Regarding:
Smith GCS, Cordeaux Y, White IR et al (2008). The effect of delaying childbirth on primary cesarean section rates. PLoS Med 5(7): e144. doi:10.1371/journal.pmed.0050144.
Smith et al goes so far as to use dystocia, undefined by American College of Obstetrics and Gynecology (ACOG) or anyone else except as delayed labor, to make women feel guilty for delaying first childbirth. The authors found that at age 16, women have an average labour of 9.1 hours which rises slowly peaking at 10.4 hours from age 33 and above. The authors sampled myometrial strips obtained from 62 women and claim to have found a reduced degree of spontaneous contraction in older women. They used this supposed difference to define older women as having ‘impaired’ uterine function. This ‘impaired uterine function’ is then theorised to explain why women over 16 have labours that on average last up to 1.3 hours longer, explaining their increased rate of caesarean surgery. The authors did not analyse the reasons women in this study underwent caesarean surgery although as previously stated, the vast majority of caesareans are known to be due to ‘dystocia’. No one knows what would have been the outcomes if women were allowed to labour longer. Instead of the authors defining the arbitrary definition of dystocia as the problem, they blame the extra 1.3 hours that older women take to give birth and define the older uterus as dysfunctional rather than slower. Without evidence that a 1.3 hour longer average labour results in poorer outcomes, the term they use to describe older women as having a ‘dysfunctional’ uterus is, in polite terms, inaccurate. This surely is action bias in its most ageist/sexist form.
from:
Is Action bias one of the Numerous Causes of UnneCesareans? by JS Cohain, in press, MIDIRS Midwifery Digest Dec 2009
N.B. why would women who are in normal shape and state of mind, volunteer to let 'scientists' take strips of muscle from their uterus? Would you?
[Judy Cohain is a midwife in Israel]
Saturday, October 24, 2009
Thursday, October 22, 2009
Melbourne Midwives' Family Picnic
Saturday 28 November, at Elgar Park, Mont Albert (just off the Eastern Fwy – cnr Elgar Rd and Belmore Rd), 11am-4pm. [See Map of Melbourne]
Please check MIPP blog by 9am that day for alternate plan if weather is unsuitable.
Midwives and our families invite the families we know and serve to join us for a picnic lunch, to celebrate life, and birth, and mothering, and midwifery.
BYO everything – food, picnic rugs, hats, chairs &tables (if you want them), games, and your musical instrument and a song if you like.
Elgar Park has toilets, playground, lots of open space, bush areas, wetlands with boardwalk, walking tracks …
Please pass this message on to others who may be interested.
Joy Johnston
joy@aitex.com.au
04111 90448
PLEASE JOIN WITH ME IN MAKING A GIFT OF THANKS TO GOD FOR OUR CHILDREN
Anyone who would like to contribute to a group gift from TEAR Australia’s catalogue to help some of the world’s poor, such as tree seedlings ($10), or family health care ($40) or training a village health worker/ birth attendant ($60), or setting up a women’s self help group ($200), please contact me. The collection currently stands at $200. I will report back to all who donate to this project. Joy
Please check MIPP blog by 9am that day for alternate plan if weather is unsuitable.
Midwives and our families invite the families we know and serve to join us for a picnic lunch, to celebrate life, and birth, and mothering, and midwifery.
BYO everything – food, picnic rugs, hats, chairs &tables (if you want them), games, and your musical instrument and a song if you like.
Elgar Park has toilets, playground, lots of open space, bush areas, wetlands with boardwalk, walking tracks …
Please pass this message on to others who may be interested.
Joy Johnston
joy@aitex.com.au
04111 90448
PLEASE JOIN WITH ME IN MAKING A GIFT OF THANKS TO GOD FOR OUR CHILDREN
Anyone who would like to contribute to a group gift from TEAR Australia’s catalogue to help some of the world’s poor, such as tree seedlings ($10), or family health care ($40) or training a village health worker/ birth attendant ($60), or setting up a women’s self help group ($200), please contact me. The collection currently stands at $200. I will report back to all who donate to this project. Joy
Wednesday, October 14, 2009
Is the increasing rate of caesarean birth linked to the age of mothers?
An interesting discussion into the rise in caesareans took place on ABC Radio National's Health Report, 12 October. The transcript and the audio are available online.
The research team analysed data collected from all births in Scotland over a period of time, and identified women having an uncomplicated first pregnancy.
Here's a brief excerpt of concluding remarks in the interview:
Gordon Smith: There are a whole number of issues about caesarean section, and I think one of the things I would say it's about like the issues around hysterectomy 20 years ago, for a proportion of women a caesarean section is an extremely helpful and valuable intervention, but I think there is a general concern about it in terms of say health economics, that it's much more expensive to provide a caesarean delivery compared with normal delivery, from a philosophical approach that we should try to encourage normality and for many women we attach quite rightly a real importance to achieving a normal birth, and then there's also concerns about the long-term effects of caesarean section, effects on subsequent pregnancy, where there's certainly increased rates of complications. And particularly one of the things we're seeing now is women who've had high numbers of previous caesarean sections. They are a group of particular concern, because some of the most serious and life-threatening consequences that we see in obstetrics are occurring to women who are coming back with four and five previous caesarean sections where there can be real problems.
Norman Swan: The risk of rupture.
Gordon Smith: Risk of rupture, but also the risk of abnormal insertion of the placenta, particularly what we call placenta praevia where the placenta is in the lower part of the uterus and also what we call morbid adherence of the placenta, where the normal relationship, the way the placenta invades into the muscle is affected by the presence of scar tissue and in fact the placenta over-invades into the wall of the womb which can lead to life-threatening bleeding, which can be difficult to control even under optimal circumstances. So I think caesarean section has many advantages in a certain context, and particularly for those women who aren't planning many, many future births, but I think there's going to be an ultimate long-term consequence of increased rates of caesarean section which will become increasingly apparent over the next few decades.
Reference:
Smith GCS et al. The effect of delaying childbirth on primary caesarean section rates. PLoS Medicine 2008;5(7):e144
[Gordon Smith is Professor of Obstetrics and Gynaecology at the University of Cambridge.]
How does this sort of discussion inform a midwife, or a mother anticipating birth?
"Think globally"
Epidemiological research seeks to tease out information from large sources of data. The information we glean from this sort of research helps us to understand the big picture, but it does not influence the way we approach the maternity care of an individual woman. The big picture concern that Professor Smith has identified is that the women today who are having caesarean births will, in future births, face an increased risk of life-threatening haemorrhage.
The obvious conclusion that I draw is that regardless of the age of a woman, or the 'risk' of needing caesarean, the maternity service has a duty of care to do all it can to promote and support normal birth, and to use caesarean surgery judiciously.
"Act locally"
The midwife's professional advice to a woman in her care is finely tuned to that individual woman. The midwife takes into account the woman's whole self - physical, social, psychological, spiritual ... wellbeing, as well as outside factors such as the weather conditions that may have an impact on events. The woman who is working in partnership with a trusted midwife also has knowledge about herself that she shares with her midwife as her time to give birth approaches.
Every woman giving birth has elements of her situation that may enhance or detract from her chances of proceeding with physiologically normal birth. The skilled midwife acts to promote normal birth, taking into account the realities and risks, as well as the advantages that apply to an individual mother.
The research team analysed data collected from all births in Scotland over a period of time, and identified women having an uncomplicated first pregnancy.
Here's a brief excerpt of concluding remarks in the interview:
Gordon Smith: There are a whole number of issues about caesarean section, and I think one of the things I would say it's about like the issues around hysterectomy 20 years ago, for a proportion of women a caesarean section is an extremely helpful and valuable intervention, but I think there is a general concern about it in terms of say health economics, that it's much more expensive to provide a caesarean delivery compared with normal delivery, from a philosophical approach that we should try to encourage normality and for many women we attach quite rightly a real importance to achieving a normal birth, and then there's also concerns about the long-term effects of caesarean section, effects on subsequent pregnancy, where there's certainly increased rates of complications. And particularly one of the things we're seeing now is women who've had high numbers of previous caesarean sections. They are a group of particular concern, because some of the most serious and life-threatening consequences that we see in obstetrics are occurring to women who are coming back with four and five previous caesarean sections where there can be real problems.
Norman Swan: The risk of rupture.
Gordon Smith: Risk of rupture, but also the risk of abnormal insertion of the placenta, particularly what we call placenta praevia where the placenta is in the lower part of the uterus and also what we call morbid adherence of the placenta, where the normal relationship, the way the placenta invades into the muscle is affected by the presence of scar tissue and in fact the placenta over-invades into the wall of the womb which can lead to life-threatening bleeding, which can be difficult to control even under optimal circumstances. So I think caesarean section has many advantages in a certain context, and particularly for those women who aren't planning many, many future births, but I think there's going to be an ultimate long-term consequence of increased rates of caesarean section which will become increasingly apparent over the next few decades.
Reference:
Smith GCS et al. The effect of delaying childbirth on primary caesarean section rates. PLoS Medicine 2008;5(7):e144
[Gordon Smith is Professor of Obstetrics and Gynaecology at the University of Cambridge.]
How does this sort of discussion inform a midwife, or a mother anticipating birth?
"Think globally"
Epidemiological research seeks to tease out information from large sources of data. The information we glean from this sort of research helps us to understand the big picture, but it does not influence the way we approach the maternity care of an individual woman. The big picture concern that Professor Smith has identified is that the women today who are having caesarean births will, in future births, face an increased risk of life-threatening haemorrhage.
The obvious conclusion that I draw is that regardless of the age of a woman, or the 'risk' of needing caesarean, the maternity service has a duty of care to do all it can to promote and support normal birth, and to use caesarean surgery judiciously.
"Act locally"
The midwife's professional advice to a woman in her care is finely tuned to that individual woman. The midwife takes into account the woman's whole self - physical, social, psychological, spiritual ... wellbeing, as well as outside factors such as the weather conditions that may have an impact on events. The woman who is working in partnership with a trusted midwife also has knowledge about herself that she shares with her midwife as her time to give birth approaches.
Every woman giving birth has elements of her situation that may enhance or detract from her chances of proceeding with physiologically normal birth. The skilled midwife acts to promote normal birth, taking into account the realities and risks, as well as the advantages that apply to an individual mother.
Monday, October 12, 2009
who to trust?
"You need to decide now who to trust, Jenny. Me, or the hospital. I am going to offer you an alternative plan, which is quite different from the plan that has been offered by the hospital."
A case study.
A case study.
Friday, October 09, 2009
Thinking about the midwife
This past week I have been privileged to be midwife for two primiparous mothers who have given birth in their own homes. In attending these births I have worked alongside two younger midwives whose employment has been facilitated under my new private midwifery service model.
I won't tell the stories of these two beautiful births here. The focus of my reflections today is the midwives. Women who commit themselves to other women, and whose personal lives, families, and plans are interrupted from time to time, unpredictably, so that a baby can be born.
We midwives could not do what we do if it weren't for other members of our community, sometimes husband, or sister in law, or parent, or good friend, who is delighted to be the backup parent so that a midwife can go out for a birth. Midwives who are also mothers can only provide this level of full commitment to another mother when we know that our own children are safe and happy.
A midwife has a sister in law, who is a wonderfully energetic person who embraces her young nieces and nephews, so that their mother is happy to go out to a birth. The sister in law goes out of her way to give the children an especially happy time. When mummy comes home they are full of stories, and they have plenty to show, including the poster paint on their clothes as well as the pictures they have painted.
A midwife has a husband, who is deeply in tune with the moment by monent unpredictability that his life partner faces. He provides a cheerful and positive tone when answering the phone, and welcomes each new life as if the little one were a member of his own family. He recognises his mate's need for sleep after a night out, and makes the home a quiet and nurturing space for her. He knows when she would like a coffee, or when a relaxing cup of chamomile tea would be better.
A midwife has children, whom she nursed at her breast and nurtured throughout infancy. She has learnt a great deal of her midwifery from her own mothering experience, learning how to recognise a baby's cues, and how to encourage the little one to achieve. As the children grow, the emerging adult within the young child sees mummy in a different light. She is a midwife, who cares about others while planning and providing for her own. She has ambition to develop professionally. The emerging adult within the young child learns to admire the woman who previously was the personification of comfort and safety. From time to time the child needs that comfort and safety from mummy, and is reassured that those arms are as ready to embrace, and that the midwife is also in every aspect a mother. At times the child will be heard repeating advice about health promotion in pregnancy, or caring for a baby, or breastfeeding - and the mother recognises her own voice in those words of wisdom.
A midwife has friends, who respect her need to miss a tennis morning from time to time, or to be excused from another commitment at the last moment.
The whole community around a midwife supports and affirms her, enabling her to carry out the primally simple yet profound role of being 'with woman'. It's as though there is something of midwifery deep within the heart of each one, valuing the birth of a child above the small and relatively insignificant detail of their own plans at that time.
It takes a whole community - a village - to support a midwife, who in turn enables a mother to give birth to her child with confidence and strength. And the cycle continues, as a community moves in to support that family as they nurture that child.
Thankyou to the communities who support the midwives who are 'with woman' today.
I won't tell the stories of these two beautiful births here. The focus of my reflections today is the midwives. Women who commit themselves to other women, and whose personal lives, families, and plans are interrupted from time to time, unpredictably, so that a baby can be born.
We midwives could not do what we do if it weren't for other members of our community, sometimes husband, or sister in law, or parent, or good friend, who is delighted to be the backup parent so that a midwife can go out for a birth. Midwives who are also mothers can only provide this level of full commitment to another mother when we know that our own children are safe and happy.
A midwife has a sister in law, who is a wonderfully energetic person who embraces her young nieces and nephews, so that their mother is happy to go out to a birth. The sister in law goes out of her way to give the children an especially happy time. When mummy comes home they are full of stories, and they have plenty to show, including the poster paint on their clothes as well as the pictures they have painted.
A midwife has a husband, who is deeply in tune with the moment by monent unpredictability that his life partner faces. He provides a cheerful and positive tone when answering the phone, and welcomes each new life as if the little one were a member of his own family. He recognises his mate's need for sleep after a night out, and makes the home a quiet and nurturing space for her. He knows when she would like a coffee, or when a relaxing cup of chamomile tea would be better.
A midwife has children, whom she nursed at her breast and nurtured throughout infancy. She has learnt a great deal of her midwifery from her own mothering experience, learning how to recognise a baby's cues, and how to encourage the little one to achieve. As the children grow, the emerging adult within the young child sees mummy in a different light. She is a midwife, who cares about others while planning and providing for her own. She has ambition to develop professionally. The emerging adult within the young child learns to admire the woman who previously was the personification of comfort and safety. From time to time the child needs that comfort and safety from mummy, and is reassured that those arms are as ready to embrace, and that the midwife is also in every aspect a mother. At times the child will be heard repeating advice about health promotion in pregnancy, or caring for a baby, or breastfeeding - and the mother recognises her own voice in those words of wisdom.
A midwife has friends, who respect her need to miss a tennis morning from time to time, or to be excused from another commitment at the last moment.
The whole community around a midwife supports and affirms her, enabling her to carry out the primally simple yet profound role of being 'with woman'. It's as though there is something of midwifery deep within the heart of each one, valuing the birth of a child above the small and relatively insignificant detail of their own plans at that time.
It takes a whole community - a village - to support a midwife, who in turn enables a mother to give birth to her child with confidence and strength. And the cycle continues, as a community moves in to support that family as they nurture that child.
Thankyou to the communities who support the midwives who are 'with woman' today.
Sunday, October 04, 2009
*Framework* - the latest buzzword
There has been a lot of talk in midwifery circles lately about a *framework* that will enable eligible midwives to practise privately within the new environment promised under the government's package of midwifery reform. We have been informed that an "advanced midwifery credentialing framework" will be required for eligible midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors". [continued]
Wednesday, September 30, 2009
The safety of home birth: Is the evidence good enough?
There have been three recent papers published, giving strong evidence of the safety and acceptability of homebirth: a large study from the Netherlands (deJonge et al 2009), and two Canadian studies (from Ontario, Hutton et al 2009 and from British Columbia, Janssen et al 2009).
The paper by Patricia Janssen PHD and colleagues (link above) reports on Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. The study included all planned homebirths attended by registered midwives from 1 Jan 2000 to 31 Dec 2004 in British Columbia, Canada. The interpretation of the data is that "Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared withplanned hospital birth attended by a midwife or physician." (p337)
Similar findings have been reported in the other 2009 studies.
A Commentary by two Melbourne midwife academics, Helen McLachlan PhD and Della Forster PhD, titled The safety of home birth: Is the evidence good enough? was published in the same journal. My curiosity was sparked. Helen and Della have been active researchers on the local maternity scene, and from memory their work has included randomised controlled trials of breastfeeding interventions, and some on team midwifery. But I haven't seen anything from either of them about homebirth in the past.
The commentary gives wise, predictable thoughts about the debate surrounding homebirth. It gives a good listing of current references on homebirth.
The fashionable refrain from a section of the health/medical research community is that the evidence is not good enough unless it was obtained after randomisation of subjects. An interesting discussion is entered into, and the authors come up with the conclusion that "Better evidence on the safety of home birth is needed, ideally from randomized controlled trials".
The paper quotes professional discussion around the reported finding that an attempt in the Netherlands to conduct a randomised controlled trial was aborted, because women "were not willing to be randomly assigned to home versus hospital birth and declined participation because they had already chosen their place of birth."
This is a no-brainer (imho)! Of course. Yet the authors go on to discuss the importance of high quality evidence, as if another group of women - possibly those in public maternity care in Melbourne - will think differently. Why would they? How much evidence do we need in order to give a tick to spontaneous, unmedicated, un-interfered-with birth?
I can imagine the outcry if someone suggested seriously that we really don't know if conception of babies is safer in the hospital laboratory or in the home. Therefore a randomised controlled trial needs to be conducted. All eligible potential parents are to be randomly allocated to either treatment or control.
It might be difficult to enlist participants in this reseach, might it not?
Some of those who read this blog will have given birth at home; some are midwives who attend homebirths; while others are interested onlookers. If you have any knowledge of the terrain of physiologically normal birth, either in hospital or in the home, you will probably agree with me that the mother and all her support team need to be intentional about protecting normal birth. There is the intention to actively choose to work in harmony with your body; to be ready for and accept the work your body and mind must do; and to actively make decisions as events unfold. This is not the stuff of managed care and research protocols. It requires the deep and intuitive knowledge that a woman has because she is a woman, and it is best facilitated when the labouring woman knows and trusts the midwife who is responsible for professional decision making at the time.
The paper by Patricia Janssen PHD and colleagues (link above) reports on Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. The study included all planned homebirths attended by registered midwives from 1 Jan 2000 to 31 Dec 2004 in British Columbia, Canada. The interpretation of the data is that "Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared withplanned hospital birth attended by a midwife or physician." (p337)
Similar findings have been reported in the other 2009 studies.
A Commentary by two Melbourne midwife academics, Helen McLachlan PhD and Della Forster PhD, titled The safety of home birth: Is the evidence good enough? was published in the same journal. My curiosity was sparked. Helen and Della have been active researchers on the local maternity scene, and from memory their work has included randomised controlled trials of breastfeeding interventions, and some on team midwifery. But I haven't seen anything from either of them about homebirth in the past.
The commentary gives wise, predictable thoughts about the debate surrounding homebirth. It gives a good listing of current references on homebirth.
The fashionable refrain from a section of the health/medical research community is that the evidence is not good enough unless it was obtained after randomisation of subjects. An interesting discussion is entered into, and the authors come up with the conclusion that "Better evidence on the safety of home birth is needed, ideally from randomized controlled trials".
The paper quotes professional discussion around the reported finding that an attempt in the Netherlands to conduct a randomised controlled trial was aborted, because women "were not willing to be randomly assigned to home versus hospital birth and declined participation because they had already chosen their place of birth."
This is a no-brainer (imho)! Of course. Yet the authors go on to discuss the importance of high quality evidence, as if another group of women - possibly those in public maternity care in Melbourne - will think differently. Why would they? How much evidence do we need in order to give a tick to spontaneous, unmedicated, un-interfered-with birth?
I can imagine the outcry if someone suggested seriously that we really don't know if conception of babies is safer in the hospital laboratory or in the home. Therefore a randomised controlled trial needs to be conducted. All eligible potential parents are to be randomly allocated to either treatment or control.
It might be difficult to enlist participants in this reseach, might it not?
Some of those who read this blog will have given birth at home; some are midwives who attend homebirths; while others are interested onlookers. If you have any knowledge of the terrain of physiologically normal birth, either in hospital or in the home, you will probably agree with me that the mother and all her support team need to be intentional about protecting normal birth. There is the intention to actively choose to work in harmony with your body; to be ready for and accept the work your body and mind must do; and to actively make decisions as events unfold. This is not the stuff of managed care and research protocols. It requires the deep and intuitive knowledge that a woman has because she is a woman, and it is best facilitated when the labouring woman knows and trusts the midwife who is responsible for professional decision making at the time.
Tuesday, September 29, 2009
my summary of active labour and birthing
Labour and birthing is as individual as we are ourselves. I have made this simple summary to assist with discussion and planning, especially for a first birth. You can click on the picture to enlarge it, and if you Right-click you will be able to save it to your computer and print it out.
Please contact me if you have any questions. joy@aitex.com.au
Thursday, September 17, 2009
'Drive-through' birthing
Several followers of this blog have asked me how the mother and her twins are progressing, since their story was shared a few weeks ago.
I have the mother's permission to share with you the news of spontaneous labour and birth of these two babies. Our hearts are full of praise to God the giver and sustainer of life.
Labour commenced at about 7am, and was stronger than what the mother was used to for any of her previous births. We went to Box Hill hospital, and the obstetrician who had supported the plan for vaginal birth (twins, first breech) came in and worked with us.
Membranes ruptured spontaneously for Twin A, who progressed quickly to breech vaginal birth. Baby experienced some respiratory distress for most of the following hour, and we are thankful that the paediatrician kept the baby in the birth room after special request.
Twin B had turned to cephalic. Mother gave birth to the second baby about an hour after the first.
The family went home a few hours after the birth. Mother called it 'Drive through' birthing.
I have told this story as an example of a complex decision making process between woman, midwife, and hospital - without bullying or coercion, even though the 'hospital' advised elective caesarean surgery. I am glad I was able to work with the hospital in this birth, disagreeing with expert advice at times, and supporting the woman in her desire to give birth when her time was accomplished.
There is no 'one size fits all' in birthing. These births included some features which are categorised 'high risk'. Those risks were present, in slightly different ways, regardless of the birth plan. The plan to proceed under natural physiological systems was made after considering the risks and benefits of spontaneous birthing, and the alternative - planned, elective surgery. Another alternative was to change the plan at some stage in the labour, but that option was not needed.
With the benefit of hindsight I am sure that there was no better way to negotiate the uncharted and unpredictable journey of these births. In fact I think if there had been delays – such as epidural, stirrups, or a trip to operating theatre, the story could have been very different. The mother knew her babies needed to be born, and she just got down to the job of birthing – something she is very good at.
[For the birth plan, click here.]
I have the mother's permission to share with you the news of spontaneous labour and birth of these two babies. Our hearts are full of praise to God the giver and sustainer of life.
Labour commenced at about 7am, and was stronger than what the mother was used to for any of her previous births. We went to Box Hill hospital, and the obstetrician who had supported the plan for vaginal birth (twins, first breech) came in and worked with us.
Membranes ruptured spontaneously for Twin A, who progressed quickly to breech vaginal birth. Baby experienced some respiratory distress for most of the following hour, and we are thankful that the paediatrician kept the baby in the birth room after special request.
Twin B had turned to cephalic. Mother gave birth to the second baby about an hour after the first.
The family went home a few hours after the birth. Mother called it 'Drive through' birthing.
I have told this story as an example of a complex decision making process between woman, midwife, and hospital - without bullying or coercion, even though the 'hospital' advised elective caesarean surgery. I am glad I was able to work with the hospital in this birth, disagreeing with expert advice at times, and supporting the woman in her desire to give birth when her time was accomplished.
There is no 'one size fits all' in birthing. These births included some features which are categorised 'high risk'. Those risks were present, in slightly different ways, regardless of the birth plan. The plan to proceed under natural physiological systems was made after considering the risks and benefits of spontaneous birthing, and the alternative - planned, elective surgery. Another alternative was to change the plan at some stage in the labour, but that option was not needed.
With the benefit of hindsight I am sure that there was no better way to negotiate the uncharted and unpredictable journey of these births. In fact I think if there had been delays – such as epidural, stirrups, or a trip to operating theatre, the story could have been very different. The mother knew her babies needed to be born, and she just got down to the job of birthing – something she is very good at.
[For the birth plan, click here.]
Tuesday, September 15, 2009
thoughts on the afterbirth
The birth of the placenta or 'afterbirth' is known as the Third Stage or S3.
Midwives who promote normal birth are usually confident to proceed under physiological conditions through the third stage, working in harmony with the mother's natural birthing processes. The elements of physiological S3 include trust between the woman and her known midwife who is professionally responsible for conducting the birth, attention to a safe, non-stimulating birthing environment, cord not clamped prior to cessation of all pulsation, uninterrupted skin to skin contact between baby and mother - all following the spontaneous unmedicated birthing of a healthy baby by a healthy mother. The baby's instinctive movements in seeking the breast enhance the natural production of oxytocin, and the baby's pressure on the mother's abdomen encourages contraction of the mother's womb, ensuring the functioning of living ligatures within the uterine muscle wall at the placental site.
Midwives attending homebirths use oxytocics when clinically indicated.
[The attached tables show the rate of pph for homebirth mothers in Victoria each year 2002-2007. These tables do not indicate severity or degree of morbidity.]
Hospitals in Australia strongly promote active management of S3. This involves injection of a synthetic oxytocic, with or without an ergot alkaloid, soon after the birth of the baby, causing strong contraction of the uterine muscle. When there are signs of placental separation (cessation of pulsation and lengthening of the cord, and sometimes blood loss), the midwife or doctor exerts controlled traction on the cord while guarding suprapubically with the other hand, until the placenta and membranes have been delivered.
Postpartum haemorrhage (pph) is a serious and life threatening condition, which is one of the main causes of preventable maternal death globally. The International Confederation of Midwives statement on pph includes instructions for active management of S3.
[Click on the picture to enlarge - Summary of a paper by Carolyn Hastie and Kathleen Fahy, 'Optimising psychophysiology in third stage of labour: Theory applied to practice'. Women and Birth (2009) 22, 89-96. Australian College of Midwives.]
Efforts by midwives to describe a physiological approach to S3 underline the need for research into the effectiveness of such midwifery care. A recent paper by Hastie and Fahy (2009) [first page scanned above] reviews literature, defines key terms, and presents a theoretical framework of Midwifery Guardianship applied to the third stage. This paper adds to the writings of Michel Odent and others in the past couple of decades, exploring and explaining the neurophysiology of unmedicated, normal birth.
There is no 'one size fits all' in maternity. Each woman and each baby are individual, and decision making is an active process that continues throughout the episode of care. The midwife's toolkit includes the skill and knowledge to promote normal birth, and to work in harmony with the natural processes, when that is likely to lead to the best possible outcomes. The midwife is also able to intervene in a timely and appropriate manner, using current strategies that are supported by contemporary evidence, and critically reflecting on practice in an effort to continually learn and improve maternity care for mothers and babies.
Midwives who promote normal birth are usually confident to proceed under physiological conditions through the third stage, working in harmony with the mother's natural birthing processes. The elements of physiological S3 include trust between the woman and her known midwife who is professionally responsible for conducting the birth, attention to a safe, non-stimulating birthing environment, cord not clamped prior to cessation of all pulsation, uninterrupted skin to skin contact between baby and mother - all following the spontaneous unmedicated birthing of a healthy baby by a healthy mother. The baby's instinctive movements in seeking the breast enhance the natural production of oxytocin, and the baby's pressure on the mother's abdomen encourages contraction of the mother's womb, ensuring the functioning of living ligatures within the uterine muscle wall at the placental site.
Midwives attending homebirths use oxytocics when clinically indicated.
[The attached tables show the rate of pph for homebirth mothers in Victoria each year 2002-2007. These tables do not indicate severity or degree of morbidity.]
Hospitals in Australia strongly promote active management of S3. This involves injection of a synthetic oxytocic, with or without an ergot alkaloid, soon after the birth of the baby, causing strong contraction of the uterine muscle. When there are signs of placental separation (cessation of pulsation and lengthening of the cord, and sometimes blood loss), the midwife or doctor exerts controlled traction on the cord while guarding suprapubically with the other hand, until the placenta and membranes have been delivered.
Postpartum haemorrhage (pph) is a serious and life threatening condition, which is one of the main causes of preventable maternal death globally. The International Confederation of Midwives statement on pph includes instructions for active management of S3.
[Click on the picture to enlarge - Summary of a paper by Carolyn Hastie and Kathleen Fahy, 'Optimising psychophysiology in third stage of labour: Theory applied to practice'. Women and Birth (2009) 22, 89-96. Australian College of Midwives.]
Efforts by midwives to describe a physiological approach to S3 underline the need for research into the effectiveness of such midwifery care. A recent paper by Hastie and Fahy (2009) [first page scanned above] reviews literature, defines key terms, and presents a theoretical framework of Midwifery Guardianship applied to the third stage. This paper adds to the writings of Michel Odent and others in the past couple of decades, exploring and explaining the neurophysiology of unmedicated, normal birth.
There is no 'one size fits all' in maternity. Each woman and each baby are individual, and decision making is an active process that continues throughout the episode of care. The midwife's toolkit includes the skill and knowledge to promote normal birth, and to work in harmony with the natural processes, when that is likely to lead to the best possible outcomes. The midwife is also able to intervene in a timely and appropriate manner, using current strategies that are supported by contemporary evidence, and critically reflecting on practice in an effort to continually learn and improve maternity care for mothers and babies.
Monday, September 14, 2009
monthly review
Thismorning I have written my 'Monthly review' in the countdown to 1 July 2010.
I am not trying to sugar-coat anything - the future still looks bleak for independent midwives and for the women who we care for. I hope that by tracking the progress of the so called 'reforms', we will have hope that solutions can be found. Australians do have a belief in fairness and equality.
[Photo: That's me and Noel, with our first baby, the beautiful Miriam. If you look through her FB photos, you might even see the 70's kaftan on her!]
I am not trying to sugar-coat anything - the future still looks bleak for independent midwives and for the women who we care for. I hope that by tracking the progress of the so called 'reforms', we will have hope that solutions can be found. Australians do have a belief in fairness and equality.
[Photo: That's me and Noel, with our first baby, the beautiful Miriam. If you look through her FB photos, you might even see the 70's kaftan on her!]
Friday, September 11, 2009
What will Medicare rebates mean?
A guest editorial 'Medicare rebates for midwives: An analysis of the 2009/2010 Federal Budget' appears in the September issue of the Journal of the Australian College of Midwives [to read more, click here]
...
Medicare fragments care into 'items' - fragments a woman into prenatal, intrapartum, and postnatal care, as most Australian women today experience. Medicare causes buck-passing between federal and state health departments.
...
Holistic primary maternity care by comparison is woman-centred, meaning that the pregnant woman/mother-baby dyad are central throughout the continuum of care. Midwives providing woman-centred care work with caseloads, or at the very least in small group practices. Notions of partnership between a woman and her known midwife, promotion of normal birth, and preventative measures - all of which are fundamental elements in the international definition of the midwife (ICM 2005), are nigh impossible in fragmented models of MEDI-care.
...
BTW
Privately practising midwives have been told that the Minister is concerned at the lack of support (from us) for the maternity reform process.
I have to say from my persptective the feeling's mutual.
We're back to Alice's adventures in Wonderland - "curiouser and curiouser!"
...
Medicare fragments care into 'items' - fragments a woman into prenatal, intrapartum, and postnatal care, as most Australian women today experience. Medicare causes buck-passing between federal and state health departments.
...
Holistic primary maternity care by comparison is woman-centred, meaning that the pregnant woman/mother-baby dyad are central throughout the continuum of care. Midwives providing woman-centred care work with caseloads, or at the very least in small group practices. Notions of partnership between a woman and her known midwife, promotion of normal birth, and preventative measures - all of which are fundamental elements in the international definition of the midwife (ICM 2005), are nigh impossible in fragmented models of MEDI-care.
...
BTW
Privately practising midwives have been told that the Minister is concerned at the lack of support (from us) for the maternity reform process.
I have to say from my persptective the feeling's mutual.
We're back to Alice's adventures in Wonderland - "curiouser and curiouser!"
Thursday, September 10, 2009
waiting
Waiting is one of those basic requirements for normal physiological birth.
A mother who wants normal birth has to accept it, and a midwife who attends normal birth has to also.
In our organised world, with clocks and appointments and deadlines, waiting for the right time can be a challenge. You are feeling full and heavy. You go for a walk in the evening, and your womb is becoming very tight. You wonder if the baby will come tonight? You wake up in the morning - nothing happened! "Don't be disappointed," you say to yourself. "Baby will come at the right time." Then one morning you wake up and wipe away a bit of blood stained show. Aha! You know something is happening in there. Trying not to be too eager, you do those few last minute jobs that need to be done. You notice that the air feels different today. What a wonderful day to give birth to this precious little one.
I remember these beautifully deep feelings as I wait, this time as the midwife, the older woman, for a young woman to tell me she is ready to give birth.
The phenomenon of waiting for a baby to be born is as old as human existence. Many times as a child I heard the old language of the King James translation of the Bible, in the Christmas story. "Elizabeth's full time came that she should be delivered; and she brought forth a son." (Luke 1:57) "And so it was, that, while they were there, the days were accomplished that she [Mary] should be delivered. And she brought forth her firstborn son ..." (Luke 2:6,7)
Elizabeth's 'full time' came; Mary's 'days were accomplished': and they both 'brought forth' their children. Waiting for the time is in a sense passive, then the time comes for actively doing the job of 'bringing forth'. The women's knowledge passed down over millenia in these simple stories has informed my birth-giving, and my midwifery practice.
When anticipating physiological birth we experience the waiting as part of our nesting. I make the distinction here, because the only person who can do the physiological work of nesting, waiting, labouring, and birthing, is THE woman. Just as nesting can be interrupted by a sense of handing over to the 'expert', the waiting is also interfered with, deep in the mind of the woman who is unwilling to work with her body in birthing, who has given up her ability to reach her full time, to accomplish her days.
It is no wonder that this one may also experience difficulty in 'bringing forth' the child.
A mother who wants normal birth has to accept it, and a midwife who attends normal birth has to also.
In our organised world, with clocks and appointments and deadlines, waiting for the right time can be a challenge. You are feeling full and heavy. You go for a walk in the evening, and your womb is becoming very tight. You wonder if the baby will come tonight? You wake up in the morning - nothing happened! "Don't be disappointed," you say to yourself. "Baby will come at the right time." Then one morning you wake up and wipe away a bit of blood stained show. Aha! You know something is happening in there. Trying not to be too eager, you do those few last minute jobs that need to be done. You notice that the air feels different today. What a wonderful day to give birth to this precious little one.
I remember these beautifully deep feelings as I wait, this time as the midwife, the older woman, for a young woman to tell me she is ready to give birth.
The phenomenon of waiting for a baby to be born is as old as human existence. Many times as a child I heard the old language of the King James translation of the Bible, in the Christmas story. "Elizabeth's full time came that she should be delivered; and she brought forth a son." (Luke 1:57) "And so it was, that, while they were there, the days were accomplished that she [Mary] should be delivered. And she brought forth her firstborn son ..." (Luke 2:6,7)
Elizabeth's 'full time' came; Mary's 'days were accomplished': and they both 'brought forth' their children. Waiting for the time is in a sense passive, then the time comes for actively doing the job of 'bringing forth'. The women's knowledge passed down over millenia in these simple stories has informed my birth-giving, and my midwifery practice.
When anticipating physiological birth we experience the waiting as part of our nesting. I make the distinction here, because the only person who can do the physiological work of nesting, waiting, labouring, and birthing, is THE woman. Just as nesting can be interrupted by a sense of handing over to the 'expert', the waiting is also interfered with, deep in the mind of the woman who is unwilling to work with her body in birthing, who has given up her ability to reach her full time, to accomplish her days.
It is no wonder that this one may also experience difficulty in 'bringing forth' the child.
Friday, September 04, 2009
Two-year exemption from indemnity insurance announced today
a brief reprieve at least.
[If you don't know the siginficance of the Bilby, check this post for the introduction of this little endangered marsupial into the midwifery reform story.]
Sunday, August 30, 2009
a baby born
Normal birth does not belong to any particular group of people, any special lifestyle, or set of beliefs. Normal birth does not happen as a result of any particular course of childbirth education, reading any book, or getting instruction from any birthing teacher.
A beautiful young woman gave birth to her first child on Friday, in a fashionable suburban unit in a medium-density housing estate. The home has very little 'garden', and no shovel or other tool to dig a hole in the earth to bury the placenta, so I brought the placenta home to my garden.
The significant features in the labour and birth of this baby girl were, from a midwife's point of view, as near to ideal as I could hope for:
• A healthy mother
• Baby in an optimal position, back on the Left, head engaged from about 36 weeks
• Spontaneous onset of labour at 40 weeks +11 days in the early morning
• Labour became strong, and mother felt an urge to push by about midday
• Baby was born through water before 2pm in good condition
• Mother sat on the couch, with baby skin-to-skin, cord uncut, for the next hour or so, while baby searched for and took the breast.
• The placenta was birthed spontaneously about an hour after the birth. Mother’s blood group was Rhesus negative, so cord blood was collected from the vessels on the placenta. The pathology company’s courier came to the home and took the cord and maternal blood to the laboratory.
• There was minimal blood loss.
• There was a small first degree perineal tear which was not sutured.
This birth will be recorded in the Victorian government health department's perinatal data for 2009 as an unassisted vaginal birth, a homebirth attended privately by a midwife as the primary professional care provider, a water birth, and all the detail specific to this mother and child. I have chosen to put this birth on the record because the uncomplicated, normal, physiological birth often goes unnoticed.
The second midwife who assisted me in this birth is a recent graduate from one of the Bachelor of Midwifery programs in Melbourne. This is a midwife who will be able to carry authentic midwifery knowledge and skill into future decades.
A midwife's skill, working in harmony with each birthing woman, is like a dance. Most of the time the woman leads, and the midwife accompanies. There are moments when the woman experiences huge challenges that threaten to overwhelm her, when the midwife takes the lead. This truth was recorded many 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”.
Attributed to Tao Te Ching, about 2000 years ago.
Thursday, August 27, 2009
why midwives promote normal birth
The promotion of normal birth, within a framework of watchful readiness to intervene if needed, is a fundamental duty of care of all midwives. The Definition of the midwife, a core document of the International Confederation of Midwives, states that the midwife's care "includes preventative measures, the promotion of normal birth, the detection of complications ..." (ICM 2005, emphasis added)
In this respect, a midwife is not free to support the 'every woman, every choice' slogan of our leading consumer and midwife advocacy organisation, Maternity Coalition. Every 'choice' includes caesarean, induction, epidural ... the works ... on demand. The midwife who is practising authentic midwifery will act in such a way that enables a woman to accept and embrace her birthing strength, rather than cower and demand that her body be numbed and her baby removed like an unwanted growth.
Wishy-washy notions of choice in maternity care abound in our society. Paradoxically the one choice that is difficult to access in the developed world, including our land of Oz, is normal birth. I think there are many reasons for this, including de-skilling of the midwifery workforce, medical control of the birthing continuum, and medical oversight of all things maternity. It is unusual today to find a midwife in mainstream care, or medical practitioner who has a commitment to promoting normal birth, coupled with the skill to work in harmony with hormonally mediated natural processes. Instead, the reliance is on machines, drugs, and surgery.
A woman phoned me the other day to talk about engaging a midwife who would accompany her for birth in a private hospital.
First baby,
well prepared as far as all the standard childbirth education classes are concerned,
healthy,
and pretty excited about having a baby.
BTW, hubby is petrified! Not likely to be much support ...
I willingly launched into an explanation of what I or another independent midwife could offer in such a situation. I explained why it's important to trust your baby and your body ... and why we encourage women to use water and position and massage ... in learning to work with the pain of labour.
"I'm not really concerned about drugs. But a friend of mine had a baby recently and her doctor put her legs in stirrups, and I would prefer not to have that. I want someone who can tell me I don't need to have stirrups."
[OK! How to answer that one? Stirrups may have been a good idea in that particular birth.]
But, if you have the drugs, you may not be able to be active. You know narcotics are dangerous drugs, don't you? You know epidural anaesthesia is a pretty major medical procedure, with real risks, don't you? And the narcotics and anaesthetics pass to your baby ...
I do hope this woman has found someone who will help her to avoid the indignity of stirrups - to have the birth of her choosing. I don't think she is looking for a midwife.
In this respect, a midwife is not free to support the 'every woman, every choice' slogan of our leading consumer and midwife advocacy organisation, Maternity Coalition. Every 'choice' includes caesarean, induction, epidural ... the works ... on demand. The midwife who is practising authentic midwifery will act in such a way that enables a woman to accept and embrace her birthing strength, rather than cower and demand that her body be numbed and her baby removed like an unwanted growth.
Wishy-washy notions of choice in maternity care abound in our society. Paradoxically the one choice that is difficult to access in the developed world, including our land of Oz, is normal birth. I think there are many reasons for this, including de-skilling of the midwifery workforce, medical control of the birthing continuum, and medical oversight of all things maternity. It is unusual today to find a midwife in mainstream care, or medical practitioner who has a commitment to promoting normal birth, coupled with the skill to work in harmony with hormonally mediated natural processes. Instead, the reliance is on machines, drugs, and surgery.
A woman phoned me the other day to talk about engaging a midwife who would accompany her for birth in a private hospital.
First baby,
well prepared as far as all the standard childbirth education classes are concerned,
healthy,
and pretty excited about having a baby.
BTW, hubby is petrified! Not likely to be much support ...
I willingly launched into an explanation of what I or another independent midwife could offer in such a situation. I explained why it's important to trust your baby and your body ... and why we encourage women to use water and position and massage ... in learning to work with the pain of labour.
"I'm not really concerned about drugs. But a friend of mine had a baby recently and her doctor put her legs in stirrups, and I would prefer not to have that. I want someone who can tell me I don't need to have stirrups."
[OK! How to answer that one? Stirrups may have been a good idea in that particular birth.]
But, if you have the drugs, you may not be able to be active. You know narcotics are dangerous drugs, don't you? You know epidural anaesthesia is a pretty major medical procedure, with real risks, don't you? And the narcotics and anaesthetics pass to your baby ...
I do hope this woman has found someone who will help her to avoid the indignity of stirrups - to have the birth of her choosing. I don't think she is looking for a midwife.
Tuesday, August 25, 2009
"Why bother coming here if you won't let us manage you the way we think is best?"
Why indeed!
This is the question that a mother was asked by a doctor. Not a junior, down the line doctor, in a small under-resourced hospital. It was the senior obstetrician in one of Melbourne's three tertiary, state-of-the art, well resourced referral hospitals.
I am writing about this case because I am witnessing a more intense effort by hospital staff at coercion and bullying to make this woman comply than I had anticipated or experienced in the past.
The mother's problem is that she is carrying twins, AND 'Twin A' is presenting breech, AND she wants to give birth spontaneously, rather than agree to elective caesarean surgery.
In good faith the mother accepted my advice to attend the hospital for review after her twin pregnancy had been confirmed.
The hospital's reason for insisting on surgery: they can't be sure there will be a doctor who is competent for a vaginal breech birth, let alone twin breech, when the time for birth comes. Even in a tertiary level hospital, funded to provide competent staff round the clock to provide appropriate obstetric and midwifery services for any woman, the pressure is on to manage a slightly complex case in the day shift.
The midwifery profession has clear guidelines for consultation and referral, and I find these guidelines reasonable. In a situation such as this one, when a woman planning homebirth in my care is found to have twins, I encourage her to obtain information from the back-up hospital, and make an informed decision about her birthing. I do not push vaginal birth at any cost. The safety and wellbeing of mother and child(ren) is my primary concern.
Although I have no visiting access in hospitals, I don't need that to practise my skill as a midwife. All I need is the partnership of trust with the woman. As long as she is confident to proceed in harmony with her body through the birthing process, I can reassure her, and guide her professionally if decisons need to be made.
I have not shut the door to homebirth with twins. It is not my door to shut. The woman needs to make her choice, and I am committed to being with her as her midwife in the setting she chooses.
I know this woman has a good chance of giving birth safely and spontaneously to her two babies. I know this from my knowledge of the woman, and her previous births, and her wisdom and deep faith in God, the giver of life.
I also know the decision points that may be reached in vaginal birthing of twins.
The question, "Why bother coming here if you won't let us manage you the way we think is best?" offers a clue as to the real problem. The mother does not want to be 'managed' in the first instance by anyone - doctor or midwife. She wants to proceed in her birthing under her own natural process. If the baby or babies became distressed, or if her labour failed to progress, the hospital is able to offer specific remedial action - surgery. But that's a decision point that has not yet been reached yet.
I fully support the woman in her desire to hold off that decision until, if, and when it needs to be made.
This is the question that a mother was asked by a doctor. Not a junior, down the line doctor, in a small under-resourced hospital. It was the senior obstetrician in one of Melbourne's three tertiary, state-of-the art, well resourced referral hospitals.
I am writing about this case because I am witnessing a more intense effort by hospital staff at coercion and bullying to make this woman comply than I had anticipated or experienced in the past.
The mother's problem is that she is carrying twins, AND 'Twin A' is presenting breech, AND she wants to give birth spontaneously, rather than agree to elective caesarean surgery.
In good faith the mother accepted my advice to attend the hospital for review after her twin pregnancy had been confirmed.
The hospital's reason for insisting on surgery: they can't be sure there will be a doctor who is competent for a vaginal breech birth, let alone twin breech, when the time for birth comes. Even in a tertiary level hospital, funded to provide competent staff round the clock to provide appropriate obstetric and midwifery services for any woman, the pressure is on to manage a slightly complex case in the day shift.
The midwifery profession has clear guidelines for consultation and referral, and I find these guidelines reasonable. In a situation such as this one, when a woman planning homebirth in my care is found to have twins, I encourage her to obtain information from the back-up hospital, and make an informed decision about her birthing. I do not push vaginal birth at any cost. The safety and wellbeing of mother and child(ren) is my primary concern.
Although I have no visiting access in hospitals, I don't need that to practise my skill as a midwife. All I need is the partnership of trust with the woman. As long as she is confident to proceed in harmony with her body through the birthing process, I can reassure her, and guide her professionally if decisons need to be made.
I have not shut the door to homebirth with twins. It is not my door to shut. The woman needs to make her choice, and I am committed to being with her as her midwife in the setting she chooses.
I know this woman has a good chance of giving birth safely and spontaneously to her two babies. I know this from my knowledge of the woman, and her previous births, and her wisdom and deep faith in God, the giver of life.
I also know the decision points that may be reached in vaginal birthing of twins.
The question, "Why bother coming here if you won't let us manage you the way we think is best?" offers a clue as to the real problem. The mother does not want to be 'managed' in the first instance by anyone - doctor or midwife. She wants to proceed in her birthing under her own natural process. If the baby or babies became distressed, or if her labour failed to progress, the hospital is able to offer specific remedial action - surgery. But that's a decision point that has not yet been reached yet.
I fully support the woman in her desire to hold off that decision until, if, and when it needs to be made.
Monday, August 24, 2009
A change of focus in this blog
The topics that I have explored in this blog in the past six+ months have been dominated by the cloud on the birthing horizon: the knowledge that Australian midwives face a future of being unlawful if we continue practising privately without indemnity insurance after 1 July next year.
As time has passed, the cloud has become blacker, as the extent of the midwife extermination campaign becomes clearer. The threat to our professional livelihoods, and to the options available to women who employ us, has become more ominous than I had imagined would be possible.
NINE MONTHS
In the remaining nine months that I have as a midwife able to practise my profession openly, I plan to use this blog to record midwifery knowledge. I hope to identify issues as they occur in my practice, briefly exploring some of the complexities of woman centred midwifery care, and decision making that promotes and protects normality in birth.
I hope that readers will understand the urgency that I feel in recording this professional body of knowledge that I have accumulated and developed over the past 35 or so years. I know that women giving birth in harmony with their own God-given physiological power will not change, regardless of restrictive laws and regulations set up by governments. Authentic midwifery that is deeply protected in the intuitive minds of women will also survive the outrageous attempts of authorities to make birth a process that is managed with production line precision by people whose job it is to enforce compliance.
Readers who are interested in the ongoing negotiations and activism around private midwifery and homebirth, please keep an eye on blogs linked to this one, including Midwives in Private Practice, and Private Midwifery Services.
As time has passed, the cloud has become blacker, as the extent of the midwife extermination campaign becomes clearer. The threat to our professional livelihoods, and to the options available to women who employ us, has become more ominous than I had imagined would be possible.
NINE MONTHS
In the remaining nine months that I have as a midwife able to practise my profession openly, I plan to use this blog to record midwifery knowledge. I hope to identify issues as they occur in my practice, briefly exploring some of the complexities of woman centred midwifery care, and decision making that promotes and protects normality in birth.
I hope that readers will understand the urgency that I feel in recording this professional body of knowledge that I have accumulated and developed over the past 35 or so years. I know that women giving birth in harmony with their own God-given physiological power will not change, regardless of restrictive laws and regulations set up by governments. Authentic midwifery that is deeply protected in the intuitive minds of women will also survive the outrageous attempts of authorities to make birth a process that is managed with production line precision by people whose job it is to enforce compliance.
Readers who are interested in the ongoing negotiations and activism around private midwifery and homebirth, please keep an eye on blogs linked to this one, including Midwives in Private Practice, and Private Midwifery Services.
Thursday, August 20, 2009
mother-child art
Today's art by Poppy and Granny
Dear reader
If you have mother-child art that you and or your children have made, please send me a pic to include here, or a link.
In all the stress of political lobbying and the fears about loss of private midwifery in the future, remember that our bodies are wonderfully made, and celebrate the wonder of motherhood and families.
jj
Tuesday, August 18, 2009
Indemnity insurance: the great obstacle
In past months, as the momentum in activism to protect private midwifery and homebirth has increased, the general agreement among midwives and consumer groups has been to accept that indemnity insurance is in the public interest. That it is somehow the right of the consumer/woman to sue the practitioner/midwife if something goes wrong.
[Pause for a moment and check the evidence of how many people who have adverse outcomes in health care have even a remote chance of winning such a case. The winners are the insurance companies and the legal representatives.]
The plan for mandatory indemnity insurance for all health professionals has been in government circles for years now – and I have been fighting it for many years. When midwives' indemnity insurance ceased about eight years ago, I was a member of the Nurses Board of Victoria, and mandatory insurance was being introduced into draft legislation. I stated that it was unreasonable for anything to be mandated if it was not accessible, and argued that, if required, the Board should provide it with registration. For my troubles I was declared to have a conflict of interest, and any time the issue of professional indemnity insurance was mentioned in Board minutes, my conflict of interest was noted.
[Yes, it is personal!]
I think we are being naïve to just lie down and accept this requirement, when what is being required is inaccessible. There’s no established ‘consumer right’ to anything about indemnity – it’s a market $$$ issue. I find it interesting (from Lisa’s blog) that the UK NMC (Nursing and Midwifery Council) said: "We do not have the legal power to impose indemnity insurance on nurses and midwives. It is extremely difficult to obtain indemnity insurance on the open market. Imposing such a requirement could place an unreasonable expectation on nurses and midwives because they may not be able to find the insurance. For these reasons we have reinforced the need for them to be honest with their clients about this situation."
So we shouldn’t argue that insurance for all health practitioners is a right, and we should not support its introduction unless it is accessible on equitable terms. If there’s no legal power for the UK NMC, there’s probably no legal power for the Australian health practitioners board. But as long as we believe there is, we will never challenge it.
The only real human right in birth and parenting is that basic ‘natural law’ right to do what our bodies were created to do. As it happens, that’s the terrain of homebirth midwifery. If a woman can’t or doesn’t want to act in concert with her own body’s physiological processes, she has to find the best on offer from the medical obstetric system – and that’s not a right, it’s a ‘privilege’ that we have in a wealthy developed society, that our sisters in many other countries do not have.
We midwives really have to think for ourselves in this, what’s ethical and moral. The Health Minister has two choices – either provide indemnity for ALL midwives in a way that is affordable and accessible, or don’t mandate it.
[Pause for a moment and check the evidence of how many people who have adverse outcomes in health care have even a remote chance of winning such a case. The winners are the insurance companies and the legal representatives.]
The plan for mandatory indemnity insurance for all health professionals has been in government circles for years now – and I have been fighting it for many years. When midwives' indemnity insurance ceased about eight years ago, I was a member of the Nurses Board of Victoria, and mandatory insurance was being introduced into draft legislation. I stated that it was unreasonable for anything to be mandated if it was not accessible, and argued that, if required, the Board should provide it with registration. For my troubles I was declared to have a conflict of interest, and any time the issue of professional indemnity insurance was mentioned in Board minutes, my conflict of interest was noted.
[Yes, it is personal!]
I think we are being naïve to just lie down and accept this requirement, when what is being required is inaccessible. There’s no established ‘consumer right’ to anything about indemnity – it’s a market $$$ issue. I find it interesting (from Lisa’s blog) that the UK NMC (Nursing and Midwifery Council) said: "We do not have the legal power to impose indemnity insurance on nurses and midwives. It is extremely difficult to obtain indemnity insurance on the open market. Imposing such a requirement could place an unreasonable expectation on nurses and midwives because they may not be able to find the insurance. For these reasons we have reinforced the need for them to be honest with their clients about this situation."
So we shouldn’t argue that insurance for all health practitioners is a right, and we should not support its introduction unless it is accessible on equitable terms. If there’s no legal power for the UK NMC, there’s probably no legal power for the Australian health practitioners board. But as long as we believe there is, we will never challenge it.
The only real human right in birth and parenting is that basic ‘natural law’ right to do what our bodies were created to do. As it happens, that’s the terrain of homebirth midwifery. If a woman can’t or doesn’t want to act in concert with her own body’s physiological processes, she has to find the best on offer from the medical obstetric system – and that’s not a right, it’s a ‘privilege’ that we have in a wealthy developed society, that our sisters in many other countries do not have.
We midwives really have to think for ourselves in this, what’s ethical and moral. The Health Minister has two choices – either provide indemnity for ALL midwives in a way that is affordable and accessible, or don’t mandate it.
Subscribe to:
Posts (Atom)