Social Media and midwives

Two of my precious grand-daughters, Poppy and Amelie

I want to declare my interest in the use of social media by midwives.

This blog site provides ample evidence of my commitment to and fascination with openly available websites. This blog is a notice board; a library; a magazine; an ongoing journal of my opinions and comments about midwifery and about life.   It is also an ongoing record of special people in my life, such as the two precious little girls pictured today.

I began this blog in 2006, and it sat, unused and dormant, until mid-2007. At that time I felt a strong need to communicate with young women, particularly those who searched the internet for information in preparation for the births of their babies, and I realised I could do this as a blogger. From time to time over the years I had received emails, usually from women in other countries, thanking me for The Midwife's Journal, which they had found on my old website. A woman from Holland referred to The Midwife's Journal, which had been written at least 10 years prior (ie before the word blog existed in my vocabulary, at least), as a 'blog'.

It occurred to me then that I could continue The Midwife's Journal as villagemidwife, the blogger.

These are the headings from that new beginning [link]:

• Natural birthing in Australia today 
• The culture of birthing 
• Vaginal breech birth 
• Who let the dads in? 
• Nurture and nourishment of the newborn baby 
• Paternal behaviours 
• Mother-infant bonding, and maternal instincts 
• Giving birth 
• The life of the unborn child in the womb, and imprinting at birth 
• Commenting on some of life's big moments 
• Midwife for Christ’s birth 
• You are free, my dove 
• The homeborn newborn: how do mothers manage breastfeeding when there's noone to show them what to do? 
• Protecting normal birth 
• Why protect normal birth? 
• Birth Trauma 

The regulator for health professionals in this country has announced a review of its social media policy:

The National Boards will consult publicly on social media policy in coming months The National Boards in the National Registration and Accreditation Scheme (National Scheme) will release a consultation paper on a social media policy in October/November 2012.

A draft of the social media policy has been released as a preliminary consultation paper to targeted stakeholders for initial feedback, ahead of a wider public release. The preliminary consultation process aims to ‘road test’ the initial draft to weigh operational impact, issues or initial concerns. We are pleased that this early draft is generating a lot of interest, especially on social media. National Boards are monitoring feedback closely and will take the issues raised into account when refining the draft social media policy before it is released for public consultation on the National Boards’ websites.

If you would like to contribute feedback on the preliminary draft social media policy, please email your considerations to socialmediaconsult@ahpra.gov.au by close of business 14 September 2012. When the formal public consultation process opens, the National Boards encourage feedback from registered health practitioners and members of the community on the draft social media policy. The National Boards will publish the public consultation document on their websites, and will encourage wider distribution to seek extensive feedback.

Until then, visit the News section of the National Board websites (via www.ahpra.gov.au) for updates on past and current consultations, general communiqués from National Boards, media releases and more.

I have read the draft policy, which reminds health practitioners that in using social media, we must comply with the National Law, Advertising Guidelines and the code of conduct.


Midwives who in recent years had published testimonials at their websites have found themselves being directed to the law that prohibits the use of testimonials.  Birth Stories, on the other hand, seem to be permitted.

There will be times when I have used experience from real life in my writings, and it is possible that some of those who read my accounts may at times recognise the woman, even if I have been careful not to identify her. Whether this could, in a narrowly defined mindset, be seen as a breach of privacy, is yet to be seen.

There is nothing sinister about blogging, or any other aspect of social media, per se.  The medium is neither good nor bad: it's simply a medium.  The content is what can be anything from wholesome and useful, to trivial navel gazing self absorption, to defamatory and destructive.   The author has the ability to communicate in a way that is useful, or not.  I hope to continue writing in this medium, and I hope there are readers who value the material posted and thoughts expressed.


Your comments are, as always, welcome.

availability of midwives for homebirths

Today I would like to explore a few issues around the availability of midwives to provide professional services for homebirth, and suggest what I see as a way forward.

These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.

'Risk' - however defined - is a major obstacle.  The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital.  This narrow mindedness is not informed by evidence or by logic.

The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.

With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded.  A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program.  Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.

Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.

These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes.  Yet midwives say very little. 

These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder.  An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care.  Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth.  Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access.  When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.

$$ Cost is significant in private homebirth.  While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives.  Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging.  For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate.  The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.

The other factor in cost of private homebirth is the number of midwives.  Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more.  A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth.  I disagree.  Strongly!

I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives.  I cannot support this option - it scares me.  I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula?  A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".

Practical matters: the main one that comes to mind is the distance across this wide brown land.  Gone are the days of the village midwife on her bike.  Each time I visit a client, I am using precious fuel.  Likewise, each time a woman comes to me.  If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife.  (An exception is a few special women who I have attended on several occasions over the years.  I have become a part of those families, and it's lovely to return for the birth of the next baby.)

Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home.  Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.

Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.   

What am I saying?

I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth. 

• midwives need to think critically about risk
• midwives need to work to make primary maternity care by a known midwife affordable
• midwives need to wake up to their capacity to provide midwifery services in homes and hospitals, for all women.

Getting information

I have been pondering the question of how do women get the information they want in relation to their maternity decisions.

We have always talked, shared, and explored 'women's business' - in the past over the back fence, or over a cup of tea.  These days it's via social networking, via the iPhone or tablet.  The details of the horrible nausea, or the results of the most recent ultrasound scan, complete with picture, are updated for all one's 'friends' to see, and many check the 'like' button.  Questions are asked at internet forums, and there seems to be no shortage of guides who are willing to assist the inquirer with their tried and true remedies.  Women wanting to get pregnant can download their 'fertility tracker' free!  (How did we get pregnant before we had fertility trackers?)

Today I entered 'nausea and vomiting in pregnancy' in a search engine, and got more than 1.3 million hits.  Take your pick from ginger, vitamin B6, acupuncture, ...

The first site I went to told me that morning sickness is "generally considered to be the result of a combination of elevated oestrogen levels and low blood sugar" [that's news to me!]

So, how does someone get reliable information about a pregnancy issue?  How does one make informed choices?  How should a midwife advise a woman who is experiencing nausea, retching, and vomiting in early pregnancy?

Midwife academics Lisa McKenna and Meredith McIntyre published a literature review on the use of over-the-counter medicines by pregnant women.   The authors reported that ‘preparations used included cold cures, antihistamines, pain killers, herbal teas, antacids and laxatives – all of which are easy to obtain …  and are considered as low risk [of causing any harm to the developing fetus].’ (McKenna and McIntyre 2006, p637)  A Cochrane review by Matthews and colleagues (2010) reported a lack of high-quality evidence to support professional advice on complementary and alternative treatments for nausea and vomiting in early pregnancy.

I have found in practice that many women who seek primary care from a midwife, especially a midwife who attends homebirths, will have established patterns of alternative health care, including self-care, which the woman may not mention unless specific questions are asked.   The scientific paradigm that midwives and many other regulated health professionals follow in understanding evidence may not be accepted or understood by people who follow alternative health care systems.  To complicate matters even more, there are many midwives and doctors who have integrated alternative therapies into allopathic models of care.

In reviewing over the counter medicines for pregnant women, I came across the RANZCOG College Statement  (C-Obs25) on evidence supporting vitamin and mineral supplementation in pregnancy and lactation.  I recommend this statement for those who are seeking reliable information on folate, vitamin B12, B-group vitamins, vitamin D, vitamin K, and minerals such as Iron, Calcium, and Iodine.

the death of a baby

I am writing with deep sympathy for the family who lost their baby in late 2010, and for the midwives and doctors who attended the mother.

I am writing about this because the Melbourne Coroner is currently hearing evidence from the various parties.  In time the Coroner's report will be published.  The Coroner's job is to find out what happened, in a respectful and unbiased way.  At present fragments of information have been published in newspapers and online news sites.  Some pieces of the information circulating in the media are factual, while others are contested.

I am writing because this case raises issues that are similar to a case that I wrote about a couple of months ago.

It is difficult for me to write.  I know the midwives; they are my colleagues, and we have shared in professional and personal journeys over the years.  I know the hospital; I have been there with women many times over the years.  I know the mother, who was a member of a peer support group I facilitated a few years ago.

The big issues as I understand this and similar cases are around a midwife's duty of care, a woman's decision-making, and the need for women to be able to feel respected in maternity hospitals.

The questions that I asked in my previous post are still pertinent:
"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and
"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"


I have many thoughts that I will not make public at present. 

More evidence ...

... demanding action.

For many years the buzz word in maternity care has been 'evidence'.  'Evidence-based' maternity care guidelines can be found everywhere. 

Application of the evidence into mainstream maternity care is quite another matter.

From my perspective, it's great to see another piece of reliable evidence supporting midwifery continuity of care /caseload midwifery/ one-to-one midwifery.  This evidence is published in a respected professional journal, BJOG, and International Journal of Obstetrics and Gynaecology, reporting on research carried out under the strict rules of randomised controlled trials, by the La Trobe University team of midwifery academics, led by Associate Professor Helen McLachlan.

The title of the paper is:
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Authors: McLachlan et al, BJOG (2012).


The team of authors of this paper includes midwife academics who were prominent in the 'Team Midwifery' research from LaTrobe Uni more than a decade ago.  'Team midwifery' was adopted into many mainstream maternity units, in an attempt to reduce the huge number of midwives who provided care for individual women during their prenatal, intranatal, and postnatal experience.  Women were allocated to the 'Green team' or the 'Pink team'.  Midwives work ordinary hospital nursing shifts.  Women under 'team midwifery' are usually attended in labour by midwives who are strangers. 

Two papers addressing Team Midwifery, authored by Professor Ulla Waldenstrom and others, and Mary-Anne Biro and others in 2000 in the journal BIRTH presented the research findings, and a commentary was written by Karyn Kaufman.  Kaufman, a midwife academic and a member of a community-based midwifery practice in Canada highlighted in her review the lack of difference between the control or ‘standard care’ and the intervention, team midwifery.  Kaufman commented that “midwifery care that follows strict medical protocols is not the same as midwifery care that is enacted from a philosophy of normal birth and is individually negotiated with labouring women.”  This statement sounds logical, yet many Australian midwives at the time may not have realised that midwifery care for well women can be enacted from a philosophy of normal birth.

The primary outcome of the continuity of care by a primary midwife (caseload midwifery) trial is that

"In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk shows promise for reducing caesarean births."  

Besides having fewer caesareans, women allocated to 'caseload' were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care.  

Good for mother, good for baby.

Good for the midwife, too.

In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

When a reduced likelihood of caesarean can be demonstrated for women at low risk of complications, it's time for the midwifery profession to celebrate.  

Evidence demands action.

This is reliable evidence.

This research was carried out under strict controls.

Midwives and maternity services must be challenged to apply the evidence to practice.  The usual practise of midwifery should be in a caseload model, working autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A').  Not as shiftworker nurses in hospitals who work as assistants to obstetricians.  

Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.

The Midwives Work DVD

Uploaded to YouTube by Midwives magazine on Jul 25, 2011

The Midwives Work DVD premiered at the International Confederation of Midwives Congress in Durban South Africa in June 2011, in front of 3000 midwives and others interested in maternity care from over 100 countries, has attracted huge interest. It highlights the importance of the role of the midwife in reducing maternal and infant mortality as well as the issues and challenges they face.

Category: Nonprofits & Activism
Tags: midwives midwifery
 RCM License: Standard YouTube License

(Thanks to Julie Garrett for the link to this film.)

Back to study

It starts on Monday.
I am planning to keep a record at my other midwifery blog Click here.

hospitals and independent midwives

When a midwife walks into a hospital with a woman for whom she is providing private midwifery services, that midwife faces a complex and often challenging work environment.

Recently I went to hospital with a woman who I will call Melissa, who was planning VBAC.  Melissa's first child had been delivered by emergency caesarean, after induction of labour at 42 weeks.  This time Melissa was well informed, and intentional about all her decisions.

Melissa had experienced a difficult week 39-40 in her pregnancy.  There were several nights without much sleep, and she had a cold.  A couple of days after her expected due date, Melissa asked me to assess her internally, and consider a 'stretch and sweep' of the membranes at her cervix.  I was pleased to report a well applied head, a very thin cervix, and about 1.5cm dilation.  With very gentle stretching of the cervix, I felt confident that the labour was imminent.

Sure enough, Melissa called me a few hours later, and I went with her as she was admitted to the hospital birth suite.  Melissa laboured strongly, and together we considered any decisions that needed to be made, following 'Plan A'.  I continued 'with woman' through the labour and birth, and afterwards.

There is nothing remarkable about this little account.  However, the matter that has prompted me to write about hospitals and independent midwives is the question of what to call a midwife who goes to hospital with a woman in her care.

I call that midwife a midwife.

Others call that midwife a 'support person', or a 'birth support person', or even 'only support'!

Why?

Because the independent midwife does not have visiting access/ clinical privileges/ credentialling in that hospital.

This is true - Victorian public maternity hospitals have dragged their feet on this matter.  Despite government-supported indemnity insurance for private midwives providing intrapartum care in hospital, there is no likelihood of hospital visiting access in the near future.

So does a midwife cease to be a midwife, just because the hospital refuses to roll out the red carpet?  Of course not!  A midwife is 'with woman': not with a setting for birth.  The midwife's registration is with the regulatory body, which is not under the management of the hospital.  And, let's remember that if a midwife acted in a way that was considered unprofessional, she or he would expect to be reported to the regulatory authority as a midwife, not as a 'support person'.

The ICM definition of the Midwife
declares that the midwife's Scope of Practice is:

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.

'Support' is listed in the definition as one of the elements of midwifery.  I do not want to seem to devalue support.  But the point I want to make is that support is a part of the midwife's scope of practice: not an alternative to midwifery practice, and definitely not an alternative to the title 'midwife'.

Thankyou for your comments.

24/7

"Within the [ ] health services financing structure, there is no room for financing the disutility of 24/7 availablity." [Mariel Croon, Human Rights in Childbirth conference, 2012]

One unavoidable feature of midwifery practice in primary maternity care is that a midwife needs to be accessible to a woman 24 hours a day, and 7 days a week, except, of course, if the birth is a medically scheduled and managed event.  If the midwife and the woman have agreed prior to the birth that they will work together when that time comes, that means the midwife is under a considerable degree of commitment.

I have often pondered the wastefulness, from an economic/time management point of view, of caseload midwifery. Of course I can understand the bean counters, who want midwives to be rostered to hospital wards, for shifts that can be predicted. Of course I understand why inductions of labour happen in hospital maternity systems, as managers attempt to match peak activity periods in the hospital with the times when adequate staff have been booked.  Of course I understand why midwives choose to work shifts in hospitals.

At present I am waiting for three babies: one 'due' last week, one this week, and the third in a week or so. Babies in my practice often cluster, and I can't worry about it because it is outside my control.  I must see each woman as an individual, and not allow stress about the time of onset of spontaneous labour to complicate our relationship.

The quote above, and particularly the phrase  "disutility of 24/7 availablity" caught my attention when I read it. 
The dictionary meaning is:

'disutility'
a. the shortcomings of a commodity or activity in satisfying human wants
b. the degree to which a commodity or activity fails to satisfy human wants
[Collins English Dictionary – Complete and Unabridged © HarperCollins Publishers 1991, 1994, 1998, 2000, 2003]

mmm!

My decision to work as a midwife, placing the 'activity' - the needs and wishes of a birthing woman above my need to 'satisfy human wants' - be able to plan my time for work and play and sleep and whatever else - is a decision on principle, not on economics.  The principle relates to my understanding of the unique trust relationship that can be established between a midwife and a woman, enabling the woman to proceed down the often unpredictable and challenging path that leads to the unassisted, unmedicated birth of her child. 

CULTURAL HYSTERIA?

Readers of this blog are probably familiar with the historical roots of 'hysteria'; the Greek word ὑστέρα (hystera) meaning womb, the condition of the wandering womb, and recommended treatments.

"Galen, a prominent physician from the 2nd century, wrote that hysteria was a disease caused by sexual deprivation in particularly passionate women: hysteria was noted quite often in virgins, nuns, widows and, occasionally, married women. The prescription in medieval and renaissance medicine was intercourse if married, marriage if single, or vaginal massage (pelvic massage) by a midwife as a last recourse.[1]" [Wikipedia]

The Medical Dictionary that my computer's online dictionary led me to offers this information:

hysteria hys·ter·i·a (hĭ-stěr'ē-ə, -stēr'-) n.

A neurosis characterized by the presentation of a physical ailment without an organic cause, such as amnesia.

Excessive or uncontrollable emotion, such as fear.[Link]

I wish to contend here that there is a cultural hysteria in response to midwifery.  A cultural neurosis that leads to excessive and uncontrollable fear about that highly contested terrain, childbirth.

While midwives are recognised internationally as essential providers of primary maternity care, Australian midwives (and our sisters in many other developed countries) face exclusion and restriction when simply practising our profession.

Cultural hysteria with regard to midwifery depicts the midwife as someone who lacks skill in management of obstetric emergencies, events that are bound to happen, leading to a mass fear reaction.  Cultural hysteria sets up a fearful scenario, and uses that scenario to prove its point.

I don't have answers to every possible scenario, but I do know that in the State of Victoria, where I live and work, data from privately attended planned homebirth have been collected and reported on for many years, demonstrating the clinical effectiveness of planned homebirth in the care of a midwife.

The mothers who planned to give birth at home have not been uniformly 'low risk': they include births after Caesarean, mothers who are older, or who have had more births, or whose babies are bigger than average.  They are ordinary women, who just want to give birth to their babies.

The midwives have not undertaken any special courses of study: they are simply competent midwives, who seek to work in harmony with physiological processes, and who, generally, refer women appropriately when complications are suspected. 

The Victorian government’s Perinatal Data Collection (PDC) unit within the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) publishes an annual profile that captures all planned homebirths in the state, and puts the data alongside cumulative data from hospitals and statewide totals. These reports, although retrospective, carry a high degree of reliability.

The reports over the past 20+ years have shown planned homebirth in the care of a midwife as a safe option in terms of maternal and perinatal morbidity, with many features that are considered protective of the mother’s and baby’s wellbeing and safety. 

For example, in 2008, the most recent set of published data in this series:
• 91.5% of women planning homebirth had unassisted cephalic births, compared with 55.4% state-wide.
• Approximately 5% of women planning homebirth at the beginning of labour had caesareans, compared with 19% in small ‘low risk’ (<100 births) hospitals, and 31% statewide.

When looking at the baby outcomes for the same group (2008),
• 95.6% of babies born to mothers who planned homebirth at the beginning of labour did not require admission to a hospital nursery, which is approximately the same as the rate for small hospitals with less than 400 births per year.

These data support our contention that there is safety and protection of wellbeing for mother and baby when midwives attend women for planned homebirth.


I recognise that individual cases may be held up as examples of things going very wrong in birth, whether that birth takes place in a tertiary hospital, a private hospital, the woman's home, a birth centre, or in the back seat of the car. 

There are risks associated with birth, as there are particular risks linked to any life event.

I believe that the safety and wellbeing of mothers and babies in our community is enhanced by a strong midwifery profession that is recognised as essential in effective primary maternity care.

WHY I DISAGREE WITH THE CORONER'S RECOMMENDATIONS

Having written last week about some of the complexities of the decisions made by women about their birth-giving, and the roles of midwives, I would like today to briefly explore why I disagree with (most of) the South Australian Coroner's recommendations in the recent case.

I have summarised the recommendations as:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

Rather than starting with #1 and plodding through this minefield, I will start with what I see as easier, and pick my way through the minefield, trying to state my opinions clearly. (And, dear reader, I must warn you that I often delete a great deal of what I write, so that you see the heavily edited version)

6) education for public distribution on homebirths and risks 

This is not a bad idea. My only hesitation relates to what sort of education, and who writes it, and who defines the risks, and ...

 5) "establishment of alternative birthing centres" 

Also not a bad idea - for the 1980s, that is. Midwifery theorists proposed that hospital rooms dressed as 'home-like' settings would help women to feel OK about birth.  Some women did well, while many were excluded by risk protocols, and moved into standard (the alternative to 'alternative') obstetric care.  I gave birth to my fourth child at the Women's Birth Centre in 1980, and that experience helped me come out of medically managed and dominated midwifery.  I know many other midwives who have learnt to work in harmony with physiology in unmedicated birth, and to trust their midwifery knowledge when detecting and acting upon complications, during their time working or giving birth in a birth centre.  Perhaps that's a good reason to establish birthing centres.

4) "establishment of a position known as the Supervisor of Midwives"

I need to sit on the fence for this one.  The role of Supervisor of Midwives is one that I don't fully understand.  How would these people be appointed?  What would their role entail?  Would all midwives be supervised, or only certain midwives?    The UK-style Supervisor of Midwives is different from the New Zealand system.  Psychologists work under a system of professional supervision.  I believe a thorough exploration of this proposal needs to be had by midwives, ethicists, psychologists, lawyers, and maternity consumer spokespeople, and some agreement reached, before yet another regulatory control be imposed on the profession.

1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"

NO!
Australia does not need to outlaw unregulated midwifery services.
Australia needs to protect and support the midwifery profession, so that midwives can provide midwifery services in homes and hospitals; so that women will feel safe in the professional care of midwives as primary carers, who are able to work seamlessly with specialist services when indicated.
Modern societies, and the legislators and coroners and others in positions of authority need to recognise that spontaneous labour and birth is a fact of nature, not something that a midwife controls or gives permission for, and that women under natural law are able to use the professional services provided in their community, or not.  It's their choice.

2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"

NO!
Midwives who understand the ethical and moral duties of our profession, who by definition work 'in partnership' with a woman, will REFUSE to report women on the grounds of a plan for homebirth.  My own practice for many years has been to encourage women to see the choice of place of birth as a decision they make as labour becomes established, and not before.  I believe this is best practice, as the midwife is committed to the woman, not to the planned setting for birth.

8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

HOW would this work?  Will that woman be arrested and forced to listen to 'appropriate advice' being delivered?

I have not tried to tease out which risk factors the Coroner thinks would be used to initiate reports or the giving of advice.  There are few absolutes in midwifery.  Regardless of what risk factors may be attending a particular situation, physiological birth always starts with spontaneous onset of labour, and spontaneous onset of labour happens in the woman's own time, in her own world, in her own body.  The woman has to make a decision to call a midwife, or not; to go to hospital, or not.  This decision cannot be taken from her.

This set of recommendations exhibits a shallow and linear view of life, risk, and decision-making.  The question that the Coroner seemed to avoid is:

"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and

"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"



Australia is a society which supports a wide range of freedoms for the individual.  I don't have the words to describe the legal and ethical framework that this is built upon, but I know that when a State (government-sanctioned authorities) is given power to control the most intimate relationships between a woman and her child, that comes with a great loss of basic freedom.

Civil disobedience by midwives has been recorded many times, when the midwives believed that the lives or wellbeing of the mother and/or her baby were at risk.  The Hebrew midwives, Shiphrah and Puah, who were prepared to disobey and deceive the autocratic, absolute authority of Pharoah, are our model.

The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, "When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.  But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live.  So the king of Egypt summoned the midwives and said to them, "Why have you done this, and allowed the boys to live?"  The midwives said to Pharoah, "Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwives come to them."  So God dealt well with the midwives; and the people multiplied and became very strong,.  And because the midwives feared God, he gave them families. (Exodus 1: 15-21, From the New Revised Standard Version (1989) of the Bible)

Understanding what's behind an adverse outcome

Today I am recording a few of my personal thoughts in relation to the (lengthy) Coroner's report that was released this past week, in Adelaide.  I have written about it from the perspective of Australian Private Midwives Association (APMA) at the privatemidwives blog.

Principles of accountability and transparency must be applied to professional practice.  When something goes wrong in birth, our society wants to know, and has a right to know what happened.  It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear?  How must I act when a woman in my care understands her personal risk differently from the mainstream?

A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain.  The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity.  So, when I read in the SA Coroner's report that 

"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."

I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?

The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.

This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:

• if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);  
• if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean; 
• if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean) 

That is a superficial, linear argument that fails to recognise the complexities of maternity care.  This suggested course of action ignores the increased risk that each caesarean places on the woman's reproductive future: a risk that does not really show up in the statistical reports.  It passes over the fact that many women who seek private midwifery care are consciously avoiding mainstream services.  It fails to notice that highly skilled, experienced midwives have been excluded from practising in any setting except the home.  And then there are all the issues of trust and continuity in providing optimal maternity care.

I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result.  The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation.  She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]

Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive.  The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives.  The emergency code had been rehearsed, prepared for, and was called into action.  Perhaps that group of midwives will be more ready and competent when it really is called for???

In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety.  I cannot control another person's actions.  I also cannot use these experiences as a reason to stay out of hospital in future situations.  The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.

I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
***********

The Coroner's recommendations are listed at the end of the 106-page report.  In this blog I am attempting to summarise the recommendations, for future reference:


1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

TWO WHO ARE TWO

TOO good!

In this past month I have had many opportunities to enjoy the two little ones, James and Eve, who joined our family two years ago.

I have seen the two mothers go through amazing processes of learning to cope with the complexities of their lives, while mothering their babies.   I have seen two fathers adapt and learn how to love in a new way, and to become daddies.

I have reflected on the enormous investment of time, energy, money, and other entities that probably can't be described in a few words - investment by the child's parents, wider family, and community. Investment in a precious resource, a human life, and in the hope for a new generation.

Today I am posting a poem written my our beautiful daughter in law, Anna, celebrating Eve's second birthday. Anna has given me permission to share this tender love-poem with my readers. (Thankyou, Annie)

A Poem for Eve Dulcie - our La Dolce Vita (life is sweet), on your 2nd birthday..... 

I love your sense of humour-

Feeding breakfast to your toes

Declaring that it is "pickle day"

Or that you've lost your nose

I love your creativity, on paper (or on walls!)

The way you tell me stories

Or play dress-ups with scarves and shawls

You are my little encourager

Telling me that I'm good

At vacuuming or singing

Or playing Robin Hood

I love your little bird song

I could listen to your voice all day,

Singing songs in the bath

Or while you laugh and play

Your heart is so precious

Saying more than a love letter

You make me want to do my best

And as a mum, be better

The type of love you give is rare

So accepting and forgiving

An Evie filled life is one,

That is all the more worth living

I'm still learning to be your mum

I've made plenty of mistakes

But I'm head over heels for you kid

With every step we take

My curly headed rascal

My beautiful green eyed girl

Mummy's little hero, Daddy's little pearl

I love the way you love me

Always wanting to hold my hand

At breakfast or watching TV

Or playing in the sand

Your infectious belly chuckle

Your heart-warming grin

Your dainty royal wave

Your porridge covered chin

When I wake at morning

And when I sleep at night

I thank God for giving me you –

My Eve, my hearts delight."

Woolly warmth for babies

Ame meets the sheep not in the meadow

As the days and nights in Melbourne become cooler I am enjoying the warmth of wool.  Our world has been overtaken by fake fibres - the polyesters that never show a wrinkle and the lycras that stretch and the polar fleeces that are light and keep the cold out.  But I am convinced that nothing beats wool.

Recently a young mother, Brenna, has pointed me to her business, selling beautiful baby clothes at woollykins which are quite inspiring. 

If you share this love affair with wool and other natural fibers, I suggest you visit Brenna's blog, Cobbled together.

One of the essentials in a baby's 'layette' (I don't think anyone uses that word now-a-days) is a pure wool blanket.  The warmth from pure wool is good warmth, moisture is held without becoming hot or stifling.

Knitting and crochet are crafts that value wool.  Knitting and crochet are also activities that midwives have, over many generations, taken with us into the birthing space.  We need to be present, but we need to quietly and unobtrusively stay out of the labouring woman's way.  Lighting is dim - often a couple of candles, burning embers in the fire place, or a little daylight through the closed drapes.  Simple patterns are good - ones that can be interrupted at any stage.  We need to do nothing that will distract the labouring woman.  The repetitive nature of these wool crafts has the effect of keeping adrenaline and other stress hormones at minimal levels.  Women have often said to me that as their labours demanded more from them they felt reassured that I was quietly getting on with my crochet.

Years ago I went to Emma's home.  She wasn't labouring well - it was that frustrating preparatory stage.  I didn't want to go straight home, and it was a week-day, so I went to the local craft shop and bought a couple of balls of wool and a couple of crochet hooks.  I spent that afternoon teaching a couple of Emma's children the basics of crochet.  The next day Emma gave birth.  When I did my final postnatal visit I was delighted to see several of the children working on crochet projects.  They had found websites and learnt much more than I had showed them, and were already experimenting with colour and shape.

By the time Emma's next baby was born, the family had a couple of sheep, spinning wheels, and fleeces being spun, knitted and crocheted.  Emma gave me some of her homespun wool, the natural dark brown, as well as the white, and I have loved working with it, making shawls and squares.

Happy International Day of the Midwife

Today I am enjoying the global webinar
http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2012
[Recordings are posted at this site when the presentation has been completed]

At present there are 100+ guests logged in, and Prof Lesley Page has given the first lecture.
Lesley said:
The world needs midwives who can practise to the full extent of their power now, more than ever.

[I will add links and my comments as the program proceeds]
One world birth - Go to this site for video interviews with outstanding leaders in the childbirthing movement around the world, and much more!

http://www.facebook.com/HumanRightsInChildbirth/likes 

Lisa Barrett from Adelaide, South Australia addressed the topic Birthing at Home Regardless of Risk: Educated Choice or an Extreme Sport?. This presentation is significant in the homebirth midwifery terrain that we are progressing through today. Lisa's position is, in my opinion, one end of the spectrum that spans the childbirth-midwifery-obstetrics debate. Yet Lisa is paying the price for her idealism, in that she has relinquished her midwifery registration and is now identifying herself as a birth advocate.

Michelle Zimmerman from Sydney spoke about her vision for 'WOMBS' a Women’s Birth Society: the Social Maternity Model That Returns Childbirth to Women and Their Local Communities.  I envy anyone who can work to the principles that maternity 'care' should be provided in group settings, in which women gather around each other for support and nurture, and in which the midwives work alongside other women in a volunteer, non-heirachial, unstructured way.  This sounds like the ideal 'village'.  Unfortunately it's not the world in which I live and work!

Kate Emerson, presented Nuchal Cord: Ritual and Routine, in which she explored her own experience and the literature, looking at the training midwives receive to routinely check for, and then intervene in, the presence of nuchal cord - and how this may contravene the midwifery model of care and commitment to evidence-based practice. Women’s experiences of nuchal cord management are explored in this session, along with a discussion of the more serious outcomes associated with routinely cutting a tight nuchal cord.

The presentation by Dr Rafat Jan, Associate Professor, School of Nursing and Midwifery, Aga Khan University, Pakistan is a very worth-while presentation. Midwives in Pakistan would appreciate support from midwives in other countries. The wonders of technology are there to be used! I will add information here, and look forward to virtual meetings with some of my colleagues in Pakistan!

Anna Maria Speciale, Midwife, Research Associate, Instituto de Cooperación Social Integrare, Barcelona, Spain addressed the United Nations' H4+ High Burden Countries Initiative (HBCI) See the report Delivering health, Saving Lives
 

[I spent about 9 hours in the virtual meeting as it went to air, and I look forward to listening to the other presentations.]