midwife-centred language

We midwives have theories about woman-centred care.  The woman and her baby are the focus, and their individual needs guide the planning and providing of maternity care.  The provision of basic primary maternity care through the months of the pregnancy, birth, and neonatal period from a known midwife facilitates, in theory at least, the development of a unique partnership between the woman and her midwife, and supporting woman-centred care.

Many times, in reality, 'woman-centred care' is a hollow and meaningless phrase.   Aspects of the care are dictated by the service providing maternity care, limited by staff numbers and funding arrangements, and fragmented into 'items' that can be entered as numbers into databases.

My attention was piqued the other day when a midwife in a hospital used the word 'passive' in relation to the third stage.  The mother who was about to give birth spontaneously, without medication, had indicated that she did not want synthetic oxytocin to be injected into her after the birth.  The midwife, correctly, informed the woman that the hospital's policy required her to perform active management of the third stage.  The woman replied "No, thankyou."  The midwife then referred to what proceeded as 'passive management'.

• ... passive [management], as opposed to active management

Before you nod your head and say, "OK, passive means not administering the oxytocic, not applying cord traction, not checking the fundus for evidence of separation of the placenta (and whatever else, such as cord clamping, is considered part of active management)", let me explain what is wrong with the concept of 'passive' third stage.

• midwife-centred language

Active management, or passive [non-]management are terms that refer to the midwife's actions.  The woman is virtually invisible.  This is not woman-centred care.

• ignorance

I witness appalling ignorance within the mainstream midwifery and obstetric community with regard to the uninterrupted physiological processes that lead to safe and optimal completion of the third stage of labour.  The 'broad brush' approach, treat everyone, regardless of the need, as required by the hospital's policy, leads to the deskilling of midwives who ought to be competent in protecting and supporting the physiological processes in childbirth.  This is also not woman-centred care.

• denial of a woman's ability to make an informed decision

A woman who is progressing spontaneously in birth, and who indicates that she prefers a spontaneous and unmedicated third stage, can easily be denied the opportunity to proceed when the midwife uses the 'hospital policy' card. 


What is a physiological third stage?
Put simply, a physiological third stage is the spontaneous and unmedicated completion of the birthing process, after the birth of the baby (second stage), resulting in the expulsion of the placenta and membranes.

The Women's Hospital guidelines* defines physiological management of third stage as:

Physiological management: The birth of the placenta and membranes are expelled by maternal effort only and without using uterotonic agents or controlled cord traction.

[note the midwife-centred language: turning the focus from the woman, whose body is achieving a significant and healthy function, to the midwife.]

This is a totally inadequate definition, and is evidence of my previous assertion that midwives and obstetricians have become de-skilled in supporting physiological processes in birth.

I have described aspects of physiological third stages in recent posts, for example:

... The cord was not clamped.  We supported the mother as she stepped out of the birth pool, holding her treasure to her chest, dried them off, and sat them quietly in the prepared chair.  As contractions returned, the mother stood, then squatted over a plastic bowl, all the time holding her naked baby against her naked body, and the placenta was expelled spontaneously.  Blood loss was minimal.  [from The After-Glow]

 and

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

What is the midwife's role in physiological third stage?

Having accepted that a woman who gives birth spontaneously and unmedicated, and who is intentional about continuing in the natural physilogical mode unless there is "a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: a practical guide),  the midwife's role is (obviously) to support and protect that natural process.

In the two birth accounts that I have referred to above, the midwife's role included assisting the mother into a supported position, such as sitting upright on a chair, with warm, dry wraps around herself and her baby.  The midwife manages the environment, rather than the labour, encouraging the mother to focus exclusively on her baby who rests quietly in her arms before seeking the breast.  The midwife ensures any activity around the mother is kept to a minimum.  If photos are being taken, this is done in an unobtrusive way.  The midwife notices signs of separation of the placenta, and instructs the baby's father on how to support the mother as she stands or squats over a bowl to expel the placenta, if she needs to.

There is nothing at all passive about the midwife's role in supporting and protecting the natural physiological processes in birth. 

I need to sign off now, as a mother is in labour and I expect to be called soon to attend.

The message of this post is that when we, the midwives, focus on the woman, we are able to work with her.  Our language reveals the focus of our care: either the woman, or ourselves.


*Active Management: go to the Women's Hospital guidelines and click on 'Labour-Third Stage Management'

The midwife

I have been enjoying the BBC series 'Call the Midwife', which has been shown on Australian ABC TV.  This week we will see the fifth and final episode in the series.

(If you go to You Tube you can apparently download and watch the full first series.)

Since I began writing my stories in the mid 1990s, in The Midwife's Journal,  I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested.  The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.

Last week I wrote about women's rights in childbearing.  This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife.  The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.

Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.

Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young.  Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.

A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few.  They may follow pregnancy-birth related social media groups and forums.  She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.

I said it's a potentially overwhelming burden of knowledge about aspects of birth.  I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try.  I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax.  I wonder where he obtained this knowledge.  I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.

One mother who gave birth about a week ago had confidence.  I have been with her for several of her babies.  She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze.  Her preparation for birth included good food, adequate rest, and work about her home.

As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet.  I rested on the couch.  Then she invited me into her bedroom: "it won't be long now," she told me.

Quietly and steadily she guided her baby down and out.  There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it.  Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation.  The third stage proceeded without the need for any medical intervention, and there was minimal blood loss.  When I visited this mother she was sitting outside in the gentle spring sunshine.  I saw a well mother, with a well baby at her breast. 


In telling this story I have not mentioned the buzz word of the day: collaboration.  Those in authority today will insist that collaboration is the key to safe maternity care.

Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees.  The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications.  This is basic midwifery.  The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.


Thankyou for your comments.

Millennium Development Goals: How are we progressing with the maternity goals?

Millennium Declaration

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 diseases
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.   

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. 

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.

midwives in the making

(c) Picture used with permission

Yesterday I had the privilege of presenting a 1.5 hour talk on private midwifery practice to the midwifery students at Deakin University in Burwood. I love having the opportunity to inspire the next generation of midwives.

I know some visitors to this blog are studying midwifery, in many countries. In today's post I want to give you an outline of my presentation, and links to some of the key documents.

The parts of the presentation were:

• Overview and introduction: developing a strong 'midwife identity'
• Private midwifery practice, changes in legislation with Medicare rebates and other changes for eligible midwives. Go to Midwives Australia for more information and links
• Planning for birth: philosophy of birth based on the statement that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996); decision-making concepts of 'Plan A' and 'Plan B', birth preparation meeting handout
• DVD of a beautiful home/water birth [One picture used here with permission - the visual image is sooo powerful!]
• Highlighting aspects of midwifery practice that can apply only when the whole labour progresses under natural hormonal, unmedicated processes: physiological third stage, and baby's transition from the womb
• Questions

Please follow these links if you are interested in the topics mentioned. I intend to prepare a post on 'Planning for birth' at my private midwifery blog - will do that as soon as I can.

For the record, my relationship with the Deakin University School of Nursing and Midwifery is that I am employed as a casual lecturer, and as a tutor and marker for some of the midwifery Professional Development Unit Learning Packages. Several years ago I prepared one of the Learning Packages on the midwife in the community (PDU 323) and more recently I have written a Learning Package on Caseload and Homebirth midwifery, which is being processed in preparation for release.

Midwifery knowledge

click to enlarge

One of my current projects is to lead the review of the Maternity Coalition INFOSHEETs - see the APMA blog for more detail. I also headed the previous working group which put together these information sheets in about 2006. Our aim was, and is, to provide reliable information that supports informed decision making for women and midwives who seek to promote normal physiological birthing, and to work in harmony with the natural processes in pregnancy, birth the perinatal period.

It's a big project, and the working group is asked to consider current evidence and practice, and check the information provided on the INFOSHEET. Recently we completed the first to be reviewed, A Baby's Transition From the Womb to the Outside World, (see jpeg file above) and are now working on The Third Stage of labour. Unfortunately I do not know how to link a .pdf file to this blog, so if you would like a copy of the revised document emailed, please send a request to me joy[at]aitex.com.au

A midwife commented to me that "what we need to say loud and clear is that we use Midwifery Knowledge which is very different and definitely not less than obstetric and surgical belief."

Yes, I (sort of) agree – but remember that ‘midwifery knowledge’ is not well defined, as is also the case with some 'medical' practices, or 'alternative health' knowledge. If our knowledge embraces truth, it's true regardless of whose it is. Midwifery knowledge should not belong to midwives only - it should be common knowledge.

If 'midwifery knowledge' is to be accepted as reliable it has to be well articulated and put out to scrutiny. I believe that’s what these infosheets are trying to do.

Management (or non-management) of the Third Stage (S3) and the time interval from birth to clamping of the umbilical cord are two examples of what I would call 'midwifery knowledge', compared with rituals that have been widely accepted by modern obstetrics and midwifery, without any evidence to support them.

I am excited to see changes in the mainstream maternity attitudes to time of clamping the cord, and protocols for active management of S3. This has been in response to evidence, just as the virtual mandating of active management of S3 in hospitals was in response to flawed evidence.

We must continually engage in critical review of all that we do. Many hospital ‘guidelines’ require [that’s an oxymoron I know] immediate clamping of the cord, and none of them that I have seen have a reference linked to it.

Watch the APMA blog in the coming weeks for developments in the revision of this INFOSHEET. This is all voluntary work, and it is put out in the public domain to encourage involvement of anyone who is interested.

Today’s Age newspaper has an article about a research program for which ethics approval is being sought for a cord blood trial, and the relationship between a baby receiving its own placental transfusion and cerebral palsy. There are many questions that this research, if well done, may begin to provide answers to. The proliferation of private facilities that collect and store cord blood, without any reliable evidence that the baby will benefit from it - and without any evidence that the baby has not been harmed by the withholding of that placental blood at the time of birth - is evidence that many parents have taken a punt on this issue.

Your comments are welcome.