Back to midwifery

There is a lot of swirling in midwifery recently - the past 2 weeks have been rather tumultuous.

Which made me realise that I've not posted about midwifery in a long time. Lots of reasons - I am only 15 weeks away from finishing my degree, I have applied for a graduate position after a LOT of heartache and back and forthing with TheHusband, and it's just been a damn hard slog. I'm a little over it but I also need to dive back in.

But recently there's been a lot in the media - one midwife dragged into court to face a very one-sided roasting, midwives running around like chickens sans head about nothing, and lots of mentions about the rate of homebirths going up. All things to tempt me out of the hermitage!

And getting my brain working again. What I think this adds up to is that there is a push to define what a midwife is. Not just in the ways it's been done (to death) already but in a specific, task-oriented, check this list kind of way. So that if you palpate a belly, check any physiological measure, or whatever I've spent the past 5 years learning how to do - not the important stuff of working with women but the practical skills - then I need to be registered. And just as practicing medicine without a license is a crime, so practicing midwifery without registration will be.

And what that means is that only registered midwives will be allowed to practice midwifery. So midwives who are off the register won't be allowed to practice. Not just "are not allowed to call themselves midwives" but won't be allowed to support women in pregnancy or birth. Which I think is what some midwives in private practice have been working towards all along. And it will be the undoing of midwifery and be more limiting that freeing.

Midwifery will get more few layers. Doulas who do the old-fashioned and SO VALUABLE stuff of midwifery of supporting women in their travail with no medical advice involved; lay midwives who combine herbology, aromatherapy, body work, psychology and so much else to caring for women in their community; registered midwives in private practice hog-tied by insurance and regulation to not attend anyone who is not perfectly "no risk"; eligible for Medicare registered midwives doing even less midwifery and more paperwork; and the rest of the midwives who are able to go to work in the system.

And thus there will be another change in how women are served. We started off attending the births of our friends and neighbours, then worked on our own, trained apprentices doing the attending and so on. We tended our gardens and the ill, laid out the dead and welcomed the new, and our reputations were the most important.

Then changes came with the invention of anaesthetic and forceps and thus obstetricians were separated from midwives and the skills were separated. And so much was lost for the women.

Then into the hospitals.
Then into the universities.
And now this.

Call me paranoid but I think the persecution of Lisa for her role in a tragedy that had little to do with her and instead is part of the push to define midwives and limit practice of my craft to only those that hold registration.

On night shift and life

Night shift is kind of hard to describe. Unless you've worked in an industry that does night shifts of some flavour, you don't really know what it's like. So let me explain:

On Monday, I took the day pretty easy. I had Sally in childcare that afternoon and had an hour-long nap. When she got home, I had another hour-long nap with her. Then dinner late (7pm instead of the usual 6pm), changed and dressed with a coffee by 8:30pm for a 9pm start.

I have to take another meal to eat overnight. I tend to get a break around midnight, and express at that point as well, then another break around 3am. I eat an extra meal at midnight (what do you call that? It's not supper to me, but it's between dinner and breakfast so I don't know?) with a coffee as well. Then another snack at 3am, with a tea or something sweet. By this stage I've been awake going on 24 hours with only 2 hours of naps in there, and I'm using anything I can to stay focused and alert.

It's a strange time, those hours past about 11pm til about 6am. I don't usually feel tired per se, but am obviously fatigued. I have to focus on drinking water and not focusing on the clock too much. Time goes strangely without reminders of what time it is.

So 6am ish comes around and I'm sent home as there's not much else going on. I get home and eat breakfast. Then feed Sally and TheHusband takes her to a friend's house who then drops her to childcare for me to pick her up in the afternoon.

Have I mentioned how much I love my friends?

Then I wash my face and brush my teeth and go to bed by about 6:30am. Today I slept til 1pm with only a brief up/loo/drink moment. So only 4.5 hours of sleep. But as today is my "day off", which I use very loosely as it's really a sleep day after a night shift, not a day that I can do much in, I don't want to be anything other than tired because otherwise I won't sleep tonight and will be messed up for the next few days.

So that gives a small thumb sketch of how a night shift goes. If it's more than one in a row obviously, I would be napping and preparing mentally for another night. Night shifts are fine in short bursts and the HUGE fabulous point of this is that this is the LAST ONE that I have to do until October.

And no, I don't know what I'm doing next year and whether I'll have to do more of these. So many options, so many variables, so much but so little time as well.

Big changes afoot

This is a complicated post. Maybe grab tea before trying to read?

I have been on the hunt for childcare for Sally. Ugh. How do you choose? I asked some local friends for their recommendations and had a few names to try. The advice I got was to turn up unannounced and explain that you wanted to have a look. So I did that. And to go with my gut.

Well I did that. The first one I went to - well, let's just say that I wanted to go there myself. They have dirt. And gardens. And chickens and bunnies. And attachment theories. And lots of play equipment. Healthy food. Carers holding babes as they slept because they felt safer there. Patience.

And a 6-12 month waiting list. Sigh.

The next one I went to, was different. No natural light. No grass - just fake grass. No sky either. Just big sunshades. And the redeeming feature offered to me by the office manager was that they were recently enrolled in a new formula trial.

But I could get in immediately.

Sigh. Ugh. Fuck. SUCH hard things to find someone to do some of the raising of my child. Because that's what I think childcare is.

So I had to look very closely at why I need childcare. I have to renew my first aid certificate which will take a day. I am blessed to have friends who would help me out with that. But I also have to do a metric fuckload of placement next year to finish the groundhog day / never ending story / degree that never ends. Yup I'm enrolled to go back to school next year to finish two subjects to finish it. They are two 1/2 semester subjects though, so lots of work, and LOTS of placement. And TheHusband can't take enough leave to cover all of it. And I have to finish this damn degree next year.

The other thing is that Sally LOVES to be around other children. Especially childerbeasts of her own age. Loves it. And it'll be fabulous for her to have a carer beyond me and TheHusband. And stimulation and so forth. Plus having 2 days to do stuff is going to be interesting. I don't know what I'll do with myself but I'll tell you about it.

Anyway, the complicated part of this is that I feel, ever so urgently, the need to push on and finish this degree so I can move on into the industry. Or not. I have that small dream as well - to do my breastfeeding counsellor and community educator training with the Australian Breastfeeding Association, do a doula course and some childbirth education work, do more photography, and then go and do everything except register but do some work still with women and birthing.

You see, homebirth is under attack in another forum with the decision yesterday of the Supreme Court that the assistant coroner can investigate a stillbirth because there were signs of life. I can't imagine how traumatic those words would be for a mother to hear that her child had signs of life, when she has made some kind of peace perhaps with the past and that her midwife did all she could to help her birth the baby alive. But from a midwifery point of view, this is world-changing. When someone is mentioned in the same decision as manslaughter because they attended a birth that ended badly, it makes me stop and think about whether this is a situation that I want in on as an independant midwife.

I got into this when I didn't have a plan B (hell I didn't even have a plan A!) and now it looks that I might need another plan.

More about yesterday's post - that AJOG article

Which can be read here.Just a short point while I eat dinner. The exclusions for this study:

To identify a low obstetrical risk population, we excluded multiple gestations, preterm deliveries <37 weeks, smokers, women with pregestational or gestational diabetes, chronic hypertension, hypertensive disorders of pregnancy, or prior cesarean. Demographics included maternal age, race, education, and timeliness of registering for prenatal care. Maternal morbidity measures in this low-risk population included chorioamnionitis (clinical diagnosis of chorioamnionitis during labor made by delivery attendant, usually includes 1 of the following: fever, uterine tenderness and/or irritability, leukocytosis, fetal tachycardia, any maternal temperature 38°C [100.4°F]), fetal intolerance of labor (in utero resuscitative measures, eg, any of the following: maternal position change, oxygen administration to the mother, intravenous fluids administered to the mother, amnioinfusion, support of maternal blood pressure, and administration of uterine relaxing agents; further fetal assessment includes any of the following: scalp pH, scalp stimulation, acoustic stimulation; operative delivery is operative intervention to shorten time to delivery of the fetus, eg, forceps, vacuum, or cesarean delivery), prolonged labor (labor that progresses slowly and lasts for >20 hours), precipitous labor (labor that progresses rapidly and lasts for <3 hours), and meconium staining (staining of the amniotic fluid caused by passage of fetal bowel contents during labor and/or at delivery that is more than enough to cause a greenish color change of an otherwise clear fluid). Newborn morbidity included assisted ventilation (infant given manual breaths for any duration with bag and mask or bag and endotracheal tube within the first several minutes from birth, excludes oxygen only and laryngoscopy for aspiration of meconium), assisted ventilation >6 hours (infant given mechanical ventilation [breathing assistance] by any method for <6 hours, includes conventional, high-frequency, and/or continuous positive pressure), birth injury (defined as present immediately following delivery or manifesting soon after delivery, includes any bony fracture or weakness or loss of sensation but excludes fractured clavicles and transient facial nerve palsy; soft tissue hemorrhage requiring evaluation and/or treatment, includes subgaleal [progressive extravasation within the scalp] hemorrhage, giant cephalohematoma, extensive truncal, facial, and/or extremity ecchymosis accompanied by evidence of anemia and/or hypovolemia and/or hypotension; solid organ hemorrhage, includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma), neonatal intensive care unit (NICU) admission (admission into a facility or unit staffed and equipped to provide continuous mechanical ventilatory support for a newborn), seizures (seizure is any involuntary repetitive, convulsive movement or behavior; serious neurologic dysfunction is severe alteration of alertness, such as obtundation, stupor, or coma, ie, hypoxic-ischemic encephalopathy, excludes lethargy or hypotonia in the absence of other neurologic findings, excludes symptoms associated with central nervous system congenital anomalies), 5-minute Apgar
score <7, and birthweight <2500 g.

 Way to go for reinforcing lots of "risk factors" not supported by research. And why exclude fractured clavicles and transient facial palsy?

Shame on you, Auntie

On Stateline last week, there was a snippet about calls to change laws over stillbirth investigations (link is to video with sound). In a shocking example of "jouranlism", the story went from a woman who wanted her interuterine fetal death at 28 weeks (I'm guessing there - she said "7 months") investigated for some kind of explaination, to a beat up about homebirth. The woman's horrible experience had NOTHING to do with homebirth - she was under the care of a hospital and birthed there.

The tenuous bow that seems to have been drawn between these two stories was that one woman had her baby die in her pregnancy, and another had her baby die during birth, and that latter woman was birthing at home. The case of the latter woman has now rocked the entire concept of "life" because the assistant coroner seems to have an axe to grind about homebirth.

The findings of the case make for interesting reading (go on, read it - it's only 14 neatly formatted and well spaced pages). The assistant coroner seems to have ignored eminent experts in the area of cardio-thoracic medicine and has decided that something akin to the heat left in a boiled kettle, now constitutes life. Instead of leaving the Spencer-Kock family to grieve and live their lives, the decision has been made that their baby was in fact alive at some point and therefore is a "person" under the law and so the coroner has jurisdiction to investigate the death and make recommendations under other laws, like criminal law, against people involved.

This is a scary, scary path to go down. Life has to begin somewhere, just as it has to end somewhere. Funnily enough, the definition of life and the definition of death aren't the same thing - one can be dead but a teeny bit alive as is the case of organ donors. But the line in the sand has always been that "signs of life" be seen in a baby - heartbeat, breath, movement, crying, reaction to stimulus. If these are absent, and the baby is stillborn (oh how my heart aches to write that), then no investigation can be held, no charges laid, no blame attributed. This is a two-edged sword, no doubt - but it also means that until that baby is apart from its mother and is alive, it is not a person. Augh it's confusing and I'm sure someone has been offended by the way I've put it.

Anyway Lavender, as the president of the AMA in SA, then claimed in the Stateline article (yes I was getting back to my point) that homebirth is 7 times more likely to result in a baby's death, which is (a) not true, (b) not supported by any research the whole freaking world over, and (c) not what the recent Flinders University research said. The "data point" that Lavender is referring to ERRONOUSLY is the one I've previously blogged about and kind of indicates that not only is he an idiot, but he also didn't bother reading the study and only read the press release.


Add to that recent beat ups about homebirth being more dangerous with triple the neonatal (first month - hardly a lot to do with homebirth) death rate, which is hard to comment on as the actual study doesn't come out until September, and there is a lot of attack on the process from many sides. Add to that changes here in Australia to registration and insurance for midwives and you have a very muddy water from which to sup. I'm sure there's a line there about babies and bathwater but meh, I can't be bothered.

What I can be bothered with though is to say to the ABC - shame on you for such appalling and upsetting and shallow "journalism". You didn't check the facts, you didn't bother getting any other side of the story, you didn't stop to question what agendas might be being wheeled through your "story" and you certainly didn't bother to notice that a story about stillbirth suddenly turned into a witchhunt for homebirth.

And you didn't stop to think about what this means. Let's say that all stillbirths from 28 weeks onwards get investigated. That is a lot of deaths, firstly, because not all pregnancies end in a live baby. So the coroner is now overwhelmed with them. And what if the parents do not want an investigation? What if the answer is that someone is to blame, that something could have been done, that something could have changed the course of events? How would that help the family? Instead of supporting them, financially and socially, they'll be dragged through the courts. The coroner could then autopsy babies, which means that parts of their bodies can be kept for analysis.

And the funny thing is that hospitals, where 98% of births occur, will suddenly have to be party to many more inquests. And for what?

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From Medscape Medical News

Less Medical Intervention for Home Birth Linked to Increased Neonatal Mortality Rate

Laurie Barclay, MD

July 2, 2010 — Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate vs planned hospital birth, according to the results of a systematic review and meta-analysis reported online first July 1 and will appear in the September 10 print issue of the American Journal of Obstetrics & Gynecology.

"The American College of Obstetricians and Gynecologists does not support home birth, citing safety concerns and lack of rigorous scientific study," write Joseph R. Wax, MD, from Maine Medical Center in Portland, and colleagues. "We sought to systematically review the medical literature on the maternal and newborn safety of planned home vs planned hospital birth."

Selection criteria for the meta-analysis were English-language peer-reviewed publications from developed Western nations, in which maternal and newborn outcomes were reported by planned delivery location. The investigators calculated summary odds ratios with 95% confidence intervals for these outcomes.

Compared with planned hospital births, fewer maternal interventions were associated with planned home births, including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. Women who delivered at home had lower rates of lacerations, hemorrhage, and infections, and their offspring had lower rates of prematurity, low birth weight, and assisted newborn ventilation.

Perinatal mortality rates were similar for planned home and hospital births, but neonatal mortality rates were significantly higher with planned home births.

"Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate," the study authors write.

Limitations of this study include those inherent in the included studies, self-selection of women for home birth, and insufficient data for some outcomes.

"Future research needs to be directed at identifying contributors to and reducing the apparently excessive neonatal mortality among planned home births," the study authors conclude. "Data regarding maternal mortality, maternal and newborn readmission rates and indications, and newborn neurologic injury are insufficient for evaluation and comparison.... Ideally, the results of such work will contribute to an obstetric and newborn best practices model benefiting women and children regardless of chosen birth location."

The study authors have disclosed no relevant financial relationships.

Am J Obstet Gynecol. Published online July 1, 2010.

Support for birthing at home

I have a lot of people respond to our plans for me to birth at home with "Oh I couldn't do that because my husband/partner wouldn't support me / is scared / refuses / said no".

Ok so I get a lot of other responses too but this one is the topic of this post so I'll leave them for another day. And yes, your partner's opinion could have very little to do with your birth because it's yours and not his, but that's not always the be-all and end-all of the situation, is it? I'm a strong woman but if TheHusband was not onboard then I'd have a struggle on my hands because I need his support more than I need to be right. Doesn't mean I wouldn't argue every single day for the entire gestation of course.

So - let's say you have no desire to birth in a hospital but the realities of your relationship mean that your partner is not going to support you to do that.

REGARDLESS of the reason, valid or not, if you can't argue the point to a homebirth conclusion then here's some advice I wanted to pass on.

Even if you don't/can't stay home to birth - and your partner being completely against it, and either has a lot of anger, fear or reluctance - you need to make it clear that you will absolutely be staying home until the latest possible time. This could be until you are feeling pushy, or when contractions are very close together (2 minutely, established that way for a while)

I am not suggesting you trick him into a homebirth. But he has to be on board to support you labouring at home. He has to understand that going to hospital early will not get you a baby early. It will get you stuck on a short and artificial timeline, and get you a lot of intervention so if you absolutely can't birth at home, at least only turn up with a little while to go.

Birth is not a spectator sport and nor is it a two-person tagteam game - he can't birth for you. He can only support you in your journey. It is about you and your body and your future. Acquiescing to his preferences to go to hospital early on isn't going to help when it's your body and your experience and your future.

Perhaps get him to read birth stories where the husband/partner/father to mentioned - they are often described standing there stunned, crying, angry, upset, devestated, etc etc at the process and the outcome, and compare them to homebirths (stories, youtube, pics) where the husband is the woman's rock and is in the pool with her or rubbing her back or cheering her on with sweet words. Try to get him to understand how much impact this'll have on him too.

I am SO not saying that all hospital births are like this, or that homebirths are all awesome. This is advice for people birthing in hospitals as well. When you set foot inside those doors, your body and your labour and birth are theirs. You are on their turf and on their timeline. There is no way that someone without an idea of the process (your husband/partner for eg) can support you and advocate for you if you can't. That's what a midwife who does walk with women is your best asset - but in a hospital this is a lottery and there are sometimes few of them, or they are against a lot of pressure from the institution.

Birthing from Within coming to Australia!

If you're interested - PLEASE email Mara to let her know! Especially that we want it here in Adelaide and NOT to have two workshops on the east coast.

From: Mara Dower [mailto:maradower@optusnet.com.au]

Sent: Thursday, 4 February 2010 9:22 AM
To: mara@childbirthmagic.com
Subject: Birthing From Within Team Come to Australia: EXPRESSION OF INTEREST

Dear Family and Friends

Sorry for the duplicate email but for some reason, the text that was originally attached to the first email, mysteriously disappeared, so there was no content but this flyer. So I do apologise.

So let me try to relay what was first written.

I have the pleasure (with others around Australia I believe) in assisting the Birthing From Within Team in coming out to Australia. It's their first time to Australia, and not sure when they'll be returning so it's an opportunity not to be missed!

To make this viable for them, they're interested in knowing who would like to attend their 3 day workshop. They're also trying to decide what State to run the workshop and whether more than one workshop in different States is viable. (Obviously, I'll be cheering for a Melbourne workshop :-))

For those who don't know Birthing From Within, you can get more information from http://birthingfromwithin.com/ Pam England has written a book based on her classes that presents a beautiful way to assist mothers in their birthing journey. Birth Art is one of the components of the class, with other gentle and very practical philosophies for mothers & their partners. The Birthing From Within book was the only resource I used for my 2 births (thanks Jacinta for passing this on) and think it's just wonderful.

So this email is an EXPRESSION OF INTEREST and it would be GREATLY APPRECIATED IF YOU COULD FORWARD TO ANY FAMILY/FRIENDS, INTERESTED CONTACTS/NETWORKS, etc. It would be a wonderful gift for any woman that's pregnant.

I would need to know who would like to attend by the end of next week. PLEASE EMAIL ME AT: maradower@optusnet.com.au or phone/text 0403 290 414

Here's some further information the 3 day BFW workshop and approximate cost:

• The Birthing From Within Introductory Workshop runs for 3 full days, generally Friday morning until Sunday evening (9:00-6:00 each day).
• The registration fees are as follows:

• Registering 60 days before to the workshop is $350 USD/$396 AD*
• Registering 30 days before the workshop is $399 USD/$452 AD*
• Registering within 30 days of the workshop is $450 USD/$509 AD*
• *AD - based on current exchange to Australian Dollars

• The registration fee includes participation in the 3-day workshop, materials and light snacks each day. Participants are responsible for their travel, food and lodging expenses.
• There is excellent and detailed information about our intro workshop on our website at:

• http://www.birthingfromwithin.com/introductory_workshop

• The course is for anyone who cares about birth in our culture and is especially focused for birthing professionals, educators, nurses, doctors, midwives, doulas, yoga teachers, holistic health professionals, therapists, lactation consultants, mothers and grandmothers. And, YES -- natural therapists would LOVE the content of this workshop!
• We would absolutely entertain the possibility of offering two Australian events in Melbourne and Sydney. It just depends upon interest. If there is enthusiastic support for two workshops, we'd be delighted to do them!

For further information, feel free in emailing me and I can get Amanda in the USA to answer any questions.

Your assistance in passing this on is greatly appreciated. I look forward to sharing the BFW workshop with you.

Much Love and Thanks

Mara

Planned home and hospital births in South Australia, 1991–2006: differences in outcomes

The Medical Journal of Australia has released a paper and is claiming wildly increased rates of deaths among home births in South Australia. Read the synopsis - complete with 27 times higher! 7 times higher! bad APGARs!! - and then read the study and LOOK at the contradictions. It is appalling that this stuff ever gets published. And what's with the random throwaway inclusion of SIDS in there? I don't even begin to understand that inclusion...

Edited to add: and interviewed for on NewsRadio!!
Mon 10:45 - Babies are seven times more likely to die during a homebirth labour than a hospital labour -- according to a new study ... (audio)
Mon 10:50 - Homebirth advocates have accused the AMA of conducting a scare campaign ... (audio)

So let's take it apart as Joy has done, just for kicks - cause we all know that the "dead baby" card is a winner, regardless of the facts. Lisa has written a great summary of this as well.

• Although presented as research, it is not - it is a report on the statistics that were available. In research terms, this is the lowest of the low and has no control for biases and no statistical power which is interesting as I am (a) hopeless with statistics and (b) unschooled in them. The conclusions drawn are not backed up by solid numbers so are no better than opinion which is interesting because if you listen to the above interview (first one) the guy is not actually saying what is being reported. He clearly says that homebirth is safe.
• The planned homebirths that are reported are confounded three ways - no one can tell whether they were under the care of a registered and experienced midwife, or were unattended births, or under the supervision of a hospital-based program; the "planned homebirth" number is ~1000 and the actual number is ~300 so we're not talking about actual homebirths - just those that at the first antenatal appointment said they'd like one; and lastly - the way statistics are gathered changed during the time period reported.
  
• The title tells us something - it was about planned hospital and planned homebirths, at time of booking. This is a LONG way from the actual outcome, some 8-9 months later and the study author clearly states that they are unable to separate planned homebirths to actual homebirths out. Lots of planned homebirths don't eventuate for lots of reasons, and not all of them have anything to do with the pregnancy or maternal health. Having filled in the form that is being used here, I can tell you - the midwife looks at the Handheld Record and writes something down. No discussion is entered in to about the whys and wherefores of what changed those plans.
  
• There are probably only 2 situations in all those years where someone's baby died and it was at home and they planned to be there. 2. In 16 years. 1 had known high-risk indicators as it was a twin pregnancy. So we're down to 1 surprise death. In 16 years. That's pretty good odds.
  
• There is no way to look at such a rare outcome of intrapartum death with a small sample. Someone else has pointed out that with those odds you'd need 10,000 births at home to demonstrate this. I'm not a statistician so can't comment on those.
• I've listened to an interview with the author and he does say quite clearly that homebirth is a safe option as long as the woman is prepared, is assessed for risks, and is close to a hospital.
• I agree with Hannah Delaney (as Joy quoted her): I find it amazing that in a broken system, with uninsured midwives with no rights in hospitals, the death rate is actually no different.
  
• The intervention rates are STARKLY different - c-section 9.2% in planned homebirth vs 27.1% in hospital births, episiotomy rates of 3.6% in planned homebirth vs 21.7% in planned hospital births (one sixth the rate!!!!! And CLEARLY shown to be a bad idea anyway. 3.6% is also for the "planned homebirth" women, 70% of whom birthed in a hospital so is not "of women who birthed at home" but includes a large number of women who were perhaps treated the same (ie were likely to have a 21.7% chance of an episiotomy anyway) so the actual % would be lower still).
• Lisa's comments about PPHs got me thinking: that the comparison of post-partum haemmorhage is ridiculous enough to call the whole thing in to question. The numbers are similar once the authors took out the know reasons for PPH in hospitals (episiotomies, induction and augmentation, surgery etc) and so the author concludes that oxytocic drugs are used with the same gay abandon at home as they are in hospitals. Um - no. You the author firstly don't ask if drugs are used, so you can't make that conclusion from the stats. And further you clearly have NO idea how homebirth works and that the calm nature of birth, along with skin-to-skin immediately, breastfeeding, bonding, known care provider and so on decreases the risk of PPH. Even something as simple as keeping the room warm is said by people such as Odent to help. And perhaps because you took out all the confounding factors that are iatrogenic to the birth process in hospital, and found the same number, there is always going to be a background level of PPH and that nothing can be done to avoid a small number of them. It comes down then to how they are managed.
  

Women will always choose this and my concern is that this is going to go even more underground than it already is. I've heard women saying now that these changes make them LESS likely to hire a midwife to birth at home. Not less likely to have a homebirth but less likely to be attended by a registered, trained and competent professional. They are saying they are more likely to freebirth or just hire a doula for comfort. This is going to make the outcomes worse, not better, and probably not change the numbers.

The authors state that ‘women's autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law'. It is about autonomy. Others have said "The excess mortality continues to be found in high-risk women and women need to be informed of this risk." but are missing the point - that even when informed of the risk, some women would rather birth at home and not go to a hospital. And there are some practitioners who will take on those at high risk.

This does give me pause for thought about my own practice. What risk appetite do I have? As a beginner practitioner, I am prepared to go with some known knowns - breech, grand multip, reasonable distance from a hospital - but not twins, or pre-term, or probably a few others. The unknown unknowns I am trained to deal with and know that I have a whole heap of midwives at my phone-tips to call and discuss with, and I can't assess those beforehand so just need to keep up my training and skills and calm to deal with them.

Lastly - this is about the babies. Think of the children!! But there is no measure made of the maternal mortality, and only a very crude analysis made of maternal morbiditiy. No measure of maternal satisfaction.

Hoyden About Town said:
"If this study had shown a substantial increase in fetal deaths with home birth, this would still not be a reason to place legal restrictions on reproductive choice. It would not be a reason to imprison women in hospital by State force, and it would not be a reason to stop women from making informed decisions about our own bodies. They are our bodies, and until a fetus is born, we get the final say in what happens to us."

And therein is the crux of this - it is about the women and their bodies. The fetus does NOT exist legally until it takes its first breath. So what we are talking about it restricting the rights of roughly half the population. Sure, they are rights that a lot won't exercise, and choices that many of them will never make but - just like I have the choice to smoke - I have the choice about where I have this baby.

Reflections on the exam of doom

I only sat one exam this year as the other one I "took ill" in - I ran out of the exam to throw up and spent 3 days feeling very ill afterwards. This was for the subject that I've had to repeat because of my motor vehicle accident in 2007, and so it's effectively taken me 3 tries to sit.

Anyway, there were 13 questions. Of those, I barely had time to write (and certainly not neatly) everything that I wanted to, so chased the marks that were there and moved on.

But there were several questions that reminded me of why care providers are often lambasted as "scare providers". There were a couple of questions about:

- breech presentation
- being "over due"
- induction
- posterior babies

and usually the question was structured around "what is the definition of this / types of this" and then "what are the care options".

Now these questions are really important to ask and discuss and to know your stuff. But - they also put the frame around looking at these problems from a really frightened, defensive point of view.

Let's take breech for eg. The options for care and birth in my opinion are:
- do what you want/can to turn babe (moxibustion, acupuncture, rebozo, visualisation, chiropractic work, external cephalic version)
- find an attendant who is confident with attending you and embrace your breech babe

and if you can't:
- book a c-section for when you go into labour (contradiction in terms of course)

But if you're anywhere near a hospital for care for your pregnancy, the options would be:
- see an obstetrician
- have multiple scans
- have your otherwise lovely normal pregnancy pathologised
- book a c-section for immediate action before you go into labour
- panic, stress and worry

So you can see what my choice was for answering this question in the exam - chase the marks or being a hippy wingnut who isn't afraid of something not strictly in the "norm". And also you can see that student midwives are indoctrinated from such an early stage to be afraid of breech birth. And OP babies. And "post dates" which is so irritating as on one hand we're told that pregnancy goes to 42 complete weeks before being "overdue" and yet we as midwives are taught to get hysterical and Take Action at 40 weeks.

Go read The Lie of the EDD: Why Your Due Date Isn't when You Think to see more.

A step somewhere...

This motion from Senator Siewert that was moved in the Senate and agreed to today:

Senator Siewert: To move—
(1) That the following bills:
Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009
Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009
Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009,

be again referred to the Community Affairs Legislation Committee, together with the Government amendments to the bills circulated on 28 October 2009, for inquiry and report by 1 February 2010.

(2) In undertaking this inquiry, the committee shall consider:
(a) whether the consequences of the Government’s amendments for professional regulation of midwifery will give doctors medical veto over midwives’ ability to renew their licence to practice;
(b) whether the Government’s amendments’ influence on the health care market will be anti-competitive;
(c) whether the Government’s amendments will create difficulties in delivering intended access and choice for Australian women;
(d) why the Government’s amendments require ‘collaborative arrangements’ that do not specifically include maternity service providers including hospitals;
(e) whether the Government’s amendments will have a negative impact on safety and continuity of care for Australian mothers; and
(f) any other related matter.

How does it go?

blah blah blah state of the world etc etc and btw i'm pregnant

congrats. where are you having it?

at home

oh

is that safe?

well yes - i have a private midwife and am well supported with my husband and friends

oh

but it's not safe to do it at home! think of the children!!!

************************************

I have to bite my tongue because:
(a) it's none of your business where I have my baby
(b) not safe based on what? Have you looked at the research? Because in making an informed decision, I have done a lot of research. Have a look at Wikipedia or a recent Canadian Medical Association Journal article for easy understanding:
Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
(c) not safe compared to what?
(d) still none of yur business
(e) I don't think that FOR ME, birth in a hospital is normal, natural or safe and to have a normal vaginal birth in a hospital without unneccesary interventions is a miracle rather than the norm and those interventions cause problems. There are lots of potential downsides to birthing in a hospital - they're used for treating sick people, there is little to no continuity of care or carer, there are clocks everywhere, they are a business and fast turnover is of the essence, the definition of normal is very narrow and anything outside of it is scary to care providers, and the outcomes are no better for all the interventions.
(f) I am a fit young healthy woman and have no need to hire a surgeon for a natural life process, I have hired a professional and expert in normal birth, and am quite prepared for a natural birth, "pain" and all.
(g) There is no pain free way of giving birth, and I am prepared to work with the sensations rather than against them, so don't need to plan my pain relief now beyond having a spot for a birth pool and knowing that we have unlimited hot water.

Same goes with having ultrasound scans, or blood tests, or xrays, or pelvimetry, or combinations thereof.

Informed choice does not mean agreeing with you.

I don't have to agree with you and you don't have to agree with me.

How do I marry these opinions with being a student in the health care system though? I am quite capable in a professional capacity to offer you choices (or are they decisions between two options? A topic for another post I think), discuss them with you, note which you've chosen and go from there. It is none of my business what you do with your body or baby, except from a point of view of a professional discharge of my duties. When in a traditional care situation (hospitals) I can't care for the outcome of your pregnancy from anything other than a professional point of view, because I would burn out. And if I believed in ethical practice, which I do, I also believe in autonomy and the right to self determination in health care. And by the time I see people on a postnatal or labour ward, they've made their decisions and chosen their care path and it is none of my business to judge those decisions. I don't have to agree with yours and you don't have to agree with mine.

And yes, I could just say "local hospital" or "random doctor" and lie about where I'm birthing, to avoid these conversations and having to justify myself. Instead I just smile and say "I've hired a private midwife to undertake my care" and leave it at that. Which is hard and harder at the moment when I'm in a private hospital on placement. I just try to choose who I discuss these things with.

************

And the upsides of birthing at home? Here are 10:

1. I know where stuff is, and so does my hubby. That means we have some of the power back in this situation cause mw Julie will have to ask where things are!
2. The house is colonised with our bugs already. I doubt there's anything nasty hanging around (dust bunnies not counted here).
3. I don't have to go home after giving birth.
4. I don't have to be alone unless I want to be.
5. I don't have to ring a bell and wait for anything or anyone.
6. There are no machines that go ping. Except for the microwave.
   
7. There is not going to be a trip in a car in labour.
8. I get the absolute and final say over who is going to be at my birth.
9. I will not be up on a bed at a convenient height for my birth attendant.
10. My babe will be born where they were conceived.
11. I don't have to have a change of care provider mid-labour, or explain my birth plan, or decline drugs, scans, CTGs, vaginal exams, etc etc, at every turn.
    

What is the big deal about changes to midwifery?

It's not about whether you agree with birthing at home - it's about whether it should be made very difficult (if not illegal) to be attended by a qualified professional in the place of your choosing. It's about whether midwives should be allowed to register and practice as midwives in a setting of their own choosing, and in line with the guidelines that already guide their practice.

It's about women's rights as well. If the push was to stop elective c-sections, or the use of epidurals, then there'd be outrage! But because it will only affect a small number, it's apparently ok to take away this right?

And the small number of births probably has a lot to do with the fact that it will cost upwards of $3k to birth at home, whereas a birth in a hospital costs nothing, because one is covered by Medicare and the other isn't. This, plus the small number of midwives in private practice, means that a lot of women just aren't able to access the option, regardless of their preference.

From Hansard today...

"We have seen a much more progressive attitude in the private sector in Western Australia where the benefits of this legislation will also be immediately utilised. The private sector in Western Australia is poised and ready to deliver community health care to Western Australians in ways that have never been imagined before. I have one large charitable organisation in Western Australia which is currently examining the concept of providing home services which are a virtual hospital. They can employ nurse practitioners and other

health professionals to go out into patients’ homes and provide Medicare subsidised elements of health care ordinarily available only in hospitals. We know that that will have some distinct advantages in assisting people to remain in their own homes. Most of us prefer to be at home than to be admitted to hospital."

This was spoken regarding the nurse practitioners and midwives bill(s) before Parliament at the moment. But not relating to homebirth or midwifery services. This smacks of rank HYPOCRISY - that a Labor member can get the concept that people want to remain at home for health care, but not that they want to birth their babes and start a family in the privacy of said home.

Q: What do you think is the primary fact that causes women to fear, or not trust, birth?

A: Fear mongering from the press and medical establishment. Lack of options. Difficulty connecting with natural birth support networks.

Nine essential elements to achieving the birth you desire:

1. A deep conviction in your ability to birth
2. At least one person who shares this conviction to support you through the entire journey
3. Birthing with practitioners who are committed to birth rights, compassionate and normal birth and motherbaby-friendly standards of practice
4. Taking responsibility for your physical and psychological well-being and preparing yourself
5. Avoiding birth conversations with people who don't share your conviction
6. An ability to sort through or tune out all the conflicting and fear-based information and advice which bombards pregnant women
7. An ability to say NO
8. An ability to explore the unconventional
9. Patience

A petition

I wanted to draw your attention to this important petition that I recently signed "Save Private Midwifery and homebirth choices".

I really think this is an important cause, and I'd like to encourage you to add your signature, too. It's free and takes less than a minute of your time.

Thanks!

------------------------------

Why is this so important? I can hear you thinking that

• you've had your babies so this doesn't affect you
  
• or alternately, babies aren't for you
  
• people who birth out of hospitals are nuts
• midwives who work in the community are hippies
• why on earth would you not want to birth in a hospital?
• obstetricians are the best
• there are perfectly free options available
• why would you want to pay $3k+ for something that you can get through private health insurance?
• why would you want pain during birth when you can go to hospital and have it "painfree"
• who cares about women's choices when my sister/next door neighbour/best friend would have died if she'd birthed at home?
  

I'm not here to debate this with you, except to say that I have different views on all of these things from the mainstream and so do other women, and just as you don't have to agree with abortion, or homosexuality, or voting Liberal, or putting sugar in your coffee, or driving to work rather than catching a bus - you would probably fight tooth and nail for the RIGHT of other people to do these things.

What I am here to say is that women have the right to a birth with an educated attendant. The recent proposed changes to the legislation regarding midwives goes like this:

• there will be a register of midwives (which is actually a HUGE deal as it is the FIRST TIME EVAH that midwives will NOT be classed as nurses!!! Yay!!! Now take another 20 years to get over people assuming that I'm a nurse)
• it will be a national register, rather than a state-based one
• to be on the register, I will need to show that I have insurance that indemnifies my practice

Why is this insane?

1. How do you propose that I register when I finish my degree? If by registering I am saying that I have insurance, then how do I get a job that requires me to be registered or be eligible to be registered in order to apply? It's a chicken-and-egg problem - I need a job to show that I have insurance, but I'd need the job and insurance to get registered. This is not the situation at the moment. And makes it insane if I chose to do something like an Honours year, or take a year off.
   
2. How do you propose that I register if *gasp* I don't WORK as a midwife, for an employer? What if I'm also a nurse and I'm working in sexual health or an abortion clinic, as a NURSE, and there is no way in hell my employer indemnifies me to practice as a midwife? Even though I am staying in touch with my midwifery skills through my job (there is a gap between the absolute letter of a position's description and the reality), I am not able to register as a midwife.
   
3. Alternately - what if I don't work for an employer? What if I am an independent practitioner? I am unable to get insurance, through no fault of my own, as there is no insurance option available. Ergo I won't be able to register, or work as a midwife as it's a controlled term and without registration I can't call myself a Midwife.
4. The insurance will not cover out of hospital services.
   

What does this mean?

• That I am wasting my time studying for a degree that I won't be able to use because I do not want to get a job just to register. I will get a job in a hospital to pay the bills, and I am realistic about the speed at which I'll be able to build a practice, but I don't want to have to get a job just to register to practice.
  
• It, if possible, get worse. Let's say we were trying to make OS#1 (offspring #1) right now. That'd be a due date of March 2010. If it's next month (July) that'd be April 2010, August (May 2010) and September (June 2010). No problems. Lots of registered midwives for me to choose from. If we waited until October 2009 though - bam July 2010. I am left with the option of choosing a hospital birth, or going it alone at home. Yes - going it alone. Because I won't be able to employ a midwife to do that. That would risk a $30,000 fine for me, and one for her for good measure. I kid you not - it would be enticing a professional to work outside the scope of her practice. Which also means that I will not be able to practice in a homebirth setting. It will essentially be ILLEGAL for me to do so. And for you or I, or your sister, housemate, best friend, daughter etc to do so.

I can think of no other situation where something that has been shown to be as safe, or safer, than the mainstream option, is going to be illegal in a sneaky way. Or alternately where the way I choose to practice will be restricted.

I understand that many obstetricians and doctors would love nothing better than to have midwives return to being glorified obstetric nurses and not jump or squeak without their permission. I get that homebirth scares the crap out of women who are told that birthing in hospital is safe, easy and guaranteed not to leave you with a dead baby or lifelong issues (bwahahahahahaha - excuse my while I laugh at the ridiculousness of that idea). I appreciate that birth is scary and unknown and complicated sometimes but for the most part, it is a normal life process and the experts in this process are the midwives.

What made me so upset last night that I swore at the acting president of our national body, and cried in a meeting, is that the people in charge just. don't. GET. it. My future dreams are being offered up as the sacrificial temple virgin so that the other great things can go through. Because it affects so few women (and the VAST majority of midwives are women, though not 100% of them) then it is seen to be OK to give something up in the negotiations that are happening. To be told that something has to give, and in this case it is homebirth, and that I should consider the glass half full rather than half empty, makes me despair at the future I face. The people who are "negotiating" this are at the end of their careers and are doing work in the political upper eschelons because they are experienced and amazing - but they also need a smack up the side of the head for even being party to this process.

Where are the industry-wide protests? Where are the rolling strikes? Where are the midwives demanding freedom to practice, regardless of whether they agree with the practice or not? I'll tell you where they are - they are secretly glad that something like this will stop the "craziness" that they consider happens when a midwife walks with a woman who doesn't fit a low risk model of care - someone with twins, or a breech baby, or a medical condition, or obstetric history, or something other than being 22 years old, in perfect health and with a pelvis like a bucket.

My options are now looking like being to go overseas to practice how I want to. I've had one offer from Washington, and one from Waikato - any further?

Today Nicola Roxon introduced two Bills to Parliament.

1) Health legislation amendment (midwife and nurse practitioner) Bill 2009
This Bill is about accessing Medicare and PBS, there is nothing currently written in this Bill that discuses eligibility - there is no comment within it at present that states anything about homebirth. However, in her speech today she openly stated that there will be no MBS for Homebirth.

2) (and this is the clincher) Midwife Professional Indemnity (Commonwealth contribution scheme) Bill 2009
This Bill excludes midwives from providing intrapartum homebirth care.

THIS IS A SAD SAD DAY FOR THE WOMEN OF AUSTRALIA!

C.F. the Homebirth Australia’s media release and a poster for the Sept 7th rally in Canberra– we know of 100s of women who will be attending from all over the country – we need 1000s so print it out, pass it on and email it around! You can register your attendance on our facebook page

Australia is going to be the laughing stock of the Western world – what a tragedy! Our new website will be going live by tomorrow morning (I hope) – for regular updates go to www.homebirthaustralia.org

Cheers

Jo Hunter
National Convenor
Homebirth Australia

Public Perceptions of Breastfeeding

This is not my article originally but Radical Midwife brought it to my attention and a quick search of Google shows that LOTS of people are reposting it!

Society is so sexualized that they have forgotten what God created our breasts for in the first place. They throw hissy fits over breastfeeding in public and expect us to feed our babies in dirty, stinky bathrooms. So I ask you to judge for yourself, which breasts are truly offensive here? And I understand some of you won't think ANY of them are offensive. But I am making a point by showing how ridiculous it is that society looks upon scantily clad women in sexy ads as ok, even GREAT, but providing important nourishment and nutrients to your child in public by breastfeeding is offensive, distasteful, disgusting, whatever. Give me your feedback. :)


Wait... well, this is a bad example. Let's try again...

Hmmm... just a minute. Surely i can find better ones than these...

Eh... still not racy enough. I'll check one more time.

That's better. LOOK AT THAT! I see about an inch of boob! Totally disgusting.

Ugh! Look at that indecency!! She must be from some third-world country to be exposed like that!!

Now that's just... There's no words to describe how inappropriate that is. Something needs to be done!!



Now this takes the cake!! How dare they actually put such a disgusting image on the cover of a magazine where teenage boys might see it. This simply must be disposed of ASAP via a shredder, before teenage boys learn what boobs are really for!!


This just makes me want to vomit!

...but why stop at breastfeeding women? There are boobs everywhere. Beware! If you thought the above photos were offensive, you WILL DEFINITELY be offended by the photos below.



Not this one though. This was in plain view on newsstands and in mailboxes in 19 countries worldwide!

Not this one either. This one actually won an award!

Oh, and i guess this ones fine too, since everyone knows you can't sell jeans without someone being topless.

or beer, for that matter!

or sunglasses...

or movie tickets...

or CDs...

...you know what? Maybe I'm crazy, but i think that someone mixed up some photos here. The first batch are offensive, but the second batch are just fine and dandy???

People who live in glass bras:


shouldn't throw stones:

Which message is healthier?

Breastfeeding which is medically approved to give HUMANS the best start in life. . . or


Images that promote STDs, unattainable beauty standards, sexual promiscuity, plastic surgery, and just plain TRUE indecency?

Which would you rather your daughter live up to?

Ifyou think women have the right to breastfeed their children no matter where they are, please re-post this. The least you can do is help some children get the best nutrition they can get. Breastfed babies have lower instances of obesity, asthma, allergies, certain childhood diseases, learning disabilities, and other health problems. For each woman who feels like she shouldn't be breastfeeding right where she is, there is an innocent baby who is losing out. Don't be responsible for any child's health problems. support breastfed babies and their right to eat in public like the rest of us.

Maternity Services Review - what a WASTE of time and what a missed opportunity

It's like asking a vegan and a butcher to work together to improve the lives of animals

Comment made regarding the attachment the report has for the word "collaboration" when it isn't defined, and is completely alien in hospital-delivered maternity care. Many midwives work around obstetricians, many obs expect midwives to be their handmaidens, and the women don't get any continuity of care or carer in many cases.

The Australian article is here. And the actual review is here. I am appalled at stupid things like this:

The Review Team noted that a number of state and territory governments have developedprograms and policies to allow for publicly funded homebirths, under specific conditions. For example, New South Wales Health prescribes comprehensive requirements for homebirths, including safety, monitoring, evaluation, credentialing of the midwife and compliance with incident reporting requirements. While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time. It is also likely that professional indemnity cover support for a Commonwealth funded model that includes a homebirth setting would be limited, at least in the short term.

Meaning that as of next year, homebirth will be illegal as you would have to have indemnity insurance (the type of insurance that professional medical officers like OBSTETRICIANS have because the Government SUBSIDISES it and therefore it is available to them - two things that are not the case for midwives) (ie it's NOT AVAILABLE and if it was, it'd be heinously $$$ and not suited to midwives anyway).

Remind me to get pregnant in the next 3 months so I can birth at home with a midwife of my choice, without her working illegally.