Families

In the past week or so my mind has been drawn into a family-related project that I call 'Pictures and memories from long ago'.

With a strong sense of purpose, I have scanned pictures and documents, and copied accounts of the lives of some of my forebears. These fragments of memories have been drawn together, as I have remembered people and stories from the past.

The two women pictured in this post are truly wonderful women, from whom I have learnt values and been inspired to follow their guidance. The stately old lady is Jane Eliza Harriet White, aged 95 when this picture was taken, I think. My Grandma lived in the old homestead overlooking the bay at Redland Bay, Queensland. The tall palm trees made the house visible from a mile or so away as we headed towards School of Arts Road. Grandma had given birth to, and cared for her eight children, through terrible times or war and the Great Depression.

The beautiful younger woman, with two little girls, is my mother, Ella White. Mum's story includes missionary work in China, where she met and married my father. She gave birth to, and cared for her seven children, through the 50s and 60s. I have written about my mother in this blog in the past, especially as I waited for my own daughter to give birth.

Both Mum and Grandma included twins amongst their children. Mum had trained as a triple certificate nurse: nurse, midwife, and infant welfare sister. Grandma had done lady-like preparation for life in the early 20th century, including learning to paint landscapes. These two women have given me my two passions that go beyond family: midwifery and art.

My work of collecting and collating pictures and stories has been inspired by my enjoyment of digital technology. A simple e-book format that I used for my first book, Midwifery from my heart, has been readily adapted to the job at hand. I am bringing out the old albums, scanning the pictures, and presenting them in a way that tells a very special story.

My children and grandchildren are not very interested in their heritage at present. They have busy lives. But one day they may find, as I have, great pleasure in remembering and adding to my memories.

IS HOMEBIRTH SAFE?

and,

IS THAT A VALID QUESTION?

I am not wanting to write at length about this very significant question today, but would like to direct readers to Amy Romano's comment and debate at the Lamaze blog.

In what appears to be a global race to discredit homebirth, people who should know better have shamelessly manipulated retrospective data from planned homebirth, and come up with conflicting and often confusing results that have been published in peer-reviewed literature.

Note in this context the critiques of the Australian Medical Association's publication of the Kennare et al (2010) Planned home and hospital births in South Australia, 1991-2006: differences in outcomes. The wild claims of increased risk of perinatal death or morbidity are just that: wild claims made on deeply flawed research.

Amy Romano writes:
The (in)famous Wax home birth meta-analysis hit the scene over a month ago. But the buzz doesn’t seem to be dying down. In the weeks since the original pre-publication and press release, editors at The Lancet and BMJ have both weighed in, and there’s a steady stream of media attention. While all of the media have dutifully quoted midwives in leadership positions saying the meta-analysis is flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier post – did we need a meta-analysis to establish the neonatal outcomes of planned home birth? We had, after all, a very large, methodologically rigorous study on home birth safety involving over a half million women that was published less than 2 years ago. Won’t that suffice? ... (continued)

Collaborative arrangements for midwives

photo: Mizz with Josh

Readers who have been following the political developments in the world of midwifery will know that the Australian government has signed into law a requirement for midwives to have 'collaborative arrangements' in order to entitle their clients to claim Medicare rebates on their charges. Midwives may become eligible for Medicare provider numbers after 1 November this year, if all goes to plan.

Midwives have known since early in the maternity reform process that the Health Minister is committed to collaborative arrangements. Midwives and childbirth advocates have repeatedly lobbied the Health Minister and her bureaucrats about the fact that the requirement for collaborative arrangements for midwives, without any matching requirement that doctors should engage in such arrangements, was an effective veto of private midwifery practice. There is no incentive, no reason why any doctor would consider signing a collaborative arrangement with a midwife in private practice, who is, in a small way, competing with the doctor for business.

Press releases and discussion about the Gillard government's action in progressing the small piece of legislation, 'National Health (Collaborative arrangements for midwives) Determination 2010' under subsection 84(1) of the National Helath Act 1953 can be reviewed at recent posts to the MiPP blog.

My intention in commenting here on this matter is to work through a scenario that I, and a woman who sought my services, would encounter if we tried to comply with the requirement for collaborative arrangements as laid down in this piece of legislation.

Section 7 requires that (1) an eligible midwife must record the following for a patient in the midwife's written records:
(a) the name of at least 1 specified medical practitioner who is, or will be, collaborating with the midwife in the patient's care (a named medical practitioner);
(b) that the midwife has told the patient that the midwife will be providing midwifery services to the patient in collaboration with 1 or more specified medical practitioners in accordance with this section;
(c) acknowledgment by a named medical practitioner that the practitioner will be collaborating in the patient's care;
(d) plans for the circumstances in which the midwife will do any of the following:
(i) consult with an obstetric specified medical practitioner
(ii) refer the patient to a specified medical practitioner;
(iii) transfer the patient's care to an obstetric specified medical practitioner.

Under this section, the woman who is my 'patient' requires a named medical practitioner (a) of whom the woman has been informed (b), and who agrees in writing to be the collaborating doctor (c).

I don't know where to start looking for this doctor (or doctors). My clients at present come from as far away as Epping in the North, Point Cook in the S-W, and the Yarra Ranges in the East - from 20-50K in each direction. I do not know the local doctors. Most of my clients are healthy women who take good care of their bodies and their families, and who don't have much need for doctors.

I have no idea how the named medical practitioner of this section is going to make him/herself available 24/7. Midwives take small caseloads so that we can respond at any time, day or night. Critical decision making in maternity care, particularly when the midwife is committed to protecting, promoting and supporting the natural physiological processes, is not something that happens in office hours. Most doctors have work hours; many medical practices are closed out of hours. Is this doctor going to give me his/her private contact details, and engage with the midwife at any time, under this collaborative arrangement?

I can only imagine how the insurance company of the named medical practitioner of this section will respond to any potential claims. The indemnity issue alone will probably be off-putting enough for even those most supportive of midwifery practice.

The requrement (d), plans for consultation and referral and transfer of care are not a problem at present. A midwife, by definition, arranges medical referral when and if required.


The legislation continues:
(2) The midwife must also record the following in the midwife's written records:
(a) any consultations or other communications ...
(b) any referral ...
(c) any transfer ...
(d) when the midwife gives a copy of the hospital booking letter for the patient to the named medical practitioner - acknowledgment [signed -received]
(e) when the midwife gives a copy of the patient's maternity care plan to the named medical practitioner - acknowledgment [signed - received]
(f) if the midwife requests diagnostic imaging &c for the patient - when the midwife gives the results to the named medical practitioner - acknowledgment [signed - received]
(g) that the midwife has given a discharge summary to the named medical practitioner and the GP - acknowledgment [signed - received]


Reading this section makes me wonder how I would be able to comply with all the complexities of this system.  I don't have a secretary sitting at a desk and organising my letters and paperwork. I wonder if this doctor is going to be happy with faxes, or with results sent by mail from the pathology lab?

My conclusion is that the future looks unpromising for midwives who are hoping to set up Medicare - supported practices.



In the Radio National's Life Matters program today, midwife Liz Wilkes and obstetrician Ted Weaver spoke on "collaborative arrangements".

For those who'd like to hear the online audio, download the podcast, or make comment, the website is:
http://www.abc.net.au/rn/lifematters/

Liz spoke well. Ted Weaver has his head in the sand. He reckons doctors haven’t been asked if they would sign a collaborative arrangement so that a midwife’s clients can access Medicare. He suggested obstetricians will agree to increase their clinical load without being paid – he used the term altruism!

Midwives are regulated practitioners in our own right.  Yet the Medicare reforms put us not only at the mercy of the medical profession, but also asking for their generosity.  There is really no sense, from a doctor's point of view, in supporting someone in competition for business.

RANZCOG on trial

The new Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) C-Obs 38, issued July 2010 by the College of Obstetricians and Gynaecologists, RANZCOG, requires critical review.

Yesterday I commented in another blog on the 'risk' picture presented in this Statement.

The ultimate statistic:
RANZCOG notes an "extremely low but clinically important frequency of adverse outcomes", notably maternal death, for women who have elective repeat caesarean surgery (ERCS). However, RANZCOG deftly attributes the reason for the "apparent association" to "women with complex medical and obstetric problems [who] are much more likely to feature in the ERCS". This statement is dishonest and misleading. Women with no medical or obstetric problems have added to maternal mortality and serious morbidity statistics after caesarean surgery that has been undertaken for non-medical reasons, or after a cascade of interventions that began with medical interference in an otherwise uncomplicated pregnancy.

Homebirth for VBAC
While the 'H' word is not prominent in the RANZCOG statement on VBAC, it is understood from a previous College Statement (C-Obs 2) that RANZCOG "does not endorse home birth". This position has been clear since 1987, and has effectively prevented any useful dialogue on home birth between midwives and most obstetricians.  It's a matter of joining the dots.

Having declared its standard for antenatal preparation; intrapartum care; contraindications to Trial of Labour (TOL), and TOL in risk-prone circumstances, the RANZCOG statement on VBAC has defined the option of "TOL" in "risk-prone circumstances" as "sub-standard care" [emphasis added].
"A TOL may become particularly risk-prone where: there is a lack of services for safe provision of emergency care (eg a TOL conducted at home, birth centre or centre without ready access to obstetric, anaesthetic and paediatric support); there is a failure to provide or accept adequate intrapartum maternal and fetal surveillance; and there are clinical circumstances such as outlined above (eg more than one previous caesarean section)"

It is pretty clear to me that RANZCOG's TOL is unlikely to proceed to a spontaneous vaginal birth, with a healthy mother and baby. This statement exposes the lack of recognition of childbirth as a physiological process that is normal and good; a process that is in delicate hormonal balance. Throughout the document the reader is reminded repeatedly of the risk of rupture. It comes up like an advertisement: "remember you might need an obstetrician".

How often is the risk of rupture likely to result in catastrophic outcomes?

About 1 in 2000 labours for planned vbac.

*****

There are many factors to be considered by women who have had one or more previous caesarean births. The Births after Caesarean INFOSHEET, available at the Maternity Coalition website, summarises the choices that these women may face.

Midwives who agree to provide primary care for women planning VBAC, whether the birth is planned for home or hospital, face potential criticism based on the RANZCOG Statement. The Statement advises that before a midwife agrees to "administer care in risk-prone circumstances, that the women agree to counselling by a senior obstetrician who should ... [read on, there's a real sting in the tail of this one! That selfish woman needs to know that she is potentially imposing "considerable demands on the limited resources of the health team, with potential adverse consequences not just for her and her baby, but also for other women and their babies"]

Feeling guilty now?

Why don't you just roll over?

*****

In this RANZCOG Statement on Planned Vaginal Birth after Caesarean Section I have found material for all the bullying and manipulation that is needed to force women into submission to the medical system. While acknowledging a woman's right to make choices, the Statement sets the stage to shackle those who have the ability and skill to recognise and address complications early if they occur, while working in harmony with the natural physiological processes that lead to safe and joyous birthing.  Under this Statement the rate of Caesarean births, and all the related complications, is likely to continue to rise in Australia and New Zealand.

Notes from my practice

A baby has been born, at home. After a couple of days of pre-labour, frustratingly coupled with winter colds being suffered by the whole family, the labour began. I was called at about 3 am, and headed out into the country, driving through towns, and past vineyards and farms.

The midwifery student arrived just after me, and we went into the home together.

The student has kindly shared her reflections with me:

"When we arrived the woman was upright, pacing with her ipod on and using lots of heat packs. The room was lit by candles and the fire was burning.
"Suprisingly we did not do an assessment on arrival but instead proceded to unpack things. I helped to test and check the emergency equipment and positioned everything in unobtrusive but accessible places in case they were needed (they weren't). After about 20mins of setting up we were ready to do an assessment. It the very first of many stark contrasts to hospital midwifery in that this only included a temperature and fetal heart rate. The midwife explained that as the woman's BP had been stable all along there was no evidence to support it being unstable in labour, in addition we already knew the baby was cephalic and well engaged (from our previous appointments) so a palpation was unnessessary. A VE [vaginal exam] was also unnessessary as it wouldn't change the course of action/treatment at that time. No timings either, as there is no syntocinon to put up. All in all our assessment was about observing behaviours."


It has been an interesting exercise for me to see this birth through the eyes of someone who is new to the profession. Someone who recorded, after the birth, 
"It was the first time I have seen:

• An upright first stage
• Labouring in water
• Birthing in water
• No meds to hurry labour
• No analgesia in labour
• A physiological 3rd stage
• A woman taking cues from her body, not from hospital staff
• Family and friends with active labour involvement
• A woman eating and drinking freely in labour
• Waters breaking without someone breaking them
• Kids in labour
• Video camera in labour
• A baby being swadled in sheets etc that the family had been using prior so it had their scent on it
• True woman-centre care"

My enduring memories from this birth centre on the normality of everything that happened, contrasting with the potential threat of illness. The illness that this mother, father, and family faced at the time was that they all had colds - common garden variety upper respiratory viral infections. Coughing, congestion, chills, sleeplessness ... they had it all.

By the time labour was established the mother was weary.
As the time for birth drew closer, and the mother became frustrated by her physical weakness, I asked her to rest quietly in the womb of warm water. Some would call it transition. The light from candels was dimmed. The support crew withdrew to the kitchen, and had cups of tea and pieces of toast.

The miracle of birth unfolded and a beautiful pink baby boy, with a shock of black hair, was lifted out of the water by his mother and taken into her arms.

The miracle of birth continued as the child transitioned from placental circulation to strong, normal breathing, and began his lifelong search for good food.

The miracle of birth continued as the mother stood and released her baby's placenta, with only minimal blood loss.

Mother and baby are well and happy.


Another mother is waiting for her baby to be born.

She is a mother who has experienced the cascade of interventions in her previous pregnancy, with induction of labour, epidural, caesarean birth, separation from her baby, the baby being given formula feeds, and weeks of distress, pain, bonding and breastfeeding difficulties.

She is a mother who is longing to give birth to her baby, and who is learning to face her fears and work with a simple decision making process as each day passes.

ANNOUNCING: Midwifery from my heart

Midwifery from my heart is the first in a new e-book series.

If you would like a copy of Midwifery from my heart, simply send a small donation of at least $10 to a charity providing services or relief for needy mothers and families, and let me know that you have done so when you request Midwifery from my heart. [email: joy@aitex.com.au ]

Charities to consider include
TEAR Australia
World Vision
CP Australia
ACM Scholarship fund for Aboriginal and Torres Strait Islander midwives


Introduction to the Villagemidwife e-book series

I am writing
To record my knowledge
To tell my stories
To teach others

I am a midwife. My words, thoughts and actions have been formed over many years and a unique set of experiences: the world into which I was born; the mother who bore me; the family that nurtured me; the towns and communities that have allowed me to be me, and this wide open land and its people.

I like to think that these are my thoughts, yet I know that much of what I say is my own filtering and organising of what I have absorbed from those around me. Although I am the speaker, I am not the source.

Midwifery belongs to women. The midwife is ‘with woman’, a companion for a distinct and definable childbearing event, in a special partnership. Midwifery does not belong to theorists, although the clear expression of the ‘with woman’ partnership by thinkers has helped set great value on this simple phrase.

Midwifery is women’s business, evolving and moving with women, in our own time and space, along with our joys and sadnesses, our changing bodies, our children who are sometimes wonderful, and sometimes bring us near despair, and our hopes always for a better future.

Midwifery from my heart is about the life I know and love. It’s from my heart because I have learnt it, deep in my own life, and in the homes and lives of the women who have taken me with them. It’s midwifery because it’s ‘with woman’.

...

The unexpected journey

"By choice, in our adult years, many of us choose to travel away from our home base, to go on journeys of various lengths, from the small to the epic. We seek adventure, novelty, change. We launch ourselves on ventures near and far, with the comfort of both a phone card and a return ticket in our hip pocket. From a secure base, we revel in being on the move, delight in the foreignness of our encounters and welcome the rejuvenation of self that accompanies these departures from our norm.
...
"When a journey is not of your choice, if you are ill prepared for the road, if you have little idea where you are going, how long you will stay, where or when you might find a place to rest, how to speak the language, the allure of travel fades." [Quoted from a paper 'The inside journey through care', given by Jennifer McIntosh, PhD, Clinical Psychologist, Family Therapist, Researcher, 2001]

The universal expectation of pregnancy is the birth of a baby. The 'knowledge' is not only knowing in our minds; it's also known and prepared for hormonally in every cell of the mother's body. Even the father's body may experience hormonal changes that are likely to prepare him for the anticipated change.

Just as the fact of a baby is hormonally heralded, the normal physiological process of childbirth anticipates a specific journey for the mother and her child. We know there is an intense (internal as well as external) period of nesting; then the onset of spontaneous labour which builds as oxytocin pulses, and uterine muscles contract and retract, and opioid-like substances surge, and the cervix is drawn up and opened to release the child. The peak of adrenaline just prior to the expulsive phase prepares the child for the huge transition he must make in leaving one world and entering another.

The journey that is physiologically anticipated includes the mother's recognition of newborn's cry; a babe in her arms; a babe with all the sounds and smells and movements that stimulate further surges of the love hormone; a babe who soon begins his life-long quest for food and proceeds to draw milk from her breast.


The unexpected journey shocks and confuses the mother in this finely balanced hormonal state.

Hours later she is numbly aware that her arms are empty; that her breasts have not been touched. Her mind searches for explanations; for a map to guide this journey that she did not choose.

Preterm labour

This document, Neuro-endocrinology Briefing 35: Preterm labour is available online at the British Society for Neuroendocrinology.

The briefing was sent to me by my friend and mentor, Wolfgang Jochle, who lives in New Jersey, USA. Wolfgang's life work has focused on understanding the physiology of animal reproduction. A conversation with Wolfgang always extends my thinking, even though my education in the biological sciences is very limited.

My interest in the topic of preterm labour was heightened just this morning, as a colleague and I discussed a recent experience of working with a woman in spontaneous labour at 35 weeks' gestation. The timely arrival (by air-snail-mail) of this document in today's mail was just one of life's interesting coincidences.

Here's a brief excerpt ...
"But why is birth difficult to delay long enough to reach term? The answer may lie in the recruitment of the oxytocin neurones which, once primed by the initial signals, then respond to any small trigger (including uterine factors/contraction and or psychological situations such as stress that activate parallel brain pathways). This results in an ever-increasing positive feedback that promotes oxytocin secretion in larger pulses which inevitably precipitate further uterine contraction and birth. So, far from uterine mechanisms sustaining labour, brain activity is crucial, and drugs targeting oxytocin neurone priming mechanisms may be an appropriate way forward for therapeutic intervention in preterm labour." (Author: Dr Alison J Douglas, Edinburgh, UK)


A midwife working with healthy, socially well supported, well nourished women planning homebirth does not see much preterm labour. In fact we worry more about pregnancies that extend beyond 42 weeks. (I wonder if the science of neuroendocrinology has a physiological explanation for prolonged pregnancy?)

The time, and nature, of the onset of labour hold many mysteries. The image of "ever-increasing positive feedback that promotes oxytocin secretion in larger pulses" fits well with my understanding of the vastly varied experiences women have as they approach that tipping point, which means their baby will soon be born.

A midwife is conscious of this intricate balance of physical and psychological factors in birthing.

A year in review

A year ago I wrote in this blog: "We (the community of independent midwives and homebirth parents) are all wondering what will happen to homebirth after July next year."

I encouraged my small group of readers to write submissions to inquiries, to attend rallies, to contact the radio stations .... 

I argued that the legislation which mandated something that was not possible to access (professional indemnity insurance) in order for a midwife to practise "denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing."

Now, with only a few days remaining before the new legislation comes into force, I am content that the time-honoured profession of the midwife attending a woman in her own home will continue. 

I am not suggesting that the government has managed maternity reform well.  They have not.  Concessions have been made in response to the unprecedented outcry by the small but resillient group of homebirth parents and the midwives who attend them, as well as other fair-minded supporters. Midwives attending homebirth have been given a temporary (2-year) exemption from the insurance requirement. This awkward exemption may in fact protect lives, by averting the alternative, of driving homebirth underground or into the hands of unregulated birth attendants.

I am not suggesting that the government will manage maternity reform better, now that Australia has our first female PM.  Julia Gillard was Opposition Health spokesperson a few years ago, and made all sorts of positive gestures to birth activists and midwives in the lead up to the election.  Julia Gillard appeared to be listening to reason; appeared to be impressed by evidence supporting the safety and importance of enabling women to make their own decisions about childbirth, in a partnership with a known and trusted midwife who provides primary care throughout the pregnancy-birth-newborn care periods.  Once Ms Gillard became deputy to the PM, the spirit of working together with women for better birthing was quickly forgotten.

Many midwives are not satisfied with the way things are. The cost of indemnity insurance that will meet the requirements of the national registration law is between about $2000 and $7,500. (see the MiPP blog for detail) A midwife whose private practice brings in less than $10,000 annually is required to have insurance, the same as the midwife who is earning $80,000 annually. The cost of insurance will either be passed on to the client, or some midwives will cease private practice because they can't afford to continue.


There have been some positives as well as many negatives in this past year of preparation for our brave new world.

On the positive side of the ledger,

• I have seen some independent midwives take action to lobby government agencies.  One particular midwife comes to mind; I won't name her.  She has made an exceptional contribution from which all private midwives stand to benefit.  She has brought together professional and political interests at great personal cost.  Many readers will know to whom I refer, and I thank her.
• I have seen midwives who had no experience in homebirth declare their intention to move into private caseload practice, and learn homebirthing
• I have seen people in the community - childbearing women as well as men and older folks - willing to reflect and discuss the importance of what happens when a baby is being born.

I will not list off negatives, but I have observed members of the midwifery profession acting as people under threat, and being ready to verbally attack others whose opinions differ from their own. I am looking forward to a period of healing within the midwifery profession.

Note: Part 2 of this review is at the Private Midwifery Services blog

Midwifery knowledge

A colleague who practises privately in a small and closely knit rural community told me the story of a recent birth; of what she, the midwife, experienced in the days and weeks prior to the birth; of the response of the local doctor who supported the homebirth plan; of the response of the various professionals in hospital, and of the parents themselves who are delighted with their beautiful child.

The details of this birth are not mine to tell.

As I listened to the story unfold, I commented "You know, there are two sets of birthing knowledge."  There's the general set that is understood by doctors and midwives who have had the most basic education in maternity care.  Then there's the specific midwifery knowledge.  The knowledge that midwives who practise in primary care, in partnership with each woman, learn from the women and from other midwives.

Midwifery knoweldge includes

• strategies for reducing anxiety in labour.  The midwife enters the woman's space and speaks only when the mother is able to listen, minimising interruption, quietly and confidently.
• strategies for being present without taking over.  The midwife settles quietly to wait in a place that's out of the way after satisfying herself that the labouring mother and baby are well, rather than positioning herself in a dominant or intrusive way near the woman.  This midwife may have knitting or crochet in her hand - repetitive work the does not demand a lot of concentration, but keeps the midwife observant and present.
• strategies for moving the baby in the womb.  Some midwives rely on physical manipulation of the pelvic bones.  Others have espoused the Rebozo technique taught by Mexican midwives.  My preference is to encourage exaggerated pelvic movement using the birth ball.  Each of these techniques, and probably others I haven't thought of at the moment, enable centering of the woman's body and the baby's head, the presenting part, to adjust its position in relation to the mother's cervix.  This brings progress.
• strategies for getting labour started.  The old fashioned castor oil and orange juice has been used to kick start many labours, but it comes at a cost of an irritated bowel for many women.  I would not recommend this method as a first line of action.  Some midwives encourage women to have acupuncture, or a spicy meal, a long walk, or repeated love-making, or all of the above.  My usual strategy is to encourage the woman to stimulate regular contractions for a period of time by touching the areola around her nipples.  This brings a uterine contraction in response to the natural oxytocin release from the nipple stimulation.  The woman is encourage to walk while having a contraction, then to sit on an exercise ball and do pelvic circles and tilts, then stimulate another contraction, walk, ...  In some instances the woman has progressed quickly into strong labour after stimulating only one contraction artificially.  It's as though her body was ready at the starting line, and the first contraction was the tipping point that got her going.
• strategies for enabling a woman to accept the work of labour.  The woman who asks a midwife to attend her, especially in home birth, knows that noone can give birth for her.  The woman knows that the midwife doesn't have dangerous drugs or procedures that will take away the sensations of birthing.  The woman's own hormonal mix of oxytocin, the love hormone, with endorphins, the natural opiates are used to advantage in the home where the woman feels safe and uninterrupted, unwatched.
• strategies for monitoring the progress of labour without performing frequent internal vaginal examinations.  An internal examination is a significant interruption to the hormonal flow of spontaneous physiological birthing, and is performed only when the information it gives is important.

The key to midwifery knowledge is the relationship between the midwife and the labouring/birthing woman.  The known and trusted midwife with whom the woman has spent substantial amounts of time prior to the onset of labour enables decision making that is appropriate for the individual mother/baby dyad.    The midwife's skill in working in harmony with the natural physiological processes in birthing is essential in promoting health.

mother and daughter

Mother with daughter as daughter becomes mother: this is a timeless tradition that spans generations. It's a time when deep bonds are strengthened; when some of life's secrets are passed wordlessly from one generation to the next.

The older woman travelled to be with her daughter, and entered her home. She felt respect for her daughter's personal world, her husband and all that made up their lives. She experienced a sense of pride in her daughter's strength of character, and her desire to know and do what is good and right for her family; her child.

>>>>>>

And so we shared the days: preparing meals and carrying out ordinary tasks, all the time welcoming reminiscences. When pottering in the garden, or going to the shop for something that might be useful when the time came, we enjoyed the harmonising of two lives for a brief period of time. We shared words of faith in God, the giver and sustainer of life.


We remembered times with my mother. My daughter remembered her grandmother's gentle, loving care. She recalled the holiday at the Gold Coast, when she had helped Grandma make pumpkin scones and a baked jam roly-poly.

I also remembered my mother's gentle, loving care. I recalled how she had been a midwife to me when I gave birth to my second daughter; how the simplest act by her had nurtured me in the way that my lonely heart needed; how the simplest meal that she prepared had met a deeper need than hunger.

This time of birthing has brought three generations of women together, even though my mother's life journey was completed many years ago. She accompanied me, as I accompanied, and at times guided my daughter.

... Her womb prepared to give up its treasure.

... She gave birth, and took her child to her breast.

... She accepted and embraced the work of mothering.

Praise God from whom all blessings flow.

the womb

The womb grows quietly,
surrounding and guarding the new life within,
sealed until the right time.

A single round window softens,
its fibers are thinned and taken up,
ready for the opening.


The womb gives up its charge, silently closing.

The one in the womb grows quietly
in a warm, watery world.
Secure in a closed and protected space.

The wee one hears sounds from outside,
feels mother's laughter, her song, and her sobs.


Two people: mother with child.
They are together, sharing each moment.

The wee one knows joys and sadness,
loving and longing;
learning life's patterns from within that womb.

At the right time the wee one is guided to a place of readiness.
The round window becomes a vast opening.
The womb that held its treasure so patiently finds new strength
to powerfully and completely expel its contents.

There is a second womb waiting to receive the wee one.
A womb that is bounded by mother's arms, her loving face, and warm strong body.
Within the new womb are her breasts with a bountiful provision.

The child grows, knowing safety, warmth, satisfaction and peace in mother's arms.

Joy Johnston (May 2010)

Celebrating International Midwives' Day 5 May 2010

These pictures are in memory of my mother Ella Davidson, who was a nurse and midwife in Brisbane during  the second world war.  After the war she went as a missionary nurse to China, where she met and married my father.  My sister Marion has written that story.
The second of these pictures is also my mother, holding our second daughter, Rebecca, in 1975.  We were living in Haslett Michigan at the time.


Please join with midwives around the world as we celebrate our day.




If you would like to join in with others in a 24-hour global techno-feast of live online celebration, click here.

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"The world needs midwives now more than ever"

From routine episiotomy to routine caesarean

It's not easy to challenge accepted culture.

Dr Michael C Klein is a Canadian family physician who has challenged the accepted culture of routine episiotomy. I heard him speak on the topic at the Women's in Melbourne, probably 10 or more years ago. Recently Klein has published an article with the title From routine episiotomy to routine cesarean section: HOW SOCIETY CAME FROM REJECTING ONE TO EMBRACING ANOTHER. The link will take you to the article. Here are a few excerpts.

Klein writes:
"My views about episiotomy were formed by an experience in the early 1960s in Ethiopia, where I worked with midwives who attended births without routine use of episiotomy. Twenty years later while on sabbatical at Oxford University, I collaborated with midwives who rarely employed episiotomy yet obtained good results. Back in my usual setting in Montreal, our family practice maternity group employed the techniques and approaches that I had learned in England.
Our episiotomy rate was less than twenty-percent while the institutional rate was in excess of sixty-percent overall and greater than eighty-percent among women experiencing their first birth."
...
"In the 1980s many physicians still viewed the laboring woman with some suspicion, considering the female reproductive system as complex and intrinsically untrustworthy. It needed to be managed, controlled, and improved. Birth needed to be expedited, the fetus liberated from an unsafe environment. The place of episiotomy in this model was clear. In fact, labour can be slightly shortened by employing episiotomy. Those who felt this procedure was important often expressed concern about the negative effects of birth without episiotomy. In the absence of episiotomy, they were concerned about pressure on the fetal brain, maternal soft tissue support, and subsequent pelvic floor function, including delayed morbidity–such as urinary incontinence. Keep in mind that such thinking characterizes the thinking of the current proponents of elective Cesarean section."
...
"It turned out that episiotomy caused the very trauma that it was supposed to prevent, and those practitioners with the highest episiotomy rates had the highest rates of virtually all other procedures as well."
...
"Reconciliation of differing and often confusing views about normal childbirth among the maternity care disciplines and women is essential for the benefit of women and their families."
...
"Next Steps: At the age of almost seventy-two, I have now decided, along with my multidisciplinary colleagues, that we know pretty much what is going on in practice, education and training. And to correct the faults that have led to many of the problems uncovered will not be easy.
We cannot fiddle with such a flawed system and expect to improve it. But in the next few years, the dearth of obstetricians, family physicians and midwives available to serve pregnant and laboring women, will make it necessary to come up with major creative solutions. This will need to include new collaborative models of care, new interdisciplinary practice and teaching models, new financial arrangements and a whole new way of helping us partner with pregnant women in a way that supports and honors rather than frightens them. And of course we will have to control our own fears and anxieties or we will be unable to make the needed changes in a system that is poised to collapse.
Governments, policy-makers and educators will have to be helped to appreciate the ultimate financial and human costs to which the current path leads. It is rare to be able to help make a change that is both the right thing to do while also saving money for the system.
Hopefully we will not only study change but help make the changes that we will study."

DANGEROUS DRUGS?

ps [added 17 November 2012]
This US FDA website gives reliable guidance on codeine ultra-rapid metabolisers.



A baby's ability to breastfeed is one of the key 'performance indicators' that I observe after birth.

The majority of my work is with women and babies who are free of medication, giving birth to healthy babies at Term. Babies behave in the normal physiological fashion when the mother takes her child to her breast, and they remain together, skin to skin, for the next couple of hours. Babies seek the breast, making licking and rooting movements and moving in a distinctive way until they are in place and can take the breast and suckle effectively. This process is known as the breast crawl.

When a woman giving birth requires surgery she is given drugs. The anaesthetist and the obstetrician will prescribe whatever they consider to be necessary.

I am concerned about the current drug of choice for postnatal pain relief, Endone.

In the past year I have worked with three women who received Endone postnatally, and I believe I have observed a strong sedative effect of the drug on two of these babies. They became quite uninterested in the breast after the first breast feed, which had been unremarkable.

Recently another client of mine had a caesarean for obstructed labour, and I talked with her and the midwife in the postnatal ward 12 hours after the birth. The analgesia ordered was Endone (for 48 hours), Panadol and Voltarin. We agreed that if she was needing Endone she would breastfeed first, then take the drug. She has progressed very well with breastfeeding, went home on the third day - in fact this baby does a little breast crawl like a pro for every feed!

I am now checking for research literature specifically on Endone (oxycodone) and breastfeeding. Other midwives have said they share my concerns. A quick Google search came up with a very clear statement: "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child." [at http://www.mydr.com.au/medicines/cmis/endone-tablets]




A colleague who lives in regional Victoria told me that one of the local hospitals uses Endone less than the others, and that the local GPs, who provide anaesthetic services for the hospital, are still giving spinal morphine 1mg which works so well that very few women require more than Panadol and Voltaren.

I spoke to the pharmacist at a tertiary materntiy hospital in Melbourne, and he gave me some more information. He agreed that it's a very potent opioid that has a high transfer ratio into the milk, and variation from person to person as to how they metabolize Endone into morphine substances - hence variation in effect. He said the doses given appear to be pretty hefty.

The medical justification seems to be relatively short half life - 3-6 hours; that it's only used for 48 hours, claiming that the majority of babies are not sedated, and that the amount of colostrum the baby gets is pretty negligible anyway !!. Read here breastfeeding isn't something 'we' care much about!


The Lactmed site notes that "Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics, particularly in the first week of life."

Dr Tom Hale, a world-respected expert and author on medications and mother's milk, has a forum

Hale states that "Oxycodone is a categoryL3... moderately safe, to be used only if the potential benefit to mother justifies potential risk to baby, and it has a half life of 3-6 hrs." Potential benefit to mother justifies potential risk to baby. I wonder how many mothers are given the opportunity to consider the risk/benefit before they swallow the tablet?



A newborn infant has important work to do, including learning how to breast feed. A newborn infant who is being systematically sedated through dangerous drugs that are passing from mother's blood to mother's milk, is being put at risk of breastfeeding delay leading to dehydration, jaundice, and a subsequent cascade of interventions, each with their own package of risks. The mother, receiving powerful sedation, is also likely to experience iatrogenic (physician-induced) difficulties with bonding and establishing breastfeeding.

I have often mused on the fact that "would you like something to help with the pain?" really means "would you like me to give you a dangerous drug?" I wish I knew a friendly cartoonist.

The anaesthetists and obstetricians really need to be questioned about this.
We live in a culture of acceptance of 'doctor knows best'. Women who undergo surgery for birth place an enormous trust in their surgeons and the other medical people - we need to act in their interests and on behalf of their babies.

I would like to ask that anyone reading this blog who works in the system, and who observes any cases where the baby of a mother receiving Endone in the early postnatal days appears sedated or performs poorly at breastfeeding, please draw attention to it. Speak to the obs and anaes departments, and point out what you observe. Ask them if they are aware of other such problems. Speak to the midwife manager of the unit, and ask her if she would support an internal audit of use of Endone. Find out what application is needed to get data from the general records. How often is it prescribed? What doses? (the pharmacy should be able to tell you this) Does the hospital have a protocol for the use of Endone? (you may find this on the hospital's intranet) What is the rate of supplementation of breastfeeding babies who were born by Caesarean (all the Baby Friendly hospitals should be able to give this data easily. Feeding on discharge is recorded on the Victorian perinatal statistics, so there could be some initial comparisons done.)

And while we're on the topic, I think some midwives are telling women in early labour to take some Panadeine and go to bed. Has anyone else heard this? In that case the codeine part of the drug will be added to the opioid soup in baby's system in the early days.


This is just not good enough!

when a baby needs to be born

There are many processes that midwives and others in the know about matters maternity are constantly checking. Today my thoughts are directed towards the first-time mother, known as a 'primip' from the Latin words primi (first) and para (birth), as she progresses through her pregnancy to that day when her labour will establish and her baby will be born.

It is normal/ usual for the baby's head to position itself deep in the mother's pelvic cavity from about 36 weeks of the 40 week gestation - weeks before the birth. The mother feels a sense of 'lightening', as there is a fraction more space under her ribs when the baby's head has engaged. When I palpate this engagement I am reassured that all is going to plan. This does not happen by chance. The mother's body is working in the way it was designed - wonderfully. It's as though the baby has discovered the door to this big world, and is waiting for it to open.

So what about the babies who haven't found the passage leading to the door? The baby who thinks she should come feet first, to start out running? The baby whose head stays high and mobile past 38, 39, even 40 weeks? What's the hurry, anyway?

Should the midwife just reassure the mother - we know a baby can be born spontaneously and safely in a breech presentation, and we know that occasionally a head does not engage until strong labour contractions direct it into the pelvic cavity - even in a primip!

Balancing this knowledge is another body of knowledge, which includes the standard of maternity care in the hospitals with which a midwife practising privately needs to collaborate occasionally. I cannot close my mind to the need for a smooth transfer and transition to medically led care from time to time.

I am constantly reflecting on the skills that promote, protect and support physiological processes that lead to spontaneous, safe birthing in the majority of cases.


Three primips in my care come to mind. I will call them A, B, and C. They are aged between 27 and 35, and are strong, healthy women, with caring husbands/partners. They are also normal height and weight - or normal BMI according to statistical charts. In other words, they are beautiful, healthy young women who would be expected to be able to give birth without complication.

A asked me to work with her for birth in a midwife-led Birth Centre attached to a large Melbourne hospital, Mercy Hospital for Women. When I palpated A's baby at about 38 weeks, I found the head engaged, with the fetal back on A's left side.

B asked me to work with her for planned homebirth, and has a booking at the Women's. At 36 weeks her baby was presenting head down, but the head was mobile. At 39 weeks the baby had turned to a breech presentation. I wrote a letter of referral to the hospital, and asked for review and consideration for external cephalic version (ECV). The ultrasonographer showed B that the baby was indeed presenting breech, and reassured her that there was plenty of amniotic fluid, which is considered necessary for ECV. B was told that the hospital preferred to do ECV at 37 weeks; that there was only about 20% chance that it would be successful at almost 40 weeks. B was determined, and she was invited to attend the next day for an ECV. She did not enjoy the sensation of tachycardia (fast pulse) that she experienced when Salbutamol was administered (to relax her uterine muscle). But the turn was successful. I visited her a couple of days later, and confirmed that the little head had stayed where we wanted it to be.

C is also planning homebirth, and her hospital backup is Monash Medical Centre at Clayton. The collaboration agreement with Monash is that the mother is seen in the hospital antenatal clinic at about 36 weeks, and if the midwife detects any issues of potential concern, an obstetrician also reviews the woman's care. As it happened, C's baby's head was high and very mobile. C was not concerned, as her mother had experienced the same situation and gone on to birthing spontaneously, but the doctor expressed his concern.


My midwifery ethos includes the statement "In normal birth there should be a valid reason to interfere with the natural process." (WHO Care in Normal Birth, 1996)

The question is, "Is there a valid reason in any of these cases to interfere with the natural process?"

Is there a valid reason to interfere with A's natural process? I think most midwives would say No, and I agree.

Is there a valid reason to interfere with B's natural process: baby presenting breech? If so, what should the interference be?

Is there a valid reason to interfere with C's natural process: baby's head high and mobile at Term? If so, what should the interference be?

[Any comments are welcome, of course!]


The birthing dance
One midwifery 'intervention' that I am currently asking my clients to consider, that I think may help that wee child find the way to the door in preparation for exiting her or his mother's womb, is a dance that brings on good 'practice' contractions of the womb. From about 37 weeks this dance will include upright movement, while intentionally increasing the release of natural oxytocin through loving body contact, including gentle nipple and clitoral stimulation with the purpose of bringing on a contraction.

Scope of practice

The midwife's scope of practice is a topic that has become central in many discussions as we approach the introduction of the government's reforms into maternity care. I have written a lot about the countdown to 1 July in another blog.

Midwifery requires skill and wisdom - knowing how to work in harmony with normal physiological processes in pregnancy and birthing. The midwife who works independently, as the professionally responsible primary maternity care provider for a group of women and their babies, has the opportunity to work to the extent of her scope of practice. There are boundaries, and defining these boundaries also requires skill and wisdom.

It's no secret that a midwife is confident and delighted when a birth proceeds without incident, and a strong mother takes her baby joyfully to her breast. This birth is truly within the midwife's scope of practice.

But what about the birth that has some complexity? Is a breech birth, or twin birth, or even a birth at 36 weeks' gestation, or birth to a woman who has had previous caesarean surgery ... - are these within a midwife's scope of practice? Does that midwife, and that woman, have the *right* to choose the setting for the birth: the woman's own home? Or is there some line over which the midwife must not step?

I would be foolish to try to define a midwife's scope of practice in this blog. My hope is that by raising the issue, readers will reflect and learn in the way that is most useful to them.

The Australian College of Midwives has, since 2004, published National Midwifery Guidelines for consultation and referral (which can be downloaded as a .pdf file). The Guidelines claim to be "internationally comparable and based on the latest available research evidence at the time of publication."  The Guidelines cannot, in themselves, set boundaries for a midwife's scope of practice.


The uniqueness of birth, and of midwifery, is that BIRTH IS NOT AN ILLNESS.

Birth is not an illness.

Certainly there are illnesses that can complicate birth: anything from a chest cold to life threatening diabetes or heart disease can and do result in risk to the mother's and her baby's ability to successfully and safely negotiate the birthing journey.  No midwife has a guarantee of wellness or safety.  Safety is achieved by enabling health and refraining from interfering in sensitive hormonally mediated processes, at the same time as being able to access relevant specialist medical services in a timely and effective way when appropriate.

What we do as midwives is different from any other health profession - even obstetrics. The key is the woman's desire to give birth under physiological conditions, which is what a midwife's scope of practice is able to offer, rather than a medically managed birth, which is effectively the only way the doctor knows.

Midwives who work in medical settings are often prevented by service protocols from working to their scope of practice, sometimes to a degree of restriction that is ridiculous and not based on any evidence. I have been told that midwives providing homebirth services under a new pilot scheme for a hospital in Melbourne's outer suburbs have been told that they will be dismissed if they do not abide by the 'rules'. An example is the management of the third stage. The hospital's protocol requires the midwife to undertake active management of the third stage. Women are informed that if they do not agree to active management, they will not be allowed to proceed in the homebirth group. There is no discussion.


When a midwife and woman are working in a partnership based on trust and reciprocity, and there is an aspect of the care for which the midwife's scope of practice may be broader than that which falls under a set of guidelines, it's an opportunity for decision making. The woman needs to know where she fits within the ACM guidelines, and any other contemporary standards - written or assumed. She needs to know what her midwife can offer.  She may need to investigate what the alternative model of care to which she may be referred can offer, and weigh up the potential and perceived benefits against the costs and risks.  She needs to know this so that she can make her own decisions.

Decision points that arise at any time in the professional relationship can be addressed in this way.

Plenty of love to go round

There are times when an ordinary person is able to experience such an overwhelming sense of love that we want to hold on to that moment for ever.

The uncomplicated birth of a healthy baby is a time when love literally abounds. The cup of love fills up and overflows from the mother, particularly, to her infant, her husband and other children, her midwife, and everyone else with whom she shares the intimate experience. In that awesome moment, a mother receives her child to her breast, accepting the work of mothering.

Since as recently as the 1990s, this love phenomenon has been understood as being related to a surge of the hormone of love, oxytocin. Oxytocin is the natural substance that causes the womb to contract in a systematic way that, at the right time, leads to the opening of the cervix and all the complex processes that are summarised in the simple word 'birth'. Oxytocin continues to orchestrate birth, with the successful separation and expulsion of the placenta, the emptying of the womb of all trace of the baby, and the closure of the mother's blood flow through the placental site.

A surge of oxytocin is repeated many times in ensuing days, months, and years, as the baby stimulates mother's breasts and achieves the let down of milk.

A surge of oxytocin is also felt with sustained loving physical contact, building to a peak in sexual climax. Oxytocin supports and directs the normal physiological activities that lead to mammalian conception, pregnancy, birth, and nurture of the young.


In the years since I began to learn to work as a midwife, in harmony with natural physiological processes in the birthing journey, I have learnt to enjoy oxytocin. I have come to a deep appreciation of this wonderful substance in the lives of those for whom I am midwife, as well as in my own life.

As a midwife I see, over and over again, a woman progress through childbirth. I see a woman become a mother, and a couple become a family. I am sometimes privileged to return to that family a few years later when they welcome a new member.

I don't want to sound idealistic about this transformation. While most progress well, I also see some who start out beautifully become hurt and scarred by unrelated events. I see some whose own ability to love has been deeply marred in their early life, and they struggle to trust even themselves, let alone anyone else. I see some for whom illness or fear or destructive social forces hinder the development of strong bonds within families.



Today is Good Friday, and Christians around the world are celebrating a totally different love; love that saves and redeems lost humanity. This morning, as I sat with my family in our Church and meditated on Christ's love, I reflected on the profound difference between oxytocin-love and, for want of a better term, divine love. The elements of bread and grape juice; flesh and blood; a broken body and blood poured out, are symbols representing love that goes beyond any human achievement.

The human physiological love processes directed by oxytocin require flesh to be broken and blood to flow in order for new life to emerge. The symbolic representation of divine love is also in a broken body and poured out blood. New life begins.

The human physiological love processes directed by oxytocin are fragile, easily interrupted. The work of divine love is completed.

There's no milk like mum's milk - part 2

It was the third day after a caesarean birth in Melbourne's tertiary hospital which is also accredited as 'Baby Friendly'.

[For the first part of this discussion, click here]

Mother had received excellent midwifery support and care during and after the birth, and the midwife on duty had arranged to stay with the little family in the Recovery room so that baby could initiate breastfeeding immediately.

Baby breastfed well in the hour or so after the birth.

In the next 24 hours, baby made some effort at breastfeeding, without attaching and sucking. Midwives helped the mother massage her breasts, express colostrum and give it to baby. I visited them in hospital and encouraged mother in this plan.

The following day I was unable to visit, as I had come down with a nasty head cold which I did not want to share. I spoke to the mother on the phone. Baby was only about 30 hours old, and had had limited success at the breast. Mother was happy giving her expressed colostrum.

The next morning - the third day - the midwife announced that baby looked jaundiced, and was dehydrated. Baby was weighed, and of course had lost weight. Although the loss was not excessive, that did not seem to be taken into account in the new care plan. Without making any effort to support breastfeeding, the midwife announced that the baby needed a blood test for jaundice. This recorded jaundice at the lower limit of the range requiring phototherapy. The mother was informed that baby needed to go 'under the lights' and would be given formula milk to complement the expressed breast milk.

The parents reluctantly agreed to the formula - there was really no alternative. They asked that they be able to give it via a cup or syringe, to avoid using a teat. The nurse's response was that that takes too long, and there's no problem with a teat anyway!

...

That nurse undermined the good work by midwives and the medical team in the preceding days, who had worked to promote, support and PROTECT breastfeeding.

Not only did the mother receive conflicting advice; she had reached a point where she was no longer able to trust the guidance of the midwives and other hospital staff. Breastfeeding was compromised by the formula, which took away the baby's appetite and interest in the breast, the enforced separation that came about with phototherapy, and the use of a teat.

...

Someone may be asking, "What alternative plan was there?" "What would a truly 'baby friendly' maternity service have done in this instance?"

At the very least, giving the supplement by cup or syringe, as requested by the parents, would have minimised the risk of nipple confusion.

Secondly, there was scope for more effort to help the mother with breastfeeding, while continuing to observe the baby for any medical problems such as jaundice and dehydration. In this case there was no cause for concern: the baby was at term, and would not be harmed by a more conservative approach than was taken.

And finally, I need to challenge the acceptance of artificial formula as a suitable alternative to a mother's own milk. The first alternative is human milk from another mother - yet Australian health authorities have put their collective heads in the metaphorical sand. Human milk banking, providing donated and pasteurised human milk for human infants, is the best supplement when a mother's own milk is unavailable.

Yet babies are routinely exposed to the bovine milk, and all the other micronutrients derived from plant oils and any number of foreign and potentially allergy-forming sources, when donated human milk would be far more suitable.

"There's no milk like mum's milk!"

A landmark day for midwifery in Australia?

Yesterday the federal government's spin doctors announced that the passing of legislation through the Senate "provides long deserved recognition of Australia's highly skilled midwives.
... giving "midwives access to the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for the first time."
... improving the "choices for Australian women to access high quality, safe maternity care as well as providing support for our talented midwives."
... establishing "a new Government-supported professional indemnity scheme for eligible midwives."

"Today marks a new era for our health workforce - ensuring smarter use of our skilled workforce, and more encouragement to work in multi-disciplinary teams.
This will help deliver better health and better results for patients.
"As a Government, we are extremely proud to be delivering these changes - providing new and innovative options for thousands of women and the community."

The Health Minister's press release makes it all sound great. BUT?

The Australian College of Midwives also welcomes the legislation.
"From 1 November this year, women will be able to choose to see a community midwife, and receive Medicare rebates for their visits to the midwife. The midwives will provide pregnancy and postnatal care in the community, and women may have the option of birth care in hospital from their chosen midwife.
“We welcome Nicola Roxon’s support for women to receive Medicare rebates when they choose the care of a midwife’ Dr Gamble said.
... ‘But we remain concerned to see that access to professional indemnity insurance becomes available for all midwives, including those providing professional care for women who choose to labour and birth at home.”

It's POSSIBLY a landmark day for SOME midwifery. But for miwives like me, who have chosen to be employed privately by women for homebirth or for other private midwifery services, the legislation gives us little to cheer about. Even the promise of Medicare and prescribing rights, to be implemented by November this year, appears to be so wound up in bureaucratic micro-management that we wonder if we will ever be able to meet the criteria. We are doubtful that the Medicare-funded midwife will be able to provide any service that is acceptable to clients, at the same time as providing a reasonable livelihood for the midwife.

The Greens Senator Rachel Siewert spoke up about the systematic discrimination against a small group of midwives and the women who employ us, declaring that "Major parties unite against midwives and homebirths.

"The Federal Government and Coalition have united to ensure that homebirth in Australia will be further marginalised by rejecting amendments to provide midwives with access to indemnity insurance irrespective of the location or venue of the births that they attend
...
"In addition the government chose to reject Greens amendments that would have taken away the power of doctors to veto aspects of midwifery practice, such as homebirth, that they are philosophically opposed to, despite the near universal evidence that safe low risk homebirth has positive outcomes for mother and child.

"We have consistently said that the Government amendments to their Midwives legislation give doctors too much control over midwives practice," said Greens health spokesperson Senator Rachel Siewert.

"It is extremely disappointing to see the major parties side together against the interests of midwives in refusing a Greens suggestion to broaden the scope of collaborative arrangements between midwives and medical practitioners to include health services, thereby ensuring that doctors can't veto homebirths."


Time will tell whether these legislative 'reforms' actually do what the government is claiming they will do, or if the culture of medical dominance is further strengthened.