Why is it important to support maternity organisations?

Last month I wrote down some thoughts on maternity organisations. Although I did not identify a particular organisation, it would have been easy to deduce that I was referring to Maternity Coalition. I have been a member of Maternity Coalition continuously since the mid '90s, and have held roles on the national management committee including Editor of the quarterly journal Birth Matters, and Treasurer.

Yesterday afternoon the annual general meeting of Maternity Coalition was convened. This is an AGM like no other, as members link up by telephone, using FreeConference telephone conference call technology. Four other members joined me in my home office, with the telephone on speaker, between 4 and 5.30pm. There were, we are told, 27 members in attendance, in several time zones across the country. Approximately 50 proxy votes had been received. I consider that evidence of widespread interest in and support of the organisation.

In Maternity Coalition, the purpose of the AGM is to confirm the minutes of the previous AGM, to receive from the committee reports upon the transactions of the Association during the previous financial year, to declare all positions vacant, and elect officers and committee members of the Association.

Yesterday's meeting gave strong support to a new president, and general members of the management committee. The job of chairing a large conference call meeting, together with the logistics of allocating votes to members present, and to the proxy voters, was managed very well.

Some readers may wonder what incentive there was for all these people to give up a Saturday afternoon, and to vote in a team of volunteers to manage the affairs of Maternity Coalition.

I believe we are reaching a critical point in reform of publicly funded maternity care in Australia. Quite a few of the articles I have written on this blog, as well as the MIPP and BaBs blogs in recent months have focused on the federal government's maternity service review. The time for reform has come. The monopoly of funding, which restricts the ability of a midwife to practise midwifery, while supporting the obstetric profession's control of maternity care, is not in the interest of public health. Our current government has shown clear signs that it is prepared to dismantle this unfair monopoly. Maternity Coalition needs to be a strong voice at this crucial time, bringing together the shared interests of mothers and midwives in improving maternity services for all mothers and their families.

Maternity Coalition has, over the past decade, been recognised as a peak body - a key stakeholder in maternity issues. The organisation has grown from 20 or so members in Melbourne in the early 90s, getting together on a Sunday afternoon, to a national body with branches in all States and Territories. It may be coincidental that the exponential growth of this organisation has come in the same decade when most homes have become connected to the internet; when websites and email have opened up communication in a way that we would not have imagined twenty years ago. The move from face to face meetings to telephone conference calls has been essential in supporting the growth of the organisation nationally.

The National Maternity Action Plan (Maternity Coalition 2002), which was written by mothers and midwives in Maternity Coalition, sets out the right of women to have the choice of a known midwife to care for them throughout pregnancy, birth and the first few weeks after the birth. That is, essentially, what is missing from most Australian maternity services. Although a person who has the midwife qualification will usually be attending a labouring-birthing woman in hospital, the woman does not know the midwife, and vice versa. Although midwives staff maternity wards they do not have an opportunity to develop a partnership with the women in their care. The care is service-centred, not woman-centred.

I feel as though I am just getting started on this theme, but I know I must be brief. I hope that all women of this country will soon be able to access authentic midwifery care: a partnership of a woman and her midwife through the pregnancy-birth-early parenting continuum. The midwife's duty of care, working in harmony with natural processes, includes promoting normal birth, and is balanced by a duty to collaborate with other health professionals when this is appropriate.

IN THE SUNDAY AGE

A major article 'In Safe Hands', and an Opinion piece 'Homework is the mother of prevention' with the sub-title 'Many pregnant women put more preparation into buying a new car than they do into the process of giving birth' caught my eye as I leafed through the paper while eating my porridge and enjoying a cup of tea thismorning.

I felt the need to comment critically on some of the points made in these articles. Years ago I would have invested energy into writing a letter to the editor. We know that about one in 10 such letters are published. Now I see the opportunity to write a blog, and perhaps send some of it off to letters@... The topics I have chosen to comment on are:
"what's best for the mothers"
"midwives who practise in isolation without the involvement of other medical staff"
"to defer to their doctor's opinion and to the institutional imperatives"

Dr Christine Tippett is the central topic of 'In Safe Hands'. Christine Tippett is an obstetrician who I respect in many ways. However, her comments on midwifery are misleading and ill informed. I do encourage my readers to read the article (linked above), and come to your own conclusions.

It's good to note that Dr Tippett is anticipating reform - federal funding for maternity services provided by midwives. Until midwives and doctors are able to achieve parity, equal pay for equal work; and until women are able to choose without financial or professional restriction a midwife to provide the basic maternity care, or primary care, the medical monopoly of public funding for maternity care will continue unchecked. And until the medical monopoly of public funding for maternity care is disbanded, the medicalisation of the pregnancy-birthing continuum for mothers and their babies will also continue unchecked.

As I read through 'In Safe Hands', I was pleased to see that Dr Tippett acknowledged "Doctors don't own the women, midwives don't own the women" - TRUE. However, the statement goes on " ... We have a responsibility to look not at what we want but at what's best for the mothers we look after." That where the arguments lost me. Who decides what's best for mothers? From the context, it appears that 'we' (the professionals) do.

Evidence based practice, as defined by statistics derived from randomised controlled clinical trials, has been for many years held up as the gold standard for all areas of health care. The whole evidence movement grew up from the work of an obstetrician, Archie Cochrane, who argued that much of what is done in maternity care had little evidence to support it, other than the lowest level which is opinion. The Cochrane Library has, for years, consistently supported midwife-led care as being safe and effective. A recently published review has added to the evidence, confirming that Midwife-led care confers benefits for pregnant women and their babies and is recommended. Surely, if 'we' (the maternity professionals) were committed to "what's best for the mothers we look after" we would have implemented midwife led care as an easy option for any woman to choose. But those who have actually tried to access midwife led care in any of its many forms and dilutions, will tell you that they are easily transferred out of the birth centre and passed on to a new midwife; that the 'Know your midwife' program was full; that noone told them about the midwife led option at the local hospital until it was too late; that they were directed down the private obstetrics pathway and midwife led care was not an option; and so on. Those who are well informed and understand the evidence of "what's best ..." will sometimes choose to give birth at home because that's the only option for such care.

Dr Tippett takes the opportunity to make some very damning statements about "midwives who practise in isolation without the involvement of other medical staff"
Midwives who, supposedly, don't understand collaboration, yet when a complication arises "the woman is often brought to the hospital to be treated by doctors she has never met ..." Excuse me! Isn't that what a medical specialist does? Isn't that what happens when complications arise with any other part of our bodies? Are we supposed to stay in touch with a brain surgeon in case our brains need operating on?

Dr Tippett goes on to explain that midwives committed to a home-birth model "do things in a homebirth setting that no maternity service around the developed world would think is a good idea", and are "engaged in dangerous practice." No mention is made of the women having any say in the choice to give birth at home after a caesarean, or of the very occasional plan a woman may make to give birth to twins at home.

I am one of those apparently reckless midwives who will plan homebirth after a previous birth by caesarean. This is not a simple choice. It is also not my choice. I am not giving birth. The one item that I can offer is continuous basic midwifery care through pregnancy, birth, and the early parenting continuum. That is the most evidence based option in maternity care.

If a woman has had a previous birth by caesarean, and chooses to work in harmony with her body's natural process in giving birth, there are several hurdles that apply to all normal birth. Spontaneous onset of labour at Term. Establishing strong labour without relying on uterine stimulants or pain killing drugs. Progressing within a reasonable time, and giving birth to a healthy baby under her own power. Completing the third stage (expelling the placenta) without excessive blood loss. This is the way to safe vbac - regardless of the place of birth. If complications arise at any point in the process, that's the time to collaborate, and have a discussion with a medical/obstetric team as to the best way to progress. These decisions can only be made in real time. It is not possible to make informed decisions until the decision point is reached.

After an article which completely avoided any understanding of the mother as having an interest in the decision making, it was heartening to read Monica Dux's opinion piece. The mother's role as the writer experienced is summed up in the statement "Despite all the rhetoric about the importance of consent and respecting the patient's wishes, my experience of giving birth in a big hospital is that women are encouraged to take a passive role, to defer to their doctor's opinion and to the institutional imperatives. If you argue, you are often told,'that's just the way we do things'." There is bluntly honest truth in this article. However there is also a complete absence of the midwife.

My conclusion is that Monica Dux has experienced birth as many do in Melbourne and other Australian cities today. She may have been aware of someone on the hospital staff who had the title 'midwife', but she never experienced the true role of midwife: with woman. She proceeded through her experience of birth alone, an individual who had to negotiate a system that cared little about her as an individual.

It is my hope that as the federal government's Maternity Services Review progresses, and as reforms are introduced, the number of women who experience birth without authentic midwifery will be quickly minimised.

IN SAFE HANDS?

With reference to the article “In Safe Hands’ in the Sunday Age.

I think Christine Tippett is actually giving a hint as to how RANZCOG is lobbying the federal government with reference to the Maternity Services Review. It’s OK to extend the ‘allowed’ practice of midwives in hospitals where we can keep an eye on them, BUT we can’t allow those maverick independents any freedom.
It’s the old strategy, divide and conquer. Divide the midwifery profession into the acceptable and the unacceptable …

The Victorian branch of RANZCOG (or was it RACOG then?) did the same thing in 1993 when the new Nurses Act was brought in. An 11th hour fax (everyone didn’t have email then) to the health minister claiming that it would be unsafe to remove the regulations (which required a doctor to supervise a midwife’s practice, amongst other items) resulted in the retention of the regulations until they sunsetted in 1996. Although the regulations have been dead and gone for more than a decade, many midwives in Victorian hospitals are still working under protocols that assume the historical restrictions that existed under the regulations.

I think the midwifery profession as a whole needs to strenuously object to the statement by Dr Tippett that “It’s important that there’s not federal funding for people who are engaged in dangerous practice”, in the context of the claim that some independent midwives attend vbac and twin births at home.

Our laws provide a means of regulating midwifery practice, as well as obstetric, dentistry, or any of the other health professions. Midwifery is not regulated by the obstetric profession. If Dr Tippett has information that leads her to believe a registered midwife has “engaged in dangerous practice”, surely the right thing to do would be to notify the regulatory body of the matter, rather than using the public media to set up a scare campaign against independent midwives. As with any other profession, the regulatory process is a carefully managed and is accountable. It’s not perfect (imho), but it’s what we have, and even midwives have a right to expect fairness in law.

Please tell me if I'm being paranoid here. If not, would everyone who cares about protecting the right of midwives to practise midwifery in any setting, whether they are employed by a health care provider or by the woman, please take this matter seriously. When a person of Dr Tippett's profile is willing to make a statement about midwives engaging in dangerous practice, we must conclude that midwifery is under threat from RANZCOG. And it's not about the twin births or vbacs at home. The issue is who chooses what's best for women?

Is childbirth education possible?

I used to call myself a childbirth educator. I used to teach classes for expectant parents whose minds were as thirsty for the words and concepts of childbirth as the desert sand is for rain. I used to use the doll and pelvis, and speak with authority on optimal fetal positioning. I knew that to stand in front of a room full of eager, intelligent women and their men was a rewarding, satisfying event. I had what they wanted - the knowledge of childbirth.

As time has passed I have become progressively less interested in trying to explain the secrets of birth in a didactic, classroom setting. In fact, I ask myself the question in the title of this blog, "Is childbirth education possible?" A short course in obstetrics, or even midwifery, does not educate anyone to be able to give birth.

Of course you can be educated about what happens as labour gets established; about the colour of the amniotic fluid and normal progress in labour. "We" (those in the know) can educate "them" (those anticipating childbirth), using language passed down over hundreds of years of our civilisation - many of the words being Latin. Those being educated quickly learn that the labia are the lips; the cervix is the neck; the liquor is fluid; rubra means red, and alba means white.

Some forms of childbirth education have moved away from the medical language and call the uterus the womb; contractions are surges; the ilium is the hip bone and the ischium is the sit bone.

When teaching childbirth classes in a hospital I had access to wonderfully coloured charts and educational aids. A class in the series was about the options for pain relief in labour. There was a plastic model of the spine, with each vertabral bone sticking out from the plane, and an illustration of where the long needle was placed so that an epidural or spinal anaesthetic could be injected. Another class included a tour of the labour ward. Fathers-to-be were particularly impressed with the machinery of birth: the machine that goes 'ping', the electronic fetal monitor, being able to attract a crowd of curious onlookers. Classes like this are going on in maternity hospitals every week. Education about obstetrics; orientation to the maternity facility; preparing people for what will be done when the time comes for their babies to be born: yes. But education for childbirth? Not really.

I have listened to education that focuses on emotions experienced in labour. Dads-to-be are exhorted to support and encourage their partner in practical ways. Mums-to-be are prepared for their crisis of confidence. Supporters are told that the (support) chain is only as strong as the weakest link. You must hold faith. You must believe.

When I was pregnant with my first child in 1973, I was impressed with the Lamaze childbirth education, and attended a series of classes. The French doctor Lamaze, who taught breathing techniques and psychoprophylaxis and talked about Pavlov's dogs and conditioned reflexes, had eclipsed his English colleague, Dr Grantly Dick-Read, who taught that pain in childbirth could be minimised when the labouring woman understood what was happening, and thereby approached birth without fear. Dick-Read is considered by many to be the father of the childbirth education movement. Today I encourage mothers to learn in a maieutic way, intuitively.

Today many classes are available, and I cannot make comments on individual styles of education for childbirth. My observation is that education is about head knowledge. It's about understanding the processes, rather than enabling the fulfilment. As I said, a short course in obstetrics, or even midwifery, does not educate anyone to be able to give birth.

Giving birth is not an act of a conscious mind. It is not something that we can plan or organise or control. Giving birth is the climax of an amazing process in which physical, emotional, and hormonal systems are orchestrated within the bodies of the mother and child. Giving birth requires the mother and all who are close to her to firstly learn to work in harmony with her body, then when the time comes to yield to her birthing power. That learning is done on the job. The mother must willingly engage with her labour, without any distraction, and learn intuitively what will assist and what will hinder her progress. She must choose to be strong; not expecting to share her job with anyone. Her support team or even her midwife cannot do this for her. It is internal learning, and knowing.

A young mother had been labouring through the day, and her labour became strong as the night progressed. From palpation I knew that her baby was a good size. I estimated that she should be coming up to full dilatation by about 1am, and I prepared myself for a birth at home. Baby's heart beat was consistently good.

By 3am I was wondering where the baby was. I checked internally and found that the cervix was probably fully dilated, but the head was high - well above the ischial spines. It had barely entered the birth canal.

By about 7am, after doing all we could to encourage progress, we agreed to transfer to hospital and get some help. However, the traffic in Melbourne at that time of day is heavy, so I suggested we wait a while.

By 8am a major change had occurred. The young mother had found the way! With new strength that she could not have known existed, she brought her baby through her birth canal, and on view. Each effort was amazingly effective.

How did she do it? Childbirth education classes had not taught what she needed to know that morning. She learnt from within herself, using the God-given intuitive knowledge that mothers have to enable normal childbirth. It wasn't the encouraging words of "You can do this", or any instruction from me or anyone else. A woman gave birth to her first child.

Our hearts were overflowing with thankfulness to the giver of life as we welcomed that beautiful child.

MATERNITY SERVICES IN VICTORIA, AND THE FEDERAL GOVERNMENT’S MATERNITY SERVICES REVIEW

The Review by federal Health Minister Nicola Roxon has attracted an unprecedented number of responses. Maternity services are important to our society!

Victorian government’s policy Future Directions for Victoria’s Maternity Services (2004) is the framework that will guide developments over the ensuing 5-10 years. The policy seeks to “work towards quality birthing services where providers have a multidisciplinary approach and where women are informed and have choices.”

The current mix of federal and state funding for maternity care restricts a woman’s access to care by a known midwife of her choice, and protects a monopoly of doctors as the only providers of maternity care. Birth is not an illness, yet public funding for maternity care, as well as private health insurance, fragment the care into medical items within schedules.

What is the state of maternity services in Victoria today?

1. Choice of midwife led primary care is available to some women – see Attachment 1 ‘Having a baby in Victoria’ below.

2. Detailed information on hospitals and number of births is available from Vic Perinatal Data Collection Unit (PDCU) perinatal.data@dhs.vic.gov.au

Attached copies from the PDCU 2007 report Hospital Profile of Maternal and Perinatal Data (attached to this blog as photographs - not particularly good quality, but I can't see how to link a scanned page to this blog!)

• P20 Onset of labour for women who gave birth 2006, with comparison of data for public hospital, private hospital, and homebirth
• P21 Epidural/spinal analgesia in labour primiparae and multiparae- comparison of data for public hospital, private hospital, and homebirth
• P22 Intrapartum analgesia
• P22 Type of birth
• P23 spontaneous vaginal births, forceps births, vacuum births - comparison of data for public hospital, private hospital, and homebirth
• P42-43 graphs of public and private data for maternal age group, maternal postnatal length of stay, type of labour, and type of birth

3. Care options are dictated by private health insurance – approx 36% of women in Victoria give birth in private hospitals
• Bookings at private hospitals are made through specialist obstetricians – (very few general practitioners)
• Outcomes for private hospital intervention rates are consistently higher than public hospitals, even though women with complex medical needs are often referred to public hospitals
• Midwives, who by definition have a duty of care to promote normal birth, are not able to be primary care providers for any women in private obstetric care. The midwives in these hospitals are subservient to the obstetricians in all care decisions.
• Maternity Service Performance Indicators are published giving detailed data for public hospitals, and only aggregate data for private hospitals.

Attachment 1.
Source: Janie Nottingham - used with permission
‘Having a baby in Victoria’
In 2006, 68 547 women utilised birthing services in Victoria, in 2007 this has grown to 72 000.

64.1% of Victorian women utilised public maternity services

200 women gave birth at home by choice

The Victorian State Government issued a paper on maternity services reform, Future Directions. This document supports the establishment of primary midwifery models of care, with particular emphasis on ‘caseload models’. Caseload midwifery is where one midwife cares for one woman. The benefits and cost savings of caseload or 1-2-1 midwifery are well documented. The World Health Organisation considers this care the most appropriate for the 75-80% of women that experience normal, healthy pregnancies.

Despite the cost savings and benefits there are few public funded ‘caseload models’

Sunshine Hospital has recently established a caseload service for 1000 women

Geelong offers a service for 470 women per year. They are turning away up to 25 women per month who want to access the service.

Royal Women’s is currently conducting a trial caseload service for 1000 women. It is well known that trials in innovative maternity care (despite positive outcomes) rarely transform into established services.

Box Hill has a Know Your Midwife service. Ironically this service does not include care in labour (the most critical time to have a known carer)

Since 1997 37 rural based obstetric units have closed, with Daylesford planned to close later this year. Only one has re-opened (Seymour). Women and their families are forced to travel for basic healthcare. The financial and emotional costs to families are considerable. There is a wealth of evidence outlining the safety and improved health outcomes of local maternity care (particularly primary midwifery care)

Rosebud Hospital closed its maternity service in 2007. Officially this was due to a loss of Obstetric cover. This decision contradicts current evidence, Victorian policy (via Future Directions) that demonstrates the safety and success of primary midwifery units.
The Angliss suspended its caseload midwifery service despite stunning outcomes in 2004. Ironically just before the release of future directions
The midwifery workforce, Australia-wide is not used to its capacity. Midwives are educated and registered to provide the entire care to healthy women.

Data sourced from the perinatal data collection unit stats

Maternity organisations - members

A maternity organisation may have begun with a small number of members who all worked together towards an agreed end. These people met and talked and each one learned how they could contribute to the work. They saw the need to formalise their structure, so they obtained a model constitution, adapted it to their needs, and became incorporated. Money was needed, so a membership fee established. A treasurer was chosen, and bank account set up. The rules required certain other office bearers, and before long it was time for annual reports and financial audits and an annual general meeting.

The decision making process in a maternity organisation has usually been, in my experience, based on consensus. While everyone is working together, this style has worked well. Members of the organisation's executive are likely to reach agreement quickly, with minimal debate, on proposed actions. The person who proposes a course of action is often the one who takes leadership of that project on behalf of the organisation. There does not seem to be a need for a parliamentary style of motions being seconded, discussion, amendments, more discussion, and voting.

Is consensus decision-making any less robust or reliable than the parliamentary style? I asked this question years ago when I was a beginner in voluntary associations. I was told that the consensus style is more feminist, while parliamentary style is more male. Female processing makes a lot of sense for anything maternity! For the time being I accepted that explanation.

Today I would say that although I still support the consensus style, this should not be confused with complacency. I see every member of a committee as having responsibility for the actions of people on behalf of that committee or board or group. It is important that proposed actions be agreed upon, and the notes of the meeting record the fact. It's also important that someone follow through and report progress until the action is completed. It's all too easy to sit back and expect someone else to do the work. It's also dangerous if the group becomes a rubber stamp committee, when one person dominates the meeting, and everyone else agrees without using their own minds to question or engage in critical review. As the complexity and cost of projects increases, so does the expectation of transparency and accountability.

As more members are signed up into the maternity organisation, and more money is brought into the organisation's bank account, there is an increasing amount of work for someone acting on behalf of the committee to process and manage memberships. As a volunteer organisation, the committee depends on volunteers whose skill or commitment may be more or less competent or available at particular times, for all sorts of reasons. A reliable process of managing membership subscriptions, so that membership lists are kept up to date, and financial accounting can be correct, becomes essential. It becomes increasingly expensive if paid professional services are engaged to do the work. Yet a point will be reached where the volume of work and the skill required exceeds that which can be reasonably expected of a volunteer.

Maternity organisations will always need volunteers who are elected by members to manage the work of the organisation. As the organisation grows, prudent planning by its office bearers can ensure succession planning for the various positions. An organisation that has annual elections for all office bearers is put at risk of losing corporate knowledge if there is a large turnover. The rules can be changed to protect the organisation from this, by having, for instance, three-year terms of office, and a requirement for only one-third of the office bearers' positions to be voted on each year. However the advantage of having one-year terms is that office bearers who are not performing well can potentially be voted out sooner rather than later.

Leadership styles

The style adopted by the leaders within an organisation can either support or inhibit the work. Organisations with a maternity focus draw most of their committee and members from the people most interested in maternity issues: mothers and midwives. Some volunteers come into both categories. Occasionally a person whose 'tag' is father, or granny, or something else, will put up their hand to work to achieve the purposes of the association.

The hormonally-driven behaviours common to mothering across many animal species encourage a mother to protect her own young. The bonding between a mother and her infant, resulting in focused attention of that mother to that baby without limit, is a natural phenomenon that no modern technology or systems can replace. Midwives encourage new mothers to listen to the intuitive promptings within their relationsips with their babies.

Mothers of babies and young children are unlikely to be able to devote vast periods of time to voluntary work. Most volunteer mothers and midwives have complex sets of commitments to their families, their paid jobs, and their personal interests. Most volunteer mothers find time when their children are asleep to go to their computers, read messages, write replies, make phone calls, and do the work they have committed themselves to.

A leader who encourages others to engage in the work they have committed to, and to give their best to the work is at the same time supporting the newer volunteers to improve their capacity in that work. A leader who undermines the work of a volunteer, or who takes a strongly authoritarian position (sometimes called micro management), will find a diminishing supply of voluntary workers.

A leader who recognises potential in a person who is showing some interest in the work, and who mentors and guides by example, will find others who take up the challenge of the work, and who develop new skills and new confidence over time.

I have found that there is usually far more work that could be possibly done within a voluntary association, than capacity within the people who are active at any time. We always face limitations, both personal and financial. Each group needs to prioritise, and the activities planned will usually be those that match the interests and abilities of the committee at the time. A leader or president who lacks trust in others' ability to act on behalf of the organisation is in fact limiting the work of the organisation to what she or he can perform. That leader can only continue if the committee is willing to 'rubber stamp' any plan suggested by their president. A leader who facilitates and enables others to take responsibile action multiplies the potential output of the group.

There is no place for carelessness in a voluntary association. There is no place for "I'm just a volunteer". An action that is agreed upon should be carried out to the best of the ability of the person who agrees to do it. All who take on roles in the organisation are expected to be accountable, and to act in the interests of the group.

In considering leadership style I recognise that I am seeing the issues from a midwife's perspective, not that of a business person. A midwife develops a relationship with each woman, and learns to work in harmony with the woman's own strengths and weaknesses to promote natural physiological processes. A business executive, on the other hand, has definite expectations of performance and outcomes.

An organisation that seeks to improve the maternity experience in some way for mothers and babies, or for families, does well to model itself on the mother-midwife partnership in promoting normal birth. I would encourage all who commit to such work to truly value each other, in whatever capacity you and other committee members are able to work. There are practical ways that each person can contribute to achieving an organisation's purposes and goals.

Thoughts about maternity organisations

Today I am beginning a new theme, maternity organisations, which I plan to write about over the coming weeks. I hope that these thoughts will be productive, in supporting those who generously volunteer their time, skill, and energy to improving maternity care for all women in a society. I am writing about issues, not individual people. If any reader wishes to suggest an issue or topic, for my comment, or to make a guest comment on this blog, please contact me.

Voluntary associations require a set of rules and a committee to manage the affairs. The rules are the constitution, and if an organisation has become incorporated in law, the rules and an annual statement are lodged with a statutory body, such as (in Victoria) the Office of Fair Trading and Business Affairs at the Department of Justice.

Anyone who is interested in understanding how organisations work can check websites such as Our Community, or read well respected text books such as N E Renton, Guide for Meetings and Organisations, volumes 1 and 2.


THE TATE FAMILY

The TATE family are members of our Club.
First of all, there is DICK TATE, who wants to run every activity.
Then there are his two brothers - RO TATE, who tries to change everything, and POTEN TATE, who wants to be the big shot.
Their sister, AGI TATE, likes to stir up trouble and her cousin IRA TATE, often helps her. Another cousin, IMI TATE, wants the Club to mimic everybody else.
The parents, HESI TATE and VEGE TATE, pour cold water on all proposals put forward by the committee.
The annual meeting always groans when another relative, DEVAS TATE, stands up to speak. But FACILI TATE often moves constructive amendments.
The most delightful member of this large family is FELICI TATE, while old ES TATE is always welcome for is generous donations to Club funds.
(Source: Renton, 6th edition (1994), Volume 1, page 306)

Normal Birth: the baby

What is normal for a baby?
What conditions are optimal for a newborn child as the transition from life in the womb to life out here takes place?
What does a baby expect, in a normal physiological sense, in those moments after birth?

Recently I watched a wildlife documentary from Africa, following the annual migration of wildebeest. As the birth of a wildebeest calf was documented, the point was made that the cow and calf needed to forge immediate bonds essential for survival of the young. Senses of smell, taste, and hearing become central in the attachment between mother and child.

I believe the human mother/infant bonding process is no less dependent upon these normal, physiological factors. I believe our 'advanced', medicalised birthing rituals have become so accepted that we as a society have all but forgotten the importance of natural, normal forces that are keys to normal birthing. Our babies deserve the best start that we can provide for them. That best start is, without a doubt, being born strong and energetic, free of mind-altering drugs, and being taken by the mother to her breast with no unwarranted interference from other people.

During pregnancy a baby gets to know one person - her or his mother. The way that woman moves and breathes and talks and reacts: this is all home ground for that developing fetus. After birth the baby is absolutely at home in the arms of the woman who has carried him or her through the past nine months. Her voice is familiar; her laugh brings a memory of the laugh inside that warm safe place, when the little one learnt that with the laugh, or the embrace of the loved one, comes a surge of good hormones.

Not only does the baby recognise her mother's movements and sounds; she is also prepared for the microbiological world of her own mother. Her blood stream is already primed with antibodies to any organisms that the mother's immune system has encountered. As the newborn child is held naked against her mother's naked breast; as the mother whispers words of welcome and kisses the little nose, the baby's skin, digestive and respiratory systems are quickly populated with the normal bacterial flora from the mother and her home.


As a mother enters the most demanding stage of normal labour, as she experiences that altered state of consciousness, she may feel extremely weary. A thought flashes through her mind "how much longer can I keep going?"

Then, with the birth of the baby, the tiredness leaves her. A surge of adrenaline and other stress hormones passes through her, and her baby, supporting the birthing effort. The baby's body is physiologically primed to respond, and make the amazing adjustments that are essential in normal birth. There are several simultaneous events: the cooling of the air on his face; the change from a warm, dark, uniformly fluid filled environment to the air, light, and sound of our world. As the baby's chest moves out of the birth canal, his arms passively move away from his body, free from the previous constraints. That physical action draws air into the lungs, and together with the other complex changes initiates normal breathing. Changes in blood flow from the heart to the lungs happens simultaneously, quickly reducing the blood flow to the placenta, as the newly opened lungs take over the job of providing essential oxygen. Baby's eyes are open; pupils dilated; all senses fully primed. Smell, sight, hearing, touch, taste - and the baby's mind is recording and processing every sensation.

This is a mere thumbnail sketch of the amazing transition that happens every time a baby is born in harmony with the natural birthing processes.

normal birth

In this video I summarise the 'bare necessities' of normal birth.
If you would like a .pdf file to print out a page on this discussion, please contact me via the comments section, or by email joy@aitex.com.au
The video is very brief - it takes about a minute.

NORMAL BIRTH: The bare necessities

Understanding that physiologically normal birth is a quintessential female act
• only women can give birth
• other people can greatly influence a woman’s ability to work in harmony with her natural processes.
Each woman chooses her professional care provider(s), as well as her own trusted team, which may include
• Partner
• Family members
• Friends
• Other supporters such as lay birth helper (doula)

Recognising the importance in physiologically normal birth that a mother is able to
• feel safe, personally respected, in a personal, intimate space
• be flexible – the mother can change what she wants/ doesn’t want
• move out of her thinking mind, and work in harmony with her intuitive brain
A mother who is able to take control of her environment, the space in which she labours, or the amount of light in the room, or personal touches such as her own music, or essential oils, can minimise feelings of alienation in labour, and enable her body to work effectively.

Minimising sensory stimulation in labour protects normal birth. Interference from anxiety, fear, higher brain activity, such as thinking about
• time between contractions,
• amount of dilatation, and other calculations that are in fact indicators of progress, which may inhibit normal birth
A woman may also be inhibited by the feeling of being observed, through photography, or strangers entering her labouring/birthing space. Any sensory stimulation may be unwelcome, and many mothers ask midwives to please refrain from using perfumes when attending births.

Being well. Healthy women usually give birth to healthy babies. Healthy diet, exercise, no exposure to smoking or other harmful substances in the environment, good social/emotional support in pregnancy and after the birth, access to professional care (eg dentist, physiotherapist, GP) as needed support wellness in pregnancy and birthing.

Knowing and trusting the midwife who can act with authority and take professional responsibility for primary maternity care. Being attended by a known midwife helps a woman to
• understand choices and make informed decisions
• have confidence in the knowledge base of her care provider
• be realistic about expectations


If a decision is made to accept medical intervention, the change of plan is made from the physiologically normal birth, to the best birth that can be achieved with the collaborative efforts of the maternity care providers in that situation.

Copyright: Joy Johnston 2008
[If you would like a .pdf of this document, to use as a handout without charge, please contact me joy@aitex.com.au)

MIDWIFE Wordle

This word cloud was made by posting the url to this blog at the Wordle site.

Wordle - Beautiful Word Clouds

Wordle - Beautiful Word Clouds

normal breastfeeding

Recently I received an email message from someone named Nimal, who I do not know, in Sri Lanka, saying

"I was quite impressed by your website in which you talk to many mothers and mothers-to-be with your in depth experience. I feel a website like this helps many mothers who are looking forward to be mothers and those who are already mothers. I found there are so many useful articles in your website.
I feel you could add another valuable article to your website, thats about the crucial importance of breast feeding, the length of it etc etc."

Thankyou, Nimal, for this invitation to write more about breastfeeding.

Briefly, one cannot promote physiologically normal birth without also promoting physiologically normal nourishment and nurture of the newborn child. Breastfeeding is part of that natural continuum. In fact, if the woman is privileged to experience minimal disturbance in the crucial moments around the time of birth, it is unlikely that the midwife in attendance will need to do anything about breastfeeding. The mother and baby proceed on the intuitive journey, in skin to skin contact, making eye contact, and soon the baby searches for the breast.

Once the baby knows that food is found at the breast, and the mother has mastered a few basic skills such as holding the baby in a relaxed way, lovingly molding baby's body to her own, with baby's chest agaist her chest, baby's chin against her breast, baby's head slightly tilted back ... breastfeeding happens whenever baby is hungry or just needs mummy's special comfort*.

How long should this continue before weaning begins? That's easy. As long as it takes.

By this I mean, until baby starts putting pieces of suitable food into his or her own mouth, and tells mummy it's time to give me more than the breast milk. This is usually around 6 months of age. There should be no dairy or soy artificial alternatives to mother's own milk, except in situations so dire that an inferior substitute is truly all that's available.

This discussion leads me to an obvious line of comment: what about the mother and baby who do not experience physiologically normal birth and initiation of breastfeeding?

I have often used the principles of the breastcrawl for babies who have spent time away from their mothers, or whose experiences at learning to breastfeed have been less than satisfactory. Babies have an amazing capacity to learn, and it seems that the triggering of that instinctive ability to seek the breast and obtain mummy's milk is not well understood.

* The asterisk is on comfort. Breastfeeding is the essence of comfort, for both the mother and baby. Too often, in Melbourne the city where I live, where babies can be seen as accessories for the woman who has everything, the phrase 'comfort sucking' is used, usually in a negative way. What a shame!

Preventing and treating post partum haemorrhage

Since attending a study day last week, I have been reflecting on the way midwives and obstetricians 'manage' the third stage of labour, and the effect this has on the amount of blood loss a woman experiences.

Karen Moffatt, a senior midwife at the Women's, illustrated the unreliable nature of the estimates of blood loss recorded after birth. The test is to ask midwives, doctors, and students, to record their estimates after looking at fake blood that is poured and spread over sheets and pads, in a way that is meant to approximate what we see as we clean up after a birth. The results of these tests are usually that we are more correct on smaller amounts, such as 100-300 ml, and seriously less correct on the larger amounts, such as 1000ml. My guesses were, too. I underestimated the larger amount.

Blood loss in excess of 500 ml is recorded as a post partum haemorrhage. But if we are mis-recording the amounts, it's difficult to make any conclusions from what we record.

I would like to ask any blog readers who are interested in this topic to tell me what you think of it.

At the study day the presenters were unequivocal - they require midwives in the hospital to practise active management of third stage because it's supported by the evidence. The International Confederation of Midwives and FIGO, the international peak body for obstetricians, have written a joint statement, requiring all skilled birth attendants to carry out active management of third stage of labour.

Independent midwives attending homebirth in Australia carry the oxytocic drugs (Trade names Syntocinon and Syntometrine), and would usually use them as treatment rather than prophyllaxis. This means taking a 'wait and see' attitude, or as Michel Odent says, "don't manage the third stage".

I do not want to argue against the evidence, which applies to most women in hospital settings. But I do want to argue that women who are giving birth to the baby safely under optimal physiological conditions are more likely to ALSO safely complete the process by expelling their placentas without excessive blood loss and potential morbidity.

What are the optimal physiological conditions I speak of? This will be slightly different for each woman, because it will be her own space. The same undisturbed space in which she entered the deepest and most demanding stage of her labour. The personal, quiet space. There can be many 'non-medical' disturbances and disruptions, some of which are inadvertently brought on by the mother herself or her midwife. Photography, family congratulations, phones, showing the baby to the children - these are often enough to take the mother out of her birthing space, and interrupt the intense hormonal and physical process of receiving and bonding with a newborn baby.

Since establishing my private practice about 15 years ago, I have needed to learn from women how to work in harmony with the wonderful natural processes in birth. I did not know about physiologically normal third stage. I knew how to administer oxytocic, how to apply controlled cord traction, and how to record blood loss.

In my early years as a homebirth midwife I experienced one serious post partum haemorrhage, and transferred that mother to hospital for a manual removal of the placenta. It was a horrible experience for the mother, the father, the second midwife, and for me.

The promotion of normal birth includes protecting women from excessive blood loss. That's obvious. I am concerned, and have therefore written this blog, because the way to achieve the protection from excessive blood loss for well women seems to be so very different from the way it's done in mainstream maternity services. I look forward to hearing from anyone who has wisdom on this matter.

Joy

A new law

This past week has seen the passage of a new law through the Victorian parliament - the Abortion Law Reform Bill 2008. In responding to this new law, I hope to present a brief summary of how I believe the decision to terminate the life of an unborn child impacts of our lives, and on our society. I do believe there is another higher law, that of God the creator and sustainer of life, to which we are all answerable. This principle is often referred to as the sanctity of human life.

Abortion has been available through medical referral in Victoria for the past 40 years or so. The 'new' law takes abortion out of the criminal code.

Most terminations of pregnancy are carried out prior to 22 weeks' gestation, and are performed on the grounds that the mother's physical or mental health would be compromised by continuing the pregnancy.

A case that received a great deal of publicity in 2000 and subsequently, when a group of doctors at a Melbourne public hospital performed a termination of pregnancy at 31 weeks for a baby with dwarfism has been, I believe, a driver for the new legislation. This case is discussed in a 2004 MJA article, Abortion: time to clarify Australia's confusing laws.


My purpose in writing this blog is to state that I am shocked and disturbed by our society's huge reliance on abortion. The rate quoted in the abovementioned article is "more than one for every three livebirths. Less than 2% of these abortions are for fetal abnormality." Most of the terminations of pregnancy are for social reasons.

In the 40-year period since abortion became not only legal but more commonplace, there has been a parallel loss of ability with normal birth. Women choose regional anaesthesia, taking away their ability to feel the passage of the baby through their highly sensitive birth canals. Women are ending up on the operating table for caesarean surgery at an alarming rate. The highest rates of interventions in birth occur not among the unhealthy, low socio-economic groups, but among healthy, well educated women with private health insurance, booked at private maternity hospitals.

Why is this so?

In recent generations women have been told we have an absolute right of control over our bodies, and the baby we carry. Modern technology has 'forced' us to make decisions about prenatal screening, and sometimes to consider terminating the pregnancy. We move quickly along the production line, with an early pregnancy blood test and ultrasound, giving risk ratios that predict the likelihood of Down Syndrome. If the risk is considered too high, we have to decide whether or not to have an amniocentesis. Then at 18 weeks or so we have the 'anomaly' ultrasound scan, checking all the organs and measuring the parts. Another decision point has been reached. Some women are shocked at this time to be told of 'ecogenic foci' or 'soft markers' for Down Syndrome. Words that they have never before encountered suddenly become a cruel refrain that plays over and over in their minds. "Is my baby alright?" Yet this deeply distressing decision process accounts for only a tiny minority of abortions. Most abortions are for babies who are conceived at a time that is inconvenient in the mother's life.

Our bodies are wonderfully made. The ability to conceive and give birth to our children is among the most life-affirming, intimate acts that we will experience. But something so precious is also very easily damaged.

One of the reasons some women are unable to tolerate the pain of even normal birth is the memory of previous sexual or reproductive experiences. This memory is deeply stored, and may even be hidden for many years. When labour is progressing the memory surfaces, and may overwhelm the mother, adding to her pain and distress.

I believe the progressive increase in surgical births - an indicator of women's inability to give birth safely under natural processes - is strongly linked to our society's teaching that women can terminate pregnancies that they don't want.

Although I believe there is a greater principle of sanctity of human life, I do believe the laws of the land need to be carefully written to provide for legal abortion. Even with the new law, abortion carries definite physical risks to the mother; infection and haemorrhage being the main ones. The alternative of backyard, septic abortions, is too terrible to allow.

When I have the opportunity to counsel a woman about prenatal screening, or about the possible detection of abnormalities in their babies, I try to encourage them to face the situation carefully and honestly. We cannot guarantee a 'normal' or 'healthy' child - whatever those words may mean. Life is not about perfection. A child is not a commodity - an accessory for the girl who has everything. Some of the most tragic disabilities that parents face as their children grow are conditions that cannot be detected prenatally.

When the penny drops

It was good to spend two days with other midwives this week, in a conference on 'emerging issues in pregnancy, birth and postnatal care' at the new Women's hospital There were many interesting presentations by midwives who are involved in research on topics including estimating the volume of blood loss at a particular time; urinary incontinence experienced by women who are pregnant with their first child; an audit of treatment of newborn babies with antibiotics; expressing breast milk; and 'New look' postnatal care in Barwon Health, where well women with healthy babies are 'cared for' in a way that is radically different from standard medically based postnatal care.

An outstanding presentation, in my opinion, was given by several midwives who are providing one-to-one primary care through the Cosmos Trial. These midwives told about the changes they have experienced since managing their own caseloads. They expressed pride, and satisfaction, and told of the positive responses of women who are enlisted in the trial, and who have been allocated to receive the 'intervention' - a known midwife.

It is interesting to note that a new Cochrane Review of Midwife-led versus other models of care for childbearing women has been released. This review recommends that "all women should be offered midwife-led models of care" - that is, primary maternity care by a known midwife who is committed to attending that woman as the responsible professional in pregnancy, labour and birth, and through the postnatal care. This is what the caseload midwives at the Women's, and at Sunshine, Geelong, and other places are offering. It's also what independent midwives do.

It is quite thrilling to me to see this 'evidence based' model of midwifery care being implemented and researched in the major, mainstream maternity services. The midwives who have stepped out of their previous shift work, hospital nurse mode, and embraced the full midwife identity are excited about what they are doing. That's what I mean by 'when the penny drops'. Midwifery becomes so much more meaningful. We ARE 'with woman'. It's real.

Some readers of this blog may remember how, several years ago, there was strong consumer outcry objecting to the closure of the Family Birth Centre at the Women's. Many women have used Birth Centres over the past 30 years. My fourth child, Josh, was born at the Women's Birth Centre.

The hospital is seeking now to enable normal birthing for any woman in its care; that the focus be on the woman rather than the facility. Having heard the presentations by the caseload midwives, I believe this is now beginning to happen.

Thinking about choice

The maternity reform movement has for many years now used 'choice' as a key demand. Women want choice. My body, my baby, my choice!

Today, I encourage women to avoid what I call the supermarket attitude to choice in maternity care: "I want that, and I don't want that, and I'll have a pink one of that, and two of that ..." Choice is still a key demand, but it's a limited choice.

There is really only one choice at any time in maternity care: either you do it yourself, or you ask someone else to do it for you. While you can proceed under natural, intuitive processes, you are free to decline all other offers of help if you so choose. However, once you choose an unnatural pathway, whether it's speeding up the labour, or taking away the pain, or surgical birth, you relinquish your right to choice. How strange it would be if you were asked would you prefer a 14 or 16 gauge cannula in your vein! Or into which intervertebral space would you like the epidural anaesthetic to be administered?

The midwife's commitment is to work in a way the promotes normal birth. The partnership between a woman and her midwife supports the woman who chooses to work in harmony with her natural processes.

About seven years ago I worked with a group of committed consumers and midwives in Maternity to produce and publish the National Materntiy Action Plan (2002) which included the key demand that women have the right to choose a midwife as their leading or primary materntiy carer.

"The National Maternity Action Plan is a blueprint for reform of Australia's maternity services.
It has been put together by pregnant women and mothers who are committed to seeing women have the choice of a known midwife to care for them throughout pregnancy, birth and the first few weeks after the birth.
The right to choose a midwife as her lead carer is available to women in many other OECD countries, but not to women in Australia. It is based on scientific evidence that shows women and babies have very good outcomes from midwife-led care. The National Maternity Action Plan explains why reform of our maternity services is needed and how women and babies will benefit.
It calls on governments to respond as a matter of priority."

It is encouraging to note that the current national Review of Maternity Services quotes the National Maternity Action Plan in the call for "urgent reform to promote access to community midwives, including funding, legislation, standards of care, and indemnity arrangements." (from the Introduction)

I am thinking about choice, as it applies to maternity care today.

In the early 1970s I was amongst the outspoken young women who demanded that our husbands be allowed into the birth room. As a recently graduated midwife, and obviously pregnant, I proudly and somewhat naiively told the hospital matron about my choice. She looked icily at me as she said "Mark my words, Sister, there can only be trouble from that. Men don't belong in the delivery room." I quickly dismissed her warning - how could she understand my choice?

In the '80s the wonder of ultrasound became available, and I and many others presented in early pregnancy, holding on to a full bladder, and took home the grey polaroid image of a fetus. My choice, no questions asked.

In the early 90s there was a government report in the UK which identified 'choice, continuity and control' as what women want. At that time I was beginning to identify strongly with the birth reform movement, and I embraced those demands. Anything about midwifery in the UK, where midwives could be real midwives, had to be so much better than what we have. I bowed uncritically to a higher authority, and went about integrating the notion of 'choice' for women into my midwifery identity.

By the early years of this century, with the State and National caesarean birth rates rising by about 2% each year, word got out that women were increasingly choosing caesarean. These were said to be sensible, organised women, who wanted to be able to schedule the birth of a child into the other important matters of their lives, like work and maternity leave. These included women who were averse to the unpredictable nature of natural childbirth; who wanted to keep their "honeymoon vagina" and were "too posh to push". Their choice. And they found doctors who would respect their choice without question.


I do not want to suggest that choice should not continue to be a key demand of the birth reform movement. Yet when the 'choice' for costly and possibly harmful interventions into birthing is made for no reason other than preference, I object. I do not think it is reasonable for hospitals, doctors, and all the other staff to be distracted from their ongoing professionally valid work in order to provide a consumer items and interventions at public expense, unless those interventions are likely to improve the outcomes for the mother or her child. The items to which I refer come from a long list, including induction of labour, continuous electronic fetal monitoring, narcotic pain killers and epidural anaesthesia, and caesarean surgery.

A mother who was particularly anxious about her healthy newborn baby is not able to 'choose' to place the child in a high dependency special care nursery. That would be ridiculous. The mother does need help to develop skills and confidence in caring for the newborn, and that support can be provided by a midwife or sister or friend. Yet the 'choice' of epidural or caesarean on demand is not dissimilar. With good support that mother can learn how to work with her labour, and make truly informed decisions as the labour progresses. Having an epidural or a caesarean is not a failure, or in any way wrong in itself, when the decision is made carefully. But a system that allows women to choose such major and potentially harmful options, without first exploring less harmful alternatives, is failing in its duty of care to the woman and her child.

Someone might say that they are choosing carefully, and they choose an elective caesarean. At present that's not difficult to do, particularly in the private maternity system. The same public funding is applied through hospital funding arrangements, and Medicare, and the Medicare Safety Net, and the Private Health Insurance tax incentives, as would apply for caesarean surgery on medical grounds. That is, in my opinion, an abuse of public funding.

Midwives have choice too. We can choose to get alongside women, establish partnerships based on trust, and organise ourselves so that our services are available and we minimise the risk of burnout. Or we can choose to be obstetric technicians, managing the monitoring and surveillance of women in birth, and making sure that the paperwork is up to date.

I don't think many midwives can, in the present maternity terrain, choose to be self employed. The stresses of irregular bookings, and unreliable income, and unpredictable work hours are too much for many to take on. But changes are occurring throughout the public hospital materntiy system, particularly in places like Sunshine, Geelong, Casey, and the COSMOS trial at the Women's. I am watching these places, and others, with keen interest.

Understanding pain

There is something unimaginable about the pain that another person experiences. It's never easy to witness. My response is to want to do something that will end the pain.

But surely, I am a midwife, I should be used to the intense pain of labour. I tell women to work with their pain; to accept and use it. I know both the mental haze of narcotic drugs, and the total differentness and mental alertness of spontaneous unmedicated birth for myself, and for many of the women I have been with, and the latter is the winner without a doubt. I haven't personally experienced the numbness of regional anaesthesia (such as epidurals and spinals), but I cannot imagine anyone would choose that over the physical achievement and mental exhilaration of normal birth.

Yesterday I was at the home of a mother who was looking forward to the birth of her second child. She was strong and well, and had prepared beautifully, and was now in labour. Her husband gave unconditional personal support, and her sisters and whole family all had their support roles. The bedroom was quiet and almost dark; she spent time on the exercise ball, and resting as the hours lengthened. The birth pool was set up in the bathroom, and soft candle light made the space all the more special as an intimate place to welcome the precious newcomer. Labour had begun in the morning - a lovely clear sunny day in Melbourne. As the afternoon sun set, and the sounds of labour became more regular and stronger, I expected that undefinable change to occur, as a woman surrenders to the enormous power within her body, and her baby is brought forth.

But that didn't happen. The sounds became more distressed. We waited. I withdrew for a while, not wanting the mother to feel pressured. She told me today she wondered if I didn't believe she was really in a lot of pain. I did, and I was concerned about what I was hearing and feeling. I was intuitively sensing what we refer to as 'failure to progress', although intellectually that didn't make sense. It doesn't usually happen with a second labour, when the first baby was born at term, vaginally.

The minutes passed into hours, and the mother became more tired, and vomited. I checked internally for progress. Cervix about 5cm dilated; bulging forewaters; and a very high head that could be easily pushed away. I was careful not to rupture the membranes. The only advice I could give was that we should go to hospital. I hoped we would see progress of this baby, and my intuition would be proved wrong.

It was about six hours later that this family welcomed their new baby, with the help of the midwifery and obstetrics and anaesthetics and paediatric teams at the Women's. The hoped-for progress did not eventuate, and gradually the little one became more distressed. A caesarean birth was the best birth possible, and I was grateful.

I called this post 'Understanding pain'. My understanding of pain in labour includes the belief that there is a pain that is OK, and there is another pain that is intolerable. The distinction between the two is not easy to make, either by the labouring woman or by others. I think a midwife develops an intuition, but I am always ready to question my intuition. The labouring woman is the only person who can say, "this is OK" or "this is not OK". Many women have said, in effect, "this is not OK", in transition, and then gone through the paroxysm of pain, into the wonder of new life and love. But when "this is not OK" continues, without relief, the message is a different one.

By reflecting on an experience such as this one, I am reminded that I must hear what the woman is telling me, whether it fits with my perceived knowledge base or not. I must approach the decision points carefully, with clear thinking and without fear.

Promoting normal birth through BaBs

I have added babs-ies a new blog to my blog list, so I would like to tell my readers a little about babs.
BaBs stands for Birthing and Babies Support.

The Goal of BaBs is to be "a Health Promotion charity, which enables pregnant women and new mothers to increase control over, and to improve, their health in pregnancy and birthing, and in the nurture of their babies."

BaBs was born in 2006, after brainstorming meetings I had with two lovely young mothers, Erika and Deb. A quick stick-figure sketch that I did became the 'babs girls' At the time I was an executive member of Maternity Coalition (MC), and BaBs was set up as an organisation under the umbrella of MC, in a similar way to MIPP. Meetings began at Clota Cottage Neighbourhood House in Box Hill. Since then BaBs groups have been set up in other locations in Victoria and Queensland. BaBs is now incorporated, independent of MC, to enable growth.

The mission of BaBs is to "establish local peer support groups for pregnant and parenting women and their families in their own communities. We work to support women to make informed choices, take action about pregnancy, birth and parenting, to feel empowered and confident in their choices to improve their health, parenting, and life skills."

BaBs groups have been successful in obtaining small grants from local councils to buy books and other material, to print brochures, and to help with the costs of room hire. There is no attendance charge for BaBs groups - a donation is welcome, but not required.

BaBs groups depend on the voluntary support of mothers and midwives who work together to plan and facilitate the program in their own local neighbourhood. I am involved in the Box Hill group, which is close to my home.

I would like to encourage all midwives reading this blog to find a way by which you can make a commitment to mothers in your community - not just the mothers who pay you as their midwife, or the mothers at the hospital where you work. A midwife's duty of care includes to 'promote normal birth' [ICM Definition of a midwife]- and it's a bit late to do that when you arrive for a shift and are told to work with the woman in room 3 who has a Synt drip and an epidural.

I would like to enocourage all mothers who read this blog to find a way to meet with other mothers and midwives with the purpose of promoting health in birthing women and their babies. Normal birth includes a whole raft of 'normal' or physiological activities, including normal attachment and breastfeeding. There is no safer or better way to give birth than the way our bodies were designed, and there is no safer or better way to nurture a child than the physiologically normal way.

Birth Plan

A birth plan may be set down as Plan A and Plan B.
Plan A: "I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby."
Plan B: "If a medical intervention is recommended in order to achieve the best outcomes for myself and my baby, I need to be given the following information in order to make an informed decision:

• what do you want to do? (procedure, test, intervention, ...]
• why do you want to do that?
• what is likely to happen if I say 'no' - if I don't allow you to do it?"

In this way you will only allow interventions - Plan B - that you believe are best for you and your baby.

See Preparing your birth plan at Maternity Coalition's INFOSHEETS site.

Understanding fetal monitoring

An article, 'Mother's plea after death of newborn' on p3 of the Saturday Age today has a sad tale, from which I have excerpted a couple of lines:
"[Jane] (the mother) said CTG machines, which monitor an unborn baby's heart rate, were not working properly and her partner had to alert staff when the heart rate dropped well below normal.
"Jane said it seemed obvious that 'our little girl wasn't coping', but she kept being told everything was OK. Shortly after the birth by caesarean, Jane's baby girl died."

I feel great sympathy for these parents. They were isolated in a hospital room, with monitor straps around Jane's belly and the machine that goes 'ping'. The alarm on the monitor would have started sounding when the baby's heart rate dropped - or was it just loss of contact [ie not working properly]? Why was the partner the one who had to alert staff? How did the partner know what was OK or what was not? Jane says it seemed obvious that 'our little girl wasn't coping', so where was the midwife?

The answer seems to be that the midwife was not in the room. It seems that the hospital did not have enough staff to keep a midwife in that room at that time.

Cardio Tocograph (CTG) machines are used consistently and often continuously in hospital births. As with any test, the information provided by the machine needs interpretation - not at some time in the future, but as it happens. That interpretation should not be the job of the partner, or the alarm function on the machine. It should be the work of the midwife who is in the room continuously with the woman.

I would encourage anyone who agrees to electronic fetal monitoring (EFM); having a CTG trace, that you agree ONLY if a person who is able to take responsible action on the results of the trace is present at the time.

Continuous EFM, or any other type of fetal monitoring, including doppler or pinard stethoscope, does not ensure the safety and wellbeing of the baby. It is useful only when appropriate action can be taken on the information that is provided, and the person who receives the information understands its meaning.

Continuous EFM can give a false sense of security, as well as a false sense of doom. The usual response to a non-reassuring CTG trace in today's maternity services is to rush to the operating theatre and have an emergency caesarean birth. In the case highlighted in this story, that did not happen soon enough, with tragic consequences.

The protection of the wellbeing and safety of mother and baby are the guiding principles in all midwifery. A midwife working in a hospital should not leave the room if she considers that a mother requires continuous EFM.

You might say that's unreasonable.
Midwives have to leave the room, to do paperwork, to go to the toilet, to have meal breaks, or whatever.
That's true. So turn off the CTG machine, and take the belts off the woman, before leaving the room. It's unreasonable to expect the mother and her partner to become defacto watchers of the EFM in the absence of a midwife. They are not able to understand what they are hearing and seeing. That's a professional act, and if there is truly a reason to keep the machine running, there must be a person in attendance and an intention to intervene.

midwifery debate in newspapers

I sent the following letter to The Age in response to a small article 'Doctors Attack Midwives Proposal' (most of this was published in Letters to the Editor 12 Sept)

The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.
Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.
I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.
Joy Johnston

Reflecting on a difficult birth

After visiting the new parents and their beautiful baby yesterday afternoon, only 12 hours after his birth, I have felt that I need to reflect carefully and write on this birth. Although I enjoy writing, this is not a simple task. The complexities of life, and of each birth, mean that I have to choose a small aspect of the whole experience and write on it. By reflecting on the experience that I had, within a professional partnership as midwife to this woman and her child, I am using the maieutic mode of enquiry. This is the essence of a midwife's work both as a teacher and as a student: enabling learning through reflection on experience.

The dictionaries explain the connection:

Maieutic = act as midwife. Pertaining to the Socratic method of bringing out ideas latent in the mind. [Webster's]

Gr maieutikos maieuomai = act as a midwife. [Concise Oxford]

In summary, the mother, who I will call M, was a primigravida at 41 weeks plus 3 or 4 days' gestation. For the previous week, and particularly for the past few days, M had been experiencing pre-labour contractions, day and night, every 7 to 10 minutes. Each time we spoke, I encouraged M to trust her body's signs, to rest when she could, and to be ready for the establishing of labour. I saw her on Tuesday, and found that her the baby's head was well engaged, and the cervix very thin. Very good! However, M was becoming discouraged. She did not think she could keep going. She had noted a reduction in fetal movements, and we were not sure of the significance of this.

M had chosen to give birth at the Mercy Hospital for Women in Heidelberg, and had an appointment at the hospital the next day. When offered induction of labour, M agreed to having her waters broken, but wanted to see how she could progress without IV oxytocic. Contractions became more frequent, and labour was underway.

Over the next few hours there was little dilatation of her cervix, and the doctor encouraged M to have the oxytocic. Having no alternative plan, this further step in 'Plan B' was agreed to, with an epidural.

It sounds trite to just say 'with an epidural'. Women who have planned for spontaneous unmedicated birthing, and who understand that an epidural comes with at a cost as well as having the apparent benefit of pain obliteration, express grief at this time. But when they see it as the best option, they make the decision. Well, there's no guarantee, and this epidural did not work, and had to be resited. Even when it was correctly placed, there was a persistent painful area in one of M's legs. The anaesthetist was patient and consistent in trouble-shooting, and eventually achieved the desired pain relief. By this time there were 'non-reassuring' fluctuations in the baby's heart trace.

The hospital midwife told M that it would be best to put a scalp clip on the baby's head, in order to monitor more reliably. M asked me what I thought. We agreed to make a decision after we knew what progress the baby had made, with several hours of oxytocin augmentation. Good news - M had dilated to 'fully'. M declined the scalp clip, and found a sitting position which allowed for better external monitoring.

With a deep anaesthesia from the epidural, M's efforts at pushing were insufficient to get this baby born. The heart rate continued to fluctuate. With M pushing, and the doctor pulling, using the Ventouse vacuum cap, the baby was born in good condition. With the baby came thick, heavily meconium stained liquor. He needed to be born, that's for sure.

When attending a complicated birth, with the increasing possibility of harm to the baby (as indicated by the baby's heart rate and rhythm), it is not possible to predict what may happen. In this case, I do not believe the baby would have been in good condition at birth, able to stay in mummy's arms, if the birth had been delayed much longer.

The matter I want to reflect on, and I hope my readers are also able to ponder, is that decision to move from 'Plan A' to 'Plan B' - in this case, accept induction of labour. Here are a few of the points I am conscious of in this decision:

• the woman is the one who makes the decision
  
• I am committed to being 'with woman' in her birthing
• I want to give the woman information so that she can make decisions that she believes are best for her
• obstetric and anaesthetic interventions in birth, although they are common, cannot guarantee good outcomes
• once we have moved to 'Plan B' we can't go back to 'Plan A'.

My question to myself is, was there something else M could have done, rather than accepting induction of labour? How will I advise a mother in a similar situation next time?

With the wisdom of hindsight in this case, I believe M's decision to accept 'Plan B' was the best option she had. Her body had been trying, for the past week, to get started. She was feeling discouraged, and exhausted. Her baby was showing signs of tiring too.

M asked me what I would have done if we had been planning homebirth. I believe my advice on key decisions would have been the same.

CONTESTED TERRAIN

I don’t want to over-dramatise the issue, but it’s an unavoidable fact: midwives who offer homebirth are in competition with doctors for the work. The contested terrain is the place of birth, and it’s not an equal contest. It’s one of those mad experiences from Alice’s wonderland, when she is either enormous and unable to fit, or so small that she’s likely to be stepped on and squashed.

Homebirth midwives who work independently don’t have ‘much’ to offer – except HOMEBIRTH, that is. And when professionally attended homebirth is not available any other way than through a private agreement between a mother and a midwife, independent homebirth midwives continue to work despite the social and professional restrictions we face each day. If it weren’t for the fact that homebirth makes so much sense to a small number of birthing women that they are prepared to pay for it, we would soon be out of work. We can’t buy insurance; we can’t get visiting access to the same hospitals that are very happy to employ us as ‘their’ midwives; we have to ask women to go to the local GP to request even the most basic blood tests and investigations, and to prescribe oxytocics that are considered essential in preventing or treating post partum haemorrhage.

I am referring only to professionally attended births. There is a steady trend, possibly growing, in which women give birth unattended. Some are surprised by the speed and intensity of their labours, while others consciously delay going to hospital, until the baby is ‘coming: ready or not’. These out of hospital, unattended births have always happened, and will continue. A few Australian women today make a decision to give birth at home without professional attention; possibly with an unregulated lay birth attendant.

Back to my initial statement, that midwives are in competition with doctors for the work of attending birth. There’s a complication that arises in looking at the contested terrain of birth. It’s not only homebirth. We have to include small birth centres and hospitals that are separate from 24-hour anaesthetic or obstetric care. These hospitals and birth centres, like homebirth, can ‘only’ support spontaneous birth. I say ‘only’, and ask, “What’s ‘only’ about that? Is that not enough? It’s huge.” Yet, how available is it? Many rural health services are sending these women to larger regional centres to give birth, because there is no obstetric or anaesthetic cover at a particular time. Do they have midwives? Of course they do. Why can’t those midwives take professional responsibility for the births? Because they never have been expected to work on their own authority, and in many cases they don’t want that responsibility. The hospital system, and those who work in it, expect doctors to be on hand to induce labours, and order narcotics and epidurals. The hospital system, in most cases, has women booked under the name of a doctor. The midwives work shifts, and the mother-to-be is not likely to know or trust the midwife who is working when she comes to the hospital in labour. The midwife is effectively, doctor’s assistant.

You would think that the leaders of a rational, sane society, like ours, committed to providing essential health services for all, would say “Right, there are going to be about 300,000 (and growing) babies born in Australia each year. At least half of these women (actually many more, but I’m not wanting to inflate the calculation) are likely to give birth to healthy babies without any complications. That means a midwife could provide the maternity care, and it means they can give birth wherever they choose.” If those 150,000 women were in the care of a midwife or group of midwives who were competent in attending birth on their own responsibility, which incidentally is what ALL midwives are declared able to do when they graduate, they could all give birth in primary level care, isolated from specialist obstetric or anaesthetic care. That is, almost all could give birth in the small country hospitals, freestanding birth centres, or in their own homes. The few who experience unexpected complication in labour would be transferred to a hospital that provides the service they need, in the same way that women and midwives planning homebirth make informed decisions as labour progresses.

The current annual rate for homebirth is 0.2%, approximately 600. I don’t have the number of babies born in primary maternity units without obstetricians and anaesthetists on call, but it’s also likely to be very small. The hospital based programs that have been offered in recent years have struggled to maintain management support. 600 out of 150,000.

Evidence of the contested terrain of homebirth is clear in the statement against home births by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG). The statement “The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) does NOT endorse home birth.” (http://www.ranzcog.edu.au/publications/collegestatements.shtml). This statement has been in effect since 1987, and was most recently updated June 2008. I suspect very few obstetricians have attended or seriously investigated homebirth.

The RANZCOG statement lists a set of recommendations for those women who are planning homebirth, including the statement that “Women choosing home birth should be cared for by both an experienced medical practitioner and a registered midwife, each of whom has agreed to participate”. This paternalistic recommendation is a curious one, as very few medical practitioners in Australia or New Zealand today are attending homebirths. It says: “Don’t do it, but if you do, here’s what you must do!” There does not appear to be any literature quoted in the RANZCOG statement to support this recommendation.

Midwives and obstetricians collaborate in providing expert maternity care for women and their babies. Obstetricians rely on midwives to admit women to hospital maternity units, assess progress, report to, and summon them at certain times. Obstetricians cannot provide maternity care without midwives’ support and collaboration. A RANZCOG statement such as this one imposes a wedge between the midwifery and obstetric professions. Some individual obstetricians support homebirth, having worked in countries where midwifery practice in offering homebirth is accepted and respected.

The midwife is the only professional who offers birthing services without requiring the support of other professional groups, and the only time that sort of birthing service can be offered is when the woman herself does the work. The healthy woman comes into spontaneous labour at term, progresses without artificial stimulation or analgesia, and works with her own body’s power to give birth to her unmedicated, healthy baby. The midwife works in harmony with the woman, and does not interrupt or intervene or disturb the wonderful process of birthing. There is no need in these births for hospital specialties: nursing, anaesthetics, obstetrics, paediatrics, or any other medical specialty. There is also no need for alternative therapies. The woman is not sick; she is giving birth. All she needs is a midwife.

This is the root of the contested terrain of birth.

I think that’s enough for today. Another time I will explore medical dominance of the terrain of birth, and how midwives have apparently accepted a subordinate position.