When we attack one another rather than working together

19 March 2009
One of the advantages of keeping a blog is that I can write whatever I want to. In this particular blog I want to attempt to address a matter of great concern to me.

Today's topic has arisen out of a message I received this week. Apparently several people who attended the same workshop as I did last weekend have reported that I said certain things with relation to the Maternity Services Review and the actions of the College of Midwives.

I am proudly a member and fellow of the College, and have held positions on the Victoria branch executive.

I don’t know what I said that could have been construed in the way that has been presented to me. I believe everything I said was consistent with what I have been writing - very publicly - on this blog and the MIPP blog http://midwivesvictoria.blogspot.com/

I don't know who has complained about me, but I hope they will read this attempt at clarification, and I hope it is satisfactory. I am writing to ask those midwives who may have misunderstood me to please work with me and the others in Victoria who seek to protect the rights of women to employ a midwife, and the rights of midwives to practise our art in the setting of our choice. I am very concerned that some midwives attack one another rather than working together towards our common goal. This is the behaviour of an oppressed group, and we cannot afford to waste our energy on internal fighting. We need to stand tall, and proud, as midwives who have a skill that our community will always need.

It has been alleged that I indicated a belief that RANZCOG (the College of O&G's) and the College of Midwives have done a deal to ensure the demise of midwives providing homebirth services.

NO WAY! Let me tell you what I understand and have said publicly:
I have understood from their press releases since before the Report was published that RANZCOG is opposed to 'independent' midwifery. RANZCOG has a statement against homebirth at their website (no link provided). It looks as though RANZCOG have successfully sold this line to the Review team. I know of no arrangement between RANZCOG and ACM.

It has been alleged that I have said the College of Midwives is not supportive of privately practising midwives.
NOT QUITE! I have stated openly that I do have concerns that the College may be unable to do much on behalf of privately practising midwives. That is quite a different matter from the College's support. This opinion was further enforced when I listened to the Minister on Insight. See my comments at http://villagemidwife.blogspot.com/2009/03/lack-of-insight.html

For this reason I have encouraged everyone who is concerned to take action now, and not to leave the work to the College of Midwives, or Maternity Coalition, or any other group.

I have been encouraging people to contact their federal MPs about why they want to be able to employ a midwife privately, and why they want to be able to choose homebirth, or employ a known midwife to attend them in hospital.

At the study day I requested and was given a few minutes for Janie Nottingham (Materntiy Coalition Victorian Branch leader) and me to speak to the group. We asked people to take the handouts that I had brought. Anyone who would like copies of the handouts can request one - please tell me your email address. Many of the hospital midwives who spoke to me said they had no idea of the national registration.

The matter of the Report's attitude to the women who choose to employ a midwife privately for homebirth has been summarised by birthing activist Bruce Teakle at http://midwivesvictoria.blogspot.com/

"Women choosing homebirth are a trivial minority:
A strong point [in the Report] is made of the small number of homebirths which occur in Australia:
P16: shows a graph of declining numbers of homebirths in Australia from 1991 to 2006.
P16: “Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia, compared with 2.7 per cent in England and Wales, 2.5 per cent in New Zealand, and 0.6 per cent in the United States.”
P20: “New Zealand maternity data for 2004 found that, while 4.5 per cent of mothers had planned a homebirth, only 2.5 per cent actually experienced a homebirth.”

"The reasons for the small Australian numbers are not explored, in particular the great difficulty most Australian women have accessing information or care for homebirth.

"No comparison is made with other minority choices, such as caesarean section on request, and there is certainly no consideration of banning these choices.

"The Reviewers acknowledge the high number of individual submissions from women who desired greater access and funding for homebirth. Despite this, it appears the Reviewers have been more responsive to the input of those who want to control women’s choices."


Women (and a few men) who went to a lot of trouble to prepare submissions to the Review have been told that their views are not important because they are a minority. Would this be an acceptable response if it were an ethnic or religious minority? Not at all!

In conclusion, I hope midwives will stop and think before they attack one another in this or any other campaign. We may have different opinions. That's fine. We may think things should be done differently. That's healthy.

The fact is that the College of Midwives or any other organisation can only lobby the Minister for Health, who will make decisions about the actions that proceed from the Maternity Services Review. It's up to everyone who cares about the future of midwifery, and the maternity choices women have, to look at the Report and to listen to those who are writing about it, and form your own opinion. If you are not satisfied with the Recommendations made by the writers of the report, please make an effort to inform your local federal Member of Parliament. Together we can show that even a minority has the right to be heard in this country.

birthing alone

[The following is an edited version. This post was taken down for a few days out of respect for a family whose baby was stillborn.]


A major article 'Home deliveries' appeared in the Sunday Age yesterday.

The article focuses on the issue of 'free birth', and one proponent in particular. Comments by representatives of the College of Midwives, Homebirth Australia, a public hospital maternity service, a homebirth mother-lawyer, and an independent midwife are sandwiched between the sensationalist story about and comments by a woman who prefers to be an "autonomous care provider".

There are many points in this article that would be worth discussing further. The fear that home births are being pushed underground has been explored by midwife academic Jenny Cameron. The victims of restrictive government policies that force women into the care of unregulated and sometimes unscrupulous operators are women and their families. Midwives offer excellent primary maternity services in communities, working with women in complex ways to promote physiologically normal births, with the wellbeing of mother and baby being central to all professional guidance and advice.

The woman is reported to believe "that nothing bad happened quickly in labour and that there would be time to get to hospital if things went wrong." A person who believes that is simply uninformed.

The issue of birthing alone, by choice, is one that questions the very foundations of midwifery. What has brought women to the place where they believe it's best to DIY? Is this the ultimate adrenaline rush; the ultimate search for meaning?

I have been told that there are variations of the 'solo' birthing phenomenon. Often the woman's partner is present, having been instructed ahead of time as to what is expected. There may also be an unregistered birth attendant. That person may have been present for a number of births, and there may be an expectation that she would act to help if there was a need.

Someone suggested that the partner could do a first aid course in resuscitation of a baby. Resuscitation is only ever needed if a baby is unable to breathe unassisted, and this is a true emergency.

Most people would not like their tooth filled by someone who had gone along to an evening class to learn about dentistry. How much more important is the newborn child, than a tooth needing to be drilled and filled?

In many parts of Australia the only way to access midwifery services for homebirth is privately. The obvious pun on 'free' birthing is that you don't pay a midwife's fee - which may be from around $2000 for one midwife to around $5000 for two, who provide a package of professional services through the pregnancy, birth, and postnatal period. In fact, 'free' births may not be free. Lay birth attendants may charge around $1000 for a prenatal chat and the labour.

We do not know how many planned unattended home births there are. Of the planned homebirths, some are born before the midwife arrives. In my practice alone, I might see one or two a year. There are many more unplanned 'out of hospital' births - the babies that come quickly, before the mother has got to the hospital: in the bathroom at home; in the car; on the freeway ....

Some authorities claim that most planned unattended births are that way because the woman has no access to a midwife who is able to attend birth in the home. I don't think anyone really knows, but that has not been the case in the planned 'free' births I have heard about lately.

Midwife means 'with woman'. Since women began having babies, other women have been 'with' them, and out of this phenomenon the professional midwife has evolved. Something has gone very wrong when a woman believes she is better without any skilled professional attendant. I grieve for that woman. A true midwife will be with woman, while at the same time supporting her desire to be free. It is expressed beautifully in the ancient statement attributed to Tao Te Ching, about 2000 years ago,

You are a midwife.
You are assisting at someone else's birth.
Do good without show or fuss.
Facilitate what is happening
rather than what you think ought to be happening.
If you must, take the lead.
Lead so that the mother is helped, yet still free and in charge.
When the babe is born the mother will rightly say
"We did it ourselves".

choices that most don't know about

A couple of weeks ago I wrote on Choice with reference to an Opinion piece by Age Editor Lucy Beaumont, who had stated "Women don't have a choice when the health system can't deliver."

I responded with the claim "There is only one *choice*, that a woman either accept the work her body is doing, or accept the medical intervention." I stand by this statement, as far as the basic natural processes in that amazing childbearing continuum are concerned.

However ...

[Yes, life is complex. There are no simple answers]

... There are a whole lot of choices in childbearing that most women don't know much at all about. Most come under the banner of 'routine' or 'standard' actions by health professionals, and most are done with little discussion and not even a pretense of informed decision making. These include:
. group B Streptococcus screening and subsequent antibiotic treatment in labour
. the induction of labour
. assessment of size of an unborn baby
. assessment of fetal wellbeing
. antenatal prophylactic Anti-D immunoglobulin for Rhesus Negative women
. assessment of dilation of a cervix
. time taken and progress in labour
. 'management' in Third Stage, and blood loss
. measurement of blood loss
. Vitamin K for newborn babies
. Hepatitis B Vaccine for newborn babies

A woman who simply accepts the standard care in this set of issues, and many more, may find that she has, in reality, no choice. She gets swept up on a production line conveyor belt.

Learning how to take responsibility for your own decision making probably begins before conception. Reliance on the little blue line with pee-on-the-stick pregnancy diagnosis rather than quietly accepting changes that come with early pregnancy; imagining that bonding is enhanced via the blotchy grey image on a computer screen, while paying no attention to the timeless event of 'quickening'; ... these technological advances while being very useful for a few, are probably setting most women up so that they follow each other like sheep going down the shute towards their ultimate fate.

Sara Wickham's study day

Today midwives had a good study day with Sarah Wickham, hosted by Capers.

Sara's topic was 'Women, midwives, risk and decisions'.

Many of Sara's articles, including discussions and references on Anti-D, vitamin K, Group B Strep, and post term pregnancy are available at her website www.withwoman.co.uk

A blog worth reading

This blog is by a woman Lauredhel. I have added a link to my blog list, and have left a comment after the post Maternity Services Review: Medicare payments to OBs up from $77m to $211m since 2004.

Here's the comment:
I am one of the independent midwives in Victoria facing loss of my livelihood if the recommendations of the Review are implemented. Most of my colleagues are keeping quiet. Perhaps it will go away!

I find the Report wishy washy and lacking any direction other than backward. The Discussion Paper advised that: “Improving the delivery of maternity services in Australia is not the responsibility of any single party. While there are actions which could be undertaken by the Australian Government on its own, substantial change requires a combined approach.”

Let's get real. Most of the Recommendations could be done without the Australian Government's permission. The Minister has the opportunity to move the focus of maternity care from a broken system, and a financial monopoly privileging the medical profession, to the woman, by funding a woman to obtain the basic care she needs.

Yet from the Report, and the Minister's statements on the SBS Insight program on Tuesday night, she seems unaware that if she follows the advice of the Recomemndations she will be setting birth back into the doctor supervision era that most midwives remember. It was only 1996 when Victorian midwives were free of the old regulations (1985) that required us to have a doctor's permission to do a vaginal exam. Whose vagina, you may ask?

LACK OF INSIGHT

The SBS INSIGHT program that went to air last night had the title
'Why are more Australian women having Caesarean sections?'

Guest panelists included mothers, midwives, and obstetricians. The Health Minister, Hon Nicola Roxon, joined the discussion by video conferencing. The transcript and video are available at the website. You will also find at that site a growing number of comments (over 500 at the time of writing this blog) from interested people.

What was clear to me, while watching the program, is the serious lack of insight that Nicola Roxon has. She played the safety card – where does she get that information from? Where is the evidence? She followed the script of the Report almost to the word.

There was no sign of acknowledgment or understanding that by implementing the recommendations she will be ushering in a new era, more restrictive to midwifery practice and to women’s choice of care provider than we have ever known before. We need to ask serious questions about the quality of advice about midwifery the Minister has been given. It’s not just about homebirth. It’s about a midwife’s right to choose to practise midwifery in any setting, and about a woman's right to access midwifery care privately if she chooses.

The absolute arrogance and lack of insight by obstetricians Ted Weaver and David Molloy astonished me – and you would think I had been around long enough not to be astonished. Would they recommend specialist primary care in other areas of medicine and surgery?

I was proud of the efforts of midwives in the program, and the women who spoke of woman centred care.

We have a big job ahead of us. We have a health system that supports every medical/technological choice, and restricts those who want to give birth in harmony with their body’s physiologically normal processes; clearly the safest and most satisfying way for most women.


Jo Hunter from Homebirth Oz has sent out a message about a petition

Please also sign our online petition to keep homebirth legal.

http://www.ipetitions.com/petition/australianhomebirth

A BIG PUSH FROM WOMEN

If you would like to join in the 'BIG PUSH', please go to the MIPP blog

Please let me know how your MP responds when you contact her/his office to tell them why it is important that Australian women are able to access private midwifery services, and why it is essential Australian midwives are able to work in the full scope of midwifery practice, including homebirth.

Thankyou.
Joy

A response to the Maternity Services Review

"It appears that the Reviewers have conceded to fear of extreme medical voices, over the interests of women. Hopefully the Minister, who is directly accountable to women, will be braver." [Bruce Teakle, Maternity Coalition Queensland Branch]

As anyone who has read this or other Australian midwives' blogs will understand, the Report of the Maternity Services Review recommends that the Federal government should prevent midwives from practising as private practitioners, which also means, in most of Australia, an effective outlawing of homebirth.


In response to this very real threat I feel there is an urgent need in Victoria that we work for free homebirth options, and widespread caseload, with the option of homebirth, for midwives working in the public system. (If any of the private hospitals want to join in that’s fine, but I’m not holding my breath!)

I don’t think women should have to declare ‘home’ or ‘hospital’ until they are ready. The midwife should have competence and unrestricted practice to go with the woman wherever she wants to give birth. As we have often said, it’s not about the bricks and mortar, or the curtains. The Report's language of 'informed choice' and 'access' to 'evidence based' models of care is mere rhetoric, when the recommendations of the Report announce that the very model which many of its submissions promoted and backed with significant evidence is to be summarily withdrawn.



The Report draws attention to the fact that a very small proportion of Australian women choose homebirth; that many of the submissions were from mothers who were dissatisfied with the choices available to them, and in fact had chosen homebirth or other midwife led models; and that moving to a mainstream private model of care incorporating homebirth 'risks polarising the professions' (whatever that means!). As Bruce Teakle has observed, the Reviewers "have conceded to fear of extreme medical voices, over the interests of women."

As Allison Leemen said (ABC Unleashed) "Homebirth with an independent midwife is a great model of care for lots of reasons, key among them that it provides continuity of care with a known carer - something the Maternity Services Review says it wants to see in hospital -based models. So why is it killing off the only model that reliably delivers that care?”

We must insist to our professional associations as well as to the government that homebirth is not about the marginal minority of women or midwives. Internationally homebirth is recognised as normal midwifery practice and is a safe and reasonable option for many women.

We know that many more women would want homebirth if it was free, and this has been demonstrated in the Review by the rates of homebirth being highest in NT, WA and SA where publicly funded options are currently available for some women. People do not, without strong reason, ask for something that is not available. Those who are prepared to pay for homebirth are usually well informed. Other women are on a journey of discovery when they become pregnant, and if the system offers them a reliable care option, such as homebirth, they will think about it then. Shutting down homebirth options by shutting down independent midwifery makes no sense at all. Furthermore, midwives in Victoria will quickly lose competence and confidence in homebirth practice if we are forced to cease our practices. If, on the other hand, there were publicly funded homebirth models on offer, whether or not independent midwifery continues, many more midwives could be upskilled quickly by those who are currently experienced in homebirth.

Happy International Womens Day

Most who read this blog are women, and most are deeply interested in that amazing, demanding, sometimes overwhelming, but quintesential womanly time of life, when we bear and nurture our children.

The following message is from VICTORIAN WOMEN’S TRUST

Dear Friends of the Trust,

Wishing you a happy International Women’s Day this Sunday!

The Women’s Trust will have a stall tomorrow (Friday 6 March) at the Queen Victoria Women’s Centre market (just behind the QV building, 210 Lonsdale Street) from 11am-3pm. If you’re in the city and can drop by, come over to the Trust table, check out our publications and merchandise (including the Women’s Anthem CD) and say hello.

Also at the market will be the Brunswick Women’s Choir who will be singing the Women’s Anthem ‘Love & Justice’ during two 15 minute sets at approximately 12.05 and 12.45pm.

The Anthem ‘Love & Justice’, which we commissioned Kavisha Mazzella to write last year as part of the Centenary of Suffrage in Victoria, will also be getting some airtime this weekend as part of IWD celebrations.

A recording of the inaugural performance of the Anthem late last year (with a choir of over 450 women) will be played on:

*774 ABC Melbourne – Tracy Bartram, who led a verse of the Anthem at the inaugural performance, is filling in as host this weekend on the Saturday Morning program (7 March). She will interview Executive Director Mary Crooks after the 7am news bulletin, as well as play the live recording of the Anthem.

*ABC Radio National (Melbourne 621 AM) - Paul Petran of Music Deli will be playing the Anthem at the end of his program on Friday evening (6 March) (program starts @ 8.05pm), and on Saturday morning 7 March (program starts @ 4.05am (for insomniacs and shift workers!). It will be repeated at the end of the program on Sunday 8 March (program starts @ 4.05pm). The program goes for one hour - if you miss it you can listen in to the podcast for a month afterwards on www.abc.net.au/musicdeli


The Trust has in stock copies of a CD which includes (1) Mary Crooks’ introduction providing the historical context of the anthem, (2) the inaugural performance of the anthem, (3) Convenor Dur-e Dara’s gifting to the women of Victoria and beyond, and (4) practice tracks, with Kavisha Mazzella singing each part for you or your choir to learn from. Copies are available for $10, including postage. If you would like to obtain a copy of the CD, please email women@vwt.org.au or phone (03) 9642 0422.

Have a great long weekend!

IF

IF
the federal government provides an affordable indemnity arrangement for independent midwives, before 1 July 2010
THEN
midwives will be able to continue attending women who plan homebirth, and accompany women who go to hospital, as we do today.

IF
there is no indemnity provision for independent midwives
THEN
* the only homebirth options will be those provided under public funding
* the only midwives will be those who are employed by hospitals, health services etc
* midwives will not be able to provide any private fee for service consultations
* some women will engage unregistered attendants to attend them when giving birth at home (that is, go underground). This puts mothers and babies at risk, as there is no regulation or accountability of the attendants.



SINCE
there are no publicly funded homebirth programs in Victoria

AND
the refusal of the Maternity Services Review to do anything about funding homebirth nationally means that the buck has been passed from the federal health portfolio back to the state

THEREFORE
mothers and midwives and anyone else who considers midwife led models of care with the option of homebirth a reasonable choice need to make a concerted effort to approach the State Health Minister, and their local state government MPs, to urgently request action in the public interest.

CHOICE?

A birth made to order? What a joke

Author: Lucy Beaumont
The Age Opinion March 2, 2009

"Women don't have a choice when the health system can't deliver."

Journalist Lucy Beaumont has written about her own devastating experience of birth. And she seems to have concluded that she was hoodwinked into believing that "this labour thing was going to be tough, but "good tough". More intense than anything I'd ever physically known before but essentially positive. And for some reason I felt entirely up to the challenge, supremely confident after a fairly stress-free pregnancy."

The memory of lapsing into unconsciousness as she haemorrhaged; of the doctor at the business end, and the midwife next to her giving her face a slap in an effort to bring her back - that memory will be with her as she approaches the birth of her next child.

I value the opportunity to reflect on this account, and am writing for those readers who are wondering how might this experience have been different.

Beaumont is right, "Women don't have a choice when the health system can't deliver."

But I would like to take that statement a step further. "Choice" in childbirth is one of the hugely misunderstood concepts. There is only one *choice*, that a woman either accept the work her body is doing, or accept the medical intervention. The only choice that this woman had, after experiencing prelabour for 48 or so hours, and the 'postmature' stamp, was to agree to induction of labour or to continue waiting for spontaneous labour to establish. Once you step over the line, into 'Plan B' I call it, you have very little choice. In fact, the idea of choice becomes a bit of a sadistic game: "Have you had enough of natural birth now? See, you can't do it yourself. Let's get this epidural in and move into the 21st century!"

We can all be wise with the help of hindsight. If I had been advising this woman at that time of her critical *choice*, would I have had the confidence that I now have in writing about choice?

The difference in my role is that usually I would only be involved in that *choice* if that woman had asked me, personally, to advise her as her primary carer. And that arrangement is usually set up in early pregnancy, giving us the opportunity over the months of the pregnancy to build confidence and trust in our shared decision making. It's called midwife led continuity of carer. It's the sort of maternity care that is based on good evidence! The Cochrane Review (Hatem 2008) not only confirmed the safety of midwife led care, but concluded that “All women should be offered midwife-led models of care and women should be encouraged to ask for this option.”

"All women ..." What a paradox we face at present in Austrlia today that the very providers (self employed midwives) of such a care option are facing deregistration because our government's reviewers of maternity services don't consider the women who employ us, or the midwives who work this way, worth protecting.

So if Lucy had been in my care (or any other midwife who accepts the 'caseload' primary carer role seriously, whether employed or independent), we would have been able to explore what was important to her. I could have encouraged her with words like, "You and your baby are well. You are obviously getting ready for labour. There is no valid reason for us to interfere with your body's preparation for spontaneous labour."

I know these things are true, because any mother or baby who were not in good shape at the beginning of the induction process would not have proceeded to a vaginal birth.

There are times when a woman in a midwife's care decides that her best choice is to step out of 'Plan A' into 'Plan B'. The known and trusted midwife continues working with her, using her knowledge and skill to promote normal birth. The partnership between the woman and her midwife is often the key to maintaining good progress, or alternatively, to moving into further appropriate medical or surgical management.

Home birth: the unheard horrors

Thankyou everyone who has sent messages of support and concern for the midwives who face loss of our livelihood because we are unable to access professional indemnity insurance.

If you have been following this blog I hope you will see that I have attempted to present issues in independent practice, and homebirth which is the main practice terrain for independent midwives, in an unbiased way.
Yes, I am outraged.
Yes, I am wondering how I will make a living next year.
I'm not really old enough to retire; my superannuation savings have been disappearing at an alarming rate; and I don't think I would be strong enough to work shifts in hospitals.
My heart would break anyway, even if the arthritis in my knees and back could be managed.

But today a letter in The Age has brought the debate to a new low level. It's such an outrageous letter that I will take the trouble to copy it into this blog, and I will place my comments in [BOLD - AND YES, I AM SHOUTING!]:

Home birth: the unheard horrors
I WISH to object to Alison Leemen's criticism of the Federal Government's maternity review (Letters, 25/2) and her claim that the Government is "criminalising home birth". The Government is sensibly responding to the overwhelming data that in Australia, home birth is three times as risky for both the mother and her baby. [THIS IS SIMPLY NOT TRUE. THERE IS NO SUCH DATA. ALL MIDWIVES ATTENDING HOMEBIRTHS SEND THE DATA TO THEIR STATE OR TERRITORY'S PERINATAL DATA COLLECTION UNIT, AND WOMEN WHO TRANSFER FROM PLANNED HOME BIRTH TO HOSPITAL ARE ALSO REPORTED ON.]

There is no way that even a "skilled and qualified" midwife working on her own in a home is able to deal with the sudden and often life-threatening complications that can occur in childbirth. [THE WOMAN WHO GIVES BIRTH AT HOME IS A WELL, STRONG WOMAN, WHO COMES INTO SPONTANEOUS LABOUR, PROGRESSES WITHOUT STIMULATION OR ANALGESIA, AND GIVES BIRTH PHYSIOLOGICALLY. BOTH MOTHER AND BABY ARE PROTECTED FROM MANY OF THE SUDDEN AND POTENTIALLY LIFE THREATENING COMPLICATIONS SIMPLY BECAUSE THEY ARE NOT RECEIVING THE MEDICAL INTERVENTIONS/INTERRUPTIONS/INTERFERENCES THAT ARE COMMON IN HOSPITALS] Compare this with a team of professionals, including a team of midwives and more experienced doctors, being immediately available. [A TEAM HEADED BY DOCTORS BECAUSE IN MOST CASES THE BIRTH HAS BEEN MEDICALLY MANAGED FROM THE START. MOST DOCTORS WOULD NOT HAVE A CLUE HOW TO BEGIN WORKING IN HARMONY WITH WOMEN'S AND BABIES' WONDERFUL BODIES IN BIRTHING]

A woman has the right to give birth at home, but she takes an increased risk and legally she must be advised about this. We see the avoidable disasters after attempted home birth daily in hospitals [I THINK THIS IS A GROSS EXAGGERATION AND WOULD LIKE TO SEE THE ACTUAL FIGURES FOR THE ALBURY-WODONGA HOSPITALS. THE MIDWIVES I KNOW IN THAT AREA ARE RESPECTED MIDWIVES, AND SINCE THERE ARE ONLY ABOUT 200 HOMEBIRTHS IN VICTORIA ANNUALLY, AND ONLY ABOUT 20% OF PLANNED HOMEBIRTH WOMEN GO TO HOSPITAL, I DON'T KNOW HOW DR MOURIK SEES WOMEN DAILY. WE KNOW THAT THERE ARE NO GURARNTEES EVER IN BIRTH. WE SEE AVOIDABLE DISASTSERS AFTER ATTEMPTED HOSPITAL BIRTH TOO]. These women do not go to the media with their horror stories to warn other women; we only hear if it goes well.”

Dr Pieter Mourik, obstetrician, Wodonga

&^&^&^&^&^&^&

It is likely that some of the misinformation about risk in Australian homebirth relates to a publication in 1998 in a respected journal by Bastian, Keirse and Lancaster (reference given below). Methodological criticism of the study by Wagner (1999) illustrates that less than three quarters of the data was collected by an ‘orthodox and acceptable’ method, giving a perinatal mortality rate of 3.8 per 1000 births, comparing favourably with other homebirth studies and the general Australian rate at the time. The remainder of the data was derived from ‘unorthodox and unacceptable’ methods, which Wagner considers unreliable. The latter group had an inflated perinatal mortality rate of 20.8. Wagner suggests that conclusions drawn about unacceptable death rates from unreliable sources are not valid.

References:
Bastian H, Keirse MJNC, and Lancaster PAL 1998. Perinatal death associated with planned homebirth in Australia: population based study. British Medical Journal 317(7155):384-388.
Wagner M, 1999. Critique of BMJ Article. Homebirth Australia Newsletter No 52, 53 April p.18.

What does the Report of the Maternity Services Review mean?

Having read the Report and its Recommendations, I understand that Australia could very well be looking at the end of private midwifery practice.

For those who aren't aware of the expected changes in regulation of midwives, and other health professionals, the new system of national registration is to be implemented 1 July 2010. Without insurance, self employed midwives will be unable to register. The hope within professional circles was that the federal government would provide the means by which indemnity insurance could be available, just as they did for the obstetricians when their medical defence organisations were in strife a few years ago.

The mention in the recommendations of 'consideration' of insurance for midwives (and privately practising midwives are the only ones who need it) is so couched in provisions and escape clauses that I for one feel it's a very remote possibility.

The 'consideration' of an indemnity arrangement would [only] be for "appropriately qualified and skilled midwives, within collaborative team-based models". What does the reviewer think a midwife is? Our qualification is obtained and kept within a standard process of education and annual renewal - just as is the case for other professionals. A midwife who provides primary maternity care, the most basic level of care there is, has skill working in harmony with the natural processes in pregnancy, birth, and care and nurture of a newborn baby. The definition of the midwife (ICM 2005)
requires a midwife to promote normal birth, and to work in partnership with women - amongst other things. Curiously missing from the government's Report is any notion of the midwife's duty of care to promote normal birth, and partnership with women ????

The use of the term 'midwife' throughout the document is incongruous with the international definition of a midwife. When you read 'midwife' in the report, it may make more sense if you substitute the term 'maternity nurse' or even 'obstetric assistant'.

By the end of this year, without a professional rescue arrangement, independent midwives throughout Australia will have to stop making bookings for births after 1 July 2010.

The report recommends providing indemnity for midwives in “collaborative team-based models”. What does that mean? Collaborative models usually have doctors and midwives working together – even though midwives do midwifery and doctors do obstetrics which is a different job. Even the privately operated midwifery group practices would not, I fear, be considered collaborative models.

Independent midwives do work in collaborative models. We make bookings at public hospitals for women planning homebirth - in Melbourne the Women's and Monash Medical Centre accept these bookings on the authority of the midwife's referral. If we consider a medical review is advisable we can write a letter of referral, and ask the hospital to advise on further action. That's collaboration, and it's consistent with common sense and the ACM national midwifery guidelines for consultation and referral. But I don't need to convince readers of this blog about that - it's obvious to anyone with their eyes open.

I don't understand the need of the Review to sacrifice the independent midwife - to use us as a scapegoat. We offer a service (one to one primary care midwifery with the option of homebirth) that is not available under other maternity models of care. Our outcomes are excellent.

What should the 250 or so women who plan homebirth each year in Victoria do? What should the 30 or so midwives in Victoria, who currently provide homebirth services, do?

Many of the submissions to the Review asked for consideration of homebirth as a publicly funded option. The Review has come back with a strong NO on that one. Why? Here are a couple of quotes ...

"Many of the consumers who participated in the Review consultation process had strongly held views about government funding for models of care that included birthing in a home setting. A number of submissions to the Review referred to the evidence of positive outcomes for homebirths for low-risk pregnancies. The Review concluded that, while homebirth is the preferred choice for some women, they represent a very small proportion of the total." (p20)

Excuse me! Didn't you notice that it's very difficult and costly to organise homebirth - surely the consistent small number says something about how important homebirth is?
...
"In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term)." (p21)

Sooo ... the midwives and women don't count - it's all about maternity health care professionals. Peace and harmony in the home is more important than equity and fairness. Homebirth does not require a bunch of experts - it's about well women giving birth with a midwife or 2 in attendance. It's not rocket science! But it gets better ...

"The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing
the expansion of collaborative approaches to improving choice and services for Australian women and their babies."

So the Review, in its wisdom, has decided that, rather than "polarising the professions" it will shut down the choice of homebirth.

Homebirth women, a minority group within the Australian birthing community, can be dismissed. They don't matter. Homebirth midwives, a minority group within Australian midwifery, can be deregistered. Our professional commitment, our livelihoods, don't matter.

And do you know what's a real worry? It's the silence of midwives - my colleagues in both private practice, and in employed midwifery. There has been very little discussion or comment on any of the forums, email lists, or blogs that I have checked out. Keep your heads down ladies. Perhaps it's just a bad dream?

Recommendations 17 and 18

Blog readers will have noticed the information on the Maternity Services Review, and the Report which was published yesterday.

If you are wondering why this is important, the big question that looms, and that there was a widespread hope for a lifeline through the recommendations of the review, is the future of independent midwifery in Australia. Next year, from 1 July 2010, new legislation will be enforced requiring all health professionals to demonstrate suitable indemnity insurance arrangements for their private practices, in order to be registered. Every health profession, EXCEPT midwifery, is able to buy indemnity. The Australian government provides special indemnity arrangements for obstetricians and procedural GPs so that they can afford insurance.

The recommendations of the review are a long way from structural reform that will in any way change the status quo. The last two recommendations, #s 17 and 18, are of interest to midwives who provide primary care through the birthing continuum.

Recommendation 17:
That, noting the potential issues to be resolved including the potential interaction with Private Health Insurance arrangements, the Australian Government gives consideration to arrangements, including MBS and PBS access, that could support an expanded role for appropriately qualified and skilled midwives, within collaborative team-based models.

Recommendation 18:
That, in the interim, while a risk profile for midwife professional indemnity insurance premiums is being developed, consideration be given to Commonwealth support to ensure that suitable professional indemnity insurance is available for appropriately qualified and skilled midwives operating in collaborative team-based models. Consideration would include both period and quantum of funding.

...
Recommendations 17 and 18 give me no indication that any self-employed midwife – even those in privately operated group practices – will have any future under these proposed reforms.

Although we (self employed/private/independent midwives) collaborate constantly, using the ACM Guidelines (and basic common sense and knowledge of a midwife’s scope of practice), it would be difficult to argue that we practise in “collaborative team-based models” that would satisfy our colleagues. I wonder where the evidence supporting whatever is meant by that phrase comes from.

It was clear from the RANZCOG responses to the review and statements to the press that ‘independent’ midwives are not acceptable, and I am not in the least surprised by the lack of support for the midwife’s right to be employed directly by the woman, or the woman’s right to employ her own midwife/ves.


So ...
Although there is talk in the recommendations of indemnity insurance, there is no commitment to providing it so that midwives can continue our private practices. The next 16 months, leading up to 1 July 2010, will provide interesting subject material for this blogger.

Public and private maternity hospital outcomes

A new research paper, 'Adverse outcomes of labour in public and private hospitals in Australia: a population-based descriptive study' (authors: Stephen J Robson, Paula Laws and Elizabeth A Sullivan) has been published in the Medical Journal of Australia, and is available online.

It’s interesting that the publication of this paper coincides with the release of the report of the National Health and Hospitals Reform Commission, the federal government’s main advisory body on health reform – a report which seeks to send 14% of wages to private health funds!!!. See the article in today's Age.

I think the paper itself fails to identify the most important issue in private maternity care - that in private care the woman has a known primary or leading carer who is committed to overseeing all professional decisions, whereas in most public care the woman has no such trusted primary carer. We know that women have higher levels of satisfaction with private care when compared with fragmented public options. It’s a no-brainer!

Some years ago I spoke on Jon Faine’s ABC radio program, and Christine Tippett was also there. Dr Tippett said that she loves to do midwifery, indicating that she gets quite a buzz out of an uncomplicated spontaneous birth. I think this is a widely held view in obstetrics, and although I was firstly puzzled then outraged, I have realised that it’s probably true. Doctors who are providing primary care for well women who require no ‘help’ to get their babies out are doing the work of the midwife, in having a sort of partnership with the woman, who trusts them. The person in the room who actually has the qualification of ‘midwife’ is functioning as an assistant to the primary carer who actually happens to be a specialist obstetrician. And please note that that midwife could not provide a similar service as the doctor, because the woman trusts the doctor, not the midwife.

There is no sense at all in supporting ‘public’ over ‘private’ maternity services as they are currently offered in the Australian context. All women giving birth need to be able to trust the person who is making professional decisions, and 'public' women ought to be able to access that option too. We know that the midwife is able to provide this service, and collaborate with specialist doctors and services when complications arise. This is the point that midwifery and consumer advocates need to make loudly and clearly.

Mirrors, stools and other birth gadgetry

As I have read blogs of other midwives, I have found that some of the issues they are writing about remind me of what we used to do years ago, that I have dropped from my midwifery practice.

Today I want to reflect on mirrors, and birth stools. Another such topic, for another day, is psychoprophylaxis breathing routines, and other strategies that I was introduced to in the early 1970s; firstly as a midwifery student and then as a mother to be in the Lamaze childbirth classes.

MIRRORS
I don't use mirrors at all. I don’t have one in my kit, and a mirror is not on the list I ask mothers to look at in preparation for birth. I think they are one of those active childbirth gadgets from the 70s and 80s that we should move on from.

My reason for this belief is very personal - I found the mirror a hinderance rather than a help, and I think I now know why. When I was giving birth to my first 3 children (in 73,75,&77), I lived in Michigan USA. As the birth became imminent I was put on a 'delivery table' in an operating room; my hands were strapped down with velcro so that I wouldn't contaminate a sterile field (as if there was one!), and someone held a *mirror* so that I could see how I was going once the head was on view. And, doing as instructed, I pushed with all my (considerable) might, got petichial haemorrhages in my eyes and on my chest, and tore my perineum - as you do.

It was not until years later, as I began to assimilate the knowledge of brain activity and intuitive processes, that I remembered the mirror. This was a shock to me at the time (I had recently graduated as a midwife, so of course I had held mirrors too). Using a mirror requires complex neocortical brain activity, as you become aware of the reverse image a mirror gives. The very part of the brain that needs to be kept quiet is stimulated. I have come to the conclusion that if people really want to use mirrors they should try using them for practice while the engage in other activities in the generative region, and see what happens.

I now encourage mothers, if they are unsure, to put their hand on their baby to gauge how much head is there, and just how much push they need to keep the baby moving. The touch sensation, by which we feel our own labia, and we feel that ‘other’ (ie not self) is a profound sensation. I don’t understand brain physiology very well, but I think the link formed in our minds by that sort of touch is very different from the link initiated by sight that is reversed.

Why did our Creator make our bodies to give birth out of sight? Perhaps we don’t need the help of vision for the job we need to do. I think if we were meant to see our births we would have been made with extendable eyes or much more flexible backs or something like that.

BIRTH STOOLS
I came across discussion about birth stools at http://radicalmidwife.blogspot.com/. This midwife is setting up her practice, and she notes “I'm having a hard time deciding which birth stool to purchase. I want one that doesn't inhibit the sacrum, which is harder to find than you'd think.”
There are a number of comments to the blog; mostly giving their opinions about the best type of birth stool. One respondent, a midwife educator Sarah Stewart from New Zealand wrote “I have had women who had had nasty anterior tears using birth stools so I tend to encourage women into other positions like kneeling. Is that a general trend or just peculiar to me?”

I haven't used birth stools for years now. The idea of the birth stool seems to be linked to closely managed second stage, with the midwife pondering the perineum and directing the pushing. I have also seen tearing and bruising and nasty haemorrhoids after birth stool second stages. Like Sarah, I think kneeling is often preferable to sitting, and many women like waterbirth so no other support needed (and it's likely that noone sees the birth). I encourage the mother to guide her baby's birth by keeping her hand on the head as it emerges, so that her pushing is appropriate to the baby's movement. Occasionally a couple of good pushes sitting on the toilet gets the baby moving in the right direction.

I remember the days (and nights), in the late 80s and early 90s, when I was working in hospital birth suites – St Georges first, then Mitcham Private. Birth stools were in use, and as I read current literature and reflected on my midwifery experiences I developed a practice of encouraging the mother to move from one position to another in second stage. I felt that by changing from sitting to kneeling; by intentionally moving the pelvis as a belly dancer does; the mother is able to rock the baby’s head slightly, and release any muscle tension, which can achieve progress. When I was with a mother who was struggling with progress in second stage, I looked for several positions that she was willing to use, in sequence. The birth stool may have been one of those positions, used for only 2 or 3 contractions at a time.

The birth stool has been in various cultures for many years. But is it not just another way of containing or ‘confining’ the birthing woman? The freedom to find a position when the birth becomes imminent is a key to active birthing. Does the presence of a birth stool not subtly suggest to the labouring woman that she ought to use it?

A safe place to give birth

A baby girl is sleeping, safe and sound, in her home in the hills to the East of Melbourne. She was born on Monday morning, just as the early assessments of the extent of the devastation caused by unimaginably powerful firestorms on Saturday was coming through in the news.

The forest all around is dry - there has been precious little rain for a long time. The magnificent eucalypts surround the little timber houses: tall mountain ash, with huge slabs of bark hanging and flapping carelessly against their trunks. It's these loosely draped bark sheets, and other dry bits and pieces, that ignite quickly and are caught up, becoming burning missiles in the strong dry winds.

On Monday morning I was not listening to the radio, although it was on. I was focused on being 'with woman'. It was only later that I heard about the number of people who had died; the number of homes that had been destroyed; and the communities that had been left as blackened piles of rubble. And the numbers have continued to grow, as the stories and pictures have circulated, and people try to come to terms with the worst bushfire on record. Our world has changed.


The mother mentioned to me, after her baby had been born, that she had had a dream the previous night. She had dreamt that her waters had broken, and for some reason she was on the back of a ute, in labour, being taken to my house. She woke up and found that her waters had indeed broken, and her bed was wet. She got up, had a shower, and called me to let me know about the waters - didn't mention the rest of the dream though.

When the labour became intense the mother knelt on the floor and gave birth in the front room of her home, with her husband and two little boys, and me, her midwife, nearby.

It was only the next day, as I returned for a postnatal visit, that I realised the meaning of the dream. Saturday had been the hottest day on record for most of Victoria. The sky was an eerie smoky brown colour. The wind was strong and menacing. I had stayed inside the house, and when I stepped outside it was like going into a fan forced oven. I realised that this was the environment in which this mother's body was preparing for its moment of release of the little one. In her sub-conscious mind the mother must have known she would need to find a safe place, should a fire start to threaten anywhere near her home. In her subconscious mind she must have seen my home, where she has been coming for prenatal checks, as a safe place. (I don't have an explanation for the ute!)

The mother told me her little boy had been unwell on Saturday - a high temperature, dehydrated. She had been cooling him down with wet cloths, and giving him extra drinks. He improved on Sunday, and the weather was mild. The mother was able to move on from caring for her sick child, to birthing her new baby. She felt safe enough, but in her subconscious mind there was the plan to get out if the fire situation should threaten once more.

Perhaps I am imagining things; making up a dramatic explanation to someone else's dream. I don't think so. The need for a safe place is one of the most basic factors in the nesting instinct of not only human mothers, but other animal mothers too. In the deep sadness that I and everyone who has been touched by last Saturday's fires feel, I am truly privileged to be a midwife, and to help in some way to provide a safe place where a woman can give birth.

SMH daddy blog 'Home deliveries'

Here's a good 'Home deliveries' article by blogger Sacha Molitorisz, with lots of comment - the good, the bad, and the pathetic. I guess that's what blogging is all about.

Later (Thurs 5 Feb)- Well there are now 84 comments, and the blog was written just 2 days ago! I reckon that's a clear indication of the eagerness people have to share their opinion on birth.

'protecting the public'

In recent weeks I have had discussions with several midwives who are concerned about complaints that have been made to their registration authority, about them. This is a difficult and potentially distressing time for a midwife. While it would be unwise of me to mention anything that could link this entry to the particular midwives, I would like to explore the general matter of regulation by law, 'protecting the public', as it applies to midwifery.

Midwives who are self employed, who practise midwifery independently, or in private practice, may feel that we come under more scrutiny now than we did when we were employed as midwives in hospitals. While I don't have figures on the number of complaints received by the registration boards about self employed midwives compared with the rest, it's likely that there is a huge proportionate disparity.

A midwife employed in a hospital or health service can expect to be called to the manager's or director's office for a chat, and even given warnings, if she is thought to be practising at a less than expected standard. As an employee there are routine appraisals and other processes to help improve staff performance. Hospitals want to retain their staff, and internal processes are constantly being used to maintain the standard of compliance with the agreed standard. Procedures and protocols are in place as a risk management strategy, and the staff are required to apply the hospital's protocols. I don't want to denigrate the hospitals - that's the way risks are managed, and insurers provide cover. The broad brush approach sees conditions and interventions rather than what we refer to as a woman centred approach.

An independent midwife cannot ignore current practices. We confront this from time to time if a woman in our care has twins, or her baby is presenting as a breech at Term. While a woman may refuse any intervention that is offered in maternity care, the midwife will be judged differently, especially when a complication arises that professional peers consider could have been avoided, had the care been 'managed' differently.

For example, a woman who has had a previous caesarean experienced release of the baby's fluids (ruptured membranes) at 40 weeks, and did not come into labour. The woman agreed to regular monitoring, and blood tests, but refused a repeat caesarean or an induction of labour. The pregnancy continued, without infection or other complication, until 14 days later when she laboured and proudly birthed a healthy beautiful baby in her own good time.

I don't expect there will be any complaint about any midwife or doctor involved in that woman's care. It was the woman who had informed herself of her rights, and who checked from time to time with a trusted midwife. She kept to 'plan A' because she had no reason to accept 'plan B'. Efforts to stimulate labour 'naturally' - walking, nipple stimulation, intercourse, castor oil, stuff from the naturopath, acupuncture, ... - only gave her wind.

*****

If any person makes a written complaint to the midwife's registration board or council, the board is required by law to investigate the complaint. The board's officers make an initial inquiry, and advise the appointed members of the board on the severity of the complaint, and what action should be taken. If a complaint is found to be without substance, or is vexatious, or a waste of time, the decision may be to not investigate. A serious, well substantiated complaint may lead to immediate suspension of the midwife's qualification and right to practice, while the investigation proceeds. In this way the laws are designed to 'protect the public'. The more serious investigations into professional misconduct or unprofessional conduct are usually highlighted in the public media. Most of us would agree that a rogue professional whose unethical or incompetent actions are likely to hurt people who trust them should not be allowed to practise.

When it's a self employed midwife in the spotlight, it's possible that the issues are more subtle. A midwife who supports a woman who wants vaginal birth after caesarean(s), and in the process challenges the hospital culture that she believes might have made the woman more likely to have the surgical births in the first place, may be seen as overstepping professional boundaries. A midwife who transfers a newborn baby to hospital after homebirth, and continues to support the mother's desire to exclusively breastfeed her baby during the hospital stay, may be accused of interference by the nursery staff. The midwife may feel confident that she has acted professionally, but if a complaint is lodged, she will need to argue her case, under the legally authorised system under which she is registered.

In a little more than a year from now a new process will be implemented across Australia for national registration and regulation of health professionals. The intergovernmental agreement covers all states and territories, and is set to become effective 1 July 2010. Professions included in the agreement are physiotherapy, optometry, nursing and midwifery, chiropractic care, pharmacy, dental care (dentists, dental hygienists, dental prosthetists and dental therapists), medicine, psychology and osteopathy.

Despite these changes, the jobs that are currently managed by the state and territory nursing and midwifery boards and councils will more or less continue. The first objective of the national scheme (point 5.3 of the agreement) "to be set out in the legislation, [is] to:
(a) provide for the protection of the public by ensuring that only practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered;"

*****
What can independent midwives do to ensure that we are practising in a competent and ethical manner?
We don't have managers or directors, but midwives can support one another, and be accountable to one another, with peer discussion and reflective learning. The requirement for proof of ongoing professional development activities is to be implemented with the new national health regulation. The MidPLUS portfolio, set up by the Australian College of Midwives, provides a system of recording and accounting for professional development.
Independent midwives are usually well represented at educational events. Many independent midwives demonstrate excellence in their professional activities.

I don't have an easy way out for a midwife who is required to answer questions about her practice. But if we always practise with professional integrity, assuming that everything we do could be seen and judged by others, then we should be proud to undergo peer review or investigation. We have chosen to practise independently, which means we are in a select minority within our profession. We can expect that we will be noticed, and, unfortunately in the land that cuts down the tall poppy, sometimes we will be an easy target for anyone who wants to take a pot shot at us. (mixing metaphors, but I hope you get the point)

I welcome any comments that you may like to make, either on this blog or by email to joy@aitex.com.au

Inquiry into Public Hospital Performance Data

I became aware of this inquiry last week, and initially thought it could slip by without requiring my input. However, it occurred to me that it was unlikely that anyone else would inform the committee of the need for public hospitals to provide back-up for planned homebirths. Therefore, I realised, I had better get to work on a submission.

There are three areas, under the general topic of public hospital performance data, that the committee has asked for comment on:
To inquire into and report on
1. the capacity of hospitals to meet demand, standards and quality of care,
2. resourcing and access levels, and
3. the accuracy and completeness of performance data
for Victorian public hospitals.

Background on homebirths
Birth in the home is unusual in Australia, with only 0.2% of births being recorded as homebirths in 2005 (AIHW 2007), and a similar number being unplanned out of hospital births, known as ‘born before arrival’ or ‘bba’ births.

Most planned homebirths in Australia are attended by self employed midwives, with a fee-for-service arrangement between the woman and the midwife. The State with the highest rate of homebirths is WA, at 0.6% of births (155 births) in 2005 (AIHW 2007). In WA, a publicly funded homebirth program has been operating in Perth and Fremantle through Community Midwifery (CMWA) (http://www.cmwa.net.au ) since 1997.

Reports produced by the Victorian Government’s Perinatal Data Statistics Unit (PDCU), including the annual Hospital Profile of Perinatal Data - Homebirth Report, and the Births in Victoria Report, provide accurate and reliable epidemiological data for planned homebirths that are attended by midwives, and planned homebirths for which transfer of care to hospital took place.

A review of 440 planned homebirths in Victoria 1995-1998 (Parratt and Johnston 2001) reported that:
• Spontaneous labour rate was 96.4%
• Spontaneous cephalic birth rate 91.6%
• Transfer to hospital rate 20%
• No perineal trauma in 64.2%
• Post partum haemorrhage 5.5%
• Retained placenta 1.1%
• Four perinatal deaths in this cohort were unrelated to their risk status or place of birth.

A woman planning homebirth faces certain requirements before homebirth becomes a possibility: she needs to come into spontaneous labour at term, and progress in labour without analgesics or stimulants, so that she can give birth spontaneously. The midwife works in a way that protects the mother’s wellness, and her baby’s transition from the womb to the outside world, and has the capacity to intervene when required to protect mother and baby, in the same way as she would attend a spontaneous birth in a hospital or birth centre. Homebirth midwifery is not remarkably different from hospital midwifery for well women in spontaneous labour. The midwife’s competencies are the same. The consideration by midwives to attend homebirths is a logical step after caseloads in establishing autonomous practice.

Developed countries in which midwives attend homebirth within the usual scope of midwifery practice include the Netherlands, UK, Canada, New Zealand, and other parts of Europe and USA.

Although the number of women who plan homebirth in Victoria is small, they are a significant group, and should not be ignored.

[This post has been condensed from my submission to the inquiry. Joy]

Angelina

In a simple timber home near the North Pine River, in the Colony of Queensland, Angelina gave birth to her little boy, who she named Ben. Her friend Mrs Fogg, whose husband owned the general store in Petrie town had come to help her; the older children were being cared for by a neighbour. It was mid-December, and the frequent storms and hot, humid weather had sapped her of her energy. She had felt the pressure of this pregnancy for many weeks now, as her body sagged under the strain of too many babies.

Mrs Fogg was not a midwife, but was a sensible woman who was trusted in the district. Her own child had died very young, and she had had several miscarriages, years ago. There was a midwife and even a doctor in Caboolture, or Redcliffe, but the distances were too great for most ordinary folks to contemplate.

For a couple of days after the birth Angelina had rested in bed, waiting for her strength to return. Mrs Fogg stayed with her, and brought food, and helped her wash. The baby was often fretful, and Angelina patiently nursed him at her breast. She remembered the early days after each of her births, as the babies eagerly took what they could. Then the milk came in, and a peaceful hush settled on the child and the home.

A few more days passed, and rather than feeling stronger Angelina became feverish, and was in pain. Her lochia had developed an offensive odour, obvious to anyone entering the room. The milk that had come in, dried up, and baby Ben became more demanding and unsettled. It was thought best that he be nursed by a young mother from the Church, whose own baby was a few months old. Angelina had encouraged her as she had faced her own challenges, and she was more than willing to do what she could.

By seven days Angelina was barely aware of what anyone said. Her husband James knew they faced a critical situation, and his heart was heavy as he went about his work on the farm each day, with the help of the older boys. He had watched this woman, his beloved wife of sixteen years, and had admired her strength and wisdom. He saddled his horse and rode several hours to find the doctor, who gave him some powders for the fever and pain, and promised to come as soon as he could.

It was Christmas eve, two weeks after the birth, when Angelina experienced a severe secondary haemorrhage. In her already weakened state, her gentle face was listless and ghostly pale. They had tried all the remedies and treatments available. As each minute, each hour passed, those who knew her prayed for her recovery. Two days later, as she ceased to breathe, her stricken husband gathered the children around him, and committed her spirit to their loving Heavenly father.

The Reverend C Clarke from the Presbyterian Church officiated at Angelina's burial the next day at the North Pine Cemetery. Other witnesses are recorded as John Todd, Archibald Hamilton, and Joseph Slater.

Several weeks later James again saddled his horse and returned to Caboolture with the documents, so that he could register her death. The cause of death was recorded as 'in child bed'. 'None' was recorded against the question 'Medical attendant by whom certified'.

Angelina's children's names are listed on her death certificate, and their ages: 14, 12, 11, 10, 8, 6, 5, 4, 2, 1 and 16 days. My grandfather, Frank White, was her four-year old son.

We don't know much about Angelina - most of the detail in this brief note is from her death certificate. It seems right to record the names of those who shared this journey with my great grandfather, my grandfather, and his brothers and sister. I don't know who attended to Angelina's needs in her last days: the role Mrs Fogg played is fictional.

The only photo we have of Angelina shows a strong young woman, dressed handsomely, next to a piano. Angelina, who was born to Samuel and Elizabeth Smith in London, probably came with her family to Queensland in the early 1860s.

In telling Angelina's story I want to value her as a mother; and as one whose mother-love and strength of character was passed on to her children's children, in spite of her too-early death.

A MIDWIFE'S HOUSEKEEPING

Today I was able to spend time doing office work - the 'housekeeping' for my midwifery practice. This is a time for critical reflection, and learning. It's a real privilege to provide primary care for women who choose me as their midwife. But with privilege comes responsibility, and I am constantly reminded that these families have entrusted me with some of the most lasting and memorable times in their lives.

I have checked through my active folders; filed away those that are complete; and checked that all payments are entered properly in my QuickBooks accounting program, ready for the next BAS (Business Activity Statement) to the Tax Office next month. I have tallied my births for 2009, and looked at any challenging situations that I needed to address.

I find myself reviewing carefully the couple of births in which our plans changed.

One mother, a primip, was in very early labour when her membranes ruptured spontaneously, revealing meconium in the liquor. I listened to the baby, who did not seem distressed. We decided to go to the hospital, and in spite of the continuous fetal monitoring, the labour progressed well, and we experienced a physiologically normal birth. The hospital was very busy (there is a baby boom at present), and the midwife allocated to care for my client was happy to manage the paperwork and watch, while I knelt on the floor beside the young woman and guided with my voice and her hands as she received her baby from her body.

Another mother who transferred from home to hospital, in labour with her second child, had called me to her home. She was progressing nicely, late at night, when we heard the distinctive sound of cracking, breaking, and falling as a huge branch of a large gum tree next to the house fell. It was a frightening sound, and I was immediately concerned for the safety of my client and her baby. It was dark, and we couldn't see if anything had been damaged. I felt it best that we go to hospital, and the parents agreed. About 30 minutes after we arrived at the hospital, the mother gave birth to a bonny, healthy baby boy. Later we looked at the tree, and found that the branch which had broken off had become caught in the fork of another branch, and was suspended above a parked car, next to the house. Had it fallen all the way, the car would have been squashed, and some of the house would probably have been damaged.

Another transfer to hospital was for a mother who was not progressing well, with her second baby. This can be a very difficult call for a midwife, and the woman, to make. When is the mother needing to accept the pain, and when does she need to ask for medical help? When is pain unbearable, intolerable? When does the lack of progress indicate a problem? As time passes the baby becomes tired, and is less able to tolerate contractions.

When transferring to hospital in a situation like this, we ask the hospital staff to work with us, using all the skill and resources that are available in achieving the best birth we can for that mother and baby. In the case I am reflecting on, the birth was caesarean. Not what we had planned for, yet the best on offer in that situation, that night.

I had a few planned hospital births too. I am a plain midwife, and if a woman wants to be in hospital I go with her, despite the restrictions that hospital have placed on me and my kind. Birth can proceed well in hospital or at home. One mother had a beautiful vba2c in a private hospital. Her two previous births had been caesareans because the babies had, for some reason which she did not understand, been distressed in early labour. This labour took some time to establish, but the baby held in there beautifully. That mother's face, as she took the wet and beautiful newborn child to her breast, declared a moment of utter triumph.

Another mother gave birth to her twins, just eight minutes apart, without any medical intervention. We had arrived at the hospital in good labour. Without having planned to do so, I happened to 'catch' both babies, while the hospital midwives worked alongside me. This is unusual - most hospitals will tell an independent midwife that she is not to carry out any clinical care. I am not keen to challenge the system when I am 'with woman'. I seek to collaborate with the hospital colleagues, knowing that the woman and I have a special partnership which cannot be over-ridden by protocols or rules. But really, I don't think anyone could insist that receiving a baby who is being born spontaneously is an exclusive professional act. The mother is giving birth! As they say, it's not rocket science.

My 'housekeeping' today also helps me prepare for the births I will attend as the weeks and months of this year unfold. Each consultation, both before and after the birthings, and each birth, is a time when I must give my full focus to the individual woman. I cannot guarantee a particular outcome: what I can do is offer to accompany her through the amazing journey she has begun.

DUTY OF CARE?

A midwife friend has recently posed this question:
How many health professionals involved in midwifery, obstetrics, anaesthetics and paediatrics are breaching a duty of care?

I questioned what she meant by midwives 'breaching duty of care':
A: "the collaboration in the system induces midwives not to inform women properly especially in the private system and they participate in medical delivered care often without question. ... All professionals have a duty of care, to do no harm. Informing women about the effects of opioids and other drugs is avoiding harm when we know from the research the effects on the foetus via the placenta and the newborn via breast milk."

This is a serious accusation. 'Duty of care' is "a legal obligation imposed on an individual requiring that they adhere to a reasonable standard of care while performing any acts that could foreseeably harm others." (Wikipedia)

This midwife is stating a belief that is clear enough to those who know midwifery, but I don’t think the general public, or even most midwives, would understand. Most women who receive dangerous drugs commonly used in labour, such as Pethidine or Morphine by intramuscular injection, or similar opioid drugs in epidural cocktails, would have a vague understanding that these are powerful substances, and many who receive them would have commenced labour with a birth plan of some kind stating that they wanted to avoid such drugs. It's a good/bad, "yes I want what's good /no I don't want what's bad" plan. But by the time she agrees to the offer of an injection to 'help' with the pain, the level of distress the woman is experiencing is intolerable, and any warning that the substances given may harm the unborn child or impair the child's ability to breast feed effectively will seem irrelevant. "What's the point if this is killing me anyway?" The woman who cannot find a way to work with her labour becomes effectively trapped in an unrelenting barrage of pain. Her feelings of entrapment can lead to fear, with vomiting, dehydration, and emotional distress accompanying a failure to progress.

I have at times been present when a woman who had planned unmedicated birth requests medical pain management - usually an epidural. The anaesthetic doctors are usually very careful to inform that woman that although the procedure is considered appropriate, and they are willing to proceed with it, she needs to understand that there is a small risk of certain complications including infection, nerve damage, ongoing pain, and even paralysis and death. The doctor waits for the woman to give consent, before proceeding.

Midwives seek alternatives that are less intrusive, less 'medical', and we believe, less likely to harm either mother or baby. We have promoted active birthing, danced and climbed stairs, loved water emersion, massage, and words of gentle assurance. Although it's difficult to 'prove', the research evidence seems to indicate that women are less likely to request medical forms of pain management/relief if they are being cared for in labour by a known midwife. The trusting partnership between a woman and her midwife, and vice versa, is of great value.

Women who have the constant company of a lay birth attendant (or doula) in labour seem to be more able to accept the work of labour, and are less likely to ask for medical alternatives, if their professional care providers support their desire for normal birth. The birth attendant does not have any agenda other than to provide the labouring woman with company and physical assistance. The birth attendant does not have any responsibility to achieve particular outcomes, and should not be guiding or 'coaching' the woman.

However, regardless of the skill or other characteristics of those in attendance, there will be women for whom medical pain relief and medical/surgical procedures are the safest way for both mother and baby to negotiate the birthing journey. How many women, you ask? It may be 5% or it may be 15% - that doesn't really matter. If it's you, you will be thankful that appropriate emergency obstetric care can be accessed. No woman can consider that her birthing will be free of complications. It's not a matter of choice or planning.


I have formed an opinion that a midwife has a particular duty of care, which is more specific than standing in the way of the possible evils of a system which relies too heavily on medical management of birth. That duty of care is to be a midwife, all that contemporary midwifery entails, in an effort to achieve optimal birthing outcomes for both mother and baby. Unfortunately the maternity care system as we know it leads midwives to be submissive to the more powerful medical model, rather than to act within a midwifery framework and attempt to not only prevent unwarranted interference, but to work in harmony with the woman’s natural process.

I know a midwife in a public hospital who refused to put up Syntocinon to augment a labour, because she, the midwife, assessed progress to be satisfactory. The midwife had a complaint against her and had to defend her action to her employer. Another midwife recently supported a woman’s wish to have a waterbirth in a private hospital – that midwife has received a ‘first and final warning’ from her employer. The mother in that case is very pleased with the midwife's actions in attending her, and enabling a safe and intimate birth that happened to be in water. When the midwife asked her managers about the woman's choice, they laughed at her, and said that in an institution we can't afford to be led by what patients want. That midwife may be more careful, and perhaps less supportive, the next time a woman wants to do something outside the hospital's usual process.

So although some midwives understand our 'duty of care' to promote normal birth, it will not become an acceptable ‘duty of care’ to be applied across the profession until the broader professional and lay community agree. That is a long way from where we are today. It would probably take a midwife to have a serious complaint made against her, that she as a midwife failed to promote normal birth (or other midwifery imperative) by taking a certain action, and that complaint would be a test case before the registration body. At present if a complaint like that was received, I expect it may be considered vexatious or frivolous, and therefore no action taken.

To any midwives who read this blog, I want to encourage you to take seriously your professional commitment, call it a duty of care if you like, to learn to work in harmony with natural processes, and promote physiologically normal birth whenever you can. Only when there is a valid reason to interfere with the natural process can we make decisions about the most appropriate medical or surgical intervention, whether it's induction of labour, augmentation, painkilling drugs, anaesthesia, or surgically managed birth.

To mothers and mothers to be who read this blog, I want to encourage you to choose a model of care that will support your choice to give birth under your own power (Plan A), unless there is a valid reason to move to 'Plan B'. It is likely that the experience of birth, particularly with your first child, will take you way beyond your expectations, and out of your comfort level. Your midwife is able to be present, with you, and reassure you that all is well.

This has been a long post. I hope it contains valuable insights for readers.
Joy Johnston

Old midwives' tales

I thought I had blogged my last entry for this year when I wrote yesterday about the 6-week postnatal consultation. However, an opinion piece in today's newspaper has, sadly, left me feeling that I need to defend my profession, yet again!

'Orgasmic birth and other old midwives' tales' has appeared in various Fairfax newspapers.

I have made a nice cup of tea, enjoyed a chocolate (there are too many sitting around after Christmas!), and am imagining how this article will impact on women who are considering the possibility of planning homebirth. As one of the 'old midwives' practising in and around Melbourne today, I need to reflect on the notion of orgasmic birth.

I don't have any comments on the film, Orgasmic birth - the best kept secret. I haven't seen it. I don't feel I need to defend Ina May Gaskin, the 'hippie guru'. I have met her once, and listened to her give an inspiring talk at a homebirth conference. But Ina May would agree with me, I am sure, that the work of a midwife is not about being a guru, or any other tag. It's all about a presence, being 'with woman'.

Natural, physiological birth does not belong to any cultural group, hippie or homeschooler, or even home birthing. Natural birth does not belong to any professional group; midwife, doctor or anyone else. The knowledge of natural birth is stored deep within each woman's intuitive mind, and this knowledge becomes available in the same way that other hormonally directed behaviours are awakened at certain times in our lives.

Midwives carry knowledge and skill that helps us to work in harmony with each woman's own natural processes in birthing and nurture of the newborn. We see some women giving birth quietly, with apparently minimal pain or distress, and we see other women struggling and roaring through the enormity of their labours. We watch the birthing of not just a child, but also of a mother, as she receives her child into her arms, and intuitively does what mothers do. We hear women from both ends of the experience spectrum, and from many points in between, tell of their satisfaction or their disappointment. Although the rates of normal birth are high for women whose primary carer is a midwife, we can not guarantee a particular outcome.

I don't know how many of the women I have attended for birth would jump on the 'orgasmic birth' bandwagon, and claim that they had 'it'. I don't care. My job in being 'with woman' includes being constantly mindful of the wellbeing of mother and baby. If they are both well, it doesn't matter if the mother smiles at her beloved, or moans or closes her eyes. It doesn't matter if she stands proudly to give birth, or curls up in a pool of water. The experience of birth is a deeply etched memory which the mother takes away from the birth, and she can interpret the experience as she pleases.

Childbearing women today are influenced by sales pitches and marketing of every aspect of the childbirth experience, including the experience itself. When 'good' is no longer good enough; when the length of labour, and the power of the contractions is just right, and the urge to push is as the person who gave the class said it would be, and the noise coming from deep in your throat is the most powerful birth song you have ever imagined, and whole experience of birth needs to be the most ecstatic ...

No! This is all wrong.

Let's not compete over birth, as if the bits that come together to make up the whole are items you can select from a supermarket shelf, or learn from watching a film. Birth is a new beginning, a new life, full of potential. Giving birth is one of the most complex and awesome acts that we will ever be privileged to participate in, either as the mother, or in a relationship with the birthing mother. Once we set out on the journey of birth we cannot know where we will end. But we do know that in birth journeys there is no safer path than the natural process, unless a decision point is reached in which a valid reason for interference is apparent.

Will it be agony or ecstasy? You can't know. But you will never know unless you choose to engage in one of life's most demanding and most rewarding journeys. Today you have a choice: either to seek to work in harmony with your body's natural ability, 'Plan A', or to ask a doctor to dull your senses and remove the baby from your body. A skilled midwife can be with you, but only you can achieve 'Plan A'.

May the year 2009 bring many women to a new knowledge of their amazing birthing ability, with happy and healthy birth days.

6 weeks after the birth

I was talking with a midwife colleague who has recently set up her own independent midwifery practice, and she asked me about the 6 week postnatal check. Is it important? What are we trying to achieve?

Since I began private practice I have invited women in my care to come back to my home office at about 6 weeks. I don't mind if one comes at 5 weeks, and another at 8 weeks - I see it as a milestone, in that the mother and her baby return to visit me, after I have completed the postnatal 'care'. It's a good time for 'show and tell', and marks the end, for most new mothers, of their post-birth healing period.

So what do I expect to talk about, and to achieve in that follow-up consultation?

A midwife and woman who have established a bond of trust and respect within the professional partnership appreciate the opportunity to meet again. The 6-week visit is a time to close the professional relationship, which can be renewed in the future if the mother asks me to be her midwife again.

I can't overstate the value of focused, face to face, un-rushed time spent together without distraction. A great deal is communicated in eye contact, body language, and subtle, non verbal means.

I try to give the mother an opportunity to tell me any concerns that she might have. If there are any questions about what happened in the labour or birth, or postnatally. It's an opportunity to go through my notes with her in detail, and to give her a copy, if I haven't already done so.

I have a little list to work through, and discuss further when indicated:
Mother's general condition: does she look well? are you sleeping enough? how much?
Mother's recovery from birth: is your fundus palpable? has the lochia ceased? when? is your perineum fully healed, if there was a tear? would you like me to look at your perineum? are you experiencing any incontinence?
Mother's family planing: have you resumed sexual intercourse? have you any concerns about contraception? do you understand LAM (Lactation amenorrhoea method)?
Baby: general appearance - colour, activity, hearing, tummy time, fontanelles, smiling, responding, include weight and full physical check if the mother wishes
Baby's feeding: this is an opportunity to discuss any concerns the mother has. Most babies will want a feed during the consultation, and I look for opportunities to guide and encourage
Support network: have you linked in with peer support groups, such as BaBs (Birthing and Babies Support) and ABA (Australian Breastfeeding Association), mother groups through the Maternal and Child Health centre, or local community groups and churches?

There are no specific questions in my list that are intended to explore mental health issues. However, if there are cues for exhaustion or postnatal depression, this is an opportunity to go further if the mother is willing.

If we identify any matter in which healing or recovery is incomplete at 6 weeks, we can make a plan for further review, considering appropriate medical consultation.


An independent midwife is working primarily with well women: women who are healthy through their pregnancies, who carry their babies to Term, come into spontaneous labour, choose to work in harmony with their bodies in labour, progress without needing drugs for pain relief, and give birth to their babies under their own power. This evidence of 'wellness' is in fact an awesome achievement, for which our bodies are wonderfully made.

Yet we cannot assume that every woman and every baby will be well, even those who return for the 6-week postnatal check. A midwife's skill, in working with wellness, is also to identify anything that is abnormal, and guide her client in making a plan to address that issue. The same active decision making process that we use in pregnancy and birthing applies postnatally.

Midwives with caseloads are especially privileged in the way we can work, one to one, with women. But with that privilege comes an increase in our responsibility to the individual woman. The 6-week postnatal consultation is an opportunity for me, the midwife, to review the episode of care, reflect on the way in which I have learnt from this experience, and effect closure without leaving any loose ends.

Christmas Greetings

Wishing you a happy Christmas, and all the very best in the new year.

Thankyou for your comments both at this blog, and by email, and in person. You have encouraged me to do all I can to record my midwifery knowledge and make it available to others.

The Christmas season is a time when we celebrate the birth of THE child. My prayer is that mothers throughout the world will be enabled to value their amazing strength in birthing, and choose to give birth and nurture their children to the best of their ability; and that midwives will value our role in being 'with woman', in promoting and protecting normal birth.

My husband Noel and I would be honoured if you would care to read our annual letter to our relatives and friends.

childbirth: a half-baked product of evolution?

Having made it clear that I am outraged by this suggestion last week (see previous post), I would like to spend a little time working through the idea.

My understanding is that birth is indeed "a normal function of life". This does not mean that birth is meant to be uneventful or without challenge, any more than breathing, or any other normal function, is. Breathing can, in certain situations, be linked to life-threatening situations, as can birth.

The writer loses my respect with the outlandishly simplistic assertion that "The belief that nature intended women to give birth in a certain way only holds if you believe intelligent design rather than science. If you believe in evolution, ..." The issues of childbirth are not about belief in theoretical frameworks that seek to explain life through evolution, intelligent design, or indeed, creation. Childbirth is a fact of life. Intelligent design is a concept that has been used in recent decades, particularly by educators in the US, in the creation-evolution debate. The observation that nature 'intended' women to give birth in a certain (natural, physiological) way has nothing at all to do with a belief system.

Regardless of how we happened to get here, one of the realities of modern human existence is that there is STILL no safer way, physically and emotionally, for most mothers to give birth to their babies than by working in harmony with natural processes. Only when a valid reason exists to interfere with the natural process does the possibility arise that the risks of intervening may be less than the risks of doing nothing. When a point is reached in the critical decision making for a particular mother-baby pair, the subsequent progress and outcomes will be irrevocably influenced by the decision that is made.

Darwinian principles of natural selection, when applied to human reproduction, would result in natural limitations to the individuals for whom natural conception, gestation and childbirth is difficult or dangerous. Natural selection also applies to other mammals that produce relatively large offspring. A small bitch who is carrying pups from a genetically larger dog will not have good rates of success, or reproductive fitness, under natural whelping conditions.

In Western cultures there is little natural selection in human reproduction today. Women who in previous generations would be unable to bear a child are assisted and supported. If we detect distress in the fetus, or failure to progress by a labouring woman, the decision to operate is quickly facilitated.

Instead of mourning the discomforts and potential reproductive hazzards associated with "fat brains and narrow hips" which apparently compromise "the ease of pushing out offspring", I would like to briefly mention a few of the features of the natural process in childbearing which can only be described as awesome. My list of marvels includes courtship and loving; the nesting instinct; spontaneous onset of labour at Term; the changes in a woman's behaviour in physiologically normal labour; the spontaneous adjustments made by a newborn baby at birth; the separation and expulsion of the placenta; the search by the baby for the mother's breast and the psychological attachment of mother and infant; and many more. Each of these natural processes, within physiological birthing, may be disturbed and inhibited by interference, with ongoing consequences to the mother and baby.

As far as I know these potentials have been part of the childbearing process for as long as any historical record exists. The changes we know of have been in our ability to intervene in the natural process. Whether we women reached our current physical and psychological makeup as a result of natural selection, survival of the fittest, and evolution, or whether our first parents had the same natural processes that we possess, is outside the realm of recorded history, and is therefore open to congecture.

For those who have read thus far, I am happy to put it on the record that I accept the Christian belief that our God is "creator of heaven and earth" (from the Apostles Creed). I do not claim to understand HOW God created. I think it reasonable that the creature (I) may not be able to fully comprehend the work of the creator (God).