Tag Archives: women’s rights

Responsibility in birth: Who owns it?

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Who is really responsible for intervention that happens in our births? Is it us or our health professionals? Or is it both?

In this blog post, I’m referring to situations where unnecessary intervention has taken place. Of course there’s a place for intervention in some labours and this post does not address interventions that are truly necessary. However that’s defined!

Some women argue that birth – and what happens in birth – is their responsibility and they take charge of all decisions and also take responsibility for the outcome of those decisions – good or bad. Women in this category would never dream of blaming their care provider for a bad outcome because the decision was theirs alone and they made a fully informed decision that they were comfortable with. When things go well, they attribute that great outcome to their good preparation and decision making.

Other women will outsource decision making to a health professional such as a midwife or a doctor. “They’re the experts”. In life, we outsource all sorts of decisions, so it’s not surprising that women may choose to do this for pregnancy and birth.

When things go according to plan – a woman has the birth she was hoping for, the baby is healthy, breastfeeding goes really well – there’s no issue at all. When things don’t go as planned, issues of responsibility (and sometimes blame) come up.

Over the years, I’ve sat back and observed women’s reactions when things don’t go well.

I think there are two parts to things not going well. One is the woman’s responsibility for her decisions and the other is the health professional’s conduct.

I’ve observed that when things don’t go to plan, very few women take responsibility for the choices they made that might have led them down a path that they never planned to walk. Eg women who might really want a natural birth who choose a hospital with a very high caesarean, episiotomy, epidural and induction rate. “It won’t happen to me” and then it does.

Some go right back to the same care provider and place of birth – it’s what they know and what they’re comfortable with – even though the outcome is not what they really want. Should they complain about their [caesarean / epidural / induction / forceps / episiotomy] and say they’re not responsible: their care provider is? I think not – choosing the right care provider and place of birth is each woman’s responsibility. If the hospital / health professional has a 50% caesarean rate – yep, that applies to you too.

Some people argue that women can never take full responsibility for their births because the information that’s relevant to them is hidden, disguised, not available until it’s too late and so on. In these cases, some argue that the woman could not have possibly got the information that would have assisted them to make a choice for their birth that is more aligned to what they’re trying to achieve. But if this is the case, how do we account for women who do magically find information, make decisions that are compatible with their needs, and experience the birth they had wanted? What sets these women apart from other women? Determination? A strong sense of self-efficacy? Confidence? Having options?

Information is all around us. We can talk to care providers, hospital midwives, friends / family, google relevant articles and information, talk to private midwives and obstetricians and so on … there’s lots of information out there, even in rural / remote areas, thanks to the WWW. In NSW, hospital statistics are publicly available. Is there any excuse for not knowing your hospital’s caesarean rate if you live in NSW?

When we buy a car, we know we have many choices. Not just the make of the car, also auto / manual, number of doors, convenience features, comfort features, safety features and so on. If we only go to Toyota and buy a car that’s not suited to our needs – and this becomes apparent a couple of weeks later – is this Toyota’s fault? Maybe, but only if Toyota falsely advertised the car’s features. We’re responsible for the choices we make. Likewise, if we choose hospital X without exploring other hospitals, or settle on Dr Y or Midwife Z without interviewing others who might be better suited to our needs – is it the doctor’s / hospital’s / midwife’s fault if the birth has more intervention than the woman had hoped for?

In all industries, it is the responsibility of the consumer to first work out what they want, and next to set about finding a service / product that meets their needs. Is birth any different? It is true that we cannot control birth, but if we want a drug-free birth and we know from the outset that our care provider only attends epiduralised births, is this a compatible choice?

Now, the other side of this whole argument is the issue of conduct. While I firmly believe – and know – that information is out there, freely available, and that women are most definitely responsible for choosing the right care provider and place of birth for their needs, I also appreciate that health professionals are responsible for their conduct.

Negligence says that a health professional owes a duty of care to the patient, the duty of care is breached, the patient suffered harm, and the harm is a reasonably foreseeable consequence of the breach of duty of care.

If this happens, then of course the health professional is to blame and the patient ought to raise this as an issue so that it can be addressed either legally or within the profession. Drug errors, incorrect surgical technique, performing the wrong operation, failing to gain consent, working while under the influence of drugs or alcohol – these are all serious issues that ought to be reported.

So, in summing up, I think that responsibility for birth is a complex issue. While women are most certainly responsible for choosing the right care provider and place of birth (amongst other decisions), health professionals are responsible for how they practice their profession.

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Turbulent times

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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?

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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.

Well-off mothers spend thousands on private midwives

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

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

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

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

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

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

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

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

Visit my website to explore homebirth and hospital birth.

Homebirth Position Statement

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

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

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

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

  • Studies of planned homebirths with a registered provider/s, compared with planned hospital birth
  • Research articles that also addressed maternal and neonatal outcomes
  • Articles from developed countries, written in English and with a publication date between 1995 and 2011.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Rules on patient safety hit midwives

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

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    Homebirth supporters claim bureaucrats are restricting women’s choice by stopping some midwives from managing higher-risk homebirths, particularly women who have had a caesarean delivery.

    Homebirth Australia said it was aware of more than 20 recent cases … where midwives had been deregistered or had conditions imposed on their registration because of claims they were working outside safe guidelines.

    … The Weekend West is aware of a WA midwife who was ordered last week to stop providing care for planned homebirths in women at higher risk, including those who had a caesarean and wanted to have a normal birth in the next pregnancy.

    The Australian Health Practitioner Regulation Agency wrote to the midwife, saying the condition was imposed by the WA Nursing and Midwifery Board because the midwife had not proved he or she could provide a safe homebirth environment for a planned vaginal birth after a caesarean.

    “The board formed the reasonable belief that because of your alleged conduct issues, you pose a serious risk to persons, and it is necessary to take immediate action to impose conditions on your registration to protect public health or safety,” the letter said.

    … the move could force women to have unattended homebirths, putting them and their babies at risk. “We can’t by stealth deregister or pose conditions on midwives which rob women of access to a registered health professional,” she said.

    Australian Medical Association WA president Dave Mountain … questioned whether the health system should allow higher-risk women to exercise the choice of homebirth when there were clear risks for them and their babies.

    What a huge ethical debate – largely unresolved. All women have the right to autonomy – the right to make choices, have control over what happens to their body, to accept or reject advice and interventions, to decide when, where and by whom they will be cared for, to access care – or not. It is a fundamental human right that is enshrined in law.

    On the other side – the health practitioner has a duty of care to the woman and her unborn baby and is obliged to provide safe care at all times. Safety is defined in terms of what the average midwife would do, or by accepted professional standards, or by laws relating to practice. A health practitioner cannot be incited to practice unsafely: they must make a judgment and adhere to professional standards.

    So where does this leave us all when the two positions collide? Although we have guidelines on what we ought to do in those situations, as we can see from the above article, they do not hold water. The consequence for now is an increase in the number of women opting to freebirth – that is an unassisted homebirth (no midwife present). I am hopeful that in time, the regulatory authorities will support midwives to support all women.

    The tragic dangers of home births, by coroner

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    A senior coroner has urged a change in the guidelines for midwives on home births after two breech babies died.

    … He said midwives should make explicit the dangers of home births for infants in the breech position. They should note their advice in writing and even get a parent to counter-sign the record.

    His warning came after inquests yesterday into the deaths of Phoebe Baker and Christopher Gurney …

    … The inquest heard that Penny Baker gave birth to Phoebe at her home …

    She told the coroner’s court that her midwife … realised the baby was very likely to be a breech, but she did not want a caesarean section.

    Mrs Baker said: ‘The facts were put to us and it was our choice what to do with the facts.’

    Although the birth appeared to go smoothly, Phoebe had to be resuscitated …

    Mrs Baker said her daughter was feeding happily when the midwives left but by the following evening she was ‘sleepy and unresponsive’.

    … a routine check … found the baby was not breathing and had no heart rate.

    … attempts to resuscitate her failed. The cause of death was an adrenal haemorrhage, brought on by lack of oxygen at the time of the delivery …

    He was also told of the case of Yvonne Gurney who gave birth to Christopher at home …

    He was also found to have been ‘upside down’ during delivery and died an hour later …

    Dr Knapman said he would write to the Nursing and Midwifery Council asking them to consider ‘that in respect of home birth the guidance given should be extended to include explicit recording, in writing, in what terms the risks have been explained, including a recommendation, if any, and perhaps even to encourage the mother to counter-sign’.

    … the Royal College of Midwives said … ‘Midwives record all discussions held with the mother but we would have reservations about counter- signing because it might put emotional pressure on her.’

    Mrs Baker and her husband Hugh … said they felt no bitterness towards their midwife … ‘I chose a home birth because during my first pregnancy I had an appalling experience of the NHS.’

    It’s an erroneous assumption that hospital birth per se would have “saved” these babies. Many women birth their babies in hospital but do not follow the policies or recommendations of the staff, potentially making the birth no safer than a home birth. Supposing these babies were born in hospital under the physiological conditions that are present at home: upright and active labour, no epidural, no forceps to the after-coming head, no episiotomy, a quiet, dimly-lit room with one midwife in constant attendance … would the outcome have been any different? Women do have the right to make their own decisions about their care. It might be helpful to develop some standardised information that can be given to families who are planning to birth at home, or have a vaginal breech birth, or any other type of birth, because after all, all births carry some risks that we do assume merely by becoming pregnant. A well-informed family who are motivated by love, not fear, will generally make the best decisions for their family.

    Lisa Barrett has some amazing home breech birth blog posts.

    After the first caesarean, a second one is much more likely

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

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    TRACY HART had intended to have her first child … naturally. But when Ariane failed to move into the normal birth position, Mrs Hart was told that a caesarean was the safest option.

    Second time around, Mrs Hart, 35, was eager to try again for a natural birth, but at 41 weeks and two days into her pregnancy, she still had not gone into labour. A caesarean was ordered – because doctors thought an induction might have been too hard on her scarred uterus – and four days ago son, Saxon was born …

    … Mrs Hart said, ”I was mortified and cried, because I had mentally prepared myself for a natural birth. A lot of women who don’t have any problems giving birth don’t realise some women just don’t have a choice.”

    Unfortunately Mrs Hart didn’t know that all women have a choice about how their baby enters the world. Some choices are safer than others; some are safer for the mother while others are safer for the baby; but whatever way you look at it, all women have a choice.

    First-time mothers with no obvious health problems, and subsequent births like Mrs Hart’s where the first was by caesarean, are overwhelmingly the biggest contributors to the NSW epidemic of caesarean births, state data shows for the first time.

    Twins, and babies in the breech or other difficult positions in the uterus, account for a much smaller proportion of the one in three babies now born by caesarean section …

    During that time, the overall caesarean rate increased from 19 to 30 per cent of all births. But subsequent caesareans increased much faster, at an average 5.3 per cent a year during the study period.

    Among first-time mothers, caesareans grew fastest – on average 6.8 per cent a year – among those who did not go into labour or whose labour was induced, suggesting a big rise in planned procedures. Among first births where the woman went into labour and later delivered surgically, the increase was only 3.5 per cent a year.

    … the new data provided the first comprehensive state-wide picture of factors behind the surge in caesareans, which NSW Health has pledged to bring back to 20 per cent of all births by 2050. It suggested that concentrating on promoting normal birth among first-time mothers would have the biggest impact on reducing the overall rate …

    I have always known that promoting normal birth – via private midwifery care – to all first time Mums, all women who have had a previous caesarean, and all women who have had a previously traumatic birth – would dramatically lower the cesarean rate.

    The research … showed it was highly unlikely the increase in caesareans could be legitimately attributed to complications such as the older age and the increase in overweight mothers … because most of the rise had occurred in women with apparently few medical risks …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Our legislation is a threat to the freedom to practise and women’s rights in childbirth

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

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    Ireland is also going through the process of requiring professional indemnity insurance for all health practitioners, including midwives. Midwives will have access to insurance, provided that they practice according to strict guidelines, much the same as we now have in Australia.

    The recently-reported horrors endured by home birth midwives in Hungary are but a pale shadow of those planned for midwives in Ireland.

    Agnes Gereb faced five years in jail for assisting at a home birth: Irish midwives face up to 10, if they breach the HSE’s onerous terms and conditions.

    … the Nurses and Midwives Bill makes it unlawful for midwives … to practice without indemnity.

    Making insurance mandatory is key to compliance with State bureaucracy: lurking underneath Section 40 lies an invisible undercarriage of rules and regulations binding independent midwives hand and foot. Surveillance is tight: the HSE requires midwives to surrender client files before issuing payment.

    Sixty years ago in Ireland, childbirth was women’s business. Having a child at home was the norm. Midwives were self-governing, albeit via a London board. Today, so powerful has the health bureaucracy become that women have lost their power over birth. Midwives have lost the freedom to practise autonomously, and women have lost a fundamental liberty: the right to decide how and where their child will be born; the terms under which midwives are legally required to work; and the conditions under which women are obliged to give birth.

    However, there are signs of hope. The European Court of Human Rights recently ruled that denying women the freedom to give birth at home denies them their human rights.

    The Court ruled that the circumstances of giving birth incontestably form part of one’s private life and that, under Article 8 of the European Convention on Human Rights, prospective mothers have the right to choose those circumstances. Only an independent midwifery profession can enable that choice.

    Subordinate to a nursing board, midwives in Ireland have lost the freedom to rule themselves. They have all but lost the right to offer the services of their choosing in the community.

    They can no longer decide whom to accept as a client, or when a pregnancy ceases to be normal. And when a mother exhibits some change in her condition, however minute, that is deemed a disqualifier for home birth and their indemnity lapses.

    Care is to be withdrawn from the mother at home, even during the height of labour. New draft guidelines suggest the calling of ‘relevant stakeholders’ …/em>

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Midwives offered home-birth cover on HSE terms

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    SELF-EMPLOYED community midwives will be indemnified by the State Claims Agency to attend at home births only if they sign a memorandum of understanding with the HSE …

    Minister for Health Mary Harney told the Select Committee on Health and Children she was a supporter of home births for “low-risk” women.

    … “If something goes wrong, the Clinical Indemnity Scheme will provide indemnity as long as the midwife has signed the memorandum,” she added.

    … They say provisions in it will deny some women the right to have a home birth as self-employed community midwives will not be covered to attend at home births in some circumstances, and not at all if they refused to sign the memorandum.

    Krysia Lynch, co-chairwoman of Aims Ireland, said the Bill was “taking away a mother’s human and constitutional right to choose where to have her baby, having informed herself of any risks”.

    … Among the issues covered by the memorandum are the qualifications a self-employed community midwife must have, their professional conduct, performance management and risk-management practices.

    The reason for the new arrangements are the withdrawal by the former Irish Nurses Organisation of insurance cover from community midwives in 2008 as they were deemed too high a risk …

    … the memorandum of understanding would mean women could continue to have home births by guaranteeing insurance was available to midwives who operated to the highest clinical standards and offered their services to women who were low-risk cases.

    … Any midwife who attends at a home birth for reward, who does not have adequate clinical indemnity insurance will be guilty of an offence and could be subject to a significant fine, a period of imprisonment or both.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Your body, your choice

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

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

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

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

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

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

    Wong’s experience isn’t unique.

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

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

    Birth trends

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

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

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

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

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

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

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

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

    Medical interventions

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

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

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

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

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

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

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

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

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

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

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

    The big ‘C’

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

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

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

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

    Disturbed birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Take control

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Fight for home birth continues: Ireland

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    Supporters of a woman’s right to have a home birth say the practice could be driven underground if new legislation is passed. Tomorrow, the Association for Improvements in the Maternity Services (AIMS) Ireland will deliver a petition to the Dáil while picketing the building to highlight their concern that the Nurses and Midwives Bill 2010 will effectively prevent the practice of professional midwifery in the home.

    “This is taking away a mother’s human and constitutional right to choose where to have her baby, having informed herself any risks,” … Among those who would not be allowed to have a home birth are Caitríona Ellis … who delivered her second child at home last week.

    If the legislation had been in place last week, Ellis would not have been allowed to give birth at home … The proposed bill states that a mother in labour must be transferred to hospital if 24 hours have passed since her waters have broken and she has not given birth. Ellis gave birth 32 hours after her waters had broken.

    … “This is a human rights’ breach. The legislation takes away the woman’s right to choose the birth she wants,” …

    Catríona Clarke … would not have been allowed to have her second baby at home five weeks ago either because her first baby was born by Caesarean section. Under the bill, all women in her situation would have to give birth in a hospital.

    “I thought I was more likely to have a natural birth at home and more likely to have interventions in hospital. I really believe that childbirth is a natural process that has become medicalised and that home was the best choice for me,” says Clarke, who says hers was a “beautiful, gentle” natural home birth.

    Any midwife assisting in a birth in situations where these criteria are not met would be liable for a fine of up to €160,000 and a prison term of up to 10 years …

    These two stipulations mean that self-employed community midwives (SECMs) will need to have insurance managed by the State … since clinical indemnity is not available to midwives on the open market.

    … If a home birth were to go wrong and the parents sued, the State could have to make an enormous payout. The legislation is an attempt to minimise that possibility.

    It was decided that the scheme would cover only low-risk births, where there was no history of medical or surgical problems that might affect pregnancy and no present or previous complications.

    … Canning says the proposed legislation could contravene both the constitutional rights of the midwife to practise and an EU council directive requiring member states to facilitate midwives in the practice of their profession.

    “In the context of mandatory insurance, it is questionable whether a restrictive package of insurance constitutes the facilitation of the midwife to practise when insurance is otherwise inaccessible,” she says.

    From a practical point of view, if a pregnant woman refused to go to hospital 24 hours after her waters had broken, the midwife would have to leave the scene under the new legislation.

    … Canning … the the midwife has a duty to remain in attendance on the mother in childbirth, even if the mother refuses to comply with her advice.

    She spends a lot of time with her expectant mothers, talking them through the experience of childbirth and securing their agreement that, if in her professional opinion they need to go to hospital, they will do so.

    Any midwife is relying on the mother to trust her judgment and be willing to follow it. Under the legislation, were the mother to fail to comply, the midwife would be at risk of prosecution if she stayed on the scene.

    Gillian Kane … had her first baby by elective C-section in hospital and planned a home birth for her second.

    As the second birth progressed, Canning diagnosed a serious problem and transferred Kane to hospital, where she remained with her.

    Kane had to have a second C-section, but she says her baby benefited from having a normal labour that was allowed to progress as far as it could at home.

    “When the decision to go to hospital was made, it was by a medical professional I trusted – I had developed such a strong relationship with her and had such belief in her,” says Kane.

    It is that relationship of trust that those opposed to the bill want to protect.

    Canning says the legislation will make the role of a midwife one of coercing women to go to hospital … “The right to informed decision-making is a well-established minimum requirement for woman-centred care. Professional ethics demand respect for the choices women make.

    “The home birth scheme and the terms for SECM insurance. . . give no recognition to the role of the mother as an active participant in her own care.”

    I believe this is what we’re headed for in Australia once the 2-year exemption from the requirement of insurance for home birth passes. I would not be surprised if homebirth is funded and indemnified, albeit under stict guidelines for “suitability” for homebirth.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Politics of birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Home births in Wales double over decade

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    VBAC Women Denied Acces to Midwifery Care in Most States!

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Midwives in Jeopardy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Legal birthright choice for women

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    PREGNANT women could be given the right to choose where to give birth by law under proposals being considered by the [UK] Government. Any risks to the mother and child would have to be taken into account, but the plan could see parents given the right to choose a home birth, hospital birth or one in a midwifery-led centre.

    The entitlement would be enshrined in the NHS Constitution, which sets out a patient’s rights by law.

    … It tells expectant parents: “You will be offered the opportunity to choose where you want to give birth to your baby.

    “The Government supports this principle and will consult on an entitlement around choice of place of birth, following further research.”

    … Furthermore, both mothers and fathers with babies on neonatal wards would be offered accommodation so they can both stay in hospital overnight.

    Hospitals are being told to “recognise the importance of involving fathers for a baby’s development and making families welcome”.

    The document also promises joined-up local services “so that families have continuous care and support from early pregnancy to at least the child’s sixth month” …

    Fantastic news for the UK. Hopefully we will have the same in Australia.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Homebirth: The great debate

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    IS giving birth at home a positive experience or and unnecessary risk?

    ASK any expectant mother what she’s hoping for when she gives birth, and she’ll probably tell you the most important thing is to deliver a healthy, happy baby. But in recent years there’s been great debate about the best way to do this.

    Is the ideal to have a child in the relaxed comfort of your own home, or does the medical expertise provided in hospital far outweigh the notion of giving birth in your own living room?

    Although homebirth advocates argue the former, it appears the choice may soon be taken out of their hands.

    Reports last year revealed that four babies in Sydney died in homebirths in the space of nine months, the NSW Government responded with a strong announcement: from July 2010, independent midwives will be unlikely to gain professional indemnity insurance – effectively making it illegal for them to assist at homebirths. The consequence? Homebirths are facing extinction.

    Obstetrician Dr Pieter Mourik believes the ruling will stop women taking unnecessary risks.

    “Women who choose to give birth at home expect everything to be normal, but they often don’t consider how far they are from expert help …” he says.

    “Eighty per cent of women can have their babies in a paddock – but the problem is choosing these women. You just never know what will happen.”

    However, Justine Caines, spokesperson for Homebirth Australia, says putting a blanket ban on homebirths will simply drive the practice underground.

    … “Many mothers have had bad experiences in hospital and won’t repeat that.”

    She continues: “Why does the government fund women who are choosing to have C-sections, but not women who are choosing to give birth at home?”LAST month a study of over 500,000 women in the Netherlands who gave birth at home … showed there was no significant difference between planned hospital births and planned homebirths in terms of babies dying during labour.

    It’s important to note when making a comparison between Australia and the Netherlands, that the Netherlands only has low-risk home birth. If there are any complications in the pregnancy or labour, women see an obstetrician and birth in hospital. This is not the case in Australia at present, but it’s the system that the Govt is trying to set up.

    … Dr Mourik says the study is misleading. “Firstly, we must remember Holland has very well-trained midwives who act almost like Australian GPs,” he says.

    “It’s also a small country with maternity units often within 10 minutes of someone’s house. The conclusions of this study are based on the availability of well-trained midwives through a good transportation and referral system – and that simply isn’t the case in Australia.”

    It’s not currently set up in Australia, but there’s no reason why it couldn’t be. A positive approach would be to set in place a system that supports women to birth at home, and a system that protescts the midwives who support women to birth at home. Home birth has always been and will always be. We can set it up so that it is safe, or we can hope it just goes away … it won’t.

    However, despite warnings from obstetricians, women are still choosing to have their babies at home …

    “Women should have the right to give birth wherever they feel safest – it’s up to them whether that’s in hospital or at home. But taking away our choice isn’t right. If there were more options within the hospital system, then perhaps more women would feel comfortable going to hospital.”

    I disagree that women should make the decision: it should be made within the midwifery partnership. This debate is not about the right of women to bitrh at home: this right is protected by law. This debate is about the mdiwife’s responsibility to pracice safely.

    The Health Minister is putting in place a system that will enable more women to access continuity of midwifery care with their chosen midwife in and out of the hospital system. Once this is in place, there will be more options within the hospital system, and hopefully fewer women who are traumatised by the hospital system.

    So is there a way to keep everyone happy?

    “Homebirth Australia would like the government to present a package for pregnant women that works a bit like the baby bonus,” … “Every woman would be given a sum of money to spend on her pregnancy treatment, then it’s up to her whether she sees a midwife at home, or an obstetrician in a hospital. It’s putting the choice back into women’s hands.”

    What about the option to have a baby in hospital with a midwife, or the ability for an obstetrician to attend a woman at home?

    However, Dr Mourik believes that when it comes to choice, the only factor to consider is the mother and baby’s health.

    “Only a tiny minority of foolish women would risk their own lives and that of their precious babies for an ideal,” he says.

    “How many doctors support homebirth? None I know – it’s too bloody risky.”

    Many studies opint to the safety of home birth for low-risk women who are attended by a midwife. Women who birth at home are amongst the most health- and safety-conscious people I know. It is offensive to comment that women who birth at home are
    risking their own lives and that of their babies, especially when the evidence is to the contrary.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Advocates defend their rights for homebirths

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    THEY were defending their right to give birth at home … Across the country hundreds of women held rallies …

    Homebirth supporters claim doctors and the Government are taking away the rights of women.

    Under the proposed Bill … doctors will have the final say if a woman can have a homebirth supervised by a midwife. Previously, private midwives could assist in a homebirth without a doctor’s consent but could not access Medicare rebates.

    Passionate homebirth advocate Andrea Smith … said, “We should have the right to choose however we want to birth.” …

    After July, midwives will need to work collaboratively with doctors. This will be the case if we are to attend homebirths or if our clients wish to access Medicare benefits for our services.

    Collaborative arrangements have not yet been defined so it is hard to say at this stage how they might look. It’s almost certain that high risk homebirths will be off the cards, so no breeches, twins, VBACs, post term or preterm women, or those with high blood pressure or problems in the pregnancy will be able to have a home birth. Women are concerned that these changes will limit their right to a home birth, but the government is concerned for the provision of safe homebirth services. These new laws do not actually prevent “high risk” women from accessing home birth, they just restrict the ability of the midwife to attend them by legistating that midwives will only be able to attend low-risk homebirths.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Newborn blood used in research angers parents

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    WASHINGTON – A critical safety net for babies — that heelprick of blood taken from every newborn in the U.S. — is facing an ethics attack.

    After those tiny blood spots are tested for a list of devastating diseases, some states are storing them for years. Scientists consider the leftover samples a treasure, both to improve newborn screening and to study bigger questions, like which environmental toxins can harm a fetus’ developing heart or which genes trigger childhood cancers.

    But seldom are parents asked to consent to such research — most probably do not know it occurs — raising privacy concerns that are shaking up one of public health’s most successful programs. Texas is poised to throw away blood samples from more than 5 million babies to settle a lawsuit from parents angry at what they call secret DNA warehousing …

    Advisers to the U.S. government hope to have national recommendations by in two months on how to assure all babies still get their newborn tests while allowing parents more say in what happens next.

    … Newborn screening … began in the 1960s, and today every baby is supposed to be tested for at least 29 rare genetic diseases in hopes of catching the fraction who need early treatment to help avoid brain damage or death. Now being added to the list: Bubble-boy disease, formally known as SCID for severe combined immune deficiency.

    The program catches about 5,000 babies a year in need of treatment.

    Because newborn screening is mandatory, only a handful of states provide much upfront parent education. Leftover spots mainly are used for double-checking that newborn tests are accurate. Sometimes, families ask geneticists to study them after a child’s death from a disease doctors can’t immediately diagnose.

    … While blood spots are stripped of identifying information before being handed over to scientists, people generally need to consent to participate in research.

    … Among their worries: that genetic information about the children could fall into the wrong hands.

    … “DNA is your personal signature, and it uniquely identifies us,” …

    … found three-quarters would be willing to have their baby’s leftover blood spot used for research if they were asked first. But they generally oppose that research without consent …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Greens midwives report

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    The Australian Greens are deeply concerned that a Commonwealth plan to effectively give doctors veto over the rights of midwives to practice will erode women’s care choices.

    “The Government amendments to their Midwives legislation are unnecessary and give doctors too much control over midwives practice” … “… any requirement that midwives must work in formal collaborative arrangements with doctors as a condition of insurance will further restrict women’s choices”.

    ” … the Midwives Bills do not address the needs of many Australian women who make the choice to give birth outside the hospital system, and we will continue to fight for greater choice and less interventionist maternity care. The amendments proposed by the Government further erode women’s choices …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    54% of maternal deaths in Africa are due to unsafe abortion

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    About 54% of all maternal deaths in Africa are due to unsafe abortion because of restrictive legislation and lack of access to modern family planning methods …

    … should reject leaders who do not treat the lives of mothers humanely saying that mothers should not be coerced into motherhood.

    … women in developing world … are dying from unsafe abortion even though there are great advances in medical technology.

    … ‘Women are not dying from the diseases that we cannot treat but they are dying because societies have yet to make the decision that their lives are worth saving’. …

    In Uganda, the maternal mortality rate is at 435 deaths per 100,000 live births …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Home births: deadly or desirable?

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    After six hospital births … Melissa Read decided to bring her seventh child, Ayla, into the world at home.

    “Doctors had told me home births were incredibly risky but I did a lot of research and the midwives understood what I was talking about and how I felt,” Ms Read said.

    “It was an incredible experience that was more than I expected for myself, my husband and my kids.”

    Independent midwives have slammed reports this week that home births put babies at a greater risk of dying than those born in hospital.

    A widely reported … study showed that babies born at home are seven times more likely to die of complications and 27 times more likely to die from lack of oxygen.

    The Australian Medical Association (AMA) and the National Association of Specialist Obstetricians and Gynaecologists used the study to warn against the dangers of home birth.

    But the report, which compared 297,192 planned hospital births with 1141 planned home births … also showed that the perinatal death rate was similar for both kinds of births.

    The 16-year long study recorded nine perinatal deaths in the planned home-birth group, seven of which were actually born in hospital, and 2440 deaths in planned hospital births.

    Home birth advocates criticised the report, saying the research was flawed. The report itself states “small numbers with large confidence intervals limit interpretation of these data”.

    However, homebirth studies in Australia can only include small numbers because less than 1% births occur at home.

    “In the 16-year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth or timing of transfer to hospital might have made a difference to the outcome,” says the report.

    … the study showed there was only a slightly higher risk in choosing a home birth. And if done properly with a low-risk pregnancy, there was no real difference.

    Exactly. What the study really shows is that low-risk, midwife-attended home birth is a *safer* option than hospital birth. The issues are around risk assessment and management … and the right of women to accept or reject advice.

    “The risk is mainly in people who have home births that shouldn’t have them, such as having twins, a breach birth or people too far beyond their due date,” Prof Keirse said.

    These outcomes of these births is better when they occur in hospital.

    “A mother has to be responsible when deciding what kind of birth to have and these mothers are taking unacceptably high risks.”

    Prof Keirse said he was scared by the number of women choosing to have home births after already having had a caesarean.

    “When a problem happens and you are at home you have no real way of dealing with it,” he said.

    “One of these days we will not only lose a baby but a mother as well.”

    Homebirth Australia national secretary Justine Caines said the reporting of the study by the AMA was irresponsible.

    “I think they are trying to push a political agenda and outlaw or force home birth underground, which is incredibly irresponsible,” Ms Caines said.

    “The report says there are 7.9 deaths per 1000 in planned home births, compared to 8.2 in planned hospital births, but they didn’t all stay home births and the real figure of births that actually occurred at home is 2.5 deaths per 1000.”

    The study title states it was looking at *planned* home birth and *planned* hospital birth. Actual place of birth was not the focus of the study. If the study focussed on the babies that were born at home, it would have had to include babies who were intended to be born in hospital, but arrived too quickly at home. These births are possibly riskier than planned home birth.

    Last year the Federal Government refused to include home birth under its midwifery indemnity scheme.

    The decision forced many midwives underground and threatened to increase the number of women ”freebirthing”, or delivering at home without any medical supervision.

    This has not happened as the changes will not come into effect until July 1, 2010.

    Ms Caines said from July this year midwives were at risk of not being able to be registered under the Commonwealth reforms.

    “In the UK there is a legislative right that if the woman choses a home birth there is a responsibility that they have a trained health professional with them,” she said.

    In the UK, it is illegal for women to have unassisted births. We do not have this law in Australia.

    “A woman has a right to make an informed consent to a home birth and if she understands the advice she’s received it’s not my right to say you can’t do that.”

    AMA president and obstetrician Andrew Pesce said the study supported the association’s stance against home births.

    “The current evidence would mean we could not support home birth given that it is associated with higher risk of babies dying,” Mr Pesce said.

    “The risk of what is happening now needs to be acknowledged and the midwives and people involved in home births need to put plans in place to manage those risks.”

    The AMA admitted the study revealed many positives for home birth but maintained it was too great a risk for mothers and babies.

    SA independent midwife Julie Garrett said midwives were aware of the complications, but had a duty to support the choice of a mother.

    And this is the crux of the matter: midwives do not act irresponsibly. We do inform women of the risks. But women are free to choose amongst options and to make the right decision for them.

    Ms Garrett said the culture in Australia needed to change to support midwife-based care as an alternative.

    “In England and New Zealand they are bringing in home births, while Holland has an almost completely midwife-based care model. It’s the culture here that needs to change. Women should be able to choose.”

    In the UK, NZ and the Netherlands, health policy supports low risk home birth. Even in a country such as the Netherlands, where home brith is a normal birthing option, the home birth rate is only 30%. 70% women need to birth in hospital or choose to birth in hospital, and there is no stigma attached to it. In a country such as Australia, with a caesarean rate in excess of 30%, a maximum of 70% women will be “eligible” by risk-assessment standards, to birth at home. Add to that twins, breeches, women going over 41 weeks or less than 37 weeks, high blood pressure, gestational diabetes, big babies and so on, and you can understand that even if home birth is a government-supported option, it will not be an option for the majority of women.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    The AMA says we are “shooting the messenger” re homebirth critique

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    Further to the posts below on the homebirth study, the AMA has sought right of reply.

    Dr Andrew Pesce … is the president of the AMA (which opposes homebirth), an obestetrician and gynaecologist, one of the reviewers of the new study, and also the author of the MJA editorial on the study.

    He writes:

    “Home birthing is a controversial issue in Australia and this week’s debate around the South Australian study is proof of this.

    As would be expected, both sides of the debate put their cases strongly and passionately. Unfortunately the passion sometimes gets in the way of the facts and the evidence …

    My editorial was primarily about the politics of home birth. Most neutral commentators have commended me on the balance of the editorial.

    As AMA President, I transparently declared a potential conflict of interest based on the policy of the AMA. I presume the College of Midwives, which strongly advocates for home birth and the role of private midwives, has similarly declared its potential conflict of interest …

    … The seven-fold increased risk is a statistical prediction of the most likely risk according to the data …

    The overall rate of perinatal deaths was not different, but only if you ignore the fact that a larger number of women planning to give birth in hospital have risk factors and complicated pregnancies.

    When adjusted for prematurity and low birth weight, the overall perinatal mortality rate for all pregnancies planning a home birth was double that of planned hospital birth …

    Remeber that the study is on *planned* home birth and *planned* hospital birth, regardless of where the birth actually took place.

    The study identified the same contributing factors that were found in a previous larger Australian review … poor adherence to risk assessment, lack of monitoring of foetal wellbeing and delayed response to emerging complications in home births …

    If a justification is needed for the AMA highlighting the concerning results of this study, it is that home birth advocates continue to deny the higher risks of current home birth practice, and the need for adequate risk assessment and management.

    … my editorial did mention the lower intervention rates, the similar rate of post partum haemorrhage and other favourable outcomes of home births found in the study.

    … The AMA … supports women having choice about where they have their babies. The AMA media release stresses the need for evidence and safety …

    • Dr Andrew Pesce is President of the AMA and a practising obstetrician and gynaecologist at Westmead Hospital in Sydney

    Meanwhile, Croakey has just caught up with the 22 Jan issue of Australian Doctor … including details of a study of the first 100 births through the St George Hospital Homebirth Program in NSW, published in the Australian and New Zealand Journal of Obstetrics.

    The story says the study has reported “reassuring outcomes” and that “a growing number of obstetricians are calling for more support for safe homebirth models despite the AMA’s resolute opposition to the practice”.

    Professor Michael Chapman, who has been involved in the St George program, is quoted saying that homebirths involving experienced midwives following strict hospital transfer protocols were appropriate for a small group of low-risk women who preferred to give birth at home.

    He said: “Homebirth conducted in a random disorganised manner with independent midwives and patients who are pushing the boundaries of safety have given it a bad name. But in a controlled environment, I do believe the risks are minimal.”

    Update: The AMA has been in touch to advise that Dr Pesce was a reviewer on this paper as well.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Don’t believe the home-birth horror headlines

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    If you’ve been half awake in recent days, you might have heard of a new study showing that “babies are seven times more likely to die during home births”.

    It’s worth having a close look at what the study actually found … and also considering some of the broader context that has been sadly lacking from most of the coverage I’ve seen and heard.

    … The researchers compared the outcomes for 287,192 planned hospital births that took place in SA between 1991 and 2006 with those of 1141 planned home births. Note that this latter group was defined as any birth intended to occur at home at the time of antenatal booking, but about 30% actually ended up occurring in hospital …

    During those 16 years, there were nine perinatal deaths in the planned home birth group (seven of which actually occurred in babies born in hospital) … two deaths occurred among the 792 infants born at home, one of whom had congenital abnormalities.

    … the rates of caesarean sections and other interventions were significantly lower in the home-birth group. Nine per cent of women who’d planned a home birth ended up having a caesarean …

    The home-birth babies were more likely to die during labour and delivery …

    … home-birth babies were 27 times more likely to die from lack of oxygen during delivery. Again, this finding had wide confidence intervals, with the estimate ranging from eight to 89 times greater — clearly, another one to take with caution.

    … The researchers note that … “there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth or timing of transfer to hospital might have made a difference to the outcome.”

    It is also worth noting that one of these three deaths occurred in a twin. The reason the parents persisted in a home birth despite being advised against it was that they “had had unsatisfactory hospital experiences during previous pregnancies”.

    … it seems more pertinent than ever to borrow the final words of the study’s authors:

    Although it is not anticipated that large numbers of women will opt for home birth, women’s autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law.

    Respecting their choices and achieving the best outcome for all concerned is likely to remain a challenge that will require more light and less heat than it has received thus far …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Homebirth ban may create risk

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    AN ONLINE poll has found huge opposition to draft Federal Government laws which would effectively ban homebirths and could lead to women choosing to freebirth.

    The parenting social networking site BellyBelly.com.au found 94 per cent of the 400 respondents opposed the amended legislation …

    … 30 per cent of respondents said they would consider freebirthing – giving birth without medical assistance – if not allowed to choose their own midwife.

    Under the Federal Government’s draft health practitioner regulation law, independent midwives could be deregistered unless they have private indemnity insurance.

    So far, the government has failed to include homebirths in the indemnity scheme while insurance companies refuse to insure private midwives.

    Proposed changes … would also see midwives forced to work alongside obstetricians.

    … “Women are very angry, passionate and strong-willed on this topic and feel that their rights as a woman are being threatened,” she said. “Many members commented that they are appalled that the government thinks it has the right to choose where and how they birth their babies.”

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Home birth advocate slams health service check-up

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    A … home birth advocate says she cannot excuse the … Area Health Service for calling in police to check on a pregnant woman.

    Rochelle Allan, who wanted a home birth and did not want to be induced, was nearly 14 days overdue when she missed an obstetrics appointment.

    … the police were sent to Ms Allan’s home on Friday to conduct a “welfare check” because the midwives could not reach her by telephone.

    … the actions of the hospital staff will not be investigated because they had the best intentions and were concerned for Ms Allan.

    … a woman should be able to make her own birth choices without someone looking over her shoulder.

    “The hospital, they’re service providers, they’re not a regulatory body for pregnant women,” …

    “These checks … they’re not mandatory, so it’s entirely up to that woman if she chooses to attend those hospital checks or not.”

    … Ms Allan had the baby at home … with a private midwife.

    Interesting situation. The hospital owes a duty of care to its patients. If it had failed to conduct a “welfare check” and the woman’s baby had died, the news report would read that the hospital was grossly negligent and how could they allow this to happen? It’s been my experience that these situations can be managed very well by the midwife and woman being upfront with the hospital about the intentions of the woman. When this happens, the hospital is satisfied that the woman is receiving care and sees no reason to send the police around. Some people have questioned the use of police services for this purpose however the hospital staff are generally not permitted to attend patient’s homes in these circumstances.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Home birth program that delivers

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    It took Bailey … only 75 minutes to slip calmly into the world, amid the comforts of his own loungeroom, unaware he was quietly making history.

    Bailey … is one of a handful born at home under the guidance of midwives from St George Hospital, which runs the first publicly funded scheme of its kind in NSW …

    ”After having a hospital birth for my first child, [Bailey's birth] was very, very different and it was amazing to be told that everything was my choice, my decision,” his mother, Claire, 32, said yesterday. ”It was unbelievably calm and relaxed.”

    Home birthing … is now regarded by most obstetricians as controversial and dangerous.

    Last year the Federal Government refused to include home birth under its midwifery indemnity scheme, which forced many midwives underground and threatened to increase the number of women ”freebirthing”, or delivering at home without any medical supervision.

    Private home birth services have not been forced underground!

    … home birthing advocates are hoping a review of the program … could change the way birth is viewed …

    This would be wonderful! The program opens the home brith option to a more mainstream population who might not otherwise have considered home birth.

    A study of the first 100 women booked to use the service found 63 per cent successfully delivered at home with no intervention or pain relief and minimal vaginal tearing.

    Thirty women were sent to hospital before going into labour and seven were transferred during labour …

    ”It shows that in a controlled environment where midwives are protected by the policies and protocols of a public hospital, home birthing is a safe option for women at low-risk,” the co-director of Women’s and Children’s Health at St George Hospital, Michael Chapman, said yesterday. ”… I’d hate for this study to be used to support programs where there are not over-arching checks and balances in place, but this shows it can be a safe process.”

    The program, launched in 2005, was helping to improve home birth’s poor public image, but was still too restrictive for most women, and had abandoned some in the late stages of their pregnancies, the secretary of Homebirth Australia, Justine Caines, said. ”… this program excludes women without a strong evidence base,” she said.

    ”Women have a right to informed consent and there is an ethical responsibility for a health service not to abandon [them], instead to offer the best health care possible consistent with a woman’s choice.”

    While the home brith service might be considered restrictive, this can also be considered to be providing a safe margin within which home birth services can commence and continue. Birth centres are also considered restrictive by some, but most women wo book into a birth centre will birth there safely.

    I do not agree with the comments about the program “abandoning” women. To my knowledge, this has never happened. A public health service is obliged to provide a basic and safe level of care, and this is done. When a woman’s clinical situation suggests that birth centre or delivery suite care would better meet her needs, this is provided. This is not abandoning women.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    More midwives needed

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    Indonesia needs more dedicated midwives to help reach maternal and infant mortality targets set by the United Nations’ Millennium Development Goals (MDGs) by 2015 …

    … “Most people in the area are poor; they scrape a living as farmers, and most don’t have a senior high education,” …

    … “If access to clean water remained out of reach, the quality of women’s and children’s health would have declined, and their lives would have been in danger,” …

    Listiani … said she and a new graduate midwife on a temporary posting in the local community were the only health workers in the area, handling childbirths for the 874-hectare village that had a population of more than 7,000 people.

    “… together we can serve around 40 patients a day,” she said.

    … “The lack of midwives in remote areas … is behind the low quality of health of the people there, as well as the increased number of dying women and babies,” …

    Indonesia expects to achieve a maternal mortality rate of 102 per 100,000 live births by 2015, down from the current rate of 228 per 100,000 live births.

    It also expects to achieve an infant mortality rate of 23 per 1,000 live births by 2015, down from the current 34 per 1,000 live births.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Obstetric Fistula In Africa

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    “Poverty is the biggest factor. Access to a Caesarean section to relieve the pressure of obstructed labor is the most common way of preventing an unborn child from pressing so tightly in the birth canal that it cuts off blood flow to surrounding tissue,” … Side effects often include inability to control the bladder or bowel movements, and those women “are often abandoned or neglected by husbands and family …” …

    Often in the places where obstetric fistula is most common, the capacity for treatment can’t meet the needs of all women who require it …

    “… the existence of fistulas means the health system has failed somewhere…”…

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Home birth service closed as report claims midwives put babies at risk

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    A pioneering home birth service has been axed amid concerns it had 10 times the normal rate of babies born with serious complications such as brain damage.

    The Albany practice, an independent group in South London previously described as a “gold standard” for the midwifery sector, had its contract with the NHS terminated after an inquiry into alleged poor practice over 30 months.

    The move has prompted a campaign by the group’s supporters, who … claim the service was terminated because NHS managers preferred hospital births. Under the Albany group, all women have their babies delivered by the first midwife they see during their pregnancy, with almost half giving birth at home.

    … a spokesman for King’s College Hospital, which commissioned the report … defended the decision.

    … “While the report reinforced our view of the excellent relationships formed between Albany midwives and their expectant mothers, it also highlighted serious shortcomings in terms of non-compliance with [hospital] trust policies and risk management procedures, particularly during labour and with newborn babies.”

    The report revealed that the hospital identified 11 cases where brain damage was caused by a lack of oxygen and blood to the brain … It concluded that “risk factors for a poor outcome in pregnancy were being overlooked by Albany midwives”.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Right to Homebirth Threatened in Australia

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    Homebirthing is a common phenomenon in most parts of the world, but in Australia, fears surrounding the process are threatening its acceptability.

    In New Zealand, Canada, the UK and the Netherlands, giving birth at home is a reasonable choice, supported by both governments and insurers.

    In Australia, however, the choice is threatened by proposals from Health Minister Nicola Roxon to leave midwives without insurance or funding to assist home births.

    The curbing of that choice started last year when Ms Roxon initiated the Maternity Services Review and announced Medicare funding for midwives in the 2009 budget. In conjunction, she proposed the National Registration and Accreditation Scheme (NRAS) legislation, which would require health professionals to hold indemnity insurance so as to safeguard consumer safety.

    … the great omission in her proposal was homebirth midwives, who were not offered funding or indemnity insurance … In effect, this would condemn homebirth midwives to operate illegally if they wanted to continue delivering babies.

    … Gary Hastie, who has delivered all four of his children at home while supporting other home birthers, believes homebirthing “is the most natural process for the woman”.

    However, he has observed an increasing fear of home births, distrust of a woman’s ability to have a natural birth and a demonisation of … woman’s choice. “It’s a woman’ right to choose where and how and with who she gives birth,” he said.

    Nicola Roxon says she supports women having a choice, but is concerned with the consumer and ensuring a system of registration. It is “about lifting standards and ensuring that people are both registered, accredited and insured,” she said.

    … Dr Ted Weaver, says it is not only the size of Australia that is a problem, but also cultural differences. “The infrastructure in other countries is completely different from the infrastructure in Australia–these countries have a tradition of home birth.”

    Dr Weaver said the biggest danger lies when women get transferred to a hospital after complications arise …

    Doubts are expressed too about how qualified Australian midwives are. Dr Weaver says: “Their [overseas] midwives are better trained and act along more stringent guidelines, and the selection for home birth is much more rigorous than in Australia.”

    … While most high-risk women will be referred to a hospital by a midwife, … a very small portion of these women who consciously choose home birth … if they are considered “high risk”. “High risk” includes women who are having twins …

    Many women, including those considered “high risk”, do not want a hospital birth, which is considered high intervention and impersonal …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Rudd unmoved by homebirths protests

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    Prime Minister Kevin Rudd says he is not moved by protests from doctors and midwives upset at changes to the health system.

    Doctors have rallied … because they are concerned new super clinics will put an end to the family doctor and drive young general practitioners away from the profession.

    … protesters … are objecting to changes which force private midwives who attend homebirths to work in collaboration with a doctor.

    Mr Rudd says … “Our job is to govern in the national interest – that means implementing what we said before the election in these critical reform areas, getting on with it … ”

    “… we intend to implement that which we said we’d do.”

    Protesters say amendments to the Medicare for the Midwives Bill will result in a medical veto over midwifery practice and homebirths …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    The future of private midwifery

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    There has been stong interest on the issue of the future of private midwifery since the Health Minsiter’s announcement that clarified the meaning of “collaborative practice”. Collaborative practice will mean that every private midwife must have a collaborative agreement with a private obstetrician who can effectively sign off on the midwife’s work. If s/he does not agree with the plan of care for the woman, the obstetrician may sever the collaborative arrangement. Furthermore, with RANZCOG and the AMA being opposed to home birth, home birth will not be an option in the private system, as it is currently. The exemption that was granted to home birth will have no meaning since collaborative arrangements will be a requirement for registration for private midwifery practice.

    There are several issues:

    - Midwives will no longer be able to practice in accordance with the International Definition of the Midwife. In the current climate of a world-wide midwifery shortage, it makes no sense to prevent currently practicing midwives from continuing to practice.
    - Midwives’ practice will be subservient to obstetric practice, potentially increasing Australia’s already high caesarean, induction and epidural rates. This, of course, increases morbidity for mothers and babies and compromises Australia’s safe record of maternity care.
    - It is likely that obstetrician’s insurance will forbid them from working with midwives unless the midwife works very closely with the obstetrician, for example in the obstetrician’s rooms. The obstetrician’s insurance company will no doubt not want the obstetrician to be taking responsibility for things that s/he has no direct control over (despite the fact that the midwife will have insurance too).
    - Home birth will not be an option in the private setting. Publicly-funded models will remain an option, but these are few and far between.
    - Private midwifery care in hospitals will restrict women’s choices, eg vaginal breech, vaginal twins and so on. It is highly unlikely that an obstetrician will agree to work collaboratively with a midwife who is supporting a woman to have say a vaginal breech birth.
    - The net effect will be the erosion of women’s choices, especially in the private system, and the restriction of a midwife’s practice to employed models within hospitals.

    No other profession is denied the opportunity to practice privately. No other profession is required to have sign-off from a different profession. And no other profession is legislated against providing the full scope of care by international definitions.

    While it is clear that the maternity reforms are not intended to be in any way related to home birth, it now seems that even private midwifery care for hospital birth is under complete threat of extinction.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Doctors to gain veto powers over midwives and birth choices

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    Below is an important brief that has been prepared by Bruce Teakle of Maternity Coalition. It explains what the situation will be after July 1, 2010 for private midwifery practice for home birth and hospital birth. It affects all women who may be birthing their babies after July 1, 2010.

    On 5 November the Government announced that the “Medicare for midwives” Bills would be amended to require midwives to have “collaborative arrangements” with “medical practitioners” before being eligible for professional indemnity insurance or Medicare rebates:

    * before the midwife can access professional indemnity insurance, and

    * before women can claim a Medicare rebate for midwifery services.

    Doctors must approve each midwifeʼs entry to private practice:
    * Midwives will be required by Commonwealth law to have “collaborative arrangements” with “one or more medical practitioners” before being eligible for Commonwealth-subsidised professional indemnity insurance (PII).

    * PII will be a prerequisite for a midwife to enter private practice, under new national registration laws, being enacted state by state.

    * Doctors will be able to unilaterally withdrawal from collaborative agreements with a midwife, rendering her uninsured, and legally unable to practice in a private professional capacity.

    * This legally mandates medical control over midwives’ ability to register and work in private practice.

    * This will be set in Commonwealth law, which can only be changed by Commonwealth Parliament.

    * These provisions are contained in the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009.

    Doctors must approve womenʼs access to Medicare rebates for midwifery care:

    * Midwives will also be be required by Commonwealth law to have “collaborative arrangements” with “one or more medical practitioners” before their services are eligible for Medicare rebates.

    * This puts women’s access to private midwifery care under medical control.

    This is potentially defacto “parallel regulation” of the midwifery profession:

    * Medical practitioners will control the registration status of midwives, despite their being a discrete, separately regulated profession.

    * Medical professional organisations could set guidelines for collaborative arrangements, potentially forming defacto regulatory standards for midwifery endorsement and practice.

    This gives doctors right of veto over womenʼs choices in birth care:

    * Any birth care choice using private practice midwives, or developed under the Commonwealth’s new arrangements, will be subject to medical control or veto.

    * This gives medical practitioners unprecedented control over women’s choices and access to care.

    “Collaborative arrangements” may be legally restricted to privately practicing doctors

    * The amendments do not specifically include hospitals as able to form collaborative arrangements with midwives. They require medical practitioners to be “of a kind or kinds specified in the regulations”.

    * It is unclear whether a hospital, health service district or authority may be included within the definition of “one or more medical practitioners”.

    * Doctors who are employees of public hospitals can’t make “collaborative arrangements” as employees of the hospital they work for. They work for the hospital, attend their workplace when rostered on and collaborate in line with hospital policies.

    * A range of very serious consequences would flow if these arrangements were restricted to privately practicing doctors. Consequences could include:

    o No new midwifery models in public hospitals.
    o No private midwifery practice.
    o No homebirth care from midwives in private practice.
    o Practice midwives in private obstetricians rooms could be the only viable model of private practice or Medicare-funded midwifery.

    This brief represents the best information available to Maternity Coalition on 8 November 2009. We are actively seeking ongoing clarification and dialogue with Government in order to ensure women and families have access to accurate information. For full text of amendments click here.
    For more information contact: Bruce Teakle 07 3289 0231

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Women to protest maternity reforms

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    … women will rally … to protest the … government’s maternity services reforms.

    Health Minister Nicola Roxon … announced that Labor would amend draft laws before parliament to make it clear … midwives could only access the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme if they worked in collaboration with a doctor.

    The Australian Private Midwives Association is concerned the requirement will make … midwives beholden to doctors.

    “Placing one profession at the complete mercy of another … makes a mockery of professional regulation in this country,” … “Many choices such as homebirth … may be lost if doctors do not form … agreements with midwives.”

    Homebirth Australia … said the government was trying to make homebirths an “administrative impossibility” for women.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Women need choice, not caesareans

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    The latest maternity figures released yesterday for England are very concerning. Reduced spontaneous deliveries, increased medical interventions and high caesarean section rates mean that women are not getting the type of birth they want and many are not getting the safest birth.

    There’s a 4% increase in the number of births in consultant wards and a decrease in birth in NHS midwifery facilities. This is exactly the opposite direction to that intended in the government policy, Maternity Matters, which includes the government’s promise to allow women in England to choose where they give birth.

    … Large numbers of women do not have a realistic possibility of choosing between a birth centre run by midwives, a consultant unit or a home birth.

    If women did have choice, we would be expecting to see a falling caesarean section rate, far fewer women choosing obstetric units, a network of birth centres being used by 20-40% of women and a home birth rate approaching 30%. When healthy women can choose care at home or in a unit run by midwives, they are more likely to have straightforward births that are a safe and positive experience.

    … England’s caesarean section rate is at 24.6%, well beyond the World Health Organisation’s recommendation of 10-15%. Obstetric units are there for women and babies with medical problems. It is quite wrong to fill them with healthy women who, given the option, would not choose them …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Most women cannot choose where to give birth

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    More than 95 per cent of women in the UK are not able to choose where to give birth …

    The National Childbirth Trust (NCT) … claims that some 95.8 per cent of women do not yet have access to a real choice between the three options of home birth with a midwife, a local midwifery facility or birth centre and an obstetric unit in a hospital.

    These are the three choices defined in the 2007 Government report Maternity Matters, which guaranteed that women in England would have choice of place of birth by 2009.

    Sarah Banks … who is mother to a 10-month-old girl, said she was given no choice when it came to childbirth … ‘The first thing the midwife asked me was ‘which hospital do you want to go to?’

    ‘There was no discussion about other options and no mention of the birth centre nearby.

    ‘I told her that I wanted to have my baby at home and she refused to discuss it as she said it was too early and wouldn’t be advisable as it was my first baby.’

    … “across the UK, Government policies support women with this choice. However, in reality this is not even close to being delivered yet.

    ‘We want the governments to act now … ‘We know there are some financial policy obstacles hindering the achievement of choice the NHS could make much faster progress if it corrected these.

    NCT believes that … women who are given the choice have an increased likelihood of straightforward births, while for the maternity services, increased choice is likely to lead to reduced costs, as currently most women give birth in an obstetric unit in a hospital, which is an expensive option …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Home birthing: the fiscal nips and tucks to our health system

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    All politics is local, and more often than not personal. Just a fraction of Australians birth at home but their fervour is at times
    evangelical. In Canberra’s grey rain this week, 2,000 devoted mums and midwives won a two-year reprieve from being
    deregistered and fined if they attend a home birth.

    But there were few cheers for Minister Roxon’s back flip. Landmark reform stemming from the recent National Maternity
    Services Review proposes autonomy for midwives around prescribing certain drugs and ordering tests as well as long-awaited access to Medicare and indemnity cover. But for home birthing midwives, there will neither be Medicare support nor any form of indemnity protection.

    When it comes to the safety of low-risk mums birthing at home, the world’s foremost medical evidence authority is the Cochrane Collaboration. With appropriate hospital support … home birth and hospital mortality for low-risk
    bubs is comparable …

    A final fillip for home births is that Cochrane acknowledges that outcomes for mums may actually be worse in hospitals

    … For many mums, the traumatic hospital experience is the centrifugal force pulling hundreds out of our maternity wards to
    deliver at home. Midwives have followed, disenchanted by the “clock-in clock-out” hospital work and the constant turnover
    of care. They see hospitals as fragmented, overly medicalised and homebirth as a relationship-based approach rather than a technical exercise in baby delivery. The cascade of hospital interference includes needles and gas, probes and clips
    through to forceps, extractors and ultimately caesarean section.
    For most of us gadgets and tools are part of the safe baby syndrome, the community expectation that every baby arrives in
    perfect health …

    … home births exert a counter-pressure upon our hospital system. Birth plans, continuity of care, the demand for fewer interventions and the reemphasis upon emotional attachment to mums are all hospital trends originating from the home birthing movement.

    Few realise that the emerging threats to home birthing have more to do with the global financial crisis than any bigotry, intolerance or obstetricians. Late last year, flawed Treasury modelling prescribed a ridiculously large stimulus which threw Australia into debt … it’s too late to recover the cash. Now it’s up to Treasury to claw back the balance sheet. From alcopops and cataracts to IVF and pathology, our health system is paying the price for the ill disciplined spending elsewhere.

    Until now the fiscal nips and tucks to our health system have been politically painless … Conception however is the most incendiary moral issue in medicine and our elected officials are about to learn birthing isn’t far behind. Australians rarely march in the streets; certainly not for blood tests or eye operations. But mums choosing home births do so in the context of historical resistance to their choices.

    The Health Minister understands that extending indemnity cover to include community midwifery will come at a cost … actuarial analysis is complicated by the infrequency of intranatal misadventure and the potential for multi-million dollar payouts …

    The Health Minister’s two-year moratorium is a brief reprieve before home birthing again becomes illegal. Bad policy in two years is still bad policy. Its one thing to decimate home birth by setting up an exclusive “registration” club for midwives which excommunicates those attending home births … Such an approach will draw
    quality mainstream midwives out of home birthing and imperil safety.
    The Minister would be far better advised to draw midwifery together under a single maternity care system of registration, indemnity and support. Home birthing will never disappear; we owe our mums and their babies a comprehensive system which recognises, insures and drives high quality maternity in hospital and at home …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Do we owe unborn babies a duty of care?

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    Traditionally, fetuses are not owed a duty of care by midwives and doctors. The duty of care is owed to the woman who carries the baby, and her decisions are generally respscted, even if those decisions are not in the best interests of the baby. This case challenges the notion that midwives and doctors do not owe a duty of care to a fetus.

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    Does an obstetrician have a duty of care to an unborn child?

    … a 2008 court decision that found a doctor had no such obligation in the case of a girl born with birth defects because of an acne drug prescribed to her mother, says no.

    But the family of another child says yes.

    The issue will be argued today in a London …. courtroom. The … family … has brought a motion before the courts on behalf of their 8-year-old son, Kevin, born with hypoxic ischemic encephalopathy, or brain damage caused by oxygen deprivation.

    He has since been diagnosed with cerebral palsy – the result, his family says, of negligence on the part of three obstetricians and four obstetrical nurses at … Hospital.

    For the last seven years, the [family] have been embroiled in a legal battle with the hospital … claiming that the mother … was given too much of the drug oxytocin to speed up labour and then not adequately monitored.

    The defendants deny the allegations … the court will deal explicitly with the duty-of-care issue …

    The family’s lawyer … says the [family] were recently thrown a curve ball by the defendants, who are claiming to have no duty toward an unborn child.

    … the hospital cites an important legal decision that came down last year … which found that doctors cannot owe a duty of care to unconceived children because their primary obligation is to their female patients.

    “Because the woman and her fetus are one – both physically and legally – it is the woman whom the doctor advises and who makes the treatment decisions affecting herself and her future child,” the decision read.

    The case involved Jaime … who was left with birth defects from an acne drug taken by her mother.

    A [doctor] … prescribed the drug Accutane, which is known to cause catastrophic injuries to a fetus. He believed there was no chance the mother would become pregnant because her husband had undergone a vasectomy. But the vasectomy failed and Jaime was born without a right ear and with portions of her face paralyzed.

    “The decision of (the) … Court of Appeal … is … that no such duty [of care to an unborn baby] was owed,” …

    But Legate maintains the two cases are entirely different and argues that the findings from the Paxton case should have no bearing on Kevin’s.

    … the … Superior Court of Justice, arguing that health-care providers did, indeed, have a duty of care to Kevin in the critical hours leading to his birth …

    The finding could set a precedent for future cases and potentially see interventions forced on women that are felt to be in the best interests of the (unborn) baby.

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    Home Birth: Safer Than You May Think

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    Giving birth in the hospital is a relatively new option. For most of our time on the planet … humans have given birth right at home. More recently, birth in developed countries has been moved to a hospital setting. While people are now accustomed to the more sterile environment, and are often reassured by having the equipment and staff on hand to mitigate complications, a new study … suggests that for women with low-risk pregnancies, there’s no place like home.

    A team of researchers compared the safety of planned in-hospital births attended by physicians … or midwives … with planned home births attended by midwives … All of the women included in the study were eligible to have a home birth, meaning that they had no conditions that could put them at higher risk for complications …

    … the rates of infant deaths were lowest among those who planned a home birth, followed by those who planned a hospital birth attended by a midwife. Women who planned home births had significantly fewer interventions and complications than their hospital-birthing counterparts, including electronic fetal monitoring, assisted delivery, post-partum hemorrhage, and significant tearing. In addition, newborns in the home birth group were less likely to need resuscitation at birth or oxygen therapy beyond their first day, or to have meconium aspiration, a potentially serious problem affecting the lungs.

    … A US-trained midwife practicing midwife … who took part in the study explains, “Home birth is for low-risk pregnant women. In my practice, just because a woman wants a home birth, doesn’t mean she always gets one. We spend the entire pregnancy monitoring her pregnancy health and discuss the appropriateness and safety of home birth for her individual case. A woman has the right to choose her place of birth, but my job is to guide her safely in her choices. Sometimes that includes talking some women out of a home birth.”

    When it comes to home birth safety, Duong says, “What few people are aware of … is that midwives attend home births well-equipped with emergency medical equipment, including oxygen, IV’s, and medications, and are able to initiate emergency procedures in a home birth setting. In British Columbia, midwives are required to recertify in emergency skills, including obstetrical skills and neonatal ,more frequently than physicians who attend births. Lastly, midwifery is so well integrated into the healthcare system here in BC that we have very good systems in place for the safe care of women and their newborns should transport to the hospital become necessary when a home birth is planned.”…

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Emotional Impact of Cesareans

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

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

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

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

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

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

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

    Women report experiences that fall into the following categories:

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

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

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

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

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

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

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

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

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

    This is the norm in Australia too.

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    The real safety issues in maternity care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Amnesty International Report Highlights Maternal Mortality ‘Emergency’ In Sierra Leone

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    “One in eight women in Sierra Leone risks dying of pregnancy and childbirth complications exacerbated by a combination of poverty, discrimination, inequality and government mismanagement,” …

    … despite “promises from the government to provide free health care to all pregnant women,” thousands of women and girls die “because they are routinely denied their right to life and health,” … “less than half of deliveries are attended by a skilled birth attendant and less than one in five are carried out in health facilities.” Most women “die in their homes. Some die on the way to hospital, in taxis, on motorbikes or on foot,” …

    Six out of the country’s 13 districts do not have a single hospital that offers emergency obstetric care and there are only 78 doctors for 5.8 million people … The cost of interventions are another challenge in Sierra Leone, “where 70 percent of the population lives below the United Nations poverty line of $1 per day.” But “the critical delays that increase the risk of maternal death start at home where women have little decision-making power over their reproductive lives,” …

    “‘… maternal deaths are a human rights emergency in Sierra Leone,’ … although “[a]dditional money is desperately needed in Sierra Leone,” it “will not reach women and children in remote areas who are at greatest risk.” She added, “The lives of women and girls will only be saved when the health system is properly managed and the government is held to account,” …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Mum fights good fight over birthing bungles

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    A … mother whose daughter is severely disabled after midwives botched her resuscitation at birth has taken her fight for an independent inquiry into the maternity sector to Parliament’s health select committee.

    Jenn Hooper’s … daughter … has severe cerebral palsy and spastic tetraplegia, and up to 200 seizures a day. Two midwives struggled for an hour to correctly intubate Charley when she did not start breathing after being delivered.

    Last week Mrs Hooper … told politicians her harrowing story and those of other women whose children either died or were disabled during childbirth, in a bid to have the system changed. Her … submission … backed up a petition the women delivered to Parliament …

    It called for the independent review, a database which counts the deaths, disabilities and near misses in childbirth, a review of the training and supervision of lead maternity carers (LMCs), and the creation of a crisis team to support families whose babies die or are disabled during childbirth.

    “All we’re after is ensuring healthy, safe, live mothers and babies,” …

    Following major maternity reforms between 1990 and 1996, most New Zealand mothers-to-be now choose a midwife who becomes their LMC until they give birth.

    … “It’s supposed to be a matter of choice. We’ve actually had our choices slashed,” Mrs Hooper said.

    The Good Fight wants bonuses and incentives paid to LMCs who book their client at a private birthing facility or non-tertiary hospital stopped, including a $60 bonus for midwives whose clients do not need to be admitted to hospital.

    Mrs Hooper was also concerned with the training required to become an independent midwife, and that midwives no longer had to first be a nurse.

    I’m not sure I understand this view. Why would a midwife need to be educated as a nurse in order to improve safety? Midwives do not need to be educated as mechanics, accountants or physiotherapists to be safe; why is nursing any different?

    In 1990, at the start of the maternity reforms, New Zealand ranked 20th in the OECD for its infant mortality rate, counting babies who die in the first year of life. By 2002 it had dropped to 24th out of the 30 developed countries.

    … When the group delivered the … petition to Parliament, [the] Health Minister … said several matters they raised were already being worked on. Government initiatives in the 2008-2012 maternity action plan included longer postnatal stays, three-way visits for at-risk women with their LMC and GP, refresher obstetrics training for GPs and rural midwifery recruitment.

    The strong desire to opint fingers and blame others – particularly the professional – is strong whenever there is a bad outcome. Sometimes, it’s not about a broken system; sometimes it is. Sometimes the professional stuffed up; other times they did not. Sometimes things just go wrong. I think we have an expectation that birth will always go well, and that every pregnancy will result in a live, healthy baby. It’s simply not the case. Not in any species. If the midwives present at the birth had been negligent, NZ has processes in place to ensure that remedial steps are taken. The NZ system of encouraging midwifery as the primary model of care to pregnant and birthing women is fantastic. It is in line with WHO guidelines and best practice. The education and supervision of midwives may need tweaking, but that’s a separate issue to Mrs Hooper’s assertion that the system effectively needs to be changed.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    midwife helps moms give birth at home

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    On Great Plain Avenue … a white placard with a cartoon stork on it announced the birth of Mary and George Georgilas’ daughter, Lila Elisabeth, who was born a week earlier within yards of that sign — inside the family’s home.

    “It was peaceful, magical, wonderful,” said Mary Georgilas, describing her daughter’s birth at the home.

    The couple was able to experience a natural, at-home birth thanks to Nancy Wainer, a longtime midwife who coincidentally lives just up the street from Mary and George Georgilas.

    Wainer operates Birth Day Midwifery from her Great Plain Terrace home. She has been a midwife for about 15 years, and has been on her own for about 15 years …

    … Wainer began down the path of midwifery and conducting natural births in homes after she decided to give birth to her third child at her home. She preferred the experience to the hospital births of her two older children.

    “For most women, being with a familiar care provider, it’s better being in their own environment without technological interferences,” …

    … Wainer limits herself to about 35 to 40 births due to amount of attention she feels each mother-to-be needs.

    “We get to know the mothers very well,” said Wainer, who has assisted in an estimated 1,400 to 1,500 births during her career. “Many women had their first births at other places and in seven minutes, they see several different people. Mothers get to know who their midwives are, and the birth becomes a loving, caring event.”

    Wainer noted she prescreens the mothers to make sure they are healthy enough for a home birth. If she feels they would need special medical attention, she refers them to hospitals. And if a woman does experience complications during childbirth, Wainer would immediately send her to the hospital for treatment. But she said the vast majority of complications can be avoided if precautions are taken during the pregnancy.

    “Almost all emergencies are precipitated from a situation that needed to be addressed before the childbirth,” Wainer said. “If it escalates into a complication, we won’t let it escalate to an emergency.”

    … “From the very beginning, we wanted to avoid procedures and drugs that could be harmful to the baby,” Ben Ramsey said. “We felt like we didn’t want to fight the system.”

    Milly Ramsey described the birth as intense, but doesn’t regret her decision to have the baby naturally and at home.

    “I was very comfortable at home,” Ramsey said. “It was intense. … I felt very supported. I felt like I wasn’t alone … they didn’t take him [the baby] away. He stayed with me.”

    … Molly Scanlon … plans to have a natural, at-home birth with Wainer. Even though she works at a hospital, she said she feels intimidated by the atmosphere and preferred having the birth at home.

    “It’s been great; she makes me feel very confident and secure,” Scanlon said. “I felt like there’s a comfort level in being at home.”

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Arguments On Safety, Risks Of Home Births

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    … The percentage of home births dropped dramatically in the U.S. during the first half of the 20th century. Currently, less than 1% of births in the U.S. take place at home, compared with nearly 30% in the Netherlands.

    Canadian and Dutch studies have found that home births attended by qualified midwives appear to be as safe as hospital births for low-risk women. However, many groups still oppose the practice because of safety concerns …

    Erin Tracy, an ob-gyn at Massachusetts General Hospital and ACOG’s delegate to AMA, said that the studies in Canada and the Netherlands were not large enough to adequately assess potential problems during home births.

    What?!?! How large do the studies have to be? The Dutch stidy had over 500,000 women in it!

    … Alice Bailes, a certified nurse-midwife, said that those in her profession have “wonderful relationships with hospital-based practices,” including ob-gyns and midwife practices. She added, “These relationships … are important for peace of mind for us and our clients and for safety.” Bailes said women rarely need to be transferred from home to the hospital — about one in nine end up being moved — because nurse-midwives refer higher-risk patients to hospital-based practices before they go into labor …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Study Showing Abortion-Premature Birth Risk Points to Cerebral Palsy

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    A Canadian researcher says a new study showing confirmation of the link between abortion and premature birth is significantly important …

    … women who have just one abortion in either the first or second trimester of pregnancy have a 35 percent increased risk of having a low-birth-weight baby in the next pregnancy and a 36 percent increased risk of having a baby born prematurely.

    Women having multiple abortions have a 93 percent increased risk of subsequently having a premature baby and a 72 percent increased risk of having an underweight baby.

    … the Shah meta-study showed “very strong evidence [that] the most common induced abortion procedure, ‘suction’ abortion” has a “risk of a later preterm birth or the low birth weight baby.”

    … there were 1,096 newborn babies in the United States born at a low birth-weight, and who developed cerebral palsy, due to their mother’s prior induced abortions.

    The cerebral palsy link is important because “babies under 32 weeks’ gestation have 55 times the cerebral palsy risk as full-term (at least 37 weeks) newborns.”

    As a result, if abortions increase the risk of a low birth-weight baby and low birth-weigh significantly contributes to an unborn child having cerebral palsy, then the performance of abortions clearly results in more children diagnosed with the condition.

    “Swingle reported that women with prior induced abortions raised their relative odds of a birth under 32 weeks’ gestation by 64 percent,” …

    … “women should receive informed medical consent about the abortion-premature birth risk of prior induced abortions before the procedure is performed.”

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    The Unkindest Cut

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    “I’m afraid of something happening to me that I don’t want,” I said. The other women nodded their heads. “Yeah,” said another, “when you’re out of it.”

    We had been instructed to form a group separate from our partners to discuss our fears about the labor experience and our expectations of what we would get out of this Childbirth Education Class, now in its first session. But for some of us it was like therapy in a bomb shelter. The issue looming overhead was not the risk our own bodies might present to us, but the risks we knew were standard protocol in the hospitals we were suddenly being farmed out to.

    … we learned in mid-May that no more births could take place … [at] the Birth Center … the Birth and Women’s Health Center had been part of the for-profit Associates in Women’s Health Care for the past four years. But midwifery, the care provided at the Birth Center, is not terribly profitable when placed alongside the cash cow of modern obstetrics …

    … “One cannot help an involuntary process. The point is not to disturb it.” So renowned French physician Michel Odent articulated the philosophy that has been the cornerstone of birth assistance worldwide since human birth began.

    … in the early 1800s the average woman in this country gave birth at home attended by a woman midwife … However, in the 1900s birth moved to the hospital, due in part to industrialized America’s starry-eyed wonder at technology and the male-dominated medical profession, and in part because physicians who’d formerly shunned poor women began to offer their services at free clinics for the purposes of experimentation and instruction …

    … “Over the past 30 years, obstetric management has converted what should, in most cases, be a healthy, normal process into a high-tech event.” And while some would argue that we’re better safe than sorry in our caregivers’ preparedness for crisis … the vast majority of hospital births in this country find mother and baby at greater risk for complications due to unnecessary medical intervention …

    … “The best way to avoid a c-section is to be informed,” … Despite informed consent laws and assurances from administrators that all procedures are the mother’s decision, few women go into labor confident that they know better than their doctors which procedures are useful and when …

    … hierarchical protocols in hospitals sharply reduce the authority of midwives in favor of the medical model, making the obstetrician the authority.

    Why not trust the obstetrician? Won’t she or he want what is best for the patients? The answer is complex and alarming: Not always … For example, a woman’s likelihood of having a cesarean depends very little on her or her baby’s physical condition. The factors that sway the statistics much more include where she is giving birth (a hospital, freestanding birth center, or at home), who is assisting (an obstetrician, family practitioner, or midwife), hospital culture and policies, and–the strongest determinant–her caregiver’s cesarean rate. These factors influence not only who has cesareans, but who receives most of the medical procedures and drugs currently in fashion. These include fetal heart monitoring (the machine that goes ping!), episiotomies, IV, labor induction, epidural anesthesia, forceps and vacuum delivery and a host of other technologies that studies show compromise the health of the patients with little or no benefit.

    One more factor significantly increases the likelihood of unnecessary procedures: profit. Obstetricians often receive hundreds of dollars more for ceseareans than vaginal births, and hospitals can receive thousands of dollars more. An epidural jacks the bill up another grand. Fetal heart monitoring saves hospitals money by allowing one nurse to monitor several babies, as does the heartless practice of whisking the baby away to the nursery once born.

    The philosophy of obstetrics management posits that childbirth is a pathological condition requiring the intervention of surgeons. Hospitals are our culture’s centers of crisis and disaster, and that is why the majority of births do not belong there.

    … In the 1970s, women’s dissatisfaction with the medical model of childbirth gave rise to the concept of the freestanding birth center. Birth centers, usually located close to but separate from a hospital, provide more supportive, less technologically oriented maternity care for low-risk women by certified nurse-midwives. By 1989 there were 132 freestanding birth centers operating in the US, delivering about 20,000 babies each year … birth centers offered medical care comparable to hospitals for low-risk women, often at half the price …

    I asked the eight women in Childbirth Education class if any were planning a home birth, and only one raised her hand … Home birth in Tucson, together with prenatal and postnatal visits by a midwife, costs around $2,000–a pittance compared to the astronomical costs of hospital birth, which can be over $10,000. Ironically, though most of us had been “lucky” enough to have insurance that covered the birth center, none of our plans cover home birth however inexpensive, so hospital birth has become our only affordable choice.

    … Now the 49 women who were due to deliver at the birth center next month, and those like myself who were due not long after, are hauling our backaches around Tucson to check out our alternatives.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Homebirthing a mother of a dispute

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    PLAYING in the sand with her family, Elsa Dillon looks far from the dreadlocked hippie people stereotypically assume she is. To some, the mother of six has chosen the irresponsible path of having four of her six children at home.

    Like any female, Dillon has the right to home birth, but it doesn’t mean it’s easy … “The doctors have had me in tears about my decision to home birth,” says Dillon, who had her first two children in Newcastle Private Hospital and the rest at home, supported by her husband Richard.

    “They give you the hardest time and it’s shocking. But, we do it [homebirth] responsibly. We just don’t go off and do it; we research it. You learn how to resuscitate the baby if something goes wrong and have the knowledge of every possible scenario that could happen.”

    Like many, Dillon is celebrating the news this week that midwives have been given a reprieve allowing midwives to practice legally until 2012, but says there is still a long way to go.

    … Not matter which side you take, the point is the way women give birth around the globe and in our own backyards is a polarising issue.

    Homebirthing advocate, Hollywood actress and former talk-show host Ricki Lake has travelled the world voicing her opinion after having her … second [child] … in the performer’s bathtub in 2001, which is on show for the world in her 2007 documentary The Business Of Being Born.

    Talking exclusively to the Daily Telegraph the 40-year-old says it’s not about homebirthing versus hospital, but more about giving expectant mothers the information to make informed decisions.

    “I know it’s a huge issue in Australia and it is looking like homebirths could be illegal, which is shocking to me, but I am not advocating home birth,” says Lake, who will also feature as part of a segment on the topic for Channel 7′s Sunday Night program.

    “I am advocating the choice, and home birth is not for everyone, but for me it was the right choice.”

    Most of the 285,200 Australian children born last year were born in hospitals and birthing centres. However, 780 were born at home, almost all with the help of qualified private midwives.

    Private, qualified and trained midwives have been practicing since 2001 without insurance …

    … celebrities including models Elle Macpherson and Cindy Crawford, actress Pamela Anderson and Bill Grainger have had their children delivered at home.

    Like them, Dillon says she felt more at ease delivering between her four walls.

    “In a hospital it is very public and no private time for you and your baby,” Dillon says. “They also push the drugs quite a bit and I wasn’t prepared to do that. But it’s all about being comfortable in yourself. If you’re not comfortable with yourself you shouldn’t do it at home. We just knew we could do it. The one line I always say is homebirthing is not an illness. People freak when you mention home birth, but it’s an empowering experience for the whole family. Maybe that’s what doctors are scared of.”

    Jenni Ridley from Killara on Sydney’s North Shore agrees. Of her five children, four were homebirths including five-month-old Yindi.

    For Ridley, who is of Aboriginal descent, homebirthing is also about her family connecting with their ancestry … being born at home … [is] about bringing back some of our culture to our family …

    Obstetrician Dr Pieter Mourik studied for 12 years and has 30 years experience in birthing after delivering more than 5500 babies. He is unequivocal in his belief that homebirthing should be banned.

    On 100 occasions he has helped deliver babies after homebirths went wrong.

    He says one in 1000 women request a homebirth, and of them, 50 per cent are either not suitable, or fail and are transferred to hospital anyway, which can sometimes lead to unexpected legal ramifications for doctors.

    “All studies done on homebirth confirm there are three times more complications for the mother and baby,” he says. “Complications and avoidable disasters from women classified as low-risk are seen almost every week in the major maternity units.

    “Unfortunately the doctor who receives the woman in hospital is exposed to legal claims as medical litigation follows the patient and no midwife has medical indemnity. The argument for increased homebirth must be resisted … The government has a responsibility to educate the public that … the safest place to have a baby is in hospital where the woman is received and monitored by qualified midwives.”

    Ahem. I’m not sure that Dr Mourik has read the latest research around the safety of low risk, professionally-attended home birth. But he does have a point about the legal ramifications for doctors: since midwives do not have insurance, if the patient needs to sue, she’s better off suing the doctor or hospital since most midwives do not have the private funds to support lengthy court cases and pay outs. Indemnity for private midwifery is what is needed, as a matter of urgency. Or a no-fault legal system.

    I’m not sure where he got his stats from, but where he says that 50% are either not suitable, or fail and are transferred to hospital, he may have a point that judging by obstetric standards, most women who are currently accepted for home birth are unsuitable. The guidelines are very strict and forbid home birth for VBACs, anyone with a history of anything (eg bleeding after birth, previous prem baby and so on), as well as current issues like high blood pressure, baby not growing well and so on. These guidelines are supported by research from the Netherlands, Canada and the UK (except that the Canadian guidelines support home birth after 1 prior caesarean).

    Melissa Maimann, Essential Birth Consulting 0400 418 448