May, 2009&#58;

For further information on nutrition and exercise in pregnancy, contact Melissa Maimann at Essential Birth Consulting.

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Obese women should gain only 11 to 20 pounds during pregnancy, according to updated guidelines from the Institute of Medicine.

The recommendation builds on the agency’s earlier guidelines that recommend a weight gain of 15 to 25 pounds for overweight women, 25 to 35 pounds for normal women, and 28 to 40 pounds for underweight women.

Researchers have included recommendations for obese women since body mass index (BMI) and gestational weight gain have increased among women across the country.

… The new ranges are more conservative, with the underweight BMI category starting at 18.5 instead of 19.8.

… This will result in better outcomes for both mom and baby, he said, since it is “remarkably clear that pre-pregnancy BMI is an independent predictor of many adverse outcomes.”

Interventions in diet and exercise — both before and during pregnancy — will be essential in assisting women in meeting the guidelines, especially those who are obese, he said.

“The idea is that it will require an effort by many people,” Dr. Catalano said. “It’s not just something that one healthcare provider during pregnancy can do. It includes a host of other people including a nutritionist, dietician, and even an exercise physiologist.”

… “Women don’t need to eat for two, but for 1.1,” he said.

… There is no continued support for lower-range weight gains in women under 20, as younger women and adolescents often need to gain more to improve birth outcomes.

Melissa Maimann, Essential Birth Consulting 0400 418 448

New York Times Series Examines Maternal Mortality In Tanzania

May 29th, 2009

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

The New York Times on Sunday examined maternal mortality in Tanzania … the country has a maternal death rate of 578 per 100,000 births, though the World Health Organization puts the count at 950 maternal deaths per 100,000 births. Roughly 13,000 Tanzanian women die of pregnancy- or childbirth-related causes annually, giving it “neither the best nor the worst record in Africa,” the Times reports. Tanzania is one of the world’s poorest countries and faces shortages in several areas — including health workers, drugs, equipment and infrastructure — that contribute to maternal mortality.

The Times profiled obstetrical care at a rural hospital in Berega, Tanzania, that typifies efforts to reduce maternal mortality in Africa. Facing a shortage of doctors and nurses, the hospital has been training “assistant medical officers” to perform caesarean sections and other procedures. Meanwhile, the government also is attempting to train more assistants and midwives, build more clinics and nursing schools, offer housing to attract health workers to rural areas and provide places for pregnant women to stay closer to hospitals.

… many women who die in childbirth are young and healthy, and most maternal deaths are preventable with basic obstetrical care. The five leading causes of maternal death are bleeding, infection, high blood pressure, prolonged labor and complications resulting from abortions … In discussing maternal mortality, experts often refer to what are known as “the three delays”: a woman’s delay in going to the hospital, the time spent traveling there and the hospital’s delay in starting treatment upon the woman’s arrival. Although only around 15% of births have dangerous complications, the problems are almost impossible to predict, and seemingly normal labors can quickly progress into serious emergencies. Worldwide, more than 536,000 women die annually from pregnancy or childbirth, according to WHO …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mothers’ birth choices linked to rise in childhood diabetes

May 28th, 2009

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

The increasing trend for Caesarean births may be linked to a rise in diabetes cases.

The increasing popularity of Caesarean births and having children later in life are contributing to a dramatic rise in cases of diabetes in young children.

The number of children under five with Type 1 diabetes is likely to double by 2020 and there are ‘substantial’ increases among older children, say researchers.

Modern lifestyles are partly to blame, with children born to older mothers and by Caesarean section being at greater risk, while reduced exposure to germs is also a factor.

Doctors say all these factors reflect the fact that Type 1 diabetes and the development of a child’s immunity system are linked.

Increased height and weight among infants, and rapid growth during the first year of life are also contributory factors, says a report published on the The Lancet medical journal’s Online First website.

It looked at data from 17 European countries from 1989-2003 when there was an overall rise of almost 4 per cent a year in incidence of Type 1 diabetes, with the biggest rise of 5.4 per cent among 0 to four year olds.

… About 250,000 people in the UK have Type 1 diabetes, many of whom are children and young adults. Most need insulin injections daily to control the illness which, when poorly managed, can lead to long-term complications such as blindness, kidney failure and heart disease. There is no cure.

Dr Chris Patterson of Queen’s University … said the increasing number of cases over time was so rapid that it cannot be related to genetic factors alone.

‘Environmental factors are driving this,’ he said. ‘We know children born to older mothers, for example, are more at risk. There is a 20 per cent extra risk for babies born as a result of Caesarean section, while those putting on weight rapidly during the first year of life are also at increased risk. Breastfeeding reduces the risk.

‘In addition there are other environmental issues behind the rising trend, such as children being exposed to fewer germs.

‘Type 1 diabetes is very much involved in the development of the immune system – which, in the case of Type 1 diabetes, turns on the body and stops it producing insulin. But it is still a rare disease.’

Dr Iain Frame … said: ‘This evidence that children are developing Type 1 diabetes at an increasingly younger age is worrying.

‘Parents have the task of giving their children or babies insulin injections several times a day.’

He said their children would be at risk of short-term complications such as hypoglycaemic episodes – where the brain does not get enough energy through blood sugars – or diabetes ketoacidosis – where the blood can become dangerously acidic – both of which may require hospital treatment …

So, having a caesarean is a risk for children developing diabetes. I wonder if women are told this as part of the informed consent process that needs to occur before a caesarean is performed? I am also puzzled by the article’s title, “Birth Choices Linked to ….” because caesarean is rarely a birth “choice”. Most women prefer a natural birth. And they can achive it with the right support! The title of the article seems to shift blame for a child’s development of Type 1 diabetes onto the child’s mother. This displacement of blame is unnerving. Women only ever want the best for their children, and they make decisions based on their information they receive from their care providers.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Disclosing Medical Errors to Patients

May 27th, 2009

3 comments

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

… The policy of Open Disclosure mandates that clinicians explain, take action, express regret and apologise for unexpected outcomes. In an effort to acknowledge patients’ concerns following adverse events and their preference for open communication, Open Disclosure policy is being mandated at national and international levels.

I wonder if this extends to birth-related outcomes, especially when unnecessary interventions take place. You know, inductions for “big” 3Kg babies, caesareans for “failure to progress”, limited options for VBAC (well, I really mean no option – repeat caesarean or repeat caesarean).

New legislation which may come through will mandate all health professionals to report colleagues whose practices are deemed to be unsafe. Currently, we ought to report unsafe practices; this new legislation will make it mandatory.

Melissa Maimann, Essential Birth Consulting 0400 418 448

WA: Time for hospital water births

May 26th, 2009

For further information on home birth or water birth, contact Melissa Maimann at Essential Birth Consulting.

WA maternity hospitals should allow water births as part of a more flexible approach to cater for women disgruntled with mainstream services, a report into the safety of WA home births has found.

An independent review by Sydney obstetrician Michael Nicholl and professor of midwifery Caroline Homer has found that home births in general are not riskier than hospital births, but calls for tighter scrutiny to make childbirth safer, particularly for high risk babies.

The report was commissioned by the WA Health Department after a series of apparent deaths among home births. It found that while 18 babies with planned home births died in the review period of 2000-2007, none was reported in 2006 and 2007.

… It calls for an urgent review of the State’s home birth policy developed in 2001 and warns that home births are more likely to become unsafe if they are marginalised and out of the mainstream services.

The review found some women were opting for home births because they had limited choices in traditional maternity units, including access to water births, which were often discouraged by hospitals, and women wanting to have a normal delivery after a previous caesarean.

“It seems apparent that the maternity systems are, for some women, too medicalised and restrictive, and do not meet their needs,” the report found.

Professor Homer said when home births were well supported they were a safe option for some but not all women. “Our report does not support that home births in general are unsafe but we need to have the right mechanisms in place,” she said. “We need continued education and more checks and balances.

“What many women really want is continuity of care and services close to their home. They don’t necessarily want a home birth but they want all the things that they perceive home birth women get.” …

It’ll be great if waterbirths can be given the go-ahead in WA, as currently there are no hospitals in WA that support water births. But … having a waterbirth policy does not mean that women will be able to birth in the water. Restrictive policies around fetal monitoring often mean that women are not “allowed” to labour and birth in water. When you remove women who are:
over 42 weeks
under 37 weeks
VBAC
prolonged ruptured membranes
being augmented or induced with syntocinon
having twins
baby ? too small
gestational diabetes
hypertension
any bleeding in pregnancy
long labour
meconium in the waters
having an epidural
had pethidine or morphine

and anything else you can think of, you will see that very few women are actually able to labour and birth in the water. Some hospitals in Sydney offer waterbirths, but only if you don’t fall into one of the above categories, and only if a midwife is on duty who is comfortable with waterbirth. If water birth is important to you, the best way to facilitate this is to book a private midwife for a home birth.

Melissa Maimann, Essential Birth Consulting 0400 418 448

“Eating For Two” Has Consequences For Mom And Baby

May 26th, 2009

For further information about nutrition in pregnancy, contact Melissa Maimann at Essential Birth Consulting.

There is more medical evidence that pregnant women should steer clear of advice to “eat for two.”

Alison Stuebe, M.D. … reviewed data for more than 1,300 women and found that those who consumed extra calories … were more likely to gain more than is recommended during pregnancy that’s 35 pounds or more for a woman with a normal body mass index, or BMI.

Stuebe found that eating an extra 500 calories a day increased the odds of gaining too much by 10 percent. “That’s the number of calories in a muffin or a bagel with cream cheese at Dunkin Donuts,” Stuebe says. “It doesn’t take much for the calories to add up.”

Gaining too much weight is linked with complications at birth, such as pre-eclampsia or requiring a C-section, as well as higher odds that both mom and child will be obese later in life.

… Several eating habits reduced moms’ risk of gaining too much. Women with vegetarian diets in early pregnancy were half as likely to gain an unhealthy amount of weight, and those who exercised vigorously for a half hour a day reduced their risk by 20 percent. The researchers also found that consuming more monounsaturated fat, found in olive oil and nuts, was linked with a lower risk of excessive weight gain.

… It might be obvious that a healthy diet and exercise reduce the odds of gaining too much weight during pregnancy, but more and more women are doing just that. Part of the problem is that providers don’t counsel moms on weight gain, Stuebe says. Other studies have shown that moms who get advice from their doctor or midwife are more likely to gain in a healthy range.

… Eating fried foods “was a huge predictor of excessive weight gain,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Estimating intrapartum-related perinatal mortality rates for booked home births: when the ‘best’ available data are not good enough

May 25th, 2009

For further information about homebirth, midwifery, or anything relating to pregnancy and birth, contact Melissa Maimann at Essential Birth Consulting.

It’s interesting that whenever some pro-homebirth data is published, the medical community find something wrong with it. The Netherlands study was very large. Its results are consistent with other research that has also concluded that low-risk, midwife-attended home birth is safe.

Even more interesting is that this abstract details the comments of a mere six members of a multidisciplinary group. What would the medical community say if a group of six midwives published comments about a medical journal article that included a sample of over half a million women?

ABSTRACT
Objective:
To critically appraise a recent study on the safety of home birth (… BJOG 2008;115:554) and assess its contribution to the debate about risks and benefits of planned home birth for women at low risk of complications.

Design:
Critical appraisal of a published paper.

Setting:
England and Wales.

Population or Sample:
Home births from 1994–2003 and all women giving birth in the same time period.

Methods:
Six members of a multidisciplinary group appraised the paper independently. Comments were collated and synthesised.

Main outcome measures:
Assessment of: overall methodology; assumptions used in estimating figures; methods used for calculations; conclusions drawn from the results and reliability and consistency of data.

Results:
Although there were some positive aspects to the study, there were weaknesses in design and an inaccurate estimate of risk. Our evidence suggests that the conclusions drawn did not reflect the results and the methodological weaknesses found in the study rendered both the results and conclusions invalid.

Conclusions:
On the basis of our critical appraisal, the study does not contribute to the existing evidence about the safety of home birth to inform decision-making or provision of care. The limitations could have been identified by the peer review process and the problems were compounded by an inaccurate press release. Great care needs to be taken by journals to ensure the accuracy of information before dissemination to the scientific community, clinicians and the public. These data should not have been used to inform national guidelines.

“Great care needs to be taken by journals to ensure the accuracy of information before dissemination to the scientific community, clinicians and the public.” – aka “doctors should be in charge of what the public get to read”. Anyone else come to that conclusion?

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women Still Drinking During Pregnancy

May 24th, 2009

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

Despite [warnings] that alcohol can affect unborn children, pregnant women haven’t changed their drinking habits much over the past two decades, the CDC said.

The average annual percentage of pregnant women who drank remained relatively stable at about 12% for any alcohol use and 2% for binge drinking …

… The U.S. Surgeon General has consistently advised women against drinking alcohol during pregnancy. National prevalence of fetal alcohol syndrome is about 0.5 to 2.0 cases per 1,000 births, but the other fetal alcohol spectrum disorders occur about three times as often …

… Women with the highest rates of drinking during pregnancy were older, college graduates, employed, and unmarried.

Between 2001 and 2005, 17.7% of pregnant women ages 35 to 44 reported having at least one drink in the past 30 days, compared with 8.6% of women ages 18 to 24.

… While it’s not well understood why drinking habits differ across certain aspects of social status, the researchers had a few possible explanations. It could be that older women may be more alcohol dependent and have more difficulty abstaining from alcohol while pregnant, they speculated.

Also, they said, more-educated women and employed women might have more discretionary money to spend on alcohol.

… healthcare providers should routinely ask women of childbearing age about their alcohol use and inform them of the risks of drinking during pregnancy.

Alcohol use levels before pregnancy are a strong predictor of alcohol use during pregnancy … Many women who use alcohol continue to do so during the early weeks of gestation because they don’t realize they’re pregnant, as about half of all births are unplanned.

Melissa Maimann, Essential Birth Consulting 0400 418 448

VBAC safer for baby than elective repeat caesarean

May 23rd, 2009

2 comments

For further information about VBAC and birth options, contact Melissa Maimann at Essential Birth Consulting.

[Elective repeat caesarean] doubles odds for intensive care compared to vaginal birth newborns, researchers say.

Babies delivered by elective, repeat cesarean section delivery are nearly twice as likely to be admitted to the neonatal intensive care unit (NICU) than those born vaginally after the mother has previously had a c-section [VBAC], a new study finds.

These c-section babies are also more likely to have breathing problems requiring supplemental oxygen, the researchers say.

“In addition, the cost of the birth for both mother and infant was more expensive in the elective repeat c-section group compared to the vaginal birth after c-section (VBAC) group,” …

… Nationwide, the c-section delivery rate keeps rising. According to the study authors, by 2006, 31.1 percent of deliveries in the United States were done this way.

Australia’s caesarean rate was 31% in 2006, and our national VBAC rate was 16.5%. In NSW hospital VBAC rates can be as low as 2%.

Furthermore, women who have delivered once by c-section have a greater than 90 percent chance of undergoing another, the authors noted. But experts continue to debate whether these women should try labor and vaginal delivery, or automatically undergo another c-section, as there are risks are associated with each method.

… Kamath and her colleagues turned to records from the perinatal database at the University of Colorado Denver. Those records ran from late 2005 through mid-2008 and focused on babies born to 343 women who had planned a repeat, elective c-section and another 329 who planned to try vaginal birth after having previously had a baby via c-section.

The researchers looked at the differences between groups in newborn admissions to the neonatal ICU and the need for oxygen for breathing problems, as well as cost differences.

Kamath’s team further divided the women into four groups. Of the 343 repeat c-sections, 104 went into labor before the c-section and 239 did not. Of the 329 women who attempted vaginal delivery, 85 failed … and went on to have a c-section.

Kamath’s team found that 9.3 percent of the c-section babies were admitted to the NICU, but just 4.9 percent of the vaginally delivered babies were. And while 41.5 percent of the c-section babies required oxygen in the delivery room, 23.2 percent of the vaginally delivered babies did. After NICU admission, 5.8 percent of the c-section babies needed the oxygen compared to 2.4 percent of the vaginally delivered babies.

The median hospital stay was three days for babies who were delivered vaginally and four days for the other three groups …

“The failed VBAC babies required the most resuscitation and had the most expensive total birth experience,” Kamath concluded. But, overall, the VBAC group did better than the c-section group …

Women who opt for a repeat c-section should first understand these risks and differences before they make their decision, Kamath said.

The study results suggest another important take-home point … “The decision to have your first c-section is very important,” he said. “There should be a clear medical indication [because] your first may dictate subsequent [delivery methods].”

Women also need to know that vaginal delivery is possible for many women who have already undergone a c-section, Fleischman said. Some hospitals do not allow vaginal delivery after a prior c-section, however, so he suggested that any woman who is planning on one find out early on what her hospital’s policy is.

If you are planning a hospital VBAC, employ the services of a private midwife to advocate for you and provide support and advice. Australia’s hospital VBAC success rate is very low, however homebirth (private) midwives have a high VBAC success rate – some as high as 90%. By taking a private midwife with you to hospital, you can benefit from the high success rate while also being in your chosen birth environment.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Hospital VBAC?

May 22nd, 2009

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

Ruby Wales holds her newborn, Carson. Her first doctor worried more about the risks of vaginal delivery than of cesarean, so she found a different one.

After an emergency cesarean with her first baby, Ruby Wales was holding out for a vaginal birth with her second one.

With a toddler underfoot, the 33-year-old Mission Viejo woman wanted a faster recovery. But finding a physician to deliver her second child wasn’t easy. Her first obstetrician turned her down flat. “She said, ‘No — no way,’ ” Wales recalled.

Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

Same stats as we have in Australia ….

With that surge has come an explosion in medical bills, an increase in complications — and a reconsideration of the cesarean as a sometimes unnecessary risk.

It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.

“We’re going in the wrong direction,” said Dr. Roger A. Rosenblatt … “in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions …”

… Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs …

… The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade.

We have the same situation in Australia: every year, the CS rate only goes up.

The problem, experts say, is that the cesarean … exposes a woman to the risk of infection, blood clots and other serious problems. Cesareans also have been shown to increase premature births and the need for intensive care for newborns …

Inducing childbirth — bringing on or hastening labor with the drug oxytocin — also is on the rise and is another source of growing concern. Experts say miscalculations often result in the delivery of infants who are too young to breathe on their own. Induction, studies show, also raises the risk of complications that lead to cesareans.

Induction may also fail. The majority of failed inductions end in caesarean.

Despite all this intervention — and, many believe, because of it — childbirth in the U.S. doesn’t measure up. The U.S. lags behind other developed nations on key performance indicators including infant mortality and birth weight.

And in at least two areas, the U.S. has lost ground after decades of improvement: The maternal death rate began to rise in 2002, and the typical American newborn is delivered at 39 weeks, down from the full 40 …

… “Cesarean birth ends up being a profit center in hospitals, so there’s not a lot of incentive to reduce them,” said Dr. Elliot Main, chief of obstetrics for Sutter Health, a Northern California hospital chain.

But there is a lot that hospitals can do to reduce them … Among California hospitals, cesareans range from 16% to 62% of births.

NSW caesarean rates vary from 15% to 46%. The average is 29%, two to three times that recommended by the World Health Organisation.

Such variation means a lot of women are getting unnecessary cesareans, Main said. “There’s no justification for that kind of variation.”

Physicians … have been blamed for failing to make women fully aware of the consequences of cesareans, and for promoting them for convenience.

But change is underway. The Institute for Healthcare Improvement’s Strategic Partners program trains hospitals to implement a set of guidelines, such as the careful use of oxytocin, and a ban on elective deliveries before 39 weeks. In four years, 60 hospitals have signed on.

… 48% of newborns admitted to neonatal intensive care units were from scheduled deliveries, many of them before 39 weeks.

… After being notified of the correlation, the physicians changed their practices and reduced neonatal ICU admissions by 46% in three months.

The rise in avoidable first-birth cesareans has had a multiplier effect. Most U.S. physicians discourage vaginal deliveries after a cesarean because of some widely publicized cases several years ago in which the uterus split disastrously along the prior incision.

That’s why Ruby Wales’ first obstetrician refused.

“She said it was because there is a 1% chance of a uterine rupture,” Wales said. “And I thought that was weird because there’s more chance of things going wrong with a cesarean section.”

VBAC rates in Australia are very low. Some hospitals flat out refuse to “do” VBACs. Others openly discourage them.

But some obstetricians believe that new evidence supports allowing some women the option of trying for a vaginal birth.

… Saddleback supported Wales’ desire for a vaginal birth. Nine days after her due date and after 30 hours of labor, she gave birth — the way she wanted — to an 8-pound, 11-ounce boy.

“I was so glad nothing happened at the last minute to have an emergency C-section because I’d gone through all this work,” said Wales, resting in her hospital bed with baby Carson in her arms. “I’m so relieved that I don’t have to deal with a [cesarean] recovery because I have a 2 1/2-year-old at home who is very active.”

It can be very hard to achieve a VBAC in hospital. It’s far easier to have a VBAC at home. Hospital policies typically work against natural labour, and interventions such as continuous fetal monitoring and vaginal examinations every 2 or 4 hours will most likely see you labouring on your back in bed. This doesn’t allow you to work with your body to see you through a natural labour.

Melissa Maimann, Essential Birth Consulting 0400 418 448

An Obstetrician’s views of caesarean

May 21st, 2009

2 comments

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

I’m not sure where this doctor got his information from. Aaahh well (deep breath ….)

Women are often urged to opt for a “natural” birth – such as having a baby at home – wherever possible.

But in this week’s Scrubbing Up health column, Philip Steer, emeritus professor of obstetrics and gynaecology at Imperial College, London, says rejecting Caesareans is like rejecting technological advances in transport or energy generation.

… Most of us “really, really want” to be healthy and yet many of us eat hamburgers …

For the several million years that we were hunter-gatherers, a mixed diet and lots of walking was unavoidable and this is what our physiology and metabolism is adjusted to.

… This sets up a tension between how we are programmed to behave and the logic of what we know is good for us.

There is a widespread misapprehension that human beings behave logically, but many of society’s ills illustrate that most of us are driven instead by our primitive instincts and emotions.

Discussions about choices in childbirth demonstrate a similar dislocation between emotional drivers and logical behaviour.

Until as recently as the 1930s, maternal mortality around the globe was horrendous.

… In many parts of Africa, the current figure is one in 16, and the global toll is more than half a million deaths per year.

Advances in the technology of surgery, anaesthesia, blood transfusion and antibiotics have so dramatically improved outcomes in developed countries that mortality is now one in 10,000 or fewer.

You would think that these technological advances would be greeted with universal acclaim, but many women see childbirth as an essential “rite of passage” and exhort others of their gender to eschew technological assistance …

Advocates of home birth have, within the last month, claimed that “the vast majority of women have low-risk pregnancies”.

… Delivery by Caesarean section now accounts for almost a third of all births in many developed countries, and is remarkably safe – certainly as safe as many of the cosmetic operations that do not excite similar criticism.

And yet many still argue against allowing women the autonomy to choose their mode of birth, either on spurious economic grounds or by suggesting that “birth is natural so we mustn’t become dependent on technology”.

Without the technology of agriculture, transport, housing and energy generation, how many of the world’s population would survive?

Probably our survival depends on recognising our primitive instinct-driven behaviour and learning how to substitute rational lifestyles instead.

Thank goodness it’s only one person’s opinion. Funny how the doctor polarised his ctance so much – home birth versus caesarean. Most women are somewhere in between those two.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Death twice as likely by caesarean

May 21st, 2009

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

BABIES born by elective caesarean are almost 2½ times more likely to die within their first month than babies born vaginally, researchers have found, adding weight to the argument that caesareans should only be carried out in emergencies.

The study, which involved more than 8 million births in the US over four years, is the first of its kind to focus on full-term babies born to women with no medical reason for choosing a caesarean over a vaginal delivery, an increasingly common phenomenon in Australia.

One in three babies are born by Caesarean in Australia: most of these caesareans are elective. The most common reason for performing an elective caesarean is for a previous caesarean. This is despite evidence that suggests that a vaginal birth after a caesarean (VBAC) is safer for women and babies.

… babies … born before the onset of labour are often unresponsive and unable to breathe without help.

They are frequently admitted to neonatal intensive care units because their lungs cannot eliminate secretions and they lack catecholamines, a vital chemical secreted during labour that keeps them alert and eager to feed.

“We are designed to give birth vaginally. When will people wake up and realise this?” the secretary of the NSW Midwives Association, Hannah Dahlen, said yesterday. “When a baby is born vaginally, fluid is squeezed out of the lungs as it is pushed through the birth canal. The baby can then inhale with clean lungs … A baby born by caesarean quite often comes out gurgling because its lungs are full of fluid, requires suction and is non-responsive because it lacks the hormonal surge delivered during labour.”

… babies born vaginally with high levels of catecholamines were usually alert and quick to seek out their mother’s breast …

The study … only included women who had not had a previous caesarean; were giving birth to a single baby which was head down in the cervix; were between 37 and 41 weeks gestation and had none of the 16 common risk factors, such as diabetes or hypertension, associated with birth complications, in a bid to ensure that only low-risk births were evaluated.

It found the mortality rate for babies born vaginally was less than one in 1000 births while the rate for elective caesareans was 1.73 per 1000 …

Midwifery care reduces the caesarean rate and increases the VBAC rate.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Woman dies during caesarean operation

May 20th, 2009

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

It’s often said that caesareans carry higher risks than vaginal birth. In the case below, it seems that an unnecessary induction led to an unnecessary caesarean during which the woman died. So it would appear that the woman died unnecessarily.

A nurse who spent years undergoing IVF treatment died after suffering brain damage giving birth and never saw the baby she had longed for …

Joanne Lockham had an emergency Caesarean operation to deliver her son but surgeons accidentally starved her brain of oxygen for as long as 30 minutes, it was claimed.

Mrs Lockham, 45 … had been through several rounds of failed IVF treatment when she finally became pregnant. Her baby was six days overdue when she went to Stoke Mandeville Hospital in Aylesbury to have labour induced on 9 October 2007.

Coroner Richard Hulett told the inquest in Amersham today that surgeons had intended to give Mrs Lockham an epidural but because her labour was taking so long it was decided at 6pm to give her a general anaesthetic.

Mrs Lockham sobbed to midwives as she was told of the change of plans but was assured that she would soon be holding her first child in her arms. However, problems arose in the operation theatre after Mrs Lockham went under anaesthetic.

The jury heard that three attempts were made to give her oxygen via a tube before it was eventually believed to have been successful.

However, within moments of the birth, Mrs Lockham suffered a cardiac arrest.

Asked if the intubation had been successful [the doctor] added: “From my point of view, it was possibly not correct.”

Mrs Lockham was transferred to the hospital’s intensive care unit but was certified dead two days later after sustaining irreversible brain damage.

Her husband … is now bringing up their son … alone at their home …

A post-mortem examination concluded that she died as a result of a lack of oxygen to the brain resulting in cardio-respiratory arrest, with a second cause as multi organ failure.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Midwifery care: changes for the better – for hospital birth

May 20th, 2009

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

Caroline Homer, Professor of Midwifery, UTS, writes:

It’s a landmark night for maternity services for Australian women …

Tonight’s announcement goes towards redressing the balance in access and equity in maternity care in this country, enabling midwives to, for the first time, to work as private practitioners, provide services subsidised by the Medical Benefits Schedule and prescribe medications subsidised under the Pharmaceutical Benefits Schedule.

The Improving Maternity Services Package is an initiative for all Australian women. It is an important move forwards and is strong evidence that the recent Review of Maternity Services has been addressed …

Of course the devil is in the detail. What exactly does “subsidised medical indemnity for eligible midwives working in collaborative arrangements in hospitals and healthcare settings” mean for midwives who provide homebirth services? How will an “advanced midwifery credentialing framework” fit with the existing national peer review process for midwives?

… This is the moment to take a deep breath and develop new and more constructive ways of working together recognising and respecting our different skills and capacities. We must keep women and babies at the centre of the discussion, not our various professional perspectives.

This is the time to move forwards using the available workforce in the best way, ensuring that midwives, GPs and obstetricians can each work to their full scope and capacity to ensure the best possible maternity service for all Australian women.

***

Justine Caines, Maternity Consumer Advocate – Mother of seven, living in rural NSW, is also calling it a “Landmark Day for Women and Babies”. She writes:

The budget has announced new funding of $120 M over 4 years to introduce Medicare funding for midwives.

This heralds a new age for maternity care. To date maternity care has catered to the needs of health professionals rather than women and their families. The all powerful medical lobby has dictated the terms. It would seem that their greed has been a major part of the reform agenda.

In the 4 years since the Medicare safety-net was introduced, Obstetricians have increased their charges by approx 300%. This budget has reeled these obscene costs in with a cap to the safety-net. By enabling private practice midwifery through Medicare, private health funds will be able to finally offer choice to women. Importantly midwifery care will also have the capacity to reduce unnecessary costs (by reducing interventions, especially caesarean section and associated costs esp when babies are harmed through surgery and spend time in special care nurseries).

With the introduction of Medicare for midwives rural women can breathe a sigh of relief … The social dimension of midwifery is well placed to make in-roads to close the gap for Indigenous Australians …

The only down-side is that homebirth is not yet to be funded. It would seem medical groups will ‘die in a ditch’ over funding homebirth services … Men in white coats wrangle to keep control of women’s bodies. Overall thumbs up to Nicola Roxon, I look forward to working through the implementation.

Private midwifery for hospital birth will be funded, but home birth will not be funded. Insurance will be tied to registration, and insurance will not cover home birth, only hospital birth wihtin a collaborative model. There is a possibility that private home birth services may still be possible, albeit unfunded and uninsured. There will be increased scope for midwives to provide services to women in a range of locations – hospitals and birth centres – either in a solo practice or a group practice. The finer details of collaboration and advanced practice have not been worked out as yet.

Melissa Maimann, Essential Birth Consulting 0400 418 448

It’s official: Doctors perform caesareans to avoid being sued

May 19th, 2009

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

“States classified as having a medical liability crisis or crisis brewing by ACOG [the American College of Obstetricians and Gynecologists] have significantly higher rates of cesarean delivery, and this may reflect a pattern of defensive medicine in response to the liability climate,” said Elizabeth A. Platz, MD, from the Medical University of South Carolina in Charleston.

Total cesarean and primary cesarean rates are currently as high as 30% of total births in the United States, up from 4.5% in 1965.

Very similar to Australia’s CS rates.

In 2003, 76% of all American obstetricians reported at least 1 litigation event, with a median award of $2.3 million for medical negligence in childbirth. A common accusation is failure to perform cesarean in a timely manner, and concern has been voiced that obstetricians as a result are turning to cesarean delivery at any sign of complication.

According to the findings that Dr. Platz presented here at the ACOG 57th Annual Clinical Meeting, that fear is well founded.

In discussing the increase in total and primary cesarean delivery rates, Dr. Platz began by noting that it remains poorly understood. As a possible explanation, she cited maternal characteristics (including increasing maternal age, obesity, the number of multiple gestations, and declining rates of feedback) and physician practice patterns.

Dr. Platz said that her results also reflect results from the ACOG’s
1985 survey, which examined changes in obstetrical and gynecological practice behavior that were thought to affect the rate of cesarean delivery. These changes included an increased number of referrals, consultations, tests, and diagnostic procedures.

It has been suggested that medical-legal pressures are a factor in the rise in cesarean deliveries. A number of studies have borne this out.
Localio and colleagues (JAMA. 1993;269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery. Murthy and colleagues (Obstet Gynecol.
2007;110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean sdelivery.

Dr. Platz’s study was designed to establish whether state-specific cesarean delivery rates differed by medical liability climate. This cross-sectional observational study reviewed cesarean delivery rates and malpractice activity measures.

The states were classified by an ACOG formula, and demographic and population data were obtained from the US census and the National Center for Health Statistics. Malpractice activity variables were obtained from the National Practitioner Databank. The study used ACOG classifications for malpractice.

The Kolmogorov–Smirnov test was used to measure normal distribution, and bivariable associations were analyzed with Pearson’s correlation coefficients. A multivariable linear regression model was performed using a stepwise regression (mixed effects and interactions model) to include all variables and variants, Dr. Platz explained.

She noted that variables associated with higher cesarean delivery rates included ACOG’s Red-Alert states, payout reports, obesity, the percentage of African American women, smoking, and poverty. Red-Alert states have a cesarean delivery rate of 29.9% and are deemed to be in crisis. States with a rate of 28.1% are defined as having a crisis brewing, and those with a rate of 27.2% or less are not considered in crisis.

Commenting on the results to Medscape Ob/Gyn & Women’s Health was Kurt L. Barnhart, MD, MSCE, member of ACOG’s Committee on Scientific Program. Dr. Barnhart is director of women’s health research at the University of Pennsylvania in Bryn Mawr, and served as director, with Janice L. Bacon, MD, of the Papers on Clinical and Basic Investigation.

“First of all, I applaud the abstract, that it quantifies a perceived problem,” Dr. Barnhart said. “We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,” Dr. Barnhart said.

“What one does about it is a little bit more difficult. But with objective evidence . . . that fear of liability is causing C-sections, we can address the problem by reducing liability, thereby reducing 0D C-sections,” Dr. Barnhart explained. “So instead of just telling physicians not to do C-sections, this identifies [the need] to remove the risk, and then they’ll do fewer C-sections.

“So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.

The study was funded by the Medical University of South Carolina. Dr.
Platz has disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting: Papers on Current Clinical and Basic Investigation.

Our national caesarean rate was 31% in 2006. The VBAC rate was 16.5% nationally. So 83.5% of the women who have a CS will have another one for future children. I believe the solution is universal midwifery care for women, unnless there is a good reason to consult with a doctor. Under midwifery care, most women will have a vaginal birth, and most VBACs (80%) will be successful.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Formula Milk may make babies fat

May 19th, 2009

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

Mothers who fail to notice signs that their babies are full tend to overfeed them, resulting in excess weight gain when the infants are between 6 months and a year old …

The finding comes from a study … of 96 … mothers who formula-fed their babies. The mothers recorded information about their babies’ feedings, and researchers visited the mothers when the babies were 3, 6 and 12 months old to observe feedings and to weigh the babies.

The study looked at a number of possible variables linked to infant weight gain and found that the number of feedings a day at 6 months approached significance in predicting weight gain from 6 to 12 months. It also found that mothers who were less sensitive to signals that their babies were full had infants who gained more weight.

“More frequent feedings, particularly with formula, are an easy culprit on which to assign blame,” the researchers wrote. But a mother’s “unwillingness to slow the pace of feeding or terminate the feeding when the infant shows satiation cues may be overriding the infant’s ability to self-regulate its intake,” they said.

Do we need any more research on the risks of formula and the benefits of breast milk for babies? Formula is completely processed and artificial. Maybe formula vs breast milk its akin to McDonalds vs grilled fish and veges for a meal.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Homebirth: Study Reveals Conflict Between Doctors And Midwives

May 18th, 2009

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

Link to article

Two Oregon State University researchers have uncovered a pattern of distrust – and sometimes outright antagonism – among physicians at hospitals and midwives who are transporting their home-birth clients to the hospital because of complications.

Oregon State University assistant professor Melissa Cheyney and doctoral student Courtney Everson said their work revealed an ongoing conflict between physicians and midwives that is reflective of discord across the country.

The pair recently examined birth records in Oregon’s Jackson County from 1998 through 2003, a period when that county saw higher-than-expected rates of prematurity and low birth weight in some populations. The researchers wanted to assess whether those rates were linked to midwife-attended homebirths.

The findings revealed that assisted homebirths did not appear to be contributing to the lower-than-average health outcomes and, in fact, that the homebirths documented all had successful outcomes. But even more importantly … discussions with doctors and midwives uncovered a deep gulf between the two groups … with doctors expressing the firm belief that only hospital births are safe, while midwives felt marginalized, mocked and put on the defensive when in contact with physicians.

… Cheyney, who is a practicing midwife in addition to being an assistant professor of medical anthropology and reproductive biology, said she was surprised that physicians, when presented with scientifically conducted research that indicates homebirths do not increase infant mortality rates, still refuse to believe that births outside of the hospital are safe.

“Medicine is a social construct, and it’s heavily politicized,” she said.

Last year the American Medical Association passed Resolution 205, which states: “the safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex…” The resolution was passed in direct response to media attention on home births, the AMA stated.

What is interesting, Cheyney points out, is that 99 percent of American births occur in the hospital, but the United States has one of the highest infant mortality rates of any developed country, with 6.3 deaths per 1,000 babies born. Meanwhile, the Netherlands, where a third of deliveries occur in the home with the assistance of midwives, has a lower rate of 4.73 deaths per 1,000.

One of the biggest problems Cheyney sees is that physicians only come into contact with midwives when something has gone wrong with the homebirth, and the patient has been transported to the hospital for care. There are a number of reasons why this interaction often is tension-filled and unpleasant for both sides, she says.

First is the assumption that homebirth must be dangerous, because the patient they’re seeing has had to be transported to the hospital. Secondly, the physician is now taking on the risk of caring for a patient who is unknown to them, and who has a medical chart provided by a midwife which may not include the kind of information the physician is used to receiving.

Hence the benefit of women booking in to a hospital: if their resources are needed in an emergency, or even for consultation, the hospital has information about the woman, her history and her risk factors.

And because the midwife is often feeling defensive and upset, Cheyney said, the contact between her and the physician can often be tense and unproductive. Meanwhile, the patient, whose intention was not to have a hospital birth, is already feeling upset at the change in birth plan, and is now watching her care provider come into conflict with the stranger who is about to deliver her baby.

“It’s an extremely tension-fraught encounter,” Cheyney said, “and something needs to be done to address it.” As homebirths increase in popularity, she added, these encounters are bound to increase and a plan needs to be in place so that doctors and midwives know what protocol to follow.

She is working with Lane County obstetrician Dr. Paul Qualtere-Burcher to draft guidelines that would help midwives and their clients decide when they need to seek medical help, based in large part on Cheyney’s research, and another that would ask physicians to recognize midwives as legitimate caregivers.

Qualtere-Burcher said creating an open channel of communication isn’t easy.

… Qualtere-Burcher said he believes that if midwives felt more comfortable contacting physicians with medical questions or concerns, there would be a greater chance that women would get medical help when they needed it.

“Treat (midwives) with respect, as colleagues, and they’ll not be afraid to call,” he said.

Qualtere-Burcher doesn’t expect immediate buy-in, but hopes that if a small group on each side agrees to the plan, it will provide more evidence that a stronger relationship between physicians and midwives will lead to better outcomes for mothers and infants.

“We’re having a meeting in early May to propose a draft for a model of collaborative care that might be the first of its kind in the United States,” Cheyney said.

Cheyney is also pushing to get hospitals and the state records division to better track homebirths. The department of vital records had no way to indicate whether a birth occurred at home until 2008, and without being able to pull data, Cheyney said it’s hard to explore the nature of home birth in Oregon.

I think this article raises some excellent points. Hospital transfer rates for home births vary from around 40% to as low as 10% according to research and anecdotal reports. Publicly-funded home birth models have higher rates of hospital transfer, and first time mothers have higher rates of transfer.

The article mentions, “As homebirths increase in popularity, she added, these encounters are bound to increase and a plan needs to be in place so that doctors and midwives know what protocol to follow.” Some Area Health Services have such plans in place; sadly, not all Area Health Services have plans in place. There is, however, a Dept of Health policy on home birth transfer situations that states that homebirth transfer women are to be treated with respect at all times.

The article also mentions, “She is working with Lane County obstetrician Dr. Paul Qualtere-Burcher to draft guidelines that would help midwives and their clients decide when they need to seek medical help” We have such guidelines in Australia, but sadly they do see most women needing a consultation, if not transfer of care. However, consulting does not mean that the woman must agree with what is proposed by medical staff: she is free to make her own decision with the support of her midwife. The guidelines potentially make it difficult for the midwife to provide care if the woman declines to follow medical advice once it has been sought though.

The articale speaks of, “pushing to get hospitals and the state records division to better track homebirths”. In Australia, midwives are required to report all births to the health dept for stats. Most midwives put their stats in, however freebirths most likely are not reported. The oft-quoted 0.2% homebirth rate in this country is possible higher, but this is not known. It would be fantastic if we could compile all homebirth stats to see how safe homebirth really is in Australia. What a great push that would give to make midwife-attended private home birth a medicare-funded option!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Offspring’s Behavior Influenced By Trauma Experienced By The Mother Even Before Pregnancy

May 18th, 2009

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

Juat an interesting article I came across ….

new study in rats at the University of Haifa reveals that tauma experienced by a mother even before pregnancy will influence her offspring’s behavior.

The findings show that trauma from a mother’s past, which does not directly impact her pregnancy, will affect her offspring’s emotional and social behavior. We should consider whether such effects occur in humans too,” stated Prof. Micah Leshem who carried out the study.

A mother who experienced trauma prior to becoming pregnant affects the emotional and social behavior of her offspring …

The effects of trauma that a mother experienced in the course of pregnancy are known from earlier research, but until now the influence of adversity before conception has not been examined …

The researchers chose to investigate rats, as social mammals with cerebral activity that is similar in many ways to that of humans. The present study examined three groups of rats: one group was put through a series of stress-inducing activities two weeks before mating, allowing the female time to recover before becoming pregnant; the second group was similarly treated over the course of a week immediately prior to mating; and the third, control group, were not given any form of stress. When the rats’ offspring reached maturity (at 60 days), the researchers examined their emotional behavior – anxiety and depression – and social behavior.

The main finding revealed that trauma experienced by the females prior to conception had varied effects on the offspring … these effects varied between groups and between male and female offspring; but their behavior was without doubt different from that of the rats from the control group.

All the offspring of stressed mothers showed reduced social contact compared with that of the control mothers’ offspring: these rats spent less time with one another and interacted less. In other tests, there were important sex differences. The female rats displayed more symptoms of anxiety, while the males exhibited less anxiety. Finally, those rats whose mothers became pregnant immediately after being stressed were hyperactive, indicating that how long before pregnancy adversity is experienced, is also important. “Everyone knows that smoking harms the fetus and therefore a mother must not smoke during pregnancy. The findings of the present study show that adversity from a mother’s past, even well before her pregnancy, does affect her offspring, even when they are adult. We should be prepared for analogous effects in humans: for example, in children born to mothers who may have been exposed to war well before becoming pregnant,” Prof. Leshem concluded.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Hospital doctors fear losses of staff

May 18th, 2009

3 comments

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

Link to article

MIDWIVES will not flee the state’s chronically understaffed public hospitals, despite budget moves to allow them to set up private practices from the end of next year, the Australian College of Midwives said.

The Federal Government’s overhaul of maternity services will allow some of the nation’s 12,000 midwives to prescribe drugs subsidised by the Pharmaceutical Benefits Scheme and claim Medicare rebates for managing pregnancies, deliveries and postnatal care.

Independent midwives will also be granted indemnity insurance and visiting rights to hospitals, despite opposition from doctors’ groups.

… “[These changes] potentially meet the needs of the majority of women … from the middle of our largest cities to remote communities. It is not about midwives being independent of the system. We have always worked with doctors and we always will. It is the safest and best way, but these changes will make it more financially viable for everyone.”

But obstetricians are concerned that public and private hospitals could be stripped of experienced midwives, putting women at risk. “They are saying that won’t happen but we just don’t know yet,” the president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Dr Ted Weaver, said yesterday.

“There is every chance some of these models of care being examined will be very attractive to midwives and entice them away from their traditional places of employment, such as hospitals.”

Ahem, what does that say about hospital employment, if this doctor fears that midwives will all leave if oddered an alternative way to practice?

Professor Dahlen said the changes would attract more midwives and retain those already in the system because they would be able to practise to the full scope of their abilities “rather than be frustrated by a medically-dominated model of care”. She said that not all midwives would want to manage their own businesses.

Dr. Andrew Pesce … said if the Government underwrote midwives’ indemnity insurance that could disadvantage GPs who also deliver babies.

Under a current scheme, the Government already subsidises GP obstetricians’ insurance premiums if these amount to more than 7.5 per cent of their fees for providing the service. Unless access to subsidised insurance was offered equally to both groups, doctors might be put at a “competitive disadvantage [compared to] midwives”, Dr Pesce said.

The Rural Doctors Association of Australia welcomed the changes, saying it would free GPs in regional areas.

Interesting that the issue of competitive advantage comes into play. Hannah Dahlen makes a great point that not all midwives will want to leave the hospital system. I agree totally! being self-employed and managing a business is, in many ways, much harder and more demanding (also more rewarding) than working in a hospital where a stable and dependable amount of money appears in one’s bank account every 2 weeks.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Blue Mountains Hospital

May 17th, 2009

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

Kate Benson Medical Reporter
May 15, 2009

SCORES of residents attended a public rally in the Blue Mountains yesterday to force the State Government to keep the hospital’s embattled maternity unit open.

The ward has been shut at short notice more than 120 times in the past 18 months because … a lack of available obstetricians and anaesthetists.

Staff and residents have been told the area health service was working hard to recruit more staff and keep the unit open, following a 2007 promise … that maternity services would be maintained.

But yesterday women from throughout the Blue Mountains gathered outside the hospital to protest against rumours the maternity and pediatric units would be shut permanently by November.

The hospital serves an area that has 80,000 residents, and draws more than 3 million tourists a year, but when it is shut patients have to travel to Nepean Hospital, 45 minutes away.

“This is our worst nightmare,” Katoomba’s deputy mayor, Janet Mays, said. “Monies were allocated [in this week's federal budget] to upgrade Nepean, making it quite clear that we are seen as nothing more than feeder suburbs, [and] that is offensive …”

… All seven midwives have quit in frustration because a plan to allow them to manage low-risk births, approved in November by NSW Health and due to start in July, is still in doubt.

It all seems a bit odd to me. Why not open the unit as a midwifery-led unit? High risk women can be cared for at Nepean. If this was the arrangement, women and their families would know the plan and feel more certainty in what might happen. The way it is currently, women don’t know if the unit will be open or closed when they go into labour. Or, open it as a birth centre.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Safety net changes and obstetrics

May 17th, 2009

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

Link to article

PATIENTS paid more as a result of changes to the Medicare safety net which were meant to reduce out-of-pocket costs, a Government-commissioned study has found.

The extended Medicare safety net … was directly responsible for an average 2.9 per cent rise in fees charged by most specialists …

The findings of the report by the Centre for Health Economics Research and Evaluation in Sydney have been used by the Government to justify its crackdown on excessive fees charged by some obstetricians, vascular surgeons and eye specialists …

… the study found the extended safety net not only spurred some specialists to charge much higher fees in the knowledge that patients would get most of the money back, but also benefited patients on higher incomes much more than those on lower incomes.

The safety net had … [provided] benefits that increased with doctors’ fees, regardless of how high those fees might be.

… The Government’s decision to cap safety net payments for some fees is expected to generate savings of $440 million over four years. The move has set the scene for a showdown between high-charging obstetricians, their patients and the Government, over whether the specialists will reduce their fees or expect patients to pick up hundreds of dollars in charges no longer covered by the safety net. An obstetrics leader, Andrew Pesce, has warned that the cap on fees which can be defrayed by the safety net would “significantly affect affordability” for most women under the care of private obstetricians.

… The Health Minister, Nicola Roxon, has said that excessive fees had resulted in taxpayers funding million-dollar incomes for some specialists. The top-earning 10 per cent of obstetricians were each paid an average $1.1 million a year through Medicare, including $612,000 through the extended Medicare safety net, she said.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Rural doctors welcome new powers for midwives

May 16th, 2009

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

Link to article

Giving midwives the power to bill consultations to Medicare and write scripts subsidised by the PBS will enhance maternity services for country women, rural doctors say.

… welcomed the new powers for midwives, who play a key role in maternity services in the bush already.

Under changes made in the budget, midwives will now be able to bill Medicare for their consultations. Their patients will be able to access cheaper medicines because midwives now have access to the PBS.

They will also be subsidised for professional indemnity insurance if they work in a hospital or birthing centre.

“Birthing services are extremely important in rural communities. We know that they’re valued by the rural women and their families,” Dr Maxfield told reporters in Canberra on Wednesday.

“If we can have a patient seeing either the midwife or the GP, depending on who is the appropriate person at the time, then that’s going to benefit the patients and free the GPs up to be able to see other people.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Maternity Services Reform: Fantastic news for hospital birth and private midwifery

May 12th, 2009

1 comment

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

From the budget …. significant changes that will see midwifery recognised as a profession in its own right. The proposal does not cover home birth, only hospital birth with a private midwife. But it’s a significant shift from the current delivery of services to a more woman-friendly approach. The finer details have not been ascertained as far as I can tell, and many questions remain unanswered, such as:

- which midwives will be eligible for medicare funding and access to PBS and insurance?
- does it cover private hospitals ot only public hospitals?
- how will the midwife demonstrate collaborative care?

The Government is providing $121 million over four years to reform maternity services to increase access for women and their babies to collaborative models of care, such as through greater involvement of midwives. This new spending has been achieved by removing excessive cost pressures in the health system.

The Government will provide $120.5 million over four years for the introduction of Medicare‑supported midwifery services to provide greater choice for women during pregnancy, birthing and postnatal maternity care. This measure includes $3.1 million in capital funding in 2009‑10 for Medicare Australia.

The new arrangements will allow midwives to work as private practitioners, provide services subsidised by the Medical Benefits Schedule and prescribe medications subsidised under the Pharmaceutical Benefits Schedule. The Government will also provide subsidised medical indemnity for eligible midwives working in collaborative arrangements in hospitals and healthcare settings. To ensure that Australia maintains its strong record of safety and quality in maternity care, a safety and quality framework, including professional guidance and an advanced midwifery credentialing framework, will be developed. A new 24‑hour, seven‑days‑a‑week helpline will also be established to provide antenatal, birthing and postnatal maternity advice and information to women, partners and families during the ante‑natal period and up to 12 months following the birth of a child.

The measure will also assist women in rural and remote areas by expanding the Medical Specialist Outreach Assistance Program to provide integrated outreach maternity service teams for women in under serviced areas. The expanded teams will include midwives, obstetricians, general practitioners and other health professionals, such as paediatricians and Aboriginal health workers. Additionally, funding will be provided for the professional development of midwives and for general practitioners to undertake additional training to become GP obstetricians or GP anaesthetists. The package will be implemented progressively from 1 July 2009.

The Government also understands that maternity services in Australia are under growing pressure as the number of births continues to rise and workforce shortages worsen and that many Australian women are frustrated at the limited choices available to them for their maternity care. Limited access to maternity services in rural and remote communities is also a growing concern. To address these issues, the Government is investing $121 million over four years to reform maternity services to increase access for women and their babies to collaborative models of care and to involve midwives in a more substantive role. This package makes it possible for the Government to make better use of the maternity workforce, ensuring that the right professionals can provide the right care at the right time in the right place.

The current EMSN meets 80 per cent of the out‑of‑pocket costs for out‑of‑hospital Medicare services once an annual threshold is met. This is regardless of how much the doctor charges. In 2007 it is estimated that up to 78 per cent of EMSN spending went to meeting providers’ higher fees, rather than reducing patients’ out‑of‑pocket costs. EMSN expenditure on the items to be capped has grown at an average rate of approximately 50 per cent for the past two years.

The new EMSN caps will apply on all related items, including pregnancy‑related scans for example, to ensure that specialists do not shift their high fees to items that are not covered by a cap. In conjunction with the introduction of the cap, the Government will increase Medicare Benefits Schedule items for obstetrics to reduce the incentive to charge excessive fees. The cap per Medicare Benefits Schedule item will be set at different levels depending on the schedule fee of the item. Cap amounts will be indexed on 1 January by the Consumer Price Index, consistent with safety net thresholds. Should a patient claim an item more than once in a calendar year (for example, ante natal attendance), she would be eligible for the same maximum EMSN benefit each time she claimed the item.

It seems that the incentives for obstetric care are diminishing, and the incentives for midwifery care are increasing. Hopefully this will encourage women to pursue midwifery care, resulting in a lower caesarean rate, lower postnatal depression, higher breastfeeding rates, lower rates of induction, epidural, episiotomy, forceps, vacuum deliveries …. the list goes on!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Postpartum Depression Is Top Priority For New ACOG President

May 12th, 2009

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

Link to article

Today Gerald F. Joseph Jr, MD, of Louisiana, became the 60th president of The American College of Obstetricians and Gynecologists (ACOG)… . During his inaugural speech at ACOG’s Annual Clinical Meeting, Dr. Joseph announced that postpartum depression is the theme of his presidential initiative.

“While in an ideal world, the newly delivered mother is at the peak of her reproductive health, with a beautiful child and, ideally, a supportive, loving family, this unfortunately is not always the case,” said Dr. Joseph. “Studies show that this is a most vulnerable time for our patients, especially those prone to depression or those with a history of depression.” Complicating matters is that the new mother often can’t bring herself to admit to any problems or negative emotions due to societal pressures, he said. Instead of asking for help, she may feel guilty for not being ‘grateful’ or a ‘good’ mother.

Dr. Joseph explained that the ‘baby blues,’ which affect as many as 80% of new mothers, usually start early after delivery and spontaneously resolve within a very short period of time. “But what happens when these negative feelings don’t resolve and true major depression becomes a part of the process?” he asked. “This can be devastating for the mother, the child, the partner, the family, and the ob-gyn who is caring for her.”

There are three areas in particular that need to be addressed, according to Dr. Joseph. “First, we need to determine the true prevalence and incidence of postpartum depression,” he said. … postpartum depression is estimated to range anywhere from five percent to more than 25 percent … we need to develop evidence-based guidelines for ACOG members to screen for postpartum depression.”

It would be great if there was some sot of acknowledgement of the role that pregnancy- and birth-related interventions have on the incidence of PND. It would also be great to see a study looking specifically at women with PND, to establish what sort of birth experience the woman had, and who her primary care provider was (midwife or obstetrician). It’s not hard to see that when women are told, overtly or covertly, that their bodies don’t work and that they need intervention to start labour, keep it going, or bring it to an end, that they take this learning away to motherhood, and approach motherhood with the same sense of failure.

Rates of PND are lower with midwifery care and with home births. Birth debriefing may help women who are experiencing PND.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Update on national registration and its effect on homebirth

May 11th, 2009

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

The design of the New National Registration and Accreditation Scheme has now been published.

I was initially optimistic since the report does not mention insurance being tied to registration. I thought that perhaps insurance would not be a requirement of registration. My professional body, ACMI, have informed me today that insurance may still be linked to registration.

There is also a new clause: “Mandatory reporting of registrants”. This clause states that:

“there will be a requirement that practitioners and employers … report a registrant who is placing the public at risk of harm.

… reportable conduct will include conduct that places the public at substantial risk of harm either through a physical or mental impairment … or a departure from accepted professional standards. … This requirement will deliver a greater level of protection to the Australian public.

Protection of the public is an important concern. However, we also have a situation where the AMA and RANZCOG are opposed to home birth and free-standing birth centres. We also have Guildelines for Consultation and Referral, set out by the College of Midwives. The effect of this may be to limit private home birth services. In essence what it could mean is that all moderate and high risk pregnancies and births will need to be consulted to, or even referred to, an obstetrician for management. The Obstetrician, belonging to the AMA and RANZCOG, would most likely advise against home birth. If the midwife and woman proceed with a home birth, under the mandatory reporting of registrants, the midwife can expect to be reported to the Board for placing the public at risk of harm. The midwife, at all times, must act within her scope of practice – primary care provider for normal pregnancy and birth – and must act according to professional guidelines. Undertaking a home birth that was advised against by a doctor (for any reason) may leave the midwife open to being reported to the Board, and ultimately de-registered.

Sounds fair and reasonable? Perhaps, but what about the rights of women to choose where, how and with whom their baby will be born?

Luckily, women may take a private midwife with them to a hospital birth, and although the private midwife may not necessarily act as the accoucher for the birth, the advocacy and advice is invaluable, not to mention continuity of care and ongoing support. However, this does not help women who prefer to have their VBAC, breech or twin babies at home. I think it’s time for women to take a stand and demand private midwifery for home and hospital birth.

Melissa Maimann, Essential Birth Consulting 0400 418 448

International Midwives’ Day – The World Needs Midwives Now More Than Ever

May 11th, 2009

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

Link to article

The Australian Nursing Federation (ANF) celebrated International Midwives’ Day (IMD) this year by acknowledging the important role midwives play in improving maternal health in Australia and throughout the world.

Ged Kearney, ANF Federal Secretary, said that International Midwives Day focuses attention towards the contribution and commitment shown by midwives to the health and wellbeing of mothers and babies.

“Every year Australia’s midwives expertly assist mothers to safely birth their babies, caring for mothers, their newborn and families with professional kindness and skill. The World Health Organisation recognises midwives as the most appropriate health professionals to safely manage a mother’s maternal care and the birth of their babies. Their incredible contribution should be applauded by government, the media and the community.”

The ANF pointed out that although the contribution of Australian midwives is well recognised, particularly following the recommendations in the federal government’s maternity services review, Australian midwives still need action to enable mothers and babies to receive the full benefits of their professional skills.

“Australia has some wonderful examples of midwifery services that are collaborative and use a multidisciplinary approach to maternity care;” Ms Kearney said. “These models of care must be available to all mothers and their babies for the benefit of all communities.”

“Midwives make a significant contribution to the maternity care and education of families in Australia. It is essential that all mothers and babies benefit from this care, particularly in rural and remote areas. Australia needs the skills of midwives now more than ever.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Benefits of Using a Midwife During Childbirth

May 11th, 2009

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

In Australia, all babies are born with the help of a midwife. This is true whether you’re giving birth in hospital, birth centre, at home or in an operating theatre. The question is really – what are the benefits to having a midwife as your primary care provider?

So, what is a primary care provider?
A primary care provider is someone who is responsible for your pregnancy and birth care. It will either be a doctor or a midwife, and in some circumstances, it will be both. Women may choose birth centre, homebirth or hospital midwifery care to benefit from primary midwifery care.

Primary medical care is provided by private obstetricians or through doctor’s clinics in public hospitals.

What are the benefits of having a midwife as your primary care provider?
Midwives generally have a firm belief in pregnancy and birth as natural processes that women can do. In other words, they believe that a woman’s body is perfectly designed for pregnancy and birth. They look for what’s right in the pregnancy and birth, while always being mindful of risks. Midwives help to keep pregnancy and birth normal by focussing on nutrition, lifestyle, health and well being. We that with health in general, healthy people are less likely to get heart disease, diabetes and so on. Well, it’s the same in pregnancy and birth: healthy women and babies are less likely to get sick. So midwives focus on health and well being, while always being alert for situations that need more attention.

Midwives use a holistic, or biopsychosocial model of care. What this means is that you’re not just a pregnancy or a birth to a midwife. You’re a woman, mother, friend, wife, partner, employer / employee and so on. Your midwife will seek information about your life, your family, your interests and so on, as well as your health and medical history. She will take all of this information into account when making recommendations and giving advice.

Midwives are less likely to use disruptive technologies that may lead to further intervention and complications. They’re less likely to induce labour, perform an episiotomy, perform vaginal examinations, break your waters and so on. So your labour is allowed to progress naturally. When you work with your body, it will work with you. When you interfere with your bodily processes, your body will not work as well. This is especially the case in birth where there’s a strong reliance on hormones to initiate labour and keep it going.

Women are usually very satisfied with midwifery care. They feel supported, emotionally, from seeing a midwife. They feel they can trust their midwife and that their wishes are respected. Women feel more comfortable to write a birth plan and discuss their hopes and preferences for their pregnancy and labour when they see a midwife.

So, what does this mean for birth and babies?
Well, there are lots of positives! When you have a midwife as your primary care provider, you can expect:
- choice of birth place (hospital, birth centre, or home)
- a lower rate of caesarean
- a lower rate of episiotomy
- you’re less likely to be induced
- you’re less likely to need pain medication in labour
- you’re less likely to have your waters broken
- you will be listened to and respected
- your birth plan will be respected
- you will be able to build trust with the midwife who will help you in birth
- you will be less likely to have an assisted birth (eg forceps)
- you will have a lower chance of getting postnatal depression
- you will be less likely to have birth trauma
- you will be more likely to bond well with your baby
- your baby will be more likely to breastfeed successfully
- you will most likely view your labour as being very positive

Melissa Maimann, Essential Birth Consulting 0400 418 448

Risk and homebirth: what’s at stake?

May 7th, 2009

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

Link to article

In the aftermath of the recent federal Review of Maternity Services, public debate on the relative merits of home versus hospital birth has been raging with more heat than light. Current affairs coverage of the topic has at times attracted the worst practices of the tabloid press. Alarmist headings such as “Why hospital horrors bring birth risks home” (Daily Telegraph, April 6, 2009) are not helpful to anyone engaged in this debate – not women, not midwives, not obstetricians and not policymakers.

As maternity service researchers and as mothers we make three arguments here. The first relates to media coverage of the topic. The second relates to the international evidence surrounding the safety of homebirth. The third relates to the future provision of optimal maternity services for Australian women.

First, news reporting that uses sensationalist and simplistic strategies to attract a popular readership neglects its public responsibility and imposes loss of integrity on the newspaper, its editors and reporters. Of course it is commonplace to resort to sensationalism and to reduce complex factors to dot points and one-liners but this fails to serve an inquiring and concerned public and fails to support genuine public debate. Reducing the complexity of the home versus hospital debate to a vacuous, vote “yes/no” quiz or to a journalist’s preference for extreme stories (for example, the Sydney Morning Herald, April 7, 2009) is hardly enlightening.

Public sector broadcasting has not been immune from the problems: the well-regarded Insight program (SBS, March 10, 2009) started its discussion of childbirth by using graphic images of caesarean births and stressed professional “turf wars”; and the ABC’s 7.30 Report (April 1, 2009) was guilty of clipping key comments from both a senior midwife and a leading obstetrician to produce a different meaning from their original statements. This is not just fraudulent; it undermines the professions’ reputations, and it has recently intensified divisiveness and anguish within and between them. Most of all, it is dangerous for the well-being of women, their babies and families who require health professionals to work collaboratively and with mutual respect to achieve high levels of access, universal standards and safety.

Second, the question of the safety of homebirth needs to be contextualised within debates over evidence-based practice and reviews of randomised control trials – seen by the medical profession as the gold-standard in assessing various treatment regimes.

According to the most recent review updated in April 2006, the internationally respected Cochrane Collaboration reported that “There is no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women”.

Further, “The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women”.

A recent large retrospective cohort study in Holland where 30 per cent of women typically birth at home found “no significant differences between women who gave birth at home with those who had a planned hospital birth”. Mortality and transfer to a neonatal intensive care unit was the same in both groups, namely 7 per 1,000 births.

Anecdotal evidence that in an area of New South Wales recently there have been one or two extra deaths per 1000 births fails to provide evidence about anything and may rightfully be dismissed as sensationalism and political opportunism. Unfortunately, deaths occur both at home and in hospital; the vast majority are not related to setting of birth.

Earlier studies have come to much the same conclusion, although there are some that claim much better mortality and morbidity rates for home birth.

The issue of safety hinges not simply on the woman’s physiological status before and during birth, or the health of the baby in utero, but how the woman experiences her social environment throughout labour. Physiological childbirth is a complex process which we are learning more about all the time. We do know that it is neither mechanical nor entirely predictable. Published meta-analysis of continuous social support for labouring women (emotional, comfort measures, information and advocacy) indicates that it seems to enhance outcomes as well as increase “women’s feelings of control and competence and thus reduce the need for obstetric intervention”.

The social and physical environment matters because it actually shapes what happens. Midwifery care helps create normalcy; a low-risk birth can actually depend upon social relationships with carers to achieve calm, control and confidence in the process. This is where midwifery care in collaboration with expert obstetric advice when needed comes in. It is also why many women want to exercise their human right to stay where they are in charge not medical experts.

The third point is that to achieve optimal maternity care for women in the future requires transcending ill-informed debates about the relative safety of home and hospital birth. Midwives are accredited through formal processes, and those attending homebirth are frequently the most highly qualified and experienced. Across Australia, new forms of care are already extending birthing options, but exciting opportunities and even safety are also being compromised. Funding inefficiencies, especially through public support for the private sector, overcrowding, and over-stressed staff in many hospitals, and loss of rural services due to staff shortages are the big policy challenges.

While professional tensions remain, our recent research into professional relationships in Australian maternity care has found new forms of knowledge-sharing and collaboration. For example, in several major women’s hospitals, homebirth transfers are now handled amicably and responsibly. The key question is how best to deliver healthy birth options in hospitals and homes, including provision of necessary professional indemnity insurance. Real safety is assured when we endorse models of care that incorporate reciprocal respect and recognition between midwives and obstetricians in the sole interests of women and their families. As Minister Roxon rightly commented on Insight, this is the essence of the Maternity Services Review recommendations.

What a well-written article! I belive that for true collaborative care to succeed, midwifery and obstetrics need to be recognised as equal professions in their own right. Currently in Australia, midwifery is seen as being subservient to obstetrics. Women need to be cleared by obstetricians to be accepted into birth centres or onto hospital homebirth programs. This needs to change. Midwives need to be responsible and accountable for client selection for birth centre and homebirth care. Midwives need to be key decision makers in conjunction with women. Obstetricians need to be available for consultation and referral in collaboration with women. Women need the right to choose a midwife as a primary care provider, and for continuity of care.

Melissa Maimann, Essential Birth Consulting 0400 418 448

What does it cost to have a baby with a midwife?

May 7th, 2009

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

Generally, you can expect to pay between $4,000 and $5,000 for private midwifery care. However, you may claim $900 as a tax off-set, bringing the cost down to $4100 or $3100. Some health funds provide a benefit for midwifery, up to $3000.

Some people comment that this sounds expensive. Most midwives would prefer you not let money be the deciding factor for getting the support you need. Call a midwife to discuss a flexible arrangement.

I have prepared the following information to explain how the services are broken down. Hospital and Home birth services are very comprehensive, and private 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 private midwifery 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 (no drinking, no weekends away ….)
Phone and email consultations
Research
Attending related appointments with clients (eg going with you while you have an ultrasound, seeing a doctor with you if your pregnancy is high risk)
Professional consultation with other professionals on the client’s behalf (eg midwifery consultation, medical consultation)

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 private / independent midwife for your pregnancy and birth, 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 my travel time and cut down consultation time – but I know that you’re after a service that really meets your needs, in your home, when you need it.

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 strive to provide a comprehensive service and stand by the quality of care that I provide. Women who book with me see the value in this approach. If I charged less, I simply would not be able to put the time and care in to your pregnancy and birth. Private midwifery for hospital or home birth is an investment in you and your baby, afterall. And you deserve the very best.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Crackdown on doctor rorts: IVF and Obstetrics

May 7th, 2009

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

Link to article

MEDICAL specialists will come under pressure to cut fees for some services – especially in obstetrics and IVF – under a plan in next Tuesday’s federal budget to crack down on rorting of the Medicare safety net.

Under the changes, patients charged excessive fees will have new limits put on how much they can claim back on the Medicare safety net. This could leave some people facing large out-of-pocket expenses for obstetrics, IVF… and some other services if they use high-fee specialists.

But the Government hopes its crackdown, rather than penalising patients, will instead put pressure on high-end specialists to moderate charges.

As an incentive to specialists to cut fees, the Government will increase the cap on its coverage of the services – in effect, raising the base level of its rebate.

… Since the advent of the safety net, fees have leapt by 290% for IVF and 40% for obstetrics – giving rise to claims that the system is being rorted.

… Areas targeted for cuts include artificial reproductive technology (IVF), obstetrics and varicose vein treatment, identified in a report into the scheme.

… The net will continue to cover 80 per cent of patients’ out-of-pocket costs once they reach the threshold – but only up to a new limit in “capped” areas.

… The review found that the safety net benefits were going excessively to some specialists.

For some obstetrics and IVF services, of every dollar spent on the safety net, “78 cents is going to providers and only 22 cents to reducing patients’ costs”, the review said. Providers knew patients were likely to qualify for the net and felt “fewer competitive constraints on their fees”.

Between 2003 and 2008, the average fee charged for planning and management of an artifical reproductive treatment cycle increased from $294 to $1148. The average obstetrics fee for planning and management of a pregnancy rose 40 per cent between September 2004 and 2008 – from $1238 to $1732.

Specialists’ incomes in these areas have soared. In 2008, the highest 10 per cent of IVF specialists were paid $4.5 million each through Medicare – including $2.2 million through the safety net.

In addition to providing incentives to moderate fees, the higher obstetrics medical benefits are also designed to give more incentives for obstetricians to practice in under-serviced areas …

It will be interesting to see the added effects if the changes proposed in the Maternity Services Review are implemented. Those changes will provide private midwives with the right to order tests, prescribe medications and bill through Medicare. In effect, women will have the choice of the public health system, a private obstetrician, or a private midwife. Private midwifery will no doubt be far cheaper for women than private obstetrics, and will confer greater benefits in terms of:
- lower rates of postnatal depression
- lower rates of birth trauma
- lower rates of intervention in pregnancy and labour, and lower rates of complications from said intervention
- higher rates of natural birth
- higher rates of breastfeeding
- higher rates of birth satisfaction from women
- less birth trauma for the baby
- lower rates of admission to special care nursery for the baby
- fewer antenatal (pregnancy) admissions to hospital
- more care provided in women’s homes than hospitals
- lower caeasarean, induction, epidural, episiotomy, forceps and vacuum rates
- higher rates of VBAC
- true continuity of care – even with private obstetrics, you are cared for by midwives you have not met before; with private midwifery, all your care is with the same midwife who you’ve chosen
- more choice and control in birth

Melissa Maimann, Essential Birth Consulting 0400 418 448

Vioxx maker Merck and Co drew up doctor hit list

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

Link to article

OK, so you may be wondering what on earth this article is doing on my blog. Well, it’s about Vioxx. And if you had a caesarean in the early 2000s, you may well have been prescribed this drug for pain management. I was always suspicious when a minority of hopitals I worked at prescribed this drug, as the majority of hospitals prescribed the more common frugs such as Voltaren or Nurofen for post-op pain relief.

Merck is the same company that claims to have the cure for cervical cancer in the form of the Gardasil vaccination. Many have reported side effects after using this vaccination.

AN international drug company made a hit list of doctors who had to be “neutralised” or discredited because they criticised the anti-arthritis drug the pharmaceutical giant produced.

Staff at US company Merck &Co emailed each other about the list of doctors … who had been negative about the drug Vioxx or Merck and a recommended course of action.

… It is also alleged the company used intimidation tactics against critical researchers, including dropping hints it would stop funding to institutions and claims it interfered with academic appointments.

“We may need to seek them out and destroy them where they live,” a Merck employee wrote …

Merck & Co and its Australian subsidiary, Merck, Sharpe and Dohme, are being sued for compensation by more than 1000 Australians, who claim they suffered heart attacks or strokes as a result of Vioxx.

The drug was launched in 1999 and at its height of popularity was used by 80 million people worldwide because it did not cause stomach problems as did traditional anti-inflammatory drugs.

It was voluntarily withdrawn from sale in 2004 after concerns were raised that it caused heart attacks and strokes and a clinical trial testing these potential side affects was aborted for safety reasons.

… Merck last year settled thousands of lawsuits in the US over the effects of Vioxx for $US4.85billion ($7.14 billion) but made no admission of guilt.

The company is fighting the class action in Australia.

The Federal Court was told yesterday that Merck wanted to gain the backing of researchers and doctors – or “opinion leaders” – in the fields of arthritis to help promote the drug to medical professionals when it was launched in 1999.

… internal emails … showed the company was not happy with what some researchers and doctors were saying about the drug.

“It gives you the dark side of the use of key opinion leaders and thought leaders … if (they) say things you don’t like to hear, you have to neutralise them,” he said …

The court was told that James Fries, professor of medicine at Stanford University, wrote to the then Merck head Ray Gilmartin in October 2000 to complain about the treatment of some of his researchers who had criticised the drug.

“Even worse were allegations of Merck damage control by intimidation,” he wrote, according to Mr Burnside.

… Mr Burnside told the court Dr Fries went on to describe instances of intimidation, including one colleague who thought his academic appointment had been jeopardised and another who received phone calls alleging “anti-Merck” bias.

… Merck had been systematically playing down the side effects of Vioxx and said the company’s behaviour “seriously impinges on academic freedom” …

“In every possible way the company exerted itself to present the impression to the world at large that Vioxx did not provide any increased cardio risk … when (a) it probably would and (b) it probably did,”…

Melissa Maimann, Essential Birth Consulting 0400 418 448

Breastfeeding debate revived after death of British mother Katy Isden

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

Link to article

THE death of a British mum in despair at not being able to breastfeed properly should well shock the world but will not surprise some mothers … Sitting among the flowers and cards, clutching her first-born child, my sister Lia could do nothing but sob.

Left alone in her hospital room and attempting to breastfeed her new daughter for the first time on her own, she felt her anxiety skyrocket, the mother guilt take over.

A broken emergency buzzer didn’t help, nor post-birth hormones and lack of sleep.

But almost two hours after she’d begun trying to attach her baby’s small mouth to her painfully engorged breasts, my niece was screaming and so was her struggling mum.

… Her experiences with the births of her next two children were equally traumatic, marred by a recurrent sense of inadequacy and in the case of her third, mastitis so bad she was forced to temporarily relinquish care of her family to seek medical help.

News, then, of the death of 30-year-old British mother Katy Isden, who fell to her death from a New York apartment block after becoming depressed over her bid to breastfeed, should well shock the world but will not surprise mothers with tales like my sister’s.

… “The pressure to breastfeed, the anxiety to be this super person, is just no way to live.”

The coroner said that although Mrs Isden had been depressed when she died, it was not clear if she fell or jumped. He therefore recorded an open verdict.

… The research about the benefits of feeding babies “naturally” – delivering vital nutrients and a bond between mother and child – appears black and white.

But for many it’s anything but a natural experience; rather a grey area of conflicting advice and a trauma that can torture women.

… there is no doubt support is the key to relieving the pressure.

Extra funding for the Australian Breastfeeding Association’s national helpline resulted in a 30 per cent increase in those seeking help since March, with more than 28,328 calls taken between October and April.

… “So many of us have issues,” she said. “This is a matter of seeking assistance, not being left to feel like a failure.

“The solution is for the community to get behind mothers rather than patronising them with the ‘breast is best’ slogan. It’s what’s best for you and your baby that counts, not breastfeeding at any cost.”

The ABA’s 24-hour helpline is 1800 Mum(686) 2 Mum (686)

Support is most definitely the key to successful breastfeeding, which is, without a doubt, the safest way to feed a baby – safest for mother and safest for baby. But I do wonder if we set women up to fail. Our current obstetric system churns women out as mothers who have “failed” even before they hold their baby for the first time. They “failed to progress” in labour, they were a “failed induction”, they had an “incompetent cervix”, they “failed to dilate”, their pelvis was too small. However you phrase it, the message is clear: women’s bodies don’t work; their bodies are broken. Is it any wonder that with this mindset in action, they also fail at breastfeeding?

To look at it from another perspective, breastfeeding can be effortless and enjoyable. If we look at what goes on in birth, before the breastfeeding experience, we see that a relaxed and healthy breastfeeding experience is correlated highly with a natural birth (no induction, no epidural, no caesarean etc). If you like, natural birth primes mother and baby for breastfeeding. Maybe we’re expecting too much of mothers and babies to breastfeed successfully after their induced, pethidined, epiduralised, and surgically-extracted birth. Babies are traumatised by their birth experience, as are mothers. The cocktail of natural hormones that lights the path for a successful breastfeeding experience is grossly absent. Not just absent, but the very hormones that are the anti-dote to the natural-high-hormones, are present in ever-abundant quantities.

Women report feeling a disconnect with their baby when they meet their baby for the first time after a labour and birth that has been marked with various interventions. They report not bonding. That they really had to work at the relationship with their baby. And some women even resent their baby. All of this is very uncommon after a natural birth without drugs, induction, epidural, forceps, episiotomy and of course caesarean.

The best way to achieve a natural birth is to choose a care provider who specialises in natural birth. Currently, we have 2 types of maternity care providers: midwives and obstetricians. Obstetricians are surgical specialists. That may come as a surprise for some! But it’s true: obstetrics is not a medical specialty. It’s a surgical specialty. Obstetricians, on the whole, do surgery. And most do it very well. Thankfully!! Midwives on the other hand, are natural birth specialists. We’re trained in recognising normal, keeping pregnancy and labour normal, and in getting help when things are no longer normal. If you see a midwife and have a natural birth, you’re highly unlikely to ever have the issues with breastfeeding that are described in this article. Not to mention, if you did have problems with breastfeeding, your private midwife would be following you up for 6 weeks after your baby is born, so you would have a midwife on the end of the phone, 24/7 who knows you well, who has known you the whole of your pregnancy. The continuity of care provided by a private midwife is known to reduce breastfeeding complications and postnatal depression, whether you birth at home or in hospital.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Do women prefer caesareans?

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

Link to article

Study results suggest that women do not really see decision-making about birth method as their “choice” and challenge the notion of choice currently prevalent in international debates about cesarean delivery for maternal request (CDMR).

CDMR is currently perceived as a leading reason for increasing cesarean section (CS) rates by obstetricians worldwide.

… study researchers explored the views and experiences of 454 primigravid women accessing National Health Service maternity care to analyze decision-making surrounding birth method.

In total, 72 percent of the 397 women who returned their questionnaires reported that they would prefer to give birth vaginally, while only 3 percent reported a preference for planned CS.

By late pregnancy the proportion of women expressing a preference for CDMR declined to 2 percent, while those reporting a preference for vaginal birth increased to 80 percent. Furthermore, only one woman out of 454 women consistently expressed a preference for planned CS.

… Moreover, women accepted that their actual birth method would be determined by the circumstances of their pregnancy, and questionnaire responses indicated that over 55 percent of women believe their right to choice should be overridden by healthcare professionals.

Carol Kingdon (University of Central Lancashire, Preston, UK) and co-authors recommend, in light of the study findings, that birth options should be revisited and discussed at different time-points throughout pregnancy.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Low birthweight, preterm delivery linked to occupational factors

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

Link to article

Study findings suggest that exposure to occupational factors such as a temporary work contract, long working hours, shift work, and physical demands during pregnancy increase the risk for low birthweight and preterm delivery.

… Physical work demands significantly predicted low birthweight (≤2,500 g), while having a temporary contract predicted preterm delivery, with corresponding odds ratios (OR) of 4.32 and 4.58, respectively.

Working long hours or doing shift work were associated with a birthweight of 3,000 g or less, but not significantly.

… “This study underlines that more attention should be given to women’s working conditions during pregnancy,” said lead study author Isabelle Niedhammer (University college Dublin, Ireland).

Melissa Maimann, Essential Birth Consulting 0400 418 448

Is Medical Advice On Prenatal Alcohol Use Really Accurate?

May 3rd, 2009

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

Link to article

… when [alcohol] consumption is reasonable and moderate, studies still do not conclude that it can cause harm to the developing fetus according to Colin Gavaghan, of the School of Law at the University of Glasgow.

Regardless of lack of new evidence, the UK government and the BMA changed their recommendations radically in 2007, advising total abstinence during pregnancy.

Nonetheless, a year later, the National Institute for Health and Clinical Excellence (NICE), and researchers from The University of London claimed that there was no support of proof of damage, as long as women drank no more than one or two units per week.

The investigation even established that the children of mothers who drank moderately during gestation had fewer behavioral and developmental problems than those whose mothers abstained entirely.

Interesting research!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Breast Is Best

May 3rd, 2009

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

April 23, 2009 (Pittsburgh, Pennsylvania) — Women who breast-fed for a year or more were less likely to develop hypertension, diabetes, hyperlipidemia, and cardiovascular disease when postmenopausal than women who were pregnant but never breast-fed …

“We were able to show that benefits were visible in anyone with six or more months’ lifetime duration of breast-feeding,” Schwarz told heartwire , with those who reported a lifetime history of more than 12 months’ lactation being 10% to 15% less likely to have hypertension, diabetes, hyperlipidemia, and CVD than those who never breast-fed.

… the findings … build on a growing body of literature that demonstrates lactation has beneficial cardiovascular effects, as well as reducing the risk of breast and ovarian cancer. “We’ve known for years that breast-feeding is important for babies’ health; we now know that it is important for mothers’ health as well,” she notes.

“… It is imperative that healthcare providers and our society support and educate women concerning the maternal benefits of prolonged breast-feeding as well as the well-documented benefits of breast-feeding for the child.”

The Risks of Not Breast-Feeding
The study examined 139,681 women enrolled in both observational and clinical-trial cohorts of WHI who had had at least one live birth. The dose-response relationship between the cumulative months women lactated and postmenopausal risk factors for CVD were examined; the average age of the women was 63 years. Lifetime duration of breast-feeding was based on patient recollection, and Schwarz admitted this could have been subject to recall bias, a point that Newton also makes in his editorial.

In fully adjusted models, those who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension (odds ratio 0.88; p<0.001), diabetes (OR 0.80; p<0.001), hyperlipidemia (OR 0.81; p<0.001), and CVD (OR 0.91; p=0.008) than women who never breast-fed, but they were not less likely to be obese. In models adjusted for all of the above variables and body-mass index (BMI), similar relationships were seen.

And women who breast-fed for seven to 12 months were also significantly less likely to develop CVD (hazard ratio 0.72) than those who never breast-fed.

Schwarz said: "We saw significant trends; the longer someone had breast-fed, the better." In his editorial, Newton says that prior analyses from the Nurses' Health Study show that women who breast-fed for a lifetime total of two years or more significantly reduced a major predictor for CVD--insulin-resistant diabetes--by 14% to 15% and had a 23% lower risk of incident MI.

We can talk about the benefits of breast-feeding but perhaps it is better framed as the risks of not breast-feeding.

Schwarz stressed an important point to heartwire . "It's not that you are better off if you have a baby and breast-feed than someone who's never been pregnant, it's that you are better off than someone who becomes pregnant and does not breast-feed. A woman who becomes pregnant and does not breast-feed is actually putting herself at risk. So we can talk about the benefits of breast-feeding but perhaps it is better framed as the risks of not breast--feeding."

... "Women put themselves at risk by becoming pregnant and not fulfilling the cycle that nature has intended," Schwarz says. "In my mind, the cycle really ends with breast-feeding. During pregnancy, the body stores up a bunch of nutrients with the plan that it's going to release much of this in the form of breast milk, a very calorific food. If this doesn't happen, what we see is that the woman's body pays the price. Breast-feeding really helps bring you back to your baseline, and it helps women recover from the stress test that pregnancy entails."

... "the antistress, probonding effects of oxytocin and intense skin-to-skin contact found with prolonged breast-feeding certainly contribute to the protective effects," he notes.

Although Bairey Merz acknowledges the findings were adjusted for BMI, she says it is well known from many studies "that women who breast-feed lose the pregnancy weight gain better than those that do not--and this likely contributes to their lower CVD risk. What we do not know is whether breast-feeding preferentially impacts the visceral fat deposits, which would be of specific benefit and should be the focus of research."

"A more intense and focused study of maternal physiology during lactation may give us critical information to limit the scourge of CVD in women," Newton concludes.

Melissa Maimann, Essential Birth Consulting 0400 418 448

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