on a personal note

Picture taken yesterday, at the home of friends

Today Noel and I are celebrating 39 years of marriage. Thirty-nine years of shared life is worth noting, and I thank God for this man!

I'm not going to try to delve deeply into personal matters, but I do want to draw attention to the importance of a stable and supportive home base. A midwife who intends to provide primary care for women across the childbearing continuum, including the occasional disruption and uncertainty that come with spontaneous birthing, needs security and stability within her home and family life. Of course this can't be guaranteed - situations can change in an instant.



Most of the women who call our home phone to speak to me get the opportunity to speak with Noel.  He's my gatekeeper when I have been out all night, and need a sleep.  He's my receptionist when I'm out, or when I'm having a shower.  When a mother and baby come for the 6 week postnatal 'show and tell' visit, he usually manages to say hello, and offer congratualtions on the new baby.

Noel's qualifications are in Veterinary science.  His Masters and PhD work at Michigan State University in the 1970s investigated the protective effect of colostrum for the newborn calf.  He demonstrated that a calf who received colostrum in the first days of life was protected against 'scours' - the term used for gastroenteritis in the dairy, responsible for high rates of death of calves.  At that time, newborn dairy calves were removed from the cows immediately after birth, and fed with 'milk replacer' - a substitute milk similar to the formula milks made up for human babies.  Noel's research also demonstrated the phenomenon of 'gut closure': the brief time immediately after birth when macro molecules are able to pass across the intestinal wall directly into the blood.  The time and significance of gut closure in human infants is still unknown. 

I believe I have benefited a great deal from Noel's studies and academic work.  The principle that the natural physiological processes across the childbearing continuum are truly awesome, and truly worth protecting, has strong foundation in my mind.  Those who remember the 1960s and 70s will recall the infatuation in health care with what they saw as science - that science could provide smart alternatives to anything natural, from clothing fabrics to human milk.  Women were being told they no longer needed to be burdened with tedious natural tasks such as breast feeding.  Women could control when they had babies, and what they did for the babies they bore.  Intellectual theorists of the 60s and 70s hailed female-male equality as the new societal standard.

The reality that was ignored in attempts to free women from the burden of nourishing their babies was that being a mother can be GOOD!  That maternal instinct is a strong force, under hormonal direction, that enables a woman to want to stay with her baby; to respond to the baby in a loving and nurturing way; to give the baby access to her breast whenever and wherever the baby is hungry or needs comfort.  Interruptions in physiological processes inevitably interfere with hormonal states, leading to non-physiological and often adverse outcomes. 

I had not learnt about maternal instinct in the midwifery course that I had completed just months before the birth of my first child.  The midwifery teachers were older single women, as were most of midwives in senior positions in the hospital.

I am looking forward to continued learning about the beauty and desirability of hormonally-mediated maternal behavioural patterns. 



Thankyou for your comments

Breastfeeding well from the start

1977, with my son Paul

Breastfeeding is PLAN A. 

Breastfeeding is what a woman's body expects to be doing, whether her mind agrees or not, and it's what a baby expects to be doing, from the start. Anything else is a variation from the biological, hormonally determined, norm. Anything else is a compromise, as far as the natural physiological processes are concerned.

Although breastfeeding is 'natural', it's not simple. For many women and babies, it's not easy. For many women, alternatives appear attractive.

Today I want to focus on breastfeeding well from the start. This is not possible for all mothers and babies, but it is possible for most. As with 'Plan A' in birth, 'Plan A' breastfeeding can best be achieved when the mother, the midwife, and all involved, accept and work in harmony with sensitive natural processes. As with 'Plan A' birth, 'Plan A' breastfeeding can be interferred with by a well-intentioned but misinformed person, resulting in distress for all and possibly long-term consequences.

The midwife who understands these truths will protect the mother-baby pair during pregnancy, labour and birth, anticipating the wonders and challenges that lie ahead; will support the woman and baby as they learn about and explore each other from the moment of birth; and guard the bond between mother and baby after birth, guiding and instructing the new mother only when the need arises.

The title of this post, 'breastfeeding well from the start', puts breastfeeding into the context of a continuum.  Breastfeeding is a relationship, not an act.  The same word, 'breastfeeding' describes what the baby is doing, and what the mother is doing.  Yet the actions taken by the two participants are very different.

Consider the breastfeeding continuum within the series of firsts:
. the first moment
... the first hour
..... the first day
....... the first week
......... the first month
.......... the first year

Breastfeeding well from the start is, like any other natural phenomenon, most likely to continue on the right track if it starts on the right track.  By this I mean, the mother and baby who are well at the onset of labour; who proceed spontaneously, without medical stimulants or emotional coaching or analgesia or anaesthesia to a normal birth; who experience the wonder of falling in love in the moments after birth, bringing with it a huge surge of the love hormone, oxytocin; enabling the mother to release her baby's placenta without excess blood loss, and enabling the baby to use his senses of sight, smell, taste and touch to search for the breast and achieve a deep attachment; suckle, and swallow the sweet, precious colostrum.  This is usually happening in the first hour after birth, before anyone else has held the newborn. 

The first hour quickly passes, and the first day unfolds.  Mother may pass the precious little person to the father, or another trusted family member, so that she is able to empty her bladder, and wash herself.  She needs to eat and drink, and rest.  Each time baby is alert, the instinctive actions of both mother and baby culminate in breastfeeding.  Baby goes to sleep, and mother can't because she is too high!

2011.  Bec and James (18mo)

The first day opens out into the first week.  Baby works strongly and confidently at the breast, and soon the breasts are swelling and producing a bountiful flow.  Baby's feeding and sleeping pattern changes, as does the colour of his stool.  Mother sleeps well between breastfeeds at night, and is quickly returning to strength.  She accepts the closeness of the relationship between herself and her child.  Someone asks "Do you feed your baby on demand?" and she has to think what that might mean.  Not really - her baby has never learnt to demand a feed.  She looks at her baby, or her baby looks at her, makes a sound or a movement of his mouth, and together they proceed with the most satisfying and beautiful work that either knows about.

And so it goes, through the first month, and the first year, or two, or ...



Thankyou for your comments

Looking forward

From time to time I have taken the opportunity on this blog to write about the complex and often challenging position I and other midwives have found ourselves in as we work through and apply government 'reforms' and changes to our practices.

Now, at the end of the first week of January 2012, I want to summarise my position as a midwife, attending individual women for birth and associated prenatal and postnatal care, and what developments I expect and hope for in the coming year.

Firstly, on the positive side of the ledger:

• Babies are being born, and thriving - beautifully.
• Women are being transformed in the process of giving birth.  That's a wonderful thing to witness.
• Collaborative arrangements are being set up with a couple of supportive GP-obstetricians, who are happy to give women referrals for the midwifery services they choose.
• Collaborative arrangements are being set up occasionally with obstetricians, after the woman and baby have been discharged from hospital, enabling one-to-one postnatal care for the woman.
• Medicare rebates are being paid to women who use the services of participating midwives.
• I am happy to bulk bill additional antenatal and postnatal visits, which continue until the baby is 6-7 weeks old.

On the negative side of the ledger:

• Some public hospitals at which women make homebirth back-up bookings are refusing to acknowledge the collaboration in the way that has been spelt out in the legislative determination, in that there is, for example, no provision for a 'specified medical practitioner', who is "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.", or any acknowledgment "when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy" ...   
• Midwives eligible for Medicare are required to sign an undertaking to complete a course in pharmacology within 18 months, yet there is no such course accredited.  
• No midwives have access arrangements to privately attend women admitted in hospitals.  This means that women who choose to give birth in hospital, with their private midwife in attendance, must accept the hospital's employed midwife as the leading midwife at the time of the birth.  This situation can lead to unnecessary conflict.
• There is no insurance product to indemnify midwives attending women privately for home birth.  The government has exempted midwives from the requirement until 2013, and we don't know what (if?) plans are afoot to rectify the situation.

Logically, indemnity insurance does not change outcomes - it simply provides a pot of money that can be fought over in the law courts, should there be an adverse outcome.   I consider the only solution to the insurance problem is to set up a no-fault compensation scheme, to which all health professionals contribute, which provides a suitable level of financial support to those who suffer disability or loss, separate completely from the apportioning of blame.

Midwives who face regulatory or coroner's inquiries into incidents in which they were involved are being advised to obtain legal representation.  While ideally a professional should be investigated by peers, it seems that the process of investigation into conduct is becoming increasingly formalised, with inherent costs and isolation of the practitioners.

I have recently accepted a role as Vice President in Australian Private Midwives Association (APMA), which represents private midwives nationally.  I have been a member of this organisation, and have written and edited the APMA blog for the past couple of years.  It is a privilege for me to work alongside the President Marie Heath and the other committee members.  Keep an eye on that blog if you are interested in the national private midwifery scene.

I continue my involvement in Midwives in Private Practice (MIPP), which represents midwives practising privately mainly in Victoria.  See the MIPP blog.  MIPP is a participating organisation in Maternity Coalition (MC).  The concept of partnership between the woman and the midwife is carried through into the relationship between MC and MIPP. 

There are plenty of challenges to keep me busy in the midwifery profession broadly, as long as I have the (physical, mental, spiritual) strength to continue my practice.  I enjoy consulting with women and attending them professionally in their homes, mentoring  other midwives, giving lectures to midwifery students at Deakin University School of Nursing and Midwifery, and my involvement in the Professional Development Unit at Deakin.

Family and home responsibilities keep me busy, and my beautiful grand-children remind me of the every-changing needs of our most precious resource.

Thankyou for your comments