Medical dominance in maternity care

A culture of medical dominance in maternity care today is so deeply ingrained that few people are aware of it.

For decades, until ‘sunsetted’ as recently as 1995, Victorian Midwives Regulations required supervision of midwives by doctors. A midwife was required, for example, to have a doctor’s permission to carry out a vaginal examination of a woman. There was no mention of informed consent from the woman.

This culture came into direct conflict with professional developments in midwifery, organised and promoted globally through the International Confederation of Midwives (ICM), and clearly articulated in the ICM Definition of the Midwife, which is a foundational document in all Australian midwifery education and codes of practice.

At the same time, in response to the tragic outcomes linked to loss of breastfeeding in developing countries, UNICEF and World Health Organisation (WHO) introduced the global Baby Friendly Hospital Initiative. Protecting women’s and babies’ physiological processes in breastfeeding is an extension of such protection in birth, and is an ongoing challenge to the midwifery profession.

The federal government’s Maternity Services Review (2008), its Report and the 2009/10 Budget Package: “Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives”, ignored or conveniently side-stepped homebirth, the main practice area of privately practising midwives. While promoting choice for women through access to privately practising midwives, preference was given to ‘collaborative’ models, under obstetric control, which often exclude midwife led primary maternity care options. The carrot of more choice (for women) came with the stick of what was called collaboration (for midwives) as defined in the law, which could be more realistically interpreted as supervision.

In providing ‘more choice in maternity care’, the reform package actually gave veto power to a doctor, over the midwife’s ability to provide Medicare rebate to a woman in her care. The National Health (Collaborative arrangements for midwives) Determination 2010 requires very specific signed collaborative arrangements to cover all aspects of a midwife’s practice. There is no requirement or onus on doctors to sign a collaborative arrangement, and in many instances women have experienced frustrating refusals by doctors, who refuse to ‘collaborate’ with a midwife in the legislated way. More choice? No!

Midwives in most States have experienced outright refusal when we have requested processes to achieve clinical privileges in public hospitals, despite government-guaranteed and heavily subsidised indemnity insurance for midwives. Midwives are welcome, as long as, and only if, they are employees. There is no process for private midwifery practice.

I have pondered the changes I would experience in my professional life, if I were able to have clinical privileges in a hospital. Here are some initial thoughts.
My current caseload is around 20 births per year; most being planned homebirths. Some months I have 4 or 5 bookings; some months none. If the work was more reliable, I would like to have a more consistent caseload for myself, and even work in a group practice with two or more other midwives. With hospital visiting access I would soon be able to increase to a full time caseload - in round figures, to book two planned hospital births each month in the local maternity hospital (Box Hill, which is about 15 minutes' drive from my home), and continue to book two women each month for homebirth.

I would be able to plan to have no bookings for at least one month each year, and would have another midwife cover my practice as a locum for that month.  It all sounds good.

At this point in time I do not know if I will apply for clinical privileging at a public hospital, even if that were available. I will need to weigh up the 'cost' against 'benefit'. It would be difficult to make such a major transition without the expectation of a reasonable caseload, and a supportive environment in which to work. Learning the systems and processes within a hospital will require a lot of commitment and support. I might need to leave that ground-breaking work to midwives who have recent experience in hospitals.

I am putting my thoughts on the record here, because I would really love to see the change in mainstream public maternity care that will not only accept midwives working privately with women, but embrace and support the change.  Only when this is happening will we start to see an easing of crippling medical dominance in maternity care, and at the same time see unbiased collaboration between midwives and doctors within hospitals.

protecting and enhancing the chance of a natural birth

Today I received a message from a midwife who has read some of my blog thoughts, who has asked me:

What do you think are the most important rules for protecting and enhancing the chance of a natural birth?

Where do I begin?

Perhaps there are no rules.

Rules tend to exclude some, and anyone who has been with woman will know that when a woman discovers her own strength, she seeks to organise her life so that she will not be denied that potential when she is at the peak of her labour. Perhaps the only 'rule' is an active decision making process that has the wellbeing of mother and baby at its centre.

There is no safer or more satisfying, fulfilling way for most women to give birth than to proceed as far as they reasonably can without medical or surgical assistance. Years ago, when I was experiencing my own intellectual awakening to the wonderful potential of our bodies in bearing, birthing, and nurturing our babies, I read some reports on birthing from the UK Health Department. One of the messages these reports promoted was that women want the 3C's: choice, control, and continuity.

Yes, I agreed!

So I worked hard to promote choice, control, and continuity in maternity care. But as I explored my own practice, and the midwifery literature, I have had to re-think each of the 3C's.

Choice is very limited. There is really only one choice: to promote health and intentionally work in harmony with the natural processes - this is what I call 'Plan A'. Any other notion of choice has little connection with reality.

Control must be relinquished. The only way most women can progress without medical assistance in the most demanding part of labour is when they surrender the neo-cortical thinking, relinquishing mind control to the powerful hormonally mediated intuitive processes within their bodies.

Continuity is an ideal that cannot be guaranteed. I mean real continuity of carer, with the midwife primary carer who is personally committed to the individual woman and who forms a partnership based on reciprocity and trust with that woman. This is the way I try to work, and with a very small caseload, I have been privileged to attend almost every birth that I have been booked for. But it is idealistic. I have been blessed with a robust body and good health. I won't labour this point. I recognise that mainstream publicly funded maternity services will need to trade off some of the idealism of continuity for the realism of sustainability.

So, dear reader, what rules are there to protect and enhance a woman's birthing potential?

The parallel of healthy natural birth and breastfeeding is obvious to me. In both, the midwife's role is to protect, promote and support the physiological processes, and when an intervention is made, to restore normality, restore to the mother her own body's health-affirming prerogative, as soon as possible. This requires education, skill, personal will power, intelligent action and much more. It's not a matter of sitting back and letting nature take its course, because we know that the natural course often leads to chaos. It's a matter of knowing and intentionally guiding at times. That's midwifery. It's a matter of the midwife-woman partnership having an intention to work with 'Plan A', and knowing when to move to 'Plan B'.


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