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postnatal depression

Antenatal depression

Jan 28th, 2012
by Melissa Maimann.
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There’s a lot that is said and written about postnatal depression, that is, depression after a baby is born, but not a lot is said or written about antenatal depression.

Some women will experience anxiety and depression in the months leading up to the birth of their baby, and this can stem from many areas.

Financial concerns, concerns about relationship changes, fearful of how motherhood might change your life, relationship or job, changes in lifestyle, and so on can all create the perfect environment for antenatal depression to arise. It is thought that as many as 10% of women will experience antenatal depression. Of course, this is only the number of women who are actually diagnosed, and many more will go undiagnosed.

Most care providers will screen women for signs of depression in pregnancy with a simple questionnaire that can even be self-administered. This enables midwives and obstetricians to intervene in the pregnancy so that the woman feels more supported and less depressed. This approach also helps reduce the incidence of postnatal depression. It’s known that women who are depressed in pregnancy often experience postnatal depression.

If you have antenatal depression, you might experience:
fatigue
mood swings
irritability
difficulty concentrating
difficulty falling asleep, or waking early
loss of appetite

Some women are more susceptible to depression, perhaps having a history of depression even before pregnancy. A general lack of support is also a trigger for depression in pregnancy.

The trouble with leaving antenatal depression undiagnosed is that it often matures into postnatal depression, but often in a worse form that what was experienced in pregnancy, and this can be harmful for the woman, her baby and family.

If you are feeling depressed in your pregnancy, the best thing would be to speak with your midwife or obstetrician about how you are feeling. They can refer you to a specialised program for pregnant women, or refer you privately to a psychologist.

Visit my website to learn more about my services.

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

Jan 18th, 2012
by Melissa Maimann.
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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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Rates of C-sections and postpartum posttraumatic stress disorder on the rise

Dec 1st, 2011
by Melissa Maimann.
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The birth of Helen Dunn’s first son didn’t go nearly as smoothly as she had envisioned. Induced two weeks early because of concerns about the baby’s health, the Vancouver clinical counsellor endured 17 hours of painful contractions before her baby went into distress … She had an emergency caesarean section, the whole experience proving to be a traumatic one with terrible, lasting effects.

“I immediately felt disconnected from him when they showed him to me,” … “I didn’t recognize him. I wasn’t attached to him; in fact, I had an aversion to him. I wanted them to take him away, which is hard to admit. After that it was very difficult for me, it was a long process of panic attacks, which I’ve never experienced before, and full-blown agoraphobia.

“I didn’t want to tell people how I felt; I felt a tremendous amount of shame about how I felt toward my child, the difficulty I was having bonding with him,” she adds. “I was diagnosed with postpartum depression, but I had no idea about postpartum posttraumatic stress disorder.”

Looking back now, she can see that those panic attacks were among the condition’s telltale signs … PTSD after childbirth is characterized by two key elements: experiencing or witnessing an event involving actual or threatened danger to oneself or others and a response of intense fear, helplessness, or horror. Symptoms include obsessive thoughts about the birth; feelings of numbness, detachment, or panic; disturbing memories of the birth experience; nightmares; flashbacks; and sadness, fearfulness, anxiety, or irritability.

… the reported prevalence of postpartum PTSD ranges from 1.5 percent to 6 percent …

Dunn was even more struck by the effects of her traumatic birth following the delivery of her second son six years later. She laboured for 17 hours again, but this time delivered vaginally with the assistance of a midwife in hospital and went home soon after.

“I didn’t have any problems,” Dunn says. “He immediately looked familiar to me — he looked like my sister — I felt bonded to him, attached to him.” The stark differences between her two childbirth experiences prompted her to explore other women’s feelings of attachment to their newborns among those who delivered via emergency C-section as well as vaginally in her Master’s thesis. Now she wants to raise awareness among health professionals and the public alike of two pressing issues: postpartum PTSD—in particular signs, early intervention, and effects on maternal-infant attachment—and the high rates of C-sections in this country.

Although C-sections clearly play a vital role in maternal health and can be life-saving, about 26 percent of deliveries in Canada take place this way, which is nearly double the rate recommended by the World Health Organization.

Then there is the way postpartum PTSD is so widely misunderstood and overlooked, in Dunn’s view.

“When I did reach out for help, people would say, ‘You’ve got a healthy baby; what do you have to complain about?’ or ‘This was so long ago; why is it still bothering you?’

… “When someone says, ‘I don’t want to see my child… I really wish someone would have said to me at that point, ‘Can we help you?’ When I told a nurse I was feeling strange, having panic attacks, she said it was because of the medication. Even one gesture of support or kindness from somebody on the front lines can go a long way to help a woman gain a sense of control of what’s happening to her. I think it could have been handled a lot better in my case. I think I would have benefitted from more support had there been more knowledge around it.”

Maternal-health expert Michael Klein … says that … women who have emergency C-sections without adequate support or communication from their caregivers suffer from posttraumatic stress disorder far more frequently than those who don’t.

“What we know about the psychological experiences of women is that women who have a sudden, unexpected, emergency caesarean section without any chance to really adapt to it are the most likely to suffer psychological distress,” … “Posttraumatic stress disorder is much, much, much neglected.”

… Klein emphasizes that the primary determinant of whether a woman will suffer PTSD after child birth is not the mode of delivery. Rather, it’s how she’s cared for. In other words, the condition can occur in women who have vaginal births, deliveries that require forceps, midwife-assisted labours, and in other situations. The crucial factor throughout is how her care team responds to her needs.

Other factors come into play as well, such as prior psychological and psychiatric disorders and the woman’s prepregnancy mental state.

… “We know that women never forget their childbirth experiences,” … “They can be transformative in a positive way or transformative in a negative way. Talk to any 50- or 60-year old woman and she can tell you every minute of their childbirth experience.” …

Continuity of care – that is, being cared for by one person who is trusted and liked throughout the pregnancy, birth and postnatal period – is vital for minimising the chance of PTSD. Continuity models include private obstetric care, where a woman has all of her pregnancy care with one obstetrician and that same obstetrician is on-call for her birth. Continuity models also include private midwifery care where a woman has the same midwife for all of her pregnancy, birth and postnatal care. Obstetric care can be accessed through eligible midwives who have collaborative arrangements with obstetricians.

Visit my website to learn more about my services.

Study researches birth satisfaction for first time mothers

Sep 18th, 2011
by Melissa Maimann.
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A pilot … study investigating factors that contribute to birth satisfaction for first time New Zealand mothers has led to a bigger nationwide study examining how birth preparation impacts on birth satisfaction.

… birth satisfaction is important because how a mother perceives the birth of her child influences her confidence in mothering abilities and consequently the early mother/child relationship. In turn this impacts on the child’s sense of security as well as family psychosocial health. … women … wanted to feel safe, have good relationships with those caring for them, and to have responsibility for and control over their birth processes.

“… they had a desire to take part in decision-making about medical interventions considered necessary,”

“These factors all contributed towards a woman experiencing birth satisfaction. In particular, vulnerable women appreciated the close relationships they established with their midwives.”

She also found that those women needing an intervention to give birth, such as a forceps delivery, were very grateful that skilled obstetric help was available.

“However, a poor relationship between midwife and specialist could contribute towards distress experienced by the women, as did an obstetrician’s lack of attention to bedside manner,” she says.

“On the other hand … a few minutes taken by the obstetric team to introduce themselves and explain their roles resulted in her retaining a sense of personal control throughout the intervention. This resulted in an empowering and very satisfying birth experience for her, despite the necessity of an unexpected medical intervention” …

Continuity models are becoming more popular, though still not the norm for most women. Private midwifery care delivers the most effective continuity for women, where women choose their own midwife and are cared for by that same midwife for their pregnancy, birth and new parenting experience.

Visit my website to explore birthing services.

Omega-3 Fatty Acid Reduces Postnatal depression

Apr 24th, 2011
by Melissa Maimann.
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Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.

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Consumption of docosahexaenoic acid (DHA) during pregnancy may decrease postpartum depression (PPD) …

… “These results offer a basis for guidelines for DHA consumption by pregnant women and for community-based efforts to increase awareness of the value of DHA/fish consumption for maternal mental health,” the authors write.

Postpartum Blues Affect Dads Too

Mar 15th, 2011
by Melissa Maimann.
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MEDICARE NOW AVAILABLE FOR MIDWIFERY CARE THROUGH THIS SERVICE!
Want to know more about home birth, hospital birth or Medicare-funded private midwifery care? Email Melissa Maimann or call 0400 418 448.

Depression in new mothers is well recognized — but new dads get depressed, too, and it can negatively affect parenting …

… “Pediatric providers should consider screening fathers for depression, discussing specific parenting behaviors (e.g., reading to children and appropriate discipline), and referring for treatment if appropriate,” the group recommended in their paper.

… As with new moms, fathers appear to be at the greatest risk for depression in the first year after their child’s birth …

But getting clinicians to “embrace paternal perinatal depression screening with the same vigor” as for maternal screening could be less than straightforward, they predicted.

“The field of pediatrics is now faced with finding ways to support fathers in their parenting role much in the same way we support mothers,” …

… Overall, 7% of the men reported a major depressive episode within the prior year.

Although these depressed dads were less likely to be employed and more likely to report substance abuse, they were not less likely than other fathers to have spoken with their child’s doctor in the prior year.

The analysis focused on four aspects of parenting commonly considered at well-child visits: playing games, singing songs, and reading stories to children at least three days in a typical week, and spanking.

Both depressed and nondepressed dads were just as likely to engage in interactive play and singing songs or nursery rhymes with their children, at 94% to 95% and 75% in both groups, respectively.

… Depressed fathers were 62% less likely to report reading to their children at least three days a week …

… Irritability and anger as common symptoms of depression may be implicated …

… Depression may also take away motivation or interest in reading to children …

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

Your body, your choice

Nov 17th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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

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

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

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

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

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

Wong’s experience isn’t unique.

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

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

Birth trends

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

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

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

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

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

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

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

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

Medical interventions

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

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

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

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

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

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

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

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

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

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

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

The big ‘C’

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

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

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

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

Disturbed birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Take control

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

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

Nov 3rd, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Fact or Fiction: Fathers Can Get Postpartum Depression

May 27th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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… Previous research has found rates of depression in new dads that range from 1 percent to 25 percent, but a new meta-analysis … found that an average of 10.4 percent suffered from depression sometime between the first trimester of their partner’s pregnancy and the child’s first birthday.

Rates of paternal depression were highest three to six months after birth (25.6 percent) … All of these numbers are considerably higher than the annual rate for adult male depression, which is 4.8 percent …

… Extreme examples of parental depression can lead to suicide or to harm or neglect of the baby, but even mild to moderate depression in fathers has been shown to have lasting negative effects on their children for years to come.

… “there’s a general cultural myth that men don’t get depressed,” … “Because of that cultural myth, men oftentimes think they shouldn’t get depressed, and when they are depressed they try to hide it.”

… for people who have clear cases of clinical depression, there are cues beyond typical parenting troubles, such as persistent detachment, feeling hopeless or worthless, or thoughts of death.

… doctors and pediatricians usually see new fathers less often than they do new mothers … Even though screening for depression in mothers is far from perfect, it is much easier to do given their more regular contact with the health care system …

… The sleep deprivation that comes along with being a new parent can alter neurochemical balances in the brain, making some people with underlying risk factors more vulnerable to depression …

… A personal history of depression puts both mothers and fathers at a higher risk, as does a sick baby, financial strain or relationship problems. Add to that list the changing expectations pushing dads to become more involved parents … and many new fathers are left feeling overwhelmed and at greater risk for anxiety and depressive symptoms.

… Like mothers who are depressed, fathers who suffer from depression can have negative impacts on their children’s development years down the road.

“When Dad is depressed, Dad tends to interact less with the child and bonds less with the child,” …

… “depression in fathers during the postnatal period was associated with adverse emotional and behavioral outcomes in children aged 3.5 years.” …

… children whose fathers had been depressed during their early infancy were more likely to have behavioral problems by the time they were school age …

Depression in dads also seems to correlate with depression in mothers. Although the relationship is not one-to-one, having a partner with this sort of depression seems to increase an individual’s likelihood of having it, too …

… Paulson recommends investigating treatment that focuses on whole families, addressing depression “as a family problem, not an individual problem.”

Courtenay proposes ways to help prevent paternal—and maternal—depression from becoming a problem in the first place. With a growing checklist of risk factors … the best thing to do is address any of them “before the baby comes along.”

… The first step … is improving awareness that paternal prenatal and postpartum depression exists and is likely to affect about one in 10 fathers …

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

Feb 23rd, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

informed consent and childbirth

Every woman who is competent to consent, has the right to refuse any or all professional care. Informed consent must be obtained prior to any procedure being performed.

how to minimise labour intervention in a hospital?

The best way to minimise intervention in a hospital is to be as well informed as you can possible be about all things related to pregnancy, labour, birth, breastfeeding and babies. Read widely, attend independent childbirth education classes and consider employing a private midwife to be with you throughout your labour. She can help you to decide if the proposed interventions are necessary in your situation, she can support you emotionally, mentally and physically and she can aso help to ensure that your birth plan is respected without a fuss.

Do any independent midwives in Sydney offer prenatal care for women who are planning to freebirth?

Yes! This service enables women to access antenatal care from a midwife without the midwife attending the birth. Postnatal care is available if needed.

Do you think there are advantages to continuous monitoring for low-risk women

In a word, no. Intermittent auscultation is the method of choice. Continuous monitoring will increase the chance of a caesarean with no benefit to the mother or baby.

How much is a private midwife

Prices range from $3000 – $6000. Melissa Maimann offers for her clients to pay by the hour, making the service one of the cheapest.

What is a good caesarean rate?

The World Health Organisation recommends that no more than 15% births need to be caesareans. The WHO argues that when caesarean rates exceed 15%, the risks to the mother and baby increase on the whole. You’ll be hard-pressed to find a hospital with a caesarean rate of less than 15%, but birth centres and private midwives have caresarean rates of less than 10-15%.

What is the best hospital in sydney for delivering babies?

It all depends what sort of birth experience you’re after! If you’re wanting a natural birth, home birth will be the best option. If you want a natural birth in a hospital setting, the best options would be birth centre or private midwifery care for a planned hospital birth. If you’re wanting to have intervention in your birth, a hospital birth would be best. If you choose an obstetrician, you’re far more likely to have a caesarean, episiotomy, epidural, forceps or vacuum. Choosing your care provider is the single most important decision you will make in birthing.

Is there a birth centre at westmead hospital?

No, there isn’t. If you’re after a natural birth, the best choice would be a home birth.

C section or natural delivery midwife?

Midwves cannot perform caesareans. If a caesarean was needed, the midwife would call a doctor in to perform it. Most caesareans that are performed are unnecessary and increase the risks to the mother and baby. A natural birth is the safest way to birth, and midwives are qualified specialists in natural birth.

giving birth after birth trauma

Private midwifery care will be really important so that you can have the same midwife all the way through pregnancy, birth and postnatally. It’s also important to debrief your last experience and come to a place where you feel safe to birth again.

high risk midwife sydney

Midwives are not qualified to care for high risk pregnancies. We refer these women onto obstetricians. In most cases, one or two consultations is all that is needed with the obstetrician and the midwife continues the care of the woman.

how many births proceed naturally

What a great question! It all depends what care provider you choose and where you have your baby. You see, if you choose a private midwife and birth at home, you have about a 95% chance of having a vaginal birth. If you birth in a private hospital, you have about a 33% chace of having an unassisted vaginal birth. In some hospitals, the caesarean rate is more than the vaginal birth rate! Sad but true.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Never again in a public hospital

Jan 9th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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The Age special report on maternity care drew a range of responses …

I GAVE birth to my first child last year in the … maternity ward as a public patient.

Nothing could have prepared me for my horrible birth experience – ”herding yards” does not go nearly far enough in describing the way the hospital treats new mothers and babies. The need to minimise expenditure combined with an almost zealous obsession with promoting breastfeeding created an experience so stressful that, for me, resulted in what I call post-traumatic birth disorder – a fear of ever having another child in a public hospital.

My baby was born with fairly high levels of jaundice, which results in a very sleepy baby who is unable to feed well. Bar going under the UV lights, the only means of reducing the jaundice levels is to ”flush” it out with fluid.

Now that would be fine except for the fact that mothers do not produce milk for at least two days after a natural birth and up to five days after a caesarean. Not once was I offered formula to try to provide extra fluid for my baby. Instead, I was told to breastfeed and express extra fluid in between feeds.

So, in pain after major surgery, with a baby too weak to feed well and not producing milk, I was left struggling for hours to try to provide enough fluid to help my baby.

On day four I was about to be discharged when the attending doctor told me my baby had developed ”nappy rash” and might need antibiotics. At first the doctor said it would need a cream and I would still go home that day. A few minutes later another doctor said it was a ”severe” rash and my baby might need oral antibiotics.

Then the head of pediatrics came to look at the rash. The attending [midwife] said they thought it was a hospital-borne staph infection, which was later confirmed. At this point I was about to have a breakdown from being exhausted, stressed and furious that no one had mentioned the staph to me.

Following this diagnosis, I was discharged from maternity and my four-day-old baby was admitted as a pediatrics patient to be given IV antibiotics. The pediatrics ward is for children only so despite just having the caesarean and still being on painkillers, I was not considered a patient. I had to sleep on a fold-out couch to continue three-hourly breastfeeds but was given no food or additional pain relief …

No perfect system

WHEN my wife fell pregnant, our GP referred her to an obstetrician without discussing any options, such as the public system, birthing centres, home birth etc. This referral sent us down the path of the private health industry. We were keen on more natural options for childbirth, but it became increasingly apparent that our obstetrician was not interested in these options. Through our own research we found out about birthing centres, and decided that this was the go for us.

… our daughter was breech. Through the birthing centre we were told of an obstetrician who manually turned babies in utero. We consulted him, and our daughter was turned. I am sure that had we stayed in the private system with our original obstetrician, we would not have been made aware of this option, and my wife would have had to endure a caesarean. This is one example of the ”over-medicalisation” of childbirth by the private health care industry.

However, the birthing centre was far from perfect. My wife gave birth at 7.10pm on a Saturday. At 9.30 the next morning we were pressured to leave. We refused, and spent our full allotment of two days in the centre. A couple of days after we left, we received one follow-up visit from a midwife. She noted that our daughter was jaundiced, and advised that we put her in the sun for 10 minutes.

Later that day I took my wife to hospital because she was experiencing pain after the birth. While we were there, a [midwife] noted that our daughter was jaundiced, and requested a blood test. The result was that she was rushed to the neonatal intensive care unit in a serious condition. An hour later the head of the unit informed us our daughter was suffering from a level of jaundice so severe that they saw it only once or twice a year, and that as a result, she could be brain-damaged and suffer hearing loss, among other issues. If I hadn’t insisted on taking my wife to hospital for her pain, I dread to think what might have been …

Happy on home front

I HAD a satisfying birth at home with the help of two lovely independent midwives. The continuity of care from our midwives has been exemplary.

When I read accounts of less-than-adequate hospital-based maternity care, I can only say that home birth is worth every cent we paid.

Improving the maternity system is simple: the Government needs to stop attempting to put independent midwives out of business.

Support midwives

MY HUSBAND and I saved our stimulus packages to pay a private home-birth midwife for the birth of our second child, due any day now. The continuity of care, with antenatal appointments in our own home, is wonderful. I feel much more comfortable ringing my own midwife with questions than I did when I was seeing a different midwife every time at the … Birth Centre …

It’s not all gloom

WHILE there is room for improvement in any hospital system, the headlines in your report unnecessarily spelt doom and gloom.

In the past 10 years I have had three babies at the public … [hospitals] Each time I have been impressed with the service and care provided …

My first baby could not attach to the breast, and … we were allowed to stay in hospital until day five after the birth. Every time I needed to feed her I buzzed for the midwife to help me, and never had to wait more than a few minutes.

With my second and third babies we went home on day two, but we were ready … Postnatally, a midwife from the hospital visited me each day for two days after the birth. The midwives were caring, knowledgeable and helpful.

Motherhood’s trauma

I GAVE birth to both my sons as a public patient … There is almost no difference between the private and public patient experience, so having private health cover was of no benefit. My doctor was away both times but the on-call obs I had both times gave good care. Of course, they’re only there for the end bit and it’s the midwives who do all the work anyway.

… my key criticism is that they sometimes forget the strangeness of becoming a mother for the first time. We are not used to being mostly naked in a room full of other people … We are flooded with hormones that leave us lost and confused. We think motherhood will be a tender and graceful time, when in fact it can often be a time, particularly the first time, when you feel frighteningly laid bare. I would have appreciated someone to facilitate a more caring and dignified transition into my new role.

A cry for help

A LARGE public hospital means a huge variation in staff on different shifts, which leads to inconsistent care and the danger of ”falling through the cracks”.

Hence, many women benefit from having their own private midwife with them throughout the experience.

Three days after the birth of my baby, I developed … postnatal depression … The [midwifery] staff … were seemingly inexperienced … I never had the same [midwife] more than once, which meant they were generally unaware of my worsening condition, which didn’t appear to be written in my medical notes. On the fifth day when I was to be discharged, I was stuck with terror at the thought of being home alone to cope with my newborn son …

At home, things got worse. Feeling like you’re in an evil, black hole and not wanting to look after your own baby is not a pleasant state to be in. I had enormous problems with breastfeeding, which added even more stress to my already unwell mind.

It was the visiting midwife from the hospital who was the catalyst in getting treatment for me. At first she offered me generic advice in a way that to me seemed somewhat ”hippie dippy”, so I had to persist in letting her know how bad I felt. Eventually she gave a card for the hospital’s crisis assessment team hotline. The team member I spoke to was exceptionally understanding and gave me some calming advice. The team followed up with regular phone calls to check I was OK before they were able to send out a diagnostic team, including a psychiatrist, a couple of days later. They were also responsible for my being admitted into a mother and baby unit in the hospital’s psychiatric ward soon after.

Intensive counselling, medication, individual monitoring and support finally got me back on my feet. I am now what I would consider a ”normal” happy mother.

Forgotten option

YOU seem to have left out the home birth option in your report. Provided the woman is healthy, well-informed and well-supported, there is no reason she cannot give birth at home, with the aid of a trusted midwife. My wife did so three times …

If necessary, a doctor can be called to render extra assistance, and in the rare case of complications, which usually become apparent slowly, the woman can be taken to a hospital.

If more women gave birth at home, this would relieve the pressure on hospital resources. It would also enable women to give birth calmly, in a familiar environment, with loved ones close at hand, and usually escape the effects of postnatal depression.

Rich feedback about our current hospital system. It will be interesting to follow the changes once private midwives are able to birth with their clients in hospital. We know that continuity of care is sought-after, as is explained in the above quotes. Private midwifery in hospitals will enable more women to access midwifery care on their own terms.

I was surprised that the stories of women who were told they could not get the type of birth they wanted – such as vaginal breech, vaginal twins, VBAC and so on – were not mentioned.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Breast-Feeding Can Help Mom’s Heart

Dec 3rd, 2009
by Melissa Maimann.
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Breast-feeding … can significantly lower a woman’s risk of metabolic syndrome …

… Breast-feeding for longer than nine months dropped the risk of metabolic syndrome by 86 percent in women with gestational diabetes. Women without gestational diabetes saw a 56 percent reduction in their risk of metabolic syndrome …

… The benefits of breast-feeding for infants … include lower risk of ear infections, stomach problems, respiratory illnesses, asthma, skin allergies, diabetes and SIDS. For women, breast-feeding appears to lower the risk of type 2 diabetes, breast cancer, ovarian cancer and postpartum depression …

Metabolic syndrome [includes] … abdominal obesity, high blood pressure, low levels of HDL (“good”) cholesterol, high levels of LDL (“bad”) cholesterol, high triglycerides, insulin resistance, elevated markers of inflammation and a tendency for blood to clot …

Melissa Maimann, Essential Birth Consulting 0400 418 448

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

Nov 1st, 2009
by Melissa Maimann.
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…70 percent of Australian mothers say they do not get enough support from those close to them …

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Emotional Impact of Cesareans

Oct 14th, 2009
by Melissa Maimann.
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Every 30 seconds in the US, a cesarean is performed.This overuse of cesarean surgery puts moms and babies at risk—not just physically, but emotionally … A cesarean can reach far beneath the bogus smile on mom‘s face. It can scar her heart, as well as her uterus.

A baby girl is born. She grows and begins menstruating. She becomes sexually active and becomes pregnant. She births her baby. She breastfeeds her baby. This is life—normal and natural, yet exciting and important. In the continuum of life, pregnancy, birth and the postpartum period are milestone events. These experiences profoundly affect women, babies, fathers and families …

When a woman gives birth, she has to reach down inside herself and give more than she thought she had … There is a moment when every woman thinks, “I can‘t do this.” If she is lucky, she has a midwife … to whisper in her ear, “You are doing it.” As she does it, she becomes someone new: a mother. If the birthing process is skipped or occurs in a hostile situation, or if the interventions become overwhelming, she becomes a different mother than she would have been if she had only had a supportive, midwifery model of care.

… A woman‘s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care and by the environment in which she gives birth.

To control and actively manage a woman‘s labor and delivery, modern obstetrical practice relies on conformity. A woman is “subject” to rules, restrictions and protocols … Physicians and the hospital staff have authority—there is an unbalance of power … I say: You can only consent to that which you are capable of refusing. If you can‘t refuse the test, the drug, the procedure or the surgery, then you did not consent to it. This is coercion and it leads to disempowerment of women …

Many women who have cesareans suffer in silence because society expects them to “just be happy about their baby.” …

… Research has shown that when we stray from evidence-based maternity care, we have a high degree of obstetric intervention that is associated with acute trauma symptoms … how a woman perceives the event, not the event itself, plays a vitally important role in whether she has trauma symptoms.

Women report experiences that fall into the following categories:

* A sense of loss: birth didn‘t turn out like expected, loss of the experience of participating in the birth experience, not being there when the baby enters the world
* Interrupted relationship with baby: feelings of detachment from her baby
* Altered identity: sense of failure, feminine identity altered; lowered confidence in her body
* Intimations of mortality: surgery gives “rise to fears about mortality”
* Feelings of violation: from surgery where the body boundaries are violated, feeling “mutilated” or “butchered”
* Anger at caregivers: particularly regarding “what was perceived to be an unnecessary cesarean, lack of involvement in medical decisions, feeling unsupported by hospital staff before, during and after the cesarean”
* Dissociation: feeling that the surgery was taking place on someone else or from a distance
* Humiliation: being scolded
* Helplessness: not being able to take care of herself or her baby
* Posttraumatic Stress Disorder symptoms: anxiety, trouble sleeping, panic attacks

Let‘s consider that a moment. What if we went to a wedding today and while waving the couple off in the limo, we see it get hit by a truck before it turns the corner. If the bride were to spend her honeymoon in the hospital, no one would tell her, “Well, at least you have a healthy husband.” …

… Some women have such a traumatic experience, they close themselves off to the possibility of more children. They never consider the idea that it doesn‘t have to happen that way …

… Women who have had cesareans have higher rates of voluntary … infertility … This is often due to their determination that the trauma, whether physical or emotional, was too much to repeat.

Men are in a unique place during labor. They have been asked to be the support person and the labor coach. Now they are asked to be the protector. While historically men have taken the role of protector, I submit that the labor room is not the place men want to be trying to protect their wives.

Is it fair to expect this of partners? How are partners to be effective protectors / advocates when it is their partner and baby going through the experience? Is it fair to expect this role on anyoen who does not have the qualifications and experience to advocate?

Husbands of women who had had cesareans responded … mainly with fear and anger … “The pall that the experience placed over our entire relationship was stronger than a death in the family, because we both feel that we should have been able to do better. She has an alibi and can say she did all she could. I have no such explanation.”

Another husband expressed … he was “ashamed that I let them hurt my wife as I stood by.”

What is a husband protecting his wife from? We trust our obstetricians to provide care that is safe and effective for women and their babies. Yet, in the US, the norm in maternity care that is provided is technology-intensive and not consistent with the best available research.

This is the norm in Australia too.

Healthy women often are given … interventions that could have been avoided. In the hospital, some procedures or interventions are done freely and routinely, whether or not the mother or baby has shown a clear need. These interventions are disruptive, uncomfortable, can cause serious side effects and often lead to the use of other procedures …

… Birth has become extremely interventive and this includes everything from the seemingly minor … to the most invasive—the cesarean. It has become so interventive that it takes something away from what the experience should be. As a result, many women find themselves grieving.

… Partners witnessing birth trauma are also at risk of developing depression, caused by feelings of helplessness during the traumatic event. Men are more likely to express their feelings of depression through anger and abusive behavior. Truman stated, “The cesarean completely destroyed my faith in the medical community … ”

… Tim stated: “I‘m mad and bitter—disillusioned. That likely won‘t change with time. Recovery is not a term I would use. I‘m not recovering. I have learned a lesson.”

How the couple process their experience can determine whether the marriage survives. Chris said, “… It put us at the brink of divorce. I didn‘t understand fully what happened and my wife thought I didn‘t care.”

The cesarean may be difficult for the father. A husband may have seen his wife rushed to the OR. He saw her uterus taken out of her body. He was worried about her. He may not have words to describe the experience, but he needs to process it.

When I broached the subject of intimacy after cesareans to husbands, some asserted, “Everything‘s fine there, thank you.”

Others report having to work hard to restore intimacy to their marriages: “It took more than a year for intimacy to start returning. More than a year.”

One husband, when asked, snorted, “Hah, are we seriously going there? Personally, it has left ’intimacy‘ out in the dark. She is embarrassed about her scar and she thinks it makes her less sexy. I guess it‘s more of an emotional hardship for her and she just doesn‘t feel sexy anymore.”

The cesarean recovery has an impact on the couple‘s ability to resume intimate relationships. The immediate problem is healing of the incision and recovery from the surgery itself. There also is long-term impact that is rarely noted by the medical community. Some women report a loss of feeling around the scar. Others are hypersensitive to any touch or pressure in the scar area—which may be psychological as well as physical. They report pain and discomfort.

Intimacy is an emotional connection. After a cesarean a number of things may interfere with this connection. The husband may have been frightened by the sight and sounds of—or the scenario that lead to—the cesarean. He may be hesitant to resume relations, worrying that he might hurt her. What if she gets pregnant again? He certainly doesn‘t want to do that again. His wife might feel the same way. She has to focus on her own recovery, which takes away from what she can give to their relationship.

… Stephanie‘s cesarean changed her husband‘s view of the medical community. He said, “… To know that people we trust with our lives and the lives of our children are so careless and insensitive about our lives and the little ones they savagely bring into this world.”

The veil has been removed—even doctors no longer believe in the Hippocratic Oath. They cite liability as the main reason they do many things, including unnecessary surgeries and banning VBACs. Since they are more concerned with money than with the health and safety of women and babies, we must now claim the right to have full and complete information about the risks and benefits of, and alternatives to, every test, drug, procedure and surgery. We must claim the right to make medical decisions for ourselves and in behalf of our babies.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The real safety issues in maternity care

Oct 13th, 2009
by Melissa Maimann.
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Maternity care provides a classic example of the pitfalls of a specialist-driven model of practice in health care. It results in more expensive and interventionist care, rather than a community-based approach which could also help ensure a more equitable distribution of services. It has led us to talk about obstetrics, which implies a focus on a particular professional group, rather than maternity care, which implies a broader focus on the woman’s and baby’s needs, both before and well after the birth.

Professor Lesley Barclay … is a leading proponent of the need to reorient maternity care around the needs of women and babies …

“When women talk about what matters to them when it comes to childbirth, the issue they repeatedly mention is safety.

But their understanding of safety around childbirth is often quite different to how health systems and many professionals define it.

For women, a safe childbirth is not only about what occurs at the time of the birth. It also refers to longer-term issues, such as their social and emotional wellbeing in the weeks and month after the birth.

When women talk about safety, they are also thinking about the increased rates of depression and anxiety that manifest after operative birth or the consequences of wound infection on general health.

The Australian health system often makes it difficult for women to make wise choices around birth …

For example, evidence shows for most women most of the time birth does not need to take place in hospital. Some women will only feel safe however, whether this is evidence-based or not, with specialist medical services and technology.

The term “maternity care” … incorporates their social and emotional needs. It puts them – rather than the professional or the service …

Evidence shows maternity care can be provided by both midwives and obstetricians in public and private sector hospitals and can be safely provided at home.

… evidence also shows that safety from morbidity is less likely for Australia’s healthiest and wealthiest women cared for by private obstetricians in private hospitals. More recent epidemiological evidence shows as volumes of operative birth increases, deaths of mothers and infants are also increased by overuse of the very operation that was developed to save lives.

So where does choice fit in this repertoire of terms, locations, professionals, services and outcomes?

Safe birth should be the goal of choices offered to women and decisions taken by those who provide care for them.

Unfortunately, the choices some professionals offer or accept are self or income centered and ignore evidence. As a consequence of gender-located power historically, and a rapid increase in the numbers of more technically oriented professionals in recent decades, health services and costs do not reflect women’s needs or evidence.

The most important example of this is allowing caesarean birth to be a choice rather than only using this as the lifesaving emergency procedure it is.

… caesarean birth is rapidly becoming a life threatening procedure itself because of excessive use … maternal death reviews and coroner’s reports now show the risks attached to using a major surgical procedure as a routine mode of birth.

Maternal mortality is between two and seven times higher for surgical than vaginal birth …

… The physical, social and emotional morbidity attached to women who experience this mode of birth is not recognised therefore ignored within acute care hospitals but is evident in their homes and the community.

Research has identified that physical morbidity associated with CS is five to ten times higher than for women birthing vaginally. No less importantly there are also psychosocial consequences of surgical birth with women less satisfied, more concerned about the baby’s condition and fearful. Women delivering by CS report feeling less in control than women who have birthed vaginally.

Research also shows rates of post natal depression significantly different between women who birthed vaginally and the group of women who delivered either by planned or unplanned CS … Women who birth by CS evaluate their babies less favourably, are less likely to breastfeed and/or feed for a shorter duration.

Paradoxically, the choice to have a normal, safe, confidence affirming birth that is low cost and relieves pressure on hospitals is only available to a small minority of women.

This is not possible for Australia’s most vulnerable women and families, who, the evidence suggests, would benefit most. How many rural or remote living Aboriginal women can opt for a home birth attended by a skilful midwife?

… 1 in 10 remote living Aboriginal women in one large community avoid hospital services or skilled professionals because of the unacceptable risks to them of being evacuated from their community …

Other Australian women with more options are also taking this route, fed up with what they see as biased, self-interested advice and unacceptable risks of our current system.

To have real choices, one needs options and good information on which to base decisions. Better resourced women … can chase evidence themselves, or question doctors, hospitals and midwives …

… there are some ultimate arbiters beyond opinion. One of these is the impartial review of evidence provided by such as the Cochrane data base.

I saw to my great delight a writer (male and medically qualified) who also a Member of Parliament, recently quoting this source in a newspaper. His message, while aimed at indemnifying home birth midwives, was that home birth is safe.

… home birth is indeed safer at times than hospital birth when planned and supported by good hospital care for rare emergencies.

I wish the current president of the AMA, an erstwhile obstetrician, would be similarly correct with his claims that certainly are not recognisable as fact to those familiar with the evidence.

Choices for women are difficult when all they receive is highly partial and ill-informed opinion. Choices around birth are important or women will opt out of a system that does not meet their needs.

…. Should it be a matter of choice though for women to give birth via major abdominal surgery? Should we permit choice that means their babies avoid the process of vaginal birth that prepares them to live and breathe? Should it be women’s or obstetrician’s choice that health pays or heavily subsidises the avoidable costs of unnecessary operations that prevent other necessary surgery being performed and add to waiting lists? I think not.

We need to recognise that operative birth is the option to use only when the risks associated with the alternative are unacceptable. This is not a matter of choice.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Antidepressants May Be Linked to Birth Problems

Oct 10th, 2009
by Melissa Maimann.
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Taking a popular type of antidepressant during pregnancy may increase the risk for preterm birth, the need for treatment in a neonatal intensive care unit and lower overall health for the baby …

Researchers compared birth outcomes among babies born to 329 women who took selective serotonin reuptake inhibitors (SSRIs) during pregnancy, 4,902 women who had a history of psychiatric illness but did not take SSRIs during pregnancy and 51,770 women with no history of mental illness.

Compared with women who had no history of mental illness, those who took SSRIs during pregnancy gave birth an average of five days earlier and had double the risk for preterm delivery. Babies of mothers who took SSRIs during pregnancy were significantly more likely than infants in the other two groups to have a five-minute Apgar score of seven or lower … or to be admitted to the neonatal intensive care unit …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Childbearing Increases Risk Of Metabolic Syndrome

Oct 3rd, 2009
by Melissa Maimann.
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Childbearing is associated directly with future development of the metabolic syndrome abdominal obesity, high triglycerides, insulin resistance and other cardiovascular disease risk factors and for women who have had gestational diabetes, the risk is more than twice greater …

… After controlling for preconception measurements of body mass index (BMI), all metabolic syndrome components and physical activity, Lewis and her colleagues found that women who had given birth to one child or more than one child were independently associated with a higher incidence of the metabolic syndrome (33 percent and 62 percent higher, respectively) than women who had not had children. Among women with gestational diabetes, once baseline adjustments were made, the researchers found that they were nearly two-and-a-half times more likely to develop the metabolic syndrome than those women who had not had gestational diabetes-complicated pregnancies.

“Our findings suggest that childbearing can contribute to the development of the metabolic syndrome and that part of the association may be through weight gain and lack of physical activity,” Lewis said. “And, although women with gestational diabetes had the highest relative risk of developing the metabolic syndrome, those with non-gestational diabetes pregnancies made up the larger at-risk group.”…

… the best way for everyone to prevent disease … is to make the necessary lifestyle changes: exercise regularly and eat a healthy diet.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Breastfeeding reduces chance of postnatal depression

Sep 9th, 2009
by Melissa Maimann.
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According to recent research … mothers who bottle-feed rather than breastfeed are putting themselves at greater risk of postnatal depression … an absence of breastfeeding has been connected with the death of a child, and … the decision to bottle-feed mimics that loss … those who bottle-fed their babies scored much higher on a postnatal depression scale than those who breastfed.

Melissa Maimann, Essential Birth Consulting 0400 418 448

No Psychological Risk In Children Next-Born After Stillbirth

Jul 23rd, 2009
by Melissa Maimann.
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There is no evidence that children next-born after stillbirth are clinically at risk compared to children of non-bereaved mothers … However, the study did find evidence of less optimal mother-child interaction.

Anecdotal accounts have suggested that children born subsequent to stillbirth of a sibling may be psychologically vulnerable …

The researchers found no significant between-group differences in child cognitive or health assessments … However, mothers … reported increased child difficulties … and there were higher levels of maternal criticism of the child’s behaviour …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Rights and Responsibilities: Where did they Go?

Jun 9th, 2009
by Melissa Maimann.
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Feminism is a dirty word, especially if you are a pro-establishment columnist. Recently, the mass media have spurned the safety of homebirth. Doctors were outraged at the death of four babies, without revealing any case facts … Not one mainstream piece has explored why a number of women feel the need to give birth without any health professional, nor have they explored simple tested legal concepts of informed consent and right of refusal. It would seem far more sensible to herd all women into hospitals where they can be controlled. Women cannot be trusted, especially those who challenge the fierce medical domination of childbirth.

As an owner of a female body I have taken it for a test run seven times. I have chosen to use limited medical technologies … I took ultimate control of my body and became responsible for the life growing within me … I paid a price however. My decision to give birth at home with a registered midwife was not respected or funded. At the same time my taxes paid for a system controlled by medicine—a system with virtually no accountability, that allegedly enabled gross sexual assault under Dr Graeme Reeves. These assaults were extreme but lower level violence continues in maternity wards every day …

With this environment how could a woman previously damaged by the system feel safe? We have a maternity health system that leaves one in four women experiencing birth as a ‘battlefield’ and suffering debilitating post natal depression or even post-traumatic stress disorder, usually reserved for soldiers and victims of crime. Whilst women cry out for a mainstream midwifery option that puts their needs first, the medical establishment remains largely unaccountable.

Federal Health Minister, Nicola Roxon put her toe in the water, by announcing the Maternity Services Review last September. As expected the women who have been denied their rights and are funding others …

While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time.

The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.

As a woman and lawyer, Nicola Roxon is well placed to oversee the design of a maternity system with the established principles of informed consent and right of refusal at the centre. Arguments of safety and wellbeing are thin guises of tightly held power and control by medical lobby groups …

I attended a roundtable meeting of key stakeholders as part of the Maternity Service Review last year. The topic discussed was ‘high-risk pregnancy’. … many women and babies are classified as ‘high-risk’ by an obstetric community that is largely dogged by fear and distrusts women and women’s bodies.

My conclusion was sadly confirmed at the roundtable meeting, when a senior obstetrician said without hesitation that he ‘would be loathed to think a woman would have the final say in her care.’ … As a consumer, passionate about the rights of women to make informed choices, I believe the paternalism that pervades obstetrics and the widespread midwifery practice of maintaining the status quo pose a major threat to reform.

This view is in direct contradiction to common law in Australia. Kim Forrester, a member of the Queensland Bar states, ‘all adults who are of sound mind and considered legally competent have an absolute right to consent, or refuse to consent, to medical intervention and/or treatment. This is the case regardless of the opinion of health professionals as to what is in the “best interests” of the patient or client.’

… A US appeal case heard in 1914 made a landmark decision still quoted today: Schloendorff v Society of New York Hospital, clearly articulates, ‘Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient’s consent, commits an assault.’

The culture of fear and control in obstetrics has enabled these legal principles to be ignored. Women are consistently misled about procedures performed on them. Ironically most women are grateful and believe that either their own or their baby’s life was saved, often after an unnecessary intervention.

Obstetric dominance pervades midwifery. Virtually all models operate with exclusion criteria that are not based on evidence. A woman with a previous caesarean section is unable to give birth in a bath in a birth centre with a midwife sometimes only seconds from operating theatres. Her safety can only be assured in a ‘labour ward’ sometimes only metres away from the birth centre. The capacity for a healthy woman to deliver her placenta without oxytocics is doubted and feared …

The birth reform process is likely to bring with it guiding principles. The Australian College of Midwives developed guidelines for establishing midwifery models. The recent second edition was mindful of the need to enshrine informed consent and right of refusal. They state:

Ethical principles underlying health care and health law emphasize the importance of respecting the autonomy of those receiving health care and the rights of individuals to choose among alternative approaches, weighing risks and benefits according to their needs and values. Midwives, like all health professionals, are responsible for being clear about their scope of practice and limitations, giving recommendations for care if appropriate and for informing women about risks, benefits and alternative approaches.

Should a situation arise in which the woman chooses care outside the recommendations in the Guidelines the midwife must engage with the woman and her family and with hospital staff through identified channels where applicable, in a thorough discussion of the request, looking for options

The Royal Australian New Zealand College of Obstetricians and Gynaecologists (RANZCOG) do not accept these guidelines … they have released their own guidelines …

It would seem that unless a woman conforms to obstetric dominance she is not informed. If this wasn’t so serious it would be funny.

For too long we have chanted that birth needs to come back to women. Now is the time to empower women with rights too often denied. How can we have a maternity system that largely treats women as incubators where emotional wellbeing is dissected from her uterine cavity; and yet come post-natal discharge the same woman walks out into the world to make major life decisions for her child for the next 16-18 years? As with maternity reform, empowering women will take time, but if the reform process respects the rights of midwives to practice a full scope of practice and that of women that determine how and by whom their bodies are handled (if at all) a true woman-centred approach is possible.

Neither the church nor the state has the right to control a woman’s body. Maternity reform must be based on the three R’s – rights, responsibilities and respect. Consumers have the right to a funded registered health professional in any setting, and the responsibility to demonstrate they have made informed decisions. They deserve these decisions be respected …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Postpartum Depression Is Top Priority For New ACOG President

May 12th, 2009
by Melissa Maimann.
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Today Gerald F. Joseph Jr, MD, of Louisiana, became the 60th president of The American College of Obstetricians and Gynecologists (ACOG)… . During his inaugural speech at ACOG’s Annual Clinical Meeting, Dr. Joseph announced that postpartum depression is the theme of his presidential initiative.

“While in an ideal world, the newly delivered mother is at the peak of her reproductive health, with a beautiful child and, ideally, a supportive, loving family, this unfortunately is not always the case,” said Dr. Joseph. “Studies show that this is a most vulnerable time for our patients, especially those prone to depression or those with a history of depression.” Complicating matters is that the new mother often can’t bring herself to admit to any problems or negative emotions due to societal pressures, he said. Instead of asking for help, she may feel guilty for not being ‘grateful’ or a ‘good’ mother.

Dr. Joseph explained that the ‘baby blues,’ which affect as many as 80% of new mothers, usually start early after delivery and spontaneously resolve within a very short period of time. “But what happens when these negative feelings don’t resolve and true major depression becomes a part of the process?” he asked. “This can be devastating for the mother, the child, the partner, the family, and the ob-gyn who is caring for her.”

There are three areas in particular that need to be addressed, according to Dr. Joseph. “First, we need to determine the true prevalence and incidence of postpartum depression,” he said. … postpartum depression is estimated to range anywhere from five percent to more than 25 percent … we need to develop evidence-based guidelines for ACOG members to screen for postpartum depression.”

It would be great if there was some sot of acknowledgement of the role that pregnancy- and birth-related interventions have on the incidence of PND. It would also be great to see a study looking specifically at women with PND, to establish what sort of birth experience the woman had, and who her primary care provider was (midwife or obstetrician). It’s not hard to see that when women are told, overtly or covertly, that their bodies don’t work and that they need intervention to start labour, keep it going, or bring it to an end, that they take this learning away to motherhood, and approach motherhood with the same sense of failure.

Rates of PND are lower with midwifery care and with home births. Birth debriefing may help women who are experiencing PND.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Benefits of Using a Midwife During Childbirth

May 11th, 2009
by Melissa Maimann.
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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. It will either be a doctor or a midwife, and in some circumstances, it will be both. Women may choose birth centre, homebirth or hospital midwifery care to benefit from primary midwifery care.

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 generally 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, birth centre, 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 birth trauma
- 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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Crackdown on doctor rorts: IVF and Obstetrics

May 7th, 2009
by Melissa Maimann.
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MEDICAL specialists will come under pressure to cut fees for some services – especially in obstetrics and IVF – under a plan in next Tuesday’s federal budget to crack down on rorting of the Medicare safety net.

Under the changes, patients charged excessive fees will have new limits put on how much they can claim back on the Medicare safety net. This could leave some people facing large out-of-pocket expenses for obstetrics, IVF… and some other services if they use high-fee specialists.

But the Government hopes its crackdown, rather than penalising patients, will instead put pressure on high-end specialists to moderate charges.

As an incentive to specialists to cut fees, the Government will increase the cap on its coverage of the services – in effect, raising the base level of its rebate.

… Since the advent of the safety net, fees have leapt by 290% for IVF and 40% for obstetrics – giving rise to claims that the system is being rorted.

… Areas targeted for cuts include artificial reproductive technology (IVF), obstetrics and varicose vein treatment, identified in a report into the scheme.

… The net will continue to cover 80 per cent of patients’ out-of-pocket costs once they reach the threshold – but only up to a new limit in “capped” areas.

… The review found that the safety net benefits were going excessively to some specialists.

For some obstetrics and IVF services, of every dollar spent on the safety net, “78 cents is going to providers and only 22 cents to reducing patients’ costs”, the review said. Providers knew patients were likely to qualify for the net and felt “fewer competitive constraints on their fees”.

Between 2003 and 2008, the average fee charged for planning and management of an artifical reproductive treatment cycle increased from $294 to $1148. The average obstetrics fee for planning and management of a pregnancy rose 40 per cent between September 2004 and 2008 – from $1238 to $1732.

Specialists’ incomes in these areas have soared. In 2008, the highest 10 per cent of IVF specialists were paid $4.5 million each through Medicare – including $2.2 million through the safety net.

In addition to providing incentives to moderate fees, the higher obstetrics medical benefits are also designed to give more incentives for obstetricians to practice in under-serviced areas …

It will be interesting to see the added effects if the changes proposed in the Maternity Services Review are implemented. Those changes will provide private midwives with the right to order tests, prescribe medications and bill through Medicare. In effect, women will have the choice of the public health system, a private obstetrician, or a private midwife. Private midwifery will no doubt be far cheaper for women than private obstetrics, and will confer greater benefits in terms of:
- lower rates of postnatal depression
- lower rates of birth trauma
- lower rates of intervention in pregnancy and labour, and lower rates of complications from said intervention
- higher rates of natural birth
- higher rates of breastfeeding
- higher rates of birth satisfaction from women
- less birth trauma for the baby
- lower rates of admission to special care nursery for the baby
- fewer antenatal (pregnancy) admissions to hospital
- more care provided in women’s homes than hospitals
- lower caeasarean, induction, epidural, episiotomy, forceps and vacuum rates
- higher rates of VBAC
- true continuity of care – even with private obstetrics, you are cared for by midwives you have not met before; with private midwifery, all your care is with the same midwife who you’ve chosen
- more choice and control in birth

Melissa Maimann, Essential Birth Consulting 0400 418 448

Breastfeeding debate revived after death of British mother Katy Isden

May 6th, 2009
by Melissa Maimann.
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THE death of a British mum in despair at not being able to breastfeed properly should well shock the world but will not surprise some mothers … Sitting among the flowers and cards, clutching her first-born child, my sister Lia could do nothing but sob.

Left alone in her hospital room and attempting to breastfeed her new daughter for the first time on her own, she felt her anxiety skyrocket, the mother guilt take over.

A broken emergency buzzer didn’t help, nor post-birth hormones and lack of sleep.

But almost two hours after she’d begun trying to attach her baby’s small mouth to her painfully engorged breasts, my niece was screaming and so was her struggling mum.

… Her experiences with the births of her next two children were equally traumatic, marred by a recurrent sense of inadequacy and in the case of her third, mastitis so bad she was forced to temporarily relinquish care of her family to seek medical help.

News, then, of the death of 30-year-old British mother Katy Isden, who fell to her death from a New York apartment block after becoming depressed over her bid to breastfeed, should well shock the world but will not surprise mothers with tales like my sister’s.

… “The pressure to breastfeed, the anxiety to be this super person, is just no way to live.”

The coroner said that although Mrs Isden had been depressed when she died, it was not clear if she fell or jumped. He therefore recorded an open verdict.

… The research about the benefits of feeding babies “naturally” – delivering vital nutrients and a bond between mother and child – appears black and white.

But for many it’s anything but a natural experience; rather a grey area of conflicting advice and a trauma that can torture women.

… there is no doubt support is the key to relieving the pressure.

Extra funding for the Australian Breastfeeding Association’s national helpline resulted in a 30 per cent increase in those seeking help since March, with more than 28,328 calls taken between October and April.

… “So many of us have issues,” she said. “This is a matter of seeking assistance, not being left to feel like a failure.

“The solution is for the community to get behind mothers rather than patronising them with the ‘breast is best’ slogan. It’s what’s best for you and your baby that counts, not breastfeeding at any cost.”

The ABA’s 24-hour helpline is 1800 Mum(686) 2 Mum (686)

Support is most definitely the key to successful breastfeeding, which is, without a doubt, the safest way to feed a baby – safest for mother and safest for baby. But I do wonder if we set women up to fail. Our current obstetric system churns women out as mothers who have “failed” even before they hold their baby for the first time. They “failed to progress” in labour, they were a “failed induction”, they had an “incompetent cervix”, they “failed to dilate”, their pelvis was too small. However you phrase it, the message is clear: women’s bodies don’t work; their bodies are broken. Is it any wonder that with this mindset in action, they also fail at breastfeeding?

To look at it from another perspective, breastfeeding can be effortless and enjoyable. If we look at what goes on in birth, before the breastfeeding experience, we see that a relaxed and healthy breastfeeding experience is correlated highly with a natural birth (no induction, no epidural, no caesarean etc). If you like, natural birth primes mother and baby for breastfeeding. Maybe we’re expecting too much of mothers and babies to breastfeed successfully after their induced, pethidined, epiduralised, and surgically-extracted birth. Babies are traumatised by their birth experience, as are mothers. The cocktail of natural hormones that lights the path for a successful breastfeeding experience is grossly absent. Not just absent, but the very hormones that are the anti-dote to the natural-high-hormones, are present in ever-abundant quantities.

Women report feeling a disconnect with their baby when they meet their baby for the first time after a labour and birth that has been marked with various interventions. They report not bonding. That they really had to work at the relationship with their baby. And some women even resent their baby. All of this is very uncommon after a natural birth without drugs, induction, epidural, forceps, episiotomy and of course caesarean.

The best way to achieve a natural birth is to choose a care provider who specialises in natural birth. Currently, we have 2 types of maternity care providers: midwives and obstetricians. Obstetricians are surgical specialists. That may come as a surprise for some! But it’s true: obstetrics is not a medical specialty. It’s a surgical specialty. Obstetricians, on the whole, do surgery. And most do it very well. Thankfully!! Midwives on the other hand, are natural birth specialists. We’re trained in recognising normal, keeping pregnancy and labour normal, and in getting help when things are no longer normal. If you see a midwife and have a natural birth, you’re highly unlikely to ever have the issues with breastfeeding that are described in this article. Not to mention, if you did have problems with breastfeeding, your private midwife would be following you up for 6 weeks after your baby is born, so you would have a midwife on the end of the phone, 24/7 who knows you well, who has known you the whole of your pregnancy. The continuity of care provided by a private midwife is known to reduce breastfeeding complications and postnatal depression, whether you birth at home or in hospital.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Why Birth at Home?

Apr 1st, 2009
by Melissa Maimann.
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For further information, contact Melissa Maimann at Essential Birth Consulting.

Homebirth provides a familiar and safe environment for birthing. This helps to keep stress hormones low, and positive birth hormones high, and can therefore make the birth easier and less painful.

Women choose a homebirth because they believe in their body’s ability to birth, wish to involve their partner and other children more, or prefer to reduce the chance of intervention in their labour. And becuase let’s face it: pregnancy and birth are normal, healthy and natural experiences. We don’t go to hospital to experience other normal, healthy and natural bodily experiences such as food digestion, urination, menstruation, defecation …. we trust that our bodies work, and that these processes work too.

Women choose homebirth to:
Experience fewer complications in labour
Reduce the need for interventions
Use less pain medication
Lower their chances of a caesarean from about 35% to around 5%
Remain in comfortable and familiar surroundings
Have a baby who has fewer problems after the birth
Increase their success with breastfeeding
Avoid time limits being imposed on labour and birth
Experience antenatal and postnatal visits in their home
Improve bonding with their baby
Provide a gentle birth for their baby
Involve other siblings and family
Have choice and control
Reduce birth trauma
Receive care from the same midwife right the way through
Benefit from having more choices available
Benefit from sound education and birth preparation
Have a great birth!

Melissa Maimann, Essential Birth Consulting.

Quality of Life After Normal Birth and Caesarean.

Feb 19th, 2009
by Melissa Maimann.
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Comparing the quality of life in women after normal delivery and cesarean section.

A study suggests that vaginal delivery might lead to a better postnatal quality of life than cesarean delivery, especially with regards to physical health. Significant differences were found for vitality, mental health and physical functioning … The findings indicate that in the short term, vaginal delivery might be preventive of postnatal depression.

I’m not surprised by these findings. Caesarean is major surgery; having a major operation and then having to care for a new baby must be a very stressful experience. Other research has shoen that operative births are more likely to leave a woman traumatised following her birth. Continuity of midwifery care is known to reduce the need for caesarean.

Melissa Maimann, Essential Birth Consulting.