Melbourne in mid-winter is grey and damp and cold. The tall concrete buildings block the weak, angled sunlight.
This week I have sat for two days in a tired meeting room in a city hotel that has passed its prime: not old enough to be interesting; not fresh enough to be attractive. The plate glass windows in the conference room revealed nothing more than the boarded up windows of a derelict multi-storey building on the other side of Little Collins Street.
The conference provided opportunities for comment on homebirth, and particularly homebirths that have gone wrong. Lawyers presented papers on topics such as 'Managing the Risks inherent in Women's Choice in Obstetric Care', and 'Practical Obstetric Risk Management: defending your care'. It sounded simple.
Human rights in the childbirth process were eloquently discussed by other lawyers who drew from both their knowledge of the law and their personal experience.
'Open Disclosure' was discussed by two speakers, and I concluded that, in order to 'defend' oneself against potential legal or disciplinary action, an adverse event in a hospital is met with what seems to me to be a charade called 'open disclosure' that is not very open, and that doesn't disclose much. Don't be too literal about the meaning of 'open' or the meaning of 'disclosure'. A curious conundrum!
A Coroner delivered, with barely an inflection in his voice, a keynote address on 'Lessons to be learned from the Home Birth Cases in Vic and SA.' In this presentation, seven cases were reviewed, the common thread being that they had been planned homebirths, with either a registered midwife or a previously registered midwife in attendance. When considering risk factors such as previous big babies, previous caesarean births, and a twin pregnancy, the conclusion was that most of these cases should not have been planned homebirths; that the midwife had a duty of care to transfer care to an obstetric unit.
In 6/7 cases, the baby deaths were declared by the Coroner to have been
potentially preventable. The Coroner does not attempt to apportion
blame, merely to discover the facts, and to make recommendations. The Coroner's filtering of the information presented at the inquest failed to notice any possible reason that a woman might have had for trying to avoid a medically managed birth; any mention of her desire to hold her baby to her breast within moments of birth; or even any recommendations that maternity hospitals provide pathways for women who want to have a known and trusted midwife providing continuity of care within the hospital.
I want to be perfectly clear here: I cannot speak for either the mothers or the midwives. I am merely an onlooker, and I have read the Coroner's findings that have been put in the public domain. I am also shocked at the tragedies that precipitated these cases into the Coroner's court.
The points made by those who spoke about women's rights were either ignored or not understood by those who spoke from the professional duty of care perspective. The fact is that pregnant women have personal autonomy; that decisions do not have to be approved by, or even understood by, those who attend for birth.
***
The presentation following that by the Coroner was from the Victorian Perinatal Data Collection Unit. I noted down a point that was briefly made, without any further comment, that, of the approximately 900 perinatal deaths in this State annually, 63% are found to have potentially avoidable factors.
The loss of a baby's life is, thankfully, uncommon in our world. Yet it is one of the most heart-wrenching experiences imaginable. Whether the death is linked to homebirth or not, everyone needs to take what lessons are available from the facts of the case. I ask myself, what lessons have I taken from these seven tragic cases?
***
I believe the huge challenge that lies ahead for midwives and the whole maternity world is to find a balance between providing advice and care that protects the wellbeing and safety of the mother and child, while at the same time respecting the woman's decisions and choices. This is not going to be easy. It is an ongoing process, and demands trust and commitment between the midwife-woman, and the midwife-obstetric/hospital system. The paternalistic dictatorial style of hospitals has, in many instances, demanded submission to hospital policies and processes. This needs to change. The misunderstanding of risk in maternity care, as was clearly demonstrated in the cases reviewed, will likely continue to open the door for self-educated, internet-researched women to make the choice of birthing without a midwife in attendance. This needs to change, to include intelligent dialogue and planning that is specific to the individual woman/pregnancy. The misunderstood partnership between woman and midwife, as was also clearly demonstrated in the cases reviewed, may from time to time place unreasonable weight on the woman's choice, and devalue the midwife's skill and knowledge. This also needs to change, enabling midwives to practise more autonomously and accountably.
Women who engage a midwife to attend them at home for birth, having an identified risk profile, such as a previous caesarean, a previous post partum haemorrhage, or multiparity, or any of the other features that are classified as risk - these women, and these midwives, need support rather than being driven underground. The midwife who is ready to go with her client to the hospital, and continue supporting the woman's informed decision-making process within the hospital, will accompany that woman to the best birth that she can have.
And, we only want the best.
Your comments are welcome.
ps - this link to the story of a maternal death is, sadly, what we will see more of if we don't maintain a midwifery profession that is 'with woman'.
Showing posts with label mortality. Show all posts
Showing posts with label mortality. Show all posts
Saturday, June 22, 2013
Friday, January 13, 2012
Millennium Development Goals: How are we progressing with the maternity goals?
Millennium Declaration
The 8 Millennium Development Goals are:
1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women
7 Ensure environmental sustainability
8 Develop a global partnership for development
Each of these goals has a potential to improve maternity outcomes in the world's poorest countries. Goals 4 and 5 give direct measures of maternity care.
If you would like to see the UN 2011 table summarising progress, click here.
Readers may wonder what significance the MDGs have in the context in which I practise midwifery. Private midwifery in and around Melbourne is, surely, for a privileged minority, who are usually healthy, well educated women, and able to pay for the maternity care they choose.
This is true.
Women who plan homebirth in my practice understand that my role includes arranging transfer to hospital if complications are detected. Well staffed and equipped maternity hospitals are within easy reach by car or ambulance, in most instances. Availability of appropriate referral services is a key to safe and optimal outcomes, whether the referral is from planned homebirth, or from small primary maternity care units in rural towns.
Women in places where maternal mortality is high may not be within reasonable reach of emergency obstetric services; may face prohibitive costs if they do go to hospital; and often delay in seeking medical intervention. Their bodies are often weakened by anaemia, malaria, HIV/AIDS, intestinal parasites, and other preventable conditions. Mothers and babies die from Tetanus, because the mothers have never been vaccinated against Tetanus. Women do not have access to acceptable family planning measures; child-brides are pregnant before their bodies are fully developed; too many women develop obstetric fistula; and the list goes on.
The challenge that I see in comparing maternity care here in Melbourne, with maternity care in some of the world's most disadvantaged settings, such as Sub-Saharan Africa, or the highlands of Papua New Guinea, is the continuing and increasing reliance on medical and surgical management of birth in the West. This logically equates to a loss of knowledge, a loss of expertise, in working with natural processes in the childbearing continuum. The excessive and unnecessary medicalisation of birth and everything related to maternity care, as is seen in mainstream maternity care in Melbourne, will not improve maternal or infant health in less developed countries. Melbourne hospitals are teaching doctors and midwives who will pass contemporary practices on to their students in all parts of the globe. Melbourne, which has world-best facilities for those who need them, must set an example of best practice in protecting each woman's ability to give birth under her own amazing power - 'Plan A', unless there is a valid reason for 'Plan B'.
For decades we have seen the global impact on the lives of babies of the loss of collective confidence in breastfeeding. Efforts to protect, promote, and support breastfeeding are required in the rich world if we want to have any impact in poorer countries. The Baby Friendly Hospital Initiative (BFHI), which in Australia is known as the Baby Friendly Health Initiative, has the expectation of the same high standards in each of the '10 Steps to successful breastfeeding', whether the hospital provides care for those who pay big money, or those who are in low socio-economic settings.
Childbirth is not very different from breastfeeding. The loss of confidence in natural physiological processes in childbirth, including the spontaneous onset of labour, progress in labour, giving birth without medical pain relief or physical assistance, expelling the placenta, and establishing breastfeeding, to name a few key points, needs to be recognised and rectified in Australian mainstream maternity care. There is no safer or more reasonable way to proceed with childbirth, for most women, than to do so under the natural, hormonally-driven processes within each woman's body. Only those for whom a valid reason to interrupt the natural processes will be better off with such intervention.
I expect any readers are likely to be already convinced of these facts, so I won't press on.
The 1996 'Care in normal birth' instruction from World Health Organisation, that
"In normal birth there should be a valid reason to interfere with the natural process" is as relevant when applied to the Millennium Development Goals, as it is in a Birth Centre in the rich world.
In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. In September 2010, the world recommitted itself to accelerate progress towards these goals.
The 8 Millennium Development Goals are:
1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women
4 Reduce child mortality
5 Improve maternal health
6 Combat HIV/AIDS, malaria and other diseases7 Ensure environmental sustainability
8 Develop a global partnership for development
Each of these goals has a potential to improve maternity outcomes in the world's poorest countries. Goals 4 and 5 give direct measures of maternity care.
If you would like to see the UN 2011 table summarising progress, click here.
Readers may wonder what significance the MDGs have in the context in which I practise midwifery. Private midwifery in and around Melbourne is, surely, for a privileged minority, who are usually healthy, well educated women, and able to pay for the maternity care they choose.
This is true.
Women who plan homebirth in my practice understand that my role includes arranging transfer to hospital if complications are detected. Well staffed and equipped maternity hospitals are within easy reach by car or ambulance, in most instances. Availability of appropriate referral services is a key to safe and optimal outcomes, whether the referral is from planned homebirth, or from small primary maternity care units in rural towns.
Women in places where maternal mortality is high may not be within reasonable reach of emergency obstetric services; may face prohibitive costs if they do go to hospital; and often delay in seeking medical intervention. Their bodies are often weakened by anaemia, malaria, HIV/AIDS, intestinal parasites, and other preventable conditions. Mothers and babies die from Tetanus, because the mothers have never been vaccinated against Tetanus. Women do not have access to acceptable family planning measures; child-brides are pregnant before their bodies are fully developed; too many women develop obstetric fistula; and the list goes on.
The challenge that I see in comparing maternity care here in Melbourne, with maternity care in some of the world's most disadvantaged settings, such as Sub-Saharan Africa, or the highlands of Papua New Guinea, is the continuing and increasing reliance on medical and surgical management of birth in the West. This logically equates to a loss of knowledge, a loss of expertise, in working with natural processes in the childbearing continuum. The excessive and unnecessary medicalisation of birth and everything related to maternity care, as is seen in mainstream maternity care in Melbourne, will not improve maternal or infant health in less developed countries. Melbourne hospitals are teaching doctors and midwives who will pass contemporary practices on to their students in all parts of the globe. Melbourne, which has world-best facilities for those who need them, must set an example of best practice in protecting each woman's ability to give birth under her own amazing power - 'Plan A', unless there is a valid reason for 'Plan B'.
For decades we have seen the global impact on the lives of babies of the loss of collective confidence in breastfeeding. Efforts to protect, promote, and support breastfeeding are required in the rich world if we want to have any impact in poorer countries. The Baby Friendly Hospital Initiative (BFHI), which in Australia is known as the Baby Friendly Health Initiative, has the expectation of the same high standards in each of the '10 Steps to successful breastfeeding', whether the hospital provides care for those who pay big money, or those who are in low socio-economic settings.
Childbirth is not very different from breastfeeding. The loss of confidence in natural physiological processes in childbirth, including the spontaneous onset of labour, progress in labour, giving birth without medical pain relief or physical assistance, expelling the placenta, and establishing breastfeeding, to name a few key points, needs to be recognised and rectified in Australian mainstream maternity care. There is no safer or more reasonable way to proceed with childbirth, for most women, than to do so under the natural, hormonally-driven processes within each woman's body. Only those for whom a valid reason to interrupt the natural processes will be better off with such intervention.
I expect any readers are likely to be already convinced of these facts, so I won't press on.
Midwives, we carry the knowledge of normal birth! We must value that knowledge, and hold on to the skills of working in harmony with women's natural physiological processes, whether in early labour, breastfeeding, birth, or the third stage.
"In normal birth there should be a valid reason to interfere with the natural process" is as relevant when applied to the Millennium Development Goals, as it is in a Birth Centre in the rich world.
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