Monthly Archives: June 2009

New York Times Examines Maternal Mortality, Abortion In Africa

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Focusing on Tanzania, the New York Times examines maternal mortality and abortion access in Africa. According to the New York Times, “[p]regnancy and childbirth are among the greatest dangers that face women in Africa, which has the world’s highest rates of maternal mortality – at least 100 times those in developed countries. Abortion accounts for a significant part of the death toll.”

Data from the WHO shows that the estimated 19 million “unsafe abortions” each year around the world kill 70,000 women annually and account for 13 percent of maternal deaths worldwide. More than two million women have serious abortion-related complications. Although reliable Tanzanian abortion statistics are “hard to come by,” the WHO reports that its Eastern African region has the “world’s second-highest rate of unsafe abortions,” the New York Times reports.

“In most countries the rates of abortion, whether legal or illegal – and abortion-related deaths – tend to decrease when the use of birth control increases,” according to the New York Times …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Even best hospitals not immune from birth trauma

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The case of Eric Victor Cojocaru, a now-seven year-old boy born with severe brain damage and permanent physical disabilities, is a tragic reminder that there are risks associated with childbirth, even at a medical facility with the sterling reputation of BC Women’s Hospital.

Childbirth seems miraculous to most of us, but it is not mistake-proof. Untoward events happen and bad outcomes are the result.

Last month, Justice Joel Groves of the B.C. Supreme Court, awarded the boy and his mother, Monica Cojocaru, just over $4 million in damages after finding the hospital, three doctors and a nurse negligent. The hospital and health professionals have filed a notice to appeal.

In his decision, the judge said:

“Tragically, Ms. Cojocaru did not receive the care she should have. … While in a situation of being virtually unsupervised, although a high-risk patient, her uterus ruptured and hemorrhaged and her son … suffered acute asphyxial insult.”

The judge found that the obstetricians did not find out from her former doctor in Romania the orientation of a scar Cojocaru had from her previous caesarean section delivery. If they had got that information from the operative report, they would have realized that she had had a previous C-section with a vertical uterine incision, and she was unsuitable to risk a vaginal delivery.

… Birth trauma is defined as injury to newborns that may be anything from a minor bruise or laceration to a major brain or skeletal injury occurring during delivery.

… In an attempt to bring down the c-section rate in the last decade, doctors have determined that a previous C-section may not preclude the more “natural” vaginal delivery for subsequent births. So women who fit a low-risk profile may be offered a chance at labour in the hopes that they can experience childbirth without surgery and the potential risks that go along with it.

The national average for caesarean births is 25.6 per cent.

Classical (vertical) uterine incisions do carry a high risk of uterine rupture, and therefore women who have had a previous classical incision are advised to have an elective repeat caesarean for future births.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Is maternal-choice caesarean section a symptom of a broken system?

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I have been reading the June 09 issue of “Women and Birth: Journal of the Australian College of Midwives”. This is Australia’s national midwifery peer-reviewed journal.

There is an article entitled “Swedish Caregivers’ Attitudes Towards Caesarean Section on Maternal Request”.

I was astounded to see that the CS rate in Sweden was a mere 17.7% in 2006. Contrast this with Australia’s rate of 31% in 2006! Swedish midwives and obstetricians who were interviewed for this study displayed a conflict between resistance and respect of the woman’s decision for maternal-choice caesarean.

The Context of Swedish Maternity Care

Antenatal care in Sweden is organised within the public primary health care system with the midwife as the primary caregiver, taking care of all pregnant women in a certain geographical area during pregnancy. Care during labour, birth and the postnatal period occurs in hospitals with midwives as the independent caregiver for uncomplicated cases. Midqives work in collaboration with obstetricians if complications occur. There are no alternative birth settings in Sweden and continuity of caregiver between episodes of care is rare.

Formally, caesarean section is not an option women can choose themselves. The obstetrician has to be convinced of the need to perform surgery without a medical indication. The majority of obstetric departments in hospitals have established qualified teams who provide support for women who suffer from childbirth-related fear. If a woman wishes to have a CS, she is referred to such a team before she meets the obstetrican for the final decision.

Several things interest me about this system.

There is no private system. No private hospitals, no private obstetricians, and no private midwives. There are no birth centres. Why do we have such a range of options in this country? On the surface, it may seem logical to believe that since all women are different, they have different needs, and hence we need many options to try to keep most women happy. But are most women happy with the birth options that are open to them? Unfortunately, I’d have to say the answer is no. Sure, we have some birth centres and some midwifery models of care, we have private obstetrics or midwifery and so on, but since all of these options are not available to every woman, in some ways I think this creates even more dismay about current options.

So, we have lots of options, presumably because women are all individual and want different things. But are women happy with the current services? I’d say a resounding no. I would also challenge the opinion that women are all individual and want different things out of their maternity care. I think women all want the same thing, when push comes to shove. They want continuity of care, from someone they know and trust. They want input into their care, they want to be a part of the decisions that are made. I think the reason we have so many options in this country is that each option is woefully inadequate. Each successive option is an attempt to patch-up the broken maternity health care system. I think the more options we have, the stronger this argument is. We have birth centres because hospital delivery suites are too clinical and cold …. and most will not “allow” water birth. We have homebirth midwives because birth centre inclusion criteria are too strict or because women want consinuity of midwifery care. We have private hospitals because some public hospitals look too worn and uncomfortable to birth in. And sometimes the food leaves a lot to be desired! We have private obstetricians because women wish to know the doctor who will attend them should anything go “wrong”. And so on.

What is we simply fixed the system???

Sweden recognises and protects the role of the midwife as the primary care provider for well, healthy women. And it recognises and protects the valuable input of obstetricians when things deviate rfom normal. In this manner, they no doubt have a much larger midwifery work force, relative to the obstetric workforce that we’d see in the metropolital areas on Australia. And no doubt a more appropriate use of midwifery and obstetric resources.

Sweden provides support for women who fear birth. This is only available privately (psychology) in this country, although some hospitals also offer social work services for women who fear birth. What a great system to have in place, that women who fear birth are referred for psychological help. Afterall, do doctors routinely place colostomies in people if they fear defecation? If not, then why do they perform caesarean sections on women who fear birth?

I believe the changes that are suggested as part of the budget and the maternity services review will go a long way to reform maternity care in this country. Women will be able to access a private midwife as their primary care provider, with access to an obstetrician if needed. Birth will be in hospital or birth centre. If home birth is desired, this option will not be funded by medicare or insured – much the same as our current situation.

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Aggressive Neonatal Care Improves Extreme Preterm Survival

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Even extremely preterm infants have a high likelihood of survival today in settings with active perinatal care, a large Swedish study has found.

… Among 707 infants born before gestational week 27, some 91% were admitted to neonatal intensive care units and 70% survived to one year …

The overall perinatal mortality was 45%, and ranged from 24% among infants at 26 weeks gestation to 93% at 22 weeks …

Preterm births have been increasing worldwide, and advances in perinatal medicine have been saving some of the most immature infants, but uncertainties remain about survival rates, developmental difficulties, and high costs.

… Of 305,318 total infants born, 1,011 arrived before week 27, for an incidence of extreme prematurity of 3.3 per 1,000 infants.

A total of 707 babies (70%) were live born, while 304 (30%) were stillborn.

There were 102 multiple births (11%).

… 7% of the pregnancies resulted from in vitro fertilization.

Clinical complications such as preeclampsia or antepartum hemorrhage occurred in 36% of the pregnancies.

A total of 210 live-born babies (30%) died before one year, including 152 (22%) who died during the first week of life. Of those who died, 8% died in the delivery room, and 5% died between days 7 and 27, the investigators found.

… an increased risk of death was associated with the infant being small for gestational age (OR 1.69, 95% CI 1.12 to 2.58, P=0.04) or a multiple birth (OR 1.70, 95% CI 1.04 to 2.77, P=0.01).

Among the infants who survived for at least 24 hours and were born at 22 weeks, the chance of one-year survival was lower than for those born at 23 or 24 weeks (OR 0.22, 95% CI 0.06 to 0.71, P=0.01).

Those infants, in turn, had a lower survival rate than those born at 25 or 26 weeks (OR 0.50, 95% CI 0.32 to 0.78, P=0.002), according to the investigators.

Overall survival at one year was:
10% for infants born at 22 weeks
53% for those born at 23 weeks
67% for those born at 24 weeks
82% for those born at 25 weeks
85% for those born at 26 weeks

… factors the investigators identified as being associated with a lower risk of death were:

Antenatal tocolytic treatment (OR 0.60 … )
Antenatal corticosteroid treatment (OR 0.41 … )
Surfactant treatment within two hours after birth (OR 0.48 … )
Birth at a level III hospital (OR 0.78 …)

Cesarean delivery, however, was not associated with a lower risk of death (OR 0.98 … ).

… The findings of the study highlight the improvements in survival among extremely premature babies since a previous cohort of 931 Swedish babies born between 1990 and 1992 at less than 1,000 grams was studied.

… Aside from a more interventional approach, egalitarian Swedish health policies also may have helped in the increased rates of survival, with adherence to antenatal care programs being nearly universal.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mums charged $20,000 to give birth in hospitals. Private Midwifery: affordable, safe, respectful

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WEALTHY expectant mothers are being charged as much as $20,000 to give birth in private hospitals.

An investigation by The Daily Telegraph reveals NSW is home to some of the most expensive obstetricians in the country, with some women paying more simply because of where they live.

The revelation comes as the state’s chief obstetrician Dr Alec Welsh revealed many of his colleagues appear to have jacked-up up their fees in order to milk the taxpayer-funded system.

Dr Keith Hartman – considered the obstetrician to the stars – charges $9345 for his services.

That makes Dr Hartman … one of the most expensive obstetricians in the country.

And if an expectant mother chooses to have Dr Hartman and give birth at Sydney’s top private hospital, Mater Hospital at Crows Nest, she could be hit with a bill of more than $20,000.

Mater Hospital is the birth place to many wealthy celebrity bubs, including Indigo Packer and Cate Blanchett’s three sons.

… where you live can determine how much you are charged for a private obstetrician.

In Penrith, Dr John Pardy charges more than $3000 while in regional areas such as Orange the average fee is about $1200 to $1400.

The Federal Government has just ordered a crackdown on skyrocketing fees by changing the amount women can claim back through the safety net.

It hopes by doing this doctors will either lower their fees or women will chose a cheaper option.

Private midwifery provides this option. Fees range between $4000 and $5000 in Sydney, and private midwives do not charge more simply because women live in a wealthy suburb. Whereever you live, you are assured the same high quality care and service, all in your home, at a time that suits you. Private health insurance benefits may apply, and services qualify for the net medical expenses tax off-set. Private midwifery is available for home or hospital birth.

But Australian Medical Association’s newly elected president Dr Andrew Pesce, who is also an obstetrician, believes the Government’s reforms don’t go far enough.

“I believe the Government didn’t estimate for the majority of women who are seeing private obstetrician who will be worse off under the funding arrangement,” he said.

“Some women will not meet the threshold of $1100 and they won’t get a single cent back.”

So this, in effect, provides women with a financial dis-incentive to have private obstetric care. is this such a bad thing, if healthy pregnant women are forced to consider other options that are actually safer for them, such as midwifery care? Maybe it will go a long way in reducing the country’s disgraceful record of medical intervention, most of which is unjustified.

Obstetrician fees increased by 16.2 per cent between 2006 and 2007 – from $1088.55 to $1264. By July 2008, the average fee was $1980.

The dramatic increase in costs means that Medicare is now paying three times as much in fees per private birth as it was a decade ago. It was $721 per birth in 1997-98 compared with $2357 per birth in 2007-08.

Women’s advocacy group What Women Want organiser Justine Caines said unless the birth was considered high risk, there wasn’t much difference in the services offered.

I love Justine, but I disagree with this comment. Private midwifery care means all care in your home. Consultations are 1 to 2 hours long. And the midwife isn’t just called for the birth – maybe making it, maybe not. The midwife is there throughout the labour, birth and early postnatal period. It’s true continuity of care. I calculated that the average private midwifery service may include 86 hours of care. Name an obstetrician who provides this level of care.

“Sometimes you don’t even get your obstetrician that you paid thousands for at your birth because he/she isn’t working that late at night or weekend,” Ms Caines said.

“All women should have choices and we are not criticising if a woman decides she wants an obstetrician.

… While obstetricians are cagey about their fees, one leading specialist has spoken out about the exorbitant costs.

NSW chair of the Royal Australian and New Zealand College of Obstetrician and Gynaecologists Alec Welsh said he wondered whether obstetricians would “fix their fees at the same level” if they knew the Medicare Safety Net was covering the majority.

“If a private practitioner feels their skills are worth a certain amount, that’s fine but I don’t think that should necessarily come from a national purse and that’s particularly at a time when the hospitals are struggling,” he said.

Professor Welsh, a strong advocate of the public system, is also head of a program at RHW in which midwives are in control of low and medium risk births – a necessity caused by a shortage of obstetrician in the public sector.

And no doubt demand for services that are woman-friendly, that give women a sense of control, and that allow women to have a known midwife with them the whole way through their pregnancy, birth and postnatal period.

“It’s very hard for us to fill public hospital specialist positions, even with some of the major teaching hospitals in Sydney, because from the perspective of personal remuneration the alternative is so attractive,” he said.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Many mums smoke through pregnancy

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The research is published in the Australian and New Zealand Journal of Public Health

Many Australian women who smoke don’t quit during pregnancy … and when they cut back it’s only by a couple of cigarettes a day.

… 37 per cent of the women were smokers before they fell pregnant, and this declined to about 25 per cent once they became aware of their condition.

Those who continued to smoke … reduced their intake from an average of 16 cigarettes a day to 13.

Smoking during pregnancy increases the risk of miscarriage, and a host of health problems for the baby linked to an increased risk of premature birth and low birth weight.

… The study also found that more than 40 per cent of women in the study were overweight or obese, they consumed half the recommended serving of fruit and a third of the recommended serving of vegetables.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Blood loss from caesarean was mistreated

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REBECCA MURRAY was chatting to her husband and doctor less than an hour after delivering a healthy baby girl by caesarean section.

Twenty minutes later her blood pressure dropped so low that her condition qualified as a medical emergency. Within hours she suffered cardiac arrest. The following day she was dead.

The rapid decline of the 29-year-old mother was compounded by a catalogue of oversights by nursing and medical staff, an inquest into her death heard yesterday, and should not have ended in her death.

Ms Murray had an emergency caesarean at Bathurst Hospital in June 2007 after her waters broke while the baby was in breech position.

… postpartum haemorrhage was a known complication of vaginal and caesarean births and severe cases occurred about once a week in major hospitals across Western Sydney.

Here we see a situation where one set of risks are substituted for another. Would the outcome have been the same if this woman was “allowed” to start labour spontaneously and birth her breech baby vaginally?

Melissa Maimann, Essential Birth Consulting 0400 418 448

Factors to Consider before Birthing Your Baby

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Deciding between a home and hospital birth is a difficult decision for some couples. Although a general perception exists that hospital births are safer than homebirths, this is actually not the case. An additional factor to consider is the general philosophical framework in which birth is placed in each setting. Most homebirth midwives consider labor and childbirth to be a normal natural process; many doctors view childbirth as an event they must control in order to avoid catastrophe. When problems do arise at a homebirth, midwives are prepared to deal with them, and they know when hospital interventions are necessary. But the vast majority of births, when they are allowed to unfold physiologically, are straightforward and considered normal at the very least, if not beautiful and sacred by homebirth midwives.

If the mother`s contractions pause briefly after she reaches full dilation and before an urge to push materializes, most midwifes recognize that this is a common and normal part of birth … If during pushing the baby appears to retreat some in the birth canal after each push forward, the midwife recognizes this as a dance of two steps forward, one step back that is more likely to result in an intact perineum for mom (no tearing). The burning sensation experienced by the mother during this phase also keeps the pace in check and protects the perineum. After birth, the baby`s umbilical cord is usually only cut after it visibly stops pulsing – when it has shunt all of the baby`s blood back into his body.

At the hospital, in general, any pause in labor is considered cause for concern, not for rest. During pushing, the faster the fetus emerges the better. Burning pain? No problem. This can be eliminated by a local anesthetic, sometimes without the mother`s consent. After birth, the cord may be cut as soon as possible in order to speed up the delivery of the placenta, as many doctors pull on the cord or inject Pitocin into the mother to hurry the afterbirth along. The focus on speed and the air of emergency can render the atmosphere of many hospital births as pathological rather than as a sacred initiation of life.

Not all hospital births proceed as described above, and many doctors … respect birth and the process of childbirth. Expectant moms should try to be sure that they and their care providers share similar visions of what birth should be.

The most important determinant of your birth outcome is the care provider you choose and your place of birth.

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AMA Conference: Nicola Roxon

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Nicola Roxon’s opening address at the AMA conference

Maternity Services

It is also the patient – especially the mother and child – we had in mind with our maternity services package as well.

The Government conducted a review of maternity services headed by the Chief Nurse and Midwifery Officer, Rosemary Bryant and the budget changes respond to that review.

As a result we will allow eligible midwives to write PBS scripts, and make their services eligible for Medicare rebates. This is a key plank of our $120.5 million maternity services reform package. In addition, we will support indemnity insurance for midwives working in collaboration with doctors. Something I imagine you will support, given the similar role played by the government when medical indemnity insurance was having some challenges.

Again, I stress this will be a collaborative relationship. We want the support of midwives, GPs and obstetricians in implementing this reform. We are about improving collaboration and teams – not setting up competing structures.

… Again, this change is about sustainability and choice and putting the needs of the patient first …

Reason for tough Budget decisions

So, as you can see, our workforce, rural and maternity packages are all about improving access to quality care for patients – no matter where they live …

But it’s also about sustainable access. We want to lock in investments for the future. We don’t want positive reforms or useful programs threatened because costs are spiraling elsewhere in the system without delivering benefits.

That’s also why we have also made tough decisions in the budget to improve affordability and fairness. It is in no-one’s interests, least of all the patient, if Medicare expenses get out of control. So we have made decisions that some of you won’t like – nevertheless I’d like to take the time to explain them and I’m confident you will see the logic of doing so.

Medicare Safety Net

For example, our changes to the Medicare Safety net ensure every single item that is currently eligible, remains eligible …

The changes are to introduce a cap to the amount that can be claimed in a number of areas that have fallen prey to some excessive fees.

An independent review of the Safety Net found that for every dollar spent in 2007, as much as 78 cents went direct to the specialist’s wallet, rather than reducing patients’ out pocket costs. Now while that might be good news for a few of your team – you can easily understand why it makes everyone else jumpy.

Cancer specialists, for example, feared we would make changes affecting their patients when the safety net has been very effective in reducing their costs. Because of this and because there was no evidence of a spike in fees – we introduced no caps in cancer at all.

But excessive medical fees and profits were evident in a few areas – obstetrics, Assisted Reproductive Technology, injection of therapeutic substances into the eye, hair transplants, and varicose vein treatment.

In these areas, we are imposing a cap on the benefits which are payable under the Medicare Safety Net, from January 2010.

If reasonable fees are charged, patients will continue to be supported by Medicare and the safety net, but if the charges continue to be excessive then taxpayers will not be picking up the cost. We hope the high end chargers will chose to moderate their fees, but if they don’t we’ll be asking patients to vote with their feet – and go to specialists who charge sensibly. This will benefit not just them, but all taxpayers.

It will mean change – but it will ensure publicly funded services remain viable.

Medicare should always put the patient, not the specialist, first.

We believe these changes strike the right balance between reasonable costs incurred by specialists, and affordability for taxpayers…”

Melissa Maimann, Essential Birth Consulting 0400 418 448