Natural: is it good, bad, neither, or both?

It has been months since I put (virtual) pen to (also virtual) paper in this blog.

I have needed time to reset my body clock; to recover from the exhaustion and burnout after many years of midwifery and related professional activism.  I don't know if I have fully recovered yet.  The reality of ageing gives much to ponder; a relentless march towards exhaustion.

In recent months, with no midwifery to absorb time and energy, I have taken up some new challenges.  These photos show the performance of the 'Human Knitting Machine' at the Kyneton Show.

performance of the 'Human Knitting Machine'

The finished product

I am enjoying our new home, and the rural Central Victorian lifestyle.  The daily patterns of weather; the sun and clouds and wind; the subtle changes in the seasons; the growth and change in the garden - these natural life factors add wonder as well as sometimes concern to our days.

We are often delighted, and sometimes concerned, by the little members of our family and friendship circle, as they proceed through their developmental milestones.  This is all part of natural processes: sometimes good, sometimes bad, sometimes neither, and sometimes both.



Just as with retirement from attending births my life has changed, so has my capacity for writing.  Blogging has, for me, been closely linked with practice.  In the past, as I pondered the events of my professional life, the thoughts that surfaced became seeds for comment in this blog.

I now find that I need to shift my point of view from that of a midwife who was intimately involved in the day by day decisions related to maternity care and the lives of mothers and babies, to a more distant view.  As a retired midwife, my view is that of guardianship of birthing within the bigger picture of living.  I care deeply about what my society does to mothers and babies.  My right to comment continues as in the past.  Readers will need to decide whether my thoughts are valid and useful, or not.


Today I would like to consider *natural* in the maternity context.  Previously I wrote:

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. 

I know of no better way for birth than to proceed under the spontaneous, hormonally mediated natural process from conception to birth, and beyond to nurture and mothering of the infant - MOST of the time.

Natural pregnancy, birth, and nurture of our children is good - MOST of the time.  Regardless of race, wealth, or other social factors, our bodies and minds are set to the 'default' that whatever is natural will be, unless something is done to redirect the course of events.

Whether we apply this principle to maternity issues, or any other ordinary life event, *natural* can be awfully unpredictable, and unmanageable.  There is no therapy that can make it work better, or reign in the unpredictability.  There is no drug that will 'fix it'.  Modern Western medical management of maternity care seeks to minimise 'risk', and in so doing reduce the impact of the spontaneous natural process: to remove the 'MOST' element, and make maternity just another predictable, manageable medical event that complies with medical guidelines and protocols.


For the midwife who is committed to working in harmony with natural processes, except when there is a valid reason to interfere, the big challenge is to know when the natural process is likely to result in harm; when medical and other interventions are likely to lead to improved outcomes.  This requires clear thinking by the midwife or other primary care professional, and independent clear thinking by the woman who receives the advice that a process other than the natural one is being recommended.

I want to emphasize the need for independent thinking by the woman.  The first decision to interrupt the natural birthing process is profound, and the woman must take responsibility for it as her own decision.  It doesn't matter how much trust there is between the woman and her midwife, or doctor for that matter.  The first intervention, which can quickly cascade into a whole bunch of subsequent interventions, can be a life and death decision point.  As can the decision not to intervene!

I started this post by saying that

I know of no better way for birth than to proceed under the spontaneous, hormonally mediated natural process from conception to birth, and beyond to nurture and mothering of the infant - MOST of the time.

During the past couple of decades I have experienced progressive increases in reliance on medical intervention in maternity decisions, paralleled by loss by women in their ownership of their commitment to natural, spontaneous, unmedicated birth.  In Australia today, the woman's ability to make her own consumer choices has eclipsed any valuing of or protecting physiology.  This has made maternity decisions more like walking down the aisle in the supermarket and making selections based on price, packaging, or some other possibly insignificant factor.

I'm not wanting to suggest that I think maternity care was better 20 years ago, when I was busy with midwifery and maternity activism; or 40 years ago, when I was having my own babies; or even 60 years ago, when as a young child I learnt much about mothering from my own mother.

Twenty years ago we were working to demand that midwives be called midwives, not nurses, in hospitals.  We had supported the release of a Code of Practice for Midwives in Victoria.  We were promoting the Baby Friendly Hospital Initiative, through which maternity hospitals were supported in the protection, promotion and support of breastfeeding as the health promoting natural resource of mothers and their new babies.

As time has passed the indicator of reliance on medical rather than natural processes has been the consistently increasing rate of caesarean births in otherwise healthy pregnancies. 

Women don't, on the whole, choose caesarean surgery.  They enter systems of care that sets up the cascade of interventions, so that there is no safe alternative but to bring it all to a conclusion, and when that happens the most rational and helpful option is surgery.  Women, midwives and doctors play games that set up a mirage of choice as the prize, when in reality there is no choice.

Natural birthing can be very good, or very bad.  It can be neither good nor bad.  It can be both good and bad.  Society will either benefit or pay the price for its reliance on the natural physiological processes in maternity decisions.

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

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

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

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


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

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

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


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

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

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

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

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

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


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

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

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

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

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

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

Why?

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

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



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

the importance of trust

I (Joy Johnston, aka villagemidwife - see note at the end of this post) often say to women in my care, "I need to trust you, and you need to trust me."

This sounds reasonable to me, particularly within the context of primary maternity care that spans the pre-, intra- and postnatal periods.  While midwifery is not rocket science, the commitment a woman and her family make to a new baby is perhaps the most far-reaching investment they will ever make.  Trust is something to value: it's not lightly given; it's not easily won; and once won it can be lost.  I can not assume that a woman in my care is trusting me, and she may not know if I am trusting her.  This is the case especially when difficult decisions need to be made: when I am asking the woman to trust my professional judgment and advice in order to protect the wellbeing of the mother or child.

According to contemporary thinking, midwives and women engage in a partnership that is based on reciprocity and trust (a phrase coined, as far as I know, by sociologist-academic Karen Lane.)  It's a two-way relationship.  It's a relationship that builds over time, and is tried and potentially strengthened as each woman and her midwife navigate the unique terrain that each pregnancy-birthing episode offers.

Partnership should not be seen as an idealistic notion: the current internationally accepted definition of the midwife includes:

... The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.... (International Confederation of Midwives)

The stark reality of life is that some people find it difficult to trust anyone, while others give away their trust lightly to anyone who sounds as though they know what they are talking about.  Most people fit somewhere between the two extremes.  The definition of the midwife is looking at the big picture, while the experience many women have with a midwife or midwives may be far removed from any sense of working in partnership.  Similarly, midwives who provide continuity for their own caseload of women may find themselves in situations in which the sense of partnership is sub-optimal.

A young midwife told me she felt that a woman in her care does not trust her because she has had only a few years' midwifery experience.  A couple of comments that the woman made left the midwife wondering if she was able to continue as midwife. 

That discussion prompted me to think a lot about what it means to trust, and the importance of trust in midwifery - in the processes of decision-making that a midwife uses.

I do not, ultimately, trust birth.  Birth, like any other part of life, is able to be complicated by disease and corruption.  The midwife's role in maternity care is to firstly work in harmony with awesome natural processes, and secondly to recognise complication and intervene to prevent loss of life or damage. If I trusted birth there would be no need to work as a midwife.  I would simply accept 'Que sera sera' (what will be will be).

I have reflected on the many women for whom I have provided midwifery services over the years, and wondered if my statement, "I need to trust you, and you need to trust me" is true.

Many women have gone through the birthing process with minimal intrusion or action by me: my job is to be 'with woman': to watch and occasionally give support, then fill out the paperwork.  In almost all of these cases there has been, I believe, a working partnership based on reciprocity and trust.  The woman who is trusting her midwife is able to surrender to the work of her body when the time comes.

Some women have needed more than I have been able to give them in community based midwifery care, and we have transferred care to a hospital maternity service.  I expect that in some of these situations the woman's ability to trust me as her midwife, or to trust herself as the birth-giver, has been less than optimal.  In some, my ability to trust myself as midwife, or the woman as the birth-giver has been compromised.  At times I may have been too weary, or emotionally drained, or fearful, or ...




Spring 2013

Tomorrow is the official start of Spring in the southern hemisphere.  It's exciting to see the tender young leaves on deciduous trees, and flowers on the fruit trees.

Spring 2013: Bonsai Japanese Maple and azalea

The signs of new life are within the natural processes that offer endless wonder and thrill to those who are ready to see.

Midwifery has taught me to respect and work in harmony with the natural processes as much as is possible.

These little bonsai trees have been in my care for several years. 






postscript...
Don't believe everything you see on the internet!
I began today with "I (Joy Johnston, aka villagemidwife...)" because, for some reason Blogger (the program I use to write this and other blogs) thinks I have changed my name. Probably my own fault - I told my sister I would help her get started writing a blog, and somehow Blogger now thinks that I am my sister - Barbara Clark. Everything I have written is now attributed to her, so I need to either find out how to get into my blogger profile and change my 'name', or get used to writing under a pseudonym. I have followed the instructions to go to Blogger profile, but keep getting a message "oops that didn't go well"!

I'm just venting, but if you have a suggestion for fixing it, I'm keen to get it sorted out! XXjoy

pps
Thanks Paul for fixing it.

availability of midwives for homebirths

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What am I saying?

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

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

More evidence ...

... demanding action.

For many years the buzz word in maternity care has been 'evidence'.  'Evidence-based' maternity care guidelines can be found everywhere. 

Application of the evidence into mainstream maternity care is quite another matter.

From my perspective, it's great to see another piece of reliable evidence supporting midwifery continuity of care /caseload midwifery/ one-to-one midwifery.  This evidence is published in a respected professional journal, BJOG, and International Journal of Obstetrics and Gynaecology, reporting on research carried out under the strict rules of randomised controlled trials, by the La Trobe University team of midwifery academics, led by Associate Professor Helen McLachlan.

The title of the paper is:
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Authors: McLachlan et al, BJOG (2012).


The team of authors of this paper includes midwife academics who were prominent in the 'Team Midwifery' research from LaTrobe Uni more than a decade ago.  'Team midwifery' was adopted into many mainstream maternity units, in an attempt to reduce the huge number of midwives who provided care for individual women during their prenatal, intranatal, and postnatal experience.  Women were allocated to the 'Green team' or the 'Pink team'.  Midwives work ordinary hospital nursing shifts.  Women under 'team midwifery' are usually attended in labour by midwives who are strangers. 

Two papers addressing Team Midwifery, authored by Professor Ulla Waldenstrom and others, and Mary-Anne Biro and others in 2000 in the journal BIRTH presented the research findings, and a commentary was written by Karyn Kaufman.  Kaufman, a midwife academic and a member of a community-based midwifery practice in Canada highlighted in her review the lack of difference between the control or ‘standard care’ and the intervention, team midwifery.  Kaufman commented that “midwifery care that follows strict medical protocols is not the same as midwifery care that is enacted from a philosophy of normal birth and is individually negotiated with labouring women.”  This statement sounds logical, yet many Australian midwives at the time may not have realised that midwifery care for well women can be enacted from a philosophy of normal birth.

The primary outcome of the continuity of care by a primary midwife (caseload midwifery) trial is that

"In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk shows promise for reducing caesarean births."  

Besides having fewer caesareans, women allocated to 'caseload' were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care.  

Good for mother, good for baby.

Good for the midwife, too.

In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

When a reduced likelihood of caesarean can be demonstrated for women at low risk of complications, it's time for the midwifery profession to celebrate.  

Evidence demands action.

This is reliable evidence.

This research was carried out under strict controls.

Midwives and maternity services must be challenged to apply the evidence to practice.  The usual practise of midwifery should be in a caseload model, working autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A').  Not as shiftworker nurses in hospitals who work as assistants to obstetricians.  

Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.

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)

Bungee jumping on a short cord

Midwives who attend strong, healthy women for their births are used to seeing mothers give birth unassisted, unmedicated, and with an ecstatic and triumphant cry. We are used to seeing labour establish and progress in a purposeful way. We are used to the power of the birthing process, which takes the woman beyond any limit that she imagined she possessed.

Occasionally we are surprised, even confused.

Especially when the woman has other babies who have all followed the standard 'normal' journey. ... when labour seemed to be established in the morning, so the midwife and the birthing team were summoned. After the greetings, and a cup of tea, and some conversation, and another cup of tea, and talk about what we should do for dinner, and mother lies down because she's feeling tired ... and the fetal head is still floating high and mobile. This mother has given birth previously, and there is nothing apparent in the size or presentation of the baby. Her contractions appear strong when she stands up and walks, but they become weak and infrequent when she rests. 

I could name several women who fit this picture, the most recent last week.  When I looked at the placenta with the mother we commented on the short cord.

The image I have in these 'slow start' multiparous births is that the baby was bungee jumping – pressing down on the cervix when the contraction’s there and mothers upright, and floating away when mother lies down or is not contracting. 

The cord may be short because of entanglement, or simply short.  The distance from the baby's umbilicus to the point of insertion of the placenta on the uterine wall does not change.  The distance between the placenta and the cervix can be reduced by amniotic fluid release, by contractions, and by the mother's position. The critical 'tipping point' will be reached only when that fetal head can dilate the cervix and enter the birth canal.  Then, it's "coming, ready or not!"

This is an article from Midwifery Today 

The Cord and the Strength of Life 
I have observed babies being birthed with the placenta detached and following right behind them for over 20 years. Throughout that time I have kept mental notes, observing, recording, pondering.

Then one day, finally, it all added up. The explanation is a short umbilical cord, a phenomenon that requires us to allow time for the baby, the cord and the placenta to descend slowly through the birth canal, in the wisdom of nature, for a healthy and natural birth. My first encounter with a short cord began with a false labor. The mother thought this was the day. She called me, and I stayed with her until labor ceased several hours later. The mother and baby were fine. There was no good reason to intervene, despite the fact that she was multiparous with 4 cm dilation and the baby was not engaged. I warned her of possible cord prolapse and asked her to be aware of her baby’s activity. A couple of days later she called me again. The birth was very quick and the baby was born with shoulders and body entangled in a barely pulsing cord. The newborn had some blood on his bottom because the placenta had separated at the time of birth. He required stimulation and oxygen, but it was all resolved quickly and within the realm of the normal. I have watched vigilantly for short cords ever since.

Two weeks ago, some twenty years after I noticed it for the first time, it happened again. This time it was with a mother who had had three babies. The last two had been very fast. She had always had mild contractions before going into labor, but this time she had more. As she was multiparous, I initially did not think there was a problem. About ten days after her due date I thought she was going to have her baby. Her uterus looked so low that it was “by her knees.” But it did not happen. “Something is strange,” I thought while checking her. I sighed. The baby was floating, even though the uterus was very low. It seemed the baby ought to be engaged, but he was not. I then listened to the baby’s heart tones and found normal heart tones but with minimal decelerations. The heart tones were at 140 and descended to 126 or so in the middle of mild contractions. I listened to the heart tones every three days. The mother was noticing movement. We decided she should try to induce herself through nipple stimulation and an enema of medicinal plants. I gave her an exam in which I stimulated the opening of the cervix. The contractions began, and she dilated another centimeter easily. The heart tones remained within normal ranges.

... However, everything stopped after a few hours. The mother was already at 5 cm, but the cervix remained inflexible. Although the baby’s head was in a good position, he was not engaged, and therefore was not exerting pressure. After the second attempt I sat down to think. I concluded that we were dealing with a short cord. In any other situation a vaginal exam, some nipple stimulation and an enema would have produced labor.

But beyond the mother and me, the wisdom lies between the baby, the cord, the placenta and the uterus. You can confirm that you are dealing with a short umbilical cord by observing the abdomen. During contractions, and sometimes without them, the baby appears engaged, even though a vaginal exam reveals that she is floating. It is important to avoid interventions that force the mother’s body to enter the birth process before the placenta and uterus are ready. The fundus has to descend with the baby. This process takes time. Contractions that cease despite dilation of 2–5 cm in a mother with previous fast births and no other complications indicate the possible existence of a short cord. Observation without intervention is important in these cases. 

—  Marina Alzugaray Excerpted from “The Cord and the Strength of Life,” Midwifery Today, Issue 70

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.

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.