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.

Shared antenatal care at the Women's

Changes that are being implemented in midwives' practices, with the availablity of Medicare funding (I am still being patient - I have not yet received notation as eligible for Medicare), have led me and some colleagues to apply to be recognised as Shared Care affiliates at public hospitals. I have recently received my certificate from the Women's. Click here for more detail on Shared Maternity Care.

General practice doctors who have qualifications in obstetrics (GP-Obs) are usually the providers of Shared Care at public hospitals. The Shared Care Affiliate provides regular check-ups, and orders blood tests and other investigations for women who are planning to give birth at the hospital. The Shared Care Affiliate does not usually have any involvement in the acute care, from onset of labour to discharge of mother and baby.

Shared Care with a midwife at the Women's is available for women who live in the catchment area. It is possible that, with Medicare rebates for antenatal and post natal care, some women will choose to have their antenatal and postnatal visits with a midwife, without having the expectation that the midwife will also attend them in labour. However, midwives who provide primary care are, by definition, committed to working with a woman through the continuum or pre, intra, and postnatal care. When a midwife is a Shared Care affiliate at a hospital, she is also able to provide midwifery care during labour at home, to attend hospital and be 'with woman' through the birth, and support the amazing transitions that a mother and her baby go through in the early days and weeks after birth.




Thankyou for your comments

Homebirth, freebirth, and doulas ... a broken maternity system

The latest issue of Women and Birth, the journal of the Australian College of Midwives, contains a paper by midwife academic Hannah Dahlen and two colleagues, M Jackson and J Stevens, titled:
Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system.

First MOTHERBABY group gathering for 2011

We sat around the table thismorning with cups of tea and glasses of water and listened to each other. What a delight it is to welcome a new baby into our world, and today we welcomed three into our little group. Arwen, Matthew, and Scarlett are pictured here with their mothers.

Reflecting on midwifery practice

Matilda is on the ball!  (it's never too early to prepare for good birthing)

In preparing for my recent professional practice review, I was able to identify several incidents in which I believed it was important for me as the midwife to act within my professional skill to ensure the safety and wellbeing of the mother and/or baby. In other incidents I engaged collaboratively with specialist maternity care providers, also with the goal of ensuring safety and wellbeing.

'hands-off'?

I don't know who first came up with the idea of the 'hands-off' midwife: the midwife who has a good set of hands and knows how to sit on them.

Midwives are not universally 'hands-off' when we should be, nor are we always 'hands-on' when we ought to be. That latter point is what I am attempting to write about today.

Reviewing the past couple of years

To Daddy

A couple of years ago the federal Health Minister announced a Maternity Services Review, declaring that the government intended to provide “More Choice in Maternity Care – Access to Medicare [funding] and PBS [prescribing] for Midwives”. The monopoly of government funding for maternity care being available only for services provided by doctors and hospitals was to be broken.

Midwifery exam, 1973

click to enlarge

I found this exam paper when going through an old file.
I read through the questions, and this is what I noticed:

• Questions on breech presentation: diagnosis, ECV, indications for Caesarean section, and foetal risks associated with [vaginal] breech delivery.
• A question on [vaginal] delivery of the second twin.
• Questions on anaemia, fundus not equal to dates, varicose veins, onset of second stage, increasing parity, indications for forceps, polyhydramnios, placenta succenturiata, inversion of the uterus, and infants with sticky eyes, thrush, physiological jaundice, and cephalhaematoma.

Global Forum, Day 6

Spring roses in our garden

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question: Over the weekend we would like you to continue to discuss the question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 5

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 4

For the online discussion, click here. The forum community is continuing to grow with 624 members from 86 countries!
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:
Today we will continue to discuss the role of the lay health workers. However, we would like you to elaborate more on the specific issues below:
- What wider social roles, such as promoting female empowerment, should lay health workers take on in communities?
- What approaches that have been used in different settings to motivate and retain lay health workers, to improve the quality of the services they deliver and to promote the delivery of high priority services for maternal and newborn health?

Global Forum, Day 3

Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum

Today's question:

Community or lay health workers are health care providers who have no formal professional or paraprofessional tertiary education but are usually provided with job-related training.They can be involved in either paid or voluntary care. The term 'lay health worker' is therefore very broad in scope and includes, for example, village health workers, promotoras, treatment supporters and lay counsellors. Lay health workers may take on a wide range of different health-related tasks including giving help and advice about child health, child illnesses, pregnancy and medicine taking. In some studies, lay health workers also treat or refer people for particular health problems.

Global forum, Day 2

The forum leaders have written:

Today we continue to discuss Day 1's question on:

"What practices or tasks should be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?"

Reducing maternal and newborn mortality and morbidity at the primary health care level

Today's discussion topic in the Global Forum is:
What practices or tasks can be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?

My quick response is to ask the same question differently, placing the focus on the woman-baby unit, rather than the tasks:

What needs do mothers and babies have that can be addressed at the primary health care level by health care providers other than medical doctors, and how will the addressing of these needs accellerate the reduction of maternal and newborn mortality and morbidity?

Global forum: optimising the effectiveness of Health Workers to achieve MDG's 4 and 5

The WHO Guidance Global Network invites you to join a NEW online discussion forum.
8-16 November 2010
The World Health Organisation and partners are developing global guidance on enhancing the effectiveness of different cadres of health workers through evidence-based practice to improve maternal and newborn health care.

Theme: Crossing professional boundaries to define what safe and effective practices can be delivered by different cadres of health workers at the primary and community level to improve maternal and newborn health.

Register: to participate and receive a daily discussion digest, click here.

Reminder
MDG 4: Child health
MDG 5: Maternal health
To review the eight UN Millennium Development Goals, click here.

Spring roses in the front garden

“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."

~ C.S. Lewis

Women may 'go it alone' on home births Ireland

[Posted: Fri 15/10/2010 by Niall Hunter, Editor - www.irishhealth.com]

A campaign group has warned that some women may opt for home births without professional care as a result of problems with indemnity insurance for qualified home-birth midwives.

The Association for Improvements in the Maternity Services-Ireland (AIMS) says proposed new midwifery legislation will in effect make it illegal for a home birth midwife to provide antenatal and birth care if the pregnant woman's circumstances do not meet criteria set in a current memorandum of understanding which midwives have to sign with the HSE.

Krysia Lynch of AIMS told irishhealth.com said the memorandum, which will be used in the legislation, outlines the criteria for State indemnity insurance cover for midwives in home births but these criteria were too restrictive.

She claims they are based on a misinterpretation by the HSE of evidence-based guidelines for home births and claims the HSE is attempting to restrict home birth and midwife-led services.

AIMS says the restrictive criteria could lead to midwives becoming uninsured in the middle of a home birth should the mother's clinical circumstances change.

Midwives attending women having home births could face could face fines or imprisonment or both if they are found in breach of the new legislation, which is expected to be passed by the Oireachtas before the end of the year, AIMS says.

It adds that a growing number of women who do not want to attend maternity hospitals are saying that if professional midwife-led home birth services are not available to them, they will "go it alone" with their home birth without professional care providers.

Ms Lynch said this type of "underground home birth movement" has already taken root in other countries where home birth services are restricted.

AIMS says it understands a group of lay midwives without medical training are now offering their services to women who have difficulty in finding professionally-registered midwives.

The organisation is calling for revisions to be made to the Nurses and Midwives Bill in order to change the professional indemnity criteria for home births.

It is organising a petition calling for a changes in the proposed legislation.

Further details on this issue, and a petition to sign, are available here

I have signed the petition - signer #873:

Ireland's Home Birth Services: MOU and Nurses and Midwives Bill 2010.

The Australian Government's current effort to reform maternity services is also likely to have this negative effect of directing women with known 'risks' into the underground home birth movement.  Midwives are faced with real and imagined restrictions when providing care for women who have had previous caesareans, or whose pregnancies continue beyond Term, or who are over weight, or ...  These women would likely benefit greatly from a known midwife primary carer.

Understanding statistics

Those who want homebirth to be, if not outlawed, at least so marginalised and dirty that noone with any sense would go near it, are able to use statistics to coerce their listeners into compliance, and to assure authorities that they are acting 'in the public interest'. There have been a couple of outstanding examples of this phenomenon in the past year.

Firstly, remember the Australian Medical Journal's publication of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), using shameless distortion of facts gathered in the research. I wrote about it and set up links to the paper at the MiPP blog in January this year. Alarm bells sounded, and media picked up the story from the abstract: X7 higher risk of intrapartum death and X27-fold higher risk of death from intrapartum asphyxia in the planned home births group.


The second doozie [for readers who are unfamiliar with this word, it's Australian slang - not sure what it really means, but it seems to fit here] is the Wax et al 2010 paper on maternal and newborn outcomes for homebirths in North America.

Various reliable midwifery organisations have critiqued this paper for its methodology and conclusions. The Medscape "Attention-Grabbing No Doubt, But Uninformative" comment by Andrew Vickers, copied in full (below) is worth reading.

Midwives can also understand statistics.

"Home Birth Triples the Neonatal Death Rate": Attention-Grabbing No Doubt, But Uninformative
Andrew J. Vickers, PhD

Posted: 09/27/2010

Home birth, according to a position statement from the American College of Obstetricians and Gynecologists, is "trendy" and "fashionable." Moreover, women who choose to deliver a baby at home "place the process of giving birth over the goal of having a healthy baby."[1] Interesting thoughts, I guess, but hardly evidence-based. Has anyone actually interviewed home-birthing parents to determine, for example, that they rate having a healthy baby at, say, 5 out of 10, whereas being allowed to listen to druid chanting during the second stage of labor is rated an 8? And with respect to being fashionable, have researchers really evaluated the wardrobes of home-birthers compared with those choosing to labor in the hospital, finding in the former a higher proportion of Marc Jacobs and Manolo Blahnik?

So it is nice to finally see some data that quantify the relative benefits and harms of home birth. Joseph R. Wax and colleagues conducted a meta-analysis, combining data from 12 studies including more than a half million deliveries, in order to report on a wide variety of outcomes, including process (eg, use of epidural), maternal morbidity (eg, vaginal laceration), neonatal morbidity (eg, prematurity), and mortality (of both mother and child).[2] What isn't so nice is the spin. The study authors themselves, who are from a department of obstetrics, report a highly alarming statistic -- that home birth is associated with a triple the risk for neonatal death. The American College of Nurse-Midwives, predictably enough, finds fault with the methodology of the study and cautions against overinterpretation of the findings.[3]

I am sympathetic toward the critiques. A meta-analysis is only as good as the studies that are entered, and it is somewhat disconcerting to see a mixture of prospective and retrospective observational studies all mixed in with a single randomized trial. (On which point, it is even more disconcerting to find that the paper referenced for the randomized trial was a discussion piece, not a trial report.) But for the sake of argument, let's assume that the paper is perfect and accurately represents the true outcomes of home and hospital delivery.

First off, how should we interpret a "tripling of death rates"? This is what statisticians call a relative risk, and it is widely known to be problematic for decision-making. As a simple example,[4] would you buy a pair of slippers if I told you that they were 90% off? Well, no, you would want to know how much they cost. It is the same with risk; it is the absolute amount that matters. The classic example is the contraceptive pill and breast cancer. One estimate is that the pill raises the risk for early breast cancer by 50%. This sounds pretty scary until you realize that most women's risk is so low that this translates to about 1 woman with breast cancer for every 10,000 on the pill. Most women would feel that is a risk worth taking, given the benefits of the pill and the possible harms of the alternative: pregnancy, which after all, has dangers of its own.

In place of a "tripling in death rate," the more informative statistic is the absolute increase in neonatal death associated with home birth. On the basis of the results tables, it is possible to calculate that this turns out to be 1 neonatal death per 1000 women who choose home birth. However, the results tables show that those women would also experience some benefits, including 40 fewer premature labors, 45 fewer cesarean sections, 140 fewer vaginal lacerations, and 140 fewer epidurals. This type of cost-benefit analysis -- trading off neonatal mortality against maternal morbidity -- can seem sort of cold-blooded. But if the only thing we cared about was a healthy baby, then we'd do cesareans on all pregnant women at 38 weeks (as well as insist that all women conceive once they turned 21). We implicitly trade off risks and benefits anytime we consider a medical procedure. Let's do it explicitly rather than implicitly, on the basis of decision-analytic statistics such as absolute risk, rather than headline-grabbing statistics such as a "tripling of the death rate."

References
1. American College of Obstetrics and Gynecologists. ACOG statement on home births. Medscape OB/GYN and Women's Health. 2010.Available at: http://ww.medscape.com/viewarticle/725383 Accessed September 9, 2010.
2. Wax JR, Lucas FL, Lamont M, Pinette MG, Carlin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol. 2010;203:e1-e8.
3. American College of Nurse Midwives. The American College of Nurse Midwives expresses concerns with recent ACOG statement on home births. Medscape OB/GYN and Women's Health. 2010. Available at: http://ww.medscape.com/viewarticle/725382 Accessed September 9, 2010.
4. Vickers AJ. Top scientific papers vs. furry green slippers: which should you trust? Medscape Business of Medicine, 2010. Available at: http://ww.medscape.com/viewarticle/722723 Accessed September 9, 2010.

The current state of private midwifery practice

This is a brief summary - more detailed information can be sourced, of course.

Private midwifery practice for planned homebirth
Midwives continue to practise as we have for many years, providing the full scope of pre-, intra- and postnatal services for women who want to give birth at home, working without medical interference, without drugs to stimulate labour or relieve pain, and in harmony with natural physiological processes.

Midwives continue to provide statistical data to the government data collection agencies, as we have done for many years.

Midwives inform our clients that we are not able to purchase professional indemnity insurance for homebirth, and that the government has provided a 2-year exemption from this requirement, until June 2012. We don't know what will happen after that date.

The Nursing and Midwifery Board (NMBA) is preparing a Safety and Quality Framework document which (according to the most recent draft) is:

• "consistent with the principles underpinning provision of primary maternity care (Attachment 1) and
• "recognises the full scope of midwifery practice.
• "recognises that women will make the final choice about their care and birthing choices in most circumstances [MOST circumstances ???]

"It is incumbent upon privately practising midwives (PPMs) to provide balanced and contemporary clinical advice to ensure that informed decisions are able to be made."

The Framework also relies heavily on the ACM National Midwifery Guidelines for Consultation and Referral (2008). A further 'guidance' document on collaboration is being prepared under the auspices of the National Health and Medical Research Council (NHMRC) - we have not seen drafts of that yet.

Private Midwifery practice for planned hospital birth
Many women who intend to give birth in hospital employ a midwife to attend them for birth, and provide continuity of care through the pregnancy to the postnatal period. Although private midwives do not have visiting access arrangements with hospitals, the partnership between the labouring woman and her known and trusted midwife is able to transcend most situations in which a hospital protocol might derail normal birth. The woman and her private midwife make decisions about when to travel to hospital, as the midwife uses her knowledge and skill to protect the natural processes in birth and early parenting.

This aspect of private midwifery practice goes unrecognised in Australian birth reports. The woman who plans homebirth, then transfers her care to hospital can be tracked statistically, but not the woman whose plans include a private midwife for planned hospital birth. The position of the private midwife in hospital has not been mentioned in all the so-called 'reform' that we are engaged in at present.

Private midwifery practice and Medicare-eligible midwives
This is the aspect of private midwifery practice that is set to emerge from 1 November, less than one month away. There are more questions at present than answers.

The Medicare-eligible midwife who I will refer to as the 'MEDI-WIFE' will be a very different person from the ordinary privately practising midwife. The MEDI-WIFE will:

• have a close working relationship with a group of obstetricians (no doctors work 24/7 these days
• provide prenatal checks in the community, possibly in 'rooms' shared with obstetricians or other doctors
• attend births in private hospitals where she has visiting access, and where the 'senior' member of the professional team is always the obstetrician
• be able to order basic tests and prescribe basic drugs, such as oxytocics
• provide postnatal services for mothers and babies in hospital, and possibly at home.

The Australian Medical Association has published Collaborative arrangements: what you need to know, in preparation for the birth of the MEDI-WIFE.

A great deal of discussion is taking place in the world of midwifery about the signed collaborative agreements that have been required, under law, for a midwife to be eligible for Medicare &c. Go to the MiPP blog for more information.

Midwives are now being asked to record examples of our efforts to comply with the requirements of the Determination, so that the implementation of the government's maternity 'reform' can be reviewed over time.

What is the position and/or importance of independent midwives as an option for pregnant women?

This is a question put to me by a lawyer representing a midwife who is answering charges of unprofessional conduct with the regulatory board. I will express my opinion on the position and/or importance of independent midwives as an option for pregnant women, and provide statistical information as to the current status of independent midwifery practice in Victoria.

My report is based on my midwifery qualification and more than 30 years’ experience in midwifery, including teaching, writing, professional and regulatory work.

It is my opinion that midwives are capable of practising privately and independently as primary maternity care providers, ensuring safety and wellbeing for the mother and child, and effectiveness of the service provided. Some current statistical information will be provided below.

The Definition of the midwife (ICM 2005) (the Definition), which is accepted in Australian midwifery education and professional codes of practice, states that “The midwife is recognised as a responsible and accountable professional ... to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”

The Definition does not comment on issues of employment by an agency, or self-employment. Although most Australian midwives work as employees of maternity hospitals, the option of being self employed has existed historically. The midwife who practises privately enters an agreement with the individual woman (client) who pays the midwife’s fee. There is no government funding for privately employed midwives, which compares with free hospital based maternity services.

The Definition states that “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.” The independent midwife is the only provider of home birth services in most communities. The current exceptions in Victoria are publicly funded home birth programs based at Sunshine and Casey hospitals.

The question of the importance of independent midwives as an option for pregnant women is a personal one. Childbirth is not a medical condition, and many women who choose home birth object to what they perceive to be excessive and unnecessary use of medical intervention in hospital births.

A woman planning to give birth at home understands that the midwife does not use drugs to stimulate labour or to take away pain, as is commonly available in hospital.

The Definition addresses situations in which transfer from home to hospital may be advised: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”

The ACM (2008) National Midwifery Guidelines for Consultation and Referral (Guidelines) are also used by midwives in the provision of primary maternity care. These guidelines are not designed to be prescriptive, and are to be used within the context of informed decision making by the individual woman.

When a complication such as non-cephalic presentation is detected, the midwife will usually seek to arrange consultation with a specialist medical practitioner (obstetrician). The woman is able to make decisions based on the advice she receives. Transfer of care from planned home birth to a hospital or private obstetrician will only occur if the woman chooses that option.

When transfer of care occurs, the independent midwife usually continues to provide private midwifery care within the context of the new care plan.

There are occasions when, after a midwife has advised and referred a woman for specialist medical consultation, the woman chooses to continue with a plan for spontaneous labour and birth. This may be against medical advice. The woman makes an informed decision as a competent person.

The number of women who give birth at home is small, approximately 0.2% of all births in Australia (Laws and Sullivan 2009, p21).

There is controversy about the safety of planned homebirth in Australia, particularly since the publication in the Medical Journal of Australia of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), in which all births recorded as planned homebirths over a 16-year period were reviewed retrospectively. Many questions have been asked about statistical method and conclusions drawn. There are probably only two women in the study whose babies died who started labour at home planning a homebirth. The others whose babies died had all transferred before the onset of labour, which means that the management of the labour was in the hands of the hospital, not the independent midwife.

Annual reports on perinatal data are published in Victoria by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, within the Department of Human Services. The most recent published report refers to births in 2007 (CCOPMM 2009). Of the 253 women whose births were coded as planned home births, seven babies were admitted to hospital nurseries. This is a similar rate of admission to the group of babies born at small hospitals with less than 100 births annually. (CCOPMM 2009, page 30). I am not able to draw conclusions about these births.

There is a degree of uncertainty in all births.

[If you would like the references quoted above, please contact me joy@aitex.com.au to request them, or leave a comment with your email address)

RCM Campaign for normal birth

The Royal College of Midwives (RCM), the professional body for midwives in the United Kingdom, has a Campaign for normal birth.

The protection of normal birth will, without doubt, save lives of mothers and babies and reduce morbidity in both developed and developing countries.

The promotion of normal birth is a message that must be a top priority for all midwives and other maternity care providers in an age that embraces gadgets, quick fixes and technology, and ignores the sensitive intuitive processes that are essential to human life.

The support of normal birth is contingent on the undeniable fact that the safest and most wonderous way for a baby to be brought into this world is, in most cases, in harmony with natural physiological processes.

The midwife holds the key to protecting, promoting, and supporting normal birth. The midwife has the skill and duty to be 'with woman' as the first level (primary) care provider, and to engage and work with other specialist providers when and if the individual woman or her baby need specialist intervention.

It seems to me that 'normal birth' is perceived to be the default position in midwifery care: if there are no complications, 'normal birth' will ensue. In fact, nothing could be further from the truth.

Having practised independently for the last 15+ years, I have learnt, mainly through refelctive learning, that the practice of promoting, protecting and supporting normal birth is in fact the most demanding, engaging professional challenge that I have ever known.


Here is an example of the very useful links featured at the Campaign for normal birth site:
Latest news
* Cathy Warwick comments on the Lancet editorial which criticises homebirth and midwife-led care
* Promoting normal birth key to cost savings
* Midwifery Care and Normal Birth - Recent Policy statement by Canadian Association of Midwives
* Specialist preparation pre-pregnancy produces no measurable outcome benefits
* Giving birth at home is as safe as doing so in hospital with a midwife



Readers of this and related blogs will be aware of the enormous threats that are at present being experienced by midwives who practise privately in Australia.  Government 'reform' of maternity services threatens to restrict midwifery with excessive bureaucracy and rules that ignore women's basic human rights and autonomy in choosing their care provider and place of birth.  Rather than focusing on the dog's breakfast of 'guidelines', 'frameworks' and regulations, I call on all midwives to shift our focus to a campaign for normal birth.

Breastfeeding babies exclusively

These two mothers breastfed their babies at a rally outside the Health Minister's office.  Well done!

Exclusive breastfeeding for the first six months of life, followed by continued breastfeeding as well as a diet made up of nutritious family foods to the age of two years and beyond is the gold standard in infant nutrition.

Far too few babies in our world get past the first week exclusively breastfed, which sets them up for subesquent feeding difficulties.

I won't try to explain why exclusive breastfeeding is so important to both mother and baby. Sufficient to say that the principle "In normal birth there should be a valid reason to interfere with the natural process" applies as much to the establishment of breastfeeding as it does to progress in labour. Interferences will likely interrupt natural physiological processes, including mother-baby attachment, bonding, onset of lactogenesis 2, baby's ability to suckle, baby's gut flora, jaundice, and a mother's acceptance of the maternal role, just to mention a few.

A baby who is born at home, whose mother takes the baby to her breasts and who is able to initiate breastfeeding without interruption in the next hour or so is very unlikely to ingest anything other than his own mother's milk in the first week of life. It's a busy week, with baby eagerly taking the breast frequently through the day and night, and often with both parents facing endurance challenges. Some mothers and babies face some of the not uncommon difficulties with flat nipples or very large breasts or whatever. But by about day 4 or 5 there is an abundance of wonderful milk, a baby who sleeps blissfully after spending time at the breast, and there's light at the end of the tunnel.

The over-medicalisation of birth has led to many babies experiencing non-physiological challenges at birth, and this leads on to wasting of the baby's energy resources, painful surgical wounds in the mother, and separation of mother and baby. The end result is that babies are given artificial formula feeds to 'supplement', 'top up', or 'complement' what the baby is able to get from the breast.

Where the natural provision for a baby is ideally suited to the baby's physiological needs, of small volumes of colostrum that coats the digestive tract and supports cell proliferation and colonisation of the gut with the normal bacterial flora, the baby who is given, at 2 hours of age, 30ml of the white chemical concoction that is called infant formula has the whole process interrupted and interfered with. While that baby's energy needs may be met a whole lot of other needs are being denied.

A midwife recently told me that she was concerned about her client giving birth in a particular hospital because any baby born over 4 kilos was immediately treated as if at high risk of hypoglycaemia. The baby would be taken to the nursery, separated from the mother soon after birth, and blood glucose levels tested. With interruption to the first breastfeed, and separation, it's likely that a 'negative' result - blood sugar level lower than the required amount - would be obtained. That baby would then be given a formula feed, and the whole process repeated in a couple of hours. A mother who objects to the infant formula will be given information about the horror of hypoglycaemic brain damage, and only someone who is well informed knows that she has another option - to breastfeed effectively.

With approximately one in three babies in hospitals being born by caesarean surgery. The usual post operative pain management regime in hospitals in Melbourne maternity hospitals is Endone (a narcotic, dangerous drug that comes with the warning, "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child."), Panadol and Voltaren. I have written about Endone at my villagemidwife blog



Anyone who takes exclusive breastfeeding seriously knows it's an uphill battle in most hospitals. Even the Baby Friendly hospitals. It has been 15 years since the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was produced and adopted. The Declaration, adopted by all WHO and UNICEF Member States, has been a key strategy on improving health of infants and young children through optimal nutrition. [for more information go to Innocenti + 15]

Maternity care today is so wedded to infant formula use that it will take a major reformation to change the trend. The community must demand protection of the infant's right of access to the breast. We must also demand that human infants are given only human milk: that milk banks should be available for any additional requirements of breastfed babies.

VBAC - assessing safety and success

This Reference will be of interest to readers who seek to understand vbac.

Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success.

Cahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones GA.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA. cahilla@wustl.edu

Comment in:

* BJOG. 2010 Jul;117(8):1034; author reply 1034-5.

Abstract

OBJECTIVE: To estimate the rate of success and risk of maternal morbidities in women with three or more prior caesareans who attempt vaginal birth after caesarean (VBAC).

DESIGN: Retrospective cohort design.

SETTING: Multicentre, from 1996 to 2000, including 17 tertiary and community delivery centres in north-eastern USA.

POPULATION: A total of 25 005 women who had had at least one prior caesarean delivery.

METHODS: Women who attempted VBAC with three or more prior caesareans were compared with those who attempted after one and two prior caesareans. Univariable and stratified analyses were used to select factors for multivariable analyses for maternal morbidity. Maternal characteristics were compared using a Student's t test, Mann-Whitney U test, chi-square test or Fisher's exact test, as appropriate.

MAIN OUTCOME MEASURES: The primary outcome was composite maternal morbidity, defined as at least one of the following: uterine rupture, bladder or bowel injury, or uterine artery laceration. Secondary outcomes were VBAC success, blood transfusion and fever.

RESULTS: Of 25 005 women, 860 had three or more prior caesarean deliveries: 89 attempted VBAC and 771 elected for repeat caesarean. Of the 89 who attempted VBAC, there were no cases of composite maternal morbidity. They were also as likely to have a successful VBAC as women with one prior caesarean (79.8% versus 75.5%, adjusted OR 1.4, 95% CI 0.81-2.41, P = 0.22).

CONCLUSION: Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.

more on risk management

In a previous post I explored the presentation of 'risk' by a doctor to a woman who was planning for vaginal birth of her second child after a caesarean birth of her first.

We live in an information era. Our challenge, as midwives, is to understand reliable information and to present it in a way that enables our clients to make good decisions. A good decision is, literally, a decision that leads to good outcomes for that mother and her baby.

Managing risk is a difficult topic to write about, and can be even more difficult if you are confronted with decisions needing to be made. The pendulum of risk-managed maternity care has swung a long way from the centre, to the point where any identified increase in risk is immediately considered a valid reason to interfere with the natural process.

When research has been carried out on a group of 'patients' in a way that quantifies a particular risk, the practitioner has a duty to inform the client about the research. This is obvious. Yet, in my mind, the prevailing risk-averse culture in maternity care today robs women of any semblance of informed decision making. Instead, by even mentioning risk of death (known as 'shroud waving'), maternity services ensure a high level of compliance with the prevailing culture of intervention, and devaluing the spontaneous physiological birth process.


Recently I was with a woman who was advised to have an induction of labour a couple of days after 41 weeks' gestation. The reason given was that the volume of amniotic fluid (AFI) around her baby was less than the normal range (AFI 5-25) - a feature that was identified coincidentally when untrasound examination was carried out for another reason. The fetus was active, and there were no other unreassuring features identified.

The doctor who presented induction of labour as the planned course of action explained that there was an increased and unacceptable risk of death of the baby. In quantifying 'risk' he stated that at 41 weeks there was a risk of 1 in 1000; while if the AFI was reduced the risk was 3 in 1000, or 1 in 333. Furthermore, the doctor stated, induction of labour at 41 weeks does not increase the 'risk' or likelihood that a baby will need to be born by caesarean.

The numerator in the equation is death of a baby at or around the time of birth. The denominator is all births with that particular set of features.

Most women who hear words such as "we need to induce labour because there is an unacceptable risk to the baby if we don't induce labour" will be frightened, and immediately agree to whatever plan is presented to them. They cannot contemplate the thought of losing this precious baby. They cannot ask questions that enable careful consideration, because that makes them feel as though they are willing to place their baby's life at risk.

Words such as 'unacceptable risk' are used deliberately. The argument by the doctor is that he or she would be taking an 'unacceptable risk', from an indemnity point of view, if he or she did not recommend action to get the baby born without unreasonable delay.


The pathway to healthy, normal, physiological birth begins long before labour, including:
* a healthy mother, who cares for her body and the child she carries
* a fetus who has grown normally
* a fetal head whose position inside the maternal pelvis, in relation to the internal os of the cervix is able to bring about normal onset of labour

We don't know what gets human labour started in nature. Not 'knowing' makes waiting for spontaneous onset of labour an 'unacceptable' delay in many situations where an increased risk has been identified.

Logically an increase of 2 in 1000 births is not a big risk. As I have discussed previously, there is a background risk for death of a baby of about 1 in 100 for all births. Many of the babies who die have increased risk because of abnormality, prematurity, or illness of the mother. That means that the real risk to a healthy woman with a healthy baby is greatly reduced.


The question I am placing to myself, and to other midwives who may face this dilemma, is:
at what point does it become unreasonable to wait for spontaneous onset of labour,
or,
at what point does it become important to move out of Plan A?


A midwife's decision-making is a constant process, and it continues throughout the episode of care. The woman whose baby has not been born by 41 weeks, and who has been told by a doctor that she needs induction of labour, may look to her midwife to help her unpack the issues so that she can understand the situation well enough to make a wise decision. The informed woman who accepts induction of labour, or any other departure from 'Plan A', does so because she believes it is the best course of action for her and her baby at that time.

A midwife in the situation described here would be unwise to insist in a blinkered way that 'natural is best' - yet she could also be challenged if she supported the plan for immediate induction of labour.

The midwife has to see beyond the risk of a perinatal death, and evaluate all the other reasons for promoting, protecting and supporting physiological processes in the childbearing continuum. The birth of a baby, although hugely significant, is not the 'end point'. It's only a beginning. The ability of a mother to accept her baby, to form lifelong bonds, to nurture the child, to feel well physically and emotionally in herself: to get along in life, cannot be trivialised. Similarly, the ability of the baby to make those huge natural transitions from the womb to the outside world, to search for and take life-giving milk from the mother's breast, and to become resillient and grow strong: these are all matters of immense value to the mother and her child, and the midwife.


I have written enough for today. I have a big pot of soup on the stove, and am looking forward to enjoying a bowl with my family. I hope that today's discussion supports other midwives and women who have to confront risk management in their daily lives.

VBAC statement from RANZCOG

A new College Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) has been issued (July 2010) by the College of O's and G's, RANZCOG. 

Midwives who are monitoring the current state of maternity reform in Australia are aware of increasing pressure on both women and midwives to comply with RANZCOG's professional guidelines.

In this statement RANZCOG has summarised its statement of risks to mother and baby, of both 'Trial of labour' and repeat elective caesarean surgery, and its recommended plans of care. 


Recently I was with a woman who was planning vbac at home in my care, as an obstetrician was reviewing my client whose pregnancy had progressed to 11 days past 40 weeks.  The doctor listened with empathy as the young woman explained that she felt severely traumatised by the caesarean birth after induction of labour for her first baby.  The doctor considered that a trial of labour was a good plan, but was adamant in objecting to the plan for home birth. 

The doctor's explanation of risk was:
"One in 200 women who attempt vbac will experience uterine rupture.
"One in 10 of those who have uterine rupture will experience serious consequences - either serious (maternal) haemorrhage or still birth."

These risk figures are consistent with the references quoted in the College Statement on Planned VBAC.  Multiply 200X10, and according to this doctor there is a risk of 1 in 2000 that an attempted vbac will have an adverse outcome.


The doctor did not mention to my client that elective repeat caesarean increases the risk to her, particularly in her chance of serious haemorrhage, leading to hysterectomy, and even death.  Her risk of abnormal placenta implantation (previa and accreta) was increased in subsequent pregnancies.


Pregnant women are often faced with many risk calculations.  In early pregnancy when they have screening for Down Syndrome they are greeted with risk ratios that would be more familiar to bookmakers than to most mothers-to-be.   Many feel bullied by the use of statistical reckonings that seem to have been pulled out of thin air.

Here are a few other statistics to consider:

Despite impressive advances in technology and treatments Australian parents experience the tragedy of loss of a baby in approximately 10 in 1000, or 1 in 100 births (perinatal mortality rate in 2006, from the National Perinatal Statistics Unit).

The rate of babies born with Apgar scores less than 7 at 5 minutes in 1.5 in 100 births or 15 in 1000 births (PDCU 2007) in Victoria.

Women giving birth in hospitals have approximately a 30%, or 30 in 100 chance of caesarean birth.  Women having their FIRST baby in certain private hospitals have a 50%, or 50 in 100 chance of caesarean birth. 

Comparing these risks with the 1 in 2000 risk of adverse outcomes for vbac makes vbac sound relatively safe.

Midwives advising women who are intending to give birth physiologically will encourage minimal interference as labour establishes and progresses.  If their plan is to go to hospital for the birth, the transfer will usually occur after the labour has established.  Key features of midwife care for planned vbac include:
.trust: the woman and midwife establish a partnership based on reciprocity and trust
.the woman calls the midwife to be with her at her home when her labour has established
.the midwife carries out basic assessments of fetal and maternal wellbeing, and progress, in an unobtrusive way
.the woman is able to proceed to home birth vbac, or to make an informed decision to go to hospital when and if needed

The RANZCOG College Statement sets out advice on TOL (trial of labour), including:
.admission to hospital relatively early in labour
.intensive maternal and fetal surveillance intrapartum, including continuous electronic fetal monitoring.

Clearly there is a huge difference in the way independent midwives and obstetricians approach vbac.   There is no evidence of poor or worse outcomes when women plan vbac at home.  Some go to hospital; some proceed to vaginal births in hospital and some proceed to another caesarean birth.

Reviewing July 2010

In a world that is constantly changing, one thing stays the same: babies are conceived and grown, in the bodies of their mothers, and the time comes for every one when she or he must be born.   The physiological, natural process is the standard way, just as breathing is usually done without drugs or machines.

In the past few weeks Australia has seen its first female Prime Minister, Julia Gillard, take over the reins of government, and a federal election has been scheduled in August.

The polls tell us that women are preferring Ms Gillard. Is she worthy of our trust?

Julia Gillard was the Opposition health spokesperson in the leadup to the last federal election. She was instrumental in assuring women that maternity reform was a high priority for the Labor Party.

The Australian people elected the Rudd Labor government, and Julia Gillard became the Deputy PM. The Health portfolio was passed to Nicola Roxon; the Maternity Services Review and various offshoot inquiries were held; and the government meekly followed the directions laid down by the medical lobby.

That's all on the record.

Birth IS important to women, and to their midwives.
Birth IS NOT an illness - to be managed, treated, and cured.

Decisions made by any woman going through any natural physiological process, such as pregnancy and birth ARE of profound significance to that person and her family. The mother not only (literally) takes the baby home; she takes her body and mind home. Many new mothers do not make the adjustments well; many suffer depression and post traumatic stress for years after what should have been a satisfying time of personal growth and development.


A group of mothers and midwives in Brisbane, under the Maternity Coalition banner, rallied yesterday as the PM and the Health Minister announced funding for mental health initiatives.

“We welcome Julia Gillard’s announcement about increased funding for mental health. Suicide is the leading non-direct cause of death for new mothers. We know that good quality maternity care, including from a known midwife, is likely to be protective against post-natal depression”, said Melissa Fox, West End mother of two and Vice President of consumer group Maternity Coalition’s Queensland Branch.

We know that rates of depression can be reduced when women receive primary care, with appropriate social support, from a known and trusted midwife. As it happens, primary maternity care from a midwife is THE very issue that the Australian health care system refuses to support.

Why?

Simply because the medical profession considers it in the public interest that all maternity care be carried out under medical supervision and strict medical protocols.

Ms Fox noted “The Government has committed $120m to Medicare for midwives. We call on the Government to remove the legislative barrier to enable the reforms to work. No action on the part of the Government would result in no improved access for women to midwifery models care ”.


In a similar press release, birth activist Justine Caines claims that:

"Women’s Rights Removed under Female PM - Sometimes it does Matter that the PM is a Woman.
The new Gillard Government has removed the basic rights of women in childbirth, with legislation that requires medical permission for all elements of [maternity] care.

"These moves mean that a doctor not a woman will decide. Most women seeking private midwifery care have gone out of their way to seek this option" Ms Caines added

"The Gillard government has just annihilated those choices, giving doctor the say over women's bodies and births."

“Minister Roxon’s total mismanagement of the Medicare for Midwives initiative will have far reaching consequences across the health sector. Childbirth accounts for the greatest number of hospital bed stays and yet we have a Health Minister putting doctors hip pockets over whole of maternity reform.”

Links:
Maternity Coalition Queensland blog
Maternity Coalition website
Homebirth Australia

post script:
The world of private midwifery practice for women planning homebirth is not very different today than it was prior to the last election. The substantive difference is that midwives now must:

• have indemnity insurance to cover all pre- and postnatal work, with homebirth being exempt
• obtain consent from women that they wish to proceed in the care of an uninsured midwife if they give birth at home.

The current status of access to homebirth midwives will have changed in some communities, particularly in rural areas.  A number of midwives who had previously attended a small number of homebirths each year have withdrawn from homebirth practice.   Many midwives are confused about the indemnity insurance rules and products.  The information and links at the MiPP blog is up to date.  A disproportionate number of midwives in private practice are currently under investigation by the regulatory authority, and one Victorian MiPP has had her licence to practice suspended.
Some MiPPs are preparing to be eligible for Medicare, hospital visiting access, and other extensions to practice (prescribing and ordering tests), which is scheduled to be in effect in November this year.  There are many unanswered questions in this arena - pregnant women whose babies are due in November and subsequently should not hold your breath for Medicare rebates for your midwife's fees, or for your chosen midwife to attend you privately in a public maternity hospital.

A year in review -part 2

It is just one year since the formation of Aitex Private Midwifery Services (APMS), and I am reflecting on the question, "How has APMS performed in the past 12 months?"

[The business model I had prior to 2009 was that I was self-employed. The difference with the APMS business model is that I now employ other midwives, as well as personally being employed by APMS]

The goals for the year 2009-2010 were:
APMS intends to establish a robust business model for achieving its purposes. Prior to July 2010, APMS aims to:
• provide primary maternity care for (x) women
• employ and mentor two midwives as primary maternity care providers, and as ‘second midwife’ for planned homebirths
After 1 July 2010, with changes in legislative arrangements for midwives, APMS aims to
• find ways of providing ongoing private midwifery services
• provide support for women and midwives affected by the legislative changes
Long term goals include midwife education in caseload primary maternity care practice and homebirth; consumer education; and mother to mother peer support.

The following notes are condensed from the APMS Annual Report.

1. The business model has been developed.

2. Midwives employed by APMS have signed employment agreements, submitted time sheets for hours worked, and are paid by APMS. Superannuation has been paid when midwives have earned $450 or more in a month.

3. Clients have been receiving primary maternity care through their pre, intra, and postnatal episode.

4. The three midwives have been employed and mentored.

5. Plans for AFTER 1 July: One midwife has indicated her interest in continuing as a midwife in private practice, and has agreed to working as the first APMA 'partner'. Another midwife has spoken to me about coming under a mentorship agreement.

6. Midwives in private practice are required to have professional indemnity insurance to cover prenatal and postnatal services after 1 July 2010. Homebirth is exempt. All APMS midwives will confirm that they have appropriate indemnity insurance.

7. At present two insurance products are available [see MiPP blog]. The APMS fee for primary care has been increased by $100 to pass on that extra cost to the clients.

8. Midwives who attend women for homebirth are required to inform their clients of the lack of indemnity insurance for homebirth. An agreement form which clients and midwife sign acknowledging the lack of insurance has been developed.


APMS employment model
Since a midwife in private practice works with individual women, the APMS employment model links the midwives to the women who engage us for private midwifery services.

This model enables midwives to be employed either as a partner/colleague, or at an agreed rate of pay that compares favourably with the rate that midwife would be paid as a casual employee in a hospital, but is the same regardless of weekends or public holidays.


Vision for the future
I envisage growth in APMS, with increasing numbers of women receiving maternity care, and increasing numbers of midwives being supported and mentored through this practice.
I envisage good birthing outcomes in the care of APMS midwives.
I envisage a robust midwifery workforce, developing strong midwife identities, engaging in ongoing learning and professional development, and reflective, critical practices.
I envisage midwives who are located distant from Melbourne coming under the APMS employment and mentoring model.
I envisage expanded opportunities for peer support by mothers and midwives through APMS
I envisage midwife partners mentoring others, as part of their roles in this practice.


Note: Part 1 of this review is at the villagemidwife blog

what midwives will NOT accept

The obstacle that has been obvious to midwives throughout the maternity reform process is to do with the requirement for a 'collaboration' agreement between a doctor and the midwife.

OF COURSE midwives want collaboration. We do it all the time.

BUT we will not agree to another professional (a doctor or anyone else) being given authority to sign off on a midwife's professional decisions. That is not collaboration, it's control.


In recent weeks an announcement has been made by the Health Minister Nicola Roxon that a government-supported insurance policy is now available for midwives to purchase. This MIGA policy, as it stands, does not meet the needs of private midwifery practice, and is unacceptable.

Professional Indemnity insurance, which is not available for homebirth, is mandatory from 1 July this year - with an exemption for homebirth. Midwives whose field of practice centres on women who intend to give birth at home, employing a midwife privately to provide a professional service, do not want an insurance that covers birth in hospital. Hospital visiting access is simply not available for midwives, so why would they want to buy an expensive insurance product that covers hospital birth, if they have no opportunity to attend their private clients in hospital?
For more discussion go to the MiPP blog.

The Australian College of Midwives (ACM) has issued a press release supportive of the MIGA insurance, and hospital birth attended privately by a midwife. ACM spokeswoman, midwife Tina Pettigrew states that:
“To be able to look after a woman throughout her pregnancy, follow her into the hospital to have her baby and follow her home again afterwards to help her settle into being a new mother is what I’ve always wanted to do. Now I can to do all this with full indemnity cover”
ACM also claims that:
"The provision of insurance cover for private midwives is one of the necessary precursors to midwives gaining access to Medicare funding for their care from 1 November this year.
"Medicare funded midwives will be able to work in practices in the community, with other midwives, with doctors and with allied health professionals as well as in hospitals to offer more women the choice of having one-to-one care from a known midwife throughout their pregnancy, labour, birth and early parenting."


The deadline, 1 July, is approaching. Many midwives in private practice have indicated in discussion that we we plan to buy the cheapest insurance product that meets the requirements of the new national registration and accreditation legislation.

Insurance does not protect the mother and baby in our care. Good midwifery practice, and promotion of health in pregnancy, birth, and mothering does. As I wrote in August last year, the insurance debate is more about smoke and mirrors than safety.
It's more about business at the top end of town than protecting the little person.

Until our government provides a no-fault insurance product that deals equitably and fairly with all consumers who suffer loss or disability in health care, the insurance industry, and the law industry, will be the only ones who benefit.

"not for the faint-hearted"

Private midwifery practice is reaching a watershed. Many midwives who have in the past practised privately, providing a vital professional service for women who want to protect and work in harmony with their bodies' natural processes in birthing, are quitting.

Midwives who are continuing are arranging insurance policies that will comply with the new laws (NRAS). The cost of insurance will be passed on to the consumers. Midwives are likely soon to be less available and more expensive.

This may sound pessimistic when the spin from the Health department is that "Private midwives to be covered by insurance".

Health Minister Roxon is reported as saying "This will make a real difference to expectant mums, who can now elect to see a private midwife who will have government-subsidised insurance and, from November 1, have the cost of those services covered by Medicare," Health Minister Nicola Roxon said.

The government-subsidised insurance covers midwives attending birth privately in a hospital. At present we know of no hospital that is willing to extend visiting access to midwives. We will be interested to know of developments in this direction.

Details of the government-subsidised insurance, and links, are at the mipp blog.

The second insurance option, called 'Mediprotect' and available through insurance agency VERO, provides cover for private midwifery services in pregnancy and postnatally, EXCLUDING birth.

A letter from the Victorian branch of the nurses and midwives union, ANF, received by a member today, informs us that the ANF Vic members insurance policy is also with VERO. VERY interesting. To date ANF Vic has responded negatively to requests from members to find an insurance policy that also covers private midwifery services in pregnancy and postnatally, EXCLUDING birth.

Back to the title of this post, "Not for the faint-hearted."

There are a number of midwives in private practice who are currently awaiting formal hearings by the statutory body, into complaints about their professional practices. One well known midwife in a rural Victorian setting has, a couple of days ago, had her registration suspended pending a hearing.

It appears that there is an escalation in the number of complaints that are being made about private midwives.

The mandatory reporting requirements of the new NRAS define notifiable conduct as (the usual impairments, sexual misconduct, ...) and
"(d) placed the public at risk of harm because the practitioner has practiced the profession in a way that constitutes a significant departure from accepted professional standards."

We midwives must be prepared to gather credible evidence and define accepted professional standards. It doesn't say "in the local hospital" or even "according to the professional body".

Midwives in private practice stand out like sore thumbs, and can expect to be reported.

We can also report. Can our community accept midwifery that results in 50% of primipara having caesarean surgery, with the subsequent increased risk to the mother and future children?

There is a huge theory-practice gap. Everyone involved in education knows that. We have to use that theory-practice gap to declare what is acceptable, and what's not. We have to be prepared to question what we see and hear, gather information, and write reports to the Board. Even if they are dismissed, the concerns that we all talk about need to be put on the record.