Baby dies after mum waits five hours for a room

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THE Health Department is investigating whether the tragic death of a baby at a … hospital could have been averted.

It is alleged the expectant mum … was forced to wait in an emergency department after her waters broke, only to be told five hours later when she finally got a room that her baby had died inside her …

… She got to the emergency department … and doctors asked that she be put in a room and monitored, as is the practice with women who have gone into labour.

However there were none available and she was told to wait in the emergency room while experiencing contractions.

She remembers her baby was still kicking and seemingly fine.

Five hours later when a room became available, an ultrasound was taken and it was discovered that the baby had died.

Ms Otoreno had to be induced to give birth to her baby …

A tragic outcome for this woman and baby. One-to-one midwifery care can avert situations such as these. It is unfortunate that there is such a shortage of midwives that it is not possible to staff labour rooms with one-to-one midwifery care, as is the gold standard of care, however women who choose a privately practicing midwife can be assured that they will have a midwife by their side.

To find out more about the services I offer, please visit my website or call me on 0400 418 448.

Obstetricians take big steps to avoid malpractice

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Delivering babies can be a high-stakes undertaking for hospitals, with the threat of multi-million-dollar malpractice damages when serious mishaps occur. But a team of Manhattan obstetricians says it has beaten the odds—dramatically reducing errors and slashing their department’s medical malpractice payouts by more than 99%.

“Any hospital could do it—it’s not about money, it’s about changing the culture to make it safer to deliver babies,” …

The new measures reduced errors and helped ward off unwarranted suits by clearly documenting everything doctors did right in cases where a bad outcome was not their fault … these safety initiatives reduced so-called “sentinel events”—such as avoidable deaths and serious injuries—to zero in 2008-09, down from five in 2000.

Consumer advocates are hailing the report as a breakthrough in patient safety and a better way to curb malpractice costs than tort reform. “People don’t get sued if they don’t get hurt,” …

… the safety changes resulted in annual medical malpractice payouts dropping from an average of a $28 million from 2003 to 2006 to $2.6 million a year from 2007 to 2009. With no sentinel events reported in 2008 and 2009, those totals are expected to drop still further.

Among the easier changes was doing away with the labor and delivery unit’s dry-erase whiteboard, which staff used to communicate patients’ progress …

Instead, the team came up with a new electronic application to do the same job better, a record that can be accessed through any Internet browser. No paper charting is allowed, both for improved communication and with an eye to leaving a clear legal record in case of a poor medical outcome.

Some of the staffing changes cost money. The unit hired a full-time patient safety nurse to educate staff on new protocols the doctors wanted and to conduct emergency drills, such as what to do when a mother started to hemorrhage …

Reasoning that doctors tend to make mistakes when they are deprived of sleep, the department hired three physician assistants and a “laborist,” which is a new term for an obstetrician who works for a hospital full-time, instead of just having admitting privileges there. At Weill Cornell, the laborist works nights and weekends, reducing the time other obstetricians need to be “on call” in their off hours.

Though many aspects of the plan were costly, the authors concluded that the savings in medical malpractice payments “dwarf the incremental cost of the patient safety program.”

To find out more about the services I offer, please visit my website or call me on 0400 418 448.

Midwives gaining in popularity

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When Christy Gasstrom gave birth to her son five years ago, the first-time mom from Ilion received care from an obstetrician.

But when a Utica doctor told her during her second pregnancy that she no longer was a candidate for natural birth because of her previous Caesarean section, she decided to go a different way.

“I didn’t like that answer so I did some research and ended up moving over to the midwives at Bassett (Healthcare),” she said.

A few months later, Gasstrom successfully delivered her daughter Logan …

Midwives … are gaining popularity as more women embrace natural childbirth, local practitioners said.

Officials at Mohawk Valley Women’s Health Associates in New Hartford and Bassett Healthcare in Cooperstown said the majority of their maternity patients now work with midwives at some stage of their pregnancy. And statewide, more new midwifery licenses were issued in 2010 than in any year since 2006, bringing the total number of licensed practitioners to 879.

A state law that took effect in October also gave midwives more freedom to practice without direct doctor supervision …

Gasstrom, who had a midwife … at her delivery last year, said the experience was drastically different from the labor that led to her C-section. The midwife spent more time with her and was “more involved” than her first doctor had been …

… Joann Roberts, one of four certified nurse midwives who work with Mohawk Valley Women’s Health Associates, said midwives bring a different perspective to childbirth than most obstetricians and have been shown to reduce Caesarean rates. Rome Memorial Hospital, where she performs deliveries, for example, had an 8 percent Caesarean rate in 2010 compared to the national average rate of 26.5 percent reported in 2007.

“We always expect that our mother will be having a normal birth right from the beginning, unless an emergency comes up,” Roberts said, adding that patient education and patience with the labor process are key in her practice.

Many midwives considered it a victory last summer when then-Gov. David Paterson signed the Midwifery Modernization Act, which allowed them to begin practicing without written agreements from doctors. But Roberts, who works with two physicians, said the professions complement each other and that she expects most midwives to continue working in partnership with them.

… Dwynn Golden, one of the certified nurse midwives at Bassett Healthcare’s new birthing center in Cooperstown, said collaborative arrangements also give patients the widest choice of available options without changing providers.

New patients at Bassett meet with a midwife during their initial visit and are given resources explaining the differences in training and experience between midwives and doctors. They then choose to work primarily with a midwife, alternate visits between a midwife and a doctor, or see a doctor exclusively.

“With the popularity of natural childbirth, midwives are viewed as the ideal provider of prenatal care and attending the birth,” … (But) for some women who prefer inductions to be scheduled and desire an epidural throughout labor, they may not view the role of the midwife as essential to their experience.”

Golden said facilities such as Bassett’s birthing center also offer some mothers more peace of mind because they have access to tools for facilitating natural birth, such as birthing balls and private Jacuzzi tubs, but know there is emergency medical equipment nearby should something go wrong.

To find out more about the services I offer, please visit my website or call me on 0400 418 448.

Link between Mouth-rinse and Preterm Birth

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A new study reports that the use of non alcohol antibacterial mouth-rinse is linked to a decreased incidence of preterm birth … Of mothers who used the mouthwash twice a day, 6.1% delivered prematurely, compared with 21.9% of the control group, who did not use the mouthwash.

… the rate of premature birth in those who used the mouthwash was around two-thirds less than those who did not … The results of the study emphasize the importance of preventative dental care during pregnancy.

To find out more about the services I offer, please visit my website or call me on 0400 418 448.

Induced Labor Linked to Raised Risks for First-Time Moms

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I’d like for my readers to appreciate that there is a place for inductions for some women in some pregnancies. And in those pregnancies, an induction might be the best course of action for the mother or the baby – eg pre-eclempsia, gestational diabetes that is not well-controlled, a post-term pregnancy and many other reasons. Certainly, an induction because it’s Tuesday and it fits into the diary is not a good idea. There should be a clear clinical need for all inductions – they are interventions and there should be a valid reason to intervene in any pregnancy.

If your midwife or obstetrician has advised that an induction will be the safest course of action, then this advice needs to be balanced against the information below (and any other information you might learn). If you are unsure, please talk to your midwife or obstetrician and ask them why they have recommended an induction. If you are still unsure, you may wish to seek a second opinion from another midwife or obstetrician.

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The increasingly commonplace decision by pregnant women and their doctors to induce labor for convenience rather than for medical necessity entails some health risks to both mother and child …

The new report, which highlights the negative impact of what is known as “elective induction” for first-time mothers, indicates that going that route increases the chances of a Cesarean delivery, while also boosting the mother’s risk for greater loss of blood and a longer post-delivery hospital stay.

“The benefits of a procedure should always outweigh the risks,” … “If there aren’t any medical benefits to inducing labor, it is hard to justify doing it electively when we know it increases the risks for the mother and the baby.”

… about one-third of those who elected to have labor induced had to undergo a Cesarean section compared with just one-fifth of those who were not induced.

… In addition, babies born after induced labor appeared to face a higher risk for needing oxygen following delivery and special care in the neonatal intensive care unit.

The study authors noted that women who had previously given birth might not suffer the same negative consequences … your body knows the drill and can do it again,” …

To find out more about the services I offer, please visit my website or call me on 0400 418 448.

Women push for midwives under bulk bill reform

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

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MIDWIVES cannot register fast enough to meet growing demand from women for services after historic changes that allowed them for the first time to bulk bill using Medicare …

About 14 midwives have been registered … since the changes took place in November, a spokeswoman for the college, Hannah Dahlen, said.

… women were increasingly demanding the services and her own practice was already booked out until September, she said.

In order to qualify for Medicare, midwives needed to work with a medical practitioner such as an obstetrician, or a GP who provided obstetric care …

… Mrs Newman had found Mahli’s birth easier than that of her daughter Isabella, which she attributed to the different style of care provided by her midwives.

“The way they got me to birth was really different; they weren’t forcing me to push and it was much more relaxed,” …

I have calculated that there are at least 20 eligible midwives in the country. Collaborative arrangements are a pre-requisite for women to claim Medicare benefits, so it follows that not all of those midwives will be able to provide medicare-funded care, however demand for private midwifery care is certainly increasing. Enquiries about my own private midwifery service have doubled and women are booking-in for their care at a fast pace. Private midwifery care is certainly a very popular choice and now that Medicare funding has made is so much cheaper, women, babies and families can benefit. I have negotiated several options for collaborative arrangements – including a model of care that provides for continuity of private midwifery care with a known back-up obstetrician. This model is proving to be very popular. The first baby will soon be born under this wonderful model of care … watch this space!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Wales delivers on home birth rates

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Wales is leading the way in a rise in home births

WHEN Lindsey Gage decided to have her baby at home, husband Andrew was anxious.

He worried about the risk, the mess and how long it would take to get to hospital in an emergency.

In the event … Andrew, 34, held Lindsey while she gave birth at their home …

This type of idyllic home birth is what midwives recommend for all women with low-risk pregnancies who want it.

Yet just 4% of babies are born at home in Wales, just up on the 3% figure for across the UK, but still only a tiny proportion.

Until 40 years ago giving birth at home was the norm … This changed with the 1970 Peel Report saying hospital beds should be available for the safety of mother and baby.

Almost overnight giving birth became medicalised, putting doctors rather than midwives in charge.

By the 1990s women wanted to reclaim birth and a National Childbirth Trust study showed intervention was twice as likely in hospital, even in straightforward cases.

… Today, requests for home births are increasing and once again …

Since the Welsh Assembly Government launched its strategy to increase home births in 2002, they have more than doubled …

… rates vary enormously with some areas, including Porthcawl and Pyle, recording 25% to 30% home-birth rates.

… it’s partly growing requests from women, partly the WAG strategy and the fact that Wales is relatively small making communication and change easier.

… England followed this lead after visiting Wales to see how our Know Your Midwife scheme worked …

… Helen Rogers, director of the Royal College of Midwives in Wales, hopes rates will snowball as women see home birth works and says we should still aspire to 10% and more.

Science teacher Clare Sklavounos … who had both her children … at home, has no hesitation recommending it.

Husband Chris delivered both babies in the living room which he describes as an “amazing experience”.

Clare says she began to realise during ante-natal classes that intervention was more likely in hospital and wanted as natural a birth as possible.

After discussing home birth with midwives she says she was confident it was safe and the best option for her.

… “I was totally uninhibited and could eat and drink when I wanted.

“When it started to get intense I got into the birthing pool and gave birth. I didn’t want any pain relief and didn’t need it.

“The midwives were brilliant. They monitored the babies’ hearts during both labours quite regularly but it didn’t feel intrusive and I felt normal afterwards because it was treated as something normal.

“It all felt so natural. I had the labours I wanted.”

Chris says the experience was very different from when his first child Mia, five, from a former relationship, was born.

“Mia was born in the University Hospital Wales in Cardiff. It was my first child and it was amazing but different,” he recalls.

… “I was shattered and got no sleep,” she says.

“I had an epidural which I didn’t want but I did have to have because the baby got stuck and I couldn’t push.

“I was then told to lie on my back and hold my legs up to give birth but it felt wrong. With my second labour at home I stood up and then delivered standing and squatting.

“The home birth was lovely as births go.

… “He got to bond with the baby and he cut the cord.

… Although this type of birth might not be everyone’s choice, the Royal College of Midwives and Royal College of Obstetricians issued a joint statement in 2007 saying home birth should be available to all low-risk women wanting it.

The colleges added that “if women had true choice” home-birth rates would rise to between eight and 10%.

“There is ample evidence showing labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby,” the statement reads.

Not everyone agrees, however.

Last year medical journal The Lancet said “women do not have the right to put their baby at risk” in response to research from the USA suggesting home birth tripled the risk of neonatal mortality – babies dying within a month of birth.

The RCM responded by saying the research didn’t reflect the situation here where midwives are highly experienced and properly equipped to carry out home births.

… Here the RCOG agrees childbirth is unpredictable and says while it supports home birth in low-risk pregnancies, women birthing at home should also have quick access to obstetric care if an emergency occurs.

The RCM, which represents most of the 1,800 midwives in Wales, says choice and proper care are vital wherever you are.

“RCM policy is that women should have choice,” Helen Rogers explains.

“As part of that we expect low-risk women with no complications should be able and encouraged to have home births.

“I believe we are leading the way on this in Wales.

“It’s slow and there are times when I’d like to increase the rate more quickly but it’s a steady increase. I believe midwives are much more confident about home births now.

“In many areas of Wales the demand for home births has always been there and women have pushed for it.

“There has been a world-wide attack on home births. Some of it is the medical profession which seems to think that hospital is the safest place to have a baby.

“But the vast majority of women are fit and healthy and childbirth is a normal, physiological process. They don’t have to be in hospital.”

Helen says there’s no evidence mothers are less safe having babies at home and disputes any suggestion that home birth might be promoted as a way to cut costs.

“I don’t think health boards would promote home birth because it’s cheaper,” she insists.

“It’s more likely they’d cut them and put all staff in one place.

“As services get more cash starved it’s often so-called luxury services, like home birth, that get hit.

“The WAG supports home birth and its strategy to increase home birth has certainly helped.

“We didn’t get 10% home birth rates across Wales although we have more than 10% in many places and that will probably increase throughout Wales as more women have home births.

“A few years back it was only women who went to National Childbirth Council classes who had home births.

“Now women from all walks of life are having them. They’re seeing their friends and husbands’ friends’ wives having home births.”

… Wherever women give birth, studies show those who have positive births are more likely to recover faster and less likely to develop post-natal depression …

… “We find people birth quicker at home because there’s a sense of confidence and security.

“If you feel anxious and frightened you get the flight-and-fright reflex and release adrenalin which stops the labour.

“Anxiety happens because people are frightened of hospitals.

“Hospitals are wonderful places if you need to be there, but if you’re low-risk, home is as safe or safer.”

… “With a home birth women are in control of their birthing experience. They are in their own home and more relaxed.

“Nature gets on with it and you don’t have to interfere. It’s a very nice experience.”

… “When we talk about taking birth away from doctors people ask, ‘What if something happens?’,” she concedes.

“The women we deal with have uncomplicated pregnancies but if we need to transfer women from home or the birthing unit to hospital it’s because labour is not progressing as we’d want.

“Midwives are the experts at looking after women in normal births, not doctors.

“We have very, very experienced midwives with excellent equipment and they continue to train and update their skills. When women choose to go to hospital because doctors are there and it’s safer there are certain times of year, March and August, when junior doctors change rotation.

“In the first instance you might see a junior doctor. Doctors are my best friends and we need to work together but birth is normal and we should encourage women to give birth at home.

“Once you start on intervention it leads to another. If it’s an uncomplicated pregnancy, home and midwife-led birthing centres are social environments whereas hospital is a medical environment.

“I’m not saying things never go wrong but in this country, on the whole, you are dealing with healthy women.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Home births: A womb of my own

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

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In the 1960s, one in three women in the UK gave birth at home; now the figure is less than 3%. But why? Recent studies show the added risk of a home birth is tiny and that there are many benefits. Here, a mother of two reveals how the extreme language of both camps leaves mothers-to-be feeling lost.

“Women do not have the right to put their baby at risk.” This was the response of the Lancet to American research, published last July, that suggested home birth trebled the risk of neonatal mortality … The reaction was swift. There is “a concerted and calculated global attack and backlash against home birth,” said Cathy Warwick, general secretary of the Royal College of Midwives. The original American research was a “mishmash… that wouldn’t have been published in this country,” said Professor James Drife of Leeds University. “A powerbase in the US is producing phony research to validate its own role,” said author Sheila Kitzinger, a pioneering figure in the home-birth movement. Soon Woman’s Hour was debating the “backlash against home birth”; Sam Taylor-Wood, who had her third child at home, used her guest editor spot on the Today programme in December to discuss why her decision was labelled “brave” and even “irresponsible”.

In recent years, home birth has become a cause célèbre, particularly among a certain slice of the Mumsnet generation who advocate natural labour and “traditional” forms of care … NHS maternity statistics suggest that between 2000 and 2008, home births in the UK rose by 54% … Since 2007, government policy has stated that “women should be offered the choice of planning birth at home”. In Wales the number of women who give birth to their children at home has doubled since 2002 …

Despite such initiatives, the number of home births remains small … Holland is unusual among developed countries in having a home-birth rate of 30%. And, as the Lancet demonstrates, it is easy enough to find those who suggest that women who choose to give birth at home are committing a controversial act, even endangering the lives of their babies.

This may be the “controversy” attributed to minority activities, cultural anomalies. Or it may be the wages of a historical legacy: home birth has been “controversial” since the rise of modern obstetrics and the hospital, which moved birth out of the home. Before that there was no controversy, because there was no alternative. Women’s experience of childbirth was influenced by watching other family members give birth; now for most women their first experience of being present at a labour is their own. A major change came in the 1970s when the Peel Report advised that most women should give birth in hospital, although its findings were not based on statistical evidence. Now it seems we have lost confidence in our ability to give birth naturally: today one in four babies is born by caesarean …

… the home-birth debate is laced with words such as “risk” and “patient choice”. These words transport me back to the nerves and suspense of two recent pregnancies. I’ve given birth twice in the past four years, and I remember how my ordinary scepticism was destabilised by the edgy protective instinct I felt for my unborn child. I became a supplicant before sundry medical professionals, entreating them to tell me the right thing to do. I was transfixed by talk of risk: the risk of miscarriage in the early weeks, the risk of my baby having Down’s syndrome, the risk of miscarriage after amniocentesis, the risks of going beyond 42 weeks without being induced, the risks of induction…

I read about home birth versus hospital birth, felt buffeted one way then the other. Home birth: liberation from patriarchal control of the body. Home birth: unbridled agony promoted by macho women and their atavistic midwives. Modern technocratic medicine has saved you from pain and the fear of death. Modern technocratic medicine has silenced your body. Even in the depths of my confusion, I began to sense a gap emerging between these theoretical extremities and my own far more contradictory experience. Yet I couldn’t determine where theoretical extremity ended and individual experience began. And as soon as anyone mentioned a risk to my baby, I doubted myself, felt bound to comply.

The Lancet’s report demonstrates how emotive the issue is. It is also an example of the fraught relationship between statistics and the individual … the research is defined as a “meta-analysis” … All this data – derived from different countries, from several decades, but no study from Britain more recent than the 90s – was crunched together into sundry percentages and “findings”. The key finding, said the authors, was that the risk of neonatal death is trebled by home birth. The percentage rose from 0.04% for a hospital birth to 0.15% for a home birth. Yet the risks for perinatal mortality … were similar for home and hospital birth. Home birth was also found to reduce the risk of interventions …

Should a risk of 0.15% deter you? Is it real – and relevant to the UK – anyway? If a woman opts for a home birth here, is the risk of her baby dying definitely trebled, in Yorkshire as in Cornwall, in Powys as in Perthshire? Each woman, each baby? One of the authors of the American report, Dr Joseph Wax, suggested that the findings were “likely to be applicable to the UK”. Only likely, not definitely. For every meta-analysis from the US you can find another report, such as the Dutch study of 2009, which concluded that planning a home birth was as safe as planning a hospital birth, “provided… the availability of well-trained midwives and through a good transportation and referral system”.

How do women choose between home births and hospital births? I can only really speak for myself: the matter is so private, bound up with traits of personality, autobiography, circumstance. When I was pregnant for the first time, I thought at first I’d have a home birth. I hadn’t spent a night in hospital since my own birth and fragile infancy. (I was induced a month early by doctors who told my mother that the x-ray showed – for certain – that I was full-term. When I was born I was dramatically underweight, clearly premature. I was put in an incubator for two weeks; separated from my parents.) So perhaps this was significant. Also, I was attracted to the idea of giving birth where I lived. I didn’t want to be stranded in a hospital after the birth, calibrating the hours by the arrival of the drugs trolley, my partner banished each evening. Still, a month before I was due to give birth I was living in a tiny flat with no bath, scant room for a birthing pool, a half- broken church clock outside the window tolling furiously every quarter of an hour. I quite hated that flat, and I had no desire to give birth in it. So I booked myself into the John Radcliffe hospital, Oxford. I was faintly ambivalent about that, but then I was faintly ambivalent about the prospect of giving birth anyway.

A few friends had told me labour was painful. One explained how it made her understand what it was like for soldiers in the trenches, when their limbs were amputated in field hospitals without anaesthetic. A few others had told me it wasn’t as painful as they had expected. But what had they expected? I spent 36 hours in pain, a remorseless, probing pain which escalated even as I struggled to “manage” it, as the midwife encouraged me to do. As I wondered how I could possibly manage something that rolls you around like a crocodile, drags you deep down, so you can’t catch a breath, so you think you must be dying, I was given various “strategies for coping” – a Tens machine buzzing at my back. Suggested “labouring positions”, though no one compelled me to move my limbs in a prescribed way. Anyway, after a while I couldn’t move at all; I was bent double in a rocking chair, inhaling gas and air like an addict. Someone explained – so calmly it enraged me – that I was only a third of the way through. I was very tired; I felt as if I was being repeatedly impaled. So I asked for an epidural – I remember the midwife telling me it would take 10 minutes to work. Contorted on a thin, creaking hospital bed, staring crazily at the clock, I was indifferent to controversies about birth, technocracy versus the natural way and the rest.

My son was born 12 hours later, weighing nearly 11lb. I narrowly escaped a caesarean. It was gory and agricultural, and then there was the moment of surreal joy when I first held him. My daughter, too, was born in a hospital, for another complex of reasons. Neither birth “traumatised” me, as we are sometimes told they might. They are engraved on my memory, but as if I dreamed them. Yet I do, fairly distinctly, recall how kind and professional the midwives and doctors were.

At times, after the birth of my son, I wondered if we might both have died, in another era, without the Lethe of the epidural. It’s impossible to know. My experiences can be immediately counterbalanced by those of friends, including one who gave birth at home in two hours; her husband helped her deliver the baby while talking on the phone to the hospital. She felt no pain at all, simply mild discomfort, and recovered within hours.

Sheila Kitzinger had five children at home. She describes how “when you are on your own territory you don’t have to think about what you are doing. You are able to express the powerful emotions and excitement of birth.” Kitzinger’s daughter, Tess McKenney, had a “wonderful” water birth with a first baby who was just as heavy as mine: “The only injuries I sustained were red marks where my back rubbed the side of the birthing pool.”) Equally, a hospital will not inevitably dull the senses or force a woman into an escalating series of interventions. Abigail Reynolds, an artist, had a violent, elemental labour, without analgesics: “I felt as though I was in a dark forest howling away among the scrubs and prickles, performing some solitary act. I was sweating and struggling about on the bed. The midwife told me to stop screaming because I needed all the energy I had for pushing…” The location? Guy’s and St Thomas’ Hospital, London.

… In Britain the Royal College of Obstetrics and Gynaecology and the Royal College of Midwives jointly support home birth for “low-risk” pregnancies, emphasising that “women have less pain at home and use less pharmacological pain relief, have lower levels of intervention, more autonomy and increased satisfaction”. However, in America (as in Australia and New Zealand), the College of Obstetricians and Gynecologists (ACOG) has stated its “long-standing opposition to home births” and advised women not to be “influenced by what’s fashionable, trendy, or the latest cause célèbre” …

This reveals a crucial problem for mothers-to-be trying to decide what to do: professional opinion is completely divided. Highly qualified, experienced doctors and researchers will tell them wildly contradictory things. Philip Steer, professor of obstetrics at Imperial College School of Medicine, suggests that first-time mothers should give birth in hospital because they simply don’t know if they are likely to have a good labour or not: “The figures for home births are that one in 20 women who eventually have a successful birth will need to be transferred to hospital at some point during the labour. But when you are considering first-time births, that proportion rises to one in four. Transfer is very bad.”

However, Lawrence Impey, consultant obstetrician at the John Radcliffe, doesn’t believe all first-time mothers should automatically go to hospital: “People forget that with home birth women are more relaxed. If you make someone scared and nervous, then you are more likely to have a complication …” …

Perhaps the debate isn’t as simple as homebirth versus hospital birth. There are many other variants that influence the outcomes for mothers and babies such as the model of care and the knowledge, skill and judgment of the care provider. Also important are the decisions that the woman ultimately makes. A birth can be very unsafe in a hospital, despite safe choices, due to a deficit in the skill of the care provider. A birth can be unsafe because of the choices that the woman has made. These things are ultimately not so much about place of birth, as much as the competence of the care provider and the quality of the decision making of the parents.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Brain-damaged boy awarded £6.4million settlement

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A little boy who suffered severe brain damage during his delivery at an NHS birth centre was today awarded £6.4 million in settlement of his medical negligence claim.

… Mr Justice Tugendhat expressed his “admiration and sympathy” to the boy’s parents, Janet Evans and Earnie Kramer, of Welwyn Garden City, Hertfordshire, over the “catastrophe that Theo has suffered”.

He said: “It is, I’m afraid, not unique to read about events as awful as these, but one sitting as a judge can only be in admiration of the way in which Theo’s parents have looked after him.”

The payment to Theo will be made by Barnet and Chase Farm Hospitals NHS Trust on behalf of the Edgware Birth Centre in north-west London.

In a statement issued after the hearing, the family’s solicitors said the trust “has admitted the birth centre was negligent and was responsible for the appalling injuries suffered by little Theo”.

… Theo’s mother was aged 38 when she became pregnant. His parents wanted him to be delivered in “the most natural way whilst at the same time minimising any risk to their much wanted baby”.

… “Janet and Earnie were told the midwives at the birth centre were better trained and more experienced than many midwives working in hospitals.

“They were also reassured the birth centre would be safer for their baby and in the event their baby needed to be delivered in hospital this would be arranged as fast if not faster than for a woman already in hospital.

“Sadly this was not the case. Janet was left in the care of a student midwife. Theo’s heart rate was not properly monitored and the student midwife failed to realise that Theo was in severe distress and needed to be delivered.

“Theo was gravely ill when he was born because he had been deprived of oxygen and there were further delays in arranging for him to be transferred to Barnet General Hospital.”

Theo, an only child, cannot sit up without support, will never be able to walk and has severe learning difficulties.

… “The Government is pushing forward with greater focus on the use of birth centres but needs to realise that higher standards and safer environments cost money and proper training, and support is needed if tragedies like this are to be avoided.”

… “This is a particularly tragic case where Earnie and Janet feel rightfully angry that they were misled into choosing an NHS birth centre to deliver Theo when a safer option in his case would have been a hospital maternity unit.”

In a statement, the trust offered its “sincere apologies” to Theo and his family for the injuries he suffered.

Often, it’s not so much the place of birth that influences the outcome of the birth, but more the knowledge, skill, judgment and experience of the care provider.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Law Gives Nurse Midwives More Independence

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

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When New York City’s St. Vincent’s Hospital closed its doors for good last year, the certified nurse midwives who held practice agreements with the hospital had nowhere to turn. Now, thanks to a landmark piece of legislation that was signed into law in June, every licensed CNM in New York state can practice independent of a physician.

… “Midwives are the acknowledged experts in normal birth — and this legislation ensures that New York’s women have the right to choose the birth options and healthcare providers they desire — including the care of highly educated and licensed midwives.”

… midwives handle low-risk births but have formal or informal relationships with physicians in case complications arise … midwives typically have admitting privileges and the support of the hospital’s attending physician …

Passage of the bill was heavily opposed by the American Congress of Obstetricians and Gynecologists, which says it has concerns regarding safety and the competition it creates with physicians.

What a fantastic outcome! Everyone was very concerned when St. Vincent’s Hospital closed its doors as it was the only hospital that provided written practice agreements with midwives – a requirement of a private midwife’s practice. However, the passage of this Bill paves the way for many women to access safe midwifery care.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women choosing midwives

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When Lisa Unger was pregnant … she saw a gynecologist for medical care. Then she made the switch.

… “I decided I wanted a midwife, I was pregnant, it was not an illness, I didn’t need a doctor. I was going with a midwife who could empower and coach me through the natural function of my body. I wanted to do it in the hospital, I wasn’t comfortable with a home birth … ”

… “The term ‘midwife’ means ‘being with women’. We support them, empower them. We tell them how wonderful they’re doing. ”

The midwife and mom-to-be establish a bond, since midwives are able to spend more time connecting with their patients over time …

Visit my website to learn more about my services.

Caesarean rate continues to rise

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

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The number of women undergoing a Caesarean section in Ireland is continuing to rise, while the number of those opting for home births is on the decline …

… 26.7% of total live births were delivered by Caesarean section. In 1990, this figure was 20.4%.

There were 158 home births attended by independent domiciliary midwives in 2008, compared to 186 in 2007.

… Meanwhile, the perinatal mortality(death) rate was 6.8 per 1,000 live births and stillbirths in 2008. This figure has fallen by 17.1% since 1999, when it was 8.2 per 1,000.

The perinatal mortality rate was highest for babies born to mothers aged 40 to 44 (11.3 per 1,000). The lowest perinatal mortality rate was for babies born to mothers aged 35-39 (5.8 per 1,000) …

Melissa Maimann, Essential Birth Consulting 0400 418 448

How ultrasounds affect mums

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What pregnant women think about routine ultrasound tests for fetal abnormalities is largely ignored by the health profession …

… while prenatal screening in New Zealand is officially referred to as a choice, there has been little discussion about the pros and cons and the first trimester scan for fetal abnormalities test has effectively become an automatic part of pregnancy care.

“Women have been done something of a disservice in this area. Minimal information or support is provided and, in spite of the expectation that women give their informed consent, they are not encouraged to see ultrasound screening as something they need to deliberate over.”

Dr Donovan interviewed a group of women in the Wellington region with varying experiences of ultrasound screening. Some chose not to have a scan, several had false positive tests and one a false negative test during their pregnancies.

She says the accuracy of screening has recently been improved with the addition of a second check, requiring a blood test, but the results still need to be recognised as not completely reliable.

“Amniocentesis … is the only way to diagnose Down Syndrome with certainty and this carries the risk of miscarriage.

“Many women don’t realise that screening is not a precise science. Having a scan can be a negative experience because it can make women feel that pregnancy is a risky business. For those who had an abnormality detected it was a frightening and lonely experience. They felt they were left alone to make the decision about whether to opt for termination or proceed with the pregnancy.”

Dr Donovan believes the majority of women do back the availability of prenatal screening but want more information and support around deciding whether to have a scan and what to do if abnormalities are detected. She says a pamphlet on screening options has recently been developed, but this will only be beneficial for women if their GP or midwife takes the time to offer it and talk it through early enough in the pregnancy.

“There is an unrecognised tension between how screening is understood within the medical profession and how it is experienced by pregnant women themselves. The public health sector endorses screening which is seen as a health good and an economically useful approach.

… “There are actually a range of views out there including women who believe families should have the right to give birth to a disabled child and not be discriminated against for their choice.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘We know the reality of childbirth’

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A new report on NHS maternity care has revealed divisions between midwives and obstetricians. One of the disputes … is over the best way to give birth. While midwives, and the government, advocate natural birth, many female obstetricians opt for a caesarean when they have their own children. Do they know something we don’t?

… Sher, 38, chose an elective caesarean … because she decided it was the safest method … Sher makes decisions on delivery and surgery every day, and she understands the consequences more than most – she is a consultant obstetrician.

One London study … reported that 31% of female obstetricians would personally prefer a caesarean birth. In the US, the figure is almost 50%. Many female surgeons and GPs quietly take this option too – though, as one told me, “to admit as much is still massively un-PC”.

In April 2007, the then health secretary, Patricia Hewitt, launched her strategy for the future of maternity care. Maternity Matters trumpeted “choice”, promising better access to “normal” deliveries via home births and midwife units. Her plans chimed with recent guidelines from the National Institute for Clinical Excellence (Nice) drawn up to reduce caesareans – currently 23% of all births – by advising obstetricians against granting them without medical justification. The official disapproval of elective C-sections means Sher daren’t talk under her real name; Stephanie Sher is a pseudonym.

So while the government promotes “normal” deliveries to the public, its employees are privately planning caesareans. Why do so many obstetricians opt not to push? What do they know that we don’t?

It’s important to remember that it is the obstetrician’s and the surgeon’s task to remedy the rarer complications and consequences of childbirth. Unlike midwives, who oversee successful, normal births every day, doctors bear witness to the worst-case scenarios.

Inevitably this difference in experience manifests itself in an ongoing debate on how best to manage childbirth. Midwife groups advocate normal delivery and “natural” births while obstetricians tend to see medical intervention as a benefit rather than a bane. Yesterday, the healthcare commission published a report highlighting several key problems in Britain’s maternity services, one of which was an inherent tension between midwives and doctors on maternity wards. Caught up in the middle are the mothers.

Maternity experts across the board believe that a straightforward vaginal delivery is by far the best for both mother and baby. Most women agree: 63% of mothers see childbirth as a natural experience that should not be interfered with unless necessary. In “putting women at the centre of maternity provision”, the government’s strategy reflects the overwhelming consensus.

Nevertheless, among all the furore that surrounds the issue of childbirth, for Sher and her colleagues, one thing is clear: the government’s promotion of delivery “choice” is a promise rarely kept. “There is nothing wrong with hoping for a natural event,” Sher says, “and for everything to happen beautifully. But it just isn’t like that for a large proportion of women.”

Sher’s greatest fear was not the pain of spontaneous labour. It was the prospect of emergency intervention, if the birth went wrong. According to the most recent NHS maternity statistics made available (2005-6), just under half (47%) of expectant mothers have a regular, uncomplicated “normal” labour. The rest have interventions ranging from induction, to forceps, to an emergency caesarean. In other words, when a woman tries for a normal birth and the best, safest kind of delivery, she has only a 50% chance of achieving it. For a significant number of others, the birth will be more complex.

I wonder if those women had access to one-to-one midwifery care for their pregnancy, birth and postnatal care? When women are put through a system that sees women having a different midwife at every antenatal visit, shifts of midwives in delivery suite and then shifts of midwives in postnatal, it’s no wonder that most women do not experience a natural birth. bur when women are cared for by the same midwife right from the first visit to 6 weeks postnatal, the outcomes are very different. The ability to develop trust, rapport and understanding are paramount to experiencing natural birth.

With odds like this, it is not illogical to consider alternatives, particularly not if your line of work exposes you to the most extreme of cases. Many obstetricians find the second safest solution is a planned caesarean. The National Caesarean Section Audit (2001) revealed half of obstetricians think this is the safest delivery method for the baby – though not for the mother.

The surgical risks of a planned caesarean include haemorrhage, thrombosis and infection. Scarring on the uterus means the more caesareans you have, the more risky later pregnancies become. But Sher knew she only wanted two children and made the choice that suited her best – both were delivered by C-section. The baby’s safety was her primary motive – but not, she adds, the only one. “The other issue was the risk of pelvic floor damage. Again small, but to me, just not worth it.”

… Michelle Thornton, a colorectal surgeon, sees around 100 women a year suffering from faecal incontinence. “I’m seeing the end result of a traumatic birth,” she says. “Very few of my colleagues would opt for a vaginal delivery and, if any of them asked me, then it’s an elective C-section.”

What about planning for a natural vaginal birth and preparing well for an intact perineum and a short second stage? Private midwives are expert at working with women to achieve these aims. Most women who birth with private midwives do not need stitches and experience a healthy return to normal pelvic floor function.

… Not all experts agree that the risks of a surgical birth outweigh the benefit of protecting the pelvic floor. But calibrating clinical percentages is different from witnessing the lives of women with faecal incontinence, says Thornton. “It’s definitely altered the way I think about childbirth. The thought of being faecally incontinent – to have a life like my patients – I don’t think I’m strong enough.”

… Thornton has half a dozen women in their early 30s. They have “bonding issues with their babies . . . as well as young partners expecting to resume a normal sexual relationship. Two of the couples have split up because of the traumas.” She counsels patients both psychologically and physically. “Emotionally it is tough,” she says. “Having those patients with you when they get upset is tough.” When treatments fail, “it’s terrible, because the patient is absolutely gutted”. Her patients know a permanent colostomy is the only solution. Imparting this news always makes Thornton anxious. “It’s a terrible feeling. It’s like giving them a cancer diagnosis.”

When it comes to medical matters, we assume that knowledge is a good thing. Looking at the childbirth choices made by some female doctors, we might think their superior professional experience makes them right. But many admit their exposure to complications inevitably taints their personal choices. Is it really better to know what they know? Perhaps it’s not that most women don’t know enough – but that female doctors, and particularly obstetricians, know too much.

… If you’ve seen deliveries, she says, “you know the reality.” And “maybe that’s why doctors go and have caesareans – they know it is quite a risky time”.

Interesting, as many midwives opt for homebirths when they have their babies.

Consultant obstetrician Virginia Beckett also puts it plainly: “When I was 14 weeks pregnant I dealt with 12 stillbirths in one 24-hour shift. You can imagine that might skew your view of how to manage your labour.” (Beckett has had two caesareans, the first because her baby was breach, the second was elective). On that particular shift, her baby was too small for her to feel any movement. Emotionally drained and anxious, she scanned herself in the middle of the night. She needed to know her own baby was still alive.

Beckett has worked in obstetrics for more than 16 years, but dealing with stillbirths “doesn’t get any easier”. As the obstetrician, you “go in with the machine and with the patient’s eyes boring in to the side of your head, make the diagnosis and break the news”.

Every time it happens Beckett finds it “heartbreaking, sometimes I do cry actually, not in front of the patient. You feel terrible . . . But there’s nothing you can do.” In the middle of a busy shift there is no time to reflect. “You can’t spend half an hour coming down from every case,” Beckett says, “because there will be another one along in a minute.”

Complications include “abruptions, where the placenta separates and mum and baby can bleed to death. We see people having seizures with pre-eclampsia or eclampsia. We see people’s uteruses rupturing when they’ve had a caesarean section in the past. We see acute fetal distress. We see very complicated vaginal deliveries using instruments, at which various degrees of injury can be sustained . . . All life is here as they say.”

It is the obstetrician’s job to control the less palatable, natural, consequences of childbirth. And they are very good at it. The UK is one of the safest places in the world to have a baby. And of the 1,917 babies born each day in this country, just 11 will be stillborn. “We know that when we work effectively we’re able to make a difference and that’s why we keep doing the job. When it goes to plan, you feel very positive.”

And when things go badly? “You feel absolutely awful: drained and disempowered, really.” Choosing a caesarean, admits Beckett, is one way of redressing this because “you realise how out of control things can be sometimes” and ultimately, “how fragile life is”.

The medics making this choice are unlikely to find support among their colleagues in the midwife unit or even, in some cases, their employers. Current Nice guidelines discourage obstetricians from offering C-sections on “maternal request”. Instead, natural births top the government’s maternity “menu”, with home births promised alongside other “normal” delivery options by 2009.

Privately, however, many obstetricians believe women should be able to choose a caesarean, if they are aware of the risks. Consultant obstetrician Sara Paterson-Brown has publicly asserted a woman’s right to an informed choice because “mothers must live with the consequences”. Her hospital has not since suffered a stampede of women eager for the surgeon’s knife. “Women are counselled and fully informed and recommendations are made,” she says. “We don’t feel threatened by women expressing their choice.”

Paterson-Brown won’t tell me how her own children were delivered, but resolutely feels “the best way to have a baby is normally with no complications. The trouble is, you don’t know if that’s going to be you or not.”

The vast majority of women want a vaginal birth. Just 3% of women even ask for a caesarean without medical indication. Almost 25% will end up having one anyway – largely in emergency circumstances – and a substantial number find their “normal” delivery will go seriously off plan. “There is a lot of luck involved,” says Beckett, “and sometimes the luck isn’t there for you.” Doctors know this, lay women don’t; and when things go wrong, they blame themselves.

Luck? Is it “luck” if we get a uni degree? Is it “luck” if we pull off a dinner party? Is it luck if we get through a very busy week with everything achieved as planned? Or, is it good planning, good information, good support and confidence in our abilities? There is so much a woman can do to achieve a positive, natural birth: she can inform herself, plan for a great birth, increase confidence and engage supportive care providers. Without this, intervention is the most likely result because that is the world we live in today: a world that is fear-ridden and that seeks to control that which we do not fully understand. I believe that most pregnancy and childbirth “complications” are mediated emotionally and mentally. When women are supported, informed, confident, prepared and cared for by a care provider who supports natural birth, she is most likely to birth her baby naturally.

Dr Abigail Fry remembers one birth as a medical student which turned from “calm” to “completely crazy” when a cautious doctor intervened. It became a difficult forceps delivery. Afterwards she remembers “the registrar doing the woman’s stitches and saying: ‘Do you think this bit, you know, should go there?’ And I was like ‘I don’t know!’ It was a mess.” Unlike her obstetric colleagues, Fry chose a home birth.

… “I really enjoyed it.” …

A recent study also found a huge polarity between pregnant women’s expectations of birth and the reality. Expectant mothers need not be frightened by rare, unlikely risks, but they should be given realistic information about the pain and unpredictability of childbirth.

How is that not frightening women? “It’s going to hurt like nothing else … it’ll be excruciating. Oh, and by the way, birth is also unpredictable so don’t have any expectations because they’ll be shattered”. How about, “The sensations of birth can be managed in many ways such as with water, hot packs, movement, position changes (etc). Birth can be unpredictable and so it might be helpful to spend some time going through some of the more likely issues that can come up and to look at how they might be managed at the time.” The latter is far more empowering and less fear-provoking than the former.

Instead there exists a misguided, competitive birth culture; where “lucky” or natural “birthers” are praised for their success, while mothers who “succumb” to medical intervention openly admit they’ve “failed”. Elective caesarean births are so low on the league table they can barely be mentioned without fear of acrimony.

“Women need education,” says Linda Cardozo, a professor in urogynaecology, who blames the “brand of doing it naturally” for this competitive approach as well as the trend for the “madness” of home births. “Most are perfectly safe,” Cardozo admits, “but if something does go wrong you’re in the wrong place to deal with it.” Childbirth is a natural process, but she thinks we’ve forgotten it’s also “a natural process for far more mothers to be damaged and far more babies to die, and medical intervention is absolutely wonderful because it’s prevented that”.

But this does not make Cardozo an advocate of elective caesareans. She remembers colleagues choosing them 20 years ago, but personally felt differently. “You see bad experiences in all deliveries, not just vaginal,” she says, besides which, “I truly don’t believe the risk is worthwhile.

Caesarean section is an operation and all operations carry a complication rate.” So Cardozo did what most women in the UK do, and delivered her three children vaginally, in hospital. Two were twins, one delivered by forceps. “And I’m not incontinent – yet,” she says …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Obstetricians are ready to quit

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ALMOST a third of obstetricians are considering quitting private practice due to changes to the Medicare safety net, which slash the amount patients can claim for pregnancy services.

… Most said they have had a drop in private bookings since the changes to the rebate and the majority said the fall had been between 10 and 40 per cent.

… Federal Health Minister Nicola Roxon moved to cap Medicare safety net payments for women who use private obstetricians after the specialists were accused of raising fees to take advantage of the scheme …

… 49 per cent of 740 patients said they would use the public health system.

Obstetricians are losing business but what is really happening is an incentive for women to use primary care in pregnancy: a private midwife. Private midwives who have Medicare provider numbers are required to work collaboratively with obstetricians, hence assuring that there will always be a mechanism to provide for obstetric care for women who need these high-level services. The future of private maternity care sees women accessing midwifery care for the most part, and private obstetricians when needed, on referral from the midwife.

Melissa Maimann, Essential Birth Consulting 0400 418 448

New era born as Rossendale birthing centre opens

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I’m impressed by the positive way in which the obstetrician in this article talks about the new midwifery models of care that are being offered.

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A NEW era for birthing in East Lancashire begins today with the opening of the Rossendale Birth Centre.

The unit … will have two home-from-home, en-suite birth rooms, with a birth pool in one of the rooms, and will be managed by midwives, encouraging healthy women to give birth naturally in a relaxed, friendly atmosphere.

… healthy pregnant women in East Lancashire can now choose between a birth at home, supported by midwives, at their nearest birth centre, or in the £32million centre in Burnley.

Women who are likely to have more complex births are advised to have their babies in hospital.

Rineke Schram, consultant obstetrician and medical director of East Lancashire Hospitals Trust, said: “Different women have very different needs during birth, and our new model of care allows us to make sure everyone’s needs are fully catered for.

“The midwife-led birth centres are a fantastic choice because they foster a relaxed atmosphere in which they can go through labour at their own pace, in the position most comfortable for them.

“A stress-free birth is the best possible start a mother and baby can have.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Continuity of Midwifery Care

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HE’S the fourth son born to Natalie … but the first child born as part of the new midwifery group practice model now offered by Manly Hospital.

… From the moment she came under the new model, launched on October 15, Mrs Sengchanh has only had one midwife … by her side.

… “Previously I’d go to the clinic at the hospital and see whichever midwives were on at that time,” she said.

… The difference … between the previous births and her latest is stark.

“I can’t remember the names of any of the midwives who helped me deliver my first three sons,” she said.

“Sometimes a midwife would come and visit me but it would be a different one each time.

“This was definitely my best labour.

“I was calm the whole time because Anne was there and she knew exactly what I wanted.”

And a lovely comment followed:

I am so pleased to see Manly is implementing this model of midwifery care.

Seeing the same midwife throughout your pregnancy and birth is proven to result in better outcomes for mothers and babies … That option wasn’t available when I had my two children, so we employed our own, independent midwife. For the most amazing, personal experience of my life I wanted someone who I knew and trusted to be looking after me. She was there in the hospital with us for my first child when I had to be induced – and thanks to her being there I was still able to have a waterbirth, and at home with us for our second. She was on call 24/7 …

The difference between public continuity of midwifery and private midwifery care is that private midwifery care practically guarantees the woman a) choice of midwife and b) that the midwife that she has chosen will be the midwife to deliver all of her care. Pubic models tend to work in a team fashion whereby a woman has a named midwife (not necessarily chosen by the woman) but the named midwife works in a group with 2 or 3 other midwives. Midwives may rotate on-call work and have weekends and days off. Hence, women are not guaranteed that their named midwife will actually be with her when she births.

The other important difference is that a private midwife usually has a much lower caseload than a public hospital midwife, and hence she is a) more available to her clients in pregnancy; b) far less likely to be attending another birth at the time that you go into labour and c) provides more extensive postnatal care, generally for 6 weeks.

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Unnecessary C-Sections on the Rise

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Australia’s caesarean rate was 31.1% in 2008.

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Five years ago, Jill Arnold got some unwanted news at her obstetrician’s office. At 37 weeks pregnant, Arnold was told her baby was too big for her body to deliver naturally. Flipping open a calendar, the obstetrician asked when Arnold would like to schedule a cesarean section.

Fact: You cannot know that a baby is “too big” until you give labour a go.

Unconvinced she needed the surgery — the doctor “couldn’t provide any statistics or data” her baby was too large — Arnold delivered her 10-pound, 3-ounce (4.6 kilogram) baby the old-fashioned way. Since then, the now 36-year old … delivered another baby weighing 11 pounds, and now pens a blog called The Unnecesarean.

Women like Arnold, however, are becoming increasingly rare. Between 1996 and 2007, the number of C-sections performed in U.S. hospitals rose by more than 50 percent to an all-time high: Almost one in three pregnant women …

“The most concerning problem is the high rate in first-time mothers,” …

… The shift is toward a more streamlined labor and delivery, and profoundly affects mothers-to-be.

… this shift is not likely to reverse any time soon.

In 2009, 26-year old Ann Carter … labored for 14 hours. With her cervix dilated to only 6 centimeters … her doctor told her it was time for a C-section.

“I was devastated and scared,” Carter said, “I knew it was a possibility but I was hoping it wouldn’t happen.”

During the surgery, the doctor discovered the umbilical cord had wrapped around the baby’s neck, which explained why Carter’s labor had stalled. The C-section saved the baby boy’s life.

Um, actually, it is very common for the cord to be around the baby’s neck, and it rarely causes concerns.

“Most times the decision to perform a C-section is based on the physician’s judgment,” Zhang said, “but there are great variations in decision-making among physicians.”

… there are “few clear-cut indications” of when to do one.

… For example, the American Congress of Obstetricians and Gynecologists (ACOG) lists “failure to progress” during labor, as an indication that cesarean delivery is needed … When things slow down, there is an element of judgment involved where a physician determines whether to continue to wait, induce or perform a C-section … it can take hours to determine whether or not labor is progressing.

In Zhang’s study, however, he found that many patients weren’t given a sufficiently long time period to allow their labor to progress. In other words, doctors were calling it quits on waiting and opting for a C-section too soon — often before the patient’s cervix was dilated to 6 centimeters.

This was especially true in cases of induced labor … Almost half of the C-sections in these women occurred before they were 6 centimeters dilated …

Still, it is not clear whether inducing labor raises the risk of C-section, or whether other factors are involved that contribute to why women were induced in the first place …

… Another factor contributing to the record-high cesarean rates is a drastic decline in vaginal births after cesarean … 70 percent of women in his study who had previously undergone a cesarean delivery had C-sections with their subsequent pregnancies, without attempting vaginal delivery.

One reason for this is a fear of lawsuits. If a physician doesn’t perform a C-section, and something goes wrong with a patient who previously had a C-section, the law often does not protect the physician …

… the number of malpractice claims involving obstetric and gynecologic surgery are the second highest of all medical specialties. In 2009, the claims totaled over $133 million.

Fears of legal action also explain why at least 30 percent of all U.S. hospitals have official bans prohibiting VBACs …

The risks associated with a vaginal birth following a C-section have been somewhat exaggerated, however, Zhang said.

“Women and physicians may be concerned about uterine rupture, but the risk is less than 1 percent,” …

To help reduce rising cesarean rates, the American Congress of Obstetricians and Gynecologists announced less restrictive guidelines in July, stating that vaginal birth “has fewer complications than a repeat cesarean….restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against her will.” …

… some medical experts have suggested the rapid rise of C-sections in the last decade is also due in small part to mothers-to-be requesting them, not doctors. Still, data on “patient choice cesareans” is lacking, as statistics used as support of their frequency are often based on ambiguous procedural codes used on hospital discharge records.

In any case, women who opt for a C-section may not be getting adequate information about risks, and may fear they have no other option …

… To curb the rise, many advocate giving women more autonomy over their labor and delivery, and combining the strengths of modern medicine with the principles and practices of midwifery.

La Follette’s California office is an example of this more comprehensive approach: After participating in a larger practice for 12 years, she now works with two experienced midwives and another physician. Her practice has a successful VBAC rate of 75 percent.

“We take into account the expectations and ideas of the mom and balance that with medical guidance,” La Follette said.

As more women consider practices with midwives and home births — which can be dangerous if complications arise — much of the medical establishment has been digging in its heels. In 2008, the American Medical Association’s House of Delegates proposed a resolution to declare hospitals the only safe place for labor, and only midwives who work under the supervision of physicians as safe.

The Midwives Alliance of North America declared the resolution “seriously out-of-step with the ethical concept of patient autonomy in healthcare [that] distracts from other critical issues in maternity care.”

If there is any chance of lowering the rates of C-sections, professional organizations will need to review all the available evidence, Zhang said.

But any change won’t be easy. On the one hand, doctors need to include expectant moms in their own care; on the other, it sometimes seems that doctors who are worried about potential legal consequences can’t focus on a patient’s best interests.

“We’re fighting a cultural issue,” Scott said, that extends beyond C-sections.

She said, “We need to change the entire way we view birth and we have to be able to trust our caregivers. The alternative would be terrifying.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Oxytocin Medication Often Unnecessary In Normal Deliveries

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It is standard practice … to use oxytocin to stimulate a labour that has been slow to start or has grind to a halt for a few hours. However, it is also fine to wait for a further three hours in first-time mothers …

… Healthy first-time mothers with normal pregnancies and a spontaneous start of active labour were monitored throughout their deliveries, with a follow-up one month later. Those with a slow or arrested first stage labour, were randomly allocated to early oxytocin treatment or expectancy for 3 hours. All of the women were given the same access to pain relief and staff support.

The results showed that there were no differences between the groups in terms of the number of caesareans, ventouse deliveries, major haemorrhages, significant tears, or newborns needing neonatal care. In the expectancy group, treatment with an oxytocin drip was avoided in 13% of women and, as expected, the deliveries took slightly longer time. A month after delivery both groups of women were equally positive or negative about their birth experience.

… “A normal first delivery and positive birth experience are extremely important and impact on future pregnancies and deliveries,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Use Of DHA Fish Oil Capsules Does Not Decrease Postpartum Depression In Mothers Or Improve Cognitive Or Language Development Of Offspring

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In contrast to the findings of some studies and the recommendations that pregnant women increase their intake of fish oil via dietary docosahexaenoic acid (DHA) because of the possible benefits, a randomized trial that included more than 2,000 women finds that use of DHA supplements did not result in lower levels of postpartum depression in mothers or improved cognitive and language development in their offspring during early childhood …

… “Despite the paucity of evidence, recommendations exist to increase intake of DHA in pregnancy, and the nutritional supplement industry successfully markets prenatal supplements with DHA to optimize brain function of mother and infant. Before DHA supplementation in pregnancy becomes widespread, it is important to know not only if there are benefits, but also of any risks for either the mother or child,” the authors state.

“Current recommendations suggest that pregnant women increase their dietary DHA to improve their health outcomes as well as those of their children. Such recommendations are increasingly being adopted with women taking prenatal supplements with DHA,” the authors write. “However, the results of [this trial] do not support routine DHA supplementation for pregnant women to reduce depressive symptoms or to improve cognitive or language outcomes in early childhood.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Increased forceps training ‘could cut caesarean births’

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Additional training in difficult births could help [lower] caesarean section operations …

… extra training could reverse the trend for caesarean sections being used in cases where an instrumental delivery would have been more appropriate.

… emergency caesarean sections carry a risk of “severe obstetric morbidity”, while proper use of forceps can be much safer – and make vaginal birth easier in the future …

If an assisted birth is needed, forceps are more likely than a vacuum to result in a vaginal birth. The vacuum is more likely to slip off, sometimes several times, before a caesarean is called for, whereas the forces are far more likely to result in a vaginal birth. Having a caesarean for the first birth makes all future pregnancies and births labelled “high risk” and will dramatically lower a woman’s chance of ever having a vaginal birth. So it’s really important to maximise the possibility of a vaginal birth for the first baby. Following births are generally much quicker and easier!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Avoid Giving Birth on the Back and Follow the Body’s Urges to Push

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

Most commonly in birth centres and private midwifery practice, women are encouraged to birth their babies in upright birth positions such as kneeling, all fours and standing. As well, they are encouraged to find and use their body’s own signals for pushing / breathing their babies out. Doing so results in fewer tears, fewer distressed babies and perhaps a slightly longer second stage, however this is not concerning if mum and baby are well. In hospitals however, women are often encouraged to push (“take a big breath in, hold and it, and push really ard, right down into your bottom ..;”) while in the most difficult birthing position of all: semi-recumbent. This article below provides some great info on the second stage of labour.

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… Throughout history, images depicted in art show that women have used many positions to give birth to their babies, including standing, sitting, hands-and-knees, and side-lying. Until doctors began using forceps in the 17th century, women rarely were shown giving birth lying on their back. With the support and encouragement of family members and community midwives, laboring women used objects such as posts and ropes to gain leverage during pushing. They often used birthing supports or stools to help them squat, crouch, or kneel … More recently, research has helped us understand how laboring women push when no one is telling them to push a certain way. Women following their own urge to push usually will wait for each contraction to build and then push for about five seconds, take a few short breaths, and then push again …

In contrast, a recent survey … reported that 57% gave birth lying on their back, and an additional 35% gave birth propped up in a semisitting position … Only 21% of women in the survey followed their own urge to push. The rest of the women reported that … health-care providers told them to push a certain way.

… By choosing the positions that feel most comfortable, you can create an overall more positive birth experience. Just as importantly, doing this enhances the progress of labor.

Using several positions during the bearing-down or pushing part of labor helps you work with your baby as she turns and comes down through your pelvis. The positions that you choose often will make you more comfortable and help your baby’s progress. There is no one position that is best for every woman and every baby. Each position has advantages and disadvantages and can be helpful in different situations …

Upright Positions
Upright positions—such as standing, kneeling, or squatting—take advantage of gravity to help your baby move down into the pelvis …

Positions That Do Not Use Gravity
… Lying on your side will help slow down a labor that is progressing too fast and may help avoid tearing of the area between the vagina and anus as the baby comes out … the hands-and-knees position helps ease back pain in labor …

Types of Pushing
When you push in response to the natural urge to push, it is called “spontaneous pushing,” meaning you are doing what your body tells you to do. This natural urge comes and goes several times during each contraction. Each of these bearing-down efforts or urges usually lasts from five to seven seconds. However, when you are directed by your caregiver and those around you to hold your breath and push to a count of 10 seconds, repeating this two to three times during a contraction, you are using directed pushing.

Responding to the urge to push with short periods of holding your breath … has many advantages. Your baby will get more oxygen through the placenta, you will be less likely to become physically exhausted, and there is less chance of damage to the perineum and the muscles of the pelvic floor in the vagina … If you are having a very difficult time pushing the baby out, directed pushing might help. However, pushing spontaneously will usually be easiest and safest for both you and your baby.

What Research Tells Us
… the use of any upright or side-lying position compared with lying on your back with your legs in stirrups is associated with the following results:

* shorter second (pushing) stage of labor;
* a small decrease in the use of vacuum or forceps;
* fewer episiotomies;
* less chance of experiencing severe pain;
* fewer abnormal fetal heart tracings;
* a small increase in second-degree tears (in the upright group only); and
* an increase in estimated blood loss, although there was no evidence of serious or long-term problems from the extra blood loss …

Lying on your back may cause lower blood pressure and less blood flow to your baby due to the weight of the uterus on major blood vessels … When you lie on your back with your legs up in stirrups, you are actually pushing your baby out against gravity.

Research does not support the routine use of directed pushing, and some researchers suggest it is harmful. Holding your breath for a long time naturally decreases the flow of oxygen to your baby. Research suggests that this is stressful and may even be harmful for your baby … Also, the excess force of directed pushing can be harmful to your perineum, resulting in more tears and weaker pelvic floor muscles several months after the birth … Weakness in these muscles is associated with incontinence … Listening to your body, working with the pushing urges, and birthing your baby between contractions reduce the risk of tears …

One study showed that the average length of the pushing part of labor is 13 minutes shorter in women who use directed pushing … However, there is no medical benefit to a shorter second stage of labor as long as you and your baby are doing well … Because there are no important benefits to directed pushing and there is the possibility of harm when it is used, it is best for you and your baby if you push how and when it feels right to you …

Melissa Maimann, Essential Birth Consulting 0400 418 448

I was pregnant for 10 months

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

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Jack, my third child, arrived last month, 20 days late. My first two babies were 15 days late. But a day shy of week 43? That is virtually record-breaking – and, some would say, slightly mad …

Historically, tales of weirdly overdue babies are not unprecedented. The actor Jackie Chan claims his mother carried him for 12 months before he was born by caesarean section, weighing 12lb. There is also a story of a woman in a prisoner of war camp who allegedly waited until the camp was liberated to give birth – at 12 months’ gestation.

… I held out as long as I could, but in the end Jack was induced. I wish it could have been otherwise. The day before he was born, the hospital consultant had made it clear that she didn’t agree with me remaining pregnant for a day longer. Despite the fact that there were no signs that there was anything wrong, there was a risk of stillbirth, she said. “How does that apply to this pregnancy in particular?” I asked, as all my tests were clear. “You’re very overdue,” came the answer. I could have waited another day or two maybe. But I wasn’t happy acting against the hospital’s wishes.

The induced labour was not a terrible experience – Jack was born with no complications in 50 minutes – but it was not ideal. I had wanted him to come out when he wanted to. Not when a doctor ordered him to. It turned out that he was large, but not abnormally so (8lb 12oz; his sister was larger at 9lb). And he had no signs of being post-dates: no wrinkly skin, and the amniotic fluid was clear …

So why is 40 weeks seen as the norm when only 5% of babies arrive on their due date – and when it is 41 weeks in France? Could we be inducing babies who don’t need to be induced – exposing both them and their mothers to unnecessary risk?

The US midwifery guru Ina May Gaskin thinks so. She believes that every baby will come in its own time, and she is currently campaigning for 43 weeks – rather than 42 – as the definition of “late”. The dates in themselves, says Gaskin, do not indicate the need for induction. There are clear signs if there is something wrong and the baby needs to come out: reduced foetal movement, for example, a deceleration in growth, or reduced amniotic fluid – all of which could be picked up by the mother or a midwife.

In recent years the ultrasound dating scan at 12 weeks has been seen as the best measure of due date in the UK. Statistics suggest it is marginally more accurate than the traditional LMP … date …

The trouble is that very few women fit the “average” – hence the huge variation in the dates when babies are born. Seventy per cent arrive after their due date. And yet it has become a fixed point by which we measure everything in pregnancy. Meanwhile, induction rates in England are rising …

Hannah Latham … was 18 days overdue when she gave birth to Noah, now six weeks old. “I do wish they could give you a ‘due window’ of three weeks instead of a due date,” she says. “It becomes very stressful. You have all these people hassling you, saying, ‘Isn’t he here yet?’ Because, of course, you tell everybody your due date. Which in future I wouldn’t do.” Latham consented to an induction in the end because an ultrasound scan showed that the amniotic fluid was starting to run low.

“Until then there was no good reason to induce. But they pressure you from when you are a week overdue. They say to you, ‘Are you aware that you are putting your baby at risk?’ I said, according to what statistics? They said, ‘We don’t know.’”

This is the problem with overdue babies: there is very little evidence because so few women allow their pregnancies to go past 42 weeks. As US midwife Gail Hart points out, the most-cited statistic about post-dates babies (that their risk of stillbirth “doubles after 42 weeks”) comes from a 1958 study – a time when mortality rates were 10 times what they are now. Also, as Hart argues, induction is hardly risk-free: it carries higher rates of caesarean section, uterine rupture, foetal distress and maternal haemorrhage.

These risks were what put me off induction. Home birth was also a factor, as it is for many: if you agree to induction, it has to happen in hospital. This usually means you end up being monitored, wired up to a machine to measure the baby’s heart rate, and you will have to deliver flat on your back. Having given birth twice, I know that I cope best if I am free to rampage around the room. Because my midwife knew me very well … she helped me to stand and move around, while still being monitored …

… Joanne King’s second baby was born at 43 weeks plus three days. She writes: “I explained [to the consultant] that I thought the risk of being induced versus carrying on with the pregnancy – when the baby and I were well – was not one worth taking. She agreed with me.”

… The latest baby Jokinen delivered was 44 weeks gestation. “As a midwife you know if a baby is truly post-mature by the state of the skin. It’s drier and flakier. They look like someone who has been in the water too long.” But according to one American study [cited by Gail Hart in Midwifery Today], more than 90% of supposedly “late” babies born at 43 weeks in fact show no signs of post-maturity.

Gaskin argues that in the US there is a new medical complication, “iatrogenic” (“doctor-caused”) prematurity – “inductions where babies turn out to be premature and then spend a week or more in the neonatal intensive care unit”. She says in four decades of experience and thousands of pregnancies, she has seen only one woman who needed to be induced. “We’ve had experience with many Amish families in which 43-week pregnancies seem to be the norm.”

To most hospitals, Gaskin adds, a lack of symptoms – and the patient’s history – is irrelevant: “This habit of making absolute rules that are applied to cases that used to be open to individual treatment has contributed to the dumbing down of maternity care.”

This is true in the UK too. I couldn’t understand why my doctor was not interested in all the heart monitoring (every two days after 42 weeks) – and all perfect – or in the ultrasound scan. Nor was there any interest in my birth history (two late babies and fast births, which I thought made me a poor candidate for induction). All that mattered were the statistics – from 1958 …

Many aspects of birth care are not studied because we have clinical practice guidelines / best practice guidelines in place (which may be based on good research, not-so-good research, expert opinion, or “it’s just what we do here”). The effect of these clinical practice guidelines is to establish a standard of care that can reasonably be expected. That being the case, it would then be unethical to randomise the care of women to an experimental arm of a study trial that might cause harm. Hence, we do lack research around management of post term pregnancies (those that continue beyond 42 weeks). It may be the case, as is pointed out in a RANZCOG publication that some women do not benefit from induction at any gestation, such as women who have previously had a baby and whose pregnancy is free of complications.

Another aspect that is not studied, and which might not be ethical to study, is that of continuous fetal monitoring in labour for women with risk-associated labours. It is standard practice, according to NICE guidelines, hospital policies, RANZCOG Guidelines and so on, to continuously monitor labours which fall into certain categories (over 42 weeks, less than 37 weeks, induction, high blood pressure, gestational diabetes on insulin, VBAC, prolonged rupture of the membranes, pre-eclampsia, augmentation of labour, “prolonged” labour, breech, twins or meconium-staining of the amniotic fluid). The alternative to this, as offered in the NSW Health policy, is for intermittent CTGs in labour: having the CTG on for a certain period of time and then removing it for a period of time before re-applying it. Now that CTGs have become the accepted standard of care of women who are labouring with identified risk factors, it would be considered unethical to randomise women to either continous monitoring, or the other alternative which would be intermittent auscultation (where the midwife listens in with a water-proof doppler) every 10-15 mins. My personal opinion is that one-to-one midwifery care in labour (that is, a dedicated midwife who does not leave the labouring woman) combined with regular (10 – 15 minutely) doppler auscultation is as effective and safe as a CTG. If any concern was raised with this doppler monitoring, a CTG would be applied. Of course, my idea is not evidence-based as there is no evidence for this standard of care, and nor will there ever be a study on this as the accepted standard has already been set.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Plan ahead for collaboration

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

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The AMA is urging GPs to sign-up to the government’s plans for them to work in collaborative arrangements with nurses and midwives, despite risks that the move could leave doctors out-of-pocket.

Ahead of the November start date for reforms to allow nurses and midwives to get MBS and PBS access, the AMA is calling on GPs to jump on the band-wagon.

… Federal President Dr Andrew Pesce insists there is a “real need” for the move.

… The AMA advises GPs to check with their indemnity provider to confirm they are covered while within the collaboration and to have a written agreement with the midwife or nurse.

Doctors should also ensure that any collaborative arrangement does not extend beyond their current area of practice, and to be prepared for arrangements that do not work out and need to be terminated, the AMA says.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Natural childbirth: whose birth plan is it anyway?

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With the trend for ‘natural’ childbirth growing and a government setting targets for home births, are British women really free to choose how they’d like to go through labour, or must they bow to a new earth-mother ideology? …

Hannah Hancock was pregnant with her first child she was keen on the idea of a drug-free birth. But … when labour pains kicked in, ideals were abandoned. ‘It was a long labour. At first I was on an oxytocin drip, then on pethidine, and a few hours later when they asked me if I wanted an epidural I was shouting, “Give it to me now!”‘

This is a common occurrence in hospitals where women do not have continuity of care and women don’t have access to resources and preparation to help them through natural labour and birth.

Two years later Hancock gave birth at a London teaching hospital. There the experience was very different.

‘I knew I wanted an epidural but the midwife ignored me, saying, “Why do you want pain relief? You’re doing really well.” I was crying, saying, “I don’t want to do well!”‘ Hancock begged her to find the anaesthetist. ‘But she just stood outside the door not going anywhere.’

Another scenario that doesn’t generally happen with continuity of midwifery care and in particular private midwifery care. In these cases, the woman and midwife have formed a trusting and caring relationship so that the woman has been able – ahead of time – to let her midwife know her intentions for her birth and the midwife is then able to support her.

In the end Hancock gave birth to her daughter using just gas and air. ‘It didn’t help at all. I was panicking so much at the prospect of no pain relief I couldn’t relax and tore really badly. I couldn’t understand this patronising attitude … It really coloured my view of the birth. When Ines was laid in my arms it was a special, dreamy moment. The second time I was in such shock, I’d been in so much pain without anybody helping, I could barely look at the baby.’

Birth trauma happens after natural birth as well as after birth with intervention.

As any woman with children knows, the politics of childbirth are so highly charged they make infighting between Labour and the Tories look like a teddy bears’ picnic. On one side sit the medics, portrayed by their detractors as men in white coats intent on cutting women open so they can avoid litigation and clock off on the dot of six. On the other sit the midwives, scoffed at as strident feminists denying women modern analgesia in favour of whale-music CDs and back rubs. In the middle of these competing philosophies is a labouring mother, her wishes drowned out in the clamour of debate.

Maureen Treadwell of the Birth Trauma Association, which supports women who have had difficult births, says that far too often ideology takes precedence over individuals’ needs. ‘The consequences can be unbelievably cruel. The truth is that what suits some women can be distressing and wholly unacceptable to others. Some women are obsessed with a natural birth and are distraught if this doesn’t happen. But for others – say, a 40-year-old woman who has had three miscarriages – the priority may be having the safest birth possible with naturalness very low on the list.’

At the heart of much of the argument are the philosophies of Grantly Dick-Read, a British obstetrician who was convinced that much of labour pain came from society conditioning women to expect it. His 1942 classic Childbirth Without Fear expounded his belief that women educated to be free of fear and tension would experience birth as a ‘normal and natural defecation’. Pain relief, he said, was undesirable because it affected the baby and slowed down labour, frequently leading to interventions, such as the use of forceps or the ventouse vacuum pump, or emergency caesareans.

Dick-Read became the first president of the Natural Childbirth Trust, promoting better understanding of his system. This later became the National Childbirth Trust (NCT), whose antenatal classes are seen as a rite of passage for all middle-class couples …

While acknowledging that pain is subjective, Belinda Phipps, the NCT’s chief executive, defends such a stance. ‘A lot of women who feel they are denied an epidural are on the verge of starting to push the baby out and don’t actually need one any more … an experienced midwife will know she’s actually getting ready to push and persuade her to wait a few more minutes. She should reassure her that what she’s feeling is normal and let her know it won’t last much longer …

Others, however, are furious their wishes were ignored. ‘I talk to women who have been left screaming in agony because they were either not offered or were refused pain relief,’ Treadwell says. ‘Afterwards, they’ve needed psychological help, their relationships have been scarred, they’ve been afraid of getting pregnant again, they don’t bond with their babies.’ …

Fashions in giving birth are as variable as hemlines. Tina Cassidy, the author of Birth: A History, asserts, ‘The way we choose to give birth reflects the culture of the age. Whenever women feel their choices are being limited by political decisions, they push back and say, “We can do what we darn well want.”‘

In the early 20th century the church preached that suffering in childbirth was the curse of Eve and that to try to avoid pain was a sin. Outraged by such repression, the suffragette movement embraced the introduction of ‘twilight sleep’, a mixture of morphine and the amnesiac scopolamine injected during labour to made women forget the pain. Obstetricians initially expressed doubts about drugging women, but were rapidly shouted down. The result was that birth quickly became so medicalised that by the 1970s another generation of feminists were fighting for the right to experience childbirth awake.

‘In the 1980s, when women were in thrall to “having it all”, they embraced epidurals that rid them of pain while allowing them to be conscious,’ Cassidy says. ‘In the 1990s, when the focus was on technology and convenience, there was a vogue for elective caesareans.’

In today’s eco-conscious society, the pendulum has swung back towards nature. On Manhattan’s Upper East Side society women reputedly send out birth announcement cards embossed with the words natural childbirth in gold letters …

In Britain the number of home births has risen from a low of one per cent in the 1980s to nearly three per cent today, a trend that the government seems eager to assist …

The debate becomes even more heated when it comes to elective caesareans. The National Institute for Clinical Excellence (Nice), responsible for government guidelines, is pushing for a reduction in the caesarean rate from 23 per cent of all births to the World Health Organisation’s recommended ten to 15 per cent. In fact, while acknowledging that a caesarean is major surgery, some women prefer the idea of a planned operation to the unpredictability of a vaginal birth. When pregnant for the first time, Leigh East, 37, from West Yorkshire, was terrified at the prospect of natural childbirth, not least because so many of her friends’ attempts had ended in traumatic emergency caesareans.

‘At my antenatal class they acted out a caesarean, showing you how there would be 12 people in the room,’ she says. ‘This was portrayed as a negative thing, but for me it seemed like a no-brainer. Why would I not want everyone I could possibly need around me?’ Certain she wanted a caesarean, East had to battle to get one on the NHS. ‘Midwives judged and lectured me,’ she says. Eventually a consultant agreed to her request. ‘It was the most amazing, calm experience, and I knew I had made the right choice.’

East has since had another caesarean and set up a website, csections.org, giving ‘a balanced view of caesareans’. ‘Some people are very negative about it, but the site’s not saying planned C-sections are the best answer; it’s just being pro-choice, letting women know about a route that organisations like the NCT keep quiet about. So much emotion surrounds the birth of the baby that rationality goes out of the window, which I find very frustrating. Birth is the most physically exhausting thing that is ever going to happen to you, and who is anyone else to tell you how to do it?’

East’s sentiments are echoed by Julia Wilson, yet their attitudes could not be more opposed. Last year Wilson chose to give birth to her second child, Maddy, at home unassisted by even a midwife, a trend known as ‘freebirthing’.

‘Birth is a sacred process and nothing should interfere with it,’ she tells me from her home in Worthing, East Sussex. ‘I had a midwife for the home birth of my elder son, and her presence put me off. I believe that having a professional present poses more of a risk than being left alone, because they try to interfere when it’s completely unnecessary.’

When Wilson first mentioned her plan to friends and family, most were horrified. ‘At check-ups midwives were equally dismissive. They didn’t even support a home birth, because my low iron levels meant I might haemorrhage. But that was just nonsense. It was so empowering just believing in myself, rather than relying on other people telling you how to manage your body.’

Such a view makes Pat O’Brien, a spokesman for the Royal College of Obstetricians and Gynaecologists, shake his head. ‘In India and Africa thousands of women with potential complications give birth at home without support because they have no choice, and it ends in disaster. But in the West childbirth has become so safe that people have just about forgotten that there can be major problems. It’s been written out of people’s psyches.’ After all, the risk of dying in childbirth is one in 28,000 at Queen Charlotte’s hospital in west London, compared with one in seven in Niger.

It does seem extraordinary that an event that lasts at most a couple of days compared to the lifetime of actually bringing up a child can provoke so much controversy. Yet Belinda Phipps points out that nature probably has its reasons for this. ‘If we just dropped babies like eggs without noticing, what would that say about the responsibilities we’re taking on for the next 20 years? Birth marks you out as a mother and a carer for a very long time.’

Melissa Maimann, Essential Birth Consulting 0400 418 448

More mums giving birth before reaching hospital

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

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A Queensland academic says the number of children born before their mothers could get to hospital has more than doubled in the past decade.

The professor of midwifery at the Australian Catholic University, Sue Kildea, says the number has risen from 79 in 2000 to 359 in 2008.

Professor Kildea told the Australian College of Midwifery conference on the Gold Coast about half of Queensland’s non-metropolitan maternity services have closed in the same period.

“Their local units have closed down and women have had to travel much further than they used to in the past and so they are not getting to the hospital in time,” she said.

“The births happened quickly and the births happened well, but it is much better for women to have skilled providers.

“We call them skilled providers, so midwives by their side during labour and during birth just in case anything does happen, so it is still an ideal circumstance.”

“A lot of the Indigenous elders that I have worked with are saying what we are doing around birth at the moment is actually causing some of the poor statistics that we have in maternal infant health in Aboriginal and Torres Strait Islander women in Australia.”

In non-rural and remote areas, the question needs to be asked: why women are delaying going to hospital until the very last minute. Perhaps this is also a sign that our hospital policies are unacceptable to women and so they are choosing to wait “as long as possible” before leaving for hospital.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Why Home Births Are Worth Considering

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

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A new analysis … comparing home births and hospital births … not only presents misleading conclusions, it drives a wedge between two groups that cannot afford a greater divide: medical doctors and midwives.

The study documents similar perinatal … mortality rates for home and hospital births, but claims a three-fold increase in neonatal … mortality for home deliveries. Yet this analysis contains serious limitations and concerns those of us who practice midwifery in an out-of-hospital setting.

Beyond the issue of the flawed methodology, which has been addressed by several national organizations … there are serious cultural implications to this study.

As a medical anthropologist, I am concerned with the chasm with doctors and the medical establishment on one side, and midwives and the home birth movement on the other. In Oregon, where we have both licensed and unlicensed midwives working in home and in birth center settings, research has shown deep mistrust between doctors and some midwives. Many doctors have expressed the belief that only hospital births are safe, while midwives say they often feel marginalized and disrespected.

Such studies only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate across a cultural divide. Instead of a maternity system based on fear and misinformation, we need a system based on collaboration and mutual respect.

The United States is already the butt of jokes in the international public health community. We spend more on health care than any other high-income nation, while simultaneously serving the lowest percentage of pregnant women, as several of our key health indicators continue to decline each year … the U.S. now has the highest number of maternal deaths relative to all other high-income nations, and we also rank second worst for perinatal deaths.

The U.S. has not reported a significant decrease in maternal mortality rates since 1982, and the Center for Health Statistics indicates that the rate of cesarean section in this country is now at a whopping 32 percent, marking the 11th consecutive year of increase. As the incidence of cesarean section rates rise, so do medical complications for mothers and babies, along with associated health care costs …

The answer among the U.S. medical establishment has been to throw more expensive technology at the problem rather than retracing our steps to see where we went wrong. Instead of admitting that something is fundamentally broken with the system, organizations like the American College of Obstetrics and Gynecology continue to endorse the idea that medicalized hospital births are the only safe route for women.

We know that 99 percent of women in the U.S. are giving birth in hospitals, yet the United States has one of the highest infant mortality rates of any developed country … Meanwhile, the Netherlands, where one-third of deliveries occur in the home with the assistance of midwives, has a lower rate of 4.73 deaths per 1,000.

… other nations … have superior maternal and infant health outcomes, … and rely more extensively on cost-effective midwives as a public health strategy.

… homebirth midwives charge $2,000 to $4,000 — a fee that includes care from conception through the postpartum period. Exploring the option of home and birth center birth with midwives for low-risk women should be at the core of national health care reform and research. Instead, several generations of high-tech, low-touch birth and a pervasive cultural belief that birth is imminently dangerous — even in healthy, low-risk women — has led to powerful cultural blinders that limit options for women.

In anthropology, we say that “normal is simply what you are used to.” The power of socialization and the dominance of biomedicine have kept us from systematically examining a variety of birthing environments and providers as viable alternatives to the expensive and interventive hospital delivery that has become the norm in the U.S.

… [the] study found no difference between home births and hospital births when measuring perinatal death, which is the primary indicator for evaluating the safety of a mode of delivery. Yet, the study chose instead to focus on neonatal death, generally accepted as death within the first 28 days of birth and to emphasize this part of their research. A complex mix of psychosocial and clinical factors, including congenital anomalies, Sudden Infant Death Syndrome, unsafe home environments, and poverty, can all contribute to death in the first month of life … after removing low-quality studies and out-of-date statistics, the Wax study actually demonstrates no difference in outcomes between home and hospital-based delivery, even for neonatal mortality.

Yet the authors included faulty data in their total analysis, comparing apples to oranges by mixing different types of data sets, such as grouping low-risk with high-risk mothers, and including babies born unintentionally at home.

… There is something to be learned from the centuries-old traditions of midwifery, and I believe that if doctors and midwives, including those who work in the home setting, could be willing to learn from and respect one another, women and babies in our country would benefit. After all, we are all working for the same end result: a happy and healthy mother and baby. Our differing visions of how to get there will require an attitude of cultural humility and a willingness to listen. Studies like the Wax study take us in the wrong direction.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Politics of birth

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

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After five hours of active labour, Kate gave birth to her second, healthy baby boy. Holding him tenderly she is oblivious to the drama unfolding … She is hemorrhaging.

Her uterus has failed to contract after the birth causing massive blood loss … the registrar tugs at her umbilical cord in an attempt to remove her placenta. Unable to do so he proceeds manually. There is no explanation, sedation or consent as he plunges into her uterus.

Meanwhile a midwife has been instructed to ‘wring out’ her uterus by gripping her hands deep around Kate’s stomach. Kate is screaming in pain and her partner begs them to stop. Instead he is removed from the room and their baby is taken away … What happens next is hazy for Kate as she passes in and out of consciousness. But what is clear is since that day, four years ago, Kate has been managing posttraumatic stress. Unable to go back to hospital her following two births are at home with no medical practitioners present.

“I know it sounds reckless but … We just can’t fathom going in to the hospital because that previous experience had been so bad,” she says.

“… I felt an unassisted homebirth was safer for me than going back to hospital to let them do the things to me that they did that time.”

Kate is now planning her fifth pregnancy and wants an independent midwife to attend her birth at home. She has been advised to seek a collaborative agreement between her midwife and the Women’s and Children’s Hospital (WCH) as per new Federal laws governing homebirths.

Called the National Health (Collaborative arrangements for midwives) Determination 2010, they were passed by Federal Health Minister Nicola Roxon days before the election was called. They state that for an independent midwife to access Medicare and insurance they must have an obstetrician agree to care plans created for clients.

However when Kate contacted the WCH she was told that they “do not participate in collaborative agreements”. In a statement to The Adelaide Review the hospital says: “The public-funded Homebirth strategy from the Commonwealth is part of the broader National Maternity Services Plan which is yet to be endorsed by the Health Ministers of Australia.”

It reads like a straightforward strategy for insurance purposes, yet it has been met with confusion and anger. Firstly, insurance providers are yet to create a product that allows independent midwives indemnity while attending a homebirth.

The Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) does not support homebirths and believes women who choose them are putting the birth experience above that of risk. RANZCOG President Dr Edward Weaver welcomes the new legislation and hopes it will curtail the number of high-risk cases that do birth at home.

He believes: “Virtually every obstetrician would have had an experience where he’s been called in to a situation where a woman has been brought in to hospital by an independent midwife and has had difficulties dealing with that situation.”

In 2008 there were 115 planned homebirths or 0.5 percent of births in South Australia. While 94 of those occurred at home, 21 women transferred to hospital for care before they could birth.

RANZCOG advocated for collaborative agreements in submissions to the Maternity Services Review, which informed the legislation. However they concede they cannot make their members adhere to them.

And here lies the problem: a midwife needs to have a collaborative agreement to remain in practice, but there is no requirement on an obstetrician to participate in an agreement. This threatens the ability of women to access midwifery care at all, and threatens the midwife’s ability to remain in practice. At a time when there is an acute shortage of midwives, these moves only mean that there’ll be fewer midwives left to care for pregnant and birthing women and new mothers and babies.

Australian College of Midwives Vice President Hannah Dahlen has found obstetricians will not enter into these agreements because they do not want to take responsibility for a midwives’ practice.

It should not be a case of an obstetrician needing to take responsibility for a midwife’s practice. Midwives are autonomous and regulated practitioners. We do not require an obstetrician to be responsible for our practice any more than an ENT specialist, cardiologist or orthopedic surgeon is responsible for a GP’s practice.

“If our most moderate and collaborative obstetricians are telling us that they are not going to be entering in to signed agreements,” she says. “Then we are potentially stymieing the reform that is going to be rolled out from November.”

Yet one of Dahlen’s greatest concerns is that the reforms go against the World Health Organisation (WHO) definition of a midwife. The WHO states a midwife promotes a natural birth, can detect complications and is able to carry out emergency procedures if required. Hannah is concerned these new laws will end up seeing “one practice of medicine veto and regulate another”.

Christine is an independent midwife with close to two decades of experience in the maternity sector. She has birthed hundreds of babies both within a hospital setting and independently. More than 20 women who want to birth at home have employed her until April 2011.

“I’m happy to work alongside a doctor when it is required but I do not agree, and no midwife will agree, that it is ok for them to sanction our practice,” she claims. If this does not get resolved she is adamant homebirths will go underground with women birthing with unregistered midwives.

… RANZCOG and the Australian Medical Association deem homebirth a high-risk proposition. Of the 202 perinatal deaths in 2008, one was in a homebirth setting. In June the State Coroner ruled to investigate the circumstances surrounding a baby who died at a homebirth in 2007. While this was widely reported in the media, the coronial inquest of an obstetrician who lost two babies to ventouse extraction at the same time was left unreported.

“If a baby does not make it into this world, and not every baby is going to, and it is a midwife’s domain, (they) are really crucified,” says Christine. “But for doctors to lose babies and make mistakes, it is a very different thing.

South Australian MP Frances Bedford is an advocate for a woman’s right to birth at home. She was unable to be interviewed for this article but said in a statement to The Adelaide Review: “(I) find it extraordinary that a woman choosing caesarean section without any medical need is apparently acceptable to the medical fraternity (with Australian taxpayers funding most of those costs) yet a woman choosing to maximise her chances of health and wellbeing through homebirth is discriminated against.”

As this debate continues in the medical fraternity, Kate remains sceptical she will have the birth she wants. Instead her partner has become versed in birth advocacy.

“We should be able to share everything we need with (a midwife) and same for the hospital,” she says. “Our partners should not have to go in there and be aggressive and advocate on our behalf.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mum nurses baby back to life

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AN Australian mum has made headlines worldwide after cuddling her tiny baby back to life.
The grieving mother had given up hope of saving newborn Jamie, after doctors pronounced the tiny boy dead.

While Jamie’s twin sister, Emily, was delivered safely, doctors worked for about 20 minutes to get premature Jamie to breathe before declaring that he couldn’t be saved.

… “I unwrapped Jamie from his blanket. He was very limp. I took my gown off and arranged him on my chest with his head over my arm and just held him. He wasn’t moving at all and we just started talking to him.”

Ms Oggs said she and her husband, David, had given up saving Jamie, who was born at 27 weeks and weighed less than 1kg.

… after about two hours of being hugged, touched and spoken to, little Jamie miraculously showed signs of life.

“Jamie occasionally gasped for air, which doctors said was a reflex action,” Ms Oggs said.

“But then I felt him move as if he were startled, then he started gasping more and more regularly.

“I gave Jamie some breast milk on my finger, he took it and started regular breathing.”

… “A short time later he opened his eyes. It was a miracle,” Ms Oggs said.

“Then he held out his hand and grabbed my finger.

“He opened his eyes and moved his head from side to side. The doctor kept shaking his head, saying, ‘I don’t believe it’.”

The Sydney mum spoke publicly to highlight the importance of skin-on-skin care for sick babies.

The technique, known as kangaroo care, is often used in neo-natal wards and is thought to promote a more stable temperature, better breathing and weight gain …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Home births in Wales double over decade

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I live for the day that we have these headlines here in Australia!

The number of women who give birth to their children at home in Wales has more than doubled in less than a decade …

Since 2002 … they have risen from 604 to approximately 1,395 last year.

There has also been a rise in women giving birth in midwife-led units.

… the assembly government has encouraged healthy women with low-risk pregnancies to have their babies out of hospitals.

In 2002, maternity services in Wales were asked to reach a 10% home birth rate by 2007, making it the only nation in the UK to have a target.

Midwives say that while it was a very ambitious aim and many areas have not managed to reach it, it has helped transform the choice in maternity services.

On average, 4% of births in Wales last year were at home, which is higher than the UK average of 3%.

Laura Williams gave birth to her daughter Megan at home in Porthcawl, Bridgend county, on 5 November, 2009.

… “I wanted to be in a more comfortable environment – I liked the fact that with a home birth I could use my own shower and sit on my own sofa.

“As it was, I had a fantastic birth at home. I borrowed a friend’s pool and was really relaxed. The midwife even cleared everything up afterwards – I saw no mess.

… “I also think the fact I was at home and relaxed helped my recovery from the birth – the next day I was up and about and even popped to the shops.”

… “Midwives are continuing to work towards it because many see the benefits home births bring.

“They are cost effective in that women don’t need to stay in hospitals.

“And for the mother, there is less risk of medical intervention, the birth is well planned, she is in a relaxed environment and often doesn’t have to leave other children.”

… Rather than staffing a large obstetric unit at a hospital, which midwives have to do in more populated areas, they can “focus on staffing women’s needs”, she said.

… The issue of home births has been in the headlines recently after medical journal The Lancet said mothers-to-be should not be able to opt for them if they put their babies at risk. Under UK law women can override medical advice.

It came after research published in the American Journal of Obstetrics and Gynaecology suggested home births were more risky than hospital delivery.

But the Royal College of Midwives said the research was “flawed”, and the assembly government insisted that only women with low-risk pregnancies were encouraged to have their children at home.

The chief nursing officer for Wales, Rosemary Kennedy, said: “It is for midwives and other health professionals to explain to pregnant women the birthing options available to them, and decide on the most appropriate option after considering their medical history and preferences.”…

Melissa Maimann, Essential Birth Consulting 0400 418 448

Bonding, Oxytocin and Fatherhood

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The hormone oxytocin has come under intensive study in light of emerging evidence that its release contributes to the social bonding that occurs between lovers, friends, and colleagues. Oxytocin also plays an important role in birth and maternal behavior, but until now, research had never addressed the involvement of oxytocin in the transition to fatherhood.

A fascinating new paper reports the first longitudinal data on oxytocin levels during the initiation of parenting in humans. They evaluated 160 first-time parents (80 couples) twice after the birth of their first child, at 6 weeks and 6 months, by measuring each parents’ oxytocin levels and monitoring and coding their parenting behavior.

… At both time-points, fathers’ oxytocin levels were not different from levels observed in mothers. Thus, although oxytocin release is stimulated by birth and lactation in mothers, it appears that other aspects of parenthood serve to stimulate oxytocin release in fathers.

… this finding “emphasizes the importance of providing opportunities for father-infant interactions immediately after childbirth in order to trigger the neuro-hormonal system that underlies bond formation in humans.”

The neuroscientists also found a relationship between oxytocin levels in husbands and wives. Since oxytocin levels are highly stable within individuals, this finding suggests that some mechanisms, perhaps social or hormonal factors, regulate oxytocin levels in an interactive way within couples.

Finally, the findings revealed that oxytocin levels were associated with parent-specific styles of interaction. Oxytocin was higher in mothers who provided more affectionate parenting, such as more gazing at the infant, expression of positive affect, and affectionate touch. In fathers, oxytocin was increased with more stimulatory contact, encouragement of exploration, and direction of infant attention to objects …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Woman reportedly pregnant for nearly two years

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Unbelievable!

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Chien’s husband, Duong Van Tuan .. .claimed that his wife has been pregnant for 21 months. He explained that his wife saw doctors the first time when she was over three months pregnant.

Doctors examined her and made an ultrasound scan, saying the child was a boy and very healthy. They calculated that she would give birth in early September 2009.

The woman had no labor pain on the days that doctors anticipated … doctors examined her again and told the family they must wait because Chien has not begun labor yet. The placenta clung to the womb, so they couldn’t perform an operation, which could cause hemorrhaging.

For two months afterwards, Chien still have no sign of labor pain though she still felt the child move. When she was 11 months pregnant, the couple went to the Central Obstetrics Hospital in Hanoi and doctors still said that they must wait.

“I have been waiting for my wife’s labor for nearly one year. But I can’t wait anymore because the fetus is 21 months old already. Doctors at the Central Obstetrics Hospital made an appointment for us on August 20 to decide on an operation …

Dr. Tran Danh Cuong, chief of the Central Obstetrics Hospital’s Obstetrics 1 Ward, said this is a very weird case. He stated that no child can live for over 45 weeks in the womb. “No doctor should let a woman be pregnant for 21 months,” Cuong confirmed.

Correction: some babies can live beyond 45 weeks. It is unheard of in today’s times because most babies are induced even before 42 weeks (which is still considered normal pregnancy). In our grandparent’s generation and prior, some babies did indeed remain inside until well beyond 42 weeks and survive.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Doctor-midwife tensions run deep

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Last week, midwives and clients of Andaluz Waterbirth Center in Portland announced plans to file a federal lawsuit to “cease intimidation and threats against midwives” by the Oregon Health Licensing Agency and Oregon Health & Science University.

Midwives say doctors and nurses at OHSU have filed baseless complaints to the licensing agency meant to thwart competition … The threatened lawsuit spurred a passionate online debate among supporters and critics of home birth.

Conflicts between midwives and doctors run deep. One of the biggest problems: Many physicians deal with midwives only when a laboring mother experiences difficulties during a home birth and requires transport to a hospital, sometime urgently.

“It’s an extremely tension-fraught encounter,” according to Melissa Cheyney, an Oregon State University assistant professor and practicing midwife who studied the interactions of midwives and doctors in Jackson County last year. Nearly every physician interviewed by Cheyney and her graduate student expressed the view that births must take place in a hospital to be “safe.”

Studies including higher-risk pregnancies have found that fetal deaths are more likely in home births. But in low-risk pregnancies, most research shows no significant difference in risk to the baby, while home-birth mothers experience fewer complications. In a study in British Columbia last year, women giving birth at home suffered fewer than half as many serious perineal tears, and about a third less postpartum bleeding.

By choosing a hospital birth, women substantially increase the risk of having a surgical delivery. More than 29 percent of hospital births in Oregon resulted in a cesarean during the years 2006-2008. Less than 4 percent of home births ended with a cesarean in a 2005 study of 5,400 births attended by midwives in the U.S. and Canada.

Women who choose home birth often cite the desire to keep birth free of medical intervention. Heather Hermans … transferred to the care of a midwife because she wanted to try a vaginal delivery rather than schedule a cesarean section, as her obstetrician-gynecologist recommended.

“My ob-gyn didn’t remember me from appointment to appointment,” Hermans said. “I was treated like pregnant cow No. 45.”

Many women will choose midwifery care to receive personalised care where they can develop a relationship with the midwife who will attend their birth.

Hermans experienced complications during labor and took an ambulance to OHSU, where a surgeon delivered her healthy baby boy by emergency C-section. The surgeon filed a complaint about Hermans’ midwife to the state … Roy Haber, an attorney hired by the midwives, said the Oregon Health Licensing Agency withdrew all six investigations after he challenged them.

Conflicts aren’t inevitable. Cheyney is working with midwives in Lane County and a Eugene obstetrician, Dr. Paul Qualtere-Burcher, on guidelines for smoother, more collaborative relations. Qualtere-Burcher and his colleagues have agreed to help midwives get access to laboratory testing and ultrasound screening for their clients. Midwives are referring higher-risk home birth clients to the physicians for assessment and another perspective.

“We’d like them to come in and see us before it becomes a big issue during labor,” Qualtere-Burcher said. “I think it’s been very successful.”

Home birth by the numbers

Planned home births in Oregon last year: 877 out of 47,675 total births, or 1.8 percent.

Risk of baby dying in a midiwife-attended home birth: 1.7 percent versus 0.6 percent in hospitals, based on a 2009 British study including women with breech births, twins, or attempting a vaginal birth after a previous cesarean (VBAC).

I’d be interested to see what these stats are when high risk homebirths are removed from the data set, or to analyse the risk of each “risk factor” in isolation to determine the riskier “high risk” situations, for example, is HBAC less risky than twin homebirth?

Risk of baby dying in a midwife-attended home birth when comparing only low-risk mothers: 0.5 percent versus 0.3 percent in hospitals.

Chances of giving birth without medical intervention: 78 percent with a home-birth midwife versus 54 percent in hospitals, according to the 2009 British study.

A women’s chances of having cesarean section when giving birth in an Oregon hospital, 2006-2008: 29 percent.

Fetal deaths in births attended by licensed midwives in Oregon, 2001-2007: 4 in 2,906 births, about 0.1 percent.

Fetal deaths in births attended by physicians in Oregon, 2001-2007: 1,455 in 274,278 births, about 0.5 percent.

This would account for the fact that midwives mostly manage uncomplicated pregnancies and births, while doctors are referred higher risk women and babies.

Number of home birth midwives who are licensed in Oregon: 64, up from 54 in 2008.

Complaints lodged against licensed midwives, 1999-2007: 40.

Disciplinary actions imposed by the Board of Direct Entry Midwifery, 2000-2004: 12

Midwife guide

Direct Entry Midwife – A general term for practitioners who train directly into midwifery without a nursing or medical background, and attend births outside of hospitals. Oregon law allows direct entry midwives to practice with no licensure.

Certified Professional Midwife — Direct entry midwives certified by the North American Registry of Midwives, which requires written and practical examinations and practical experience attending 40 births.

Licensed Direct Entry Midwife — Direct entry midwives who obtain a license in Oregon are authorized to use some prescription drugs and medical devices. They must pass a national examination, demonstrate experience in attending births, and complete continuing education every three years. They are licensed by the Oregon Board Direct Entry Midwifery and subject to disciplinary actions if they violate professional standards.

Certified Nurse Midwife – Registered nurses who go on to complete an accredited nurse-midwifery program. Oregon requires certified nurse midwives to obtain a Masters degree. CNMs are the only midwives that practice in hospitals. They are licensed by the Oregon State Board of Nursing.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Home birth—proceed with caution

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The increased demand to give birth outside hospital has increased the rate of home delivery. In the Netherlands, a third of women now have home births. In the UK, 3% of total births occur at home, while in the USA home delivery accounts for 1% of births or 25 000 deliveries per year.

In Australia, 0.6% babies are born at home. This rate has increased in past years.

Home birth rates have been increasing in the USA partly because of the increasing proportion of births by caesarean delivery … because doctors and hospitals opt not to do a vaginal birth after a caesarean to avoid liability lawsuits …

Although home birth seems to be safe for low-risk mothers and, when compared with hospital delivery, is associated with a shorter recovery time and fewer lacerations, post-partum haemorrhages, retained placentae and infections, the evidence is contradictory for outcomes of newborn babies delivered at home … The problem arises when planned home births become hospital births when complications arise, and this can then lead to an underestimation of the risk and overestimation of the benefit of home births. Data from the Netherlands, for example, suggest that up to 40% of nulliparous women who start labour at home are transferred to the hospital. Most studies also rely on different midwifery models for home delivery, which are not generalisable.

Professional organisations … have issued contradictory policy statements regarding home deliveries. The Department of Health of South Australia has a detailed policy for home birth among women with low-risk, singleton term pregnancies, while the UK’s Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives jointly support home birth in women with uncomplicated pregnancies. By contrast, ACOG does not support home birth, citing safety concerns and the lack of rigorous scientific evidence. Choosing to deliver a baby at home, states ACOG, is to show preference for the process of giving birth over the goal of having a healthy baby.

A recent meta-analysis … provides the strongest evidence so far that home birth can, after all, be harmful to newborn babies. The research incorporated 12 studies and 500 000 births from several industrialised nations … The data show that planned home births to healthy and low-risk mothers compared with planned hospital births in the same group of women doubled the risk of neonatal deaths (0·2% vs 0·09%). And when infants with congenital defects were excluded, the risk of neonatal mortality tripled. The main attributable factors for the increase in mortality were the occurrence of breathing difficulties and failed attempts at resuscitation—two factors associated with poor midwife training and a lack of access to hospital equipment. In the USA, for example, only a third of home births are accompanied by a certified midwife.

Analysing the outcomes of these studies, what we can learn from this meta-analysis is that homebirth is safe for low risk, healthy women, whereas high risk homebirth translates to mroe complications for mothers and babies.

Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk. There are competing interests that need to be weighed carefully. Hospital delivery should be the preferred method of delivery for high-risk pregnancies … Home delivery is an option for mothers with uncomplicated pregnancies, provided they are advised of the risks involved, have one-to-one midwife care (that includes good resuscitation skills and accreditation by a local regulatory body), and live in a location that allows quick access to obstetric care.

The situation in Australia is that fetuses do not have any rights until they’re born and breathing, therefore, the woman’s preferences are supported in pregnancy. An ethical stance would hold that the duty of care to the fetus increases as it reaches term.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Who controls childbirth: women or doctors?

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That I am pregnant again is an act of either incredible optimism or mind-blowing amnesia. As the sonogram technician squirts jelly over my abdomen for my 20-week checkup, I think it’s the latter. Watching this baby, who the tech tells me is a boy, I am not caught up in visions of his future; I’m caught up in visions of mine. All of a sudden, I know with a certainty I haven’t allowed myself to confront before: Somehow, I am going to have to deliver this baby.
Obviously, you say. But my first birth was traumatic, and although my son and I emerged fine, I lost a year seeking treatment for post-traumatic stress disorder and all the depression, fear and anger it brings. I imitated mothers who seemed normal to me, cooing and tickling my son. In truth, I was a zombie, obsessing about how I had ever let what happened happen.

What happened is this: In my 39th week, I am induced because of high blood pressure. At the hospital, I am given Pitocin, a synthetic form of the labor-inducing hormone oxytocin, and Cervidil, a vaginal insert used to dilate the cervix. Within two hours, my contractions are one minute apart. I had lasted as long as I could without an epidural because I had read that they sometimes slow dilation. That’s the last thing I need: I’m at a pathetic 2 centimeters. My doctor comes up with a solution for the pain: a syringe full of a narcotic called Stadol.

“I have a history of anxiety,” I tell the nurse who has brought in the syringe, as I always warn any medical professional who wants to give me drugs. “Is this drug OK for me?” “It sure is,” she says.

It is not. Within 10 seconds, I begin hallucinating. For five hours, I hallucinate that I’m on a swing that’s soaring too high, that houses are flying at my face. My husband has fallen asleep on the cot next to me, and I’m convinced that if awakened, he will turn into a monster — literally. I’m aware this notion is irrational, that these images are hallucinations. But they are terrifying. I buzz the nurse. “Sometimes that happens,” she says …

By noon the next day, 24 hours after I had arrived, I am only 3 centimeters dilated. The new nurse, a nice lady, tells me the induction isn’t working. “Your blood pressure isn’t even high anymore,” she says. “Tell the doctor you want to go home.”

When my OB comes in, I say, “I’d like to stop this induction, if that’s possible. I’m worn out. I hallucinated all night … I just don’t think this is working out.”

“OK,” he says. “Let me examine you. If you’re still not dilating, we’ll talk about going home.”

My previous dilation exams had been quick and painless, if not entirely pleasant. This one takes a long time. Suddenly, it hurts. “What are you doing?” I scream. “Why does it hurt?”

No answer.

“He’s not examining me,” I scream at my husband. “He’s doing something!” My husband grips my hand, frozen, unsure.

I scream to the nurse, the nice one who had suggested I go home. “What is he doing?” She doesn’t answer me, either. I writhe under the doctor’s grasp. The pain is excruciating.

The first sound I hear is the doctor’s directive to the nurse, in a low voice: “Get me the hook.”

I know the hook is for breaking my water, to speed my delivery by force. I scream, “Get off of me!” He looks up at me, as if annoyed that the specimen is talking. I imagine him thinking of the cadavers he worked on in medical school, how they didn’t scream, how they let him do whatever he wanted.

“You’re not going anywhere,” he says. He breaks my water and leaves. The nurse never looks me in the eye again.

Eleven more futile hours of labor later, I am exhausted and terrified when the doctor comes in and claps his hands together. “Time for a C-section,” he says. I consider not signing the consent form, ripping off these tubes and monitors, and running. But the epidural I’d finally gotten won’t allow me to stand up.

It’s nearly midnight when I hear a cry. My first emotion is surprise; I had almost forgotten I was there to have a baby.

I was desperate to find someone who could tell me what had happened to me was normal. To say, “You hallucinated? Oh, me, too.” Or “My doctor broke my water when I wasn’t looking. Isn’t that the worst?” Nothing …

Now, I’d never loved my doctor … I’d found him patronizing — “Normal!” he’d shout at me, when I asked a question — I thought his assuredness might be a good antidote to my anxiousness. It seemed to work, until it didn’t.

… I also didn’t have a birth plan … Sure, I had a plan for the birth: Have a baby using whatever breathing method I’d learned in the hospital’s birth-preparedness class, maybe get an epidural. But I didn’t have the piece of paper that so many of my friends have brought to the hospital with them … in my opinion, the very act of creating such a contract was to ignore what labor is: something unpredictable that you are in no way qualified to dictate.

… people who hear my story ask … Did I consider a home birth? A midwife instead of an obstetrician? … The answer is no. I am not holistically minded. My philosophy was simple: Everyone I know has been born. It can’t be that complicated.

The women who ask me about my preparations for my first son’s birth — who imply with these questions that I could have prevented what happened to me if I’d been more diligent — are part of an informal movement of women who are trying to “take back” their birth — take it back from the hospital, the insurers and anyone else who thinks he can call the shots.

But hospitals aren’t so interested in giving women back their birth … stipulations dealing with labor and delivery (“I want only one medical professional in the room at a time”) garner barely a glance. University OB/GYN in Provo, Utah, even has a sign that reads, “…we will not participate in: a ‘Birth Contract’, a Doulah [sic] Assisted, or a Bradley Method delivery. For those patients who are interested in such methods, please notify the nurse so we may arrange transfer of your care.”

… This question of whether I could have prevented my trauma has lingered in my mind since that day; now that I am pregnant again, it has become deafening. I have a chance to do it all over. Would I benefit from thinking more holistically? Should I bother taking back my birth?

During my pregnancies, friends gave me two books; their spines are still barely cracked. The first is called “Ina May’s Guide to Childbirth.” … The other book is “Your Best Birth” by Ricki Lake and Abby Epstein; it’s an offshoot of their 2008 documentary, “The Business of Being Born.” Their urgent message is that women who want to deliver vaginally can do so if no one intervenes. Instead, doctors and hospitals are doing all they can to “help” the laboring woman along … and failing. Inductions like mine, epidurals given early in labor, continuous fetal-heart monitoring — all of them have been associated with a higher risk for cesarean section. The result is an epidemic — 32 percent of U.S. births were C-sections at last count, the highest rate in our history. Individual surgeries may be medically necessary, but as a matter of public health, the best outcomes for mothers and babies come with a rate of no more than 15 percent, according to the World Health Organization.

Sam … was five months pregnant when watching “The Business of Being Born” convinced her that hospitals could be dangerous and a home birth would be more meaningful. She and her husband found a midwife … and spent the rest of the pregnancy preparing.

After 24 hours of labor, Sam’s contractions were two or three minutes apart, yet when her midwife examined her, she was only 3 centimeters dilated. The midwife gently told her that she was nowhere close to delivering, despite her contractions, exhaustion and pain. Sam asked to be taken to the hospital.

The change of scenery did her good. “At that point, I had been in labor for 40 hours,” she says. “I entered the relaxed zone. The epidural took the edge off … It was a sacred space.”

After her son’s delivery, Sam passed out, having lost 50 percent of her blood volume in a postpartum hemorrhage. Needless to say, she was relieved that she was in a place where blood transfusions were readily available … she believes she will want midwife care at a hospital next time.

… Bialik’s first birth didn’t go the way she wanted. After three days of labor at home, she stalled at 9 centimeters, one short of the goal. Her midwife suggested they go to the hospital, where after a natural childbirth, Bialik’s son spent four days in the neonatal intensive-care unit. “My son was born with a low temperature and low blood sugar, which isn’t unusual in light of the fact that I had gestational diabetes,” she explains. “I understand doctors need to err on the side of caution, but there was nothing wrong with my child. All of our plans for bed sharing, nursing on demand, bathing him — gone.”

The experience was scarring. “I felt a sense of failure that I had to call my parents from the hospital,” Bialik continues. “Yes, I know vaginal birth in the hospital is the next best thing to a home birth.” …

I point out that natural childbirth in the hospital — her “failure” — was my best-case scenario. But I also understand when she says, “Everyone is allowed her own sense of loss.” She realized her vision when her second son was born at home.

The second time around
I don’t consider myself a candidate for a home birth. The risk of uterine rupture from an attempt at vaginal birth after cesarean (VBAC) makes it unthinkable … I’m also not really interested in a home birth … But I’m also not interested in another C-section …

So I’d like to attempt a VBAC, but I know that it doesn’t always succeed. I have a new doctor — the 10th I interviewed following my son’s birth — at a new hospital, and he has agreed to help me try. But my primary goal is more modest: not to be retraumatized. Even now, my heart pounds at the sight of hospital receiving blankets, the antiseptic smell of the maternity ward.

The common thread in Bialik’s and Sam’s stories that impressed me was how supported and safe they felt with their midwife …

In an e-mail Bialik sends after our meeting, she goes back to my idea that some women weren’t meant to have babies the holistic way. “There are those among us who believe that if the baby can’t survive a home labor, it is OK for it to pass peacefully,” she writes. “I do not subscribe to this, but I know that some feel that … if a baby cannot make it through birth, it is not favored evolutionarily.”

I think about my appendectomy, back in 2003. Had I not made it to the hospital in time, I would be dead. What would it be like to refuse medical intervention? I’d call my family, say my good-byes. “I’m sorry,” I’d say. “But I’m not evolutionarily favored. It’s time for me to go.”

This attitude, that everything was better back when there were no doctors, seems strange to me. C-sections, although certainly done too often, can save lives. Orthodox Jews still say the same prayer after childbirth that those who have been in near-death experiences say — and with good reason. A birth that leaves mother and child healthy may be commonplace, but it’s also a miracle every time.

As the weeks pass and my belly grows, I can’t stop thinking about Sam. Her pregnancy was a sacred time, and she had truly looked forward to labor. Is that what I should try for — a meaningful birth, as well as an untraumatic one? At what point had people like Sam and me learned to feel entitled to a meaningful birth?

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.”

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.” …

… In the past three weeks, I’ve had the same dream. I’m in a field (I believe at Ina May Gaskin’s Farm), and women in braids are dancing around me as my baby is born, painlessly, joyously. As I reach down, I notice my C-section scar is gone.

I wake up upset. Am I truly under the impression, subconscious though it may be, that taking back this birth will undo the damage of the last one?

“I don’t understand this phrase ‘take back your birth,’” nurse-midwife Pam England, creator of “Birthing From Within,” … tells me. “Who took it? What would a woman tell herself it meant about her if she failed to meet the criteria she made up for ‘taking back’ her birth? I am concerned that this phrase, meant to generate action and a feeling of empowerment, may actually be generated by or feeding the victim part of her.”

England is right: Having a childbirth that I deem successful this time will not change what I haven’t overcome from the first. I try to find a way to make what my doctor and nurses did to me OK, but my mind rebels. I feel loss — no, theft — of an opportunity for me to have a baby the way so many other women do: a carefree pregnancy, a labor that could still go any way.

Maybe I’m not so different from the women I spoke with, after all. Bialik had a successful natural childbirth but felt like a failure because it was in the hospital. Women who had a C-section also used words like failure. Perhaps part of the problem is that our generation of women is so ambitious, so driven, that we don’t know how to do anything without quantifying it as a success or failure.

According to Dr. Gregory, women are now requesting a C-section for their first birth, even without indication. “A lot of people are uncomfortable with the unknown,” she says. Plenty of people are wary of C-sections by choice, from holistic moms to obstetricians. But isn’t this, too, taking back your birth? Refusing to be out of control seems to me the epitome of taking it back. You don’t have to have an unattended birth in the woods to be considered a real woman.

Deciding that you can’t control the uncontrollable — and committing to that decision when you are, in fact, out of control — is also taking back your birth. It’s what your grandmothers did. It’s what their grandmothers did.

With this, I realize that I have already taken back my birth, but not as part of any movement. I have stopped judging women who take extra precautions as defensive and started to understand that everyone has to find her way.

I don’t know how this story ends. I’m still not convinced my body was made to deliver vaginally. But here’s what I do know: I will insist on kindness. I will insist on care. And I hope I will be open to being treated kindly. It’s harder than it seems.

I have another hope, too. I hope there will be a moment when … I will look down at my baby — whether he is handed to me on my belly or from behind a curtain as my body is sewn shut — and I will remember what I’ve known from the beginning, when I looked down at that plus sign and we were alone together for the first time. Before these questions wrapped around my neck, choking me for answers. I will know that I am his mother and he is my son. And maybe, in that moment, I will be ready to say that the only success and failure is the outcome of the birth, that we are healthy …

I’m concerned that birth is defined in terms of success and failure, and that after this author’s journey, she has determined that health is the only important factor. In this day and age, it is entirely possible to have a safe VBAC – a safe birth experience as well as a satisfying one. The vast majority of women who choose VBAC will be successful provided that they choose the right care provider.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Focus on waterbirth

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NSW’s runaway caesarean birth rate is set to be reined in by one-third under an ambitious five-year plan to normalise the process of giving birth and reduce unnecessary intervention in public hospitals.

The proportion of surgical births should be reduced to 20 per cent by 2015, from 30 per cent now, and first-time mothers would be attended by the same midwife throughout labour.

The option of labouring in water, although not necessarily water birth, would be offered universally under the mandatory policy.

It’s a wonderful idea to introduce policies around use of water in labour, but not necessarily waterbirth. Most units don’t permit labouring in water, either due to lack of baths / pools or because the policies do not support it. Waterbirth challenges some doctors and even some midwives; promoting the use of water in labour is a fantastic starting point and from that, let’s hope waterbirth becomes more of a standard option in delivery suites. This move also complements the re-intruduction of private midwives back into hospital delivery suites with visiting rights.

The policy, the first of its type in Australia, is modelled on a 2005 British one credited with starting to reverse that country’s escalating caesarean rate.

The Minister for Health, Carmel Tebbutt, said the directive was ”designed to support women to have a birth that is as free as possible from invasive medical intervention, while also recognising that labour occurs across a wide spectrum … The safety of mother and child are, of course, paramount.”

The president of the Australian College of Midwives, Hannah Dahlen, said: ”For the last 15 to 20 years [birth interventions] have just gone up and up and up. At some point we have to start coming down again. The policy says, ‘Let’s stop, let’s regroup and try to get a balance.’ ”

She emphasised it would remain ”the safest option for some women to have a caesarean section, and women should not feel lesser because they had to have an intervention”.

Only about 13 per cent of women now achieved a vaginal birth after a caesarean, while up to 80 per cent could do so if properly supported. The NSW targets specify a 30 per cent rate by 2012 and 50 per cent by 2015.

”It all depends on how women are supported and how the facility as a whole supports it,” said Associate Professor Dahlen, a member of the committee that drew up the plan.

It always interests mt that VBAC rates vary so much. 80-90% with private midwives and as low as 1% with private obstetricians. Yes, it’s defintely about the level of support that a woman receives.

Ted Weaver, the president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, applauded the NSW policy to have a single midwife attend first-time mothers, but said this would require a shake-up of workplace rules.

Dr Weaver said the appropriate caesarean rate was about 25 per cent of all births, because the current generation of women represented ”an older population, a fatter population, and a lot of first-time mothers”, Factors which raised their risk.

Michael Chapman, professor of obstetrics and gynaecology at St George Hospital, said the policy would require more senior doctors, who had the expertise to continue with a vaginal birth when manageable complications arose …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Comprehensive support for pregnancy, birth and baby just a phone call away

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

The Federal Government is providing more support for Australian women and their families with a new, expanded national 24 hour Pregnancy, Birth and Baby Helpline commencing on 1 July 2010. Women, their partners and families will be able to call the Helpline on 1800 88 24 36 for advice and information about pregnancy, birth and the first 12 months of a baby’s life. The independent charitable organisation, Royal District Nursing Service Ltd, will provide this free service, offering information and counselling on a wide spectrum of topics relating to pregnancy, birthing and life with a new baby – including issues such as nutrition for mothers and babies, breastfeeding, relationship support and health care options.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Your birth after July 1, 2010

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

I came across this interesting article detailing an American woman’s experience of giving birth in an American hospital: Mom fires OB during birth when threatened with a cesarean! The woman writes:

… I let myself be pushed into inducing. We were at 42wks … My family was all becoming quite impatient and there was a lot of pressure to have her out. I agreed to be induced and get things started.

… 6 am we were at the hospital. I took a ton of food in with me, because I was not going to do this with no fuel. We got settled, the first nurse got us all checked in did all the paperwork and started the IV. They had a change of shift, so the next nurse, Anna, come-on and she was wonderful.

Anna spoke with us and I told her how things were going to go. To call the doctor if she needed but I was the one birthing a healthy baby, and unless the stats of baby changed, this is what I wanted …I told her we would be doing the pit slowly. I only wanted an increase every 45 min to an hour, not the every 15 the Dr. had ordered. She called the Dr and it was agreed. So off we set. We had a cervical check and I was barely dilated 2 and my cervix was very posterior.
I had no idea how the pit would work on me and baby so we just waited. Annabella was so squirmy, they couldn’t keep her on the monitors, Anna had to hold them on and move with her …

After awhile the Dr came in and wanted to look for Annabella and when she couldn’t find her well stated the baby was breach and we needed to go have a c-section. I looked at this woman and told her no, baby had not flipped I would have felt it, and I was not getting a c-section today. That if baby had turned, then we would turn off the pit, and I would go see my Chiropractor to help move her around again. I don’t think the Dr liked me. I didn’t care. So she ordered an ultrasound just to see, and I was later told she knew baby was breach and had started the paperwork to send us on.

Annabella was in fact not breech. She was head down just not really engaged. I felt so good knowing I was right. All this happened about 11am. There had been no increase in the pit for awhile … We started upping it again.

During these times since Annabella wasn’t staying on the monitor anyway, I was up. I walked and rolled on the ball. I leaned over the ball to do pelvic tilts. Pretty much anything I wanted. I really enjoyed that. I was eating and drinking … At 2pm I declined another cervical check …

I was standing and rocking my hips back and forth during the waves, and they were nice. Just these waves, they never were uncomfortable. I didn’t feel I needed to go in to off during them so I just stayed in center moving as I felt I needed to. Anna would come in and check baby with a Doppler, and the let us do our thing.

About 4 the Dr was back, she wanted to see where we were so we checked. I was 4cm, and my cervix was no longer posterior, about 70% effaced.

• The Dr. said I was not where she would like to see me by now. She wanted to break my waters and move things along.
• I told her no thanks; I felt we were doing fine. Baby was fine, so was I.
• She didn’t look surprised. She did get quite nasty though, and told me if I didn’t do things the right way this will land in a c-section and was putting myself and child at risk. That she was going off shift and there would be someone else.
• I … looked her square in the eye and told her that my child in fine.
• I am not having a c-section to please her that if she had not noticed this was MY birth. I was the one doing things, until someone can show me that my child was unsafe I would do this all night if needed. That was the RIGHT way.
• Also that it was a good thing that she was going off shift, because she was fired. I didn’t want her back in my room. I didn’t need any one in there being negative. I was sure there were other people around who could catch this child, and if not I would do it myself.
• She left the room in a quick hurry, and as I turned around again, my husband and … the nurse were all just kind of staring at me.

My husband was stunned, and asked if I could do that, firing the Dr. I told him I didn’t care if I could or not, she wasn’t coming back to my room …I don’t know how things happened from there, but another Dr. came in and introduced himself about 45 min. later and was way more respectful than that woman had been.

We continued, at 7pm the waves were more intense and almost on top of one another … I started to shake and shiver but I wasn’t cold. I vomited all over, and then with the next wave I felt pushy. soon there after my waters broke during one of the pushy waves.

… My body had taken over, I had no choice but to push … Annabella was born at 8:06pm 7lbs 10oz. 21 inches long. She cried for a bit but was so awake and alert. She is just perfect. She latched on and nursed minutes after birth. I am so happy with this birth. I did it the way I wanted even if it didn’t start the way I choose. I wish the dr had been more supportive. But you can’t have it all.

Let’s consider this case from the perspective of private midwifery care after July 1, 2010. This woman went to 42 weeks. The ACM Guidelines stipulate that at 42 weeks, the midwife must refer the woman to an obstetrician for opinion. No doubt the opinion will be that induction is warranted. The woman may accept or decline this advice. If she declines, and if the obstetrician does not agree to the midwife’s continued care of the woman, the woman will be left without care under the Government’s insurance policy. On the other hand if the woman agrees and accepts induction, this will take place according to the obstetrician’s preferences or hospital policy. As the story above shows, the woman advocated for herself throughout. She declined a caesarean, artificial rupturing of her membranes, a vaginal examination and continuous monitoring. Currently, women can birth in a hospital with their private midwife and their midwife can advocate for them provided that the woman has a birth plan that clearly states her preferences. After July 1, our continued involvement in the woman’s care will be dictated by the obstetrician in attendance or with whom we have a collaborative agreement. In the interests of maintaining a collaborative agreement and ongoing income, the midwife will need to remain silent when the woman is outside of the ACM Guidelines and does not agree to the care being suggested. After July 1, women must fend for themselves if the care being suggested is at odds with their preferences.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Midwifery care? An Uncertain Future.

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

Houston, we have a problem.

At July 1, 2010 eligible midwives must work in a collaborative agreement with an obstetrician. This agreement must be signed by the obstetrician. It legitimises obstetric control over women’s choices. Even basic choices such as limited (or no) vaginal examinations in labour, refusal of continuous monitoring in women who are planning a VBAC, delayed (or no) induction and so on. Of course, it also depends on how reasonable the obstetrician is.

You see, in order for an eligible midwife to be insured for her practice, she must work collaboratively with an obstetrician and this is evidenced by a signed collaborative agreement. No signed agreement = no collaboration = insurance will not respond to any claims and therefore the midwife is working uninsured (and therefore outside the conditions of her registration) and may be de-registered.

Once in the collaborative agreement, the midwife, woman and obstetrician must reach agreement about the plan of care if the woman’s condition is classed as a B or C in the ACM Guidelines.

What sorts of conditions are listed as B in the Guidelines?

Previous post-partum haemorrhage
Hypothyroidism
Weight over 100kg
History of mental health disorders
Mild asthma
IVF pregnancy
Previous forceps or vacuum delivery
Having baby number 5 or more
Previous shoulder dystocia
VBAC
Long labour (<1cm/hr progress)
And the list goes on. These women must have a consultation with an obstetrician and the ongoing plan of care must be agreed by the woman, midwife and obstetrician.

What sorts of conditions are listed as C in the Guidelines?

Type 1 diabetes
Coagulation disorders
Lupus
Twins
Pre-eclampsia
Breech in labour
Gestational diabetes requiring insulin
Prem labour
And so on. These women cannot be cared for by a midwife; their care must be transferred to an obstetrician. The midwife’s continued involvement in the woman’s care must be agreed by the obstetrician. Even though the woman engaged the service of the midwife, has a contract of care with the midwife and has paid her midwife.

There is no right of refusal. The midwife will consult with an obstetrician on the woman’s behalf if the woman refuses to consult in person. If the obstetrician does not agree to the plan of care – the midwife cannot continue care of the woman because the woman’s condition is considered outside the scope of the midwife’s practice (and therefore outside of insurance and registration).

This system of collaboration is in place in other countries such as The Netherlands, NZ and Canada. The difference in those countries is the professional respect and standing of midwives that enables them to act as autonomous care providers to their women. Have you read The Birth Wars? Read it – it’s an eye opener and provides great insight into the current maternity system. Nicole Roxon wants obstetricians and midwives to work together. It seems she’s thrown us all into the bucket and simply said, “make it work!”. Unfortunately, entrenched attitudes and beliefs do not change quickly.

Collaboration will work when:
Collaborative agreements are negotiated at College level, not local level.
Obstetricians are mandated to require with collaborative agreements. At present they can refuse to sign a collaborative agreement.
Midwives have an avenue for appeal if they – or their clients – are treated unfairly.
Visiting rights are in place.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Risk for babies born one week early: Serious health problems more likely

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

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Babies born only a week early are at higher risk of a host of serious health problems from autism to deafness …

A study of hundreds of thousands of British schoolchildren found that those born at 39 weeks are more likely to need extra help in the classroom than those delivered after a full 40 weeks in the womb.

… With most planned caesareans carried out at 39 weeks, the finding raises concerns that women who have the operation for non-medical reasons could unwittingly be endangering the health and prospects of their children.

… Almost 18,000 had been classed as having special educational needs. The term covers learning disabilities such as attention deficit hyperactivity disorder, autism and dyslexia, and physical problems such as deafness and poor vision.

The risk was highest in those who spent the shortest time in the womb. For instance, babies born at between 24 and 27 weeks were almost seven times more likely to need help at school than those delivered at 40 weeks. But even being born just a few weeks early made a difference …

Those born at 37 weeks were 36 per cent more likely to have learning difficulties, while for those born at 38 weeks the figure stood at 19 per cent.

Babies born at 39 weeks … were 9 per cent more likely to have special needs …

… These findings … suggest that deliveries should ideally wait until 40 weeks of gestation … ‘However the cause of early birth may contribute to the risk, for example, a baby who’s already sick may need to be delivered early to give it a chance of survival …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Canadian Researchers Suggest Review Of Current Guidelines On C-Sections

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

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A recent study showing that the rate of cesarean sections performed at hospitals across … Canada, varied between less than 15% and more than 27% — with only 2% requested by the women — prompted researchers to recommend “revising the current guidelines” on when it is appropriate to perform a c-section … Difficult labor was found to be the most prevalent cause for a c-section …

It will be interesting to read what the new guidelines say. Certainly, some factors promote vaginal birth such as staying at home for as long as possible in labour, planning a homebirth, receiving midwifery care, being well prepared – emotionally, mentally and physically – for birth, reading widely about pregnancy and birth to be well-informed and more comfortable with the process and having the continued support of a midwife who is experienced in supporting women through natural birth.

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

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

framework for privately practicing midwives

The Quality and Safety Framework is not out yet in its final version. A final draft has come out and it is now in the hands of the Nursing and Midwifery Board to accept or reject the Framework in whole or in part. I will update this blog once I know more details about the QSF.

Midwifery in the home nsw legal

Yes, midwifery is – and will remain – legal at home.

Private health insurance, private midwifery care, australia

Yes, Private Health Insurance may cover the cost of private midwifery care. Some health funds are more generous in their benefits than other funds so it’s worth doing your homework before becoming pregnant so you can get the cover that’s most advantageous.

Private midwife vs obstetrician

The role of the obstetrician is to provide care for women with complicated pregnancies and births, so they’re called in to manage things that are not seen to be progressing normally. The role of the midwife is to take care of healthy, well pregnant and birthing women (and their babies) and to refer to obstetricians when it’s necessary. Private midwifery care is holistic in nature, so women can expect that their midwife will be interested in getting to know them, they can expect their pregnancy consultations to be very thorough and to last for 1-2 hours. Private midwives attend the whole labour and birth, we do not just attend for the end of birth. Private midwives take on a much lower caseload – you’ll be hard-pressed to find midwives with more than 4 births a month, so we’re more available to our clients.

Water birth experts australia

That would be a midwife! More specifically, a private midwife or birth centre midwife. We regularly attend waterbirths.

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

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

Exorbitant prices with Sydney obstetricians, alternatives?

There’s a great alternative: private midwifery care. While private midwives may not be cheaper than private obstetricians, the service is experienced by women to be more personalised, thorough, caring and supportive. Consultations are one to two hours in duration, so there’s plenty of time you to get to know your midwife and to talk through all fears and anxieties. All questions are answered thoroughly and there’s time for things like birth planning, childbirth education as well as the clinical things. Of course, if any problems are detected, midwives refer to obstetricians who can provide obstetric care.

How much will it cost me to access a private midwife as my care giver

The fees vary and in Sydney you’d be looking at anywhere between $4000 and $6000.

Refusing to be induced at hospital

All women have the option to accept or decline interventions. The hospital will want to ensure that you understand why they want to induce you, the risks of not inducing, and that you’re accepting responsibility for your decision. You’re perfectly within your rights to refuse interventions and to birth at your chosen birth place with support.

How to have a baby naturally in a hospital

In short, take a private midwife with you! the most important decision you will make in your pregnancy will be choice of care provider. Typically, midwives have lower rates of intervention than do obstetricians. Private midwives have even lower rates of intervention than do hospital-employed midwives. Safety is never compromised.

Home birth fetal auscultation

Yes, this is common-place in homebirths. Your midwife will have with her a doppler which may be used in the water if you are planning a waterbirth. It is common place for midwives to check your baby’s heart rate every 30 minutes in labour and more often if they feel that there is a problem. If your midwife suspects that your baby is distressed, she’ll arrange for you to be transferred to hospital where she will remain with you every step, providing advice, reassurance and support.

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘Love drug’ may help mums bond to babies

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

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It’s a shame the resesrchers in this study haven’t considered ways of boosting the natural form of this “love drug”: natural bitrh and breastfeeding are the most effective ways to promote this chemical and enhance bonding.

A hormone nasal spray may help mothers bond better with their babies.

A world-first trial by Sydney researchers involves giving mothers a synthetic version of the hormone oxytocin, often dubbed the ”love drug” or the ”cuddle chemical”. Past studies have shown mothers who are deficient in oxytocin are less sensitive to their babies’ cues than mothers with high levels of the hormone.

It’s interesting to take a look at the things that diminish the mother’s production of oxytocin: epidurals, infusions of syntocinon (the artificial form of oxytocin that’s given to women to induce or speed labour), caesareans and pain-relieving medications.

… University of NSW school of psychology have launched the Mothers Early Experiences of Parenting (MEEP) project, which will use oxytocin nasal spray in combination with infant massage and play sessions. They will then measure eye contact, affectionate touch and feelings of closeness and warmth to see if there is improvement in attachment between mother and child.

… although the role of oxytocin in childbirth and breastfeeding was well documented, scientists were increasingly interested in the hormone’s role in human social interaction. It is known to reduce fear, increase empathy and improve memory, especially of happy events.

Hence the research that points to increased rates of violence, suicide, anti-social personality disorders and the like in children who have experienced a raumatic entrance to this world.

”It allows us to recognise and feel connected to loved ones,” Professor Dadds said. ”So after eye contact, cuddling, even an orgasm, with a loved one, you get a big shot of oxytocin, which increases trust and connection.”

Professor Dadds said oxytocin delivered by nasal spray had very subtle effects but could be a powerful intervention when combined with psychological therapies. ”It’s a new age of psychology and medicine working together and magnifying the effects of each other,” he said.

I’d rather see psychology and midwifery working together: midwifery to promote and protect natural birth, and psychology to work with women to reduce the fear surrounding natural birth, to debrief women of their past traumatic birth experiences, and for supporting programs to be developed that enable women to feel safe and trusting again.

… between 10 and 20 per cent of mothers had post-natal depression, and at least a third of those women had trouble bonding with their babies. An impaired early bond is associated with adverse developmental outcomes for children.

And the major cause of PND and impaired bonding is a traumatic birth experience.

”There’s a huge body of research showing that the more securely attached you are by age three to five, the better your outcomes for mental health,” she said …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Homebirth: What to expect

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There is no standard of events for women who give birth at home. Homebirth care is always individualised to the needs of the woman and family.

The following information can help you to understand what may happen in labour, to give you a sense of your options and lessen any surprises. When you birth at home, you can expect to:

- Wear whatever you like in labour
- Have vaginal examinations when / if you want them. Your midwife may suggest an examination if she feels it is needed, which is not very often as we know that babies are born whether vaginal examinations are performed or not and many women prefer to avoid them wherever possible.
- To have your temperature, blood pressure and pulse taken when it is necessary to do so – sometimes this is not done at all
- Have your baby’s heart beat listened to with a hand-held doppler that allows you to remain in the bath or shower.
- If additional fluids are needed, you can expect your midwife to offer you lots of drinks – this will also help to keep up your energy levels. In fact, your midwife will probably offer food and fluids regularly throughout your labour anyway.
- We don’t use ID bands at home. Not for Mum, not for baby. No chance of anyone getting lost, everyone knows who’s who, and no mother is handed the wrong baby!
- Your waters are very unlikely to be broken at home.
- You can expect to give birth in the position that’s most comfortable to you at the time. For many women, this is kneeling (so you can catch your own baby) or all fours (and your partner can catch the baby).
- Waterbirth is a common birth method at home.
- While “pain relief” is not offered, your midwife will make suggestions to assist your level of comfort such as position changes, hot packs, bath, shower, massage and so on.
- You will find that your body will push instinctively when the time’s right.
- Many women will not tear and episiotomy is very rare at home.
- Placentas usually come of their own accord, in their own time provided that the blood loss is not excessive.
- Your baby’s cord will be cut after the placenta is born, and some women prefer to leave it intact and have a lotus birth.
- There is no separation of mother and baby.

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Hospital birth: What to expect

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There is a fairly normal standard of events for women who give birth in a hospital setting, whether public or private.

The following information can help you to understand what may happen in labour, to give you a sense of your options and lessen any surprises. When you go to hospital in labour, you can expect to:

- be asked to remove your clothes and wear a hospital gown.
- To have a vaginal examination when you are admitted and at least every 4 hours thereafter.
- To have your temperature, blood pressure and pulse taken regularly throughout labour
- In some hospitals, continuous monitoring is used for 20-30 minutes when you arrive. In many cases, it is left on for the whole labour.
- Many women will have a cannula in their arm. Some women will have antibiotics put through this cannula; others will have IV fluids.
- You can expect food to be limited in labour. Some hospitals have a policy of ice chips only when in labour.
- You will have one or two ID bands placed around your wrist.
- If you’re giving birth in a private hospital, it’s fairly standard to have your waters broken in labour by the staff.
- You can expect to give birth lying on your back in bed with the back rest elevated somewhat. In some hospitals, stirrups are used.
- In many hospitals, pain relief is routinely offered.
- You will most likely be told when and how to push.
- Many women will be given an episiotomy.
- You will routinely be given an injection to speed the delivery of the placenta.
- Your baby’s cord will be cut before it has stopped pulsating.

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Professional indemnity insurance for midwives

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

Link

“… I am pleased to announce that the Government has signed the contract to provide the first ever Commonwealth-supported professional indemnity insurance for midwives.

The insurance will be provided by Medical Insurance Group Australia.

Privately practising midwives will be able to purchase their own insurance, and be covered from 1 July 2010.

This is the first time since 2002 that midwives can purchase professional indemnity insurance.

This is an important step for Australia’s midwives. It is also an important step for Australian women and their families.

This insurance arrangement will help midwives who wish to provide high quality midwifery services to Australian women as part of a collaborative team with doctors and other health professionals.

It is a key part of the $120 million package of maternity reform measures the Government announced in the last Budget to improve choice and support for Australian mothers.It also helps underscore the importance of midwives in providing high-quality, safe maternity care in Australia.

It builds on the new legislation passed by the Parliament on 16 March 2010 to give midwives access to the MBS and PBS.

The Commonwealth-supported insurance will not cover services provided during home births.

Medical Insurance Group Australia were selected via a tender process and has been providing insurance to doctors and other health care professionals in Australia for many years.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Risk assessment in pregnancy and birth

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Risk assessment has been around for a long time in maternity care and has become more widely spoken about as midwifery-led services have expanded. Risk assessment is a way of identifying potential problems and minimising risks to the woman and baby. Some form of risk assessment is used in almost every profession and although the actual risk assessment process is not perfect, it’s the best tool we have at present. Risk assessment is used on OH&S, education, food service, health, media, emergency services, law and so on.

In maternity, risk assessment is an incredibly useful tool. The benefit of risk assessment is that it is based on science and evidence. We can state with certainty the risks of certain complications such as pre-eclampsia and this is helpful when preparing women for what to expect and things to be on the look-out for. In this way, risk assessment actually lowers the risk to the woman because she can become more involved in her care and more alert for signs that mean she needs to get help.

The downside of risk assessment is that it does tend to categorise women according to a tick-box system. Although the risk might be there, it might not necessarily apply to the woman sitting with us. This might be because the study that exposed, defined or quantified the risk does not apply in the current situation.

How can risk assessment be useful?

Risk assessment can be an incredibly useful tool for both women and midwives in helping to plan care that will meet the woman’s needs safely. Midwives are primary care providers and are responsible for proving care to healthy, low-risk women and babies throughout pregnancy, birth and the postnatal period. So a risk assessment tool helps the midwife and woman to know when a referral is needed.

Risk assessments can also highlight potential problems that would benefit from early organisation and planning before labour. This might include reviewing the birth plan, reviewing place of birth, engaging other health professionals and putting in place supports so that the woman can cope well after the baby is born.

Risk assessment can also be useful for discussing homebirth with women and their partners. Some women are perfectly suited to homebirth: they’re healthy, their pregnancy is going well and they’re wanting a natural birth. In this case, risk assessment can be used to explain to the woman that she’s safer at home.

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The Mother Friendly Childbirth Initiative

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

Link

… maternal mortality is on the rise in the U.S … two of the four preventable pregnancy-related deaths were associated with cesarean section-the failure of hospital staff to pay attention to worsening vital signs after women have the operation, and the staff’s inability to respond appropriately to hemorrhage resulting from a cesarean. The two others are uncontrolled high blood pressure and undiagnosed fluid build-up in the lungs of women with pre-eclampsia … by following the principles of the evidence-based Ten Steps of The Mother Friendly Childbirth Initiative (MFCI) and giving low-risk women access to midwifery care mothers’ lives could be saved.

… The Initiative is an effective wellness model of maternity care that offers safe choices to overused and costly high-tech birth interventions that often lead to avoidable cesareans …

… compared to maternity care provided by physicians to low-risk women, women cared for by professional midwives have a lower incidence of hypertension and pre-eclampsia, fewer hospital admissions for complications during pregnancy, fewer cesareans and more VBACs … the risks of maternal mortality are increased with repeat cesarean section compared to vaginal birth after a prior cesarean …

The Mother Friendly Childbirth Initiative:

1. Offers all birthing mothers:
• Unrestricted access to the birth companions of her choice, including fathers, partners, children, ¬family members, and friends;
• Unrestricted access to continuous emotional and physical support from a skilled woman—for ¬example, a doula,* or labor-support professional;
• Access to professional midwifery care.

2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.

3. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, ¬values, and customs of the mother’s ethnicity and ¬religion.

4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.

5. Has clearly defined policies and procedures for:
• collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
• linking the mother and baby to appropriate community resources, including prenatal and post-¬discharge follow-up and breastfeeding support.

6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, ¬including but not limited to the following:
• shaving;
• enemas;
• IVs (intravenous drip);
• withholding nourishment or water;
• early rupture of membranes*;
• electronic fetal monitoring;
other interventions are limited as follows:
• Has an induction* rate of 10% or less;†
• Has an episiotomy* rate of 20% or less, with a goal of 5% or less;
• Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
• Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.

7. Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.

8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.

9. Discourages non-religious circumcision of the newborn.

10. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:
1. Have a written breastfeeding policy that is routinely communicated to all health care staff;
2. Train all health care staff in skills necessary to implement this policy;
3. Inform all pregnant women about the benefits and management of breastfeeding;
4. Help mothers initiate breastfeeding within a half-hour of birth;
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;
6. Give newborn infants no food or drink other than breast milk unless medically indicated;
7. Practice rooming in: allow mothers and infants to remain together 24 hours a day;
8. Encourage breastfeeding on demand;
9. Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics.

Melissa Maimann, Essential Birth Consulting 0400 418 448