generations of a family - shared in the moment of birth.  I look at her, and wonder what her life will bring.  I practice using her name.  This is a new name; a new person who I will treasure and pray for, for the rest of my days.  I look at her features; the colour of her hair, the exquisite tone of her skin, the wonderfully made body.  I observe the deep bond that is apparent in her mother, her father, and her 'big' brother; instinctive and intentional behaviours that protect the new child within a family unit.  I have so much to be thankful for.

Yet even as I am awash in the joy and newness of new birth, I know there are times when even our best is insufficient.  Times when a baby cries with tummy ache, or when a mother is overwhelmed with tiredness.  Times when the needs of other children must be attended to.  Times when we seek medical expertise for health problems that can sap us of energy.  Times when our best is simply not good enough.


An abiding lesson that I have learnt from my contact over the years with newly born babies; my own children, the children of my friends and clients, and my grand-children, is the picture of the baby's craving for mother's milk.  This analogy was drawn by Peter: "Like newborn infants, long for the pure, spiritual milk, so that by it you may grow."  (1Peter 2:2) 

In the same way as the newborn infant craves her mother's milk, and cannot be satisfied without it, the skill of the midwife is to work in harmony with this primal natural process.

The Midwives Work DVD

Uploaded to YouTube by Midwives magazine on Jul 25, 2011

The Midwives Work DVD premiered at the International Confederation of Midwives Congress in Durban South Africa in June 2011, in front of 3000 midwives and others interested in maternity care from over 100 countries, has attracted huge interest. It highlights the importance of the role of the midwife in reducing maternal and infant mortality as well as the issues and challenges they face.

Category: Nonprofits & Activism
Tags: midwives midwifery
 RCM License: Standard YouTube License

(Thanks to Julie Garrett for the link to this film.)

24/7

"Within the [ ] health services financing structure, there is no room for financing the disutility of 24/7 availablity." [Mariel Croon, Human Rights in Childbirth conference, 2012]

One unavoidable feature of midwifery practice in primary maternity care is that a midwife needs to be accessible to a woman 24 hours a day, and 7 days a week, except, of course, if the birth is a medically scheduled and managed event.  If the midwife and the woman have agreed prior to the birth that they will work together when that time comes, that means the midwife is under a considerable degree of commitment.

I have often pondered the wastefulness, from an economic/time management point of view, of caseload midwifery. Of course I can understand the bean counters, who want midwives to be rostered to hospital wards, for shifts that can be predicted. Of course I understand why inductions of labour happen in hospital maternity systems, as managers attempt to match peak activity periods in the hospital with the times when adequate staff have been booked.  Of course I understand why midwives choose to work shifts in hospitals.

At present I am waiting for three babies: one 'due' last week, one this week, and the third in a week or so. Babies in my practice often cluster, and I can't worry about it because it is outside my control.  I must see each woman as an individual, and not allow stress about the time of onset of spontaneous labour to complicate our relationship.

The quote above, and particularly the phrase  "disutility of 24/7 availablity" caught my attention when I read it. 
The dictionary meaning is:

'disutility'
a. the shortcomings of a commodity or activity in satisfying human wants
b. the degree to which a commodity or activity fails to satisfy human wants
[Collins English Dictionary – Complete and Unabridged © HarperCollins Publishers 1991, 1994, 1998, 2000, 2003]

mmm!

My decision to work as a midwife, placing the 'activity' - the needs and wishes of a birthing woman above my need to 'satisfy human wants' - be able to plan my time for work and play and sleep and whatever else - is a decision on principle, not on economics.  The principle relates to my understanding of the unique trust relationship that can be established between a midwife and a woman, enabling the woman to proceed down the often unpredictable and challenging path that leads to the unassisted, unmedicated birth of her child. 

CULTURAL HYSTERIA?

Readers of this blog are probably familiar with the historical roots of 'hysteria'; the Greek word ὑστέρα (hystera) meaning womb, the condition of the wandering womb, and recommended treatments.

"Galen, a prominent physician from the 2nd century, wrote that hysteria was a disease caused by sexual deprivation in particularly passionate women: hysteria was noted quite often in virgins, nuns, widows and, occasionally, married women. The prescription in medieval and renaissance medicine was intercourse if married, marriage if single, or vaginal massage (pelvic massage) by a midwife as a last recourse.[1]" [Wikipedia]

The Medical Dictionary that my computer's online dictionary led me to offers this information:

hysteria hys·ter·i·a (hĭ-stěr'ē-ə, -stēr'-) n.

A neurosis characterized by the presentation of a physical ailment without an organic cause, such as amnesia.

Excessive or uncontrollable emotion, such as fear.[Link]

I wish to contend here that there is a cultural hysteria in response to midwifery.  A cultural neurosis that leads to excessive and uncontrollable fear about that highly contested terrain, childbirth.

While midwives are recognised internationally as essential providers of primary maternity care, Australian midwives (and our sisters in many other developed countries) face exclusion and restriction when simply practising our profession.

Cultural hysteria with regard to midwifery depicts the midwife as someone who lacks skill in management of obstetric emergencies, events that are bound to happen, leading to a mass fear reaction.  Cultural hysteria sets up a fearful scenario, and uses that scenario to prove its point.

I don't have answers to every possible scenario, but I do know that in the State of Victoria, where I live and work, data from privately attended planned homebirth have been collected and reported on for many years, demonstrating the clinical effectiveness of planned homebirth in the care of a midwife.

The mothers who planned to give birth at home have not been uniformly 'low risk': they include births after Caesarean, mothers who are older, or who have had more births, or whose babies are bigger than average.  They are ordinary women, who just want to give birth to their babies.

The midwives have not undertaken any special courses of study: they are simply competent midwives, who seek to work in harmony with physiological processes, and who, generally, refer women appropriately when complications are suspected. 

The Victorian government’s Perinatal Data Collection (PDC) unit within the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) publishes an annual profile that captures all planned homebirths in the state, and puts the data alongside cumulative data from hospitals and statewide totals. These reports, although retrospective, carry a high degree of reliability.

The reports over the past 20+ years have shown planned homebirth in the care of a midwife as a safe option in terms of maternal and perinatal morbidity, with many features that are considered protective of the mother’s and baby’s wellbeing and safety. 

For example, in 2008, the most recent set of published data in this series:
• 91.5% of women planning homebirth had unassisted cephalic births, compared with 55.4% state-wide.
• Approximately 5% of women planning homebirth at the beginning of labour had caesareans, compared with 19% in small ‘low risk’ (<100 births) hospitals, and 31% statewide.

When looking at the baby outcomes for the same group (2008),
• 95.6% of babies born to mothers who planned homebirth at the beginning of labour did not require admission to a hospital nursery, which is approximately the same as the rate for small hospitals with less than 400 births per year.

These data support our contention that there is safety and protection of wellbeing for mother and baby when midwives attend women for planned homebirth.


I recognise that individual cases may be held up as examples of things going very wrong in birth, whether that birth takes place in a tertiary hospital, a private hospital, the woman's home, a birth centre, or in the back seat of the car. 

There are risks associated with birth, as there are particular risks linked to any life event.

I believe that the safety and wellbeing of mothers and babies in our community is enhanced by a strong midwifery profession that is recognised as essential in effective primary maternity care.

WHY I DISAGREE WITH THE CORONER'S RECOMMENDATIONS

Having written last week about some of the complexities of the decisions made by women about their birth-giving, and the roles of midwives, I would like today to briefly explore why I disagree with (most of) the South Australian Coroner's recommendations in the recent case.

I have summarised the recommendations as:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

Rather than starting with #1 and plodding through this minefield, I will start with what I see as easier, and pick my way through the minefield, trying to state my opinions clearly. (And, dear reader, I must warn you that I often delete a great deal of what I write, so that you see the heavily edited version)

6) education for public distribution on homebirths and risks 

This is not a bad idea. My only hesitation relates to what sort of education, and who writes it, and who defines the risks, and ...

 5) "establishment of alternative birthing centres" 

Also not a bad idea - for the 1980s, that is. Midwifery theorists proposed that hospital rooms dressed as 'home-like' settings would help women to feel OK about birth.  Some women did well, while many were excluded by risk protocols, and moved into standard (the alternative to 'alternative') obstetric care.  I gave birth to my fourth child at the Women's Birth Centre in 1980, and that experience helped me come out of medically managed and dominated midwifery.  I know many other midwives who have learnt to work in harmony with physiology in unmedicated birth, and to trust their midwifery knowledge when detecting and acting upon complications, during their time working or giving birth in a birth centre.  Perhaps that's a good reason to establish birthing centres.

4) "establishment of a position known as the Supervisor of Midwives"

I need to sit on the fence for this one.  The role of Supervisor of Midwives is one that I don't fully understand.  How would these people be appointed?  What would their role entail?  Would all midwives be supervised, or only certain midwives?    The UK-style Supervisor of Midwives is different from the New Zealand system.  Psychologists work under a system of professional supervision.  I believe a thorough exploration of this proposal needs to be had by midwives, ethicists, psychologists, lawyers, and maternity consumer spokespeople, and some agreement reached, before yet another regulatory control be imposed on the profession.

1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"

NO!
Australia does not need to outlaw unregulated midwifery services.
Australia needs to protect and support the midwifery profession, so that midwives can provide midwifery services in homes and hospitals; so that women will feel safe in the professional care of midwives as primary carers, who are able to work seamlessly with specialist services when indicated.
Modern societies, and the legislators and coroners and others in positions of authority need to recognise that spontaneous labour and birth is a fact of nature, not something that a midwife controls or gives permission for, and that women under natural law are able to use the professional services provided in their community, or not.  It's their choice.

2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"

NO!
Midwives who understand the ethical and moral duties of our profession, who by definition work 'in partnership' with a woman, will REFUSE to report women on the grounds of a plan for homebirth.  My own practice for many years has been to encourage women to see the choice of place of birth as a decision they make as labour becomes established, and not before.  I believe this is best practice, as the midwife is committed to the woman, not to the planned setting for birth.

8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

HOW would this work?  Will that woman be arrested and forced to listen to 'appropriate advice' being delivered?

I have not tried to tease out which risk factors the Coroner thinks would be used to initiate reports or the giving of advice.  There are few absolutes in midwifery.  Regardless of what risk factors may be attending a particular situation, physiological birth always starts with spontaneous onset of labour, and spontaneous onset of labour happens in the woman's own time, in her own world, in her own body.  The woman has to make a decision to call a midwife, or not; to go to hospital, or not.  This decision cannot be taken from her.

This set of recommendations exhibits a shallow and linear view of life, risk, and decision-making.  The question that the Coroner seemed to avoid is:

"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and

"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"



Australia is a society which supports a wide range of freedoms for the individual.  I don't have the words to describe the legal and ethical framework that this is built upon, but I know that when a State (government-sanctioned authorities) is given power to control the most intimate relationships between a woman and her child, that comes with a great loss of basic freedom.

Civil disobedience by midwives has been recorded many times, when the midwives believed that the lives or wellbeing of the mother and/or her baby were at risk.  The Hebrew midwives, Shiphrah and Puah, who were prepared to disobey and deceive the autocratic, absolute authority of Pharoah, are our model.

The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, "When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.  But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live.  So the king of Egypt summoned the midwives and said to them, "Why have you done this, and allowed the boys to live?"  The midwives said to Pharoah, "Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwives come to them."  So God dealt well with the midwives; and the people multiplied and became very strong,.  And because the midwives feared God, he gave them families. (Exodus 1: 15-21, From the New Revised Standard Version (1989) of the Bible)

H+BAC=?

TROUBLE!
[H+BAC stands for Home + Birth After Caesarean]

I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].

Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.

Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.

Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.

Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.

Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.

Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.

Q. And progressing without medical assistance - that happens best at home?
A. Correct.

Q. And that's where the midwife is experienced and competent?
 A. Correct.

Q. So, why is homebirth contraindicated?

[But there's a hole in the bucket, dear Eliza ...]

Of course this little Q&A sequence is overly simplistic.

But the point I am trying to make is that 'home' is not the key issue.  The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby.  The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.

Achieving vaginal BAC is core business of midwifery.  It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.

Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.

Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices.  Either we continue to attend women with scarred uteruses professionally, or we refuse to do so.  The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.

The central issue is not about the big 'H' - homebirth.  The central issue is the midwife's right to engage in professional practice.  A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions.  In some cases that may mean going to hospital; in others it means staying at home.  At all times the wellbeing and safety of mother and baby guide the midwife's professional advice.  Home is only a setting.  Healthy mothers and babies are the outcome we desire.

Reflection on practice

Today I am using Gibbs' reflective process in reviewing an experience I have had recently, attending a woman, who I will call Linda (not her real name), giving birth in hospital. I do not want to approach this from an idealistic standpoint, or to 'deamonise' the hospital. Birth, as with the rest of life, is full of unpredictable moments when those who are present are called upon to do their best.

Alena welcomes her baby brother, Christopher

I want to assure readers that mother and baby are well.  However, I am left with some difficult questions. I question my own actions as well as those of colleagues in the hospital.

1. What happened?
Linda was treated unnecessarily (imho) and aggressively for obstetric haemorrhage.

2. Feelings: What was I thinking and feeling?
I was shocked, surprised, and bewildered when I realised that there was a full-scale emergency 'code' being performed, with not only active management of the Third Stage, but additional oxytocic drugs intramuscular Syntometrine, intravenous Syntocinon (40 IU in 1 litre of fluid) administered urgently.

3. Evaluation: What was good and bad about the experience?
What was good? Having experienced respectful care from the doctors and midwives through the pregnancy, and engaged in carefully informed decision-making up to the moment of birth, this incident was an over-reaction to Linda's known risk factors (including multiparity, and a previous caesarean birth)
What was bad: I realised that I had facilitated this chain of events, because I encouraged Linda to agree in early labour to having the IV cannula sited in her arm.

4. Analysis: What sense can I make of the situation?
I can understand why this incident happened, because I know about other very difficult incidents that this group of midwives were dealing with.

5. Conclusion: What else could I have done?
At present a midwife practising privately is not able to have visiting access for clinical privileges in hospitals in Victoria. I cannot over-ride the clinical decision of another midwife, and when an emergency code has been called, I would be foolish to interfere. My long term hope is that I will be able to have clinical practice rights in public hospitals, and in this case I would be able to take responsibility for my own clients.

6. Action Plan: If it arose again, what will I do? 

As I noted in #3 above, I had encouraged Linda to agree to the hospital's policy and have an IV cannula sited in preparation for an incident such as a post partum haemorrhage (pph). I believe Linda would have declined the offer if I had not spoken to her about it. In this case I think it was the fact that the cannula was in situ, and the hospital midwife was basically 'set up' for a pph, that somehow set the pathway.

In another similar situation, I will be careful to inform the mother that once a cannula has been sited, it is easier for staff who may be on edge for totally unrelated reasons, to 'jump the gun' and treat her as though she is in an emergency, when this is not the case.

old-style midwifery

I have tried to capture the essence of the 'extraordinary'

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

[From APMA Blog]



Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

idealism in midwifery

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

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

Where do I start?

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


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

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

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

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

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

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


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

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

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

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

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

Your comments are welcome.

The villagemidwife e-book series

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

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

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

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