Nipples that hurt

A mother who welcomes her newborn child to her breast is filled with a surge of love, a surge which is repeated each time they engage in this intimate act. The mother feeds her baby, and the baby feeds from her mother: a dance that takes two people working harmoniously.

Our nipples are beautiful, important, and highly sensitive parts, essential to mother-baby bonding and nurture. And because they are so important, they are also points of vulnerability in the establishment of strong mother-baby attachments. And when nipples become grazed, blistered, and cracked the relationship between that woman and her baby is truly tested. There is no easy option - a newborn baby needs milk from her mother every time she indicates interest or hunger. The act of giving and taking the milk is part of the life struggle that forges a strong bond between them.

Breastfeeding unites mother and baby in a health and wellness cycle. As in birthing, there should always be a 'valid reason to interfere with the natural process', and any interference carries a potential cost. Sometimes there is a valid reason. Bleeding, severe pain, horrible, deep pain. It's the antithesis of that serene Madonna and Child image that has been passed down over many generations.

Breastfeeding experts can list off many reasons why a mother's nipples are hurting. Often the mother gets advice from a variety of caring and concerned people, including family, friends, neighbours, and health professionals.

Damaged nipples usually present in the early postnatal days. There is no single solution to this problem. No matter what caused the initial damage, the process of recovery will require careful and consistent management by the mother, who needs strategies for healing as well as for ensuring that her baby is fed. The mother needs consistent advice from a midwife who she trusts, and who is competent in advising and making interventions that protect nature's goodness in providing the breastmilk for the baby. It's essential to keep the interests of both mother and baby in mind - baby needs frequent feeds that are sufficient to send her off to sleep. Mother needs the milk removed from her breasts, establishing the supply-demand cycle, and protecting the breasts from engorgement.

I have seen many mothers and babies struggle through the early days with painful nipples. My heart goes out to each one - each mother who feels the pain and the distress, and each baby who does all she or he can to get that precious milk from mummy. And I have seen them come through, days or weeks later, proud and confident, with healthy nipples, healthy lactating breasts, and healthy happy babies.

How many midwives do you need?

I was surprised when Sue, who is planning homebirth, told me that Karen, her midwifery student, was not 'allowed' to be present when she gives birth. Karen has come to several prenatal checks, and is doing the 'Follow Through Journey' with Sue.
"Why?" I asked.
"Karen's mentor from the University told her that she was not allowed to be there because you [referring to me] don't require a second midwife at the birth." was the reply. "She (Karen) said she thought it was a requirement of the Nurses Board, so that students aren't expected to stand in as the secondary midwife."

My surprise turned to annoyance. I felt I needed to defend myself. The logical implication was that I was in some way offering care that was of a lesser standard than those midwives who attend homebirths in pairs. In fact, there is NO requirement of the regulatory board, and there is definitely NO expectation that students will stand in as the 'secondary' midwife, whatever that may mean. I felt annoyed that an assumption had been made about my professional decisions in attending this birth. Anyone who has talked with me about my practice, or looked at the names on the calendar on the wall of my office, would know that whenever possible in homebirth I arrange to have a second midwife as an 'apprentice' - a midwife who is working on making the transition from hospital shiftwork to caseload practice. This is done at no cost to the woman, and is a wonderful opportunity for midwives to extend their knowledge and skill. But it's not done because I need the help, or because the birth becomes in any way safer in having another pair of hands. If I wanted that I would be working in a big hospital with emergency buzzers and operating theatres.

Karen's mentor, appointed by the University, is an independent midwife who does routinely book a second midwife for each planned home birth. That puts her practice and mine in competition for business - women may choose me because the fee they would pay two midwives is considerably greater than the fee I charge. The decision to require two midwives is a risk management strategy, in the same way that some people in Melbourne make a booking with a medical practitioner as well as one or two midwives. That doctor is able to extend the possible interventions that are available: antibiotics or Pethidine can be given, or a Ventouse extraction can be attempted - options that a midwife cannot offer. Women planning homebirth in Melbourne's leafy Eastern suburbs have the choice of a solo midwife, or two midwives, or a midwifery group practice, or a midwife and a doctor.

I want to make it clear that I do not intend to argue that a midwife working 'solo' is better than a midwife working with a partner. I do believe each woman planning homebirth needs to make the decision for herself as to what she needs. If a woman feels she will need a lot of 'support', she will probably not ask me to be her midwife.

One of the main arguments presented as the reason for requiring two midwives is that at the time of birth, both mother and baby may require professional attention. Without going into detail in this brief discussion, I would like to outline some major differences in homebirth as I know it, when compared with standard medical models of maternity care.

• mother and baby are usually well in the labour - no analgesic medications or stimulants of labour are used in homebirth
• the baby's umbilical cord is not cut at birth, and usually not cut until after the placenta has been birthed
  
• because the baby's umbilical cord has not been cut, any resuscitation of the baby must be done with the assistance of the mother. This would usually be done with the baby lying on a towel on the floor, and the mother kneeling near, and facing the baby. The midwife works to resuscitate the baby in this position
  
• if the mother is experiencing excessive blood loss after the birth, an injection of synthetic oxytocic may be used by the midwife in quickly managing the bleeding.
  

It is not possible to guarantee a particular outcome. However, when working 'solo', a midwife is relying on working with the mother in promoting normal birth, rather than relying on the number or the skills of people in attendance.

If I was setting up a maternity care program with government funding so that all prospective mothers could have access to services that are likely to promote the best health outcomes, that program would include the choice of homebirth. Each woman would be in the care of a midwife who is her primary or first midwife, and a second midwife, who backs up the leading midwife, and assists at the birth. These two midwives provide primary care throughout the pregnancy and birthing journey.

One aspect of working in a little team, with a second midwife, and a midwifery student, that I thoroughly enjoy, is the sharing of knowledge, and the reflecting together on events. Midwives learn from each woman, and from other midwives, each time we enter the intimate birthing space of a woman. Midwives learn to access our own intuitive knowledge, sensing the progress and the struggles that women must engage with as they in turn learn to work in harmony with their bodies.

NOT QUITE 24/7

On Sunday I was feeling quite unwell, and thought I was coming down with a cold, so I asked Karen if she could do a postnatal home visit for me. It was good to stay in my nightie and spend a quiet day, rugged up by the fire.

I had agreed to cover for Andrea on Sunday night and Monday, as she was taking the Lactation Consultant (IBCLC) exam. On Monday morning I woke up feeling stronger and was thankful that I had not been called out that night. Shortly thereafter the phone rang, and it was the husband of Andrea's client, who I will call Jen. Jen was having some contractions; her waters had not broken, and she had not noticed a show. She didn't want me to come yet - just wanted to know that I was available for her.
It was not long before Jen's husband rang again and asked me to come. I headed down the new East Link toll road, and found the house without difficulty.
This was Jen's second baby, and she progressed quickly and beautifully. After getting into the bath she asked me if I thought she had long to go. "Not long now" I said. "Are you just saying that?" she asked, with a look of surprise. The next contraction was strong and she felt the unmistakable bulge. I called her husband, and she gave birth in the bath tub to a healthy baby boy. The baby's bag of waters had not broken until after his body had birthed, so I lifted back the membrane as we welcomed the little one.

As I drove home I reflected on midwives covering for each other. We do our very best to be there 24/7, but there are times when we need to be somewhere else. I had conflicting emotions. I felt delighted to be asked to be able to stand in for Andrea, and I was also very happy to be able to ask Karen to cover for me the previous day; yet it was difficult for me to come to that point of acknowledging that I needed to ask for help.

I have chosen to be a solo practitioner, 'independent' within what I consider reasonable limits. It is uncommon for me not to 'be there' for women who book with me. I don't have any dependent children, and have sustained a caseload of 3 or 4 births a month, providing the continuity of care for each woman. The other fairly obvious fact in independent midwifery practice is that we are paid only for what we do. A midwife who misses a birth forgoes the fee that she would have charged. If we take a day 'off' work, we do so without pay.

Some midwives form group practices and agree to cover for each other at certain times, such as one weekend in three. There are obvious benefits, but disadvantages as well. I am happy to discuss this further if anyone wants to engage in discussion.

Circles of support for mothers

"Support a mother to provide a golden start for her child! With breastfeeding everyone wins!" These statements are themes that are being promoted by WABA for the World Breastfeeding Week 1-7 August [http://www.worldbreastfeedingweek.org/].

Thisafternoon I sat with a circle of women and their children at the Box Hill Birthing and Babies Support (BaBS) group http://birthingandbabies.info/
BaBS groups are sometimes chaotic, with toddlers and little children, babies, and mothers all being who they are.
Today we supported each other in being mothers, and members of families and communities, the way women have since time began. We listened to mothers speaking of their lives, and we grieved with those who spoke of emotional pain and frustration, and the one who shed tears. We talked about maintaining our emotional reserves so that we can cope with the often unpredictable ups and downs in ordinary life. We used butcher paper and drew pictures that recorded our feelings, and some of the children added their squiggles and lines and blotches to complete the picture. We acknowledged that a mother's life is never separate from her children - her life and theirs' are constantly interconnected.

The WABA World Breastfeeding Week program this year is promoting the Global Initiative for Mother Support, and is using the Olympic Games circles to remind us of the need for 'circles of support'. WABA states that:
MOTHERS DESERVE AND NEED

• empathetic listening
• basic, accurate and timely information
• skilled and practical help
• encouragement

These four points are the 'circles of support'.

Mothers don't just need circles of support for breastfeeding - they need it for all aspects of normal birthing and nurture. Breastfeeding is an absolutely important aspect of what I would call 'normal' parenting. Not necessarily 'usual' or 'most common' parenting - normal in that this is the physiologically normal, and the most basic way of enabling health and nourishing and nurturing the infant and young child.

The four WABA 'circles of support' apply equally to the promotion and support of normal birthing as they do to breastfeeding. In promoting normal birth, we are establishing the best set of circumstances for the initiation and establishment of a strong breastfeeding bond between mother and baby, and consequently strong emotional bonding. This is true even when the mother experiences complications or illness in her pregnancy or birthing or breastfeeding: the promotion of normal birth within a partnership between a woman and her midwife enables good decision-making, and protects the mother's sense of personal autonomy in her care.

Next month we will hear a lot about the world's best sporting performances. Let's also remember to: "Support a mother to provide a golden start for her child!"

When birthing becomes abnormal

I want to tell you, my readers, about Julie's birthing of her first baby. Julie asked me to be her midwife, and I worked with her obstetrician and the midwives at a Melbourne private hospital. We did not achieve normal birth, but I believe it was a very good birth.

I have heard some independent midwives saying that they don't accept bookings for private hospital births; that women who go down that track aren't trusting their bodies; that they, the midwives, feel unable to truly exercise their skill when they go into hospitals. I do not agree. All I ask is that a woman who engages me as her midwife is planning to do all she can to give birth, and will not interrupt or interfere with her natural processes without a good reason. I am not committed to either home or hospital - I believe the woman should be free to decide the right place for birthing when she is in labour. Sometimes women planning homebirth go to hospital, and sometimes women planning hospital birth make the intentional decision in labour to give birth at home.

Julie is a beautiful woman: healthy, fit, and in her late 20s. As we approached the due date her baby's head had not engaged, and we chatted about what that might mean. My usual advice is to remain active, but not to try to bring on labour until after 41 weeks. I planned to talk to Julie about a couple of 'self-induction' options such as a does of castor oil, and/or a program of nipple stimulation and pelvic movement. Julie's doctor talked about induction of labour at 10 days after the due date. However Julie's labour started spontaneously at 41 weeks. She was awakened with early contractions one night, and they continued irregularly through the next day.

Labour established that night, and Julie asked me to be with her. The sheer physical demand of a couple of sleepless nights was telling on her and her husband. I sent him off to bed, and Julie's mother and I kept her company. When I palpated I noticed that the baby's head was in a good position, well flexed, engaged, but high. An internal examination confirmed this assessment. There was a lot of work ahead - this baby was not going to slip out easily.

Labour progressed and we went to hospital. As often happens, contractions that had been close and strong became irregular and infrequent. It was frustrating as the hours rolled on, and the 'team' became more weary. By late morning Julie was nearly fully dilated, and the baby's head had progressed - a very encouraging sign. Someone (not I!) suggested a lunchtime birth. (in your dreams, I thought) Soon Julie was pushing, and got her baby deep into her pelvis. In the next couple of hours we tried different positions and all we could do to move that little one a bit further, without effect.

Some readers may think that Julie would have been able to do more if she wasn't in hospital, or if she was in a tub of water. I don't think so. This baby's head was such a tight fit and Julie was doing all she could, which was not enough.

The doctor was prepared to attempt an assisted birth, but warned that he may still need to do a Caesarean birth. This is a professional decision point that obstetricians face from time to time, and in today's private maternity system the die is often cast in favour of the surgery.

Julie pushed, and her doctor pulled, and after three good pulls the very elongated, molded head was birthed. Julie took her little boy to her breast as I and another midwife dried him, and after a couple of minutes he cried lustily - a wonderful sound.


Recently I have been reminded of the work of Dr Catherine Hamlyn, repairing obstetric fistulae in Ethiopia. The women with fistulae have had complicated births, and face dreadful incontinence and social exclusion. These women may have laboured for days in agony before their babies died, and were eventually stillborn. The link to the ABC TV interview is:

http://mpegmedia.abc.net.au/tv/talkingheads/vodcast/talkingheads_2008_catherine_hamlin.wmv

Catherine noted in the interview that they are now educating midwives to go into the communities and attend the women in birth.

Midwives are required, by definition, to promote normal birth. This duty of care must be understood alongside our knowledge of abnormal birthing, and our other duty to access appropriate care when complications occur. Always the wellbeing of the mother and child are foremost in our minds.

We live in a privileged society. Even if Julie had been planning homebirth I believe, with the benefit of hindsight, that we would have needed to go to hospital and ask for obstetric assistance with the birth. I also believe that we could have expected the clear decision making process and personal respect that Julie received, in a public maternity hospital. Good maternity care should not be linked to wealth or insurance status.

Safe motherhood in a safe country

I am sure I am not alone when I admit to being overwhelmed when I hear of the lack of safety for mothers and their little children in many of the poorest communities in this world. The tragedy of loss of the life of a baby is heartbreaking, while the loss of a mother cannot be comprehended.

Here I am, a midwife in Melbourne, Australia. Any time I am concerned about a woman in my care I can make a telephone call to a large, well equipped maternity hospital, and refer the woman for complex investigations, or for skilled management of whatever the problem is. Women can travel by car or, if needed, by ambulance, at any time of the day or night. Although there are no guarantees in this or any other life event I have no reason to fear. I can certainly find fault with the mainstream public hospital system, and I believe it could be improved particularly in providing services for well women, but it is pretty good when women or babies are ill, or develop complications. Most of the women in my care give birth to healthy babies at home, without drugs to stimulate labour or to relieve pain, and with very little or no help from me.

A story in the World section of today's newspaper describes a woman in Peru, pregnant with her seventh child, who hiked for hours through the Andes mountains to a health clinic where she gave birth. The clinic's notable difference from hospital maternity care is that women are encouraged to give birth standing up. (Sunday Age, July 13 2008, p11) The program described in this article encourages mothers who had previously given birth at home to go to the health clinics in an effort to reduce Peru's awful maternal death rate of185 per 100,000 births. This compares with around 10 women per 100,000 births in Australia (http://www.aihw.gov.au/publications).

A call has recently gone out from World Health Organisation and other leading organisations to the G8 leaders to address maternal and child health. "We don't need a new cure to save the lives of 6 million women and children. What we need is political leadership and investment. The Partnership has issued a Global Call asking G8 Leaders to fund basic health services for women, newborns and children." http://www.who.int/pmnch/en/ This call is in concert with the UN Millennium Development Goals, particularly #4 and #5 http://www.un.org/millenniumgoals/
The Countdown to 2015 http://www.countdown2015mnch.org/ has been set up "to track progress made towards the achievement of the United Nations Millennium Development Goals 1, 4 and 5 and promote evidence-based information for better health investments and decisions by policy-makers regarding health needs at the country level."

The message I have heard, and that I want to send out to any readers of this blog is that "we don't need a new cure to save the lives of 6 million women and children." We need midwives who work at the primary care or basic level in all communities. For the majority of women we need to protect normal birth. That may be, as in Peru, saying it's OK to stand up to give birth. But you can't stand up to give birth if you are loaded with narcotics or if you are numbed by epidural. You can only stand up and give birth actively, or kneel, or choose to lie down, if your mind and body are strong and working in harmony with your God-given birthing power.
For the minority of women and babies who experience complications or illness we need health clinics and referral hospitals that are accessible when they are needed.

Alice’s adventures giving birth

Alice looks radiant as she soaks in the golden beams of afternoon light. Not long ago she was that little girl in a Wonderland inhabited by the strangest of creatures and a Queen and things great and small. I can now see Alice in the after-time, herself a grown woman, as she awaits the birth of her first baby. She finds herself in another Wonderland, also inhabited by strange creatures and people with incredible powers that can make her feel great or very small, and she follows the White Rabbit into the hole in another mystery journey.

There are three strong voices competing for Alice’s attention as she approaches her special time. Voices 1, 2 and 3: Prima, Secunda, and Tertia (in Latin, making them seem so much more important than they really are.)

“Imperious Prima flashes forth

Her edict “to begin it”;

In gentler tones Secunda hopes

“There will be nonsense in it!”

While Tertia interrupts the tale

Not more than once a minute.”

Prima, the first, is direct and clear – there is one way, the right way, the normal way. Like the Queen of Hearts she gives her pronouncement. But is ‘normal’ what is normally done, or is it something else? Having never been there before Alice wonders how she will know the right way when she sees it.

The second voice Secunda is less sure, and more pragmatic, expecting she will somehow find a way through the underground maze. With a label that says ‘Drink me’, she offers all the choices as if they were of equal worth. Alice wonders if it is safe. “the wise little Alice was not going to do that in a hurry. “No, I’ll look first,” she said, “and see whether it’s marked ‘poison’ or not”; for she had read several nice little stories …”

“Would you like something to help with the pain?” Secunda inquires, and Alice says “Yes, please”. “This bottle was not marked “poison” so Alice ventured to taste it….” She did not see the locked cupboard where it was stored, with “Dangerous Drugs” on the front.

Tertia, meanwhile, has the oversight of all things obstetric, and considers herself in charge. With stop watch in hand, and pointing to (Capital E) Evidence, she demands that the times and calculations be correct. Alice becomes quickly confused with Tertia’s arguments:

“If you knew Time as well as I do,” said the Hatter, “you wouldn’t talk about wasting it. It’s him.”

“I don’t know what you mean,” said Alice.

“Of course you don’t!” the Hatter said, tossing his head contemptuously.

Being very keen to please, Alice listens to all the voices. !,2 and 3; 3, 2 and 1; 2,1 and 3 and in whatever order they speak.

Alice found her way out of Tertia the Mad Hatter’s Tea Party; escaped Secunda’s potions and cakes that made her alternately very large and very small; and stood up to Prima, the Queen.

“Stuff and nonsense!” said Alice loudly. “The idea of having the sentence first!”

“Hold your tongue!” said the Queen, turning purple.

“I wo’n’t!” said Alice.

“Off with her head!” the Queen shouted at the top of her voice. Nobody moved.

“Who cares for you?” said Alice (she had grown to her full size by this time). “You’re nothing but a pack of cards!”

Alice returned to the grassy bank in the golden afternoon light and decided not to go down that rabbit hole again. She stayed above ground and with her sister accompanying her, they took the path that was ahead of her. The path became steeper in places, and at times there were forks in the road that appeared to offer an easier way. Accepting her sister’s wisdom they stayed on the main path. They could see the goal, and knew that they must persevere. Alice’s mind and body became strong: she accepted the demands of each climb. Alice’s sister stayed with her, and encouraged her to keep the goal in sight. Then, as Alice began to doubt and cried out for help, her child was born. Alice rested a moment as the little one gave its first cry, then triumphantly and with her heart almost bursting with joy, took her child to her breast.

Joy Johnston, 11 July 2008.

[Note: Quotations are taken from Alice’s Adventures in Wonderland, by Lewis Carroll. First Published 1865 by Macmillan & Co Ltd.]

"Thanks, Noel!"

When lactating breasts become blocked in the early weeks and months after birth the mother feels very unwell, very quickly. A fever, severe flu-like aches and pains, a red painful quadrant of the breast, a very sore nipple - and often at a very inconvenient time.
This happened to 'Annie', whose baby is six weeks old, and she phoned on Sunday evening when I was out and another birth was imminent. Noel, my husband and No1 helper/supporter, took the call and said he would contact me. "'Annie' has a temperature of 39.5 and wants to know what to do."
I didn't have time to ask questions about other symptoms, and assumed that it might be mastitis.
Noel gave my instructions - "keep on feeding baby, massage the blocked part of your breast, take 2 Panadol, and a big drink, and have a bath. Then go to bed."

The next day I received an email from Annie:
"Thank you and Noel for bringing me to health again. Just talking to Noel decreased my temperature one degree! and then it started slowly getting back to normal. I feel better today, the temperature is normal, the breast hurts less. I'm little bit weak after a high temperature, but still can do all my usual things. I am happy to continue breastfeeding S... - she needs it very much. Thank you for your advice very much."

Breasts are one main point of vulnerability in an otherwise healthy woman postnatally. A blockage can occur very quickly. If the blockage is relieved quickly there is no need to treat with antibiotics, and the mother is able to recover naturally.

Expecting better days

Tonight I am feeling weary from a night out for a birth last night, but very hopeful that there is a trend towards better days for homebirth mothers and their families.

A couple of weeks ago a young woman and her man came to see me, and asked me to accept a booking for homebirth, and the baby was due any day. This woman had not had any prenatal care, and did not know her blood group, or any of the other basic screening results that are usually done. There was no local GP who she could ask to do this work, and expect anything other than rejection.

I spoke to the clinical midwife specialist at the local hospital, Sunshine. The midwife was happy to support this woman, and guided her through making a booking at the hospital. The blood tests were done without any fuss. The blood group was Rh Negative, so the midwife prepared request slips and tubes. The baby was born beautifully, at home, last night. An hour after the birth I collected blood from the large venous sinuses on the fetal side of the placenta - the homebirth 'alternative' to cutting the cord immediately after birth to collect cord blood. [I must remember to write a blog on the undisturbed third stage of labour.] The hospital pathology department processed the blood samples, and the midwife organised the Anti-d immunoglobulin and paperwork for me to collect.

Any midwife reading this may wonder what's so special about all that? That's what is supposed to happen.

What we have experienced in this case is a seamless interface between independent midwifery practice and a public hospital. I am blogging because I am so pleased that it has happened this way.

We talk about 'woman centred' care; we talk about 'collaboration'; we talk about 'partnership' between the woman and the midwife. This care was 'woman centred' in that each time a decision point was reached and a need was identified it was simply and efficiently met. The care was collaborative - the hospital midwife and I collaborated in accessing a service that was appropriate, and that neither of us could provide independently. The care respected the partnership between my client and me, which was a new and fragile relationship, not the usual trust that is established during months of traveling together through the unpredictable terrain of pregnancy.

I have no idea if anyone who knows about Sunshine hospital will read this blog. It's a sprawling public hospital situated to the West of Melbourne, and it's not the maternity fashion centre. Yet Sunshine is a leader in offering midwives a new respect for our skill, and moving ahead with caseload midwifery practice. It's not a big step for the hospital to move a little further and offer homebirth.

In May I wrote a blog 'Waiting patiently', about a twin birth at the Royal Women's Hospital. This was another instance of cooperation and collaboration that I have experienced with a senior midwife employed by a large public hospital. I don't think I am wearing rose-tinted glasses. I think there is evidence of change, and I am expecting better days.

THE D I Y MIDWIFE

I had heard recently that some expectant mums were buying gadgets so that they could listen to their unborn babies whenever they felt like it. That didn't bother me - I assumed they went to one of the online supplies stores, and bought a Doppler device similar to the one I use. They're quite expensive. I suppose if you could buy an ultrasound machine some people would want one of them too. Along with all the other gadgets and monitoring devices that money can buy.

I have seen new mothers with their digital scales set up proudly in the colour and theme coordinated nursery, so that they can weigh their babies whenever they want to. Much more high-tech than the simple spring scales with the cloth 'what the stork brought' holder that I use.

The other day I was in a new client's house and saw a plastic pod with straps and a earpiece. The woman told me she bought it at [big store - unnamed]. The pod sits over the front of your belly and the straps go around your back, and you put the earpiece in your ear and listen to your baby. Not much different from the continuous electronic fetal monitoring that goes on in hospital, except a fraction of the price! So now you can have continuous electronic fetal monitoring whenever you like.

Listening to your own baby is not new. Anyone who has been pregnant and knows how to use a stethoscope has probaby listened. They are likely to get pretty bored listening to a heart beat. Whether the availability of this gadget is going to help or harm the birthing process is another question.

Some mothers-in-waiting like to check what's going on by feeling inside their bodies. One client told me she would get her man to examine her in labour to work out how far dilated her cervix was, so that she could decide when to call me. OK, I said. It's not rocket science. Anyone can give permission to another adult to digitally or otherwise penetrate or feel any part of their body.

Some people are into DIY, Do It Yourself, everything. Perhaps they are breaking some unspoken taboos by stepping inside what had previously been the territory of a professional group - in this case midwives.

Midwives often question how useful it is for us to listen to the baby's heart beat, how frequently. There is no evidence that any particular schedule of listening improves outcomes for the baby, but we do it anyhow. There have been times in my midwifery experience when I have detected a baby who was distressed, and the heart beat pattern was the tell tale sign. I have seen mothers tragically lose their babies in this situation, when the action taken was too little, too late. Everyone who has worked in acute maternity care has seen that, and would do anything they could to prevent it happening again. If they could.

If I thought that listening to an unborn baby continuously was going to help that mother give birth spontaneously, I would go out and buy one of these little gadgets. But I don't - I think it would be more likely to interfere with the mother's ability to work harmoniously with her body as labour progresses, which would increase her perception of pain, and slow the progress. Babies may in fact be harmed by the interference and subsequent interventions.

I don't want to write more detail in this blog - the topic is huge. I have just touched the surface.

To anyone who is going down the DIY pathway, I would encourage you to speak to a midwife. In order to monitor your own progress, especially in labour, you would need to maintain an active calculating-thinking brain, your neocortex. This brain activity will inhibit the deeper, more instinctive brain, that is needed as you release your mind so that your body can engage in the wonderful process of birthing your baby.

Your midwife does not - can not - do it for you, but goes with you.

CHANGING HEARTS AND MINDS

Or, Why continuity choice and control are not enough

Sue, whose life-changing experience of giving birth to Jack last year, wrote: “And also for me, what is missing, is the focus on the heart. There is birth education out there, but too much of it misses the heart, getting women back in touch with themselves, their inner voice, and waking that up.”

Sue, I totally agree.

The message that women want the three C’s, continuity choice and control, emerged in the UK with the publication of the House of Commons Health Committee’s Report on Maternity Services (1992). Together with the Changing Childbirth Report (1993), these documents set out an agenda to make maternity care more woman centred, to facilitate midwifery care for homebirth as a standard option for well women, and to normalise childbirth in the UK. Caroline Flint (1993) published the book ‘Midwifery teams and caseloads’, with the frequently repeated mantra in words and pictures “get to know her”. Continuity of carer – a caseload - became a goal for many midwives.

Women told the Health Committee that they want *choice* of care and place of birth. I and many other midwives and birthing activists have chorused ‘choice’ since that time. Yet choice is a slippery entity that easily moves out of reach when in reality the availability of a particular model of care, or a place in a birth centre or even birth at home is easily overruled by other factors. Furthermore, I am sad to acknowledge that in recent years the pendulum has swung in the other direction, with women ‘choosing’ elective caesarean surgery.

Women expressed the desire to have *control* over their own bodies at all stages of pregnancy and birth. Of course, this element is readily agreed to by the midwifery profession, and supportive theories of partnership and cultural safety have emerged. Yet midwives know that the natural processes in giving birth demand a surrender or relinquishing of mind control so that the deeper hormonally mediated forces in a labouring woman can act unhindered. French obstetrician Michel Odent has written books and papers, and taught the midwifery profession about the importance of subtle hormonal influences at all times through the childbearing continuum, and the first year of a child’s life. The term ‘undisturbed birth’ is now used for a birth in which the mother is able to progress without interruption. But a mother in advanced labour, in a quiet, familiar, unstimulating space, cannot give any attention to control. The mother who feels a strong need to control may instead choose regional anaesthesia or even surgery, rather than allowing herself to go “out of control” in a powerful hormonally driven state.

With my mind juggling these thoughts I read the new issue of Women and Birth, the journal of the Australian College of Midwives (Vol 21:2, June 2008). New Zealand midwife Joan Skinner’s Editorial titled ‘Risk: Let’s look at the bigger picture’ is a critical look at what more is needed to achieve better maternity care. “…we [midwives] in New Zealand, where the midwifery-led model of care is now the norm, are learning that autonomy and continuity of midwifery care are not, of themselves, the solution to the rising intervention rates in birth. Despite having developed a strong and autonomous midwifery profession, which now provides most primary maternity care, we have not succeeded in making a significant dent in our risk framework. Our intervention rates and our medico-legal environment attest to this. …we need to FIRST attend to changing hearts and minds, not JUST the model of care. We need to open up to possibilities of collaboration with others, rather than focusing on professional autonomy.” The writer suggests that midwives, in seeking to turn the tide of maternity care from a techno-rationalist to a truly woman centred care, need to engage with other knowledge frameworks, including biosciences, human geography, and architecture.

While midwives can strongly assert our role as guardians of normal birth, and can seek to effect this through primary care caseload midwifery, we do not have ‘ownership’ of the birthing terrain. Neither, for that matter, does the mother, although her ownership of her own body and her experiences is supremely important in a functional society. The whole society has an interest in the next generation, and whether a person is looking from the perspective of a sociologist, an architect, or a farmer, their knowledge is valuable to the society’s provision of services around birthing of children.

Without changing hearts and minds of pregnant women, future parents, fathers, grandparents, hair dressers, shop keepers, and people in all ages and stages and walks of life, the midwife’s skill in promoting and protecting normal birth will not be valued.

HOMEOPATHY in midwifery

Joy Johnston

[This original article was first printed in MIDIRS Midwifery Digest, vol 18, no 2, June 2008, pp 185–187]

Introduction

Complementary therapies which offer treatment alternatives in pregnancy and birth have been welcomed by many midwives and by women in our care (Tiran 2000). This is particularly so for those who seek to work with and protect the healthy natural processes in birth.

The increasing interest in, and availability of complementary therapies has led to Governments in many countries increasing the statutory regulation of alternative health practitioners (Williams et al 2004). This includes implementing systems which seek to protect public interest by registration of members of the professional group, accrediting courses of education, regulating products, and investigating and acting on claims of professional misconduct.

This article will focus on the use of homeopathy within the current maternity care system and will debate some of the issues that should be of concern to midwives who need to look objectively at the claims of homeopathy, and be conversant with the current, reliable advice and interventions as part of their recognised professional practice and accountability.

A brief history of homeopathy

Homeopathy was first developed and promoted by German physician, Dr Samuel Hahnemann (1755-1843). Both proponents and opponents today agree that, regardless of their ability to cure illness, homeopathic treatments were and are likely to do less damage to ill people than many of the practices carried out in the name of conventional medicine at that time. These practices included bloodletting, purging, and blistering. Homeopathy has been called, with good reason, a ‘kinder, gentler medicine’ (Stehlin 1996).

To give context to Hahnemann’s revolutionary theories, he lived prior to the emergence of knowledge about bacteria, viruses and infection. In 1847 Semmelweis identified surgeons’ hands as the route of spread of puerperal infection, and in 1865 Lister developed his system of hand washing and asepsis. (Parker 2008) It is likely that patients of Dr Hahnemann and his followers fared significantly better than those who received the other treatments on offer at that time, and it would not have taken modern statistical methods to observe the difference!

Homeopathy today uses language and concepts that may have been more familiar to the European world of the late 18th and early 19th century, than contemporary concepts and languages. Words such as ‘remedy’, ‘proving’, ‘potency’, and ‘potentisation’ have special meanings in homeopathy (Jones 2007). ‘Repertories’ and ‘rubrics’ list illnesses, symptoms, and treatments. This use of language may be seen as quaint and distinctive, alternatively the same impression may lead one to question the currency, in terms of effectiveness, of homeopathic theory.

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[Readers who would like the .pdf version of this complete paper may request it joy@aitex.com.au]

Emma Flaim's Mother Series - Lino prints 1&2

These lovely lino prints have been added to my collection of birthing art and photos. Anyone who knows me may even see me in one of them! Thankyou Emma for your work. Joy

Emma Flaim's Mother Series - Lino prints 3 and 4

Fair go!

I met with Jackie, who is having her first baby in a few weeks’ time, and she expressed frustration and dismay. How is it, she asked, that noone had told her she could have a midwife working solely with her when her time to give birth comes? All these months, visiting the obstetrician, booking in at the hospital, and going to the hospital for prenatal classes, and the idea was not once discussed. Last week she was told that the hospital midwives would come and go when she was in labour – their shifts might change, and they would have to help out the other midwives in the birthing suite. Fair enough, she said, but what about me? Then she talked to Margie, the midwife who works for her obstetrician, who suggested she find an independent midwife.

The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services. A caesarean rate of over 30% is unreasonable (see blog entry Sunday, May 18, 2008 IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS? for discussion). Caesareans that are performed without a valid reason, or because the service has failed to provide appropriate care, leave too many mothers and babies distressed and separated at a time when they need to establish strong attachments; placing many mothers and babies at higher risk of serious illness or death than they would have had in giving birth naturally; increasing the pain and depression experienced by mothers postnatally and restricting their ability to move. It wastes precious resources in hospitals – resources of staff and facilities that should be available for those who truly need specialist doctors and surgery.

During the past couple of decades I have worked hard to address the inequities in maternity care. I am seeing some progress – ever so slowly. Perhaps a reasonable benchmark for progress would be when every pregnant woman, regardless of risk status or wealth or expected place of birth, is given the opportunity to choose a midwife who will be with her as the primary maternity caregiver. After all, a midwife is with virtually every woman giving birth: why should the system not cater for the woman who wants to know that midwife?

In the late 1990s I was working part time for the Victorian branch of the Australian College of Midwives, and we encouraged midwives to be active in lobbying the Nurses Board for a Code of Practice for midwives, which was introduced in 1996 with the sunsetting of the Midwives Regulations. That Code acknowledged the International Confederation of Midwives’ Definition of the midwife for the first time in this State, a definition that clearly declared the professional scope of practice of the midwife, working in partnership with the woman, providing woman centred care, collaborating with other professionals when appropriate, and being competent in provision of primary maternity care that protects the wellbeing of mother and child.

The Australian government had brought legislative reform to prevent anti-competitive monopolies, and within this reform agenda called for various reviews of legislation, including the laws regulating provision of health services. I prepared several responses for the College of Midwives, arguing that government funding for maternity services, through Medicare and hospital funding, unfairly excludes midwives from acting as midwives and providing maternity care. The medical monopoly of funding forces women into models of care that are likely to result in medical and surgical management, without improving outcomes for mothers or babies. There was good evidence then, and much more now, demonstrating the effectiveness of midwives working at the basic or primary care level throughout the pregnancy-birthing continuum, and referring women to specialists if and when the need arises. There is no evidence supporting specialist obstetricians as primary carers.

Our arguments were sound. New Zealand maternity services had, in the early 1990s, undergone major reform, and our colleagues across the Tasman were moving into independence and autonomy, with equal pay for midwives and doctors who provided the same service, that we only dreamed of. But although our arguments made sense, the political ‘buck passing’ from State to Federal health departments, and back again, seemed to extinguish any hope for reform as soon as it appeared.

In 1985 the World Health Organisation (WHO) had published the Fortelesa Declaration, addressing appropriate technology in birth. This document became the launching pad for activity by WHO and international professional bodies to address the evidence supporting practices in maternity care. The Cochrane Collaboration (http://www.cochrane.org/ ) was established in 1993, looking initially at evidence based practices in obstetrics, and moving quickly to all health care interventions. Early research demonstrated the beneficial effect of continuity of care by a known midwife, and other aspects of midwife primary care.

The College of Midwives had, in the mid 1990s, formed a partnership with the emerging political lobby group Maternity Coalition. Our projects included a Midwifery Campaign, demanding ‘choice’ and ‘access’ for all women: choice of caregiver and place of birth, and access to models of care that enabled this choice. Soon after the turn of the century a group of consumer activists and midwives in Maternity Coalition, under the leadership of Barb Vernon from ACT and Tracy Reibel from Perth, prepared the National Maternity Action Plan (NMAP) as a framework for maternity reform. This document received widespread support, and not a little criticism, and put pressure on government health departments to address the inequity in maternity service provision, particularly for women who wanted to give birth naturally.

In the early 1990s the Baby Friendly Hospital Initiative (BFHI) was born, with its goal, the protection, promotion and support of breastfeeding. The essence of the BFHI was a world-wide program auditing maternity hospitals, using the ‘Ten Steps to successful breastfeeding’, on their practices which either supported or hindered the establishment of breastfeeding by mothers and their newborn babies. The BFHI is a major health promotion activity, which restores for women their natural authority for breastfeeding and protecting the health of their children.

When addressing breastfeeding it is logical that mothers, and midwives, will see the obvious connections between pregnancy, birth, and the nourishment and nurture of the infant. Why enable mothers to take responsibility and authority for their breastfeeding, and not their birthing? Midwives, being ‘with woman’, are able to do just that.

Internationally there was an awakening of midwifery, with midwives and women calling for reform, a ‘fair go!’. In the USA, the Coalition for Improving Maternity Services (CIMS) (www.motherfriendly.org) developed the Ten Steps of Mother-Friendly Care, in many ways projecting the BFHI into the fuller context of maternity care. In the UK maternity activists and midwives were promoting normal birth; and home birth received support at government report levels. Everywhere in the developed world caesarean rates were on the rise, while mortality rates in developing countries were shockingly high. That is still the case today. There is still much to be done. The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services.

A new and troubling element has asserted itself in the modern maternity terrain. The ‘choice’ of Caesarean birth: “too posh to push”; “honeymoon vagina”; and “I don’t want to sag down there and spoil my sex life” are a few of the reasons given. It seems that in this topsy-turvey world we live in, the consumer’s choice of major abdominal surgery is more readily provided for than the choice of the mother who simply wants to give birth naturally. A booking can be made in the hospital; all the needed personnel and gear assembled; and ‘bob’syouruncle!’. Well organised and delivered on time. Much more reliable than the mystery journey of natural birth, when labour comes like the thief in the night, and progresses according to mysterious rules and secret forces that cannot be controlled.

In promoting consumer choice, have we encouraged women to short-change themselves by opting out of one of life’s most amazing and healthy processes?

When women 'choose' models of care and interventions (such as induction, drugs, epidural, or surgery) the hospital is able to give that, and has a satisfied customer. I think this is the down side of the 'consumer choice' message. I believe there is an ethical argument that in maternity care the service providers are bound by the 'no harm' imperative to support and protect normal birth, and NOT to interfere without a valid reason. I believe caesarean should not be done on demand.

The core rationale behind the CIMS 10 steps is enabling women to give birth safely and naturally without medical help unless there is a valid reason. This is good, but can't happen unless women actually accept it, and are then able to progress undisturbed (allowing their bodies to do the work) with trust in the care provider who is leading the professional care decisions. That's where the primary carer's role becomes critical. Without models of care where the midwife and woman are able to work in partnership and protect normal birth, it’s unlikely that the increasing tide of caesareans will turn. We have plenty of proof that the status quo is not achieving the protection of normal birth.

I want to see a fair go for all concerned - the service providers, midwives, doctors, the consumers (mother and baby), the family and society, and policy makers. We will only achieve this when the consumers and the professionals work together to provide maternity care that values the wonderful natural processes in birthing, and uses technology appropriately for all who need it, not just for those who can afford to buy it.

WHAT CHOICE DO I HAVE?

I remember my first meeting with the obstetrician in his rooms in Melbourne, when I was pregnant for the first time. I came dressed nicely, and my husband Noel accompanied me. Noel was asked politely to wait – he would be invited in to meet the doctor after he had performed his examination. I was instructed to take my clothes off, to don the white examination gown, and lie on the firm narrow couch. My abdomen and breasts were palpated, and my vagina pried by a man in a grey pin-stripe suit, a crisp white shirt and a bow tie, which was the standard attire for men of such professions at the time. I was then asked to dress, and the doctor would come back and speak to me.

Innocently I informed the doctor that I was a midwife, and that I wanted a natural birth. He gave a reply that I understood as ‘we shall see’. At some pre-determined moment Noel was invited into the interview, sat on a chair next to me, and he asked some question.

“Mrs Johnston and I have already discussed that” was the reply, in a dismissive tone that indicated that the deal had already been done, so he need not exercise his mind on it.

My ‘choice’ to plan to have a natural birth was, I thought, simple. Young people today would call it a ‘no brainer’. Many of those same young women today go into maternity care with the same degree of innocent trust that I had. And many experience the authoritarian conquering power of the obstetrician who looks over her glasses and says “We shall see!”

If we stopped to assess the quality of the offered service by asking questions such as “How many first time mothers in your practice last year experienced uncomplicated, unmedicated, spontaneous birth?”, we may discover that this person is not skilled at protecting normal birth. And why should they be? They are surgeons whose education and registration prepare them as specialists, most with very little knowledge of working in harmony with and supporting natural female rhythms.

It’s as though we have blinkers on our eyes. We wouldn’t go into buying a house or a car or even a pair of shoes with the same lack of critical thinking that we seem to easily adopt when it comes to having a baby, which is surely the most significant investment of time, energy, and every other resource at our disposal that we will ever experience.

This past Sunday evening there was a segment called ‘Birth Choice’ on Chanel 9’s 60 Minutes. I watched it and became increasingly more distressed as time went by. The show presented two extremes, DIY homebirth, without a midwife, compared with the ‘too posh to push’ caesarean birth on demand. It was sensationalist and misleading not a rational or responsible presentation of the choices a woman faces in birth. Presenting the opinion of an obstetrician on homebirth is similar to asking the manager of a nursing home about parenting issues. Uninformed!

I want to be fair in my criticisms – the filming of the homebirth was done in a respectful and delicate way. It was a spontaneous, uncomplicated, unmedicated birth in water, and the baby was in excellent condition, which is what I would have expected. Yet I felt sympathy for the un-midwifed mother, who was under the prying eye of the video camera, and had noone who had the knowledge or skill to say "You are well; your baby is well. Take this beautiful little girl into your arms and love her." The mother was concerned about her blood loss after the birth, and went to the hospital. I hope she was midwifed well there.

I cannot understand the woman who chooses major surgery - surely she has been sold a lie? The notion of keeping things tight "down there". Oh dear!

There are some mothers and babies who have needed and accepted surgical births, and who are thankful for the 'good' outcomes. I am also thankful for good outcomes. This is also a 'no brainer'. But I have also seen the women who have suffered surgical complications - infections, retained swabs, drug errors, haemorrhage, impaired clotting, pain, and a great deal of psychological trauma of separation and disturbed bonding. These are not good outcomes.

It is with this knowledge that I will continue to work to protect and promote healthy natural processes, and support normal birthing when ever I can. I believe we have only one real choice - that is, to either work in harmony with our healthy natural processes in pregnancy, birth, and parenting, or to ignore them. Medical options at present in developed countries like Australia offer surgical options which come at a cost. It is important, I believe, that the cost as well as the potential benefit of avoidance of natural birthing be understood before choices are made.

HOW DO WE RECLAIM OUR BODIES?

This question is prominent in my mind as I reflect on my meeting yesterday with a wise woman of the Yorta Yorta people in central Victoria. I won't use her name until she has read what I have written and gives me permission. But what I want to say does not refer uniquely to indigenous women - it's about all women. How do we reclaim our bodies? How do we reclaim our right and privilege, as women, to give birth to our children and to nurture them at our breasts?

We sat together for several hours, and talked. A few years ago there had been a proposal for a birth centre, where indigenous and 'non-i' women could give birth. That proposal was not accepted. There is a centre where indigenous women have prenatal care from midwives and doctors, but that has not improved births for many - the rates of caesarean are high, and women come away from the birthing experience feeling shamed and distanced from their own bodies.

As we chatted a baby woke up and was hungry. Her mother was busy, so I held her close and held the bottle of white stuff. While enjoying the exquisite beauty of the little one in my arms, I could not feel anything other than sadness that she is not able to draw nourishment and warmth from her own mother's body.

The wise woman is an elder, mother, grandmother, aunty, and sister. She has sat on many committees, representing the voices of her people to government and community bodies. She is sad that her people have lost their knowledge of what was done in birth before white people came. She is sad that her daughters are feeling shamed in stead of feeling powerful in giving birth. She is sad that the beautiful breasts of these women are hidden away from their babies.

What could we do? Is there anything that can be done to enable these women to reclaim ownership of their bodies?

We talked about birth centres. Birth centres can be good, with a philosophy of protecting and supporting healthy normal birth, but there is a high rate of transfer for complications. The women who are transferred out to standard obstetric care can feel abandoned.

We talked about the midwives. Some midwives come, and try to provide better and more woman-centred care, but ... They leave after a while.

We talked about surveys, reports, summits, and funding from government departments. The wise woman looked tired, and I felt dispirited - we have been there, done that. Nothing much has changed.

Then we talked about women's business. The older women helping the younger women to give birth, and care for their babies. Spaces where only women could go. A house where they could come and learn to express themselves in arts and crafts, and tell their birth stories. A house where they could feel safe as their labours become stronger, with their sisters and aunties to encourage them. This could be a key to reclaiming their bodies.

The wise woman said she would like women to get together in a women's space and take their shirts off. They could keep their bras on if they wanted to, but you have to start somewhere. This was a new thought to me. I asked her why some of her sisters in the Centre are now having ceremonial dances with their breasts exposed. It's something that they have done to reclaim their culture.

We didn't talk for long about this, because something happened to interrupt our train of thought. But a seed idea had been planted in my mind - is this another key to reclaiming our bodies? What would happen if these women reclaimed their breasts? The older women could lead in ceremony and ritual, and encourage the younger women to cherish their breasts. What would happen if the mothers allowed their babies to find their breasts? What would happen if the mother of this bottle fed baby asked her baby to take her breast once again? I believe it could be done.

When we asked the woman at the BaBs group [http://www.birthingandbabies.info/index.html ] what they valued in the BaBs program, one said, "I can see other mothers breastfeeding. I can see other breasts!"

I believe the only way any woman can improve her chances of avoiding caesareans, epidurals, and other medical management of birth is to take responsibility for their own birthing. I call it Plan A "I intend to give birth under my own power, without drugs or stimulants, and I ask everyone who is with me to respect my plan." The woman herself has to be strong. The wise woman said that in the old days women had to be strong. They had to keep up with the group. There were no short cuts.

We need to return to those old rules for anyone who wants an opportunity to give birth. The non-i women don't need to learn the ceremony of other people groups, but we do all need to claim back the ownership of our bodies.

Early Learning

Alina has a daughter, Dina, who is a bright, energetic three year old. I am using their real names, with Alina's permission, as it would be difficult to tell their story without giving some of the detail of this family.

Today, after the birth of Alina's beautiful new baby girl, I noticed Dina looking intently at the placenta in the green plastic kidney dish on the floor. Immediately I understood - she knew about the placenta. So I held up the umbilical cord and Dina looked very pleased. Later, when I was putting away my equipment, Dina was interested in the Laerdal bag and mask resuscitation kit. Dina knew about that too!

Dina and I can't understand each other's language - she speaks fluently in Russian, and in Japanese too I think, but not English. Fortunately, Dina's parents speak English very well.

Having moved to Melbourne a couple of months ago, their priority was to be ready for the birth of this little one. They are living in a furnished unit, and waiting for their boxes to be delivered from the wharf.

As Alina and I talked and prepared for the birth, little Dina was with her mother. One day I loaned Dina a copy of 'Hello Baby' [http://www.capersbookstore.com.au/scripts/shop_item.asp?by=cat&item=2229], and I read it to her in English while Alina translated into Russian. Alina has told me that Dina has had the story read to her every day since!

It would not have been surprising to Dina when she heard her mother's noises - 'singing' an ancient and wordless song that rises and falls with the power of the new baby's progress. Dina understood that her mother was doing something wonderful, important, and very demanding; and that she had her daddy home from work today to look after her. Dina knew that the placenta came after the baby, and was happy to check it out. She had also seen a picture of the midwife's resuscitation equipment in 'Hello Baby'. She knew that her mummy needed to rest with this new baby sister, who was very hungry and needed to take mummy's milk.

Alina called me thismorning to let me know that her labour had begun. Today was 42 weeks - 'post-mature'. We had waited for spontaneous onset of labour, and Alina was confident that her baby was well. She had agreed to go to the hospital tomorrow for monitoring, but that won't be needed now.

Alina was lying on the bed, curled up in that excellent left lateral position that is so good in advanced labour, when I arrived at their house. I did not know what Alina would be expecting from a midwife. Dina had been born in Japan, and it seemed from what Alina told me that she had given birth spontaneously, and that the hospital staff had done their job around her, without really making any connection.

I sensed that she did not have long to go - she was focused and the contractions were powerful. After a while I asked if she was feeling any pressure in her bottom. She wasn't sure, but decided that was possible, so she got up and knelt beside the bed. With the next contraction she felt the baby move. Another and the waters broke. A couple more and she birthed her daughter through the intense pain. Baby was fine, and lay on the mat below her mother until Alina was ready to take her in her arms. It was a beautiful, normal, undisturbed birth. The baby took the breast and stayed there for the next hour or so. The placenta came away about 1o minutes after the birth.

After finishing my paperwork I was enjoying the quiet bliss that seemed to radiate from Alina. I mentioned that there was no hurry to bath the baby - it could be done when they felt like it. They were surprised - it had seemed such an important 'next' in the list of activities last time. "No, it's just a ritual. She's not dirty," I said.

There is so much that is just a ritual in birthing. I want to hold on to the important parts - the freedom to sing the birth song, and to share birth with a three year old, who understands it all so well.

IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS?

Since the federal Treasurer announced the new budget a few days ago, there has been a lot of public comment about the changes to Medicare, and the anticipated exodus from private health insurance. The income threshold for the Medicare levy will rise from $100,000 to $150,000 annually for couples. The Sunday Age today proclaimed on the front page that "Medicare blunder could cost $1.76bn".

I wonder if anyone included in the sums the reduction in claims on the Medicare safety net, whereby uncapped thousands of dollars are shifted from the public purse to the pockets of private obstetricians for every pregnant woman booked with them? I wonder if anyone has assessed the expected reduction in costs when women who would have booked in private obstetric care, thanks to their private health insurance arrangements, move into public maternity care? I wonder if anyone has considered that women and babies may be better off when they give birth in public maternity services?

I am not opposed to private health care per se. If I was sick and needed a stay in hospital for any reason I would prefer a private room to a busy shared 4-bed ward. I would prefer the food at Frances Perry House to that downstairs at the Royal Women's. These preferences seem obvious to my mind. I would prefer to be admitted under a doctor who respected me as a person, and did not treat me as the next case (not necessarily the case in the private-public debate, but we often have confidence in a known doctor over the unknown).

However, the fact is that most women who are having babies in private hospitals are not sick. They are victims of the 'inverse care law' - that those who least need the care receive the most. Obstetricians are medical specialists: surgeons. It is no wonder that they like to perform surgery rather than work in harmony with unpredictable female natural processes. They have no expectation to accept normal birth, whereas midwives are, by definition, expected to protect normal birth.

I have been looking at some of these figures.
There is some evidence that within Victoria's public maternity services efforts are being undertaken to reduce unnecessary intervention into normal birth. The Vic Maternity Services Performance Indicators have been published annually since 2002. The statisticians have looked at what happens to 'standard primipara' - healthy women aged 20 to 34 years, giving birth to their first baby, with no complications prior to the onset of labour. In other words, the mothers who are healthy, young, and least likely to have problems in birth. The rates of Caesarean births for standard primiparae in public and private hospital care are 18.5% and 26%.

Overall Caesarean rates in Victoria have in the past decades been rising by about 2% each year, and are currently around 30% -- 27.7% of all public hospital births, and 37.3% of all private. (Source: Hospital profile of Maternal and Perinatal Data, Victorian Perinatal Data Collection Unit, 2006). The most common reported indication for Caesareans is a previous Caesarean. It is logical that as the number of primary Caesarean births increases, the number of repeat surgeries will also increase.

I now ask the question, how many women who have private health insurance, and have their babies in private hospitals, are likely to move to public hospital care as a result of the provisions of the 2008 Budget? How many Caesarean births will be avoided by this exodus?

Here are some figures to consider:
In 2006 there were over 68,000 births in Victoria: 43,800 public and 24,500 private.
If 20% of the private hospital bookings moved to public, approximately 4,900 women would move from a 37.3% risk of Caesarean surgery (n=1,828) to a 27.7% risk (n=1357). On this calculation 471 women would avoid Caesarean surgery in one year.

That might sound like a small number out of almost 70,000 births in the year, but to those women, it would be hugely significant. And if some of those women who avoided the primary caesarean were giving birth to another child in a couple of years' time, the relative ease of the second vaginal birth should not be forgotten.

I’m not saying that a 27% risk of Caesarean birth for ‘standard primipara’ in the public system is acceptable. By no means! West Gippsland Hospital at Warragul has had a strong focus by midwives and doctors on reducing unnecessary Caesareans, and their rate for the same time (standard primipara, 2006) is less than 10%. But I am saying that 27% risk is preferable to a 37% risk when comparing like with like. Fewer maternal complications in this and subsequent pregnancies; fewer babies needing to be separated from their mothers at birth; fewer women developing postnatal depression; and so on.

Perhaps the changes are going to cost the government a lot of money in revenue, through raising the Medicare levy threshold. It's likely that private health insurance companies will feel the strain of reduced numbers, and reduced premiums paid into their coffers. It's also likely that the private hospitals and obstetricians will object to reduced business. It's possible also that the overcrowding of public maternity hospitals will reach a peak in the coming year. Some public hospitals may actually consider offering homebirth in an effort to ease the congestion in their wards. Am I dreaming? It sounds to me as though mothers and babies will do well out of the Budget.

WAITING PATIENTLY
One of the big issues in having a caseload, and accepting nature's timing in birth unless there is a clear reason to interrupt the natural processes, is that I have no way of knowing when babies will come. The booking dates on my calendar do not tell me when or in what order the mothers and babies who are important to me as my 'caseload' will make their individual claims on my time and skill. I know I will have periods of waiting, as well as times when several babies are needing to be born. This is beyond my control, and my Christian faith allows me to trust not only that my Heavenly Father cares for me and wants to guide me in all the events in my life, but that each new baby is in God's care. There are times when I am tired, and I ask God specifically for strength, wisdom, and understanding as I do my work. In a post-Christian society this concept may be unpalatable to some, but it's very real to me.

This past week I have been busy, with a baby born at home on Tuesday, and twins born in the hospital on Thursday. Today I want to reflect on my emotional journey: waiting for each labour to establish, and being 'with woman' as she labours and births. I will call the mothers, in sequence, A and B - Anna and Beth. Although their due dates were more than a fortnight apart, it became clear that they would both be needing to give birth soon.

Anna's pregnancy had reached 41 weeks when she came into labour with her first child. The waters broke late Monday night, and her labour got started. I had a phone call in the wee hours, and went back to sleep after reassuring Anna, and encouraging her to rest if she could in this early stage of her labour. By the time I saw Anna in the late morning she was labouring well, on all fours, and feeling weary. I didn't want to in any way interrupt what was happening, so I sat in the other room with a cup of tea and my crochet. I encouraged her to be upright, and she progressed quickly. At one point she came into the room where I was, and she saw that I had my crochet, and the gear that I bring to a birth, set out and ready. Anna's baby was born beautifully in the birth pool a couple of hours later.

The principle of undisturbed birth, as I have learnt it from practice, and from readings, was confirmed again. Protecting and promoting normal birth, and working in harmony with the natural processes, requires the mother herself to accept and work in harmony with her labour, as much as it requires the midwife to be quietly protecting the space the mother is in.

Beth's twin pregnancy had progressed well and was now at about 39 weeks. Beth was receiving prenatal care from the Royal Women's Hospital as well as from me, and she had prepared her birth plan carefully and discussed it with the obstetric and midwifery consultants at the hospital. Beth's plan was that she wanted the opportunity to progress naturally and give birth to her babies without interference. This sounds very logical and reasonable, but is very different from the way most twins are born in that or any other hospital today. The decision to go to the hospital for the birth, rather than plan homebirth, was one that Beth had made, after considering the information she was able to gather about twin births. I had been her midwife for her first birth, at her home.

Earlier this week Beth came under increasing pressure from her obstetric carers to have an induction. The ultrasound had suggested that the second twin was smaller than the first, and *might* not be growing well. There is a widely held belief, which I think is a myth, that twin placentas will age more quickly than singleton placentas, and that it's not safe to let twin pregnancies progress to Term. This decision point - to intervene in the interest of one of the babies - became the challenge that Beth, and as her midwife and advisor, I faced. Beth found a recent article in an online journal which seems to challenge the ageing placenta theory. (See http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijpn/vol5n2/twin.xml)
I found this article useful in understanding the big picture, yet I was also wondering if the artificial rupture of the membranes for the first twin was really such a big deal. Beth also seemed to waver in her commitment to trusting and working in harmony with the natural process. We all knew these babies would be born soon. Perhaps we (Beth and I) should be more pragmatic and accept the induction? I assured Beth that the decision was hers, and that I would support her no matter what. I also encouraged her (and encouraged myself) to value spontaneous onset of labour, or at least natural onset of labour.

It can't be called truly spontaneous, as Beth proceeded with the less medical options - acupuncture, nipple stimulation, then a dose of castor oil. On Wednesday afternoon, after the castor oil, she felt regular contractions, but not labour. The booking at the hospital for induction was for Thursday morning. On Wednesday evening Beth called the hospital to say she did not intend to come in for induction, and took more castor oil. Labour became established; we went to the hospital after 6.30am, and the babies were birthed, seven minutes apart, an hour later. It was a 'normal' twin birth - there were none of the complications that we know are possible; no drugs were used; and Beth declined continuous monitoring, and an IV cannula. The second baby was smaller than the first, which is not unusual, but the placentas were healthy - no sign of ageing.

I have mentioned only fragments of the whole story. The record I want to put down today concerns my feelings as I waited for and attended these birthings. It's as though I have a parallel existence to the birthing woman - I need to 'nest' in those final days so that I am prepared for whatever happens, and I face transitions when doubts and fears arise and sometimes swamp me. I can't have a blinkered belief that 'natural is good', because I know that in nature there are many undesirable outcomes. I have to use my knowledge of the human body and birth to protect wellness, as well as to access the best medical services if they are needed. There is no clear 'black and white' in this decision making. The guiding principle is that in birth and nurture of the infant, there is no safer way than to work in harmony with the body's own natural processes, unless there is a clear reason to believe that the natural processes are not likely to lead to the best outcomes.

In both of these birthings, these women could have easily relinquished their authority and rights as the birth 'giver'. Anna's labour could have been induced for convenience, or for 'postmaturity'. Beth's labour could have been induced for this vague idea of 'ageing placenta' or 'non-reassuring ultrasound'. Once the woman submits to the authority of someone else, a doctor or a midwife, who reaches into her vagina to artificially rupture the protective membranes around her baby, it is very difficult for that woman to take back her authority for her own birthing. The hospital's expectations for progress and monitoring become the benchmark for decision making from that moment onward. The pain that the woman feels after induction is interpreted by her as different from what she feels if her body is taking her there naturally.

Again I have been honored to witness the power of women in their birthing. I hope many other midwives are able to work in this ancient and timeless model of care, and protect the authentic role of the midwife, being 'with woman'.

A Normal Birth
I attended a birth early thismorning, and as I had no apprentice midwife with me, I am going to try to set down an account of the amazing yet totally ordinary sequence of events from a midwife's point of view. Some of the readers of this blog are midwives and midwifery students who are wanting to learn the specific skills of a midwife working with women in community settings, with the intention of promotion health and wellness, and working in harmony with the natural processes. I hope there is something in this account for you.

0200 - phone call from "Matt", "Jenny"'s partner - labour has started. Jenny came to the phone, "Yeah, they're about 10 minutes but they're str --- just a moment --- (quiet focused breathing) --- strong."
"I'm on my way. See you soon," I said.
I drove through the quiet streets, and covered the 35 or so Kilometers quickly.
I had seen Jenny a couple of days ago. She was unsure of her dates, and an ultrasound at 25 weeks had set the due date at 2 weeks ago. That day came and went, and Jenny and I felt confident that there was no cause for concern. The baby would come.
0300 - I arrived at the home, in a beautiful bushland setting on the outer metropolitan fringe. Jenny was working quietly in her dark bedroom, and the birth pool in the corner was being filled. Jenny's mother had a wood fire going and made me a cup of tea. In one corner of the main room I opened up my gear, connected the oxygen cylinder flow meter, and took out the paperwork. The basics needed for any birth are quickly put out - the pack of instruments (sterile scissors and metal cord clamps) in a big green plastic kidney dish; a pair of sterile gloves for an internal exam if needed; procedure gloves for catching the baby, and handling blood; a plastic cord clamp; the oxytocics, syringe and needle.
Then I sat quietly with Jenny, observing her and getting a feel for her labour. During this time I use both my thinking brain and my intuitive brain. Just as mothers use their intuitive brain in undisturbed birthing, a midwife learns to partner that woman in a very real sense, going through the stages, emotionally and in a deeply connected way, with her.
Very little conversation happens - I ask "is baby telling you anything --- are you getting any kicks?"
"Oh yes, with the contractions."
The mother probably doesn't realise how significant those kicks, which she alone knows about, are. Her simple statement is reassuring to me. Healthy babies cope well with labour, and a baby that gives mother a kick during contractions is doing well.
"Are you happy for me to listen to your baby after the next contraction?" I ask. The heart sounds tell me what I already know.
Jenny got in the bath and said "Aaah, that's good". Her labour progressed quickly. By 0345 she was vocalising and saying "No, I can't do it" during the contraction, then saying to me "That's transition" after the contraction. The transformation of a woman at this time of peak adrenaline together with peak oxytocin and endorphins is marvellous. Then, as she was kneeling in the water "She's here!", followed by "help me." My hand was near her hand as the little head, then shoulders emerged into the warm water, and I lifted the baby gently to the surface.
It was 0400. Noone had seen the 'birth' - that's one of the special features of waterbirth. I shone my little torch briefly and confirmed that baby's colour was good. We waited for the best part of a minute while the newborn adjustments took place wonderfully, followed by a little cry and other movements. There was no hurry. This child was unstressed, peaceful, and well.

Jenny settled back into the water and rested, looking alternately at her beautiful daughter, and to her lover. I don't remember if anything was said. I was happy to just be there, in the background, keeping the space.
We had a comfortable arm chair set up next to the tub, draped with an old shower curtain, towels, and an absorbant pad. My notes tell me that Jenny got out of the birth pool at 0415. We supported her and dried her off as we assisted her to get out, while she held her baby to her breast. After a couple of strong contractions Jenny felt the placenta coming, and she moved forward in the chair. I received the placenta, with minimal blood, in the green plastic kidney dish. Together we checked the placenta, and Jenny and Matt felt the surfaces as I explained it. Jenny had decided not to cut the cord, so we wrapped the placenta in an absorbent 'bluey', and placed it near the baby.

In the next couple of hours Jenny fed her baby; I got the paperwork done; the two big brothers met their baby sister; we all had tea and toast with vegemite, honey, or peanut butter; photos were taken; more logs were put on the fire; and as Jenny snuggled up in her bed with her sleeping baby she asked me to close the door. I left the home confident that everyone was strong and well.