Ethics, AMA and that South Australian Homebirth 'study'

Barbara Katz Rothman, Ph.D,  Professor Department of Sociology,  City University of New York, is the author of fabulous books such as The Tentative Pregnancy and In Labour: Women and Power in the Birthplace. W.W. Norton and Company, 1982, now updated as Laboring On: Birth in Transition in the United States, With Wendy Simonds and Bari Meltzer Norman. Routledge, 2007.

Professor Katz Rothman famously said "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 made another great comment about how whenever there is a move to return power to women, patriarchal interests rise up in protest to reclaim their position. I haven't got the exact quote, but something along that line.

What is particularly interesting right now is that the negative voice of reproductive medicine headed by their president, is growing louder and louder, warning everyone that birth is dangerous!  The voice is getting louder, telling women and the community that birth at  home is dangerous, just as the Federal Government begins to move to increase women's birth choices and position midwifery as the health care profession most suitable and appropriate to provide primary health care for childbearing women.

Coincidentally, a report on homebirth in South Australia was published recently in the AMA medical journal.

Medical Journal of Australia article on SA homebirth

The president of the AMA Dr Andrew Pesce, wrote the editorial of the issue of the AMJ which published the 'study'. He listed his competing interests this way

"I am President of the Australian Medical Association, which is opposed to home birth in Australia".

The title of Dr Pesce's editorial is "Planned home birth in Australia: politics or science?"

Dr Andrew Pesce (Dr 3am)'s Editorial in the MJA

Good question, Dr Pesche, all looks good and transparent on the surface so far!

Dr Pesche discussed the controversy surrounding homebirth and midwifery practice and quoted the following 'facts' from the 'study' of SA homebirth statistics:

"planned home birth was associated with a sevenfold increase in risk of intrapartum perinatal mortality compared with planned hospital birth, and a 27-fold higher risk of death due to intrapartum asphyxia.6 These differences were significant despite a sample size of only 1141 home births. Overall perinatal mortality standardised for gestation and birthweight was more than double that of planned hospital births, but because of low numbers these differences were not statistically significant. Of course, not all severe adverse perinatal outcomes in labour can be avoided, but they are better avoided, statistically speaking, when birth is planned to take place in a hospital birth unit".

Deeper analysis of the 'data' reveals the statistics are somewhat skewed. I have written else where about the results of this 'study'.  As the old truism goes there are 'lies, damned lies and statistics' - it requires enormous rigor and willingness to look at one's blind spots when interpreting statisics.  One of the ways to assist with blind spot removal is to have independant reviewers go over the results of data interpretation. Everyone would presume the AMJ would do that to maintain credibility and transparency. A reasonable assumption given that the Journal’s website links to the World Association of Medical Editors Position Statement on “Conflict of Interest in Peer-Reviewed Medical Journals”: http://www.wame.org/conflict-of-interest-in-peer-reviewed-medical-journals

However, following various online articles debunking the analysis of the statistics, including an article by Melissa Sweet at Crikey.com  Don't believe the homebirth horror headlines galvanised Dr Pesche and the AMA to seek a right of reply.

In his reply to the criticism of both the article and his editorial, Dr Pesce said

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

As Croakey comments "Dr Andrew Pesce, for those who haven’t been following the story thus far, 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".

Now wait a minute! Dr Pesce was one of the reviewers of the new study? Hmmmm  and wasn't Dr Mark Keirse, an obstetrician,  one of the authors of the discredited Bastion study also cited by Pesce as evidence of the dangerous nature of birth at home?

Uh oh.  Excuse me,  the bias is showing.

I'd love to know who the 'neutral commentators' were!

Using 'science' to back up biased opinions is hardly new or unique to this particular study and the rhetoric which surrounds it.  However, frightening childbearing women and the community about the safety of birth in any context is unethical, given what we know about the way that the hormones of fear impact upon both the fetus and the woman.

Dr Pesce also asks the reader

"...to be fair, 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".

Dr Pesce needs to listen to the despairing voices of midwives and student midwives who struggle daily with the way that medicine interferes, disrupts and pushes the birthing process into places that women are not ready to go with disabling consequences.

for example

"So, after watching BOBB (The Business of Being Born) and doing my current reading about the history of midwifery/hospitals/medicine, my eyes have been opened, yet again (still!) as to how harmful the hospital environment can be towards childbirth and women.

Yes, hospitals, medicine and nursing care can save lives. However, ever notice the trickle down effect of us *causing* some of the problems in the first place?"

Some self loathing, some guilt, and a whole lot of venting

It's time Dr Pesce to stand back and look at who's interests are being served in this 'debate' and controversy?  This 'shroud waving' and 'spin doctoring' of facts is an 'emperor has no clothes' kind of situation. What do we make of it in light of the fact that over $2.11 million dollars of tax payer's 'safety net' money has been siphoned off into the pockets of some doctors?

Changes to obstetric safety net are fair, despite foul cries – Croakey

The big question is how do we get to work together so that the woman is in control of her body and reproductive process and we as health care professionals are there to support and encourage every woman to feel safe in her own body and respected for her evidence informed choices?  There are some great doctors who really respect women and believe that the natural brilliance of the birth process works well when women are informed and supported to labour and birth undisturbed in the place of her choosing. These doctors are there, respectfully supportive for the rare occasion when some kind of intervention is warranted.


Birth is as safe as life gets Dr Pesce.  The therapeutic use of self as a health care practitioner is what makes both life and birth safer. As Barbara Katz Rothman says "birth is about making strong and capable mothers". Time to stop pulling the rug from under women's sense of self with all this 'turf war' rhetoric!

Birth at home Safer than at Hospital: eMJA: Planned home birth in Australia: politics or science?

Good news from the latest review of homebirth statistics. Despite the fact that the AMA can't read research, and then go on to make gooses out of themselves by quoting incorrect statistics to frighten people about birth, the news for women who want to have their babies at home is very good.

The correct information is this:

1. The rate of perinatal mortality for the period under examination (1991-2006) was 8.2 per 1000 births for planned hospital births; for infants born at home 2.5 per 1000 births.

According to the reviewers, one of the two infants who died after being born at home

"had congenital anomalies suspected on ultrasound; the parents declined further investigation, and the infant had palliative care and died from lethal anomalies. The other was a fresh stillbirth from a water birth. Although birth under water was thought not to have contributed to the death, closer monitoring during labour may have changed the outcome.

The evidence clearly shows that birth at home is safer than birth in hospital!

Image from Wikipedia

The reviewers said:

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.4 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.

A pity that the AMA has chosen the route of "Lies, damned lies and statistics" to further their 'shroud waving' agenda to frighten women and their families about birth.

Image from http://www.mothersbliss.com/nine/birth/hospital.asp

eMJA: Planned home birth in Australia: politics or science?

The really important point amidst all this stupid shroud waving and fear mongering on behalf of the AMA is that women do best where they feel safest. Our jobs as health professionals is to be supportive of women's choices and provide an environment where women feel supported and cared about and to intervene appropriately. That's it.

Sadly, the AMA has forgotten about the therapeutic use of self. Using fear to coerce women into submission to fit the 9-5 agenda is not kind, good or ethical.

Overdue NSW woman gets police check up | News.com.au

A New South Wales woman, Rochelle Allan and her partner Daniel Jones, have been seeing their private midwife throughout her pregnancy and attending the local hospital for the screening tests that are routine in pregnancy. Rochelle and Daniel's intention was to have their second baby at home with a midwife they knew and trusted.

Rochelle and Daniel, looking forward to their new baby (from News.com.au)

"Ms Allan said that she had decided on having a home birth after a "horrific experience" at the same hospital two years ago when their son Bailey was born. I was induced and I spent 48 hours in labour," she said. "I don't want to go through with that again."

Ms Rochelle Allan was twelve days overdue and attended the hospital for a routine,  "CTG" a monitoring process, that records the fetus's heart rate and the woman's uterine activity together. The idea of this test, is to pick up any signs of fetal distress. The CTG is a useful tool, but no guarantee. The best way to ensure a fetus is well and happy is to ensure the woman feels relaxed, connected with her baby, well supported and knows her baby's movements - the mother is often able to detect if things are not 'right' and contact her caregiver for a check up. The CTG was normal and reassuring, however the doctors decided that Rochelle needed to be induced because she was 12 days overdue (not even two weeks overdue!) and booked her for induction the next day. Rochelle declined to be induced and told the hospital staff that and reminded them that she was giving birth at home with her midwife. Ms Allan rang the hospital and told them the next day that labour was beginning and she wouldn't be coming in.

The hospital staff sent the police around to 'check up' on Rochelle.

"I couldn't believe it when I saw the police officers at my door," Ms Allan said. "They told me they had been asked by the hospital to check on my welfare because I had not attended".
"The hospital knew I did not want to be induced and they gave me no medical reason why I should be."
Throughout her pregnancy, Ms Allan and her partner Daniel Jones have been regularly attending the hospital's antenatal clinic for mandatory tests and scans to monitor the baby's progress. A hospital spokeswoman confirmed police were sent to Ms Allan's house to conduct a "welfare check".

http://www.news.com.au/national/overdue-pregnant-nsw-woman-gets-police-check-up/story-e6frfkvr-1225820277538


Now, I didn't know that NSW was a police state! I live here and I didn't know that.  Well, clearly the decision to send the police around was made in error, because the next day, the following headline appeared in the 'news'.


Home birth mum receives apology

http://www.news.com.au/breaking-news/home-birth-mum-receives-apology/story-e6frfku0-1225820359124

The report says:

The Greater Western Area Health Service today offered Ms Allan an apology for the unexpected police visit, saying they just wanted to check she was alright.

"We are sorry if it ... caused her any distress but our intention was to check on her welfare," area health spokeswoman Sue-Anne Redmond told ABC Radio today.

The health service denied it was trying to pressure Ms Allan into being induced.

Sure sounds like 'pressure' to me!

Sending the police to get people to comply in a health related matter like this is 'bullying' and as such, is against the law. We all know what bullying does to a person's physiology! What an outrageous thing to happen to a pregnant woman, especially at this stage of her pregnancy, when peace, calmness and support are the ideal environmental conditions for a happy labour and birth.

There is a very happy ending to this story, as well as the very welcome news that the health service very sensibly apologised, as they should, for their heavy handed tactics with this young woman.

Rochelle gave birth to her beautiful baby this morning, in the peace and quiet of her own home, with her husband and her midwife. Her midwife drove three hours to be with Rochelle and her partner for the birth! Well done team!

  Welcome to your new baby Rochelle and Daniel. I bet Bailey is thrilled.

Changes to obstetric safety net are fair, despite foul cries – Croakey

Dr Hilary Joyce, President of the National Association of Specialist Obstetricians and Gynaecologists (NASOG), wants to work with the Federal Government early next year to find an alternative solution to lessen the financial impact on mothers-to-be. NASOG is concerned that pregnant women are in for a New Year shock as the Government's budget cuts to the antenatal safety net package takes affect. NASOG distributed a media release about their concerns.

http://www.aushealthcare.com.au/documents/news/15970/NASOG%2004.01.10.pdf

Dr Sally K Tracy is Professor of Midwifery at the University of Sydney. Professor Tracy admits she has a vested interest. Her vested interest, as stated on the Crikey blog, is in encouraging the Commonwealth government to increase accessibility to midwifery care for all women; and fully supports the Commonwealth government’s initiatives under the maternity services reform package. A pretty good vested interest to have as the evidence has repeatedly demonstrated that childbearing women and their babies are safer with midwifery care.

Professor Tracy: "thought a little historical context might give readers a deeper understanding of the issues involved, and reassure women that the reform is aimed at creating a fairer system".

and explained

“The Medicare Safety Net was aimed at protecting all Australians from high out-of-pocket costs for medical services provided outside hospital.
In March 2004 the Howard Government changed the Medicare Safety Net to allow for an unlimited, non means tested increase in the supplement payable for Medicare benefits for these charges over and above a threshold set by the government each year.
The inherent risks in introducing an unlimited benefit were soon realised when it was discovered that the safety net was not necessarily benefiting those with a low to middle income or who were sickest in the community, despite the existence of a lower threshold making it easier for them to qualify.
The people who really benefited were the providers themselves. It was found that some doctors were cleverly taking advantage of the safety net to increase their fees with the knowledge that the majority of the cost would be refunded by the government. In 2008 this cost Medicare (and the taxpayer) the sum of $211.3 million.
In fact in the five years since the introduction of the new safety net, fees charged by private obstetricians for in-hospital services reduced by six per cent, whilst the fees charged for out of hospital expenses such as the ‘antenatal care package’ increased by 267 per cent".

Now, who is it that has vested self- interests? How interesting is it that the original intent of the safety net was to help the public, but the doctors found a loophole and benefited themselves to the tune of $211.3 million of tax payers money.
read more here

Changes to obstetric safety net are fair, despite foul cries – Croakey

Mother, baby revived after 'dying' in labor - Heart health- msnbc.com

What a blessing that this young mother and her baby revived and survived.

Mother, baby revived after 'dying' in labor - Heart health- msnbc.com

What I found particularly interesting is that the woman had an epidural minutes before the circulatory collapse. Her husband noticed her colour was blue and when the nurses checked her, she had no pulse.

The fact that an epidural had been administered had not made it into any of the news reports that heralded the story about the miracle of this woman and her baby's survival.

The doctors are at a loss to explain what happened to this young woman.

Yet, there are several possible explanations with the administration of an epidural in labour:

1. The anaesthetic agent could have been inserted into a vein by mistake causing cardiogenic shock
2. The epidural block may have been too high, causing paralysis of the intercostal muscles and respiratory arrest and then cardiac arrest
3. Allergic reaction to the anaesthetic agent

None of these possibilities have been explored in the news. What this story does of course is add to the general fear cascade around 'birth' in western culture. The 'problem' in this story is not with labour, it is with the intervention, the epidural administration. The problem needs to be attributed to where it rightfully belongs. Where most of the problems with birth lie is with the interventions that are 'done to' birthing women. Instead of providing every childbearing woman with one to one midwifery care that enables a woman to feel valued and cared about, work through her feelings about becoming a mother and then supported to give birth in her unique way, according to her own body biorythms, women are fed a steady diet of fear and problems, anaesthetised, poked, prodded and pushed. The way that the normal natural process of birth is tampered with is what leads to the problems that women experience.

Fear is a powerful force for shaping women's experiences of birth. The trouble lies in our cultural conditioning and media portrayals of birth. Fear makes us compliant and anxious. Instead of women perceiving the birth of their babies as something special and transformational, they are encouraged to rush to take 'whatever' modern medicine provides for deadening the feelings associated with the experience.

Unfortunately the 'cure' can often be far worse than the experience itself.

This story should have read " Mother, baby revived after 'dying' post epidural"

Australia's maternity system like 'herding yards'

Mother Care: It's like herding yards

JULIA MEDEW
January 2, 2010

"Chronic shortages in Australia's maternity system have left mothers feeling like cattle being pushed through herding yards that put both their own and their babies' lives at risk.

A survey of 2792 mothers by Fairfax Media found that about half of those who had given birth in the past five years believed the maternity system was not coping well enough with soaring demand".

WHAT MOTHERS SAY

''There should be more continuity of care. Knowing your carer and trusting your carer removes the fear from childbirth and fear leads to more interventions.''
''There is a severe shortage of birth centre places available and in many areas it is not even an option.''

''There are so many time limits imposed on women which completely disregard the natural progression of labour in women's bodies. Doctors are too quick to intervene, too impatient to wait and allow the body to do its job.''

Chronic shortages in Australia's maternity system

A child is born

One to one midwifery care puts the woman at the centre of care and ensures that she feels valued, listened to and cared about. Nicola Roxon needs to listen to what women want and ensure that private midwifery is a viable option for those women who want individualised maternity care. The move to publically funded midwifery models of care is a welcome move, however, those models are unable to provide what a private midwife can provide and all models are needed to meet the individual needs of Australian women.

Breastfeeding is Normal

The women who made this video said:

"The purpose of our video is to encourage mothers to feed their child, no matter where they are! And to give encouragement to new and expecting mothers that breast is best, and nursing IS normal".

YouTube - NIN CHARLOTTE

Midwifery-led maternity care safe

HSE.ie - Health Service Executive Website - Presentation of the “MidU” study – a major trial comparing midwifery-led and consultant-led maternity care

"The 'MidU' ('Midwifery Unit') study showed that midwifery-led care, as practised in these units, is as safe as consultant-led care but uses less intervention in pregnancy and childbirth".

What's interesting is that the report says midwifery care is as safe as consultant care. My reading of the statistics means that midwifery care is safer than consultant care for that group of women.

Midwifery takes a northern look: UofA program supports Nunavit women to birth at home

U of A program supports Nunavit women to birth at home

By Jodie Sinnema, Edmonton Journal December 18, 2009

"A healthy community has to be one where women can give birth," said O'Brien, who has been travelling to Nunavut for three years to speak with traditional midwives, most in their 80s. They share stories of feeding the best cut of meats to expectant mothers and delivering babies in ice houses, or tents made of furs. That history is informing the new midwifery program"

The aim of the program is to train midwives locally so more Nunavut mothers can give birth in their home communities.

Kango, a traditional midwife who learned her skills from her mother-in-law, sister-in-law and other northern elders, is now sharing her knowledge through Nunavut's first midwifery training program.
"Before colonization", Kango said "there were no doctors or nurses in Nunavut, so men and women stepped forward to be midwives. But in the 1960s and '70s, when western medicine arrived full force, mothers had to leave their homes, husbands and children six to seven months before their delivery to give birth in distant hospitals".
"With this kind of method of hospitals to send the mother out without husband or parents to attend, it was hard for the mother," Kango said. "With increased stressed, they would smoke more, lose their appetite and lose interest in looking after themselves. Oftentimes, health professionals couldn't speak any Inuit languages, leaving the women isolated in pain".
Midwifery takes a northern look

More women choose do-it-yourself births - Pregnancy- msnbc.com

By Linda Carroll

msnbc.com contributor

updated 1:05 p.m. ET Dec. 6, 2009

"Jennifer Margulis thinks birth should be a private party — no doctors or midwives invited. So when her daughter Leone Francesca was born at home last month, only Margulis and her husband, James, were in attendance.

“My husband and I were the only ones there when she was conceived,” says the 40-year-old writer from Ashland, Ore. “I thought we should be the only ones there when she was born.”

Margulis is part of a very small but growing number of women who are choosing to deliver their babies at home without the presence of health professionals. Some choose to have a husband or another family member help, while others opt to deliver their babies completely on their own."

Jennifer Margulis, 40, of Ashland, Ore., gave birth to her daughter Leone Francesca at home Nov. 4 without medical or midwifery help.

I can understand why women would choose to birth on their own or with their loved ones in this modern climate around birth. These women are telling us in the health care industry that they are not happy with what we are doing. If we want to have a place at birth with intelligent, self aware women who understand the process and feel comfortable with their bodies then we have to pay attention to what they want.

I personally love it when I am redundant at birth. When the women are fully present and aware and confident. They manage their labours beautifully, they breathe their babies and their placentas out easily; they and their babies are well and healthy. When I've sat on my hands and enjoyed the process and the woman's sense of self mastery, that's my idea of a good days/nights' work.

Unattended births can be problematic, that's true. So can attended births.  The issue, no matter where or with whom women chose to give birth,  is how does the woman feel, what does she know, is she well nourished, does she love her partner and how is their relationship, how confident is she in herself and what else is going on?

For women in developing countries it is often a very different situation. The problems for birthing women in developing countries are multifactorial.  These women are usually anaemic, have no birth control and therefore too many babies already, they are tired and poorly nourished. They usually work too hard and don't have any support of any kind. These women often don't have the stamina and energetic resources to stay mindful and present to the birthing process to keep safe.

Let's listen to women, find out what they want. Rather than seeking to undermine their confidence to get compliance with our agendas, let's listen and change what we are doing to be more likely to be invited to be part of the most amazing experience on earth. 


More women choose do-it-yourself births - Pregnancy- msnbc.com

Obstetricians' peer pressure: the problems with one sided mandated collaboration

Dr Jenny Gamble, President of the Australian College of Midwives, in her appearance before the Senate Committee on Thursday, 18th December 2009, explained how her private midwifery practice changed overnight because doctors changed their mind about 'collaboration'.

"About 15 months into the arrangement the three obstetricians, whom we had written agreements with, pulled out within the space of 10 days. We lost our livelihood. All of the women on our books—and there were a significant number; they were providing the livelihood of four midwives—who were still in pregnancy and still had their pregnancy, labour, birth and postpartum care to go with us, were now left without the option of continuing care with us and having a hospital birth. Effectively, we were forced into a home birth practice

In fact, the state government had to step in at that stage to make interim arrangements for the
remaining women on our books so that they could continue under our care and have a hospital birth, after much ado—minister visitors, lobbying, submissions. So we were on thin ice—‘Yes, I’ll have a collaborative arrangement with you; oops! No. I’ve changed my mind.’

We did not have any mishaps. We did not have a postpartum haemorrhage. We did not have a baby admitted to a special care nursery. Nobody died. In fact, we have had outcomes from our practice which are world’s best—a seven per cent caesarean section rate, with no postpartum complications and no re-admissions to hospital. We had excellent outcomes and they all pulled out within the space of 10 days—and I always thought it was because they had no-one to sit next to at the Christmas dinner! They had a lot of pressure from their peers not to do it."

Jenny continued, explaining how the proposed bills before the Senate would impact midwifery practice. 


"Under this arrangement, you will not be forced into a home birth practice; you will be forced out of
practice". 

Obviously women's choice of caregiver and place of birth will also be severely curtailed by this legislation.

People point to the fact that Belmont Birthing Service has excellent collaborative agreements, based on the Australian College of Midwives Guidelines for Consultation and Referral.

Thanks to Dr Andrew Bisits, the champion of choice, that's true.  But what would happen if Andrew were to retire, or move elsewhere? Who would take up the challenge to support the practice?

Would the situation have the same outcome for Belmont as it did for Jenny's service when the obstetricians changed their mind? If there was no obstetrician prepared to state categorically that he/she would take over from Andrew Bisits, would the health service continue to provide that option for women?  Worth noting that up the valley, within the same health service, opposition from local GP's means there is no comparable midwifery based service for the women in the area, despite there being local midwives who would like to practice in a continuity of care service and women who lobby to have that care.

Dr Jenny Gamble explains the issues with the proposed amendments to the bills and the idea of mandating a 'collaborative' relationship for midwives only:

"Collaboration is a very important thing in health care and we know that you know that. We also buy in completely to the idea of collaboration and I know my colleagues will talk about how that is already embedded in regulatory frameworks, registration and clinical governance of midwives. At every level we accept collaboration as a concept. When you collaborate with people when one party must and the other party may and there might be reasons that the person who may collaborate does not want to, you do not have collaboration and that is the fundamental problem with all of this. Just because some medical practitioners may, do and will collaborate does not actually make for collaboration and to legislate that you have a signed written agreement with a medical practitioner becomes meaningless and unworkable.

Perhaps we have heard examples today of where the medical practitioner may choose not to collaborate with the midwife in relation to homebirth but in fact from the college’s point of view, we can think of thousands of clinical examples where the woman may make choices that the doctor does not think are in her best interests.

The midwife wants to respect the woman’s right to self-determination, give her information and ensure she is fully informed but also respect her right to make the decision, even if it is a decision the midwife disagrees with—and then she will not be able to find a collaborating doctor to help care for that woman, because the doctor will choose not to participate in care that the doctor does not think is in the woman’s best interests. So right away we have this funny relationship: ‘I’ll decide what’s in your best interests and that’s the sort of care I’ll support.’  

 We are not talking about surgery here; we are talking about having a baby, a normal physiological process for many women with vulnerabilities and risks that might need referral to medical care.

To legislate that one party has to have a collaborative arrangement with another party to practise is
problematic. What we are unclear about, and what has not been able to be cleared up for us, is how far this goes in restricting midwives. If you cannot get a collaborative arrangement with a medical practitioner, does that mean you cannot practise? Does it mean you cannot get access to MBS? Or do they put it in the professional indemnity insurance product that you have to be eligible or have to have a collaborative arrangement to access professional indemnity insurance? And you cannot even get professional indemnity insurance, and you cannot even register. All of that is completely unclear. With all these things being unclear and those questions being unable to be answered by any of the bureaucrats that we have spoken to, it seems to me that to put it in the legislation is a highly flawed position. There are a number of other mechanisms to ensure collaboration. The college, our members, midwives generally and doctors generally all agree collaboration is a good idea. 

It is a benevolent patriarchy when the doctor can decide with whom and when they will collaborate. 

It is not freedom if your freedom is granted by others. (emphasis my addition)

The problems associated with having a group of professionals 'in charge', especially when those professionals can have widely differing viewpoints and practices, means that those who have to work with (read 'under') those professionals are vulnerable to the whims of those they work with.

In the case of midwives and obstetricians, collaboration works well when you have strong, open minded, women friendly, birth comfortable obstetricians together with health services which put women at the centre of concern. When health services put women at the centre of concern, the work of both midwives and obstetricians is equally valued and neither group is preferenced above another.  Of course, when health services are more driven by the culture associated with 'professional silos', then the individual woman and birth friendly obstetrician is under incredible pressure to conform to the 'norm'. As in Jenny Gamble's example, such pressure is difficult to endure without succumbing.

However, those women centred health services and woman and birth friendly obstetricians are few and far between. If obstetricians perception of their 'right to rule' is strengthened by legislation, then support for optimising women's natural processes and midwives ways of working are doomed.

Consensus, collaboration and power imbalances - words from the Senate Hearing on Women's choice of birthplace and midwife's role

From the Senate hearing

Senator SIEWERT—The issue around consensus is about somebody who has spent years of her life in a
consensus system—a consensus decision-making process. One of the things I clearly know is that, if there is a power imbalance, consensus tends not to work, because at the end of the day the people holding the power can say, ‘I don’t care what you think; we’re the ones that sign on the dotted line at the end of this process.’ That seems to me to be one of the keys here. You can say that the medical practitioners will collaborate and want a consensus approach, but at the end of the day it is the medical profession and obstetricians who will be responsible for signing off on collaborative care arrangements under the current process, and that is what
people are concerned about. It seems to me that it is clear that there is a power imbalance when you are happy with this amendment but patients, midwives and nurse practitioners are not happy with it. So that says to me that fundamentally there is an issue here.

Dr Pesce—All right. We have lots of very happy patients that do not seem to be unhappy with the power
balance. But in trying to address—

Senator SIEWERT—We have 2,000 emails from people saying that they do not like the current
amendment.


Dr Pesce—And there are 280,000 births a year. But we do not have to get stuck on that. In terms of the
power imbalance, if there is a power imbalance, I suspect that it emerges from the fact that we have different
competencies and that, at the end of the day, when something goes wrong—in an abnormal or high-risk
pregnancy—it is an obstetrician that is required to perform an instrumental delivery or a caesarean section,
which is not within the competency of a midwife. If there is an imbalance, I suspect that it emerges from the
fact that midwives can care for a patient to a certain point and then, if something goes beyond that, they need
to enlist the services of a collaborating obstetrician. But that obstetrician obviously is hesitant to just become a
technician and say, ‘I will just step in when I am asked to.’ They would like to step in at the right time. So, if
there is a power imbalance, it arises from the different competencies of the people who work in the team,

Community Affairs Legislation S12666.pdf (application/pdf Object)

Proof Committee Hansard

SENATE

COMMUNITY AFFAIRS LEGISLATION COMMITTEE

Reference: Health Legislation Amendment (Midwives and Nurse Practitioners) Bill

2009; Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill

2009; Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009

THURSDAY, 17 DECEMBER 2009

CANBERRA

CONDITIONS OF DISTRIBUTION

This is an uncorrected proof of evidence taken before the committee.

It is made available under the condition that it is recognised

as such.

BY AUTHORITY OF THE SENATE

[PROOF COPY]

TO EXPEDITE DELIVERY, THIS TRANSCRIPT HAS NOT BEEN SUBEDITED

Great work by everyone at the Senate Committee hearing yesterday! Rachel Siewart (Green's senator) asked insightful questions.

Some comments below, from members of Maternity Coalition around the subject of safety - dynamic Dr 3am's catchcry - where was he when The Butcher of Bega was out and about?

"Mrs McIntosh —The way we see it is that the woman should be at the centre of that—her choices be
respected; all the information given; and safety looked at, not only physical safety for her and the baby but
also emotional and psychological safety. They are paramount not only to a woman’s experience through
pregnancy, labour and birth but also to breastfeeding, postnatal depression, relationships, bonding and ongoing
issues with siblings. They are all so intertwined that, if a woman is not right at the centre of the collaboration,
it is probably not going to be all that effective.

Ms Catchlove—Nobody has more interest in the safety of a baby than the mother of that baby. I make a
decision for my baby and myself, and I am absolutely 100 per cent motivated by safety. And I am the only
person who can weigh up what is a safe choice for me and my family.

Mr Teakle—Safety is about being comfortable with the risks. There is no way of defining something as
being safe or unsafe. We have a bunch of different people here who are going to have different feelings about
what risks they are comfortable with. Some doctors might be comfortable with the risks of a caesarean,
because that is something they are familiar with and they feel in control of it; a midwife might feel
comfortable with something else. Once we get into an argument about other people deciding what is safe for
the woman, then we have lost focus. The woman needs to decide what she feels safe with, on the advice that is
provided to her by experts who can give her really good advice about that. That is why in other countries
informed choice has been understood as the way of getting out of these arguments.
It is terrible to have arguments going on in the media about what choices women should make. That is not
about safety; that is about control".


S12666.pdf (application/pdf Object)

Ex-Bega doctor faces 52 more charges

 From the Sydney Morning Herald Newspaper, Australia

DYLAN WELCH

December 15, 2009

"Former doctor Graeme Reeves appeared in court today, facing 52 more charges in regard to sexual assault, bodily harm and fraud offences. The new charges, which involve as many as 21 incidents, date back to 1989.
The previous set of more of than 100 charges Mr Reeves faces were all related to offences allegedly committed between 2001 and 2003.

Mr Reeves's bail was continued during a brief appearance at Parramatta Local Court just after midday"
Nine officers from Strike Force Tarella sat in the court, across the room from Mr Reeves, who sat quietly.
Also tendered in court today was a 180-page fact sheet relating to the new charges.
Included among the new allegations were 17 fraud charges.

"These fraud allegations basically flow from an allegation that he was not entitled to practise as an obstetrician,” Mr Murray told magistrate Vivian Swain. (my emphasis)


Known as the Butcher of Bega, "Mr Reeves, 59, is already charged with nine counts of aggravated sexual assault, six of indecent assault, one of genital mutilation and one of maliciously inflicting grievous bodily harm. The charges relate to 10 women on whom he operated between 2001 and 2003 while working at Bega on the NSW South Coast and in Richmond, in Sydney's north-west.
He has waived his right to a committal hearing and has yet to make a formal plea.
Strike Force Tarella has been investigating allegations of sexual assault, medical misconduct and genital mutilation involving Mr Reeves since it was formed in February 2008".

Midwife Maggie-Lecky Thompson, supported thousands of women and their families to birth their babies safely at home.  Maggie was de-registered in 1998 largely on the testimony of the now notorious Dr. Reeves, the Butcher of Bega.

What else don't we know about those who argue against midwifery care and seek to limit women's choices about who they choose to birth with and where they have their babies?  Who are these expert doctors who fight against women being given support by highly skilled and talented midwives, like Maggie, who provide excellent midwifery care throughout the childbearing period; care that is respectful, individual, one to one and valued by women and their families.

As Kelly from BellyBelly forum says  "Isn't it amazing that even with his rap sheet, there's still no justice for a homebirth midwife who supported thousands of families to have safe homebirths".

 

 

I wonder what dynamic doctor 3am thinks about this? 

Ex-Bega doctor faces 52 more charges

Mom fights, gets the delivery she wants - CNN.com

"(CNN) -- Seven months into her pregnancy with her fourth child, Joy Szabo's obstetrician gave her some news she didn't want to hear: Because she'd had a previous Caesarean section, the hospital where she planned to deliver was insisting she have another one.

Szabo wanted a vaginal delivery, and argued with hospital executives, but they stood firm: They refused to do vaginal births after Caesareans (VBACs) because they have a slightly higher risk for complications.
After they lost that fight, Szabo and her husband, Jeff, made an unusual decision. About three weeks before her due date, Szabo moved nearly six hours away from their home in Page, Arizona, to Phoenix to give birth at a hospital that does permit women to have VBACs".

Isn't this a lovely photo?  Joy Szabo and her baby Marcus after a normal birth on 5th December. 

The hospital executives made the claim that VBAC's have slightly higher risks for complications? Compared to what? Normal births? Repeat caesareans? Don't they understand that it is the way that women are treated during childbearing that leads to either lower or higher risks of complications????


Mom fights, gets the delivery she wants - CNN.com

Midwives damn AMA-induced amendments to maternity reform – Crikey

Midwives damn AMA-induced amendments to maternity reform

by Professor Lesley Barclay and Professor Sally Tracy

A wonderful piece of writing by two of our leading midwifery professors. Clear, reasoned, succinct and accurate in the description of the threat to women's self sovereignty and midwives and nurse practitioners' right to practice unimpeded posed by the power laden antics of the likes of dynamic Dr 3am and his union.

Midwives damn AMA-induced amendments to maternity reform – Crikey

Chloë's Birth Story

Thanks so much to Emma for permission to share this precious time. The images are beautiful, the words are precious. The experience is something those of us who work with women wish for all birthing women and their babies.

Chloë's Birth Story

Planned-Home-Births.pdf (application/pdf Object)

Amidst all the predictable power based rhetoric about birth place and care provider from the Australian doctors' union, led by the self appointed arbiter on women's choice and midwives' freedom to practice, Dr Andrew Pesce, there is a beacon of light on the subject from British Columbia

The College of Physicians and Surgeons of British Columbia have just released their position statement, which says:

The College’s Position

The College supports a woman’s right to personal autonomy and decision making in obstetrical care.

Planned-Home-Births.pdf (application/pdf Object)

Updated November 2009
Board Approved December 2009

Although this statement does not go as far as saying that homebirth is safe and that homebirth is a wise choice, as the evidence from around the world clearly demontrates it is, the statement does provide an indication that at last (some) doctors are officially recognising that women are autonomous and have rights. This recognition of women's rights is a step in the right direction for a profession which has traditionally, well, at least for the last couple of hundred years or so, positioned itself as the powerful elite.

This statement is refreshing news and makes Dr Andrew Pesce's posturing on his ability to influence The Australian Minister of Health, the Honourable Nicola Roxon to remove and restrict choice in both birth place and practitioner for childbearing women and limit the practice of midwives, appear as sad, pathetic and out of step with evidence informed practice as it is.

Not only has Dr Pesce got his sights on controlling midwives and birthing women, he and his other unionists are also seeking to deprive the Australian public of another group of excellent health professionals, the Nurse Practitioners. Australia has seen the 'turf wars' raging for several decades now, as doctors use power tactics to keep control of the health system and ensure nurses, midwives, patients and childbearing women remain subservient.

However, the winds of change are blowing.

The disgraceful thing is that while some Australian doctors seek to live in a time warp and glorify the days when doctors were gods, nurses and midwives were handmaidens and patients and childbearing women were subservient by undermining initiatives to improve choice and access to optimal health care, they will unnecessarily hamper true progress in health and health care provision.

American Academy of Family Physicians Launches Consumer Alliance With First Partner: The Coca-Cola Company -- Media Center -- American Academy of Family Physicians

I read on Belly Belly  http://www.bellybelly.com.au/ that the American Academy of Family Physicians partnered with Coca Cola. I found that hard to believe so went to the source and sure enough, there on the AAFP's website was the proudly stated announcement that on the 6th October, the AAFP announced the Consumer Alliance, a new corporate partnership program, with its first alliance partner, The Coca-Cola Company.

According to the media release:


"The Consumer Alliance is a program that allows corporate partners like The Coca-Cola Company to work with the AAFP to educate consumers about the role their products can play in a healthy, active lifestyle".

Coca Cola? Healthy active lifestyle? What role Coca Cola's products can play? What a minute! Isn't Coca Cola full of sugar? Isn't obesity increasingly associated with a frighteningly increasing list of health problems for people in the western world?

The media release continues:

"As part of this partnership, The Coca-Cola Company is providing a grant to the AAFP to develop consumer education content on beverages and sweeteners for FamilyDoctor.org, an award-winning consumer health and wellness resource".

Aha! Money. This buy ability and the subliminally associated street credibility is why no company that manufactures breastmilk substitutes is able to fund midwifery or breastfeeding related educational materials or conferences (for ethically sound organisations)

"The AAFP recognizes the significant influence that consumer companies have on consumer health,” said Lori Heim, M.D., president-elect of the AAFP. “We look forward to working with The Coca-Cola Company, and other companies in the future, on the development of educational materials to teach consumers how to make the right choices and incorporate the products they love into a balanced diet and a healthy lifestyle.”

This statement would be really really funny if it weren't so sad and distressing.

"About the AAFP Consumer Alliance
In addition to health care providers, AAFP recognizes that consumer products companies have significant influence over consumer health. Therefore, the Consumer Alliance is a strategy whereby AAFP aims to partner with companies who demonstrate good corporate stewardship and a strategic focus on consumer health."

My understanding is that we all have blind spots. Our role as health professionals is to examine evidence and use evidence to inform our practice, seeking to identify and overcome our blind spots, gaps in information and overall ignorance.

Seemingly, we can convince ourselves of anything if the reward is great enough.

The aafp News Now newsletter November 2009 • Volume 5 • Number 11 (online) states proudly:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/ann/monthly-pdfs/november-09-pdf.Par.0001.File.dat/Nov09-ANN.pdf

"The Consumer Alliance program also will create a new source of funding for AAFP, which, in recent years, has broadened its search for funding outside the pharmaceutical industry. “We’ve made a conscious effort to diversify our sources of revenue,” Heim said. “This is the first of what we hope will be many Consumer Alliance agreements".

American Academy of Family Physicians Launches Consumer Alliance With First Partner: The Coca-Cola Company -- Media Center -- American Academy of Family Physicians

Tragic suicide of a New Midwife after she wrongly thought she was to blame for baby's death | Mail Online

What a sad, tragic loss of a beautiful, enthusiastic young woman on the start of her midwifery journey.

Theresa Naish's despair and her distraught response to the sad and distressing loss of a baby following an obviously precipitate labour and birth of an 'at risk' baby raises so many questions about how this hospital runs, how information is shared, how problems are flagged so staff are aware of potential problems and how new staff members and junior staff members are treated. How is it that this baby's situation wasn't 'known' by all the seniors on duty? How is it that a well articulated plan for the birth of this baby wasn't given a high priority? How is that the plans and needs for this baby weren't clearly documented/flagged so that everyone could immediately see, from the notes, that the baby was 'at risk'?

From this statement:

'She did amazingly well to get the mother to the labour ward as quickly as she did".

it would seem the mother was on the antenatal ward when Theresa came on duty. Theresa clearly noted the woman was in labour and took her to the Birthing suite.

This disturbing event illuminates our responsibilities in health care to ensure that our staff are well supported by processes and structures that facilitate appropriate communication of any woman/fetus/baby needs and presenting problems. 

Theresa's death is a stark reminder that when adverse events occur in health care, as they do, that the staff who were involved in the situation and the families of the afflicted person need, deserve and must get the best possible support to help them negotiate and deal with the emotions that rage after such an event.

Theresa's suicide indicates that she had a caring and sensitive nature and was distressed at feeling responsible for the baby's death. I sometimes hear midwives say things like "I couldn't live with myself if I did anything wrong". Midwives who say things like that are the sensitive, caring, respectful, gentle souls whose passion is palpable. Theresa perhaps felt like that.

Midwifery is mostly about joy and happiness. Occasionally our work involves tragedy. When there is a a distressing event, we have to do more to prevent another tragedy like Theresa's suicide. We can't afford to lose bright, sensitive, caring midwives like Theresa.

King's College Hospital would be examining their processes to improve them. We all need to learn from Theresa so her death is not in vain.

Sincere condolences to Theresa's parents, sister, relatives and friends. Sincere condolences to the mother and relatives of the little baby.  Words are never easy and never enough at these sad times, but please know that people's hearts are with you.

Midwife hangs herself after she wrongly thought she was to blame for baby's death | Mail Online