Why do private midwives need hospital visiting access?

Yes, I gave birth to my four children in hospital. This is #1

In a perfect world, would every woman want to give birth in the privacy of her own home?

Perhaps.

In a perfect world, there would be no sickness, no pain, no decay, corruption ... no need for hospitals either.

But we don't live in a perfect world.  No matter what steps we take to optimise health of mother and baby; to optimise the positioning of the baby in the womb for a normal birth; to prevent infection; to prevent social disorders that result from smoking, substance abuse, and obesity ... no matter ... the midwife is always watching and observing in case complication or illness arises.

Home is a wonderful place for birth when the woman and baby are well, and progressing normally.  At any time the decision to stay at home may need to be reviewed.

Some people may tell me I am being driven by fear in saying this.  We in the 'natural birth' realm see slogans such as 'Trust Birth'.  I hear midwives speaking of the physiological processes in birth as though they come with an iron-clad guarantee.

No! and No!

Don't get me wrong.  Birth is an amazing, awesome process - most of the time.  Natural physiological processes in birth and breastfeeding, together with the cocktail of hormones, and the physical and psychological factors that can influence these processes are truly wonderful - most of the time.

There is no better way for most than the natural process.  God the creator made the woman's body as well as the man's, mysteriously in the image of God, and said it is good.  That is a profound truth.  The balancing truth is that today we are able to protect and save life, through medical intervention, to a greater degree than ever before.

That's where hospitals come in to my thinking today.

I'm not talking now about a perfect world.  However, a better world is a reasonable goal.

There will always be women who need or choose to give birth in hospital.   These women ought (in a better world) to be able to use the services of a known and trusted midwife in hospital.  That option is not commonly available in the world we live in today.  Some women are fortunate that they have a wonderful midwife allocated to care for them in their labour, or even in a caseload/know your midwife program.  But the usual feature of birth in Australia today is that a woman is attended in labour by a stranger - someone she has not met prior to coming into labour.  Women with financial resources and private health insurance might have an obstetrician who has provided their antenatal care, with whom they feel a bond of trust, but that doctor is not in continuous attendance - the midwife/stranger is. 

In a better world, women would be able to engage their own midwife, or small group of midwives, who are committed to providing continuity of care that spans the community and the hospital.

In a better world, midwives would be able to choose to work either privately or as employees of a hospital or health service; either as shift workers, or with a personal caseload, or in one of the multitude of hybrid models of care that are designed to meet the individual needs of the women as well as the midwives.  These options should provide reasonable rates of pay and conditions.  Midwives can only do our job well when we are in good shape ourselves.  We teach women to be intuitive about the needs of their children and themselves - we ought, in a better world, to apply the same thinking to ourselves.

The journey to maternity reform has been an uphill one.  I am hoping that it won't be long before we see a pathway to a better world of maternity care.

Thankyou for your comments.

transferring to hospital

I am reflecting on a few recent situations in which I have made the 'call' that we need to go to hospital.  In my mind there has been no doubt. 

It's fairly clear to me, that when a woman and baby are strong and well, home is ideal.

But ...

when the mother is not well, physically or emotionally, it's not good at home.  Even a mother who has no continuous support in her home - should she be left alone a mere 3 or 4 hours after the birth, when I pack up my gear and go home?


Midwives have a set of guidelines, published by our College (ACM), to set down systems for decision-making about consultation and referral (see previous post).  They do not actually address homebirth, but are a list of the conditions in which a midwife would expect to work collaboratively with an obstetrician or an obstetric unit in providing maternity care - meaning that the woman is in hospital for the birth and any other continuous acute care. 

The ACM Guidelines list hundreds of 'indications' for consultation (with) and referral (to) specialist obstetric or newborn or other medical services.


Rather than focus on 'indications' or medical/obstetric conditions, I prefer to turn the coin to the other side, and ask the questions:
"Is the mother well?",
"Is the baby well?"

If the answer to each is "yes", there is no reason to intervene prior to the onset of labour, so we wait for labour to establish spontaneously.  This is the only woman who, in my opinion, is fit to proceed with home birth. 

If the answer to either is "no", the hospital probably has real advantages.  Homebirth requires strength, and intentionality about wellness.


Many women who plan homebirth have serious concerns about what might happen in hospital.  They know about continuous monitoring in labour, and scheduled vaginal exams, and narcotic analgesia being offered at the time when they are vulnerable to suggestion.  They know about protocols for normal progress; about high rates of inductions and augmentations, and all-time high rates of caesarean births.  They know about babies's cords being cut, and babies being separated from their mothers. 

Yes.

When I say to a woman, who has gone to considerable expense and trouble to plan homebirth, that I want her to go to hospital to give birth to her baby, I know that she may experience difficulties with the system.  Hospitals are not committed to protecting, promoting and supporting natural physiological processes in birthing.  Hospitals are concerned about patient/staff ratios, availability of emergency services, and a hundred and one issues that make hospitals relatively safe places for the majority of patients and staff and visitors.


Transferring care from planned homebirth with a humble midwife, to a hospital with 'teams' of midwives, nurses, and a heirachy of doctors from the new Resident to the obstetric Consultant, can be a daunting process.  I will recommend that transfer if I believe the woman's and her baby's needs are likely to be better served in hospital than at home.   The best is all that I want.


The person who owns the natural processes in birthing (and nurturing of the baby) is the mother.  She is the only one who can give permission for a staff member, or a privately employed midwife, to take her pulse, or listen to her baby's heart beat, or assess her cervical dilation and the station of her baby's presenting part.  The mother owns her body, regardless of where she is intending to give birth.

This ongoing process of decision-making is guided in my practice, not by a 84-page spiral bound guidance manual, but by the two simple questions:
"Is the mother well?",
"Is the baby well?"