freedom to make decisions

From time to time I receive emails from students, asking me to tell them about my midwifery practice. This week's student email had an attachment with about 20 questions under the heading 'Issues that affect midwifery practice'. Rather than spending a couple of hours completing this questionnaire, I have referred the inquirer to this blog, and others, where many of the questions have already been answered.

Today I have selected a question from the list:

"Do you believe pregnant women today have more freedom to make decisions about their birth than they have previously?"

My answer is No, and Yes.

Fence-sitting is probably not very helpful, but I will try to explore the question further. I don't want to sound like the old crone telling stories about the 'good old days' either.

I will link my comments to what I know now about:
1. the freedom that a pregnant woman has to make decisions today
2. the freedom I experienced about 30 years ago, when I was the pregnant woman
3. the freedom my mother, who was also a midwife, told me of her experience about 60 years ago, when she was the pregnant woman.

I say 'No' - that women today do not have more freedom to make decisions about their birth than we had either 30, or 60 years ago (or further back in time, for that matter). Today's mothers face information overload; so many choices that they can easily lose sight of the fact that bearing a child is as normal as life gets.

Many women today are captive to fashion and custom that are driven by capitalistic and humanistic ideologies that have developed in recent generations. There are so many products and gadgets and services that go with the baby business that the reality of the miracle of precious new life can easily be missed.

Today's mother is uncritical as she welcomes technology that invades the privacy of the womb, giving proof of a heart beat in the early weeks, and progressing on to amazing 3D pictures of an unborn child; and answer the question, is it pink or blue? She does not ask for proof that this is safe for the child, or for the next generation. She is encouraged to justify the experience as an opportunity for bonding.

Yet a darkness falls on her life when some small item, called an anomaly, is 'discovered' on the flickering screen. The longed-for child becomes a condition that has to be managed. Dreadful decisions have to be made.

Thirty years ago ultrasound was new technology, available to only a few. Sixty years ago it was beyond imagining. The mother carried her child in the secret place, and experienced meeting her child and discovering its features all in good time.

Thirty years ago the midwife learned to use the Pinnard stethoscope, and the labouring woman was 'managed' lying on a bed. For the birth the woman was often placed in the 'left lateral', the teaching position. The midwife, and a group of students, stood on the right side of the bed, watching and managing the (sterile - no touch) business of birthing, while another midwife stood on the left side of the bed and administered the gas.

Sixty years ago the movements in the womb, felt by the mother, were the primary indicators of wellbeing. A baby whose movement had ceased was stillborn. Still before birth, as well as still after birth.


AND I say 'Yes', women are more free today than in previous generations, to make decisions about their births, because today we try to protect human rights such as autonomy in decision making. Today noone can touch you, or take your pulse without your permission. Anyone expressing that idea 30 years ago would have been quickly put in their place. I felt extremely anxious in 1980, as a pregnant woman booked to give birth to my fourth child at the Royal Women's Hospital Family Birth Centre, when I declared to Dr John Neil that I did not wish to have a glucose tolerance test. He rubbed his chin and said "Well we do let birth centre patients have some say in these things", and generously gave his OK.

My generation of mothers fought for, and won the right to have our husbands at our side in the labour ward, while our parents had been separated at the fathers waiting room. Today I wonder if we have progressed. Although midwives today have learned to operate sophisticated pumps and monitors and beds that are like transformers, many have lost the skill that my mother had 60 years ago, being 'with woman'.

making sense of risk management and safety in maternity

In the past couple of months the Australian homebirth and independent midwifery world has been experiencing a new level of challenges and threats to our very existence. The precipitating event was the release of the report of the Maternity Services Review. I have attempted to keep a running record of the published articles and other media, at the MiPP blog.

The safety of homebirth is the key issue in the minds of those who support, and those who are seeking to outlaw homebirth. How can 'safety' be so contentious? Is one party so biased that they can't see what is clear to the other? Are these professional people, on both sides of the fence, not intelligent, well educated, and supposedly ethical people? And what about the parents - consumers who choose homebirth, even though they have to pay for the privilege of not using the hospital? Are these people blinkered, uninformed, even careless about the safety of women and their unborn children?

I know most of our regular blog watchers are aware of these and other related questions, but for those who are still unsure, here are a few recent links:

Largest study in the world confirms homebirth is safe

SMH reporter Miranda Devine, in A home birth is not a safe birth ...

Dr Pesce's comment [ABC Unleashed] on 6 baby deaths in WA in 4 years, which he considered to be proof of the danger of homebirth. "The WA health department said:
"... that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths."

Another statement in the same article reported "a three-fold increased risk of a full term, otherwise healthy baby dying during a planned home birth ..." The paper from which this information was sourced has come under strong criticism for its methodology. Internationally respected epidemiologist Marsden Wagner, in reviewing the paper, noted that conclusions drawn about unacceptable death rates from unreliable sources are not valid.

There are many more references - both in favour of, and against, homebirth. The use of numerical data (quantitative) in understanding evidence must also be balanced with the qualitative research that seeks to report on 'why', and 'how' a particular decision is made or outcome is reached, rather than just 'how many'.

Complicating the whole picture is the rise in the number of unattended home births. There are anecdotes of the tragic death of babies born at home, and 'near miss' experiences, in recent months. Within the stories I have heard about births that have gone wrong, I have been shocked at assumptions that people have made, in justifying choices and decisions.

For example:
A mother planning unattended birth was told to send her husband or a friend to a St John Ambulance resuscitation course, to learn how to resuscitate a baby that is born not breathing.
Another mother took that plan a step further by employing a midwife to be present at her birth, but did not allow that midwife to auscultate the baby's heart sounds prior to the birth.
A mother giving birth unattended experienced delay from the birth of the baby's head to the birth of the rest of the baby. It took many minutes - too long - and the baby did not survive. A midwife would have been expected to intervene in an attempt to protect the life of the child.

I feel that I'm stating the obvious, but it needs to be said. Resuscitation does not work if a baby is already dead.

Much of the risk management in maternity care - both midwifery and obstetric - is to identify babies or mothers 'at risk' of poor outcomes in birth, and to take steps to prevent damage or death. None of us have a crystal ball: it's all about drawing a line. Homebirth is safe because there are important features of homebirth that minimise risk: for example, the mother's own environment; the absence of dangerous drugs and uterine stimulants; the one-to-one focused attention of the midwife. The Dutch maternity system, in which about a third of all births are at home, and for which safety has been clearly demonstrated, requires the midwives to screen women for risk. Women are expected to be referred to specialist (hospital) care if they develop complications, or if they are not progressing well, or ...

I cannot make generalisations about the practices of independent midwives and homebirth in Australia. It is likely that some have their heads in the sand (or in the clouds?), and are ignoring risk. What about homebirth for babies in breech presentations, twins, failure to progress? VBAC? Post maturity? Grand multiparity?

These are not yes-no answers. As some of my clients know, I will attend homebirths for women who would not be acceptable under most risk management selection criteria that I am aware of. That's one of the benefits of being 'independent'. Each woman can be addressed as an individual; each decision can be made individually; the care is woman centred in a way that may not be carried through in service guidelines. My commitment is to be 'with woman' - not to homebirth. If the woman is well and progressing well in spontaneous labour, she is free to decide where is the best place for her to give birth.

Birth of a calf

[Pic: Poppy and Uncle Al check the cow and the new calf]


I had a call from our daughter Bec on Friday morning. A cow who had begun labour had bulging membranes, but nothing had happened for a while. Was it alright? Should anything be done?

My response was that I thought it was best to leave the cow to give birth in her own time. And keep the puppy away. I thought that if there was a problem something could be done later in the day, as we were heading to the farm to visit them for lunch. Noel, my husband, did his Veterinary post graduate studies with dairy cattle when I was busy bearing and nurturing our own babies.

An hour or so later, as we headed up the Calder Hwy, we received the news that a calf had been born and all was well. At the farm we saw the cow and calf, separate from the rest of the herd, and unstressed. Membranes still hung from the cow's vagina. Later we noticed that the afterbirth had been passed. All part of the normal daily occurrences on a farm. My son in law Al says his cows are not too posh to push.

Normal birth of a human baby at home is not very different from normal birth of a calf in the paddock. The oversight that a midwife provides includes keeping the space free of disturbance so that the mother is able to progress in her own time. The midwife does not try to hurry things up, or manage the birth, and would only consider interference if the natural process had in some way become unsafe.

When the labour starts the cow withdraws from the herd, and finds a safe place, such as near a big tree, or rocks. She is patient.

The labouring woman also needs to withdraw. She needs unstimulating space around her, and her own home is often the ideal place. If her children are there, she needs to know that they are being cared for well so that she can move away from them. She will not labour well until she can do this.

A cow does not need to be taught how to give birth. It happens, under instinctive hormonally mediated processes. The human mind also has strong instinct and our bodies secrete powerful hormones, but we often suppress our instinctive thinking, and take over, or interrupt, with 'higher' brain activity - the activity of the neocortex. Anything that is specifically human is neocortical activity. Artificial lighting; managing progress; calculation of times and measurements. How many women think their main job in labour is to record the frequency and length of contractions? How many women become overwhelmed by labour, as they try to intellectually integrate the information give to them by their doctor or midwife? What does 5 cm dilated really mean?

The preparation and learning that a human mother needs to do, and that a cow does not need to do, is to learn how to accept her body's work and not to interrupt it. The secret to this, in most instances, is to withdraw - emotionally and physically - from anything else that might stimulate intellectual (neocortical) thinking or in other ways cause stress.

A fine line: undisturbed, unassisted, and unattended births

Midwives who are experienced in unmedicated spontaneous birth will often take a quiet, unobtrusive role when attending a labouring woman. By the time labour is established, the room is quiet and often lit only by a candle or other soft light source, and no interruptions are allowed. Any voices are hushed, and only when the woman is resting between contractions – not during contractions. If the woman has planned to use water immersion in labour, the tub has been set up and is ready for use. The midwife is constantly observing, expertly using her senses of hearing and sight and intuition (heart). The midwife experiences a parallel journey, as she intuitively harmonises her thoughts and actions with the woman’s. Any observations that require touch, such as listening to the baby’s heart tones, are done in a way to minimise disturbance to the woman. The midwife is not ‘assisting’ the birth; she is in attendance – with woman.

The term ‘undisturbed birth’ has been used by author Sarah Buckley (2005, p110), with reference to her own experience of giving birth to her fourth child, without a midwife in attendance. Other terms used for unattended birth, when it is intentional, are free birth, pure birth, self birth, and unassisted birth.

The fine line that the midwife sometimes walks is being able to be with woman, and yet enabling the woman to proceed without physical or emotional disturbance. Many women would consider that they were able to enter a special ecstatic place in which they remained undisturbed through their birth experience, with a trusted midwife present.

However, if a midwife identifies a complication or condition in the mother or baby, for which she recommends referral to specialist services, the act of disturbance may be in the interests of the wellbeing of her clients, both mother and baby. This is within the professional duty of care, and is the midwife’s skill. The midwife’s guiding principle, that “In normal birth there should be a valid reason to interfere with the natural process” (WHO 1996, p4) informs both the non-interference, and the alternative, in midwifery care.

Dr Buckley argues cogently that the complex natural hormonal mix, and particularly the role of oxytocin, that is the physiological norm in childbirth is also what we experience in loving, passionate sexual intercourse. This connection has previously been clearly described by Michel Odent in many of his writings and lectures. “[oxytocin] is the ‘hormone of love’. Whichever facet of love we consider, oxytocin is involved.” (Odent 2002, p72)

The connection that Dr Buckley makes, in describing and idealising an unattended birth as undisturbed, may encourage other mothers to give birth without professional attention. In Dr Buckley’s case, both she and her husband who was also present, had medical skill and knowledge that could have been used. This is a very different scenario to unattended birth where no person present has a foundational knowledge of progress in labour, normal birth, or normal transition of the newborn from the womb to the outside world.

Dr Buckley observes that “When a midwife’s intuitive skills and ways of knowing are increasingly sacrificed to technology, more and more invasive procedures will be needed to get information that, in other times, her heart and hands would have illuminated.” (p111) The fine line the midwife walks is to use technology appropriately, while valuing and enhancing her skills in promoting normal birth.

The midwife’s goal can and should be ‘undisturbed’ or ‘unassisted’ birth in any situation where there is no valid reason to interfere with the natural process. A midwife cannot ethically support planned ‘unattended’ birth, which is the antithesis of maternity ‘care’, as that situation removes the experienced critical eye and ear and heart of a midwife, and puts the responsibility on the labouring woman, and anyone else who is with her at the time.

evidence based maternity care

In the context of current discussion about birthing without a professional attendant (which is known as free birthing, pure birthing, self birthing, and probably others) a blogger-mother wrote,
"If evidence based care is the best antenatal and labour care, and some evidence based care leads to interventions, and intervention - any intervention - is perceived as a terrible thing, then if no one checks you or you baby, ..."

This statement has prompted me to explore the meaning of evidence based maternity care.

The statement suggests that some women are avoiding professional monitoring in pregnancy and birth because they don't want to know. Every investigation and test, no matter how seemingly trivial, is done so that action can be taken if it is deemed the best course of action. Knowledge brings responsibility. Every time I put my hands on a woman's abdomen to palpate the baby, I am responsible for my response to what I discover in that palpation.

Over the past few decades some basic maternity care rituals have changed in the light of evidence. Mothers 30+ years ago were given enemas and shaved - sometimes all visible pubic hair and everything as far back as the anus; sometimes just below the pubic ridge. Either way, the regrowth was unpleasantly itchy (speaking from experience), and the chance of cuts from razors was fairly high. Enemas were to empty the lower bowel. These measures were apparently to prevent germs from contaminating the birth, which was treated as an operation site, with green sterile drapes.

World Health Organisation declared in 1985 (Fortelesa Declaration) that there was no evidence supporting enemas and pubic shaving, and in 1996 (Care in Normal Birth: a practical guide) listed enemas and pubic shaving to be "practices which are clearly harmful or ineffective and should be eliminated".

The removal of enemas and shaves from standard maternity care was relatively successful (some people today 'choose' these procedures) but other 'non-evidence based' positions that have been promoted for decades are ignored by many professional maternity services. These include, for anticipated normal birth: continuous fetal monitoring, induction of labour, amniotomy, vbac, lithotomy position ...

Current discussion over the choice some women have made to give birth at home without a professional midwife in attendance focuses on the big issues of potentially avoidable death and damage to the mother or child. Today's news reports that Sydney Dr Andrew Pesce "said he was aware of at least four deaths and another four homebirth babies who sustained possible brain damage since last July." The report does not differentiate between planned homebirth in the professional care of a midwife, and the DIY unattended version. Evidence from Australian and other sources support planned homebirth in the professional care of a midwife for women who are low risk and come into spontaneous labour at term to be no more likely to experience adverse outcomes than those of similar status in hospital maternity care.

It's no good hiding behind a sweeping statement such as "babies die in hospital too". The decision making process that midwives use, regardless of our practice setting, is to try to identify babies and mothers for whom intervention is likely to improve outcomes. This is where midwives are constantly reviewing our practices, so that we can act quickly and decisively when we need to; but also so that we can understand the scope of normal birth, without unnecessary interferance. A woman who is well at term, in spontaneous labour, and progressing well without needing pain relief should expect a well baby. If the baby is not coping well with the stress of labour, the midwife is able to identify the problem when listening to a baby's heart sounds after a contraction. There may also be signs of potential problems in the colour or consistency of the amniotic fluid. A midwife will make professional judgments, and give advice, on what she sees.

There are aspects of the maternity care world today that are like the scary 'wonderland' world of Alice. Issues become enormous, or tiny, without warning or reason. The person with power makes nonsensical edicts. Alice is caught up in a wild stream of frightening experiences.

In my vision I have made Alice's sister her midwife, going with her in her journey towards birthing her child,
"Alice returned to the grassy bank in the golden afternoon light and decided not to go down that rabbit hole again. She stayed above ground and with her sister accompanying her, ..."

Every Woman Every Choice ???

Every Woman Every Choice

It's a catchy slogan!

What does it mean?

Is it something we want in maternity care?

I found this slogan on a campaign letter from Maternity Coalition - an organisation that I have belonged to, and helped to build, for the past 15 or so years.

In today's world of fast electronic communication there are many statements and articles that come to my email inbox, that I read quickly and delete. It's not that they are unimportant - it's more likely that I don't see the need to engage with them at the time.

However this slogan caught my critical eye.

EVERY WOMAN?

Does this refer to every woman, regardless of her other health needs, her location, her wealth or personal circumstances?

EVERY CHOICE?

Which choices are these? Drugs to induce or stimulate labour, or to relieve pain? That's been an 'acceptable' choice in most maternity services for the past few decades. Elective caesarean - that seems like the easiest to organise these days.

How about care of a known midwife who will attend a birth at home or in a birth centre that's committed to promoting physiologically normal birth? Now that's a choice that is supported by solid research evidence. Let's organise that!

Anyone who has attempted to 'choose' the latter will know that it doesn't happen easily. Birth centres are booked out; many women booking in a birth centre are transferred out to 'standard' care at some time, under strict protocols; many midwives are reluctant to accept caseload midwifery; and so on. Homebirth is available with public funding in a few locations, and with independent midwives in a few others.

How many women who have had a previous caesarean birth, for whatever reason, are able to choose the sort of care that makes vaginal birth likely? Not many. Look at the statistics, such as the recent Victorian Maternity Performance Indicators.

The notion of 'Every Woman Every Choice' is NOT a goal that I can share. At best it's just a hollow slogan; at worst it's a sellout to medical and technological dominance of women's lives. And although it appeared in a Maternity Coalition (MC) statement, it's actually in conflict with the statement of purposes of that organisation.

The Statement of Purposes of MC, within its constitution, includes:
"iv To protect pregnancy and childbirth as a natural process"

Protecting pregnancy and childbirth as a natural process means that we argue AGAINST the 'every choice' trend. It means that we focus on learning how to work in harmony with our sensitive physiology, and that we promote care options that demonstrate excellent outcomes.

I would prefer that every woman has access to appropriate maternity services. Of course defining what is appropriate would not be easy. What is appropriate for a woman who lives in a city or rural area; whether she is 16 or 46 or somewhere in between; whether she is having her first baby or her 9th?

Every pregnant-birthing woman deserves access to maternity services that protect wellness in an equitable way. Midwives can provide that level of maternity services for the majority of women, and midwives working with medical, obstetric and anaesthetic hospital services can provide appropriate maternity services for those who experience complications or illness.

Should Every Woman have Every Choice?

Even if that were a realistic notion, I don't think it's something a government should be asked to provide within its package of funded and regulated health care.

Our society is not equitable. Money buys choice for the few.

Should Maternity Coalition, or any other ethical body support the notion of 'Every Woman Every Choice'?

NO!

The following comment has been received from Lisa Metcalfe, NSW President of Maternity Coaliton.
Joy
All of your points about the reality of choice are true, however we have taken this step to counter the current trend in intervention and lack of control or choice that you so clearly express. How can our maternity system support obstetric care and elective c/s but not a woman who chooses a midwife and only deep water for pain relief??

If the political, medical and social world will accept the choice for elective c/s then there must be equal acceptance of the the choice to birth with a known care provider in a location that is acceptable to the women. This campaign is specifically designed to highlight all of the issues that you raise and include the troublesome issue of the potential loss of the ability of midwives to have a private practice because of National Registration requirements.

MC is not walking away from any of its commitment to birth as a natural process, but by highlighting just how hard it is to achieve this we may still break through the discriminatory maternity service provision in this country.

more about choice

My thoughts have returned again to the issue of choice, and what are the limits or boundaries around the whole notion of choice for women giving birth.

A young mum-2-B told me she was shocked when the midwife at a suburban public hospital told the group of expectant parents that they were not to argue if the doctor wanted to put forceps on their baby's head to deliver it. Preparing for birth, in this situation, included an attempt by someone who is called a midwife to ensure submission by the woman to those who are in positions of authority.

I would like to work with this young woman so that she understands the broader context of consent; so that when the time comes for her to labour and give birth to her child she will be confident in her own decision-making; so that if indeed she needs to face the question of forceps or any other intervention, her acceptance or refusal will be based on a principle of her knowledge of her own body, and making the best choice she can make at the time; not on the bullying of someone who wants to ensure compliance with the dominant authority structures in the hospital.

I would like to work with this young woman so that she understands her own ability in birthing. The physiological processes that our bodies expect to engage in are profound and extremely sensitive. The physical and hormonal changes in labour and birth can be disturbed by seemingly small interruptions that may not be considered interferences or interventions. It's about being able to access that innate power to do whatever it is that women do in birthing. How can a woman actively *choose* to work in harmony with her body's natural processes, and *choose* to avoid situations that will interrupt those natural processes. That is the essence of choice in childbirth.

****
Another aspect of choice:
A midwife attending a planned homebirth was distressed when the labouring woman refused her requests to listen to the baby's heart beat. The labouring woman was exercising her autonomous right to refuse - her choice.

But it doesn't end there. The midwife's duty of care includes attending to the baby's wellbeing as well as the woman's. Listening to the baby's heart sounds from time to time in labour is a non-invasive and usually acceptable way midwives use to ascertain how the baby is responding to events (uterine activity and subsequent progress). The midwife is responsible not only to her client, the woman and baby, but to the society that gives her the right to practise midwifery. Midwives are required to answer to peer review of our practices from time to time; and particularly when there is an adverse outcome. Reviewers in this case would, I believe, encourage the midwife to reflect on how she might act if this situation happened again.

A reader of this blog recently wrote to me, in the context of discussion about women's choices "It really disappoints me to hear a midwife disrespecting womens choices in birth. Surely it should be for no-one but the woman to decide."
This is a good question. Should women expect to have absolute freedom to choose what happens when they give birth? Are there no boundaries?

There is no other 'freedom' that we exercise that is absolute, even in a free society. Think about travel. We can choose when we leave home and where we go for whatever reason, but we are required to act within certain limits. The way we drive our cars, or ride our bicycles, is regulated by law.

Once a child comes into our lives, our freedoms are further limited, as we have a responsibility towards that child. The midwife's duty to protect the child in its transition from the womb to the outside world is not in opposition to the mother's freedom or ability to choose. The partnership between a midwife and the woman should be harmonious, working together to achieve the very best outcomes for both.


Those who are thinking about the choice of unassisted childbirth, I would like to recommend that you read http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2009/3/25/freebirthing.html

freedom in birthing

A true midwife will be 'with woman', while at the same time supporting her desire to be free. This is expressed beautifully in the ancient statement attributed to Tao Te Ching, about 2000 years ago,

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

When we attack one another rather than working together

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

birthing alone

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


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

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

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

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

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

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

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

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

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

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

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

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

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

choices that most don't know about

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

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

However ...

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

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

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

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

Sara Wickham's study day

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

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

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

A blog worth reading

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

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

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

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

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

LACK OF INSIGHT

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

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

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

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

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

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

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


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

Please also sign our online petition to keep homebirth legal.

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

A BIG PUSH FROM WOMEN

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

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

Thankyou.
Joy

A response to the Maternity Services Review

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

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


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

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



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

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

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

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

Happy International Womens Day

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

The following message is from VICTORIAN WOMEN’S TRUST

Dear Friends of the Trust,

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

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

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

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

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

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

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


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

Have a great long weekend!

IF

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

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



SINCE
there are no publicly funded homebirth programs in Victoria

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

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

CHOICE?

A birth made to order? What a joke

Author: Lucy Beaumont
The Age Opinion March 2, 2009

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

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

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

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

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

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

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

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

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

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

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

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

Home birth: the unheard horrors

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

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

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

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

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

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

Dr Pieter Mourik, obstetrician, Wodonga

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

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

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