Simple pleasure

My life as a midwife brings the personal and the professional into an unpredictable, ever-changing mix. As long as I have mothers and babies on my books, I am conscious of the possibility that I may be called out at any time. This is particularly important to me at Christmas time.

Today is Boxing Day, and I am reflecting on our family's Christmas celebration. I want to record here a few of the simple pleasures that I experienced this Christmas. I call them simple, because they happen without any fanfare or note, but actually these pleasures are part of a wonderfully complex natural order that is ours to enjoy.

• I treasure the births of two babies in recent days, with all the struggles and challenges birth brings. The knowledge that a young mother can confidently nourish and nurture her child, with loving support from the baby's father, gives me great pleasure. 
• I treasure the singing of carols, reading of the scriptures, and reflecting on the reason for the celebrations.
• I treasure the feasting: meals with family and close friends, sharing good food and fellowship. 
• I treasure being able to take food from our garden and include it in the festive meals: eggs, herbs, peas, spinach, broccoli, leek, spring onion. 
• I treasure the special festive foods that we make and eat: the stuffed turkey, the pudding in a cloth, the big fruit cake, the decorated gingerbread house 
• I treasure the special family gatherings: this year we had a memorable performance of the Owl and the Pussycat from our seven-year old Poppy, who has realised that she can read even nonsense words like 'runcible'.

There are many more simple pleasures that come to mind.  Yet I know, dear reader, that this time of year also brings its share of pain and sorrow for many people.  Families with fractured relationships, and people suffering illness.  The experience of loneliness and loss will often destroy pleasure and suck hope out of life.  There is no simple answer, no easy fix, when sadness and fear threaten to overwhelm us. 

With this in mind, whether times are easy or difficult, I am reminded that the principles for a life of integrity are, "to act with justice, to love kindness (mercy), and to walk humbly with our God." (Micah6:8)

Thankyou for your comments

Hospital back-up for planned homebirth

This post is a continuation from the MIPP midwivesVictoria blog

Midwives in this part of the world use the public maternity hospitals to make backup arrangements when we are planning homebirth. As a general rule, we plan to use the hospital nearest to the woman's home, that has the capacity to provide emergency obstetric services at any time of the day or night.

My home is situated about 20K East of the Melbourne CBD - about 30 minutes' drive from the Women's Hospital in Parkville. It takes approximately the same amount of time for me to get to either of the other two major 'tertiary' referral centres: the Mercy in Heidelberg, and Monash in Clayton. Box Hill hospital's Birralee Maternity Unit is about 15 minutes' drive from my home; the Angliss in Ferntree Gully is about 30 minutes.

I am happy to attend any hospital, either when my client requires transfer from planned homebirth to obstetric/hospital care, or when a woman in my care chooses to give birth at that hospital. The focus of a midwife's care is the *woman* - not the planned place of birth. I have often said to other midwives, and to women in my care, that *homebirth* is not an outcome. It's a location - a setting for birth.

The importance of having a plan for transfer to hospital from planned homebirth has been highlighted since the new regulatory authority AHPRA has been set up, with a long list of codes, guidelines, and statements that define a midwife's practice.  The NMBA Safety and Quality Framework for Privately Practising Midwives attending homebirths  has a requirement for  "Clearly articulated referral pathways for referral and /or consultation in accordance with ACM Consultation and Referral Guidelines."

Homebirth is the unique domain of women who intend to give birth without medical intervention, establishing labour spontaneously at Term, and progressing to birth without the need for medical or surgical assistance.  Babies born under such conditions are usually well, and require little or no assistance to make the transition from the womb to the outside world.

The midwife's role in planned homebirth is to determine when, and if, complications arise.  At that point the decision may need to be made to transfer to hospital.  Such a decision cannot be made at the time of booking, or even at Term prior to the onset of labour.  The decision-making process is an ongoing, dynamic one, which must take into account all the related factors at that point in time.


Your comments are welcome.

a womb-baby's heart

 A couple of weeks ago I reflected briefly upon some of the uncertainties that parents face, especially when an abnormality is detected in their womb-baby.  I linked to the evolving story, as told by Petrina and Dave on their blog, whose womb-baby's heart was in distress; whose little body was distended with fluid that the wee heart was failing to direct through the tiny body.

We are a family who believe in the power of prayer, and we are asking GOD to protect this unborn child and mother; to guide the minds and hands of the professional care providers, and to bring blessing through this difficult time.


Some years ago a young couple spoke to me about their womb-baby, who had been diagnosed with a serious heart defect at the 19 week anomaly scan.  They had been anticipating the wonder and joy of the birth of their first child.  Instead they experienced unutterable shock.  They had been advised to abort the baby.  They quickly and confidently declined the offer.

Our faith community at that time united in prayer for the young couple, and for their womb-baby.  We prayed for him each time he had surgery, and we have watched him grow. 

This week his story has been told in a Herald Sun newspaper article.

IN Melbourne's eastern suburbs on Friday, a boy called Kush will join classmates at a graduation dinner celebrating the end of his primary school years. Last year, he qualified for his school's cross-country competition and he plays cricket every weekend.
He's a kid who was never expected to live long enough to even start primary school, let alone finish it. This little chap functions on only three heart chambers. He's cheeky and smart and he has a mile-wide smile.
He has endured four open-heart surgeries - the first was when he was just five weeks old.
At 19 weeks gestation, medics discovered he had a serious congenital heart defect. They recommended termination because of the likelihood he would die early and painfully.
But his parents would not consider abortion.

In reflecting about our young friend Kush, and about Petrina and Dave and their womb-baby, I want to encourage midwives to remember that the life of a baby in the womb, even a womb-baby who has an imperfect heart, is a gift from God to that family.  As they learn to do whatever is possible to promote health and wellness, they also learn to accept the possibility of loss of a child - a journey that one would never choose.  These are life lessons, and are the lessons our parents and grandparents had to learn, in a different time, when the possibilities of restorative medical and surgical interventions were vastly less than they are today.

I am sure it has been difficult for Petrina and Dave to share their journey, often not knowing what the next day will bring, with an open audience.  Yet I sense that they and others will be helped, as a little network forms around a tiny and less than perfectly functioning womb-baby's heart, knowing that they are not alone. 

In a society which pretty well assumes that it's *best* that a baby who may not survive birth should be aborted - terminated - I honor parents who stand against the prevailing trend, and treasure the life of that womb-child.


Thankyou for your comments

HYPOGLYCAEMIA and newborn babies

From time to time I have an opportunity to participate in a Baby Friendly Health Initiative (BFHI) assessment of a maternity hospital.   I have participated in BFHI since the early 1990s. Today I am reflecting on one such recent assessment, and the importance of protecting, promoting and supporting breastfeeding.

BFHI is a global initiative of WHO and UNICEF. Hospitals implement infant feeding policies consistent with the 'Ten Steps to Successful Breastfeeding', and ethical marketing practices for the distribution of artificial milk formulas for babies.

Hypoglycaemia (low blood sugar) is the *diagnosis* under which many breastfed babies in Australian hospitals receive formula feeds in the first hours of their lives. Babies of mothers with poorly managed diabetes - that is, mothers whose blood sugar levels are abnormally high - can become very ill very quickly when their sugar supply is abruptly cut off at birth. Please refer to the Women's hospital CPG on infant management of Hypoglycaemia 1. for further review of definition and management guidelines. The brief comments I wish to make in this post will be made with consideration of that CPG as a statement of the way I understand contemporary practice.

Definition of terms

Hypoglycaemia: There is a lack of consensus on a definition of neonatal hypoglycaemia. It is recommended that clinical practice be guided by operational thresholds (i.e. blood glucose levels at which clinical interventions should be considered). Clinical signs which suggest clinically significant hypoglycaemia are non-specific and include jitteriness, irritability, high pitched cry, cyanotic episodes, apnoea, seizures, lethargy, hypotonia or poor feeding.

When BFHI assessors visit a hospital, we have a series of questionnaires that are designed to gauge the hospital's compliance with the global BFHI criteria. Midwives, doctors, and other staff who advise women on breastfeeding are asked to state three acceptable medical reasons for use of breastmilk substitutes. The usual response includes 'hypoglycaemia'. The assessor is required to explore the meaning of 'hypoglycaemia' further to check if the staff member is confident of what is an acceptable reason.

The BFHI acceptable medical reasons include

• newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age, or who have experienced significant hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic) if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.

Usually the hospital's own clinical practice guidelines will be quoted. The assessor is able to then check the hospital's guideline on management of babies with hypoglycaemia. 

Why is this important?

The short answer:  Diabetes.


A longer (incomplete) answer:
'Hypoglycaemia' is one of the main reasons for breastfed babies in hospital receiving formula feeds.  Diabetes and hypoglycaemia are closely linked, and breastfeeding may prevent the development of diabetes later in the child's life.

A hospital that has a breastfeeding policy consistent with the BFHI '10 Steps to successful breastfeeding' is required to implement management guidelines for hypoglycaemia that are consistent with the breastfeeding policy. The 'steps' in which a hospital's management of suspected hypoglycaemia has a potential to interfere with the establishment of breastfeeding are:

Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff

"exclusive breastfeeding in the first six months of life

• protects against chronic conditions in the future such as type-1 diabetes, ulcerative colitis and Chron's disease

Breastfeeding during infancy is associated with

• ... lower prevalence of type-2 diabetes, overweight and obesity during adolescence and adult life
  ..." [from BFHI Australia Booklet 1, p16]

Step 2: Train all healthcare staff in skills necessary to implement this policy

Protecting, promoting and supporting the natural physiological processes in birth and nurture of a baby requires skill and commitment by all care providers.

 
Step 3: Inform all pregnant women about the benefits and management of breastfeeding

Women who are well informed will be able to make informed decisions about any interventions that are recommended in the care of themselves or their babies.  Those who know they are at risk of having babies who develop hypoglycaemia are able to take some measures to avert the need for breastmilk substitutes, including careful dietary measures and avoidance of sugary foods.

Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.

The hospital's definition of 'medically indicated' must be consistent with the BFHI acceptable medical reasons.  Also, note the need for true blood sugar level to confirm hypoglycaemia.

Step 7: Practise rooming-in - allow mothers and infants to remain together 24 hours a day

Babies identified as 'at risk' who are asymptomatic should stay close to their mothers and breastfeed normally. 

• infant with risk factors for hypoglycaemia but no clinical signs - blood sugar level < 2.0 mmol/L [Women's CPG]

Step 8: Encourage breastfeeding on demand


Step 9: Give no artificial teats or dummies to breastfeeding infants

The hospital policy and guidelines need to be reviewed critically at regular intervals, by people who are well informed and who are skilled at asking good questions.  

The protection of breastfeeding in potentially complex clinical situations is not a yes-no, black or white situation.  Guidelines can, and often do, help us to avoid unnecessary and potentially harmful interventions into normal physiological breastfeeding situations.

For example, a baby weighing 4 Kg at birth may in some cases be at risk of hypoglycaemia, and in other cases be healthy, consistent with the size of his or her parents and siblings.  In the latter case a clinical judgment would be made by the midwife, not to measure blood glucose levels as this baby is judged to be a well, term infant.


Thankyou for your comments

A letter to obstetricians

I have sent letters to obstetricians practising in my area.

Re: Medicare rebates for private midwifery services

Dear Dr XXXX
I am writing to inform you of my current private midwifery practice since obtaining notation as a Medicare ‘eligible’ midwife. 

Examples of the services I am able to provide are:
• a part of the woman’s care such as postnatal only (after discharge from hospital)

• antenatal care that is shared with an obstetrician or hospital,
• primary maternity care for the whole episode of care, whether the woman is planning to give birth at hospital or in the home.
[Note: At present midwives do not have visiting access/clinical privileges in hospitals. However, this is a goal to which public hospitals are working, through the Three Centres group project on ‘Collaborative arrangements with eligible midwives for Victorian public hospitals’. I am a member of the Expert Reference Group for this project, and am keen to see privately practising midwives able to obtain visiting access in hospitals.]

Medicare scheduled fees and rebates for private midwifery services are listed on the attached document Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011.

Since becoming eligible for Medicare, I have found that some women appreciate more postnatal visits in their homes, with Medicare rebates making the service more affordable, than was previously the case. Rebates are available for postnatal consultations in the six weeks following the birth, and for a 6-7 week review. I am now able to write referrals to obstetricians and paediatricians, and request tests and investigations related to childbirth. I do not yet have PBS authorisation, and Victorian law is yet to be amended to enable midwives to prescribe.

In order for women to claim Medicare rebate on fees for antenatal and postnatal visits the participating midwife is required to document a collaborative arrangement, by which a specified medical practitioner is identified as the person to whom the woman will be referred if indicated. Referral is one type of collaborative arrangement, described in Section 5(1) that the “patient is referred, in writing, to the midwife for midwifery treatment”, in this case antenatal and/or postnatal services, and that [Section 5 (2)]: “For subsection (1), the arrangement must provide for: (a) consultation between the midwife and an obstetric specified medical practitioner; and (b) referral of a patient to a specified medical practitioner; and (c) transfer of a patient’s care to an obstetric specified medical practitioner.”

That is, the collaborative arrangement to be entered into is that I, the midwife, will provide midwifery services (treatment), with consultation and referral to you when/if indicated. Under such collaborative arrangement, I am required to send you (the named medical practitioner) a Maternity Care Plan (proforma attached), results of any tests and investigations, and referrals.

Also I am required to send a discharge summary to you and the patient’s GP.

I would appreciate your support through referral or other collaborative arrangements. I am happy to make an appointment to meet with you and discuss this with you further if you wish.

There is a small number of midwives in Victoria who now have Medicare provider numbers, and others who are waiting for their applications to be processed. I anticipate gradual expansion of private midwifery services in response to the government’s maternity reforms.

Thankyou for considering this request.
With best regards
Joy Johnston

Attachments: 
Health Insurance (Midwife and Nurse Practitioner) Determination 2010
Maternity Care Plan proforma

When women choose maternity options against the recommendations of their midwife

Having written a post on the new ACM Position Statement on Homebirth Services 2011, together with a 'guidance' document and literature review, for the APMA blog yesterday evening, I find that my mind is dwelling on the situations in which women "choose a planned homebirth when this is not recommended by a health care provider."

What are the forces that are exerted within our communities, pulling women, and midwives, toward professionally acceptable standards and actions?

How does a midwife make a clear and timely call, telling the woman who has employed her to provide homebirth services, that homebirth is no longer recommended?

Where is the cut-off, between low- and high-risk? 



The ACM National Midwifery Guidelines for Consultation and Referral (ACM Guidelines 2008 - which are available to download free as a .pdf) set out situations in which a midwife is expected to consult with, and refer a woman to, an appropriate medical/obstetric service provider.  Conditions listed under category C, requiring referral, include chronic hypertension, pre-eclampsia, multiple pregnancy, breech presentation at Term, coagulation disorders, diabetes requiring Insulin treatment, and many other medical and obstetric conditions and complications that may co-exist with the pregnancy, or arise during pregnancy, birth, or the postnatal period.  A woman experiencing these complications requires coordinated maternity care from a team of medical, midwifery, and possibly other disciplines.

Another all-too-common-today situation is a woman who has had caesarean surgery for one or more previous births.  According to the ACM Guidelines (2008), previous caesarean is category B, meaning that the midwife is required to facilitate consultation with a medical or other health care provider.  The ACM Guidelines do not attempt to differentiate between those for whom homebirth is not recommended. 

The South Australian Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 recommendations state clearly that "A previous caesarean section and breech presentation are contraindications for home birth."

As noted at the APMA blog, obstetrician Andrew Pesce has given advice on a way forward for those who want to bring homebirth into mainstream maternity care, with:

"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."

  

It's clear to me that there are important conversations that the midwife needs to take responsibility for, when complications or new risk factors are identified.  The midwife's professional duty of care requires that the situation, and a plan of action, be clearly outlined and any questions responded to, to the best of the midwife's ability.   The woman's response can be to agree, to disagree, or to explore further.  Simple questions that I encourage women to ask, if at any time someone wants to interrupt the physiological processes are:

• What do you want to do?
• Why do you want to do that?
• What is likely to happen if I say "no"?

The partnership between a midwife and a woman requires honesty and trust both ways.  A woman who fears that her midwife may 'make' her transfer to hospital, for some trivial reason, will not make an informed decision.  Similarly a woman who takes no responsibility for her own decisions, but puts herself meekly in the hands of her midwife, is not making informed decisions.  Trust always has limits.  Midwifery is not a cult; midwives can not ask for blind acquiescence.

As a wise colleague put it,  

"I find the 'trust birth' claim far too naive ... but I think a lot of women in their bubble want to believe it. Perhaps all our easy access to IT - internet/emailgroups/facebook etc has something to do with which women choose homebirth now and why and who and how cult followings get supported, possibly blindly."

I wonder today if some women are misusing maternity care, and abusing the trust of their midwives, in a cult-like way that over-rides partnership, and puts the woman's experience first and foremost. 

 

Thankyou for your comments

Learning Medicare

My mind has been challenged recently as I have attempted to learn the technology associated with Medicare rebates.

I decided that a portable EFTPOS machine would be the best means of processing bulk billing and client rebates through Medicare.  This process requires a lot of technical support - well beyond my skill. The bank sent the machine, and set it up for me. 

The next step was for Kirsty, a lovely lady who works for Medicare, to enter my provider number, and the item numbers for my work.  Kirsty worked through it with me, and I watched her process one claim, then did one myself.  Those payments have now shown up on the bank account statement.

Yesterday I took the machine to a postnatal visit, and attempted to process the bulk bill payment on the spot.  It didn't work.  I obtained a signed authorisation from the client, determined to work it out.

Today I opened the manual, followed multiple instruction steps, and identified the point at which I had been stumped.  I was able to complete the transaction.  YAY!


Medicare has offered me the immediate opportunity to do more postnatal work for my clients.  This is great.  I am thankful.

what are the boundaries for homebirth midwifery practice?

The short answer:

"I don't know."

The midwife purist answer:

"I am 'with woman', not 'with' or committed to a setting for birth or a model of care. The midwife is able to provide primary maternity care throughout the continuum for any woman who proceeds spontaneously through pregnancy, birth, and the postnatal period, and to advise on potential complications and refer the woman to specialist services if the need arises."

The midwife pessimist answer:

"I must restrict my practice to 'low risk' women, or I am likely to face complaints and even suspension of my registration, and loss of my ability to earn a living while complaints are investigated."

My answer:

"I'm not prepared to define boundaries. I am willing to explore possibilities with any woman who asks me."

For example:

"I am starting the process of looking for support for a home birth. My first two children were born via c-sections (breech, then a failed hospital VBAC). I am wondering if HBA2C something that you can support?"

Similarly, a colleague midwife called me to discuss her client whose pregnancy has now gone past 42 weeks. Is it 'safe' (for the mother, the baby, and the midwife), to proceed with a plan for homebirth after 42 weeks?

Am I being evasive, even dishonest, in saying that I do not want to give a yes or no?  I don't think so.

Here's what I hope to achieve:

• Optimal outcomes, and the best level of care possible for each mother and baby.  I surely do not want any adverse outcomes. 
• Each mother feeling safe, and confident in making decisions as her pregnancy-birthing journey unfolds.
• Each mother feeling respected, even when and if the journey leads her on a pathway that she would not have chosen.

I acknowledge that the only place where I can act as the responsible professional care giver is, at present, the woman's own home.  Hospital visiting access for midwives is 'in the pipeline', so to speak, but I'm not holding my breath. 

I have attended many women in labour after Caesarean birth.  Some have given birth spontaneously at home, while others have transferred to hospital for the birth.  Some of the hospital births have been spontaneous, and some assisted medically, physically, or surgically. 

The confidence I need to have in each woman and baby, as they progress in pregnancy and labour, and in the crucial moments and hours after birth, is "Are you well?"  "Is the mother well; is the baby well?"

When the answer is "Yes", I can be confident to continue under natural, physiological processes.

When the answer is "No", or "possibly not" or even "I'm not sure", I must move into a new state of alertness and planning, and inform the mother as to my recommended plan of action.  That's the only way a mother can make an informed decision.  I can't make the decision for her.  Her husband can't either, although of course there is often a shared decision-making process entered into willingly by the woman.

Midwives have often said that we sit on our hands.  We refrain from all unnecessary interruption, interference, and intervention, as we observe a labouring woman.  Our skill is in enabling and encouraging the woman to continue working with her own body.  However, a capable midwife also recognises when intervention is required, and acts confidently and appropriately.  The non-interventionist intention of a midwife must always be balanced by skill and knowledge, and an ability to act in the interests of mother and baby when indicated.


Returing to the question: "I am wondering if HBA2C something that you can support?"
Yes, it is.  My role as a midwife is to be 'with woman'.  If that woman makes an informed decision to plan homebirth, and asks me to be with her, I can support her plan.  However, in accepting the role as midwife to that woman, I am not committing to home birth, or even to natural birth.  Those decisions are yet to be made, and will be made by the woman as events unfold.

And the other question, "Is it 'safe' to proceed with a plan for homebirth after 42 weeks?"

For some women it is, and for some women, definitely not.  I must advise the woman on her own position, to the best of my ability.  I encourage the woman to listen to other voices of expert advice: the doctor at the hospital where she has a booking, for instance.  The woman must make the decision that she considers best at that point in time.

Thankyou for your comments

WOW!

In the previous post on this blog I reflected briefly on newspaper reports about 'ex-midwife' Lisa Barrett (for want of a better description of Lisa).

Thismorning I have been repeatedly shocked and challenged as I have read Lisa's blog 'Free for all', and its screeds of comments in the day or so since the account was posted.

The struggle to protect an Australian woman's right to choose the maternity care she receives, and her right to plan homebirth, has continued over many years. I have participated in that movement for the past 20 years. I have seen colleagues in the press limelight briefly; I have seen organisations take a lead in efforts at political lobbying. In recent years I have witnessed changes under a socialist health policy, offering hope (the carrot) of better maternity services for all, that have introduced a level of bureaucracratic control (the stick) that has not previously been imagined by independent midwives.

As I said in my previous post, it is not possible to judge a case when we have only fragments of information. It is also not possible to obtain consistent information, or judge the reliablility of information, through blogs and the media.

Yet the big issue that I am seeing as I read Lisa's blog, and the linked comments, concerns the rights of parents to keep and protect their newborn babies. The case study that Lisa has presented exemplifies the harsh reality that the State can, and apparently in some circumstances will, exercise protective custody of a newborn baby when and if it chooses. This is a statutory right in developed societies, set up to protect innocent lives. Its misuse, which is what this chilling account clearly suggests, will surely instill fear into the hearts of midwives and caring parents.

Many independent midwives, including yours truly, have chosen a less confrontational pathway through the current maternity reform process, than the one Lisa Barrett has - very publicly - taken.  BUT the scenario presented in this case: a mother giving birth in hospital to a well baby, after planned homebirth, going home with their baby hours after birth, and making an apparently informed decision that this is better than staying in hospital ...

I could name women in my practice who have signed themselves and their babies out of hospital care in very similar circumstances.  Occasionally over the years, women have been reminded that they could be reported to child protection services.  It's the trump card that can be pulled out to force non-complient mothers into line.  Once initiated, there's a legal minefield ahead.

Your comments are very welcome.

a preventable death?

Whenever I hear of the intrapartum death of a baby, or other major morbidity or mortality around birth, I wonder what actually happened: was it preventable?

What were the critical decisions leading up to the adverse outcome?

Speculation is not helpful. When my sources are limited to media reports, blogs, and email discussions, I am unlikely to ever know the detail, or be able to form an opinion, on a particular case. However, there is great value in critical reflection on my own experiences, considering what happened, why it happened, how I responded, and how I might respond in the future if faced with a similar situation.

Readers of this blog are probably aware of the Coroner's inquiry that has been proceeding in Adelaide, into the homebirth deaths of two babies, and the well-known homebirth advocate Lisa Barrett who was in attendance at these births. Now Lisa has again been mentioned in a newspaper report, of "the death last week of a newborn twin".

An American blogger who is definite and unrelenting in her anti-homebirth position, Dr Amy Tuteur, has informed her audience of this newspaper report.

The key point of difference between those who support homebirth is whether the choice to plan homebirth can be made by the woman, or if that is a matter requiring professional 'duty of care' in declaring whether or not homebirth is considered a 'safe' option. Can a woman be allowed to make an informed decision? 

The International Confederation of Midwives' (ICM) position is that

“The ICM supports the right of women to make an informed decision to give birth at home.”

Australian Private Midwives Association (APMA)’s ‘position’ is

“We support home birth with a midwife in attendance for women who have uncomplicated labours.”

I don’t think anyone would argue that a twin birth can be called uncomplicated prior to the birth. But the big question is what the midwife does when a woman who knows she has twins on board makes what she considers to be an informed decision to give birth at home.

I’m not wanting to put my head in the sand; to shift the blame from the midwife to the woman. A decision to plan to give birth at home requires a whole series of conversations, during which the midwife and the woman consider the situation, and the woman decides whether to stick with 'Plan A', the natural, physiological process, or to move to 'Plan B'.

A woman who thinks she has made an 'informed' decision  can be horribly ill-informed, whether the decision related to home birth or to medically managed birth in hospital. For the record, here's a recent example:

A woman who has a young baby believes she made an informed decision for the birth and nurture of her child. The woman has been treated by a specialist psychiatrist for depression. The psychiatrist *informed* the woman that her depression could become worse if she was sleep deprived, and encouraged her to suppress lactation and artificially feed her baby - to prevent sleep deprivation. The obstetrician supported this plan, and furthermore encouraged the woman to undergo elective Caesarean surgery - also in order to keep everything well controlled. The *informed decision* that was reached, in consultation with both doctors, was that a Caesarean operation would be performed without labour; that the baby would not go skin to skin on the mother's breast; that the mother would receive medication to suppress lactation; and that the baby would be separated from the mother, and cared for in the hospital's nursery for most of the mother's hospital stay.

This scenario leaves me wondering. 

Thankyou for your comments

Notation on the Register

The notation on my registration states:

Mrs Joyce Johnston is an eligible midwife competent to provide pregnancy, labour, birth and postnatal care and qualified to provide the associated services and order diagnostic investigations required for midwifery practice, in accordance with the relevant State and Territory legislation. Eligible midwife, but NOT qualified to obtain endorsement under section 94 to prescribe Schedule 2, 3, 4 & 5 medicines required for midwifery practice in accordance with State & Territory legislation.

I had applied for this eligible status last December, so it is with a considerable sigh of relief that I acknowledge this achievement.

Anyone reading this post who is not familiar with current maternity care in Australia may question the wording of the notation. I am now an 'eligible midwife'. I am now "competent to provide pregnancy, labour, birth and postnatal care" - care that I have been providing on my own authority, independenty, for most of the past 20 years.

So what's new?

The main new feature of my practice is that some women in my care will, as a result of this notation on the Register, be able to claim rebate from Medicare on my fees: women who have Medicare cards, and for whom I am able to set up sutiable collaborative arrangements with a doctor. As soon as I can organise the software and other technology, I hope to be able to process Medicare rebates from my office directly to a woman's nominated bank account.

Another new feature is, as the notation states, that I am now able to order diagnostic investigations required for midwifery practice. In the past I have asked women to have routine blood tests and any other investigations requested by their GPs.

I am not yet able to prescribe medication. I have signed an undertaking to complete a medication course for midwives , within 18 months of being recognised as an eligible midwife. However, to date the Board has not approved a program of study in prescribing, so I am waiting for that approved course to be announced.

Another feature of the government's midwifery reform package that is yet to be realised is the ability for midwives to attend women privately in hospitals. At present, when a midwife goes to hospital with a woman for whom she has provided prenatal care, the midwife's status is a sort of support person who has no professional role, and who can be seen as persona non grata. Midwives' ability to provide professional intrapartum care in hospitals is part of the government's Midwife Professional Indemnity Scheme.

In the 2009-10 Budget, the Government announced the 'Improving Maternity Services Package'. The package provides for the introduction of Medicare supported services to provide greater choice for women during pregnancy, birthing and postnatal maternity care, including the provision of professional indemnity for midwives. The Midwife Professional Indemnity Scheme (MPIS) includes a Commonwealth contribution initiative designed to assist with claims made against eligible midwives and encourage the provision of indemnity insurance policies for private independent midwives. The Midwife Professional Indemnity Scheme provides financial assistance to eligible Insurers who provide indemnity to eligible midwives.

There are now a handful of Medicare-authorised midwives. In Victoria, you can get Medicare rebates for private midwifery from a midwife in Echuca, and from a few midwives in Melbourne.  There is no Medicare rebate, or indemnity insurance for home birth.  Midwives are exempt from being required to have insurance for homebirth until the end of June 2013.

You can search for a midwife on Google, or go to Midwives Australia .

Thankyou for your comments

continuity of carer

Pic: Ash labouring in hospital - used with permission

A mother-to-be who I will call Jenny came to my office for a pre-natal check.  Jenny is planning to give birth to her first baby in hospital, and I am providing shared antenatal care*, and planning to be with her in labour, birth, and continuing the care after her baby has been born, and visiting her at home.

Jenny has read the blogs I have written in the past week or so, and newspaper reports, about the emerging situation when a midwife is with woman in a hospital.  Jenny asked me for more information about these matters.  Jenny's questions were particularly focused on how the insurance/ reporting issues would affect my plan to be with her as her known and trusted midwife.  Jenny reiterated, without any prompting from me, that the reason she wants her own midwife to be with her in labour is her need for continuity.  

Continuity of carer refers to “a model of care providing relational continuity between each woman and midwife by continuity of midwifery carer throughout the full process of pregnancy, birth and the postnatal period, responsive to the needs and preferences of the individual woman." (Fontein 2007, p37- see full reference below)

In an ideal world that midwife would be the responsible, accountable primary care provider, who attends and 'conducts' uncomplicated births in the setting of the mother's choice, and refers to and collaborates with specialist obstetric and nursing providers when and if the need arises, all the time maintaing a unique professional relationship with the woman, regardless of the level of complexity or simplicity encountered. We clearly don't live in the ideal world, but we try to make the best of what we have.

If women were to lose the right to continuity and not be able to access personal support and interaction with their own midwife in hospital; the midwife with whom they have formed a special relationship - dare I say friendship - over a substantial period of time, those women will be the ones most adversely affected.  The old-fashioned word 'confinement' which used to be applied to childbirth is an apt description of such a situation, bringing with it the loss of liberty in personal association, and loss of freedom to choose.  It sounds like the other type of confinement, imprisonment.

But the important point to remember here is that the concept of  "offering continuity of care, and where possible carer, as a key element of quality care": a key principle agreed upon by federal and state health ministers, and published in a 2008 statement by Australian Health Ministers Advisory Council (AHMAC), Primary Maternity Services in Australia - A Framework for Implementation.  These key principles for primary maternity services have been carried through into current regulatory documentation for midwives, such as the Safety and Quality Framework for Privately Practising Midwives attending homebirths, which can be downloaded as a .pdf at the NMBA website.


STOP PRESS: 4pm, 2/9/11
A statement has just been circulated by the Nursing and Midwifery Board of Australia, concerning the role of the midwife who supports a woman admitted to a public hospital.  If you would like the full statement contact me joy[at]aitex.com.au
 

... The midwife may choose to withdraw when the care of the woman is assigned to the health facility’s health care professionals. However, should the woman request it, the midwife may choose to remain as a support person to the woman either as paid or unpaid as agreed between them. The Board recognises that the midwife has no obligation to stay with the woman and that it is an individual decision for the midwife.

If the midwife chooses to stay with the woman - and therefore take on a support person role - the midwife must articulate the change in role to the woman, who should then consent to the midwife’s involvement as a support person only. The midwife should also clarify her change in role from midwife to support person with the health service.

The decision by the midwife to remain as a support person is linked to the woman’s right to choose the person(s) whom she wishes to be with her during birth. ...

*Note: (Shared antenatal care means that Jenny has a few key reviews at the hospital, and that I provide the other antenatal checks.)

Reference: Fontein Y, 2007. Making the transition from ‘being delivered’ to ‘giving birth’. A literature review and reflections on the potential for introducing the UK model of ‘caseload midwifery’ to the Netherlands. MIDIRS Midwifery Digest, vol17, no1, March 2007, pp35-40.

A message to women and midwives

Dear Reader
If you have read the other blogs that I write, you will know that midwives are worried about being reported when we go with our clients to hospital.

I would like to reassure you that I, and midwives with whom I work, are continuing to practise in a way that we believe is consistent with contemporary evidence and best practice.

Please take strength from the message of Spring. These little Bonsai trees bring great encouragement. There is new life and hope.
Joy

"Needy" mothers

A colleague who works in a hospital midwifery unit made a comment something like this: "Continuity of care sometimes makes the mothers more needy."

The thought of the 'needy' mother - the woman who needs a lot of help/care/attention/support - caused me to reflect and question my own assumptions and beliefs about women, particularly those in my care.

A further layer of this reflection was my questioning, "Does continuity of care every make mothers more needy?"

In theory,

• Midwifery care is woman-centred. 
• Centred on the woman, the mother-baby unit, who is like the heart of the flower. 
• Each woman, regardless of her situation, her beliefs, her culture, her wellness, her illness, her wishes ... the petals, stem and roots of the flower. 
• Each woman, regardless of her neediness - the external and internal threats that are like pests and disease to the flower.

Maternity care that is centred on the woman seeks to enable that woman to be as well as she can be, to use whatever strength and ability she has, as she traverses the pregnancy-birthing terrain that is often unpredictable, at times challenging, and sometimes devastating.

Maternity care that is centred on the woman seeks to provide the best available and most timely intervention for those women who experience complications and needs that present a real threat to their wellbeing or their babies' wellbeing.

Maternity care that is centred on the woman seeks to promote physical and emotional resilience within individuals and within families.

Maternity care that is centred on the woman seeks to provide a trusted partner - a midwife - who accompanies that woman through the maternity experience, and who has the expert knowledge and skill to promote, protect and support the natural processes, and to identify complications.


As a result of this reflective journey I have concluded that continuity of midwifery care/ caseload/ known midwife does not make a woman more needy. However, the woman who is feeling needy/ vulnerable/ unsupported may turn to her known and trusted midwife for more support than she may have sought from a midwife who is a stranger to her.

Thankyou for your comments

In the first few days of life ...

In the first few days of life ...

I have been visiting a mother and her baby - her first child - daily since the birth on Wednesday afternoon. "What's news-worthy about that?" you may ask. That's what midwives do.

This young woman and her little one are making good progress in all the developments and transitions that are normal and necessary for the continued wellbeing of each, and of the two of them as a little team.

This young woman, and her husband, felt exhausted after a sleepless night in early labour. They are still exhausted after three more nights in which the little chap has worked strongly at his mummy's breast to get the wonderful colostrum into his stomach. They tell me they haven't had much sleep. But they look wonderful! Less than 3 days after giving birth, this young woman and her infant have pretty well mastered the complex art of breastfeeding. Baby is taking his fill of milk, settling down to sleep, and waking up a couple of hours later to do it all again. Baby is strong, and that's good!

Breastfeeding is a huge challenge for a new mother-baby pair. Nurture, nourishment, bonding, wellbeing and contentment are all inextricably linked to that basic mother-skill of putting a baby to the breast, and that basic baby-skill of drawing milk from the breast.

This little one spent the first hour or so of life skin to skin, resting on his mother's chest. He made brief attempts at breastfeeding during that period, but didn't achieve much active sucking. He was born at home, and after a few hours I left him in the care of his parents. I gave the mother the standard advice, that she should feed him when ever he was awake and interested.

The next day I visited in the morning, and was told that attempts at breastfeeding had not been very successful. The little one was eagerly sucking on his lower lip and tongue. The instinct to suck was strong - he just hadn't worked out what he was meant to be sucking. With a little assistance he took the breast and stayed there, sucking strongly and consistently.

Over the next two days both mother and baby learnt from each other. The powerful intuitive forces that exist in the minds of both baby and mother brought these two together, and they worked it out. My visits brought encouragement and reassurance, but I could see that the wonderful natural processes were working well.

This is one of the great moments in midwifery - to realise that they are doing it themselves, and doing it well.



Thankyou for your comments

Birth Plan and Birth Preparation checklist

[This is the checklist that I review with women in my care at our Birth Preparation meeting at about 36 weeks]

BIRTH PLAN

A BIRTH PLAN is a guide for those who are with you when decisions need to be made.

A simple Birth Plan has two components, A and B.

PLAN A: “I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.”

PLAN B: “If medical intervention is recommended in order to achieve the best outcomes for myself and my baby, I need to be given the following information in order to make an informed decision:
• What do you want to do? [procedure, test, intervention, advice …]
• Why do you want to do that?
• What is likely to happen if I say 'no' - if I don't allow you to do IT?”
With this decision-making process you will only allow interventions that you believe are best for you and your baby.

BIRTH PREPARATION

(This list is only a guide – Please raise with your midwife any issues that you consider to be important)

LABOUR AND BIRTH:
1. Planned place of birth?
2. Backup hospital (for planned homebirth)?
3. Do you have a written birth plan?
4. Who do you want with you in labour and birth?
5. Information about complications.
6. Ruptured membranes and the risk of infection.
7. Options/preferences for pain management/relief.
8. Immediate contact with the baby.
9. Cutting the baby’s cord.
10. Blood loss, oxytocics.
11. Third Stage, caring for the placenta.

AFTER BABY HAS BEEN BORN
1. How long does my midwife stay?
2. Midwife’s involvement if hospital birth.
3. Assistance with baby care and breastfeeding.
4. Milk supply, meeting baby’s needs, breast fullness, expressing milk.
5. Blood loss, after pains, involution of the womb.
6. Healing of perineal tear, regaining muscle tone.
7. Vitamin K?
8. Newborn screening test?
9. Hepatitis B vaccine for baby?
10. Support at home – meals, cleaning, other children ...
11. Maternal and Child Health services? Community services and support groups.
12. Sexuality and contraception after having a baby.

Access to medical services

Midwives working in modern cities have excellent access to medical services when and if they are needed. The catchment in which most of my clients live is well serviced by public hospitals that are leaders in complex obstetrics and neonatal care. I live within a 20 kilometer radius of Melbourne's three 'tertiary' (now called Level 5) hospitals: the Women's, Monash Clayton, and the Mercy. I am also close to Box Hill and the Angliss. Within about an hour's drive I can expand my access to medical services to include Dandenong, Casey, Frankston, Sandringham, Mercy Werribee, Sunshine, and Northern. [click here for map]

In reflecting on this level of access, I am thinking of my friend and colleague Jacinta, who is working as a midwife with MSF in a very remote town in central Africa. If you click to her blog, you will read that at present the service has

"no OBS/GYN and no surgeon, so there is no-one in Aweil who can do a caesarean section. One of the other MSF OCs has a surgeon in Gogrial, a very bumpy 2-3 hr drive away, so we can transfer there BUT only between the hours of 7 AM – 3 PM due to curfews in place for security reasons."

I plan to reflect more on access to medical services, and write about it here, after I have done the postnatal visits today.


[some days later]

I have had a few attempts at composing the rest of this post, and deleted them. The reality in my world is a different reality from that of previous generations of my family, and from that of remote places in Australia, Africa, or the frozen Canadian wilderness.

If a woman in my care needs medical intervention, it's available 24/7; it's considered to be at the level of world best practice; and if there are adverse outcomes, everyone involved expects questions to be asked by peers and regulaory authorities.

Australian privately practising midwives are coming under serious scrutiny even when outcomes are good, as in the recent case of a midwife who attended a woman for VBAC (vaginal birth after caesarean) at home. That midwife has been denied the right to continue her private practice while the case is being investigated. See the post on HBAC at Homebirth Australia's FB site.
Other midwives have experienced lengthy periods of suspension or restrictions to their practices, when in the minds of their peers they have provided excellent midwifery care.

Women who are looking for a midwife in Melbourne today often ask lots of questions, “what would you do if ... (breech, twins, post maturity &c)” Those who have experienced Caesarean birth may ask the midwife under what conditions she will agree to attend HBAC.

My answer is that I don’t have a fixed answer. Decision making is an ongoing process, rather than a concept of ‘choice’. The safety and wellbeing of mother and baby are the guiding principles for every midwife. The midwife's duty of care is a different issue from the mother's autonomy over her own body. Sometimes the midwife and the mother will disagree on the best course of action – we have to live with that.


Modern society has become accustomed to Caesarean births. The national rate of Caeareans in this country is approximately 30%. There is a small but significant number of women who are strongly motivated to planning VBAC in their own homes, and their desire is to find a midwife who has the skill and the willingness to work with that plan.

The Australian College of Midwives (ACM) position on homebirth is that:

"Women have the right to choose where and how they wish to give birth. ... Whatever place of birth a woman chooses, a women and her family have the right to expect that the care she receives is provided by appropriately skilled attendants and is safe."

The difference of opinion between competing care providers for births after Caesarean is mainly in an assessment of risk. See MidwivesVictoria blog for a midwifery perspective that considers the woman and her baby to be at low risk, and midwifery care in the home to be optimal, provided the pregnancy and labour progress without complication.

Medical/obstetric care, which includes care provided in most hospital settings, considers the risk of harm to mother and baby in births after caesarean to be such that requires continuous electronic monitoring in labour. This intervention is intended to give the best possible level of surveillance, with the intention that if the baby shows signs of distress there is the option of emergency caesarean surgery. Midwives working in the home do not have continuous electronic monitoring, and rely other methods of monitoring progress and wellbeing of both mother and baby.

For more discussion on VBAC and risk, go to the posts on this blog in July and August 2010, for example, here.

With an estimated risk of 1 in 2000 for catastrophic harm (discussed here), such as death or serious brain injury to the baby from hypoxia, and death or serious haemorrhage of the mother, any midwife or doctor providing care in planned vbac must be conscious of the possibility of an escalation of complications.



Thankyou for your comments

Why I chose homebirth

This guest post was written by Miranda Davies.

Almost 3 weeks ago, I gave birth to my second child at home, a gorgeous little boy, in the bath at home, with my husband and two midwives present. It was an amazing experience that I will cherish forever.

I cannot describe how wonderful it is to be able to give birth in the comfort of your own home, at your own pace without people trying to interfere or tell you what to do. I came to understand what it meant for ‘me’ to be in charge of giving birth, no one would do it for me, which is so far removed from the concept of the Dr. or midwife ‘delivering’ the baby. Yet I was also well aware that I was in good hands if something was so come up, which meant I felt very safe.

When I first became pregnant I could not have imagined ending up having my baby at home. Homebirth sounded like an ideal situation, but we don’t have much exposure to it in our society. It is assumed that you see a Doctor and have your baby in hospital. Towards the end of my first pregnancy I watched ‘The business of being born’. It immediately clicked with me. My husband and I both thought that having a homebirth just made sense, not this time around, but in the future. The birth of my first child went reasonably smoothly with only a relatively small amount of intervention.

When we got pregnant again for the second time, we once again discussed the idea of homebirth, but were not 100% sure. We knew that we wanted midwife care; I firmly believe that for healthy pregnancies an obstetrician is overkill, pregnancy is not an illness. I also knew that the rates of intervention are significantly lower with a midwife. In 2008 a Cochrane review was published examining the outcomes of midwife compared to other models of care http://www2.cochrane.org/reviews/en/ab004667.html if you are interested.

It was only because a friend also became pregnant at the same time and was certain she would have a homebirth that it suddenly did not seem such a far-fetched idea. Given my job (as an epidemiologist) I became very interested in looking up original research papers that looked at the outcomes of planned homebirths, reasons for complications and risk factors etc. The more I read the more confident I felt about the safety side of having a homebirth.

It also became very apparent to me that many of the things that are ‘standard care’ in hospital were not things I necessarily wanted or had good evidence for doing them. I became aware that I would most likely have a battle on my hands, which really isn’t conducive to good birthing!

It was suggested that I read ‘Ina May's guide to childbirth’. I finished the birth stories section and realised I wanted my birth to be like those in the book! And if I wanted that I really needed to have a homebirth with a midwife that believed that 95% of the time pregnancy and childbirth are totally natural processes.

But how to pick a midwife? Given my background/job my main concern was a midwife who was a bit too ‘hippy’. I wanted to know that if I really did need to go to hospital the call would be made and early on. It was probably a bit of a silly concern as no midwife would put a mother or baby in harms way to maintain ‘natural childbirth’. I now attribute this thought to the media portrayal of homebirth midwives. The deal sealer for me was a connection with a girl I went to school with. Joy had been present at the birth of her daughter and also her sister’s child at home. I emailed Joy that same day and arranged to meet. As soon as we started chatting I was certain this was perfect for us, lucky for me my husband agreed!

I had my first antenatal appointment at 24weeks. It was in stark contrast to any appointment I had had in hospital. Firstly it was about an hour long and in the comfort of Joy’s home. I didn’t wait for an hour with 30 other pregnant women just to be rushed through with a quick ‘how are you feeling?’, blood pressure check, measure and heart rate check. My appointments weren’t filled with comments about me being either ‘too big’ or ‘too small’. They were a time where Joy and I got to know each other, we chatted about all manner of things, feelings, fears, statistics, certain protocols and philosophies. These are the things that are important, yet are things that are now lost. Busy Obstetricians and midwives don’t have the time to sit and really get to know you and what you want, there is only time to tick all the necessary questions and tests off the list.

Choosing an independent midwife and homebirth really are no brainers. You get the continuity of care through your pregnancy, labour and post-natal period. Having experienced both sides of it, I can tell you the level of care is far superior. You have someone who comes to your house when you are in labour, brings all the medical gear for if something crops up and more importantly has the experience and knowledge to let you know its all going fine and that you can stay at home or that maybe something isn’t going as expected and it is time to go to the hospital. There are no strangers and no shift changes. There is no pressure to ‘deliver’ a certain way, to get out of the pool, to have your waters broken or that IV put in. No one is telling you ‘your baby is not in an optimal position’ or you are ‘ONLY 3 cm’ neither of which are helpful. A wonderful thing that Joy said to me was ‘if you make it an issue it will become one’ very wise words that in many ways can bear weight to the high intervention outcomes of childbirth we see today.

I am not a crazy hippy, I did not have a terrible first birth, and I’m not anti the medical establishment. I went to university and have a PhD epidemiology and biostatistics. I like to research the choices I make in life and like things to be backed up with strong evidence. I feel like I am one of the few that know a secret. Being able to give birth your way, at your pace, free of inhibitions so you can get into your ‘labour song’ (as Janie called it), in a location you feel safe in, with people you already know and trust, is probably the most amazing and empowering thing a woman (and her partner) can ever do.

If even a small part of you thinks you might like care from an independent midwife and/or a homebirth, I say go for it, you wont be disappointed.



Thankyou for your comments

Action on maternal mortality in developing countries

Talk point: Maternal health - can MDG5 be achieved by 2015?

A global shortage of midwives is reducing the chances of countries hitting millennium development goal 5 to reduce by three-quarters the maternal mortality rate. Tell us what you think about maternal and child health, and the progress of the MDGs

Click on this link to guardian.co.uk for an insightful series of videos addressing maternal death rates and maternity care in Africa and Nepal.


A midwife from Melbourne, who is working with MSF in the African country of South Sudan, wrote recently:

"In the short time I had been in Aweil, I had seen more miscarriages, more stillbirths, more premature births resulting in death than in my 8 years as a midwife in Australia. I was faced with doing things that caused me so much distress and heartache. To balance this somewhat, I have seen more twin births (nearly all of them vaginal) here than in Melbourne – it seems to be a norm in Africa, maybe to balance all the other babies who die. It is difficult here – for all who live here – and part of the work is to try to get women to the hospital sooner so that their bodies, which are already so depleted in so many ways, are not left recovering with no baby, as they have stayed away too long. This is all too familiar a story. They are in labour for 3-4 days at home, they come to us with a baby that’s already dead. There are also many who come with their babies still alive but then they seem to give up right at the end and we can’t resuscitate them. It is normal for there to be meconium stained liquor. Too many dead babies…The women have many pregnancies, and their bodies don’t often have time to recover before they’re expected to be pregnant again. So, we are also looking to do education in antenatal clinics, trying to encourage women to come earlier to the hospital."

Thankyou for your comments

Transfer from home to hospital

A transfer from planned home birth, to hospital, can bring challenges to both the mother and the midwife, testing the partnership and trust between them.

From time to time, and at times unexpectedly, I need to arrange transfer to hospital. Being able to transfer care, without anxiety, from midwife-led primary care in the woman's home, to medically supervised specialist care in hospital is one of the most basic 'acts' that a midwife must be able to carry out in protecting the wellbeing of mother and baby.

Midwives working in hospital-based homebirth programs, and even birth centres, have a strict set of rules to follow. Any clinical finding that could be interpreted as an unacceptable 'risk' (such as previous caesarean surgery) or an escalation in 'risk' for mother or baby (such as meconium stained liquor) means that the midwife has no choice other than to follow the risk management process set down by the hospital.

Midwives working independently, in a private employment relationship with each woman, are able to consider the situation more broadly. This does not mean that midwives practising privately are unconcerned about risk. But it can allow a more holistic (whole-person) assessment of the situation, often meaning that the woman who is considered unacceptable for 'low risk' hospital-managed models (homebirth or birth centre) is able to proceed without any complication to giving birth to a healthy baby in her home, in the care of a midwife.

A publication that has guided and informed my practice in a significant way since the mid-1990s is the World Health Organisation (WHO)'s Care in Normal Birth: A Practical Guide (1996).

This paper does not primarily deal with the issue of 'home birth' or 'hospital birth': it focuses on 'normal birth'. That's a really important point. If birth is normal, the place of birth is of little consequence as long as the mother's and baby's needs are met. The midwife is fully able to attend such a birth, providing appropriate care.

The WHO (1996) paper provides a clear discussion of the 'Risk approach in Maternity Care' (p3), stating that

"An assessment of need and of what might be called "birthing potential" is the foundation for good decision making for birth, the beginning of good care. What is known as the "risk approach" has dominated decisions about birth, its place, its type and the caregiver for decades now (Enkin 1994). The problem with many such systems is that they have resulted in a disproportionately high number of women being categorised as "at risk", with a concominant risk of having a high level of intervention in the birth. A further problem is that, despite scrupulous categorisation, the risk approach fails signally to identify many of the women who will in fact need care for complications in childbirth. By the same token, many women identified as "high risk" go on to have perfectly normal, uneventful births."

The picture of the process of ongoing decision making in the birth process is described in some detail, including this series of highlighted paragraphs:

"Risk assessment is not a once-only measure, but a procedure continuing throughout pregnancy and labour. At any moment early complications may become apparent and may induce the decision to refer a woman to a higher level of care." (p3)

"We define normal birth as: spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. The infant born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.
However, as the labour and delivery of many high-risk pregnant women have a norml course, a number of recommendations in this papeer also apply ot the care of these women." (p4)

"In normal birth there should be a valid reason to interfere with the natural process." (p4)

In recent years I have perceived a strong movement by the birthing consumer movement in this country, whereby a woman's 'choice' has become the guiding principle in calls for better maternity care. Choice that is not balanced by the critical judgment of a skilled midwife or other professional can be more dangerous than Russian roulette. A midwife cannot provide optimal maternity care if the woman's choice is more important than any other factor.

A woman giving birth has only one real choice: to either do it herself, or to submit to the medical care available. If there is a valid reason to interfere in the natural process, the midwife is bound to advise that intervention, even when it clearly goes against the woman's 'choice' or wishes.

This is often the situation when a midwife recommends transfer from home to hospital.

One of the key principles articulated by midwives in practising privately for planned home birth addresses the time of transfer:

"We support seamless and reliable processes by which midwives are able to make hospital bookings for women planning homebirth, and arrange transfer to the hospital in a timely way when needed."

[APMA Position Statement on Planned Home Births with a Midwife]

Thankyou for your comments

A new book from Michel Odent - part 2

[Continuing on from the previous post]

Having now finished, and enjoyed this book, there's one additional point I would like to explore. It's a small detail.

In the epilogue, Odent indulges in some fanciful thoughts about childbirth in the land of Utopia, January 2031. [That's only 20 years from now, and my grandchildren may be having babies at that time!]

This chapter has appeared previously in Odent's newsletter, and republished with permission at the midwivesVictoria blog in 2009.

My interest in this utopian dream was piqued by a question "What if the prerequisite to be qualified as an obstetrician would also be to have a personal experience of giving birth without any medical intervention and to consider birth as a positive experience?"

... at which time the participants in this utopian scenario all shouted "Eureka!"

Odent has previously proposed this prerequesite for the authentic midwife. It's idealistic, but fascinating.

My response, which may be influenced by personal bias, culture, and anything else, is to immediately say "no way!" as far as obstetricians are concerned.

Obstetricians should perhaps be required to have major abdominal surgery after 36 hours of sleepless activity, then be required to tend to a little creature who needs all that a newborn baby needs. Even that would not start to mimic the emotional/hormonal cocktail that a new mother experiences.

A midwife is 'with woman', bringing a special partnership to the childbearing event that allows the woman to proceed under natural physiological influences without fear. This allows her body to do whatever it needs in the growing and birthing and nurturing of a baby.

There is no similar concept of 'partnership' in medical/obstetric ethics or standards. The doctor/obstetrician is required to be an independent thinker, who brings special surgical skill to births that would not do well under natural physiological processes. The doctor is not there to be 'with' the woman.

For this reason I reject any suggestion that the obstetrician in the utopian setting would be someone with "a personal experience of giving birth without any medical intervention and to consider birth as a positive experience." Indeed, if an obstetrician had that level of experience, I would suggest that obstetrican could also be admitted to the profession of midwifery.



Thankyou for your comments

A new book from Michel Odent

I am, once more, enjoying a book written by Michel Odent, the French doctor who has contributed an enormous amount to my understanding of the physiology of normal birth.

Last week I sat in a workshop and listened to Michel speak, without notes or anything remotely modern, such as a data projector, for three hours. It required a lot of concentration to understand his accent, which seems more 'French' than it was a few years ago, the last time I heard him speak. There was also a problem with the microphone, which didn't help. I chatted with him at lunch time, and he autographed my copy of his new book.

This octogenarian champion of birth physiology is not going to please many of his readers all the time. For instance, he has come down hard on the natural childbirth movement, for its penchant for birth videos, its teachings about 'support', its masculinization of the birth room, and much much more. You will have to read the book to get the full picture. Here is a brief quote from p47-48:

Language is a specifically human stimulant of the [neo]cortex. This implies that in situations associated with intense activity of archaic brain structures, such as giving birth, exposure to language should be avoided. ... Of course, after thousands of years of culturally controlled childbirth, silence as a basic need cannot be accepted overnight. It is all the more difficult today since many theories that are at the root of 'natural childbirth' movements have reinforced a deep-rooted cultural conditioning and have introduced to the birthing place a guide (a 'coach') who does not hesitate to use language.

There are statements that will not please midwife intellectuals and researchers, particularly his apparent uncritical acceptance of recent publications such as the meta analysis by Wax et al (2010) which report increased adverse outcomes for women at low risk who plan home birth (see p60). This study has been strongly criticised for its methodology and conclusions.

When reading this book I detect an idealism that seems to suggest that all women will be fine if only they can progress within an appropriate setting that is silent, unstimulating, free of husband and other onlookers, free of language, and with a midwife who is knitting in the corner. There seems to be an avoidance of recognition of the midwife's role in detecting complications and accessing appropriate specialis care when progress is abnormal. I am willing to understand this apparent bias as an assumption that readers already know about such matters.

There is a very interesting discussion around the phenomen of two midwives attending a birth together. This practice is widely promoted in Melbourne by hospitals and independent midwives: indeed some of my colleagues have told me that they consider it unwise and possibly unsafe for me to attend a birth as a solo midwife. Don't I know there could be two people needing my attention at once?

Another obstacle is a deep-rooted tendency to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. In many societies one of the women around plays the role of the midwife, often accompanied by relatives or neighbours. Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or SOuth America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: When there are two midwives, the baby's head is crooked". (p63)

A further comment in the context of people who have been introduced into the birthing room:

"The doula phenomenon is such a sudden international phenomenon that it must be analysed and interpreted in the context of the twenty-first century." (p 63),

and

As long as the studies [about doulas] were conducted in low-income Hispanic populations [in the US], the statistical results clearly confirmed the positive effects of the presence of a doula. The findings were different in the context of middle-class American populations, ... where the presence of a doula had no impact on the rates of caesarean deliverise and other operative deliveries." (p64)

I have not yet finished reading 'Childbirth in the age of plastics', but wanted to get these comments up on the blog pronto!


Thankyou for your comments

Vernix

Vernix covering the face of a precious newborn baby

After every birth I find something of value upon which to reflect. It may be something unexpected, or it may have been the ordinary-ness of the whole event. Ordinary, yet extra-ordinary. It may have been something about myself, and my personal ability to fulfil the role of midwife. And my reflective review may take place at several different levels.

I love returning to homes as midwife for the second time, and more. It's a wonderfully privileged place for me. The mother knows me, and I know her, in a deeper way than the first time 'round.

The picture in my mind now is a mother whose second baby is nursing contentedly, naked against her warm, naked breast. It's a mild autumn day outside, with some light rain, and occasional sunshine. We are in the bright, airy room that is a closed-in verandah at the rear of the house. The setup is very much the same as it was three years ago when this mother gave birth for the first time.

I had been called out a few hours earlier, and had worked with the mother; my few words and actions being carefully chosen to act in hamony with the wonderful natural process that was progressing and unfolding. But that's another story. Today I am thinking about vernix. The little one of today's reflection was born with thick slathers of the white creamy substance on her back, and sizeable globs of it in the water of the birthing pool.

I know I'm not the only midwife who is fascinated by, and has a special love for, vernix. Not the vernix on the baby's skin. That stays there, and has often disappeared, apparently absorbed by the baby's and mother's skin, when we take another look at the baby after a couple of hours. Water birth has made the vernix that has separated from the baby more accessible than it used to be. The vernix in waterbirth floats to the surface of the water, while in conventional births this vernix ends up on the absorbant under-sheet with amniotic fluid, blood, and anything else that issued from the mother's body at the time of birth.

I don't know if it's an old wives' tale, but I heard a long time ago that midwives in France would collect vernix for use in the cosmetic industry. A blob of vernix is, to me, an attractive little bonus to glean when all the hard work of birthing has been done. I scoop up a bit of it, and apply it, usually to my arms. A few years ago I was conscious of a small scaly patch of skin that had been for some time on my forehead, and I rubbed vernix into it. Having grown up in the Queensland sub-tropics, sun exposure has left my skin with some damage. The skin healed over soon after.

It's likely that any readers who are interested enough to read a post about vernix will also use an internet search engine and see what comes up. That's how I came upon a very interesting, comprehensive paper:

Vernix Caseosa: The Ultimate Natural Cosmetic?
By: Johann W. Wiechers, PhD, JW Solutions; and Bernard Gabard, PhD, Iderma
Posted: August 31, 2009, from the September 2009 issue of Cosmetics & Toiletries.

The authors of this paper also state that "rumor has it that midwives apply some of the vernix caseosa they remove to their own hands, rendering them soft and well-hydrated."



Your comments are, as always, welcome.

Midwife-blogger

Midwife-blogger is the title of my presentation to be given at the global 24-hour Virtual International Midwives Day webinar, Thursday 5th May, hosted by midwife Sarah Stewart in New Zealand.

I have been maintaining midwifery blogs since 2006, with the aim of recording and sharing midwifery skill and knowledge, promotion of normal birth, and making critical comment on current issues in maternity care.

In the mid-1990s, as I was establishing my private midwifery practice, I kept a hand-written journal with photographs and other mementos from many of the births I attended. This journal became the source for the chapters of ‘The Midwife’s Journal’, which has been a section of my website since 1997. The Midwife’s Journal was my first attempt to use electronic media. I sought to write about my personal journey through the terrain of childbearing, rather than make a record of birth stories.

Blogs and web-based books such as The Midwife’s Journal are readily translated into e-books. My two midwifery e-books are Midwifery from my heart, published in 2010, and Mother Daughter and Midwife, published in 2011. I have more e-books planned.

I would like to encourage midwives to use reflective writing as an aid to developing a strong midwife identity, and in processing both the joys and challenges and sadnesses that we face on a daily basis. A blog can be set up with open access, or to be accessed only by those who the owner permits. Privacy issues must be considered, of course.

Today I have received a very special email message from a young woman in London. This is what she wrote:

I wanted to send you an email and whilst searching for your address I came across the beautiful birth story you wrote about me in your journal (Homebirth Far From Home). I am so grateful you did that as it brings back such wonderful memories, and makes me so proud. Thank you.

The reason I wanted to email you was to let you know that I have just completed my midwifery training and will be starting a job at Kings College Hospital in London in June. I chose to apply KCH because of their 7% home birth rate (one of the highest in the UK) and the strong philosophy that permeates their care in keeping birth normal.

I know I have said it before but I wanted to let you know what an inspiration and role model you have been to me on this journey. Although we live on opposite sides of the planet, and [her son's] birth was over 12 years ago I still feel that you have played a strong part in my success at starting and completing the rewarding but often challenging training involved. You have also influenced my every day practice and my belief in the power of women to birth their babies as they choose.

With much love and respect,
[name]

Dear reader, can you imagine how wonderful it is to receive this letter?

I have just now gone back to the account of 'Homebirth Far From Home', and my eyes are moist as I recall that beautiful young woman giving birth confidently to her strong and healthy child. I feel totally privileged to know that my brief role with her more than 12 years ago has contributed to the development of a new midwife who is about to set out on her professional career.

As women give birth to their babies, midwives beget baby midwives.

Midwives who are reading this, let me encourage you now to treasure every experience you have when being 'with woman'. One of those women may, with your support, begin or progress in the journey towards becoming a midwife herself.



Thankyou, dear reader, for your comments.