the myth of choice

1983 - working night shifts a the Women's

For a couple of decades now, *choice* has been a pillar of the natural birth movement.

An organisation that I am a member of has the vision, that
"Every woman can choose how, where and with whom she births."

This vision has troubled me for some time.  Today I am attempting to critically explore the notion of choice, and whether it is desirable or imaginable that every woman choose "how, where and with whom she births."


Firstly, some historical considerations:

• The Fortelesa (Fortaleza) Declaration (1985) on appropriate use of technology in birth challenged interventions, from shaves and enemas, to inductions of labour.  This seminal document also declared that "The whole community should be informed about the various procedures in birth care, enable each woman to choose the type of birth care she prefers".  *CHOICE!*
• Changing Childbirth in the UK (early 1990s) declared that women want the 3C's: *choice*, control, and continuity of care.
• A call for *choice* of place of birth (home/hospital) and care provider (such as individual midwife or the maternity system) was clear in the Australian National Maternity Action Plan (2002).

At the same time,  twenty years ago,

• emerging trends in medical research led to the Cochrane Collaboration, defining the reliability of evidence;
•  UNICEF and World Health Organisation introduced the Baby Friendly Hospital Initiative, with a key document being the Innocenti Declaration  of 1990. 
•  various state and territory governments around this country were conducting broad reviews into birthing services, and producing their reports. (eg Having a baby in Victoria 1990)  These reviews sought consumer comment as well as professional.
•  WHO prepared a series of basic publications on maternity care, including Care in Normal Birth: a practical guide (1996).  This document brought a consensus statement that "In normal birth there should be a valid reason to interfere with the natural process"

During the past two decades the world has experienced the digital revolution.  Twenty years ago, in 1994, few households had computers: the world wide web and email had only just been invented.   This phenomenon exploded communication and access to reliable information.  Our home went 'on line' in the early 90s, with a (very slow, and unreliable) dial up connection, and we were leaders in the field.   Prior to that, if I needed to send an email, I would ask my husband Noel to send it from his office at the university.  He kept up with the expansion of knowledge via inservice education, and a very helpful secretary, Jean.  He became the 'IT' expert in our home, until our children absorbed the knowledge and quickly spoke the language, as children do.  (but I have digressed from my topic!)

Twenty years ago, professional peer reviewed scientific publications were held in libraries, and accessed by scholars and the intelligencia.  Today, there is an inexhaustible wealth of knowledge at the tip of our fingers, from our computers, tablets, and phones.

Twenty years ago, information about natural childbirth was passed from teacher to student couples in highly motivated childbirth education.  Today women join social media groups where they share everything from their nausea and indigestion, to ultrasound pictures.  These groups, as well as personal blogs and microblogging, have introduced a degree of sharing of opinions, and introspection ('navel gazing'), that would have been unimaginable when person to person communication was limited to a telephone or over the back fence or a tea room at work.

So, what about choice?

In discussing choice in childbirth with colleagues and other interested folk, I have been a little surprised to observe that the woman's right to decline (a treatment/intervention) is often perceived to be the same as a choice in maternity care.  A woman's autonomy in any care situation (whether it's her toe nails or the birth of her child) is often limited to the little word "No!"

By way of example:

Jill is in hospital, in labour with her first baby.  Jill has been told she needs a Caesarean, because she has been labouring without adequate progress, and the doctor is concerned that her labour is obstructed and her baby is becoming distressed.

Jill does not want a caesarean birth, but she has no other options at this time, other than to do nothing, and that may lead to injury/death to her baby.  She has planned for a natural birth, because she believes that's the best way for her and her baby.  Jill has written in her birth plan/preferences document that if she truly needs a caesarean birth, she wants her baby's umbilical cord to remain uncut, and the placenta delivered intact (known as 'lotus' placenta).  She wants her baby to be placed skin to skin on her chest, and to remain with her in the operating room and in recovery so that breastfeeding can be initiated without delay.  She is aware of 'natural' caesarean births, discussed on her social media forum, and likes the idea. 

Jill communicates her wishes to her doctor.  If that doctor has previously supported women's choices in this way, he/she might be willing to agree.  But Jill is a patient in a public hospital.  The doctor who is performing the surgery is being supervised by the consultant obstetrician, and does not feel able to accommodate such a radical plan.  The hospital's policy is to send the baby and the father to the nursery while mother is in recovery, and Jill is told that the hospital is not able to provide suitable staff to accommodate her choices.  Jill has run out of options.  She needs the help of the hospital to get her baby safely born, and she finds to her surprise that the notion of choice doesn't work in this situation.

 Jill thought, prior to coming into labour, that she had chosen:

how: a natural birth 
where: in the local public hospital
with whom: the hospital staff at the time

'how' Jill gives birth is something that cannot be predicted, whether she chooses a private hospital with the most popular obstetrician according to the online rating system, or the guru homebirth midwife who has amazing skill and, according to social media, can do all sorts of things to make birth work as it's supposed to.  The best Jill can find out when she is choosing her care provider is an approximate rate of spontaneous unmedicated births that person reports for woman in their care.

I (frequently) remind women that they have only one choice in childbirth - to do it themselves, or to ask someone else to take over. This is the case, whether it's avoiding induction, having a vaginal breech birth (vbb), a vaginal birth after caesarean (vbac), a physiological 1st, 2nd or 3rd stage. (Haemorrhage and death are also physiological). 

There's an obvious rationale for the skilled midwife in these equations. A primigravida who wants to have a natural unmedicated birth, booked at Caesar's Palace, in the care of a knife happy OB, may have chosen where and with whom she births, but doesn't have much chance of achieving the 'how'.  

Choice is also dependent on money $$$.

The woman who chooses a caesarean for her own (not clinically indicated) reason can get a private doctor to deliver her baby if she can pay the doctor's fee (Medicare + out of pocket) and the hospital fee. But she has very little say about who else is in the room - her partner is likely to be welcome but may be asked to step outside. 

If we have a vision that every woman should be able to choose how - including elective C/S - do we think our public health $ should be supporting that so that women who can't afford the co-payment are also able to rock up and *choose*?
 
I am very concerned about over-spending of health $.  

The only sustainable policy direction in maternity care is to protect, promote and support the natural processes in birth wherever that is reasonable. The workforce needed as experts in achieving this goal is midwives whose duty of care by definition includes "promote normal birth". This does not remove the woman's right to make an informed decision to decline or accept the plan. Medical and surgical options should of course be available to those for whom they are likely to lead to better outcomes, but that's not a matter of the woman's *choice*.


Your comments are welcome.

breech

For several years now there has been a growing movement of consumer and professional opinion about the 'best' way to give birth to babies presenting breech. [See Breech Birth ANZ website]  This has come as a small pendulum swing away from the prevailing policy of elective caesarean for breech babies, which was quickly adopted after the Hannah et al (2000) paper on the Term Breech Trial, published in the Lancett.

Another historical grab, before I tell my breech story.

Please see the attached picture of the midwifery exam which I undertook in 1973.   Midwives then were required to have a basic understanding of breech presentations.   I don't want readers to imagine that the work of a midwife (or mother giving birth) was somehow ideal back then - in fact the medicalisation of childbirth, and the dominance of medical 'men' over the more subservient female nursing profession (which included midwifery) was entrenched, as can be seen in the previous post I wrote about this midwifery exam.

click to enlarge

I have always held that if for no other reason than the surprise breech, a midwife attending births needs to be competent in vaginal breech birth (vbb).   My involvement in workshops and education about vaginal breech births, and in the few vbbs I have attended, there has been an emphasis on having obstetricians who lead the cause of promoting vbb.  I have felt uncomfortable with this.  Obstetricians are surgeons.  Midwives need to claim breech births as being well within their scope of practice, as well as the identification of those for whom a vaginal birth is not likely to lead to good outcomes, and being able to refer to and collaborate with obstetricians.

Recently I have had the privilege of attending a birth at home, which turned out to be a surprise (undiagnosed) breech.  As the mother rested with her baby in her arms, she asked me to be sure to write a story about this birth.

Without identifying her, I am pleased to record the birth - through a midwife's eyes, with a midwife's knowledge and decision-making.  I don't consider myself an expert in breech or any other type of birth.  In fact, the only births that I take professional responsibility for are the ones that are very likely to proceed under the mother's and baby's own power, driven by an amazing natural physiological process.  My job is to work in harmony with those natural processes, and to protect, promote and support the natural processes, with the intention to intervene only if illness or complication arise in the birth and nurture of the baby.   In the case of breech births, the most critical period can be the birth of the baby's arms and head, and it is important that all midwives and doctors who take professional responsibility for birth are skilled in the decision making and simple manoeuvers. 

Working as I do, attending births privately usually in the home of the woman giving birth, I have a background knowledge of a mother before she tells me her labour has started.  In this case, I had been midwife for the birth of another child in this family, five years ago, also at home.  Reflections on the previous birth had also been tenderly preserved in my blog.

The first clear indication that this baby was presenting breech was the information that the waters had broken, and were "clear, with a bit of blood, and a black blob."  Labour was strong when I arrived.

I quickly set up my gear: the baby resuscitation box, and oxytocic, syringe and needle, and procedure gloves within reach; the oxygen cylinder connected up and ready if needed; a few clean bath towels to keep baby warm after the birth.   The 'nest' had been prepared - the couch draped with a waterproof cloth, so that the mother could kneel on the couch, facing away from me: an ideal upright position for a breech birth! (and a very reasonable position for an older midwife)

I saw more meconium, and asked the mother if I could examine her internally to confirm the presenting part.  The baby's bottom was 'at spines' - well on the way to being birthed.

I had a decision to make: I spoke simply to the mother and the father.  "The baby is coming, and it will be born bottom first."  I advised them that I did not expect any problems with the birth, but as an extra precaution I would like an ambulance to be called, in case we needed to transfer to hospital.

I would now like to describe each part of the birth as it proceeded.  Contractions were approximately every five minutes. 

As the baby's rump came on view a purple, swollen scrotum also appeared, and a stream of urine was passed from a swollen little penis.  I didn't mention these facts - the mother had work to do, and she would be able to discover her baby's gender in her own time.  From that moment it must have been 10-15 minutes until the birth was completed.  At some stage the 'first response' paramedic arrived, and I confirmed that the birth was going well.  He stood back.

• Next contraction: a big push and one leg plopped out.
• Next contraction: a slight rotation of the baby's bottom, and the second leg came down, and a little 'cycling' action of the legs (as though he said, "Thanks Mum, that feels better! Now, what should I do?")
• Next contraction: the baby's body was born past the navel, then to the nipples, and a large, full blue and white umbilical cord was central.  The body hanging was unsupported - I had not touched him to this point (Hands off the breech!).  I was delighted to see the cord positioned beautifully in the little protected channel between the baby's two breasts that were squeezed together in the tightly stretched vaginal opening.  I gently checked the pulse - about 120, which is good.
• Next contraction: first arm popped out, a little rotation, then second arm.  Baby's colour reasonable.
• Next contraction: no progress.  I placed my thumb and fingers over the cord, close to its insertion.  Pulsing had slowed to about 80.  Time to get this little one out and breathing! 
• With mother in the kneeling position, I placed my right hand in over the baby's chin, and a finger into his mouth.  The left hand went behind the baby 's head to flex it, and the head was born with minimal effort on my part.
• Baby was initially pale as he lay on the birthing mat under his mother, with his cord intact, as mother turned to look at him, and ask how he was.  I dried him, checked the pulsing of the cord, blew on his face, and before the first minute was up, he had taken a gasp of air.  His colour began to improve.  A few more minutes before he was ready to cry, but all the time he was making the transition from womb to the outside world, there was no reason for me to interfere.
• By 5 minutes, he was in his mother's arms, pink and strong. 
• By the next day when I visited them, he had been breastfeeding strongly and effectively, and doing all the things newborn babies are expected to do. He weighed just over 4 kilograms.

midwifery: protecting health across generations

Maria Lactans (17th Century) Antwerp

One of the truly compelling reasons that I have for practising midwifery the way I do is the knowledge that there is no safer, no better way for a baby to be born and nurtured than the way our bodies have been wonderfully created to do it.  The marvels of science and medicine have not come up with a better process.  

I'll call it NORMAL birth: normal from a biological, physiological perspective in ideal conditions.
Not what *normally* happens today.
Not what is most common in birth today, or 100 years ago, or in a primitive society .... 

NORMAL birth requires a strong healthy woman who carries her pregnancy to term, and comes into spontaneous labour.  It requires the mother to accept and work with her body in labour, and to progress, without medication, to the climax of birth.  It requires the mother and baby to work together in establishing breastfeeding, within a nurturing family-community setting that supports the mother in these challenges.

This 'ideal' is what a midwife seeks to facilitate. "In NORMAL birth there should be a valid reason to interfere with the natural process." (WHO 1996)

At any point in the process we can face challenges, complication, illness, and the need to intervene.  That's when science, medicine, obstetrics ... become life-saving.


There are obvious and unquestioned benefits to a mother and her baby when the NORMAL processes are protected, promoted and supported.

• A mother's body and mind respond in unison to the changes in hormones in her blood, as she prepares, and progresses.  
• The mother's thinking brain is suppressed, in a quiet and unstimulating environment where she does not feel that she is being observed, so that her instinctive mind is free to proceed with the final nesting, and the surrender that accompanies strong labour.  
• The baby is born alert and healthy, ready to engage in the instinctive breast crawl as breastfeeding is initiated.   
• Early and effective suckling at the breast, together with the physical pressure of the baby's weight against the mother's uterine fundus, lead to strong contractions and completion of the third stage.  
• Once the placenta and membranes are completely expelled the risk of haemorrhage is minimised, and continuing breastfeeding supports the involution of the uterus.  
• Close physical contact from the time of birth supports the development of normal bacterial flora on the baby's skin and digestive organs, preparing the baby's immunological processes for ongoing function.  
• Bonding between a mother and her newborn proceed as they make eye contact, with uninterrupted close contact, and the mother's body is awash with love hormones.

I have not mentioned the midwife.  Yes, the midwife is present, working in harmony with the NORMAL processes, and guiding and supporting when things get difficult, but staying quietly and unobtrusively out of the limelight.  The midwife is guardian - protecting the mother and her child, and providing a safe space for them in NORMAL birth.

When there is a valid reason to interfere with the natural process, the midwife guides the woman, and provides appropriate explanations.  The midwife seeks only the health and wellbeing of mother and child.


Today I am looking further than the primary episode of care, spanning the nine months of the pregnancy, and the six weeks of the postnatal period.

I am looking at future generations.


The study of epigenetics: "the study of heritable changes in gene activity that are not caused by changes in the DNA sequence" offers huge challenges in health care, and particularly at the beginning of it all; conception, pregnancy and birth.  Emerging within this field of science is a new respect, for example, for the effect of nutrition during a woman's pregnancy on the health of her grand-children - the children of the child forming in her womb.

I have no claim to expert knowledge in biology, but would encourage readers to keep exploring this field.

Our bodies are wonderfully made.

I have recently become aware of a new film project,
micro birth

"MICROBIRTH" is a feature-length documentary looking at birth in a whole new way, through the lens of a microscope.
The film explores the latest scientific research into the microscopic events that occur during and immediately after birth.
This compelling, brand new science is starting to indicate that if the natural processes of childbirth are interfered with or bypassed completely, this could have devastating consequences for the long-term health of our children.
Just to be clear, this film is not calling for an end to interventions as many times they are essential and they can be life-saving.
But as this new science is starting to indicate, the use of synthetic oxytocin to induce or speed up labour (Pitocin / Syntocinon), antibiotics, C-section, the routine separation of mother and baby immediately after birth and formula feeding, could significantly raise the risk of our children developing serious disease later in life.
And as the film shows, the medicalisation of childbirth could even be contributing to a potential global human catastrophe predicted to happen by the year 2030.

...

Birth statistics

Source: Victorian Health Department 2009

I expect readers will find the trend in the number of women achieving planned home birth (Table 33)  interesting.  (click on picture to enlarge)

To access the full Victorian Consultative Council on Obstetric and Paediatric Mortality & Morbidity (CCOPMM) Annual Report for the year 2009, click here.
[This is the most recent of the annual reports]

Midwives are the only professionals who attend women for planned home birth these days.  In years past there were a few GPs, but time and cost of insurance has caught up with them.  Midwives are attending homebirths privately without professional indemnity insurance, under a special exemption that is in place until June 2015.


I note:

• the gradual increase in homebirths as a percentage of all confinements*, from 0.2 in 1985, to 0.4 in 2009 (Table 33).
• Table 34 indicates the type of birth for all women who were recorded at the onset of labour as 'planned' homebirth.  Women planning homebirth in 2009 had 90% 'unassisted vaginal' birth (the overwhelming majority of these being spontaneous, unmedicated); 6% caesarean birth, and the rest forceps, vacuum, or unknown.  
• This compares with only 38.6% of all women in 2009 coming into spontaneous labour without augmentation (same report, p61), and 54.6% having unassisted vaginal births (p64).

AIHW 2010 - click to enlarge

We do not yet have a 'Births in Victoria' report for 2010 or subsequent years.
 
This 2010 national report is from the Australian government's Mothers and Babies publications site.

I note:

• In Table 3.18 (shown here), the number of babies born at home in Victoria has increased from 300 in 2009 (PDCU) to 567 in 2010. 
• This is the actual place of birth, including those who planned to give birth in hospital, and the baby beat them to it, and those who intentionally gave birth unattended ('free birth')
• The AIHW 2010 data does not report on home birth by intended place of birth in Victoria (Table 3.19, p29)
• 2010 was the year that the two public hospital homebirth trials commenced at Sunshine and Casey.  The number of homebirths births through those hospitals was small (40)
• 2010 was also the year that the federal government's maternity reform package was implemented, with midwives becoming eligible to provide Medicare-rebated antenatal and postnatal services from November 2010.

AIHW 2011 click to enlarge

 The 2011 national report from AIHW provides more information on home births in Victoria, as it includes the breakdown of those women who gave birth at home, having planned (intended to) give birth at home.

I note:

• The number of planned homebirths in 2011, in Victoria,  was 432, accounting for 0.6% of the State's births.  
• Looking back at Table 33 (above), the increase from 300 in 2009, 0.4%, is substantial.
• Midwives in Victoria quickly accessed eligibility for Medicare, and promoted primary maternity care options for women.
• The only place in Victoria where a midwife can practise privately is in the community, for planned homebirth.
• No Victorian hospital has yet established processes whereby midwives can apply for clinical privileges and attend their clients in the hospital
• Since 2010, a number of experienced midwives have resigned from mainstream Victorian hospital and birth centre employment and joined the ranks of midwives offering homebirth.

The following excerpt from AIHW 2011 provides interesting comment:

Homebirths 
In 2011, there were 1,267 women who gave birth at home, representing 0.4% of all women who gave birth. The highest proportions were in Victoria and Western Australia (0.8%) (Table 3.18). It is probable that not all homebirths are reported to the perinatal data collections.

The mean age of mothers who gave birth at home was 31.7 years (Table 3.49). The proportion of mothers younger than 20 was 1.3%, and the proportion aged 35 and over was 29.8%.

The proportion of mothers who gave birth at home who identified as being of Aboriginal and Torres Strait Islander origin was 1.1%.

Most women who gave birth at home were living in Major cities (70.8%) (Table 3.49). Of mothers who gave birth at home, about one-quarter had their first baby (22.3%), and 77.4% were multiparous.

The predominant method of birth for 99.3% of women who gave birth at home was non-instrumental vaginal (Table 3.49). The presentation was vertex for 97.6% of women who gave birth at home.

Of babies born at home in 2011, 99.2% were liveborn. The mean birthweight of these liveborn babies was 3,614 grams (Table 3.49). The proportion of liveborn babies of low birthweight born at home was 1.6%, and the proportion of preterm babies born at home was 1.3%. (AIHW 2011, pages 65-66)

I note:

• There were 10 babies of the 1,301 homebirths in 2011 recorded as fetal deaths.  These data do not provide detail as to how or why those deaths occurred.
• The midwife is duty bound to promote the wellbeing and safety of the mother and baby in her care, above preference for place of birth, or other factors.

*The word 'confinements' is used in these reports, as a tally of the number of women who have given birth, rather than the number of births, which includes multiples.  Readers might like to suggest a better word!

Birth stories: why are they important?

A few days ago I wrote a blog post about Birth Stories.  That article has attracted a large number of visitors to the site, about X10 the usual tally, and impassioned discussion on social media sites.

The problem that I have written about there is that a revised advertising guideline for midwives, to be in effect 17th March 2014, states that "the use of patient stories to promote a practitioner or regulated health service" is a testimonial, and prohibited under the Health Practitioner Regulation National Law.  The revised guideline has taken the word 'testimonial' to mean "a positive statement about a person or thing".  


In drawing attention to this matter I hope the regulatory Board (NMBA) will see that the writing and sharing of birth stories is an important part of social dialogue between women and midwives and the whole birthing community;  that birth stories are not written primarily to promote the midwife or her practice, and therefore should not be considered testimonials.  Birth stories help the mother to recall and record for all time the often amazing journey that she undertook in bringing new life into her family.  The midwife is a small part of the birth story.  The woman and her baby are the central focus.


Having used the word search function of this site, I found a 'birth story in pictures' that I wrote in February 2010.  At the end of that post I wrote: "Please note that midwives and other registered health professionals are not permitted to use testimonials to advertise our services."

In March 2011, I wrote about 'The birth of Richie Jack', and in that post linked to the birth story blog written by his mother, Ashley.  In my post I wrote:

...

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

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

I have always encouraged mothers in my care to write their birth stories, and will continue to do so, regardless of the revised guideline and its position on 'patient stories' that may mention me, the midwife, in a positive (or negative) way.  The internet and social networks are here to stay, and a mother who uses the internet as a means of sharing her story should be free to do so.


Your comments are welcome. 

The bigger picture

Grand-daughter's photography - you can see that I love her!

I have a lull in my bookings at the moment, and have set myself the challenge to consider the bigger picture.

Questions of birth/maternity care/midwifery that comprise the bigger picture are along this line:

• How well does Australia measure up against global midwifery?
• What is being done in Australia to protect sustainability in the midwifery profession?
• What can a woman in Australia anticipate as she carries, births, and nurtures a baby?

It would be easy for me personally to be dismissive about the bigger picture.  Leave that to the younger generation!  I have enjoyed my career, have had many incredibly beautiful experiences with women who have given me their trust, and have invited me into their lives at their most intimate moments.  I have written many of my stories down in journals and blogs and argued my point in articles and published papers.


How well does Australia measure up against global midwifery?
The home of global midwifery is the International Confederation of Midwives (ICM).  The Australian College of Midwives (ACM) is a member organisation of ICM, and Australian codes and standards are based on the ICM Definition of the Midwife (2011).

ICM lists the following key concepts.  I will use them as a basis for my assessment of Australian midwifery as I know it, and give each point a score out of 10. I will not attempt to justify or give references, since this is a statement of opinion.  However, my opinion is based on careful reading of midwifery literature, and careful reflection on a lifetime of midwifery practice.  If the reader considers that I have made a statement that is wrong, or unsupportable, please tell me why.

ICM Key midwifery concepts that define the unique role of midwives:

• partnership with women to promote self-care and the health of mothers, infants, and families;
• respect for human dignity and for women as persons with full human rights;
• advocacy for women so that their voices are heard;
• cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
• a focus on health promotion and disease prevention that views pregnancy as a normal life event.

1. partnership with women to promote self-care and the health of mothers, infants, and families:
Promoting self-care and health of mothers, infants and families is a wonderful, big picture statement. 

I would suggest that we look at rates of spontaneous unmedicated birth as an initial measure of health promotion, self care, and wellness of mothers and babies.   Spontaneous unmedicated birth will be most likely to proceed when the midwife is practising as an authentic midwife, establishing a partnership with the woman based on reciprocity and trust.   WHO (1996) stated that "In normal birth there should be a valid reason to interfere with the natural process."  Achieving spontaneous unmedicated birth is a measure of the capability of the midwife as much as the mother.  There is no safer or better way, in most instances, than for the midwife and the woman to work in harmony with natural processes.  The midwife acts in a way that minimises disturbance, disruption, interference, interruption, while observing and assessing progress and wellness.  The woman learns to minimise neocortical activity, and access her amazing supply of natural opiates.  Her oxytocin and adrelanine peak as she gives birth, providing for her baby the ideal transition to life outside the womb, and giving herself the ability to contract her womb strongly and expel the secundines (an old fashioned word meaning the afterbirth) without excessive bleeding.

In Australia more than 30% of women have caesarean births, completely by-passing these physiological states. Only about 25% of women have no analgesia for birth.  Only a tiny minority of the women receiving maternity care in Australia are cared for in labour by a known midwife - one of the evidence-based measures by which we can anticipate improved outcomes for mother and baby.  There is much room for improvement!

SCORE 4/10

2. respect for human dignity and for women as persons with full human rights
What measure is there for respect of human dignity?  I don't know.
There are many cultures in Australia, and it's not possible to generalise.  The planned homebirth 'culture' is quite exceptional.  These women are  usually not wealthy, but find the money so that they can have private midwifery care.  They value their personal dignity, within their own homes.  They accept the work of childbearing, as their own job, and give it their best. 
On the other hand, I consider the educated, relatively wealthy segment of our population, whether they are cared for in private or public hospitals, there are many examples and anecdotes of a lack of respect, an expectation by the midwives and doctors in the hospitals that they will submit to the superior training and knowledge of the medical practitioner who is most senior at the time.
My conclusion is that in Australian mainstream maternity care, there is a lack of respect for the human dignity of women as persons with full human rights, and this is backed up by the Australian Medical Association Position Statement on maternal decision making  (2013)

1. A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.
   
2. A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.
3. Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies. ...

There is, again, much room for improvement!

 SCORE: 5/10

 

3. advocacy for women so that their voices are heard

Australian women have for many years attempted to have their voices heard, and organisations such as Maternity Coalition have advocated on behalf of women.  I and many of my midwife colleagues have been in the thick of it.  Many of the stories since about 2007 can be found on this, and linked blogs.  Here are a couple of pictures that describe advocacy for women:

Mothers, babies, and midwives outside a politician's office in Melbourne

more than 2000 rallied in the rain, on the lawns of Parliament House in Canberra

In response to advocacy, the government of the day (2008) announced a Review of Maternity Services, and asked the public to tell them what they wanted.  Thousands of ordinary people, mostly childbearing women, sent submissions.  Many of them asked for choice - that they could choose where they had their babies, and with whom.  Many told their stories about wonderful empowerment in giving birth at home, with their own midwife. Yet, when the report of the Maternity Services Review was published, homebirth was excluded from the reform package.  

Midwives now have indemnity insurance, but not for homebirth!  We now have Medicare, but not for homebirth!  We now have the processes so that hospitals can award clinical privileges to midwives, but except for a few in the S-E corner of Queensland, this just is not happening.

There is, again, much room for improvement!

SCORE: 3/10

4.  cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies.
It would be politically correct for me to launch into discussion of the plight of Australia's aboriginal peoples in addressing this topic.  There is a great need for such work, and for improvement in all sorts of health outcomes and health promotion.  But I do not see many indigenous people, and in my years of practice have cared for only a handful.   Not many women with indigenous heritage will seek out the services of an independent midwife.

Painting by Odetta Moore (Copyright).  "This is our baby boy waiting to be born.  That's him in the middle.  The circles round him are me, holding him and protecting him.  The tortoises in the corners are his protectors."

There is another vulnerable cultural group that we midwives are seeing, and for whom we need to improve care.  Women who are in this country on work visas, either for themselves or their husbands.  Many come from India and Pakistan, some from Africa.

The visas that these women use do not entitle them to publicly funded health care under Medicare.  The visas require health insurance, but the insurance policy usually does not cover childbirth.  These women enquire at public hospitals, and are told that they will be required to pay $11,000-$15,000 upfront for maternity care.  Some have no prenatal maternity care, and present at a public hospital in labour.  Some are choosing homebirth, as the cheaper option.  Many are Moslem women, fully covered when outside the home, and it's common to see very low levels of Vitamin D, and iron deficiency anaemia.

What can we do to improve the health outcomes for these women and their babies?

SCORE: 5/10

5. a focus on health promotion and disease prevention that views pregnancy as a normal life event.
Health promotion in maternity care in Australia relates to initiatives such as smoking cessation, obesity, family violence, and baby sleeping arrangements.  There is little recognition of the fact that pregnancy is a normal life event; that health outcomes are best when technology and medicine and surgery are used sparingly; and that health outcomes are best when exclusive breastfeeding is initiated at birth.

Pregnancy is seen, in mainstream maternity care, as a minefield; a disaster waiting to happen.  Women are investigated, tested, and explored - in expectation of something awful.  Concepts of informed decision making are poorly understood, and even more poorly followed.  Women report being bullied if they question a plan of action, or try to decline an offered treatment.

Australian maternity services are medically driven, with obstetric hierarchy dominating most services and decisions.  The RANZCOG College Statement on Homebirths, while attempting to support personal autonomy and informed decision making, leaves little room for discussion, and a great deal of room for coercion:

"... While supportive of the principle of personal autonomy in decision making, RANZCOG cannot support the practice of planned homebirth due to its inherent risks and the ready availability of safer options for labour and delivery in Australia and New Zealand. Where a woman chooses to pursue planned homebirth, it is important that reasons for this are explored and that her decision represents an informed choice, considering all the possible benefits and potential adverse maternal and perinatal outcomes. ..."

There is, in my opinion, ample evidence supporting planned homebirth, with plans for transfer of care to hospital in a timely manner when indicated.

There is, again, much room for improvement!

SCORE: 3/10

TOTAL SCORE: 20/50

40%

FAIL!

collaboration, coercion, and concocted evidence

Today I would like to write about an experience that I have found very difficult, and I know the parents of the baby shared my concerns.

It is not easy for me to write about this.  I'm usually a peace maker.  I'm usually more pragmatic; I don't like being idealistic about birth issues, simply because life is not perfect.

This post follows the previous one, in which I have written about some of the 'carrot and stick' aspects of maternity reform.   One 'stick' is the cost of midwifery services.  While one-to-one primary maternity care by a midwife, and use of hospital facilities only when indicated - the basic best practice model - describes pretty much the scope of private midwifery services, and thousands of dollars are 'saved' by the state for each woman who does not require hospitalisation for birth, the women who choose care from a midwife pay for the privilege.   

The second 'stick' that I want to consider is collaboration. 

Collaboration, which in theory means that professionals work together so that the consumer/patient receives optimal care, is a requirement for eligible midwives who wish to enable women in our care to claim Medicare rebates (See Collaboration Determination 2010).   I have no problem with collaboration.  BUT, I have a big problem when, instead of collaboration a woman in my care is subjected to coercion, bullying, and fear-mongering with concocted data being presented as evidence.  I have a big problem when a bureautically-defined process that's called collaboration is a requirement for midwives, but no doctor, and no hospital is required to reciprocate.

From time to time as I write at this blog I include stories from my experience.  Today's story of (non-) collaboration, coercion, and concocted evidence goes like this:

Background:

Jill and her husband Jack (for want of better names) were expecting their third baby.  Jill is a healthy young woman, and she gave birth without incident to her other two children at home in my care. 
When Jill spoke to me about maternity care for the birth of this baby, I explained that we needed to find a suitable doctor to provide a referral to me for antenatal and postnatal midwifery services, in order to comply with the medicare collaboration rules. 
The local GP who Jill had seen previously agreed to collaborate, and it all looked good.  Jill was happy to see the GP and had routine tests and investigations arranged.  The doctor asked Jill to come back for some checkups during her pregnancy.

>>> fast forward to 36 weeks
I visited Jill and Jack and the children in their home.  I noted that Jill had found the summer heat rather taxing!  We had had a run of four or five very hot days, which is taxing for everyone.  I palpated her abdomen, and thought the baby was not very big.  I remembered that neither of the other two children had been large.  OK, I thought, let's see how this baby looks in a couple of weeks' time.  Jill had been having some troublesome pre-labour contractions, especially in the evening.  I encouraged her to rest, to eat nourishing food, and to keep her baby growing in her womb for a couple more weeks.
A couple of days later Jill's GP saw her, and told her there was a problem: the baby was too small.  An ultrasound to estimate the size of the baby was arranged.  Jill was told her baby was small, and she had too little amniotic fluid.  Jill's GP told her she was to go to the tertiary referral hospital for review.  Jill is a logical thinker, and she tried to discuss her options.  No discussion!  And you had better rethink the plan for homebirth too!
Jill phoned me and told me she was feeling bullied.  She respected the doctor's opinion, and was prepared to accept investigations, but she felt she was being pushed up against a wall.
The next couple of weeks were busy, with visits to the GP, visits to the fetal monitoring unit at the big hospital, arranging family members to care for the children, and arranging time off work for Jack.

>> 38 weeks
Time for another ultrasound growth scan. 
Would you believe it, the baby's not growing as well as we would like!  Estimated weight 2.4 Kilos.
Baby's placenta is fine, but it might not continue to function well.
Advised to have an induction of labour tomorrow.
Jill talked it over with me. 

[I could not help but ask myself, would I have raised the alert about this baby; about this pregnancy?  No, I don't think so.  Had I missed something important?]

Jill was finding the pressure overwhelming.  I reassured her, that she could choose the pathway.  I encouraged her to make the best decision that she could in the situation; that I would work with her at the hospital or at home.
Jill decided to accept the hospital's offer of induction of labour by artificial rupture of membranes.

 ...

The labour and birth progressed normally, and five hours after arriving at hospital, Jill gave birth without incident to her healthy baby boy.   I looked down at him and thought, "he's not too little!"  He later weighed in at a healthy 2.8 kilos.

Later that evening, Jack and Jill wanted to take their new baby home.  The doctor from the paediatric department arrived in their room, and told them the hospital required Jill to remain in hospital for 24-48 hours, so that the baby could be observed for the symptoms of early onset group B streptococcus (EOGBS). 
Jill had received an antibiotic in labour to prevent EOGBS, and argued that she was an experienced mother, and would recognise if her baby became ill.  The doctor then presented some concoction of evidence - who knows what she actually said!  What Jack and Jill heard, and told me, was that they were told that 50% of the babies of mothers with positive GBS swabs will die from the disease.  That's scarry!  Jack phoned me and asked me to talk through EOGBS with them, which I did.  They went home.  Baby continued to feed from Jill's breast and thrived.

[For those who are interested, I would like to note here that GBS is a serious infection.  There is a high mortality statistic related to GBS, but it did not apply in any way to Jill's baby.  A baby who develops GBS and is not treated, either in labour or after birth, would have approximately a 50-50 risk of dying from the infection.  That's why we treat infection in labour or after birth so seriously.]

The coercion and concoction of evidence that Jill has experienced in this episode of care is a very distressing phenomenon.  I wish it was an isolated event.  Sadly it's not.  And I regret that Jill and Jack experienced the coercion and bullying as a result of my collaboration.

some of the carrots and sticks of maternity reform

A few weeks ago I wrote:

Regulatory pressures that have increased since the previous government's maternity reform package was implemented in 2010 are like the carrot and the stick.  The 'eligible midwife' carrot is that certain midwives earn special privileges:  Medicare rebates, clinical access to hospitals, and prescriber authority.  The 'eligible midwife' stick is the linked requirements and cost of professional indemnity insurance, collaborative arrangements with obstetricians, and getting over increased bureaucratic hurdles such as the midwifery practice review.  There is no reliable evidence that this approach will make birth safer for mothers and babies, or eliminate the fear of a rogue element in midwifery. ...

Today I would like to look closer at an example of what I mean by the 'stick'.

• One-to-one midwifery is accessible only to the relatively wealthy, who can afford to pay, and the lucky, who are accepted into public hospital caseload programs,

'Sacred organ', or 'hazardous medical waste'?

I am forwarding this message with permission of it's author, midwife

Irene Athina Avramidou

GOOD NEWS FROM GREECE!

The trial of 79 people (doctors, midwife and parents) who were accused for environmental pollution from the placenta in homebirths and false medical certification came to an end once and for all !

79 parents, doctors and me (midwife) were acquitted !

In a trial that lasted up to five hours, the only prosecution witness was the president of Midwives Association of Thessaloniki, a court seat that fully respected the accused and a district attorney who in his speech said that this case should ΝΟΤ have reached the court from the beginning !

midwifery directions for 2014

Greetings to my little band of readers and thinkers and birth nerds.

In my first blog entry for 2014, not knowing what lies ahead, I hope this new year brings you valuable learning and the satisfaction of knowing that you have contributed well to whatever your work is.

There is an old saying that the pen is mightier than the sword.  I am using the internet to wield a (virtual) pen/sword (whatever that might mean in today's world) in my campaign to protect, promote and support health through childbirth.  The midwifery-childbirth scene is in need of protection. The context is discussion around the future of midwives and homebirth in Australia, stimulated by midwife-blogger Rachel Reed.  I would encourage you to read the post, and the comments.

Holidays: time to reflect and reminisce

Thanks to Kate for the lovely bunch of flowers

The week between Christmas and the New Year is a very special time for me.  This year I don't have any babies due, and I am enjoying the 'holiday'.  I don't need to do much meal preparation, as we have leftovers from the Christmas feast to work through.  Tonight I have made a pot of risotto, with stock made from the turkey carcase, ham and vegetables.  We have plenty of fruit to enjoy: stone fruits from the trees in the back yard, and melon, pawpaw, cherries ... - more than we can eat.  Today the dehydrator is humming as a batch of apricots are being dried.  Noel has made up a couple of pots of jam - plum and apricot so far.  The figs will be ripening soon.

Cultutal heritage in need of urgent safeguarding

Recently my attention was drawn to the UNESCO cultural project to develop a list of Intangible Cultural Heritage in Need of Urgent Safeguarding.

Intangible cultural heritage is knowledge and skill that, unlike monuments or collections of clay pots, cannot be touched.  The UNESCO list includes a fascinating range of human activities, from Mongolian calligraphy, to Watertight-bulkhead technology of Chinese junks, to many examples of traditional music and singing.

Readers of this blog may already have joined the dots, and wondered if some aspect of 'midwifery', or 'spontaneous, unmedicated *normal* birth' (or both) could be considered an under intangible cultural heritage in need of urgent safeguarding?

Is the reality of normal (natural unmedicated physiological) birth something that can be called a cultural heritage, and something worth protecting? I say "YES".

a time for quiet reflection

As I drive, alone in my car from my home to the home of the woman in labour, I enter a special time of reflection. 

This past week I have attended the births of two babies, and in both instances I had about 45 minutes of driving.  Both mothers called me in the 'wee hours', and each baby was born spontaneously and without incident at home.  My aim in writing about something as ordinary as driving from my home to the woman's home for birth, then returning when it's all over - something that midwives have done since the beginning of time -  is to hold on to a very special memory.

As I head out from my home my thoughts are initially focused on the task at hand.  Gather the various bags containing the equipment and supplies I may need - all packed and ready to go.   Paperwork for registering the birth and statistical reporting is also ready.  Remember to take the oxytocics out of the fridge.   Pick up an apple to eat on the way home.  Water bottle.  Possibly re-check the map if I am not confident of the directions.

Then, as I pull out of the driveway and head down the deserted street, my thoughts move to the mother who is labouring.  In the night I see only the small, moving perimeter that is lit by the car's headlights.   That's the special world I am entering.

Each mother in my care is an ordinary person - there are no idealistic notions of perfect bodies, perfect natural processes.  It's a fallen world.  I know some of her strength, and her vulnerability.  She has told me some of her fears.  I commit her to our loving Father's care, as she prepares to give birth. 

I think about the baby.  I know a little about this baby - the recorded, technical points such as gestation, heart rate, position, ...  I have also put my hands over this baby, palpating and holding the precious little form in my two hands, through the covering of the mother's skin, and said "Hello baby" each time I have checked.

I think about the family.  The father, and the siblings.  What arrangements are being made for the care of the older children.  Are there supportive grandparents on hand, or a strong community network?

Thus my mind is prepared for the birth journey which may be quick, or slow; may be uncomplicated, or difficult; may be as the mother anticipates, or not.  I seek wisdom, strength, and courage as I enter the birthing space.

...

Now I am driving home, in the daylight. 

I gather my thoughts about the mother, the baby, and the family I have just left.  I ask God's protection and wisdom for that mother, father, and family.

Having had little sleep in the past 24 hours, I am conscious of my own weakness; my need to be alert and safe in driving home.   Before switching on the radio, I commit to memory any tasks I might need to do to complete the job. 

In the wonderful early morning light I notice the features of the land and trees - the forest of tall, grand mountain ash trees, with tree ferns graciously spreading their fronds in the Dandenong National Park; or a new townhouse development site in the urban sprawl to the south-east of Melbourne. 

...

I must close this brief post now, as I need to return to a new mother and baby for a postnatal check. 

Why do private midwives need hospital visiting access?

Yes, I gave birth to my four children in hospital. This is #1

In a perfect world, would every woman want to give birth in the privacy of her own home?

Perhaps.

In a perfect world, there would be no sickness, no pain, no decay, corruption ... no need for hospitals either.

But we don't live in a perfect world.  No matter what steps we take to optimise health of mother and baby; to optimise the positioning of the baby in the womb for a normal birth; to prevent infection; to prevent social disorders that result from smoking, substance abuse, and obesity ... no matter ... the midwife is always watching and observing in case complication or illness arises.

Home is a wonderful place for birth when the woman and baby are well, and progressing normally.  At any time the decision to stay at home may need to be reviewed.

Some people may tell me I am being driven by fear in saying this.  We in the 'natural birth' realm see slogans such as 'Trust Birth'.  I hear midwives speaking of the physiological processes in birth as though they come with an iron-clad guarantee.

No! and No!

Don't get me wrong.  Birth is an amazing, awesome process - most of the time.  Natural physiological processes in birth and breastfeeding, together with the cocktail of hormones, and the physical and psychological factors that can influence these processes are truly wonderful - most of the time.

There is no better way for most than the natural process.  God the creator made the woman's body as well as the man's, mysteriously in the image of God, and said it is good.  That is a profound truth.  The balancing truth is that today we are able to protect and save life, through medical intervention, to a greater degree than ever before.

That's where hospitals come in to my thinking today.

I'm not talking now about a perfect world.  However, a better world is a reasonable goal.

There will always be women who need or choose to give birth in hospital.   These women ought (in a better world) to be able to use the services of a known and trusted midwife in hospital.  That option is not commonly available in the world we live in today.  Some women are fortunate that they have a wonderful midwife allocated to care for them in their labour, or even in a caseload/know your midwife program.  But the usual feature of birth in Australia today is that a woman is attended in labour by a stranger - someone she has not met prior to coming into labour.  Women with financial resources and private health insurance might have an obstetrician who has provided their antenatal care, with whom they feel a bond of trust, but that doctor is not in continuous attendance - the midwife/stranger is. 

In a better world, women would be able to engage their own midwife, or small group of midwives, who are committed to providing continuity of care that spans the community and the hospital.

In a better world, midwives would be able to choose to work either privately or as employees of a hospital or health service; either as shift workers, or with a personal caseload, or in one of the multitude of hybrid models of care that are designed to meet the individual needs of the women as well as the midwives.  These options should provide reasonable rates of pay and conditions.  Midwives can only do our job well when we are in good shape ourselves.  We teach women to be intuitive about the needs of their children and themselves - we ought, in a better world, to apply the same thinking to ourselves.

The journey to maternity reform has been an uphill one.  I am hoping that it won't be long before we see a pathway to a better world of maternity care.

Thankyou for your comments.

Caseload midwifery - women do well, midwives love it, so what's the down side?

Five beautiful cousins enjoying a day out at the Weribee Zoo

A recent publication on Caseload midwifery brings together evidence from leading Australian midwifery researchers and academics.  Caseload midwifery is good for the mothers, good for the hospitals, and good for the midwives.

"In Australia, the growing popular choice for expecting mothers is to stick with one midwife from pregnancy to post-natal care. Anne Marie George looks at why caseload midwifery has more to offer than a boutique service." [article]

Good for mothers:

• less use of medical interventions in labour than women in standard care
• less use of painkillers (aka 'dangerous drugs')
• 22% fewer caesarean births than women randomly assigned to 'standard' care.

Good for hospitals:

• saves the hospital money
• appropriate use of midwives compared with rostered staff
• less sick leave for midwives

Good for midwives:

• autonomy, giving the midwife a strong professional identity
• flexibility, enabling the midwife to integrate midwifery work with other daily activities
• arrangements for backup when needed
• commitment to the women

Everything good comes with a price tag.  If caseload midwifery is so good for women, for employers, and for midwives, what's the down side?

I am writing from my own experience, over the past 20 years, with a caseload.  The caseload research referred to above was done in hospitals, while my experience has been in private practice.  The place of birth for most of the women in caseload research has been a public hospital, while my work has been with women who are usually planning homebirth.  But the commitment of the midwife is the same, regardless of where the birth is intended, or who pays the midwife.

When I began to practise independently, with my own caseload, I experienced the development of a strong midwife identity that has only grown over time.  I began blogging before we knew what a blog was.  In 1996-97 I wrote The Midwife's Journal, bringing together my experience and learning as a midwife against a backdrop of ordinary daily experiences of my life.  I appreciated the flexibility and freedom that caseload midwifery offered me, when compared with rostered shift work.

From my perspective, caseload midwifery is all about families - the family that is being made/extended with the birth of a new little person, and the family of the midwife who commits to being 'with woman' throughout the journey.

Most midwives are women, and most women have children, and the responsibility for caring for children is, for considerable periods of time, a mother's responsibility.  And so it should be.  It would be ridiculous for the amazing processes of bonding and attachment that are mediated by a hormonal cocktail through the pregnancy-birth-nurturing continuum to simply shut down.

If a midwife is also a mother of dependent children, she needs reliable support at any time, day or night, in order to take a caseload.  This fact prevents some midwives from taking up the caseload options - until the children are old enough.

I began caseload midwifery in 1993, when the youngest of our four children, Josh, was 12.  I knew that he, and his three older siblings, were reliable and responsible, and could be trusted to let themselves into the house after school, find something to eat, get on with his homework or music practice, and would be safe if I was out.

The down side of caseload midwifery is the very thing that makes it so valuable.  Commitment costs the midwife.  Getting up at 11:30 pm or 3:00 am is never easy, but that's what a midwife does - for the woman in her care.  Going through a journey that presents difficulties or distress is never easy, but if the midwife is 'with woman', they go through it together.

I began this post with a picture of our five precious grand children - the next generation in our family.  Midwives who have caseloads are guardians of the next generation, protecting wellness and promoting health in families.

does private midwifery have a future in this country?

Pear blossoms: it's spring time in Melbourne

This question presents itself to my mind. Should I encourage younger midwives to take up the opportunities for private practice?

There are a couple of major challenges which, depending on decisions outside our control, may either open up or close down this career option for midwives.

• (affordable and appropriate) professional indemnity insurance: This is a global problem, and next week in the UK "Due to new EU legislation that demands all health professionals possess indemnity insurance by October 25, independent midwives will be rendered illegal overnight – unable to pay the premiums of £20,000 per year, which for some is more than their annual salary." (The Telegraph) and
• hospital visiting access

Professional indemnity insurance 
One of the wonders of the digital era for me as a blogger is that I can retrieve what I have written in the past.  A search of 'insurance' on this site took me to posts I had written in mid 2009, when the decisions about not indemnifying midwives for privately attended homebirth were made by the government. 

Then came the news that we would be given a 2-year exemption for homebirth.  That exemption has been extended a couple of times, and is now in place until 2015.

The two options for private midwife insurance are products marketed by MIGA and Vero Mediprotect.  The former is underwritten by the Treasury, and indemnifies midwives for claims arising out of their practice, as long as the birth is in a hospital where the midwife has been credentialed for clinical privileges.  If a MIGA-insured midwife attends a woman who plans to give birth in the home, she/he does so uninsured.

The Vero Mediprotect insurance is several thousand dollars cheaper than its competitor, does not have any government underwriting, and does not have any intrapartum (birth) cover.  Since hospital visiting access is available to only a few midwives in the S-E corner of Queensland, the only indemnity cover most midwives need is for antenatal and postnatal services.

Why is professional indemnity insurance (PII) mandated?
The Australian governments have been committed to mandatory PII for many years.  I know this because I was a member of the Nurses Board of Victoria (NBV) for three years 1999-2001, and I sat on the legislation committee.  

Until that time, midwives had been able to buy PII that was capped at 5 or 10 million dollars.  Then the bottom fell out of the global PII market, and the underwriters (Lloyds of London) ceased providing cover for midwives.  This effect was passed down to the Australian Nursing Federation (ANF) which, until then, had included PII cover for all members within their membership fee.  ANF continued to provide PII cover for all members EXCEPT independent midwives.

When I informed the NBV of the fact that all independent midwives were now without PII, an attempt was made to have me resign quietly.  I resisted, and with the support of other members of the Board, retained my position.  I attempted to argue that if the government was intending to mandate *something* (in this case, PII) of all health professionals, it was the job of the government to ensure that that *something* was accessible and affordable.  If the provision of that *something*, PII for midwives, was delegated to the insurance industry, the insurance industry became a de facto second tier of regulation of the midwifery profession.  The insurance industry's first commitment is not to what's called 'public interest'; safety and wellbeing of mothers and their babies.  The insurance industry is a business that exists to make money for its shareholders.

I would love to see a test case in which some brilliant lawyer could argue that this free market situation, where everyone is required to insure themselves, regardless of the feasibility, is not reasonable for a regulated profession that provides an essential service. That it is in the public interest to enable midwives to practise, as much as it is in the public interest to have a regulated profession. Countries such as Netherlands, Canada, NZ have insurance arrangements that do this. Midwives (and women) have to accept certain boundaries and constraints.  I believe that, in a free society, women should always able to employ midwives if they want to, and midwives should be able/expected to attend births in hospital as well as home.

... which brings me to the second point, hospital visiting access.


Hospital visiting access
Many Australian independent midwives have become so used to working outside hospitals, and see hospitals as 'bad' - to be avoided if possible - while homebirth is 'good' - for all sorts of reasons.  This approach is simplistic, and potentially harmful to the mother and her baby.  Even if 95% of women who truly wanted to give birth spontaneously, within physiological processes (that we know often work well in the home), that leaves 5 women in every 100 for whom home is not a safe place to give birth.  Those 5 women have a need for professional midwifery services, just as much as the woman who experiences an uneventful process.  A midwife is 'with woman': the setting for labour and birth is a secondary consideration.  

If midwives are serious about promoting and protecting health in childbirth, we must protect the 'normal', while at the same time being expert in timely recognition of situations when intervention is needed.  We must work to make hospitals as well as homes settings where a woman's own natural processes in giving birth are respected and protected.