March, 2009:

Tips for a Successful VBAC

As published on the Essential Baby website

Author: Melissa Maimann www.essentialbirthconsulting.com.au

http://www.essentialbaby.com.au/parenting/pregnancy/tips-for-a-vbac-20090209-81a2.html

February 9, 2009

Are you planning or considering a vaginal birth after a caesarean (VBAC)? With the Australian caesar rate up to 31% more and more women are reconsidering a subsequent caesar. Read Essential Baby’s tips to help you put your plan into action.

Most women choose to have VBACs because they believe it to be safer for them and their baby. Many women want to attempt to have a different birthing experience for myriad reasons. Either decision will be hotly argued by differing camps, so it’s important you read up and make the best decision that you feel comfortable with.

For the majority of women, VBAC is a safe decision, for some women, an elective repeat caesarean section may be safer. This might be for reasons such as placenta praevia, previous classical incision, or a previous uterine rupture. Please discuss with your care provider and conduct your own independent research when deciding between elective repeat caesarean and having a VBAC.

The risk of VBAC is a uterine rupture, which affects between 0.2% and 0.7% women. The risks associated with elective repeat caesarean section (ERCS) include:

• Hysterectomy
• Injury to bladder or bowel
• Reduced fertility
• Severe bleeding, perhaps requiring blood transfusion
• Increased risk of infection
• Increased pain after birth
• Blood clots in the lungs, legs, or elsewhere
• More difficulty establishing breast feeding
• Increased risk of breathing problems for your baby
• Possibility of separation of mother and baby, if baby is admitted to the nursery
• Delayed bonding

Australia-wide, the proportion of women having caesarean sections increased from 20% in 1997 to 31% in 2006. In 2006, the most common reason for a caesarean was a previous caesarean having been performed. As more caesareans are performed, we are beginning to see more complications from this surgery. In 2006, Australia-wide, only 16% of women had a VBAC. ERCS occurred for 84% of women.

So, you might be thinking, “Wow, I’d really like to have a VBAC, but it seems an uncommon outcome. How can I increase the chances of my VBAC being successful?” Well, the good news is, there’s plenty you can do to have a successful VBAC.

1. Choose your place of birth carefully.
Hospital birth, as you can see above, leads to an average VBAC rate of 16%. Homebirth, on the contrary, has a VBAC success rate of at least 70% – 80%. This is most likely due to the very low caesarean rates that primary midwifery care entails (home birth results in a caesarean rate of less than 5%).

2. Choose your care provider carefully.
Obstetricians are specialists in providing care to women with complications in pregnancy and birth. Midwives are specialists in normal birth, so midwifery care is far more likely to result in a successful VBAC. If you choose an obstetrician, choose one who has a high VBAC success rate.

3. Choose your birth support people.
If you decide to birth in hospital, consider hiring a private midwife or a doula to provide support and advocacy. A private midwife can provide support, advice and clinical care outside of hospital, whereas a doula can provide support only. Sometimes VBAC women need extra support – you have more hurdles to overcome and sometimes friends and family don’t often know how to support you well. Resist the urge to discuss your plan to VBAC with people who don’t support you. Just surround yourself with supportive people who believe in you. The right kind of support is most important!

4. Educate yourself!
Read widely, ask questions of your care provider, get second opinions from different care providers, take independent childbirth education classes and research on the net. Learn about normal physiological birth. When we understand how labour and birth work, it’s easier to see why our bodies work with us and against us during labour.

5. Value birth preparation
Birth preparation such as Calmbirth and Hyponobirthing can make the difference between natural birth and medicated birth for some women. Affirmations and visualisations act like a rehearsal for your mind and body. Trusting your body and believing you can do it – the mindset – is critical.

6. Avoid interventions in labour
Typical interventions such as continuous monitoring and epidurals can really work against a successful VBAC. Instead, get up off the bed, move, get in the bath, do whatever feels comfortable. Plan to stay at home as long as possible, or even birth at home with a midwife.

Melissa Maimann, Essential Birth Consulting.

Fetal Monitoring in VBAC Labour

Mar 31st, 2009

by Melissa Maimann.

2 comments

For further information, contact Melissa Maimann at Essential Birth Consulting.

As published on the Birthrites website http://www.birthrites.org/

Caesarean section rates have risen in the past twenty years to a rate of approximately 20% - 25% in the United States (McMahon, 1998, p.369). Repeat caesarean section is cited as the most common indication for caesarean section (McMahon, 1998, p.369). It is hoped that by promoting vaginal birth after caesarean section, we will halt the increase in the caesarean section rates (McMahon, 1998, p.369). A trial of labour should be encouraged after a previous caesarean section, provided that there are no absolute contraindications to vaginal birth, such as placenta praevia or cephalo-pelvic disproportion (Wing and Paul, 1999, p.836). Due to the greater risk of uterine rupture in women having vaginal births after previous caesarean sections (Menihan, 1999, p.40), it is necessary to monitor the labour to minimise maternal and fetal mortality and morbidity (McMahon, 1998, p.369). The midwife plays a vital role in monitoring the well being of woman and fetus during labour, hence the focus of this options paper will be intrapartum fetal monitoring for women who have had previous caesarean sections.

It is known that changes in the fetal heart rate may signal an impending or actual uterine rupture (Menihan, 1999, p.40), so the monitoring of fetal heart rate is vital to the success of vaginal birth after caesarean section. There is indecision regarding the most appropriate method of intrapartum fetal monitoring in women attempting a vaginal birth after caesarean section owing to a lack of research in the area. Therefore, I have reviewed the literature regarding fetal monitoring in high risk women (including vaginal birth after caesarean section), and fetal monitoring in general. Unfortunately, there is no consensus as yet; fetal monitoring in labour remains a controversial issue.

Fetal bradycardia may be the first sign of an impending uterine rupture (Menihan, 1999, p.40). Late decelerations, variable decelerations, or prolonged decelerations may also occur (Menihan, 1999, pp.40-46). Furthermore, there is loss of variability, and reactivity may be poor (Menihan, 1999, pp.40-46). It is important that intrapartum monitoring enables the detection of these decelerations. The goal of fetal monitoring in labour is to detect fetal hypoxia early, so that interventions may be instituted to prevent a neonatal death (Mahomed, Nyoni, Mulambo, and Jacobus, 1994, p.497; Vintzileos, Nochimson, Guzman, Knuppel, Lake, and Schifrin, 1995, p.149).

Until the 1960s when the electronic fetal heart rate monitor became commercially available, intermittent auscultation was the only method of monitoring the fetal heart rate (Seymour, 1995, p.47). Intermittent auscultation may be performed by the midwife, using a doppler sonic aid, or a pinard stethoscope (Seymour, 1995, p.47). Alternatively, the midwife may monitor the fetal heart rate continuously with an electronic fetal heart rate monitor, either externally, or internally with a fetal scalp electrode. Since these methods rely on the interpretation of changes in the fetal heart rate, it was thought that a more objective assessment of fetal well being may improve outcomes (McNamara and Dildy, 1999, p.671; Greene, 1999, p.641). Fetal well being may be ascertained by obtaining a fetal blood sample and analysing acidity (pH). This is a medical intervention, and will be evaluated as a method of fetal monitoring that complements intermittent auscultation. The remainder of this options paper will describe and evaluate each of the above-mentioned methods of assessing intrapartum fetal well-being.

Intermittent auscultation involves periodically auscultating the fetal heart rate. Gilles, Norman, Dawes, Gee, Rouse, and Newnham (1997, pp.143-148) reviewed methods for intermittent auscultation. They found no consensus regarding appropriate intervals for auscultating the fetal heart rate. In first stage labour, recommendations ranged from auscultation every two hours to every ten minutes, with most sources advocating auscultation every thirty minutes (Gilles et al., 1997, p.145). During second stage labour, guidelines for intermittent auscultation ranged from Ôat intervalsÕ, to every fifteen minutes, to after every contraction (Gilles et al., 1997, p.145). It was generally accepted that auscultation should be performed after every contraction. Intermittent auscultation, as discussed in this options paper, will imply auscultation every thirty minutes during first stage labour, and after every contraction during second stage labour.

The pinard stethoscope was invented during the 1800s for the purpose of auscultating the fetal heart rate (Seymour, 1995, p.47). It is placed firmly on the womanÕs abdomen, at right angles to it, with the midwifeÕs ear in close contact with the stethoscope (Bennett and Brown (eds.), 1999, p.224). The pinard stethoscope is portable and readily available, and is an excellent tool for monitoring the fetal heart rate as long as the midwife is confident in interpreting what is heard (Seymour, 1995, p.47). The only disadvantage of the pinard stethoscope is that only the listener may hear the heart beat (Seymour, 1995, p.47).

Mahomed et al. (1994, pp.497-500) conducted a randomised controlled trial on the effectiveness of different methods of intrapartum monitoring. They found that abnormalities in the fetal heart rate were more reliably detected by doppler sonic aid, compared with a pinard stethoscope. They also found that auscultation with the pinard stethoscope was uncomfortable for the woman as it sometimes required a change of position, and that the woman remain still during auscultation (Mahomed et al., 1994, pp.497-500). Lower apgar scores were more common in the groups monitored with the pinard stethoscope, and neonatal seizures occurred only in the groups monitored with the pinard stethoscope (Mahomed et al., 1994, pp.497-500).

During the late first stage and second stage of labour, contractions are the longest and strongest; theoretically, this period poses the greatest risk of uterine rupture (Arulkumaran, Gibb, Ingermasson, Kitchener, and Ratnam, 1989, cited in Chua and Arulkumaran, 1997, p.7). Anecdotal evidence suggests that auscultation of the fetal heart rate with a pinard stethoscope is often difficult to perform at this time, as the baby has descended into the pelvis. This makes intermittent auscultation difficult to perform, at a time when uterine rupture and possible fetal heart rate abnormalities are the most likely to present. For these reasons, women attempting vaginal birth after caesarean section are best not monitored with the pinard stethoscope as the main method of fetal monitoring.

The doppler sonic aid is the electronic equivalent of the pinard stethoscope, and has the advantage of enabling the woman to hear her baby’s heart beat (Seymour, 1995, p.47). It is possible to auscultate the fetal heart rate with the woman in any position, and there are waterproof probes available for use in the shower or bath (Steer, 1999, p.858). In their study, Mahomed et al. (1994, pp.497-500) found that detection of fetal heart rate abnormalities was better with the doppler sonic aid than with the pinard stethoscope, and that the perinatal outcome was no worse than that achieved by intermittent electronic fetal monitoring.

The American College of Obstetricians and Gynecologists (1989, cited in Cibils, 1996, p.1382) recommends that intermittent auscultation and continuous electronic fetal monitoring are equally acceptable methods of fetal monitoring, even in high risk labours. In a Birth Centre study of vaginal birth after caesarean section, Harrington, Miller, McClain, and Paul (1997, pp.304-307) used intermittent auscultation as the main form of fetal monitoring. It was performed during at least one contraction, every fifteen minutes. In both the study and control groups, the average apgar scores were 8.5 at one minute, and 9 at five minutes, and no five minute apgar scores were less than seven (Harrington et al., 1997, p.306). Neonatal outcomes were similar among both study and control groups (Harrington et al. 1997, p.306). These studies demonstrate the safety and acceptability of intermittent auscultation to monitor the fetal heart rate in women attempting a vaginal birth after caesarean section.

Generally, the literature supports intermittent auscultation as a safe method of fetal heart rate monitoring. Enkin, Kierse, Renfrew, and Neilson (1995) conclude that intermittent auscultation is just as effective in preventing intrapartum death as continuous electronic monitoring. Thacker, Stroup, and Peterson (1995, pp.613-620) studied the efficacy and safety of electronic fetal monitoring, and found that neurological consequences occurred in similar frequencies in babies monitored by intermittent auscultation and continuous electronic monitoring. Kripke (1999, p.2421) describes intermittent auscultation as a Òhigh touch, low-techÓ method of lowering the caesarean section rate for fetal distress. Gilles et al. (1997, p.147) suggest that intermittent auscultation may also play an important role in neonatal outcome, as the personal support provided by a midwife during intermittent auscultation of the fetal heart rate may contribute to reduced pain relief requirements and improved progress of labour. These are important aspects of the care of a woman attempting a vaginal birth after caesarean section.

To conclude the literature review of intermittent auscultation, use of the doppler sonic aid improves neonatal outcomes when compared with the pinard stethoscope. Literature comparing use intermittent auscultation and continuous fetal monitoring, even for high risk labours, concludes that intermittent auscultation is at least as effective in preventing neonatal morbidity and mortality. Current and accepted recommendations are for the fetal heart rate to be auscultated every thirty minutes (minimum) in the first stage of labour, and after every contraction in the second stage of labour.

The alternative to intermittent auscultation is to continuously monitor the fetal heart rate internally via a fetal scalp electrode, or externally via doppler ultrasound (Bennett and Brown, 1999, pp.418-419). A tocotransducer, strapped to the fundus of the uterus, is also used to monitor the frequency, intensity, and duration of uterine contractions (Bennett and Brown, 1999, pp. 418-419). This form of monitoring is known as cardiotocography (CTG), and the electronic fetal monitor produces a print-out of fetal heart rate in relation to uterine contractions. The fetal heart response to contractions (and fetal movements) is monitored to determine fetal well being in labour (Bennett and Brown, 1999, p.418). Continuous fetal monitoring was introduced with the hope of detecting early signs of fetal compromise, enabling early intervention to reduce neonatal mortality and morbidity (Boehm, 1999, p.623; Parer and King, 2000, p.982).

Continuous fetal monitoring was seen as an important development in the reduction in neonatal mortality and morbidity, however, proponents of CTG failed to acknowledge the contribution that improved antenatal and neonatal intensive care have made to neonatal well being (Dover and Gauge, 1995, p.18).

In fact, it has been suggested that CTG, as a screening tool, has been far from beneficial for most women. There is a lack of agreed interpretation of fetal heart rate traces (Anonymous, 1997, p.1385; Low, 1999, p.725), with the result of increased intervention in the form of caesarean section and forceps deliveries (Boehm, 1999, p.623). The adverse effects of false positive and false negative CTGs suggests that, as a screening tool for fetal distress in labour, the CTG fails miserably (Low, 1999, p.725).

A study conducted by Vintzileos, Nochimson, Antsaklis, Varvarigos, Guzman, and Knuppel (1995, pp.1021-1024) suggested that CTG was superior to intermittent auscultation in detecting fetal acidaemia at birth. This conclusion was correct, however, the authors failed to state the false positive rate of CTG in their study, as opposed to intermittent auscultation. Cibils, (1996, p.1383) states that over 40% of fetal heart rate patterns are abnormal on CTG, yet Vintzileos, Nochimson, Antsaklis et al. (1995, pp.1021-1024) found that only 8.0% of neonates had acidaemia at birth. Although CTGs were able to accurately detect changes in the fetal heart rate suggestive of acidaemia, there must have also been a substantial number of fetal heart traces suggestive of acidaemia that were in fact perfectly normal. A meta-analysis by Vintzileos, Nochimson, Guzman, et al. (1995, pp.149-155), found that one perinatal death may be prevented by the continuous fetal monitoring of one thousand women in labour (p.154). The authors accept that this would occur at the expense of a higher rate of surgical intervention.

A benefit of continuous CTG monitoring in labour is a reduction in neonatal seizures (Greene, 1999, p.647; Boehm, 1999, p.625) and one minute apgar scores of less than four (Thacker, Stroup, and Peterson, 1995, p.615). However, the authors of these articles conclude that the long term effect of this reduction must be balanced against the increase in caesarean and operative vaginal delivery rates (Thacker et al. 1995, p.619; Boehm, 1999, p.623; Greene, 1999, p.647).

Wing and Paul (1999, p.843) and Scott (1997, p.536) advocate continuous CTG monitoring for women planning a vaginal birth after caesarean section because abnormal fetal heart rate traces are the most common signs of uterine rupture. The incidence of uterine rupture among women planning a vaginal birth after caesarean section is quoted at being between 0.3% and 1.7% (Chua and Arulkumaran, 1997, p.6). Fetal heart rate abnormalities occur in 50%-70% of uterine ruptures (Scott, 1997, p.538), but they also occur in at least 40% of labours with an unscarred uterus (Cibils, 1996, p.1383). The literature failed to address how the midwife or doctor may distinguish fetal distress related to uterine rupture, requiring emergency caesarean section, from fetal heart rate abnormalities resulting from occurrences such as cord compression or head compression (Menihan, 1999, p.45). In fact, Menihan (1999, p.40) states that there is “no single, specific change in fetal heart rate (FHR) pattern predictive of uterine rupture prior to the onset of a profound bradycardia”. Furthermore, since abnormal CTG patterns alone cannot accurately distinguish well fetuses from distressed fetuses, I question the accuracy of this form of monitoring in women planning vaginal births after caesarean sections.

A review of the literature suggests that continuous fetal monitoring affords no overall benefit; the reduction in neonatal seizures and low one minute apgar scores occurs at the expense of increased operative deliveries. The options presented thus far are not sufficient enough to conclude that intermittent auscultation is the safest method of fetal monitoring in the woman attempting a vaginal birth after caesarean section. These women require closer monitoring than intermittent auscultation can provide, however, they may suffer unnecessary intervention from the use of continuous monitoring. A compromise is needed.

Fetal blood sampling to ascertain pH (acidity) was developed in the 1960s with the aim of clarifying uncertain CTG patterns (Greene, 1999, p.641). On the basis of CTG patterns alone, false-positive diagnoses of fetal distress are likely to be made (Greene, 1999, p.645). A meta-analysis demonstrated that without access to fetal blood sampling, women who were monitored continuously experienced a four-fold increase in caesarean section rates compared with intermittent auscultation, with no improvement in fetal outcome (Greene, 1999, p.647). When fetal blood sampling was used in conjunction with continuous monitoring or intermittent auscultation, this rise in caesarean section rates was less marked (Greene, 1999, p.647). It is essential that all forms of fetal monitoring be supplemented by fetal blood sampling where indicated, to reduce unnecessary intervention (Steer, 1999, p.859).

Fetal blood sampling has some disadvantages: it is time-consuming to perform (Steer, 1999, p.859), it is unreliable if performed in the presence of oedema or caput succedaneum, and it can only be performed intermittently (Greene, 1999, p.648). However, when it is indicated it may accurately determine fetal acid-base balance in fetuses suspected of compromise on intermittent auscultation of the heart rate. Therefore, it may either confirm the diagnosis of fetal distress, or reassure care givers of fetal well being. Although it is not part of the midwifery management of fetal monitoring, it is capable of complementing intermittent auscultation in women planning vaginal births after previous caesarean sections, thus increasing the safety of vaginal birth after caesarean section, without increasing intervention rates unnecessarily.

In conclusion, the midwifery management of fetal monitoring in women planning vaginal births after caesarean sections is controversial. Standard practice is to continuously monitor the labour using technology that is known to increase operative delivery rates with no proven benefit. On the basis of a literature review, this paper has presented the available options of fetal monitoring. The evidence suggests that even without access to fetal blood sampling, intermittent auscultation is superior to continuous monitoring in correctly identifying fetuses in need of immediate delivery. In the presence of an abnormal fetal heart rate detected by intermittent auscultation, fetal blood sampling may indicate those fetuses that require immediate delivery, or reassure the midwife of fetal well being. Ultimately, the woman needs to be informed of her options for care, and their relative risks and benefits, as she will be the one to experience and live with the consequences (positive or negative) of labour care. This options paper is only a guide, based on the conflicting literature available at this time. Since we cannot say with 100% certainty that one method of monitoring is superior over another, perhaps midwives could best care for women by providing accurate information that facilitates involvement and choice.

Melissa Maimann, Essential Birth Consulting.

Birth by surgery: The skyrocketing cesarean rate

Mar 30th, 2009

by Melissa Maimann.

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For further information, contact Melissa Maimann at Essential Birth Consulting.

Story By Mary Beth Pfeiffer • Photos By Lee Ferris • March 29, 2009

Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called “emotional damage,” may have been a rush to judgment.

It is well-known that ultrasounds are inaccurate for estimation of fetal size in the third trimester. Why is it still being used as a basis for clinical decisions??

“It’s very hard to go up against your physician, especially at the 12th hour,” said Ashley, 38, of Hopewell Junction. “I think doctors are very quick these days to get scared. They would rather opt for the surgical solution.”

Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son. … From 1999 to 2007, the proportion of New York babies born by cesarean section skyrocketed 42 percent. In 1999, just under 1 in 4 babies was born surgically. By 2007, the figure was 1 in 3 — or 34 percent of births — and there is nothing to suggest that the relentless uptick, evident locally as well, is showing any sign of slowing.

In Australia, the national CS rate is currently over 31%.

In Ulster and Dutchess counties, with cesarean rates in the top sixth of counties statewide, surgical birth rates increased from 1999 to 2007 by 64 percent and 36 percent respectively …

Don’t women question why their caesarean is deemed “necessary” with a wide window of suspicion? If the CS rate is 42%, that’s 280% higher than what is recommended by WHO.

At Vassar Brothers Medical Center in Poughkeepsie … 40 percent [of babies were born by caesarean]. In Ulster County, Kingston Hospital had a cesarean rate of 40 percent in 2007, the latest figure available, while Benedictine Hospital’s was 35 percent, nearly double what it was in 1999 …

The World Health Organization calls for a maximum cesarean section rate of 15 percent in any nation in the world. Anything above that “seems to result in more harm than good,” according to a 2006 research summary in the British medical journal Lancet.

Physicians, midwives, childbirth experts and researchers point to a confluence of factors behind the growing rate of cesarean section … Some say that more mothers are older, obese, more prone to multiple births and, in particular at Kingston and Vassar Brothers hospitals, less healthy, increasing risks of surgical measures. Others contend that overused interventions to induce and augment labor, manage pain and monitor for fetal distress have driven cesarean rates to unnecessary heights.

I disagree. The only important variable is the care provider’s support for birth as a natural process.

All agree that fewer women are opting for once-popular vaginal birth after cesarean, or VBAC, as Ashley did. But some believe doctors emphasize its risk – that the scarred uterus could tear – while minimizing the drawbacks of surgery. VBACs have declined precipitously at five local maternity hospitals … In 2007, just 3 percent of post-cesarean women birthed vaginally at Kingston Hospital, where the procedure is officially banned. The figure was 33 percent in 1999.

VBAC rates have also declined because they are not supported by care providers.

Amid the debate, there is widespread agreement that medical factors are only a part of the story. Cesareans have become so common and accepted that first-time mothers – frightened by societal depictions of overwrought laboring women — sometimes request them simply to avoid labor; doctors, hospitals and insurance companies acquiesce. Moreover, obstetricians, who pay $84,500 a year for malpractice insurance in Ulster and Dutchess and $137,600 in Orange, may see cesareans as a way to avoid lawsuits over injuries to infants from vaginal birth — as well to manage precious time. “I see colleagues around me who seem to operate out of fear,” said Dr. Ira Jaffe, a Rhinebeck obstetrician, [commented]. “They always have in the back of their mind, ‘How is it going to look in court?’ It’s the defensive medicine.” “It’s not in the best interest of women and babies to do this many C-sections,” he said.

….

For a community of activists who say the cesarean section rate is out of control, the question is whether women like Revak are getting both sides of the story – on one hand that cesarean sections no doubt save lives in high-risk circumstances and are generally safe, but that they contribute in other cases to prematurity, cause respiratory problems in babies and increase maternal bleeding and infection.

“Women are getting cheated by not being encouraged to believe both in their ability to birth and that birth can be a positive experience,” said Christie Craigie-Carter, Hudson Valley coordinator of the International Cesarean Awareness Network, or ICAN.

A Paulin bill, signed into law last year, requires the state to educate women on birthing procedures, such as the induction of labor and use of pain-numbing techniques like epidurals, that increase risk of cesarean section. Paulin, a three-time mother who had two midwife-attended babies at home, believes that cesareans are often performed for reasons of convenience, fear and liability. “We have a huge problem,” she said.

“There’s more fevers, wound infections associated with C-section,” acknowledged Dr. John McAndrew, chairman of obstetrics and gynecology at Kingston Hospital, where the cesarean rate hit 43 percent in 2006. “However, it’s safer for the baby.”

Physicians and researchers concerned with rising cesarean rates take issue with that assertion, which they say fails to weigh the risk that a baby will be damaged or die in vaginal delivery.

“In low-risk or no-risk mothers, studies have consistently shown higher morbidity (illness) in infants delivered by cesarean section,” said Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta … “There is no evidence that cesarean is safer for the baby,” said Dr. Jed Turk, newly appointed obstetrics and gynecology chairman at Vassar Brothers Medical Center and a proponent of lower cesarean rates. “It is not a good trend.”

…

Vaginal birth undoubtedly has risks. One in 5,000 to 10,000 babies suffers permanent shoulder damage, and one in 1,000 suffers moderate to severe brain damage, according to a 2006 article in the professional journal Seminars in Perinatology. These injuries, as well as 6,000 stillbirths, could be avoided nationwide if the nation’s 3 million annual vaginal births were performed surgically at term — but that would mean additional costs and maternal and infant complications.

…

“C-section is major surgery, which involves a longer recovery time for the mother and can have other significant consequences,” said Barbara McTague, family health director for the state Health Department.

The cost of cesareans in a cash-starved health-care system is just one consequence. A cesarean birth cost the state Medicaid program $7,200 on average for hospital care in 2007 – 49 percent more than a vaginal delivery. The state’s cesarean price tag was $189 million.

Of greater concern may be the effect of cesareans on babies that are increasingly being delivered early. Thirty-six percent of elective cesareans were performed before 38 weeks, according to a study published in January in the New England Journal of Medicine, producing infants who had high rates of breathing problems, prolonged hospitalization and sepsis, a severe bacterial infection.

As significant, the study found that 10.2 percent of all cesarean-born babies were admitted to neonatal intensive care units, and 4.4 percent suffered from respiratory distress syndrome caused by fluids that are normally wrung from infant lungs during labor and vaginal delivery. … death rates of C-section babies before 28 days were nearly triple those of vaginal deliveries, according to a 2006 study by researchers at the U.S. Centers for Disease Control in Birth: Issues in Perinatal Care.

Studies have also found 20 percent higher incidence in both childhood-onset diabetes and asthma among cesarean babies, who have one-third to three-quarters the level of healthy bacteria in their intestines as vaginally born babies.

“When a baby comes out the normal way, they swallow vaginal mucus en route and get a nice dose of healthy bacteria to jump start their digestion,” said Dr. Joseph Malak, a Poughkeepsie pediatrician who called “surreal” the number of cesarean babies he sees on hospital rounds. “This doesn’t happen when babies come out through an abdominal incision.”

Malak believes that the rising cesarean rate may be linked to “a dramatic increase” in recent years in infants with colic, acid reflux, eczema and milk allergies – effects that, some say, obstetricians do not consider when weighing vaginal versus cesarean birth.

While cesarean delivery is safer than ever for the mother, it is not risk-free. According to a 2008 report in the American Journal of Obstetrics and Gynecology, 2.2 women died for every 100,000 cesarean births – 10 times higher than for vaginal births. “Cesarean delivery is associated with an increased risk of postpartum maternal death,” concluded a 2006 report in the same journal.

In New York, the rate of maternal mortality rose 70 percent from 1997 to 2007, when 40 women died as a consequence of pregnancy … three of the major causes of maternal death as embolism, hemorrhage and infection – all of which occur at higher rates in cesarean section.

Growing complications
Indeed, serious obstetrical complications increased by 27 percent from 1998-99 to 2004-05, according to a 2008 report in Obstetrics and Gynecology. These included renal failure, pulmonary blood clots, shock, blood transfusion and ventilation — upticks that parallel rising cesarean rates.

“It looks like there’s an association,” said the study’s author, Dr. Susan Meikle, an obstetrician and medical officer at the National Institutes of Child Health and Human Development …

“There is an awful lot of lying to women about cesarean,” said Dr. Marsden Wagner, former director of women’s and children’s health for the World Health Organization and author of several books on childbirth. “All of those thousands of women who are getting unnecessary cesareans in New York state are at double or more risk of dying and the babies are at risk of dying.”

The argument over cesarean’s benefits is perhaps most pointed when it comes to vaginal birth after cesarean; many doctors fear that the scarred uterus will tear, resulting in hemorrhage and loss of oxygen to the infant.

“There’s a real risk,” said Dr. Maureen Terranova, obstetrics chief at Northern Dutchess Hospital. “They have to be willing to accept that 1 percent risk of uterine rupture.”

“When it occurs, it can be catastrophic,” said Kingston Hospital’s McAndrew.

Melissa Ptacek, 47, of Garrison in Putnam County, said it took her years to recover from a uterine rupture from which her daughter – now a normal 11-year-old – had to be resuscitated. “I wouldn’t want anyone to go through what I had to go through,” she said.

In a study published in the New England Journal of Medicine in 2004, 124 women suffered uterine rupture among 17,898 who attempted vaginal birth after cesarean — a rate of 0.7 percent. Seven babies suffered brain damage, including two who died. A 2000 research summary by the American College of Obstetricians and Gynecologists put the risk of rupture in vaginal birth at 0.2 to 1.5 percent for most women with one prior cesarean.

Proponents of vaginal birth after cesarean say the risks of rupture must be balanced against the downsides of surgical birth. “The conversation about VBAC doesn’t touch on dozens of other concerning outcomes that favor vaginal birth,” said Sakala of Childbirth Connection, noting that cesareans make breastfeeding difficult, lead to adhesions and cause significant pain for up to six months. More than 7,000 repeat cesareans would be needed to save the life of one baby from a ruptured uterus, she said, citing a 2004 British Medical Journal study.

Other proponents argue that not all ruptures are catastrophic and some have actually been caused by labor-enhancing medications, called prostaglandins, whose dangers for post-cesarean women are now recognized.

Melissa Maimann, Essential Birth Consulting.

Sex after baby

Mar 30th, 2009

by Melissa Maimann.

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As published on Essential Baby

For further information, contact Melissa at Essential Birth Consulting

Sex after baby
Melissa Maimann
January 12, 2009

Welcome to parenthood! New babies are amazing, wondrous beings, aren’t they? But, for someone so small, they can bring with them endless tasks. Is there any time or desire for sex?

Your new to do-list reads something like: nappies, feeding, settling, general household chores, shopping, washing, more nappies, more washing, feeding, tending to the older kids, work – the life of a parent is busy indeed. Sleep seems a pretty tall order, let alone sex. After the birth, it might be the last thing on your mind!

Both men and women can have issues with sex after birth. For men, the concern is often, “What if I hurt her?” Women, too have concerns about sex after birth, such as “will my stitches open up?” or “will it hurt or feel different for us both?” Women may not feel like sex for several weeks, months or even a year or more after birth. After giving birth, some women feel detached from their sexuality whilst they adjust to motherhood. This is a very normal response to having a new baby.

Women who have experienced physical trauma from birth are more likely to experience painful sex in the months and sometimes years after birth. In particular, a forceps birth and/or an episiotomy can often result in vaginal and perineal pain. Some other reasons why you might not feel like having sex are:

- Recovering from a long labour
- Exhausted from lack of sleep
- Sore and tender stitches
- A baby who is unsettled, perhaps having problems with feeding
- Experiencing an emotionally or physically traumatic birth
- Changing hormone levels
- Fear of another pregnancy

All of these concerns are normal and valid. It is important for couples to talk to each other about their fears and be sure to allow yourself the time you need.

When can we have sex again?
As a guide, it’s best to wait for any bleeding to stop before having intercourse, to minimise the risk of infection. This can take two to six weeks. Some women wait until they have their 6-week check with their doctor or midwife. Others wait longer. For some women, sexual desire returns soon after birth, while for other women, it takes many months. Generally speaking, you can resume sex as soon as you feel physically and emotionally comfortable to do so. It’s important not to have sex purely to please your partner as this can help resentment to build. Have sex when you’re both ready.

Birth Trauma

Mar 29th, 2009

by Melissa Maimann.

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As published on the Essential Baby website http://www.essentialbaby.com.au/parenting/baby/birth-trauma-20081013-4zm2.html?page=-1

For further information, contact Melissa Maimann at Essential Birth Consulting.

October 13, 2008

birth trauma

Birth trauma can affect any woman who has given birth. Although it is experienced by many women, most women do not talk about it and many may not even know they have it. This silence does nothing to help women move past their trauma; it is my hope that this article will help you along the path to recovery.

What is Birth Trauma?
Birth trauma is a normal reaction to events in labour and birth that you perceive as being scary, out-of-control, helpless, or painful. Birth trauma can result from pregnancy, birth or even during the postnatal period. The woman’s response may be one of intense fear, helplessness or horror. Sometimes the events trigger memories of earlier trauma that remain unresolved. Symptoms might not emerge for many months after the birth, or even later, when you plan for the birth of your next baby.

How will I know if I have Birth Trauma?
The symptoms of birth trauma are many and varied. A common theme is that the trauma interferes with your enjoyment of daily life. The trauma issues may surface at different times, and then completely disappear. Some women experience:

• Flashbacks of the event and sudden, vivid memories. You will usually feel distressed, anxious or panicky when you’re exposed to things that remind you of the event

• Avoidance of anything that reminds you of the event. Some women never talk about their births or avoid hospitals. In contrast, other women talk about their birth trauma all the time; this is their way of expressing their extreme hurt, anger and fear.

• You may also experience emotions such as anger, irritability, and hyper-vigilance (feeling jumpy or on-guard all the time)

• Nightmares of the birth

• Physiological responses when you are exposed to events resembling the traumatic event, such as panic attacks, sweating and palpitations

• Numbed emotions

What causes it?
Most of the causes of Birth Trauma can be avoided or lessened considerably by those looking after the woman, through simple measures such as understanding the woman’s needs and expectations and providing sensitive care in response. This is where continuity of care programs offered by midwives really benefit women! Explanations need to be provided before interventions are carried out, and your permission needs to be sought before any treatment, procedure or examination takes place in order for you to feel respected and safe. Women also have a role to play in clearly communicating their needs and expectations to their care providers. One way to do this is through a birth plan.

There is no standard cause of Birth Trauma. Some experiences than can result in birth trauma include:

• Traumatic birth – eg episiotomy, caesarean, forceps, a baby who was injured during birth
• Emergency situations, including caesarean section
• Lack of pain relief when pain relief has been requested
• Impersonal treatment
• Loss of control over the experience, or the perception that your wishes were not respected
• Being cared for by strangers
• Invasive procedures such as vaginal examinations, episiotomy, stitches
• Separation from your baby
• Feelings of loss of control - eg an induction that you did not want to have, a caesarean for a breech baby when you wanted a vaginal birth etc
• Invasive procedures without explanation or your permission
• Forceps delivery or suturing without adequate pain relief
• Post Partum Haemorrhage

Treatment Options for Birth Trauma
During your path to recovery, you will need a few helpers along the way. A trusted friend or relative can help enormously – someone who knows you well, understands what it’s like to be you, and who accepts you. They need to be empathic and non-judgmental.

Some women see professionals to help them recover, such as psychologists and midwives. Psychologists are educated to provide therapy for people who have experienced trauma and they provide excellent services for as long as you need them. Independent midwives have usually studied counselling as part of their education, and they have the added bonus of knowing about pregnancy and birth.

Family and friends can help too – for example, babysitting while you get some sleep or time out from your baby / toddler. Some women like to talk to other women who have experienced birth trauma as this helps them to see that they are not alone. Sharing experiences is very healing and allows you to gain perspective and validation about what has happened.

During these times, it’s easy to forget to take care of yourself. Remember to eat well and get some daily exercise. This will do wonders for encouraging a restful sleep and high energy levels during the day. Limit caffeine, sugar and salt, and tuck into veges, fruit and whole grains. Balance this with fish, chicken, eggs, nuts and seeds, and you have a recipe for health!

Natural therapies can help a lot – therapies to try include yoga, massage, reflexology, aromatherapy, homoeopathy, naturopathy and yoga.

Journaling is a great exercise; some women also draw. This gives the added bonus of being able to use colour and “left brain” action to express yourself. When you’re journaling, you might want to record your birth story. Some women write it a few times. You might like to write your birth story from your perspective, then from the perspective of your baby, partner, midwife or doctor, and so on. When you’re writing about your experience, pay attention to any feelings that come up for you as you write. Notice how writing makes you feel in your body. As you write your story, you may begin to discover more clearly which events are particularly hard for you to deal with, or to clarify your emotions.

Read books or articles on birth trauma.

Some women also like to write a letter to their care providers (no need to post it), as this helps to express their emotions in a safe way. Other women explore the option of writing a formal complaint to the hospital or Health Care Complaints Commission.

Another option is to obtain a copy of your medical record. Simply contact the hospital medical records department or the Patient Representative. A fee may apply for this service. Once you have a copy, it’s a good idea to go through your record with a professional such as a GP, midwife or obstetrician who can interpret all the “medical-speak” for you and help you to make sense of the notes. This exercise can go a long way to answering the “why?” for you.

In the end
There is a positive end for all women who have experienced birth trauma. The personal growth that this event affords you, the insight into your values and beliefs, and the journey of healing are all very positive outcomes that can help you move forward in all ways in your life.

Advice for pregnant women
So, what can you do to avoid birth trauma? There are many things you can do!

• Be assertive about your needs. Change your care provider if you need to; ask for help; research your options from a wide variety of sources
• Explore what sort of birth experience you would like and then set about finding a care provider who will support you in achieving this
• Write a birth plan so that your care providers know your preferences
• Consider home birth as this will allow you more control over the experience
• Get help early if you need it
• Consider what you will need in order to feel safe during your pregnancy, labour and birth

Melissa Maimann, Essential Birth Consulting.

Women’s Experience of Miscarriage

Mar 29th, 2009

by Melissa Maimann.

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As published on the Essential Baby website http://www.essentialbaby.com.au/parenting/pregnancy/womens-experience-of-miscarriage-20081111-5m5v.html?page=-1

November 11, 2008

For further information, contact Melissa Maimann at Essential Birth Consulting.

The experience of miscarriage is often misunderstood by women’s friends, families and the medical community, causing feelings of isolation, frustration and fear.

When Essential Baby asked me to write an article on miscarriage, I found several resources that addressed the medical side of miscarriage, but few resources that explored the emotional issues. In this article, I will not elaborate on the medical issues surrounding miscarriage: whether a woman has a 1% chance of miscarriage or a 50% chance of miscarriage is of little consequence when she has just discovered there is no heart beat. What she really needs in that moment is an empathic ear, validation of her experience, to be listened to and to be treated with compassion.

The emotional experience of miscarriage
Miscarriage can be a frightening and lonely experience. Your loss might have been so sudden that there was no way to prepare for it. Or you might have suspected for a while that something was wrong. Or you may not have wanted to admit that this pregnancy just felt different to your others.

Whatever your circumstances, there are many emotions surrounding miscarriage such as disbelief, anger, shock, confusion and a deep sense of loss and grief. These feelings come and go, with different intensities. You have some good days and some bad days. But whatever your experience, you are not alone!

After a miscarriage, you grieve for a baby you never knew, and for a relationship that will never be. Your baby is a baby from the moment you find out you are pregnant. You grieve for the experiences you will not have – discovering what your baby looks like, what sort of personality she has, or how it feels to cuddle him. As Lia, an Essential Baby member found, “To us, this is a loss of life. A life that was very much wanted, even if not planned. Women have already developed a bond with their baby, they’ve made plans, got hopes and dreams, just like any other new or expectant [mother].”

Women react differently to the experience of miscarriage. You might accept what has happened and look at it philosophically, or you might feel devastated. You might be feeling numb and be in denial that it has happened. Or you might feel guilty because you were unsure if you wanted to be pregnant, or you had a drink or smoked a cigarette. There is no wrong or right way to grieve.

Physically, you might be constantly tired, yet have difficulty sleeping. Some women cannot eat, while others eat constantly, trying to numb their raging emotions.

For Nicole, an Essential Baby member, “the breaking point was when I found out it was a girl and that there was no obvious reason for her not making it.” Rebecca feels that “I don’t think that I will ever heal.” Miscarriage is such a profound experience and women deal with it in many different ways. “I just wanted to be pregnant straight away, to take away the pain,” Donna, Essential Baby member.

In contrast, Debra says, “I don’t think I really grieved that much. Perhaps deep down I knew it was going to happen. All my dreams had gone out the window and then I started to think of all the things I did that could have caused the miscarriage. We fell pregnant again… I didn’t feel confident from day one although I tried to tell myself everything was ok. I started bleeding at 6 weeks and knew it was all over again. I was much more upset this time. I cried and cried and cried. The first time it happened, I thought, we can do it again, it’s ok. The second time, I thought, so we can conceive, what if I’m never able to carry full term?”

Women who experience miscarriage and then go on to have pregnancies to full term often experience the pregnancy with disbelief and a lack of attachment to their baby. It wasn’t until about seven months that I admitted to myself I may be having a baby and started enjoying the experience. The innocence of a pregnancy is gone, at least until [you] and are safely past that week [that you lost your baby].

Men and miscarriage
Men and women grieve differently and each person’s emotions can seem foreign to each other. Some feel that their partner does not understand them and this can be hurtful and isolating. For some men, the dominant emotion is powerlessness ‘ they feel powerless to protect their partner and powerless over the events that have taken place. What can happen when someone feels powerless is that they sometimes react with anger and withdrawal.

Lia’s husband felt that the emphasis is placed on the woman, whereas men grieve too: “they were his babies that were gone!” Lia’s husband felt helpless watching her go through that pain. “No-one really acknowledged how badly he was affected.”

Melissa Maimann, Essential Birth Consulting.

Home delivery too hot to touch

Mar 28th, 2009

by Melissa Maimann.

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For further information, contact Melissa Maimann at Essential Birth Consulting.

Link to article

Supporters of homebirth are asking why the topic is still seen as too hard to handle in this country, writes Thea O’Connor | March 28, 2009
Article from: The Australian

WHEN Natalie Hemingway gave birth to her son 10 months ago, doing so at home seemed an obvious choice. She had already given birth to her daughter at home three years earlier, and both of her sisters had been born at home.

“That’s what I saw when I was growing up, so birthing at home was normal to me,” says Hemingway, 27, who lives on Sydney’s lower north shore.

Homebirth in developed countries was the norm up until the past 50 years or so. In Australia today, homebirth can seem a radical choice, and the women who chose it anything from brave and alternative to misguided and loopy.

The recent federal government review of maternity services has done little to help bring the practice into the mainstream. It has inflamed an already heated debate over homebirths by stating it does not support Medicare funding of independent midwives attending homebirths …

Part of the problem is that both advocates and opponents of homebirths have research evidence to support their arguments.

According to Hannah Dahlen, associate professor of midwifery at the University of Western Sydney and spokeswoman for the Australian College of Midwives, the best available evidence comes from a large prospective study of 5000 women planning a homebirth in the US in 2000.

The results, published in the BMJ in 2005, showed that the rate of babies dying during labour or within 28 days of birth … was 1.7 deaths for every 1000 uncomplicated intended homebirths. The study (2005;330:1416-1419) said this was similar to risks in other studies of uncomplicated home and hospital births in North America.

Dahlen says it is also similar to the risk of first-time mothers having an uncomplicated birth in an Australian birth centre … or Australian hospital … (2007;34:3:194-201).

When the high-risk births … were included in the analysis of the US study, the rate was two deaths for every 1000 births.

- When women have home births with a midwife, and they are low-risk (term, singleton baby, head down, no blood pressure problems etc), home birth has been shown in many studies to be safe. Not only that, women who have home births experience a greater level of satisfaction with their experience, and mush lower rates of intervention compared with hospital birth.

The highly regarded Cochrane database … concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women”.

Andrew Pesce, president of the National Association of Specialist Obstetricians and Gynaecologists, believes we have enough evidence to worry. He points to Australian data that indicates babies have a two to three-fold increased risk of death with homebirths.

A study of 7000 planned homebirths in Australia between 1985 and 1990, published in the BMJ (1998;317:384-388) reported that deaths occurring during labour and not due to malformations or immaturity were higher than the national average. …

Dahlen counters that this study provides low-level evidence: the study design was retrospective, it included births by non-registered midwives, it used a number of methods to collect the data, including searching newsletters for death notices …

- While there is strong support for midwife (registered, qualified) assisted home birth for low risk women, there is very little evidence that birth at home without a qualified and registered midwife, for women who have risk factors, will yield a good outcome.

Pesce also refers to the 12th report of the Perinatal and Infant Mortality Committee of Western Australia. It documents a 2000-04 death rate for babies that is three times higher for homebirths. The report said the numbers were too small to be conclusive.

… In December 2007 the West Australian Department of Health stated “a preliminary review of medical records indicates that it is likely the setting of the birth did not affect the outcome in at least five of the six deaths”.

- We need clarity on this matter. Babies die in hospitals and they die at home too. The question needs to be thus: In low risk, healthy women, is the home birth death rate higher than a low risk, healthy opulation of women birthing in hospital. The answer, according to a large North American study, is no.

Distinguishing the outcomes of uncomplicated births from high-risk births helps to make sense of the conflicting data …

The study concluded that while homebirth for low-risk women could compare favourably with hospital birth, high-risk homebirth was “inadvisable and experimental”.

The Australian College of Midwives supports this conclusion.

Dahlen says women should still have the right to attempt high-risk births, provided they are well informed of the risks, as well as their chances of success.

- A woman’s right to autonomy must be respected. It would be great if high risk women were supported to achieve the birth they want within a hospital setting.

“Women wanting to give birth vaginally after a caesarean, for example, have a 70 to 85per cent chance of success,” she says.

Versus hospital VBAC rates which sit between 2% and 15%.

“I don’t know of any other area where the battle over women’s bodies is as intense as this. We have to make sure we don’t end up with situations like those in parts of the US, where midwives are put up on criminal charges and women are arrested and taken from their homes to hospital if they are intending any birth at home the medical establishment considers risky.”

Keirse, who has also worked in obstetrics in the Netherlands, characterises the debate as a demarcation dispute. “Holland went through that in the 1970s. When midwives were granted free access to hospitals in the early 1990s, that made a big difference and contributed to improving safety rates.”

Britain’s Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have managed to agree. Their 2007 joint statement, which supports homebirths for women with uncomplicated pregnancies, reads: “There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe.” … In the Netherlands, 30 per cent of all births take place at home.

“The culture is conducive to homebirths in Holland,” says Keirse. “It’s an accepted government policy and the midwives who conduct homebirths are considered part of the medical profession. They have rights that allow them to continue caring for their clients if they need to transfer to hospital.

“In Australia, there can be large distances between home and hospital, independent midwives have no hospital rights and they are not incorporated into the healthcare system.

“This means that training of homebirth midwives isn’t regulated, which it should be.”

- The training of midwives is most certainly regulated. All registered, qualified midwives have a university degree or two or three. Some are educated to maters level.

One research finding that is not disputed is that homebirths result in fewer medical interventions … compared with the relatively low-risk hospital group, intended homebirths were associated with lower rates of electronic foetal monitoring (9.6 per cent v 84.3 per cent), episiotomy (2.1 per cent v 33 per cent), caesarean section (3.7 v 19.0 per cent) and vacuum extraction (0.6 v 5.5 per cent).

Melissa Maimann, Essential Birth Consulting.

Birthing your Baby at Home

Mar 28th, 2009

by Melissa Maimann.

2 comments

As published on the Essential Baby website

For more information, contact Melissa Maimann at www.essentialbirthconsulting.com.au

http://www.essentialbaby.com.au/parenting/pregnancy/birthing-your-baby-at-home-20081027-596s.html

Author: Melissa Maimann

October 27, 2008

Essential Baby member Alinta homebirthed baby Mason on 9 September, 2008

Essential Baby member Azalia homebirthed baby Mason on 9 September, 2008. Photos: Fiona Colvin

Homebirth is increasingly being spoken about as an alternative to hospital birth. Some hospitals are now offering a homebirth program, and of course homebirth is available through independent midwives. Homebirth remains a less common choice for birth, with the majority of Australian women birthing in hospital. So why are some women deciding to birth at home?

For many, the belief in the safety of homebirth is an important factor. Women who choose homebirth do a lot of research into their decision. Isis, an Essential Baby member, states, “I began my parenting journey as a trusting, somewhat ignorant and yet positive 24-year-old. My resulting [birth in hospital] and recovery from it taught me a lot about myself and my birthing body. I learnt a lot about our maternity system, about research and evidence based practice. Interactions with hospital staff during that pregnancy and after my son’s birth angered me, witnessing the postnatal treatment/distress of a [new mother] only cemented the knowledge that I didn’t need, or want to be in the system, unless absolutely necessary for any subsequent children. So my third baby was a planned home birth even before conception.”

For some women, the decision to homebirth is made because of distance from the hospital and/or a history of fast labour, making homebirth a safer option: these women face the very real risk of birthing on the side of the road or in the car, unattended by a midwife. Heidi, an Essential Baby member recalls that in her first birth, she did not realise she was in active labour. The birth centre staff encouraged her to stay home. Eventually her “waters broke and I had an overwhelming urge to push. We drove in school hour traffic to the hospital and it was terrifying. I was so scared that I was going to give birth in traffic. The pain during contractions while going round corners or over speed humps was unbearable.” When she got to the birth centre, she was full dilated.

Cesca planned a birth centre birth with her first baby, but realised that in an emergency it would be a 15 min ambulance trip to hospital, whereas it was a 5 min trip to hospital from her home.

For other women, the decision to have a homebirth is informed by the fact the fewer interventions are used at home, and therefore women having homebirths can avoid complications that often result from intervention that is commonly used in hospital – things like induction, epidural, breaking the waters and episiotomy. Suzy (an Essential Baby member) wanted to avoid having “midwives doing extensive internal exams causing extreme pain completely unnecessarily.” KM saw The Business of Being Born, a documentary on home birth and maternity care in the U.S. “After seeing this, I knew that home birth was the best option for me due to it being safe and having less chance of interventions for birth (I had interventions for my first two births – induction and drugs through labour that I had more knowledge of the impacts of now 9 years after my last child).”

Essential Baby member and new Mum Reenie says, “The more I learned about intervention, the more concerned with hospital births I became as this state has an incredibly high rate of Caesarean section. I found it bizarre that you weren’t allowed anything stronger than a Panadol while pregnant, but they wanted to put all sorts of drugs into you while in labour!”

For other women, the decision to involve children in the birth is important. Waterbirth is a common method used in homebirth, and this is not permitted in some public and private hospitals. This was a motivating factor for Suzy and KM.

What sort of care and services are available from homebirth midwives?
Isis states, “The care provided by my midwife was second to none. Having 1-2 hour appointments in my own home were such a treasure, compared to the rushed 5-10 minute face-to-faces that the hospital offered (and that doesn’t include the 20-80 minute wait times!). The relationship we built over the pregnancy was one that ensured total reciprocal trust and respect between us. The parameters set upon the birth were personalised to our requirements, not a faceless hospital policy. Labouring in my house meant no restrictions. After the birth – having my own lounge to sit on, privacy, security. My shower, my family, my home.”

New Mum Reenie states, “My midwives were completely focused on me. No running off down a corridor to some other woman.”

Typically, homebirth midwives book no more than four women each month. This allows the midwife time to get to know each woman during pregnancy – to find out what is important to her, her wishes for her pregnancy, labour, birth and postnatal period, and to build a firm relationship. Generally, each visit includes a physical check of the woman, antenatal education, health promotion, a discussion of what to expect in coming weeks and birth preparation. Midwives attend you at home when you are in labour, and then provide home visits (often daily) after your baby is born.

Heidi states, “Having a homebirth was the best decision I’ve ever made. It was the most wonderful experience of my life. To experience birth like that – painless, blissful, profoundly beautiful.”

So then, what are the disadvantages?
For some women, the cost of homebirth with a private midwife is prohibitive. In Australia, homebirth costs anywhere between $2,500 and $5,000. Despite the cost, Heidi sees the benefit, “I wouldn’t have paid for a private midwife because they are very expensive where I live ($4k). I would now though, because I know how much better homebirth is.”

New Mum Reenie mentions, “I had to educate my fiancé so that he was comfortable with the idea. Like most, he viewed birth as potential disaster, rather than a normal process. He was reluctant at first, but after attending a ‘choices in childbirth’ talk and hearing all the facts, (as well as some hospital horror stories from people attending) he was all for it!”

Can I have a home birth?
Safety is an important factor. While homebirth is an excellent choice for some families, others may choose a birth centre or hospital birth. Women who choose a hospital birth may:
-    have a pre-existing medical condition
-    prefer the option of epidural pain relief
-    feel safer in hospital/birth centre
-    have a condition called placenta praevia, where the placenta covers the cervix.

Heidi points out that “there is the assumption in our society that (homebirth) is generally unsafe”, and therefore some professionals will encourage all women to birth in hospital, regardless of whether they are high or low risk. Gail (username Midwitch) was “told I couldn’t birth vaginally. When I did with no problems, I was told the next one would be too dangerous to birth vaginally. By my fourth homebirth I was also having very large, very late (14 days) babies, all increasing my risk. Luckily my midwife never doubted me or feared I couldn’t do it … I’ve now had seven babies, five at home. No complications, no problems.”

There are some complications and pre-existing medical conditions for which a hospital birth would be a safer option. For further information about your individual situation, please speak with your midwife or doctor.

What happens if something goes wrong during my homebirth?
This question is commonly asked when the topic of homebirth comes up. Put simply, if something goes wrong, you transfer to hospital. There is a strong reliance on the midwife’s skills at ensuring that you are low risk at the start of your pregnancy, and that you remain low risk throughout your pregnancy, labour and birth. At any time the midwife has concerns, she will discuss them with you and will work together with you to devise a plan of action. This might involve getting a second opinion from another midwife, getting a consultation with an obstetrician or complementary therapist, or referring you to hospital.

KM had a post-partum haemorrhage which was managed by her midwives.

“Unfortunately my pulse and BP would not stablise afterwards and my midwife could not get a line in.” KM transferred to hospital and her midwife went with her, advocating for her at the hospital. Cesca also has a post-partum haemorrhage but “it was mild and the midwife could control it with drugs at home.”

Gail transferred in labour: “My third baby (second homebirth), I transferred in for foetal distress. He had the cord around his neck and two true knots in it. He birthed quickly in good condition so we went home two hours later.”

The other common reasons a women may transfer in labour are for a labour that is not progressing, or the woman’s decision to have an epidural.

What does the research say?
A Canadian study involving 5,418 women who had planned a midwife-attended homebirth found that 12.1% of those booked for homebirth transferred to hospital. 4.7% women had an epidural, 2.1% had an episiotomy, 1% had a forceps delivery, 0.6% had a vacuum extraction, and 3.7% had a caesarean section. In other words, 94.7% women had a normal vaginal birth! The study found that these rates were substantially lower compared with low risk US women having hospital births. The neonatal mortality rate was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. The authors concluded that planned, midwife-attended home birth for low risk women in North America was associated with lower rates of medical intervention and similar intrapartum and neonatal mortality to that of low risk hospital births in the United States. (BMJ 2005;330:1416)

Pre-Eclampsia During Pregnancy Could Indicate Future Heart Disease Risk, Studies Say

Mar 27th, 2009

by Melissa Maimann.

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For further information, contact Melissa Maimann at Essential Birth Consulting.

Link to article

Women who experience pre-eclampsia during pregnancy have more heart attacks, strokes and blood clots later in life than women without the condition, according to several studies, the New York Times reports … Researchers do not know what causes the condition, which is marked by high blood pressure, protein in the urine, severe swelling, headaches and vision problems. Although pre-eclampsia usually disappears soon after delivery, a “growing body of evidence” indicates that women who develop pre-eclampsia have twice the risk of having a heart attack or stroke later in life, the Times reports.

….

According to the Times, most researchers do not believe that pre-eclampsia directly increases the risk of heart disease. Smith said that it seems more likely that the condition is an early indicator of the health of a woman’s heart … Williams now advises women with pre-eclampsia to have frequent screenings for cholesterol levels, blood sugar and blood pressure, and to seek treatment if the levels are high.

- This seems similar to gestational diabetes, which, rather than being a disease in its own right, is more a marker for the development of later-onset type 2 diabates.

Melissa Maimann, Essential Birth Consulting.

Is Homebirth Right for me?

Mar 26th, 2009

by Melissa Maimann.

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For further information, contact Melissa Maimann at Essential Birth Consulting.

For most women, home birth is a safe and responsible decision. Homebirth is possible for women who:

Are having their first babies
Are having their second, third or subsequent babies
Are having a vaginal birth after caesarean (VBAC)
Have had a previous traumatic birth
Had a very fast birth last time
Prefer a more natural experience
Are healthy

Why choose homebirth?
Some women find that having their baby in the comfort of their home provides a supporting environment.

This helps to keep stress hormones low, and positive birth hormones high, making the birth easier and less painful.

Other women homebirth because they believe in their body’s ability to birth, wish to involve their partner and other children, or prefer to reduce the chance of intervention in their labour.

A number of different research studies have looked into the safety of homebirth – all reliable research has found that for healthy women, homebirth is a safe option.

Keeping Homebirth Safe
A common question I am asked is, “What if something goes wrong?” Private / independent midwives take several precautions to keep home birth safe. This includes things such as:

Screening women carefully so that only low-risk, healthy women birth at home
Careful monitoring during pregnancy and labour to ensure that any possible risks are detected early, allowing time for transfer to hospital or consultation with obstetric staff
Building a relationship with the woman that is based on mutual trust and respect. This is central to an effective relationship between woman and midwife.

Midwives who birth with women at home are educated and experienced to assess the wellbeing of mother and baby throughout pre-pregnancy, pregnancy, birth and the postnatal / neonatal period. Midwives use the ACMI Guidelines for Referral and Consultation to support clinical decision-making in consultation with the client. Of course, with a homebirth, you have the right to make your own informed decisions about your care and your decisions are respected.

The Cost of Homebirth
Some people believe that private / independent midwifery care is expensive. I have prepared the following table to explain how the services are broken down. Home birth services are very comprehensive, and home birth midwives spend many hours with women and their families, building a strong relationship during the pregnancy that carries through to the birth and beyond. Typical home birth services consume a whopping 86 hours of a midwife’s time, assuming 1 hour of travel to and from your home, 13 antenatal visits, 5 postnatal visits, and of course labour and birth attenance.

PLUS
On-call – 24 / 7 for 5 weeks
Phone and email consultations
Research
Attending related appointments with clients
Professional consultation with other professionals on the client’s behalf

As you can see, the service provided by a private / independent midwife is comprehensive and does not compare easily with other maternity services in terms of continuity of care, hours of contact, follow-up and availability. When you choose a home birth with an independent midwife, you are choosing gold standard service.

As you can understand, when midwives provide this level of service, it is impossible to book more than two or three clients each month. I could see women in a clinic setting for 30 minute appointments – that would eliminate travel time – but I know that you’re after a service that really meets your needs.

Some women ask me whether I will provide reduced services such as no postnatal care, one or two antenatal visits, a late booking, and so on, in order to reduce the cost. I prefer to provide a comprehensive service and the women who book with me see the value in this approach. A home birth is an investment in you and your baby, afterall. And you deserve the very best.

Melissa Maimann, Essential Birth Consulting.

The IVF revolution is money badly spent

Mar 26th, 2009

by Melissa Maimann.

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Jill Singer

March 26, 2009

BABIES are priceless, precious beings who can melt the hardest of hearts.

But they don’t come cheaply, as any parent knows, even when they arrive on the scene with relatively little effort.

Sadly, about one in six couples find babies don’t come to them easily, or at least without medical assistance.

I have enormous sympathy for people experiencing infertility, but, even so, the time has surely come for us to question just how much the public purse can stretch to help finance people in their quest to either become parents for the first time, or add to their existing brood.

No other country is as generous as Australia when it comes to pouring taxpayer dollars into the lucrative baby-making industry … Medicare rebates cover the bulk of scheduled fees and the Medicare safety net kicks in to cover 80 per cent of out-of-pocket costs once a patient has spent just $1111.60 in any year (a mere $550 if you’re getting family tax benefits).

What’s more, patients can elect to have an unlimited number of fruitless IVF cycles subsidised … Not surprisingly, the axe is hanging over the funding scheme for IVF as the Federal Government examines ways of reining in the annual $300 million safety net.

Access Australia, the main lobby group is gloating about its success in flooding Canberra with an orchestrated email protest campaign. Its use of language is enlightening:

it refers to “consumers” rather than patients.

IVF clinics are also exhorting potential patients … to write protest letters to politicians and the media.

The IVF lobby wields enormous power and is used to winning, thanks to the emotional power of the issue. ….

In 1995, 1 per cent of babies born in Australia were the result of assisted reproductive technologies. In just a few years the figure jumped to 2 per cent and is now more than 3 per cent.

Let’s consider some of the consequences. What are we getting for our money … ?

Australian Institute of Health and Welfare figures reveal that in 2002, 27 per cent of these babies were born prematurely.

That means more than a quarter required expensive, taxpayer- subsidised neonatal care …

As recently as 2005, the AIHW was made aware that the perinatal death rate was 7.3 deaths per 1000 births in even the most responsible forms of IVF – where a single embryo was implanted …

And for those babies who do make it, the risks continue.

ICSI … involves injecting the flawed sperm of an infertile man directly into a woman’s egg. Medical evidence is mounting that sons conceived through ICSI inherit their father’s infertility.

The problems with ICSI have been long known, though … Belgian researchers canvassed studies proving the link between the procedure and congenital abnormalities in the children resulting from it.

All IVF carries risks for children … a systematic review … revealed a 30-40 per cent increase in birth defects when comparing IVF and ICSI babies with naturally conceived children.

The fact is that we are paying to create a faulty gene pool, turning Darwin’s theory about survival of the fittest on its head.

What other species would be so foolish as to encourage this form of un-natural selection?

- This is a fair question to ask, and it also begs the question if any of the common interventions we accept in the child bearing process are justified.

Melissa Maimann, Essential Birth Consulting.

Need for Transparency Increases as Cesarean Section Rates Rise

Mar 25th, 2009

by Melissa Maimann.

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Raleigh, NC (March 19, 2009)—CIMS, the Coalition for Improving Maternity Services, a group working toward transparency in maternity care, today announced that the 2007 US birth statistics, just released, show that 31.8% of births are via cesarean section.

- This is the same in Australia: in 2006, our CS rate was also over 30%

The percentage of cesarean deliveries has increased by 50% since 1996 and is more than double the World Health Organization’s recommended rate of 15%.

- In fact, WHO recommends 10% for healthy women, and 15% for women with complicated pregnancies.

Currently, cesarean rates vary widely across the US.

- As they do in every part of Australia!

The 2007 birth data highlight this variation; for instance, a woman giving birth in New Jersey has a 73% higher chance of having a cesarean than a woman in Utah. This strong variation in rates isn’t only geographic; it is also seen among individual hospitals in a community.

- Again, we have the same sitiation in Australia. In 2005, Kareena Private had a caearean rate of 46.4%. In 2006, The Mater’s CS rate was 46.2%, and Prince of Wales Private’s CS rate was 44.3%. Considering these hospitals take the healthiest women (women with significant risk factors or very prem babies are transferred to nearby large public hospitals whose services can cater to women and babies with higher lavels of need). In contrast, Auburn (public) hospital’s caesarean rate was a mere 15.8%. Should women be informed of this before they book into a hospital? I think so!

Many believe that this variation is due to high risk sicker mothers and babies that these hospitals serve; however, that is only part of the story.

- Actually, it forms no part of the story in Australia. The healthiest, wealthiest, and most highly educated women access private hospital care. In my experience, well informed women choose natural birth and natural birth methods. Once they have full and impartial information, they understand that when you work with nature, nature works with you. The women and families who access private obstetric / private hospital care are clearly not incapable of receivign information, considering their options and making an informed decision. For these professionals, business people, CEOs etc, this forms part of their daily routine. So why do so many private women have a CS if this is not the safest way to bring a baby into the world? Are the mis-informed by the one or two sources they rely on so heavily for information? Are they only given two choices, when really there are at least five? Are they told their baby will die if they don’t do as the doctor recommends? I have my ideas – what do you think? Read on ….

Extensive research has shown that these huge variations are strongly linked to the practices and policies of individual hospitals and providers not just the health status of mothers and babies.

- I believe this is the answer. It’s certainly been my experience in my career as a midwife. Working in 23 different hospitals on contracts and as an employee, it was strikingly obvious to me that this was what was at play here. In one hospital, as soon as a woman asks for an epidural, she is given one. Even if her baby’s head is visible and will be born in the next few minutes. While in another hospital, when a woman asks for an epidural you provide emotional and physical support – suggest a position change, a shower, bath, something different. Then, if she still feels she needs an epidural, she has one. The difference? An epidural rate of 80% versus an epidural rate of less than 20%. A caesarean rate of 45% versus a caesarean rate of 20%.

The average women accessing hospital services is not well informed compared to the average woman accessing home birth services. The average women accessing hospital services will believe what you tell her. Sad, but true. If you tell her that she needs a caesarean, she’ll consent. If she was in another hospital that was not as pro-surgery, she would not hear the word caesarean. Most women do not ask for caesareans: they have them on the advice of their care provider.

“Most women believe that they will only have a cesarean section if they experience complications in pregnancy or labor.

- Do most women know what constitites a complication? When women have a caesarean because their baby is too big, too small, has not engaged, has not come by 40 weeks and 1 day, I wonder. And where do they get this information from? Which sector (public / private) are you more likely to hear this sort of mis-information?

But research tells us that most of the factors affecting a woman’s risk of a cesarean have nothing to do with her health or that of her baby. One of the most effective strategies for avoiding a preventable cesarean is choosing a provider and birth setting with a low cesarean rate.

- Absolutely! From http://midwivesvictoria.blogspot.com/ :

Homebirths Australia-wide have an 8% c/s rate compared to a nearly 40% c/s rate nationally.

Other studies have found that home birth has a 90%+ normal birth rate. And really, it’s very simple: if you want surgery, see a surgeon (obstetrician – a surgical specialist). If you want a vaginal birth, see a midwife (natural birth specialist) for home birth or hospital birth. If you want to have control over what happens to your body as well as having a vaginal birth, see a private or independent midwife. Do you go to Michel’s Patisserie when you want to buy fresh apples? No, because the closest you’ll come to fresh apples at Michel’s Patisserie is apple crumble. Likewise, if you want a natural birth, seek out a care provider (midwife) who actually provides it.

In the United States, we are seeing increased public reporting of outcomes and procedure rates for facilities in surgical and cardiac care, but, access to maternity care data remains almost non-existent,” says Amy Romano, MSN, CNM. … C-section can be a life-saving procedure, but it is a major surgery that carries extensive risks for both mother and baby, risks that are not present in a vaginal birth. Research conducted by the World Health Organization shows that these risks of cesarean outweigh the benefits when the c-section rate exceeds 15%. Currently, women have no way of knowing if their local hospitals exceed this recommended rate.

- As in Australia. In NSW, we are fortunate that stats are published per hospital (albeit we have no current data – the most recent is from 2005. 2007 stats were due out at the beginning of this year ….) However, in other States, hospital data is not published. How are women to make informed decisions on where to have their babies if there is no published hospital data that they can access?

“Women can unknowingly increase their risk of unnecessary surgery based on their selection of where and with whom to birth. To enable women to make informed choices, maternity care data must be available at the facility level. Whether requiring a c-section or planning a natural birth, women need data in order to choose the facility that most closely matches their needs,” said Elan McAllister, Founder of New York’s Choices in Childbirth and Co-chair of the Transparency in Maternity Care Project. … Studies have shown that public reporting of intervention rates and outcomes leads to better healthcare …

Melissa Maimann, Essential Birth Consulting.

Cesarean section and pelvic organ prolapse

Mar 25th, 2009

by Melissa Maimann.

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30 Mar 2009
Source: American Journal of Obstetrics & Gynecology 2009; 200:243.e1-243.e4.

Cesarean section is associated with a significantly reduced future risk of pelvic organ prolapse (POP) compared with vaginal delivery, according to new findings from a study of more than 1 million women …

The study … was prompted by conflicting evidence … on whether or not cesarean section confers some protection against future POP …

The researchers … found a significant association between cesarean section and a reduced risk of POP … They conclude that … cesarean section is associated with a significantly lower risk of inpatient diagnosis of POP than vaginal delivery, and that there is a further decrease in risk after several cesareans compared with several vaginal deliveries.

It would be interesting to further analyse this research: The authors state that the study was conducted on women who had their babies between 1973 and 2004. It is well-known that babies born in the 70s were more likely to have been delivered with forceps, compared to today. Considering we know that forceps deliveries result in more POPs than natural vaginal births, I would be interested to see the comparison between normal birth, forceps and caesarean.

Melissa Maimann, Essential Birth Consulting.

Homing in on their birthright

Mar 24th, 2009

by Melissa Maimann.

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BY MARK BARBELIUK
24/03/2009

ADVOCATES of home births are calling on the Federal Government to reject a recommendation in its maternity service review that could see an end to babies being born outside hospitals and birthing centres from July next year.

Members of the Sutherland Shire Natural Birth Group said the proposed changes effectively took away a woman’s right to choose how and where she gave birth.

The controversial section of the review involves indemnity of midwives.

The group said the proposed changes meant midwives could not obtain registration to practice without insurance …

While the St George Hospital home birth service is covered by Medicare, the women describe it as inadequate, restrictive and unacceptable. [I have had several enquiries and bookings from women who have been disqualified from this program. Women are not cleared for home birth until they pass their 36-week GBS swab, along with all other compulsory tests. When you book a home birth with an independent midwife, you have more control. You do not have this right when you access a publicly-funded home birth program. Nor do you have any control over transfer to hospital].

Sally Dillon said the government-funded service had a strict screening process …

Amber Johnstone said in the three years the St George Hospital service had run, about 50 babies had been delivered and the “success” rate was 50 percent, meaning half the women who opted for home births ended up delivering their babies in hospital. [That's an appalling transfer rate. While a transfer rate is a good thing to have - it shows you practice safely - it should not be over 20%].

At present, private home births are not covered by Medicare and those who opt to deliver at home pay $4000-$5000, which includes pre and antenatal care. A standard vaginal in-hospital delivery starts at $5800.

Brian Nicholson said home births … “It binds a family,” he said. “I felt I was able to provide so much support and wasn’t shoved to the side like I would have been in a hospital.

“A lot of the home birth experience is about being comfortable in your head,” Ms Johnstone said.

“It’s a far better experience.”
…
“Women who birth at home are less likely to have interventions including assisted deliveries and caesarean sections.

Melissa Maimann, Essential Birth Consulting.

Emergency birth brings Destiny, Hope

Mar 24th, 2009

by Melissa Maimann.

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SALISBURY — To look at Kitten Panthera and midwife Lauren Olson Sidford today, one would never know they shared a life or death struggle only six weeks ago.

It was on Jan. 27, when Panthera’s twin daughters made a month-early, impatient demand to be born, not in a hospital, not in a planned home birth, but in the tiny bathroom in the seaside cottage Panthera rents on Salisbury Beach. Destiny-Grace and Hope Panthera made their appearance with Sidford crouched beside Panthera in the bathroom and most of the day shift of the Salisbury Fire and Police departments in the small abutting kitchen waiting for an ambulance to arrive.

“It was a baptism by fire, absolutely” Sidford said recently. “I’d been a labor coach and birth assistant for about 20 years. But this is my first year as a midwife, and this was my first home birth on my own. Usually home births are attended by two and sometimes three midwives. Because I only expected to give Kitten a ride to the hospital for an ultrasound, I didn’t even have my midwifery bag with me. I had no medical equipment.” ….

With an ultrasound scheduled, Sidford found a third midwife willing to attend the home birth of twins, if the ultrasound showed the babies were fine and in a good position.

… Panthera, 38, has a strong spiritual belief and [is] “very much in tune with my body,” she said, and took the fear out of the childbirth for her.

“Women have been giving birth since the beginning of time,” Panthera said. “I know some people might think I was jumping out of a plane without a parachute, but God is my parachute. I knew in my gut everything was going to be fine and I didn’t need to worry.”
…
[Speaking about the birth]: “The second baby was breech,” Sidford said. “And not just a simple breech. One leg was down. It’s called a single footling breech. I’ll never forget it; it was the right leg.”

With no other equipment but a single plastic glove passed to her by a firefighter, Sidford reached back to her training, both women trusted each other and nature, and Destiny-Grace didn’t appear to know her life was in jeopardy. With the assistance of Sidford, two strong emergency workers supporting Panthera’s weight, she delivered a healthy second daughter.

“The babies were beautiful,” Sidford said. “They breathed and pinked up right away when they were born. They’re thriving now; eating well, gaining weight.” ….

It’s amazing how well nature works, when we let it! For the majority of women and babies, birth is a normal, natural, healthy event, not a medical emergency.

Melissa Maimann, Essential Birth Consulting.

Extreme Birth

Mar 23rd, 2009

by Melissa Maimann.

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The fearless—some say too fearless—new leader of the home-birth movement.
By Andrew Goldman
Published Mar 22, 2009

On a dreary morning not long ago, Cara Muhlhahn is tooling through Brooklyn in her dented Prius, which she calls her “Mobile On-Call Unit.” Since Muhlhahn is a home-birth midwife, appointments both prenatal and postnatal—and, of course, the big show itself—take place within clients’ homes, and she spends a great deal of her time speeding between boroughs and racking up two grand a year in parking tickets …

This morning’s first appointment … is Kristy Bloom … Bloom is a first-time mother … in her 38th week of pregnancy. In her first weeks of pregnancy, she’d watched the 2008 Ricki Lake–produced low-budget documentary The Business of Being Born. “I cried through the whole movie,” she says. “And then I was in the bathtub and I had this whole vision of the birth and Cara was there. And I came out of the bath and said, ‘Babe, that woman’s going to be our midwife.’ ”

Since participating in The Business of Being Born … Muhlhahn has become the most visible proselytizer of the home-birth movement. She just released a memoir called Labor of Love, in which she headily describes her work: “Day after day, I deliver babies, save lives, facilitate and witness near miracles.” … she’s hoping to grow her home-birth service to handle the increasing demand in New York.

You couldn’t ask for a better home-birth sales pitch than BOBB. The film presents a horrifically plausible portrayal of a hospital childbirth system gone insane, of labor turned into a medical pathology: the continuous fetal heart-rate monitoring that makes it difficult for a mother to get off her back and into a position that actually encourages birth; the fear of lawsuits that compels doctors to perform C-sections on babies experiencing even normal distress during labor; the “failure to progress”—medicalese for laboring in a rentable hospital bed too long—that causes doctors to initiate a chain of “unnecessary interventions” like the artificial-induction hormone pitocin paired with epidural anesthesia, which seem to manufacture their own fetal distress, which in turn produces more C sections … [which] has done nothing to improve infant- or maternal-mortality statistics.

BOBB didn’t really break news, but it did introduce the natural-birth argument to a new mainstream audience. More than anything else, BOBB de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety. There are only two options when it comes to childbirth, the film seems to say, comparing shots of ecstatic mothers hoisting their babies at home with shots of women under bad hospital light screaming for rescue.

Muhlhahn is offered up as the eminently reasonable alternative to the medical mess, shown in her East Village apartment in the predawn hours, tucking her instruments into a doctor’s bag, looking like the medical pro she is, a dean’s-list graduate from Columbia’s School of Nursing … She looks nothing like the hippie-midwife stereotype. “Downright sexy” is how Ricki Lake has described Muhlhahn, a youthful 51-year-old with low-rise jeans and a husky Debra Winger laugh.

She also doesn’t practice like a typical midwife. Personal experience has led her to dismiss many of what she calls the “myths” that are still taught in school as the bedrock of safe practice. The big babies … are nothing more than “fit challenges” to Muhlhahn, necessitating only patience. She regularly does vaginal births after C-section at home, and has even home-delivered the riskiest births, breeches and twins …
….
But even more essential than promised nirvana or perfect aesthetics is the implication that messing with the birthing process can affect the bonding between mother and child. In BOBB, French obstetrician and natural-birth pioneer Michel Odent contends that a “complex cocktail of love hormones … create a state of dependency, addiction” between mother and child. Interrupting that natural flow with drugs or a Cesarean, he posits, invites dire consequences. “It’s simple,” he says. “If monkeys give birth by Cesarean section, the mother is not interested in her baby … So you wonder, what about … the future of humanity?”

When you ask Muhlhahn’s many happy customers to recount their birth stories, they struggle a bit; you suspect they feel the way an astronaut might attempting to describe space travel to someone who’s never flown in a plane. “When you get through that transition, and you experience the birth of your child, you get the endorphins, the best bonding experience … ,” says Jeannie Gaffigan, who delivered her second child with Muhlhahn. … women turn to Muhlhahn because she inspires confidence in them—confidence in her clinical skills and knowledge of the birth process but also confidence that their bodies are fully capable of the arduous task. Her admirers say that she’s gifted at intuiting when a laboring mother needs cheerleading and hand-holding and when she needs her to step back and leave her to labor in peace …

But labor is an unpredictable thing, and sometimes the experience is more nightmarish than poetic. Muhlhahn’s patient Sandra Garcia was one week overdue when her water finally broke on a Sunday night in early November. She labored that night and through the next day assisted by her husband, Jeff Wise, and her doula, a former NYU postpartum nurse who was now working for Muhlhahn. (Muhlhahn, busy with another labor, appeared only sporadically.)

Monday night, Garcia was approaching 24 hours of labor. Most hospitals insist that a baby be delivered no more than 24 hours after membrane rupture because of the risk of infection, but Muhlhahn isn’t a big clock-watcher. Instead, she takes precautions to avoid infections: “After rupture,” she says, “no routine exams, no baths, no sex.” By 10 p.m., the doula decided that Garcia was about to deliver. So, with candles lit, Garcia got in the birthing tub, which, because of the risk of infection, represents the endgame, the mother’s pushing venue. Except it wasn’t time to push. At Garcia’s insistence, Muhlhahn performed an exam at around 3:30 a.m. and discovered she was only a half-inch dilated. The doula had somehow misjudged her progression. Still, Muhlhahn wasn’t concerned. “There’s no such thing as stalled labor,” they remember her assuring them. “Labor just takes a long time.” With that, she left to deliver another baby.

Late Wednesday afternoon, nearly 72 hours into his wife’s labor, Wise started to freak out. The doula had gone home to rest. It was getting dark. They had no instrument to check the baby’s heart rate. His wife’s face was pallid, her knees and elbows raw from supporting her weight during the contractions …

“How long is too long for a woman to be in labor?” Wise demanded to know when Muhlhahn finally returned to the apartment that night. “Never,” Muhlhahn replied flatly. Her philosophy was simple: Trust the wisdom of the body to send the baby out when it’s ready. But she agreed to examine Garcia again. If she hadn’t progressed significantly, they’d go to St. Vincent’s. The results were startling: two centimeters. She had hardly progressed at all.

Garcia crouched on all fours in the back seat of Muhlhahn’s Prius as they drove to the hospital … The next morning, Garcia woke with a 103-degree fever, a sign of infection … after 84 hours of labor, she was still less than five centimeters dilated. The baby had to come out by C-section. Remment Garcia Wise weighed in at eight pounds, eleven ounces, about two pounds more than Muhlhahn had estimated. Rem was whisked away to the Neonatal Intensive Care Unit, where he stayed for five days …

“How do you feel about having a C-section?” Muhlhahn asked the couple at a follow-up appointment to discuss what had happened … Garcia felt the question was barbed with the implication that if she’d only had more patience—tried harder—she could have had a vaginal birth.

Muhlhahn calls St. Vincent’s her “backup hospital.” About 10 percent of her patients end up transferring there during labor. “St. Vincent’s is her dump,” says one former obstetrics resident … “She’d bring her patients in, holding their hands, find out we were going to have to do a section, and then she’s out the door.” [In Austrtalia, the mdiwife generally stays with the woman in the case of transfer].

There is, of course, a long-standing animosity between doctors and midwives, particularly those who take births out of hospitals. In a 2008 policy statement, the American College of Obstetricians and Gynecologists reiterated its position against home birth: “Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre.” But St. Vincent’s seems to have bridged the divide better than most hospitals. George Mussalli, the chairman of obstetrics and gynecology since 2006, has fostered much goodwill within the midwifery community. … JJB Midwifery actually have hospital privileges there.
….
For all her home-birth successes—she has delivered more than 700 babies—Muhlhahn has also had some tragedies. In 2003, she and her former birthing center settled a $950,000 malpractice suit brought by the parents of a child who was injured during delivery. As the baby’s head was crowning, he suffered a shoulder dystocia, when a baby’s shoulders get stuck behind the mother’s pelvis. It was imperative to get the baby out quickly, because he couldn’t breathe in that position … The child survived, but the cervical nerves in his neck were damaged, rendering his right arm paralyzed, a condition called Erb’s Palsy … Garcia’s complaint argued that Muhlhahn should have known that the baby would be too large for a vaginal delivery. [There's no way of knowing with certainty if a baby will fit or not. Shoulder dystocia can happen at home or in hospital; some would argue that it's more likely in hospital because women are usually restricted to birthing on their back].
….

The panel’s star, however, might be Jessica Robinson, who receives gasps from the impressed crowd for revealing a thumbnail of her experience: 76 hours of labor, which included a 30-block walk on her third day and an episode in which Muhlhahn had to coax her out of the bathroom of a Brooklyn acupuncturist’s office. The adventure eventually yielded a ten-pound, twelve-ounce boy, the heaviest baby Muhlhahn had ever delivered to a primip. “It just seemed,” Muhlhahn says, savoring the victory, “like a completely normal delivery.”

Melissa Maimann, Essential Birth Consulting.

Federal review rejects funding for home births

Mar 23rd, 2009

by Melissa Maimann.

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HOME births could be pushed underground in “fragile, secretive arrangements” after a Federal review rejected funding for the practice, an academic says.

A review of maternity services … has recommended changes to Commonwealth funding arrangements to support a greater role for midwives.

It also suggests the Government provide professional indemnity insurance support to midwives, but rejects Commonwealth funding for home births.

Leading midwifery expert Jennifer Cameron … said moves to regulate the role of independent midwives in home births was not in the best interests of women.

“The report was very clear in that it did not support reforms that increased or funded women’s access to home birth,” she said.

“Women will continue to have babies at home; removing independent midwives and saying we won’t do home births won’t solve the problem.

“Most women birthing at home without a trained caregiver do so because they are unable to access midwifery care at home, and are unwilling to use hospital-based services … Ms Cameron said more women would be “pushed into” unattended home births.

- I firmly believe that what needs to occue is a reform os hospital birth services so that women with “high risk” situations such as VBAC, breech, twins etc can have natural births in hospital. The Maternity Services Review paves the way for this to happen.

Melissa Maimann, Essential Birth Consulting.

Home deliveries

Mar 23rd, 2009

by Melissa Maimann.

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John Elder
March 22, 2009

JANET Fraser is in labour. Her plan is to drop the baby on the loungeroom floor, or wherever feels good at the time. Has she called the hospital to let them know what’s happening? “When you go on a skiing trip, do you call the hospital to say, ‘I’m coming down the mountain, can you set aside a spot for me in the emergency room?’ I don’t think so,” says Fraser, whose breathing sounds strained.

This is pretty much where we end the conversation that started with me calling Fraser and asking if it was true that her organisation, Joyous Birth, was advocating that women go it alone giving birth at home, with no midwife …

“Free-birthing, plenty of women do it,” she says. In fact, Fraser is doing it right now. “I prefer to be an autonomous care-provider,” she says.

By the time she tells me the birth of her third child is “impending”, Fraser has already talked intensely about the likelihood that home births attended by midwives will be illegal from July next year, when the national registration scheme for health professionals kicks in …

She has also talked about how the Joyous Birth group, of which she is national convener, wasn’t encouraging women to free-birth as a means of flouting the law, but to run their pregnancies and birthing in the manner they desire.

“If that happens to be free-birth, then you go for it … We don’t advocate hospital-based birth or being beholden to all sorts of authority figures,” she says.

Janet Fraser’s son, 5, was planned as a home birth, but came into the world via an emergency caesarean after Fraser was transferred to hospital. Her daughter, 2, was born at home …

Fraser is 40. She hasn’t seen a doctor or any health professional since becoming pregnant this time. No ultrasound, no genetic testing, no internal examinations, no stethoscope. [Internal examinations do not form part of the routine care of pregnant women.] Does she have any feeling for how long the labour will go? “I could do this for days. My daughter’s birth was 50-something hours. You just do it — it’s just birth, a normal physiological process.”

At the time of publication, Ms Fraser’s labour was continuing to progress slowly.

[A very small proportion of Australian choose to birth at home].

The home-birth crowd has always been loud, but if they are more strident of late it’s possibly because they are feeling left behind in an evolving birth scene, where hospital midwives are increasingly required to train for emergency situations, including home-birth complications.

St George [Hospital] is one of a number of hospitals in NSW trialling home-birth programs where two midwives are required to attend a birth, and the home births need to be sanctioned according to a set of low-risk protocols [that do not see the majority of women as low risk, and therefore the woman cannot access that services. Women are not "cleared" for home birth until 36 weeks when they have a compulsory swab to determine if they have group B strep, which may or may not be present when they do into labour, perhaps some 4 - 5 weeks later]. Independent midwives generally work alone, with a more lenient policy on risk. For example, independent midwives will home-birth twins, breech presentations and … VBACs.

The status of midwives is the key to where birthing is headed. The Maternity Services Review has recommended an expanded role for them. One option on the table would see their services covered by a Medicare rebate for the first time. However, this would not be extended to independent midwives attending home births.

There is growing enthusiasm for the case that continuous care by a midwife through the prenatal, birth and post-natal stages tends to result in happier and healthier outcomes for a pregnant woman. And that if the midwife role was expanded … then a significant portion of … hospital resources could be freed up, and the nation’s health bill somewhat reduced. [Not to mention the outcomes for women and babies would be greatly improved].

Within this context, home birth might sit more comfortably in the public mind as a viable option.

Justine Caines, secretary of Homebirth Australia, [says]: … “It’s only the home-birth mothers who have experienced one-to-one midwifery who advocate for change … The vast majority aren’t passionate about their experience basically because … The system basically treats them as someone to shuffle through. The whole passion around home birth is about the experience of one-to-one midwifery care.”

Caines sees midwives as the great hope of the overburdened health system. “We fund private obstetrics to hundreds of millions of dollars through Medicare … fees for services that don’t relate to case load. Most of it is a waste of money,” she says.

“(Federal Health Minister) Nicola Roxon could offer a $5000 birth package that would cover continuous care for each pregnancy … as opposed to women engaging in private obstetric care spending $20,000 believing they have the best care money can buy.

“I have a midwife come to my home every day for the first seven to 10 days. The most expensive is $4000 for the entire package … and no health fund covers it. People could get better, cheaper care.”

Barbara Vernon, chief executive of the Australian College of Midwives, says this message gets lost in media sensationalism sparked by organisations such as Joyous Birth and a small number of midwives who don’t make risk minimisation their primary focus, whereas most midwives working privately — and there are only 50 registered with the college, possibly 100 throughout the country — are “very risk-averse”.

“Midwives have the skills and equipment for the safe care of a mother and baby in a home-birth situation, and they recognise quickly when something’s going wrong.

“What fails to compete with the sensationalism is … the evidence showing that a trust relationship between a woman and a midwife, established from early in the pregnancy, means that the woman in labour is feeling safe and less anxious. It’s a better experience.”

Vernon says the flow-on effects of continuous midwife care include shorter labours, a reduced need for drugs and pain relief, reduced admissions to neonatal intensive care, reduced vulnerability to post-natal depression and improved rates of breastfeeding to 12 months of age.

“Even if she has a caesarean, the woman is not traumatised by the process … “It’s the women who get run over by the system that feel most vulnerable after that experience. They can’t understand why all of that happened.”

… is a hospital-governed home-birth system the answer to mainstreaming home birth? Free-birther Janet Fraser says: “It would be a disaster if hospitals ran home birth. Hospitals are dangerous.”

Justine Caine says: “Not until obstetric care is kept in check. The problem with most of (the trial schemes) is that women and midwives are not able to make decisions. Hospital midwives are handmaidens of the doctors. Obstetricians call the shots and much of the exclusion criteria is not based on evidence.”

Veteran private midwife Robyn Thompson, who has spent 30 years assisting home births, says: “It wouldn’t be a disaster. I’m welcoming whatever it takes that makes it good for women.”

Thompson says the average transfer rate over those 30 years had been about 17 per cent … “You anticipate what’s happening…”
…..
Barbara Vernon says: “RANZCOG has a position statement where home births are not endorsed. But some women are going to always birth at home.” [And therefore the approach needs to be one of harm-minimisation, not making home brith illegal by denying midwives access to professional indemnity insurance, and therefore registration].

- I guess the real question is – who owns birth? Midwives? Obstetricians? Maybe it’s time for women to claim birth.
……
Home-birth advocates insist that doctors only have a role to play when a birth becomes problematic. They say doctor intervention has led to skyrocketing induction, epidural and caesarean rates, issues that were at the heart of the Maternity Services Review. [And this is true. Midwives do not intervene in these ways. We cannot perform caesareans, we do not authorise inductions and we cannot insert epidurals. These are in the medical domain.]

In April 2007, Melbourne lawyer Ann Catchlove was told by her obstetrician that she needed a caesarean with her first child because her pelvis was not big enough. “He said, ‘You can keep going if you want but we’ll still be here at 3am’,” she says … The doctor told Catchlove that her future babies would have to be delivered by caesarean. Research on the internet convinced her otherwise. “I found the original caesarean probably wasn’t necessary.”

She also found research that indicated vaginal birth after caesarean was a reasonable option. She started thinking about a birth centre “but none of them would accept me”.

Last November she gave birth to a son at home. “… once I’d made the decision, and met the midwives, I never had any doubts. There’s an idea of hippies burning incense in the background, which is wrong. They were very focused on safety … the birth itself was very smooth and relaxed, other than the pain. I felt very safe and in control.”

Obstetrician Pieter Mourik warns ominously that graveyards are full of “failed home births”. He has called Janet Fraser’s Joyous Birth group “a bunch of nutters” and Fraser herself “a fool”. When told Fraser was free-birthing at home, Mourik was quieter than usual, less on the soapbox.

Fraser had said she didn’t expect anything to happen for another couple of days; that nothing bad happened quickly in a labour and that there would be time to get to hospital if things went wrong.

Mourik paused. “She told me (during a debate) she’d had a caesarean. That’s how a uterus is most likely to rupture. If that happens, there won’t be time … Well, I wish her well.”

Melissa Maimann, Essential Birth Consulting.

Evidence Increases For Risks In Cesarean Surgery As National Rate Continues To Rise, USA

Mar 20th, 2009

by Melissa Maimann.

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As research continues to mount for the risks of cesarean surgery, the CDC released new, staggering statistics today reporting that 31.8% of women endure birth by cesarean in the United States (2007). [This is no different to the stats in Australia as of 2006. No doubt our caesarean rate is higher now]. This announcement comes after the release of significant findings from the New England Journal of Medicine reinforcing that birth by cesarean surgery before 39 weeks of pregnancy causes increased complications in newborns.

Despite the latest advances in medical technology, health care providers cannot determine a baby’s due date with 100% accuracy. [Babies can come anywhere between 37 and 42 weeks and still be considered term. So if a baby was not destined to come into this world until 42 weeks, and a caesarean was performed at say 38 weeks, that baby would be 4 weeks premature]. Therefore, cesarean surgeries scheduled before a woman’s estimated due date could result in a baby born as early as 36 weeks to a few days before the baby is actually due. During the last few weeks of pregnancy, a baby’s lungs mature and a protective layer of fat forms, both of which are vital developments for a healthy baby … Without time during labor to prepare the baby to breathe, lungs cells may not be ready. Thus, babies born by cesarean surgery, even when they are full-term, need to go to an intensive care unit more frequently than babies who were born vaginally to get help breathing.

Research … [suggests] that cesarean surgery performed prior to 39 weeks of pregnancy increases poor outcomes in babies. Of the babies in the NEJM study born before 39 weeks, more than 26% had complications, including the need to be on a ventilator, respiratory distress syndrome, low blood sugar and severe infection (sepsis).

“Overuse of cesarean surgery complicates the otherwise natural process of birth,” says Lamaze Institute Chair Debra Bingham, LCCE, MS, RN, DrPH, “Allowing the natural process to occur not only reduces risks for mothers in this and future pregnancies, but also reduces health risks for her baby.”

Spontaneous labor is almost always the best indication for a baby’s physical readiness for life outside of the womb. As one of the key steps to a healthy birth, Lamaze International recommends that women let labor begin on its own. … When a birth outcome is good, mother and baby can bond and start breastfeeding immediately after birth-both of which provide the best start for a baby’s growth and development.

Lamaze International President Pam Spry, PhD, CNM, FACNM, LCCE says, “Maternity care in the United States is at a crossroads. The most commonly used practices don’t align with the best evidence for a healthy birth.” …

Cesarean surgery … also carries risks for women, such as blood loss, clotting, infection and severe pain, and poses future risks, such as infertility and complications during future pregnancies such as stillbirth and placenta problems like percreta and accreta, which can lead to excessive bleeding, bladder injury, hysterectomy and maternal death …

Two of the most important decisions a woman can make are where she gives birth and who she chooses as her care provider.

Melissa Maimann, Essential Birth Consulting.

Yes! Yes! Yes! It’s coming!: Orgasmic Birth

Mar 20th, 2009

by Melissa Maimann.

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Is it really possible to climax during labour? Viv Groskop talks to women who say they have and explores the controversy surrounding orgasmic birth.

Amber Hartnell did not intend to have an orgasmic birth – it just happened. “Trying to have an orgasmic birth defeats the object,” she says, “I just got into this ecstatic state where I had these peaks of orgasm. There were these rolling waves coming through me where I was laughing and crying. I didn’t feel like I was having contractions. They were more like rushes. I did not actually experience pain, I experienced intense sensations.”

… Hartnell says this is definitely what happened during labour with her son Orus … She had a water birth at home over a 12-hour period and the “orgasmic rushes” kept coming from about two thirds of the way through. “It was the most overwhelming pleasure I have ever felt in my life,” Hartnell says …

Now her experience has gone global. Hartnell … features in a documentary, Orgasmic Birth … “It was a really major deal sharing the most intimate and vulnerable moments of my life with the world,” she says. “But I had the sense that sharing this story could help other women to break through their fear and have a beautiful experience of birthing.”

The response to the film has been one of both fascination and horror. For many women the idea that childbirth can be orgasmic is at best hippyish and possibly offensive … One heavily pregnant blogger writes that she “can understand pain being natural in childbirth and letting your body take over and making it as enjoyable as you can. But orgasmic? No. Whoever finds that orgasmic needs help, in my opinion.” Hartnell, however, reports receiving hundreds of messages from enthusiastic supporters, including from several pregnant women who changed their birth plans after they had watched the film.

The title of the documentary is actually slightly misleading. Because while it features interviews with several women who swear they have had an orgasm during labour (and even shows eye-popping footage of them experiencing this), it is really about “undisturbed birth” – natural labour in a home setting, without drugs, or even gas and air …

The documentary features Ina May Gaskin … she says that an ecstatic birth “is the best natural high that I know of. Women don’t have a way to know how their body works until they really try it out in birth.”

The idea that birth can be orgasmic isn’t new. The British birth guru Sheila Kitzinger says that she has met “hundreds” of women during the course of her career who report experiencing orgasm during labour – some were hoping for it, others were taken completely by surprise. “It is difficult for a man to understand,” she says “hard, too, for any woman who has had an average hospital birth. But it can be one of the most profound psychosexual experiences in a woman’s life …” She puts this partly down to simple biology. “The pressure of the baby’s head against the walls of the vagina and the fanning out of the tissues as the head descends bring for some women an unexpected sensation of sexual arousal, even of ecstasy.” But is this really an orgasm? Or just a very unusual sensation? “It can be orgasmic …”

The film’s producer, birth educator Debra Pascali-Bonaro, says a woman’s ability to feel intense physical pleasure during childbirth is “the best-kept secret”….

Women in the documentary have been criticised online for kissing their husbands … during labour … many of the processes associated with labour also happen during sex, such as the release of oxytocin and endorphins into the bloodstream …

Why then do we feel so uncomfortable about the idea of women having an orgasm when they are actually giving birth? “It crosses the margin of decency – which I think is wrong,” says Kitzinger, “We’re told that sex is different from childbirth. In the same way, it is considered indecent to experience intense physical satisfaction from breastfeeding.” …

- I regularly lend out the Orgasmic Birth DVD to clients. The feedback is always positive – it’s a different way of looking at birth, and of approaching contractions.

Melissa Maimann, Essential Birth Consulting.

Memory of Labor Pain Influenced by a Woman’s Childbirth Experience

Mar 19th, 2009

by Melissa Maimann.

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By Megan Rauscher
NEW YORK (Reuters Health) Mar 11 – Research shows that for about half of women who give birth, memories of the intensity of labor pain decline over time. However, for some women, their recollection of pain does not seem to diminish and for a minority, their memory of pain increases with time.

The study also shows that the memory of childbirth pain is influenced by a woman’s overall satisfaction with her labor experience.
….
Women who reported labor as a positive experience 2 months after childbirth had the lowest pain scores, and their memory of the intensity of pain had declined by 1 year and 5 years after giving birth.
“Memory of labor pain declined during the observation period but not in women with a negative overall experience of childbirth,” the team notes in the March issue of BJOG ….

Roughly 60% of women reported positive experiences and less than 10% had negative experiences. For women who said that their childbirth experience was negative or very negative, on average, their assessment of labor pain did not change after 5 years.

“A woman’s long-term memory of pain is associated with her satisfaction with childbirth overall,” Dr. Waldenstrm said, summing up. “The more positive the experience, the more women forget how painful labour was …”

The researchers also found that women who had epidural analgesia remembered pain as more intense than women who did not have an epidural …

- I was not surprised to read that women who have epidurals rate their labour as more painful. Generally, those women may have had an expectation of having pain relief, or of having a pain-free birth. Hence, any pain would have been experienced negatively, and perhaps also they would not have had good birth preparation. I find that women who are well-prepared for labour and birth, have positive experiences and rate their satisfaction with labour very highly.

It is well-known that continuity of care from a known midwife is key to a positive labour experience.

Melissa Maimann, Essential Birth Consulting.

The Trouble With Repeat Cesareans

Mar 18th, 2009

by Melissa Maimann.

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By Pamela Paul
Thursday, Feb. 19, 2009
To avoid another C-section, Barton has to drive 100 miles to deliver in Los Angeles.
For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. (It’s often the same in Australia, unless you have a private midwife or doula with you) Jessica Barton knows this all too well … her first child ended up being delivered by cesarean section, she can’t find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he’s not on call the day she goes into labor? … in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles.

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries … the International Cesarean Awareness Network (ICAN) … found that 28% of [hospitals] don’t allow VBACs … ICAN’s latest findings note that another 21% of hospitals have what it calls “de facto bans,” i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them …

Why the VBAC-lash? … The risk of uterine rupture during VBAC is real–and can be fatal to both mom and baby–but rupture occurs in just 0.7% of cases … only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.

After 1980 … more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued [a] … report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall–even though 73% of women who go this route successfully deliver [vaginally].

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be “readily available” during a VBAC to “immediately available.” …

Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all …

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births … 26% [of OBs] said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation …

Of course, the alternative to a VBAC isn’t risk-free either. With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta–in which the placenta attaches abnormally to the uterine wall–has increased thirtyfold in the past 30 years …

… while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them … 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

… “the pendulum has swung too far the other way,” So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. [Concern arises that perhaps doctors will forget how to do VBACs.]

- Well, fortunately, you “do” a VBAC the same way you “do” a natural birth. By supporting the natural processes that women’s bodies are designed to perform. In this country, VBAC rates are between 10% and 16%. In some private hospitals, the rates are as low as 1%. In homebirth, the rates of VBAC are at least 80%. And it is a numbers game, so put yourself where the numbers are stacked with you, not against you. Plan a home birth for your VBAC, or employ a private midwife for a hospital birth.

Melissa Maimann, Essential Birth Consulting.

Pregnancy Increasing In Women With Type 2 Diabetes

Mar 18th, 2009

by Melissa Maimann.

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The number of women with Type 2 diabetes who are becoming pregnant has increased by almost 50 per cent in five years … serious pregnancy complications, including major congenital malformation, stillbirth and death of the child shortly after birth, fell for women who received pre-pregnancy care.

As well as having diabetes, the women in the study also had other factors that increased risks during pregnancy such as age over 40 years andweighing more than 100kg at the start of pregnancy.

It has been known for some time that women with diabetes have high-risk pregnancies. As more and more women of child-bearing age are being diagnosed with Type 2 diabetes it is crucial that they have access to appropriate care and support before and during pregnancy.

To improve the chances of all women with diabetes having a healthy pregnancy, Diabetes UK wants to see them … provided with preconception care and counseling that emphasises the need to keep tight control of their diabetes …

Melissa Maimann, Essential Birth Consulting.

Early pacifier use linked to shorter breastfeeding

Mar 18th, 2009

by Melissa Maimann.

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Mothers who want to breastfeed their baby successfully may want to hold off on giving their infant a pacifier, new research from Denmark shows.

Nearly two-thirds of the women reported giving their baby a pacifier. Pacifier use was associated with a shorter duration of breastfeeding, independent of breastfeeding technique.

Use of the pacifier “should be avoided in the first weeks after birth by mothers who want to breastfeed,” the researchers conclude.

SOURCE: Birth, March 2009.

- Use of dummies has long been identified as something that works against successful breastfeeding. The World Health Organisation and UNICEF 10 Steps to Breastfeeding advise against dummy use for the reasons stated in the study above.

Melissa Maimann, Essential Birth Consulting.

Australia is not so baby friendly

Mar 17th, 2009

by Melissa Maimann.

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Ms Randa Saadeh, a Senior Scientist with the World Health Organization (WHO), is speaking at the Australian Breastfeeding Association’s national seminar series … [she] is stressing the need for hospitals, workplaces and the community to support mothers and babies to continue breastfeeding.

Current infant feeding practices in Australia are resulting in unnecessarily high hospitalisation rates. Early weaning increases, by five fold, the risk of respiratory disease, gastro, middle ear infections and obesity.

The Baby Friendly Health Initiative (BFHI) improves breastfeeding rates which result in fewer child health interventions, including costly hospital admissions. In Australia however, the number of BFHI accredited hospitals is just 20%. New Zealand boasts 90% of their hospitals with BFHI status as a result of strong government support.

Melissa Maimann, Essential Birth Consulting.

Breast-Feeding May Reduce Risk for SIDS by Half Throughout Infancy

Mar 17th, 2009

by Melissa Maimann.

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Breast-Feeding May Reduce Risk for SIDS by Half Throughout Infancy
Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

Breast-feeding reduces the risk for sudden infant
death syndrome (SIDS) by approximately 50% … Exclusive breast-feeding at age 1 month was associated with half the risk for SIDS. Although partial breast-feeding at age 1 month was also
associated with lower risk for SIDS, this risk was not significant …

SIDS is a leading cause of death in infants … [the] SIDS risk was 2-fold higher in formula-fed vs breast-fed infants … However, breast-feeding is not universally included in SIDS prevention guidelines.

- Yet another benefit of breastfeeding!

Melissa Maimann, Essential Birth Consulting.

Fed:More Aust newborns tipping the scales at over 4kg

Mar 17th, 2009

by Melissa Maimann.

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Full text

16/03/2009 – Australian babies are becoming increasingly big bundles of joy, and health experts warn it’s not always something to be happy about … gestational diabetes [results in] heavier babies [and contributes to] a rising rate of newborns weighing in at more than four kilograms.

… there is evidence of a relationship between high birth weight and the increased future risk of asthma, type one diabetes and a number of cancers, including infant and childhood leukaemia, and breast, prostate and colon cancer,” said Dr Hadfield, who is postdoctoral research fellow at the University of Sydney at Royal North Shore Hospital.

“As well as the potential for lifelong health consequences, higher birth weights may also result in injury to the infant and the mother at the time of delivery.” ….

Another contributing factor was the fact more women were waiting later in life to have children, but Dr Hadfield also said not all of the increase could be accounted for.

- What is not mentioned, is that perhaps women are looking after themselves really well in their pregnancies, eating healthier food, and that this is contributing to bigger babies. Of course, there’s also the obesity epidemic, so the onus is on women to take care of their nutrition, exercise and health during pregnancy. A low-GI diet combined with exercise is a great start!

Melissa Maimann, Essential Birth Consulting

Making Tough Decisions Without All the Facts: How Inadequate Informed Consent Puts Childbearing Families at Risk

Mar 12th, 2009

by Melissa Maimann.

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Making Tough Decisions Without All the Facts: How Inadequate Informed Consent Puts Childbearing Families at Risk
WASHINGTON (March 10, 2009)

Imagine you are a woman in labor and your doctor tells you that electronic fetal monitoring is necessary to record your baby’s heartbeat. Without any further information about the monitoring or its risks, you are given a consent form to sign. Believing the doctor is doing what is best for you and your baby, you sign. By neglecting to tell you that electronic fetal monitoring can result in labor complications and increases the need for cesarean surgery, your doctor has not held up his or her end of the informed consent process.

This shocking scenario plays out nationwide thousands of times a day across a range of procedures. The purpose of informed consent is to ensure that before a health professional or researcher does something to a patient’s body, the patient must understand what is being done and give his or her voluntary consent. But in all aspects of medical care, informed consent can fall short of the mark. In the instance of childbirth, women and their partners may be asked to make decisions without being well-informed of the risks and potential outcomes that can affect moms and babies.
….
A recent article published … reveals how sub-par information provided by health care providers undermines the purpose of informed consent. This results in parents having incomplete information when making decisions with potentially grave implications, such as whether or not to use medication or submit to obstetrical procedures during childbirth. [Inadequate informed consent is] a major barrier to women benefiting from evidence-based maternity care.

- I have seen this many many times in hospital settings in this country. Most women do not give truly informed consent because their care providers only tell women what care providers want them to know. I believe most women would not sign up to the vast array of interventions offered on the “menu” if they really knew the risks, benefits, potential complications resulting from the intervention, and the lack of research that has been done (especially in the case of fetal monitoring) prior to the introduction of the intervention on a wide scale.

Why does it matter? It matters how babies are born. It matters for women and it matters for babies. Intervention in birth that is not what you signed up for, can lead to postnatal depression, birth trauma, being labelled “high risk” in your future pregnancies and births, complications in your current birth and future births, not bonding with your baby, breastfeeding problems, and the list goes on.

All women birthing in hospital, planning “natural” births – whatever that means to each woman – needs support in labour. Australia’s caesarean rate is over 31%. Many NSW hospitals have caesarean rates of over 40%. Most women have a “high risk” label of some sort. If you want a successful natural vaginal birth, you need good support. The best support will come from a private / independent midwife.

Melissa Maimann, Essential Birth Consulting.

Advice on Coping with a Miscarriage

Mar 10th, 2009

by Melissa Maimann.

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As published on the Essential Baby website http://www.essentialbaby.com.au/parenting/pregnancy/advice-on-coping-with-a-miscarriage-20081111-5m73.html?page=-1

November 11, 2008

For further information, contact Melissa Maimann at www.essentialbirthconsulting.com.au

Essential Baby member and midwife Melissa talks to EB members about how they coped with their miscarriage and what advice they can share with others.

Give yourself time
Grief takes time. Especially if it’s combined with anger, confusion and isolation. Give yourself permission to be sad, to grieve. Some people will try to offer advice: accept this if it helps you. Try not to shut out your partner and helpful friends and family.

Say goodbye to your baby
When we move from one phase of our life into another, it is important to acknowledge what was, and is no longer, by saying goodbye. This comes in various forms. Jamie-lee “had been keeping a pregnancy journal, so I wrote a goodbye. My husband read it and signed the book as well. The next day I felt different: a lot calmer.” Lia was able to say goodbye to her baby physically. Lia’s “OB came in to see me and picked her up and put her in my hands. It was really wonderful of him, he kind of knew I needed to do it, I’m glad I did I would have regretted it if I hadn’t.”

Seek answers
It’s important to get answers – especially if you have experienced more than one miscarriage. Roony found it helpful then her “obstetrician sent tissue from the D&C for chromosomal analysis and it was found that there was an abnormality incompatible with life. So I had a reason and also knew that this wouldn’t affect my chances of falling pregnant again.”

Heather did not blame herself for the miscarriage when she found that the cause was likely to be a chromosomal/genetic abnormality.

Support from loved ones
Heather told her family about her pregnancy at five weeks. “This turned out to be a blessing as we had acknowledgment and support from our loved ones, which made it much easier to deal with.” Rebecca found that talking to others who had gone through the same experience helped. Don’t be shy to ask family and friends to help with housework, shopping, or the care of other children.

Seek professional support
Lia was given literature and support from Pastoral Care. “She took the time to not only talk to me, but also my husband who was having a really hard time with it.”

Some women find enormous benefit in talking to counsellors or psychologists about their experiences.

Providing sensitive care: advice for friends, family and care providers
Many people do not realise that miscarriage requires a full period of mourning and grief. It’s important to recognise this period and validate the woman’s experience. When Amanda was told, “It’s meant to be, there was something wrong with it”, and “at least you know you can fall pregnant”, these comments made her really angry. She “just wanted someone to say “you poor bugger, I am here to listen”. Nicole’s advice to family and friends is “Just listen. The best thing you can do is let the person simply talk when they want to, cry when they want to and not try to make them feel better.”

Rebecca’s experiences were upsetting as she recalls, “It may be an everyday occurrence for them, but it is not for us. This is the loss of a life, that we wanted very much, not just yet another person having a miscarriage. I would have loved for the staff to be a bit more caring and understanding towards me. Just because I was young and not married … does not mean the baby was not wanted, or that my partner was going to leave me.”

Sally feels that some kind of recognition is needed: “Nothing was ever said to me about what happened to my child after the D&C. If you lose a baby later in pregnancy, they encourage you to hold it, photograph it, bury it, etc. I think there should be some recognition of that life even if it was so short. It was like the baby had never existed.” This is also important so that parents can say goodbye.

Jamie-lee wanted information about when she could try again for a baby. She found, “the doctors at hospital were very vague. They said to wait a few months, but couldn’t tell me why I should wait. Then they said if you fall pregnant straight away its not a problem! This confused me.” Consistent advice with good reasoning is really important.

Professionals can provide sensitive care by allowing the woman time to talk, debrief and ask questions. It’s also important to provide choices wherever possible. Roony cautions health professionals: “Don’t use the term ‘abortion’. Even though it’s the medical term for a miscarriage, when people hear it, they think ‘termination’. Explain things and don’t rush to see other patients. Provide a follow-up 4-6 weeks post miscarriage to see how everything is going. Consider investigating possible causes of the miscarriage sooner rather than later.”

Lia said, “There was one nurse who stands out in my memory. She wiped my tears away. She stroked my hair as they sedated me, and she was still there when I woke up to console me. Nothing could have made it easier, but this lady cared.” It’s about compassion.

Heather’s experience was eased when a nurse recognised her loss. “We had a dreadful experience in the hospital, except for one kind male nurse who expressed compassion for both my husband and I. His simple ‘sorry for your loss’ permitted me to cry and begin to grieve. A little kindness and compassion goes a very long way.”

Alison recalls, “I saw two different GPs for my pregnancies, and sadly both of them seemed to lack the detailed knowledge of what is normal in early pregnancy. Even when things were clearly not going well, they were just too upbeat and optimistic.” In contrast, “My OB was great – he is a man of few words, but said to me ‘I’m sorry you are going through this’ which made all the difference to me at the time,” Ed.

- There is a link between high blood levels of heavy metals, especially mercury, in women who experience recurrent miscarriage. You might try eating smaller types of fish to reduce your mercury levels.

For further information, contact Melissa Maimann at www.essentialbirthconsulting.com.au

Double is trouble when caring for premature babies

Mar 10th, 2009

by Melissa Maimann.

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For further information, contact Melissa Maimann at Essential Birth Consulting.

Julie Robotham
March 10, 2009 – 8:02AM

Care facilities for the most fragile premature babies are under mounting pressure in NSW, as a baby boom collides with rising numbers of twins – the result of fertility treatment and the increasing age of new mothers.

… half of the state’s neonatal intensive care units were now regularly closed to new infant patients, as unpublished figures … show twins and higher multiple births made up 22.5 per cent of … admissions in 2006 – despite in-vitro fertilisation clinics’ insistence they are reining in multiple births …

NSW’s birth rate leapt 3 per cent in 2007 alone, to 93,583 births … Demand for intensive care has also been rising steadily, by 14 per cent between 2001 and 2006, when there were 2296 admissions.

… twins conceived in profitable private clinics frequently fell to the public hospital system for care when they were born sick and fragile. “The cost to the public purse is huge and the people who are running [fertility clinics] are very wealthy.”

Associate Professor Evans, who runs the hospital’s newborn intensive care unit, said twins were born on average at 37 weeks of pregnancy, and those born before 35 weeks could suffer feeding and breathing problems. Along with the overall rise in births, he said, “there’s no doubt [twins] create a significant service load for us”.

Doctors said the state’s 10 units for the sickest newborns were now often on “code red” – meaning they cannot accept any more infants … “the state is full almost every day,” said the head of another neonatal department … Our safety margin continues to be diminished.” But hospitals would always find a place for a premature infant among the 88 beds statewide, he said.
….
Michael Chapman … at … IVF Australia, said the proportion of IVF births that were twins or triplets was falling as single embryos were replaced in most cases …

IVF clinics did not benefit financially from producing twins over single pregnancies, said Professor Chapman …

Lillian and Erin, now three, were born at 30 weeks, after Mrs Carswell’s blood pressure soared as a result of pre-eclampsia. The girls needed hospital care for two months but have avoided long-term consequences.

An interesting debate. No doubt as medical technology increases, we will be able to keep younger and younger babies alive, with increasing qualitity of life.

I wonder what impact effective preconception care may have on this issue. If women accessed effective preconception care that increased their ability to conceive without IVF, then this could well see fewer preterm babies in our neonatal nurseries.

Melissa Maimann, Essential Birth Consulting.

Petition to Keep Home Birth Legal!

Mar 10th, 2009

by Melissa Maimann.

3 comments

Hello everyone,

please sign this petition to keep midwife-attended home birth a legal – and safe – option for women in Australia.

Melissa Maimann, Essential Birth Consulting.

‘Silence’ on risks of baby formula

Mar 10th, 2009

by Melissa Maimann.

1 comment

For further information, contact Melissa at Essential Birth Consulting

Link to article

* Leo Shanahan, Canberra
* March 10, 2009

FORMULA feeding is not being described as a health risk to children because researchers are too scared to do so … despite weighty evidence that breast-fed children are less likely to suffer from type 1 diabetes, allergies, infections, die of infant death syndrome or develop certain cancers, researchers are not willing to name formula as a danger in the titles or summaries of studies.

… The Royal Australasian College of Physicians advice says breastfeeding is superior to formula with studies showing among other things that breast-fed babies have lower rates of diabetes and obesity, higher IQs and as well as lower breast cancer rate in breast-feeding mothers – but have found the causes remain inconclusive.

We’ve known that breast feeding is superior to formula feeding for many many years now. The only thing that surprises me is that it continues to be researched. Surely the research funds can be allocated to more under-researched issues? The target needs to be around mass eduction campaigns around breastfeeding and ensuring compliance of hospitals with the WHO Breastfeeding Guidelines. Next, money needs to be put towards supporting women to breastfeed – eg paid maternity leave for all women for 6-12 months.

Melissa Maimann, Essential Birth Consulting.

Legal Homebirth After 2010

Mar 8th, 2009

by Melissa Maimann.

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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

Hi Everyone,

The Maternity Services Review handed down its report on February 21st, 2009. This report made the 38th inquiry into maternity services since 1985. I believe the only issue more investigated into is petrol prices. The needs of women and their babies should come before that of vested interest groups, however repeatedly this isn’t what happens.

The Report examined midwifery practice, which is long overdue. The care of a known midwife from early pregnancy through labour and birth and the early post-natal period has considerable benefits. These benefits can be measured financially through a reduction in unnecessary surgical birth and other interventions. More subtle but important benefits are increased rates of bonding and breastfeeding, lower rates of post-natal depression and greater satisfaction with the experience of childbirth. This greatly assists a woman entering motherhood.

Unusually the Report does not examine the urgent need to redress obstetric practice in Australia. Many practices currently employed by obstetricians are not based on sound research evidence, but rather custom and practice. This leads to varied outcomes, for example one hospital may have a caesarean section rate of 16% while another of similar size and capacity has a rate of 45%. Maternity outcomes in Australia are based on post-code. There is currently not a bench-mark for quality and safety. The cost of maternity care is spiraling out of control. The Medicare Safety-net was established in 2004 to assist Australian families with the cost of health care. In just over 4 years payments made to Obstetricians under the Medicare Benefits Schedule have increased by approximately 300%. Such increases are not sustainable and have the capacity to see the demise of the Medicare Safety-net, something that will impact many Australians.

Private health costs have risen again this week. The cost of maternity care is considerable. Childbirth is the highest volume area of health and accounts for the greatest number of bed stays. Private maternity care is totally anti-competitive. As a taxpayer who funds the Governments 30% rebate on private health insurance premiums I object to a system that is unnecessarily expensive, not based on evidence and gives women no choice but medically dominated services.

The report of the Maternity Services Review states that the Government will not support the costs of private homebirth services under the Medicare Benefits Schedule, nor will they provide indemnity insurance assistance to midwives working in private practice. Midwives in private practice are the only health professionals in Australia currently without indemnity insurance. This is not due to their practice, or claims history; it is simply due to the fact that we are small in number. Medical practitioners and their clients currently enjoy indemnity protection at an estimated cost of $500 Million.

There are currently plans to establish a national registration body for health professionals by mid next year. An appropriate requirement for registration is professional indemnity insurance. If midwives in private practice are not assisted, they will be prevented from registering. If we practice midwifery unregistered we face a jail term and/or a large fine. If national registration proceeds as planned women choosing homebirth will be unable to access a registered midwife, and essentially the practice will go underground. It is not acceptable that women are unable to choose the care of a registered midwife to give birth at home. This is a violation on human rights, specifically the Fortelesa Declaration of 1985 (from the world health organisation). Homebirth is a nationally funded option in the United Kingdom, Canada, New Zealand and The Netherlands. I am now asking that you support a woman¹s right to choose where and with whom she gives birth, regardless of your own birthing choices, by advocating for midwives in private practice. I ask this as every woman has the right to choose her maternity care giver.

I am writing asking for your help. Regardless of where you choose to give birth or how you choose to give birth, homebirth with a midwife in private practice should still be a viable option to available to women. This is affecting every midwife in private practice around Australia. If we don’t speak up now our daughters will have no options but a medicalised childbirth. I know I want my children to be able to make that choice themselves, not because they have no options available to them.

How you can help:

1. Join the Maternity Coalition. It is only $40 for individual membership.

2. Write to Nicola Roxon and list your concerns share the options that you had had available to you when you went into labour.

Nicola Roxon
Minister for Health and Ageing
Parliament House
CANBERRA, ACT, 2600
nicola.Roxon.MP@aph.gov.au

3. Write to your federal MP.
Visit the AEC website to find your MP

4. Pass this message onto every woman, man, sibling, aunt, uncle, grandparent etc that you know. If we don’t stand up now, we will have no choice in the future.

For further information, contact Melissa at Essential Birth Consulting

Please help save the homebirth midwife and join my campaign.

When push comes to scalpel

Mar 7th, 2009

by Melissa Maimann.

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For further information, please contact Melissa Maimann at Essential Birth Consulting.

Link to article here.

New mothers seeking a drug-free, minimal-intervention childbirth face an increasingly uphill battle, writes Bianca Nogrady | March 07, 2009

Article from: The Australian

WHEN a journalist from The New York Times asked British mountaineer George Mallory why he was planning to scale Mt Everest, the reply was simple: “Because it’s there.” I feel the same way about a drug-free childbirth.

When confronted with the opinion that because modern medicine has developed the pain-free, push-free labour, all women should fall over themselves in gratitude, I can’t help but think of Mallory. Why do I aspire to a drug-free and hopefully intervention-free labour? Because I can.

There’s more to it than the notion that simply because my female ancestors did it this way, I should too. My female ancestors were far likelier to die in childbirth because of a lack of basic sanitation or bleed to death because physicians of the day had limited surgical skills or knowledge. Their babies also were on the wrong side of the survival odds thanks to pathogens and complications.

I am eternally grateful to be pregnant and facing labour in this era, when I am confident my doctors will be able to fend off almost all the threats that in the not-so-distant past may have put my life, and that of my baby, at risk.

But I am a healthy, fit 33-year-old woman who has been lucky enough to have a pretty normal pregnancy so far.

I’m not quite in the right shape to scale Mt Everest, but I’m approaching labour with the same sense of expectation, excitement, trepidation and motivation.

This is my first child. As a medical journalist, I’m well placed to look up all the facts and figures about childbirth, judge the strengths and flaws of scientific studies, ask probing questions of my healthcare providers, write a birth plan and reassure myself with the illusion that I have some degree of control over this whole process …

The subject of birth choices is a highly emotive one. Everyone has an opinion, and the tone of the debate about caesareans v trial of labour, midwives v obstetricians and private v public suggests most people think the best way to defend their opinion is to attack everyone else’s. For a first-timer … this makes an already fraught decision-making process much more difficult.

If a woman aspires joyfully to a drug-free birth, she risks being hit with the hippie tag and inadvertently offending those who choose an epidural or a caesarean. If she says she’s open to pain relief, then there’s the … criticism of being weak … And god forbid that she should express a desire for a caesarean section up-front: then she’s likely to be stopped in the street and berated for not being a real woman …

For me … the most reassuring thought is that my body is designed for this: all women’s bodies are … Hormones loosen the pelvic ligaments to allow the passage of a baby. There are painkiller hormones so strong … Energy-giving hormones provide labouring women with a boost like no other and help kick-start newborns into activity. Another hormone may well be the ultimate love drug, binding … a mother and her newborn baby. Labour is like being let loose in the pharmacy without having to worry about overdosing, side effects or cost.

It’s a balancing act of hormonal influence. The notion that we can blithely throw a synthetic version of a recently discovered opiate into the mix and improve things smacks of large angry animals in kitchenware establishments. And the notion that cutting open healthy tissue and manually removing a baby is an improvement on millennia of physical evolution seems naive at best …

I’m not for a moment suggesting that caesarean sections have no place in childbirth … Should that situation arise, I’ll be gladly handing my obstetrician the scalpel (figuratively speaking). My drug-free, intervention-free preferences are all subject to the iron-clad caveat that if my baby is likely to come to harm, all bets are off.

… it bothers me that so many caesareans are being conducted. Have women’s bodies suddenly taken a turn for the worse and rendered a significant proportion of us completely incapable of doing something that women have been doing in mud huts, fields, baths and beds since the dawn of time?

Teasing apart the reasons for, and effects of, interventions during birth, whether drugs, forceps or caesarean sections, is difficult ….

Research suggests that most women who undergo elective caesarean section do so out of concern for their baby’s safety, contrary to the popular notion they are “too posh to push”. But they make that choice on the advice of medical experts working in a highly litigious, pro-interventionist and, some would say, overly fearful environment …

As soon as the word breech was mentioned, hot on its heels was the phrase elective caesarean. Just a decade ago, breech vaginal deliveries were considered relatively routine. But a single study … put an end to that by suggesting that there might be an increased risk to the baby from a vaginal breech delivery.

Now most obstetricians wouldn’t touch a vaginal breech delivery with the proverbial barge pole and the skills required to navigate through the unique challenges of a breech delivery steadily are being lost.

I’m probably luckier than most because … I know where doctors go for their decision-making information. I’m able to ask questions about the evidence and subject it to necessary scrutiny.

Yet even armed with this knowledge and research, I feel utterly powerless when I’m told by a midwife that a caesarean is the only way to go and I should book it in as soon as possible to ensure the medical team is prepped and ready. Oddly enough, the only voice suggesting that I might still be able to deliver a breech baby through trial of labour came from an obstetrician, not a midwife. ….

No one told Mallory his aspiration to scale the tallest mountain on Earth was primitive and he should just fly over it like other civilised people.

The author raises an interesting point about the lack of breech birth skills that have developed over the past decade. With our caesarean rate at well over 30%, it’s a wonder if soon, all vaginal birth skills will be lost.

Melissa Maimann, Essential Birth Consulting.

Hospitals curb caesarean births

Mar 7th, 2009

by Melissa Maimann.

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For further information, contact Melissa at Essential Birth Consulting

Link to article

The Sunday Times
February 15, 2009

Hospitals curb caesarean birthsSarah-Kate Templeton, Health Editor

NHS trusts have … barred women from routinely having elective caesareans because they cost too much. The procedure, which costs twice as much as a natural birth, will be rationed … so that it is only available to women with specific medical conditions.

Some top obstetricians condemn the decision, arguing that, while it will curb the fashion for choosing caesareans to reduce the pain of childbirth, it will also penalise those who opt for them on the grounds that they are safer for the mother.

Caesareans have been placed on the same lists for rationing by the NHS trusts in Greater Manchester as infertility treatment, cosmetic surgery and acupuncture.

The lists, called Effective Use of Resources Policies, state that planned caesarean sections should only routinely be offered to women in particular categories. They include women who have previously already had at least two caesareans.

About 23% of deliveries in Britain are by caesarean section, and, of these, more than half are emergency operations.

The CS rate quoted is 23%. If only our National CS rate could be that low! In 2006, Australia’s CS rate was 31%, up from 28% in 2005. Maybe it’s 35% now? I was interested to read that VBAC is not an indication for elective repeat CS, but VBA2C is. Sounds sensible! I’d like to see something similar here in Australia. It’s a shame that here, a woman has a greater right to a caesarean, than a homebirth. We all know which option is safer, cheaper and more satisfying for mothers and babies. It also begs the question – how many women would opt for an elective caesarean if they had access to continuity of midwifery care?

Melissa Maimann, Essential Birth Consulting.

Undoing the ‘Big Baby’ Trend

Mar 6th, 2009

by Melissa Maimann.

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For further information, please contact Melissa Maimann at Essential Birth Consulting.

As infant weights rise, parents are urged to take steps early to prevent obesity
HealthDay, Sunday, March 1, 2009

SUNDAY, March 1 (HealthDay News) — … The trend toward bigger and bigger babies is drawing concern from health experts as well … American infants up to 6 months of age are 59 percent more likely to be overweight than were babies born 20 years ago, a recent study found.

And though chubby babies might be viewed as cute and healthy, parents need to think about preventing obesity at the earliest stages of life, health experts are warning. That means paying attention not only to infant weights, but also to a mother’s weight before conception and her weight gain during pregnancy.

“A mother’s weight gain during pregnancy, particularly gaining more than is recommended, is associated with an increased likelihood of childhood obesity,” said Dr. Christine M. Olson, professor of community nutrition at Cornell University, in Ithaca, N.Y.

The impact was greater among women who were overweight or obese before they became pregnant.

“… overweight mothers are at risk for having overweight infants,” he said. “Mothers who have gestational diabetes … are also at greater risk….”

What to do? Greer and Olson have a number of suggestions.

Besides getting down to a healthy weight before becoming pregnant, women should follow the weight-gain guidelines during pregnancy …

Breast-feeding for the first four to six months can help reduce the chances that a child will become overweight …

- Health and nutrition during pregnancy are vitally important for the health of the woman, her baby, and ultimately the family and community. Maintaining a healthy weight can be achieved through good nutrition, motivation, goal setting, exercise and know-how. I have worked with many women – and men, to achieve a healthy weight, more energy and better quality sleep.

For further information, contact me at Optimum Health & Nutrition, or Essential Birth Consulting.

Low Levels of Vitamin B12 May Increase Risk for Neural Tube Defects

Mar 6th, 2009

by Melissa Maimann.

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For further information, please contact Melissa Maimann at Essential Birth Consulting.

From http://www.nih.gov/news/health/mar2009/nichd-02.htm

Low Levels of Vitamin B12 May Increase Risk for Neural Tube Defects

Children born to women who have low blood levels of vitamin B12 shortly before and after conception may have an increased risk of a neural tube defect … Women who consume little or no meat or animal based foods are the most likely group of women to have low B12 levels, along with women who have intestinal disorders that prevent them from absorbing sufficient amounts of B12.

Neural tube defects are a class of birth defects affecting the brain and spinal cord. One type, spina bifida, can cause partial paralysis. Another type, anencephaly, is a fatal defect in which the brain and skull are severely underdeveloped.

Researchers have known that taking another nutrient, folic acid, during the weeks before and after conception can greatly reduce a woman’s chances of having a child with a neural tube defect.

… “If women wait until they realize that they are pregnant before they start taking folic acid, it is usually too late,” Dr. Mills said.

“Our results offer evidence that women who have adequate B12 levels before they become pregnant may further reduce the occurrence of this class of birth defects,” Dr. Mills said.

Vitamin B12 is available in milk, meats, poultry, eggs, as well as fortified cereals and some other fortified foods … Folate is found in leafy green vegetables, fruits, and dried beans and peas.

An interesting study that highlights the importance of preconception care and good nutrition before and during pregnancy.

Changing your food habits is often a difficult thing to do. Optimum Health & Nutrition can provide assistance.

Melissa Maimann, Essential Birth Consulting.

Maternity group urges publicly funded home birthing

Mar 6th, 2009

by Melissa Maimann.

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From http://www.abc.net.au/news/stories/2009/03/04/2507192.htm

For further information, please contact Melissa Maimann at Essential Birth Consulting.

Posted Wed Mar 4, 2009 1:36pm AEDT

An advocacy group on the New South Wales far south coast says recommendations in a Federal Government review of maternity services have not alleviated the strain on hospital maternity units … The recommendations made in the report are positive overall, but … an option for publicly-funded home birthing was not proposed.

… many local families and mothers want the option of home birthing, but are put off due to the high costs – … around $3,000 to $5,000,” she said.

The president of the Australian College of Rural and Remote Medicine, Dr Dennis Pashen, says he is unsure whether home birthing would occur.

“People have always got a personal choice as to how they have their delivery,” he said.

“I think that was looked at very closely and there’s some very [strong] advocates of home birthing.”

Home birth is available privately through midwives who generally charge $4000 – $5000 in Sydney. The services are comprehensive. Typically, women can expect antenatal home visits for 1 – 2 hours, labour and birth at home, and postnatal care at home too, for up to 6 weeks. When you break down the cost of the home birth hour-for-hour of the midwife’s time, the midwife may only earn $50 per hour. Private home birth services are very time-intensive – we like to form a really strong relationship with the women and families we care for.

Melissa Maimann, Essential Birth Consulting.

Cost of midwife cover an obstacle to homebirth service

Mar 5th, 2009

by Melissa Maimann.

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From http://www.theaustralian.news.com.au/story/0,25197,25140735-5013871,00.html

For further information, please contact Melissa Maimann at Essential Birth Consulting.

Adam Cresswell, Health editor | March 05, 2009
Article from: The Australian

SUBSIDISING indemnity payments for midwives could cost taxpayers an estimated $12 million to $24 million annually if the federal Government were to treat them as favourably as specialist obstetricians.

Insurance experts warned yesterday that despite public perceptions that mothers who delivered their babies with a midwife faced fewer risks, premiums to insure midwives against bad outcomes were likely to be similar to those faced by obstetricians — who can pay from $60,000 to $100,000 a year for their policies … Midwifery advocates are warning that without government intervention on indemnity, private midwives and hundreds of homebirths each year will be driven underground because practising uninsured will no longer be legal from mid-2010.

[The Maternity Weervices Review] … fell short of recommending indemnity subsidies to cover midwife-led homebirths …

… Dr Nisselle said that if a midwife performed 100 deliveries a year and charged $2000 each, earning $200,000, a $45,000 premium would exceed the 7.5 per cent threshold by $30,000.

If midwives were granted the same deal as obstetricians, the subsidy would amount to $24,000 per midwife.

Official estimates have suggested between 500 and 1000 midwives would be needed to take pressure off existing birthing services, creating a potential subsidy cost of up to $24 million.

No commercial insurer has offered cover to private midwives since the medical indemnity crisis of 2002-03. Dr Nisselle said medical insurers might be reluctant to fill the void for fear of alienating their own members, many of whom are at best cautious about independent midwifery.

Barbara Vernon, executive officer of the Australian College of Midwives, said the problem needed addressing but the Government had a range of other options, such as capping midwives’ liability, and providing cover itself, as the Northern Territory Government had already done.

Midwives generally birth no more than 40 babies a year. That equates to 4 births a month, with 2 months “off”. I put that in inverted commas because babies come when they’re ready, some early, some late. So in planning to have 2 months off, you actually get about 3-4 weeks off.

We also do not charge $2000. In Sydney, midwives charge $4000 – $5000. This fee includes all antenatal, birth and postnatal care. So a midwife might make $180,000 if she was fully booked. On that sort of income, a $45,000 premium would cost the midwife $20,000, assuming she had access to the PSS. Tax on $180,000 would be $61,000, so the midwife would end up with $180,000 – $61,000 – $20,000 = $99,000. But, many midwives do not book 40 women each year – some book only 10 – 20 women a year. For these midwives the cost of indemnity would be prohibitive, and a cost that they would definitely need to pass onto the consumer.

Melissa Maimann, Essential Birth Consulting.

Homebirths may have to be secret

Mar 2nd, 2009

by Melissa Maimann.

1 comment

From http://www.theaustralian.news.com.au/story/0,25197,25124579-601,00.html

For further information, please contact Melissa Maimann at Essential Birth Consulting.

Adam Cresswell, Health editor | March 02, 2009
Article from: The Australian

HUNDREDS of women each year who choose to give birth in their homes are likely to face greater medical danger for themselves and their babies with the introduction of regulations that could force the practice underground.

From the middle of next year, midwives will be required to hold professional indemnity insurance as a condition of practice, under the Rudd Government’s plan to streamline registration requirements for all health professionals.

No commercial insurer has been prepared to offer an insurance policy to an independent midwife since the medical indemnity and wider insurance crises of 2001. When the new regime comes into effect, it will no longer be legal for these uninsured independent midwives to attend home births …

… More than 50% of the submissions to the federal Government’s recent maternity services review came from women calling for greater support for homebirthing services, which claim up to a 10-fold greater share of births in some overseas countries …

Since 2001, an estimated 150 midwives have provided homebirth services to women, at a typical cost of between $3000 and $5000 …

Sarah McLean, a volunteer with the Homebirth Access Sydney consumer group, is pregnant with her third baby and is planning to deliver at home. She said the prospect of losing the option of homebirth was “quite devastating”.

“It’s ridiculous to effectively make homebirth illegal, when other countries like Britain have publicly funded homebirth programs,” Ms McLean said.

Caroline Homer, professor of midwifery at the University of Technology Sydney, said the “worst-case scenario is that women would be unattended” when giving birth.

“Another scenario is that the midwives will continue to practise under other names, but there won’t be any standards of care, and no peer review or evaluation … ” Professor Homer said.

“Removing independent midwives and saying we won’t do homebirths won’t solve the problem; women will continue to have babies at home.”

Obstetrician Andrew Bisits, director of obstetrics at Newcastle’s John Hunter Hospital, said there was no reason that the federal Government should not support midwives’ indemnity costs as it already did for obstetricians and other doctors. ….

Evidence for the safety of homebirths is disputed. US research published in the British Medical Journal in 2005 found low-risk women giving birth at home with midwife supervision had lower rates of medical interventions, such as the use of forceps, and no greater risk of their baby dying either during birth or soon afterwards.

It interests me that the Government is concerned about freebirthing, where women birth their babies at home, unassisted by a midwife. Some women birth with a doula for birth support. So while the government is concerned about this, it is also acting to prevent midwives from attending homebirths. Homebirth will not disappear simply because the government refuses to provide indemnity. Women will continue to demand homebirth services on their terms, and some midwives will continue to provide this service.

Melissa Maimann, Essential Birth Consulting.

UK: Mothers face crackdown on epidural births

Mar 1st, 2009

by Melissa Maimann.

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For further information, please contact Melissa Maimann at Essential Birth Consulting.

From http://www.timesonline.co.uk/tol/news/uk/article5822051.ece

Mothers face crackdown on epidural births
Sarah-Kate Templeton

HOSPITALS are under attack from staff and patients for trying to stop large numbers of women from having epidurals during birth … The controversial restrictions … aim drastically to reduce the number of women having epidurals, caesareans or other artificial procedures to 40%.

In some hospitals the proportion of first-time mothers now having epidurals is far higher at 60%.

The targets are contained in a guidance document, Making Normal Birth a Reality, drawn up by the National Childbirth Trust (NCT) with the backing of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

The document argues that mothers and doctors are too ready to resort to medical intervention and that any such procedure brings risks …

Professor James Walker, a consultant obstetrician at Leeds Teaching Hospitals NHS Trust, said … “Epidurals should not be done without reason; they should be kept to a minimum. There are some women, however, who require an epidural because they cannot cope with the pain in any other way.”

Belinda Phipps, chief executive of the NCT, argues, however, that there are medical reasons for trying to restrict the procedure. An epidural, she says, is more likely to result in a baby being delivered with forceps or a ventouse – a suction device – because the mother is less able to push the baby out.

A British review … found the procedure prolonged labour and increased the chance of further medical intervention by 40%.

When I did my midwifery degree, midwives were supported by management and other midwives to support women through natural labour, if that was their intention. We all know that at some point in labour, many women want something, anything – epidural, caesarean, whatever! But that is where the skill of the midwife really comes in. It is about calming the woman, helping her to change position, getting her a hotpack, moving into the bath, talking calmly to her, surrounding her with love and supportive people – these “interventions” are both safe and effective.

Epidurals have been demonstrated to have complications associated with their use: longer labour leading to augmentation (breaking waters or using an infusion of syntocinon), fetal distress from augmentation, malpositioning of the baby (such as posterior), back ache, spinal tap, infection, increase in the caesarean rate as a consequence of being continuously monitored, and forceps or a vacuum birth because of the woman’s inability to feel to push.

With all these consequences of epidurals, is there any question why there’s a push towards normal birth?

It does, however, beg the question – who should decide what intervention a woman has in her bitrh? Surely it’s the woman’s choice, and hers alone. I agree with this comment, and happily support women through hospital births where they may elect to have an epidural. However, I tend to find that a well-informed woman who has attended comprehensive childbirth education and perhaps Calmbirth classes, will be far less likely to choose an elective epidural.

Smriti Singh, mentioned in the article, alludes to the potential for birth trauma related to the pain of birth. Most quality research points to their being less birth trauma for women who have experienced natural birth, than women who have experienced interventionist birth. Mitigating factors are things such as birth preparation, having an awareness and understanding of all available options, and the presence of a supportive person during your birth.

Melissa Maimann, Essential Birth Consulting.

Homebirth Ban

Mar 1st, 2009

by Melissa Maimann.

1 comment

For further information, please contact Melissa Maimann at Essential Birth Consulting.

From http://www.abc.net.au/unleashed/stories/s2501831.htm
Homebirth Ban
Author: Alison Leemen, Homebirth Access Sydney
The Maternity Services Review report, released last weekend, was an attempt to delivery continuity of care and midwife-led services to more Australian women. In so doing, it has stripped that very same care and service from the only women who currently have it – homebirth mums.

The fact that it did this in the face of having received the majority of its submissions from homebirth parents is galling and speaks volumes for the way “public consultation” occurs in this country. But the fact that the report’s recommendations, if accepted by the Government and made law, would criminalise the high quality care currently delivered to women who choose to give birth at home by registered, professional, independent midwives to their clients is radical and dangerous.

Good intentions have paved the way. The MSR was established partly in response to rising birth intervention rates and widespread concern that women were being poorly served by a maternity care system that was fragmented, expensive and increasingly medicalised.

But the process became hijacked by professional lobbying, deal-making and perhaps a strange reflex of governments to favour institutionalised power over the rights of individual constituents. The report is fairly forthcoming about this:

“In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions…”

So as long as the AMA and RANZCOG are hostile to homebirth -ideologically, not evidentially – the government is not prepared to stare them down.

In the next paragraph, the Report notes the existing small-scale state-funded public homebirth schemes, with no evidence that such models were polarising, or that they were being undermined by a poor relationship between maternity health care professionals, or that there were any justifiable safety concerns. But the MSR is not engaging with the evidence, it’s playing politics.

The public consultation process is made farcical when over half the submissions are lightly dismissed without reasons of substance. Such deal-making reveals a government prepared to bend to the powerful medical lobby even against the weight of public submission and international evidence.

The Review concluded that, “while homebirth is the preferred choice for some women, they represent a very small proportion of the total.” Since when has being in the minority constituted an acceptable reason for discrimination? The fact that only a small proportion of the population will need heart transplants is no reason to ban them or block public funding to them. The small minority of families who choose private education due to religious beliefs are still supported by Commonwealth funding. And of course homebirth will be unpopular when it is the only way to give birth in Australia that receives no public funding whatsoever.

The report notes that in countries where homebirth is publicly funded – New Zealand and the United Kingdom, for example – homebirth rates are ten times those in Australia.

But the MSR report goes further than merely continuing to deny homebirth funding. It becomes dangerous when it takes a back-door route to criminalisation of homebirth.

Under the proposed new National Registration and Accreditation Scheme, to apply to midwives from July 2010, midwives must have professional indemnity insurance to obtain registration. This is not currently the case – hospital insurance schemes cover their employed midwives; homebirth midwives work uninsured. The report notes that this latter situation is unacceptable. Homebirth consumers and midwives agree and have repeatedly sought Federal assistance in obtaining appropriate insurance.

But the report, while recommending Commonwealth-supported professional indemnity for midwives in collaborative team-based models, withholds such support where homebirth is concerned, since “it is likely that insurers will be less inclined to provide indemnity cover for private homebirths and, if they did provide cover, the premium costs would be very high.”

Neither evidence nor logic support this. The reason insurers have not offered coverage to privately practising midwives since 2002 is not the risk profile of midwives. It is that the pool of homebirth midwives shrank to an uncommercial size during the insurance crisis in 2002 – which was caused by astronomical compensation payouts against obstetricians, not midwives.

Everyone in the industry suddenly became uninsurable, yet the then government’s bailout package, under the Premium Support and High Cost of Claims Schemes, saved only GPs and obstetricians. So midwives had to work uninsured or give up their practice. Unsurprisingly, many quit attending homebirths.

Even if the risk profile of homebirth practice did make premiums too high, that would only put midwives in the same boat as GPs and obstetricians, who receive substantial government support under these schemes. The simple, obvious answer is to extend the schemes to midwives.

Instead, by cutting midwives loose on insurance, the government is effectively outlawing homebirth, since by mid-next year uninsured midwives will be unable to obtain registration, and unregistered midwifery is a criminal offence. There is no surer way than this to make homebirth unsafe.

Consumers rely on registration to ensure that they are choosing a skilled and professional carer. To remove this indicator of quality away from consumers, not on the basis of professionalism but on the availability of a suitable insurance scheme, puts women at risk. More women will birth unattended.

Women are entitled to choose where they give birth and with whom. They are entitled to refuse treatment and to choose it. They are entitled to give birth in a hospital, a birth centre, a home or under a tree if that’s what they want to do. Research shows that a woman is safest birthing in the environment where she feels safest. And to make it illegal for a woman who chooses to birth at home to access appropriate care is surely not the intention of this government.

However you feel about homebirth, whether you’d want it for yourself or not, the removal of a woman’s right to birth where she chooses is indefensible and should be a matter of grave concern to all women, just as if women were denied access to breast cancer treatment, epidurals, or condoms.

The government can’t ban homebirth any more than it can ban sex, but by banning professional, registered midwives from attending homebirths, it greatly increases risk.

Not funding homebirth is just bad policy: cost-ineffective to Australian taxpayers and unfair to Australian women. But making homebirth illegal is paternalistic, internationally isolated and dangerous.

Homebirth with an independent midwife is a great model of care for lots of reasons, key among them that it provides continuity of care with a known carer – something the Maternity Services Review says it wants to see in hospital -based models. So why is it killing off the only model that reliably delivers that care?

Giving birth at home with a highly skilled and qualified midwife is not new or radical. Outlawing it is.

My comment concerning another person’s comment on the article:
Melissa Maimann :
28 Feb 2009 1:15:29pm

Azrael wrote:

freedom of choice does not extend to imposing upon others – and hence to the extent that a national health system is a communal affair, we all DO have a legitimate say in how that money is spent. If you aren’t tapping in to that pool of funding, then you should be able to do whatever you wish. Otherwise the argument should be solely about what is safest

I agree with your comment and I invite you to consider that currently, a woman has a greater right to a publicly funded maternal choice (non-medical) caesarean, than she has a (much cheaper and safer) homebirth.

Extrapolating from your statement, women ought to 100% fund any “unnecessary” birth-related procedure, test etc because this takes funds from the communal pool of available funding. So there ought to be no government-funded elective inductions, no elective epidurals, no maternal choice caesareans, and no access to publicly-funded obstetric care (I’m referring to the use of the Medicare Safety Net for private obstetric care) unless it is medically indicated. If this were the case, then yes, perhaps homebirth should not be funded.

But this is not the current system. Women are being discrimated against when they cannot access the medicare safety net, private health insurance and medicare rebates for the form of care that has been demonstrated time and time again, to be safe, satisfying and cost-effective.

Melissa Maimann
www.essentialbirthconsulting.com.au

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March, 2009:

Melissa Maimann

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