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! 

Natural Births A Major Cause Of Post-Traumatic Stress? Wrong!

A Tel Aviv University researcher has linked natural birth with post traumatic stress disorder (PTSD).

Natural Births A Major Cause Of Post-Traumatic Stress

Interestingly, some people consider that PTSD is a very modern trauma

According to the Tel Aviv study, 1 in 3 postnatal women in their study sample showed signs of PTSD while a small percentage were severely affected.

What causes PTSD?  A posting on medical news today in 2009 states that PTSD is triggered by a traumatic event and that:

"The sufferer of PTSD may have experienced or seen an event that caused extreme fear, shock and/or a feeling of helplessness".

"a woman is four times more likely to develop PTSD than a man. Psychiatrists say this is probably because women run a higher risk of experiencing interpersonal violence, such as sexual violence"
Traumatic events that commonly trigger PTSD in women - these include rape, sexual molestation, physical attack, being threatened with a weapon, childhood physical abuse.

Given that labour and birth are innately highly emotional, vulnerable times for women - and that is to enable the liberation of the 'love hormone' oxytocin - the emotional 'fixative' for attachment, bonding and breastfeeding - the feeling is a natural 'high' - the reward for labour and birth;  care needs to be respectful, supportive, kind and competent for labour to go well.  Women need to feel in control, to have agency and feel safe during labour and birth.   Numerous studies have found that women labour and birth well when they have caregivers they know and trust.

Photo of joy filled mother with newborn

Women who have their emotional needs met in labour and birth enter motherhood feeling awesome!

Feeling good after giving birth is not about whether it was natural or not, it is not about whether you coped with the pain or not, although labour is much harder to handle when you are not in a good environment or in control of what's happening to you - it's about how you are treated, how well supported you are, how protected and private your birth territory is and how well you feel in control of what's done to you.

I think the good doctors need to investigate what is going on in their hospitals! They are 'barking up the wrong tree'.

The voice of reason: Researchers reject statement that co-sleeping in dangerous

So good to see this media release from researchers at The Queensland Centre for Mothers & Babies! At last, the voice of reason and evidence informed practice on this very important aspect of parenting.

Researchers reject statement that co-sleeping in dangerous

Researchers from UQ’s Queensland Centre for Mothers & Babies are concerned about recent messages that parents should never sleep in the same bed as their babies. 

QCMB Director Professor Sue Kruske said a recent comment by the Victorian Coroner, who labelled it “inherently dangerous” for a parent to sleep in the same bed as an infant younger than a year old, was not representing current evidence.

“It is not the act of bed sharing that is solely responsible for these deaths,” Professor Kruske said.

“Rather it is other environmental factors that occur in combination with bed sharing.”

She said the vast majority of these 'co-sleeping deaths' were in the context of other circumstances including smoking, alcohol and drug use and unsafe adult sleep environments.

“Prohibiting bed-sharing will actually lead to more harmful practices such as falling asleep with the baby on a couch, which is known to be dangerous, as well as increased cases of babies falling,” she said.

She said research showed many benefits for babies who bed-share safely with their parents, including improved breastfeeding duration rates, improved settling with reduced crying, more infant arousals which are protective for baby, and improved maternal sleep.

Dr Jeanine Young, Chair of SIDS and Kids National Scientific Advisory Group and safe infant sleep expert, said inconsistent messages were making it hard for parents to make informed decisions.

“To make sweeping statements about this practice would require reliable prevalence data,” Dr Young said.

“We know from the studies we have done that shared sleeping is understandably very common for families in Australia especially for breastfeeding parents. If deaths could be ascribed to co-sleeping without other risk factors present, we would expect a lot more.

“No environment for babies is risk free. Babies have died alone in cots and babies have died in adult beds. We give clear advice for reducing risks in cot environments but we have not yet addressed shared sleep environments in the same way.

“Many people die in car accidents but we don’t tell people not to drive. We tell them not to drink and drive, to wear seat belts and not speed.

“Similarly, the message for parents is that if you choose, or have no option but to co-sleep, the risks can be reduced by not overheating the baby, not wrapping the baby while bed-sharing, not having either parents as smokers, or under the influence of drugs or alcohol.

“We also know that premature or unwell babies are at higher risk of sudden infant death.”

Media: Professor Sue Kruske 0418 882 337, Dr Jeanine Young 0415 174 003, or Andrew Dunne, QCMB Communications Manager, 0433 364 181.

About the QCMB

The Queensland Centre for Mothers & Babies is an independent research centre based at The University of Queensland and funded by the Queensland Government. The role of the Centre is to work towards consumer-focused maternity care that is integrated, evidence-based and provides optimal choices for women in Queensland.

"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.  

Midwifery Care: What's in it for Women?

What is midwifery care?


The debut video for I am a Midwife, a new online series about midwives and what they do, explores just that! Eight different "real life" midwives describe the safe, satisfying and supportive care midwives in all settings provide women and their families!

From the Midwives Alliance of North America: http://mana.org/IAAM/

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.

Fetal homicide laws in WA?

On Sunday, the Perth newspapers carried the story that fetal homicide laws are to be introduced into Western Australia later this year.  A similar law exists in Queensland. 

In the rest of Australia however, under present laws, an unborn fetus has no legal status and is not recognised by the courts.

In an online poll on the site of the report asking "Do you agree with new laws to legally recognise an unborn baby as a human life?"  67% of respondants have answered 'yes'.

There are similar laws in different states across the USA.  Thirty eight states have fetal homicide laws.

At least 20 states in the USA have fetal homicide laws that apply to the earliest stages of pregnancy, that is "any state of gestation," "conception," "fertilization" or "post-fertilization".

The WA Australian Medical Association (AMA) - the doctors' union, has declared the laws are good, because it enables "reckless" mothers to be charged if there is a misadventure.

What do you think are the problems or benefits inherent in this proposed law?

Bystanding Behaviour in Midwifery

I was alerted by a friend on facebook, to this article Bystanding Behaviour in Midwifery, about the way midwives don't stand up for women and how midwifery students are acculturated and desensitised to unkind behaviour. The article, written in 2008, is by Margaret Jowitt, who did her masters in Keele in 1998 on Mothers' Experience of Birth at Home and in Hospital. The book "Childbirth Unmasked" was written as a result of her reseach. Margaret is a lay member of the Association of Radical Midwives UK and a columnist for the Huffington Post.

Margaret wrote:

"I HAVE LONG WANTED to write an article on ‘Woman's inhumanity to woman' but have shied away until now for fear of being seen as attacking midwives and failing to acknowledge all they have achieved over the years in the care they give to women, often under very difficult and alien circumstances when they are based in hospitals".

I'm very glad she found a way to move through her fear and publish this article on Bystanding Behaviour in Midwifery and good to see it online as the issues are still alive and well today and not just in the UK.  Distressing as it is to think such articles are necessary, we need to examine and digest the ideas presented in this piece and discover what we can do to change or do better. I shared the article on facebook and twitter, thinking it would be useful for midwifery students.  However, I was prompted to put this post up to explore the ideas further following a reply 'tweet' to the article on Twitter.

@Thinkbirth I was a bystander recently and it traumatized me , worse was my colleagues saying it was normal and I was being dramatic.#scary 

How many of us have had our feelings about and discomfort with the way women have been treated minimised or dismissed?

What happens to us when abuse is normalised?

When there is a disconnect between what we know is right and what is happening, between what is taught and what is practice, there is cognitive and emotional dissonance and a sense of not knowing what to do next...

Photo from Prefrontal Org Blog

How do you deal with that?

Is this your experience?