Lessons from homebirth

A midwife who starts attending homebirths with a more experienced independent midwife has an opportunity to learn all sorts of lessons, some predictable, and some unexpected. Yesterday as my colleague Karen was leaving the home, after attending a homebirth as 'second midwife', she commented on the difference between what we had just experienced, and what often happens in hospitals.

As I drove home yesterday afternoon, weary from a 3am call out, but thankful for and energised by the birth of another beautiful child, I was reflecting on the lessons we learn when we begin caseload and homebirth practice. Here are a few. Readers may want too add more in the comments section, or if you want to write a piece to add to this blog, please email it to me.

• Waiting for the spontaneous onset of labour. Does the midwife's commitment to the natural process mean that we wait passively, or is it an active waiting? How much checking and surveillance of the wellbeing of the baby is appropriate?
  
• Midwifery 'interventions' and advice for post Term pregnancies. When is it appropriate to recommend self-induction methods, such as nipple stimulation, or castor oil? Do you recommend acupuncture, or naturopathy, or other alternative medicine options?
• Technology. I sometimes call a second midwife in the middle of the night, and the phone goes to the message bank. If that happens I then call her on her mobile. I have had the experience of leaving messages on both home phone and mobile, and hoping for the best! Being on call means getting the telephones and other technology to work for you.
  
• Petrol. It's good to keep the petrol in the car above a certain point. It's frustrating and can be time consuming to have to put petrol in the tank in the wee hours.
• Directions. It's no fun getting lost, and trying to read the map in the half-light of a torch or the interior light of a car. In my practice I visit the home at about 36 weeks for the birth talk, or birth preparation meeting. This visit gives me the opportunity to think about the best roads, and check out parking and all those practical matters, when there is no pressure on my mind.
• Waiting. The father made the comment yesterday "A lot of what you do is waiting". That's right. It's very different waiting in a home than waiting in a hospital. In the hospital birthing suite there is a routine of shifts and rounds and client meals and staff meal breaks and reporting and meetings. In the home it's all about one woman. Many times the midwives move out of the room where the woman is labouring, but they don't move out of her space. Her sounds are the only sounds they hear.
  
• Finding the tea bags. This may sound too obvious to mention, but when you open cupboard doors, or rummage through a kitchen draw to find the tea bags, or a mug, or something else, there is an element of that special relationship between a woman and her midwives.
  
• Responding to pain. It's never easy to see someone else in pain. We would be heartless if we switched our minds off, and could not feel empathy. Yet the homebirth midwife does not carry pain relieving agents with her, and women who plan homebirth know it. Principles of active birthing, including movement, encouragement, massage, pressure, heat pacs, vocalisation, shower, and water immersion, are useful. Music, candles, a wood fire in the hearth, and aromatherapy may help create a personal intimate space. But it's the woman herself who decides how she can work with her own labour pain. It's the woman herself who decides when and if the pain is excessive or intolerable.
  
• When to assess internally for progress. I consider an internal exam an intervention, and there needs to be a valid reason for me to intervene/interrupt/disturb the progress of normal labour in this way. I will ask the woman for her permission to examine vaginally if I need the information that such an examination can provide. For example, a primigravid woman in advanced labour, who has some spontaneous urges to push over a period of a couple of hours, without bringing the baby on view, may have a lip of cervix. The vaginal examination will confirm this, and with permission, I can attempt to reduce the lip and push it back during a contraction. In my examination I feel for the baby's cranial sutures in order to visualise the position of the baby's head. An anterior lip, with the saggital suture off to the side, tells me that the baby's head is tilted, and is asynclitic. My advice to the mother is to walk through contractions, taking exaggerated steps that will move her pelvis, and adjust the fetal head in relation to the pelvis. Up and down stairs a couple of times is very helpful. Then as the baby descends, the mother can try kneeling on one knee, with the other foot on the floor, to tilt her pelvis, then change to kneeling on the other knee. These are fairly simple midwifery interventions, yet the woman's trust in her midwife is challenged, and they will need to work together in order to promote normal birth.
• Physiological birthing of the placenta. I think I am stating the obvious here, but physiological birthing of the placenta is probably only reasonable when the rest of the labour has also been physiological. Any stimulation or resuscitation of the baby is done with the umbilical cord intact. A midwife who makes a decision to administer an oxytocic to the mother is undertaking a professional intervention, and there is time to obtain the mother's consent for this act.
• Baby to the breast. It's wonderful to watch a healthy unmedicated newborn baby take the breast. Some do it without a second thought: some need to work hard at it. But they all love it. In homebirth the midwife needs to learn to trust the ability of mother and baby to manage this primal and essential act. Our advice is such that mother is encouraged and enabled to take responsibility, and to be confident in her own mothering.
• Leaving. A baby has been born; mother and baby are well; the paperwork has been done; and it's time for the midwife to leave - go home - get on with other work, or go to bed. This is another lesson.
• Completion. The time soon comes when no more postnatal visits are needed. I encourage the mother to call me if she has any questions, or is receiving conflicting advice and wants to know what I think. The invoice is paid, and I enter the information into my Quick Books program, in preparation for the next BAS and Tax statements. I ask the mother to come back for 'show and tell' at six weeks. After that visit I bundle her file into the filing cabinet, sorted alphabetically according to surname. Ready for next baby?
  

This list is not complete. I need to get dinner ready now, so will hit the publish button. I look forward to messages I may receive. What have you learned from home birthing?
Joy

Decision Points

Midwifery in Australia today can be one of the most satisfying occupations there is. When a midwife has a ‘caseload’, a group of women to whom she is committed through the pregnancy, birth, and postnatal period, the midwife and each woman are able to learn how to work together before the big event.

Usually the ‘big event’ is labour and birth. Occasionally it comes as a decision point before labour; sometimes there are several ‘big events’ or critical decision points.

Midwifery that is woman centred is neither woman-led nor midwife-led. Neither the woman nor the midwife dictate the terms; both recognise their own, and the other’s unique role and capability in the relationship. It is a dance in which there are separate, but interweaving and sensitive roles. And the dance is not just the woman and the midwife – there is the baby of course, whose presence is profoundly significant, as well as anyone else who the mother-to-be has invited into her presence at the time.

No matter how much research or preparation you, the mother, do, an uncomplicated labour and birth is likely to demand more physical and emotional energy than you thought you had; to take you to a place that you didn’t know existed. The time comes in most labours when you need to surrender any conscious control, and allow your body to do its work. This is the normal way babies are born, and it is usually the safest way for both mother and child. The midwife who is ‘with woman’ is with you in this often challenging and frequently demanding journey, and also has to harmonise with and in a different way surrender to the natural process. I usually come away from a birth emotionally and physically spent.

The trust a midwife has in the woman is that she, the woman, will accept the midwife’s professional partnership. The trust a woman has in her midwife is that she, the midwife, will not disturb or interfere with that deeply demanding process of birthing a child, unless ...

Unless?

Unless a decision point is reached where the mother-to-be is convinced that she is not able or safe to continue in ‘Plan A’ – doing it herself, and accepts an intervention in which she asks another person to take over – ‘Plan B’. It’s that initial decision point of handing over the controls that is the key to interference in normal birth.

This process of making informed decisions is the core of midwifery knowledge and skill. Midwives in all societies can work in harmony with a woman’s natural processes in pregnancy, birth, and nurture of the young – Plan A. Different cultures and different generations have had vastly different options for those who, for whatever reason, move out of Plan A.

The woman is free in our world to ask for, and will often receive, any intervention, including induction, dangerous drugs, regional anaesthesia, or caesarean surgery. In mainstream maternity care there does not seem to be any commitment to working in harmony with the natural process in birth. There does not seem to be any calling to account. Why does Hospital X have such a high rate of caesarean births? What are the midwives doing in Hospital X? Do they not know how to protect and promote normal birth?

A reader might think that the only people committed to working in harmony with the natural process in birth are those on the fringe – independent midwives, and midwives in birth centres or special midwifery caseload programs, who probably account for less than 5% of births. This is not so. By definition, every midwife has a set of requirements, including ‘partnership’ with women, and ‘promotion of normal birth’ (the International Confederation of Midwives’ Definition of the Midwife (2005) is copied below)

Every midwife’s duty of care can be summarised with statements from the Definition.

The midwife:

• Is a responsible and accountable professional, who
• works in partnership with women
• gives the necessary support, care and advice during pregnancy, labour and the postpartum period
• conducts births on the midwife’s own responsibility
• provides care for the newborn and the infant
• (implements) preventative measures
• promotes normal birth
• detects complications in mother and child
• accesses medical care or other appropriate assistance
• carries out emergency measures
• engages in health counselling and education

I commenced this piece with the statement “Midwifery in Australia today can be one of the most satisfying occupations there is.” A midwife has a scope of practice and a duty of care that is truly awesome. I hope that some midwives who have read this, and reflect on their own midwifery practice will find ways to make the transition to more woman-centred care in which the midwife and woman work in a partnership based on trust, respect, and reciprocity.

Definition of the Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.

Tennis on Thursday mornings

Each Thursday morning in school terms, weather permitting, a little group of women get together to play tennis in a back yard in Mont Albert. This group started more than 30 years ago. I have been in the group for about 20 years. The tennis court is situated in a lovely garden, and the owners have generously welcomed our little group.
Readers of this blog will probably wonder what that has to do with midwifery. The answer is nothing. But it has a lot to do with community, and it's one of the parts of my life that I enjoy and value. Being a member of a tennis group means that I have made a commitment to being with that group at a particular time, whenever I can. It's about being responsible to others, to the best of my ability. These women are not particularly interested in my midwifery practice - although they listen when I tell my stories, and they are accepting of my sometimes unpredictable hours. It's good that I can go to the tennis court and leave midwifery at arm's length (as far away as the mobile phone, that is) for a few hours each week.

A midwife with a personal caseload has a problem with commitment to other events - we are, at times, unreliable. We put the mothers and babies first. My children will tell you about their birthdays when I left the family to celebrate, while I headed out to a birth.
Last December, when our daughter Bec was getting married, I did the right thing and arranged for another midwife to cover my practice. On the afternoon before the wedding day I was enjoying the company of my sisters and other relatives who had come to Melbourne. We had 'open house' for tea that night, and I had prepared salads to go with meat done on the bar-b-q. The phone rang, and my client Paula said she thought her labour was getting started.
I phoned my backup midwife, Jan. Jan's reply when she answered the phone was, "You just caught me, I'm on my way to a birth." OK, plan B isn't going to work. There's no plan C, so I had better go back to plan A.
Of course my sisters and their families were able to manage without me, so I said a quick goodbye, and headed out. I had to make my way through peak afternoon traffic, and by the time I got to Paula's home she was holding a very beautiful newborn girl to her breast. The placenta came without difficulty, and I did the paperwork. By the time I got home the family were all enjoying each other's company, and someone had put aside a meal for me.

Readers of this blog probably realise that stories are my way of telling my midwifery knowledge to others. The point I want to make today is that each midwife needs friends and community linkages that are outside her commitment to mothers, babies, and birthing. For me, it's our Church, the tennis group, and of course, our wonderful family. It's not so much that they need me, as I need them.

What would the village midwife do?

My village is not an ordinary village. It has long busy roads, with lights at intersections and 40K zones outside schools. It has freeways that become very busy and clogged at certain times of the day. There are people and cars and trucks, buses and trains everywhere. It's the 'burbs of Melbourne. (I avoid the city if I can!)
So why do I call it a village?

The title 'village midwife' was given to me years ago when I was employed part time by RMIT University to provide supervision and mentoring for midwifery students at Birralee Maternity Unit (Box Hill Hospital). A hospital midwife discussing care of a woman with one of the students asked,
"What would the village midwife do?"
When the students and I sat down to reflect on the day's work in the afternoon, that question became the focus of our discussion. I was delighted to see the 'village' concept applied to a midwife's decision making. In today's globalised world, with amazing technology and communication, the challenge to give birth in harmony with nature's wonderful processes is the same as it has always been. Just as many of us value food grown in our own gardens, local grocers, schools, or clothes made in our own country, the village concept is readily applied to birth and nurture of our babies. "What would the village midwife do?" becomes a guiding question for me and others who are working to promote normal birth, whether they are out there in the 'village', or working in big modern hospitals.

My village is small, not in physical area, but in the number of mothers I can attend at any one time. This month I have three births booked. Those three women and their families become my neighbours for a brief period, and I join their lives in a special way as the midwife primary carer during their birthing experience.

Yesterday the mother called me in the morning and told me she was having 'niggles'. We spoke again after lunch, and she said nothing much was happening, but she knew her baby was coming. We anticipated the possibility of a rapid birth, as her first baby had been born minutes after I arrive at their home. I assessed the time it would take for me to get from my home to hers, up to 45 minutes, and we agreed that I should go to her home and wait. I put my gear in the car, with a MIDIRS journal to read, some wool and knitting needles, and an apple to eat on the way home (an excellent pick-up for a weary midwife), and headed out.

After a couple of hours the mother decided to have a rest in bed. Whether it was from tiredness or boredom, I don't know. The father went to his computer to check emails, and I nestled into a big red bean bag with the MIDIRS journal. The house was quiet. The bedroom door was ajar.

At about 4.30 the mother got up. Her waters had broken.
After listening to the baby's heart beat I noticed the wet undies on the bathroom floor.
"There's meconium in your baby's amniotic fluid" I said, and explained that this is a reason to consider transfer to hospital for monitoring.
However I was reluctant to cause unnecessary disturbance in this labour, which I expected to be strong and very demanding. It would take us about 30 minutes to get to the hospital, and then another 15 to settle in to a hospital birth room, if there were no delays. I decided to see what happened over the next 15 to 30 minutes - how the baby responded to contractions, and how the labour progressed. If there was fetal distress, or if the labour did not establish quickly, we should go to hospital. I called Katrina to come for the birth, and got my gear ready.

Soon the sounds coming from the bedroom were unmistakably those of strong labour. Contractions became long, with little resting period before the next contraction began. I listened again to the baby, and the heart sounds were strong and reassuring. What would the village midwife do? I was quickly confident that we needed to stay at home - that it would in fact be more harmful to try to move to hospital in this labour. The stress and anxiety of the trip, that would be added to a very demanding time of labour, with the potential for a birth in the car or in the hospital lobby, were more of a threat to this mother and baby than the meconium.

The bedroom was unlit, with a little light coming from the hallway. At about 5.30, only an hour from the time the waters broke, a beautiful baby boy lay on the floor under his mother. I untangled the cord, and wiped the fluids from his face. He was pink, but lay quietly, and I felt his chest - a good heart beat. With a bit more tactile and verbal encouragement he joined us with a lusty cry.

Katrina had just arrived, and heard this from outside the bedroom window. After a few minutes she knocked on the door and I went to bring her in.

As often happens with a very powerful labour, the strong contractions continued, and placenta came soon after. I was once again impressed with the ordinary-ness of an extra-ordinary event, as mother and baby rested in bed, with the proud daddy supporting and watching closely. I got on with the paperwork, and Katrina made a cup of tea and washed some dishes.

The village midwife today has the best of both worlds. When birth is spontaneous and normal, the home is the best place to give birth. When illness or complication is present, the village midwife links in with the team of experts in managing difficult births, and works to get the best possible birth for that individual woman and baby. There are, of course, grey areas. If in this instance I had felt anxious about proceeding with birth at home, because our guidelines say meconium stained liquor is an indication for referral, the birth of this particular baby would not have proceeded in the uncomplicated and undisturbed way that it did at home. This is the duty of care of the midwife - not just the village midwife: every midwife.

God bless you

I wrote this brief note a couple of years ago:

It was an hour or so after the birth, as we all relaxed in the quiet peaceful space that settles on a room as a mother rests and her baby takes his fill from her breast. I moved close to her and put my hand on her arm, and whispered, “God bless you, my dear.” I don’t know if she heard my hushed prayer. Then my hand rested on the small head covered with black hair, still glistening with moisture from the birth, and I said “God bless you, little one.”

I know no greater prayer. I have no deeper wish. If God blesses, what more could that one want?

“God bless you, my dear, mother of this child.
You have laboured and you have given birth in pain that went deeper than you could have imagined.
Your dark red lifeblood that sustained this little one
has spilled with the waters and meconium and your bowel’s emptying onto the white sheets.
The fears and pain left you cowering, having nowhere to hide, as the small child prepared to leave your womb.
What did you see as he struggled to take breath and become a separate living soul?
As you rest and begin to recover,
your breasts are now giving, and continuing to give.
Your baby is taking, and growing.”

Joy Johnston 2006

“Take care that you do not despise one of these little ones; for, I tell you, in heaven their angels continually see the face of my Father in heaven.” Matthew 18:10

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.

.................................................
[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.