Risk assessment in pregnancy and birth

Posted on May 20, 2012 by Melissa Maimann

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

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

The downside of risk assessment is that it does tend to categorise women according to a tick-box system. Although the risk might be there, it might not necessarily eventuate for the woman sitting with us.

How can risk assessment be useful?

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

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

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

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Homebirth transfer rates: cause for concern?

Posted on May 10, 2012 by Melissa Maimann

What is a woman really asking when she asks her midwife what the midwife’s transfer rate is?

Women often interview several private midwives when they are choosing the right midwife for their needs. Women will ask many questions of their prospective midwife, and one of the more common questions is, “What is your transfer rate?” meaning, “what percentage of the women who book with you for homebirth, end up transferring to hospital?”

On the surface, this seems like a fair question. But what is the woman really asking? I consider that the woman is really asking, “If I book with you, what’s my chance of being transferred?” and when women ask the same question of several midwives, they are most reassured by the midwife with the lowest transfer rate because they perceive that they have the lowest chance of transferring if they go with the midwife with the lowest transfer rate.

Is it a fair assumption to make, that the midwife’s transfer rate, representing her previous client’s outcomes, are a valid guage for the current woman’s likelihood of transfer? Often I find that transfers can’t be predicted at the time a woman books-in for care. If we could predict it, we’d recommend a planned hospital birth. Considering transfer rates from this perspective, a midwife’s transfer rate has no bearing on the current woman sitting with her. As well as this, some transfers occur because the woman has requested it – eg a request for transfer for an epidural, but not on the advice of the midwife as the labour is actually progressing very normally. The other situation that can arise is that the midwife forsees problems occurring and makes some recommendations to avert those problems, but the woman considers the recommendations and declines to follow them. In these cases, again, the midwife’s transfer rate has no bearing on each new client who interviews a midwife.

What’s a “good” homebirth transfer rate?

Well, many might argue that the lowest transfer rate is the best transfer rate. You’re setting out for a homebirth, right? So why go to the midwife with a “high” transfer rate?

I did some scouting around on the internet and found that transfer rates range from 10% through to 50%. The Netherlands has a transfer rate of 52%! This surprised me. In the Netherlands, 86% women start in “primary” care (midwifery care), 28% are transferred in pregnancy and 17% are transferred in labour, leaving 41% women birthing with midwifery care. Of this 41%, 30% occurred at home and 11% occurred in hospital.

The St George hospital homebirth program reported a transfer rate of 37% for its first 100 births and this was in a low-risk clientele (at the start of pregnancy). Their outcomes were excellent, however and the satisfaction of the women and midwives using / working in the service was very high.

Private midwives’ transfer rates vary – anywhere from 10% to 40% in some States of Australia as well as overseas. So there’s a wide fluctuation. What can we deduce from these transfer rates?

Well, with the exception of the Netherlands – which has large numbers – we can’t really deduce very much at all. You never can when you’re dealing with small numbers. Private midwives in Australia typically don’t attend more than 25-30 births a year, and some as few as 5 births a year. One transfer in 5 births is 20%, whereas if that same midwife had attended more births without complication, perhaps the transfer rate would have only been 10%.

There are a couple of things to consider with high and low transfer rates:
1. The risk status of the women at booking
2. The midwife’s adherence to safety and risk management guidelines and her outcomes.

The midwife with the lowest transfer rate might simply have a low transfer rate because she only attends very low risk women: women who have birthed without complication before, who have no health history and who have no problems in their current pregnancy.

The midwife with the high transfer rate might not be transferring willy-nilly, she might just be taking on a higher risk group of women and adopting a wait and see approach – eg, “yes, you have a family history of high blood pressure and you’ve had it with every pregnancy thus far, but let’s try some preventative measures and see what happens this time”, and continue with homebirth plans. If this woman’s blood pressure went up, she would have been transferred, contributing to the midwife’s “high” transfer rate. The low risk / low transfer rate midwife might not have accepted this woman for homebirth at all, hence the difference in transfer rates.

The other thing to consider with transfer rates is the midwife’s commitment to safety and risk management. Some midwives may have low transfer rates because the decision to transfer is prolonged, or because risk factors are denied. Is it good to have a low transfer rate if women or babies have been compromised?

But getting back to the question, “If I book with you, what’s my chance of being transferred?”, this question is impossible to answer.
1. We can’t tell the future. Family history and health history might shine some light on possible issues for the pregnancy, but not necessarily. We can’t predict all the paths a pregnancy can follow.
2. A woman’s determination to move towards – and remain in – a state of health and wellness is a life-long journey that pre-dates the pregnancy.
3. Although midwives will make recommendations with the aim of homebirth in mind, it is the woman’s right to consider the advice and decline it. Declining a midwife’s advice may well mean that a transfer will become necessary.
4. Midwives’ statistics are only relevant to her past clients, not the client sitting with her currently.
5. For many midwives, the goal is really safety: safety for woman and baby. We strive to achieve the safest birth in the setting that can best meet the needs of our client.

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Planning a homebirth vs having a homebirth

Posted on May 5, 2012 by Melissa Maimann

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Is it just semantics? “I’m having a homebirth” versus, “I’m planning a homebirth”? I often wonder why more women don’t plan homebirths. Planning a homebirth doesn’t rule out hospital as an option if it’s needed or desired. Planning a homebirth keeps all options open and allows women to make the decision about place of birth towards the end of the pregnancy or even in labour.

Sometimes I’m concerned when I hear, “I’m having a homebirth”. The same way I’m concerned if I hear, “I’m having an epidural / induction / waterbirth” or whatever. Yes, these are our plans, but we never really know what’s going to happen until the time.

There is a transfer rate associated with homebirth and this reflects safe practice and respect for women’s decisions. Bearing that in mind, it’s wiser to say, “I’m planning a homebirth” rather than, “I’m having a homebirth”.

Also, consider the reactions from family and friends when they hear these words. When we “plan” a homebirth, friends and family are put at ease. Plans can change if they need to. The common response, “Homebirth?!?! Isn’t that … dangerous??” is no longer needed because plans can change if risks emerge. Sometimes when people hear, “I’m having a homebirth”, they don’t understand that if hospital is needed, we go. The common questions like, “what if you need a caesarean?” “what if you need an epidural?” are valid when we frame it as “having” a homebirth because these interventions are not available at home. But when homebirth is “planned”, those questions are no longer necessary: plans can change.

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The Benefits of Using a Midwife During Childbirth

Posted on May 4, 2012 by Melissa Maimann

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

So, what is a primary care provider?
A primary care provider is someone who is responsible for your pregnancy and birth care. They may also been seen as the coordinator of your care or “go-to” person. It may either be a doctor or a midwife. Your primary care provider should know all about you and your pregnancy, attend your birth and know all about your baby. Without a primary care provider, your care will be fragmented and it’s entirely possible that some important aspects of your care will be overlooked or forgotten.

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

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

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

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

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

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

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Birthing in hospital with your own private midwife

Posted on May 2, 2012 by Melissa Maimann

Many women prefer to birth their babies in hospital, but they want to have the same midwife all the way through their pregnancy, birth and post-birth period. It’s about building trust, having a familiar face and being understood and supported. During your pregnancy, we explore what birth means to you and discuss your goals for pregnancy and birth, focussing on what’s important to you, what you need, and looking at ways of making the birth as positive and healthy as possible.

I know that no two women are the same, so your care is tailored and individualised to your needs.

Your care

As your private midwife, I provide clinical care, information, advice and emotional support as you journey through your pregnancy and birth. I meet with you regularly in pregnancy so we can learn about each other, and so you can more feel comfortable with me. I help you formulate a birth plan and de-brief previous birth experiences.

When your labour starts, we will be in frequent contact and we will decid whether I should see you at home before heading to hospital, or whether we will meet at the hospital. I will remain your midwife in hospital, caring for you through your labour until your baby is safely born. Early discharge from hospital is encouraged, and we will continue your care at home for 6 weeks.

It’s important to have an understanding of how the general hospital system (public or private) works, to really appreciate why it is so valuable to have your own privat midwife for a hospital birth. Hospital midwives are often busy caring for other women in labour: a hospital-employed midwife often cares for 2-3 labouring women at any given time, while also answering phones, performing administrative roles and so on. When you have your own private midwife with you, she is dedicated to you, and hospital staff are not involved in your care unless invited. This means you have the undivided attention of the midwife you know and trust. Other than your partner and chosen support people, formal birth support is not needed as your private midwife will be right by your side, supporting you all the way.

You benefit from:
- higher chance of normal vaginal birth
- minimal intervention during birth
- professional advice and clinical care
- lowest chance of caesarean
- lowest chance of episiotomy
- lower requirement for pain relief
- higher breastfeeding rates
- lower rates of pregnancy admissions to hospital
- access to midwife means you can change to home birth at any time and have that mifwife as your primary care provider
- midwives can monitor your baby in pregnancy and labour
- midwives can monitor your health in pregnancy and labour
- midwives can liaise with other health professionals if needed

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Options for pregnancy care

Posted on March 18, 2012 by Melissa Maimann

There are two main decisions to make about your care: one is your place of birth, and the other is your care provider.

Sometimes one decision will force another, for example an obstetrician will only deliver babies in a hospital, and birth centre care will generally mean having midwifery care.

But there are many other combinations:

Private midwife – home birth
Private midwife – hospital birth (public hospital as a private patient; private hospital as a private patient; public hospital as a public patient)
Public hospital care – midwives
Public hospital care – obstetricians
Public hospital care – shared care with a GP

and so on. There is really quite a lot of choice when you think about it.

Ultimately, if continuity is important to you, you will need to look to the private system – either obstetrics or midwifery – to ensure as much as possible that your chosen care provider will actually be there to help you in birthing.

The other thing to consider is that midwives and obstetricians, especially in the private sector – will tend to book out early. Some obstetricians will require you to book an appointment as soon as you find out you are pregnant, and will be fully booked at around 6 weeks. For many private midwives, this is the same. Other times, you my find that you can change from the public system to the private system later in pregnancy and a space will be made available for you.

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Hospital says No to cesarean

Posted on March 1, 2012 by Melissa Maimann

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A NORTH Coast mum who has been told she can’t deliver her baby by cesarean feels [that the] Hospital is prioritising policy over people.

Sylvia … said she was told by an obstetrician at the hospital she could only have a C-section … in an emergency.

“I just had tears streaming down my face – I couldn’t believe it,” …”I feel so powerless and betrayed by the medical system that my choice has been taken away.”

Ms Leveridge, who is 28 weeks pregnant, wants to avoid the 20-hour labour she experienced before undergoing an emergency cesarean to deliver her first child.

Her first baby was a whopping 4.240kg and Ms Leveridge understands this baby will be just as big.

… under the Towards Normal Birth policy, the state is aiming to reduce the cesarean rate to 20% before 2015.

Ms Leveridge said she was advised the hospital has to reduce the number of cesareans it performs in line with the policy.

… there are risks associated with cesarean section operations … the rights of the both babies and mothers have to be balanced out.

“It’s not just the mum’s choice. It’s also the baby’s choice as to how the delivery transpires. This is something that is often lost in the debate about how babies should be delivered,” …

“My problem is I have big babies and I just feel like I’m on the same treadmill,” Ms Leveridge said.

As I see it, there are four issues here:
1. Fear
2. A previous “big” baby
3. A woman’s sense of control over how she will deliver her baby, aka woman-centered care
4. Safety for mother and baby, and the health practitioner’s duty to recommend the safest course of action

Fear
It is not unusual that this woman would feel so fearful of her upcoming birth: her only experience of labour and birth had been an horrendous 20-hour labour with untold interventions delivered in a model of care that provided limited continuity, and ultimately leading to an emergency caesarean. In my practice, women have only one midwife for the whole pregnancy – baby experience. This model of care has been demonstrated to reduce women’s fear, and also promote normal birth. Around 90% women who birth with me experience a normal birth.

A previous “big” baby
A “big” baby is not necessarily a concern, and nor is it necessarily associated with a caesarean. The important factor here is whether the baby was always destined to be a larger baby that is able to fit through an ample pelvis, or whether the baby was abnormally large perhaps because of poor maternal diet or poorly-controlled gestational diabetes. Many “large” babies are born normally: these are often babies who have been nurtured with good nutrition in a woman whose pelvis is amply able to accommodate a larger baby. The labour and birth is often rapid and the baby is born healthily and safely. The same cannot be said of babies who are abnormally large because of high circulating glucose in the mother’s blood. In my practice, much time is spent with women talking about nutrition; why it is important; motivational tools to remain healthy and fit in pregnancy; and finally assisting them with a healthy eating plan that is flexible and is based on their own unique tastes and needs. The average birth weight is around 3.4Kg.

A woman’s sense of control over how she will deliver her baby, aka woman-centered care

We know from studies that a request for a caesarean is based mostly on a woman’s fear of labour. The woman in this article was quite justified in her fear: her only personal knowledge of birth was an awful labour culminating in a caesarean, and she sees herself staring down that same barrel, since she again feels that she has a big baby. I often find that women will make an initial request, for example for a hospital birth or an epidural, and through their pregnancy care experience, they grow massively in terms of their confidence, knowledge and trust, such that they are saying later in pregnancy, “Actually, maybe I can do this without an epidural. Maybe if I can labour and birth in the water, that will help and I won’t need an epidural.” Or, “I know I’ve been wanting a hospital birth all along, but I’m curious about homebirth and if all’s well, I think I might like to stay home in labour.” The power of continuity of care – where every woman has only one midwife as her midwifery care provider – is often understated in the literature.

Safety for mother and baby, and the health practitioner’s duty to recommend the safest course of action

I’ve sometimes been heard to say that as midwives, we really only have one job, and that is safety. Women engage midwives for their care because they understand that midwives have a unique skill-set that includes knowledge, experience, judgment and compassion. If women possessed this skill-set, they would have no need for midwives. It is the health practitioner’s role to recommend the safest course of action, which in this case is a VBAC. The woman is so caught up in fear from a traumatic previous experience that rationally, she is probably not even able to take any of this in. The woman should be supported, not necessarily to birth vaginally or abdominally, but just supported. Nothing more, nothing less. After working one-on-one with her private midwife, towards the end of her pregnancy, and with a healthily-grown baby, she just might see things differently and agree that a VBAC is the safest course of action for her and also for her baby. To thrust this (VBAC) upon a woman who is driven by an unresolved and justified fear state is unreasonable and shows a lack of compassion. Yes, a VBAC is probably the safest for mother and baby. But fear (and the absence of fear: confidence, calmness, surrender) is the most important driver of birth. Until we work to eliminate fear and instill confidence, we will have high caesarean rates, whether these are chosen by women or recommended by health practitioners.

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Women need a year to recover from childbirth

Posted on February 28, 2012 by Melissa Maimann

Link

New mothers may be told that they will be back to ‘normal’ within six weeks of giving birth, but a new study has found that most women take much longer to recover.

… it takes a year to recover from childbirth

… The psychological effects can also take much longer to recover from.

… hospital wards can have a negative impact on women’s ability to recoup and celebrate the birth of their child because of the constant stream of visitors and the unfamiliar rules and regulations.

Helping new mothers adapt to having a baby in the home has also changed a lot over the years.

In the past women were shown how to perform tasks such as baby bathing and were only discharged from hospital when they were ready.

Now women can go home as soon as six hours after childbirth and many feel they are just ‘left to get on with it’.

Dr Wray said: ‘The research shows that more realistic and woman-friendly postnatal services are needed.

‘Women feel that it takes much longer than six weeks to recover and they should be supported beyond the current six to eight weeks after birth.

‘However, government funding cuts and a national shortage of midwives means that postnatal services will only face further challenges. The midwifery profession must raise the status of postnatal care as any further erosion can only be bad for women and their children.’ …

Private midwifery provides women with 6 weeks of comprehensive postnatal care.

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Cascade of intervention

Posted on February 1, 2012 by Melissa Maimann

A study has found that first-time mothers who have their care within the general hospital system and have their labour induced, face a greater risk of having a caesarean section than those who wait for labour to start on its own.

In the study, 44 percent women had their labour induced, and 20% of those inductions failed (ie, labour did not start) and caesareans were performed in those cases.

By definition, induction is performed before a woman’s body is ready for labour, and this may point to the reason for such a high rate of failed inductions. In other cases, the reason for the induction is also the reason that the caesarean became necessary. For example, a labour may be induced because of concerns for the baby, and once in labour, the baby shows signs that it is not tolerating labour well and so a caesarean is performed.

The study does point to the issue that inductions should not be performed unless they are genuinely necessary. Up to 50% inductions may not be “indicated”, that is, performed for a medical reason. They might be performed more for convenience, for example. However, if we limit inductions to those which really need to be done, we would lower the caesarean rate.

There are some reasons when an induction might be a good idea, such as when the woman’s blood pressure is high, if the pregnancy goes beyond 42 weeks, if the waters have broken for many hours and labour has not started, if there are concerns for the baby and so on.

Before any induction is commenced, it’s important that women are fully informed by their care provider of the reasons for the induction, the alternatives, the process and procedure, what to expect and the likely outcome.

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Natural Twin Birth

Posted on January 26, 2012 by Melissa Maimann

I had a difficult delivery with my first baby, including posterior presentation, premature rupture of membranes, meconium staining, stalled labour, 18 hours of Syntocinon, a largely ineffectual epidural, a 4 hour second stage, and forceps delivery. My daughter had severe respiratory distress and was in the NICU for several days. It was a very tough introduction to parenthood and left me quite traumatised, especially the separation from my daughter. My husband and I decided that we would try for a homebirth if we had another baby, in the hope that a calmer environment would assist the birth process. When I fell pregnant again, we found a lovely homebirth midwife.

I started to show really early. At 8 weeks I was in maternity wear. I thought it was just because it was a second pregnancy, but a 9 week ultrasound showed TWO BABIES. We were completely shocked as there are no twins in my family. Twins of course meant that a homebirth was out of the question.

There followed many long months of argument with various obstetricians about our birth choices. We wanted as little intervention as possible. A standard twin delivery involves syntocinon (which I was very afraid of, after the previous experience), continuous monitoring (which I had hated with my first birth, as I felt chained to the bed) and an epidural prior to the second stage, in case positioning/version or a c-section is necessary to deliver the second twin. In my first birth, the epidural meant I had no pushing urge and seriously compromised my ability to deliver my daughter, hence the very prolonged second stage, so I did not want an epidural this time around, although I was prepared for Synto to be administered between the twins if labour did not re-establish. The hospital also wanted both twins delivered on the bed, which I did not agree with as I had found pushing in that position impossible the first time around. Our views were very challenging to the obstetricians and some were quite aggressive about it, although I must say the head OB was more reasonable and was prepared to admit that my refusal to consent to an epidural would be a “complete contraindication” to giving me one! Throughout this stage our midwife was a pillar of strength and information. She gave us the courage of our convictions and more than once came to the hospital to talk with the obstetricians on our behalf. Even so, the hospital was very unhappy with our birth preferences. It was a stressful time, helped somewhat by a Calmbirth ® course.

In the end all our arguments ended up being moot. At 33 weeks, I started to feel an ominous itching all over. Tests showed elevated bile salts and poor liver function results. I had obstetric cholestasis. Our midwife and the hospital agreed: the babies would need to be delivered by 37 weeks. And I knew that that early, an induction would almost certainly involve Syntocinon.

This was really difficult for me to accept. I was terribly afraid of the drug, and knew that Synto would mean continuous monitoring and therefore limit my movement, which I also feared. However, I knew that my fear would make the delivery more difficult and the pain worse. At this point the hospital dropped the bombshell that despite all their delivery rooms having deep birthing baths, I would not be allowed to use those or the shower if I had to have Synto, as they believe this risks pump damage to the Synto pump. Essentially this meant I was walking into a labour that was likely to be more painful, with less pain relief options. It was going to be down to Calmbirth ® alone, if I wanted to avoid drugs (and I did!).

I did a lot of Calmbirth ® practice from then on. But the Calmbirth ® visualisation exercises presupposed a normal delivery without intervention, and I found it very upsetting to listen to them. I hit on the idea of doing my own visualisations, of a medicalised induction process. After a few of these I was able to work through some of my fears.

On the day of the induction, we kissed our daughter goodbye at 5am and met our midwife at the hospital. Preliminary checks showed a Bishop score of 5, very promising for 36 weeks. The hospital midwife applied prostaglandin gel and sent us out to freedom. We had a lovely breakfast. I started to have sporadic contractions but nothing serious. We returned to the hospital 6 hours later. My cervix had ripened to 2cm, and the very cheerful OB was able to break the waters for twin 1 (our second daughter) at 3.45pm. No meconium staining! I dared to ask the OB how she was presenting. ANTERIOR, WOOHOO! I was very pleased with that.

Contractions came rather more strongly after that point, but were still sporadic. The felt very “knifey”, and our midwife explained this was from the prostaglandin gel. We held off on the Synto as long as possible, but at 6.25pm the drip was put up and contractions started in earnest. Continuous monitoring was in place, but via telemetry so I could have moved. Ironically, though, I didn’t feel the need to. I went deep into calm breathing and spent most of the labour sitting beside the bed on a fit ball, sometimes circling my hips but more often just breathing to ride the contractions with my husband stroking my back. Unlike my first labour, I had no real idea of when the next contraction was coming, and ended up doing my calm breathing (in for 4, out for 6) solidly for hours. I wasn’t afraid of the contractions. I could really feel them doing their work, and little twin 1 moving firm and fast down. I was determined to “get out of the way” of labour and with each contraction focused on opening up and not clenching against the pain. Our midwife was convinced things were going quickly and asked us when we thought we would be having the babies. I told her anything before midnight was a sucker bet! She said 11pm.

At 8.30pm, about 2 hours after I started having regular contractions, the pain was starting to get BIG. The OB did a cervix check – I was 5cm. I was very disheartened by this, but our midwife told me that the first 5cm was the hardest, and the very encouraging OB tried to convince me that it wasn’t all about centimetres and that my cervix felt promisingly thin and stretchy. In hindsight, even in my first labour I dilated from 5 to 10cm in under an hour, so I should have known what was coming – but I didn’t!

Throughout this time I was not making any noise. The hospital’s midwife didn’t seem to think I was in established labour, and threatened to up the Synto dose to make the contractions “strong and regular”, even though they were already sufficient to dilate my cervix 3cm in under 2 hours. I managed to insist “no. more. Synto!” She reserved judgement, but it might have been the adrenaline kick I needed, as by 9.15pm I was having enormous contractions every 2-3 minutes. I could feel them as a giant swelling band of pain stretching around my whole belly and stretching lower. At this point I started vocalising “ah, ah, ah” throughout contractions, to help me ride the pain and stop me clenching down. I remember saying “if this isn’t transition, I’m in trouble!” I didn’t believe it could be transition, though – not so early, not when my first birth had taken almost 3 days. Our midwife said she thought we would have babies by 10pm, and I didn’t believe her.

I needed to get off the fit ball and change position, and asked if I could get on all fours, although the idea of moving seemed impossible to imagine. The hospital midwife set up a crash mat and a nice beanbag for me to lean on. I leaned forward and within one contraction of moving had started making some amazing noises. Unlike my “ah ah ahs” they were completely involuntary. And then I could feel twin 1 crowning. I did not believe it had happened so quickly, and cried out “what’s happening?” Everyone still makes fun of me for this. She was born in only a couple of pushes at 9.25pm, and our midwife had to tell the hospital midwife to put her gloves on to catch her. Our beautiful daughter, with a lovely round head, pink skin and a great big yell! There is a photo of me still on all fours, with a blissed-out grin. I could not believe how easy and quick it had been. I got to hold her straight away, but contractions started up again quite quickly, and she went to her daddy for some skin to skin time.

At this point the obstetricians arrived – a registrar and resident. I wanted to stay on the floor, but the registrar managed to persuade me up on the bed to check twin 2′s position, as we knew he was breech. Contractions started up again within minutes and were really agonising now, as I had lost my Calmbirth focus and as the position (twin 2′s spine to mine) had that sort of posterior feeling to it. But within seconds I was again feeling the inexorable urge to push. The OB flicked twin 2′s feet out as he was in a squatting position, the midwife and OB flexed twin 2′s head by pushing on my stomach and with a few mighty pushes he was out too, at 9.39pm. Our son! He was handed to me but unlike J, had a bit of trouble breathing, and spent some time in the special care nursery. He was back to us almost before we knew it. I must say he had a very breech-looking head, which looked like a mighty frown, but he’s ever so handsome and cheerful now.

J weighed in at 2.98kg (I was really ticked off she could not stretch to the extra 20gm), and P weighed 3.06kg, excellent weights for 36 weekers, let alone twins!

After twin 2 was out, I lost all patience for the pain – rather a pity as the Synto kept getting ramped up to deliver the placentas and then to deal with my uterus which did not want to shrink back down. I ended up with a Synto drip all night. I tell people this birth was meant to help me deal with my fear of Synto once and for all.

Both babies had beautiful breastfeeds within an hour or two of birth, which sadly was not an omen of things to come for twin 1, but it was lovely.

Anyway, that was our birth. Twins born without any pain relief (not even hot water) or really any intervention other than the induction drugs, with 4 hours of contractions total and only about 2 of those active labour. It wasn’t the birth I had wanted but it was a wonderful experience and very healing after my first daughter’s birth. I am so proud of myself, and look back on the birth with amazed gratitude all the time.

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The Unkindest Cut: Countdown to a C-Section

Posted on January 25, 2012 by Melissa Maimann

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… “Usually I start off by telling people my C-section started even before I got to the hospital …

… Sharp Mary Birch Hospital for Women and Newborns had the highest rate of cesarean section deliveries in San Diego County in 2009. The California average was 29.8 per 100 births; at Sharp Mary Birch, the rate was 37.7.

… At 40 weeks … Cooper-Schultz’s water broke, though she was not in labor. In a birthing class … they told her, we have to get the baby out within 24 hours. So she and her husband went to the hospital right away.

“They pretty much wanted to put me on Pitocin the minute I walked in the door because I wasn’t having regular contractions,” …

… women believe their C-section deliveries at Mary Birch were the result of convenience for the doctors, fear of litigation, and/or lack of staff training in nonmedicated childbirth options.

… It is common for hospitals to use Pitocin if a woman has not gone into active labor within 24 hours after her water has broken to avoid the risk of infection. But the staff at Mary Birch wanted to give Cooper-Schultz Pitocin within the first two hours.

Cooper-Schultz refused the Pitocin at first. She wanted to get things going naturally … At the 12-hour mark, her cervix had dilated to four centimeters. She says she now understands that this “is a good natural labor progression for a first-time mom.”

But it wasn’t fast enough for the staff at Mary Birch. Cooper-Schultz … allowed them to give her the Pitocin that she says they’d been pushing since she’d arrived.

… “They weren’t honest with me. They didn’t say, ‘If you get the Pitocin, you’re probably going to need an epidural.’”

… Cooper-Schultz withstood the pain of Pitocin contractions for eight hours before she finally gave in and got an epidural … The epidural worked on only her left half.

At one point, the doctor came in to check on her and alerted the nurses that she was going home to take her kids to school. Sometime later, she returned with wet hair, checked Cooper-Schultz, found her at nine centimeters, and told her to try pushing.

“I pushed, and [the baby’s] heart rate went down … she said she’s worried about it. She said, ‘He’s not in distress, but he’s a little bit stressed.’”

The doctor told Cooper-Schultz it would go one of three ways. In the first scenario, Cooper-Schultz would push for 20 or so minutes and the baby would come out. In the second, she could push for 20 or so minutes, the baby would not come out, and they’d have to do an emergency cesarean section. Or, the doctor said, they could do a cesarean section right now.

Cooper-Schultz chose the cesarean. …
∗ ∗ ∗

Helen … welcomes me into her North Park apartment shortly after the dinner hour on a Tuesday evening in mid-September. She tells me she’s an unlikely candidate for natural childbirth.

“I’m like Woody Allen,” she says. “I am a New Yorker who likes living in the city, who likes creature comforts. And for somebody like me to be embracing [natural childbirth] is humongous.”

… Dover’s story is similar to Cooper-Schultz’s in that it begins with a desire to give birth naturally … and ends in what she considers an unnecessary C-section. One difference is that when Dover started out, she did know she might have to fight for what she wanted … She stayed home and labored for 10 to 12 hours before she went to the hospital, avoiding “the clock” for as long as she could.

When she arrived, armed with her research and her hopes for a natural birth, she found that the environment at Mary Birch had a greater impact on her than she’d imagined it would.

… The progression she’d experienced at home, from two centimeters to four, slowed drastically when she arrived at the hospital. A doctor told her that it might help if he broke her water. So she allowed it. But nothing happened …

… Dover lists her regrets: Not waiting and laboring longer at home. Allowing the Pitocin at 12 hours. Giving in to the epidural after 8 more hours. But the regrets go as far back as her pregnancy, when she chose to stay with Sharp.

“I should’ve just switched … “In order for me to switch to Scripps and go to one of the birth rooms at Scripps, which has a much better record, would have meant changing everything: changing my primary care physician, changing my OBG. I would’ve had to totally change my insurance policy. And at the time, I already had a pediatrician picked out for her and everything. We’d interviewed, and just the idea of doing all of that was overwhelming. I thought I didn’t have the strength to do it.”

… “[The doctor] said, ‘You need a C-section,’” she says. “I said, ‘I don’t understand why I need a C-section. Everything seems to be fine. Her heart rate’s not dropping.’ And he said, ‘Well, she’s stuck.’”

“… I was totally against using the suction, but anything besides the total hands-off. He said, ‘I don’t want to hurt your baby, and you don’t want to hurt your baby.’ I started crying. And I just finally said, ‘Fine. Cut me open.’” …

∗ ∗ ∗

The obstetrician a woman chooses plays as large a role in her birth experience as the place she chooses to deliver her baby. Some doctors have a reputation for being more inclined to help with a natural birth, and others for being less inclined …

Thompson cites the “bait and switch,” where a doctor claims to support a woman’s birth choices up until the final weeks, when it’s too late to change doctors. Messer says she’s seen doctors who’ve initially said they’d support the hypnobirthing process but later changed their minds.

“All of a sudden it’s, ‘That’s not going to work. No, you can’t be on your hands and knees. That’s not safe, and this isn’t,’” Messer says. “And that’s at 40 weeks. So now, where can I switch?”

… Christine Stewart, a petite redhead and mother of twin girls born at Mary Birch in September 2009, says she experienced something similar with her doctor.

… “… we took a Bradley Method childbirth class,” Stewart says, “which is a 12-week class, pretty in-depth, and we decided we wanted to do natural, unmedicated labor.”

When she first mentioned this to her doctor, Stewart says the doctor told her to “keep an open mind” and not to “fixate on any particular way of labor and delivery.” At the time, Stewart thought the doctor didn’t want her to be disappointed if natural birth didn’t work out, but now she speculates that the doctor was always leaning toward a C-section.

At 36 weeks, the doctor suggested they induce her at 38 weeks. Stewart refused.

“From what I can tell,” she says, “it’s just common that it’s more manageable to have twins at 38 weeks because of size. Sometimes they’re concerned about size. But [my girls] were normal-sized.”

The doctor suggested 39 weeks, then 40. Finally, Stewart agreed to induce at 41 weeks if she hadn’t gone into labor by then. But it was unnecessary. At 40 weeks, three days short of her original due date, Stewart went into labor.

Stewart chose Mary Birch because it had everything she was looking for. Originally, she’d wanted to deliver at Best Start Birth Center in Hillcrest, but they don’t accept women who are pregnant with twins. Mary Birch, she says, seemed like the next best thing.

“It had the facilities, doctors on hand, and all these different classes — prenatal yoga — and since I was diagnosed high-risk because I had the twins and since I was over 35,” she says, “I just thought their whole entire focus is for women and newborns, so I’ll probably get the best care because they’ve got all the resources for that.”

Stewart had heard about other women going into the hospital prematurely and getting “strapped down” immediately. But in her natural childbirth class she’d learned that mobility helps with labor. So she and her husband didn’t go in right away.

Once they did arrive at the hospital, Stewart was four centimeters dilated. She gave the nursing staff her birth plan, which stated that she did not want any mention of pain medication.

“Thankfully, they did not offer medication. They were respectful of that … I was slowly dilating in a normal time frame. They were telling me that was normal …

… Christine Stewart believes that the main reason she ended up having a C-section was that her nurses had no training in natural childbirth.

“Ultimately, the outcome was because there was no one in the labor room who had the experience to help get the babies in position to be delivered,” she says.

By the time the doctor arrived, Stewart was fully dilated. She knew her babies were healthy, that they were both head down, in a good position, face forward. Her blood pressure was not elevated, she had no fever, and she’d been in labor for less than 24 hours. Everything was normal except that the babies were wedged in, each trying to get out first.

… At 2:00 a.m., the doctor came in and said, “It’s time to meet your girls.”

… I kind of resigned myself, like, ‘If this is what we have to do, this is what we have to do.’ I felt like crying because it just went against everything I had hoped for, everything I had planned and practiced for.”

“I think the hospital has some standard protocols, and I think that if you don’t follow their standard protocols, they just don’t know what to do with you,” she says. “And a C-section is manageable. They know exactly how to do it, and I think at 2:30 in the morning it’s, ‘We can manage this, and then we can all go home.’”

∗ ∗ ∗

Last March, when her first son was two and a half years old, Elizabeth Cooper-Schultz had her second child in the back bedroom of her UTC apartment, in the company of her husband, her midwife, two apprentice midwives, and a doula.

Today, Helen Dover is pregnant again. When I ask if she plans to give birth at Mary Birch, she and Henry simultaneously answer, “No.”

“What I’ve learned is that at Mary Birch, everybody’s going to try to get you to do the birth that they want you to do,” Dover explains.

For their next baby, the Dovers will stay with Sharp in order to take advantage of the tests, which would cost them thousands of dollars out-of-pocket. They will also register at Mary Birch so that they are prepared in the event of an emergency. But they have hired a midwife to help them birth at home.

“We’re going just to get what doctors are good for,” Henry says, “and then to use the midwives for what they’re good for.”….

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Choosing the best care provider for your needs

Posted on January 21, 2012 by Melissa Maimann

Choosing the best practitioner for your needs is a very important and personal decision. Ultimately, there is no right or wrong choice: some women will choose a private obstetrician, others will choose a private midwife and others will choose public hospital care. Some women will make an initial choice of care provider and decide to change care providers during the pregnancy. Other women will make one choice in their first pregnancy and then a different choice in a subsequent pregnancy. What’s important is to have an accurate understanding all the options available so that you can feel confident to choose the best option for your needs. The best people to talk to are the people who actually provide the service, rather than a GP who is removed from the actual services of an obstetrician / midwife / public hospital. Get referred to a private obstetrician or two; interview them; reflect on how you feel after meeting them. Go and visit your local public hospital. Have a tour and speak with the midwives there. And interview a couple of eligible midwives. You do not need a GP referral to see an eligible midwife and you can claim their services through medicare. An eligible midwife is a private midwife who has met an additional registration standard that enables them to have a Medicare provider number.

When you are considering a care provider, it’s also necessary to consider where you would like to give birth and to ensure that your care provider can attend you in your chosen setting. You might choose to birth your baby in a public hospital as a public or private patient, in a private hospital as a private patient, in a birth centre or at home. It can be helpful when trying to make a decision to write down a list of questions you may have and also consider what is important to you as you make your choices. For example:

What do I want from my care?
What type of practitioner would I feel most comfortable with?
What do I need from my practitioner to feel comfortable and safe?
Do I want public or private care?
Is continuity of care important to me?

These are questions only you can answer. Other questions are for your care providers to answer with you, and it’s a good idea to interview a few care providers – midwives and obstetricians – before making a choice. Midwives and obstetricians will charge a fee for interviews and you are able to claim this through Medicare (your midwife will need to be eligible in order for you to claim a Medicare benefit). It is important during the interview that you ask all the questions that are on your mind, and to be aware of how you feel throughout the interview. Your care provider should inspire you with confidence, help you to feel at ease and comfortable, and the appointment should feel unhurried.

Likewise, your care provider may like to “interview” you, and this is so that your care provider can be sure that s/he can meet your needs. Maternity care is provided in a partnership and so it’s important that both parties feel really comfortable with the other.

There are many questions you might wish to ask your care provider; the best suggestion is to consider what is important to you and write a list of questions.

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Medicare-funded midwifery care: What you need to know

Posted on January 20, 2012 by Melissa Maimann

I am an eligible midwife. This means that my private patients can claim some of the cost of private midwifery care, much the same way we do when we see a GP. As well as Medicare benefits, some private health funds will provide benefits for childbirth education with a midwife, and costs may also be claimed through tax as a medical expense (more on that one from your Accountant). Medicare benefits and tax benefits combined are between $2,500 and $3,300. This means that care with an eligible midwife will be up to $3,300 cheaper than care with a non-eligible private midwife.

What is a Medicare-Eligible Midwife?

In order to claim Medicare benefits from care with your midwife, you will need to ensure that your midwife is eligible. An eligible midwife meets certain advanced requirements of a registration standard:

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 postnatal 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);

Pregnancy care:

45-60 minute consultations in your home or in my clinic

Childbirth education

Continuity of carer

Medicare benefits

Obstetric back-up

Birth in hospital – or at home

Continue your care with the same midwife you know and trust, with specialist obstetric back-up readily available

Postnatal care

Consultations in your home and / or my rooms

Medicare benefits

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I’m pregnant and I have private health insurance. What are my options?

Posted on January 18, 2012 by Melissa Maimann

Great question! There are a few options available to you as a private patient, as well as all of the options that are available to public patients. The private options are either a private midwife, or a private obstetrician.

Private midwife
To receive care from a private midwife and obtain Medicare benefits, your midwife will need to be an “eligible midwife” (meet an additional registration standard) and work with an obstetrician or a doctor who provides obstetric services. Some private midwives are able to provide labour and birth care in hospital settings, while others are only able to provide labour and birth care at home. All private midwives can provide pregnancy and postnatal care. Hospital options may include private or public hospitals; it’s best to ask your midwife which hospitals she attends births at. Eligible midwives provide complete continuity of care: the midwife you book with will be the same midwife who provides all of your pregnancy, birth and postnatal care.

Private obstetrician
Private obstetricians provide pregnancy, birth and postnatal care, although birth care would also be provided by hospital midwives who may be unknown to you until birth. Private obstetricians deliver babies at public and private hospitals. Continuity is provided during the pregnancy, but birth care is mostly provided by hospital midwives. Postnatal care is almost always provided by hospital midwives, with your obstetrician visiting you each day in hospital and at 6 weeks.

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Physiological third stage for women at low risk of postpartum haemorrhage

Posted on January 13, 2012 by Melissa Maimann

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No previous study has focused on true physiological third stage for women at low risk of postpartum haemorrhage. Physiological third stage is often chosen by women who birth at home or in a birth centre, however hospital policies urge active management of the third stage (injection of syntocinon, immediate clamping and cutting of the cord and then pulling the placenta out) because studies have shown that this form of management reduces bleeding. However, it is unfortunate that those studies have either a) not clearly defined physiological management or b) have not managed the “physiological” third stages in a physiological manner. Hence, those studies have shown that active management is the safer option and hospitals have gone with those recommendations.

This study clearly defines what is meant by physiological management and also the women who are suitable for physiological management. Some women are at a higher risk of PPH and so active management was recommended to those women in the study.

The study compared active management which was standard at the tertiary hospital, with physiological management which was the norm at the free-standing birth centre. At the tertiary unit, 11.2% low-risk women experienced a PPH. At the midwifery-led unit, where physiological management was practiced, PPH only occurred in 2.8% women. Active management was associated with 11.5% PPHs compared with physiological management which was 1.7% PPHs. Active management was associated with a seven to eight fold increase in PPH for low-risk women.

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Do first-time mothers have unrealistic views about having uncomplicated births, or does the health system fail them?

Posted on January 11, 2012 by Melissa Maimann

An interesting report in The Telegraph states that first-time mums have unrealistic expectations of drug-free, natural, uncomplicated births, when in reality, they have a mere 21% chance of:

a labour that starts on its own (ie, is not induced)
not using an epidural
birthing without the use of instruments or operations

If we exclude from that figure the proportion of women who also birth without stitches, that figure becomes a mere 8%. The papers would like us to believe that

first-time mothers have unrealistic views about having uncomplicated births, increasing the risk of post-natal depression

In other words, postnatal depression is caused by womens’ unmet and unrealistic expectations of an uncomplicated birth.

This suggests that the health system has no part to play in this. It is merely a case of women wanting too much from their experience. If we expect too much, we set ourselves up for disappointment, and this leads to postnatal depression!

Wow!

The article goes on to say that

expectant mothers … believe there is a 56.2 per cent chance of an uncomplicated birth, which means a baby being born without the use of forceps, suction cups, caesarean section or induced labour.

Whereas

the chance of having a medically uncomplicated birth is 21 per cent.

A further 30.7 per cent said they believed women would have uncomplicated births without needing sutures. The actual figure is 8 per cent.

My readers will well know that I don’t subscribe to the view that a crappy birth experience and postnatal depression is all the fault of the health service; but at the same time, it’s not all the fault of the woman either.

We’re each responsible for the choices we make and for informing ourselves of all available options before we make a choice. Health services are also responsible for accurately representing their services and outcomes so that women can make a considered choice. If women have a mere 8% chance of birthing normally and without stitches, that needs to be well-known so that women may seek other care options if they so choose.

The health system is here to provide a basic and safe level of care. If we expect or desire more than what can be considered “basic”, then we do need to look into other options, and these will generally be found in the private system, be it private midwifery care or private obstetric care (although I dare say that the average private obstetrician will have lower rates of normal birth than a public service).

All of that said, it seems appalling that 79% first-time Mums go through the public system and come out the other side with an intervened-with birth. In my private practice, those figures are reversed. Do women know what they are signing up for when the choose their local hospital for care? And perhaps more importantly, should the hospitals be held to account for these poor outcomes, or at least acknowledge that they are failing women?

Most first-time mums should expect to birth without intervention. Most should not need any intervention. The birthing process is a normal, natural, female bodily function. We don’t question the potential for our bodies to ovulate, urinate, digest food, menstruate, circulate blood, metabolise substances and so on. These processes generally “work”; birth generally “works” too. Provided we, as care providers, don’t mess it up with unnecessary interventions and an environment that is not conducive to labouring and birthing a baby.

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Do deceptive medical birth procedures de-humanize women?

Posted on January 10, 2012 by Melissa Maimann

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It was a rainy Wednesday late afternoon when pregnant Ana Cristina realized it was time to get ‘to know’ her unborn son João. She went to the Maternity Hospital Leonor Mendes de Barros in hopes of an easy delivery. Despite the pain and restlessness, Ana stood quietly for four hours waiting for care. “It’s a scandal that they treat you badly,” she said. After waiting so many hours … Ana was informed that there were no vacancies and she should find another place to have her son.

… They would have make it across São Paulo city to go to another facility, the … famous teaching hospital in Santa Casa renowned in Brazil for its quality of health care …

… Many women face the happiness of their baby’s arrival with a fear of dying, along with the desire to care for their child and also to be cared for by their medical team. They have confidence in the hospital as the safest place to have a child. But they also carry the suspicion that their delivery can be abused by impunity and deceptive medical ethics by some medical teams.

Some women OB/GYN patients hear humiliating phrases from their medical providers during the process of childbirth, such as:

“Aren’t you too old to be having a baby?”
“If you don’t shut your mouth…”
“It didn’t hurt to make it, right?”
“You didn’t close your legs then, now deal with it!”

Often women patients do their best not to complain and to follow the orders of the medical team …

… André François, founder of ImageMagica, an organization that promotes education, culture and health through photography, has worked to document ‘humane medicine’ … In the process he has also documented medical abuse …

Can an unwanted caesarian be a form violence against women?

… vast differences in the health care system do exist. A universal healthcare system set to serve the poor in Brazil was widely established in 1988 offering free public healthcare for the first time to many in need. The system has suffered under many financial strains though with crumbling medical facilities and the theft of medical supplies in over crowed medical clinics that have had long lines with services that have turned critical needs patients away. But improvements in many levels of care have been made as some hospitals have been equipped with the newest medical equipment and trained medical staff.

François saw Brazil’s system of health care up close when he witnessed the case of one woman from the Amazon who urgently needed a caesarean section. But her journey to the doctor would not be an easy one. To get the medical attention she needed, she would have to face 12 hours of … pain as she traveled by motor canoe to the nearest medical facility. In many regions of the country “when a woman needs a caesarean section, she will usually die,” says André.

In spite of attempts to offer free health care to many of the underprivileged, a 2010 Brazilian study, “Women and Gender in Brazilian public and private spaces,” … 1 in 4 women in the country suffer today from some form of abuse during delivery.

But is there a difference between abuse and violence against women during delivery? What is the perception?

“Women with lower education, do not consider that the treatment they received was mistreatment and disrespect,” … “Through accounts of friends and people of the same social group, they listen that the hospital delivery is like that: it will hurt, you will scream, they will scream at you,” … “There is a perception of a picture that indeed is negative, but it is seen as normal. It is not even seen as mistreatment.”

In the public hospital in the town of Ceará in northeastern Brazil there is a sign on the wall alerting patients about their human rights. It tells them that they must demand decent public medical service. At the same hospital though, another sign outlines a very different picture. On another sign is a quote from Article 331 of Brazil’s Criminal Code, known as the ‘Desacato laws,’ that prevents freedom of speech for anyone who wants to speak out against injustice, including any patient who wants to talk about their medical care.

… Female patients who come from poor, rural and uneducated families often tend to be less acknowledged or counted as they become ‘objects’ in the hands of medical staff who can and do hold authority and power over them.

The World Health Organization recommends that the rate of cesarean section in a country should not exceed 15 percent. In Brazil the latest data for cesarean in most public hospitals is 35 percent. … an alarming 80 percent of private hospital [use] cesarean section commonly. When women are asked if they want a cesarean delivery about 70 percent of women patients say no …

Cesarean section, episiotomy, oxytocin and cosmetic vaginal surgery

… “most women go to birth without information.” Many are also convinced to accept cesarean section during labor while they are suffering from acute pain and unable to make the best decision. Women who are able to give birth ‘naturally’ are also most often submitted to episiotomy during childbirth …

… 90 percent of hospital births throughout Latin America use surgical procedures for episiotomy without any medical need or indication. Without consultation with their patients numerous doctors cut and sew the vagina to shrink it after childbirth and to ‘satisfy the husbands.’ This operation is known in Brazil as the ‘husband’s point.’ …

… The time a woman takes to complete labor in birth is another issue for medical teams who want to speed up the process. “There are reports that in some public hospitals, a woman should not be in labor from one shift to another, and all cases have to be ‘fully managed’ during the same shift,” …

In addition to episiotomy, some women receive doses of oxytocin to enhance uterine contractions – and consequently the pain – so their delivery with childbirth is faster. But is it safe? Distinct dangers to the mother with incorrect use of the drug can cause fatal fetal hypoxia, a condition that denies a woman’s baby of life saving oxygen during the process of childbirth …

Is there a solution to the problems?

Why do some medical teams mistreat patients in labor? Professional studies indicate that trivialization of social injustice, especially injustice against women, may be the cause. This can affect the entire society in Brazil, both male and female.

… Finding and supporting a good team of health professionals who will seek better quality health care for Brazil is the goal of photojournalist André François …

Since 2000 the Brazilian program called ‘Working with Traditional Midwives’ … has aimed to improve care for women with birth delivery at home. They also seek to raise awareness among health professionals to recognize midwives as important partners in the birth process for women.

As the definition of violence against women during childbirth can be wide and subject to many interpretations, so can the concept in the ‘humanization’ of childbirth. Numerous advocates who believe that babies who are born through a philosophy of ‘woman-centered childbirth’ are also beginning to see how natural and appropriate approaches to new technology with birthing can work together. The hope by many women’s advocates in Brazil is to see the rates of abuse during childbirth labor decrease sharply.

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Delivering better maternity care

Posted on January 8, 2012 by Melissa Maimann

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Despite countless inquiries, initiatives and ministerial pledges … maternity care remains one of the NHS’s problem areas …

In recent weeks there have been two significant pieces of evidence published that will help shape practice affecting the UK’s 800,000 births a year. The National Institute for Health and Clinical Excellence (NICE) produced new guidelines for the NHS in England and Wales on the circumstances in which mothers-to-be should be able to have a Caesarean-section delivery.

Meanwhile the landmark Birthplace study … sought to clarify the relative risks of having a baby at home, in hospital or in a birth centre run by midwives; the study found all settings carried a low level of risk. Both documents aim to advise maternity teams on how to give mothers and their babies the best possible experience.

… It is no wonder maternity services are under pressure … England has had a 22% increase in births over the past decade …

But the maternity workforce is not just short of midwives, the roundtable heard. Of those 800,000 annual births, 94% of them take place in hospitals where doctors are present along with midwives; the others, at home (2%) and in birth centres (4%), have midwives solely in charge. But the Royal College of Obstetricians and Gynaecologists (RCOG) believes the 2,186 senior doctors working as consultants in that area of medicine is too few. It wants the NHS to boost numbers to 3,000-3,300.

Mothers-to-be would benefit because every hospital maternity unit would have a consultant on hand 24/7 and less experienced doctors would no longer be in charge overnight and at weekends …

… “the current system of maternity care is unsustainable. You have to reconfigure”. The participant meant that some maternity units should be closed – merged, in effect – so fewer, larger childbirth centres could offer mothers a better service, partly thanks to more specialist staff handling a greater number of deliveries concentrated in the same place.

It makes little sense for large urban areas to have separate maternity units just a few miles apart, a view confirmed for the speaker by seeing that sort of setup on a recent visit to Leeds and nearby towns.

Many health professionals support the concept of reorganisation. And the reconfiguration of neonatal care services in 2003, which led to fewer units dealing with sick babies but offering enhanced care, is a potential model to follow, another participant added. But there is a major obstacle to overcome first: … To close your core maternity service is a death trap as an MP. So that will not happen,” …

… simply creating fewer, but larger, hospital units is not the answer and there needs to be more midwife-led birth centres, either standalone units or situated beside hospitals, in case a mother needs urgent medical attention …

There was also a strong consensus that the huge proportion of births occurring in hospitals, 94%, is too high. While there was support for moving towards an equal split – 33% at home, 33% in birth centres and 33% in hospital – there was also a recognition that politics, entrenched attitudes and the tightest NHS budget in a generation means that will probably remain just an aspiration for the foreseeable future.

… In 2007, Maternity Matters promised women in England a choice of birth place, but the reality is that many still do not get that. One participant working on the NHS frontline said pressure on maternity services was so great in some places that midwives who usually help women to have home births are having to work, instead, on labour wards, thus depriving those seeking a home birth of that supposedly guaranteed right.

Similarly, surveys by the Healthcare Commission and its successor as the NHS regulator for England, the Care Quality Commission, have shown the promise to women of one-to-one care from a midwife during their labour is also not honoured for as many as a quarter of mothers-to-be, who are left alone and find it stressful …

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Unassisted: Home Birth in Nebraska

Posted on January 5, 2012 by Melissa Maimann

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… Birth is big business to a healthcare industry … Hospitals are reinventing themselves to create an atmosphere catering to a woman’s evolving needs. However, some Nebraska women want to take their business out of the hospital altogether, but find their choice may not be a legally viable option.

Methodist Women’s Hospital … sits just off the interstate in Elkhorn. The modern, two-building facility is a “one-stop shop” for women’s health. Women-centered facilities are not a new concept in the health care industry, but resorting back to a more home-like and natural birth experience is … the hospital’s new labor and delivery rooms … are as “home-like” as they can get.

… a lot more women are asking for natural birth plans lately, meaning births with limited medical interferences such as epidurals, labor inducing medications, and cesarean sections. After our tour, I asked Korth about the most natural of birth plans: the home birth.

“We feel like we’ve done a very good job as getting as close to that as we possibly can,” she said …

But, there are some Nebraska couples who feel a hospital will never replace the comfort of home …

“I’m terrified of hospitals,” laughed Katie. And she knows hospitals, Katie works at one in Omaha and her husband, John, is a paramedic.

“It’s just an uncomfortable environment, I think,” she said. “From the bed you’re in, to the room that you’re in, to multiple people coming in and out, in and out, not necessarily telling you what they’re doing or what’s going on—they’re just doing it. It’s just so impersonal…I’m just afraid of that.”

The couple is not expecting just yet, but is looking at their options. They prefer an assisted home birth with a … Midwife, but they will face some difficult choices in their planning. The birth experience they want is also an illegal one. Nebraska is one of two states where an assisted home birth attended by a … Midwife is prohibited. Alabama is the second.

Katie fears the professional and personal implications of having a home birth.

“I would fear for my job if I had a home birth,” she said. “But it is scary, the thought of doing it, not just my job, but with my family and society and the view of what that means.”

John said he’s also unsure of the professional implications he could face. He hasn’t told any of his paramedic instructors about their plans, but only one co-worker because he said he trusts her.

… If Katie decides on a home birth, it would be difficult to find a … Midwife willing to help. The penalties for an attending midwife can range from license revocation to jail time.

… Prentice is the owner of the WomanKind Midwifery, located in … South Dakota … She never delivers in Nebraska, but says Nebraska mothers from as far southeast as Lincoln drive hours, or days, to see her. She said these women are “desperate” to have a different type of natural birth.

Speaking from her office in Spearfish, Jeanne said, “They want a different experience, they don’t want to be induced, they don’t want an epidural, they don’t want to be flat on their back with a monitor. They want something different. They want that personal care. And they can’t get it in their home state.”

Prentice said the atmosphere that compels women to drive hundreds of miles can never be replicated in a hospital setting. Hospitals are meant to treat disease … something she sternly added pregnancy is not. And as for the new home-like atmospheres, Prentice isn’t buying it. She feels hospitals are quick to perform interventions, sometimes unnecessarily, breaking the tranquility of an otherwise quiet room.

“You can put nice Pergo floor in and you can hide your equipment, but the minute things look a little or feel a little scary to you, you drag that stuff out,” …

… Back in Elkhorn, Certified Nurse Midwife, Marilyn Lowe is one of four CNMs who make up Methodist’s new Midwifery Department. Lowe says a natural birth doesn’t have to take place outside of a hospital. After a full day of seeing patients, Lowe spoke with me after hours in her office.

“Birth is a philosophy,” Lowe said. “And it can be as natural in a hospital as it can be in a home. Our goal is to help that woman accomplish what she wants to accomplish.”

“We also have patients who want epidurals,” she said. “But if somebody wants a natural birth, that is our goal to help them accomplish that with as little intervention, but yet knowing if we need that intervention, it’s available.”

… But for Katie and John, not having the option of an attended home birth leaves them feeling unsafe and frustrated. Katie is perplexed at the notion that they can deliver themselves, but not with a trained professional.

“For me I want to have a home birth, but I don’t wanna just be by myself at home popping out a kid,” she said. “What if something goes wrong?”

“My biggest frustration is that I can have a home birth, me and my husband can have our kid at home, but we can’t have somebody who’s trained to be there with us.”

… Tony Fulton of Lincoln wants to repeal a single line in Nebraska’s medical laws: the one prohibiting … Midwives from attending home births …

Fulton was approached by Nebraska mothers asking for his help years ago … “For them to be stigmatized as strange or awkward, it’s the ultimate of ironies because these are moms,” … “And often times the stigmas are being foisted upon them by those who are not moms.”

Jessica Freeman is a mother of three and a board member of Nebraska Friends of Midwives. During her first pregnancy, she said like most newly expectant mothers, she had read many books on child birth. But when it came time to deliver, she said she experienced interventions by hospital staff she felt might not be safe.

Her doctor broke her water, and told her to push, an urge, Freeman said, she never had.

“I came out feeling… just not sure what I was doing,” Freeman said. … And that translates into your mothering.”

That experience led Freeman to seek out a home birth for her next two children. Her first home birth was performed in New York, and despite the ban, her second was in Nebraska. For that birth, Freeman imported a midwife from New York*. (*Correction: the imported midwife was not from New York, but was imported from another state)

“We’re not looking for 50 percent of births to be in the home,” she said. “We’re just saying we want the ones who know about home birth, want to be able to have a safe home birth, we want to be able to have an attendant there, to make sure nothing goes terribly wrong, and to help us if something does go wrong.”

… Sarah Jacobitz-Kizzier is in her final year as a University of Nebraska Medical Center student. She’s planning to become a family physician. I asked her why she believes the medical community is resistant to allow home births. She said it’s a “fear of lawsuits, losing their own medical license …

… in medical school, the practice of home birth is never brought up. And often, she said, the topic was “taboo” with fellow med students. She said she feels women should have as many options as they want. And she said there are widespread misconceptions about women who want home births.

“The one that is most polarizing and the most untrue, is … that women who choose to do home births are labeled as having a stronger emphasis on the process of the birth rather than the outcome …

… “Virtually every other state allows this except Nebraska,” he said. “Either Nebraska is going to be the safest place on the planet to have babies, or it’s going to stick out like a sore thumb.”

No matter how “home-like” the hospital delivery suite is, it will never be like home. There is something about being in your own private, comfortable and familiar space, using your own shower / kitchen / lounge room, eating off your own plates and being surrounded by what you know, that can never be replicated by a hospital. Of course, some women will be safer birthing in the hospital, but wherever possible, I believe women should be encouraged and supported to birth at home.

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Midwives Use Rituals To Send Message That Women’s Bodies Know Best

Posted on December 31, 2011 by Melissa Maimann

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In reaction to what midwives view as the overly medicalized way hospitals deliver babies, they have created birthing rituals to send the message that women’s bodies know best.

The midwife experience uses these rituals to send the message that home birth is about female empowerment, strengthening relationships between family and friends, and facilitating participatory experiences that put mothers in control, with the ultimate goal of safe and healthy deliveries less focused on technological intervention.

These are some of the findings from an Oregon State University researcher and licensed midwife who witnessed more than 400 home births in order to document an extensive list of practices utilized by midwives to express the symbolic difference between home and hospital births.

… “We know, for instance, that midwives have better health outcomes in some areas, such as reduced rates of surgical delivery and labor induction, than hospitals. But I wanted to examine how ritual might play a part in producing these positive health outcomes.”

… evidence shows that hospital births result in about triple the rate of cesarean section for low-risk women compared to midwife-attended home births …

What she found was a network of common practices, messages and beliefs that resulted in midwives constructing woman-centered rituals around pregnancy and birth that were set up in opposition to what they believe are the overly medicalized practices of hospitals.

For instance … midwives conducted many of the same diagnostic procedures as a physician would prenatally, from blood pressure and weight checks to blood testing and fetal heart tone evaluation …

… “Many midwives also downplayed the centrality of monitoring and resuscitation equipment setting them off to the side, or placing them under baby blankets during labor so women would not be reminded of the technology in the room. Mothers and babies were still monitored closely, but the monitoring was not made the central focus.”

The differences aren’t so much in practice … but in performance.

Cheyney also documented the use of common phrases to create birthing mantras. She lists phrases such as “don’t fight it,” “let your body do it,” “open,” and “let it be strong,” as key components … Many mothers … reported feeling strong and capable during their labors, and women who compared their hospital birth to their home birth reported feeling like they were “doing something, rather than just lying there passively waiting.” Midwives also commonly expressed the statement that they were simply “guardians,” and that women have all the tools inside of them to birth their own babies.

… It is Cheyney’s belief that both of these sets of rituals have caused a wide chasm between … hospital births and the 1 percent who choose home births.

“Just as women and their doctors who deliver in the hospital often feel convinced that their birth was the only safe and ‘correct’ way, women and midwives who deliver at home feel strongly that they have the solution,” … “They believe it with every cell in their body because they have lived it.”…

There is definitely something special and unique about homebirth that cannot be summarised in words alone.

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Low-risk births don’t need hospital

Posted on December 6, 2011 by Melissa Maimann

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A new study in England shows little difference in complications among the babies of women with low-risk pregnancies who delivered in hospitals versus those who gave birth with midwives at home or in birthing centers.

… home births are advisable only when there are low risk factors. If the patient has … [medical] conditions, is about to deliver twins, or has high blood pressure or hypertension, home births aren’t recommended …

“Home birth can be just as safe as hospital birth if people are providing it to the correct patient appropriately,” …

… “Birth isn’t an abnormal process, it’s a physiological process,” he said. “And if your pregnancy and labor is not complicated, then you don’t need a high level of specific expertise.”
… about 50 percent of pregnant women in England — those who are low-risk — should be able to choose where to have their baby.

More than 90 percent of pregnant women in England now give birth in a hospital. Some officials say the new study should prompt women to consider alternatives.

… midwife-run birth centers in England have a more homelike environment, with privacy, sofas and birthing pools.

In Britain, midwives deliver more than 60 percent of babies already. Similar care is provided in the Netherlands, where about a quarter of all births happen at home …

… researchers found a higher risk for first-time mothers planning a home birth. Among those women, there were 9.3 adverse events per 1,000 births, including babies with brain damage due to labor problems and stillbirth. That compared to 5.3 adverse events per 1,000 births for those planning a hospital birth …

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Simulator to predict chance of caesarean?

Posted on December 4, 2011 by Melissa Maimann

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Traditionally, doctors and midwives have used a technique called pelvimetry to measure the pelvis and try to determine its adequacy for giving birth. But pelvic size is just one factor in how smoothly labor will go, rendering the method largely insufficient.

Scientists in France have been working to take some of the guesswork out of labor predictions … their newly developed software, called Predibirth, predicts birth outcomes quite accurately.

The researchers used their software to process magnetic resonance images of 24 pregnant women, capturing the pelvis and fetus, and then simulating 72 possible trajectories the baby’s head might take through the birth canal. The program then uses this data to score the mother’s chances of having a normal (vaginal) birth.

… Of the 24 women in the study, the 13 who delivered normally all had highly favorable birth outcome scores. Three women who had high-risk scores underwent elective C-sections. Of the five women who underwent emergency C-section, the three with obstructed labor had high-risk scores, and the two who experienced heart rhythm abnormalities had mildly favorable or favorable scores.

More accurate measurements of labor risks might not only keep C-section rates lower and help identify necessary C-sections before they become emergencies, but these measurements could also better inform those who want to deliver at home whether it is safe to do so.

I wonder if all of those women had undergone extensive preparation for birth and had sought continuity of midwifery care? Of 24 women, only 13 delivered vaginally. That is only 54%! Private midwifery care generally had rates of normal birth up around 90%.

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Hospital births for healthy women? What does the research say?

Posted on November 27, 2011 by Melissa Maimann

The recent Birthplace Study was the first of its kind to compare outcomes for low-risk, healthy women who gave birth in midwife-led units (both alongside and freestanding), obstetric units and at home. My previous blog post described the findings for first-time Mums birthing at home, but what did the findings say about hospital birth?

The study is extremely positive and shows that birth is generally very safe for mothers and babies who are low risk and healthy. In fact, the chance of something going very wrong for the baby was so low that the researchers had to combine mortality and morbidity to get any meaningful data. There were so few deaths in the study (38 out of nearly 65,000 births) that they had to combine a host of adverse outcomes in order to come up with any statistically significant results. Therefore the “primary outcome” included baby deaths and serious morbidity (injury / illness) to the baby. Overall, a low risk woman had a 4.3/1,000 risk of having a “primary outcome” (that is, death or serious injury to the baby). For women birthing in hospital, the figure was 4.4/1,000 and was actually lower for babies born at home and in midwifery-led units. Imagine that: the risk to the baby overall was highest in hospital!

Breaking this down further, if we look at first-time Mums separately to second and subsequent time Mums, the figures look different. First time Mums had a 5.3/1,000 chance of a “primary outcome” overall. This rose to 9.3/1,000 for women who planned to birth at home, and fell to 4.5 for women birthing in a midwifery-led unit. It was 5.3/1,000 for first-time mums who birthed in hospital. Again, we see that hospital birth confers some increased risk for first time Mums.

Now looking at women birthing for the second (or subsequent) time, we find that the overall risk of a “primary outcome” was very low: 3.1/1,000. This was higher in an obstetric (hospital) unit at 3.3/1,000, lower in a midwifery-led unit (2.7/1,000) and lowest for women birthing at home (2.3/1,000). So once again, the study is showing that hospital is not the safest place to birth a baby if you are a low-risk, healthy women.

If you are having your first baby and are low-risk, the safest place to birth is in a midwifery unit, and if you have birthed before and are low-risk, the safest place to birth is at home.

Of course, midwifery units have limited capabilities to provide higher levels of care, and as labour and birth are unpredictable, there needs to be robust transfer arrangements in place. Some 10-45% of women transfer in birth. This figure is lowest for women who have birthed before, and highest in first-time Mums. As well as robust transfer arrangements, women – particularly first-time Mums – need to be aware of the chance of transfer and to be comfortable with this possibility. This is best accommodated if the woman can transfer in with her own midwife.

What were the intervention rates like?

Not surprisingly, intervention rates were highest in women who planned a hospital birth. 93% women who planned a homebirth had a normal birth, versus only 74% women in the hospital. 11% had a caesarean in the obstetric (hospital) unit, versus a mere 2.8% in women who planned a home birth. 24% women had their labours sped up with a syntocinon drip in the planned hospital birth group, versus only 5% in the women who planned a homebirth. 31% women had an epidural in the planned hospital birth group, versus 8% at home. And of course, episiotomy rates were lowest at home.

It is clear that being in hospital greatly increases risks for all low risk mothers compared to being at home or in a midwife led unit (either alongside or freestanding).

It is clear that low-risk women have much to gain by planning a birth with midwives in a birth centre or some other form of midwifery-led care. Planned homebirth does increase the risks to the babies of first-time Mums, with an increase in adverse outcomes for babies from about 0.5% to just under 1%. But what is it about planning a homebirth that increases the risk to the baby? The study used intention to treat analysis, so we are not able to know how many of those adverse outcomes occurred in those who transferred to hospital after a planned homebirth, versus those that happened in the births that actually occurred at home. We do know that the outcomes of homebirth transfers are generally worse than those who had been planned to occur in hospital, and first-time Mums are more likely to transfer. We also know that birth is generally riskier for a first-time Mum than a woman who has birthed before.

Regardless, the study is extremely positive in supporting the role of primary midwifery care and the excellent outcomes that low-risk women can achieve when they choose a midwife as their care provider. Imagine the benefits as well for high-risk women who receive midwifery care with appropriate and timely obstetric care.

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Foley Catheter is as Good as Gel for Inducing Labour

Posted on October 31, 2011 by Melissa Maimann

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New research as found that the use of a Foley catheter appears to be as effective as prostaglandin gel, but with fewer side effects. These were the findings of a randomised trial. The Foley catheter is used to inflate a balloon behind the cervix that simulates the pressure of a baby’s head to make the cervix dilate, likely by stimulating endogenous prostaglandins.

Caesarean section rates were similar in both groups, however more caesareans were performed for failure to progress in the foley catheter group, than the prostaglandin group. +Operative delivery due to fetal distress was less common with the Foley catheter than with prostaglandins.

The Foley catheter group was also more likely to be augmented with Syntocinon, though this was common in both groups and is a general feature of induction.

Why is this research important?
Women who have had a previous caesarean but require induction are often forced into a corner because many care providers are reluctant to induce labour on women who have had a previous caesarean for fear of the scar separating. This often leads to a reluctant decision to have an elective repeat caesarean. However, if women have the option of a foley’s catheter induction, this provides a safer alternative to prostaglandin induction with fewer complications.

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Turbulent times

Posted on October 28, 2011 by Melissa Maimann

A lot has been happening in the world of homebirth and midwifery. Many will have read the articles about homebirth, freebirth, midwives and maternity care that are appearing in our papers on a daily basis.

I have not posted for a couple of weeks now, for three main reasons: one I have been really busy with my practice which has not been this busy for about two years. Second, I attended the Australian College of Midwives National Conference – the ACM worked really hard to deliver an excellent conference that was appreciated by all. I had the fantastic opportunity to meet midwives from around Australia and share ideas, discuss practice and talk birthy things. I was pleased that the conference was in Sydney, because as those of you who know me will know, in my non-midwifery life I rescue and care for injured and orphaned native birds, and so I was able to make a trip home most days of the conference to feed everyone at home. They were hungry but they all survived! I digress. The third reason for not posting was that the recent issues have made me re-assess things like responsibility, accountability, safety, choice, control, autonomy, beneficence, informed decision-making and many other issues. I have no answers to report. Just lots of reflection.

Midwifery and maternity care are going through turbulent times and as professionals and organisations, I feel that we have done a major disservice to women that they feel safer birthing at home – with or without a registered midwife – in the presence of risk factors – because they so strongly believe that the hospital system will not enable them to birth in the manner of their choosing. It is a sad reflection on the health system and the professionals who work within it. Women who cannot access midwifery care because they are planning a VBAC. Women who are told that if they insist on birthing vaginally with twins, they must accept continuous monitoring, induction, epidural and birth in stirrups for twin two. Women whose only option is to birth in a hospital that is two hours from their home. We have all heard the stories.

My biggest disappointment is the lack of midwife admitting rights. We are one year into the maternity reforms on November 1 this year. We have eligible midwives with Medicare provider numbers, ordering tests and working with doctors to provide safe care to women and babies – yet we cannot access hospitals to provide this care. I well understand that there are a lot of hurdles to be overcome with midwife admitting rights, and life has taught me that nothing in life is impossible.

The release of the homebirth position statement – which I fully support as an evidence-based and safe way to provide care – combined with the lack of midwife admitting rights, is disastrous for women and midwives. Higher risk women are forced into a position of birthing in hospital without their midwife if the midwife complies with the position statement but has no admitting rights – otr else freebirthing, potentially with disastrous consequences. Overnight, this change occurred and women are fuming.

It is impossible to believe, but an eligible midwife who crosses all the “T”s and dots all the “I”s will suffer incredibly in terms of restriction of clientele, however if she were to remove her name from the register – something that I understand is very easy to do – she may do just as she pleases with no accountability, regulation or practice standards. Midwives are placed in the untenable situation of a dwindling practice, or unregistering and having a flourishing practice. Until admitting rights are in place, midwives will have no place to birth with their higher-risk clients. This situation does not see the Government supporting midwives or women. It is creating a disaster.

The various politics of homebirth and midwifery has created an enormous rift between midwives. It seems that there are the bunch who have elected to become eligible, forge ahead with collaborative arrangements, push for admitting rights and accept the increased regulation that is upon us as our profession matures. The other group opposes the increased regulation and restriction of choice, supports midwife- (or non-midwife)-attended homebirth for any woman who wants it and really wants things to just go back to how they used to be, before insurance became mandatory. Many midwives sit comfortable in the middle of this debate. It is sad to watch such division and animosity amongst midwives. We seem to lack a capacity of saying, “We don’t share each other’s vision and we have made different choices, but we are midwives and we will support each other”. As one midwife said to me, “We are each doing the best we can for the women we care for and we’re making the best of a rotten situation”.

I know 2012 will be better than 2011. Who knows? Maybe it’ll be an historic year where for the very first time, women will birth on their own terms, with their chosen midwife, at home or in hospital. I wonder how many women will insist on homebirth in spite of significant risks, if they are able to birth in hospital with their own midwife and in the manner of their choosing.

Visit my website to explore birthing services.

Natural birth in hospital?

Posted on October 8, 2011 by Melissa Maimann

Here are some ideas to birth naturally in hospital:

Read, read, read. Books, websites, any written info from your care provider … read it all. You also need to know the difference between facts presented to you in an honest and unbiased way, and facts that are being filtered through hospital policy. This is where women benefit from having a private midwife by their side.

For example, “Some risks rise slightly when a woman has high blood pressure. I am uncomfortable with letting your pregnancy continue with high blood pressure because of the risks to the baby and to you if something happens” is an honest and factual statement. You have the right to accept the risks and refuse induction. However, some women hear “I’m going to induce you today because if we don’t do this now, there is a good chance your baby will not make it”. This statement is dishonest, using a woman’s fears and her maternal instinct to encourage her to accept intervention. There is also no discussion of alternative options. Informed consent requires that women are presented with options so that they can make the best decision for them, in their situation.

Be assertive As with most human relationships, a great deal can be resolved with a calm, respectful and firm manner. Know what you want and why you want it. Engage a private midwife to assist you with obtaining relevant and impartial information.

Listen. If you are choosing to use a hospital and an obstetrician for your birth, then you acknowledge that their presence, education and experience have some value. Your wishes are important but be willing to listen even when what’s being said is really not what you want to hear. You must also acknowledge that an obstetrician is trained in all things that go wrong, and they are on the look-out for any sign of things going wrong. Midwives, on the other hand, will promote normalcy and assist your pregnancy and birth to remain normal. These differing philosophies do result in big differences in intervention rates.

Be Flexible. Understand that sometimes things don’t go the way we had planned. There might be some occasions where you’ll be happy to accommodate the hospital policy, and other times when you’ll want to stand your ground.

Ultimately, it is true that the most important aspect of birth is safety and a healthy mother and baby. But that doesn’t mean the other aspects are unimportant, and I firmly believe you can have a great birth – and a safe birth – in any location.

Visit my website to explore birthing services.

Push to get new babies home in four hours

Posted on October 5, 2011 by Melissa Maimann

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HOSPITAL to home in four hours? It would have been unheard of a generation ago when new mothers regularly spent up to two weeks in hospital, ”lying in” post-birth.

But in the NSW maternity wards of the future, it won’t be unusual for women to give birth in the morning and go home in time for lunch.

Early hospital discharge for women with low-risk pregnancies, uncomplicated vaginal births, a healthy baby and good support at home, is part of NSW Health’s Towards Normal Birth directive, to be implemented by 2015.

Women who opt to go home early would be visited by a midwife for up to two weeks after the birth …

… there was no reason why more women could not leave hospital soon after giving birth, particularly when they were under the care of the same midwife throughout.

… if women could be well cared for at home, it would alleviate pressure on maternity staff.

… ”I don’t really like hospitals and my feeling is that if you’re not sick there is no need to be in one,” she said. ”I wanted to go home as early as possible if I was healthy and the baby was healthy. I would rather be in my own home, in my own bed.”

… NSW president of the Australian Breastfeeding Association, had concerns about early discharge programs. She said the state was over-represented in calls to the association’s helpline, which she suspected was due to women leaving hospital before feeding was well established …

Early discharge hospital programs typically delivery one to three home visits per woman. Although the woman may be under the care of the hospital for up to two weeks, on some of those days, the woman will be called instead of visited and on other days, there is no phone call or a visit, but the woman is always able to call in if she has any issues and a midwife is always available for help over the phone. Private midwives provide a wide ranging schedule of postnatal visits, ranging from one or two visits only, to as many as 12 postnatal visits over a 6-week period. Most private midwives will provide postnatal are for 6 weeks. It is best to ask your private midwife for her schedule of postnatal visiting before you engage her services and to always ask if you feel that you would like more visits.

Visit my website to explore birthing services.

Choosing Your Midwife

Posted on October 3, 2011 by Melissa Maimann

Midwives are qualified and educated to care for women throughout normal pregnancy, birth and the postnatal / newborn period. Midwives are also known as the experts in natural birth, attending water births, home births and hospital births. Finding the best midwife for your needs can be a challenging task, but it’s one of the most important decisions a family will make when they decide to work with a midwife. The midwife’s knowledge, skill and experience are key to a safe and satisfying pregnancy and birth experience.

When engaging the services of a private midwife, most people will make contact by phone call or email, and then arrange for an initial consultation. At the consultation, the midwife and family interview each other to explore whether the relationship feels right for them and meets their needs. Midwives will ask about the woman’s health history, her care needs, her previous birth experiences, her attitudes and beliefs about birth and her expectations of her midwife.

What sorts of questions can women ask their midwife? Well, there are lots of questions you could ask and I’ve included some below.

Be sure to ask about qualifications and experience, including whether your midwife is an eligible midwife. You are able to claim medicare benefits if your eligible midwife has a collaborative arrangement and is able to access obstetric care for you if it becomes necessary. If you are told, “I have three years of experience” ask where that experience was obtained – in a hospital? Private practice? If in private practice, how many births does she attend a year? 2? 20? Generally for private practice, the more experience that is gained, the better: when a midwife works in private practice, she works alone and needs a good level of skill, experience and judgment to practice safely. Experience is always the best teacher.

Ask your midwife about her relationships with hospitals and doctors. This will provide insight into your midwife’s ability to negotiate and communicate.

Many women ask for references but this can be tricky as they would come from former clients of your midwife. This of course brings up issues of confidentiality, and it is against the Public Health Act for midwives to place testimonials on their websites. You can ask your midwife if she has any former clients who would be prepared to speak with you, but be mindful of confidentiality processes and women’s rights to privacy. What your midwife can do, is to provide a summary of the feedback that she has received from her clients. This will tell you that your midwife is engaged in quality assurance processes and would also provide a way of reading feedback from previous clients.

Ask your midwife what her service includes and does not include. Also ask about fees, back-up arrangements and obstetric back-up arrangements.

Are there any questions families should not ask their midwife? Generally, interviews with midwives can be approached as a job interview. Questions that are appropriate in a job interview would be fine to ask your prospective midwife. Questions regarding religion, marital status, age, previous birth experiences, previous terminations and other personal questions ought not be asked.

Finally, it’s really important that you feel comfortable with your midwife and that you feel that you trust her. Reliability is important, as is trust, respect and honesty.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Charging women for non-medical caesareans?

Posted on October 2, 2011 by Melissa Maimann

Link

The health minister has said that women in Northern Ireland who choose to have a Caesarean for non-medical reasons may have to pay for the operation.

Edwin Poots is launching a consultation on a review of maternity services.

Women at low risk will be encouraged to consider having their baby in a midwife-led unit or at home, if appropriate.

Around 30% of deliveries are by Caesarean section – the highest level in the UK and Ireland.

… giving birth was a natural process and superb assistance was available to help women through the delivery.

“It costs several thousand pounds more for a Caesarean section so there are savings to be made,” …

“… what we want to encourage, is more people to give birth naturally because it has better outcomes for the mother and the baby.

… “We want to ensure that people take the natural choice where they can and to have that back up where they need Caesarean section to take place.”

… At present, women who elect to go private to have a Caesarean on non-medical grounds pay for their pre and post-natal care.

But the cost of the delivery is met by the health service.

… women will be encouraged to have their baby in a midwife led unit

“If you want to go down that route, if you want to pay for it, it is totally up to yourself, but I don’t feel that we the public in Northern Ireland should be paying additional money for people to have the choice.”

The minister said he expected to see a “considerable” number of midwifery units being established.

“A lot of them would be set up in association with the main maternity unit, so they would be on the same site as existing hospitals,” …

“Women would be giving birth totally with the midwives but there would be a fallback position of having an obstetrician nearby if things do not work out.”

Breedagh Hughes from the Royal College of Midwives said the focus was on trying to “normalise” child birth.

… “One of the things we hope will come out in the review will be asking trusts to look at … the reasons for the Caesarean sections and to focus on trying to prevent women from having that first Caesarean section, which very often leads to the old adage – ‘once a section always a section’.”

She said a “fear” of child birth stopped many women from choosing a natural birth.

“When one in every three women gives birth by Caesarean section, you lose that critical mass of people who know what it is like to give birth normally, and women are losing confidence in their own body’s ability to give birth,” she said.

Ms Hughes also welcomed proposals to shift the focus to midwife led care.

“I think if women are given the opportunity to get to know and trust their midwife and to trust their own bodies, we’re more likely to see women saying, ‘OK, this is what nature intended me for and this is what I’m going to do’,” …

Visit my website to explore birthing services

Private midwife at public hospital

Posted on September 29, 2011 by Melissa Maimann

Our local newspaper wrote an article about the model of care I am able to offer women:

THE owner of Essential Birth Consulting at Bexley, Melissa Maimann, 33, has become the first private midwife in Sydney to be accredited to deliver babies in a public hospital.

She said this was exciting news for expectant mums who want a personalised delivery but might be experiencing a high-risk pregnancy.

Ms Maimann said her model of care was unique in Australia because it included access to a back-up obstetrician.

“I am able to support women with risk-associated pregnancies because obstetric care is available,” she said. “This is a real benefit to women as often those with high-risk pregnancies are limited to obstetric care with little, if any, midwifery input.”

Ms Maimann, who established Essential Birth Consulting five years ago, has helped deliver about 76 babies.

She was profiled in the Leader last December for becoming the first private midwife in St George to receive accreditation to provide Medicare-funded private midwifery services. This has equated to savings of about $2500 a client.

Ms Maimann limits bookings to an average of two births each month to ensure a high quality service for families. She supports natural births, including water birth, and vaginal birth after caesarean, vaginal twin and vaginal breech births.

“We know that continuity of care is the single most important factor for women in the pregnancy and birth care and I am proud to offer it,” she said.

“Women may have care conveniently in their home or in my Bexley clinic.”

There were 295,700 registered births in Australia in 2009, Australian Bureau of Statistics figures showed.

Details: 0400 418 448 or essentialbirthconsulting.com.au

China cuts childbirth mortality rate by promoting hospital births

Posted on September 23, 2011 by Melissa Maimann

link

China has slashed the death rate of newborn babies by almost two-thirds in 12 years by promoting hospital births …

Deaths fell from 24.7 per 1,000 live births in 1996 to 9.3 in 2008. Only half of women gave birth in hospital at the start of that period, whereas by the end almost all did so outside the most deprived rural areas.

… “It’s a combination of strengthening facilities, training providers, equipping them with the skills and drugs to offer better care – and, through insurance, encouraging families to give birth in hospitals.

There was still some disparity, with babies in poorer areas four times as likely to die as in wealthier urban areas – apparently reflecting poorer quality services in township hospitals.

“In urban China, babies born in hospital have a very low newborn mortality rate of 5 per 1,000, almost that of the UK, which is 3 to 4 per 1,000,” …

… It is also on course to reduce the maternal mortality ratio by three-quarters …

… the figure [maternal mortality] had fallen from 34.2 per 100,000 to 30 out of 100,000 last year …

Visit my website to explore birthing services.

Is caesarean now the ‘normal’ way to give birth, and should we be worried?

Posted on September 13, 2011 by Melissa Maimann

Link

There’s no doubt that caesarean sections are an essential procedure that can save the lives of women and babies. But around one in three Australian women will give birth by caesarean section – and that’s not just to save lives.

… The rising caesarean section rate in most of the developed world has not resulted in reduced rates of stillbirth or infant death – quite the contrary.

One Australian study showed that babies were more likely to be admitted to a neonatal intensive care unit if they were born by elective caesarean section than other types of delivery. A previous caesarean section also increases the risk of stillbirth.

In terms of outcomes for women, those who have emergency and elective cesarean sections are less likely to exclusively breastfeed. And there is growing evidence that caesarean operations increase the risk of the mother dying or becoming ill with blood loss, blood clots, abdominal organ injury and the need for a hysterectomy.

It’s important to consider the risks of caesarean births. But rather than just focus on the polarised “vaginal birth vs caesarean birth” debate – which pitches doctors against midwives, and doesn’t help women who are stuck in the middle – we need to focus on the ways we can support all women to have the best outcome from childbirth.

It seems that one of the driving forces behind the rising caesarean section rate is fear … about labour and birth, and from doctors and midwives who are themselves fearful of the birthing process.

… we should be examining why women are fearful of labour and birth and what our health system can do to reduce this fear.

Our health system is generally an unfriendly one for pregnant women and it’s likely that this compounds the fear of birth. It’s common for a pregnant woman receiving care in the public system to see up to 30 different caregivers through pregnancy, labour and birth and the postnatal period.

The opportunity for pregnant women to develop a meaningful relationship with her health care provider, discuss her fears, affirm her needs and develop confidence in labour and birth are minimal.

… One of the disturbing elements of birth in the 21st century is the lack of respect for privacy for labouring women. The entourage of people appearing uninvited into labour rooms in most hospitals is astonishing. Each labour and birth can have a multitude of spectators, including a midwife, obstetrician, registrar, resident, student midwife, medical student and on it goes.

… To address this problem and encourage Australian women to give birth normally, … In NSW, the Towards Normal Birth Policy was released last year and provides 10 steps towards supporting more women to go into labour and ultimately have a normal birth.

The policy recognises that ”… unnecessary interference in the natural process may disturb the expected course and may lead to a cascade of intervention.”

The challenge is to redesign the health system to facilitate women’s confidence and trust in birth. Fundamental changes need to occur to ensure all women are supported during pregnancy and feel confident in their ability to give birth, including:

Continuity of caregiver;

Increased options for the style of birth, with access to a birthing pool;

A positive environment, free of disruptions; and

One-to-one midwifery care in labour so women are never left alone or fearful.

Visit my website to explore birthing services.

I’m pregnant. Who should I go to for care? A Midwife or an Obstetrician?

Posted on September 9, 2011 by Melissa Maimann

Private Midwife:

Provides autonomous pregnancy, birth and postnatal care for women who are experiencing normal, healthy pregnancies

Provides care in consultation with an obstetrician when a woman’s pregnancy has risk factors (eg high blood pressure, prem labour, concern for baby’s growth, gestational diabetes etc)

Transfers responsibility for care to an obstetrician if complications emerge and continues to provide care within the midwifery scope of practice

Supports women to birth normally with a high rate of natural birth

Supports women to breastfeed

Provides pregnancy, birth and postnatal care

Pregnancy appointments allow time for questions, education and discussion with appointments typically 45-60 minutes in duration

Women are highly likely to report satisfaction with their care and experience

Private Obstetrician:

Provides autonomous care for women regardless of risk factors

Receives referrals from midwives for women with risk-associated pregnancies or births

Always provides labour and birth care (including caesarean) in collaboration with a midwife

Obstetric care on average results in a high degree of intervention such as induction, epidural, caesarean and episiotomy

Provides brief in-hospital consultations after the baby is born, followed by a 6-week check

Pregnancy appointments are generally no more than 15 minutes in duration

Collaborative care: private midwife and private obstetrician

Receive autonomous pregnancy, birth and postnatal care from one midwife and one obstetrician regardless of risk factors

No transfer of care if risk factors emerge

Supports women to birth normally with a high rate of natural birth

Supports women to breastfeed

Provides pregnancy, birth and postnatal care

Pregnancy appointments allow time for questions, education and discussion with appointments typically 45-60 minutes in duration

Women are highly likely to report satisfaction with their care and experience

Provides autonomous care for women regardless of risk factors

Supports women to birth naturally, including with twins, a breech baby or a VBAC

Visit my website to explore birthing services.

Mum sent home in taxi four hours after birth

Posted on September 8, 2011 by Melissa Maimann

Link

ON Monday night, Casey Benger gave birth to a beautiful little boy at … Hospital.

Four hours later they were on their way home.

The taxi driver who collected the mum and her new baby was outraged that she would be released in the middle of the night so soon after giving birth, but the hospital says it’s normal practice.

… under the community midwifery program, if a mother has given birth before, if it was a vaginal birth, and the delivery was uncomplicated, the mother and baby can go home four hours after the delivery.

… “I was a bit shocked at first and asked if it would be better to stay …”

“The staff are under a lot of pressure up there. They were very busy with people coming and going …

This is the experience for many women birthing in the public system where resources are stretched. Women can expect to be discharged home between 4 and 48 hours following birth, with some follow-up at home.

Visit my website to explore birthing services.

Cascade of intervention

Posted on September 1, 2011 by Melissa Maimann

In the study, 44 percent women had their labour induced, and 20% of those inductions failed (ie, labour did not start) and caesareans were performed in those cases.

he study does point to the issue that inductions should not be performed unless they are genuinely necessary. Up to 50% inductions may not be “indicated”, that is, performed for a medical reason. They might be performed more for convenience, for example. However, if we limit inductions to those which really need to be done, we would lower the caesarean rate.

There are some reasons when an induction might be a good idea, such as when the woman’s blood pressure is high, if the pregnancy goes to 42 weeks, if the waters have broken for many hours and labour has not started, if there are concerns for the baby and so on.

Visit my website to explore birthing services.

Hospital births continuing through our service

Posted on August 29, 2011 by Melissa Maimann

Given the troubled times for midwives attending hospitals in a birth support role – either for planned hospital birth or in a homebirth transfer situation – I have had many calls from current clients and women who are exploring their birthing options, asking if hospital births are still going ahead through this service. I wanted to provide reassurance that yes, my hospital birth service is continuing! I am continuing to take bookings for hospital birth and I am able to attend hospital births in the full capacity of a midwife.

Owing to an ongoing collaborative agreement and hospital arrangements, hospital births are continuing. Women book with me early in their pregnancy and have all of their care with me. Women also see an obstetrician twice in their pregnancy. Birthing takes place in a hospital setting complete with waterbirthing. We support VBAC, twin and breech births. It is an all-risk model too, so women don’t need to be “low risk” to benefit from continuity of midwifery and obstetric care. It also means that there is no “transfer” if a woman’s pregnancy becomes high risk: she can still receive the same wonderful care and support from her chosen midwife and obstetrician.

Hospital staff are not routinely involved in the care of women who book through our service and we have gone to great lengths to create a birth centre feel to the birthing rooms. Rooms are quiet, warm and peaceful and we have a variety of tools available to support natural, active birthing such as floor mats, bath, shower and birth balls and of course many women also choose to bring personal items from home.

After the baby is born, we support early discharge with many women choosing to go home four hours after the birth. Of course women may stay longer if they wish. I visit daily for the first week, twice in the second week and then weekly until discharge at 6 weeks.

Should there be any issues along the way, we have ready access to a specialist obstetrician who is known to the woman from pregnancy.

So the short answer is YES! I am able to continue to attend hospital births and am receiving many calls about the popular model of care.

Visit my website to explore birthing services.

Well-off mothers spend thousands on private midwives

Posted on August 16, 2011 by Melissa Maimann

An article
from the UK explains that women are spending thousands of pounds on private midwives to achieve the ‘perfect’ birth. The situation is not too different to the Australian experience.

In the UK, private midwives charge between £1,800 and £5,000 for a birth, but their services are in high demand from professional, well-educated women who have become disenchanted with the hospital experience. The number of mothers paying for private midwives to attend home births has tripled in the last eight years.

Demand has become so high in parts of London and the South East that some expectant mothers have been unable to find a private midwife to assist them.

Many of the expectant mothers are older and have been put off by previous experiences in NHS maternity wards.

Women who engage private midwives claim they can form a relationship with one person rather than seeing a succession of strangers.

Midwives understand that women want continuity of care and someone to talk to them and answer their questions. Women don’t want routine and unnecessary interventions in their pregnancy and birth, and they want more extensive postnatal care.

The Australian experience is the same as that in the UK. Women seek private midwifery care for home birth or hospital birth so that they can form a relationship with one person who will be with them from their first antenatal appointment, through to birth and 6 weeks after their baby is born.

In Australia, eligible midwives can provide medicare-funded care which makes private midwifery care more affordable to women, thanks to the maternity reforms.

Visit my website to explore homebirth and hospital birth.

Caesarean section? Vaginal birth? Your choice!

Posted on August 15, 2011 by Melissa Maimann

Visit my website to explore homebirth and hospital birth.

Much has been said and written about an article in The Age this weekend. The article is about a randomised study that will compare the outcomes of 500 women who choose a caesarean and 500 women who choose a vaginal birth. The study will explore psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates. It will only compare vaginal births with caesareans for healthy women with uncomplicated pregnancies.

The study has created much debate, including issues of ethics (beneficence, autonomy, non-maleficence) and professional duty of care. I wonder if part of the “answer” will not be answered by this study, since the study only addresses outcomes from the first pregnancy, but most women do not have one child, they have two, on average. It’s reasonable to assume that a woman who has an elective caesarean for her first baby, will go onto have an elective caesarean for her second baby.

In the current maternity system in NSW, a woman who chooses a vaginal birth for her first baby has the following outcomes:

only 52% women having their first baby will have a normal birth

33% will be induced

23% will have forceps or vacuum

25% will have a caesarean – and of these women, only 12% will have a vaginal birth in their subsequent pregnancy.

In other words, only 75% of first time mums who elect to have a vaginal birth will actually have one.

In contrast, a first time Mum who chooses a vaginal birth with a private midwife has about a 95% chance of having a vaginal birth.

The real question isn’t the outcomes of a first-time Mum’s pregnancy when she chooses a vaginal birth or a caesarean, but rather, what happens for the average woman who has two children, who has elected a caesarean with her first versus a vaginal birth with her first baby. In other words, how about we compare the outcomes of women who have two caesareans, with women who elect to have a vaginal birth the first time around, 75% of whom will birth vaginally, and 25% of whom will have a caesarean.

Such a study would address the issue of second caesarean risks. Serious maternal morbidity (eg placenta praevia, placenta accreta, uterine rupture, need for hysterectomy and blood transfusion) increases progressively with increasing number of cesarean sections a woman has. The first caesarean is generally very safe but increasing numbers of caesareans are perhaps not so safe.

A further issue with the study is that it does not suggest any method or support for the women who elect to birth vaginally. Will they be supported with one-to-one midwifery care, as this is known to increase vaginal birth rates? Will they include homebirthing women who are highly motivated to birth normally and without interventions? Or will it be standard obstetric / hospital-based births with high rates of intervention that are already known to result in reduced breastfeeding rates and a dissatisfaction with the birthing experience? I will wait to read the results.

Dutch abandon home birth

Posted on August 7, 2011 by Melissa Maimann

A recent article informs us that:

RISK OF DEATH INDUCES DUTCH WOMEN TO ABANDON HOME BIRTHS

It goes on to say that in the last 10 years, the percentage of Dutch women who are giving birth in hospitals has risen from 37% to 75%. They state that reasons for this include:

concern at the disproportionally high baby death rate in home birth

the rising popularity of epidurals, a pain relief option in labour which is only available in hospitals.

The Dutch system of home births has been promoted as one which other countries should emulate, including New Zealand. However, last year a large study found that the perinatal death rate was greater in low risk women who were cared for by midwives than in higher risk women who were cared for by obstetricians. The researchers concluded that the Dutch system of risk selection is not as effective as was once thought.

I have read the study that has been referred to above. The study concludes that:

The main finding of this study is that the Dutch obstetric system that is based on risk selection and obstetric care at two levels may not be as effective as was once thought. The Dutch obstetric system itself possibly contributes to the high perinatal mortality compared with most European countries. We found that delivery-related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care.

The Dutch system relies on a risk assessment. Women are either in primary care or secondary care. Women who are in primary care have midwifery care and they have the option of home birth or hospital birth. The Netherlands currently has a 22% homebirth rate. Women with risk-associated pregnancies have obstetric (secondary) care and give birth in hospital. They might have issues such as high blood pressure, diabetes, twins, a previous caesarean and so on. Overall, 49.5% women remain in primary care at the start oaf labour, and 35% women remain in primary care throughout labour and birth. 65% women either start their pregnancy in secondary care or are transferred to secondary care at some stage in their pregnancy or labour. It is a system that has worked well for many years.

However, the study has found that the intrapartum (labour and birth) death rate among term babies without congenital malformations (birth defects) was as follows:

For babies who started labour in primary (midwifery) care: 0.96/1000

For babies who started labour in secondary (obstetric) care: 0.24/1000

For births that took place in primary care: 0.91/1000

For births that took place in secondary care: 0.45/1000

For births that were referred from primary care to secondary care in labour: 1.09/1000

Babies of women who were referred from a midwife to an obstetrician during labour had a 3.66 times higher risk of delivery-related perinatal death than did infants of women who started labour supervised by an obstetrician.

The study concludes that:

The obstetric care system in the Netherlands may contribute to the high perinatal mortality

and:

the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought.

I suggest that there is another major issue involved that has been ignored in the above suggestion. In the Netherlands, midwives book 105 women per year. You read that correctly. While in Australia, midwives care for around 20-40 women per year, in the Netherlands it’s a huge caseload of 105 women per year. Therefore it is impossible for the midwife to personally attend every labour for the duration. Instead, there is a system in place where the women are cared for by a Kraamverzorgenden who stays with the woman during labour and for the first week after the baby is born. This person does not perform any midwifery care but provides support to the woman. The midwife pops in and out every two or four hours to examine the woman and perhaps listen to the baby’s heart beat – I say “perhaps” because there is no official guideline in The Netherlands that this ought to be attended at any specified interval. Hence the midwives check the baby’s heart beat as and when they choose. Acknowledging that the midwife does not sit with each women in labour, it’s plausible that the baby’s heart beat would only be checked every two or four hours. The standard of care for the UK and Australia is that the baby’s heart beat should be checked every 15 minutes in labour and after every contraction in the second stage of labour when the baby is being born. This is identified in the article:

Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes … diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours.

I am interested in why this fundamental issue has not been addressed; rather, a complete review of a system that is in place in other countries – successfully – has been called for?

Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.

Homebirth Position Statement

Posted on August 6, 2011 by Melissa Maimann

The Australian College of Midwives (ACM) is Australia’s professional body for midwives. Recently, ACM was charged with the task of preparing a position statement on home birth. This position statement will have a great impact on the future of home birth services in Australia, so it is of enormous significance to home birthing women and their midwives. As well as a position statement, ACM has developed a Guidance which clarifies the expectations for private midwives when providing midwifery care for a planned homebirth.

The documents are:
Literature Review
Homebirth position statement
Guidance for private midwives attending homebirths

Probably the best way to read these documents is to start with the literature review because it provides the context for the guidance and position statement.

ACM’s literature review was restricted to studies which met all of the following criteria:

Studies of planned homebirths with a registered provider/s, compared with planned hospital birth

Research articles that also addressed maternal and neonatal outcomes

Articles from developed countries, written in English and with a publication date between 1995 and 2011.

Any articles that did not describe studies which included a comparison group, investigate planned homebirths or relate to maternal and/or neonatal outcomes were excluded. This rigorous process identified eleven studies which formed the basis of the literature review. The review covered 352,655 homebirths from Australia and around the world.

In general terms, the studies say that for a low-risk, healthy woman and baby, midwife-attended home birth does not increase the chance of the baby dying or being harmed. Home birth does, however, increase the chance that the woman will have a drug-free, intervention-free birth: that her labour will most likely start on its own, progress normally and lead to a normal birth with little likelihood of needing any stitches. Also, she is far more likely to breastfeed and to experience her birth as very positive and satisfying. This is important because it is well-known that interventions carry risks and that there can be a cascade effect, so that when you begin with one intervention, you often end up doing more interventions as the labour progresses (eg induction leading to long labour, leading to epidural, leading to forceps delivery). This is all minimised in the group of women and babies who birth at home with a qualified midwife who has a link in to the hospital with ready access to obstetric and paediatric care if needed.

However, a small number of studies demonstrated that home birth increases the rate of perinatal mortality. The research suggests that the inclusion of high risk factors in home birth, increases the chance of a baby dying or being seriously harmed during birth (most commonly through low levels of oxygen). Other issues may relate to the time and distance to travel from home to hospital during labour if transfer is needed, as well as the woman’s acceptance or refusal of recommended interventions once she has transferred. It is important to note that the outcomes of women and their babies who transfer to hospital during labour will generally compare unfavourably with those not transferred due to the change in risk status of the women.

The ACM concludes that, “It seems evident from the literature that planned home birth is a safe option for women who are at low risk of complications and who receive care from qualified attendants with adequate access to support, advice, referral and transfer mechanisms.”

With that conclusion in mind, the ACM has developed a position statement on home birth, and following on from that, guidance for private midwives who attend home births. Much discussion has been had about these documents on various forums and email lists. Some excerpts from the position statement and guidance follow:

It is the position of the Australian College of Midwives that home is an appropriate place of birth for women considered to be at low obstetric risk, and that women must be supported in safe, planned homebirth, by midwives and/or other appropriately qualified and regulated health professionals with adequate access to support, advice, and referral and transfer mechanisms.

Some women may choose a planned homebirth even when this is not recommended by her care providers. In such circumstances, a midwife should, after discussions with each woman and in consultation with other health professionals, work with the woman looking for options and resolutions within midwifery professional standards to address the woman’s needs.

Following documented discussions and appropriate consultation and referral as may be indicated, a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies.

Midwives have a duty of care to each woman they provide care to, and this means that in labour, or urgent situations, a midwife must attend the woman.

In the absence of a consistent definition of ‘low obstetric risk’, low obstetric risk is considered to be a pregnancy, labour and birth that are anticipated to be problem free.

There are some contraindications to a planned homebirth which women should be informed of at booking. These are;
• Multiple pregnancy
• Abnormal presentation (including breech presentation)
• Preterm labour prior to 37 completed weeks of pregnancy
• Post term pregnancy of more than 42 completed weeks
• Scarred uterus

Issues identified as “B” or “C” in the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (“the Guidelines”) would require consultation with an Obstetrician prior to proceeding with a planned homebirth. Consultation is mandatory for the midwife providing care.

Women must be made aware of the midwife’s obligation to consult at – or prior to – booking-in.

Ideally, midwives should meet the criteria for gaining notation as an Eligible Midwife.

Midwives must ensure that they have documented processes in place for consultation and referral

Any decision to provide care for a planned homebirth should take into account the possibility of transfer to a hospital and the time needed for transfer to that hospital in the event that this is deemed necessary. Women should be counselled on the possibility of transfer, and midwives should ensure that the supporting hospital is provided with a care plan/documentation around the woman’s intention for a planned homebirth.

Midwives must utilise documented evidence-based guidelines to support antenatal, intrapartum and postnatal midwifery care.

Midwives should undergo a formal professional peer review process at least once every three years.

At – or prior to – booking, the midwife must advise the woman of situations where homebirth cannot be supported. At any time, the midwife is not obliged to participate in a homebirth that the midwife considers will increase the risk of harm to the woman or her baby.

Women must be respected in the choices that they make, and that includes choices to refuse a recommended course of action at any stage of her pregnancy,

An information pack should be made available to women that should include a ‘Terms of Care’ document outlining the terms under which midwifery care will be provided.
Information should also include the potential for transfer to hospital for unforseen complications.
The following information must be provided to women at the onset of their care, ideally in writing, followed up in discussion and signed by the woman:
• Midwifery scope of practice, including the Australian College of Midwives Guidelines for Consultation and Referral;
• Philosophy of care;
• Choice of birth setting, including requirements for homebirth;
• Contact information for the midwife;
• Back-up arrangements;
• Standards of practice and protocols, including consultation and referral
• Responsibilities of the woman;
• Confidentiality and access to the woman’s records (privacy agreement); and
• Financial arrangements

It’s fair to say that ACM’s position statement and guidance are not ideologically- or belief-driven. It’s clear that the documents are driven by evidence. ACM has tackled the conflicting issue of the woman’s negative right to autonomy versus the midwife’s responsibility to practice safely and within accepted standards of care. While much is being said on various forums, email lists and face-to-face about these documents, somehow, I can’t help but wonder if the issue is really about the restriction of home birth to low-risk women, or the fact that at this point in time, a woman and private midwife have no option but to birth at home.

In the whole of Australia, there is currently no clinical privileging except in one small hospital. A high risk woman’s only option via this new position statement is to birth in hospital, however her private midwife would not be able to attend in the full capacity of midwife – or even as a support midwife: it has recently come to our attention that the midwife cannot legally attend in hospital at all.

I’ll explain why: the MIGA insurance policy covers privately-admitted patients. If the woman is admitted as a public patient after being transferred from a home birth (either in pregnancy or during labour), MIGA insurance does not provide indemnity cover to the midwife in respect of the birth. Most women planning a home birth will have a back-up hospital booking as a public patient. Hence, when the midwife goes in with the woman, the midwife’s insurance does not cover her. It is against the requirements of registration to work without insurance, except at a home birth. In other words, the midwife would be attending the woman in hospital against the requirements of registration.

In time (hopefully sooner rather than later), midwives will have admitting rights where we can admit, care for and discharge our own private patients, all funded by Medicare and indemnified by MIGA but in the meantime, this is not possible.

Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.

Doctor backs call for reform of maternity care in Greater Manchester

Posted on July 22, 2011 by Melissa Maimann

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A top Greater Manchester doctor has backed a national call for reform of maternity care.

Dr Michael Maresh, clinical lead for the Greater Manchester Maternity Network, spoke out after a major report recommended a reorganisation of services.

The Royal College of Obstetrics and Gynaecology called for more midwifery-led units to be set up so women with low-risk pregnancies could be in the sole care of midwives.

It also calls for the number of consultant units be reduced so that senior clinicians are available around the clock.

… “The fact is that there are too many maternity units which means senior doctors’ availability is spread too thinly – reorganisation to provide fewer, specialist units is the only sensible solution.

“… we are in the process of reducing the number of maternity units and ensuring that the new model of care concentrates the expertise of doctors and midwives on eight, better staffed and safer sites.

“By providing a co-located midwife led facility at each of the remaining units, we are able to offer improved choice to the majority of women who experience an uncomplicated birth.”

With good referral systems and collaboration, a model such as this would work very well. The majority of women are healthy and have normal pregnancies and births, if they are given the right support, information and care. The midwifery model of care is a safe and satisfying model of care for healthy women.

Expectant mothers need facts, not fear

Posted on July 21, 2011 by Melissa Maimann

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Here we go again. A debate about home vs hospital birth.

There is only one thing … that’s more emotive than where you give birth to a baby, and that is how you feed it.

This week, the Royal College of Obstetricians and Gynaecologists … proposed that more women give birth away from doctors and hospitals. I really want to see how this works, because if there’s anyone more scared of home births than the parents, it’s doctors and midwives. (Note: not all, I know.)

I’m not a doctor, nor a midwife. I have slightly more experience of pregnancy and birth than some, by virtue of being co-founder of a parenting website for the past seven years and working as a lay rep in a large maternity hospital for four. But really, my opinion, just like so many birthing women, counts for little.

Look at what this report says: “The model we are proposing focuses on the needs of the woman and her baby by providing the right care, at the right time, in the right place, provided by the right person and which enhances the woman’s experience.” Sound great, doesn’t it? But who will decide what the right care, at the right time, etc, is? Who listens to what a mother … wants?

Hospitals are so tied by NHS policy and guidelines, and are so scared of being sued that midwives who once were perfectly capable of delivering breech babies, big babies or twins at home (yes, it can be done) no longer can, or do. So it’s easier to book everyone into the hospital. What will change? How will it change? There aren’t enough midwives as it is.

When I decided to try for a home birth I had to take myself out of the NHS system (an option that may no longer exist soon because of the threat to our independent midwives, but that is another story, for another time) because the idea so terrified almost everyone I met. I was simply deemed too high-risk. But this wasn’t based on any analysis of my actual, individual risks. It was because I ticked two boxes: “over 40″ (this is still being cited as a reason not to have a home birth) and “previous C-section” (ditto). One of the paediatricians at the hospital where I was a lay rep told me I was being irresponsible, that my scar would tear (the risk of uterine rupture is, in fact, very small) and that I’d kill myself and my baby.

“Don’t expect us to attend to you” were her actual words. Amazingly, because I wasn’t on a dual suicide/infanticide mission, and I didn’t want to leave my firstborn motherless, I asked two separate, senior midwives to go through my previous notes with a fine-tooth comb. Conclusion: no reason at all not to try for a home birth if you want to …

For many … the thought of giving birth at home is terrifying. I toyed with the idea of a home birth with my first for about 10 minutes. It was only when I saw firsthand what hospitals could offer and after five years of researching birth that I was brave enough even to think about it for my second baby.

I’ll cut to the chase. I had my home birth without drugs or incident. Yes, it was fantastic. No, you shouldn’t have to have a home birth if you don’t want to, no more than I should have had to go to hospital if I didn’t want to. This brings me on to something that no report can ever address, and that’s the baggage we all – health professionals included – bring into maternity services: our own experiences. They should inform, but not dictate.

There is one bit of the report that I think is underplayed: … “Women themselves need the support and encouragement of society, including the professionals, to take responsibility for their own health”. Indeed, we all need to take responsibility for how babies are born. Women need to stop dramatising labour, especially to their daughters. (Maternal influence is huge on a daughter’s subsequent expectation of her own labour.) Health professionals need to stop lecturing a woman on how to give birth and start listening to what women want – and then provide consistent, accurate, non-emotive information to help her set the agenda.

We all need to stop projecting our own experiences and think that’s how it will/should be for everyone else. Only then can we hope to reverse this collective hysteria that surrounds giving birth. People who make TV programmes and films: I have a special message for you, because how you portray birth is so hugely influential. I know it makes for better TV to have a woman on her back, in a hospital, screaming and tearing off her husband’s earlobes, but please, counterbalance this with women also giving birth quietly, in a position other than prone and sometimes at home. It’s partly because of you that it took me nearly 40 years to realise that it could be done.

Two mothers given wrong babies to breastfeed

Posted on July 19, 2011 by Melissa Maimann

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TWO newborn babies have been mistakenly given to the wrong mothers who breastfed them at a Geelong hospital.

The babies spent more than eight hours with the wrong mothers …

… a family member alerted the hospital staff to the mix up

The incident may have occurred after the babies’ identification bracelets were not checked against those of the mothers …

This is always a possibility if women give birth in a hospital and are separated from their babies for any reason. Some suggestions:

If you are healthy and are having an normal pregnancy and anticipating a normal birth, give serious thought to birthing at home. Mothers and babies are never separated at a homebirth.

If you are birthing in hospital, accompany your baby wherever s/he goes – whether it is to the ward nursery to be bathed, to be examined, or anywhere else – if your baby is to leave your sight, get someone you know and trust to accompany your baby.

Melissa Maimann & Andrew Pesce: Collaborating for success

Posted on July 18, 2011 by Melissa Maimann

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ALTHOUGH only a handful of collaborative arrangements have been signed between obstetricians and midwives since national maternity reforms were introduced in November, calls for a policy rethink are premature and counterproductive.

In fact, the reforms provide an exciting opportunity for collaborative maternity care that is safe, locally responsive and woman-centred.

A variety of private maternity care models are possible and we are confident these will build on Australia’s strong record of safety and quality in maternity care. They will also meet the needs of women who want the familiarity and the comfort of knowing the obstetrician and midwife who will be with them through their pregnancy, birth and new parenting experience …

Obstetricians may be concerned that the new arrangements mean they will not be directly involved in patient care until something goes wrong, while some midwives fear that the arrangements will be used to control midwifery practice, adversely impact on childbirth choices and promote anticompetitive restriction of trade.

We believe we are the first private obstetrician-midwife team in Australia to have successfully negotiated a formal collaborative arrangement and we are very happy with how it has progressed since our first discussions.

The first woman under our joint care gave birth in March this year and we have several others booked through to January 2012.

We share a similar philosophical approach to maternity care and have agreed practice guidelines that we believe to be safe, evidence-based and woman-centred …

… Women appreciate the continuity of care, and the assurance that an obstetrician they have met will be involved if medical assistance is required. Feedback from women so far has been outstanding. The main criticism has been that this model of care is not available in other hospitals.

One of the reasons why there are currently so few collaborative arrangements has been the time taken by the Australian Health Practitioner Regulation Agency to endorse eligible midwives and by public maternity units to credential midwives in private practice.

… Our agreed guidelines are explained to patients before they engage our services and childbirth choices are not restricted. In fact, choices are enhanced as the midwife is able to attend births in the full capacity of a midwife in hospital.

Importantly, our model of care does not dictate “transfer” of care, merely a shift in the balance of obstetric and midwifery care because we recognise that every pregnant woman needs her own obstetrician and midwife. We support midwife care during waterbirth, vaginal birth after caesarean section, physiological birth positioning and physiological third stage.

Change is often difficult as we all tend to be creatures of habit. This change brings with it many opportunities for obstetricians and midwives in private practice to work together in ways that are beneficial to both and, importantly, to the women in their care.

… The maternity reforms will succeed if we remember that midwives and obstetricians are in it for the same reason — to provide safe care that meets the needs of our patients, within a respectful, professional environment.

Dr Andrew Pesce is an obstetrician practising in Sydney and immediate past president of the AMA. Ms Melissa Maimann is a midwife in private practice based in Sydney.

Home birth has pros and cons

Posted on July 15, 2011 by Melissa Maimann

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The number of at-home births is small but growing as pregnant women weigh the idea of a drug-free and surgery-free birth in a familiar setting versus the risk of harm to the baby in case of complications.

When most pregnant women go into labor, they pack their bags for the hospital. When Lara Carlos felt the contractions in November 2008, she set up a birthing tub in her bedroom.

For the next several hours, Carlos alternated between padding around her home and squatting and pushing in the tub. Her midwife poured water down her back and dabbed her forehead with cold towels. When the baby (they chose the name Vincent) arrived at 1:21 a.m., he spent his first few hours cuddling with his parents in their bed.

Carlos … is one of a small but growing number of women who are choosing to deliver their babies at home. Her first son, Ivan, had been delivered in a hospital, and she says she found labor at home a dramatic improvement.

“In the hospital, there were seven medical students in the room when I was pushing my son out,” she said. “At home, it was a very quiet, slow experience, and the water helped me to relax.”

Though home births account for only about 1% of all births each year … they increased by 20% from 2004 to 2008 … The practice is most popular among well-educated mothers who favor natural childbirth without the drugs or surgeries a hospital might use.

… The increase has reenergized the fierce debate over the safety of at-home delivery. The practice is officially frowned on by the American College of Obstetricians and Gynecologists … because the absence of emergency medical equipment and specialists accustomed to dealing with complications means that problems during labor could cost the baby’s life.

“All the existing scientific evidence, as well as state and national statistics, make it ultra-clear that home birth increases the risk of death,” …

The American College of Obstetricians and Gynecologists does acknowledge that home births are associated with fewer medical interventions than hospital births … 61% of women who had vaginal delivery received an epidural in 2008, the year the report studied. And a 2006 national survey of women’s childbearing experiences showed that 55% were given Pitocin to speed labor.

“There’s no doubt that once you end up in a hospital, you end up with more interventions — that’s what drives some families away,” … home birth is reasonable as long as women have few risk factors …, have an emergency backup plan and understand the risks involved.

Women also turn to home birth in order to avoid caesarean sections, which have become more common as obstetricians became increasingly reluctant to take chances at the slightest sign of fetal distress …

What’s more, many hospitals do not allow women who have previously had a caesarean to attempt a vaginal birth because of the risk of uterine rupture, even though a 2010 National Institutes of Health advisory panel concluded that the risk of uterine rupture during a vaginal birth after one caesarean was just 1% and that more women should be offered the choice. Women wishing to have a VBAC (vaginal birth after caesarean) may have no option but to do so on their own turf.

Sarah … had two caesareans but chose a home birth for her third pregnancy, successfully delivering a baby girl in January 2010.

“We had visited numerous hospitals, and the first time I mentioned a VBAC, I was just shut down completely,” Bolson says. Doctors refused to consider it because of the chance of rupture, she recalls, and one said he couldn’t risk having his medical malpractice insurance skyrocket.

She eventually found a certified professional midwife who was willing to help her deliver at home, with a backup plan of transfer to a nearby hospital. Though initially worried about complications, “after I was able to release the fear, I was free to birth without any inhibition.”

Many home-birth moms also say they object to other aspects of hospital births, such as having to lie in a bed, abstain from food during labor and be monitored by an army of nurses.

“I believe in the intuitive power of the human body,” said Mayim Bialik, an actress and natural-birth advocate who has given birth at home. “I believe in having as much privacy as possible, in being able to move freely, to eat when I want, drink when I want, and to be surrounded by the sounds and smells of what is familiar to me.”

“Other mammals go off on their own to labor,” adds Dr. Stuart Fischbein, a Los Angeles-based obstetrician who has been delivering exclusively in homes since 2010. “When a patient goes to a hospital, she gets told to lay flat on her back strapped down with monitors with constant interruptions from hospital personnel — does that sound conducive to having a normal labor?”

Arrangements for a home birth go something like this: Early in the pregnancy a woman finds either a … midwife … The midwife provides some or all of the woman’s prenatal care and is on call as the woman approaches her due date …

During labor, many women use water tubs because they find the water soothing and pain-relieving; others choose to just move about their homes as they see fit. The midwife monitors the fetus’ heart tones with a Doppler device, and most also bring equipment such as oxygen tanks, anti-hemmorhagic medication, local anesthetic and suturing supplies in case of tearing or bleeding. If an emergency arises that the midwife can’t manage, home-birth moms are advised to transfer immediately to a hospital.

The core of the home-birth debate lies with the safety of the baby — and here, opinions and the data are sharply divided. A 2005 study of 5,418 births in the U.S. and Canada during 2000 … found that the neonatal death rates of at-home births were comparable to those of births in hospitals.

But a July 2010 analysis published in the American Journal of Obstetrics & Gynecology examined the outcomes of 12 home-and-hospital-birth studies and found that babies born at home die at two to three times the rate of those born in hospitals …

… the distance to the nearest emergency room can sometimes mean the difference between life and death. “Saying, ‘trust birth’ is like saying ‘trust the weather,’” she says, referring to a slogan occasionally used in natural-birth groups.

Just as vocal online communities have sprung up to promote home birth, so too have others populated by women whose home-birth attempts turned into tragedies … Liz Paparella’s fourth child was stillborn on her living room couch because her midwife failed to take Paparella to the hospital when she began bleeding during labor.

“I never thought it was more dangerous to have a baby at home than at the hospital,” says Paparella, who had given birth successfully at home two times previously. “In birth, the risk can change from low to high in a matter of minutes.”

… A clear answer to the safety question is hard to find because nearly every home-birth study has some flaw that is flagged by one side of the debate or the other as invalidating the results. Given this uncertainty, Ouzounian cautions women to research, prepare and choose wisely.

Home births, he says, should be considered only by those who have a well-trained midwife and are experiencing no complications with their pregnancy …

“Under the right circumstances, with the right patient selection and with a … midwife attending, the overall maternal complication rates with home births are comparable” to those of a hospital birth …

But he also advises women not to think about birth in black-or-white terms: There are many ways to make delivery more “natural” even if it takes place in the hospital …

Fischbein says that doctors could be more accommodating to their patients by providing them with information about all of their birth options — at home and in the hospital — and stand ready to serve as backups for those who wish to labor at home with a midwife.

“There’s room in this world for low-risk home birthing and for hospital birthing,” he says. “We really should support each individual woman’s right to choose how to deliver her baby.”

Arizona hospitals taking stricter stance on scheduled births

Posted on July 2, 2011 by Melissa Maimann

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Arizona hospitals are taking a stricter stance on doctors and mothers who want to deliver babies before full term.

Banner Health is the latest to join a growing number of hospitals that are informing doctors and expectant mothers that they will no longer schedule deliveries before 39 weeks of pregnancy unless there is a medical reason to do so.

Hospitals are citing medical research that shows even the last few weeks of a full-term pregnancy are critical for a newborn’s development. Babies who are born at 39 or 40 weeks are more likely to have improved brain, lung and eye development as well as lower risk of death compared with babies born earlier.

The change marks a cultural shift for Phoenix-area obstetricians and expectant mothers who have grown accustomed to planning births due to schedules, convenience, family visits or other non-medical reasons.

… Banner Health will stop scheduling elective C-sections or inducing births for pre-term babies beginning July 18. Banner’s decision will impact 19 hospitals …

… convenience births represent 20 to 30 percent of all deliveries at some Valley hospitals.

… 42 percent of babies born … last year were delivered before 39 weeks. Those deliveries covered the spectrum of births, including medically necessary births and natural births that occurred before full term. It included elective C-sections or early inductions of labor, although hospital representatives said they did not have reliable data on the number of such early, elective births.

The rate of Caesarean births climbed steadily over the past decade … In Arizona, 26.2 percent of all births were by C-section in 2007, up from 16.1 percent in 1996 …

… [the] reaction has been mixed among doctors and patients. Some doctors have said they’ve successfully induced labor or performed C-sections before 39 weeks and saw no reason to change.

… doctors have become more receptive to the policy after they reviewed medical data and told their patients about the new hospital policies. It also has emboldened doctors pressured by patients who want to schedule a birth.

“They changed their culture and basically moved forward and informed patients this is policy now,” …

Banner Health cited nearly two dozen medical reasons that would prompt an early delivery. Some common medical reasons could include high blood pressure, kidney disease, pre-eclampsia or placenta previa, a condition in which the placenta is too close to the cervix.

Organizations such as the American Congress of Obstetricians and Gynecology, Joint Commission and March of Dimes have advocated that the medical community adhere to the 39-week standard.

… those final weeks can be critical for a newborn’s development. Full-term babies are less likely to have hearing, vision, feeding or birth-weight problems. Those final weeks of a pregnancy also give the lungs, eyes and brain enough time to fully develop.

Babies born early are more likely to spend time in a neonatal intensive-care unit …

Re-thinking Maternity Care Systems

Posted on June 19, 2011 by Melissa Maimann

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… fewer than 30 per cent of women approaching their first birth attend prenatal classes, and books and the Internet are their primary sources for information about birth.

Women attending obstetricians were more favourable to the use of birth technology and were less appreciative of women’s roles in their own delivery. In contrast, women attending midwives reported less favourable views toward the use of technology and were more supportive of the importance of women’s roles …

Even late in pregnancy, questions about epidural analgesia, Caesarean section and episiotomy solicited the most “I don’t know” responses from women who took the survey. But women attending midwives appeared more knowledgeable on these issues.

“Our findings suggest that obstetricians, midwives and family physicians are caring for different populations of women, with different attitudes and expectations towards childbirth,” … “But regardless of the type of care providers they attended … many women reported uncertainty about benefits and risks of common procedures used at childbirth. This is worrisome because a lack of knowledge affects their ability to engage in informed discussions with their caregivers.”

A second study, published last month in the journal Birth, compared the attitudes toward birth technology and women’s role in their childbirth between the younger generation of obstetricians and their predecessors.

Klein and colleagues surveyed 800 Canadian obstetricians who include birth delivery in their practice. Out of 549 respondents, 81 per cent of those 40 years or younger were women (vs. 40 per cent over 40 years of age) …

… younger obstetricians were significantly more likely to favour the use of routine epidural analgesia and were more concerned about the perceived adverse effects of vaginal birth …

… the younger generation sees Cesarean section as a solution to many labour and birth problems, and incorrectly sees C-section as safer for both mothers and babies … younger obstetricians are more likely to choose C-section for themselves or their partners, and are less likely to believe women missed out on an important experience by having a C-section.

… “This study shows it’s generation, not gender, that affects obstetricians’ views about procedures like C-sections,” … “this could present a challenge to efforts to decrease C-section rates in both U.S. and Canada.” As well … up to a third of obstetricians were not evidence-based in their views. This creates concern about informed decision-making, especially for women who are uncertain about procedures that might be used in birth.

… 75 per cent [of obstetricians] thought home birth was more dangerous than hospital birth … even though home birth by regulated midwives has been shown to be safe in Canada.

… “These three studies taken together show us that educational leaders and provincial policy-makers need to seriously examine the educational models and experiences that appear to teach the non-evidence-based view that vaginal childbirth is primarily a dangerous activity,” … ” … we need more midwives … while obstetricians in training will need to have more experience with normal birth, and in the future, restrict their role to that of consultants to midwives … In this way they can maximize the appropriateness of their surgical training.

“This means rethinking the design of the entire Canadian maternity care system. Finally, if women are to be empowered with the information that they need to dialogue with their providers, new forms of accurate information transfer will need to be developed.”

Is ‘tribal’ obstetric culture endangering mothers and babies?

Posted on June 15, 2011 by Melissa Maimann

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How we are born, who supports mothers and the quality of the care provided during birth are vital to good public health and personal well being. But all is not well in modern birthing in spite of the advances of modern medicine.

In the United Kingdom, health policies aim to keep childbirth normal or natural and dynamic …

In Australia, a national Review of Maternity Services (MSR) in 2009-10 generated heated public debate. It spawned critiques of the medical control of birth and the self-interest of privately practising obstetricians.

Its outcomes remain hotly contested, particularly over women’s access midwives and home birthing.

Much health policy now promotes strategies to improve quality and safety as being critical to good patient-centred care.

But the Maternity Services Review overlooked some problems in the culture of obstetrics.

… It is their philosophy and practices that have shaped the system of modern hospitalized childbirth care.

The obstetric profession … is accountable for making sure neither practitioners nor the systems of care cause harm to women and their babies.

… several public inquiries … showed that harm was not just being caused but was covered up.

… painful details of serious harm done by doctors to women in maternity units, including unnecessary hysterectomies, assault, and even genital mutilation.

… Most worrying were the common patterns of denial: stories of damage to women were mostly not reported by colleagues out of professional or “tribal” loyalty.

Until the cases became public, they were seen just as “mistakes” or medical “misdemeanours”, or as caused by individual “bad apples” in the profession.

Even many anaesthetists, pathologists and midwives colluded in keeping silent about women’s tragedies.

… Individual, institutional and systemic problems are interwoven. Viewing childbirth care as a field full of power though allows us also to see how it can be reformed.

Encouragingly, the public inquiries point to changing times: women as health care consumers used the press to agitate for these inquiries and have lobbied for wider reform.

Midwives have also been speaking up about problems in the system.

Some obstetricians, too, are committed to the reform of professional practice …

But we need to go even further.

Obstetric undergraduate and postgraduate education also needs reform. More critical reflection on the profession’s gendered and racialized power is necessary, and greater awareness of public health and social issues.

Professional bodies … should also be expected … to develop mechanisms for critical self-examination of attitudes toward women.

Similarly, doctors need to engage seriously with midwives’ concerns about policies pushing “inter-professional collaboration”.

Too often, these seem to be on medical terms and experienced as continued domination rather than an equal, respectful relationship.

High quality obstetric care remains essential for women with complex medical problems … It should be effectively supported by public funds but obstetricians are accountable for how they use them.

… “Birth is not an illness”. Quality and safety in maternity care should not be equated with providing obstetric care.

Women deserve real choice and autonomy in childbirth. Improving care requires more than good hospital incident-reporting systems and support for staff to report medical errors. These are valuable but not enough.

Cultural change in maternity care institutions and health professions, and in the broader society’s views of childbirth care, is essential if we are to keep mothers and babies safe from harm.

QLD: Mums-to-be pushed into caesareans with private hospitals leading the way

Posted on June 13, 2011 by Melissa Maimann

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SOME of the state’s biggest private hospitals are performing caesareans on more than half the women giving birth …

The caesarean rates among the highest in the country were uncovered in hospital birth statistics from 2007-2010 obtained by The Sunday Mail under Right to Information laws.

Queensland’s “caesars palace” was the North West Brisbane Private Hospital, which performed the surgery on 56.8 per cent of women giving birth. Toowoomba’s St Vincent’s Hospital and The Wesley Hospital in Brisbane rounded out the Top 3, with rates of 54.8 per cent and 51.8 per cent respectively.

The latest figures … will reignite the turf war between midwives, who espouse natural birth, and obstetricians who defend surgical intervention.

Caesarean births are recommended as safer options for women having large babies, twins or breech births, as well as older mums and women who have had previous caesareans.

Latest recommendations from Canada suggest that vaginal birth is safest for most breech babies. NSW Health promotes vaginal birth for twins and of course we know that vaginal birth after a caesarean is safer than elective repeat caesarean provided that the birth takes place in a facility that has resources available to perform an emergency caesarean if needed. And “big” babies? This cannot be known with any accuracy ahead of time and the current recommendation is for a planned vaginal birth.

But some critics say growing numbers of medical professionals are convincing mothers to undergo caesareans just to streamline private maternity ward schedules and maximise revenue.

Across the state the figures add weight to the theory, with caesareans accounting for 27.6 per cent of births in public hospitals and a huge 48.3 per cent in private hospitals.

We know that this difference is not comprised of women requesting caesareans: only 2-3% women actually request a caesarean. Most are told they “need” a caesarean because their baby is “big” (3.3Kg), “late” at 39 weeks and 6 days, a previous caesarean, breech, twins, IVF, mum is “overweight”, mildly elevated blood pressure (130/80) and so on. I have heard all of these and more, as “valid” reasons for caesarean.

Several new mothers approached by The Sunday Mail last week said they had been pushed into having caesareans by private hospital obstetricians after initially wanting to give birth naturally.

One Coolum mum, 45, said her obstetrician told her she had “no choice” because the baby would “not fit through my birthing canal”.

This can not be known ahead of time. The only way to find out is to labour and see how it goes. Dedicated, exclusive, one-to-one midwifery care in labour from a midwife who is know to the woman by name and trusted by the woman, is the most important factor in ensuring a normal birth.

… “I just wanted a natural birth, to me that was important …

I think personal responsibility also plays a part here. If a woman genuinely wants a natural birth, she needs to consider which care provider will maximise her chances of achieving this. Consumers of any service are wise to research options thoroughly before they go ahead with them. We do more research about buying a car, house or holiday than we do when choosing our care providers. Having chosen an ill-suited care provider, it is never too late to change.

Another mum … desperate to avoid a caesarean, said her obstetrician also tried to book an induction because she had passed her due date in the Christmas-New Year period.

“The obstetrician said we can book you in for an induction because we just don’t like calling people in on public holidays,” …

But doctors point the finger at today’s “too posh to push” mothers, who they say demand caesars, as well as older mothers who have an added risk with vaginal births.

Australian College of Midwives spokeswoman Professor Jenny Gamble said the health system was driven by profit.

“It’s all about less night disturbance and more throughput; it all comes down to money,” she said. “It’s a fee-for-service model the more women obstetricians see, the more they earn.”

Australian Medical Association Queensland president Dr Gino Pecoraro rejected as “urban myth” claims that obstetricians earned more for caesarean births.

Private Hospitals Association Queensland said birthing decisions were not made by the hospital.

This is true: hospitals do not make any decisions about birth: those decisions are made by the doctor and patient. As we have read in this article, many of the decisions are “guided” by the doctor. The other factor in these escalating caesarean rates is litigation. When caesarean rates increase and doctors are reluctant to attend VBACs, the caesarean rate will automatically increase.

Not all doctors have high caesarean rates and some are very supportive of normal birth BUT … if a woman genuinely wants a normal birth, the best advice is to go a normal birth specialist.

Doctors admit C-section error in tragic baby’s botched birth

Posted on June 8, 2011 by Melissa Maimann

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TWO consultants have admitted to the parents of a baby deprived of oxygen at birth they should have performed a caesarean section earlier.

Baby Senan Michael Christopher Dodd was born at Mount Carmel Hospital, Dublin, on March 28, 2008.

There was a delay in performing the emergency birth procedure and the baby boy suffered severe brain damage due to oxygen deprivation …

He died … on March 30, 2008.

Two consultants obstetricians … acknowledged … the caesarean section should have been performed earlier.

Dr Rafferty said he contributed to the delay in delivering the baby and expressed his “profound apologies” to the baby’s parents …

[The] Midwife … told the court she called Dr Rafferty to review Roberta … due to lack of progress of labour, following an hour of active pushing.

The doctor said he gave the parents the option of a caesarean section or of an epidural with syntocinon …

Syntocinon and an epidural were administered.

But the doctor failed to look back at the trace of the foetal heartbeat, which indicated a slow heart rate at 2.45pm and another slow rate after pushing began.

… He told the inquest he should have, “been more direct and said a C-section was the way to go”.

He agreed with counsel for the family, Bruce Antoniotti, that he did not tell the Dodds there was foetal distress because he failed to perceive it, as he failed to look back far enough on the trace.

The baby’s heart rate was monitored intermittently …

This is the standard of care for women in normal labour with a healthy pregnancy and baby.

Dr Valerie Donnelly, who took over from Dr Rafferty, reviewed Mrs Dodd around 6.20pm after a prolonged period of slow foetal heart rate.

Dr Donnelly proceeded as planned and recommenced the syntocinon although it had been turned off by the midwife, who was preparing for a C-section.

“I regret I did not deliver the baby by C-section at that point. I believe my delay in making the decision to deliver him by caesarean section has contributed to his death,” …

May 2013
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