Home birth bill takes a baby step for midwives

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Want to know more about home birth, hospital birth or Medicare-funded private midwifery care? Email Melissa Maimann or call 0400 418 448.

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Every time Sheri Brinkmeyer ponders having a third child, she can’t help but think that her family’s recent relocation to Springfield wasn’t the best move. She’s afraid the state’s lack of midwife licensure will mean giving birth in a hospital, like she did with her first child when she felt poked, prodded and bossed around. She birthed her second child at home while living in Oklahoma, but in Illinois the same type of experience would mean putting her midwife in legal jeopardy.

In Illinois, certified nurse midwives, who can be found only in a few Illinois counties, can legally help mothers give birth at home. Other midwives … are illegal in Illinois and can be prosecuted for helping mothers give birth at home …

A measure approved by the Illinois Senate last year but defeated in the House would have licensed midwives based on Certified Professional Midwife credentials … the Coalition for Illinois Midwifery are pushing a similar proposal this year … which would allow, without the risk of legal action, underground midwives to transfer mothers and their birth records to a hospital in the event of an emergency.

“This really has been a response to the Illinois General Assembly refusing to come up with an answer for the home birth maternity care crisis,” … a lack of licensed providers, subject to minimum standards set by a licensing board, has created a black market for midwifery, in which there is no consumer protection. The more a midwife works to become more formally educated, the more likely that midwife is to leave Illinois … as he or she is more likely to come under investigation.

… the ultimate goal of the coalition is midwife licensure … “Most transfers are not emergency, most are due to maternal fatigue, but you do have emergency transfers that do occur … When you have underground care, you have competing issues. It’s not just about the baby, the midwife is going to be concerned about being arrested.”

… without safe passage, women might postpone going to the hospital. Because hospitals now can report a midwife if they know who she is, when an underground provider transfers a mother to the hospital the midwife’s records don’t go with the mother and the hospital is less aware of the woman’s medical condition. “We’re not telling people that they should or shouldn’t [have a home birth], we’re just saying that there’s 700 women [in Illinois every year] who do have homebirths and we want to create the safest situation for them that we can.”

The Illinois State Medical Society opposes both midwife licensure and the emergency transport measure. “I think it’s the most insane idea I’ve heard yet,” says ISMS president Dr. Steven Malkin … “This bill sort of insinuates that it’s OK to have these people deliver you at home, and if there’s a mistake … we’ll be there to clean up the mess.”

Malkin says he’s not opposed to home births, as long as mothers are assisted by “qualified personnel” – hospital-trained certified nurse midwives or doctors. “If enough women want to deliver at home that niche can be filled, but we need to make sure it is done safely and with people who are experienced. … We should not lower our standards to fill a niche.”

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

The benefit of continuous labour support

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Women who receive continuous support were less likely than women who did not to:

* have an epidural
* have any analgesia/anesthesia for labour and birth
* give birth with vacuum extraction or forceps
* give birth by caesarean
* have a baby with a low 5-minute APGAR score
* report dissatisfaction or a negative rating of their experience.

Women receiving continuous support were more likely than those who did not to have a shorter labour.

Overall, continuous support did not seem to impact:
* use of synthetic oxytocin during labor
* newborn admission to special care nursery
* prolonged newborn hospital stay
* breastfeeding at 1 to 2 months postpartum
* postnatal depression
* postnatal self-esteem
* severe perineal trauma
* difficulty mothering.

Private midwifery care provides women with continuous labour support from a midwife who is known to the woman and trusted by the woman. Typically, the private midwife would have provided all of the woman’s pregnancy care and then attends the labour and birth, providing continuous support and midwifery care. Unlike the general hospital system which sees midwives caring for up to three women at any time (and hence flitting between labour rooms), private midwives have only one woman in labour at a time, and are able to dedicate their whole time to this woman and family.

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Mothers endorse birthing program

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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FOR Gemma Newman, having the same midwife care for her throughout her pregnancy made all the difference when it came time to give birth.

The mother-of-two is one of 250 women who have used the Aboriginal Medical Service’s Murundhu dharaa birth program since it began operating 18 months ago.

The midwife-led program incorporates antenatal, birth and postnatal care.

… During her pregnancy, she was cared for by midwife Tracey Foster, who visited her at her home and at work.

Mrs Foster was present when Mrs Newman went into labour, and stayed for Mahli’s delivery at Orange Base Hospital.

… having the same midwife the whole way through her pregnancy had improved her experience this time round.

… “I’ve found it a lot better this time, especially with the after care, if I’ve had any problems with breastfeeding and things like that I’ve been able to call her at any time,” …

… The Orange Aboriginal Medical Service opened its new birthing centre on Palmer Street last Monday …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Midwife encourages natural births

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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GOLD Coast Midwifery Practice … is all for natural births.

When it comes to having a baby … a vaginal birth was the best-designed system.

”A vaginal birth has many inherent safety mechanisms that protect both mother and baby,” …

However, elective cesareans are becoming more common on the Gold Coast …

”We live in a very technocratic society where people like to have as much control as possible,”

… ”It … raises the question of a lack of continuity of care in the health system.

”Care is fragmented and many women aren’t able to form a bond with a care giver. Therefore the process of having a baby can be frightening and they opt for the easy option of having an elective cesarean.” …

Melissa Maimann, Essential Birth Consulting 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

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

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.

MELISSA Maimann has become the first private midwife in St George to receive accreditation under the Medicare benefits schedule.

I’m pleased to have been interviewed by The Leader: I am the first eligible private midwife in the St George area to receive a Medicare Provider Number.

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For expectant mums, the Medicare rebates equates to about $2500 off the total cost of using a private midwife.

Ms Maimann, of St George, said she was one of only 10 private midwives in the country to receive the accreditation, which also enables providers to access some items listed on the pharmaceutical benefits scheme.

The accreditation also legitimised private midwifery practice as an acceptable and mainstream option for giving birth, Ms Maimann said.

“It makes it really affordable for families and a lot of research and support in private midwifery practice is providing a gold standard of care to mothers and babies,” Ms Maimann said. “I’ve always wanted to be a midwife since about five.”

Mothers who use a private midwife have the choice of a giving birth at home, in a hospital or birth centre.

Ms Maimann said the most common reason that mothers chose to use a private midwife was for the “continuity of care” and because women wanted to know the person that was going to be with them “for the big day”.

“They want to have control over their care and to have more input into the decisions that are made,” Ms Maimann said.

“We can order tests and ultrasounds as well, so women don’t need to go to their GP in order to have that done.”

There were 295,700 registered births in Australia last year, figures from the Australian Bureau of Statistics showed.

The total fertility rate was 1.90 babies per woman, a small decrease from 1.96 babies per woman in 2008 and 1.92 babies per woman in 2007. Tasmania had the highest fertility rate.

‘We know the reality of childbirth’

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 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

AMA boss denies bar on midwives

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 head of Australia’s peak doctors’ group has rejected claims obstetricians are obstructing midwives’ attempts to see their own patients, saying the first agreement permitting this has just been signed …

Andrew Pesce, an obstetrician and president of the Australian Medical Association, said he signed the agreement with a Sydney midwife last week, and had all but sealed a deal covering a group of midwives.

… Dr Pesce conceded some obstetricians were unhappy with the changes, but added the new system could work well with fewer specialists around the country who were willing to participate. Under the changes, introduced on November 1, eligible midwives were allowed to see patients privately under Medicare, provided specific conditions were met.

I am proud to be that “Sydney midwife” who has an agreement with a private obstetrician to provide care to women. I believe we are the first private midwife / private obstetrician practitioners in Australia to have successfully negotiated a collaborative agreement. Our model ensures that women have care that is suited to their needs, covering everything from waterbirth to caesarean with no need for a transfer between models of care. Each woman has her care with her chosen midwife (complete with Medicare funding) and also has a known and trusted obstetrician available if her pregnancy or birth take a different path. Our model builds on Australia’s excellent record of safety in pregnancy and birth and provides continuity of care with the private midwife and obstetrician of the woman’s choice.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Obstetricians are ready to quit

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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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

Medicare … at last!

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

Many Sydney families may now benefit from legislative changes that enable women to claim medicare benefits for private midwifery care for homebirth or hospital birth. Melissa Maimann is thrilled to be one of the first 10 midwives nationally to receive a Medicare provider number.

A Medicare-Eligible Midwife meets certain advanced requirements in relation to experience, formal peer review, continuing professional development and competence to provide pregnancy, birth and postnatal care to women and babies. This provides an assurance to the public that services provided by a medicare-eligible midwife are of a high standard. In addition, in order to use the medicare provider number, the midwife must have a collaborative arrangement with a doctor to ensure a) continuity and b) a high level of care.

I am pleased to also let you know that I can now order all routine tests and ultrasounds. This saves women from having to have these attended by their GP. Medicare funding means that cost is no longer a barrier to women benefiting from private midwifery care. It is well known that when women are cared for by the same midwife throughout pregnancy, birth and postnatal, they are healthier, experience less intervention, are more likely to successfully breastfeed and are more satisfied with their birthing experience.

Melissa Maimann has negotiated a collaborative agreement with a private obstetrician enabling “Ultimate Continuity”: complete continuity of private midwifery and private obstetric care for pregnancy, birth and postnatal. Alternatively, women may obtain a referral to Melissa Maimann for private midwifery care. This referral would be from a GP Obstetrician (ie, a GP with a Diploma in Obstetrics). Please contact me if you are experiencing difficulty in obtaining a referral from your GP Obstetrician.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mothers ‘too scared to push for baby No2′ as demand for Caesareans increases

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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Expectant mothers are increasingly demanding Caesarean sections for second babies because their first births were so traumatic, say midwives.

In some maternity units, the numbers wanting the procedure has doubled in the past year.

On top of that, many women were so distressed first time around that they are putting off, or even abandoning, plans to have more babies.

The experience is often unnecessarily stressful because maternity units can be overstretched.

Women are often left alone and scared before and after labour as midwives simply do not have the time to offer them the advice and reassurance they need.

This is where private midwifery care is so beneficial for women: the private midwife does not leave the woman’s side, acting as a doula / support person and midwife all at once.

The number of expectant mothers asking for a C-section at Liverpool Women’s Hospital, one of the largest female hospitals in Europe, has increased by 40 per cent in a year.

Other maternity units … report similar trends.

Birth trauma clinics, which support women after difficult labours, say they have seen a doubling in patients in the past 12 months. Cathy Warwick, of the Royal College of Midwives, said: ‘If a midwife is very busy, clearly she won’t have time between dealing with women in labour to give others emotional support and reassurance.’

Doctors and midwives increasingly offer C-sections if women are fearful of giving birth …

Midwives also say that increasing numbers of women are suffering from tocophobia, or a fear of childbirth.

Simon Mehigan, a consultant midwife at Liverpool Women’s Hospital, blamed a lack of information or explanation about what was happening in a first pregnancy …

This is a really great point: it is so important for a woman’s first pregnancy and birth experience to be positive as this experience will shape her subsequent pregnancy and birth experiences. It can be easy to “go with the flow” and do what you are told is best for you / your baby, however this approach – almost a passive approach – will lead to a 31% chance of having a caesarean and a majority of women having their first babies with a “go with the flow” attitude will come away disappointed with their experience. It’s important not to have firm, fixed beliefs about how a pregnancy and birth will go, because no-one has a crystal ball to know exactly how things will be on the day. But it is really essential to be well informed and well supported by a private midwife who believes in birth and a woman’s ability to birth her baby naturally.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Most mothers-to-be don’t have dedicated midwife and are not sure of their birthing options

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

This is a UK article but it is just as relevant here in Australia. Birthing options here consist of a visit to the GP:
“I’m pregnant”

“Great. Your due date is xxx.”

Then the conversation generally moves to, “Do you have private health insurance?”

If yes: the woman has an automatic referral to a private obstetrician for birth in a private or public hospital.

If no private health insurance, the woman is referred to the nearest public hospital where options of care will be discussed with the woman at the booking appointment, but her chosen option will need to be approved at the next visit with an obstetrician. If the obstetrician deems the woman to be too high risk for her chosen model of care, she is – without choice – slotted into the obstetric clinic.

Women with and without private health insurance have the option of private midwifery care, for either a homebirth or a hospital birth. Even without visiting rights (which ought to be in place by early 2011 in NSW), women can have a private midwife attend all of their pregnancy and postnatal care and also birth with the woman in hospital. A hospital midwife would also be assigned to the woman – and medical care can be accessed quickly and safely at any point in the pregnancy and birth if needed. This model delivers excellent continuity of care to the woman and maximises safety and satisfaction with the pregnancy and birthing experience.

Anyway, now to the article:

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Most mothers-to-be do not meet the midwives who will care for them during their labour before the birth, a study revealed today.

The poll of more than 5,300 new mothers also found only 18 per cent had one dedicated midwife caring for them during labour and 25 per cent saw four different carers.

It also found one in three pregnant women were left alone and worried at some point during or just after the birth.

Only 18 per cent of mothers to be were cared for by one dedicated midwife during their baby’s birth

… 80 per cent of women were not aware of the four options of where to give birth …

The choice of where to give birth should include at home, in a free-standing midwifery unit, in a midwifery unit connected to a hospital or in a hospital unit led by consultants.

… many services are … seriously failing women in terms of giving them continuous support in labour and giving them a named midwife they can contact at any time …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Continuity of Midwifery Care

Visit my website to learn more about my services.

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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.

Visit my website to learn more about my services.

Oxytocin Medication Often Unnecessary In Normal Deliveries

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 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

Your body, your choice

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 transforming experience of childbirth is increasingly blotted by medical interventions. Are women making informed decisions?

LIKE most first-time mothers, Faye Wong … was incredibly excited when she got pregnant. She read baby books and magazines voraciously, signed up for ante-natal class … to prepare for baby’s arrival.

When she was 38 weeks pregnant, her obstetrician said the baby’s head had engaged and his size was quite big. The doctor suggested inducing her labour.

In the labour room, her “nightmare” began. The pain from the drug-induced contractions was a rude jolt to her system. Then she was jabbed and prodded with painkillers, IV tubes and the works.

“I was shocked, confused, and in absolute terror,” recalls Wong, 35. Finally, the induction failed and she had to be wheeled in for emergency caesarean. Thankfully, she delivered a healthy baby boy weighing 3.9kg. When she got home, she struggled with breastfeeding and suffered a severe bout of post-natal blues.

“I felt ‘cheated’ … ” Wong admits. Her son is now seven. “I was a newbie to the birthing process and was meek as a lamb led to the slaughter,” she adds. “If I’d known then what I know now, I probably would have been better prepared, stood my ground and not undergone early inducement.”
Though doctors play a role in giving women the necessary information about labour options, women and their partners need to take their share of responsibility too in making informed choices and decisions.

Wong’s experience isn’t unique.

“We see a fair amount of women who are unhappy about the outcome of their deliveries,” says Jennifer Hor of Jenlia Maternal Services. The UK-trained midwife has been running ante-natal classes and post-natal home visits for 17 years. “Some felt they had a C-section even though they didn’t want it. Or, some felt they didn’t get enough information from their doctors.”

So, are women less assertive when it comes to childbirth? Are they getting or finding the information necessary to make informed choices and decisions? And have we forgotten that childbirth, an age-old practice, is meant to be natural?

Birth trends

… the medicalisation of childbirth means what used to be a straightforward, natural process is now treated as a high-tech medical procedure.

Caesarean rates are on the rise in both developed and developing countries …

… “Women say they want to take ownership of their bodies, yet we have healthy, low-risk women who said they had a C-section for their first births because they listened to their doctors,” says Farouk, who also sub-specialises in reproductive medicine. And because of the risks from the first surgery, these women are requesting for repeat C-sections. “Ironically, women are pushing the trends that way.

“We are also seeing the use of more technology to manage pregnant mothers, for example using CTG (cardiotocography) … and ultrasound scans,” says Farouk. “It’s not all bad, but if you monitor too much, you might pick up something and wonder if you don’t take action, there might be consequences, hence the interventions.”

… Doctors come with their beliefs and agendas, based on experiences. Some underplay certain risks and amplify others. For instance, placental calcification … is not a major issue for some obstetricians if the woman is near term and foetal growth is normal. But for a different doctor, a few specks on the ultrasound scan is reason enough for labour induction.

“There can be grey areas in medical investigations. I tend to be more conservative with placental calcification and continue to monitor foetal health and growth parameters,” …

Also, fear of litigation is scaring obstetricians into defensive and often interventionist practices.

“An obstetrician is more likely to be subjected to litigation because a caesarean section was not performed or was perceived to have been performed too late …”

Medical interventions

Clearly, it’s not always true that C-sections or epidural blocks are being foisted on reluctant women. The fact is, some women don’t question their doctors, or they themselves are asking for interventions.

Labour induction, elective caesarean, epidural jabs, and routine episiotomy are some of the common medical interventions during childbirth.

Induction of labour … is usually done when the mother’s or baby’s health is at risk …

“For such cases, studies have shown that caesarean section rate has been unchanged or lower among the induced group as compared with expectant management of pregnancy … ”

“But induction of labour at 37 to 41 weeks on non-medical grounds is linked with an increased risk of caesarean section for … a woman who has never given birth and an increased risk of instrumental delivery,” …

No doubt, medical interventions can be a lifesaver for mothers and babies …

However, once the natural process of labour and birth has been disturbed, if there is no actual emergency, there is risk that the side effects of the treatment will trigger more intervention necessary to fix the problem. This sequence of events is called the “cascade of interventions”.

“Pitocin (Syntocinon), a synthetic form of the hormone oxytocin used to induce or speed up labour, often results in a rapid increase in the intensity and strength of the woman’s contractions. As a result, she may opt to use pain medications such as pethidine … or epidural anaesthetic. Babies sometimes don’t react favourably to the sudden increase in the intensity of the contractions, which may result in irregularities of the heartbeat. Thus in turn may necessitate delivery by caesarean,” …

“Many women who use epidural do not experience the urges to bear down which help them to birth their babies. Often, in this situation, the doctor will use forceps or vacuum to deliver the baby, which means he needs to do an episiotomy … Many women experience long-term perineal pain following episiotomy.”

A failed induction (when labour doesn’t started after the first cycle of treatment) can either require a rescheduled induction or emergency C-section.

“Women should received accurate information about the risks, benefits, and alternatives of induced labour and understand the possible side effects and interventions, ” …

The big ‘C’

Most women also come with the preconceived idea that C-sections are safer than vaginal delivery …

… “In fact, C-section, which is classed as a major surgical procedure, carries with it the risk of complications and shouldn’t be viewed as an alternative option to normal birth.”

… “Babies delivered by elective caesarean section at 37 to 39 weeks’ of pregnancy are at two to four times more likely to suffer from respiratory morbidity compared with babies delivered by vaginal delivery,” … WHO global maternal survey also finds that women who choose elective caesarean with no medical indication are at increased risk of maternal death and serious complications.

… Studies have linked depression and distress after birth, which affect up to one in five women, to forceps and caesarean births …

Disturbed birth

“You must be mad to give birth without an epidural!” A common reaction these days if you speak with women who have undergone labour. But as the WHO states, “epidural analgesia is one of the most striking examples of the medicalisation of normal birth, transforming a physiological event into a medical procedure.”

… in her book,Gentle birth, gentle mothering, internationally acclaimed birth expert Dr Sarah J. Buckley explains how epidurals or painkilling drugs and synthetic hormones (used during induction) interfere with some of the major hormones of labour and birth. The five major hormones: oxytocin (hormones of love); beta-endorphin (pleasure and transcendence); the catecholamines or CAs, epinephrine and norepinephrine (excitement); and prolactin (tender mothering) form a “cocktail of hormones that nature prescribes to aid birthing mothers of all mammalian species”.

During an undisturbed labour, these hormones rise in crescendo and peak around the time of birth or soon after for mother and baby, and subside over the following hours and days. “An optimal hormonal orchestration provides ease, pleasure, and safety during this time for mother and baby.” Interference with this process, by injecting drugs or synthetic hormones, will “disrupt the hormonal orchestration, making birth more difficult and painful, and potentially less safe”.

For example, epidurals lower the mother’s production of oxytocin or stop its normal rise during labour. Oxytocin causes a woman’s uterus to contract in labour. It peaks at birth and catalyses for the final powerful contractions of labour, and helps mother and baby to fall in love at first meeting.

Under stressful conditions, our body releases epinephrine and norepinephrine (CAs). Towards the end of an undisturbed labour, the mother experiences an adrenaline rush – the natural surge in these hormones gives her the energy to push her baby out, makes her excited and fully alert at first meeting with her baby.

But when a woman feels fearful or unsafe, her labour is inhibited by high CA levels. Epidurals reduce the release of the CAs, which may be helpful if the high levels are restricting her labour. However, a reduction in the final CA surge may make it difficult for the woman to push her baby out, thus increasing the risk of instrumental delivery (forceps and vacuum).

Epidural’s side effects include nausea, slowing of labour and drop in blood pressure, slowing of contractions, and headache.

35-year-old Laila Aziz of Kuala Lumpur was wheelchair-bound for four months after an epidural jab injured her nerves when she delivered her third child.

“I wish my O&G and the anaesthetist had explained in details the pros and cons of using an epidural,” says Laila, who suffered severe post-natal blues after childbirth. “I would at least reconsider whether to use the option at that time.”

… Childbirth educator and lactation consultant Christine Choong has been advocating natural childbirth for the past two decades.

“My main passion is how birthing practices affect breastfeeding. What happens when you’re in labour can have a long-term effect on your breastfeeding,” …

Research has shown that when you put a baby on his mother’s chest (skin-to-skin contact) immediately after he was born, the baby will crawl instinctively towards her breast.

“Quite often the baby won’t do that if you had used drugs during labour … because he will be drowsy the first two to three days,” … “If women use epidural, very often their babies are delivered by suction or forceps which can cause discomfort on baby’s head (a shock to the system) and baby initially will not be happy feeding on one side or the other.”

Whether a labour induction is done on medical grounds or not, the baby is – by definition – relatively immature and likely to have impaired ability to effectively coordinate sucking, swallowing, and breathing at breast …

“In a C-section delivery, very rarely the mother is given the baby straight away,” Christine adds. “Early stimulation or suckling is important to establish breastfeeding. Also a higher percentage of caesarean babies end up with respiratory problems, which results in separation of mom and baby.”

But we need to look at the whole picture – the impact on baby, feeding, and mother-baby relationship.

“It isn’t just feeding but also nurturing,” says Christine, a mother of three.

“When babies are nurtured and their needs are met, in the long term, they will become people who are secure, confident, and know how to form relationships with people.”

Take control

What do you do if your care provider says you or your baby is at risk and an intervention is necessary?

“Using evidence-based information, your doctor should explain the reason for any suggested interventions. He should also explain the benefits and risks of such procedures,” advises Choong. If you’re not sure or not too convinced by your doctor’s explanation, get a second opinion.”

“Empowerment with the correct knowledge and information is useful so women can ask the correct questions,” Chow adds. “And their fear of childbirth should be addressed by getting support and learning about the labour process and pain relief options.”

Ultimately, a woman’s satisfaction with her birth experience is related more to her involvement in decision-making than to the outcome, as Buckley emphasises. Though doctors play a role in giving women the necessary information, women and their partners need to take their share of responsibility too in making informed choices and decisions.

When Wong had her second child, she was more mentally and emotionally prepared.

“Although I ended up having another C-section (due to hypertension), I didn’t feel disappointed and helpless,” Wong says. “I felt as if I was a real mom this time around.”

As Buckley sums it up best, “birth is the beginning of life; the beginning of mothering and of fathering. We all deserve a good beginning.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Childbirth ‘over medicalised’

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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WA’s top child health researcher has stirred up the childbirth debate, claiming it is over-medicalised and saying she does not believe there is evidence that homebirth is riskier than a hospital delivery, provided it is a low-risk pregnancy.

Telethon Institute of Child Health Research director Fiona Stanley said she was strongly supportive of the use of midwives and that too many women were having caesareans, which could lead to complications for the mother and baby.

Professor Stanley said her own grandchildren had been delivered by midwives without medical intervention, and obstetricians needed to relinquish low-risk deliveries to midwives and trust there would be good outcomes.

Her comments came as pregnant women cared for by experienced midwives won the right to claim Medicare rebates from this week, as part of the Federal Government’s health workforce reforms.

“I’m strongly supportive of the increasing role that midwives are playing by preparing women for birth, by helping them plan for a spontaneous, normal delivery that will be better for mother and child,” Professor Stanley said.

“We published a study about a few years ago which showed a dramatic increase in caesareans, and that the majority of the increase was unrelated to medical risk, so it was either obstetricians wanting to deliver that way or it was the mothers demanding it.”

Professor Stanley said there were anecdotal claims that homebirth was dangerous but she had not seen the evidence.

“If people say homebirth is dangerous, show us the data, because the data we have shows they’re not if the right things are in place,” she said.

Retired Perth obstetrician Ralph Hickling, who has just published a book, Childbirth today: too many caesars, not enough joy?”, echoed the call for wider use of midwives.

Dr Hickling said the management of childbirth had been taken over by consumerism and there was a push towards an almost 100 per cent caesarean rate.

“In recent times Australia could claim having the highest caesarean rate in the world and I think WA could claim the highest in the country, and there’s no way the obstetric discipline can justify a caesarean rate of 35 per cent or more,” he said. “Pregnancy is being treated as a disease and childbirth is seen as an operation to cure the disease.”

Community Midwifery WA manager Pip Brennan said that under the program women with low-risk pregnancies were reviewed by an obstetrician and monitored by midwives during their pregnancy and labour.

“Typically women have very positive experiences,” she said … “I was in labour for quite a while but it was a wonderful experience being in my own home,” she said. “Soon after the birth I was having a cooked breakfast in bed and it was so relaxed.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

“Do midwives need a doctor to share care and collaborate for home births?”

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

There is much confusion about the maternity reforms, medicare, collaboration and homebirth.

The simple answer is that is a midwife / woman wish to claim medicare benefits, a collaborative agreement is needed. The collaborative agreement is between the midwife and specialist obstetrician, or midwife and GP obstetrician. A collaborative agreement can take a few forms:
- a written referral from the doctor to the midwife (respective of each and every woman)
- a written agreement between the doctor and midwife (1 agreement to cover several women)
- midwife’s written record of a collaborative arrangement (lots of paperwork for the midwife for each woman she has booked with her)
- a midwife being employed or engaged by a business that employs obstetricians (this may be possible if the midwife has clinical privileging at a hospital, or if a midwife is employed by an obstetrician).

If the woman / midwife do not wish to claim medicare, a collaborative agreement is not needed. In this sense, there is no “medical veto” or a doctor’s signing off of a homebirth.

Medical veto does not exist where a midwife and obstetrician are working together in partnership, each respecting the skills, experience and knowledge that each one brings. Since signed collaborative agreements are ony one option of several, and since midwives and obstetricians can choose whom they wish to have agreements with, it would surprise me that a midwife would voluntarily sign an agreement with an obsetrician who would veto her practice. These discussions would surely be had well before an agreement was signed.

Women who are wishing to claim medicare benefits for private midwifery care will need to ascertain that their midwife is an eligible midwife. Unfortunately the Board has no process as yet to assess applications for eligibility, so there are no midwives who are currently eligible. It is hoped that this proces will be in place in the next few weeks. In any case, women should verify that their midwife:
- has registration as a midwife with no conditions on their registration
- has completed a professional midwifery practice review
- has attended 40 hours of continuing professional development in the past year
- has competence across pregnancy, labour, birth and postnatal
- has at least three years of experience

These are the requirements for midwives who wish to apply to be eligible. Clients of medicare eligible midwives may claim medicare benefits provided that the midwife has a collaborative agreement as described above.

Confused? You’re not alone! Email me with any questions.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Big hurdle for home births

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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Private midwives have “yet to find” a doctor willing to engage in arrangements to gain access to Medicare rebates and the Pharmaceutical Benefits Scheme …

The college [of midwives] is building a case against the incoming arrangements … College members were asked to provide evidence of their difficulties in getting doctors to sign on to collaborative arrangements, in the hope of showing the new rules, which take effect from November, are unworkable.

President Hannah Dahlen pointed to the recent overturning of near-identical legislation in the United States, where “doctors were increasingly unhappy to sign contractual arrangements with midwives because they were worried about their own liability”.

“Doctors are quite happy to collaborate with us, but they don’t want to put their name on a document because they’re worried about their own vulnerability. They’re quite rightly saying ‘what’s in it for us’,” Professor Dahlen said.

The new rules are believed to be the result of lobbying by medical groups opposed to home births.

… Nadia Szimhart … gained access to [a] fledgling publicly funded home birth service … and gave birth to Hana Lanceley at home on January 28.

The experience was “absolutely beautiful”, but was possible only because hers was a low-risk pregnancy which met very stringent eligibility requirements – more strict than those of most private practice midwives.

Ten babies have been born through the publicly funded service since July 2009, with another six births expected by the end of 2010.

Private practice midwives are the only other option for women who want a home birth but don’t meet the public system’s stringent guidelines.

“The regulations being put in place are going to make it difficult because most of the doctors I have spoken to – including my GP – don’t agree with home birth,” Mrs Szimhart said.

The public models for homebirth have very strict entry requirements, and once accepted into the program, women must remain absolutely low risk of they will be asked to birth in hospital. Private midwifery care affords women are better guarantee of a home birth with lower transfer rates. Transfer rates for public programs range from 37% – 50% whereas private midwives have transfer rates of 5% – 20%.

Medicare funding was only meant to cover hospital birth, not homebirth. However, the catch is that doctors will not sign agreements with midwives who attend homebirths at all. This forces midwives to attend either home births or hospital births. This model does not provide for continuity of care and does not reflect the fact that along the pregnancy – birth continuum, some women will start out wanting a hospital birth and change to a homebirth later on, while other women will plan a homebirth but end up birthing in hospital.

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

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

Why has the USA’s cesarean section rate climbed so high?

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 government-sponsored study of 230,000 births between 2002 and 2007 found that the C-section delivery rate was 30.5%.

• Among women who ended up with an unplanned C-section, failure for labour to progress was cited in nearly half the cases.
• Fetal distress or non-reassuring fetal testing was listed as a reason for more than a quarter of unplanned C-sections.
• Nearly half of all planned C-sections were scheduled because the woman had had a previous C-section.

Regarding failure to progress, the accepted rate of progress is deemed to be 1cm/hour. First baby or fifth baby, this is the rate that your labour is expected to progress at. This is despite that fact that first time labours do take longer than second and subsequent labours. There is research to support 0.5cm/hour as an acceptable rate of progress but this is largely ignored. I wonder what the caesarean rate for FTP would be if 0.5cm/hour was used instead of 1cm/hour?

So what happens to the woman whose labour doesn’t progress at 1cm/hour? Well, in the first instance, her waters are broken. This is done with the aim of speeding the labour. Generally, a vaginal examination will be performed 2 hours afterwards and if the woman has not progressed another 2cm in this time, a syntocinon infusion is commenced. This is part of a package, however, and the package includes continuous monitoring. Continuous monitoring is needed because the syntocinon drip causes unnaturally stronger, longer and more frequent contractions that can stress the baby.

Which leads to the next cause of caesareans, according to the article: fetal distress or non-reassuring fetal status. This accounts for around 25% unplanned caesareans.

And finally, about 50% planned caesareans occur as a result of a previous caesarean.

Are you joining the dots yet? That initial diagnosis of “failure to progress” often leads to augmenting the labour. If the augmentation is not successful – or if the baby becomes distressed in the process – the woman is taken down the corridor for a caesarean. Having had that first caesarean, there’s a good chance all her subsequent babies will be born in this way.

What can be done to avid this? There are a few keys:
- continuity of midwifery care from pregnancy right through to 6 weeks after your baby is born
- planning to birth at home
- Ensuring that you have good support in labour from a loved one.

Melissa Maimann, Essential Birth Consulting 0400 418 448

New unit a ‘home birth in 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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MONA Vale Hospital’s new birthing unit will simply be a place for expectant mothers to have a home birth inside a hospital – but a long way from emergency care if a complication occurs – according to an obstetrician.

How anyone can consider a hospital birth to be the same as a homebirth is way beyond me! There is a very big difference between the comfort and familiarity of our homes, and a hospital environment.

Dr David Jollow, one of Mona Vale Hospital’s onsite obstetricians, said the new, midwife-run, Mona Vale birthing unit would mean women who suffer a complication during labour will have to be rushed to Manly Hospital instead of being treated by Mona Vale’s onsite obstetricians.

“The new unit is essentially a home birth that happens to be in a hospital,” Dr Jollow said.

“It would actually be safer to have a home birth in Balgowlah or Seaforth, because an ambulance ride to Manly would be quicker.”

It’s interesting that obstetricians oppose free-standing birth centres, yet we have the existence of midwife-run units where obstetricians are not available. Is ther a differnence? Is it merely a differing terminology to be acceptable to some?

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mums speak out about maternity shake-up

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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LOCAL women have expressed grave concerns about the standard of maternity services on the northern beaches, claiming a doctor-free birthing unit at Mona Vale Hospital is a risk to their health.

With the Health Department and midwives’ groups angrily denying the changes would jeopardie the health of women and their babies, The Manly Daily yesterday spoke to the most important people in the debate – new and expecting mums.

Amee Harland said she would wait for the Mona Vale maternity ward to reopen in full before having a second child there.

“I had a 24-hour labour and then they had to call the doctor because the baby’s heart rate was falling and he was there in five minutes and had to use a surgical vacuum,” she said.

… “You wouldn’t want to drive to Manly (or St Leonards) in the middle of labour …

“I would prefer to go to Mona Vale – it is my home town. Why would I want to go anywhere else? They were so good there.”

Mother-of-three Kellie Finney said low-risk births could also require immediate action.

“If there’s an emergency, the time it takes to get to another hospital would be pretty risky for babies in distress,” she said.

Luckily, research is showing that low risk maternity units are a safe option for women and babies, just as homebirth is a safe option for low risk women and babies. Several low-risk maternity units are in operation: Belmont, Wyong, Ryde just to name a few. The provide a fantastic solution to the issue of maintaining local birthing services.

“I don’t know how long exactly it takes for the baby to stop breathing or have serious medical problems.”

Thankfully, midwives can make such assessements. Transfer policies in place would ensure that women and babies who were at risk would be transferred to an appropriate facility in a timely manner.

“After the baby is born, what happens if the mother is bleeding out of control?’‘

The midwife would administer medications to stop the bleeding, insert a drip and start IV fluids, insert a urinary catheter to drain urine and supervise transfer. It is very rare for a woman to “bleed out of control” and most bleeds are controlled with medications to stop the bleeding.

… if a doctor was needed during the birth, such as to deliver the baby by caesarean, use certain medical instruments or administer an epidural injection, women will be transferred to Manly Hospital or Royal North Shore 45 minutes away.

And the problem is … ?

While mothers at the Mona Vale playgroup praised the role of midwives and welcomed the return of some maternity services to Mona Vale, they said they would not give birth without a doctor present.

You can’t please everyone! The majority of midwifery-led units are over-subsctibed with many women wanting to birth there where they’re assured a known midwife and maximum chances of a natural birth. No-one is being forced to birth at Mona Vale; women who prefer to go to manly or RNSH would be able to go there.

Most mothers said a doctor was called in during their previous births, despite some being in a low-risk category.

That might be a larger reflection on the rates of intervention in obstetric-led births rather than on actual need in a natural labour. Let’s not forget, high risk births would not take place at Mona Vale: no-one with diabetes, high blood pressure, premature, over 42 weeks, bleeding, broken waters for more than a certain period of time, anyone needing an induction or caesarean, twins, breech, anyone planning an epidural and so on.

… Catherine Kane, who is expecting her second child, said she is “not low risk enough’’ to give birth at Mona Vale.
“I wouldn’t be allowed to go to Mona Vale although I’m not high risk, I’m not low risk enough either.’‘

Andrea Whitlock, from Terrey Hills, said she would expect the maternity unit where she gave birth to have a doctor on hand.
“I had a natural delivery but if I didn’t have a doctor there I wouldn’t have been able to do it,’’ she said.

Hmm. I think you did do it! No-one else birthed your baby.

… The model will first be tested at Manly Hospital in October and is scheduled to begin at Mona Vale in December.

The Mona Vale maternity unit will also be reduced from 720 births to just 200 a year, with mothers only able to stay four hours after birth …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Doctor-midwife tensions run deep

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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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

Midwives attack new ‘veto’

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MIDWIVES are aggrieved about new rules that might curb their access to Medicare rebates and prescribing rights …

Last year Ms Roxon announced that from November this year midwives would for the first time be able to use the Pharmaceutical Benefits Scheme and Medicare rebates for their clients.

At the time, Ms Roxon said the historic move would boost a midwife’s ability to work independently and increase options for pregnant women …

But in a long-awaited change to the legislation … midwives will now have to work collaboratively with a doctor, who must endorse their practice before their clients can access financial benefits.

The requirement for collaboration was always planned to be in place, but the detail of collaboration requires that a midwife has a written agreement with an obstetrician to access medicare benefits. This is problematic: more than one obstetrician must sign an agreement because no obstetrician provides 24/7 cover, so there’d need to be at least 2 obstetricians signing the agreement. What happens if one obstetrician leaves the local area? Is sick? Goes on leave? In these situations, the collaborative agreement is very vulnerable. Not only the agreement, but the midwife’s ability to provide ongoing care to her private clients.

After eight months of debate between doctors and midwives, government records show that Ms Roxon signed a determination on the matter two weeks ago, when Parliament was out of session.

Doctors’ groups who say home birth is unsafe are believed to have lobbied the government for the changes.

Yesterday, midwives and home-birth advocates accused Ms Roxon of trying to hide what will be an unpopular decision with midwives and mothers.

Australian College of Midwives president Hannah Dahlen said the change would effectively give doctors the ability to veto their access to Medicare and the PBS.

While midwives working inside hospitals would not be disadvantaged, she said private midwives would find it difficult to find a doctor to endorse them, especially if the doctor did not support home birth.

In fact, doctors have refused to sign agreements with any midwife who attends homebirths. Is this collaboration or control?

Melissa Maimann, Essential Birth Consulting 0400 418 448

Collaborative Arrangements Will Provide Better Care For Patients, Autralia

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The AMA welcomes the Government’s introduction of new regulations that require midwives … to collaborate with medical practitioners in order to provide Medicare-funded services to patients or prescribe them medications under the Pharmaceutical Benefits Scheme (PBS).

AMA President, Dr Andrew Pesce, said today that the new arrangements would provide a safer higher standard of care for patients.

… “There is now a requirement for midwives … to establish collaborative arrangements with a medical practitioner in order for the service to attract a Medicare patient rebate or PBS benefit.

And that’s the problem: midwives are required to establish collaborative agreements, but obstetricians do not have to collaborate with the midwife. And there are fears that if the midwife does not work according to the obstetrician’s protocols, the agreement will be revoked. this does nothing to establish midwifery as a profession in its on right.

… “Evidence shows that patients enjoy better health outcomes when they receive coordinated, continuous, and comprehensive care that is delivered by appropriately trained health professionals,” Dr Pesce said.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Midwife scheme endorsed

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THE NORTHERN beaches health service will proceed with plans for a midwife-only maternity scheme at Mona Vale Hospital …

The new scheme will see the majority of northern beaches births take place at Manly Hospital, where a combined obstetric maternity service will operate, with about 200 births a year scheduled for Mona Vale, where midwives will now manage them all.

… the new “midwifery group practice model” was unanimously endorsed …

But Mona Vale obstetrician Dr Chester Kent said the hospital had no representatives on the council and that none of its maternity staff supported the decision.

“It seems there is nobody being included in the decision-making process who really represents the interest of local women,” he said.

Another hospital worker, who did not want to be named, said they were only told about the changes at a meeting on Tuesday and that neither Manly or Mona Vale staff supported the decision, which they found “very distressing”.

Pittwater State Liberal MP Rob Stokes said operating a midwifery group practice model at Mona Vale was not a bad idea, but it should not be used as a replacement for obstetric services.

… “It’s not good enough to put a delivering mother into an ambulance and take them down to Manly, or the North Shore.”

Northern Sydney Central Coast Health chief executive Matthew Daly, who was present at Monday night’s clinical council meeting, said improved health outcomes for mothers and babies had influenced its decision to endorse a “united obstetric service” at Manly.

It’s wonderful to see midwifery-led services expand. We have midwifery-led services in private midwifery practice, Ryde Hospital, Belmont and Wyong, to name a few. They’re a great way to maintain midwifery services and are proving very popular with women and families.

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

Are Today’s Obstetricians Giving Women What They Really Want?

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It seems patients of Dr. Robert Biter’s are everywhere here in North County San Diego. For a long time now, I’ve enjoyed playing the game of mentioning him when I meet one and just buttoning my lips to listen to the glowing stories that come back to me. Such tales were echoed over and over in comments on my recent post, “Why I’m Protesting for my Natural-birth Friendly OB.”

The post chronicled the buzz over the recent suspension, reinstatement and resignation of popular OB, Dr. Robert Biter, from San Diego’s Scripps Encinitas hospital last month, and the hundreds of people who showed up at local rallies in his support. Even though this piece portrays individual stories — mine with Dr. Biter and his with a contentious hospital — I’m glad to see the attention Huffington Post readers are giving it for the larger issues at play.

Dr. Biter was cleared of any wrong doing under a peer review panel and the California Medical Board declined any sanctions against him … Given the continued silence of both parties, it’s not clear what legal proceedings may still be underway. Regardless, his enormous, continued support in my community says a lot about what many women want as health care consumers today.

A central aspect of Dr. Biter’s popularity seems to be his unique ability to incorporate much of the midwife’s model of care … where birth is seen as a normal process … he puts in endless hours to stay very present in a labor, however lengthy, and tailors the care to maximize a woman’s innate ability to birth her baby without interventions …

… Over the years I’ve met more than one patient in Dr. Biter’s crowded waiting room who has driven hours just to see him. They make one thing clear, Dr. Biter does things differently than most. In addition to being more sincere and caring than some of our past doctors, he has extremely low rates for interventions like labor induction/acceleration drugs or c-sections. He also encourages women to move around during labor, as desired, to help the baby move down and out of her pelvis.

… Perhaps you are asking if Dr. Biter’s way is less safe than the norm … Even though we birth with OBs over 90 percent of the time in the U.S. … we still have the second worst newborn mortality rate of any developing nation and our maternal mortality rate has doubled in the last 25 years.

Of course, there are plenty of women who aren’t interested in a more natural birthing experience and options are abundant for them. But a real number of others are clearly starved for an OB who allows her to take her time in labor and resists the urge to intervene unless there is a genuine complication.

Like me, these women may want the option of having an epidural, or other medical tools available at their birth. But many of them don’t feel their freedom of choice is respected once they walk through a hospital’s doors.

… I do wonder why more doctors don’t offer a way of birthing with fewer medical interventions, when a doctor who does, like Dr. Biter, has such a groundswell of support?

The situation is very similar in Australia, with very few obstetricians providing natural birth services. Obstetric care frequently involves interventions such as induction, epidural, vacuum extraction and so on. Yet it’s very clear that natural birth is important to women. What will it take for obstetricians to feel mroe comfortable to provide natural birth services such as waterbirth, vaginal breech birth, VBAC, physiological birth positions, physiological third stage and so on? I expect it would take a change in our legal system and duty of care legislation to be in place.

a href=”http://www.essentialbirthconsulting.com.au/about-melissa-maimann.html”>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.

Can private midwives be fined for delivering a baby at home?

No. it’s perfectly legal for private midwives to attend homebirths. There are no fees or penalties to the midwife or family.

What is an eligble midwife?

An eligible midwife is a midwife who has:

Current general registration as a midwife in Australia with no restrictions on practice;
Midwifery experience that constitutes the equivalent of 3 years full time post initial registration as a midwife;
Current competence to provide pregnancy, labour, birth and post natal care to women and babies;
Successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care;
40 hours per year of continuing professional development relating to the continuum of midwifery care (20 hours in addition to standard requirements);
Formal undertaking to complete an accredited and approved program of study to develop midwives’ knowledge and skills in prescribing within 18 months.

Clients of eligible midwives are able to access Medicare benefits for the services provided by eligible midwives. eligible midwives are also able to access visiting rights at a later date.

Can you use a private midwife in public hospital in sydney?

Yes. You can work with a private midwife during your pregnancy and she can provide all of your pregnancy care. You can labour at home as long as you like with your private midwife, moving to hospital when you feel ready. In hospital, your midwife will ensure that your needs are met and provide support and advice. After your new family member arrives, you can return home and be cared for by your private midwife.

Sometime after November, private midwives will have visiting access to hospitals.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Hard labour

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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Australia is one of the safest countries in the world in which to give birth, so why are women more anxious than ever about their pregnancies?

FOR most women, the memory of their baby’s birth remains a vivid mental replay that awakens sensations at times as sharp and clear as the moment itself.

For Fiona Thomas, such memories are hazy, trammelled by darker ones that involved her fight for survival. All she remembers is the baby, her third, being lifted from deep within her; and then feeling faint and unwell.

As the baby lay in her arms, she was elated to discover she had a daughter (she already had two boys.) But there was tension in the room and the obstetrician seemed preoccupied. As the feeling of faintness dragged her deeper into a place she did not want to go, she signalled to the nurse to take the baby.

She remembers the anaesthetist telling her there were ”some complications” with bleeding and the obstetrician saying tersely, ”get her husband back here now” (he had gone with the baby to the nursery).

And then she was lying unconscious, monitored by the rhythmic beep of machines on a 24-hour guard. Meanwhile, the baby slept in the nursery, her life stretched out vast as an open sky.

Unbeknown to her, Fiona was suffering from placenta accreta, a potentially fatal condition in which the baby’s food supply, the placenta, attaches itself to the walls of the uterus so deeply that there’s a risk of haemorrhage if it is removed. It occurs in one in 2500 pregnancies but is difficult to detect beforehand.

In the delivery suite, the obstetrician worked rapidly to stitch up the ends of the blood vessels but the placenta was an open network, pumping blood at a rate of knots. ”My husband had a fright when he came back into the room and saw the obstetrician covered in blood,” Fiona recalls. ”I actually think it was harder for him than for me.”

… Fiona underwent an emergency hysterectomy and woke up in intensive care attached to drips and tubes that leeched donors’ blood back into her depleted body. Pinned to the foot of her bed was a photo of her daughter …

AUSTRALIA is the fourth-safest country in the world in terms of maternal mortality …

The chance of dying in Australia as a result of childbirth is remote – about one in 10,000 …

But globally, women die of pregnancy-related causes at a rate of one a minute, with 99 per cent of deaths happening in developing countries. Clearly, giving birth is a risky business. Good hygiene and better standards of living and prenatal care have gone a long way towards making it safer in this country, but that doesn’t mean it won’t go wrong.

Ironically, despite Australia’s great record, experts say many women are feeling more, rather than less, anxious about the birth process. Some blame this on our risk-averse society, saying the screens and tests and the increasing level of intervention in birth and pregnancy is geared towards making women fearful. As one expert puts it, antenatal care has become ”antenatal scare”.

Louise Kornman, associate professor of obstetrics at the Royal Women’s Hospital, says: ”Birth rarely leads to death, but it can lead to damage. The majority of pregnancies work out fine, but the reality is it doesn’t always go that way. There is a belief that technology can save you if things go wrong, and in doing so you can lose sight of the fact there are inherent risks.”

… ”Of course, women might feel that sometimes the medical profession intervenes too much in what is a natural process, but the reality is that if left to mother nature then the outcome is not very good, often, and there needs to be a sensible balance struck between not interfering in a natural process but judiciously intervening when things start to go wrong – or preferably before things start to go wrong, given that prevention is better than cure. It can be a difficult compromise to reach.”

It is worth remembering that obstetricians are at the coalface of difficult deliveries. Does this make their view distorted? 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. Midwifery groups push for normal deliveries and natural births while obstetricians err on the side of caution … Caught in the middle are the mothers.

Rather than becoming too complacent, Melissa Maimann, a private midwife and childbirth educator in Sydney, is seeing more anxiety among her patients, created, she believes, by our risk-averse culture.

”The safest place to have a baby is at home, if everything is going well,” she says firmly. ”The vast majority of people who go through the hospital system are unhappy with their experience.”

Have women been made to feel over-anxious? ”Possibly,” admits Bernadette White, clinical director of obstetrics at the Mercy Hospital For Women. ”It is easy to focus on the things that go wrong, and for some people that’s a source of stress.

”Obviously, a logical approach is to look and say, ‘Yes, that could happen, but how likely is it?’ But people don’t always have an entirely rational view when looking at things that might go wrong in their labour.

”And when you are assessing a risk, there’s a very broad spectrum of interpretation. That’s why some people will look at one set of figures and want a home birth, and someone else will look at the same figures and want an elective caesar.”
Associate professor Jenny Gamble, deputy head of nursing and midwifery at Griffith University, Queensland, has researched birth and post-traumatic stress.

Her findings show that while birth is a relatively safe physical event in Australia, it remains a hazardous psychological journey.

”If we stick with the premise that a high level of intervention has unintended negative consequences, then yes it does. We have consistently found that 30 per cent of women report that their birth was traumatic; that they feared for their life, or their baby’s life. This is a very high figure. We also know that about 6 per cent go on to develop post-traumatic stress disorder.

”Women don’t feel safe. Birth is being geared towards making them feel fearful; strangers are telling them this and that, there is screening and testing at every step and they develop a sense that at any moment they might lose the baby or something catastrophic is going to happen. It’s called ‘antenatal scare’ in the trade.”

Gamble is concerned about the ripple effects of such trauma. Affected women may find it harder to bond with their baby, and their relationships may fall apart. They may develop a fear of hospitals and doctors and even birth itself.

”Most of our gains in maternal morbidity have been based around realistic, basic things, like feeding the mother, sending out health messages such as not smoking in pregnancy and basic care in the community. I am not suggesting that we do nothing, but the pendulum has gone too far the other way.”

ERIN Horsley had her first baby in Britain. Despite her plans for a natural birth with no intervention, she ended up having her baby induced and then delivered by forceps when labour progressed slowly.

Attached to a drip and no longer able to move around, Horsley couldn’t speak through the pain. ”If you can’t tell me what’s the matter then I can’t help you,” said the midwife, brusquely.

Horsley emerged from the experience feeling emotionally battered. ”I felt let down,” she said. ”Not listened to. It caused marital problems. When I had my second baby here in Melbourne I tried to talk the hospital staff about my experiences; they said I was being oversensitive and that birth trauma doesn’t exist.”

Shae Reynolds, 31, was also hoping for a natural delivery but a late scan showed the lake of amniotic fluid surrounding the baby was ”potentially low”. (This turned out not to be the case when the waters finally broke.) In the cascade of intervention that followed, Shae found her legs in stirrups opposite an open doorway with several strangers milling around the room, including someone emptying the bins.

A vacuum extractor was attached to her baby’s head and one her most horrific memories is watching the doctor put a foot on the bed and pulling, saying, ”We have to get this baby out”. She says part of her daughter’s scalp was damaged as a result, and she suffered a big tear.

”I struggled terribly the first six months,” she recalls. ”I couldn’t have sex for over a year. I felt like I’d failed, like I hadn’t protected her.”

Reynolds’s daughter is now five and she has had two more children, both born without complications and naturally, at home.

But every birthday awakens memories of the trauma. ”It’s hard not to feel torn, because one of the happiest days of my life was also one of the most traumatic. Those precious first moments that we had as a family were destroyed. We were cheated of so much more than just the birth. We still are.”

Medics and midwives are united in the belief that it helps if a woman can feel in control, or at least informed about what is happening. Says Maimann: ”We have an excellent public health system. The government’s job is to offer a basic and safe level of care, which it does very well. It doesn’t suit the emotional or mental needs of women having babies, but I don’t think it should.”

She argues that families should be prepared by investing in independent childbirth education, or working with a private midwife who will provide continuity of care at a cost of between $3000 and $6000.
Surely this will be out of reach to many? ”We can afford holidays,” … ”It’s about valuing what you get.”

Melissa Bruijn and midwife Debby Gould run birthtalk.org, a national birth trauma support group … ”People assume that if birth is going to be safe, there has to be lots of intervention, but reducing the amount of birth trauma is not about reducing what can go wrong, because that’s not controllable.

”It’s really about meeting the emotional needs of women. Even if they find themselves undergoing emergency caesareans, they can still feel empowered and part of the process if they are looked after properly. It’s a myth to say that the most important thing is a healthy baby. Traumatic birth gets carried with you – you don’t leave it at the hospital – and it can have profound consequences for both the mother and baby.”

It is almost seven years since Fiona Thomas, 45, an occupational therapist, went into hospital to give birth and ended up in intensive care. She was fortunate to have given birth in a hospital with a good supply of blood; fortunate that there was a team on hand that worked with rhythmic precision to save her. ”You don’t expect that,” she says. ”I went in thinking I was going to have a routine caesarean, just like I’d had before. All our friends were expecting a phone call 10 minutes later with good news, but there was nothing.

”They realised something must have gone wrong and phoned the hospital. I think everyone was shocked by it. It has changed the way I view life. Sometimes I would think, ‘What happened if I had died? If those 30 seconds I got to hold her had been her only contact with me?’ But then you have to flip it around and see it the other way.
”It makes you realise that life spins on a dime.”

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

Absurd, childish and pathetic: the latest in maternity services reform

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 11 June issue of Australian Doctor carries a story … that is truely gob-smacking.

… the NHMRC has been trying to organise a meeting between the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Australian College of Midwives to develop an agreement on referral guidelines in relation to midwives being able to access the Medicare Benefits Schedule … provided they work “collaboratively” with doctors.

… RANZCOG has … refused to attend the meeting because community representatives who support homebirths have been invited.

If you were ever in doubt about the need for reform of maternity services, then look no further.

If you were ever in doubt about why reform in this area is so excruciatingly difficult, then look no further.

And if you were ever in doubt that professional interests rule in the health sector, then look no further.

This really is pathetic. Absurd and childish are other adjectives that come to mind….

It’s simply business. Midwives and obstetricians essentially compete for the same low risk women. Every low-risk woman who sees a midwife is one less woman seeing an obstetrician. Most women are low risk. Obstetricians cannot afford to lose the bulk of their “business” to midwives and unfortunately, collaborative agreements favour obstetricians in several ways:
- There is no onus on the obstetrician to collaborate, and for every midwife who cannot get a signed collaborative agreement, that’s one less midwife in private practice and therefore more women woo will see private obstetricians.
- There is no onus on the obstetrician to return the woman to midwifery care once the indication for referral no longer exists. Indeed, there is a great incentive for the obstetrician to “keep” the woman: $$$.

Melissa Maimann, Essential Birth Consulting 0400 418 448

VBAC Women Denied Acces to Midwifery Care in Most States!

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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Although this article is from America, we can expect tis to transfer to Australia in just 19 days! That’s right, in just 19 days midwives will not be able to autonomously care for women who are planning VBACs. All women requesting a VBAC will have a consultation with an obstetrician and although the woman would have booked with her private midwife for private midwifery care, her ongoing care will be determined by the obstetrician. She can expect to see the obstetrician several times in her pregnancy, homebirth will be denied to her as an option and when in hospital, the obstetrician will determine the way the woman is cared for. Any non-compliance will be met with refusal of care.

Read on for the situation in Alaska. It’s coming to Australia in less than 3 weeks.

One thing that has been on my mind lately, is my inability to utilize the services of a midwife. Unfortunately, because I have had two cesareans, heck, even if I had only had one, I am not allowed to use a midwife for my pregnancy and birth in the state of Alaska. I know that I can do prenatal care through a midwife who has a backup, but they cannot do my actual labor and birth. They are subject to losing their license if they do accept me as a client.

I don’t know who is familiar with it, but if you look at the medical model of maternity care and the midwifery model, you’ll see that the outcomes of both models are drastically different, with the midwifery model being the more positive of the two.

And Alaska isn’t the only state that does this. A lot of them do … it’s ridiculous that women attempting VBACs are being denied access to midwifery care …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Roxon’s new insurance scheme starts today: Pregnant women winners

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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Privately practicing midwives and their patients get extra protection from today with Commonwealth Government-supported professional indemnity insurance now available.

This will make a real difference to expectant mums who can now elect to see a private midwife who will have Government subsidised insurance and from 1 November, have the cost of those services covered by Medicare.

… The Government wants to better support our expectant and new mothers and this insurance will help do that. It is a key part of the Rudd Government’s $120 million maternity reform package to provide women a greater choice in high quality, safe maternity services.

Mothers under the high quality care of eligible midwives will now be confident that their midwife has the proper professional indemnity insurance coverage.

The availability of this new professional indemnity insurance product also means eligible midwives will be able to meet the requirement under the new National Registration and Accreditation Scheme for all registered health practitioners to have appropriate insurance cover. This requirement comes into effect from 1 July 2010.

This new landmark insurance product, provided by Medical Insurance Group Australia, helps to underline the importance midwives play in providing safe maternity care in Australia. It also builds on the historic legislation passed by Parliament in March that will enable the women cared for by eligible midwives to benefit from access to the Medical Benefits Schedule and the Pharmaceutical Benefits Scheme.

The Commonwealth-supported insurance will not cover services provided during homebirths. These services have a two year exemption from the National Registration and Accreditation Scheme …

————–
… Midwife Tina Pettigrew from Geelong, Victoria, is one of many midwives who is excited about this new policy becoming available.

“This is a major step forward.” Pettigrew said. “To be able to look after a woman throughout her pregnancy, follow her into the hospital to have her baby and follow her home again afterwards to help her settle into being a new mother is what I’ve always wanted to do. Now I can to do all this with full indemnity cover”

… “On behalf of all midwives, I wish to thank the Health Minister Nicola Roxon for resolving the long running lack of professional indemnity insurance for midwives” said Associate Professor Hannah Dahlen, of the Australian College of Midwives. “The College also welcomes MIGA’s interest in providing this cover”.

The provision of insurance cover for private midwives is one of the necessary precursors to midwives gaining access to Medicare funding for their care from 1 November this year.

Medicare funded midwives will be able to work in practices in the community, with other midwives, with doctors and with allied health professionals as well as in hospitals to offer more women the choice of having one-to-one care from a known midwife throughout their pregnancy, labour, birth and early parenting.

“We know that women and their babies experience measurable benefits from one-to one care from a midwife,” Professor Dahlen said. “But midwives can’t take up this historic opportunity to provide Medicare services without professional indemnity insurance, which has not been available since 2002. That’s why we’re excited about the Federal Government’s moves to make indemnity accessible again”

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

Home Births on the Rise

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 having her first child in a hospital, Lorra Jacobs decided it was an experience she did not care to repeat.
She had two more children, and she chose to have both of them at home.

“When I had my first child in the hospital … It wasn’t a real positive experience,” … “It was a stark, very impersonal feeling, treating me like I was sick and not pregnant.”

Jacobs explained she believed she had more control over many aspects of the birth when it took place at home, including whether she got to be with the baby after delivery and having the siblings there at the birth.

“Doing a home birth, I felt like I had a say,” said Jacobs. “This is not the hospital’s baby. This is my baby.”

… the Centers for Disease Control and Prevention indicate that a very small but slightly growing number of women are making the same choice that Jacobs did. While less than 1 percent of all births in the United States take place outside the hospital, the number of those births taking place at home has increased by 3.5 percent between 2003-04 and 2005-06 …
… the most recent trend might be a negative reaction to a hospital birth experience, since the majority of mothers choosing a home birth have had children before.

… “It certainly suggests it’s an experience they don’t want to repeat.”

“I suspect that economic issues are not the main issues,” … “I suspect consumers are becoming more informed … and seeing home births are a safe alternative for healthy women with a qualified provider.”

… a likely cause of any increase is a desire to avoid the interventions hospitals perform, ranging from cesarean sections and epidurals to controlling when the mother is with the newborn.
… Home birth advocates have cited several studies supporting the safety of home births among low-risk women …those studies have taken place in the Netherlands and Canada … its unrealistic to apply the findings to the United States.
“Those are highly regulated, highly integrated systems. Their system is prearranged — it’s very different from the systems available in the United States,” he said.

The same can be said for the generalisability of these studies to Australia, however that is no reason not to implement a system that can provide safe private homebirth services.

… “The mothers who are having these home births are not crazy, unaware people,” said Declercq. “They plan carefully, they think about this all the time. They think they’re better off not having the interventions that they feel will happen unnecessarily at hospitals.”

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

FAQs

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

Can my private midwife go with me to public hospital?

Yes. Private midwives attend women wherever they are giving birth. Many women who seek out the services of a private midwife will be planning a homebirth, but may other women want a private midwife to be by their side in a planned hospital birth. This may be because the woman wishes to have all her pregnancy and postnatal care requirements met by her midwife, with the option of birthing at home or labouring at home as long as possible before heading into hospital. Once in hospital, although the woman will be assigned a hospital midwife, the woman’s private midwife will be by her side providing emotional and physical support, encouragement and most of all continuing the safe and trusting relationship that has been developing over the months.

This is truly a great way of getting continuity of care within the hospital system and maximising the chance of a natural and healthy birth.

Difference between midwife and obstetrician

A midwife is a specialist in normal pregnancy, birth and postnatal. Midwives are qualified and educated to care for women and babies on their own authority while ever women and babies remain healthy and well. the other part of the midwife’s role is to detect complications in the pregnancy and to refer to an obstetrician in a timely manner. Some women will consult with an obstetrician once or twice if there are problems, while other times the obstetrician will continue the care of the woman. Obstetricians are surgical specialists who have degrees in medicine, surgery and obstetrics. While they are certainly qualified to care for healthy pregnant women, their specialty is in pregnancies and births that are complicated. An obstetrician can perform surgery such as a caesarean, and they can perform assisted births such as forceps and vacuums.

Both obstetricians and midwives are essential in our maternity care system.

Average cost parking at hospital

It can be expensive! Some hospitals offer free parking, while other hospitals may be around $30 per day. Remember to carry lots of change with you as some hospital car parks take coins only.

Can you have midwives deliver in private hospitals?

Generally speaking, no. you’ll be admitted under the care of an obstetrician and the midwife who is looking after you in labour will call your obstetrician when your baby is close to being born so that your obstetrician can “deliver” your baby.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Quality and Safety Framework for Homebirth

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

The long-awaited final draft of the QSF is now out for public consultation. I have copied excertps from it below. PPM refers to privately practising midwife.

National Registration demands that all health professionals have professional indemnity insurance that covers all aspects of the care that they provide, however there is no insurance for births that take place at home in a private capacity. The QSF is in place to provide a framework so that private midwives can continue to provide homebirth services and secure an exemption to the requirement of insurance for home birth. Private midwives will still need insurance to cover pregnancy and postnatal care.

… the Health Ministers have agreed to provide an exemption for PPMs attending a homebirth until June 2012 subject to certain conditions. No other privately practising clinicians are able to practise without insurance. This exemption only applies to intrapartum services provided in the home.

The conditions that AHMC required are that:
• PPMs report all homebirths according to the requirements of their jurisdiction
• Women booking with a PPM receive written disclosure that the PPM is practising without insurance coverage for intrapartum care services in the home
• PPMs participate in a Safety and Quality Framework for midwifery care

… For the framework to be legally required, the NMBA (Nurses and Midwives Board of Australia) will need to, using section 39 of the National Law, develop and approve a code or guideline that contains or reflects the contents of the framework. As such the final say on the contents and mandatory use of this framework will rest with the NMBA as the professional regulating body.

Context

The choices made by women about their maternity care and birthing are commonly determined by:
• previous pregnancy and birthing experiences, including … levels of intervention
• a strong desire for continuity of carer
• confidence that respect for their choice of care and carer will improve outcomes for themselves and their babies
• a personal philosophy that is congruent with a preference for care to be provided outside of a clinical setting.

The choices made by midwives in this context about the antenatal, intrapartum and postnatal care which they offer are commonly determined by:
• a preference to work as a private practitioner
• a perception that working within a clinical setting limits their ability to work across the full scope of midwifery practice
• a strong desire to provide continuity of care through pregnancy, labour and birth and the postnatal period
• a belief that the woman’s wishes can be more effectively addressed by engaging with a privately practising midwife
• a personal philosophy that is congruent with a preference for care to be provided outside of a clinical setting.

Midwives are qualified health professionals whose practice is governed by … the Nursing and Midwifery Board of Australia (NMBA) and … the requirements of … the Australian College of Midwives and their guidelines. Those in public systems also work within the parameters, and protection, of the clinical governance of the employing organisation … The NMBA Continuing professional development standard requires a minimum of 20 hours of professional development to be undertaken by all registered nurses and midwives each year.

… the National Health & Medical Research Council draft “National Guidance on Collaborative Maternity Care” was disseminated. It is acknowledged that this document, together with “Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” and “National Midwifery Guidelines for Consultation and Referral” Australian College of Midwives 2nd Edition 2008, are consistent with the spirit and intent of the development of the Framework.

… This framework will be provided to the NMBA with the intent that it is placed in a code or guideline. Once in a code or guideline of the NMBA, PPMs will need to adhere to it in order to meet the requirements of the exemption. The way in which the NMBA monitors the adherence to any code or guideline is a matter for them to decide …

Safety and Quality Framework for Privately Practising Midwives attending homebirths

To be exempt from requiring insurance for providing intrapartum care for homebirths, the privately practising midwife is expected to comply with a number of requirements. The exemption and its requirements are reflected within the National Law as reproduced below.

… to be exempt from requiring insurance for providing intrapartum care for homebirths, the privately practising midwife will be required to abide by any safety and quality framework that the NMBA has approved and required through a code or guideline. It is intended that this framework will be provided to the NMBA to consider for such a purpose. Until it is approved by the NMBA it is not a legal requirement for PPM to use this framework in order to be exempt.

The framework is written to ensure safe, quality care of the woman and her baby choosing to birth at home with a privately practising midwife. Women considered appropriate for inclusion in this option of care are women with a singleton pregnancy, cephalic presentation, at term and free from any significant pre existing medical or pregnancy complications. Further to this, distance and time to travel to an appropriately staffed maternity service should be considered when assessing appropriateness for this option of care.

The framework … is not intended as a document which is exclusionary. It does, however, articulate parameters of midwifery led care as a mechanism to balance the priorities of women’s choice and quality and safety of maternity care to deliver positive outcomes for mothers and babies.

… both the midwife and the woman need to be informed early in the pregnancy of the likelihood of needing to interact with other health professionals and the potential for transfer to other care settings. Given that access to continuity of care is a primary driver of women to choose private midwifery models, choice of appropriate models of care including clearly articulated plans of escalation and collaboration, are integral to satisfaction levels.

… the ACM Consultation and Referral Guidelines and the principles and practices outlined in the draft NHMRC National Guidance on Collaborative Maternity Care are a key element of this Safety and Quality Framework.

The midwife’s requirements to fulfil the QSF will increase the standard of care and provide the public with an expectation of safety, collaborative care and higher standards:

Minimum Quality and Safety Requirements for Interim Exemption from Insurance

In addition to holding current registration in their State or Territory, or with the Nursing and Midwifery Board of Australia after 1 July 2010, to comply with the exemption from the insurance requirement of the National Registration and Accreditation Scheme midwives need to be able to provide evidence outlined in the table below:

- written information detailing evidence informed materials (consumer information package)
- Process for complaint management (Documented process, including complaint escalation information)
- Consumer participation (Women involved in case and peer review)
- Consumer satisfaction templates
- Documented evidence informed clinical practice guidelines on which practice is based e.g NHMRC, NICE, or state & territory guidelines
- Referral pathways: clearly articulated referral pathways for referral and /or consultation in accordance with ACM Consultation and Referral Guidelines
- Comprehensive clinical notes to share with other health professionals engaged in the woman’s care
- Reporting of all births as per each state & territory requirement
- Clinical audit: Comprehensive clinical notes to guide reflective practice and enable review and evaluation of care provided
- Clinical Risk: incident & adverse event reporting – documented process in accordance with state and territory requirements
- Sentinel event reporting: documented process in accordance with state and territory requirements
- Documented involvement in case investigation.
- Risk profile analysis: documented process for identification and evaluation of clinical risk and evidence of correcting, eliminating or reducing these risks
- Professional Development: maintenance of professional standards – complies with NMBA minimum standards
- Awareness and monitoring of new procedures and practices
- Involvement in professional organisation/s and documented schedule for formal practice review and mentoring processes
- Competency standards – ensures appropriate skills and experience
- Demonstrates practice in accordance with ANMC national competency standards for the Midwife
- Continuing professional development: documented evidence of attendance at ongoing and regular education and research activities determined by the NMBA standard relating to CPD
- Maintenance of professional portfolio

The Nursing and Midwifery Board of Australia (NMBA), the principal regulatory body for the midwifery profession, is the appropriate authority to hold the governance of this framework. While significant consultation has occurred, the decision to accept or use this framework in whole or in part is a matter for the NMBA to decide.

This framework is not a legal requirement for a PPM who is exempt, until it is approved in a code or guideline by the NMBA under s39 of the National Law.

Positives:
- Insistence on high standards of private midwifery practice
- Commitment to quality and safety
- The potential for medicare-eligible midwives to offer women the option of home, birth centre or hospital birth, with all antenatal and postnatal care funded. Hospital and birth centre births will also be funded, but not homebirths. This opening up of options will improve safety by increasing options to women.
- Midwives will be able to remain the primary carers in the ecent of hospital transfer.
- This document reflects great respect for women’s choices to engage a private midwife for a homebirth and provides support to the midwife (in terms of a framework) and to women (in terms of safety).
- The enormous amounts of media generated by the maternity services reforms have had a positive impact on homebirth, just by increasing awareness of homebirth as a respected and mainstream option.

Negatives:
- Some are disappointed that twins, breech and other risk-associated pregnancies cannot be supported in a homebirth.
- The requirements on the midwife who wishes to attend private homebirths are fairly onerous if the midwife had previously not attended to any quality, safety, professional development and documentation issues.
- The cost of the government insurance is prohibitive for many midwives, although it may be possible that other insurance products may be available that will only cover antenatal and postnatal care.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Homebirth: What to expect

Visit my website to learn more about my services.

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.

Visit my website to learn more about my services.

Midwives in Jeopardy

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

Link

As she nears the last month of her pregnancy, Piper Harrell is counting on giving birth to her second child in the same place she had her first, in her second-floor walk-up apartment …

But this time, Ms. Harrell … is afraid that if she insists on having her baby at home, she will make her midwife … an outlaw.

Seven of New York’s 13 home-birth midwives … had an agreement with St. Vincent’s Hospital Manhattan that its doctors would back them up in an emergency. But the bankrupt hospital closed on Friday, and those midwives have been unable to negotiate new practice agreements with other hospitals or obstetricians, as required by state law, leaving them in the position of risking their licenses if they choose to deliver babies.

The loss of that 25-year relationship with a sympathetic hospital has left some home-birth midwives not only fighting for the legal viability of their practice but having to justify their very existence. Officials at several hospitals said … they were skeptical of the safety of home births and were concerned about the malpractice implications of taking over their clients in emergencies.

… “This is who we have to get a signature from — people who don’t believe in what we do and that we compete with,” …

The 13 midwives attend about 600 births a year, and about 50 of their clients expect to deliver in the next month.

To them and their clients, having the option of a home birth is an affirmation of their reproductive rights. It is also a reaction against the highly medicalized climate of hospital births, which, they say, has contributed to a Caesarean-section rate of more than 1 in 3 births … with some hospitals having rates above 40 percent …

To the medical establishment, home birth represents a rash choice by women who refuse to believe that things can go dreadfully wrong in an instant …

A large study of planned home births in the United States and Canada … found substantially lower rates of medical intervention compared with low-risk hospital births (high-risk pregnancies rarely, if ever, culminate with a home birth) and a similar rate of infant mortality. No mothers died. About 12 percent were transferred to the hospital. The midwives considered the transfer urgent in 3.4 percent of all intended home births.

… written practice agreements with hospitals or doctors have been a condition for all midwives to practice in New York State since 1992. But obstetricians have become increasingly wary of signing with home-birth midwives since the Congress of Obstetricians put out its strongly negative statement in 2008 …

… Fifteen other states … allow midwives to practice without them …

… midwives … expected that at least some of their clients would insist on delivering at home even without signed hospital backup. (They can still go to an emergency room and be treated.)

Ms. Harrell, 33, said she trusted her midwife … who delivered her first child … she said she was leery of trying to build a relationship with a doctor so late in her pregnancy. But she worried about putting Ms. Leonard in an untenable position.

“I’ve never felt not able to make a choice about my body for myself and my family, and it’s a paralyzing feeling,” Ms. Harrell said …

Melissa Maimann, Essential Birth Consulting 0400 418 448

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

FAQs

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

changes to medicare obstetrics

It will cost more out of pocket to have an obstetrician. Conversely, midwifery will attract medicare benefits after November, making private midwifery care more affordable to families.

waterbirths in sydney

The easiest way to have a waterbirth is to contract a private midwife and have a home waterbirth. Some hospitals are offering waterbirth. Sometimes it will depend on having a room available with a bath in it; other times it will depend on which midwife is on staff as some are accredited to do waterbirths and others aren’t.

antenatal classes sydney and independent childbirth educators sydney

The best value antenatal classes are with Julie Clarke who is an experienced childbirth educator and Calmbirth (R) Practitioner.

can i refuse use of forceps

You can refuse anything you don’t want to have. Often obstetricians will use a vacuum rather than forceps. Avoiding an epidural is the best way to avoid forceps or a vacuum.

can you go public if you have phi maternity

Absolutely! PHI is there in case you need it, but having it doesn’t mean you have to use it.

caseload midwifery and homebirth

Homebirth is the original caseload midwifery model! Each woman books with her own midwife, one she has sought out, trusts and knows well. That same midwife attends all the woman’s pregnancy, birth and postnatal care.

cost of a private midwife sydney

Anywhere from $3000 upwards. Most are around $3000 – $5000. It’s money well spent.

how will homebirth be affected by the health reform australia 2010

Truth is, we still don’t know. We’re awaiting another draft of the Quality and Safety Framework. As soon as something is released publicly, I’ll place it on this blog.

which is safer hospital or midwife?

It’s not really an either / or because midwives work in hospitals as well as in the community. Midwives attend every birth. In some cases, a doctor will also attend, but every birth is attended by a midwife.

can I have a waterbirth after a caesarean?

Of course you can!

Melissa Maimann, Essential Birth Consulting 0400 418 448