Thanksgiving

This time of the year is a time of thanksgiving in our home.  I thank God for another year in the life of the man I love, and another year since I first became a mother.

In 1973 we experienced our first Thanksgiving feast in the USA.  It must have been November 22 that year, and we were invited to spend the day with Noel's major professor and his wife.  The food that I remember was roast turkey with all the trimmings including cranberry sauce; warm apple juice that had been pressed from the fruit locally, with sticks of cinnamon floating in the pot; sweet potatoes with a whole lot of brown sugar added to make them even sweeter, corn on the cob, apple pie topped off with some sort of cream that came out of a pressure pack - we were taken on a culinary voyage of discovery.  The food - most of which we had never experienced before - was wonderful!

 Another memory from that day was that I was coming into labour.  The tightenings of my womb were becoming stronger and more regular, and I was excited.  But not too excited to enjoy the feast, which I think primed me for the work ahead.  Our first child, who we named Miriam, was born in the evening of the next day.


The Thanksgiving tradition in North America recalls the pilgrim immigrants who had established a home for themselves in the new world, where they hoped to be free to live their lives and follow their faith.  They thanked their God for preserving their lives, often through grave difficulties, and for giving them hope for the future.


Yesterday we had our own family 'Thanksgiving' afternoon tea.  We celebrate the two birthdays, which come each year at this time.   We have much to celebrate and be thankful for.


My mother used to often remind me to "count your blessings".  As I progress through the years of my life, the magnitude and number of blessings has often become more clear to me.


The photo of the seven beautiful 'blessings', lined up on the old pew near our front door, will hold me in that state of thankfulness. 

Spring in Kyneton

Nothing deep and meaningful today.  It's springtime, and I need a place to post some of the pictures I took today in the garden.

Bonsai Japanese Maples

various Bonsai pots

Japanese Maple

Bonsai pines

Wattle

... and a nice new sand pit in the shade of the birch trees.

Idealism and midwifery - continued

In the previous posting on this topic, I attempted to introduce the notion that idealism around the birth of a baby impacts on what we do and how we do it in both negative and positive ways.


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I have recently noticed a degree of idealism around the circumstances of a birth that has left me troubled.  That has led me back to writing to you, dear blog reader, as has been my custom for many years.

To set the scene, there is a social media group that focuses on childbirth and the law.  The usual contributors to the discussions in this group are midwives, a few lawyers, and childbirth educators, lay birth attendants, and women who from time to time take an activist position, particularly in relation to natural birth.

From time to time I or someone else will post a link to a Coroners report of interest to the group, such as the death of a baby soon after birth.  Recently a report was released by the Victorian coroner, on the death of baby Martha from complications in a spontaneous breech birth.  A few weeks ago the New South Wales Coroner reported on the death of baby NA, also from complications in a spontaneous breech birth.

Readers who follow the links provided will see that these two cases have little in common, except the tragic loss of a baby's life.

The matter that disturbed me in reviewing both cases, and that I call idealistic, naive, and uninformed, is the notion expressed strongly in the group that a mother might have avoided the birthing complications had she been left undisturbed, "truly unhindered".

The sort of midwifery I have practised for many years, with a high degree of safety, includes respect for the woman's need to feel unwatched.  Ina May (Gaskin)'s rule, that sphincters work best at home and when unobserved is a truism that midwives love to quote.  Michel Odent has spent his life after obstetrics teaching us that the human woman is a mammal, and has similar needs to other mammals.  World Health Organisation published an excellent handbook on normal birth in the 1990s, stating that "In normal birth there should be a valid reason to interfere with the natural process."

Somehow the pendulum has swung, in the natural birth community at least, to promote non-interference in an extreme way.  There seems to be a growing group of mothers who believe they themselves and their babies are better off if there is no professional (midwife or doctor) who will intervene in the progress of their labours and births.

When a baby is presenting feet or bottom first (breech) it's not a normal birth - even though it may be spontaneous and natural, and even though there may be no adverse outcomes.  Under the WHO normal birth rule quoted above, there may be (in spontaneous breech birth) a valid reason for interfering with the natural process.  The skilled midwife recognises points at which an intervention (interference) with the natural process is optimal and may be life saving.  There is no time then to call for assistance.  A baby being born breech whose head has become entrapped needs to be released immediately. This urgency, which does not happen in the same way when a baby comes out head first, is what has driven the medical world to preference of caesarean birth for breech babies.

The person who thinks that a woman who is totally unhindered and relaxed can birth a baby smoother and faster than the alternative situation does not understand that death and life are in the balance at the time of birth.  

Nature is under no obligation to be kind, or to give us the outcomes we want.

Idealism and midwifery

It's very easy to find evidence of idealism in anything that pertains to the birth of a baby.  After all, a new life is being brought into our world: precious, full of potential, carrying a unique blend of special characteristics of both parents - both families - into the future.

Idealism happens to some of us time and time again.  Each time I gave birth I found myself wanting to make this world better for that wee one.  I wanted to be a better mother.  I wanted us as a family to provide a better home. 

...   and then, after a few sleepless hours, with a baby who was simply doing what all healthy babies must do, which is to find food, my idealism was truly tested.  My beloved, lying wearily beside me in our bed, had no adequate solution either. 

Over time I became reconciled to the huge gulf between the ideal and the actual.  I learnt that it was, in fact, advantageous for a baby to come into this imperfect world, where the mother, despite her best intentions, is unable to solve every problem.  A world where the baby learns that there are times when both parents are unable to perform to their usual capacity; where there's no-one making eye contact or vowing their love; where even a dripping moist nipple at the end of a full breast fails miserably to meet the need.

If the home was always ideal, how would the child ever cope with the real world?

Conversely, if the mother did not have idealism deep in her heart; if she did not want the best she could possibly provide for her family, how would any child thrive?
_________________________________

A similar dilemma exists in midwifery.

The ideal is that each woman receives a primary level of professional care from a known and trusted midwife.  The ideal is that the woman and the midwife work in a special partnership that provides optimal care and achieves optimal outcomes for mother and child.   The ideal is that the mother's body will function without illness or complication.  The ideal is that the midwife's wisdom will enhance the woman's acceptance of new and primal terrain that must be traversed. 

The reality may be very different.

Our lives are often messed up, at all levels of our physical, social, psychological, and spiritual existence.   In fact, I have been amazed at how often the processes of pregnancy and birth and nurture of the newborn come together in beautiful harmony, demonstrating the wonder of creation.  The way our bodies function in health, as finely integrated systems, is good.   Illness and disease have, to a greater or lesser degree, corrupted this state of goodness.

Dear reader, I need to sign off now, but will plan to return to this theme as soon as I can.

Are we nearing the end of the villagemidwife era?

Dear reader
In seeking to answer this question, are we nearing the end of the villagemidwife era?, I would like to take you today on a reflective journey.  Please come with me along memory lane - not just our memories, but including our mothers' and grandmothers', and more.  If you would like to leave comment at this blogpage, please do so, and thankyou.

What do you know about your own birth?  If you have given birth, how does that compare with your mother's experience of giving birth?

In my lifetime, and within the broad scope of my culture, the person called midwife has progressed from a midwifery nurse, whose language included 'confinement' and the 'lying in' period, and who was required to work under medical supervision, to a highly regulated modern professional who has endorsement that enables access to public funding, hospitals, and prescribing certain medicines.  My generation of midwives experienced a movement to claim midwifery as a profession distinct from nursing.  This can be seen in the two documents pictured below, both from 1973.  The graduation certificate, from the Royal Women's Hospital in Melbourne, states boldly that I have graduated as a midwife from the hospital's School of Midwifery.  In contrast, the Certificate of Registration, issued by the Nurses Board of Victoria in the same year, declared that I was a MIDWIFERY NURSE. 

Graduation as a midwife 1973

Registration as a midwifery nurse 1973

My mother was also a midwife.  In her lifetime Penicillin was discovered, and surgical interventions in birth became safer than they had been.  My mother's generation of midwives taught young women to scald cow's milk, and add sugar and water, making it a tolerable food to replace the mother's own milk - something that became all too easy!

My grandmothers were not midwives, but they gave birth to their babies in the care of midwives who attended them at home or in a private 'nursing home', strictly enforcing requirements for bed rest, and stayed for a couple of weeks afterwards.

One of my great grand-mothers, Angelina White, died 'in childbed'.  Her death was two weeks after the birth of her child, probably from sepsis and haemorrhage: the sort of illness that I would treat with antibiotics.  My grandfather was only four years old when his mother died.



So, what do I mean by the villagemidwife era?

In the beginning, some women learnt that unique and life-affirming skill of accompanying women through their childbearing event.  Those women learnt to work in harmony with amazing, hormonally mediated natural processes; learnt how to teach others enough to prepare well, without becoming overwhelmed; learnt how to reduce and minimise fear and anxiety, so that the labouring woman accepted the work of labour; learnt how to support without interrupting the processes of mother-baby attachment, ensuring strong bonds and resilient families.  The image in my mind is that of a midwife who was known and recognised by her community as being the guardian of the next generation of mothers and babies.

I discovered the villagemidwife model soon after I set up my private midwifery practice in the early 1990s.   I was providing clinical support to a group of RMIT midwifery students at Box Hill Hospital at the time.  A midwife at the hospital asked a student "What would the villagemidwife do?", when faced with a particular challenge.

The villagemidwife then, as now, is known and recognised by her community as being the guardian of the next generation of mothers and babies. 

It was an absolute privilege for me to, over the years, return to families as their known and trusted midwife.   I also felt deeply privileged to guide women in their first birthing - a significant challenge.  And to support - and dare I say 'help' - women who felt violated in their previous birth.

Yet I need to also tell you about the other side of this coin.

There were many frustrations.   My 'village' had no boundaries.  Working with a caseload, on call 24/7 is the big commitment made by a midwife, but it is not easy.  Some of the births I committed to required me to travel one or two hours, often driving through the night.  One morning as I made my way home along Burwood Highway after a birth in the Dandenongs I realised with only moments to spare that I was heading for a tree.  A micro-second of sleep had almost robbed me of life.   I had learnt over the years of hospital night shifts to eat an apple slowly as I traveled home, giving a steady supply of sugar to my weary brain.  I could usually make an apple last the distance.  But my 'stay awake' strategies were not perfect!

I would not take a long distance booking if the mother could find a midwife who was closer.  Not only was the travel costly on my time and energy, but it meant I might not be able to provide as much postnatal care as I would have wished.  

There was a reality that I had to face - my 'village' needed to give me enough work to pay the bills.  There were times when I accepted bookings that required distance travel, or that put several women due in the same week.   There was no way of predicting when babies would be born.  Many times I would look at the calendar - two due this week, one due the following week, and one the week after that.  Then, all of a sudden, four babies would be born within a couple of days.   Add to that the travel from one side of Melbourne to the other, with crowded suburban roads to cross: not the ideal!

The commitment I made to the women in my care meant that my children had to get on without me, sometimes at special times in their lives.  I missed a couple of Paul's birthdays - to the same mother who gave birth to two of her children on that day several years apart!   There were a few occasions when I had to ask another midwife to cover for me, but the very thought of not being able to keep my commitment to that mother caused me deep sorrow.  One birth I missed when I needed to travel to Brisbane when my Dad was dying.  The fact is that the caseload commitment of a midwife is a very difficult commitment to make.

Last month I decided not to renew my midwife registration. More than a year ago I decided not to renew my professional indemnity insurance, so although I was registered I was not able to practise midwifery. During the past 18 months I have lived quietly, gradually recovering from the physical and emotional burnout that developed gradually over several years. I have been enjoying the beautiful grandchildren (and their parents) that God has sent into our care, the change of the seasons, the garden, and many simple life challenges.

It's ten years since I began writing the villagemidwife blog, telling stories and making comment on midwifery issues. It's about 20 years since I wrote what I called The Midwife's Journal http://www.aitex.com.au/joy/journal/contents.htm. These stories were initially written by hand in a book, often while I could still smell the amniotic fluid on my arms, and while the oxytocin and other wonderful hormones of life soared in my body, and I added precious photos - in the pre-digital camera days. 

During these years of writing and reflecting, I have felt that I am in a position of guardianship, recording and discussing life from the midwife's perspective. I am thankful that advances in computer technology in my lifetime have made it easy for me to do this in a systematic and retrievable way.
Although I am no longer able to do the work of the villagemidwife, I do not think I have lost the ability to think about life from this unique perspective.

I have not yet answered the question at the head of this post.  Perhaps that's for another day! 

I would appreciate comment from anyone who reads this post. Thankyou.

thoughts on motherhood

Women contemplating motherhood face enormous challenges.  Pregnancy and childbirth are just the beginning.

Many Australian women tell me that they are angry when the 'system' dictates what they can and can't do.
"It's my body; my baby", they say.
"Surely I know what's best for myself and my baby!"
"Surely you're not allowed to not allow me?"

Women also tell me that they have deep sadness as they remember and reflect upon their experiences in birth.  "I know I needed a repeat caesarean.  But I felt like a piece of meat on a slab.  My baby was taken to the Nursery, while I was in Recovery.  I didn't see him for a couple of hours, and that still makes me sad.  I was afraid for him, and wanted him with me.  If I could have had a natural birth, I would have."

Natural birth has become the ultimate, longed-for experience in childbirth.

Unmedicated, physiological birth; uninterrupted, ecstatic, even orgasmic.
No clamping of the umbilical cord.  No separation of mother and baby - at all!  Not just the first hour, but as long as it takes.

Achieved by only a few.

Who wouldn't want to join that exclusive club?

Not only does the mother appreciate the physical, emotional and hormonal bonuses of working in harmony with amazing natural processes in birth, but the baby also joins in, without any prompting, in this unique primal dance.  


The point I am trying to make, and the main reason I am writing this post, is that there's a problem - women can't pick and choose their maternity journey.  My comments may seem predictable.  How many times have I written this sort of thing, since I started blogging in 2006?  

• The choices or decisions in maternity are quite simple - to intervene or not.  The biological processes in pregnancy, birth and lactation will continue as time passes.  
• Once interventions have occurred it may be difficult to return to the natural, healthy process.
• Undesired outcomes including death may occur, with or without medical or surgical interventions.

I have heard childbirth educators who teach that women who really want natural birth need to surround themselves with a team of supporters who will not waver in their support.  "The chain is only as strong as its weakest link," they say.  "If your supporters (including friends, husband, photographer, carer for children, doula, midwives) stop believing in you, they will cause you to give up just when you should be strong!"

This sort of advice is appalling.

Noone can predict a childbearing journey.  Natural birth is not something that can be ordered like a saleable commodity.  Women can't pick and choose.  A woman's pain in labour may be an indication of serious complication which, if nothing is done to relieve it, has catastrophic consequences.  A woman who shuts down her own responses to pain, and blocks the empathy and care of her supporters is ignoring natural processes at her peril.  A midwife who is disengaged, and sits on her hands rather than guide a woman on in labour, or, make the call to escalate care, is negligent or incompetent.  This might be as 'simple' as, without words, guiding a labouring woman to change her position, thereby moving from the transition to the second stage.  It may be as profound as telling the woman that you are now advising medical intervention, with all that that means.


Advice on childbirth has multiplied in recent years, with social media and internet communications.  A childbirth blog that has (literally) thousands of 'like's, tells us that "The legal authority in childbirth lies with the woman giving birth, not the providers ..." [link]

That's nonsense. 

There is a legal and ethical 'duty of care' that providers (midwife or doctor or other health care providers) are required to take very seriously.   It's an ongoing responsibility that the care provider carries as long as they are in attendance or other relationship such as in phone contact with the recipient of care.

This doesn't mean that all advice or decisions by providers are necessarily 'best practice' or acceptable to the woman.  Some providers maintain practices that are out of date, and believe they should intervene when others consider the progress to be uncomplicated and not requiring intervention.  Some providers (midwives and doctors) take large caseloads that result in cutting corners and burnout.  Human error is a constant threat.  These factors are balanced, to a degree, by the legal right of a competent woman to decline any intervention on herself (but not necessarily on her baby after birth).

We can talk about the legal and ethical standard for informed consent, but the hospitals/doctors/midwives know that they are much more likely to be defending their actions to their indemnity provider or the coroner or AHPRA.  


And there's the uneven playing field. The provider does *it* many times every day, while the woman is doing it for the first (or whatever) time - and takes the 'outcomes' (including pelvic floor damage, surgical wounds, infection, and many other types of morbidity, not to mention mortality) home.
 

Becoming a mother - bearing and nurturing a child - is an awesome and privileged position for any woman to be in.  Our bodies are wonderfully made.  

But, we can't pick and choose what happens in our maternity journeys.

The most healthy and 'low risk' pregnancy can suddenly and unpredictably be subject to life-threatening complications.  Alternatively, a woman with recognised risk factors can proceed without any complication.

Decision-making in the childbearing continuum is an ongoing process.  The woman who can trust her care provider enough to challenge or seek further discussion when any decision point has been reached is, I believe, in the best position.  The woman who believes she is alone, and has to be strong  and resist intervention or professional advice 'no matter what', is likely to be overwhelmed with fear and may make decisions that are not in her best interest.

The death of a baby

Today I would like to comment on a case in which the baby died after induction of labour in a tertiary level obstetric hospital. 

It's a well staffed, well equipped modern facility, with all the bells and whistles.   It's a hospital where doctors and midwives and nurses are  being taught their professions, where evidence based practice is treated seriously.

This death was reported to the Victorian Coroner, who carried out an inquest and has recently published her findings.  The baby's name is Kylie.  I would like to refer to her by her name, as she is at the centre of the picture.  Other people will be referred to by their role.

I am writing about this sad case because it has a number of features are important in understanding an unexpected adverse event.  Please note that I don't have any inside knowledge.  I don't know any of the midwives or doctors who cared for Kylie or her mother, and I don't know anyone who knows Kylie's parents or family.  My source is the Coroner's report which has been placed on the public record. 


A layperson reading the report may well ask how was this allowed to happen?  Why was no action taken until (obviously, with the benefit of hindsight) too late, to hasten the birth of baby Kylie?  What's the point of having continuous CTG monitoring if the plan is to press on, even when the most basic understanding of cardio tocography indicates that baby Kylie was distressed? 

That's the big question. 

Although birth is not an illness, the process carries potential for damage and death.  In birth there is a finite point after which the baby will not do well, but it's impossible to predict where that point is.  Midwives have to accept and embrace this uncertainty, as we work in harmony with natural physiological processes which usually lead to spontaneous birth.  The decisions we make in the clinical setting take unpredictable and sometimes quick changes into account.


The language used to describe a CTG trace, such as 'non-reassuring', is, I think, deliberately vague.  We are all confident when we see a CTG trace that ticks all the boxes.  'Reassuring'!   It's the non-reassuring ones, placed in context with all the other clinical features, that challenge decision-making.  A normal trace now can not predict the condition of the baby in 2 hours' time, or 10 minutes, or any time in the future.


I found the record of the evidence of the obstetric experts very interesting (#70 onwards). Some hospitals/obstetricians have a low tolerance for non-reassuring traces.  Historically the CTG machine has become the catalyst for high rates of caesarean births, and many babies come out pink and complaining about the whole process, suggesting that the surgery was not really necessary.  The ability of the midwives and doctors who are providing professional care to know which mother-baby pair is progressing well, and who needs surgical intervention is a skill that cannot be overvalued.  The big teaching hospitals such as this one set up their guidelines that the staff are bound to follow with this in mind.
 
The idea of a chronically compromised fetus who may not have done well even if the baby had been delivered earlier is worth thinking about.  


Will this death, and the related report, lead to an even greater rate of elective surgery to avoid the possibility of low fetal reserves?  How many mothers will be operated on without valid reason, giving them and their children the increased life-long consequences of caesarean surgery?  More importantly, will the lives of babies like little Kylie be protected as they make their transition from mother's womb to our world? 



My response to this report is from a midwife perspective. For 20 or so years until my retirement last year I have been attending homebirths, without access to CTG at the primary care level. A midwife attending homebirth will usually listen to the fetal heart sounds using a doppler sonicaid machine after a contraction, and consider that observation within the context of other clinical features. If there are 'non-reassuring' features of that auscultation, such as a deceleration, it's a decision point that can have profound consequences.

searching for confidence

A young mother whose second pregnancy is at about 30 weeks phoned me, and we chatted for a while.   As I listened to her story, I felt enormous sympathy for her in her search for confidence. 

I have pondered the predicament of this young woman, who I will call Bea, and others in similar situations many times.  So, dear reader, I will share the story with you, and hope that those readers who are also searching for confidence as you approach your time to give birth will be given some useful tools.   If you think you know Bea, please read any of the more critical comments that I make as criticism of the system that leaves women dangling and lacking in confidence, rather than a criticism of any person.


Bea is booked to have her baby in a hospital, under the care of a team of doctors and midwives.  Bea is hoping to find someone who will palpate her abdomen (See RCM How to perform an abdominal examination) and tell her how her baby is growing, and whether she will be suitable for VBAC (vaginal birth after Caesarean).

Bea experienced an emergency Caesarean birth after a long and painful labour for her first child.  She felt traumatised, disappointed, confused, depressed; at times blaming herself and at times numb towards herself, her child, the child's father, and the world.

In preparing herself for this next birth, and in an effort to come to terms with her memories, Bea has had counselling.  One of the outcomes of that counselling is that Bea recognises a lack of confidence in the (nameless) people who will provide care for her in labour and birth.  Midwives, doctors, others: all with a role in the system that produces babies, yet Bea has no confidence in that system.

Bea is an intelligent woman who is used to researching every aspect of life, from the energy efficiency of white goods in her home, to the source of the food she buys.   She wants to know about pregnancy and birth specifically as it relates to her.  She reads posts from other mothers on social media.

Bea is particularly concerned about the size of her baby; whether he or she will 'fit'.  That's a big question.  It's a question that exercises the mind of every midwife.

Bea would like me to palpate her abdomen and (hopefully) tell her that her baby will fit through her birth canal.  I can palpate her abodmen, feel the fetal poles and hold her baby between my hands.  That gives me a good idea of the size of the baby - it's not much different holding a baby who is still in the womb to holding the baby in my arms.  But I can't tell if the baby will 'fit'! The only times when I would advise against progressing naturally and spontaneously into labour are when a complication presents - when the natural process would be likely to lead to damage or death.

Many times I have attended little women who have big babies.  Many of them have given birth spontaneously and quickly.  I have never tried to be a prophet, predicting events in the future.   The decision making processes in midwifery require the midwife to understand and work in harmony with the natural physiological processes, and only interfere if there is a valid reason to do so. 

Bea told me she has at least three birth plans: a vaginal birth; a caesarean after labouring; and an elective caesarean.

I told Bea that she should have only one birth plan: to do her best. 

You need to take ownership of your own natural processes which are essential if natural birth is to progress well. ...to make the best decision you can at any point when a choice or decision needs to be made.  Here are a few examples:

• The doctor tells you at 38 weeks that he assesses the baby to be large and advises an elective caesarean (without labour) at 40 weeks.  Do you think the best decision at this point is to say yes, to say no, or to make a decision closer to 40 weeks?
• It's a few days before (or after) that magical 40 weeks.  You think you are coming into labour - it's midnight and you woke up with a contraction, and felt baby make a few big moves.  Waters have not broken.   Do you get all excited and ring your support team, and ring the hospital, and wake your husband?  Or do you tell that baby to go back to sleep - you have a big day ahead if labour does begin, so you need to get some shut-eye!
• Later ... You think you are really in labour now.  Memories flood back each time your womb contracts, and you remember the early part of your first labour.  You remember using the labour ap on your phone to track the contractions.  You know you need to get organised - little Johnny will go to his granny after breakfast, DH will stay home from work, and the birth support friends will need to make arrangements for their families and work.  Contractions are coming every 10 minutes, and feel good.  You need to walk and rock through them.   Do you ask your team to come now, or to wait for another call?  Do you call the hospital now?

...

These 'decision points' might seem insignificant, but I say they are some of the most important decisions you will make.  Each decision is a fork in the road.  If you take one, you cannot take the other.  There is no turning back.  Can you feel confident about these decisions?  If you have that confidence, and you establish labour without any outside (medical or psychological) assistance, I know that you are well on the way to successful and healthy VBAC.   

Natural: is it good, bad, neither, or both?

It has been months since I put (virtual) pen to (also virtual) paper in this blog.

I have needed time to reset my body clock; to recover from the exhaustion and burnout after many years of midwifery and related professional activism.  I don't know if I have fully recovered yet.  The reality of ageing gives much to ponder; a relentless march towards exhaustion.

In recent months, with no midwifery to absorb time and energy, I have taken up some new challenges.  These photos show the performance of the 'Human Knitting Machine' at the Kyneton Show.

performance of the 'Human Knitting Machine'

The finished product

I am enjoying our new home, and the rural Central Victorian lifestyle.  The daily patterns of weather; the sun and clouds and wind; the subtle changes in the seasons; the growth and change in the garden - these natural life factors add wonder as well as sometimes concern to our days.

We are often delighted, and sometimes concerned, by the little members of our family and friendship circle, as they proceed through their developmental milestones.  This is all part of natural processes: sometimes good, sometimes bad, sometimes neither, and sometimes both.



Just as with retirement from attending births my life has changed, so has my capacity for writing.  Blogging has, for me, been closely linked with practice.  In the past, as I pondered the events of my professional life, the thoughts that surfaced became seeds for comment in this blog.

I now find that I need to shift my point of view from that of a midwife who was intimately involved in the day by day decisions related to maternity care and the lives of mothers and babies, to a more distant view.  As a retired midwife, my view is that of guardianship of birthing within the bigger picture of living.  I care deeply about what my society does to mothers and babies.  My right to comment continues as in the past.  Readers will need to decide whether my thoughts are valid and useful, or not.


Today I would like to consider *natural* in the maternity context.  Previously I wrote:

Giving birth spontaneously is, in my mind, a woman's *natural right* (not a legal right), just as we have a natural right to breathe, or walk, or perform any other natural function of our bodies.  Women do have a natural right to birth their babies.  Midwives are in the unique position to protect and work with that natural process, giving the mother confidence as she navigates the most challenging terrain.  The only way we can achieve our natural right to birth is if we stay on that natural pathway, and for the majority of women, this is a wonderful and rewarding phenomenon, working with the amazing hormonal cocktail that sets up powerful maternal instincts and bonding/attachment for mother and baby. 

I know of no better way for birth than to proceed under the spontaneous, hormonally mediated natural process from conception to birth, and beyond to nurture and mothering of the infant - MOST of the time.

Natural pregnancy, birth, and nurture of our children is good - MOST of the time.  Regardless of race, wealth, or other social factors, our bodies and minds are set to the 'default' that whatever is natural will be, unless something is done to redirect the course of events.

Whether we apply this principle to maternity issues, or any other ordinary life event, *natural* can be awfully unpredictable, and unmanageable.  There is no therapy that can make it work better, or reign in the unpredictability.  There is no drug that will 'fix it'.  Modern Western medical management of maternity care seeks to minimise 'risk', and in so doing reduce the impact of the spontaneous natural process: to remove the 'MOST' element, and make maternity just another predictable, manageable medical event that complies with medical guidelines and protocols.


For the midwife who is committed to working in harmony with natural processes, except when there is a valid reason to interfere, the big challenge is to know when the natural process is likely to result in harm; when medical and other interventions are likely to lead to improved outcomes.  This requires clear thinking by the midwife or other primary care professional, and independent clear thinking by the woman who receives the advice that a process other than the natural one is being recommended.

I want to emphasize the need for independent thinking by the woman.  The first decision to interrupt the natural birthing process is profound, and the woman must take responsibility for it as her own decision.  It doesn't matter how much trust there is between the woman and her midwife, or doctor for that matter.  The first intervention, which can quickly cascade into a whole bunch of subsequent interventions, can be a life and death decision point.  As can the decision not to intervene!

I started this post by saying that

I know of no better way for birth than to proceed under the spontaneous, hormonally mediated natural process from conception to birth, and beyond to nurture and mothering of the infant - MOST of the time.

During the past couple of decades I have experienced progressive increases in reliance on medical intervention in maternity decisions, paralleled by loss by women in their ownership of their commitment to natural, spontaneous, unmedicated birth.  In Australia today, the woman's ability to make her own consumer choices has eclipsed any valuing of or protecting physiology.  This has made maternity decisions more like walking down the aisle in the supermarket and making selections based on price, packaging, or some other possibly insignificant factor.

I'm not wanting to suggest that I think maternity care was better 20 years ago, when I was busy with midwifery and maternity activism; or 40 years ago, when I was having my own babies; or even 60 years ago, when as a young child I learnt much about mothering from my own mother.

Twenty years ago we were working to demand that midwives be called midwives, not nurses, in hospitals.  We had supported the release of a Code of Practice for Midwives in Victoria.  We were promoting the Baby Friendly Hospital Initiative, through which maternity hospitals were supported in the protection, promotion and support of breastfeeding as the health promoting natural resource of mothers and their new babies.

As time has passed the indicator of reliance on medical rather than natural processes has been the consistently increasing rate of caesarean births in otherwise healthy pregnancies. 

Women don't, on the whole, choose caesarean surgery.  They enter systems of care that sets up the cascade of interventions, so that there is no safe alternative but to bring it all to a conclusion, and when that happens the most rational and helpful option is surgery.  Women, midwives and doctors play games that set up a mirage of choice as the prize, when in reality there is no choice.

Natural birthing can be very good, or very bad.  It can be neither good nor bad.  It can be both good and bad.  Society will either benefit or pay the price for its reliance on the natural physiological processes in maternity decisions.

legal rights in childbirth?

Bec and Lucinda

For some years I have been troubled by apparently common misunderstandings of a woman's *rights* in maternity care.   I have pondered these questions publicly on this and other blogs; questions of choice and informed decision making. 

Consider these statements:

You [a competent adult] have the *right* to bodily autonomy.  This means that noone is permitted to do anything to you without your permission.

In any health care situation, including maternity care, you [a competent adult] have the *right* to decline a treatment or intervention.

These legal rights are well established, and I am not going to spend time discussing them. 

Now consider the following statement, which appeared this week in a news article titled Risky underground homebirths: freebirths tipped to rise:

"Women have the legal *right* to birth how they want to"

A legal right? 


Surely not!

Even in the most ideal maternity care situations there will be some women who, in order to protect the life and wellbeing of the mother and her baby, will be advised to undergo surgery.   What happened to these women's legal rights to birth how they want to?

Maternity care in the developing world is often far from ideal.  Women whose health has been compromised by war, social exclusion, poverty, poor nutrition, disease, and other preventable conditions give birth to babies often in shocking conditions, with high rates of mortality and morbidity.  Do these women have a legal right to birth how they want to?  No!



Giving birth is a natural, spontaneous phenomenon, if a woman's body is left to its own devices.
Babies will be born naturally whether someone is monitoring progress or not.   
The sort of birth that the mother wants, which according to the quote above is her legal *right*, may be very different from the natural outcome.  

Giving birth spontaneously is, in my mind, a woman's *natural right* (not a legal right), just as we have a natural right to breathe, or walk, or perform any other natural function of our bodies.  Women do have a natural right to birth their babies.  Midwives are in the unique position to protect and work with that natural process, giving the mother confidence as she navigates the most challenging terrain.  The only way we can achieve our natural right to birth is if we stay on that natural pathway, and for the majority of women, this is a wonderful and rewarding phenomenon, working with the amazing hormonal cocktail that sets up powerful maternal instincts and bonding/attachment for mother and baby.
   
Those who have access to modern hospitals are not bound to use their natural right: they can obtain medical management and intervention, which is provided in modern societies along with other medical services.   We are privileged to have this access, and even a degree of choice in planning the way babies are born.  But, access to choice in the way a baby is born is not a simple matter.  It's not a legal right. 

I think it would be silly to argue that women have any legal right to a particular medically managed pathway in childbirth.
 
So, with great respect, I would like to suggest that midwives and maternity activists stop saying that women have a legal right to birth how they want to. It's nonsense.


Why am I so concerned about this question?

I have read coroner's findings, acted as an expert witness, and discussed cases with peers, and the recurrent theme has been this distorted belief, on the part of the midwives, that women should be able to choose the sort of birth they want, and that the midwife should facilitate this choice.  Midwives working under this belief have forgotten the harsh reality that preventable death and disability is often not far away.

The mother who wants an 'undisturbed' birth, and tells the midwife that she does not want any monitoring of her own vital signs or her baby's.  Yes, she gives birth, and usually the baby's condition is good.   ...

The mother who has various medical conditions including unmanaged gestational diabetes, wants a VBA2C, and who decides that there is too much negative energy in the hospital, so she finds an independent midwife who commits to homebirth.  ...

The mother who feels that she suffered trauma in her previous birth, in which labour was augmented, and a forceps birth resulted in severe perineal tearing which was repaired.  She does not know what she should do.  Should she request an elective caesarean birth? ...

These mothers may not be claiming any legal right to the sort of birth they want.  But they are looking for competent professional care.  A midwife can proceed on life's path with the woman, and provide information, support, expert advice, and sometimes guidance.

The midwife can support the woman's natural right to spontaneous birth, in the setting that is considered most appropriate at the time. 



Footnote:
In relation to human rights and birth at home, the judgment of the European Court of Human Rights in the case of Ternovski v Hungary (2010) is significant.

Insurance: a pot of gold at the end of the rainbow

A pot of gold at the end of the rainbow?
A mirage?
The emperor's new clothes?
[My question is, when will we - the maternity community including midwives, hospitals, and consumers - wake up and come to terms with reality?]


Here's a thumbnail sketch of the insurance problem:

Professional indemnity insurance (PII) for all Australian health professionals became mandatory five years ago.
... BUT midwives who attend homebirth privately cannot purchase PII
... SO the exemption was introduced by the government, to enable midwives to continue being midwives.

Until recently, privately practising midwives who provide clinical midwifery services (pre-, intra-, and post-natal professional care) have purchased PII to cover pre- and post-natal services, and have, with certain conditions set down by the Nursing and Midwifery Board, come under the exemption for attending women in labour, birth, and the immediate postnatal period.  There were two insurance companies MIGA and Vero.  MIGA insurance is restricted to Medicare-eligible midwives, and includes cover for birth in hospital when the midwife has clinical privileges.  Vero, on the other hand, has provided an insurance product for midwives regardless of their eligibility for Medicare funding, and offers no cover for intranatal midwifery services.


Now, Vero has notified midwives that:

"It is with deep regret that we inform you that as of the 2nd April, 2015 Vero and Medisure will no longer be able to provide a Professional Indemnity Insurance policy to Private Practicing Midwives who are providing any home birthing or home birthing related services.

There are a number of factors that have impacted on this difficult decision, including:
• the high cost of claims that have resulted in the past 4 years
• the lack of government funding or assistance (for claims or premium costs), and
• the ability to offer an affordable policy to Private Practicing Midwives who are providing any home birthing related activities.

..."

The Vero insurance product was the only PII option available to non-eligible midwives, and was seen by some eligible midwives as more affordable, and adequate to meet the requirements of registration.

I am not surprised that Vero has come to this decision.  The wonder to my mind was that someone thought it would be do-able!  The 'number of factors' dot points listed in the Vero letter are not surprising:

• the high cost of claims that have resulted in the past 4 years

Yes, legal defence is costly.  That's what insurance is about.

• the lack of government funding or assistance (for claims or premium costs), 

This is not new.  The product has never had government assistance

• the ability to offer an affordable policy ...

This is not new either!


It has been clear to me, since privately practising midwives lost our insurance in 2001, that the private midwifery 'industry' cannot provide the sort of $$ required to insure birth.  Our annual earnings are of a similar quantum to the insurance premiums paid by obstetricians.  At that time I argued (unsuccessfully) in the then Nurses Board of Victoria that if insurance was to be mandated, there was an onus on the regulator/government to ensure that a suitable product was available and affordable.  If not, the regulator was effectively delegating its responsibility for protection of public interest through regulation of the midwifery profession to the insurer.

The purpose of statutory regulation of the health professions is protection of the public.  The insurer does not exist to protect public interest - in this case ensure safety for mothers and babies.  The insurer is a profit-making enterprise, and exists to protect the financial interests of its people - in this case midwives - and shareholders. 

When is the Australian government, the statutory regulator, and the whole maternity community going to stop chasing the pot of gold at the end of the rainbow?  When are they/we going to recognise the mirage of insurance, that in almost every case it makes no difference to any outcome for the client?





Readers who are interested in the back story and further discussion may check out these links:

Midwife Rachel Reed has recently updated her Midwife Thinking blog post on the Future of Midwifery and Homebirth in Australia.

Maternity Choices Australia (formerly Maternity Coalition) has documents and links at its website, and discussion at its facebook pages.

in two minds: why 'choice' is often a mirage

Today I am looking at (the woman's) choice, decision-making (whether it can be called 'informed' or not), and the midwife's challenge which, by definition, includes the protection, promotion and support of healthy natural processes in birth and nurture of the baby. 

From time to time a book or an article promoting women's *rights* in pregnancy and childbirth comes to my attention.  A recent feminist blog is headed with a big question "Why is it still controversial to say that women should make the decisions about childbirth?"

The group Maternity Choices Australia, which emerged out of Maternity Coalition (an organisation in which I was active for a couple of decades) has placed strong emphasis on a woman's own choices in the maternity terrain.


Who is *in two minds*?  
The woman herself. 

What are the two minds?
The woman's intellectual mind and the intuitive mind.  The same brain has separate parts that are used differently.

Why is 'choice' often a mirage?
Choices that are made (using the intellectual mind) prior to the time at which the intuitive mind takes the lead (particularly in labour and bonding) can be irrelevant, but can trap the woman. 


Although I am critical of a great deal of the maternity choice campaign as I see it today, my criticism is based on my understanding of the physiology of birth, which describes the two minds and their interaction with each other; not on feminist arguments of women's rights or fetal personhood.

The person missing from the current arguments about a woman's own choice is the midwife.  Not the generic midwife, whoever is given the task of providing midwifery services at a given moment; the one midwife who is acting as the unique professional, dedicated to working alongside and in partnership with that individual woman through the pregnancy, birth, and postnatal.

I am ready here for someone to tell me that I am being idealistic.  How can health services provide a one-to-one partnership between each woman and a committed midwife whose skill and knowledge the woman is able to trust at any decision-point?

Yes, I know it's not easy.  I have recently ceased providing this level of midwifery care, because I have become too old; too weary.  I can no longer offer to stay awake past my bedtime, or get up in the wee hours; to put aside my own needs hour after hour for the sake of what I believe to be optimal care in birth.   I still see that as optimal, even though I can no longer offer it. 

The only way I can see a maternity world that protects women's ability to make decisions about childbirth is when systematic changes are made so that midwives and women can honestly explore any choices that are presented as time progresses.  When the woman, using her intellectual mind, can explore and grasp the complexity of decision-making in labour, and can trust her midwife-partner to interrupt her from her intuitive state only if she needs to bring a matter of importance to her (intellectual) attention.  

I want to caution here, that without effective partnership, midwives and maternity services, as well as mothers, can err in over-reliance on 'natural' birth.  A UK report highlights the need for caution.  Anecdotes are common and some lead tragically to coroner's reports.


A midwife who delegates decision-making completely to the woman is foolish, lazy, incompetent, unprofessional!
For example:

Midwife A says she believes the woman is free to make any choice she wants about how long to stay in a birth pool after giving birth. 

The woman B has progressed in harmony with amazing natural, physiological forces in her body to give birth unmedicated and unassisted to her baby.  This was just what the new mother B had wanted, and she had (in her intellectual mind) chosen this pathway as having real advantages for herself and her baby.   Midwife A had supported B's plan. 

In the minutes after the birth, B stayed in the birth pool, hormonally awash in the beauty of her newborn and the afterglow of her ecstatic experience.  Midwife A was confident that all was well, and said nothing about getting out of the water.  Baby C did what healthy unmedicated babies do: she found her mother's breast.

Mother B experienced painful uterine contractions, and about 30 minutes after the birth B experienced a gush of blood, and midwife A reassured her that her placenta was about to be born.  Nothing was said about getting out of the water.

More minutes passed, with further after-pains, further bleeding, but no expulsion of the placenta.  Nothing was said about getting out of the water.

Why?

Because Midwife A believed B would know when she needed to get out of the water.

Midwife A was wrong.  Mother B was using her intuitive mind as she nurtured and bonded with her baby C.  She had no idea of time, or any other aspect of expected progress that her intellectual mind had considered prior to the birth.  The only intuition about moving out of the birth pool came much later, when B became faint.  I don't need to spell out the consequences of this error in delegation of 'choice'.



In conclusion, I can say that it is still controversial to say that women should make decisions in childbirth.  The big challenge is that midwives and women are enabled to work together, in deep respect, and with freedom to find the best course as time passes.  Neither can do it alone.

A question

Hello!

Having moved from our home of 30 years in Melbourne's leafy Eastern suburbs to a beautiful semi-rural 'lifestyle' block in central Victoria (link), Noel and I are getting used to our new way of life.  For most of the past month we have not had a reliable internet connection to our home, so have been using the free service at the Kyneton library, and other processes in an attempt to keep in touch with the outside world.

We now have the new year 2015, and an old challenge.  I have been thinking about this question, and hope I can record here something of the current situation in Australian maternity care.  This question was posted by a midwife, to a large international group that discusses human rights in childbirth.  

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have safe cesareans if they need one? 

I am quite disturbed and shocked at this question.  Why, I ask, would there be a need for passion and activism to advocate for the right of women and their babies to have safe maternity care?   

Perhaps the question is irrelevant to Australia?  Perhaps this is an issue in developing countries, or somewhere else?  

Yes, women can get relatively safe caesarean births here if they have a valid reason.  Those who can afford it, or who work out how to manipulate the public health system, can also get caesareans without needing it.  This surgery might meet all the required hospital safety protocols, but the risks of major abdominal surgery add a new dimension to the safety equation.  Infection, haemorrhage, drug errors, adverse drug interactions, issues of pain management, separation of mother and baby, interference with bonding and establishment of breastfeeding, and additional risks of catastrophic birth outcomes in a subsequent pregnancy are just a few of the additional risk factors in surgical birth when compared with spontaneous, unmedicated uncomplicated vaginal birth.

I would suggest that the big question in a modern Western society such as Australia is 

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have skilled professional services that will protect the mother's capacity to give birth to a healthy baby spontaneously?

Indeed, do we as a society value a mother's ability to give birth?  Do we value the midwife's duty of care which includes the protection of normal birth?   

No, we don't.

Maternity care in Australia is a dog's breakfast that pays more attention to a woman's ability to pay a fee for service than anything else.  It includes obstetrician-managed 'private' care for women who have no clinical need for a specialist; it includes public hospital maternity services that fail to communicate plans and tests done antenatally with the staff who provide intrapartum care; it includes midwife-led private care for planned homebirth, with no provision for the midwife to continue as the responsible professional if the decision is made to go to hospital for the birth; and it includes a fringe of women who proceed with free-birth, with what care there is directed by doulas and unregulated birth workers.

Advocacy in this country around birth is more focused on the woman's right to 'choose' than protecting and promoting natural healthy processes.  Yes, some women 'choose' just that, and make choices about their care that they believe will enhance the process.  But much 'choice' focuses more on whether or not to use painkilling drugs in labour; whether or not to induce or augment labour; planning a waterbirth, or delayed cord clamping, or vaginal breech birth, or some other aspect of care which may be very important in itself but which cannot be addressed separately from the bigger picture. 

Midwives are the only group who have (or should have) the skill and capacity to improve birth outcomes working in harmony with natural processes.  Mothers can't do it on their own.  Physiological birth requires a woman to minimise neocortical activity - thinking.  Childbirth educators, doulas, or well meaning family or friends can't do it.  They don't have the midwife's unique skill. There is plenty of evidence supporting this contention, which requires a care-partnership between woman and her trusted midwife, who is present as the leading or primary professional carer at the time when decisions are being made.  Yet many Australian midwives approach pregnancy and birth as though their role is inconsequential.  They work from an obstetric-managed philosophy of care, relying more on tests and investigations that detect abnormalities than any authentic midwifery philosophy of firstly protecting, promoting and supporting physiological processes in birth, balanced with a commitment to accessing appropriate emergency obstetric services when indicated.

So, is there a place for ' passion and activism in the middle ground, ...'?

I hope so!

That middle ground where women are valued and respected for their capacity as birth-givers; where we seek first to achieve unmedicated, healthy mothers and babies, and place restrictions on the professionals and the consumers as far as frivolous or unfounded interventions are concerned; where midwives are valued for their ability to protect and support the natural processes. 
 
This is worth being passionate about.