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November, 2009:

Women to be mothered over baby plans

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… Health authorities keen to prevent birth defects and pregnancy complications that can arise from obesity, diabetes and poor lifestyle and nutrition habits will offer the advice in new state-government-funded clinics.

An experienced midwife will run the PLaN (preconception, lifestyle and nutrition) clinics.

A trial clinic opened at the Royal Hospital for Women in Randwick … the scheme has now been expanded to … Sydney Hospital.

Women … can have consultations by phone …

“They may need to have some blood tests, then sort out … weight loss,” … “… can we make sure they’re taking vitamins, taking folic acid before they get pregnant?

… If their BMI was above 30 … they may be referred to a dietitian.

Women would also be advised to quit smoking and drinking … and take folic acid to reduce the chance of having a baby with spina bifida …

… ” … increasing numbers of people are looking to have children and this service aims to help put them on a path to a healthy pregnancy before they conceive,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women Miscalculate Time to Full-Term Birth

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I don’t agree with the suggestion that it is women who miscalculate the time to full term. While some may believe that a baby is “full term” from 37 weeks onwards, it is the obstetrician who agrees to the induction or caesarean prior to 39 weeks. I’m not comfortable with the implication that if a baby is born electively prior to 39 weeks, that it is the woman’s fault.

… the rate of preterm deliveries continues to climb … a new study suggests one reason … many women are confused about what constitutes a full-term birth …

… one-quarter of new mothers surveyed … considered a baby born at 34 to 36 weeks of gestation to be full term, while slightly more than half of women considered 37 to 38 weeks full term.

Though technically speaking, preterm births are babies born prior to 37 weeks, 39 to 40 weeks is optimal …

Many women interviewed were also unaware that babies born even a little bit premature are at a higher risk of serious health problems compared to babies born at term …

… “The data is becoming more and more clear that the outcomes of births at those earlier gestational ages are not as good as babies that are born at 39 or 40 weeks.”

… any delivery short of 39 weeks puts a baby at higher risk of respiratory distress, sepsis… and needing to be placed in the neonatal intensive care unit …

… the percentage of babies born preterm rose by more than 20 percent from 1990 to 2006 …

… the World Health Organization … defines preterm births as babies born before 37 weeks. But that definition … is outdated … studies have shown that babies born … at 37 or 38 weeks have a greater chance of chronic respiratory disease and learning disorders than children born at 39 weeks or later.

Babies born between 34 and 37 weeks are six times more likely to die during their first week or life and three times more likely to die during their first year than babies born at 39 or 40 weeks …

… The last few weeks of gestation are critical to fetal development. All of the organs continue to mature in preparation for moving from the womb to the outside world … between 35 and 40 weeks, the fetal brain grows by about 50 percent …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Right to Homebirth Threatened in Australia

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Homebirthing is a common phenomenon in most parts of the world, but in Australia, fears surrounding the process are threatening its acceptability.

In New Zealand, Canada, the UK and the Netherlands, giving birth at home is a reasonable choice, supported by both governments and insurers.

In Australia, however, the choice is threatened by proposals from Health Minister Nicola Roxon to leave midwives without insurance or funding to assist home births.

The curbing of that choice started last year when Ms Roxon initiated the Maternity Services Review and announced Medicare funding for midwives in the 2009 budget. In conjunction, she proposed the National Registration and Accreditation Scheme (NRAS) legislation, which would require health professionals to hold indemnity insurance so as to safeguard consumer safety.

… the great omission in her proposal was homebirth midwives, who were not offered funding or indemnity insurance … In effect, this would condemn homebirth midwives to operate illegally if they wanted to continue delivering babies.

… Gary Hastie, who has delivered all four of his children at home while supporting other home birthers, believes homebirthing “is the most natural process for the woman”.

However, he has observed an increasing fear of home births, distrust of a woman’s ability to have a natural birth and a demonisation of … woman’s choice. “It’s a woman’ right to choose where and how and with who she gives birth,” he said.

Nicola Roxon says she supports women having a choice, but is concerned with the consumer and ensuring a system of registration. It is “about lifting standards and ensuring that people are both registered, accredited and insured,” she said.

… Dr Ted Weaver, says it is not only the size of Australia that is a problem, but also cultural differences. “The infrastructure in other countries is completely different from the infrastructure in Australia–these countries have a tradition of home birth.”

Dr Weaver said the biggest danger lies when women get transferred to a hospital after complications arise …

Doubts are expressed too about how qualified Australian midwives are. Dr Weaver says: “Their [overseas] midwives are better trained and act along more stringent guidelines, and the selection for home birth is much more rigorous than in Australia.”

… While most high-risk women will be referred to a hospital by a midwife, … a very small portion of these women who consciously choose home birth … if they are considered “high risk”. “High risk” includes women who are having twins …

Many women, including those considered “high risk”, do not want a hospital birth, which is considered high intervention and impersonal …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Doctor gets jail after newborn is disabled

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A … doctor who caused a newborn … to suffer serious permanent disabilities was yesterday jailed for a year and fined …

The doctor was convicted of practicing midwifery without a licence and conducting a delivery though she was not qualified to do so …

The … hospital where the doctor worked was fined … for appointing her and making her work as a midwife though it was known that she did not have a licence. The hospital … failed to provide first-class healthcare for newborn babies and this caused the girl’s complications to grow worse, resulting in the disabilities.

… The newborn suffered complications during the delivery as a result of medical malpractice … This led to the baby … suffering … brain paralysis and quadriplegia.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Big girth? Then you can’t give birth

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NHS chiefs have banned mums-to-be from giving birth at their hospital if they are too fat.

The hospital’s maternity unit is only suitable for low-risk births …

Any [women] with a BMI … over 34 will be turned away … “Our foremost concern is for the safety of mothers who deliver here … Mothers with a high BMI are at increased risk in labour …

… 18 per cent of the population are obese.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Nursing mothers to get more support in ‘breast is best’ push

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MOTHERS will be encouraged to feed their babies only breast milk for the first six months as part of an ambitious new national breastfeeding policy.

The goal would require a huge rise from present norms under which only 14 per cent of mothers fully breastfeed their babies to six months. Nearly half of mothers have abandoned reliance on breastfeeding only after three months.

Federal and state health ministers yesterday endorsed the strategy which calls for more community acceptance of breastfeeding in public, more support and training for mothers before and after delivery and increased access to parental leave.

… “considering over a quarter of Australians think that breastfeeding in public is unacceptable, we know there is a long way to go,” …

She welcomed the recommendation for more support for mothers to begin breastfeeding by placing newborn babies in skin-to-skin contact with mother immediately after birth. Too often babies were taken away for jabs and checks after delivery, at odds with newborn babies’ ”extraordinary capacity to find the breast, attach and feed”.

Support for workplaces to adapt to the needs of breastfeeding mothers was also essential …

The Health Minister, Nicola Roxon, said … ”… all of the evidence shows breastfeeding children for a longer period of time than is common in Australia has enormous health benefits both for the child and for the mother.”

The breastfeeding strategy for 2010-15 also aims to increase the numbers of mothers who continue breastfeeding their babies and supplementing with solids for 12 months and beyond …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Public versus private delivery

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CHOOSING a private hospital over public is, on average, four times more expensive but you’re likely to be rewarded with a longer stay, better food and a room to yourself.

… the average out-of-pocket cost for delivering in a public hospital is $747, compared with $3087 in the private system.

A few women who delivered as public patients in public hospitals … did not pay a cent and many paid less than $300.

The average stay in a private hospital is 1.6 nights longer for vaginal births and 1.1 nights longer for caesareans.

… public hospital mothers are much more likely to complain that they were discharged from hospital too early – 28 per cent for public, compared with 12 per cent for private.

… concerns over understaffing are almost as common in private hospitals as in the public sector.

… private hospitals scored an average satisfaction rating of 91 per cent … compared with 87 per cent for public hospitals.

… private hospital patients were much less likely to have to share a room with another mum, and more likely to be able to have their partner stay.

While many women choose to go to a private hospital to have the baby delivered by an obstetrician rather than a midwife, one in 11 found their obstetrician did not end up delivering the baby …

Food was a stand-out difference, with 42 per cent of private hospital mothers rating the food as excellent, compared with 12 per cent of public hospital mothers.

I’m disappointed that this article emphasises the “frills” of private hospital care, rather than the clinical care issues and intervention rates. It does not surprise me that understaffing is perceived to be the same in pubic and private hospitals, as private hospitals are run like businesses, with staffing being the main business expense.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Protests demand maternity care choice

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Thirty supporters of maternity care choice staged a sit-in inside the Lismore office of local federal MP Janelle Saffin on November 9. They said the federal government must end plans to require independent midwives to have indemnity insurance.

… the changes restrict women’s choice in maternity care because private insurers and the government have ruled out providing midwives with insurance for non-hospital births.

In response to these moves, a campaign in support of maternity care choice has sprung up, including a 3000-strong convergence on federal parliament on September 7.

… A government review is expected to introduce Medicare rebates for some midwifery services. However, … amendments … will require midwives to make “collaborative arrangements” with medical practitioners to qualify for rebates …

… “In Holland, the option of … homebirth is the choice of around one third of expecting mothers”, she said. “A recent major study showed no differences in adverse outcomes between home and hospital births …”

O’Driscoll said: the “campaign is an important part of the struggle for women’s rights and for a health system that puts people before profit”.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Faithful Mothers Have Healthier Babies

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… pre-eclampsia … was found to be less common in women who had long-term sexual relations exclusively with the biological father, than in those who had been with their partner only for a short time …

… women who had undersized babies … were also more likely to have been in shorter relationships …

… “in normal pregnancies … prolonged exposure of the female immune system to paternal antigens following intercourse … [could induce] tolerance of the maternal immune system to the paternal antigens. But the exaggerated maternal inflammatory response in pre-eclampsia is due to a failure of the maternal immune system to down-regulate or tolerate its response to paternal antigens.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Former midwife looks back on 100 years

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A retired district … midwife has celebrated her 100th birthday putting down her longevity to ‘hard work’ while doing a job she loved.

Bertha Kilgannan was born in Jersey on November 18, 1909 and moved to Tiverton in Devon as a child where she went to school.

Her grandmother and mother were district nurses and the young Bertha followed into the profession …

… She married, to become Bertha Hookway and had a son and daughter.

… Bertha said of her career as a midwife when she would go door-to-door on her bicycle: “I loved it. I loved my babies and the mothers.

“It was hard work, but it was an interesting job – you were interested in the mothers and their babies.”

… On turning 100 … ednesday she said: “I have had a good life. It’s been a long life …

“I look back and think I wish I had done something, but it has not been too bad in the long run … I have had a good life.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Late Preterm Births Increasing in U.S.

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The percentage of babies born preterm in the United States rose by more than 20 percent from 1990 to 2006 …

… “Late preterm birth … just before term at 34 to 36 weeks of gestation, have increased quite dramatically over the last decade and a half,” …

… Overall, the rate of preterm births increased from 6.8 to 8.1 percent, according to the report.

The number of late preterm births resulting from induced labor or cesarean delivery has also increased … induced late preterm births more than doubled between 1990 and 2006, from 7.5 to 17.3 percent … The percentage of late preterm births delivered by cesarean rose by 46 percent, from 23.5 to 34.3 percent.

… “Studies have found increases in later preterm deliveries that are medically indicated, but other studies have found that there are some late preterm deliveries that are happening where there do not appear to be any medical reasons for the delivery,” …

Improved technology has made identifying infants in distress easier, and that has also contributed to the increase …

The rising rate of late preterm deliveries concerns health experts because the babies are not as healthy as babies delivered at full term …

… “They are more likely to be delivered with respiratory problems. They have a higher death rate. They are more likely to have long-term neurological developmental problems, compared with infants delivered later.”

… Facing a potential problem … a doctor is inclined to deliver the baby rather than try to manage the problem in utero until the baby reaches full term.

But no infant should be delivered preterm unless there is a medical reason …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women Giving Birth at Home Without Midwives

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When Jennifer Margulis went into labor with her fourth child, she sent her husband off to take the kids to school, then waited at home for her body to do what she felt confident it had evolved over millions of years to do on its own.

There was no rushing to the hospital, no midwife … Just Jennifer and her husband, home alone, giving birth.

“I think a lot of people think a woman who would want to have an unassisted birth would be a little bit crazy,” said Margulis, who holds a Ph.D. in literature, and is a contributing editor for Mothering Magazine. “I think I may have had that reaction as well. I am definitely not a crazy person. I am a very educated, thoughtful and caring person. I am not a person who takes a lot of unnecessary risks. The whole point is it is not risky if you do your homework.”

Nationwide, 90 percent of births still take place in hospitals with doctors attending … 8 to 10 percent are with midwives in hospitals or birthing centers. And 1 to 2 percent are at home.

… Internet traffic and books on the subject indicate more women are choosing to take control with what is becoming known as freebirth because they are concerned about the United States’ dismal record of maternity care and skyrocketing rate of Cesarean births, now at nearly 32 percent of all births …

… “… they are trying to find a way to work around a system they see as very problematic.”

Though the United States spends more money on childbirth than any other nation, it has one of the world’s worst records for infant mortality and maternal mortality …

… Margulis, a freelance writer, decided to have her fourth child at home without the help of a doctor or midwife. There are signs more women are choosing to do this … because they want a more private and intimate birth.

… an obstetrician and gynecologist at Massachusetts General Hospital in Boston and assistant professor at Harvard medical School, said most women can give birth alone without any problem, but there are still small numbers — as high as 10 percent — who will run into complications, often without warning.

“What worries me is that very often women who have absolutely no risk factors develop an emergency complication,” she said. “I can’t imagine how you can possibly recognize that yourself, particularly if you have no medical training. Sometimes you have only minutes to intervene.”

Tracy said the increase in C-sections appears driven by the high rate of obesity in America, more births of twins and triplets, more women asking for them, as well as the fear of lawsuits …

“None of these make it, I think, a wise choice to have a delivery in a setting where no one has any training,” she said.

… [Margulis] had a bad experience with her first birth in a hospital, and her second birth, which was with a midwife at home. A midwife also assisted with the third, but this midwife had half of her own 10 children unassisted, and was an inspiration for the idea. Margulis began interviewing midwives for her fourth birth, but as she learned more about doing it herself, she became convinced she could.

“I felt like when I read other peoples’ stories, I felt like those were the most amazing women in the world and they were all so much stronger than I am,” she said. “… if we let our bodies do what they evolved to do, what they know how to do, then any woman can have a safe unassisted home birth.”

Jennifer Block, author of the book, “Pushed,” said while it is impossible to track the numbers of women doing unassisted childbirth, they are highly educated, committed, motivated, and frustrated with mainstream medicine.

“… Women should be able to be in control and still have trained support with them. Emergencies do happen. I can’t imagine trying to resuscitate my own infant, or if I had a hemorrhage.”

… Laura Shanley, a leading advocate for freebirth, had her first child in 1978 without a doctor or midwife at home. She and her husband were inspired by the book “Childbirth Without Fear,” by the late British obstetrician Grantly Dick-Read … She went on to have all five of her children that way.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Doctors to be registered under national scheme

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The legislation was passed by the NSW parliament on Thursday night, making it one of the first states to adopt the new system.

The system will apply to doctors, nurses, optometrists, midwives, chiropractors, pharmacists, psychologists, physiotherapists, podiatrists and dentists.

… the new laws were a “significant step” that would give the public increased confidence in the health system.

The Health Practitioner Regulation Bill 2009 would also make it easier to avoid “appalling” situations where practitioners had gained employment in other states after they had been deregistered or suspended, she said.

… There is already an expectation that NSW doctors will report colleagues who they fear are putting patients at risk, but the rule will now be applied to a wider range of health practitioners.

Tebbutt says NSW will keep its independent investigator and prosecutor, the Health Care Complaints Commission …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Health Plans Work to Reduce the Health Risks and Costs From Elective C-Sections Before Full Term

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A combination of quality-of-care and cost issues has prompted some health plans to take steps to reduce the number of scheduled, medically unnecessary premature Caesarean section deliveries, mainly through a focus on education of both women and physicians.

… a growing percentage of women is having C-sections, many of which take place before the 39th week of gestation … between 1990 and 2005 there was a 20% increase in babies born before the 37th week of gestation and a 29% increase in births occurring at 37 to 39 weeks of gestation. Many studies show heightened risks to both babies and mothers when the babies are delivered before 39 weeks.

Although there are certainly medically necessary reasons for some of these C-sections, newborns delivered prematurely are at risk for more medical complications than those born at full term. Many of these infants are admitted to the neonatal intensive care unit, which can be much more costly for health plans than a C-section or vaginal birth without NICU admission.

There were more than 1.3 million C-sections in 2006 in the U.S., up from less than 800,000 in 1996 … plans have asked what they can do about this growing rate … “This is not the important question, but it’s the one everyone asks,” she maintains. Rather, she says, the focus should be on what these high C-section rates represent, which is a quality issue mainly with babies and the impact of neonatal costs. “The real quality issue has more to do with the infant than the mom,” …

“This is both a quality-of-care and a cost issue,” … “A baby should not be born electively before 39 weeks unless there is a clinical indication” to do so … while NICU costs “are not the No. 1 issue … they are in the top couple of issues,” she explains. Average costs for a vaginal delivery are between $5,000 and $6,000, while costs for a C-section delivery are in the $8,000 to $9,000 range. But for births resulting in a NICU stay, those costs jump to the $20,000 to $30,000 range …

… “While maternal and fetal complications during pregnancy may result in the need for a C-section, we’re concerned that some early C-section deliveries may be occurring for non-medically indicated reasons,”

… “the rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.”

… late preterm babies — … between 34 and 36 weeks gestation — are six times more likely than full-term babies to die within their first week of life and three times more likely to die within their first year. Groat says that babies born within the 37- and 38-week time frame “have twice the likelihood of going to the NICU” than babies born at 39 weeks.

… If women have already had a C-section, they can safely have a … VBAC later…

… Many plans are taking steps to help reduce the amount of scheduled premature C-sections.

… 48% of babies admitted to the NICU were born to mothers who had scheduled deliveries, many of which were before 39 weeks gestation. After the plan shared its data with the hospitals and physicians in those areas, there was a 46% decrease in NICU admissions within the first three months … “We’re taking some of the best practices and sharing them with hospitals,” she explains. … “the last few weeks of pregnancy are important to the baby,” …

… The Regence Group has a maternity management program, Special Beginnings, designed to promote a healthy pregnancy and delivery. “… we work to educate expectant mothers about the potential incremental risks to mother and infant” when the baby is delivered by C-section electively before the 39th week of gestation … “Through this program, we educate expectant mothers on the benefits of full-term, vaginal delivery to help encourage a healthy pregnancy and delivery. We also educate them about when it may be medically indicated to not have a vaginal birth.” … It also offers members a 24-hour health information line that includes mortality and morbidity information affecting both mothers and babies with elective delivery before 39 weeks … “This helps educate the mother if her doctor suggests early delivery,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Service shake-up for Notts mums-to-be

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MUMS-TO-BE in Notts will have a new phone line printed on the back of pregnancy kits to get direct access to maternity services.

NHS bosses in Notts are changing the way mums are supported while they are pregnant, as well as during and after the birth.

An extra £1.5m a year is being spent on improving services to ensure people in all areas of the county can get the same levels of support.

Concerns had been raised that Notts mums were dealt with by too many people during pregnancy and did not know who to go to for help.

Under the proposals, every pregnant woman will be assigned a named midwife who will co-ordinate their care and deal with any problems.

A phone line will be printed on the back of pregnancy tests across the county – giving access to pregnancy advice and other services.

Previously, most mums would have been referred to services by their GP, though some were reluctant to do so.

… The planned changes include creating a separate area in labour wards for women with relatively simple and low-risk pregnancies.

It is hoped they will have a calmer, more relaxing labour as a result and will be less likely to need specialist help.

… New midwives have been recruited to help put the plans into action and ensure women have more choice about where they give birth …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Fewer Options for Mums Seeking Natural Births

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Midwives are protesting the shuttering of Manhattan’s only natural birth center that served women on Medicaid. At the nation’s oldest public hospital, administrators are ending a 12-year-old effort to provide low-income mothers with natural birth options.

The Birth Center at Bellevue Hospital was designed for the kind of birth experience that many moms, even the well-connected, find elusive. Labor was to unfold in spacious, comfortable rooms with sweeping views of the East River; midwives would massage women through labor pains; and world-class obstetricians would be at hand to address any complications. All this in a public hospital that primarily serves low-income patients and the uninsured, many of them immigrants.

So when hospital administrators quietly shut down the 12-year-old center this September, New York’s tight-knit community of midwives and natural birth advocates demanded another look …

A low-tech approach

… Like most hospitals, Bellevue has seen a steep climb in its overall c-section rate, from 18 percent of births in 2000 to 27 percent in 2007. Over the same period, the birth center maintained a c-section rate below four percent … women admitted to the birth center were unlikely to experience labor complications …

According to some midwives … many Bellevue nurses proved unwilling to accommodate the pace of labor in the birth center … hospital regulations require that a nurse be on hand to document and monitor every patient …

For nurses, birth center procedures tend to be more time-intensive than those in standard labor and delivery rooms. Technology makes a difference: In the L&D suite, the laboring mother is hooked up to a monitor that measures her contractions and fetal heartbeat. This technology allows nurses to track the birth remotely, though it also constricts the mother to her bed. In the birth center, the mother is free to move around, and nurses check the fetal heartbeat intermittently with a handheld device. The low-tech approach requires more hands-on attention from attending nurses and midwives.

… Although Bellevue does not plan to reopen the birth center, women can still have a low-tech, midwife-attended birth in one of the standard delivery rooms … The hospital will retain the midwives currently on staff …

Even as the Bellevue center remains under lock and key, demand for such facilities is on the rise across New York City. Attending midwives at St. Luke’s-Roosevelt Hospital keep waiting lists of mothers who want to use the hospital’s birth center. At St. Vincent’s Hospital, the planned Eli & Abby Manning Birth Center will offer acupuncture, hydrotherapy and other forms of natural birth support.

Neither center, however, is focused on the working class, immigrant-heavy population that defines Bellevue …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Ultrasound scans linked to brain damage in babies

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… men born to mothers who underwent scanning were more likely to show signs of subtle brain damage.

… subtle brain damage can cause people who ought genetically to be right-handed to become left-handed … these people face a higher risk of conditions ranging from learning difficulties to epilepsy.

… men whose mothers had scans were significantly more likely to be left-handed than normal, pointing to a higher rate of brain damage while in the womb.

… Prof Juni Palmgren … told The Sunday Telegraph: “I would urge people not to refuse to have ultrasound scanning, as the risk of brain damage is only a possibility …”

… until further studies are carried out, scanning should still be regarded as safe by mothers-to-be …

… Dr Duck cautioned … ultrasound … has saved the lives of countless babies: “This research must be seen in context, and it should not deter anyone from having an antenatal scan.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Rudd unmoved by homebirths protests

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Prime Minister Kevin Rudd says he is not moved by protests from doctors and midwives upset at changes to the health system.

Doctors have rallied … because they are concerned new super clinics will put an end to the family doctor and drive young general practitioners away from the profession.

… protesters … are objecting to changes which force private midwives who attend homebirths to work in collaboration with a doctor.

Mr Rudd says … “Our job is to govern in the national interest – that means implementing what we said before the election in these critical reform areas, getting on with it … ”

“… we intend to implement that which we said we’d do.”

Protesters say amendments to the Medicare for the Midwives Bill will result in a medical veto over midwifery practice and homebirths …

Melissa Maimann, Essential Birth Consulting 0400 418 448

The future of private midwifery

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

There has been stong interest on the issue of the future of private midwifery since the Health Minsiter’s announcement that clarified the meaning of “collaborative practice”. Collaborative practice will mean that every private midwife must have a collaborative agreement with a private obstetrician who can effectively sign off on the midwife’s work. If s/he does not agree with the plan of care for the woman, the obstetrician may sever the collaborative arrangement. Furthermore, with RANZCOG and the AMA being opposed to home birth, home birth will not be an option in the private system, as it is currently. The exemption that was granted to home birth will have no meaning since collaborative arrangements will be a requirement for registration for private midwifery practice.

There are several issues:

- Midwives will no longer be able to practice in accordance with the International Definition of the Midwife. In the current climate of a world-wide midwifery shortage, it makes no sense to prevent currently practicing midwives from continuing to practice.
- Midwives’ practice will be subservient to obstetric practice, potentially increasing Australia’s already high caesarean, induction and epidural rates. This, of course, increases morbidity for mothers and babies and compromises Australia’s safe record of maternity care.
- It is likely that obstetrician’s insurance will forbid them from working with midwives unless the midwife works very closely with the obstetrician, for example in the obstetrician’s rooms. The obstetrician’s insurance company will no doubt not want the obstetrician to be taking responsibility for things that s/he has no direct control over (despite the fact that the midwife will have insurance too).
- Home birth will not be an option in the private setting. Publicly-funded models will remain an option, but these are few and far between.
- Private midwifery care in hospitals will restrict women’s choices, eg vaginal breech, vaginal twins and so on. It is highly unlikely that an obstetrician will agree to work collaboratively with a midwife who is supporting a woman to have say a vaginal breech birth.
- The net effect will be the erosion of women’s choices, especially in the private system, and the restriction of a midwife’s practice to employed models within hospitals.

No other profession is denied the opportunity to practice privately. No other profession is required to have sign-off from a different profession. And no other profession is legislated against providing the full scope of care by international definitions.

While it is clear that the maternity reforms are not intended to be in any way related to home birth, it now seems that even private midwifery care for hospital birth is under complete threat of extinction.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Listening to Baby’s Heart at Home May Be Misleading

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

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Expectant mothers may enjoy listening to their unborn babies’ heartbeats, but they shouldn’t rely on home fetal heart monitors to provide an accurate picture of fetal health …

The devices may provide false reassurance in some situations …

… Chakladar reported a case in which a … woman who was 38 weeks pregnant went to the emergency department because she couldn’t hear her baby’s heartbeat with her home fetal heart monitor.

A few days earlier, … she had noticed that the baby was moving far less than usual … she reassured herself that everything was OK by listening to the monitor. A couple of days later, when she listened again, she couldn’t detect anything …

… an ultrasound … found no fetal heart activity. They gave the diagnosis — intrauterine death … the stillbirth “may have been unavoidable,” but listening to the fetal heart monitor “certainly delayed presentation to the hospital.”

“Without training,” … sounds heard on the monitor “could easily be misinterpreted.” Likely, the mother had simply heard her own pulse or placental flow instead.

… the risks of having a mother delay seeking medical attention … tend to be overlooked … Medical professionals provide context that an untrained mother can’t …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Doctors to gain veto powers over midwives and birth choices

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

Below is an important brief that has been prepared by Bruce Teakle of Maternity Coalition. It explains what the situation will be after July 1, 2010 for private midwifery practice for home birth and hospital birth. It affects all women who may be birthing their babies after July 1, 2010.

On 5 November the Government announced that the “Medicare for midwives” Bills would be amended to require midwives to have “collaborative arrangements” with “medical practitioners” before being eligible for professional indemnity insurance or Medicare rebates:

* before the midwife can access professional indemnity insurance, and

* before women can claim a Medicare rebate for midwifery services.

Doctors must approve each midwifeʼs entry to private practice:
* Midwives will be required by Commonwealth law to have “collaborative arrangements” with “one or more medical practitioners” before being eligible for Commonwealth-subsidised professional indemnity insurance (PII).

* PII will be a prerequisite for a midwife to enter private practice, under new national registration laws, being enacted state by state.

* Doctors will be able to unilaterally withdrawal from collaborative agreements with a midwife, rendering her uninsured, and legally unable to practice in a private professional capacity.

* This legally mandates medical control over midwives’ ability to register and work in private practice.

* This will be set in Commonwealth law, which can only be changed by Commonwealth Parliament.

* These provisions are contained in the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009.

Doctors must approve womenʼs access to Medicare rebates for midwifery care:

* Midwives will also be be required by Commonwealth law to have “collaborative arrangements” with “one or more medical practitioners” before their services are eligible for Medicare rebates.

* This puts women’s access to private midwifery care under medical control.

This is potentially defacto “parallel regulation” of the midwifery profession:

* Medical practitioners will control the registration status of midwives, despite their being a discrete, separately regulated profession.

* Medical professional organisations could set guidelines for collaborative arrangements, potentially forming defacto regulatory standards for midwifery endorsement and practice.

This gives doctors right of veto over womenʼs choices in birth care:

* Any birth care choice using private practice midwives, or developed under the Commonwealth’s new arrangements, will be subject to medical control or veto.

* This gives medical practitioners unprecedented control over women’s choices and access to care.

“Collaborative arrangements” may be legally restricted to privately practicing doctors

* The amendments do not specifically include hospitals as able to form collaborative arrangements with midwives. They require medical practitioners to be “of a kind or kinds specified in the regulations”.

* It is unclear whether a hospital, health service district or authority may be included within the definition of “one or more medical practitioners”.

* Doctors who are employees of public hospitals can’t make “collaborative arrangements” as employees of the hospital they work for. They work for the hospital, attend their workplace when rostered on and collaborate in line with hospital policies.

* A range of very serious consequences would flow if these arrangements were restricted to privately practicing doctors. Consequences could include:

o No new midwifery models in public hospitals.
o No private midwifery practice.
o No homebirth care from midwives in private practice.
o Practice midwives in private obstetricians rooms could be the only viable model of private practice or Medicare-funded midwifery.

This brief represents the best information available to Maternity Coalition on 8 November 2009. We are actively seeking ongoing clarification and dialogue with Government in order to ensure women and families have access to accurate information. For full text of amendments click here.
For more information contact: Bruce Teakle 07 3289 0231

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women to protest maternity reforms

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… women will rally … to protest the … government’s maternity services reforms.

Health Minister Nicola Roxon … announced that Labor would amend draft laws before parliament to make it clear … midwives could only access the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme if they worked in collaboration with a doctor.

The Australian Private Midwives Association is concerned the requirement will make … midwives beholden to doctors.

“Placing one profession at the complete mercy of another … makes a mockery of professional regulation in this country,” … “Many choices such as homebirth … may be lost if doctors do not form … agreements with midwives.”

Homebirth Australia … said the government was trying to make homebirths an “administrative impossibility” for women.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The end of private midwifery practice in Australia

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

THE HON NICOLA ROXON MP MINISTER FOR HEALTH AND AGEING

MEDIA STATEMENT – 5 NOVEMBER 2009

Midwives/ Nurse Practitioner Amendment

The Minister for Health and Ageing, Nicola Roxon has today circulated an amendment the Government intends to introduce … this amendment will simply clarify in legislation that collaborative arrangements with medical practitioners will be required to access the new arrangements.

… These bills are a key plank of the Government’s 2009/10 Budget commitments which recognises for the first time the role of appropriately qualified and experienced midwives … in our health system.

The International Definition of a Midwife, as accepted by FIGO, ACMI and the International Confederation of Midwives states:

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventive measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and childcare.

A midwife may practice in any setting including in the home, the community, hospitals, clinics or health units.

When the Minister’s Media Release is read in conjunction with the ICM definitoin of the midwife, we can see how contradictory the Minister’s Media release is.

On the one hand, midwives will be required to work collaboratively with obstetricians or GP OBs, yet on the other hand, the Minister states how this “recognises for the first time the role of appropriately qualified and experienced midwives …” How so? If private mdiwives are required to work collaboratively with obstetricians, how are we working to the ICM definition as autonomous practitioners in our own right?

It will be interesting to walk this path as it plays out. Will obstetricians have the same requirement to collaborate with midwives? Will they have to ensure that all of their private patients have a private midwife too in order to access PBS, MBS, insurance, and indeed to register?

Possibly what would be a better system is a private health system that recognises midwives as experts in normal pregnancy and birth, and obstetricians as experts in abnormal pregnancy and birth. We need nationally-accepted guidelines for OBs and MWs that state whom the appropriate care provider is, and at what stage. Midwives have Guidelines for practice, as do obstetricians, however they are not the same. We would simply need to mesh these guidelines to form national gudelines for maternity care providers which would ensure that healthy, low risk women see midwives, maybe with one appointment to meet the backup obstetrician, and that women with risk-associated pregnancies see obstetricians in association with a private midwife, given that a midwife will be present at every birth.

Certainly, as this legislation stands, it does spell the end of private home birth. RANZCOG has recently issued a statement that clearly indicates their refusal to sanction home birth. What private obstetrician will work collaboratively with a private midwife who is intending to birth with women at home? Extending this further, will a private obstetrician refuse to collaborate with a private midwife who intends to birth with women in hospital if the midwife’s clients refuse say an induction at term plus 10, active management of the third stage, a vaginal examination in labour etc? These are important questions to ask. It seems that going beyond July 1, 2010, right of refusal will only exist in the public health system and midwives will not be able to work in private practice on their own authority.

Solutions, anyone?

Melissa Maimann, Essential Birth Consulting 0400 418 448

Deaths of Scottish Infants Drop Dramatically

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Delivery-related deaths of term infants decreased nearly 40% over two decades in Scotland, most likely because fewer babies died from lack of oxygen during childbirth …

The risk of delivery-related perinatal death decreased from 8.8 to 5.5 deaths per 10,000 births between 1988 and 2007 …

The decrease was mostly attributable to a significant drop in deaths ascribed to intrapartum anoxia, which fell … from 5.7 to 3.0 per 10,000 births

… “The pattern of the decline suggests that this was primarily due to a reduced number of severely anoxic infants, rather than improved neonatal resuscitation. The change was paralleled by increased rates of cesarean delivery, but there is no direct evidence supporting a causal association between the two trends,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

An Obstetrician’s Birth Plan

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Dear Patient:
As your obstetrician, it is my goal and responsibility to ensure your safety and your baby’s safety during your pregnancy, delivery, and the postpartum period. My practice approach is to use the latest advances in modern obstetrics. There is no doubt that modern obstetrical advances have significantly decreased the incidence of maternal and fetal complications. The following information should clarify my position and is meant to address some commonly asked questions. Please review this information carefully and let me know if you feel uncomfortable in any way with my approach as outlined below.
* Home delivery, underwater delivery, and delivery in a dark room is not allowed.
* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of “Natural Birth” promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.
* Doulas … are allowed and will be treated like other visitors … they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby’s well-being.
* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly … The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby’s well being.
* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.
* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.
* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.
* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.
* Episiotomy is a surgical incision made at the vaginal opening just before the baby’s head is delivered. I routinely perform other standard techniques such as massage and stretching to decrease the need for episiotomies. However, depending on the size of the baby’s head and the degree of flexibility of the vaginal tissue, an episiotomy may become necessary at my discretion to minimize the risk of trauma to you and your baby.
* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby.
* If your pregnancy is normal, it should not extend much beyond your due date. The rate of maternal and fetal complications increases rapidly after 39 weeks. For this reason, I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor … inducing labor … is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section.
* … a c-section may become necessary at any time during labor due to maternal or fetal concerns. The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.

Are there any problems with this birth plan? Maybe some of the information and rationales are inaccurate in light of research, but I believe it is great that this obstetrician gives his/her patients this information upfront, rather than having them find out in labour.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Pregnancy And Childbirth Are Becoming More Complicated

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The number of hospital stays for women who had a normal or uncomplicated birth decreased by 43 percent between 1997 and 2007 …

The … study also found an increase in stays for women who had:

– A previous cesarean section – 107 percent…
– High blood pressure … 28 percent
– Perineal trauma during childbirth – 22 percent

In contrast, stays for women who had umbilical cord complications fell 15 percent (259,000 to 219,000).

Is pregnancy and birth becoming more complicated, or are we becoming more skilled at recognising and treating complications? Or … is the legal system at fault, and are we seeing defensive practice prevailing?

Melissa Maimann, Essential Birth Consulting 0400 418 448

Hospitals to crack down on induced labors

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Hoping to schedule your baby’s birth while your mother’s in town, or before the doctor goes on vacation? Labor is becoming less of a late-night surprise, but some hospitals are starting to tighten the rules for elective deliveries — because some babies are being delivered too early.

More hospitals are expected to crack down as regulators begin new quality measurements next spring that aim to reduce too-early elective inductions and first-time cesareans.

Induced labor is on the rise for lots of reasons, some medical and some not. But recent research shows a troubling link between elective inductions and these so-called “late preemies.” These aren’t the dire too-small babies that the word premature conjures, but near-term babies who nonetheless are at higher risk of breathing disorders and other problems than babies who finish their very last weeks in the womb.

… New guidelines will require that a mother’s cervix be nearly ready for natural labor …

… Hospitals also will have to report cesareans for first-time mothers, too often a result of a failed induction.

… the American College of Obstetricians and Gynecologists have long discouraged elective deliveries before the 39th week of pregnancy. … At Utah’s Intermountain Healthcare, for example, 28 percent of elective deliveries were breaking ACOG’s rule …

Most were being induced in week 37 … those near-term babies had more than double the risk of ending up in neonatal ICU, suffering respiratory distress …

… today, only about 3 percent of Intermountain’s elective deliveries occur before 39 weeks — and infant hospitalizations have dropped …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mums-to-be should have home birth choice

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

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NHS North Lincolnshire is not doing enough to encourage expectant mothers to give birth at home …

… 2.1% mothers in the region gave birth at home last year, with the NCT arguing that Trusts with a figure of below five per cent were not doing enough to provide women with a full range of childbirth options.

… “It would be a good use of resources to have more midwives available for home births, as it wonderful for both mother and baby when births can be carried out in the home.

“However, this must be balanced with an emphasis on safety, some deliveries require hospitalisation and we must not approve cases where it would not be safe for a home delivery in order to boost target figures.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Caesarean births: high number and postcode variation worries experts

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Large variations in the numbers of babies delivered by caesarean section emerged today in figures showing a breakdown of how many mothers had had the procedure in various parts of Britain.

… a third of babies born at London’s Chelsea and Westminster NHS trust are delivered by caesarean section, a figure more than double that in Nottingham, suggesting the rates for the procedure in England could still be influenced by well-off women dubbed “too posh to push”.

The Chelsea and Westminster trust, which tops the league at 33.3% of births by caesarean, said that its numbers were swollen by women giving birth in its private delivery wing.

Other hospitals in London and the south also have rates that are significantly higher than the England-wide average, of 24.6%. The figure for Imperial College Healthcare NHS trust was 33.1%, that for Surrey and Sussex Healthcare NHS trust 30.9%, for Barnet hospital 30.8%, and for university hospital Lewisham 30.6%.

The lowest rate of caesareans was 15.8%, at Sherwood Forest NHS trust in Nottingham.

Nearly half of Chelsea and Westminster’s caesareans were planned rather than an emergency; 15.8% of deliveries were by elective caesarean, which is three times the proportion of the Peterborough and Stamford NHS trust, where 5.6% of deliveries were elective caesareans.

Chelsea and Westminster insisted that all its caesareans were done for “clinical reasons” and said the hospital was a regional referral centre for sick babies, many of whom were delivered by that method. But it said it was taking steps to bring the rate down, by measures such as increasing the consultant cover on wards, and providing one-to-one midwife support for women in labour.

… “There is now general acceptance among maternity services’ professionals that the caesarean section rates are too high and that some women and their babies are being subjected to unnecessary [medical] interventions. … different attitudes and practices among professionals can lead to lower or higher [caesarean] rates. While most caesareans will be straightforward, there are potential complications for women and their babies.”

… the “staggeringly high number of caesarean sections” was a serious cause for concern. “The fact that the rate is nearly double that recommended by the World Health Organisation is deeply worrying, especially given the concerns about the increased risks of the procedure. We urgently need to increase the number of midwives … so that mothers are given all the advice and support they need during and after pregnancy.”

Australia’s caesarean rate is not much further behind at 31% in 2006.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Anxious Pregnant Mothers More Likely To Have Smaller Babies

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… anxiety in pregnant women impacts their babies’ size and gestational age …

… the mother’s anxiety during pregnancy impacts birth outcomes over and beyond factors such as drug use, education, and race.

Anxiety during the third trimester predicted women delivering significantly smaller babies …

Low to moderate levels of anxiety in women during either the first or second trimester did not significantly affect the birth outcomes, but women who are severely anxious during much of their pregnancy should be considered for anxiety-reducing interventions …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Australian Mothers Do Not Get Enough Support From Those Close to Them: The Motherhood Study

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…70 percent of Australian mothers say they do not get enough support from those close to them …

… The Motherhood Study, which includes over 4,000 mothers from Australia and New Zealand … explores the hypothesis that mums today suffer from a lack of “organismic psychological needs” – autonomy, competence and relatedness – due to tension between innate love for their child and misleading external pressures.

To gauge the levels of these needs, Huntsman and Hedley-Ward have drafted a 112-point survey asking questions like, “How close are your relatives?” and “Are there older women in your life helping you?”

A lack of support is proving a common thread in the early analysis of data, with 70 percent of mums saying they do not get enough support from those close to them. Combine this with over 50 percent of mums saying they do not have any close family nearby, and 68 percent of them living away from their hometown, and it’s easy to see potential danger.

With only 13 percent of mums reporting that they spend regular, quality ‘couple time’ with their husband/partner, intimate relationships are another key focus within the study.

… “The goal is to let mothers feel what they feel without feeling guilty and to take away this notion that they have to be perfect,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448