There are some phrases that wend their way into the conversations of groups of people, and noone really remembers when that phrase first came up, or what it really means.
'Informed choice' is one of those phrases, and it has come into general acceptance in midwifery along with 'evidence based practice'. It is meant to refer to the consumer's ability to choose from a range of reasonable options. Sounds fair enough!
What information does a young woman who is pregnant for the first time have access to, so that she can make a choice?
The local GP says "Do you want to go private or public?" - Choice #1
"Which hospital do you want to book with?" Choice #2
... and so on. Informed choices, if you look at the information provided, and the choice made. It's unlikely that any evidence will be offered, unless this green newbie to the birthing market talks about homebirth! At this point we can skip information, choice, research and evidence, and go directly to emotional manipulation and downright bullying.
There is only one basic choice in childbearing - either do it yourself, or find someone else who will do it for you. I can not stand under the 'every woman, every choice' banner. I will wave a banner 'every woman: one choice'. And the one professional attendant who has the duty to promote normal birth, and has the skill to harmonise with the natural physiological processes is the midwife.
I live and work amongst women who are enormously privileged in access to information, options, and services. But there are some even within metropolitan Melbourne, and definitely in other parts of this vast land, who are less able to access what most take for granted.
What 'informed choice' is available to the mother who lives on a cattle property 60k out of the nearest town; where the internet connection doesn't always do the job; where midwives are nurses who assist at hospital births; where the hospital is run like a military outpost to train new doctors, and the folk are told they should consider themselves lucky that they even have doctors? Her choice is to get to the local hospital to give birth, and to do as she is told and hope for the best, or to make a booking in the city and get to the city hospital to give birth, and to do as she is told and hope for the best. Even if she is philosophically committed to 'natural' birthing, it's likely that a 'choice' will be presented that subtly but effectively removes that option.
Yet there's one key decision she has to make: either do it yourself, or ask someone else to do it for you.
AND - in case anyone reading this is not sure of the facts, if you ask what would be the safest way; what is the 'evidence based' way? In almost every case, the safest way for mother and baby is that they do it themselves, with a midwife as primary care provider, UNLESS there is a valid reason to interrupt/intervene/interfere with the natural process.
Monday, July 20, 2009
Friday, July 17, 2009
labour IS a right of passage
At a time when every spare moment has been put to preparing submissions and impact statements in an effort to prevent disastrous legislation from being enacted federally, I have noticed a couple of media comments on the statement by Dr Dennis Walsh, a MAN, and a midwife academic, who says that “labour agony is a ‘rite of passage’ and pain relieving epidurals weaken the mother’s bond with babies”.
I agree.
[I have met Denis. He comes from my home town, Brisbane, not that that makes him right. I really don't get the man midwife thing, but a few men have made midwifery their calling, and a few of them seem to be OK.]
A very useful commentary can be found at a feminist philosophers link, posted by SA midwife Lisa Barrett.
ps - there are some in every walk of life who are perfectionists, and when reading a statement by midwives about protecting and promoting the physiological, normal processes in birth, and avoiding the surgical and medical alternatives, become defensive because they know someone (or they themselves) did not achieve what they perceive to be the ultimate, perfect birth. Please remember, noone gets it right all the time. Most of us are good enough most of the time. Ponder this, and apply it to decisions in bearing a child, bringing a precious new life into this world.
I agree.
[I have met Denis. He comes from my home town, Brisbane, not that that makes him right. I really don't get the man midwife thing, but a few men have made midwifery their calling, and a few of them seem to be OK.]
A very useful commentary can be found at a feminist philosophers link, posted by SA midwife Lisa Barrett.
ps - there are some in every walk of life who are perfectionists, and when reading a statement by midwives about protecting and promoting the physiological, normal processes in birth, and avoiding the surgical and medical alternatives, become defensive because they know someone (or they themselves) did not achieve what they perceive to be the ultimate, perfect birth. Please remember, noone gets it right all the time. Most of us are good enough most of the time. Ponder this, and apply it to decisions in bearing a child, bringing a precious new life into this world.
Wednesday, July 15, 2009
Our natural law rights in childbirth
Australia's independent midwives and mothers are now working against time in a concerted effort to protect normal birth, including homebirth and the mother's right to employ a midwife privately.
(please see previous posts on the draft health practitioner legislation if you want more information)
I have received hundreds of emails and phone calls, some from people who have experience in maternity activism, and others from bewildered people who wonder what they can do to help. One email, which was forwarded from someone I have never met, held the key that helped me develop a new line of defence. The email contained personal advice from a lawyer, who pointed out that the Austrlian constitution has clauses that can be used in defence of women's rights to homebirth as a "natural law right".
The legislation denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing.
The only requirement for physiological birth is that the woman is able to proceed without medical or surgical assistance. Since pregnancy and birth are truly natural states, and are not, per se, reliant on outside management, it is reasonable to protect the woman’s natural law right to maintain personal control over such decisions, including if and when she goes to hospital.
I believe that having a baby at home instead of a hospital is a natural law right , given by GOD rather than by government, and covered under the freedom of religious belief provisions of the Australian constitution. Many religious codes have ancient guidance that can be applied to the birth of a baby. The Christian Scriptures, which are my personal supreme guide to faith and action, teach that children are a blessing from God, to be valued and protected, and give many examples of people who protected and supported the mother and child, even in defiance of government (eg Exodus 1:17). Section 116 of the constitution says that the parliament shall make no laws to restrict your religious belief, practice, and observance.
By denying midwives insurance, and denying midwives the right to practise privately in any geographic location, the government would deny a woman's right in physiological childbirth.
I think we need to stress the difference between physiological and medically managed childbirth. No person can predict a particular outcome in maternity care: the care of the midwife is a partnership with the woman, that develops as time passes and decisions are made. The best/safest/uniquely normal default position, which I call 'Plan A', is to proceed naturally without outside stimulation or pain management, as long as there is no valid reason to interrupt, interfere, intervene, or disturb that physiologically natural process. Even so-called natural therapies, and emotional 'support' can also disturb the natural process. The woman's and baby's body's subtle orchestration of hormones and physical activity cannot be replicated in managed birth. Medically managed birth - whether induction of labour, or pain relief with drugs, or anything else that the birthing woman can't do for herself, should be considered iff (if and only if) the natural process is more likely to harm mother and or child than the medical intervention.
My message today to all who read this blog is that we are fighting for something that is truly worth fighting for! But you probably wouldn't be reading this if you didn't already know that.
Be strong and courageous.
Joy Johnston
(please see previous posts on the draft health practitioner legislation if you want more information)
I have received hundreds of emails and phone calls, some from people who have experience in maternity activism, and others from bewildered people who wonder what they can do to help. One email, which was forwarded from someone I have never met, held the key that helped me develop a new line of defence. The email contained personal advice from a lawyer, who pointed out that the Austrlian constitution has clauses that can be used in defence of women's rights to homebirth as a "natural law right".
The legislation denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing.
The only requirement for physiological birth is that the woman is able to proceed without medical or surgical assistance. Since pregnancy and birth are truly natural states, and are not, per se, reliant on outside management, it is reasonable to protect the woman’s natural law right to maintain personal control over such decisions, including if and when she goes to hospital.
I believe that having a baby at home instead of a hospital is a natural law right , given by GOD rather than by government, and covered under the freedom of religious belief provisions of the Australian constitution. Many religious codes have ancient guidance that can be applied to the birth of a baby. The Christian Scriptures, which are my personal supreme guide to faith and action, teach that children are a blessing from God, to be valued and protected, and give many examples of people who protected and supported the mother and child, even in defiance of government (eg Exodus 1:17). Section 116 of the constitution says that the parliament shall make no laws to restrict your religious belief, practice, and observance.
By denying midwives insurance, and denying midwives the right to practise privately in any geographic location, the government would deny a woman's right in physiological childbirth.
I think we need to stress the difference between physiological and medically managed childbirth. No person can predict a particular outcome in maternity care: the care of the midwife is a partnership with the woman, that develops as time passes and decisions are made. The best/safest/uniquely normal default position, which I call 'Plan A', is to proceed naturally without outside stimulation or pain management, as long as there is no valid reason to interrupt, interfere, intervene, or disturb that physiologically natural process. Even so-called natural therapies, and emotional 'support' can also disturb the natural process. The woman's and baby's body's subtle orchestration of hormones and physical activity cannot be replicated in managed birth. Medically managed birth - whether induction of labour, or pain relief with drugs, or anything else that the birthing woman can't do for herself, should be considered iff (if and only if) the natural process is more likely to harm mother and or child than the medical intervention.
My message today to all who read this blog is that we are fighting for something that is truly worth fighting for! But you probably wouldn't be reading this if you didn't already know that.
Be strong and courageous.
Joy Johnston
Monday, July 13, 2009
Saturday, July 11, 2009
please write your submissions today!
TWO VERY IMPORTANT OPPORTUNITIES EXIST RIGHT NOW.
THE PUBLIC (THAT'S YOU AND ME) ARE INVITED TO COMMENT ON:
*1. Exposure draft of Exposure draft of Health Practitioner Regulation National Law 2009 (Bill B) by 17 July 2009.
"If you wish to provide comments on the exposure draft, please lodge a written submission in electronic form, marked Exposure draft, at nraip@dhs.vic.gov.au by close of business on Friday, 17 July 2009. Please note that your submission will be placed on the website after the closing date for all submissions unless you indicate otherwise." Communique - Ministers release draft legislation for National Registration and Accreditation Scheme.
*2. Senate Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills.
The Committee invites you to provide a written submission which should be lodged by 20 July 2009. A public hearing will then be held later in July. The Committee prefers to receive submissions electronically as an attached document – email: community.affairs.sen@aph.gov.au – otherwise by fax (02 6277 5829).
A couple of days ago I was speaking with a mother of four children, all born at home, who lives in a small rural Victorian town. An independent midwife in that town has been attending about 25 homebirths each year, and is loved and respected by her community. Without change to the Health Practitioner legislation and related Bills, these women will not be able to access homebirth from 1 July next year. Even though the Victorian Health Minister has made a public statement about publicly funded homebirth services to be offered in the near future, the only women who will be able to apply for that service will be those within a small radius of the city hospitals from which the model is managed.
This story is repeated time and again across the country. We must prevent the legislation denying midwives the right to practise independently in our communities from progressing any further without crucial changes being made.
We have just a few days in which to prepare our submissions. If my ideas or anything I have written on this blog, or at other sites, is of use in arguing these important points to the Senate or the government, please feel free to borrow liberally.
When you have prepared your submissions, please also send a copy to your State or Territory Health Minister, and your local MPs. Let them know how important the choice of a midwife who can work autonomously in the community, within her scope of practice, is to you.
Joy Johnston
THE PUBLIC (THAT'S YOU AND ME) ARE INVITED TO COMMENT ON:
*1. Exposure draft of Exposure draft of Health Practitioner Regulation National Law 2009 (Bill B) by 17 July 2009.
"If you wish to provide comments on the exposure draft, please lodge a written submission in electronic form, marked Exposure draft, at nraip@dhs.vic.gov.au by close of business on Friday, 17 July 2009. Please note that your submission will be placed on the website after the closing date for all submissions unless you indicate otherwise." Communique - Ministers release draft legislation for National Registration and Accreditation Scheme.
*2. Senate Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills.
The Committee invites you to provide a written submission which should be lodged by 20 July 2009. A public hearing will then be held later in July. The Committee prefers to receive submissions electronically as an attached document – email: community.affairs.sen@aph.gov.au – otherwise by fax (02 6277 5829).
A couple of days ago I was speaking with a mother of four children, all born at home, who lives in a small rural Victorian town. An independent midwife in that town has been attending about 25 homebirths each year, and is loved and respected by her community. Without change to the Health Practitioner legislation and related Bills, these women will not be able to access homebirth from 1 July next year. Even though the Victorian Health Minister has made a public statement about publicly funded homebirth services to be offered in the near future, the only women who will be able to apply for that service will be those within a small radius of the city hospitals from which the model is managed.
This story is repeated time and again across the country. We must prevent the legislation denying midwives the right to practise independently in our communities from progressing any further without crucial changes being made.
We have just a few days in which to prepare our submissions. If my ideas or anything I have written on this blog, or at other sites, is of use in arguing these important points to the Senate or the government, please feel free to borrow liberally.
When you have prepared your submissions, please also send a copy to your State or Territory Health Minister, and your local MPs. Let them know how important the choice of a midwife who can work autonomously in the community, within her scope of practice, is to you.
Joy Johnston
Thursday, July 09, 2009
the personal side of midwifery
I know many of the readers of this blog are interested and very concerned about the matters that I and other Australian midwives have been highlighting in the past months.
On Tuesday I went with several like minded colleagues, including Clare Lane from Midwives Naturally, to the Victorian stakeholders forum on the government's National Registration and Accreditation Scheme for health professionals. A report is being prepared, and I will let you know when it is available. Within the limitations of a large forum's question and answer session, we made every attempt we could to ask the Health Minister to provide a means for the continuing practice of independent midwives.
How did it go? The short answer is that we came away feeling emotionally drained, having banged our heads against a bureaucratic brick wall. The minister clearly stated that the government does not want to support the indemnity insurance for ‘a small pocket of women and midwives’, when there are what he said are ‘better ways to spend the public dollar across the whole health system’ (as he waved his arm across the room at all professionals). I asked what would happen if it was decided that all private GP practices should close, and they be required to work under the supervision of hospitals. (see previous post) The Minister assured the audience that that would not happen. That's a relief, isn't it! After the initial response on questions of homebirth, there was an audible sigh in the room every time another independent midwifery or homebirth question was asked.
Many women choose an independent midwife as their care provider because they value the fact that they have personally chosen that midwife. The same could be said for any other health practitoner - or even the hairdresser or the vet who treats your dog.
Tuesday night was the coldest night for many years in Melbourne. When the phone rang at 2.30 am, and I got into the car to head out, I was shivering a little until the car's heating kicked in. I had a distance to drive - about 35 kilometers. The mother was labouring well, and her baby was born about an hour after I, and the other midwife, Clare, arrived.
The parents of this baby do not appear to be wealthy, yet they chose to engage the private services of two midwives, and pay our fees. Clare and I are not the closest independent midwives to their home, yet they chose to employ us. The main reason the mother gave was that we had attended the birth of their first child several years ago when they lived closer to our homes. Clare and I were more than happy to travel the extra distance and be 'with woman' that night.
This particular mother would probably be eligible for a publicly funded homebirth program, if one existed. Yet should she not retain the right to employ a midwife privately?
The loss of a midwife's right to private practice from 1 July next year will impact on families in subtle and personal ways. Clare and I had both been at the forum the previous day when the Health Minister dismissed our practices as being insignificant, and the women who employ us as being unimportant. We reflected on the deeply personal side of private midwifery practice and homebirth, and will remember this and every birth we attend, as something to treasure.
The personal is political. We cannot allow our elected representatives to ignore our rights to self determination, and evidence supporting the safety of the very model of care that independent midwives offer.
Remember, birth is not an illness.
[for notes on the stakeholders forum, please go to the MiPP blog]
On Tuesday I went with several like minded colleagues, including Clare Lane from Midwives Naturally, to the Victorian stakeholders forum on the government's National Registration and Accreditation Scheme for health professionals. A report is being prepared, and I will let you know when it is available. Within the limitations of a large forum's question and answer session, we made every attempt we could to ask the Health Minister to provide a means for the continuing practice of independent midwives.
How did it go? The short answer is that we came away feeling emotionally drained, having banged our heads against a bureaucratic brick wall. The minister clearly stated that the government does not want to support the indemnity insurance for ‘a small pocket of women and midwives’, when there are what he said are ‘better ways to spend the public dollar across the whole health system’ (as he waved his arm across the room at all professionals). I asked what would happen if it was decided that all private GP practices should close, and they be required to work under the supervision of hospitals. (see previous post) The Minister assured the audience that that would not happen. That's a relief, isn't it! After the initial response on questions of homebirth, there was an audible sigh in the room every time another independent midwifery or homebirth question was asked.
Many women choose an independent midwife as their care provider because they value the fact that they have personally chosen that midwife. The same could be said for any other health practitoner - or even the hairdresser or the vet who treats your dog.
Tuesday night was the coldest night for many years in Melbourne. When the phone rang at 2.30 am, and I got into the car to head out, I was shivering a little until the car's heating kicked in. I had a distance to drive - about 35 kilometers. The mother was labouring well, and her baby was born about an hour after I, and the other midwife, Clare, arrived.
The parents of this baby do not appear to be wealthy, yet they chose to engage the private services of two midwives, and pay our fees. Clare and I are not the closest independent midwives to their home, yet they chose to employ us. The main reason the mother gave was that we had attended the birth of their first child several years ago when they lived closer to our homes. Clare and I were more than happy to travel the extra distance and be 'with woman' that night.
This particular mother would probably be eligible for a publicly funded homebirth program, if one existed. Yet should she not retain the right to employ a midwife privately?
The loss of a midwife's right to private practice from 1 July next year will impact on families in subtle and personal ways. Clare and I had both been at the forum the previous day when the Health Minister dismissed our practices as being insignificant, and the women who employ us as being unimportant. We reflected on the deeply personal side of private midwifery practice and homebirth, and will remember this and every birth we attend, as something to treasure.
The personal is political. We cannot allow our elected representatives to ignore our rights to self determination, and evidence supporting the safety of the very model of care that independent midwives offer.
Remember, birth is not an illness.
[for notes on the stakeholders forum, please go to the MiPP blog]
Monday, July 06, 2009
Bill B
Tomorrow (Tues 7 July) I am planning to attend the Victorian stakeholders forum on 'Bill B', the exposure draft of the National Regulation and Accreditation Scheme for health professionals.
I have prepared a couple of documents exploring the clauses in the new legislation, and the impact that this is likely to have on midwives' private practices. Included is a list of questions to ask the representatives from the Department of Human Services at the forum tomorrow. If anyone would like me to send this information to you, please contact me by email joy@aitex.com.au. You will need to introduce yourself if I don't already know you, because I don't want to share my work with people who might abuse it.
You may wonder why I have included a picture of a Bilby, a small mouse-like marsupial with big ears?
Midwives share a lot with the Bilby. I'm suggesting that the Bilby be adopted by midwives as our little animal mascot.
The Bilby is at present being brought back from near-extinction. The midwife in private practice is also an endangered species. We need big ears, like the Bilby, to stay alert to any danger. We need to scurry for cover at the slightest sign.
Let's hope we have the resillience and intelligence to overcome the threats to our existence, and continue providing expert one-to-one midwifery care for women in our communities.
In the interests of best practice, and safe choices for all women, I believe:
• Midwives must be able to practise midwifery without government or outside professional interference
• No group of midwives should be subjected to greater levels of regulation than any other group of midwives – independent midwives expect the same degree of regulation as any other midwife
• The midwifery profession expects the same level of regulation as other health professions
• Peer counselling and confidential review of cases should be implemented. Midwives who are acting in a way that may be unprofessional or incompetent or putting their clients at risk should be reported to the regulatory body for investigation – as for any other professional.
• Risk assessment and response to development of complications is a normal aspect of a midwife’s professional capability. Risk assessment is an ongoing process throughout the episode of care. (WHO 1996 Care in normal birth)
• Women who seek the services of independent midwives will sometimes have complex social and obstetric histories, and this makes the dedicated care of a skilled midwife essential. This option is often not available in hospital based models of care, private or public.
• We need urgently to demolish the barriers that exist in maternity care, preventing midwives from attending their clients privately in hospitals.
• The protection of the midwife’s right to attend a woman privately for maternity care in any setting is strongly in the public interest.
Thursday, July 02, 2009
ABC Radio - Life Matters
As if to celebrate the expected demise of private midwifery and homebirth by this time next year, the ABC Radio's Life Matters program has presented an outrageous interview with Dr Hilary Joyce, the new president of the College of Obstetricians and Gynae's.
You can listen to the podcast here.
I have left a comment at the guestbook.
I would like to suggest that midwives working privately should be treated no differently from doctors or other professionals working privately.
Many women who employ a midwife want to know the person who will be with them throughout their active labour, promoting normal birth, and supporting them to make informed decisions. This is best practice in midwifery, yet it's as scarce as hen's teeth in the public system. That's why women employ midwives privately. There is nothing synister about homebirth. Evidence from international and Australian homebirths shows clearly that homebirth is a reasonable choice for well women with a midwife primary carer who is able to refer to obstetric specialists if and when complications arise.
Most midwives in private practice are highly competent midwives, and we have excellent outcomes. I am one. I have practised privately for the past 15+ years, and I stand to lose my livelihood next year because I can't purchase professional indemnity insurance.
The bias of the guest Dr Hilary Joyce in this interview was not explored. The claims linking Australia's maternity obstetrics with obstetric oversight of birth cannot be supported. An outcome for which obstericians are primarily responsible is that more than 30% of Australian babies are born by caesarean surgery.
Obstetricians do not practise midwifery; midwives do not practise obstetrics. The midwife has, by definition, a duty to promote normal birth. The obstetrician is a surgeon, who should be consulted only when illness or complication arise in pregnancy or birth.
Remember, pregnancy and birth are not an illness.
You can read comments, and leave your own at Life Matters Guestbook.
You can listen to the podcast here.
I have left a comment at the guestbook.
I would like to suggest that midwives working privately should be treated no differently from doctors or other professionals working privately.
Many women who employ a midwife want to know the person who will be with them throughout their active labour, promoting normal birth, and supporting them to make informed decisions. This is best practice in midwifery, yet it's as scarce as hen's teeth in the public system. That's why women employ midwives privately. There is nothing synister about homebirth. Evidence from international and Australian homebirths shows clearly that homebirth is a reasonable choice for well women with a midwife primary carer who is able to refer to obstetric specialists if and when complications arise.
Most midwives in private practice are highly competent midwives, and we have excellent outcomes. I am one. I have practised privately for the past 15+ years, and I stand to lose my livelihood next year because I can't purchase professional indemnity insurance.
The bias of the guest Dr Hilary Joyce in this interview was not explored. The claims linking Australia's maternity obstetrics with obstetric oversight of birth cannot be supported. An outcome for which obstericians are primarily responsible is that more than 30% of Australian babies are born by caesarean surgery.
Obstetricians do not practise midwifery; midwives do not practise obstetrics. The midwife has, by definition, a duty to promote normal birth. The obstetrician is a surgeon, who should be consulted only when illness or complication arise in pregnancy or birth.
Remember, pregnancy and birth are not an illness.
You can read comments, and leave your own at Life Matters Guestbook.
Wednesday, July 01, 2009
1 July 2009
I want to mark this day, 1 July 2009.
In just twelve months from today privately practising midwives who don’t have insurance will be called ‘non-practising midwives’ under the new national Health Practitioner Registration laws. New arrangements will provide indemnity insurance for eligible midwives to practise other parts of midwifery, but NOT homebirth. Homebirth is the livelihood of self employed, privately practising midwives.
The new laws and provisions will potentially open up new freedom for midwives employed by hospitals; an item for celebration. Even homebirth may be provided by the hospitals - the insurance will be provided as part of the employer's vicarious liability arrangements.
It will be confusing and dangerous for consumers, and we need to do all we can to prevent this ill-thought-out health reform from progressing without amendment to enable a midwife to practise midwifery in any setting, which is fundamental to the international definition of the midwife.
Friday, June 26, 2009
in summary ...
From Health Minister Nicola Roxon: Historic Step forward for Midwives and Nurse Practitioners
From Australian College of Midwives: Mothers and babies at risk: Access to qualified midwives for homebirth under threat
From Maternity Coalition (by email - website not updated at the time of writing this blog) "Maternity Coalition’s vision is for all Australian women to choose who, where and how they birth. We are about increasing women’s choices so they can make informed decisions about the type of care that is right for them and their family. We are facing the prospect of having an evidence-based model of care being removed – and why? It would be an understatement to say we are concerned about this. We are VERY concerned about this."
From Homebirth Australia: "Deaths will increase with new announcements" ... "We believe every woman has the right to choose how and where she gives birth. Please stop homebirth becoming illegal and sign our online petition."
From Midwives in Private Practice (MiPP): "Can the Australian maternity community accept government interference in defining the setting of practice of a midwife? Would the medical community accept such wanton interference in its professional boundaries?"
Midwife-blogger Lisa Barrett: "I am a failure to understand why all women and midwives are totally up in arms at this. I know they aren't because many see it as better than nothing. That's really all midwives are good for, scraps from the Obs table. If every midwife decided to stop work for the day in protest then it would soon change."
Blogger Hoyden About Town "Homebirth to become illegal in a year. ... And no matter how low-risk the woman nor how much she desires a homebirth, women will not be allowed to do so legally with a midwife. Because the legislation introduced this week will ban midwives from practising without insurance; and there is no insurance provider for homebirth midwives. So long, too bad, so sad. Good bye."
Save Homebirth blog: offering support for people travelling to Canberra to protest at the Homebirth Australia Mother of All Rally, Monday 7 September.
Blogger-midwife Melissa Maimann: Access For Pregnant Women To Medicare Funded Midwifery Care On The Way: But not for homebirths
From Australian College of Midwives: Mothers and babies at risk: Access to qualified midwives for homebirth under threat
From Maternity Coalition (by email - website not updated at the time of writing this blog) "Maternity Coalition’s vision is for all Australian women to choose who, where and how they birth. We are about increasing women’s choices so they can make informed decisions about the type of care that is right for them and their family. We are facing the prospect of having an evidence-based model of care being removed – and why? It would be an understatement to say we are concerned about this. We are VERY concerned about this."
From Homebirth Australia: "Deaths will increase with new announcements" ... "We believe every woman has the right to choose how and where she gives birth. Please stop homebirth becoming illegal and sign our online petition."
From Midwives in Private Practice (MiPP): "Can the Australian maternity community accept government interference in defining the setting of practice of a midwife? Would the medical community accept such wanton interference in its professional boundaries?"
Midwife-blogger Lisa Barrett: "I am a failure to understand why all women and midwives are totally up in arms at this. I know they aren't because many see it as better than nothing. That's really all midwives are good for, scraps from the Obs table. If every midwife decided to stop work for the day in protest then it would soon change."
Blogger Hoyden About Town "Homebirth to become illegal in a year. ... And no matter how low-risk the woman nor how much she desires a homebirth, women will not be allowed to do so legally with a midwife. Because the legislation introduced this week will ban midwives from practising without insurance; and there is no insurance provider for homebirth midwives. So long, too bad, so sad. Good bye."
Save Homebirth blog: offering support for people travelling to Canberra to protest at the Homebirth Australia Mother of All Rally, Monday 7 September.
Blogger-midwife Melissa Maimann: Access For Pregnant Women To Medicare Funded Midwifery Care On The Way: But not for homebirths
Thursday, June 25, 2009
PLEASE sign a petition to save private midwifery and homebirth
GO to the petition
"... with planned national registration of all health professionals to take effect on July 1st 2010 midwives in private practice will be unable to seek registration on the basis of their inability to obtain professional indemnity insurance."
The petition asks that "the senate bring this issue to the parliament's attention and make a speedy redress to assist midwives in private practice to obtain professional indemnity insurance. We also ask that midwives in private practice enjoy the same funding mechanisms as procedural general practitioners and specialist obstetricians under the medicare benefits schedule."
The petition is at the excellent new Homebirth Australia website.
"... with planned national registration of all health professionals to take effect on July 1st 2010 midwives in private practice will be unable to seek registration on the basis of their inability to obtain professional indemnity insurance."
The petition asks that "the senate bring this issue to the parliament's attention and make a speedy redress to assist midwives in private practice to obtain professional indemnity insurance. We also ask that midwives in private practice enjoy the same funding mechanisms as procedural general practitioners and specialist obstetricians under the medicare benefits schedule."
The petition is at the excellent new Homebirth Australia website.
Saturday, June 20, 2009
not interested in anything less
I was preparing a reply to a comment in the next post, and have brought it to a new post, as the issue needs more critical exploration.
The writer stated that the care of a private midwife has suited her well, and she is not interested in anything less. That is understandable, and I believe many women - and many independent midwives for that matter, agree.
But in any society the choices that we have are defined by laws set down by government, and the Australian government - the previous Liberal one, as well as the current Labor one - have agreed that it's in the public's interest to require all health professionals to have indemnity insurance. After 1 July next year women will not be able to access independent midwifery for homebirth (unless changes are made to the legislation or to the accessibility of indemnity insurance for midwives).
The only profession for which indemnity insurance is not available for private practice is midwifery. This is a global phenomenon. Countries where midwives practise autonomously (and are not under threat as Australian midwives are) - Netherlands, Canada, and New Zealand, for example, have insurance schemes that are supported by government funds. New Zealand's system requires a percentage of the earnings of all health professionals to be placed in an accident compensation fund, from which payments are made to any patient or client who experiences harm. This is very different from Australia's system, in which anyone who claims they have been harmed in their health care has to sue their doctor/midwife/hospital in a court of law, or come to an arrangement (payout) prior to going to court.
It is unreasonable to ask that one section of the health care community, independent midwifery, have different rules than the rest. I believe a scheme similar to the New Zealand scheme, would bring equity into the maternity system, and take decisions about compensation out of the courts. Of course matters of professional misconduct or negligence would need to be dealth with at a higher level, as they are currently, and will be under the new Health Practitioner legislation.
The 'decision' that midwives providing homebirth independently should not be indemnified, and consequently the outlawing of privately attended homebirths is a decision of the current Health Minister, Nicola Roxon. She needs to hear from every person who cares, and she needs to change that decision. We, the public, have the right to tell our elected representatives, what we consider to be reasonable.
The writer stated that the care of a private midwife has suited her well, and she is not interested in anything less. That is understandable, and I believe many women - and many independent midwives for that matter, agree.
But in any society the choices that we have are defined by laws set down by government, and the Australian government - the previous Liberal one, as well as the current Labor one - have agreed that it's in the public's interest to require all health professionals to have indemnity insurance. After 1 July next year women will not be able to access independent midwifery for homebirth (unless changes are made to the legislation or to the accessibility of indemnity insurance for midwives).
The only profession for which indemnity insurance is not available for private practice is midwifery. This is a global phenomenon. Countries where midwives practise autonomously (and are not under threat as Australian midwives are) - Netherlands, Canada, and New Zealand, for example, have insurance schemes that are supported by government funds. New Zealand's system requires a percentage of the earnings of all health professionals to be placed in an accident compensation fund, from which payments are made to any patient or client who experiences harm. This is very different from Australia's system, in which anyone who claims they have been harmed in their health care has to sue their doctor/midwife/hospital in a court of law, or come to an arrangement (payout) prior to going to court.
It is unreasonable to ask that one section of the health care community, independent midwifery, have different rules than the rest. I believe a scheme similar to the New Zealand scheme, would bring equity into the maternity system, and take decisions about compensation out of the courts. Of course matters of professional misconduct or negligence would need to be dealth with at a higher level, as they are currently, and will be under the new Health Practitioner legislation.
The 'decision' that midwives providing homebirth independently should not be indemnified, and consequently the outlawing of privately attended homebirths is a decision of the current Health Minister, Nicola Roxon. She needs to hear from every person who cares, and she needs to change that decision. We, the public, have the right to tell our elected representatives, what we consider to be reasonable.
Friday, June 19, 2009
talking about homebirth
Thismorning I was woken by someone from ABC Radio 774 (the Melbourne local radio) at about 6.30. Would I speak to Red Simon about homebirth being outlawed?
Sure.
They called back, and Red wanted to know about homebirth. In the next few minutes (cut short mysteriously by the phone line going dead) I was able to reassure him of the safety of homebirth.
Red sounded genuinely surprised that 30% of Dutch babies can be born at home in this century. I think he was wanting to paint a picture of homebirth being a vestige of a bygone era, that some of us are reluctant to part with. He told me his wife went to three different hospitals to have her three children, so that she could check out the cuisine. He asked me if my children were born at home. No - I didn't know about homebirth then. I learnt about homebirth from reading professional literature. It was the evidence that convinced me.
News articles discussing the future of homebirth have appeared in several papers thismorning.
Daily Telegraph (Sydney) informs us that "HOMEBIRTHS will become illegal under tough new laws that prevent women using midwives to have children outside hospitals. The move is set to drive homebirths underground, with expectant mothers and their babies at risk."
A similar article in Adelaide Now identifies "the draft Health Practitioner Regulation National Law, released last week, [under which] a midwife cannot be registered unless she has insurance."
For more detail, please go to the MiPP blog.
It's not true that *all* homebirth will be illegal after 1 July 2010, when the Health Practitioner Regulation National Law, which mandates professional indemnity insurance as a condition for registration, is set to come into effect.
Homebirth programs that are operated by hospitals and health authorities will be able to continue. The option that will become illegal is private arrangements between a woman and a midwife. That means midwives like me, and an estimated 150 others, will be out of work, and all the women who want to arrange homebirth privately will be denied that choice.
Depending on your perspective, here are some ideas. I present them as questions, because each person with an interest in homebirth will have to make the best decision they can when the time comes.
After 1 July next year:
Will a midwife agree to provide midwifery care 'underground', and ask the parents and anyone else involved to keep quiet about their role?
Will a midwife who continues 'underground' cease any reporting to governement authorities such as Registry of Births, Deaths and Marriages, and perinatal data collection units?
Will a midwife who continues 'underground' ask for cash payments, and cease reporting income to the Tax Office?
Will a woman who wants homebirth need to arrange her own documentation of the birth - either by statutory declaration, or by arriving at a public hospital with her baby, and stating that the baby was 'born before arrival'?
Will a woman who wants homebirth and who experiences complications at home need to go to hospital without her midwife's referral or support?
Will all the women who want to plan homebirth find doctors who will attend them at home?
The doctor issue is worth thinking about. It might sound like competitive rivalry for me to bring doctors into this discussion, but the fact is that independent midwives compete with doctors to be the primary carers for pregnant/birthing women. (it's a very unlevel playing field, but that's another issue!) While the midwife offers continuity of care throughout the pregnancy and birth, the local GP offers a variety of fragmented models of 'shared care', ensuring that the woman receives care from a midwife who is a total stranger in labour. The stranger-midwife is also a feature of models in which an obstetrician is the primary care provider.
There are doctors who support homebirth; some have given birth at home themselves, while others will agree to attend homebirths. Melbourne doctor Peter Lucas is well known and appreciated for his homebirth practice.
Doctors have indemnity insurance, so they will be able to continue practising after 1 July next year. Some have insurance that covers 'procedures' - including childbirth, while others are more restricted in what they are able to do. Doctors fees are rebatable through Medicare, and the Medicare Safety Net enables the doctor to charge a fee that he/she considers appropriate, knowing that the client will be able to get a lot of it back from the public purse.
Women could, en masse, require attendance at home from doctors for home births if midwives are not able to be called. Of course the doctors might refuse to attend, but what is their duty of care in such a situation?
Another question: will public hospitals set up homebirth services that will provide the required professional care for all the women who at present would book with an independent midwife? Will the hospitals provide employment (and indemnity) for independent midwives?
These questions are all in my mind. What will I do? How will I advise women who ask me? (And, from a practical point of view, How will I earn enough to keep food on the table?)
Sure.
They called back, and Red wanted to know about homebirth. In the next few minutes (cut short mysteriously by the phone line going dead) I was able to reassure him of the safety of homebirth.
Red sounded genuinely surprised that 30% of Dutch babies can be born at home in this century. I think he was wanting to paint a picture of homebirth being a vestige of a bygone era, that some of us are reluctant to part with. He told me his wife went to three different hospitals to have her three children, so that she could check out the cuisine. He asked me if my children were born at home. No - I didn't know about homebirth then. I learnt about homebirth from reading professional literature. It was the evidence that convinced me.
News articles discussing the future of homebirth have appeared in several papers thismorning.
Daily Telegraph (Sydney) informs us that "HOMEBIRTHS will become illegal under tough new laws that prevent women using midwives to have children outside hospitals. The move is set to drive homebirths underground, with expectant mothers and their babies at risk."
A similar article in Adelaide Now identifies "the draft Health Practitioner Regulation National Law, released last week, [under which] a midwife cannot be registered unless she has insurance."
For more detail, please go to the MiPP blog.
It's not true that *all* homebirth will be illegal after 1 July 2010, when the Health Practitioner Regulation National Law, which mandates professional indemnity insurance as a condition for registration, is set to come into effect.
Homebirth programs that are operated by hospitals and health authorities will be able to continue. The option that will become illegal is private arrangements between a woman and a midwife. That means midwives like me, and an estimated 150 others, will be out of work, and all the women who want to arrange homebirth privately will be denied that choice.
Depending on your perspective, here are some ideas. I present them as questions, because each person with an interest in homebirth will have to make the best decision they can when the time comes.
After 1 July next year:
Will a midwife agree to provide midwifery care 'underground', and ask the parents and anyone else involved to keep quiet about their role?
Will a midwife who continues 'underground' cease any reporting to governement authorities such as Registry of Births, Deaths and Marriages, and perinatal data collection units?
Will a midwife who continues 'underground' ask for cash payments, and cease reporting income to the Tax Office?
Will a woman who wants homebirth need to arrange her own documentation of the birth - either by statutory declaration, or by arriving at a public hospital with her baby, and stating that the baby was 'born before arrival'?
Will a woman who wants homebirth and who experiences complications at home need to go to hospital without her midwife's referral or support?
Will all the women who want to plan homebirth find doctors who will attend them at home?
The doctor issue is worth thinking about. It might sound like competitive rivalry for me to bring doctors into this discussion, but the fact is that independent midwives compete with doctors to be the primary carers for pregnant/birthing women. (it's a very unlevel playing field, but that's another issue!) While the midwife offers continuity of care throughout the pregnancy and birth, the local GP offers a variety of fragmented models of 'shared care', ensuring that the woman receives care from a midwife who is a total stranger in labour. The stranger-midwife is also a feature of models in which an obstetrician is the primary care provider.
There are doctors who support homebirth; some have given birth at home themselves, while others will agree to attend homebirths. Melbourne doctor Peter Lucas is well known and appreciated for his homebirth practice.
Doctors have indemnity insurance, so they will be able to continue practising after 1 July next year. Some have insurance that covers 'procedures' - including childbirth, while others are more restricted in what they are able to do. Doctors fees are rebatable through Medicare, and the Medicare Safety Net enables the doctor to charge a fee that he/she considers appropriate, knowing that the client will be able to get a lot of it back from the public purse.
Women could, en masse, require attendance at home from doctors for home births if midwives are not able to be called. Of course the doctors might refuse to attend, but what is their duty of care in such a situation?
Another question: will public hospitals set up homebirth services that will provide the required professional care for all the women who at present would book with an independent midwife? Will the hospitals provide employment (and indemnity) for independent midwives?
These questions are all in my mind. What will I do? How will I advise women who ask me? (And, from a practical point of view, How will I earn enough to keep food on the table?)
Monday, June 15, 2009
Being Baby Friendly
[Pic: Barb and Cassie, used with permission]
On Saturday I attended an update session for assessors and educators in the Baby Friendly Health Initiative (BFHI). I have been involved with BFHI since it was introduced to Australia in the early 1990s, and it was good to focus on the issues of promoting, protecting and supporting breastfeeding in our maternity care system.
The BFHI is an international project that aims to give every baby the best start in life by creating a health care environment where breastfeeding is the norm and practices known to promote the health and well-being of all babies and their mothers are followed.
The BFHI Ten Steps to Successful Breastfeeding are the global standard by which health services are assessed and accredited. A 'Baby Friendly' health service is one where mothers' informed choice of feeding is supported, respected and encouraged.
In Australia, the Australian College of Midwives administers the Baby Friendly Health Initiative.
The BFHI has released a new set of booklets which will be used for health facility (usually hospital) assessments in the future. A few issues that were open to interpretation in the past have been clarified. Acceptable medical reasons for the use of breastmilk substitutes, and Standards for compliance with the World Health Organisation International Code of Marketing of breastmilk substitutes (known as the 'WHO Code' ) are clearly stated. It is likely that some 'Baby Friendly' hospitals will need to improve their policies and practices before their next assessment in order to maintain the award.
Here are a few of *my* highlights taken from the revised BFHI assessment. Please note, this list is not exclusive:
(For the full wording of each Step, click here
Step 1: The facility's breastfeeding policy is supported by clinical protocols which are evidence based.
Step 2: At least 80% of staff who assist mothers with breast feeding are able to describe two issues that should be discussed with a pregnant woman or mother who indicates that she is considering feeding her baby with infant formula.
Step 3: The antenatal education includes the importance of skin to skin contact for all babies (not just those whose mothers plan to breastfeed!) for at least the first hour of life.
Step 4: The facility has procedures which keep mothers and babies together in skin to skin contact for at least an hour after a vaginal or caesarean birth. (medically indicated procedures which vary this policy are stated)
Step 5: Mothers who are not breastfeeding confirm that they have been given individual education about artificial feeding
Step 6: At least 80% of staff who assist with breastfeeding or who provide advice on breastfeeding are able to describe two pieces of information that they will discuss with a pregnant woman or mother who is undecided, but considering feeding her baby with infant formula.
Step 7: All babies stay with their mothers 24-hours a day. Documentation will be expected for any variation from this.
Step 8: Breastfeeding on demand (without restrictions or controls on frequency or length of feeding) is the standard, with emphasis on effective breastfeeding.
Step 9: Mothers can explain why dummy use is discouraged while breastfeeding is being established.
Step 10: The facility reports on how it works with local breastfeeding support groups and services.
Friday, June 05, 2009
We live in interesting times
I would like to add to my recent discussion and state here that I believe there is a positive future for homebirth, on a much larger scale than the Australian community has known.
Any major reform requires costings and processes to be carefully developed so that it is introduced in a responsible and transparent manner. I know that there is a lot of work happening behind the scenes at the national level to address the detail for the changes that were announced by the Health Minister in the Budget. Also state and territory health departments are working on policies for homebirth and water birth. South Australia has its policies published, and I think some of the other states are also moving ahead well in this area. If anyone reading this blog knows of web links for relevant policies, please pass them on either through the comments or by email joy@aitex.com.au
Although the midwifery reforms announced in the Budget (indemnity, Medicare and PBS) are hugely significant to independent midwives and the women who employ us, the reforms are a lifeline to the whole midwifery profession. The midwife's scope of practice in all settings will be freed from some of the unreasonable restrictions that have all but stifled the profession and prevented midwives from practising as defined in the ICM Definition of the Midwife.
I anticipate that, from November 2010, midwifery will move from the obstetrician's-assistant- shiftworker-nurse model to that of a distinct professional who has authority for a unique model of care in which the woman and her known midwife primary carer work in a special partnership, with the purpose of promoting health of both mother and baby through the promotion and protection of physiological processes linked to normal birth and nurture of infants.
I anticipate that Medicare payments will enable health services to set up a range of options that are attractive to both mothers and midwives, in which midwives provide primary maternity care for women, integrating their care with the specialist obstetric and other medical services in the hospitals as and when needed. There will be no need for the cost shifting that goes on now, with women being sent to doctors for the prenatal care to take pressure off the hospital budget.
I anticipate that university midwifery departments will celebrate the reduction of the theory-practice gap that has plagued them for many years. The career options for midwives who want to practise midwifery will be greatly expanded.
I have been in touch with Patrice Hickey, Victorian branch President of the Australian College of Midwives, (ACM Vic) and I would like to acknowledge the work of the ACM throughout this process on behalf of midwives and birthing women.
We live in interesting times!
Any major reform requires costings and processes to be carefully developed so that it is introduced in a responsible and transparent manner. I know that there is a lot of work happening behind the scenes at the national level to address the detail for the changes that were announced by the Health Minister in the Budget. Also state and territory health departments are working on policies for homebirth and water birth. South Australia has its policies published, and I think some of the other states are also moving ahead well in this area. If anyone reading this blog knows of web links for relevant policies, please pass them on either through the comments or by email joy@aitex.com.au
Although the midwifery reforms announced in the Budget (indemnity, Medicare and PBS) are hugely significant to independent midwives and the women who employ us, the reforms are a lifeline to the whole midwifery profession. The midwife's scope of practice in all settings will be freed from some of the unreasonable restrictions that have all but stifled the profession and prevented midwives from practising as defined in the ICM Definition of the Midwife.
I anticipate that, from November 2010, midwifery will move from the obstetrician's-assistant- shiftworker-nurse model to that of a distinct professional who has authority for a unique model of care in which the woman and her known midwife primary carer work in a special partnership, with the purpose of promoting health of both mother and baby through the promotion and protection of physiological processes linked to normal birth and nurture of infants.
I anticipate that Medicare payments will enable health services to set up a range of options that are attractive to both mothers and midwives, in which midwives provide primary maternity care for women, integrating their care with the specialist obstetric and other medical services in the hospitals as and when needed. There will be no need for the cost shifting that goes on now, with women being sent to doctors for the prenatal care to take pressure off the hospital budget.
I anticipate that university midwifery departments will celebrate the reduction of the theory-practice gap that has plagued them for many years. The career options for midwives who want to practise midwifery will be greatly expanded.
I have been in touch with Patrice Hickey, Victorian branch President of the Australian College of Midwives, (ACM Vic) and I would like to acknowledge the work of the ACM throughout this process on behalf of midwives and birthing women.
We live in interesting times!
Tuesday, June 02, 2009
HOMEBIRTH after July 2010???
I am writing today with a foggy brain that didn't assume the horizontal until after two thismorning. But that's what midwives do, after all. I do hope this brief discussion makes sense.
We (the community of independent midwives and homebirth parents) are all wondering what will happen to homebirth after July next year. If you are not aware of the issues, please scroll down in this blog, and go to the MIPP blog for more information and links.
I've been busy with a cluster of births, and haven't had time to be worried yet, but I know some of my clients are concerned. I just have lots of unanswered questions, such as ...
What will be the impact of the midwifery changes announced in the federal budget on my ability to practice midwifery (and make a living)?
(I am writing in the first person here - that's what people seem to do on their blogs - but I know it applies well beyond my personal situation!)
With the requirement for indemnity insurance for registration from 1 July 2010, and the government's provision of indemnity insurance &c for 'eligible midwives' from 1 November 2010, what happens to my ability to earn a living, and to the women who want me to attend them professionally, during those four months? (assuming that the announced time frame will be adhered to) How can I be sure that I will be an eligible midwife?
and the BIG question:
WHAT ABOUT HOMEBIRTH?
There are no publicly funded homebirth options in my area, and even if there were, some women would prefer to engage a midwife privately to come into their home to provide midwifery services. Some women booked with me would be excluded from any service that is 'risk managed' to current hospital standards - those who have had more than six babies (they should be considered super birthers by that stage), those who have had one or more previous caesareans, those whose babies don't want to be born before that magical 42 week mark, those who are a bit too old, a bit too young, to tall, too short, or whatever.
Does this mean that I am ignorant or careless about risk?
Does this mean that women who choose my care are being ignorant or careless about their own safety or the safety of their babies?
I'm not going to say a blanket no, or yes. It all depends. No life event, and particularly not birth, can be risk free. Home and hospital both have their own sets of risks and uncertainties.
I don't know what's going to happen about homebirth.
I would encourage anyone who is interested to work at keeping yourself informed, and to take action in whatever way you can.
Keep an eye on the blogs, forums, email groups, and professional journals that are writing about midwifery and homebirth.
Read everything with a critical eye.
Be prepared to ask how would [ ] affect me - the political is personal.
Think globally,
Act locally.
and
Plan if you can to attend the Homebirth Rights rally in Canberra, 7 September, and tell others about it.
We (the community of independent midwives and homebirth parents) are all wondering what will happen to homebirth after July next year. If you are not aware of the issues, please scroll down in this blog, and go to the MIPP blog for more information and links.
I've been busy with a cluster of births, and haven't had time to be worried yet, but I know some of my clients are concerned. I just have lots of unanswered questions, such as ...
What will be the impact of the midwifery changes announced in the federal budget on my ability to practice midwifery (and make a living)?
(I am writing in the first person here - that's what people seem to do on their blogs - but I know it applies well beyond my personal situation!)
With the requirement for indemnity insurance for registration from 1 July 2010, and the government's provision of indemnity insurance &c for 'eligible midwives' from 1 November 2010, what happens to my ability to earn a living, and to the women who want me to attend them professionally, during those four months? (assuming that the announced time frame will be adhered to) How can I be sure that I will be an eligible midwife?
and the BIG question:
WHAT ABOUT HOMEBIRTH?
There are no publicly funded homebirth options in my area, and even if there were, some women would prefer to engage a midwife privately to come into their home to provide midwifery services. Some women booked with me would be excluded from any service that is 'risk managed' to current hospital standards - those who have had more than six babies (they should be considered super birthers by that stage), those who have had one or more previous caesareans, those whose babies don't want to be born before that magical 42 week mark, those who are a bit too old, a bit too young, to tall, too short, or whatever.
Does this mean that I am ignorant or careless about risk?
Does this mean that women who choose my care are being ignorant or careless about their own safety or the safety of their babies?
I'm not going to say a blanket no, or yes. It all depends. No life event, and particularly not birth, can be risk free. Home and hospital both have their own sets of risks and uncertainties.
I don't know what's going to happen about homebirth.
I would encourage anyone who is interested to work at keeping yourself informed, and to take action in whatever way you can.
Keep an eye on the blogs, forums, email groups, and professional journals that are writing about midwifery and homebirth.
Read everything with a critical eye.
Be prepared to ask how would [ ] affect me - the political is personal.
Think globally,
Act locally.
and
Plan if you can to attend the Homebirth Rights rally in Canberra, 7 September, and tell others about it.
Saturday, May 30, 2009
breastfeeding difficulties in the first fortnight
Today I want to reflect on the journeys of two first time mothers and their babies. Although these 'cases' are based on two actual babies and their mothers, the situations are not uncommon, and I hope this account will assist readers in understanding better the complexity and the wonder of the natural processes in nourishing and nurturing newly born babies.
I will call the babies Baby Boy (BB) who weighed about 3.4 kilos, and Baby Girl (BG) who weighed about 4 kilos at birth. Both were born in public hospitals in Melbourne, receiving good midwifery care. Both mothers pushed their babies out under their own steam, so to speak - spontaneous vaginal births. The mother of BG had received an injection of a narcotic a few hours prior to the birth, and the mother of BB received several doses of an oral narcotic after the birth.
Both babies remained skin-to-skin with their mothers for their first hour or so, but neither breast fed in that period. BG's mother was taken to the operating theatre for removal of her placenta, and BB's mother was taken to the operating theatre for repair of a perineal tear. Both babies slept while separated from their mothers.
By 24 hours -
Baby BB had had a couple of brief breast feeds but was still quite sleepy most of the time.
Baby BG had been to the breast several times, without attaching well. She was sucking her lower lip when awake, and seemed content with that.
By 48 hours, second day -
Both mothers and babies had gone home from hospital. Neither of the babies was feeding effectively.
I was in contact with both mothers. I encouraged each to work on learning to express milk by hand, to 'reward' any effort made by her baby with expressed milk, and to give baby as much as she was able to express. This amounted to not much more than a few mililitres. The mother was encouraged to persevere with massaging and expressing her breasts every few hours until her baby's efforts at suckling became strong and effective.
Third day -
Baby BG was checked by hospital midwife. Although she had not yet breastfed effectively, she was receiving about 5 ml of expressed colostrum milk whenever she was awake. Both mother and baby were well. Mother was encouraged to continue, and to give BG access to her breast when ever she was awake.
Baby BB had not woken much, and his mother had kept to the plan of expressing her colostrum every 3-4 hours, and giving him the milk using a syringe or tea spoon. However, that evening the result of BB's serum bilirubin test indicated moderate jaundice, which was at the lower end of the range for which babies of his age are nursed in phototherapy. The hospital nurse called BB's mother, and asked her to bring him to the special care nursery, to be admitted. BB's mother asked if she would be able to stay to continue breastfeeding, and was told 'no'. There was no bed available. The hospital would use any expressed breast milk she provided, as well as artificial formula milk to feed BB while he was in their care.
At the same time, I was visiting BB and his mother. We worked at stimulating little BB, using olive oil to massage him, and co-bathing in the bath tub. We were delighted when he cooperated, and took both breasts better than he had done previously. The mother was not willing to be separated from BB without good reason, and we felt we had turned a corner. With my support the parents made the decision to stay at home, and have BB's jaundice checked again at the hospital the following day.
I had noted that BB was tongue tied, and arranged for the hospital breastfeeding support unit to review that too. BB did a lot of serious breastfeeding overnight, and when his serum bilirubin (jaundice) level was checked the next day he was out of the range requiring admission.
Fourth day -
Baby BG had found the breast, to the delight of her parents. However her mother's nipples were grazed and ridges were forming across the nipple when she nursed. When I visited them I guided mother with a few tips on improving the positioning and attachment - fine tuning the success that they had achieved on their own.
Baby BB also seemed to be progressing well. He and his mother spent the day with the breast feeding support midwife at the hospital. The frenulum (tongue tie) was snipped; the jaundice was settling; the number of wet and pooey nappies increased; and he was settling and sleeping between feeds.
Baby BB's mother was confident to cease expressing milk by about Day 5. However, over the next few days it became clear that his breastfeeding was not as effective as BB needed, as he did not gain any weight from the fourth to the tenth day. He was going to the breast frequently, but often unsettled after feeds. The Maternal and Child health nurse assessed him as dehydrated, considered that the tongue tie was continuing to interfere with BB's sucking, and insisted that he be given baby formula milk supplements. Attempts to express milk by hand and using an electric breast pump resulted in small amounts - about 10 ml.
That evening I visited baby BB and his mother, and once again we devised a plan. This included learning a more effective bi-manual compression of the breast, and regular expressing to stimulate milk production. All expressed milk was given to BB after he had worked at the breast. The record of feeds showed a steady increase in the volume of breastmilk that was given as a supplement to BB.
By about 12 days of age BB's efforts at the breast continue to be supplemented with expressed milk. The tongue tie is to be reviewed by another doctor who is expert in such matters. Mother continues to work consistently on increasing her milk supply. Her beautiful baby boy is responding well: the more milk she gives him, the more he wants.
As I reflect on these real life situations that real mothers and their babies face I am very pleased to record the stories. The issues in getting breastfeeding right are as multi-faceted as any other aspect of life. Each mother-baby pair have their own set of challenges; some expected, and some out of the blue. Each mother-baby pair who manage to overcome their challenges and make the best choices that are available at the time are learning about life and becoming more strongly bonded together. The resulting emotional attachment supports them in dealing with the life challenges that lie ahead.
I will call the babies Baby Boy (BB) who weighed about 3.4 kilos, and Baby Girl (BG) who weighed about 4 kilos at birth. Both were born in public hospitals in Melbourne, receiving good midwifery care. Both mothers pushed their babies out under their own steam, so to speak - spontaneous vaginal births. The mother of BG had received an injection of a narcotic a few hours prior to the birth, and the mother of BB received several doses of an oral narcotic after the birth.
Both babies remained skin-to-skin with their mothers for their first hour or so, but neither breast fed in that period. BG's mother was taken to the operating theatre for removal of her placenta, and BB's mother was taken to the operating theatre for repair of a perineal tear. Both babies slept while separated from their mothers.
By 24 hours -
Baby BB had had a couple of brief breast feeds but was still quite sleepy most of the time.
Baby BG had been to the breast several times, without attaching well. She was sucking her lower lip when awake, and seemed content with that.
By 48 hours, second day -
Both mothers and babies had gone home from hospital. Neither of the babies was feeding effectively.
I was in contact with both mothers. I encouraged each to work on learning to express milk by hand, to 'reward' any effort made by her baby with expressed milk, and to give baby as much as she was able to express. This amounted to not much more than a few mililitres. The mother was encouraged to persevere with massaging and expressing her breasts every few hours until her baby's efforts at suckling became strong and effective.
Third day -
Baby BG was checked by hospital midwife. Although she had not yet breastfed effectively, she was receiving about 5 ml of expressed colostrum milk whenever she was awake. Both mother and baby were well. Mother was encouraged to continue, and to give BG access to her breast when ever she was awake.
Baby BB had not woken much, and his mother had kept to the plan of expressing her colostrum every 3-4 hours, and giving him the milk using a syringe or tea spoon. However, that evening the result of BB's serum bilirubin test indicated moderate jaundice, which was at the lower end of the range for which babies of his age are nursed in phototherapy. The hospital nurse called BB's mother, and asked her to bring him to the special care nursery, to be admitted. BB's mother asked if she would be able to stay to continue breastfeeding, and was told 'no'. There was no bed available. The hospital would use any expressed breast milk she provided, as well as artificial formula milk to feed BB while he was in their care.
At the same time, I was visiting BB and his mother. We worked at stimulating little BB, using olive oil to massage him, and co-bathing in the bath tub. We were delighted when he cooperated, and took both breasts better than he had done previously. The mother was not willing to be separated from BB without good reason, and we felt we had turned a corner. With my support the parents made the decision to stay at home, and have BB's jaundice checked again at the hospital the following day.
I had noted that BB was tongue tied, and arranged for the hospital breastfeeding support unit to review that too. BB did a lot of serious breastfeeding overnight, and when his serum bilirubin (jaundice) level was checked the next day he was out of the range requiring admission.
Fourth day -
Baby BG had found the breast, to the delight of her parents. However her mother's nipples were grazed and ridges were forming across the nipple when she nursed. When I visited them I guided mother with a few tips on improving the positioning and attachment - fine tuning the success that they had achieved on their own.
Baby BB also seemed to be progressing well. He and his mother spent the day with the breast feeding support midwife at the hospital. The frenulum (tongue tie) was snipped; the jaundice was settling; the number of wet and pooey nappies increased; and he was settling and sleeping between feeds.
Baby BB's mother was confident to cease expressing milk by about Day 5. However, over the next few days it became clear that his breastfeeding was not as effective as BB needed, as he did not gain any weight from the fourth to the tenth day. He was going to the breast frequently, but often unsettled after feeds. The Maternal and Child health nurse assessed him as dehydrated, considered that the tongue tie was continuing to interfere with BB's sucking, and insisted that he be given baby formula milk supplements. Attempts to express milk by hand and using an electric breast pump resulted in small amounts - about 10 ml.
That evening I visited baby BB and his mother, and once again we devised a plan. This included learning a more effective bi-manual compression of the breast, and regular expressing to stimulate milk production. All expressed milk was given to BB after he had worked at the breast. The record of feeds showed a steady increase in the volume of breastmilk that was given as a supplement to BB.
By about 12 days of age BB's efforts at the breast continue to be supplemented with expressed milk. The tongue tie is to be reviewed by another doctor who is expert in such matters. Mother continues to work consistently on increasing her milk supply. Her beautiful baby boy is responding well: the more milk she gives him, the more he wants.
As I reflect on these real life situations that real mothers and their babies face I am very pleased to record the stories. The issues in getting breastfeeding right are as multi-faceted as any other aspect of life. Each mother-baby pair have their own set of challenges; some expected, and some out of the blue. Each mother-baby pair who manage to overcome their challenges and make the best choices that are available at the time are learning about life and becoming more strongly bonded together. The resulting emotional attachment supports them in dealing with the life challenges that lie ahead.
Wednesday, May 27, 2009
Generation Y birthing
Young and beautiful mummies and daddies, bringing beautiful babies into the world.
Texting their messages in labour, telling a multitude of 'friends' how they feel on facebook, twittering, with baby's website being set up while the labour progresses.
Oh yes, it's not just Gen Y who do it. But, they (Gen Y that is) do it so 'naturally'.
Friday, May 22, 2009
Am I Responsible?
'Am I Responsible?' was the theme of the professional study day presented by the Australian Nursing Federation in Carlton today.
Case studies were presented as examples of the complexities that nurses and midwives face in situations where their professional actions are investigated. Coroner Audrey Jamieson explained the Coroner's role in seeking answers when a death is investigated. Barrister Ron Gipp described legal respresentation given for a nurse who was required to attend the Coroner's Court. Nurses Board CEO, Nigel Fidgeon, presented the Board's role in investigations into professional conduct.
I am interested in these matters, and value the opportunity to consider the issues from the perspective of health care professionals generally. On occasions when I accompany a woman to hospital I am able to observe the practice culture of the unit, as well as the behaviours of individual staff members.
I have recently had reason to be very concerned about what appears to be a culture of carelessness concerning drug administration in a hospital maternity unit. The young midwife had reached the end of her shift and said to the midwife who was replacing her, "I have drawn up the Syntocinon (oxytocic). It's in the fridge (and pointed to the small fridge in the room)." The second midwife seemed happy with that, and did not make any comment.
There was no emergency situation. Baby had been born 30 minutes previously, and mother and baby were well. There was no bleeding. The mother had requested physiological Third Stage.
Hospitals may not have a 'guideline' or 'protocol' on physiological Third Stage. Most hospitals promote active management of the Third Stage. Many midwives in hospitals have had little experience with any part of physiological birth.
I am not criticising the fact that the drug had been drawn up. I am critical of the casual handover from one midwife to the next. There have been far to many cases when the wrong drug has been administered. In birthing suites there have been tragic cases such as mistaken administration of a dose of Syntometrine (Syntocinon and Ergometrine, a common oxytocic mixture used in Third Stage) to a woman in labour, in stead of an analgesic such as Pethidine. The oxytocic had been drawn up 'early' and kept on hand. When Pethidine was also drawn up but the standard checking and adminsitration by two midwives had not been followed, the mistake had taken place.
I had a quiet word with the midwife, and explained my concerns. There was no adverse event at the time, but I hope that by drawing attention to the matter I will be preventing tragic mistakes at some other time. Midwives who administer any medicine or substance to women in our care have a duty of care to take full professional precautions in every instance. Once we step outside 'Plan A' - spontaneous, unmedicated birth - and use drugs and other medical interventions, the risks to both mother and baby are upped. A midwife's competence in management of these medical substances and procedures is, for that woman, just as important as her competence in promoting normal birth.
Case studies were presented as examples of the complexities that nurses and midwives face in situations where their professional actions are investigated. Coroner Audrey Jamieson explained the Coroner's role in seeking answers when a death is investigated. Barrister Ron Gipp described legal respresentation given for a nurse who was required to attend the Coroner's Court. Nurses Board CEO, Nigel Fidgeon, presented the Board's role in investigations into professional conduct.
I am interested in these matters, and value the opportunity to consider the issues from the perspective of health care professionals generally. On occasions when I accompany a woman to hospital I am able to observe the practice culture of the unit, as well as the behaviours of individual staff members.
I have recently had reason to be very concerned about what appears to be a culture of carelessness concerning drug administration in a hospital maternity unit. The young midwife had reached the end of her shift and said to the midwife who was replacing her, "I have drawn up the Syntocinon (oxytocic). It's in the fridge (and pointed to the small fridge in the room)." The second midwife seemed happy with that, and did not make any comment.
There was no emergency situation. Baby had been born 30 minutes previously, and mother and baby were well. There was no bleeding. The mother had requested physiological Third Stage.
Hospitals may not have a 'guideline' or 'protocol' on physiological Third Stage. Most hospitals promote active management of the Third Stage. Many midwives in hospitals have had little experience with any part of physiological birth.
I am not criticising the fact that the drug had been drawn up. I am critical of the casual handover from one midwife to the next. There have been far to many cases when the wrong drug has been administered. In birthing suites there have been tragic cases such as mistaken administration of a dose of Syntometrine (Syntocinon and Ergometrine, a common oxytocic mixture used in Third Stage) to a woman in labour, in stead of an analgesic such as Pethidine. The oxytocic had been drawn up 'early' and kept on hand. When Pethidine was also drawn up but the standard checking and adminsitration by two midwives had not been followed, the mistake had taken place.
I had a quiet word with the midwife, and explained my concerns. There was no adverse event at the time, but I hope that by drawing attention to the matter I will be preventing tragic mistakes at some other time. Midwives who administer any medicine or substance to women in our care have a duty of care to take full professional precautions in every instance. Once we step outside 'Plan A' - spontaneous, unmedicated birth - and use drugs and other medical interventions, the risks to both mother and baby are upped. A midwife's competence in management of these medical substances and procedures is, for that woman, just as important as her competence in promoting normal birth.
Tuesday, May 19, 2009
silence
I wonder why virtually noone is making any comment about the midwifery changes announced in last Tuesday's budget - indemnity, Medicare and limited prescribing?
The silence covers the newspapers, TV and radio programs that I have accessed, as well as midwifery and maternity-related email lists. I have been with labouring women in two Melbourne hospitals this week - Mercy and Box Hill - and most of the midwives I have spoken to were not aware that anything has happened. Others seem scared that the reforms will be subjected to excessive gatekeeping, effectively setting hurdles that are too high for ordinary midwives to aspire to, and creating a two-tiered midwifery workforce.
I expected at least a few comments on blogs, but on the whole I'm hearing silence.
Midwife Lisa Barrett has put her opinion on her blog. I have left a comment there, and most of what appears below is copied to this site.
Although I am disappointed and frustrated that homebirth has been sectioned off as a 'no-go' zone, for reasons that can not be taken seriously by anyone who understands evidence, I am really pleased that the government has taken such a big step to dismantle the medical monopoly of maternity care. And in my mind the announcements of reform were more wonderful in the wake of the report of the maternity services review which said a lot of nothing and skirted around the real issues.
The budget press releases from the College of Midwives, as well as from Maternity Coalition and Homebirth Australia were, imho, worded in a politically correct way. I am confident that ACM is the best representative we have for midwives, and I have been assured that the defining of such things as advanced practice and collaboration will be acceptable even to ordinary midwives like me who don't have even a bachelor degree, let alone higher academic quals.
I am also wondering what will be done about homebirth in situations or locations where the publicly funded models are not available. I expect there will be some midwives prepared to go 'underground', while others will seek to comply with the new rules. Noone can force a woman to go to hospital.
I have been actively working for maternity reform since 1993 when I started my private practice. We have a long way to go, but from where I sit the 2009 federal budget is the biggest step forward that I have seen so far in my lifetime. I hope the bill passes in the Senate, and I hope those who represent midwives' and women's interests in bringing in the reforms will be wise and courageous.
I have many questions, and I, like others, will have to exercise patience. That's not easy. I have enjoyed the independence that I have had in midwifery in the past 15 or so years. I accept that there will be changes in how I can practise, if at all, after the middle of next year. I hope that by the end of this year I will still be taking bookings for births beyond 1 July.
The silence covers the newspapers, TV and radio programs that I have accessed, as well as midwifery and maternity-related email lists. I have been with labouring women in two Melbourne hospitals this week - Mercy and Box Hill - and most of the midwives I have spoken to were not aware that anything has happened. Others seem scared that the reforms will be subjected to excessive gatekeeping, effectively setting hurdles that are too high for ordinary midwives to aspire to, and creating a two-tiered midwifery workforce.
I expected at least a few comments on blogs, but on the whole I'm hearing silence.
Midwife Lisa Barrett has put her opinion on her blog. I have left a comment there, and most of what appears below is copied to this site.
Although I am disappointed and frustrated that homebirth has been sectioned off as a 'no-go' zone, for reasons that can not be taken seriously by anyone who understands evidence, I am really pleased that the government has taken such a big step to dismantle the medical monopoly of maternity care. And in my mind the announcements of reform were more wonderful in the wake of the report of the maternity services review which said a lot of nothing and skirted around the real issues.
The budget press releases from the College of Midwives, as well as from Maternity Coalition and Homebirth Australia were, imho, worded in a politically correct way. I am confident that ACM is the best representative we have for midwives, and I have been assured that the defining of such things as advanced practice and collaboration will be acceptable even to ordinary midwives like me who don't have even a bachelor degree, let alone higher academic quals.
I am also wondering what will be done about homebirth in situations or locations where the publicly funded models are not available. I expect there will be some midwives prepared to go 'underground', while others will seek to comply with the new rules. Noone can force a woman to go to hospital.
I have been actively working for maternity reform since 1993 when I started my private practice. We have a long way to go, but from where I sit the 2009 federal budget is the biggest step forward that I have seen so far in my lifetime. I hope the bill passes in the Senate, and I hope those who represent midwives' and women's interests in bringing in the reforms will be wise and courageous.
I have many questions, and I, like others, will have to exercise patience. That's not easy. I have enjoyed the independence that I have had in midwifery in the past 15 or so years. I accept that there will be changes in how I can practise, if at all, after the middle of next year. I hope that by the end of this year I will still be taking bookings for births beyond 1 July.
Friday, May 15, 2009
BIG reforms for midwifery in Australia
I was on the job, 'with woman', when the announcement was made by the federal Treasurer Wayne Swan in his 2009 Budget speech to Parliament. Please go to the MiPP blog for press releases and more information.
This is a HUGE step forward in reforming maternity care for all women in Australia.
The following statement is from the Department of Health website:
12 May 2009
The 2009-10 Budget includes a $120.5 million package of measures to improve choice and access to maternity services for pregnant women and new mothers in Australia.
As a result of this package, families will have greater choice in the type of care they wish to receive when having a baby. The package also recognises the important role played by qualified midwives in the birthing experience of many Australian women.
Responding to the recently completed national Maternity Services Review, the package includes:
* Medicare Benefits Schedule and Pharmaceutical Benefits Scheme (PBS) benefits for services provided by eligible midwives, to provide greater access to maternity care provided by midwives working in collaboration with doctors – expanding choice for women.
* A Government-supported professional indemnity insurance scheme for eligible midwives.
* More services for rural and remote communities, where the state of maternity services is poor, through an expansion of the successful Medical Specialist Outreach Assistance Program (MSOAP).
* Extra scholarships for GPs and midwives to expand the maternity workforce, particularly in rural and remote Australia.
* A new 24 hour, seven days a week telephone helpline and information service to provide women, their partners and families with greater access to maternity information and support before and after birth.
These arrangements will be subject to agreement with states and territories on a National Maternity Services Plan – who will be asked to make complementary commitments and investments, particularly around the provision of birthing centres and rural maternity units.
The Government’s commitment to a National Maternity Services Plan recognises the importance attached to maternity services by the over 270,000 Australian women who give birth each year, and their families.
At this early stage it is impossible to predict the detail of the new scheme, which is to be introduced from 1 November 2010. (If anyone has questions that you would like discussed, please leave a message in the comments section.) Here are a few points:
* The Australian College of Midwives is 'at the table' with the Health Minister and her department, representing midwives. All midwives would be well advised to get your ongoing professional education systems up to date, using the ACM Mid-PLUS program.
* Maternity Coalition is seeking to represent consumer interests in advocating for women's choice in birthing their babies.
* Homebirth Australia is well positioned to lobby for women's rights to give birth in the setting of their choice, including their own home.
* Local lobby groups such as Homebirth in the Hills, natural parenting groups, and Save Birth Choices have an important role in educating mothers and the general public, and in encouraging activism at a local level.
I know that many blog readers have contacted their local MPs and spoken to them in relation to the Maternity Services Review. Thankyou for your work. I would like to encourage you to keep yourselves well informed, write letters to the editors of newspapers, call radio talk back programs ... keep maternity care as a topic worth thinking about.
This is a HUGE step forward in reforming maternity care for all women in Australia.
The following statement is from the Department of Health website:
12 May 2009
The 2009-10 Budget includes a $120.5 million package of measures to improve choice and access to maternity services for pregnant women and new mothers in Australia.
As a result of this package, families will have greater choice in the type of care they wish to receive when having a baby. The package also recognises the important role played by qualified midwives in the birthing experience of many Australian women.
Responding to the recently completed national Maternity Services Review, the package includes:
* Medicare Benefits Schedule and Pharmaceutical Benefits Scheme (PBS) benefits for services provided by eligible midwives, to provide greater access to maternity care provided by midwives working in collaboration with doctors – expanding choice for women.
* A Government-supported professional indemnity insurance scheme for eligible midwives.
* More services for rural and remote communities, where the state of maternity services is poor, through an expansion of the successful Medical Specialist Outreach Assistance Program (MSOAP).
* Extra scholarships for GPs and midwives to expand the maternity workforce, particularly in rural and remote Australia.
* A new 24 hour, seven days a week telephone helpline and information service to provide women, their partners and families with greater access to maternity information and support before and after birth.
These arrangements will be subject to agreement with states and territories on a National Maternity Services Plan – who will be asked to make complementary commitments and investments, particularly around the provision of birthing centres and rural maternity units.
The Government’s commitment to a National Maternity Services Plan recognises the importance attached to maternity services by the over 270,000 Australian women who give birth each year, and their families.
At this early stage it is impossible to predict the detail of the new scheme, which is to be introduced from 1 November 2010. (If anyone has questions that you would like discussed, please leave a message in the comments section.) Here are a few points:
* The Australian College of Midwives is 'at the table' with the Health Minister and her department, representing midwives. All midwives would be well advised to get your ongoing professional education systems up to date, using the ACM Mid-PLUS program.
* Maternity Coalition is seeking to represent consumer interests in advocating for women's choice in birthing their babies.
* Homebirth Australia is well positioned to lobby for women's rights to give birth in the setting of their choice, including their own home.
* Local lobby groups such as Homebirth in the Hills, natural parenting groups, and Save Birth Choices have an important role in educating mothers and the general public, and in encouraging activism at a local level.
I know that many blog readers have contacted their local MPs and spoken to them in relation to the Maternity Services Review. Thankyou for your work. I would like to encourage you to keep yourselves well informed, write letters to the editors of newspapers, call radio talk back programs ... keep maternity care as a topic worth thinking about.
Thursday, May 14, 2009
Little one
Tell me what you see, little one,
When the world you know has so suddenly changed.
People coming and going.
And bright lights.
Do you also see tears in my eyes?
Tell me what you hear, little one?
In a world that changes without care of you.
Different people,
Different places.
Do you also hear the voice of love?
Is that your mother's milk on your tongue, little one?
Nurture and warmth.
Blood on your head:
Distance, separation, and fear?
Reality so different from what you instinctively seek.
Loving you so imperfectly,
there are times when the best I have is to cry with you.
Yet in that poor loving you learn living.
May God be with you, to guide and bless you, little one, as you start life's journey.
Joy Johnston, May 2009
When the world you know has so suddenly changed.
People coming and going.
And bright lights.
Do you also see tears in my eyes?
Tell me what you hear, little one?
In a world that changes without care of you.
Different people,
Different places.
Do you also hear the voice of love?
Is that your mother's milk on your tongue, little one?
Nurture and warmth.
Blood on your head:
Distance, separation, and fear?
Reality so different from what you instinctively seek.
Loving you so imperfectly,
there are times when the best I have is to cry with you.
Yet in that poor loving you learn living.
May God be with you, to guide and bless you, little one, as you start life's journey.
Joy Johnston, May 2009
Tuesday, May 12, 2009
Being born is important
When you are able to take a moment for reflection, please go to Marina's blog to read this beautiful poem.
Marina is a midwife in Chiapas, Mexico.
The universal nature of deep truth about life, such as the truth so beautifully expressed in this poem, reminds me that we who know birth are the keepers and guardians of a precious treasure.
Marina is a midwife in Chiapas, Mexico.
The universal nature of deep truth about life, such as the truth so beautifully expressed in this poem, reminds me that we who know birth are the keepers and guardians of a precious treasure.
Sunday, May 10, 2009
Happy Mother's Day
... to all mothers, mothers to be, and any others reading this!
I would like to dedicate this blog to my mother, Ella White, who died 10 May 1985. The picture shows me with three of my (5) sisters: (L-R) Marion Andrews, Jane Ganter, and Annette Enchelmaier.
Today we have enjoyed a traditional family Sunday dinner after church. With a lovely white table cloth, a candle in the middle of the table, using the good crockery and cutlery, the meal was complete with roast chicken and veges, and followed by a lovely dessert, prepared my our daughter Bec.
Having family members around the table is something so basic to a mother that we can easily overlook its importance. Since my four young ones have left the nest, and set up their own homes, I treasure these special meal times. Sometimes we have to extend the table and find extra chairs; in good weather we set up tables al fresco on the deck.
A client phoned thismorning to tell me how disappointed she was; that she had thought her labour was getting underway last night. Contractions were coming regularly every six minutes for a couple of hours. Eventually she went to bed. It had all fizzled. AGAIN!
I reassured her. Her body is preparing for labour; not quite ready yet. I expect we will see this baby soon.
The final days of waiting for labour can be very difficult. It doesn't surprise me that induction of labour is frequently carried out for 'other' than valid reasons. Its not just the mother who can feel disappointed or frustrated in waiting for that indefinable tipping point. The midwife or doctor can find all sorts of reasons why, from a practical, time management point of view, it is reasonable to induce a labour.
However, the finely balanced processes that are orchestrated in normal labour and birth can be terribly disturbed with induction of labour. One intervention leads to another, and quickly the cascade of interventions become the driving force. Once the process has been started there is no going back.
I remember those nights in late pregnancy when I felt secretly hopeful that something was going to happen. I remember the doubts that came up in my mind: will I labour? will I know I am in labour? (silly questions, I know, but that didn't stop them from coming)
I think this mental turmoil is part of our instinctive nesting. We become unsettled, and perhaps difficult to live with. We become self absorbed.
That's good.
The labour will establish, and the child will be born.
I would like to dedicate this blog to my mother, Ella White, who died 10 May 1985. The picture shows me with three of my (5) sisters: (L-R) Marion Andrews, Jane Ganter, and Annette Enchelmaier.
Today we have enjoyed a traditional family Sunday dinner after church. With a lovely white table cloth, a candle in the middle of the table, using the good crockery and cutlery, the meal was complete with roast chicken and veges, and followed by a lovely dessert, prepared my our daughter Bec.
Having family members around the table is something so basic to a mother that we can easily overlook its importance. Since my four young ones have left the nest, and set up their own homes, I treasure these special meal times. Sometimes we have to extend the table and find extra chairs; in good weather we set up tables al fresco on the deck.
A client phoned thismorning to tell me how disappointed she was; that she had thought her labour was getting underway last night. Contractions were coming regularly every six minutes for a couple of hours. Eventually she went to bed. It had all fizzled. AGAIN!
I reassured her. Her body is preparing for labour; not quite ready yet. I expect we will see this baby soon.
The final days of waiting for labour can be very difficult. It doesn't surprise me that induction of labour is frequently carried out for 'other' than valid reasons. Its not just the mother who can feel disappointed or frustrated in waiting for that indefinable tipping point. The midwife or doctor can find all sorts of reasons why, from a practical, time management point of view, it is reasonable to induce a labour.
However, the finely balanced processes that are orchestrated in normal labour and birth can be terribly disturbed with induction of labour. One intervention leads to another, and quickly the cascade of interventions become the driving force. Once the process has been started there is no going back.
I remember those nights in late pregnancy when I felt secretly hopeful that something was going to happen. I remember the doubts that came up in my mind: will I labour? will I know I am in labour? (silly questions, I know, but that didn't stop them from coming)
I think this mental turmoil is part of our instinctive nesting. We become unsettled, and perhaps difficult to live with. We become self absorbed.
That's good.
The labour will establish, and the child will be born.
Thursday, May 07, 2009
Baby born in a church
'Instant baby delivered in Church'
Here is fascinating footage from youtube, recording the birth of a baby girl in an African church.
The sound and visual quality is poor, but the story is clear. Two young mothers went to the church and were placed in the 'emergency section' to receive special prayer. As the minister prayed for them, one stood up and quickly gave birth to her baby on the concrete floor. She later testifies that she had been told she had a problem with jaundice, and that her baby was obstructed. She felt the baby move into position and she gave birth.
The woman sitting next to her had asked for prayer because her pregnancy was overdue. She testified that, having witnessed the birth in church, she went home and gave birth to a healthy baby boy (whose boy parts were displayed for the record) without any problems.
Most of my readers know of my Christian faith. Although I do not share the charismatic type of religious practice that is obvious in this video clip, I am able with all my heart to praise God for these births to young women in Lagos, Nigeria.
Many midwifery writers and thinkers have drawn attention to the ecstatic, out of body experience that can be part of normal birthing. We have come to understand that in advanced labour a woman's conscious, thinking mind - the neocortex - needs to be quiet, to free her to work with her body's intuitive, instinctive abilities which are based in the deeper part of her brain. In drawing together what I know as a midwife and as a mother who has given birth without medical stimulants or painkillers, with the power I know we have in prayer to the one true God who created us, I am not surprised when I witness this amazing ecstatic birthing.
Here is fascinating footage from youtube, recording the birth of a baby girl in an African church.
The sound and visual quality is poor, but the story is clear. Two young mothers went to the church and were placed in the 'emergency section' to receive special prayer. As the minister prayed for them, one stood up and quickly gave birth to her baby on the concrete floor. She later testifies that she had been told she had a problem with jaundice, and that her baby was obstructed. She felt the baby move into position and she gave birth.
The woman sitting next to her had asked for prayer because her pregnancy was overdue. She testified that, having witnessed the birth in church, she went home and gave birth to a healthy baby boy (whose boy parts were displayed for the record) without any problems.
Most of my readers know of my Christian faith. Although I do not share the charismatic type of religious practice that is obvious in this video clip, I am able with all my heart to praise God for these births to young women in Lagos, Nigeria.
Many midwifery writers and thinkers have drawn attention to the ecstatic, out of body experience that can be part of normal birthing. We have come to understand that in advanced labour a woman's conscious, thinking mind - the neocortex - needs to be quiet, to free her to work with her body's intuitive, instinctive abilities which are based in the deeper part of her brain. In drawing together what I know as a midwife and as a mother who has given birth without medical stimulants or painkillers, with the power I know we have in prayer to the one true God who created us, I am not surprised when I witness this amazing ecstatic birthing.
Tuesday, May 05, 2009
HAPPY INTERNATIONAL MIDWIVES' DAY
[Print: thanks to artist and mother Emma Flaim]
My greetings to all midwives, and to all who value the work of midwives.
International Day of the Midwife – 5 May 2009
The World Needs Midwives Now More Than Ever!
Tuesday, April 28, 2009
Submission to the Senate Inquiry into National Registration and Accreditation Scheme for Doctors and Other Health Workers
Submissions are sent to:
The Secretary
Senate Community Affairs Committee
PO Box 6100, Parliament House
Canberra ACT 2600
I am writing to the Inquiry as a midwife. I have been a midwife since 1973, and working independently since 1993. Aged in my late 50s, I am nearing the end of a satisfying and productive professional career which includes practice, teaching, and other professional consulting and writing.
It is with great sadness that I prepare this submission, as I recognise the likelihood that the new laws governing registration and accreditation of my profession will also signal the termination of my right to practice, due to the fact that professional indemnity insurance is not available for midwives.
I am not opposed to national registration, or to the mandating of indemnity insurance as a condition for registration, but I am deeply concerned about the Government’s inequitable support for the medical profession over the midwifery profession in this instance.
In our submissions to the federal government’s recent Maternity Services Review I and many other midwives, consumers, and maternity organisations informed the Review of the urgent need midwives have for indemnity that will cover our private practices. The Report (Section 6.2) acknowledged the Government’s support for the medical profession, including the Premium Support Scheme, “which provided financial relief to specialists such as obstetricians so that their premium costs relative to other specialties became more affordable”, but failed to recommend that any similar support be available for midwives, or to offer any other lifeline to midwives.
My question to the Senate Inquiry is, “how can one professional group (midwives) be excluded from practice on the grounds of no insurance being available, when the group competing for the same work (obstetricians and proceduralist GPs) receive substantial government support to purchase their indemnity insurance?”
This anomaly appears to be in breach the intent of competition policy and monopolies supported by government funding. Yet it appears that under the Trade Practices Act, a case would need to be made under Section 45DD, that a Secondary Boycott situation existed (eg: “We found Obstetrician A colluding with Obstetrician B to prevent Midwife C from working.”) This scenario is most unlikely, as the Government’s financial support through Medicare provides the medical practitioners with an effective monopoly of prenatal (out of hospital) care, and the inability of midwives to obtain professional indemnity insurance excludes midwives from most opportunities to provide care privately in hospitals for women during the birth and post natally. Hence there is no case of ‘Secondary Boycott’ or collusion to exclude midwives from practice at a community level, as there is a systematic exclusion of midwives through Medicare and the funding of hospitals. I believe that the Government needs to remedy this situation in the public interest.
A paper 'The Trade Practices Act and the Health Sector' was presented by Professor Allan Fels, the then chair of the ACCC, in 1998. Prof Fels stated that the role of the ACCC includes "looking at health professionals' conduct to determine whether it promotes or hinders patients' interests in being able to choose among a variety of services and price options according to their needs", and "competition policy is based on the premise that consumer choice, rather than the collective judgment of the sellers, should determine the range and prices of goods and services that are available. Or in other words that the competitive suppliers should not pre-empt the working of the market by deciding themselves what their customers need, rather than allowing the market to respond to what consumers demand."
These principles have not been applied to Government funding for basic maternity care, which is the practice domain for which midwives are registered. Consumers who choose to employ a midwife as their primary carer do so, in most cases, without any government support. The medical profession’s monopoly of maternity funding and maternity care provision is not in the public interest. There is no evidence that excluding midwives from practice improves outcomes for mothers and babies.
The current restriction of the scope of practice of Australian midwives is regressive when compared with contemporary standards in developed nations. The Australian consumer ought to be free to choose the primary maternity care provider, either a midwife or a doctor, with consideration of the ability to each one to provide the service required by the individual woman and her child.
I therefore request that, in the implementation of the Government’s national registration and accreditation scheme for midwives, the Senate Community Affairs Committee ensure that midwives have equitable access to Government support for their purchasing of indemnity insurance, and for the provision of services. This is in the public interest and in the interest of free trade.
Joy Johnston
joy@aitex.com.au
The Secretary
Senate Community Affairs Committee
PO Box 6100, Parliament House
Canberra ACT 2600
I am writing to the Inquiry as a midwife. I have been a midwife since 1973, and working independently since 1993. Aged in my late 50s, I am nearing the end of a satisfying and productive professional career which includes practice, teaching, and other professional consulting and writing.
It is with great sadness that I prepare this submission, as I recognise the likelihood that the new laws governing registration and accreditation of my profession will also signal the termination of my right to practice, due to the fact that professional indemnity insurance is not available for midwives.
I am not opposed to national registration, or to the mandating of indemnity insurance as a condition for registration, but I am deeply concerned about the Government’s inequitable support for the medical profession over the midwifery profession in this instance.
In our submissions to the federal government’s recent Maternity Services Review I and many other midwives, consumers, and maternity organisations informed the Review of the urgent need midwives have for indemnity that will cover our private practices. The Report (Section 6.2) acknowledged the Government’s support for the medical profession, including the Premium Support Scheme, “which provided financial relief to specialists such as obstetricians so that their premium costs relative to other specialties became more affordable”, but failed to recommend that any similar support be available for midwives, or to offer any other lifeline to midwives.
My question to the Senate Inquiry is, “how can one professional group (midwives) be excluded from practice on the grounds of no insurance being available, when the group competing for the same work (obstetricians and proceduralist GPs) receive substantial government support to purchase their indemnity insurance?”
This anomaly appears to be in breach the intent of competition policy and monopolies supported by government funding. Yet it appears that under the Trade Practices Act, a case would need to be made under Section 45DD, that a Secondary Boycott situation existed (eg: “We found Obstetrician A colluding with Obstetrician B to prevent Midwife C from working.”) This scenario is most unlikely, as the Government’s financial support through Medicare provides the medical practitioners with an effective monopoly of prenatal (out of hospital) care, and the inability of midwives to obtain professional indemnity insurance excludes midwives from most opportunities to provide care privately in hospitals for women during the birth and post natally. Hence there is no case of ‘Secondary Boycott’ or collusion to exclude midwives from practice at a community level, as there is a systematic exclusion of midwives through Medicare and the funding of hospitals. I believe that the Government needs to remedy this situation in the public interest.
A paper 'The Trade Practices Act and the Health Sector' was presented by Professor Allan Fels, the then chair of the ACCC, in 1998. Prof Fels stated that the role of the ACCC includes "looking at health professionals' conduct to determine whether it promotes or hinders patients' interests in being able to choose among a variety of services and price options according to their needs", and "competition policy is based on the premise that consumer choice, rather than the collective judgment of the sellers, should determine the range and prices of goods and services that are available. Or in other words that the competitive suppliers should not pre-empt the working of the market by deciding themselves what their customers need, rather than allowing the market to respond to what consumers demand."
These principles have not been applied to Government funding for basic maternity care, which is the practice domain for which midwives are registered. Consumers who choose to employ a midwife as their primary carer do so, in most cases, without any government support. The medical profession’s monopoly of maternity funding and maternity care provision is not in the public interest. There is no evidence that excluding midwives from practice improves outcomes for mothers and babies.
The current restriction of the scope of practice of Australian midwives is regressive when compared with contemporary standards in developed nations. The Australian consumer ought to be free to choose the primary maternity care provider, either a midwife or a doctor, with consideration of the ability to each one to provide the service required by the individual woman and her child.
I therefore request that, in the implementation of the Government’s national registration and accreditation scheme for midwives, the Senate Community Affairs Committee ensure that midwives have equitable access to Government support for their purchasing of indemnity insurance, and for the provision of services. This is in the public interest and in the interest of free trade.
Joy Johnston
joy@aitex.com.au
Monday, April 27, 2009
emotion and fact
There are times in life when emotions threaten to overwhelm, when we fear what lies ahead, and feel unable to see a way through. This scenario can apply in times of stress or illness; it can also apply in pregnancy.
Sally's baby is due in a couple of weeks' time, and she is planning to give birth vbac (vaginal birth after caesarean) at home. It's her second baby, and she is experiencing an emotional roller coaster ride as that time approaches. Some of the anxiety and fear Sally is experiencing is related to her daughter's birth: a caesarean without labour. At the time Sally accepted that her baby needed to be taken from her, but as she has thought about it more, she has concluded that the caesarean was probably unnecessary. Someone in the 'system', for some reason, chose to give her surgery, and she agreed. She had been told that she had pre-eclampsia - a diagnosis that she now questions. Will it happen again? The fears that are surging, draining her emotionally, are difficult to put a name to; they just are.
Sally has booked at a public hospital near her home, and has also booked me to be her midwife. This means two bookings, as that hospital does not provide a homebirth backup service.
As we talk I am trying to help Sally differentiate between emotion and fact; her fears and her actual decisions.
I think every woman experiences, to some degree, an emotionally rough journey as we approach a birth. I know I did, with each baby. When embracing uncertainty we must try to hold onto instability and change. It's the same with a balloon filled with water, each movement at any point brings corresponding corrections to the whole unit. The birthing continuum has often been likened to physical experiences involving water and buoyancy: body surfing, when we are lifted and carried quickly on top of the wave, and sometimes dumped ingloriously in the turbulence; or a canoe ride down a river, with moments of quiet, as well as the rapids and the whirlpools. The principle we remember is to not panic, to wait until we come to the surface, to take in breath when it's safe to do so, and be ready for the next episode.
When a woman tells me of her emotion, anxiety, and fear, I encourage her to accept it. To own it as part of the awesome journey she has begun. It is not unusual or wrong for Sally to be anxious about the birth of this baby. The feelings she has experienced so far have led her to make certain plans for this birth. She has become well informed, and understands decision making better now than she did a few years ago.
Here are a few facts that Sally has reaffirmed today:
*that she is well, and that her baby is well
*that at present there is no safer or preferred way for her to give birth than naturally
*that natural birth requires spontaneous onset of labour
*that at any time Sally can review her plans, and make choices that she believes are best for herself and her baby
The hospital is able to provide the expert care if and when needed. But at present Sally is happy to wait for spontaneous onset of labour. The doctor who saw her last week said they needed to make a date for repeat caesarean. Sally declined the offer, and reminded the doctor that vbac requires spontaneous onset and progress in labour. The doctor, who was unwilling to accept that degree of uncertainty, attempted to convince her that at least she needed to make a date; that without that magical date she may have an emergency caesarean.
"Yes", Sally replied. Isn't that part of the usual birthing process? A midwife who heard the exchange nodded in approval and said "Yes! Good on you!"
Sally's baby is due in a couple of weeks' time, and she is planning to give birth vbac (vaginal birth after caesarean) at home. It's her second baby, and she is experiencing an emotional roller coaster ride as that time approaches. Some of the anxiety and fear Sally is experiencing is related to her daughter's birth: a caesarean without labour. At the time Sally accepted that her baby needed to be taken from her, but as she has thought about it more, she has concluded that the caesarean was probably unnecessary. Someone in the 'system', for some reason, chose to give her surgery, and she agreed. She had been told that she had pre-eclampsia - a diagnosis that she now questions. Will it happen again? The fears that are surging, draining her emotionally, are difficult to put a name to; they just are.
Sally has booked at a public hospital near her home, and has also booked me to be her midwife. This means two bookings, as that hospital does not provide a homebirth backup service.
As we talk I am trying to help Sally differentiate between emotion and fact; her fears and her actual decisions.
I think every woman experiences, to some degree, an emotionally rough journey as we approach a birth. I know I did, with each baby. When embracing uncertainty we must try to hold onto instability and change. It's the same with a balloon filled with water, each movement at any point brings corresponding corrections to the whole unit. The birthing continuum has often been likened to physical experiences involving water and buoyancy: body surfing, when we are lifted and carried quickly on top of the wave, and sometimes dumped ingloriously in the turbulence; or a canoe ride down a river, with moments of quiet, as well as the rapids and the whirlpools. The principle we remember is to not panic, to wait until we come to the surface, to take in breath when it's safe to do so, and be ready for the next episode.
When a woman tells me of her emotion, anxiety, and fear, I encourage her to accept it. To own it as part of the awesome journey she has begun. It is not unusual or wrong for Sally to be anxious about the birth of this baby. The feelings she has experienced so far have led her to make certain plans for this birth. She has become well informed, and understands decision making better now than she did a few years ago.
Here are a few facts that Sally has reaffirmed today:
*that she is well, and that her baby is well
*that at present there is no safer or preferred way for her to give birth than naturally
*that natural birth requires spontaneous onset of labour
*that at any time Sally can review her plans, and make choices that she believes are best for herself and her baby
The hospital is able to provide the expert care if and when needed. But at present Sally is happy to wait for spontaneous onset of labour. The doctor who saw her last week said they needed to make a date for repeat caesarean. Sally declined the offer, and reminded the doctor that vbac requires spontaneous onset and progress in labour. The doctor, who was unwilling to accept that degree of uncertainty, attempted to convince her that at least she needed to make a date; that without that magical date she may have an emergency caesarean.
"Yes", Sally replied. Isn't that part of the usual birthing process? A midwife who heard the exchange nodded in approval and said "Yes! Good on you!"
Tuesday, April 21, 2009
freedom to make decisions
From time to time I receive emails from students, asking me to tell them about my midwifery practice. This week's student email had an attachment with about 20 questions under the heading 'Issues that affect midwifery practice'. Rather than spending a couple of hours completing this questionnaire, I have referred the inquirer to this blog, and others, where many of the questions have already been answered.
Today I have selected a question from the list:
"Do you believe pregnant women today have more freedom to make decisions about their birth than they have previously?"
My answer is No, and Yes.
Fence-sitting is probably not very helpful, but I will try to explore the question further. I don't want to sound like the old crone telling stories about the 'good old days' either.
I will link my comments to what I know now about:
1. the freedom that a pregnant woman has to make decisions today
2. the freedom I experienced about 30 years ago, when I was the pregnant woman
3. the freedom my mother, who was also a midwife, told me of her experience about 60 years ago, when she was the pregnant woman.
I say 'No' - that women today do not have more freedom to make decisions about their birth than we had either 30, or 60 years ago (or further back in time, for that matter). Today's mothers face information overload; so many choices that they can easily lose sight of the fact that bearing a child is as normal as life gets.
Many women today are captive to fashion and custom that are driven by capitalistic and humanistic ideologies that have developed in recent generations. There are so many products and gadgets and services that go with the baby business that the reality of the miracle of precious new life can easily be missed.
Today's mother is uncritical as she welcomes technology that invades the privacy of the womb, giving proof of a heart beat in the early weeks, and progressing on to amazing 3D pictures of an unborn child; and answer the question, is it pink or blue? She does not ask for proof that this is safe for the child, or for the next generation. She is encouraged to justify the experience as an opportunity for bonding.
Yet a darkness falls on her life when some small item, called an anomaly, is 'discovered' on the flickering screen. The longed-for child becomes a condition that has to be managed. Dreadful decisions have to be made.
Thirty years ago ultrasound was new technology, available to only a few. Sixty years ago it was beyond imagining. The mother carried her child in the secret place, and experienced meeting her child and discovering its features all in good time.
Thirty years ago the midwife learned to use the Pinnard stethoscope, and the labouring woman was 'managed' lying on a bed. For the birth the woman was often placed in the 'left lateral', the teaching position. The midwife, and a group of students, stood on the right side of the bed, watching and managing the (sterile - no touch) business of birthing, while another midwife stood on the left side of the bed and administered the gas.
Sixty years ago the movements in the womb, felt by the mother, were the primary indicators of wellbeing. A baby whose movement had ceased was stillborn. Still before birth, as well as still after birth.
AND I say 'Yes', women are more free today than in previous generations, to make decisions about their births, because today we try to protect human rights such as autonomy in decision making. Today noone can touch you, or take your pulse without your permission. Anyone expressing that idea 30 years ago would have been quickly put in their place. I felt extremely anxious in 1980, as a pregnant woman booked to give birth to my fourth child at the Royal Women's Hospital Family Birth Centre, when I declared to Dr John Neil that I did not wish to have a glucose tolerance test. He rubbed his chin and said "Well we do let birth centre patients have some say in these things", and generously gave his OK.
My generation of mothers fought for, and won the right to have our husbands at our side in the labour ward, while our parents had been separated at the fathers waiting room. Today I wonder if we have progressed. Although midwives today have learned to operate sophisticated pumps and monitors and beds that are like transformers, many have lost the skill that my mother had 60 years ago, being 'with woman'.
Today I have selected a question from the list:
"Do you believe pregnant women today have more freedom to make decisions about their birth than they have previously?"
My answer is No, and Yes.
Fence-sitting is probably not very helpful, but I will try to explore the question further. I don't want to sound like the old crone telling stories about the 'good old days' either.
I will link my comments to what I know now about:
1. the freedom that a pregnant woman has to make decisions today
2. the freedom I experienced about 30 years ago, when I was the pregnant woman
3. the freedom my mother, who was also a midwife, told me of her experience about 60 years ago, when she was the pregnant woman.
I say 'No' - that women today do not have more freedom to make decisions about their birth than we had either 30, or 60 years ago (or further back in time, for that matter). Today's mothers face information overload; so many choices that they can easily lose sight of the fact that bearing a child is as normal as life gets.
Many women today are captive to fashion and custom that are driven by capitalistic and humanistic ideologies that have developed in recent generations. There are so many products and gadgets and services that go with the baby business that the reality of the miracle of precious new life can easily be missed.
Today's mother is uncritical as she welcomes technology that invades the privacy of the womb, giving proof of a heart beat in the early weeks, and progressing on to amazing 3D pictures of an unborn child; and answer the question, is it pink or blue? She does not ask for proof that this is safe for the child, or for the next generation. She is encouraged to justify the experience as an opportunity for bonding.
Yet a darkness falls on her life when some small item, called an anomaly, is 'discovered' on the flickering screen. The longed-for child becomes a condition that has to be managed. Dreadful decisions have to be made.
Thirty years ago ultrasound was new technology, available to only a few. Sixty years ago it was beyond imagining. The mother carried her child in the secret place, and experienced meeting her child and discovering its features all in good time.
Thirty years ago the midwife learned to use the Pinnard stethoscope, and the labouring woman was 'managed' lying on a bed. For the birth the woman was often placed in the 'left lateral', the teaching position. The midwife, and a group of students, stood on the right side of the bed, watching and managing the (sterile - no touch) business of birthing, while another midwife stood on the left side of the bed and administered the gas.
Sixty years ago the movements in the womb, felt by the mother, were the primary indicators of wellbeing. A baby whose movement had ceased was stillborn. Still before birth, as well as still after birth.
AND I say 'Yes', women are more free today than in previous generations, to make decisions about their births, because today we try to protect human rights such as autonomy in decision making. Today noone can touch you, or take your pulse without your permission. Anyone expressing that idea 30 years ago would have been quickly put in their place. I felt extremely anxious in 1980, as a pregnant woman booked to give birth to my fourth child at the Royal Women's Hospital Family Birth Centre, when I declared to Dr John Neil that I did not wish to have a glucose tolerance test. He rubbed his chin and said "Well we do let birth centre patients have some say in these things", and generously gave his OK.
My generation of mothers fought for, and won the right to have our husbands at our side in the labour ward, while our parents had been separated at the fathers waiting room. Today I wonder if we have progressed. Although midwives today have learned to operate sophisticated pumps and monitors and beds that are like transformers, many have lost the skill that my mother had 60 years ago, being 'with woman'.
Monday, April 20, 2009
making sense of risk management and safety in maternity
In the past couple of months the Australian homebirth and independent midwifery world has been experiencing a new level of challenges and threats to our very existence. The precipitating event was the release of the report of the Maternity Services Review. I have attempted to keep a running record of the published articles and other media, at the MiPP blog.
The safety of homebirth is the key issue in the minds of those who support, and those who are seeking to outlaw homebirth. How can 'safety' be so contentious? Is one party so biased that they can't see what is clear to the other? Are these professional people, on both sides of the fence, not intelligent, well educated, and supposedly ethical people? And what about the parents - consumers who choose homebirth, even though they have to pay for the privilege of not using the hospital? Are these people blinkered, uninformed, even careless about the safety of women and their unborn children?
I know most of our regular blog watchers are aware of these and other related questions, but for those who are still unsure, here are a few recent links:
Largest study in the world confirms homebirth is safe
SMH reporter Miranda Devine, in A home birth is not a safe birth ...
Dr Pesce's comment [ABC Unleashed] on 6 baby deaths in WA in 4 years, which he considered to be proof of the danger of homebirth. "The WA health department said:
"... that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths."
Another statement in the same article reported "a three-fold increased risk of a full term, otherwise healthy baby dying during a planned home birth ..." The paper from which this information was sourced has come under strong criticism for its methodology. Internationally respected epidemiologist Marsden Wagner, in reviewing the paper, noted that conclusions drawn about unacceptable death rates from unreliable sources are not valid.
There are many more references - both in favour of, and against, homebirth. The use of numerical data (quantitative) in understanding evidence must also be balanced with the qualitative research that seeks to report on 'why', and 'how' a particular decision is made or outcome is reached, rather than just 'how many'.
Complicating the whole picture is the rise in the number of unattended home births. There are anecdotes of the tragic death of babies born at home, and 'near miss' experiences, in recent months. Within the stories I have heard about births that have gone wrong, I have been shocked at assumptions that people have made, in justifying choices and decisions.
For example:
A mother planning unattended birth was told to send her husband or a friend to a St John Ambulance resuscitation course, to learn how to resuscitate a baby that is born not breathing.
Another mother took that plan a step further by employing a midwife to be present at her birth, but did not allow that midwife to auscultate the baby's heart sounds prior to the birth.
A mother giving birth unattended experienced delay from the birth of the baby's head to the birth of the rest of the baby. It took many minutes - too long - and the baby did not survive. A midwife would have been expected to intervene in an attempt to protect the life of the child.
I feel that I'm stating the obvious, but it needs to be said. Resuscitation does not work if a baby is already dead.
Much of the risk management in maternity care - both midwifery and obstetric - is to identify babies or mothers 'at risk' of poor outcomes in birth, and to take steps to prevent damage or death. None of us have a crystal ball: it's all about drawing a line. Homebirth is safe because there are important features of homebirth that minimise risk: for example, the mother's own environment; the absence of dangerous drugs and uterine stimulants; the one-to-one focused attention of the midwife. The Dutch maternity system, in which about a third of all births are at home, and for which safety has been clearly demonstrated, requires the midwives to screen women for risk. Women are expected to be referred to specialist (hospital) care if they develop complications, or if they are not progressing well, or ...
I cannot make generalisations about the practices of independent midwives and homebirth in Australia. It is likely that some have their heads in the sand (or in the clouds?), and are ignoring risk. What about homebirth for babies in breech presentations, twins, failure to progress? VBAC? Post maturity? Grand multiparity?
These are not yes-no answers. As some of my clients know, I will attend homebirths for women who would not be acceptable under most risk management selection criteria that I am aware of. That's one of the benefits of being 'independent'. Each woman can be addressed as an individual; each decision can be made individually; the care is woman centred in a way that may not be carried through in service guidelines. My commitment is to be 'with woman' - not to homebirth. If the woman is well and progressing well in spontaneous labour, she is free to decide where is the best place for her to give birth.
The safety of homebirth is the key issue in the minds of those who support, and those who are seeking to outlaw homebirth. How can 'safety' be so contentious? Is one party so biased that they can't see what is clear to the other? Are these professional people, on both sides of the fence, not intelligent, well educated, and supposedly ethical people? And what about the parents - consumers who choose homebirth, even though they have to pay for the privilege of not using the hospital? Are these people blinkered, uninformed, even careless about the safety of women and their unborn children?
I know most of our regular blog watchers are aware of these and other related questions, but for those who are still unsure, here are a few recent links:
Largest study in the world confirms homebirth is safe
SMH reporter Miranda Devine, in A home birth is not a safe birth ...
Dr Pesce's comment [ABC Unleashed] on 6 baby deaths in WA in 4 years, which he considered to be proof of the danger of homebirth. "The WA health department said:
"... that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths."
Another statement in the same article reported "a three-fold increased risk of a full term, otherwise healthy baby dying during a planned home birth ..." The paper from which this information was sourced has come under strong criticism for its methodology. Internationally respected epidemiologist Marsden Wagner, in reviewing the paper, noted that conclusions drawn about unacceptable death rates from unreliable sources are not valid.
There are many more references - both in favour of, and against, homebirth. The use of numerical data (quantitative) in understanding evidence must also be balanced with the qualitative research that seeks to report on 'why', and 'how' a particular decision is made or outcome is reached, rather than just 'how many'.
Complicating the whole picture is the rise in the number of unattended home births. There are anecdotes of the tragic death of babies born at home, and 'near miss' experiences, in recent months. Within the stories I have heard about births that have gone wrong, I have been shocked at assumptions that people have made, in justifying choices and decisions.
For example:
A mother planning unattended birth was told to send her husband or a friend to a St John Ambulance resuscitation course, to learn how to resuscitate a baby that is born not breathing.
Another mother took that plan a step further by employing a midwife to be present at her birth, but did not allow that midwife to auscultate the baby's heart sounds prior to the birth.
A mother giving birth unattended experienced delay from the birth of the baby's head to the birth of the rest of the baby. It took many minutes - too long - and the baby did not survive. A midwife would have been expected to intervene in an attempt to protect the life of the child.
I feel that I'm stating the obvious, but it needs to be said. Resuscitation does not work if a baby is already dead.
Much of the risk management in maternity care - both midwifery and obstetric - is to identify babies or mothers 'at risk' of poor outcomes in birth, and to take steps to prevent damage or death. None of us have a crystal ball: it's all about drawing a line. Homebirth is safe because there are important features of homebirth that minimise risk: for example, the mother's own environment; the absence of dangerous drugs and uterine stimulants; the one-to-one focused attention of the midwife. The Dutch maternity system, in which about a third of all births are at home, and for which safety has been clearly demonstrated, requires the midwives to screen women for risk. Women are expected to be referred to specialist (hospital) care if they develop complications, or if they are not progressing well, or ...
I cannot make generalisations about the practices of independent midwives and homebirth in Australia. It is likely that some have their heads in the sand (or in the clouds?), and are ignoring risk. What about homebirth for babies in breech presentations, twins, failure to progress? VBAC? Post maturity? Grand multiparity?
These are not yes-no answers. As some of my clients know, I will attend homebirths for women who would not be acceptable under most risk management selection criteria that I am aware of. That's one of the benefits of being 'independent'. Each woman can be addressed as an individual; each decision can be made individually; the care is woman centred in a way that may not be carried through in service guidelines. My commitment is to be 'with woman' - not to homebirth. If the woman is well and progressing well in spontaneous labour, she is free to decide where is the best place for her to give birth.
Sunday, April 12, 2009
Birth of a calf
[Pic: Poppy and Uncle Al check the cow and the new calf]
I had a call from our daughter Bec on Friday morning. A cow who had begun labour had bulging membranes, but nothing had happened for a while. Was it alright? Should anything be done?
My response was that I thought it was best to leave the cow to give birth in her own time. And keep the puppy away. I thought that if there was a problem something could be done later in the day, as we were heading to the farm to visit them for lunch. Noel, my husband, did his Veterinary post graduate studies with dairy cattle when I was busy bearing and nurturing our own babies.
An hour or so later, as we headed up the Calder Hwy, we received the news that a calf had been born and all was well. At the farm we saw the cow and calf, separate from the rest of the herd, and unstressed. Membranes still hung from the cow's vagina. Later we noticed that the afterbirth had been passed. All part of the normal daily occurrences on a farm. My son in law Al says his cows are not too posh to push.
Normal birth of a human baby at home is not very different from normal birth of a calf in the paddock. The oversight that a midwife provides includes keeping the space free of disturbance so that the mother is able to progress in her own time. The midwife does not try to hurry things up, or manage the birth, and would only consider interference if the natural process had in some way become unsafe.
When the labour starts the cow withdraws from the herd, and finds a safe place, such as near a big tree, or rocks. She is patient.
The labouring woman also needs to withdraw. She needs unstimulating space around her, and her own home is often the ideal place. If her children are there, she needs to know that they are being cared for well so that she can move away from them. She will not labour well until she can do this.
A cow does not need to be taught how to give birth. It happens, under instinctive hormonally mediated processes. The human mind also has strong instinct and our bodies secrete powerful hormones, but we often suppress our instinctive thinking, and take over, or interrupt, with 'higher' brain activity - the activity of the neocortex. Anything that is specifically human is neocortical activity. Artificial lighting; managing progress; calculation of times and measurements. How many women think their main job in labour is to record the frequency and length of contractions? How many women become overwhelmed by labour, as they try to intellectually integrate the information give to them by their doctor or midwife? What does 5 cm dilated really mean?
The preparation and learning that a human mother needs to do, and that a cow does not need to do, is to learn how to accept her body's work and not to interrupt it. The secret to this, in most instances, is to withdraw - emotionally and physically - from anything else that might stimulate intellectual (neocortical) thinking or in other ways cause stress.
Wednesday, April 08, 2009
A fine line: undisturbed, unassisted, and unattended births
Midwives who are experienced in unmedicated spontaneous birth will often take a quiet, unobtrusive role when attending a labouring woman. By the time labour is established, the room is quiet and often lit only by a candle or other soft light source, and no interruptions are allowed. Any voices are hushed, and only when the woman is resting between contractions – not during contractions. If the woman has planned to use water immersion in labour, the tub has been set up and is ready for use. The midwife is constantly observing, expertly using her senses of hearing and sight and intuition (heart). The midwife experiences a parallel journey, as she intuitively harmonises her thoughts and actions with the woman’s. Any observations that require touch, such as listening to the baby’s heart tones, are done in a way to minimise disturbance to the woman. The midwife is not ‘assisting’ the birth; she is in attendance – with woman.
The term ‘undisturbed birth’ has been used by author Sarah Buckley (2005, p110), with reference to her own experience of giving birth to her fourth child, without a midwife in attendance. Other terms used for unattended birth, when it is intentional, are free birth, pure birth, self birth, and unassisted birth.
The fine line that the midwife sometimes walks is being able to be with woman, and yet enabling the woman to proceed without physical or emotional disturbance. Many women would consider that they were able to enter a special ecstatic place in which they remained undisturbed through their birth experience, with a trusted midwife present.
However, if a midwife identifies a complication or condition in the mother or baby, for which she recommends referral to specialist services, the act of disturbance may be in the interests of the wellbeing of her clients, both mother and baby. This is within the professional duty of care, and is the midwife’s skill. The midwife’s guiding principle, that “In normal birth there should be a valid reason to interfere with the natural process” (WHO 1996, p4) informs both the non-interference, and the alternative, in midwifery care.
Dr Buckley argues cogently that the complex natural hormonal mix, and particularly the role of oxytocin, that is the physiological norm in childbirth is also what we experience in loving, passionate sexual intercourse. This connection has previously been clearly described by Michel Odent in many of his writings and lectures. “[oxytocin] is the ‘hormone of love’. Whichever facet of love we consider, oxytocin is involved.” (Odent 2002, p72)
The connection that Dr Buckley makes, in describing and idealising an unattended birth as undisturbed, may encourage other mothers to give birth without professional attention. In Dr Buckley’s case, both she and her husband who was also present, had medical skill and knowledge that could have been used. This is a very different scenario to unattended birth where no person present has a foundational knowledge of progress in labour, normal birth, or normal transition of the newborn from the womb to the outside world.
Dr Buckley observes that “When a midwife’s intuitive skills and ways of knowing are increasingly sacrificed to technology, more and more invasive procedures will be needed to get information that, in other times, her heart and hands would have illuminated.” (p111) The fine line the midwife walks is to use technology appropriately, while valuing and enhancing her skills in promoting normal birth.
The midwife’s goal can and should be ‘undisturbed’ or ‘unassisted’ birth in any situation where there is no valid reason to interfere with the natural process. A midwife cannot ethically support planned ‘unattended’ birth, which is the antithesis of maternity ‘care’, as that situation removes the experienced critical eye and ear and heart of a midwife, and puts the responsibility on the labouring woman, and anyone else who is with her at the time.
The term ‘undisturbed birth’ has been used by author Sarah Buckley (2005, p110), with reference to her own experience of giving birth to her fourth child, without a midwife in attendance. Other terms used for unattended birth, when it is intentional, are free birth, pure birth, self birth, and unassisted birth.
The fine line that the midwife sometimes walks is being able to be with woman, and yet enabling the woman to proceed without physical or emotional disturbance. Many women would consider that they were able to enter a special ecstatic place in which they remained undisturbed through their birth experience, with a trusted midwife present.
However, if a midwife identifies a complication or condition in the mother or baby, for which she recommends referral to specialist services, the act of disturbance may be in the interests of the wellbeing of her clients, both mother and baby. This is within the professional duty of care, and is the midwife’s skill. The midwife’s guiding principle, that “In normal birth there should be a valid reason to interfere with the natural process” (WHO 1996, p4) informs both the non-interference, and the alternative, in midwifery care.
Dr Buckley argues cogently that the complex natural hormonal mix, and particularly the role of oxytocin, that is the physiological norm in childbirth is also what we experience in loving, passionate sexual intercourse. This connection has previously been clearly described by Michel Odent in many of his writings and lectures. “[oxytocin] is the ‘hormone of love’. Whichever facet of love we consider, oxytocin is involved.” (Odent 2002, p72)
The connection that Dr Buckley makes, in describing and idealising an unattended birth as undisturbed, may encourage other mothers to give birth without professional attention. In Dr Buckley’s case, both she and her husband who was also present, had medical skill and knowledge that could have been used. This is a very different scenario to unattended birth where no person present has a foundational knowledge of progress in labour, normal birth, or normal transition of the newborn from the womb to the outside world.
Dr Buckley observes that “When a midwife’s intuitive skills and ways of knowing are increasingly sacrificed to technology, more and more invasive procedures will be needed to get information that, in other times, her heart and hands would have illuminated.” (p111) The fine line the midwife walks is to use technology appropriately, while valuing and enhancing her skills in promoting normal birth.
The midwife’s goal can and should be ‘undisturbed’ or ‘unassisted’ birth in any situation where there is no valid reason to interfere with the natural process. A midwife cannot ethically support planned ‘unattended’ birth, which is the antithesis of maternity ‘care’, as that situation removes the experienced critical eye and ear and heart of a midwife, and puts the responsibility on the labouring woman, and anyone else who is with her at the time.
Subscribe to:
Posts (Atom)