Australian Government acts to give women greater access to midwives and improve care!

An important update on the outcome of the Standing Committee on Health in regards to midwifery care.  So exciting to see this sensible development.  I know many people have been working tirelessly on getting the government to understand the issues.  My deepest gratitude to you all.

MEDIA RELEASE: 11 August 2012
Contact: Liz Wilkes 0423 580 585

Standing Committee on Health Decision will give women greater access to Midwives and improve Care.

Today’s decision by the Standing Committee on Health to enable midwives to collaborate with hospitals rather than individual doctors provides a welcome relief to Medicare provider midwives struggling to provide Medicare funded care to women.

“Until now government policy designed to provide women with Medicare access to private midwifery care has been to date severely restricted by obstetricians not wanting to be involved” said Liz Wilkes President of Midwives Australia.

“The recognition from every Health Minister across the country that midwives work collaboratively with doctors in hospitals and do not need individual doctor sign off is entirely appropriate. We applaud the sense they have shown” said Ms Wilkes

Midwives Australia has seen the legislation requiring midwives to collaborate with individual doctors has created unnecessary administrative burden and has created opportunity for medical veto over women’s access to Medicare rebates.

“What we are seeing here is the opportunity for midwives to develop license agreements and contracts with hospitals which enable true collaborative practice to continue”

“The whole hospital system relies on obstetricians being in the right place to deal with referrals of women. It is not a change in safe practice.”

“Midwifery care should not and does not require the presence of an individual doctor at a tertiary hospital when many other doctors are on staff, what matters is that there is a doctor present who is able to accept referral and transfer as doctors are employed to do this on a daily basis.”

“This week a Melbourne study found the care of a known midwife reduced the need for a caesarean section and actually improved outcomes. It is comforting to know that all Health Ministers agree on the need to make the care of a known midwife more accessible to Australian women.” said Ms Wilkes.

 We hope you will find it informative.

Best regards,
Midwives Australia

Thanks Liz Wilkes for this update! 

"midwives' views" etc have NO place in our literature. Bugger their views!”

The other evening I posted this article to twitter.

“Women who plan to birth at home with midwives are more likely to receive Evidence-based Care http://fb.me/1puDpq2un”

The article described research that found that first-time mothers who chose to give birth at home were not only more likely to give birth with no intervention but were also more likely to receive evidence-based care that women who gave birth in hospital despite care by the same midwives. (BIRTH 39:2 June 2012)

There was an immediate reply tweet from a female obstetrician who has the twitter name @obgynkenobi

Image from Twitter @obgynkenobi

Obygnkenobi  tweeted:  “primips should not then home birth according to recent bmj RCT. This article is level 9 evidence. Sorry.” 

I responded:  er no, that's not what that study showed at all

Obygnkenobi  tweeted: “p0s [nulliparas]: increased risk of adverse outcomes if home birth. Please don't make me get out of bed to get the ref. it's cold.”  

I responded: "the BMJ study showed a miniscule increase risk to the neonate with a primigravid woman birthing at home"

Obygnkenobi  tweeted: “let's not just pick and choose which evidence suits us”.  

I replied:  “birthing at home is still far safer than driving with your child in the car or having a swimming pool in one's back yard”

Obygnkenobi tweeted:  "I'm not debating the safety. I'm debating the article that stated that homebirth midwives were more likely to use EBM [evidence based medicine]” And further “Yes, the absolute risk is low but if EBM is the master we all serve, primips should not home"

I wrote back: “actually, the researchers said that people needed to be aware of the risks, not that they shouldn't”

Obygnkenobi tweeted: “because clearly, "some" midwives choose whichever evidence is more appropriate to their aims”  

I asked "clearly"? why clearly?"

Obygnkenobi replied:  "b/c some mws (and drs) don't practice EBM. Interpreting evidence based on proving a point"

That comment reminded me of the way people responded to a very poor study that changed practice overnight, so I replied “Hmmm, I guess the Term Breech Trial is a good example of your point. So many so quick to jump based on such flawed research” 

Obygnkenobi responded: “probably true to a degree. However I know many skilled docs who won't touch a breech” 

To that I commented: “then they're not skilled with breech; over decades I've seen many breech births & brilliant doctors & midwives; now fear rules”

Obygnkenobi  tweeted: “It's not just the medicolegal aspect but the trial confirmed what they had always thought”. 

I was confused by that statement, so replied: “sorry, you've lost me here” and when I thought more about what she said, I asked: “so you think they stopped doing breeches because the skewed trial confirmed what obstetricians thought all along?”

Obygnkenobi responded: “no but it probably was one of the factors #beforemytime"

I was confused by this comment too, because surely, understanding why we do what we do involves knowing one’s history and ensuring that what we are doing is evidence based. I am also aware of how one’s own cognitive bias leads us to perceive and interpret things from our own viewpoint, which is what happened with the Term Breech Trial. Cognitive bias was also happening in response to the BMJ article, so I tweeted in response “the biggest issue is ensuring the evidence is robust and real - we know how easy it is to find what you are looking for”

Obygnkenobi  tweeted: “So there IS a role for using our brain!! Who'd thought!”

I didn’t recognise this at the time as sarcasm, but I did feel confused so said: “and I'm not sure what this was in relation to either?? erk - I've missed something :( and I was enjoying this conversation”

Obygnkenobi replied:  “EBM raises a difficulty: either use our brains or use evidence. It's ok to use either but don't dress it up as EBM if it's not”

I fully agreed with that statement about evidence based [medicine] care being a difficulty, I was experiencing that in this conversation and replied: “very much so!”

Obygnkenobi  then tweeted: “precisely. And that's why the article with "midwives' views" etc have NO place in our literature. Bugger their views!” (my emphasis)

I was surprised and disheartened by that comment and replied: “I find that comment depressing :( “

Obygnkenobi responded:  “ok. How about: ebm and individuals views should not coexist in the same article. Better?” and then “individuals views are ok, so long as they're not gusseyed up to look like evidence. It's all good really.”

I didn’t respond to those two statements as it was 1230am and I was not wanting to say anything that could be misconstrued or appear rude.

The next day I tweeted:  @obgynkenobi I'm curious to know if you read the actual paper?

I haven’t received any response to my query. 

This morning I tweeted: @obgynkenobi “did you see this? Term Breech Trial 10 years on” 

That article is worth reading as it revisits the criticisms of the Term Breech Trial and highlights the fact that there has been an increase in maternal deaths with the rise of caesarean section surgery for breech presentations following that study. 

The abstract states:

Abstract:  In 2000, the Term Breech Trial was published, and its authors recommended cesarean section as the safest mode of delivery for breech-presenting babies. Criticisms of the trial were raised at the time, which the authors dismissed. Since then, maternal deaths have been recorded among women undergoing cesarean sections for breech presentations. Accordingly, those initial criticisms deserve to be revisited. (BIRTH 39:1 March 2012)

Not only did the BMJ article that Obgynkenobi had referred to earlier in our twitter conversation Perinatal and MaternalOutcomes Perinatal and maternal outcomes by planned place of birth for healthywomen with low risk pregnancies: the Birthplace in England national prospectivecohort study   not say women having their first baby should not give birth at home, they concluded: 

“Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting. Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome. A substantial proportion of women having their first baby who plan to give birth in a non-obstetric unit setting are transferred to an obstetric unit.

These results will enable women and their partners to have informed discussions with health professionals in relation to clinical outcomes and planned place of birth. For policy makers, the results are important to inform decisions about service provision and commissioning. The relative cost effectiveness of the different birth settings will also be of interest to policy makers and is being compared in another component of the Birthplace Research Programme.

Further research is needed into the avoidability of adverse perinatal outcomes, the effect of staffing and service configuration on outcomes, and more detailed analyses of transfers from non-obstetric unit settings. It is unfortunate that routine maternity information systems are not currently of a sufficiently high quality to enable the analyses presented here to be repeated without carrying out another large prospective cohort study.”

I also retweeted the article that sparked the twitter conversation:

I tweeted: @obgynkenobi in terms of evidence based practice, did you actually read the article about midwives use of evidence and place of birth? 

There is still no response, but it is Sunday!   

I would like to think that we can have good, intelligent conversations about evidence and practice without denigration and dismissive behaviour.  

Interprofessional collaboration in Delivery Suite was the subject of a research project I did in 2008. Attitudes like those displayed here by this obstetrician fit the model of Negative Interprofessional Interactions and stereotypical behaviour. This model is linked to low social and emotional intelligence of the midwives and obstetricians together with adverse outcomes for women and their babies.  Obstetricians and midwives don't feel good about these negative interactions either. I certainly feel very disconcerted with the attitude of this doctor towards midwives and our practice and the misinterpretation of these three studies.  

Giving birth is not a competition

International Women's Day has been a powerful reminder of how far we've come as a species.

IWD has also shown how far we still have to go to create a social world where the vast majority of women and many men enjoy the human rights of sovereignty and social safety to live as they desire and deserve.

From delusions of being able to create the master race to the idea that you can reduce or even eliminate risk in life, medicine and science have sought to control and dominate nature.

Nowhere is this more apparent than in the area of reproduction and in particular, for western women. Western women have come under increasing surveillance, control and criticism from medical 'experts' and the population at large during childbearing and parenting.  Conflicting advice abounds creating confusion and distress for women, all of whom want the best for their babies and want to do 'the right thing'. Women are told on the one hand that the rate of stillbirth doubles after age 40 and so induction around 37 weeks is recommended. On the other hand, other experts say that babies born early around 37 - 38 weeks with induction of labour are at risk of health problems.

What's hard to reconcile with the constant negativity with what is a very normal, human activity is that evidence shows that medical error causes more death and disability to people in hospital than motor vehicle accidents, breast cancer or AIDS. You may note that childbirth doesn't get it a look in with the comparison because the real problems with childbirth, even those caused by intervention, are so low in the western world. The other disturbing fact about hospital culture is that people are afraid to report errors because they fear recrimination. So really, we don't know what actually goes on in hospitals. Our only clue in NSW for example, is the Mothers and Babies report and that is a broad brush view.

We do not know exactly what the rate of intervention in the birthing process is doing to developing brains and human relations, but there are some signals that there are detriments.

Various individuals and groups challenge medical domination of birth and the medical profession's dismissiveness of the social aspects. There are thankfully, some enlightened doctors championing "patient" centred care and calling on clinicians to "relinquish the role as the single, paternalistic authority."

Films such as the Face of Birth, which aim to defuse the hysteria and show the social view of humanity's most primal act, have a tough gig. The media's delight in traumatic tales, coupled with 'reality TV's' depiction of birth all flavour enhanced by the medical profession's staunch opposition to birth at home and midwifery care, especially in Australia, has led to public opinion becoming increasingly hostile and disapproving of those who choose other than the 'doctor in charge' status quo. As a result, western women are becoming increasingly fearful of birth.  They are increasingly feeling under 'siege', a state of perpetual fearfulness. What is not so well known is how 'fear' affects a person's physiology.  The biochemical correlate of fear is cortisol. There is a lot of work being done on the effect of cortisol on physiological functioning and brain development for the fetus. Prenatal programming is a burgeoning field of inquiry investigating how a person's lifetime risk of disease or health is actually 'set' in the womb and dependant upon the mother's social world. We need to really wake up to what that means.

Western women are also becoming increasingly insecure about their parenting, which for heaven's sake is hard enough without the avalanche of 'advice' and disapproval from all and sundry.  I have been reading the comments under the mass media's articles on birth at home and the different perspectives are fascinating and show how we all see life through our own lenses of beliefs and experiences.  What, however is alarming, is the punitive and nasty way that some people respond to people's choices.

The scorn and criticism heaped on women who choose to do things differently, no matter what 'norm' is being touted by whichever interest group, is horrendous and needs to stop.

Where a woman gives birth and who she gives birth with is her business. For anyone to think they care more about a woman's life and baby than she does is the height of ignorance and arrogance. Our job as a society is to support women's choices because the evidence is clear that when a women feels supported and has choices her cortisol level is lower and her physiology and therefore her baby's physiology is more likely to be 'normal'.

Birth is NOT a competition.

It is about feeling safe, supported and respected.  Interestingly, the outcomes, including those of maternal satisfaction, are very very good when that is the situation. On another note, so many people downplay the need for the woman to feel good after birth - the health and wellbeing of the family are enhanced when a woman feels loved, respected and cared for, so that should be the focus of society.  We need to ask ourselves where does she feel safe and how can we, as a society support her in that?

Meanwhile, in too many countries, women are dying in childbirth.  The current estimate is that around 1000 women die every day giving birth.  That statistic is shocking and, with the right conditions, preventable.  These statistics illustrate clearly the social determinants of health and disease. Women are dying because in their cultures, they are "nothing" - they are worthless in the eyes of their culture  - they are the possessions of their partners or parents; they have no access to contraception and often have (too) many children, their nutrition is very poor, they are dreadfully anaemic, in some areas have malaria, HIV/AIDS and live with domestic violence and the threat of more of it hanging over their heads. Their living conditions are harsh. If we use Maslow's Hierarchy of Needs to think about the social determinants of health, you can readily see that these women exist without even their basic human needs being met. No wonder the challenges of reproduction are sometimes too great for them.  These women do not have the best conditions at home to give birth there - even the hospitals are poorly equipped and lacking in staff, but at least there may be someone there, with some education and training, who can support them and help them give birth safely. We know that when there is a strong and capable midwifery profession,  childbearing women and their babies do well.  Capacity building midwifery education is one of AusAid's projects to improve maternal and neonatal wellbeing and decrease mortality and morbidity rates in PNG.

People in the western world who are so concerned with what childbearing women do and where they give birth need to turn their attention to the developing world and work on making it safer for all women and their children.  We are, after all, living in a global village. What affects one, affects us all.

Instead of making birth a "who's right or wrong' competition, let's make it about cooperation, compassion and support.

If we want a peaceful society and happy mothers and babies, we would do well to ensure women felt loved and cared for, respected and nurtured, fed good food, rested, kept away from bad news and surrounded by loving family and friends and able to give birth the way they want to, with people they know and trust around them.

Strong College, Strong Midwives, Strong Mothers

I've talked previously on this blog about the fact that:

"Birth is not only about making babies. Birth is about making mothers - strong, competent, capable mothers who trust themselves and know their inner strength". Barbara Katz Rothman

The environment a woman finds herself in is a great mediator for how well she is able to develop that strength. A supportive environment is enabling. A supportive environment is capacity building.

Picture: http://www.crystalinks.com/midwifery.html

Midwives have traditionally been a vital part of the woman's birth territory where ever the woman gave birth. Midwives have protected the space and provided the support, encouragement and trust in the birth process that is so integral to women feeling free to birth and mother well. Midwives stand strong with women as they bring their babies forth into the world. Many's the time I've been with a birthing woman who would glance at me as she laboured and I'd smile and nod and she would go back to her process satisfied that she was 'on track'. Those women would invariably say later, "I was feeling frightened and when I looked at you and you smiled at me, I knew I was ok".

The word 'midwife' comes from the Anglo-Saxon "mid-wyfe" which means 'with woman'. There is a long history (at least the last four thousand years has been recorded) of the way that being with women has brought midwives into conflict with 'authorities'. The Bible gives evidence that midwives have always stood with women and protected them and their infants in the most difficult circumstances and despite powerful edicts to the contrary. Exodus (1:15-22) contains "several verses recounting the experiences of two Hebrew midwives who refused to kill male infants in defiance of the King of Egypt".

And now, in Australia, women and midwives have a new challenge.

In response to political posturing by various authorities, the Australian  College of Midwives has released an Interim Statement on Homebirth in an attempt to restrict where women can birth and what midwives can do. The statement, hastily drafted as it was, nonetheless was rapidly endorsed by the newly formed Australian Nurses and Midwives Board, even before the statement was reviewed by the College's members.  You will note that the statement endorsed by the board does not mention the word 'interim'.  What is also concerning is that the College statement references two papers whose data collection methods have been poorly regarded (Kennare et al (2010) paper on planned homebirth in South Australia, and Bastian et al (1998).

Interesting.

Submissions on the statement were requested by Friday 23rd September 2011 (after publication on the web). The College states it intends to finalise the statement in October this year. Many of us are not impressed by the statement as it stands because it does not position the woman as the decision maker. Midwifery ethics are all about the woman as decison maker.

You will find considered responses to the interim statement on homebirth by midwives who work in private practice on the following links.

Rachel Reed of MidwifeThinking's response

Australian Private Midwives' Association's position statement on homebirths

I was thrilled to see the clarity of thinking and recognition of women's rights in the response from the National Alliance for Students of Midwifery.

This statement from the International Confederation of Midwives on women's choices and birth territory is clear and unfortunately, not reflected in the interim statement by the Australian College of Midwives.

So here's my  submission to the College for consideration in the Board's deliberations over the wording and intent of the Final Statement on Homebirth.

Carolyn Hastie
Midwifery Facilitator
23rd September 2011
Dear Colleagues,
Re: Australian College of Midwives Statement on Homebirth: Women's Rights to a Homebirth and Their Right to a Skilled Attendant
Firstly, I want to know that my College supports women to have sovereignty over their own bodies and agency, including the right to choose where they give birth.

I also want to know that my College supports midwives to support women with their choices.

Guidelines and standards are important, however, risk status is an indicator, not a predictor and each woman has the right as an adult to be self determining. As an adult, a woman has the right to informed consent and informed refusal.

What enables women to be safest when giving birth is a known competent midwife, agency to choose to give birth where she feels most relaxed, a seamless means of transfer and acceptance at a local health service and collaboration with that service and prompt medical attention as required; the woman's chosen midwife able to continue to provide midwifery care with the support of the hospital's midwifery team.

Science is clear that when women have a perception of control over what happens to them, they have reduced levels of glucocorticoids in their peripheral circulation. Stress hormones are implicated in much of what goes wrong in labour and birth. Our role as midwives and as a midwifery organisation is to be 'with woman' and reduce stress, not create it.

As Barbara Katz Rothman said, "when there is a strong and autonomous midwifery profession, women and their babies do well".

We need to be a strong and autonomous midwifery profession. I want to feel proud of my College and our final Statement on Homebirth. The Interim statement both horrifies and embarrasses me, especially as it has been already endorsed and published by the Australian Nurses and Midwives Board - how on earth did that happen?

Yours Sincerely,
Carolyn Hastie
ACM Member and Fellow
MO5257

Women's rights to sovereignty and bodily autonomy are under threat and we need to stand beside them, to ensure they have the information they need to make their choices and support those choices.

That is what 'midwife' means.

We need our College to support women’s right to choose what suits them and their families and to support us to support women. We need a strong College, so midwives can be strong to support women in their choices so they can become the strong mothers they need to be.

The Environment is everything!

King hit on the funny bone: Labia room

I love humour.
I love those people who have a great sense of humour. I'm always amazed when someone can come out with just the right response to a situation. I love it when something someone says is so funny, I laugh til tears roll down my face. Quirky, off beat, clever humour like that of the Monty Python team really appeals to me. I can watch their skits and movies over and over again.

However, unkind and derogatory put downs or sling offs aimed at those who are vulnerable I find rude, offensive and inappropriate, not funny.

I also love social media. I love the way the various forms of social media provide an easy and quick way to keep in touch and gain and share information. Twitter, for example, was invaluable to many as a tool of communication during the recent natural disasters. The ability to communicate over huge distances with a minumum of fuss has meant that social media is increasingly used as a tool for health promotion. With that ease of communication enabled by the various social media platforms has come concerns about privacy, online behaviour and confidentiality. A code of conduct for online behaviour, coined 'netiquette' has emerged.

Unfortunately for many, they think their conversations on social media are the same as in the tea room, pub or corridor.

They are not.

They are permanently recorded and therefore able to be read by anyone for all time. A good way to think about it is to consider that what you say on a social media platform is like writing it on the front page of a national newspaper. If you wouldn't want what you are going to say recorded in that way, then don't use social media for that conversation.

Many of us have written about the use of social media for health professionals. I wrote an article earlier this year for midwives in our college newsletter. Still I see indiscretion amongst my colleagues posts at times that I feel concerned about. I do wonder how those who use health care think about some of the comments that are made; how would prospective employers perceive such comments if they were to look.  My understanding is that human resource departments are using social media platforms to find out more about applicants.

So a blogpost about an interaction on twitter between male doctors by Ann Marie Cunningham, a GP and lecturer in Wales UK with an interest in social media caught my attention when she said:

"I came across a discussion between several male doctors on twitter which caused me to reflect on this very topic. The doctors were using slang, which I have not come across before, to refer to the wards in which they might have been working. The terms used were 'labia ward' and 'birthing sheds' to refer to the delivery suite where women give birth, and "cabbage patch" to refer to the intensive care ward where many patients are unconscious.

I was shocked at this and angry and did query the doctors about some of the other things they said, but I felt I couldn't challenge them directly at that time about this language. One of the doctors referred to midwifes as 'madwives'"

The blogpost "Social media, black humour and professionals" and the responses are well worth reading to get a sense of what the doctors themselves and the readers of Ann Marie's blog thinks about these remarks.  There are some very interesting comments on Ann Marie's blog itself, but by far the most fascinating reaction has come on Facebook on the The Medical Registrar's fanpage.

Alongside the link to Ann Marie's blog are the words:

The medical registrar " makes no comment, other than anyone who uses terms like "space" to describe a blog is a humourless old trout until proven otherwise"

The medical registrar didn't need to say anymore, because the readers have made up for it with 72 comments at the time of writing this post. These comments are also worth reading.

The attitudes and values of the people responding are clearly discernable. A former CEO of a large Boston hospital, Paul Levy, has discussed the response to Ann Marie's post on his blog.

Paul Levy wrote that he is 'left aghast' at the some of the comments and found the mindset of a few medical colleagues 'extremely upsetting'.

According to the good doctors however, using those terms "labia wards" and "birthing sheds" for rooms where women give birth and "cabbage patch" for ICU where people are unconscious is just good old fashioned humour, a way to let off steam in a stressful environment. Others, like me, find them offensive and degrading.

Is it purely a case of 'humorless old trouts'? or something else?

What do you think?

Health Care Hashtags Resource on Twitter

I've been learning more and more about Twitter. 

Twitter is a great resource for information about anything you may find interesting.  The river of tweets provides ongoing and rapidly changing news headlines. Tweets are text-based posts of up to 140 characters displayed on the user's profile page. At any moment, you can see what people are experiencing, what is important to them and what they are thinking. If the topic of the 'tweet' is your subject area, then you can choose to interact or not. The stream of information lets you know something of interest about what is important to you. Of course, it's sensible to only 'follow' people who's work/life and/or philosophy is of interest to you.

Last week, in response to something I tweeted, I was invited to join a scheduled twitter chat about the use of social media and healthcare on Sunday night.  Here's the link to the conversation. As the benefits of social media in health care, in particular, maternity services and information sharing, is of great interest to me, I joined in.  I found the process confusing at first. The conversation is like being at a big party where everyone is talking at once.  If you read the transcript of the session you will see what I mean.

How amazing that a transcript of the event can be produced and stored in a virtual file to be accessed at any time! That resource is so useful to me.  I was able to return to the information and read it at my leisure. What's the purpose you may ask?  That conversation has much to offer. I was looking for links to any useful information; I wanted to check out how others are thinking about the use of social media, the benefits and pitfalls of doing so. I was also interested in how practitioners are talking about ways to keep professionally safe using the medium; all of which and there was much more in that conversation to explore,  provides food for thought.

For those of you who are interested in health care, Twitter offers a real opportunity to engage in real time with people from anywhere in the world about your topic of interest, from the comfort of your own home/computer.  No need to travel and lose time in getting to different parts of the world to learn from people who know what you want to know; the only expense is your computer and internet server/connection.  A really important and liberating aspect of Twitter is that there is no 'status' to get in the way of discussion or communication on Twitter.  People who are technology nerds, CEO's, journalists, mothers, fathers, PhD's, scientists of all kinds, anyone who is interested, communicate and collaborate in an open, respectful way about their chosen topic.  If anyone is not respectful, they are 'unfollowed' - no one is interested in 'fighting' or engaging with those who 'troll' and disrupt.

This morning, when I was checking the twitterstream # tags for twitterchats on health care and the use of social media (#hcsm and #hcsmanz), I found a tweet about a site that compiled all the twitter conversations about different aspects of  health care.  That site is found here.   I noted that midwifery didn't have a hashtag, so have filled out the form to create a midwifery presence on that site.  I've just been exploring the site that hosts the hashtag directory  and that web page is interesting too, well worth having a look at and considering what an online presence is all about.

If you are interested in exploring the conversation about health care and social media tonight (Sunday) on twitter, join us using the hashtag #hcsmanz in your twitter posts. If you are not yet on Twitter, go here  to learn about Twitter and to open up an account (it's free) and start tweeting!  You can 'follow' me - which means you follow my conversation. You can tweet back anytime you like in response to any tweet. If you do follow me, then put the hashtag #hcsmanz in the tweet. After you post, you can click on the hashtag and that will take you to the list of tweets about that subject. Then you can save that search as a list which can be accessed, with updates, at any time.

I look forward to our conversations on Twitter.

What do you think, will I see you there?  Comments and questions welcome.

21 strategies to help keep birth normal

NSW Health has released a policy aimed to help with increasing the rates of normal birth and decreasing surgical births. Called Towards Normal Birth, the policy "provides direction to NSW maternity services regarding actions"  to achieve those aims.

At a recent conference with about 100 midwives looking at why and how to "keep birth normal' and what we as midwives need to do, a brainstorming session produced the following list.  These strategies run from the big ticket culture change items to the seemingly small, but profoundly effective 'watch our language' individual action.

The list:
1. Avert the medical 'gaze'
2. Be powerful and able to negotiate as equals to doctors
3.  Establish a "round table culture'
4. Dispel 'urban myths' about birth
5. Support women to choose upright positions in labour
6. Educate teenagers
7. Promote the use of positive images of birth
8. Look at system issues: promote and change to woman centred midwifery models
9. Discuss what normal birth means to us and ensure we are talking about the same things
10. Listen to women with respect - what does the woman want?
11. Encourage women in labour to stay home as long as possible
12. Establish and provide support structures to help women stay at home in early labour
13.Establish and provide support structures so women can choose to stay home to give birth if desired
14. Examine our own attitudes to 'being with woman' in pain and uncertainty
15. Seek to establish a relationship with each woman
16. Allay fear: let woman know what birth is really about
17. Address anxiety of support people and other health professionals
18. Pay attention to the language we use
19. Have confidence in women's ability to give birth
20. Pay attention to our body language as body language conveys meaning: what are we saying?
21. Set up birth space intentionally - find out what makes each woman feel safe and do that.

Each of these strategies could be a blog post on its own!  What do you think? What else can we do? How do we put these strategies into practice?