"Women have the right to ..."

What right or rights do women have? What special rights do childbearing women have? What rights do mothers and babies have?

This question has played in my mind recently. Readers who have read the previous post may have noticed the statement:

"Women have the right to self determination and to be supported and encouraged to get on with ..."

Do they? Really?

What does 'self determination' look like? How does it work when difficult decisions need to be made in maternity situations? How does it work when the woman is frightened by the power of her labour? What support and encouragement is appropriate ...? Isn't that the time when the "best laid plans" come undone?


We know that in modern societies all competent persons (female or male), in the context of health care, have the right of refusal. The woman in maternity care has this right, even when her refusal may result in what most would consider to be adverse consequences for herself and her baby.

'Refusal' is very different from 'self determination'.

Consider this scenario:

Midwife: "Jane, I am advising you to go to hospital and have an induction of labour, for the following reasons [eg post 42 weeks' gestation] ..."

Jane: "I understand that you advise induction of labour. Would you please tell me what is likely to happen if I refuse your advice."

Midwife: "As your midwife I would continue to check you and your baby, and tell you if I detect any changes. I would also advise obstetric review at XX hospital. The tests that are usually carried out at this time are fetal monitoring, ultrasound studies that check blood flow to your baby, and measurement of your baby's amniotic fluid level. These investigations, which can be repeated as time passes, may detect subtle changes in baby's condition, or may reassure us that your baby is well."

Jane: "I have always planned to wait for spontaneous onset of labour, unless there is a valid reason to interrupt my natural process. I don't think 42 weeks gestation alone is sufficient reason. Therefore I will refuse induction today, and wait for labour to begin. I am willing to make an appointment for specialist obstetric review."

This conversation, in which the midwife gives professional advice (for whatever reason), and the client/consumer makes a decision, based on her understanding of principles of appropriate maternity care, and the information given to her, to refuse that advice, is what I call 'informed refusal', or 'informed decision making'.

A very different conversation would be something like:

Midwife to Jane: "You're 42 weeks. What do you want to do now? Induction or wait for labour?" [ie self-determination]

Since the early 1990s, midwives and maternity consumers have quoted the reports of the British government's inquiries into maternity care, that women want the 'THREE C's' choice, control, and continuity of care. Since the early 1990s I have worked with Australian women and midwives, and have often used the THREE C's as a guide in the uncharted terrain of birth reform.  However, this little mantra should not be seen as a statement of women's birthing rights.

I have seen situations in which a woman's choice, or her sense of control [self determination], have led to what I see as disastrous outcomes - loss of life, and potentially preventable harm.  In these situations 'continuity of care' has been 'continuity' [same person] without the 'care' from a professionally skilled person who has the duty and ability to act in the interests of mother and baby at all times.  The care has been confused, fragmented, and ineffective.   A midwife or doctor who says "What would you like to do now?", when the only responsible statement is, for example, "I must advise you that your baby needs to be born now ..." is forgetting their professional duty to that woman.

When a woman has effective continuity of care, with a midwife who she (the woman) respects, and who respects her, there will be no doubt about the differences between a woman's rights, a woman's choices, and the midwife's duty of care. 

idealism in midwifery

with Karen, and her babies Simon and Hannah, about 12 years ago

This past week I have been engaging in a review of my professional practice. One of the tasks set down is to write a personal midwifery philosophy. I am a lover of writing - bringing together thoughts and knowledge into words that can be passed on to others. Writing a personal midwifery philosophy is, so to speak, 'right up my alley'.

Where do I start?

The word 'philosophy' is made of two words, 'love' and 'wisdom'. A personal philosophy of midwifery could be a statement of what I love in midwifery, and what wisdom I find in midwifery.


In considering this challenge I hit an unexpected obstacle. The material that was sent to me to use in preparation for this review contained an example:

"Personal midwifery philosophy
"I believe:
• Pregnancy, birth and mothering are a normal, privileged, life-affirming and glorious part of life.
• Women can do it even when it is difficult.
• Women have the right to self determination and to be supported and encouraged to get on with this (most) important aspect of their lives.
• Women have responsibilities to themselves and their babies to actively participate in their health care.
• Midwives work with women and women work with midwives in a flexible, (hopefully) nurturing and synergistic relationship."

Dear reader, did you see anything in that quote that set the red lights flashing, and bells ringing?

I can’t fully agree with any part of this philosophy. IMHO it’s idealistic, naive, and indicates a potentially unprofessional mind set. Here, briefly, are my reasons for rejecting such a statement:

1. Pregnancy, birth and mothering CAN BE normal/abnormal; privileged/nothing like privileged; life-affirming/soul destroying; glorious/terrifying, depressing. What does this statement have to do with midwifery?
2. Some women can; some can’t, won’t, or don’t do whatever it is, even when it’s difficult. What does this statement have to do with midwifery?
3. Women have the right to ... What does this statement have to do with midwifery?
4. Women have responsibilities ... What does this statement have to do with midwifery?
5. Midwives work with women and women work with midwives in a flexible, (hopefully) nurturing and synergistic relationship. This statement is starting to address midwifery, but what does it mean? Do midwives need to be nurtured by the women they attend?

I hope you don’t think I’m splitting hairs here. This is a serious critique. As I read the quoted sample 'philosophy', it’s as though midwifery has become lost in idealistic notions of women’s choices, rights, and responsibilities. Of course I would like women to have all these things, but they are not part of a philosophy of midwifery. They don't say anything about what's to love in the wisdom of midwifery. 


A woman who gave birth in my care to two of her children more than a decade ago wrote to me about her experience in supporting her son and daughter in law at the birth of her first grand child:

I am again full of extreme gratitude to you for what you gave me all those years ago.
I am realising afresh what a pivotal time in my life my homebirths were.

The philosophy of midwifery care that energised me fifteen or twenty years ago is the same one that I have today. While no words can adequately describe the breadth and depth of the wisdom of working in harmony with our amazing, wonderfully made bodies, I have written:

"As a midwife working in a special partnership with each woman as her professional care giver, I seek to practise in a way that harmonises with the woman’s natural physiological processes, and promotes health. There is no better or safer way for most women and babies than to proceed through their childbearing and nurture of the newborn in harmony with natural process, with a plan to give birth without relying on analgesics, stimulants, or other pharmacological or surgical intervention.

"As a midwife my duty and responsibility to each woman and baby is also to identify any complications that may arise or be likely to arise, and to take steps to obtain appropriate and timely interventions when indicated."

Your comments are welcome.

midwives in the making

(c) Picture used with permission

Yesterday I had the privilege of presenting a 1.5 hour talk on private midwifery practice to the midwifery students at Deakin University in Burwood. I love having the opportunity to inspire the next generation of midwives.

I know some visitors to this blog are studying midwifery, in many countries. In today's post I want to give you an outline of my presentation, and links to some of the key documents.

The parts of the presentation were:

• Overview and introduction: developing a strong 'midwife identity'
• Private midwifery practice, changes in legislation with Medicare rebates and other changes for eligible midwives. Go to Midwives Australia for more information and links
• Planning for birth: philosophy of birth based on the statement that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996); decision-making concepts of 'Plan A' and 'Plan B', birth preparation meeting handout
• DVD of a beautiful home/water birth [One picture used here with permission - the visual image is sooo powerful!]
• Highlighting aspects of midwifery practice that can apply only when the whole labour progresses under natural hormonal, unmedicated processes: physiological third stage, and baby's transition from the womb
• Questions

Please follow these links if you are interested in the topics mentioned. I intend to prepare a post on 'Planning for birth' at my private midwifery blog - will do that as soon as I can.

For the record, my relationship with the Deakin University School of Nursing and Midwifery is that I am employed as a casual lecturer, and as a tutor and marker for some of the midwifery Professional Development Unit Learning Packages. Several years ago I prepared one of the Learning Packages on the midwife in the community (PDU 323) and more recently I have written a Learning Package on Caseload and Homebirth midwifery, which is being processed in preparation for release.

Vitamin D

Melbourne is a bleak and chilly place at this time of year. My little deciduous Bonsai trees have dropped their leaves. Most days there's not much sunshine - not a lot of synthesising of precious Vitamin D going on in our bodies.

This past week I have been seeking an update of my knowledge of Vitamin D. My questions were prompted when a woman in my care, who gave birth in hospital, was instructed to give her baby Pentavite (R) daily in the first year, to ensure adequate Vitamin D intake. The Penta-vite Liquid Multi-vitamins for Infants (0-3 yrs) contains 10.1 mcg of Vit.D3, as well as Vitamins B1, B2, B3, B6 and C.

The hospital midwife indicated that this protocol was now being followed for breast feeding mothers whose Vitamin D levels tested low.

I inquired about current midwifery practice amongst colleagues, and some were quick to send links to sites and articles on the importance of adequate amounts of the 'sunlight vitamin' in pregnancy, lactation, and infancy.

I recommend a current update article in Medscape ObGyn and Womens Health. Vitamin D, Deciphered, Declassified, and Defined for Your Patients written by Sandra A. Fryhofer, MD.

"In the past, vitamin D worries were mainly about bone health. That's all changed. New studies now support an ever-increasing role of vitamin D in preventing all kinds of diseases: heart disease, diabetes mellitus, cancer, infection, autoimmune diseases (multiple sclerosis, rheumatoid arthritis), and the list goes on!"

Other Medscape articles that provide useful perspectives on this topic are
ACOG Says More Data Needed on Vitamin D During Pregnancy

"June 22, 2011 — More data are needed before physicians start routinely screening pregnant women for vitamin D deficiency, according to a statement from the American College of Obstetricians and Gynecologists (ACOG), published in the July issue of Obstetrics & Gynecology."

Also ...
Protean Manifestations of Vitamin D Deficiency, Part 1 The Epidemic of Deficiency

Protean Manifestations of Vitamin D Deficiency, Part 2
Deficiency and Its Association With Autoimmune Disease, Cancer, Infection, Asthma, Dermopathies, Insulin Resistance, and Type 2 Diabetes

Protean Manifestations of Vitamin D Deficiency, Part 3
Association With Cardiovascular Disease and Disorders of the Central and Peripheral Nervous Systems


One of my midwife colleagues wrote:

"It is so important to get enough in your diet and sunlight. Our society has become sun protective obsessed that we are not getting enough. I would suggest to your client buying the best quality organic butter and slapping it on everything. If she can get hold of raw milk from grass fed cows even better. Fish oil or grass fed free range chook eggs. 10-15 min in the sun (till the skin gets a light pink colour) is enough vitamin D Daily and make sure she doesn't wash her skin after a sun bake. How long to be in the sun depends on how far North or South you live and the time of year. Best time to get your vitamin D is between 10-3pm (the time everyone is shunning the sun). The problem with getting your vitamin D from the sun is knowing when to have enough, people work or lay in the sun for long periods of time are more at risk of skin cancer... but a daily dose of light pink skin is healthy."

Having looked at the evidence and debate I will now be more committed to not only checking Vitamin D levels, and promoting healthy diet and sensible daily sun exposure where possible. I recall advice that was given to mothers in the 1950s and 1960s, that they should give baby time each day in the sun with little or no clothes on, weather permitting. Perhaps we will reinstate this old advice.

PS

From Medscape Medical News: Vitamin D Found to Be Safe for Healthy Pregnant Women

July 6, 2011 — Vitamin D supplementation of 4000 IU/day is safe and effective for healthy pregnant women and their infants, according to the results of a large, double-blinded, randomized clinical trial published online June 27 in the Journal of Bone & Mineral Research.

[I checked the amount of Vitamin D in my daily multi-vitamin supplement, and it's 200 IU.  According to the lead author Bruce W. Hollis, PhD: "Surprisingly the scientific debate has made little progress since Dr. Gilbert Forbes made a recommendation of 200 IU (international units) per day in 1963, which was based on a hunch."]

Your comments are welcome.

"When there are two midwives ...

... the baby's head is crooked."

[This is a saying from Persia, quoted by Michel Odent, in Childbirth in the Age of Plastics (2011), p63]
Here's the context:

Learning from home births

...

One of the main obstacles for easy births - particularly easy home births - is the common overuse of language. I have countless anecdotes of useless questions, comments, and advices from well-intentioned birth attendants.
Another obstacle is a deep-rooted tendancy to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. ... Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or South America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: "When there are two midwives, the baby's head is crooked".

And of course a crooked head means a painful, difficult birth. The optimal position for the fetal head is flexed at the beginning of labour in the occiputo-transverse to occiputo-anterior plane, well applied (evenly) to the internal os of the cervix, with continuing flexion of the fetal head as labour progresses. A head that is presenting posterior, or asynclitic (tilted to one side) is not well applied to the cervix, and dilation of the cervix can be difficult, and labour incoordinate.

A reader may wonder why traditional wisdom would warn that "Where there are two midwives a baby's head will be crooked." Is that just an old wives' tale, to be discarded by the modern, intelligent mind? Is there any possibility that the presentation of a baby in the womb is in any way influenced by the presence of a second midwife?

Assuming that there is something of universal worth in this saying, how can it apply to women and midwives in Melbourne, Australia, today?

Just for the record, my midwifery practice includes births at which I am the only midwife, and births at which a second midwife has been invited, and births at which I am in attendance as the second midwife.

The key: being woman-centred
Midwives understand that the woman who is giving birth is the central, focal point of everything that is happening in chilbirth. Within that woman, in her womb, is the baby. Woman-centred care is also baby-centred, because the woman and baby are one.

Midwives also understand that the woman and her midwife form a special partnership, based on reciprocity and trust. A one-woman-one-midwife partnership.

In the real world, despite the best laid plans, a midwife can never guarantee that she will be in attendance for a particular woman. The only people who can be sure they will be at the birth are that woman and her baby. In the real world, a good midwife is able to meet a labouring woman and work with her in such a way that the woman is able to optimise her birthing potential, feel safe regardless of the setting (home/hospital), and experience great satisfaction with the care. No crooked heads here.

In any physiological birthing relationship, there is room for only one birthing woman, one midwife, and one baby (at a time, in the case of multiples). If others are present with midwifery (or 'wannabe') skills; and 'others' may include midwives, lay birth attendants, doctors, alternative health practitioners, relatives, or even the labouring woman herself; these people must either step back from their professional roles, or work in harmony with *the* midwife. There is no place for different philosophies of care - they will make the baby's head go crooked.


Many midwife colleagues of mine, practising in the real world in which we live, tell me they would never intentionally attend a birth without a second midwife. There are many good reasons for the second midwife, including:

• the possibility that mother and baby are both needing active midwifery interventions at the time of birth
• a known midwife present if the other one is unable to attend
• someone who will question or challenge practices if needed
• 'tag team' if everyone is tired
• a witness if something goes wrong

The first of these is perhaps the most compelling, and any midwife will need to address this possibility with the woman who is considering her choice of care providers for home birth.  What will be done if the baby is not breathing at birth, and the woman also requires attention?

In hospital births, and in some home births, the midwives have separate roles allocated - one for the woman, and the second for the baby.  If the baby needs resuscitation attempts to be made, the person who leads that is the second midwife.  The baby is often moved away from the mother to a resuscitation table in these situations.

When a midwife is working solo in the home, the woman knows that there is no second midwife.  If the baby needs resuscitation, this is done with the baby lying on his back on a towel on the floor, in front of the mother who kneels.  The umbilical cord is not cut.  The midwife also kneels, and has good access to the baby.  They work together, and the midwife is able to talk to the mother.  A baby who is born in a distressed state, not able to initiate normal breathing, may have a very slow, or absent pulse.  It's vital in this case that as the cardio-pulmonary resusciation proceeds, and the baby's pulse increases, the baby receives the full placental transfusion via the umbilical cord.  This will bring a proportionately large volume of blood, with the fetal haemoglobin that stores oxygen, perfusing the baby's central organs and brain, protecting the baby from hypoxia.  This, in my opinion, is a better model for initial resuscitation.

Women who plan to give birth under natural, physiological processes have access to natural, physiolocal support mechanisms.  The adrenal hormones that give the 'fight or flight' response are particularly valuable.  Not only does the mother experience a surge of adrenal hormones just prior to the birth; baby does also.  The mother gets a surge of energy, and her baby is ready to do what needs to be done.  Neither mother nor baby in the home birth situation have narcotics that would suppress their ability to respond, or to breathe.  Neither mother nor baby have synthetic oxytocics that would impede the mother's ability to expel the placenta safely without excess blood loss.

The safety and appropriateness of home birth is clearly demonstrable for women (and babies) who are well prior to the onset of spontaneous labour, and who progress without complications.

Midwives and the battle of the bulge

A new draft National Antenatal Care Guidelines has been released for public consultation. The consultation period ends on 27 June 2011. The guidelines can be found here.

Today's health care world relies heavily on guidelines, and this document is being developed with government funding under the AHMAC priority to "Ensure Australian maternity services provide high-quality, evidence-based maternity care."


If anyone has had an opportunity to read through these draft guidelines, you will find much that is accepted as good practice, presented clearly and referenced. However we need to read with our critical minds switched on: otherwise there's no point in reviewing the draft. Midwives and doctors who provide antenatal care need to ponder the impact on our practices that they might have when they are approved.

Routine weighing at each antenatal visit
Please take note of

Recommendation 4: Routinely weigh women at each antenatal visit. Excessive or inadequate weight gain may have negative effects on the woman and the baby. (p vii)

This recommendation is rated as Grade 'A', which means "Body of evidence can be trusted to guide practice."

I put a question out about this to colleagues, via a midwives' email list. "Do you routinely weigh women at each antenatal visit?" It appears that there is a general consensus in the group that midwives do not currently weigh women at each visit.


It’s clear that obesity in pregnancy is linked to poor outcomes, and the midwife’s duty of care is around promoting health through good diet and weight management. Obesity is the big current focus of health promotion. However it appears to require a great leap of faith to believe that routine weighing in pregnancy will result in better weight management, and better outcomes.

As I remember being pregnant in the ‘70s, when everyone was weighed at every visit, women were harming themselves in an attempt to control weight gain. Some women were restricting their intake to the point were they were nutritionally unbalanced, leading to a lot of fluid retention, and pre-eclampsia. The doctors (bless them) were prescribing a diuretic (Lasix) to get rid of the excess fluid, which did actually give ‘better’ weight gain, but at what cost? The routine weighing potentially led to adverse effects.


The Draft Guidelines Appendix D (p138) gives the UK National Institute for Clinical Excellence (NICE) recommendations, that Weight and height be measured at the first appointment, and BMI calculated. Then this second recommendation:
“Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]”


This second recommendation from NICE has been summarily dropped for the new Draft Australian guidelines, with some review discussion around ‘new evidence’ associated with a high or low pre-pregnancy BMI that has emerged since the NICE (2003).

It would seem wrong to impose routine weight monitoring on all women, when the new evidence, even if it is grade 'A' applies only to those at the ends of the spectrum.

It's good that maternity services seek to "provide high-quality, evidence-based maternity care." BUT, any guideline that claims to be evidence-based, with an A-grade "Body of evidence [that] can be trusted to guide practice." needs to be just that. In this case, there is no evidence that routine weighing of all women will do anything to address obesity and ill health, or under-nourishment for that matter, or improve maternity outcomes.

Comments from readers are welcome. If you refer to something in the Draft Guidelines, please quote the page.

ps
Readers will be interested in the Science and Sensibility blog entries and discussion on maternal obesity.  The writer, Pam Vireday's blog is Well Rounded Mama.

career in midwifery?

wet and happy after a job well done!
[Thanks Miranda for the pic.]
Click here for Miranda's comments Why I Chose Homebirth

A young woman is considering a career in midwifery.

She is drawn by the ideas midwives write about:

• forming a partnership based on reciprocity and trust with each woman; 
• learning how to work in harmony with the woman's own natural processes; 
• promoting health in a holistic way; protecting the woman's birthing potential; 
• and providing a smooth interface between primary maternity care and medical intervention when there is a valid reason to interrupt the natural process.

The young woman has some doubts, recognising a potential clash between her own views on western medicine and the mainstream health system. She likes the idea of working as a private midwife attending well women in their own homes, but she realises that there is a journey that has to be taken in achieving a midwifery qualification, with study and experience that includes the medical/hospital system. She writes:

I'm worried that the "system" wont change, if not become even worse. Do you think it's going to become easier or even harder to practice midwifery in the way that you promote? IE- do you think i'll always be paddling up stream or, is there light at the end of the tunnel?

I have brought this discussion through to the blog, because these are questions that many are asking.

A slogan from the International Confederation of Midwives is

"The world needs midwives now more than ever"

even though ...

• The system may become worse.
• It may become even harder to practise midwifery in a woman-centred way.
• We may feel as though we are always paddling up stream.
• We may not be conscious of light at the end of the tunnel.

It is idealistic and unhelpful for midwives to focus only on the strong, healthy women and babies: women who are able to give birth spontaneously and joyfully in their homes.

Midwives, and authentic midwifery practice are needed in mainstream health care, which in this country means hospitals. True midwifery is needed for the women and babies who can't afford a private service, for women and babies in developing countries where the rates of maternal and perinatal deaths are many times that in Australia. True midwifery is needed for women who know they will need caesarean surgery in order to have the best chance of being 'delivered' safely.

The current batch of challenges in Australian midwifery are the result of a socialist government's attempt to improve maternity care. Socialist policy does not value the individual's concerns or iterests in the way that many people in the free world understand to be important. Centralised government regulation of midwives and other health professionals is likely to lead to bureaucratic red tape that restricts some midwives and women in the way the want to give birth. It is likely that we midwives will feel that we are always paddling upstream.

Governments will change. Regulations and laws will change. Women continue to need midwives who are 'with woman', regardless of the laws, regulations, or philosophies of the government.

"The world needs midwives now more than ever"

Today I received by email the picture of Miranda, with her newborn baby, and permission to use it in blogs. What a beautiful reminder that, for each midwifery partnership, there is light at the end of the tunnel. There is new life at the end of the hard work. There is beauty, and hope. Thankyou, Miranda.


ps
If you are interested in the state of affairs for private midwifery in Australia, and links to search for a midwife online, please go to the APMA blog.

learning about breastfeeding

A young midwifery student who I will call 'B' wrote to me:

Today I had work on the postnatal ward, and I had one of my "What would Joy do?" moments, as I had a particularly hard case to deal with, well for me it was hard.

I was caring for a woman who had a baby girl at term. There was some concern about possible infection, so baby was admitted to the newborn nursery soon after birth. I found the mother in her bed crying. I found myself having to be 'with' her in a very human, tangible way that I find hard to put into words.

After having a talk and her calming down, I wanted to help her with breastfeeding. The issues I saw for this mother were:
a) separated from her child
b) bottles and formula
c) sick baby
d) the fact she had only expressed once since her baby had been moved to special care 24 hours before and had minimal skin to skin/ feeding attempts since.

I showed her how to hand express, showed her how to use a pump, and helped her attach her baby in the special care nursery.

It was just one of those cases where I especially wanted her to succeed in feeding, which was what she desperately wanted too, and I wonder if there is anything else I can do for her?

This is an all too common scenario that student midwives face. I congratulate 'B' on the way she has been working through her thoughts in this situation.

A key to supporting this mother and baby are to understand breastfeeding from the baby’s point of view, and to help the mother to see that perspective too. Babies want milk; they want it in abundance and from their mothers' breasts. Any artificial substitute is inferior in the baby's mind, as well as being inferior from a nutritional perspective.

A student midwife working in a hospital has very little authority or ability to change the culture within the unit. Did that baby really need to be separated from her mother? Were all the medical processes that followed the separation necessary and helpful? ...

The ideals of the Baby Friendly Health Initiative, or the Mother-Friendly Childbirth Initiative, empowering women as mothers and promoting bonding, breastfeeding and health are not very useful to a person like 'B' working a shift in a postnatal maternity ward. 'B' needs a strategy by which she can impart hope and encouragement to the new mother until her child is returned to her care.

As soon as baby is well enough she will be looking for her mother's milk. It is usually possible to revisit the unhurried, skin-to-skin experience as could have happened in those magical hours after birth, when a baby intuitively seeks and takes milk. The midwife who is confident in understanding a baby's approach to breast feeding will also be 'with woman' in that natural process.

A personal question

"How are you?"

Grandpa and his girls

Three simple words; a question: "How are you?"
A question to which I reply "I'm OK, how are you?" - or something else.

A caring tone; a sympathetic look; honest, open concern from one who knows the deep waters I must traverse.

It's a question that needs a voice - not txt or email or a Fb poke! A question for which communication technology can never surpass the value of the human voice.

"How are you?" is a question that invites a response.

"Thanks for asking."


Dear Reader
Today I am writing about life, and not specifically midwifery. My thoughts have been prompted by a deeply personal experience which has brought me to a new appreciation of the value of that personal question, "How are you?"

As I reflect on my own experience I feel ashamed at my own failure to be with others in their distress. As I receive messages through the various (impersonal/technological) means of communication, my heart longs for the personal word.

I don't think this need to use personal communication will ever be lost, even as generations of young people who have been nurtured at the bountiful breast of information technology move into adult life.  Their basic need for human interaction will be most keenly felt when they face life's challenges and difficulties; when they need a caring voice to ask, "How are you?"

My presentation at the Virtual International Day of the Midwife webinar

I am terribly disappointed that I was unable to properly participate in the webinar today. The facilitator Carole took over and read from my .ppt notes. Thanks Carole! I don't know why my microphone failed me, but I could not get a response, no matter what I tried.

I would like to share some of the presentation with my blog readers.
Two of the topics included in the presentation, Midwife-blogger, and Vernix can be found at another blog that I write, http://privatemidwiferyservices.blogspot.com/

There were some great messages sent to the classroom. Here are examples of comments (without names of the writers) on Vernix, followed by general discussion on blogging:

Baby ColdCream

---------------------
Super moisturizer! If only we could market it!

---------------------
something i did not expect to see on my baby! it was quite a shock but it truly is a miraculous substance!

---------------------
When I was working near Mexico ALL the women in the birth room would wipe it off the baby and on their own faces :) So sweet

---------------------
good for the crow's feet!
---------------------

My last bub had it allon his back, eww! :) I think they wiped it off my hosp babies. :)

---------------------

I am a student and other midwifery students are able to use it [a blog] for learning.

---------------------
Thirst for knowledge

---------------------
Lisa's blog is how I found out about true midwifery practice
---------------------

It is a way for those who aren't yet apprenticing to be exposed to information that they may not be able to have a hands-on to yet.

---------------------
comments are really mini conversations on a blog

---------------------
I'm not a midwife yet, just going to become...But already thinking about a blog that can really help in my future practice. I'm from Belarus and homebirth here is not legal and not that popular yet. Hope to change this situation.

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It creates a feeling of community to discover that someone somewhere else is interested in similar things

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i found blogs to be the only way to uncover the real effect of the new legislations

---------------------
I found it interesting to read overseas blogs by midwives who stated they would never work in Aus because of the ongoing battle between medical and midwives.

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As students, blogs from practising midwives are excellent sources of "unconventional" learning. Dont ever stop!!

---------------------
Thank you for the lovely comments on your slides, I'll be a reader from now on, if I can find you;-)

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I learn so much from blogs

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i have always been intimidated by blogging... but now it really doesn't seem so bad!

---------------------
me too

---------------------


You see, even though I wasn't able to do my talk, the audience took over and made the best of it! Thanks to all who participated.

The making of a midwife

I have recently finished reading Patricia Harman's memoir (pictured here), Arms wide open: a midwife's journey. I have enjoyed the journey.

As I progressed through the book I welcomed insight into the way Patsy, an idealistic hippy wild child in the early 1970s, learnt about life and in that learning, she found midwifery.

I welcomed insight into the realities of the American counter-culture, war resisters, commune life, living without what most of their peers would call the basic necessities of life.

I welcomed the honesty of statements by Patsy, now a grandmother with a nice home and a day job, no longer attending births, such as "You'd think by my age I'd have everything figured out, but I don't have a clue and I'm more confused than when I was thirty."  I concur.

I found to my surprise that Patsy's midwifery journey reminded me in many ways of my own. I was at the same time, learning about life, and discovering my midwife identity in a sort of mirror image journey.

Here's what I mean by a mirror image journey.

Patsy and I must be about the same age, and we gave birth to our babies at about the same time. I was living in Michigan in those formative years, the 1970s, in a little brick house with a basement, surrounded by tall oak trees that shed mountains of brown leaves each 'Fall'. I raked leaves in autumn, shovelled snow in the winter, planted spring gardens, and enjoyed home grown veges in the summer.

While Patsy learnt how to stay warm and well in an isolated primative log cabin, I, who had spent most of my life in the sub-tropics in Queensland, learnt how to live with central heating, and cook in a kitchen that had green carpet on the floor.

While Patsy and her companions had dropped out of education, I had already graduated as a midwife in my home country. Noel, my husband was a graduate student at Michigan State, working on the fascinating and previously unnoticed protective effect of colostrum in the newborn calf. I was absorbing scientific literature and knowledge as fast as I could, broadening my understanding of reproduction, and particularly the needs of mammalian newborns.

Like Patsy, I attended the local Lamaze birth preparation classes and learnt psychoprophylaxis and Lamaze breathing. Unlike Patsy, I did not discover homebirthing. I gave birth to my first three children in the local hospital, was moved in second stage to the delivery/operating room, positioned with legs in stirrups and hands held to boards by big pieces of velcro. I was told to "take a deep breath and push push push!"

While Patsy raised her children in a loosely knit 'family' of a commune, I was away from all my family, became a full-time mother, and was satisfied with that role. Apart from the help offered by a few neighbours and friends from our Church, I needed to be emotionally and physically self-sufficient.

While Patsy developed a sort of faith in the forces of nature, I continued in the Christian faith in which I had been nurtured.


My awakening in midwifery came later, in the early 1990s, when I thought that my four children no longer needed a parent to be at home for them all the time.

I was able to move without difficulty into homebirth, even though I had not given birth at home myself.  The knowledge that stood by me had been instilled in my mind over the years of my own childbearing, building on the foundation that I had learnt in my student days at the Royal Women's Hospital in Carlton.  The years of breastfeeding had given me insight into mother-baby bonding and nurture.  The years of parenting had given me an understanding of what it means to promote health, and work in harmony with natural processes.  The years of part time shift work, usually nights, in hospital maternity wards, had taught me that I wanted to be 'with woman' - that the 'one night stands' I was having in the hospitals were not optimal in any way.

Like a butterfly emerging from its quietness in the crysalis, I had metamorphosed, and came out of that space ready for action.

Enough from me for today.  Your comments are, as always, welcome.

ps Arms wide open is Hardcover, or eBook, 324 pages.  Publisher: Beacon Press. ISBN: 978-0807001387
http://www.patriciaharman.com

When birth is no longer normal

Midwives consider ourselves the guardians or keepers of normality in birth. We attend conferences and repeat slogans about keeping birth normal. We talk about sitting on our hands, about trusting the natural process, about protecting the woman's space so that she can give birth naturally and safely.

Our definition declares that our duty of care includes the promotion of normal birth.

Here is an excerpt from that definition of the midwife (ICM 2005):

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

Australian midwives need to know this definition well. It has been adopted by our regulatory agency AHPRA, and the Australian Nursing and Midwifery Council, and is foundational to current midwifery education, codes and standards.

The big challenge for the midwife is to balance each aspect of our professional duty. Our desire to promote normal birth must not be allowed to over-ride our responsiblity to carry out preventative measures, or to detect complications in mother or child, access medical care and other appropriate assistance in a timely manner, and the carrying out of emergency measures.


I have reflected many times on what it means for a midwife to be a responsible and accountable professional. In recent submissions to government inquiries, I and other midwives have written about the processes by which midwives are required to give an account of what we do, and this is especially so when there is an adverse outcome. Our society has an expectation that professional care will be in the public interest; that the safety and wellbeing of mother and child are the primary concern of the midwife and any other person who provides professional maternity care.

A recent report by the Queensland Coroner on the death of a baby Samara Hoy has been distributed in midwifery circles.  It is a public document.  The Coroner's findings were critical of both midwifery and obstetric care (or the lack thereof) in this case. Reading the report has left me with many questions about the standard of care and culture of maternity services in that hospital.

If this woman had been planning homebirth, and her midwife had taken her to the local public hospital when meconium, fetal tachycardia, decelerations ... were observed, there would have been no question about continuous electronic fetal heart monitoring (EFM), or offering a theoretical set of options, one of which was waiting for nature to take its course.

That's the essence of midwifery: that if complications are detected, we have a process to follow, including "accessing of medical care or other appropriate assistance".

The tragedy in this story in my mind is that the woman was so alone. Although there was a person there with the role and title of midwife, there was no person with whom that mother had a partnership based on reciprocity and trust. There appears to have been no informed decision making by the woman. The decision by various midwives, and the collaborating doctor, to not even use the facilities available for checking the baby's response to the contractions suggests either a misplaced reliance on natural processes, or just plain incompetence. The physical findings of the Coroner of strangulation marks left by a tight umbilical cord around the baby's neck, and meconium aspiration, suggest that severe fetal distress would have been observable, particularly with EFM, for some time prior to the birth.

I can only surmise that the midwife was committed to a skewed idea of keeping birth normal, by sitting on her hands and keeping her head in the sand.

A young mother who has engaged me as her midwife for planned homebirth asked me under what circumstances would I think she would need a Caesarean birth.  I don't have an easy answer, but we chatted about how I know when birth is no longer normal, and what would happen in such a situation.

I know it's easy for me to be an armchair critic, but I have written this post with the hope that other midwives who read it will also reflect on what we do when birth is no longer normal.

Midwifery knowledge

click to enlarge

One of my current projects is to lead the review of the Maternity Coalition INFOSHEETs - see the APMA blog for more detail. I also headed the previous working group which put together these information sheets in about 2006. Our aim was, and is, to provide reliable information that supports informed decision making for women and midwives who seek to promote normal physiological birthing, and to work in harmony with the natural processes in pregnancy, birth the perinatal period.

It's a big project, and the working group is asked to consider current evidence and practice, and check the information provided on the INFOSHEET. Recently we completed the first to be reviewed, A Baby's Transition From the Womb to the Outside World, (see jpeg file above) and are now working on The Third Stage of labour. Unfortunately I do not know how to link a .pdf file to this blog, so if you would like a copy of the revised document emailed, please send a request to me joy[at]aitex.com.au

A midwife commented to me that "what we need to say loud and clear is that we use Midwifery Knowledge which is very different and definitely not less than obstetric and surgical belief."

Yes, I (sort of) agree – but remember that ‘midwifery knowledge’ is not well defined, as is also the case with some 'medical' practices, or 'alternative health' knowledge. If our knowledge embraces truth, it's true regardless of whose it is. Midwifery knowledge should not belong to midwives only - it should be common knowledge.

If 'midwifery knowledge' is to be accepted as reliable it has to be well articulated and put out to scrutiny. I believe that’s what these infosheets are trying to do.

Management (or non-management) of the Third Stage (S3) and the time interval from birth to clamping of the umbilical cord are two examples of what I would call 'midwifery knowledge', compared with rituals that have been widely accepted by modern obstetrics and midwifery, without any evidence to support them.

I am excited to see changes in the mainstream maternity attitudes to time of clamping the cord, and protocols for active management of S3. This has been in response to evidence, just as the virtual mandating of active management of S3 in hospitals was in response to flawed evidence.

We must continually engage in critical review of all that we do. Many hospital ‘guidelines’ require [that’s an oxymoron I know] immediate clamping of the cord, and none of them that I have seen have a reference linked to it.

Watch the APMA blog in the coming weeks for developments in the revision of this INFOSHEET. This is all voluntary work, and it is put out in the public domain to encourage involvement of anyone who is interested.

Today’s Age newspaper has an article about a research program for which ethics approval is being sought for a cord blood trial, and the relationship between a baby receiving its own placental transfusion and cerebral palsy. There are many questions that this research, if well done, may begin to provide answers to. The proliferation of private facilities that collect and store cord blood, without any reliable evidence that the baby will benefit from it - and without any evidence that the baby has not been harmed by the withholding of that placental blood at the time of birth - is evidence that many parents have taken a punt on this issue.

Your comments are welcome.

The birth of Richie Jack

It is with a deep sense of respect and privilege that I share this birth story link with my readers. You are invited to go to Ashley's blog and read her story.


As the midwife I experience a parallel journey. Together we negotiate the often unpredictable and challenging terrain that leads to birth. Our partnership requires trust that goes both ways - she needs to feel able to trust me, and I her.

As I read Ash's birth story, I was reminded of my own emotional journey, and the series of decisions that were made. I felt challenged as time passed - of course I would have loved to see it all happen spontaneously.

Today I visited Ash and little Richie, and as we had a cup of tea together we chatted about the birth, and all that has transpired since then. As we packed the deflated birth pool into its box, and put it in the car boot, there was no sense of loss in our minds. The birth pool had not been used, and Ash had given birth in the hospital. The hospital was the right place for this birth; the best place.

What more could we ask?

Midwives in Hungary

A report from Hungury, where homebirth midwives are being treated as criminals, prepared by Al Jazera


News [click here for link] has come that Agnes Gereb has been sentenced to two years in prison for malpractice, and banned from practicing both as an obstetrician and a midwife for five years.

The villagemidwife e-book series

I am writing
To record my knowledge
To tell my stories
To teach others

I am a midwife. My words, thoughts and actions have been formed over many years and a unique set of experiences: the world into which I was born; the mother who bore me; the family that nurtured me; the towns and communities that have allowed me to be me, and this wide open land and its people.

I like to think that these are my thoughts, yet I know that much of what I say is my own filtering and organising of what I have absorbed from those around me. Although I am the speaker, I am not the source.

Midwifery belongs to women. The midwife is ‘with woman’, a companion for a distinct and definable childbearing event, in a special partnership. Midwifery does not belong to theorists, although the clear expression of the ‘with woman’ partnership by thinkers has helped set great value on this simple phrase.

Normal birth for a breech baby

From time to time a presentation becomes available via this wonderful www that is really worth sharing.

Today I would like to direct my readers to the blogs of two colleagues, midwives who are committed, as I am, to sharing the knowledge and skill of authentic midwifery. I would encourage you to follow these two links, then come back and read my comments. Please feel free to make any comment here, or on the other blogs too. (You know that comments are very much appreciated by bloggers.)

Lisa Barrett has written about the Mechanisms of unassisted normal breech birth, with a superb set of photos.

Carolyn Hastie has presented this You-Tube video, which is in Spanish, with her own comments.

Patience

The matter that has occupied a great deal of my time and thinking space lately is the new world of maternity reform that centres on being 'eligible' for Medicare. A summary of the 'New Arrangements for Midwives' is at the MIPP blog.

My application for eligibility has been in the hands of the Nursing and Midwifery Board since early December 2010. I have had discussion with the Board's officer who has processed it, and my application was on the Board's agenda for this past Thursday. However, the meeting was adjourned unfinsihed, and my item was not discussed. It will be on the agenda for the reconvened meeting.

A midwife's knitting

I have had knitting or crochet projects on the go, particularly in the cooler months, for as long as I can remember. My projects are not usually complicated. I lose interest in some and pull them apart so that the wool can be used for someting else. I have to be able to put it down and pick it up without losing my place. I'm not a particularly good knitter, not particularly fast.

There are shawls and rugs and hats and slippers and simple toys.

I was a little amused to read in a notice about the Womb-ecology Mid-Pacific conference coming up in Hawaii in 2012 that one of the workshops is ‘silent knitting’

“Of course the “silent knitting” session will be the historical symbol of the paradigm shift we are dreaming of after thousands of years of socialisation of childbirth, at a time when modern physiology is teaching us that one cannot positively help involuntary processes such as the birth process, but that some situations can inhibit them (neocortical activity and adrenaline release). Participants will be in an ideal situation to realise that avoiding the use of language is a way to reduce neocortical activity, and that a repetitive task like knitting is a way to reduce the level of stress hormones: a crucial step towards the rediscovery of authentic midwifery.”

Pain

Beautiful Eve

Am I rushing in where angels fear to tread?

A recent post at the Science and Sensibility blog about Epidural Anaesthesia, written by well known Canadian family physician, Michael Klein MD, will be of interest to anyone who is interested in pain and childbearing. Dr Klein's paper is well referenced, and a reliable review of current medical knowledge about the topic.

The comments by readers reveal to me some of the myths and misunderstandings about pain and childbirth that I encounter from time to time. Comments quickly become defensive, assertive, and even aggressive in defending one camp or the other.

Caring about professional conduct

The topic of this post is one that is unlikely to attract acolades for the writer. It's one of those aspects of professional practice that implies a risk to the recipients of care, and that sometimes difficult judgments need to be made in order to maintain a professional standard.

There are people in every walk of life who develop conditions that may impair their judgment or conduct, people whose thoughts and actions are adversely influenced by alcohol or other substances, and people who fail to meet the community's standard in terms of professional misconduct and abuse of their position of trust. There are also people whose actions as professionals are significantly different from accepted professional standards. While tolerance and acceptance of difference are values many of us hold dear, we must all take seriously our duty of care, and act to protect others at times when we observe conduct that is of concern.

Risk aversion

Midwives who attend women for homebirths have often been portrayed as having an affinity or fondness for risk, accepting and even encouraging situations that would not be considered suitable for midwife-led care in hospital.

Preparing for Medicare

Wonderful artwork by Poppy to brighten the page.

In early December I wrote about the fact that I had submitted my application to be noted as eligible for Medicare (see blog). I have been told that this application is being processed.
In preparation for submitting an application, all midwives are required to participate in a Professional Practice Review approved by the Board (NMBA). The review that I undertook is the Midwives in Private Practice Professional Practice Review ('MIPP PPR' for short) which had previously been submitted to the Board for approval. Having worked on the MIPP PPR since its introduction in 2002, I enjoyed updating it to meet the written requirements of the new Board, and then undertaking a practice review, and presenting my findings to an experienced and respected midwife colleague.

Professional organisations and networks for midwives

Rally outside Julia Gillard's Werribee office 2009

In recent days I have had cause to reflect on the importance of various professional organisations and networks that are available for me as a midwife.  Here are a few:

• Australian College of Midwives - ACM, the peak body representing the midwifery profession in this country.
• Maternity Coalition - MC, advocating for consumers and midwives in maternity care
• Midwives in Private Practice - MiPP, a collective of midwives in Victoria, and a Participating Organisation in Maternity Coalition
• Australian Private Midwives' Association - APMA, representing private midwives nationally

Plans for the new year

As the sun goes down on 1 January 2011 in our part of the world, others have just seen the New Year in.

I have noticed from the statistics function on this blog that a large number of the visitors to this blog are in the United States. G'day, folks! I am delighted to have you visit. I have wonderful memories of five winters in Michigan, and have attached a family pic, with me holding our first baby, that takes us back 37 years.

New Year 1974, at our home in Biscayne Way, Haslett Michigan

Twelve months ago, I and other Australian midwives were wondering if we would be able to practise legally, after 1 November. We are practising, and intend to continue. I won't say without change - anyone who is so set in their ways that they are not willing to change should not be practising. We must continue to change and grow in our understanding of birthing processes, while we adapt and work within the limitations of our own lives (such as ageing), and the law.

Homebirths 2008 in Victoria

For summary and comment go to the APMA blog.

"a goodly child"

Christmas greetings, as we celebrate the birth of the Child.

As the Christmas season approaches each year, it is usual in our family to not only send our greetings but to briefly summarise the highlights of the previous year.

I have always found this a challenge, wanting to say something worth hearing, without being tedious. The recipients of our letter include our families and close friends, with whom we communicate by phone, email, and in person as often as we can; and other friends, some of whom we have not seen for many years, and with whom we communicate only once a year.

I have been reflecting on the highs (and lows) of this year 2010, and my mind has returned consistently to the two new babies, James and Eve, who were born into our family in May, and who are thriving in mind and body. The wonder and beauty of new life is powerful enough to keep me going for as long as I have energy to think and write.

Like ripples in a pond, my thoughts have then moved to our precious grand-daughter Poppy, and beyond her to our own four children.  I have remembered my own mother, and the generations of mothers before her.

Grand-parents are allowed to dote, quite openly, on their grand-children. Parents are often more cautious. Parents carry the weight of many responsibilities, and often struggle to achieve what they consider basic, such as feeding, clothing, educating, teaching manners, and getting the children to bed on time.


In my musings about our grand-children, and our children, my thoughts moved to the story of a baby, in Exodus 2.
"The woman conceived and bore a son; and when she saw that he was a fine baby, she hid him three months." (verse 2)

Another version says he was "a goodly child". 

The story is well known.  After three months the mother made a little basket of papyrus, and plastered it with bitumen and pitch to make it water-proof, and set in in the shallow reedy part of the Nile river where the princess would come to wash.  She set her daughter Miriam as the onlooker, ready to offer practical assistance of a Hebrew 'wet nurse', the baby's own loving mother, when the princess also saw that he was a fine baby, and decided to keep him.  This decision saved the life of that baby boy.


When the birth of a child is welcomed by a mother who sees that this is "a goodly child", and that mother does all in her power to protect and nurture the child, even in the most adverse circumstances, there is hope for the future.  It was no miracle that the mother of the child saw that he was "a goodly child", and defied the government of the day in the most strategic way in looking after him.  The miracle was that the princess shared in the vision of "a goodly child".  She knew exactly what the mother intended, and she agreed with the mother's plan to save that child's life.

When a child is born there is a flooding of the love hormone, oxytocin, throughout the mother's body, in a way that she can only experience at such a time.  This outpouring continues with each touch, look, and suckle from the infant.  It is right for a mother to look at her child and see "a goodly child".  It is right and normal for a mother to use every strategy at her disposal to ensure the safety and nurture of that child, while maintaining the closeness of the exclusive mothering bond during the infant's first years.

I want to encourage every parent who reads this blog, to take a moment to look at your child, and see that she or he is wonderfully special, a child with great potential.  See that your child is "a goodly child".  Whatever the challenges you face in ensuring the safety and care of that child, so that she or he can grow to unhindered maturity emotionally and physically, keep your vision clear, and remember the mother whose child was wonderfully saved in infancy, and later became a great leader.

I also want to encourage midwives who read my writings to see each child as carrying immense and unmeasurable potential.  We midwives are the guardians of the next generation, protecting the mothers in their ability to not only give birth, but also to see their children for what they are.

May God's blessing be on you as we celebrate the birth of the Christ child.
Joy

Loving

From time to time in this blog I attempt to write a personal letter to my readers. Many readers have never met me in person, and I don't know you. However, our common interest in midwifery and anything that touches on women's reproductive lives gives me the opportunity to use a broad range of topics in writing to you.


The wonder and beauty of human love shared by a woman and her man, are in my mind, founded on the creation story in Genesis 1. God created human kind “in our image, according to our likeness”; “in the image of God he created them, male and female he created them. God blessed them ... God saw everything that he had made, and indeed, it was very good.”

"Indeed, it was very good" the way our bodies, male and female, were created. The workings of the male-female creature, made wonderfully in God’s image and likeness, are indeed very good.

It [the way our bodies work together as woman and man] is very good whether we [intellectually] understand the processes or not. It is very good because it has been very good from the start, and we have a deep intuitive knowing that it is very good. 

This separation of intuitive ‘knowing’ from intellectual ‘learning’ fits with my understanding of normal, physiological childbirth and nurture of a baby. (I use the word ‘physiological’, to differentiate from normal meaning ‘usual’, which is often very far from the normal, natural process.)

Intuitive, or maieutic, knowing is influenced by the amazingly sensitive hormonal states within our bodies, and is not dependent on theoretical understanding of what's going on at the time. The intellectual ‘learning’, achieved through more didactic processes involving teachers/writers and students/readers, is a particularly human characteristic. Other creatures who share similar physiology do not seem to share our need, or capacity, to understand why, and how.

Although there are aspects of the whole loving – childbearing – child nurture spectrum that our minds are able to investigate and delve into, I believe that the unique opportunity that the creator has given us is that we can experience something that is VERY good best without seeking to manage, control, or even understand it.

I see this principle being worked out many times when a mother who has given birth to her child is transported into a relationship of deep love for that child.  Science calls it maternal instinct, and tells us that the primal parts of the mother’s brain are able to assert themselves, while the neocortex, or ‘new’ brain, is unstimulated.

That makes sense, and it reminds me that “indeed, it was very good.” The hormonal interactions of the normal loving – childbearing – nurture activities are “very good”. And when, as happens in these activities, there is a climax – a peak of the loving hormones, and we experience an altered state of consciousness with a huge rush of excitement, pain, wonder and amazement that we had not expected and that floods our being: indeed, that’s very good.

I don’t know if there is an ideal way for a couple to enjoy their oneness. I think it’s best not to seek that knowledge from an intellectual perspective. Each couple has the opportunity, in the privacy of their own relationship, to seek deeper and more enjoyable sexual intimacy. There is something reflecting the image and likeness of God in each of us that is, indeed, very good.

Notation on the Register

I have now completed my application for 'notation' on the midwives register, as a midwife eligible for Medicare. My CV has been adapted to comply with the AHPRA standard, and copies of documents need to be certified as correct, also in compliance with the required standard.
This process has been a challenging one for me. A few of my trusted colleagues and friends wonder why I would even try to become 'eligible'. By accepting a terribly flawed process, am I not supporting our society's attempts to medicalise women's lives, and to give a veto power to the medical profession over midwifery and women's choice of physiological birth?
Readers who have followed this process will understand that the decisions midwives must make are complex.

I have come to a pragmatic point of acceptance:
... that the government has enacted a process for certain midwives to be eligible for Medicare.

The person who will benefit from my being eligible for Medicare is the woman, not me. The woman will be able to claim back some of the fee I charge - possibly one third for planned home births, and more if and when I am able to attend a woman privately for hospital birth.
I will seek to do all in my power to prevent this process from taking away a woman's freedom, or working under medical supervision in primary maternity care.

There are several hoops to jump through yet, and it may be a couple of months before I hear back from the Nursing and Midwifery Board of Australia if my application is successful.

Update on Medicare

Bec and James

For an update on Midwives with Medicare provider numbers, go to the midwivesVictoria blog

Midwifery - much more than a job

Midwifery is the calling, the profession, the vocation that has claimed my attention and inspired me throughout most of my adult life. During the past two decades I have learnt to apply the basic knowledge and skill that I had when employed in a maternity hospital to the individual women whom I have been privileged to attend.

Midwifery is much more than a job.

When I was employed by the Women's in the 1980s, working a couple of night shifts each week, I used to feel as though I was having one night stands with women, being close to them at such significant moments in their lives, and walking away from them at the end of the shift. This was before I had noticed any professional discussion about caseloads, or continuity of care. I now see this feeling as evidence of my developing *midwife identity*. For twelve years I had a job as a midwife in a public hospital. A job that I could walk away from when the time came, and return home to my young children and my husband.

When the time came for me to move away from that *job* and set up my own *practice*, I experienced a sense of freedom that I had not previously imagined. I went into private practice like a duck to water. I could not have been in a better place, and my emerging identity as a midwife was sealed and flourished. I found that I could write and teach, sharing the knowledge I had acquired from study and from giving birth and nurturing my own children, and the principles upon which that knowledge was based.

I accepted that, in order for a private midwifery practice to be viable in this country, I needed to charge a fee that reflected the commitment I was making. When I was employed in midwifery there was always a pay packet at regular intervals. Now I would not be paid unless women paid me. All I can say is that I have not missed the regular salary one bit. Even as the main breadwinner for our household, the steady stream of clients who employ me to be 'with woman' have provided sufficient income for my needs.

The terrain of private midwifery practice in Australia is changing now. Midwives are now able to demonstrate to the regulatory authority that we are suitably competent in all aspects of basic midwifery, and through that process become eligible for private clients to claim Medicare rebates. The legislation around Medicare, particularly the requirements for collaborative arrangements, has been criticised by me and many others who have read it. The process to provide Medicare rebates is potentially arduous, and there are questions that are still unanswered.  But there is a process, and it is there for midwives to apply.

I know of a small group of midwives who are progressing towards the Medicare eligibility goal - some may already have achieved it.

I have stood back a little, attempting to line up options for collaboration with public hospitals. This is not to focus only on what I need, but to establish pathways for other midwives.

Some of my colleagues have become concerned that midwives who accept Medicare eligibility will be compromising midwifery standards, and women's rights to informed consent or refusal.   I will be watching closely to see that this does not happen.

Global forum: optimising the effecctiveness of Health Workers to achieve MDG's 1 and 5

I would encourage readers to follow, and to consider making a contribution to this global forum.
My responses to the forum questions will be posted at my 'private midwifery' blog, as well as at the forum site

I wonder what this one will teach me?

Mothers wonder ...
Midwives wonder.

I wonder what this one will teach me?

As each decision point is reached and the choice is made, this way or that, the course of events is shaped and cannot be undone. As each baby is born, and the cycle of life moves on, the mother learns something about herself, and something new about life. The midwife, in her interwoven world, also learns something about herself, and reinforces or renews her understanding of the wonder of life.

Dear reader, do you know what I am saying?

Do you understand the flow of life, and the decisions that are made - especially in the context of that basic and primal event of giving birth? Do you recognise a decision as a fork in life's journey. You choose one and you consequently reject the other. You can never come back to this decision, this bifurcation in the path.

The mothers who have had larger numbers of children; five, six, or more, are usually the ones who marvel at the uniqueness of each experience. When these mothers come to see me for a prenatal checkup I love to listen to what they have to say. I don't need to teach them about childbirth. We spend an hour or so in my little office, surrounded by my messy shelves of books and folders, and the cork boards filled with wonderful photos, and some artworks that are particularly dear to me, and my wall calendar with the names of the women to whom I am committed. I usually start with the question, "Did you have anything that you wanted to talk with me about today?" Then we pass the time in an easy, unstructured exchange. At some point I do the basic checks - blood pressure, palpation of the womb and auscultation of the baby's heart sounds. The information is noted down.

But the building of a relationship is what takes most of the hour's visit. There is no box in my paperwork to tick about trust. There is no place to note the unique sharing of lives: a woman and her midwife.


One particular day I was feeling very weary. The pressures of my personal life, and professional stuff including all the campaigning for better maternity services had left me feeling emotionally and physically low. Depressed? Yes, I was. I had become unexpectedly teary when some friends started talking about their plans for holidays. I told my sister about my feelings, and that I had not had a holiday for a long time, and she informed me that was not good work practice. Dear reader, I'm sure she didn't mean to hurt me. We love each other, and talk about things that are important to us.

Anyway, on that particular day, the phone rang. A mother told me she thought her labour was starting. She needed to contact her husband so that he would be at home to look after the children. Soon she rang again. Husband was on the way, and she asked me to come.

As I moved quickly from my introspective mood to a more organised, directed persona, I prayed for strength and wisdom. It's late afternoon. I may be out through the night. I need alertness of mind and strength of body. I may need special courage and wisdom as decision points are reached. I pray for God's special protection and blessing on the mother and child in my care.

On that particular day the labour progressed quickly. A baby was born without complication or incident. The mother sat quietly in an arm chair and focused on her little son as he worked his way to her breast and began to take his first feed. She had a couple of contractions, and I reminded her about the birth of the placenta.

Then the mother lifted the towel from her belly, and said "Joy, there's a lump here still. Could this be another baby?"

Yes, it could ... and it was.

As I put on a sterile glove to check how this baby intended to be born, there was one push, a gush of fluid, and the little sister made her entrance - beautifully.

I will never forget the mother's ecstatic face as she said "I've got TWO babies!"

That night as I returned home I reflected on not just the birth - amazing as it was - but also my physical, emotional, and spiritual journey that day. What did this one teach me? Quite a lot.