Risk assessment in pregnancy and birth

Posted on May 20, 2012 by Melissa Maimann

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

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

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

How can risk assessment be useful?

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

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

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

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Homebirth transfer rates: cause for concern?

Posted on May 10, 2012 by Melissa Maimann

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

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

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

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

What’s a “good” homebirth transfer rate?

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

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

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

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

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

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

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

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

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

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

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Planning a homebirth vs having a homebirth

Posted on May 5, 2012 by Melissa Maimann

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

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

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

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

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The Benefits of Using a Midwife During Childbirth

Posted on May 4, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

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Birthing in hospital with your own private midwife

Posted on May 2, 2012 by Melissa Maimann

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

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

Your care

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

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

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

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

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Private and public pregnancy options

Posted on April 24, 2012 by Melissa Maimann

I am often asked what the difference is between the private and public options for pregnancy and birth.

Private care generally affords women:
- Choice of care provider
- Choice of place of birth – home, hospital (public or private)

- Greater comfort and a more personalised service

Public care options often mean:
- a midwife or obstetrician will be assigned to you; you will not be able to choose your care provider
- Choice of place of birth is limited. Homebirth is only an option at a minority of hospitals and women generally have to go to the public hospital that is closest to their home
- Services cater more to the immediate physical needs with little appreciation for the emotional and mental journey of pregnancy and birth.
- Services are standardised by hospital policies. The same policies will apply to all women birthing at that hospital with little scope for movement.

The good news about medicare-eligible private midwifery care is that families are able to claim Medicare benefits for the care that is received from a private midwife. This rebate will significantly bring down the prices for private midwifery care, making it an affordable option for women wanting to birth in hospital with a private midwife, or at home.

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Decision-making: Heart and Head

Posted on April 20, 2012 by Melissa Maimann

Through my practice, I have a lot of women coming to me who are experiencing conflict with regards to the choices they have made for their pregnancy and birth. Typically, they find (sometimes quite late in their pregnancy) that perhaps the choice they made right back at the start of their pregnancy, no longer works for the, or the choice that they made was perhaps not as well informed as they thought it was. Some women find it hard to take the attitude of interviewing potential care providers before pregnancy (or very early in pregnancy) and then choosing the midwife or obstetrician who is best able to meet their needs. The end result can often be a woman who chooses an obstetrician with the goal of a natural birth, only to discover that their doctor will only “deliver” their baby if they’re on their back in bed with an epidural in place. Or that induction is performed by 40 weeks, or that all women have their waters broken and all first time Mums have an episiotomy or so on. And sometimes, the more reading a woman does, the more she realises that this is not what she wants.

I often ask the question, “What was it that made you decide on this particular care provider?”

And the responses are generally very interesting.

• My GP referred me
• My mother / sister / friend / neighbour used this midwife and she said she’s wonderful
• Well, when I got pregnant I went to my GP. She asked me if I have private health insurance and I said yes, so she wrote a referral to Dr XX.

I ask these women if they considered any other options. “What options?” comes the response.

I’m amazed that with the marvels of modern technology, internet etc, women don’t know they have other options. We have options with all sorts of things in life, and we don’t shy away from discovering them either! It seems to be to be an interesting handing-over of responsibility when it comes to pregnancy and birth, and I’m curious why it happens with pregnancy and birth, but not in other aspects of life. Do we buy a particular computer – that can’t meet our needs – because it was recommended and we didn’t know there were other computers on the market? Do we buy a large house when we need a small house because it was recommended by the real estate agent?

In most other situations where choices are involved, people will engage in a process of assessing options.

We might list all the possible options and then assess each option across a range of qualities.

We ask questions.

We consider what it is that we really want, and then match it to what’s available, seeking the most compatible choice.

But sadly, this does not happen with pregnancy and birth. Perhaps it should?

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How is a hospital midwife different to a private midwife?

Posted on April 18, 2012 by Melissa Maimann

This is a question I’m asked quite frequently so I’d like to take this opportunity to explain the difference.

Hospital midwives are employed by a hospital, either public or private. The majority of hospital midwives work shifts and there are generally 3 shifts in a day, so that each woman will go through 3 different midwives each day, in the provision of her care. Many hospital midwives do not work across the full scope of midwifery practice; instead, they work in one area only, such as postnatal. Because of this, it is unlikely that women would be afforded the opportunity to meet with the midwives who’ll be providing their care in labour and after their baby is born, first because the midwives work in shifts and it’s impossible to know who’ll be rostered on on the big day, and second because the midwives in postnatal, for example, would not work in the antenatal clinics which is where women go for their pregnancy care. The other implication is that antenatal midwives – who do not work with breastfeeding mothers – are not best placed to provide breastfeeding preparation and advice in pregnancy; likewise, delivery suite midwives would also not be best placed to advise about early pregnancy tests.

Another important factor is that hospital-employed midwives are bound by hospital policies. It’s a condition of employment. So that when something props up and the woman wants impartial information or alternative suggestions to explore, the hospital-employed midwife is not able to provide this.

Private midwives run their own businesses and are self-employed. They book their own clients and arrange their work life and hours to meet the needs of their clients. They follow their clients through from pregnancy, birth and afterwards with their new baby, generally for 6 weeks. Private midwives do not work in shifts; we are on call 24/7 for the families in our care. This means that the same midwife is accessible at all times, either by phone or in person.

Families choose their private midwife, whereas there’s no option to choose hospital midwives: you have whoever is rostered on when you’re there. Choice is an important factor of maternity care, and is a driving factor in the success of private obstetric practices where women can interview several obstetricians before choosing the one that best meets their needs.

Private midwives are not bound by hospital policies. We do follow the guidelines of our professional bodies such as the Australian College of Midwives, as well as researched and widely-accepted clinical practice guidelines, as well as legal requirements, but when it comes to exploring all options, private midwifery is the way to go. A common example might be a breech baby. Hospital policy may be to offer to turn the baby manually (ECV) so that it is head down. If this is not successful, caesarean will be encouraged. These options are also given by private midwives, as well as the natural alternatives to turning breech babies, and if the baby decides to remain breech, there is the option of vaginal breech birth and the woman will be able to approach this knowing that she has a skilled professional by her side, on her side.

Women will generally approach private midwives for the one-to-one flexible care that we provide; they want to get to know the midwife who’ll be there on the special day (or night) when their new family member arrives. It’s only natural to want to know that person who’ll be with you during the most life-changing, amazing and special moments of your life.

Generally, satisfaction with private midwifery care is very high, whether the woman birthed at home or in hospital.

Women are generally very satisfied with their care because they have far more control over what does and does not happen to them. Women have greater access to resources that helps them to feel confident with their abilities to birth naturally and fully aware of all options so that they can choose the best one for their needs.

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What to pack for your hospital bag

Posted on March 25, 2012 by Melissa Maimann

It can be really helpful to have a hospital bag packed by about 36 weeks, just so that it is ready to go to hospital when you are. Women planning a homebirth will also pack a hospital bag just in case a transfer is needed in labour.

For the most part, women stay in hospital up to 48 hours after birth. This means that you really don’t need to bring very much in the way of changes of clothes. So – what to bring?

Clothes for labour

Hospitals provide gowns, but many women prefer to wear their own clothes, or even no clothes. The best clothes to wear in labour are loose, baggy t-shirts, a dressing gown (if you are cold), tracksuit pants and so on. Nothing tight or restrictive, and nothing you can’t take off quickly if you want to. It’s also a good idea to wear old clothes, not your best new outfit. Bring a couple of pairs of underpants for labour.

Toiletries

Tooth brush, tooth paste, shampoo, conditioner, moisturiser, deoderant etc – whatever you normally use. You’ll also need 2 packets of maternity pads. Ie, not panty liners or thin menstrual pads, but heavy-duty maternity pads.

Underwear

Breastfeeding bras, lots of dark-coloured, loose underpants.

Clothes for the hospital stay

Again, whatever feels comfortable. Nighties, singlets, buttoned tops, loose clothes, tracksuit pants etc. You’re best to pack lightly, as anything that’s needed can easily be brought in from home by a relative or friend. Slippers, shoes etc – whatever you normally walk comfortably in. After you have a baby, your feet often swell a bit, so loose shoes are the key. Hospitals can often be cold places, so give some thought to layers of clothes so that you can layer up or down as you need.

Things for labour

Food and drinks, massage oil, aromatherapy, homeopathics, herbal medicines, pillows, photos / visualisation aids, CDs / iPod, anything that makes you feel ‘at home’.

For baby

Babies are small … and therefore easy to pack for! The hospital will supply baby clothes while you’re in hospital. Some hospitals provide nappies; others don’t. Best to check with your hospital. In geberal, you’ll need two outfits to take your baby home in. Why two? babies are notorious for pooing and weeing through outfits and this way you can have a change of clothes if you need them. You’ll need singlets, mittens (if chosen), nappy wipes and nappies. In winter or cooler weather, you’ll also need a beanie.

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Baby boom highlights obstetricians’ shortage in WA: AMA

Posted on March 22, 2012 by Melissa Maimann

Link

A baby boom in Western Australia has highlighted a shortage of doctors trained to deliver them …

WA has a surging population … but the State has the worst ratio of obstetricians and gynaecologists per head of population …

Naturally, as this has been reported by the AMA, the focus is on the lack of obstetricians available to deliver babies. Anyone would think from this article that a baby simply couldn’t arrive into this world without an obstetrician. Sometimes that is the case. However, for the most part, a midwife is all that is needed to ensure the safe arrival of a new baby.

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New induction policy a threat to women, or a threat to doctors? You be the judge.

Posted on February 7, 2012 by Melissa Maimann

An article in The Newcastle Herald yesterday states that:

pushing a policy to reduce caesarean births are creating rules that are potentially dangerous for patients and threatening to doctors … red tape is threatening professional independence.

It also discouraged treatment tailored to individual patients.

… Compliance with directives telling obstetricians when and how to deliver babies was mandatory, under the threat of disciplinary action and loss of indemnity cover …

… a recent directive requiring a reduction in caesarean section rates to 20per cent by 2015 was an illusory and possibly dangerous target.

What is being referred to here is the NSW Health Policy Directive on induction of labour at or beyond term. It is a well-written and thorough document that can inform best practice for induction of labour. Rather than “telling obstetricians when and how to deliver babies”, it guides practice in a woman-centered manner:

Induction of labour carries inherent risk and must be exercised with caution. There needs to be clear benefits for the mother and/or the fetus.

At term, women must be offered information about the risks associated with prolonged pregnancies, and the options available to them.

Induced labour has an impact on the birth experience for women. Labour is often more painful than spontaneous labour, and epidural analgesia and assisted delivery are more likely to be required.
Treatment and care should take into account a woman’s individual needs and preferences. Women who are having, or being offered, induction of labour must have the opportunity to receive accurate information and make informed decisions about their care and treatment, in partnership with their health care professionals.

This doesn’t sound like an approach that is potentially dangerous for patients or an approach that discourages treatment that is tailored to individual patients.

The article goes on to assert that:

Also concerning was a departmental policy that elective or pre-labour caesarean section must not routinely be carried out before 39weeks gestation, due to risk of respiratory morbidity in babies.

And the problem is? All this is saying is that an elective or pre-labour caesarean should not routinely be carried out before 39 weeks. This is not the same as saying that caesarean can never be performed prior to 39 weeks, yet the contributors to the article go on to say that:

‘‘[The policy] effectively forbids doctors in NSW public hospitals to schedule routine elective caesarean section before 39weeks,’’ …‘‘Anyone doing so risks disciplinary action and may forfeit indemnity cover.’’

This is clearly nonsense!

The policy directive does state that:

Induction of labour must not routinely be offered on maternal request alone.

Health care professionals offering induction of labour must:
• provide the woman with adequate time to discuss the information with her partner/support person before coming to a decision;
• encourage the woman to access a variety of sources of information;
• invite the woman to ask questions, and encourage her to think about her options; and
• support the woman in whatever decision she makes.

Women should be offered support and analgesia as required, and staff should encourage women to use their own coping strategies for pain relief. This includes the opportunity to labour in water.

I fail to understand what is unreasonable about this policy which is evidence-based, woman-centered and flexible so as to meet the woman’s present health needs. Most health professionals practice within evidence-based guidelines, best practice guidelines and accepted standards of practice. These are developed in consultation with industry experts and after consultation of the relevant literature on the subject. I am curious that the obstetricians in this article are critical of a policy directive that is based on evidence and safe practice, citing that such a policy would threaten professional independence. RANZCOG has policies and guidelines, as does the UK Royal College of Obstetricians and Gynaecologists. A mark of a professional body is that it possesses its own information that is unique to the profession. Why has this new policy directive caused such concern for doctors? It is merely suggesting that women should not be induced willy-nilly for no good reason and we have good evidence to justify this position.

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Cascade of intervention

Posted on February 1, 2012 by Melissa Maimann

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

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

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

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

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

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

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Natural Twin Birth

Posted on January 26, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Unkindest Cut: Countdown to a C-Section

Posted on January 25, 2012 by Melissa Maimann

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

Cooper-Schultz chose the cesarean. …
∗ ∗ ∗

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

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

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

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

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

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

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

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

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

∗ ∗ ∗

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

∗ ∗ ∗

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

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

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

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

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

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Care during Labour and Birth

Posted on January 24, 2012 by Melissa Maimann

A recent study from QLD has surveyed 20,371 women who recently gave birth. Experiences of pregnancy, labour, birth and after birth care were assessed for the most recent birth, retrospectively four to five months after birth. The findings were very interesting! The only issues with the data and study is that mothers self-reported their answers and there was no verification of the information, or cross-checking with the midwives and obstetricians who provided the care. In other words, it was based on women’s subjective experiences rather than what might perhaps be factual or accurate. That being said, I wanted to draw a few points out of the study and elaborate more on them. The other aspect to raise is that I am making an inference when I write about this study: the study compared women who were cared for in public facilities (public hospital delivery suites and birth centres: women who for the most part would have had public care providers) with women who gave birth in private facilities. Those women would, for the most part, have booked with a private obstetrician and given birth under their care. So from this, I am inferring that public care = care from public hospital staff where the woman does not choose her care provider; and private facility care = private obstetric care.

Care during Labour and Birth
Most women received labour and birth care from a midwife, and saw an average of 2.3 different midwives during their labour and birth. This is an interesting fact to consider, as many women believe they will have only one midwife in labour. The reality, in a hospital (public or private) is that midwives work in shifts, and there are three shifts in a day. Private midwifery and to a lesser degree, caseload models, do not work so much on shifts (although with many caseload models, the midwives are on-call for 12 hours at a time, so it is possible that you will go through two shifts of midwives even if you are only in the birthing facility for say 6 hours). Private midwives work their time around your labour, rather than the timing of a shift.

Half of all women who birthed in public facilities had never met any of their labour and birth care providers before, and this was significantly less common among women who birthed in private facilities because their obstetrician would be present for the birth, representing a familiar face. This is also an interesting point to raise: many women believe their obstetrician will be there with them during labour, or at least in the birth unit. This is not the case for the most part. For the most part, your obstetrician will be in the operating theatre, in his/her private consulting rooms or sleeping (eg if you’re labouring at night) and s/he comes in only if there is a problem and of course for the birth. Therefore, although there is continuity of sorts (the obstetrician you booked with will attend the birth), your actual care (which may be several hours) would be with midwives you have not met before, who all work in shifts. In contrast, private midwifery care is delivered by the midwife you booked with. Your private midwife would be there with you for the duration of your labour.

The majority of women in the study wanted to have a vaginal birth. Among women who wanted a vaginal birth, women who birthed in public facilities were more likely to have a vaginal birth than women who birthed in private facilities. This might be a reflection of the choices that women make, or of the recommendations of the woman’s care provider. For the purposes of the study, the private setting would have equated to private obstetric care because private midwives cannot admit directly to a private hospital. The possibility that obstetricians are influencing a caesarean rate of almost 50% in private hospitals in QLD was quite alarming, because many obstetricians would like us to believe that the caesareans that are performed are dome so because the women ask for them or because they are genuinely needed.

The truth is that with a study such as this, we will never really know. The women were surveyed 4-5 months after the birth of their baby, not before the birth. Before the birth, they may well have asked for a caesarean, but afterwards experienced too much bleeding, wound infection, pain, complications, separation from their baby and breastfeeding issues and come to regret their decision to pursue an elective caesarean. In this case, some women might have named their care provider as the one who recommended the caesarean, rather than admitting to themselves that they chose it. That is one view.

Personally, I do believe that some obstetricians have influenced the almost 50% caesarean rate. I believe this because every day I meet women who have birthed with, or are about to birth with, a private obstetrician. They tell me that they are scheduled for a caesarean, not because they have chosen this, but because it has been recommended to them. Sometimes the intention of the “recommendation” is to assist with “informed decision making”. This is where things get a bit muddied. The woman comes away believing the caesarean has been recommended, whereas the obstetrician interprets it as providing information to the woman so that she can then make an informed decision, and then reports that the caesarean was the woman’s choice. In any event, there are ways of wording things to illicit a response or decision that favours our bias. Some are more skilled at this than others.

For example, if I told you:

Caesareans have been shown in some studies to be safer for the baby, and given that your last labour was quite long and difficult, resulting in a painful forceps delivery with an episiotomy, you might like to consider a caesarean this time. Your baby would be spared the use of forceps, so he may well feed better than your last baby, because he won’t have a headache. You are also less likely to experience any pelvic floor issues. Most likely, given that you had an episiotomy last time, I might have to perform one again. I would try not to do this, but sometimes it is necessary. I know how painful the recovery was for you last time, so a caesarean might be preferable. Yes, you would still have stitches either way, but it’s far more comfortable having stitches on your tummy than your perineum.

Given this “information”, would you choose a caesarean? Possibly as this care provider has given some good arguments (some factual and others not so factual) for a caesarean, and has used emotive and persuasive language that plays on this woman’s traumatic last birth.

Now consider a different conversation:

Caesareans have been shown in some studies to be more harmful for the baby in terms of breathing difficulties and the need to admit the baby to the nursery. This would mean that you would be separated from your baby, and I know that after your last experience, you want nothing more than to hold your baby when he is born. Given that your last labour was quite long and difficult, resulting in a painful forceps delivery with an episiotomy, we can talk through some ideas to try that will minimise the risk of tearing. I believe that an intact perineum (no stitches) is absolutely possible for you. Also, there are many courses – such as Calmbirth – that will help you to manage the sensations of labour, along with labouring in a deep, warm bath. You know, I wouldn’t be surprised if you find you don’t even think of having an epidural this time! I know you’re worried that your baby might have a sore head and be a difficult feeder if forceps are needed, as this is what happened last time, but I’d like tor reassure you that forceps are really unlikely. Your body has birthed before and it will remember what to do this time. It would be very unusual that forceps would be needed again. This is a different pregnancy, different baby, different place of birth and different care provider. We can work together to make this experience very different – and very healing – from last time.

Given this “information”, would you choose to try a natural birth? Possibly as this care provider has given some good arguments for a natural birth, and has used emotive and persuasive language that plays on this woman’s traumatic last birth.

So, that is how it comes to be that women go with the recommendations of their care providers, and all the while, the care provider believes that it is the woman’s decision, while the woman believes it’s the care provider’s recommendation. If you’re now feeling very confused and like you don’t know who to trust anymore, my word of advice would be to interview a few midwives and obstetricians and ask lots of questions of them, and then go with the care provider that feels right for you. Also ensure that their statistics (birth outcomes) are aligned with the sort of birth you are trying to achieve. Once you have done this, trust your care provider and follow their advice if their advice makes sense to you and feels right. If it doesn’t, speak up and let them know.

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Satisfaction and support in birth

Posted on January 23, 2012 by Melissa Maimann

Being cared for well during pregnancy

The study found that women who birthed in private facilities were significantly more likely to say they were cared for very well during pregnancy than women who birthed in public facilities.

This is not surprising as women birthing in private facilities would be cared for in pregnancy by one obstetrician who was chosen by them.

Women who birthed in private facilities were also significantly more likely to report being treated with respect, treated with kindness and understanding, and treated as an individual by their pregnancy care providers.

This too is not surprising as their care provider was chosen by them.

Women who birthed in private facilities were also significantly more likely to say their pregnancy care providers were open and honest, respected their privacy, respected their decisions, and genuinely cared about their well-being.

This is all good news for continuity of carer models in pregnancy. Continuity of carer is very different to continuity of care. Continuity of care means continuous care from a small group of people – or even a large organisation – who shares a similar philosophy. It is interesting to see how far (and wide) this definition is stretched. Some would have us believe that we can give birth at the largest and busiest tertiary hospital as a public patient and receive continuity of care even though we had 30 care providers and never saw the same person twice. This definition – continuity of care – would still hold even in the above situation because all of the hospital staff would be working to the same philosophy and policies. Hence, continuity.

Continuity of carer, on the other hand, means that care is provided by one person for the most part. This is what we generally see with private obstetric care and private midwifery care.

Women who birthed in private facilities were more likely to say they were cared for very well in labour and birth than women who birthed in public facilities. However, the study found marked variations between public birth facilities with birth centres and midwifery-led units having the highest proportion of women saying they were cared for very well during their labour and birth.

This is good news for all those women who book with a private midwife or a public hospital-based caseload model.

Women who birthed in a private facility were generally more satisfied with the support they received after the birth, although only about 50% women were satisfied. The public hospital care rated even more poorly than that! This is evidence that the delivery of postnatal care needs to shift to meet the needs of women and babies.

Generally, women are discharged home early after the birth of their baby, with lengths of stay generally being around 24 – 48 hours in a public hospital. Women are then visited by a midwife once or twice following discharge; some hospitals provide more visits than this. Women who book with a private midwife generally enjoy more postnatal visits: 7 to 14 on average, with each visit lasting about an hour. A s well as this, women are generally prepared thoroughly in pregnancy for breastfeeding and baby care so that it is not so scary when the baby arrives.

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Choosing the best care provider for your needs

Posted on January 21, 2012 by Melissa Maimann

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

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

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

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

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

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

Visit my website to learn more about my services.

Medicare-funded midwifery care: What you need to know

Posted on January 20, 2012 by Melissa Maimann

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

What is a Medicare-Eligible Midwife?

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

Current general registration as a midwife in Australia with no restrictions on practice;

Midwifery experience that constitutes the equivalent of 3 years full time post initial registration as a midwife;

Current competence to provide pregnancy, labour, birth and postnatal care to women and babies;

Successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care;

40 hours per year of continuing professional development relating to the continuum of midwifery care (20 hours in addition to standard requirements);

Pregnancy care:

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

Childbirth education

Continuity of carer

Medicare benefits

Obstetric back-up

Birth in hospital – or at home

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

Postnatal care

Consultations in your home and / or my rooms

Medicare benefits

Visit my website to learn more about my services.

Doctors driving the increase in caesareans

Posted on January 19, 2012 by Melissa Maimann

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THE popular belief that caesareans are on the rise because women are too posh to push is incorrect, a new study shows.

University of Queensland researchers surveyed 22,000 Queensland mums …

… 48 per cent of women in private hospitals who had a caesarean did so on the recommendation of their [obstetrician].

Just under 40 per cent of women in public hospitals said the same.

… only 10 per cent said they had wanted to have their baby born that way.

“… the majority of women would prefer to have a vaginal birth,” …

“The increase in caesareans seems to be largely driven by the recommendations of doctors.”

… some women are going into the procedure underprepared.

Only 52 per cent of women … reported making an informed decision to have a planned caesarean …

Interesting research that backs up what midwives have known for a long time: the main driver for increased caesarean rates is not the mother’s choice to deliver by caesarean, but rather the recommendation of her obstetrician, who in most cases will be recommending a caesarean for non-essential reasons. I say this with confidence because upwards of 45% women do not “need” to deliver by caesarean for the sake of their babies or themselves. No-one could be justified in believing that caesarean rates this high are necessary in the majority of women who experience a healthy pregnancy. Private midwifery caesarean rates are well under 10%, with many private midwives having caesarean rates of around 5%.

The lesson is that a woman’s choice of care provider has the greatest impact on her mode of birth.

It is more important that her health issues, her choices and preferences for care, her previous birth experiences and her geographical location.

A woman’s choice of care provider will literally determine whether she undergoes a (possible unnecessary) caesarean or a natural birth. Late pregnancy and labour are not the times to be asking your care provider if their recommendations (for induction or caesarean) are truly necessary: women are simply too vulnerable in that state to make informed decision, and besides, informed decisions take take to research to come to an “informed” decision. When time is of the essence – in late pregnancy and labour – informed decision making almost goes out the window. Ultimately, the best strategy is to interview your potential care providers and peruse their statistics on birth. They say they support natural birth … but what are their stats on natural birth? What % of their patients have a caesarean, induction, epidural? If your care provider is vague and non-committal, that should speak volumes. If their rates are high and you are aiming for a low-intervention birth, it is not too late to identify this and seek a care provider whose philosophy – and outcomes – are more aligned to what you are hoping to achieve.

Visit my website to learn more about my services.

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

Posted on January 18, 2012 by Melissa Maimann

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

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

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

Visit my website to learn more about my services.

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

Posted on January 11, 2012 by Melissa Maimann

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

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

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

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

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

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

Wow!

The article goes on to say that

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

Whereas

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Do deceptive medical birth procedures de-humanize women?

Posted on January 10, 2012 by Melissa Maimann

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

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

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

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

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

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

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

Can an unwanted caesarian be a form violence against women?

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

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

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

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

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

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

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

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

Cesarean section, episiotomy, oxytocin and cosmetic vaginal surgery

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

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

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

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

Is there a solution to the problems?

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

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

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

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

Visit my website to learn more about my services.

Delivering better maternity care

Posted on January 8, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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Unassisted: Home Birth in Nebraska

Posted on January 5, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Balancing The Womb

Posted on January 3, 2012 by Melissa Maimann

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New research hopes to explain premature births and failed inductions of labour. The study by academics at the University of Bristol suggests a new mechanism by which the level of myosin phosphorylation is regulated in the pregnant uterus.

… phosphorylation of uterus proteins at specific amino acids have a key role in the regulation of uterine activity in labour.

A remarkable feature of the uterus … is that it remains relatively relaxed for the nine months of pregnancy … and then, during labour, it contracts forcibly and the baby is born. A special type of smooth muscle that grows and stretches during pregnancy to accommodate the fetus and the placenta forms the uterus.

Hormones such as oxytocin or prostaglandins promote labour, but the biochemical changes that allow the switch from relaxation to contractions to happen are not fully understood. This makes it difficult to predict when a woman is going to deliver. In eight to ten per cent of women delivery occurs too early … On the other hand when labour has to be induced for medical reasons, it is impossible to know whether the induction will be successful or whether it will require an emergency caesarean section …

… small biopsies of uterine tissue from women who delivered … demonstrated that contractions require both a calcium dependent pathway driven by myosin kinase and a calcium independent pathway that regulates the activity of myosin phosphatase …

… “This study has increased our understanding of the biochemical changes underlying uterine activity and may help in the design of better drugs to prevent preterm labour or to induce labour successfully at term, benefiting many thousands of women and their babies.” …

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

Posted on December 31, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Christmas baby rush

Posted on December 15, 2011 by Melissa Maimann

The original title of this article was, “Pregnant mums rush Christmas babies”. This is an interesting title as it’s not really the Mums who rush their babies’ births, but rather the doctors who authorise and perform the inductions. Health practitioners are not required to perform interventions that are not in the best interests of their patients. So perhaps the article should read, “Doctors rush Christmas babies”. That doesn’t sound as good as a headline, does it?

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MUMS-to-be are having their babies induced so they can be home in time for Christmas.

Women due around Christmas often asked to be induced early so they could spend the festive day with their other children, obstetrician Dr Samantha Hargreaves said.

But obstetrician Dr David O’Callaghan said social inductions increased danger for mother and baby by possibly triggering interventions.

Inductions raised the likelihood of epidurals, forcep and vacuum deliveries, caesarean sections and a slower recovery for the mother.

“The subsequent longer labour is more stressful on the baby, and the use of forceps is more stressful on the baby,” he said.

Richmond mum Michelle Godsall had been planning to be induced on Monday because she did not want to risk giving birth on Christmas Day, but she went into labour early yesterday afternoon.

… She was not aware of any added risks, but understood her labour could be more intense, but she decided it would be worth the extra pain.

In other words, her care providers did not explain the risks of induction.

Northcote mum Sara McCluskey, 38, who is booked in for an induction … said women should be able to have babies how they wanted.

“It’s not a lifestyle choice. I want to be able to spend Christmas with my 2 1/2-year-old daughter, who is just beginning to understand what it’s all about,” Ms McCluskey said.

If that is not a lifestyle choice, what is?

Dr Hargreaves said the surge in demand for inductions was a well recognised trend … She induced women only at 38 1/2 weeks or more into their pregnancy to avoid problems, such as being forced into having a caesarean.

It seems she too has not been informed of the risks, and that some 50% of first time Mums who are induced will actually end up having the caesarean she had hoped an induction would avoid.

Visit my website to learn more about my services.

Unneeded cesareans are risky and expensive

Posted on December 9, 2011 by Melissa Maimann

Link

Cesarean deliveries are over-used … and reducing the number of surgical births would save health-care dollars and protect women’s health. Those are the conclusions of a new white paper issued today by the California Maternal Quality Care Collaborative.

… in the last 15 years, the rate of surgical birth has increased from 22 to 32 percent of California deliveries with no measurable benefits for new mothers or their babies.

This is a concern because cesareans aren’t risk-free. After surgical delivery, women experience more pain, infection and hemorrhage than women who give birth vaginally. Women who have had a prior cesarean also have more problems with subsequent pregnancies. The placenta can become deeply implanted in scar tissue from the old incision, causing hemorrhage at the second delivery …

The white paper, which was funded by the California HealthCare Foundation, uncovered striking evidence for over-use of cesarean: Among low-risk women having their first baby, the rate of the surgery varies from nine percent to 51 percent of births based on the mother’s geographic location within California. As a press release about the paper says:

This large variation among California regions and hospitals cannot be explained by medical factors alone and therefore suggests that labor management practices and local attitudes help drive the use of cesareans during labor.

Reasons for the increase also include: physicians’ concerns about medical liability and avoidance of risk, as well as specific labor practices such as the increased reliance on labor induction, early labor admission, lack of patience in labor, and the virtual disappearance of vaginal birth after a prior cesarean …

“Over the last 15 years, cesarean deliveries have become so common that in some hospitals and communities they are considered ‘normal births’ despite the increased risks,” …

The white paper makes several recommendations for how to reduce unnecessary cesareans, including removing perverse financial incentives … encouraging VBACs … improving public education about the risks of cesarean delivery, and implementing statewide quality-improvement activities for better labor practices.

Unfortunately, there is no mention of the role of the midwife in preventing the first caesarean, or in helping a VBAC woman have a successful VBAC.

Visit my website to learn more about my services.

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

Posted on November 27, 2011 by Melissa Maimann

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

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

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

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

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

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

What were the intervention rates like?

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

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

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

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

Visit my website to learn more about my services.

Turbulent times

Posted on October 28, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

Visit my website to explore birthing services.

Natural birth in hospital?

Posted on October 8, 2011 by Melissa Maimann

Here are some ideas to birth naturally in hospital:

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

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

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

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

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

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

Visit my website to explore birthing services.

Private midwife at public hospital

Posted on September 29, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

Details: 0400 418 448 or essentialbirthconsulting.com.au

Midwives still ‘on the fringes’

Posted on September 28, 2011 by Melissa Maimann

A fantastic article that my colleague in WA was interviewed for. It explains the issues perfectly.

REFORMS to the way midwives operate in WA may have been introduced last year, but unless doctors and hospitals get on board, the reforms are meaningless according to Gosnells midwife Pauline Costins.

Mrs Costins is the first eligible private practice midwife in the State following the reforms.

The changes made it possible for her to provide a midwife service not attached to a hospital that women could claim a Medicare rebate for.

Hospitals and doctors play a part in births, at least for most women, especially those with high-risk pregnancies, so there is a level of interaction required between private midwives, doctors and hospitals.

But Mrs Costins said doctors and hospitals had not been receptive to the reforms.

… “I’ve written to 40 doctors and received one response, which was a polite ‘no’.”

… She added many hospitals would not allow her to provide her services in their hospitals

“I can’t take women into hospitals as a midwife, I have to drop them at the door. They don’t want me operating in their hospital.”

Mrs Costins said Kelmscott Armadale Memorial Hospital had made her a casual employee to let her provide her services at the hospital, but that was just a temporary solution.

She added that as well as giving a personalised service, a private midwife … offered six weeks of postnatal care in comparison to hospital midwives who provide about three days.

A spokesperson for the Australian Medical Association WA said the association was willing to meet with midwives to discuss collaborative agreements.

Our experiences in NSW have not been too dissimilar. I have contacted 26 obstetricians requesting a collaborative agreement; I am very fortunate that one Obstetrician has agreed and our model of care is working really well. As for admitting rights (recommended in the Maternity Services Review), NSW is yet to finalise a policy directive to enable midwife admitting rights. This is disappointing for women and midwives alike.

Visit my website to explore birthing services

China cuts childbirth mortality rate by promoting hospital births

Posted on September 23, 2011 by Melissa Maimann

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

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

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

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

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

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

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

Visit my website to explore birthing services.

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

Posted on September 9, 2011 by Melissa Maimann

Private Midwife:

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

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

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

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

Supports women to breastfeed

Provides pregnancy, birth and postnatal care

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

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

Private Obstetrician:

Provides autonomous care for women regardless of risk factors

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

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

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

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

Pregnancy appointments are generally no more than 15 minutes in duration

Collaborative care: private midwife and private obstetrician

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

No transfer of care if risk factors emerge

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

Supports women to breastfeed

Provides pregnancy, birth and postnatal care

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

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

Provides autonomous care for women regardless of risk factors

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

Visit my website to explore birthing services.

Choosing the right care provider

Posted on September 7, 2011 by Melissa Maimann

Choosing the right practitioner is a very personal decision and there is no right or wrong choice. Some women will make an initial choice of care provider and decide to change care providers during the pregnancy other women will make one choice in their first pregnancy and then a different choice in a subsequent pregnancy. What’s important is understanding all the options available so that you can feel confident to choose the best option for your needs.

What do I want from my care?
What type of practitioner would I feel most comfortable with?
Do I want public or private care?

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

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

Visit my website to explore birthing services.

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

Posted on September 2, 2011 by Melissa Maimann

Great question! There are a few options available to you as a private patient, as well as all of the options that are available to public patients. Specifically, 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 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.

Private obstetrician
Private obstetricians can 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.

Visit my website to explore birthing services.

Hospital births continuing through our service

Posted on August 29, 2011 by Melissa Maimann

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

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

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

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

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

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

Visit my website to explore birthing services.

‘Illegal’ midwives: Is Australia destined for the same?

Posted on August 21, 2011 by Melissa Maimann

An article from Canada explains their midwifery system which includes unregistered midwives.

Ann (not her real name) operates outside the regulated profession, living life on the edge, exposed to a constant threat of legal action should births under her watch go wrong.

She knows five other unregistered midwives working in Montreal’s so-called “parallel network.” They typically help women who are unable to secure legal midwife services to have their babies at home or in a birthing centre, and who reject the official alternative of giving birth in a hospital

There is no shortage of demand for their services. With just 140 registered midwives able to practise across the entire province, the parallel network fills a yawning gap in the market. Much of the birthing industry – obstetricians, gynecologists and some registered midwives – would consider its covert practitioners to be charlatans. But, to women determined to choose how, where and with whom they give birth, they are valued allies.

Take Teprine Baldo, who had her eldest child, now 2 years old, at home with the help of what she calls a “midwife recognized by the community. I prefer the term. It’s more respectful. People tend to talk about illegal midwives the way they used to talk about witches,” she says.

There has been one prosecution over the years. In 2006, Diane Boutin was forced to transfer a woman in her care to … Hospital after complications set in mid-labour. Following an emergency Caesarean, the gynecologist on duty filed a complaint with the provincial order of midwives … which went on to successfully pursue Boutin for illegal practice under Quebec’s professional code, a felony carrying a fine of up to $6,000.

In the days before the profession began its slow march toward legalization in the 1990s, all midwives were renegades operating outside the system, some entirely self-taught, others holding foreign qualifications unrecognized by the province. But, times have changed and as the now-regulated profession wages a PR battle for public acceptance, pushing against residual resistance from an often skeptical medical establishment, it cannot be seen to condone illegal practice.

parents are likely to be the biggest losers when things go wrong, should newborns be left damaged as a direct result of negligence or malpractice.

It’s a hugely sensitive issue. Sinclair Harris, a registered midwife at Pointe Claire birthing centre, is sympathetic with her unregistered counterparts. But, she says, “You need an understanding of pathology, of the things that can go wrong, if you are to be available for the mainstream public.”

Women like Baldo are incredulous that they are still being denied that choice, outraged that the black market midwives helping the most determined to exercise basic rights over their bodies risk prosecution.

“It’s like we’re being told we can’t birth properly,” she says. “I’m not against hospitals. My issue is that there’s often no alternative.”

At 32 weeks, she dropped out of the system, switching to an unregistered midwife

Seeking closure after a traumatic first birth in hospital, Caroline Gauthier gave birth to her second child at home with an unregistered midwife.

She was living in British Columbia, pregnant with her first child, when her dream of an intervention-free home birth went awry. Transferred to hospital by her registered midwife after her cervix was slow to dilate, she was administered hormones to speed up labour.

“I was like Jabba the Hutt, hooked up to the monitor,” she says. Staff forgot to turn on the oxygen supply to her mask, leaving her flailing about for help. When her baby finally arrived after a traumatic final push, she was barely able to touch his foot before he was whisked away.

Pregnant with her second child in Quebec, she immediately set about trying to secure a midwife at the Du Boisé birthing centre in the Laurentians. However, her place was contingent on her delivering at the birthing centre.

But Gauthier had already set her heart on giving birth at home. At 32 weeks, she dropped out of the system, switching to an unregistered midwife. Again, her labour was long, but she sat out the hours in the bath and in bed. “This time, I had a midwife who didn’t have a system to please,” she says.

After three days of labour, the baby’s head popped out while she was on her way to the bath. “In less than two minutes, the whole body was out,” she says. He didn’t immediately cry, “but nobody made a circus out of it.”

Vindicated by her second experience, she is now a fierce advocate of women’s right to give birth as they choose. “I was given the time my baby needed,” she says. “My neighbours tell me I was so brave delivering at home. My reaction is: ‘My God, you’re brave giving birth in hospital. You’re putting yourself at their mercy. You don’t know what you’re getting yourself into.’ ”

The midwife: With no insurance, every new client is a gamble

On D-day, Ann arrives on the scene with a case containing oxygen supplies, a heart monitor, synthetic oxytocin, herbal remedies, suture material and local anesthetic for stitches.

She has been practising midwifery in the parallel network for more than 10 years. Clients find their way to her by word of mouth. She has a busy schedule year round, attending to three or four clients a month.

Clients are generally women who have been unable to find a registered midwife …

Occasionally she has transferred cases to hospital …

With no insurance, every new client is a gamble. “My insurance is the trust I develop with the parents. I trust people who have the deep belief that it’s best for the birth of the baby. Nobody can be sure of the end result.”

There is a contract, though she is clearly ill at ease with cold legal realities. “It’s about ensuring the parents understand what they’re getting into,” she says. “But, sometimes I forget to get people to sign. We’re on another level. It’s not about business.”

She describes herself as a self-taught midwife eschewing a system where midwives are “too stressed, too watched.” …

The four-year university program didn’t appeal to her. “I thought it was too focused on pathology. There was no alternative medicine. No spirituality,” she says. “It’s as if only one kind of intelligence is allowed. Forget emotional intelligence.”

Midwifery was legalized in Quebec in 1999, following a five-year pilot project. Home births with the assistance of registered midwives have only been allowed since 2005.

In a 2007 Statistics Canada report, 71 per cent of women who had delivered with a registered midwife rated the experience as “very positive,” compared with 53 per cent of women who had delivered in a hospital.

According to research … midwife-assisted home births are associated with lower rates of obstetric interventions and adverse outcomes. Newborns born at home were also less likely to require resuscitation or oxygen therapy.

Australia is heading for a similar situation, brought about by a few factors: the recent position statement on homebirth which effectively prevents midwives from attending high risk births at home, the lack of visiting rights to enable most midwives to birth in hospital with their clients, dissatisfaction with current hospital-based maternity services that are seen by women to be impersonal and highly interventionist, and a differing view of things such as risk and responsibility. Although some midwives are making the choice to unregister and continue to attend births, they do face the same issues that are explained in the article.

Visit my website to explore homebirth and hospital birth.

Caesarean section? Vaginal birth? Your choice!

Posted on August 15, 2011 by Melissa Maimann

Visit my website to explore homebirth and hospital birth.

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

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

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

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

33% will be induced

23% will have forceps or vacuum

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

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

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

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

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

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

Hospital Transfers

Posted on July 24, 2011 by Melissa Maimann

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

There have been some articles in the press in the past few days about women being transferred from one hospital – the one they were booked to give birth in – to a different hospital. See here and here.

Of course the women and families concerned are, well … concerned. Any time a woman’s birth plans are disrupted without notice, the situation can be stressful.

In one situation, a woman was transferred from Campbelltown Hospital in Sydney to John Hunter Hospital in Newcastle. She was in threatened premature labour with twins. The ambulance trip took three hours. This journey happened because there were no neonatal beds available in Sydney to care for these twins.

On the surface, this seems appalling … a woman transferred by road, for three hours, carrying twins, with the possibility of delivering them in the ambulance! However, looking beneath the surface, the detail reveals that the care provided was appropriate. According to the media reports, the woman was only 26 weeks pregnant. This is called “extreme prematurity”. In cases of premature babies, we have a task of matching their care needs to the right hospitals. We have hospitals of different levels. Some are only equipped to care for term babies, being those born after 37 weeks, while others can care for babies born after 34 weeks. And very few – only 8 across NSW and ACT- can care for babies as young as these twins were.

Caring for babies as young as these ones requires immense resources.

Intensive care baby

A specialised neonatal cot, sophisticated monitoring equipment, syringe drivers, 24/7 access to pathology and radiology, a neonatologist (this is a paediatrician who specialises in the care of newborn babies) and dedicated NICU nurses. These are specialised nurses who have completed additional graduate certificates and have extensive clinical experience. In smaller hospitals, the requirement of having these skilled and competent practitioners – as well as the purchasing and maintenance of equipment that is seldom used – would represent a significant cost inefficiency. The vast majority of babies are born at term, with a mere 0.7% babies born at – or prior to – 26 weeks.

The Health Minister, Jillian Skinner, advised that there were more than enough beds to cater for the State – and this is true. On average. Averages work well most of the time, but sometimes we need more beds than we have available, and this is when babies are transferred to another hospital. Sometimes this is as simple as transferring from say Canterbury Hospital to the near-by Royal Prince Alfred Hospital. Other times, rarely, babies are transferred further away, and even interstate. And other times – though this never reaches the news – there are very few babies in our neonatal intensive care units …. and the full complement of staff has very few babies to care for. Neonatal beds lie idle. This is never newsworthy but according to the law of averages, it happens as often as babies are transferred to another hospital.

Some have argued that the woman should have been able to birth her babies at Campbelltown and then move the mother and babies to another hospital. This situation is what we call an ex-utero transfer, where babies are transferred after they have been born. unfortunately this is always worse for the babies for a couple of reasons: first, the birthing hospital may not have the facilities, staff, equipment and expertise to care for the babies, and second, when the specialised team arrives to transfer the babies, this complex transfer takes hours just to set-up in the hospital because the babies need to be switched over to the helicopter equipment and stabilised before they can be moved. Having been involved in these situations, I know it can take hours and this is all time that the fragile and delicate babies are being disturbed. So for many reasons (more than I have listed here), it is far better to do an in-utero transfer – that is, transferring babies while they are still inside their mothers.

In this woman’s case, her babies remained safe inside and were not born.

In another case, a woman was transferred in labour from a low-risk birth unit to a unit that handled higher-risk births when it became apparent that she had risk factors associated with her labour. This was a good call. A risk was anticipated that could not be dealt with at the local hospital, and the woman was safely moved to a unit that had the resources to provide safe care to her. This is no different to a woman moving from the birth centre to the delivery suite, or from a planned homebirth to hospital at any stage of the pregnancy or birth.

What’s important is that the care that is provided is safe, and part of providing safe care is recognising the limitations of a service and having a good back-up plan or transfer plan. NSW has a specialised network that communicates well to advise all hospitals of which ones have available NICU beds. In this way, a midwife or doctor can quickly arrange a transfer. Likewise, a smaller hospital will be buddied with a nearby larger hospital with formal transfer plans and agreed indications for transfer, so that if a woman presents with something that is higher risk than what the smaller hospital can safely care for, the smaller hospital will have a plan in place to communicate with the larger hospital and to arrange a safe transfer.

Two mothers given wrong babies to breastfeed

Posted on July 19, 2011 by Melissa Maimann

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

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

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

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

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

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

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

Melissa Maimann & Andrew Pesce: Collaborating for success

Posted on July 18, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Home birth has pros and cons

Posted on July 15, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lack of collaboration stalls maternity reform

Posted on July 7, 2011 by Melissa Maimann

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Midwives urge government to relook at legislation.

The government’s maternity reforms are “doomed to fail” as a result of obstetricians refusing to enter into collaborative arrangements with midwives.

… “We always feared that these arrangements would be more about control than collaboration,” … only … three [collaborative agreements have been signed] …

“Midwives are asking obstetricians in writing and calling up to 10 times to organise collaboration. Some get no response, some a polite no and others a very rude no,” …

“We did expect that this would be the case. When you put one competing professional group over another group competing for the same market share, the group in control isn’t going to do something that threatens their sizeable share. I can understand that they are threatened.”

It is true that there are only one or two obstetricians who have signed collaborative agreements with midwives, and only one that I know of whose agreement covers labour and birth care. This is disappointing because the models of care that are possible with collaborative agreements between private obstetricians and private midwives are so beneficial for women.

Arizona hospitals taking stricter stance on scheduled births

Posted on July 2, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Re-thinking Maternity Care Systems

Posted on June 19, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

Is ‘tribal’ obstetric culture endangering mothers and babies?

Posted on June 15, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But we need to go even further.

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

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

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

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

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

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

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

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

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

Posted on June 13, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Special delivery brings relief

Posted on June 3, 2011 by Melissa Maimann

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

Link

PRUE Corlette travelled up to five hours a day to Liverpool Hospital from Rose Bay.

… The twins were born nine weeks premature at Liverpool Hospital … not at The Royal Hospital for Women as she intended.

When Ms Corlette went into early labour, there was no room in the Randwick hospital where her midwife and obstetrician were.

Their 15 high-care cots in the neonatal intensive care unit were all occupied but there were ones available at Liverpool, Canberra and Newcastle hospitals — the closest one Liverpool, 45 kilometres away.

“My midwife and obstetrician (from the Royal Hospital for Women) couldn’t come with me,” …

… “I had built up a good rapport with my obstetrician … We had similar philosophies of birth.

“When I got to Liverpool, the birth philosophy was quite different. They wouldn’t even give me a hot water bottle.”

Theodore arrived first, then Hugo was born through an emergency caesarean section.

“I had a succession of different doctors see me,” …

“To be going into premature labour and to not have a consultant is terrible.

“My second baby got into some kind of distress. I heard people screaming ‘code red’ but no one explained to me what was happening.”

Ms Corlette was discharged after three days but the twins remained at Liverpool Hospital’s neonatal intensive care unit for another 10 days.

Having undergone a caesarean she was not allowed to drive so she had to make the long trip from her home on public transport.

“The staff in the neonatal unit were very helpful but the maternity ward not so good. It was very busy and overcrowded,” …

The babies were transferred to the Royal Hospital for Women when cots became available.

… “Liverpool Hospital has a well-staffed and resourced 12-bed Neonatal Intensive Care Unit (NICU), which is one of a number of NICUs in NSW that provide specialised care for premature and very sick babies from across the state,” …

… neonatal intensive care beds are networked to ensure that whenever an expectant mother gives birth, she and her baby have access to the specialist care required. “This may result in the transfer from one hospital to another due to the level of care required or bed availability.”

If I were Prue, I’d be thankful that care was available for my babies, that I did not have to be flown to Canberra (or further – say to Perth), and that we live in a country that provides such a high standard of care to mothers and babies. She did not get the care she had planned from the midwife and obstetrician that she had chosen and this was not expected, but thankfully a transfer was possible to a hospital that could provide the necessary care. Had her babies been born at RHW, they could not have received the care they needed as there were no cots available in the NICU, and presumably no staff available to care for the babies.

For some women, a transfer will be needed. This could be because the hospital doesn’t have the facilities to care for the baby – such as a private hospital or a small public hospital – or because the larger public hospital’s NICU is full. It’s not possible to staff every unit with NICU-qualified staff 24/7 and obtain and maintain the very specialised equipment that is needed so seldom. Hence, these specialised services are provided in a few centres. In Sydney, we are proud to have 6 hospitals with NICU facilities. These hospitals provide a high standard of care to preterm babies, as measured by international standards. We are lucky to live in a country where our babies can be cared for so well.

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