Reflecting on yesterday's webinar

great artwork from our girl!

Yesterday, 5 May, was International Midwives' Day, and I was very pleased to participate in a global webinar organised by Sarah Stewart, and hosted by the Otago Polytechnic University in New Zealand.  Click here for the program, and to find links to the recordings of all the sessions.

I heard most of the first 10 hours of program, which continued through the night; 24 hours in all.  My mind was overloaded when I stopped.  I look forward to listening to other presentations.

Through the night I found myself churning through what I consider to be idealistic midwifery. This matter concerned me as I listened to some of the presentations, and as I engaged with others in the 'comment' function by which participants were able to type in questions or comments.  I could not help comparing the situation of under-resourced independent midwives in Pakistan, with what I know of Australian independent midwifery.

Idealistic midwifery presents the woman as someone who will achieve whatever she chooses, whatever she really wants, if she goes about it the right way.  The idealistic midwife seems to believe in a perfect world, where women have a goddess status, where there are no regulatory or societal boundaries, and where the woman's choice is the only important issue.

A necessary by-product of idealistic midwifery seems to be the demonising of hospitals, doctors, medical interventions, and anything else that I might have referred to as 'Plan B'. 

I cannot accept the setting of the bar so high.  I accept that there will be some who need more than I as the midwife can offer.

The world in which we live and work has expectations of medical management.  There are many reasons why some women feel the need to give birth in hospital, to accept medical analgesics or antibiotics or IV fluids, or induction of labour or active management of the third stage.  I cannot appoint myself as judge and jury for each case.  I must respect that these are the result of mainstream care practices, leading to care decisions made by these women and their midwife or doctor.  When a woman in my care agrees that transfer to hospital is appropriate, the processes we must go through will be different from those at the woman's home, and so they should be.

The midwife in a primary care setting today, whether it's in Melbourne or in a developing country, has the opportunity to prepare women to accept the birthing work of their bodies, and to use their own natural resources to the best of their ability.  'Plan A' is essentially the same, across time and culture.  Women give birth spontaneously today the same way as our ancestor-mothers did hundreds of years ago.

'Plan B' is totally different for midwives and mothers in different parts of the world and different times.  It's a matter of availability of resources and emergency medical care.  While in my practice I can refer a woman to a well staffed and equipped, modern obstetric hospital where a team of highly trained and supported experts will address whatever the emerging complication or condition is, my sister-midwives in less well resourced parts of the world will face a very different 'Plan B'.  My friend who is working as a midwife with MSF in Africa has told me she had never imagined as many dead babies or dead mothers as she has seen in that place.

Idealistic midwifery ignores the fact that illness and infection and complication can strike down even the fittest and strongest among us.  Idealistic midwifery fails to notice that even people who eat well and exercise can become ill.  Idealistic midwifery forgets that the midwife's primary goal is the wellbeing and safety of mother and child.  Not natural birth, wonderful as that is; or drug-free birthing, or any other standard we might aim for.

Ideals are great.  Where there are no ideals, no vision, the prevailing culture can quickly over-ride, and principles be forgotten.  But ideals must be tempered with realism.  Life is often best when we can accept being 'good enough', doing our best with what we have, rather than being disappointed that we don't achieve perfection.
 
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