CHANGING HEARTS AND MINDS

Or, Why continuity choice and control are not enough

Sue, whose life-changing experience of giving birth to Jack last year, wrote: “And also for me, what is missing, is the focus on the heart. There is birth education out there, but too much of it misses the heart, getting women back in touch with themselves, their inner voice, and waking that up.”

Sue, I totally agree.

The message that women want the three C’s, continuity choice and control, emerged in the UK with the publication of the House of Commons Health Committee’s Report on Maternity Services (1992). Together with the Changing Childbirth Report (1993), these documents set out an agenda to make maternity care more woman centred, to facilitate midwifery care for homebirth as a standard option for well women, and to normalise childbirth in the UK. Caroline Flint (1993) published the book ‘Midwifery teams and caseloads’, with the frequently repeated mantra in words and pictures “get to know her”. Continuity of carer – a caseload - became a goal for many midwives.

Women told the Health Committee that they want *choice* of care and place of birth. I and many other midwives and birthing activists have chorused ‘choice’ since that time. Yet choice is a slippery entity that easily moves out of reach when in reality the availability of a particular model of care, or a place in a birth centre or even birth at home is easily overruled by other factors. Furthermore, I am sad to acknowledge that in recent years the pendulum has swung in the other direction, with women ‘choosing’ elective caesarean surgery.

Women expressed the desire to have *control* over their own bodies at all stages of pregnancy and birth. Of course, this element is readily agreed to by the midwifery profession, and supportive theories of partnership and cultural safety have emerged. Yet midwives know that the natural processes in giving birth demand a surrender or relinquishing of mind control so that the deeper hormonally mediated forces in a labouring woman can act unhindered. French obstetrician Michel Odent has written books and papers, and taught the midwifery profession about the importance of subtle hormonal influences at all times through the childbearing continuum, and the first year of a child’s life. The term ‘undisturbed birth’ is now used for a birth in which the mother is able to progress without interruption. But a mother in advanced labour, in a quiet, familiar, unstimulating space, cannot give any attention to control. The mother who feels a strong need to control may instead choose regional anaesthesia or even surgery, rather than allowing herself to go “out of control” in a powerful hormonally driven state.

With my mind juggling these thoughts I read the new issue of Women and Birth, the journal of the Australian College of Midwives (Vol 21:2, June 2008). New Zealand midwife Joan Skinner’s Editorial titled ‘Risk: Let’s look at the bigger picture’ is a critical look at what more is needed to achieve better maternity care. “…we [midwives] in New Zealand, where the midwifery-led model of care is now the norm, are learning that autonomy and continuity of midwifery care are not, of themselves, the solution to the rising intervention rates in birth. Despite having developed a strong and autonomous midwifery profession, which now provides most primary maternity care, we have not succeeded in making a significant dent in our risk framework. Our intervention rates and our medico-legal environment attest to this. …we need to FIRST attend to changing hearts and minds, not JUST the model of care. We need to open up to possibilities of collaboration with others, rather than focusing on professional autonomy.” The writer suggests that midwives, in seeking to turn the tide of maternity care from a techno-rationalist to a truly woman centred care, need to engage with other knowledge frameworks, including biosciences, human geography, and architecture.

While midwives can strongly assert our role as guardians of normal birth, and can seek to effect this through primary care caseload midwifery, we do not have ‘ownership’ of the birthing terrain. Neither, for that matter, does the mother, although her ownership of her own body and her experiences is supremely important in a functional society. The whole society has an interest in the next generation, and whether a person is looking from the perspective of a sociologist, an architect, or a farmer, their knowledge is valuable to the society’s provision of services around birthing of children.

Without changing hearts and minds of pregnant women, future parents, fathers, grandparents, hair dressers, shop keepers, and people in all ages and stages and walks of life, the midwife’s skill in promoting and protecting normal birth will not be valued.

HOMEOPATHY in midwifery

Joy Johnston

[This original article was first printed in MIDIRS Midwifery Digest, vol 18, no 2, June 2008, pp 185–187]

Introduction

Complementary therapies which offer treatment alternatives in pregnancy and birth have been welcomed by many midwives and by women in our care (Tiran 2000). This is particularly so for those who seek to work with and protect the healthy natural processes in birth.

The increasing interest in, and availability of complementary therapies has led to Governments in many countries increasing the statutory regulation of alternative health practitioners (Williams et al 2004). This includes implementing systems which seek to protect public interest by registration of members of the professional group, accrediting courses of education, regulating products, and investigating and acting on claims of professional misconduct.

This article will focus on the use of homeopathy within the current maternity care system and will debate some of the issues that should be of concern to midwives who need to look objectively at the claims of homeopathy, and be conversant with the current, reliable advice and interventions as part of their recognised professional practice and accountability.

A brief history of homeopathy

Homeopathy was first developed and promoted by German physician, Dr Samuel Hahnemann (1755-1843). Both proponents and opponents today agree that, regardless of their ability to cure illness, homeopathic treatments were and are likely to do less damage to ill people than many of the practices carried out in the name of conventional medicine at that time. These practices included bloodletting, purging, and blistering. Homeopathy has been called, with good reason, a ‘kinder, gentler medicine’ (Stehlin 1996).

To give context to Hahnemann’s revolutionary theories, he lived prior to the emergence of knowledge about bacteria, viruses and infection. In 1847 Semmelweis identified surgeons’ hands as the route of spread of puerperal infection, and in 1865 Lister developed his system of hand washing and asepsis. (Parker 2008) It is likely that patients of Dr Hahnemann and his followers fared significantly better than those who received the other treatments on offer at that time, and it would not have taken modern statistical methods to observe the difference!

Homeopathy today uses language and concepts that may have been more familiar to the European world of the late 18th and early 19th century, than contemporary concepts and languages. Words such as ‘remedy’, ‘proving’, ‘potency’, and ‘potentisation’ have special meanings in homeopathy (Jones 2007). ‘Repertories’ and ‘rubrics’ list illnesses, symptoms, and treatments. This use of language may be seen as quaint and distinctive, alternatively the same impression may lead one to question the currency, in terms of effectiveness, of homeopathic theory.

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[Readers who would like the .pdf version of this complete paper may request it joy@aitex.com.au]

Emma Flaim's Mother Series - Lino prints 1&2

These lovely lino prints have been added to my collection of birthing art and photos. Anyone who knows me may even see me in one of them! Thankyou Emma for your work. Joy

Emma Flaim's Mother Series - Lino prints 3 and 4

Fair go!

I met with Jackie, who is having her first baby in a few weeks’ time, and she expressed frustration and dismay. How is it, she asked, that noone had told her she could have a midwife working solely with her when her time to give birth comes? All these months, visiting the obstetrician, booking in at the hospital, and going to the hospital for prenatal classes, and the idea was not once discussed. Last week she was told that the hospital midwives would come and go when she was in labour – their shifts might change, and they would have to help out the other midwives in the birthing suite. Fair enough, she said, but what about me? Then she talked to Margie, the midwife who works for her obstetrician, who suggested she find an independent midwife.

The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services. A caesarean rate of over 30% is unreasonable (see blog entry Sunday, May 18, 2008 IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS? for discussion). Caesareans that are performed without a valid reason, or because the service has failed to provide appropriate care, leave too many mothers and babies distressed and separated at a time when they need to establish strong attachments; placing many mothers and babies at higher risk of serious illness or death than they would have had in giving birth naturally; increasing the pain and depression experienced by mothers postnatally and restricting their ability to move. It wastes precious resources in hospitals – resources of staff and facilities that should be available for those who truly need specialist doctors and surgery.

During the past couple of decades I have worked hard to address the inequities in maternity care. I am seeing some progress – ever so slowly. Perhaps a reasonable benchmark for progress would be when every pregnant woman, regardless of risk status or wealth or expected place of birth, is given the opportunity to choose a midwife who will be with her as the primary maternity caregiver. After all, a midwife is with virtually every woman giving birth: why should the system not cater for the woman who wants to know that midwife?

In the late 1990s I was working part time for the Victorian branch of the Australian College of Midwives, and we encouraged midwives to be active in lobbying the Nurses Board for a Code of Practice for midwives, which was introduced in 1996 with the sunsetting of the Midwives Regulations. That Code acknowledged the International Confederation of Midwives’ Definition of the midwife for the first time in this State, a definition that clearly declared the professional scope of practice of the midwife, working in partnership with the woman, providing woman centred care, collaborating with other professionals when appropriate, and being competent in provision of primary maternity care that protects the wellbeing of mother and child.

The Australian government had brought legislative reform to prevent anti-competitive monopolies, and within this reform agenda called for various reviews of legislation, including the laws regulating provision of health services. I prepared several responses for the College of Midwives, arguing that government funding for maternity services, through Medicare and hospital funding, unfairly excludes midwives from acting as midwives and providing maternity care. The medical monopoly of funding forces women into models of care that are likely to result in medical and surgical management, without improving outcomes for mothers or babies. There was good evidence then, and much more now, demonstrating the effectiveness of midwives working at the basic or primary care level throughout the pregnancy-birthing continuum, and referring women to specialists if and when the need arises. There is no evidence supporting specialist obstetricians as primary carers.

Our arguments were sound. New Zealand maternity services had, in the early 1990s, undergone major reform, and our colleagues across the Tasman were moving into independence and autonomy, with equal pay for midwives and doctors who provided the same service, that we only dreamed of. But although our arguments made sense, the political ‘buck passing’ from State to Federal health departments, and back again, seemed to extinguish any hope for reform as soon as it appeared.

In 1985 the World Health Organisation (WHO) had published the Fortelesa Declaration, addressing appropriate technology in birth. This document became the launching pad for activity by WHO and international professional bodies to address the evidence supporting practices in maternity care. The Cochrane Collaboration (http://www.cochrane.org/ ) was established in 1993, looking initially at evidence based practices in obstetrics, and moving quickly to all health care interventions. Early research demonstrated the beneficial effect of continuity of care by a known midwife, and other aspects of midwife primary care.

The College of Midwives had, in the mid 1990s, formed a partnership with the emerging political lobby group Maternity Coalition. Our projects included a Midwifery Campaign, demanding ‘choice’ and ‘access’ for all women: choice of caregiver and place of birth, and access to models of care that enabled this choice. Soon after the turn of the century a group of consumer activists and midwives in Maternity Coalition, under the leadership of Barb Vernon from ACT and Tracy Reibel from Perth, prepared the National Maternity Action Plan (NMAP) as a framework for maternity reform. This document received widespread support, and not a little criticism, and put pressure on government health departments to address the inequity in maternity service provision, particularly for women who wanted to give birth naturally.

In the early 1990s the Baby Friendly Hospital Initiative (BFHI) was born, with its goal, the protection, promotion and support of breastfeeding. The essence of the BFHI was a world-wide program auditing maternity hospitals, using the ‘Ten Steps to successful breastfeeding’, on their practices which either supported or hindered the establishment of breastfeeding by mothers and their newborn babies. The BFHI is a major health promotion activity, which restores for women their natural authority for breastfeeding and protecting the health of their children.

When addressing breastfeeding it is logical that mothers, and midwives, will see the obvious connections between pregnancy, birth, and the nourishment and nurture of the infant. Why enable mothers to take responsibility and authority for their breastfeeding, and not their birthing? Midwives, being ‘with woman’, are able to do just that.

Internationally there was an awakening of midwifery, with midwives and women calling for reform, a ‘fair go!’. In the USA, the Coalition for Improving Maternity Services (CIMS) (www.motherfriendly.org) developed the Ten Steps of Mother-Friendly Care, in many ways projecting the BFHI into the fuller context of maternity care. In the UK maternity activists and midwives were promoting normal birth; and home birth received support at government report levels. Everywhere in the developed world caesarean rates were on the rise, while mortality rates in developing countries were shockingly high. That is still the case today. There is still much to be done. The world we bring babies into is not, on the whole, offering a fair go – for mothers, babies, midwives, doctors, or maternity services.

A new and troubling element has asserted itself in the modern maternity terrain. The ‘choice’ of Caesarean birth: “too posh to push”; “honeymoon vagina”; and “I don’t want to sag down there and spoil my sex life” are a few of the reasons given. It seems that in this topsy-turvey world we live in, the consumer’s choice of major abdominal surgery is more readily provided for than the choice of the mother who simply wants to give birth naturally. A booking can be made in the hospital; all the needed personnel and gear assembled; and ‘bob’syouruncle!’. Well organised and delivered on time. Much more reliable than the mystery journey of natural birth, when labour comes like the thief in the night, and progresses according to mysterious rules and secret forces that cannot be controlled.

In promoting consumer choice, have we encouraged women to short-change themselves by opting out of one of life’s most amazing and healthy processes?

When women 'choose' models of care and interventions (such as induction, drugs, epidural, or surgery) the hospital is able to give that, and has a satisfied customer. I think this is the down side of the 'consumer choice' message. I believe there is an ethical argument that in maternity care the service providers are bound by the 'no harm' imperative to support and protect normal birth, and NOT to interfere without a valid reason. I believe caesarean should not be done on demand.

The core rationale behind the CIMS 10 steps is enabling women to give birth safely and naturally without medical help unless there is a valid reason. This is good, but can't happen unless women actually accept it, and are then able to progress undisturbed (allowing their bodies to do the work) with trust in the care provider who is leading the professional care decisions. That's where the primary carer's role becomes critical. Without models of care where the midwife and woman are able to work in partnership and protect normal birth, it’s unlikely that the increasing tide of caesareans will turn. We have plenty of proof that the status quo is not achieving the protection of normal birth.

I want to see a fair go for all concerned - the service providers, midwives, doctors, the consumers (mother and baby), the family and society, and policy makers. We will only achieve this when the consumers and the professionals work together to provide maternity care that values the wonderful natural processes in birthing, and uses technology appropriately for all who need it, not just for those who can afford to buy it.

WHAT CHOICE DO I HAVE?

I remember my first meeting with the obstetrician in his rooms in Melbourne, when I was pregnant for the first time. I came dressed nicely, and my husband Noel accompanied me. Noel was asked politely to wait – he would be invited in to meet the doctor after he had performed his examination. I was instructed to take my clothes off, to don the white examination gown, and lie on the firm narrow couch. My abdomen and breasts were palpated, and my vagina pried by a man in a grey pin-stripe suit, a crisp white shirt and a bow tie, which was the standard attire for men of such professions at the time. I was then asked to dress, and the doctor would come back and speak to me.

Innocently I informed the doctor that I was a midwife, and that I wanted a natural birth. He gave a reply that I understood as ‘we shall see’. At some pre-determined moment Noel was invited into the interview, sat on a chair next to me, and he asked some question.

“Mrs Johnston and I have already discussed that” was the reply, in a dismissive tone that indicated that the deal had already been done, so he need not exercise his mind on it.

My ‘choice’ to plan to have a natural birth was, I thought, simple. Young people today would call it a ‘no brainer’. Many of those same young women today go into maternity care with the same degree of innocent trust that I had. And many experience the authoritarian conquering power of the obstetrician who looks over her glasses and says “We shall see!”

If we stopped to assess the quality of the offered service by asking questions such as “How many first time mothers in your practice last year experienced uncomplicated, unmedicated, spontaneous birth?”, we may discover that this person is not skilled at protecting normal birth. And why should they be? They are surgeons whose education and registration prepare them as specialists, most with very little knowledge of working in harmony with and supporting natural female rhythms.

It’s as though we have blinkers on our eyes. We wouldn’t go into buying a house or a car or even a pair of shoes with the same lack of critical thinking that we seem to easily adopt when it comes to having a baby, which is surely the most significant investment of time, energy, and every other resource at our disposal that we will ever experience.

This past Sunday evening there was a segment called ‘Birth Choice’ on Chanel 9’s 60 Minutes. I watched it and became increasingly more distressed as time went by. The show presented two extremes, DIY homebirth, without a midwife, compared with the ‘too posh to push’ caesarean birth on demand. It was sensationalist and misleading not a rational or responsible presentation of the choices a woman faces in birth. Presenting the opinion of an obstetrician on homebirth is similar to asking the manager of a nursing home about parenting issues. Uninformed!

I want to be fair in my criticisms – the filming of the homebirth was done in a respectful and delicate way. It was a spontaneous, uncomplicated, unmedicated birth in water, and the baby was in excellent condition, which is what I would have expected. Yet I felt sympathy for the un-midwifed mother, who was under the prying eye of the video camera, and had noone who had the knowledge or skill to say "You are well; your baby is well. Take this beautiful little girl into your arms and love her." The mother was concerned about her blood loss after the birth, and went to the hospital. I hope she was midwifed well there.

I cannot understand the woman who chooses major surgery - surely she has been sold a lie? The notion of keeping things tight "down there". Oh dear!

There are some mothers and babies who have needed and accepted surgical births, and who are thankful for the 'good' outcomes. I am also thankful for good outcomes. This is also a 'no brainer'. But I have also seen the women who have suffered surgical complications - infections, retained swabs, drug errors, haemorrhage, impaired clotting, pain, and a great deal of psychological trauma of separation and disturbed bonding. These are not good outcomes.

It is with this knowledge that I will continue to work to protect and promote healthy natural processes, and support normal birthing when ever I can. I believe we have only one real choice - that is, to either work in harmony with our healthy natural processes in pregnancy, birth, and parenting, or to ignore them. Medical options at present in developed countries like Australia offer surgical options which come at a cost. It is important, I believe, that the cost as well as the potential benefit of avoidance of natural birthing be understood before choices are made.

HOW DO WE RECLAIM OUR BODIES?

This question is prominent in my mind as I reflect on my meeting yesterday with a wise woman of the Yorta Yorta people in central Victoria. I won't use her name until she has read what I have written and gives me permission. But what I want to say does not refer uniquely to indigenous women - it's about all women. How do we reclaim our bodies? How do we reclaim our right and privilege, as women, to give birth to our children and to nurture them at our breasts?

We sat together for several hours, and talked. A few years ago there had been a proposal for a birth centre, where indigenous and 'non-i' women could give birth. That proposal was not accepted. There is a centre where indigenous women have prenatal care from midwives and doctors, but that has not improved births for many - the rates of caesarean are high, and women come away from the birthing experience feeling shamed and distanced from their own bodies.

As we chatted a baby woke up and was hungry. Her mother was busy, so I held her close and held the bottle of white stuff. While enjoying the exquisite beauty of the little one in my arms, I could not feel anything other than sadness that she is not able to draw nourishment and warmth from her own mother's body.

The wise woman is an elder, mother, grandmother, aunty, and sister. She has sat on many committees, representing the voices of her people to government and community bodies. She is sad that her people have lost their knowledge of what was done in birth before white people came. She is sad that her daughters are feeling shamed in stead of feeling powerful in giving birth. She is sad that the beautiful breasts of these women are hidden away from their babies.

What could we do? Is there anything that can be done to enable these women to reclaim ownership of their bodies?

We talked about birth centres. Birth centres can be good, with a philosophy of protecting and supporting healthy normal birth, but there is a high rate of transfer for complications. The women who are transferred out to standard obstetric care can feel abandoned.

We talked about the midwives. Some midwives come, and try to provide better and more woman-centred care, but ... They leave after a while.

We talked about surveys, reports, summits, and funding from government departments. The wise woman looked tired, and I felt dispirited - we have been there, done that. Nothing much has changed.

Then we talked about women's business. The older women helping the younger women to give birth, and care for their babies. Spaces where only women could go. A house where they could come and learn to express themselves in arts and crafts, and tell their birth stories. A house where they could feel safe as their labours become stronger, with their sisters and aunties to encourage them. This could be a key to reclaiming their bodies.

The wise woman said she would like women to get together in a women's space and take their shirts off. They could keep their bras on if they wanted to, but you have to start somewhere. This was a new thought to me. I asked her why some of her sisters in the Centre are now having ceremonial dances with their breasts exposed. It's something that they have done to reclaim their culture.

We didn't talk for long about this, because something happened to interrupt our train of thought. But a seed idea had been planted in my mind - is this another key to reclaiming our bodies? What would happen if these women reclaimed their breasts? The older women could lead in ceremony and ritual, and encourage the younger women to cherish their breasts. What would happen if the mothers allowed their babies to find their breasts? What would happen if the mother of this bottle fed baby asked her baby to take her breast once again? I believe it could be done.

When we asked the woman at the BaBs group [http://www.birthingandbabies.info/index.html ] what they valued in the BaBs program, one said, "I can see other mothers breastfeeding. I can see other breasts!"

I believe the only way any woman can improve her chances of avoiding caesareans, epidurals, and other medical management of birth is to take responsibility for their own birthing. I call it Plan A "I intend to give birth under my own power, without drugs or stimulants, and I ask everyone who is with me to respect my plan." The woman herself has to be strong. The wise woman said that in the old days women had to be strong. They had to keep up with the group. There were no short cuts.

We need to return to those old rules for anyone who wants an opportunity to give birth. The non-i women don't need to learn the ceremony of other people groups, but we do all need to claim back the ownership of our bodies.

Early Learning

Alina has a daughter, Dina, who is a bright, energetic three year old. I am using their real names, with Alina's permission, as it would be difficult to tell their story without giving some of the detail of this family.

Today, after the birth of Alina's beautiful new baby girl, I noticed Dina looking intently at the placenta in the green plastic kidney dish on the floor. Immediately I understood - she knew about the placenta. So I held up the umbilical cord and Dina looked very pleased. Later, when I was putting away my equipment, Dina was interested in the Laerdal bag and mask resuscitation kit. Dina knew about that too!

Dina and I can't understand each other's language - she speaks fluently in Russian, and in Japanese too I think, but not English. Fortunately, Dina's parents speak English very well.

Having moved to Melbourne a couple of months ago, their priority was to be ready for the birth of this little one. They are living in a furnished unit, and waiting for their boxes to be delivered from the wharf.

As Alina and I talked and prepared for the birth, little Dina was with her mother. One day I loaned Dina a copy of 'Hello Baby' [http://www.capersbookstore.com.au/scripts/shop_item.asp?by=cat&item=2229], and I read it to her in English while Alina translated into Russian. Alina has told me that Dina has had the story read to her every day since!

It would not have been surprising to Dina when she heard her mother's noises - 'singing' an ancient and wordless song that rises and falls with the power of the new baby's progress. Dina understood that her mother was doing something wonderful, important, and very demanding; and that she had her daddy home from work today to look after her. Dina knew that the placenta came after the baby, and was happy to check it out. She had also seen a picture of the midwife's resuscitation equipment in 'Hello Baby'. She knew that her mummy needed to rest with this new baby sister, who was very hungry and needed to take mummy's milk.

Alina called me thismorning to let me know that her labour had begun. Today was 42 weeks - 'post-mature'. We had waited for spontaneous onset of labour, and Alina was confident that her baby was well. She had agreed to go to the hospital tomorrow for monitoring, but that won't be needed now.

Alina was lying on the bed, curled up in that excellent left lateral position that is so good in advanced labour, when I arrived at their house. I did not know what Alina would be expecting from a midwife. Dina had been born in Japan, and it seemed from what Alina told me that she had given birth spontaneously, and that the hospital staff had done their job around her, without really making any connection.

I sensed that she did not have long to go - she was focused and the contractions were powerful. After a while I asked if she was feeling any pressure in her bottom. She wasn't sure, but decided that was possible, so she got up and knelt beside the bed. With the next contraction she felt the baby move. Another and the waters broke. A couple more and she birthed her daughter through the intense pain. Baby was fine, and lay on the mat below her mother until Alina was ready to take her in her arms. It was a beautiful, normal, undisturbed birth. The baby took the breast and stayed there for the next hour or so. The placenta came away about 1o minutes after the birth.

After finishing my paperwork I was enjoying the quiet bliss that seemed to radiate from Alina. I mentioned that there was no hurry to bath the baby - it could be done when they felt like it. They were surprised - it had seemed such an important 'next' in the list of activities last time. "No, it's just a ritual. She's not dirty," I said.

There is so much that is just a ritual in birthing. I want to hold on to the important parts - the freedom to sing the birth song, and to share birth with a three year old, who understands it all so well.

IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS?

Since the federal Treasurer announced the new budget a few days ago, there has been a lot of public comment about the changes to Medicare, and the anticipated exodus from private health insurance. The income threshold for the Medicare levy will rise from $100,000 to $150,000 annually for couples. The Sunday Age today proclaimed on the front page that "Medicare blunder could cost $1.76bn".

I wonder if anyone included in the sums the reduction in claims on the Medicare safety net, whereby uncapped thousands of dollars are shifted from the public purse to the pockets of private obstetricians for every pregnant woman booked with them? I wonder if anyone has assessed the expected reduction in costs when women who would have booked in private obstetric care, thanks to their private health insurance arrangements, move into public maternity care? I wonder if anyone has considered that women and babies may be better off when they give birth in public maternity services?

I am not opposed to private health care per se. If I was sick and needed a stay in hospital for any reason I would prefer a private room to a busy shared 4-bed ward. I would prefer the food at Frances Perry House to that downstairs at the Royal Women's. These preferences seem obvious to my mind. I would prefer to be admitted under a doctor who respected me as a person, and did not treat me as the next case (not necessarily the case in the private-public debate, but we often have confidence in a known doctor over the unknown).

However, the fact is that most women who are having babies in private hospitals are not sick. They are victims of the 'inverse care law' - that those who least need the care receive the most. Obstetricians are medical specialists: surgeons. It is no wonder that they like to perform surgery rather than work in harmony with unpredictable female natural processes. They have no expectation to accept normal birth, whereas midwives are, by definition, expected to protect normal birth.

I have been looking at some of these figures.
There is some evidence that within Victoria's public maternity services efforts are being undertaken to reduce unnecessary intervention into normal birth. The Vic Maternity Services Performance Indicators have been published annually since 2002. The statisticians have looked at what happens to 'standard primipara' - healthy women aged 20 to 34 years, giving birth to their first baby, with no complications prior to the onset of labour. In other words, the mothers who are healthy, young, and least likely to have problems in birth. The rates of Caesarean births for standard primiparae in public and private hospital care are 18.5% and 26%.

Overall Caesarean rates in Victoria have in the past decades been rising by about 2% each year, and are currently around 30% -- 27.7% of all public hospital births, and 37.3% of all private. (Source: Hospital profile of Maternal and Perinatal Data, Victorian Perinatal Data Collection Unit, 2006). The most common reported indication for Caesareans is a previous Caesarean. It is logical that as the number of primary Caesarean births increases, the number of repeat surgeries will also increase.

I now ask the question, how many women who have private health insurance, and have their babies in private hospitals, are likely to move to public hospital care as a result of the provisions of the 2008 Budget? How many Caesarean births will be avoided by this exodus?

Here are some figures to consider:
In 2006 there were over 68,000 births in Victoria: 43,800 public and 24,500 private.
If 20% of the private hospital bookings moved to public, approximately 4,900 women would move from a 37.3% risk of Caesarean surgery (n=1,828) to a 27.7% risk (n=1357). On this calculation 471 women would avoid Caesarean surgery in one year.

That might sound like a small number out of almost 70,000 births in the year, but to those women, it would be hugely significant. And if some of those women who avoided the primary caesarean were giving birth to another child in a couple of years' time, the relative ease of the second vaginal birth should not be forgotten.

I’m not saying that a 27% risk of Caesarean birth for ‘standard primipara’ in the public system is acceptable. By no means! West Gippsland Hospital at Warragul has had a strong focus by midwives and doctors on reducing unnecessary Caesareans, and their rate for the same time (standard primipara, 2006) is less than 10%. But I am saying that 27% risk is preferable to a 37% risk when comparing like with like. Fewer maternal complications in this and subsequent pregnancies; fewer babies needing to be separated from their mothers at birth; fewer women developing postnatal depression; and so on.

Perhaps the changes are going to cost the government a lot of money in revenue, through raising the Medicare levy threshold. It's likely that private health insurance companies will feel the strain of reduced numbers, and reduced premiums paid into their coffers. It's also likely that the private hospitals and obstetricians will object to reduced business. It's possible also that the overcrowding of public maternity hospitals will reach a peak in the coming year. Some public hospitals may actually consider offering homebirth in an effort to ease the congestion in their wards. Am I dreaming? It sounds to me as though mothers and babies will do well out of the Budget.

WAITING PATIENTLY
One of the big issues in having a caseload, and accepting nature's timing in birth unless there is a clear reason to interrupt the natural processes, is that I have no way of knowing when babies will come. The booking dates on my calendar do not tell me when or in what order the mothers and babies who are important to me as my 'caseload' will make their individual claims on my time and skill. I know I will have periods of waiting, as well as times when several babies are needing to be born. This is beyond my control, and my Christian faith allows me to trust not only that my Heavenly Father cares for me and wants to guide me in all the events in my life, but that each new baby is in God's care. There are times when I am tired, and I ask God specifically for strength, wisdom, and understanding as I do my work. In a post-Christian society this concept may be unpalatable to some, but it's very real to me.

This past week I have been busy, with a baby born at home on Tuesday, and twins born in the hospital on Thursday. Today I want to reflect on my emotional journey: waiting for each labour to establish, and being 'with woman' as she labours and births. I will call the mothers, in sequence, A and B - Anna and Beth. Although their due dates were more than a fortnight apart, it became clear that they would both be needing to give birth soon.

Anna's pregnancy had reached 41 weeks when she came into labour with her first child. The waters broke late Monday night, and her labour got started. I had a phone call in the wee hours, and went back to sleep after reassuring Anna, and encouraging her to rest if she could in this early stage of her labour. By the time I saw Anna in the late morning she was labouring well, on all fours, and feeling weary. I didn't want to in any way interrupt what was happening, so I sat in the other room with a cup of tea and my crochet. I encouraged her to be upright, and she progressed quickly. At one point she came into the room where I was, and she saw that I had my crochet, and the gear that I bring to a birth, set out and ready. Anna's baby was born beautifully in the birth pool a couple of hours later.

The principle of undisturbed birth, as I have learnt it from practice, and from readings, was confirmed again. Protecting and promoting normal birth, and working in harmony with the natural processes, requires the mother herself to accept and work in harmony with her labour, as much as it requires the midwife to be quietly protecting the space the mother is in.

Beth's twin pregnancy had progressed well and was now at about 39 weeks. Beth was receiving prenatal care from the Royal Women's Hospital as well as from me, and she had prepared her birth plan carefully and discussed it with the obstetric and midwifery consultants at the hospital. Beth's plan was that she wanted the opportunity to progress naturally and give birth to her babies without interference. This sounds very logical and reasonable, but is very different from the way most twins are born in that or any other hospital today. The decision to go to the hospital for the birth, rather than plan homebirth, was one that Beth had made, after considering the information she was able to gather about twin births. I had been her midwife for her first birth, at her home.

Earlier this week Beth came under increasing pressure from her obstetric carers to have an induction. The ultrasound had suggested that the second twin was smaller than the first, and *might* not be growing well. There is a widely held belief, which I think is a myth, that twin placentas will age more quickly than singleton placentas, and that it's not safe to let twin pregnancies progress to Term. This decision point - to intervene in the interest of one of the babies - became the challenge that Beth, and as her midwife and advisor, I faced. Beth found a recent article in an online journal which seems to challenge the ageing placenta theory. (See http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijpn/vol5n2/twin.xml)
I found this article useful in understanding the big picture, yet I was also wondering if the artificial rupture of the membranes for the first twin was really such a big deal. Beth also seemed to waver in her commitment to trusting and working in harmony with the natural process. We all knew these babies would be born soon. Perhaps we (Beth and I) should be more pragmatic and accept the induction? I assured Beth that the decision was hers, and that I would support her no matter what. I also encouraged her (and encouraged myself) to value spontaneous onset of labour, or at least natural onset of labour.

It can't be called truly spontaneous, as Beth proceeded with the less medical options - acupuncture, nipple stimulation, then a dose of castor oil. On Wednesday afternoon, after the castor oil, she felt regular contractions, but not labour. The booking at the hospital for induction was for Thursday morning. On Wednesday evening Beth called the hospital to say she did not intend to come in for induction, and took more castor oil. Labour became established; we went to the hospital after 6.30am, and the babies were birthed, seven minutes apart, an hour later. It was a 'normal' twin birth - there were none of the complications that we know are possible; no drugs were used; and Beth declined continuous monitoring, and an IV cannula. The second baby was smaller than the first, which is not unusual, but the placentas were healthy - no sign of ageing.

I have mentioned only fragments of the whole story. The record I want to put down today concerns my feelings as I waited for and attended these birthings. It's as though I have a parallel existence to the birthing woman - I need to 'nest' in those final days so that I am prepared for whatever happens, and I face transitions when doubts and fears arise and sometimes swamp me. I can't have a blinkered belief that 'natural is good', because I know that in nature there are many undesirable outcomes. I have to use my knowledge of the human body and birth to protect wellness, as well as to access the best medical services if they are needed. There is no clear 'black and white' in this decision making. The guiding principle is that in birth and nurture of the infant, there is no safer way than to work in harmony with the body's own natural processes, unless there is a clear reason to believe that the natural processes are not likely to lead to the best outcomes.

In both of these birthings, these women could have easily relinquished their authority and rights as the birth 'giver'. Anna's labour could have been induced for convenience, or for 'postmaturity'. Beth's labour could have been induced for this vague idea of 'ageing placenta' or 'non-reassuring ultrasound'. Once the woman submits to the authority of someone else, a doctor or a midwife, who reaches into her vagina to artificially rupture the protective membranes around her baby, it is very difficult for that woman to take back her authority for her own birthing. The hospital's expectations for progress and monitoring become the benchmark for decision making from that moment onward. The pain that the woman feels after induction is interpreted by her as different from what she feels if her body is taking her there naturally.

Again I have been honored to witness the power of women in their birthing. I hope many other midwives are able to work in this ancient and timeless model of care, and protect the authentic role of the midwife, being 'with woman'.

A Normal Birth
I attended a birth early thismorning, and as I had no apprentice midwife with me, I am going to try to set down an account of the amazing yet totally ordinary sequence of events from a midwife's point of view. Some of the readers of this blog are midwives and midwifery students who are wanting to learn the specific skills of a midwife working with women in community settings, with the intention of promotion health and wellness, and working in harmony with the natural processes. I hope there is something in this account for you.

0200 - phone call from "Matt", "Jenny"'s partner - labour has started. Jenny came to the phone, "Yeah, they're about 10 minutes but they're str --- just a moment --- (quiet focused breathing) --- strong."
"I'm on my way. See you soon," I said.
I drove through the quiet streets, and covered the 35 or so Kilometers quickly.
I had seen Jenny a couple of days ago. She was unsure of her dates, and an ultrasound at 25 weeks had set the due date at 2 weeks ago. That day came and went, and Jenny and I felt confident that there was no cause for concern. The baby would come.
0300 - I arrived at the home, in a beautiful bushland setting on the outer metropolitan fringe. Jenny was working quietly in her dark bedroom, and the birth pool in the corner was being filled. Jenny's mother had a wood fire going and made me a cup of tea. In one corner of the main room I opened up my gear, connected the oxygen cylinder flow meter, and took out the paperwork. The basics needed for any birth are quickly put out - the pack of instruments (sterile scissors and metal cord clamps) in a big green plastic kidney dish; a pair of sterile gloves for an internal exam if needed; procedure gloves for catching the baby, and handling blood; a plastic cord clamp; the oxytocics, syringe and needle.
Then I sat quietly with Jenny, observing her and getting a feel for her labour. During this time I use both my thinking brain and my intuitive brain. Just as mothers use their intuitive brain in undisturbed birthing, a midwife learns to partner that woman in a very real sense, going through the stages, emotionally and in a deeply connected way, with her.
Very little conversation happens - I ask "is baby telling you anything --- are you getting any kicks?"
"Oh yes, with the contractions."
The mother probably doesn't realise how significant those kicks, which she alone knows about, are. Her simple statement is reassuring to me. Healthy babies cope well with labour, and a baby that gives mother a kick during contractions is doing well.
"Are you happy for me to listen to your baby after the next contraction?" I ask. The heart sounds tell me what I already know.
Jenny got in the bath and said "Aaah, that's good". Her labour progressed quickly. By 0345 she was vocalising and saying "No, I can't do it" during the contraction, then saying to me "That's transition" after the contraction. The transformation of a woman at this time of peak adrenaline together with peak oxytocin and endorphins is marvellous. Then, as she was kneeling in the water "She's here!", followed by "help me." My hand was near her hand as the little head, then shoulders emerged into the warm water, and I lifted the baby gently to the surface.
It was 0400. Noone had seen the 'birth' - that's one of the special features of waterbirth. I shone my little torch briefly and confirmed that baby's colour was good. We waited for the best part of a minute while the newborn adjustments took place wonderfully, followed by a little cry and other movements. There was no hurry. This child was unstressed, peaceful, and well.

Jenny settled back into the water and rested, looking alternately at her beautiful daughter, and to her lover. I don't remember if anything was said. I was happy to just be there, in the background, keeping the space.
We had a comfortable arm chair set up next to the tub, draped with an old shower curtain, towels, and an absorbant pad. My notes tell me that Jenny got out of the birth pool at 0415. We supported her and dried her off as we assisted her to get out, while she held her baby to her breast. After a couple of strong contractions Jenny felt the placenta coming, and she moved forward in the chair. I received the placenta, with minimal blood, in the green plastic kidney dish. Together we checked the placenta, and Jenny and Matt felt the surfaces as I explained it. Jenny had decided not to cut the cord, so we wrapped the placenta in an absorbent 'bluey', and placed it near the baby.

In the next couple of hours Jenny fed her baby; I got the paperwork done; the two big brothers met their baby sister; we all had tea and toast with vegemite, honey, or peanut butter; photos were taken; more logs were put on the fire; and as Jenny snuggled up in her bed with her sleeping baby she asked me to close the door. I left the home confident that everyone was strong and well.

NO GUARANTEES
In birth, as in life, there are no guarantees. However, in birth, as in life, we can act in ways that are likely to protect health and wellbeing.

Today (Sunday, 27 April) I had a call at lunch time from a news reporter, Kelly Morgan, who wanted a midwife to comment on a story that is being prepared to go to air in the Channel 10 News tonight. The story is about a new ING life insurance for women to take out, with an option to insure future unborn children (there is a 12-month waiting period) against certain congenital malformations and disabilities, and even against ectopic pregnancy and still birth. My initial response to Kelley was that I had not heard of this, but could see from the insurance company's point of view that there is a market.

I had to do some quick thinking - do I agree to say something about this story, and if so, what can I say? Kelly wanted to take a cautious line, and suggested that this sort of product is capitalising on women's fear. Yes, I agree with that. But do I have anything useful to add?

There is no bigger investment that we will ever make than our own children. Those who have never experienced such loss can only imagine the sadness of parents who see disability or serious disorders in the child who bears their name. Taking out insurance is not going to change a mother's or a child's health - it's a financial risk management strategy. It will probably sell well in the professional market, particularly for women in their late 30s, who are aware that if they are ever to have a child they had better get a move on.

I told Kelly that the big issue in childbirth today is the increasing caesarean rate, and that more caesareans have not reduced the rate of cerebral palsy. It's interesting that cerebral palsy is not listed in the newspaper article (http://www.smh.com.au/text/articles/2008/04/27/1208743315952.html)

In agreeing to be interviewed on camera I got the opportunity to say a word about promoting health in pregnancy, and that the safest way to have a healthy baby is to avoid drugs and surgery if possible.

The interview was over as quickly as it had begun. The cameraman took a few more shots as we chatted, then they packed up and went. I hope the story that goes to air is able to give a clear message of health promotion in protecting normal birth.

post script: No guarantees when dealing with the media either! Most of what I said, particularly about promoting health in birthing, was not included in the piece that went to air. Never mind - nothing ventured, nothing gained.

My big idea
This weekend there are 1000 or so people meeting in Canberra for the 20-20 Summit. All the delegates have been sorted into 10 groups, and each group is supposed to come up with "one big idea and three concrete policy suggestions - one of which must be cost free." (The Sunday Age, page 1, today)
I am one of the thousands of ordinary Australians who was not invited to participate, and who could not have afforded to go anyway. But I did send my comments to the summit website a week or so ago.

My big idea is: PROMOTE HEALTH IN BIRTH

The three concrete policy suggestions are:

1. reform funding structures to enable mothers to choose their leading professional care provider, a midwife or a GP doctor, who becomes their known and trusted carer ('case manager') and seeks to be with the woman in labour and provides guidance through the episode of care. Restrict access to specialist obstetricians, so that only women who have complications are referred to obstetricians. This reform would not result in increased costs to the health system, and would possibly reduce costs.
   
2. remove restrictions to midwifery practice that prevent us from working to the full scope of our qualification. This is also cost neutral.
   
3. educate the public and the midwifery and medical professions in health promotion through protecting and promoting healthy natural processes in pregnancy, birth and early parenting. This would cost money, but the savings in terms of health expenditure would quickly make it worth while.
   

This is my submission to the 2020 summit. It could not be submitted until I reduced what I wanted to say to less than 500 words!

I propose reform of basic maternity services, thereby improving the health of mothers and babies, while at the same time addressing workforce issues, use of medical facilities, supporting communities and families, and addressing health promotion for all Australian mothers and families, including those in poorer socio-economic groups and indigenous peoples.

The key to reform of maternity is to understand that birth is not an illness (WHO 1996. Care in normal birth). Australia's mainstream maternity services in both public and private hospitals, which cater for over 99% of births, address the care of mothers and their new babies as though they are ill. The medical/hospital system is reasonable and functions well for those who are ill, but poorly for those who are well. In this brief submission I want to offer a solution rather than giving detail of what I think is wrong.

The main change that I propose in reform of maternity funding is to focus on the woman/pregnancy/birth as the unit, in stead of the current fragmented system of 'items' that can be used by doctors in providing out-of-hospital services, and the funding mix for acute care in hospital. New Zealand's maternity services have been reformed in this way since the early 1990s.

A pregnant woman has a definite and agreed need for 'basic' maternity care, which covers her pregnancy, labour and birth, and postnatal services for mother and baby. Pregnancy does not become chronic - there is a beginning and an end to every pregnancy. When this episode of care is without illness or complication, the care is 'basic', and may be provided in primary care settings without immediate access to operative facilities. When a woman or baby require special medical services for an illness, a complication, or other event which is outside the 'basic' services, the additional expert services can be provided by hospitals and specialists as they are at present. The additional specialist services do not require reform; the basic maternity services do.

The appropriate workforce in basic maternity care is midwives and general practitioner doctors with obstetrics education. Referral to specialist obstetricians and paediatricians is an essential part of basic maternity care. Reform of basic maternity services has been described in the Victorian government's 'Future Directions' (2004) policy for maternity services.

Australia's health system does not use the midwifery workforce appropriately. Midwives are predominantly employed as nurses who assist obstetricians in hospitals, and are restricted from practising to the full extent of their qualification. Appropriate care for women requiring basic maternity services is primary care through the pregnancy-birth-postnatal continuum from a known midwife who acts to protect and support wellness, and who refers and supports linkages to specialist services when required. This woman-centred collaboration is based on evidence for best outcomes, not only at the time of birth, but with ongoing social benefits.

Australia's caesarean rates are around 30%, and will continue to increase unless reform of basic maternity care is undertaken.

What kind of support do new mothers need?
This question has been thought about by people through time.
When my mother was having her babies through the 1950s mothers were kept in hospital for two weeks, and sometimes nursed in bed for much of that time. Sponge baths and bed pans were the norm. Life was regimented in Brisbane during the post-war baby boom, and mothers and babies were expected to perform on time in all activities including eating and sleeping. Visiting by husbands was strictly controlled, and older children did not visit mother or baby in hospital. Mothers returned home to the realities of their own lives - washing, cooking, cleaning, chooks, children, and whatever else. They apparently knew that their time in hospital was important for their recovery.

When my grandmother had her children in 1910 through the 1920s she initially went to a 'nursing home' or lying in hospital which was owned and operated by a midwife. That's where her first child, Halley, and the twins Frances and Frank, were born. Subsequent births were at the farm in Redland Bay. My father told me how he and his siblings were sent to their grandparents' home, and the midwife, Mrs Heinemann, stayed at least a week with 'Mother'.

When I studied midwifery in Melbourne in 1972, prior to the birth of my first child, mothers usually stayed in hospital about one week, with 10-day stays being not uncommon. The first few days were for resting and recovery, and many of the women spent a pleasant time, enjoying the food that appeared at meal time, the clean sheets, and the company. Babies were cared for in the nursery, and mothers who were breastfeeding were encouraged to take a sleeping tablet. Breast engorgement was very common. Breastfeeding rates were at an all time low then, and midwives made up jugs of a mixture of sweetened condensed milk and water (strengths 1 in 8 or 1 in 6 1/2) and gave it to the babies. Visiting hours were fairly strictly controlled, and babies were looked at through the glass window of the nursery.

When I gave birth to my first child, Miriam, in Michigan USA in 1973, I was keen to do it my way. I went home on the third day. That would have raised eyebrows back home, but the cost of hospital care in the US had hit hard, and short stays were common there. I did not observe any rules as to how long you should stay at home and be looked after. My babies were very portable from day 1: they breast fed and slept without regard to where they were. Noel did what he could to look after me for a few days, but I was much better at cooking and home management, so it wasn't long before I took over and he was happy.

When our second baby, Rebecca, was due, my mother came to stay with us in Michigan for six weeks. I still remember how wonderful her cooking was. Shepherds pie and mashed pumpkin had never tasted so good! I learnt a lesson then about mothers.

We managed without my mother for the births of the two boys, Paul and Josh, but I always remembered how good mum's presence was in those early days after Bec's birth.

This past year or so I have been in the Box Hill BaBS (Birthing and Babies Support) group, meeting each week during the school term for peer support of mothers in pregnancy and with their new babies. Many of these young mothers are isolated from their families, and a new phenomenon that they experience today is that many of their friendships are via the internet. They chat together in chat rooms and email groups, but rarely see each other. The beauty of a BaBS group is that it is face to face; it is a community.

One of the wonderful things that has happened with the BaBS group is mothers caring for one another. The women have organised themselves to support the new mothers in the group. They have prepared food, or just gone to visit that person and see if any practical help is needed. The significant act is that they are with that new mother, in person. They become her sisters, her friends, and that's what she needs.

What kind of support do new mothers need today? There's no one answer. What they need is a caring community that is responsive to them as individuals. This can't be done by email. It takes effort and time, and face to face communication.

PAID MATERNITY LEAVE
Today's newspaper brought an article renewing calls to the Australian government to introduce paid maternity leave. I haven't been following it closely, but I understand that the matter has been referred to the Productivity Commission, which will delay action for another year.

It happens that today is Easter Sunday, probably the most distinctive and precious day in the Christian calendar, when we celebrate the bodily resurrection of our Lord Jesus. I was sitting next to Noel in our usual place in the Presbyterian Church in Surrey Hills when my phone vibrated, and I went out to answer it. A reporter from Channel 7 news asked me if I would be happy to talk about paid maternity leave. I explained that I would be available to talk in about an hour, and the reporter said she would arrange a cameraman to come to the Church at that time.

I don't have answers to the questions about paid maternity leave. How many weeks, or months? Full pay or 80%? For all workers or just those with permanent positions? What about low-paid casual workers? What about struggling small businesses? Would they simply avoid employing any woman who looked as though she might be likely to want to have a family? What about mothers who are already at home with a couple of littlies, who with their husbands have made the choice to live on one income while they have dependent children?

I can only give my answer from the midwife's perspective, in promoting health for mothers and babies.

I am deeply saddened that our society does not value the work of mothering. I am sorry that many new mothers feel that they must return to work and forego their place as mother to their young children. In making the decision to return to work, leaving a young baby in the care of someone else, a mother has, to a greater or lesser degree, to deny her natural maternal instinct and bonding with her child. She has to interfere with the natural processes in nurture and breastfeeding, while her sister who is able to learn mothering becomes intimately involved in all aspects of her child's life, and enjoys the unique attachment between herself and her child.

We like to quantify things, so for the purpose of this discussion I am going to limit my comments to the mother-baby relationship in the first year of the baby's life. I say without a doubt that any society that cares about its future must support all mothers to stay with their babies throughout the first six months, as a basic essential. I would add that ideally mothers should be able to delay any return to regular work that requires separation until the baby has past her or his first birthday.

There's no milk like mum's milk. Of course there are breast pumps that can be used in the office, and mother-friendly workplaces provide suitable spaces for mothers to express milk and refrigerate it. But breastfeeding is not just x milliliters of a white liquid - it comes with warmth, and the smell and feel of a mother's body. It comes with the voice that the little one has known since her hearing began in the womb. It comes with the unique familiar environment that is home terrain for that child.

What I am saying is that breastfeeding is a relationship - not simply an act of transferring fluid and food from a mother's breast to her child's stomach. Exclusive breastfeeding, recommended for at least the first six months of life, cannot be accomplished without the mother and baby working together. There is no substitute food so uniquely suitable for babies as their own mother's milk. Breastfeeding is not an end in itself, but it is a key that opens the door to strong mother-baby attachments and focused parenting. The health promotion, both in terms of disease prevention, and protection of normal relationships, that comes when a mother is supported in developing mothering skills and attitudes, cannot be measured in economic and productivity terms.

There is no 'one size fits all' solution to the paid maternity leave question. I would like to see all mothers supported in their early parenting, not just those who have good jobs. Programs that identify socially vulnerable women, and provide trusted peer support as well as professional carers will enable many of those women to take action to improve their own health and the health of their families. I would like to see a government working from the principle of protecting and promoting and supporting mothers and babies in achieving optimal breastfeeding as an indicator of healthy communities.

This statement may have alienated or angered some readers. You may argue that some mothers can't breastfeed. That's true, for a few, and there are alternatives available. Some couples can't conceive a child the natural way, and there are alternatives which they may try, but noone would argue that the alternatives are equally as satisfying or fulfilling to the relationship as the natural. I hope you will continue exploring this issue, and thinking carefully and critically about the importance of physiological mothering. If you do not want to leave a comment on this blog you can email me joy@aitex.com.au .

THE ‘B’ WORD

Breech. A woman today whose baby is discovered to be presenting bottom or feet first (breech) will often be given no other option than elective caesarean.

The evidence that is used in directing mothers with breech babies at Term into the operating theatres was produced in a big multi-centre randomised controlled trial. It’s the most reliable type of quantitative evidence that is available. The research concluded that it’s safer for the baby to be surgically delivered than to be born vaginally.

There are several compelling reasons why I and some other midwives and medical practitioners are reluctant to submit to the breech-caesarean rule. We know that many babies in the past were born safely feet-first, and we know that many women have a strong preference for natural, non-surgical birthing options. We know that some breech presentations in advanced spontaneous labour will be undiagnosed, and that the skill of the midwife in attendance could be a deciding factor in the safety of that baby. The unintended and unfortunate reality of a professional terrain in which vaginal breech births are rarely seen is the de-skilling of the professions.

Another consideration that I will try to briefly outline here is the fact that a randomised controlled trial cannot truly reflect likely outcomes for women who want to work, undisturbed and unmedicated, with the power of their own bodies. So, even though I cannot challenge the results of the Term Breech Trial for the people who were involved, I consider that the very fact that pregnant participants agreed to be randomised into either the ‘labour’ or the ‘elective caesarean’ groups prevented them from engaging with their own natural resources needed for giving birth themselves.

The women enlisted in a randomised controlled trial are treated as though they have a medical condition, and the trial looks at different options for treatment. The hospitals and the maternity professionals who participated in the research could not have been committed to protecting and promoting wellness in childbirth, and many may have lacked the skills of midwifery in protecting natural birthing, particularly in breech vaginal birth. The results cannot apply to women who want to work with the wonderfully powerful natural processes in birthing their babies, as these women would have refused to be enlisted in the research.

Perhaps writing for my blog gives me an unrealistic sense of my own authority. This medium allows me to declare my opinion for the world to hear.

I have two birth stories to illustrate my current practice in relation to breech births.

‘Megan’ was about 39 weeks, carrying her second baby, when she became aware of a hard round lump under her rib cage. She found herself rubbing it from time to time, and thought it might be her baby’s head. She went to the Birth Centre for a checkup, and asked the midwife if she thought the baby might be presenting as breech. The midwife wasn’t sure, and called a more experienced midwife, who palpated and told Megan she was pretty sure the head was down. Megan phoned me a few days later to get my opinion. I visited her, and agreed with her - breech. The presenting part was not engaged, and moved easily. I encouraged Megan to seek ways of turning her baby, and to ask the hospital to attempt external cephalic version. She had an acupuncturist who she trusted, and suggested that she would ask for some acupuncture and moxibustion.

Megan went back to the Birth Centre, and this time the breech presentation was confirmed. She was told that she would no longer be able to keep her booking at the Birth Centre, as she would be booked for elective caesarean. She was already close to her due date, so an appointment was made with an obstetrician.

Megan asked if the baby could be turned. The midwife phoned a doctor at the hospital, who is involved in a trial of external cephalic version (ECV). The doctor said it was too late – the pregnancy was too advanced for her to try.

Megan was disappointed, and told me that she would rather plan a vaginal breech birth at home than have an elective caesarean. I agreed that that was a reasonable backup plan. Having palpated Megan’s abdomen, and felt how readily the baby’s bottom moved, I encouraged her to persevere with the quest for ECV. She made an appointment with the doctor who does ECVs. Megan is quite small and timid, but I admired her strength in this whole process. I encouraged her to go to the hospital with her partner, and ask the doctor to put her hands on her belly and feel her baby. If the doctor then said she could not attempt an ECV, then she would have to accept it and move on.

The doctor did agree to the ECV; the baby turned easily, and after monitoring Megan and her partner went home. Megan gave birth spontaneously to a healthy baby girl who came out head first, a couple of days later.

The lesson I learnt was to persevere. The hospital maternity care system may not automatically provide the options that the woman wants, particularly when those options are in supporting and protecting normal birth. But a woman is quite within her rights to request the sort of help that Megan received, even if that help is not readily available.

The second breech birth story does not have a happy ending. I learnt about this birth when I was asked to review the case on behalf of a law firm in Melbourne, and provide a report on the role of the midwives who provide care.

The mother arrived at a private hospital in strong labour with her second child, and was admitted by a midwife. The mother did not know her baby’s presentation was breech, as her doctor had checked her a couple of days ago and told her the head was presenting. Shortly after arrival the mother felt an urge to push, and the midwife arranged for the doctor to be called to attend for the birth. Before the doctor arrived the waters broke and baby’s legs and bottom were born. The baby’s body was initially pink, but after a few minutes the cord pulsation ceased and the baby became white. The midwives did what they could for the mother, but they did not have the skill or confidence to attempt to deliver the baby’s head. The doctor arrived and the baby’s head was born with assistance, followed immediately by the placenta which had probably separated at the time when cord pulsation ceased. The baby was resuscitated, and transferred to a neonatal intensive care unit. The baby’s brain had been damaged, and the lawyers were now acting on behalf of the child in suing the hospital and the doctor.

The question that was put to me was, should a midwife have been able to assist the birth of this baby?

This tragedy happened as a result of de-skilling of midwives. Today’s new midwives and obstetricians will possibly have had little or no experience in breech vaginal births, and this scenario is likely to be repeated from time to time.

When a baby's presentation is breech, the partnership between the mother and her midwife is put to the test. Various decision points are reached, and sometimes as in Megan's case, the baby can be turned and proceed to a normal cephalic birth. Such choices were not available for the second mother, because the breech presentation was not known until the birth was underway. Any midwife reading this story will do well to review the principles of an assisted birth of the after-coming head; a manoeuver that could have prevented the hypoxic brain damage to this baby.

Decision Points

The other evening a healthy baby boy was born vba2c to Julie (not her real name). For those who don't understand the abbreviation, that's vaginal birth after two caesareans. Words can't express the elation that we all felt as Julie held her new baby in her arms.

This birth took place in a private hospital, and I worked with an obstetrician and several shifts of hospital midwives in the labour. It was not a highly medicalised birth - Julie had stipulated in her birth plan that she did not want anyone to offer pain killing drugs, and at no time did she seem to be looking for medical pain relief. Electronic fetal monitoring (EFM) was used - the hospital's new telemetry monitor was put into use, enabling Julie to move freely, and spend all the time she wanted to in the bath. Julie's doctor had agreed to her plans with the understanding that if she did not progress in labour there would be no artificial stimulation of contractions. Julie was not asked to have an IV cannula in her vein.

Many of my stories are about women who give birth without any complications, in as close as we can to an 'undisturbed' state. The use of EFM is a disturbance, no matter how up to date and wonderful the gadgets are. But Julie had agreed to that disturbance, and was able to labour without letting it bother her. Julie's previous births had both been by emergency caesarean, early in the labours, when both babies had showed clear signs of distress.

Julie and I agreed to approach this birth with the intention of 'normal until proved otherwise'. I explained decision points - any time when a decision could be made. The 'default' decision was that Julie was giving birth. Plan A. At any time an alternative plan may be considered, if a valid reason for interference had arisen. This is the same basic plan that I encourage every woman to adopt.

It was not a simple journey from the first signs of labour to the birth, two days later. We reached several unexpected decision points, and each time, after careful consideration, agreed that Plan A was good. There was the high and very mobile head which did not engage until the second day. There was the vaginal loss, clear at first, then apparently meconium stained. There were subsequent concerns about infection and fetal distress. I called the loss a hindwater leak - the obstetrician disagreed. He did agree that the forewaters were intact, so as long as Julie's temperature remained normal, no treatment was required. At the end of the first day Julie was having contractions but not dilated, and the baby's head was still high. We assessed that she was not in labour; Julie agreed to stay in the hospital; the monitor was removed, and I went home to bed.

Julie's husband called me back to the hospital the next morning, as her contractions were becoming stronger. On palpation I was pleased to discover that the baby's head was engaged. Julie had not slept much, and was now putting all her focus into working with the labour. A dilute mixture of juice and water kept her well hydrated, with a little ready energy. By midday we were all delighted that Julie had progressed to 5-6cm dilatation, more advanced than she had been in either of her previous labours. Another decision point was reached in the afternoon, when the waters were broken artificially. The baby's head was still quite high. I was still concerned enough about that baby's high head that I wondered if we would have a caesarean at that late stage.

However, shortly after, Julie began pushing. Each step had been taken, and we all sensed the birth was near.

The baby's heart rate became very slow in second stage, and the doctor was consulted. Julie's baby's birth was assisted with the Ventouse cap - she pushed and the doctor pulled, for just one contraction. He went straight to Julie's abdomen, and I dried his body as he started to take some breaths then give out a strong cry.

I won't attempt to tell the story from Julie's perspective, or from her partner's. The midwifery lesson from this birth is that patience and consistent decision making enabled the mother to come into spontaneous labour, and to work through her own birthing journey. She can rightly say "We did it ourselves".

Knowing

Denise [not her real name] is a practical, down to earth young woman who lives with her two happy little boys and their father. When she booked me for homebirth she was sure that her baby would be born without too much bother, consistent with her previous birthing experiences. Denise asked me to visit her at home for a couple of prenatal checks - she doesn't own a car, and public transport between her place and mine is not easy. She had made a 'shared care' booking at the Women's, which means that most of her prenatal checkups were with the local doctor. I felt confident in Denise's knowledge of herself, her baby, and her trust in her own body, and I was happy to take her booking.

A couple of days before the due date Denise phoned me around midnight to tell me her waters had broken, but she was not in labour. She wanted to know if that was alright - it had not happened that way previously. In a brief conversation I reviewed a few important points - a small amount of clear liquor, and baby is kicking. The head had been presenting well last time I palpated her, so I reassured her and encouraged her to get some sleep before labour became strong.

The next phone call was after four in the morning, and Denise's husband asked me to come. I put on some easy clothes, brushed my teeth, and got my gear into the car without delay. It took 40 minutes or so as I drove towards the city, and across the flat docklands. I was conscious of the early light of dawn, and the movements of a city that is waking up, and I committed my work, and this family to God. I always ask for strength and wisdom as I go to a labouring woman.

The husband greeted me at the door, and told me she was still in bed - hadn't wanted to get up, in case the baby slipped out. I greeted Denise, who looked relaxed and well, and settled in. There was no rush, but I set up the basic equipment as is my routine.

I don't want to record here a blow-by-blow description of progress in labour. Denise was surprised that her contractions were irregular in their strength, and frequency. Her expectation of quick progress was not met. Yet she was well, and her baby was well, so I had no reason for concern. At one time she asked me if it was taking too long. No, I replied. Each baby has to find its own way through the birth canal.

Over the next few hours the labour became more powerful, and Denise moved into the isolation of her bedroom. Her cries indicated the intensity of the pain she was experiencing, yet her quiet confidence between contractions reassured us that she was well. She worried about her boys, who were watching a DVD - a rare treat for them. The younger one, who is about four, came to the door and checked his mother as her vocalisations became stronger. Each time she reassured him, and he seemed quite satisfied.

A change came eventually, and at the peak of a strong contraction there was a pop, as the bag of forewaters broke. The next contraction brought a strong urge to push. Denise was working intensely with her body as she progressed the baby through her birth canal, and into view. The brother checked once again from the doorway, saw the baby's head crowning, and went back to the television. It was just before 11 am when a beautiful, healthy baby girl was taken into her mother's arms. The two little boys came in, met their new sister, and left in a very matter of fact way. Their mother had had a baby. That's what mothers do!

Many times in the past I have experienced the 'knowing' that women have about their own birthing processes. I hear the woman's expectation through a critical ear, as I know that there are times when knowing is not what we think. Although Denise's knowing, or belief, that this baby was likely to be born very quickly, did not eventuate, that doesn't matter. Time takes on a different quality in uncomplicated, undisturbed birth, than in the world of measurements and calculations. As the labouring mother's mind progresses from neocortical activity to intuitive, hormone-mediated activity, the midwife protects the space around the woman so that she and her baby are free to take the journey. This is one of the secrets of midwifery.

First child

Lovely young woman,
your body firm and fresh.
Perfect.
A precious curtain was torn in two
from top to bottom,
making a way from the sacred place
into this broken existence.

Archetype of the primipara,
feel that deep pain;
mingle unshed tears with the wonder of life that has awoken.

The wound heals over.
The suckling child urges you on,
despite daily reminders.
In giving birth, you have given strength -
wholeness.
A scar remains.
A reminder of the open gape.

When another curtain was torn in two from top to bottom
the way was made into the holy place.
Ponder these things.
Treasure them in your heart.

Joy Johnston [I wrote this poem in my diary 30/6/2001]