Andrea’s Diary

I was reading an interesting article today in the Sydney Morning Herald regarding the way journalists deal with the shocking and stressful events they witness and the high levels of post traumatic stress disorder (PTSD) that are common within the profession.

To quote the author, Geraldine Willessee,  “Many clinicians recognise PTSD as occurring after exposure to life-threatening events. And a large part of the treatment is to talk the events dry of their power”.  When I read these words, I immediately thought of the many women who seem to have an overwhelming need to talk about their horrific birth experiences, especially to those who are pregnant.  We’ve all met these women - sometimes in a prenatal class, where their stories frighten the living dayights out of those in the group expecting their first babies.  Sometimes they offload in post natal groups where the need to find the most gruesome details to recount can become almost a competition.

I have often wondered about some women’s need to go over and over their birth story, re-living the trauma and desperate feelings they experienced as they were giving birth.  I have, of course, read of the possibility of some women suffering form PTSD after especially harrowing or life threatening childbirth experiences, but I wonder if it is not a whole lot more common than we like to think.

There comes a time in many labours (perhaps all of them, to some extent) when a woman feels an overwhelming fear that she cannot go further, that what she is expected to endure is impossible and she will cry out for rescue from the frightening physical and emotional dangers she perceives she is facing. This is normal. It is called the transiiton phase of labour at the end of the first stage and mercifully, it doesn’t last long.  Michel Odent believes that this perception of imminent danger can trigger a sudden rise of oxytocin in response to the surge of adrenalin that is naturally produced when facing a threat and that this spike of oxytocin can lead to the “fetus ejection reflex”, bringing the labour to a speedy end with the rapid and safe birth of the baby. He believes this kind of reaction is designed to shorten labours, which would be of biological benefit both mother and child. He suggests that we should not attempt to “assist” the mother at this time as this may delay the birth and increase the potential for intervention.

The women who talk incessantly about their horrible labours are not, in my experience,  talking about transition, which is often quickly forgotten due to the haze of endorphins that promotes a helpful amnesia around the more arduous work of labour.  Their stories are much more likely to include events that occurred over many hours of labour, often involving various medical interventions that were undertaken either as part of hospital routines or in response to a presumed threat to the baby. Typically, they talk about not being consulted or informed,  a lackof involvement in the decision-making and feelings of helplessness.  Any woman, whose prime goal is to produce a healthy baby, and who is confonted with the news that her baby is in trouble,  may feel she has few options. She may find herself enduring a series of painful or humiliating invasive events, perhaps leading to unimagined personal suffering (physical or emotional)which she is assured, at the time, are necessary for the benefit of her baby

Even though she believes her baby was saved (presuming that it was in trouble), she may have gone through an event she would interpret as deeply traumatic, leaving her to deal with flashbacks, anxiety attacks, depression or other symptions that would fit the definition of PTSD.

De-briefing after birth, with those who were present at the time, is an important first step in acknowledging the feelings that result from all births, but especially those identified by the mother as traumatic. This de-briefing may need to occur on several occasions, perhaps frequently at first but also over a logner period of time. One goal of the process is to help the mother understand what happened and validate its impact. Another is to help her re-frame the experience as part of life, and one from which lessons can be drawn.  Going over and over the story only serves to reinforce the negative aspects and to consolidate the negative memories of the event. A more useful approach would be to find an appropriate counsellor who could assist the woman to identify the positives and draw useful outcomes from the experience, such as her resilience, strength under pressure, protective feelings for her baby, ability to overcome adversity, lessons that have been learned etc.

I believe that PTSD is a very common outcome of childbirth for many women. It is a hidden problem that may lead to an unwillingness to conceive again, rifts in personal relatonships and perhaps even problems with attachment to the baby. Let’s be honest about this issue - it is time to lift the lid on the shameful and needless trauma of PTSD that is often caused by the very system that is supposed to protect mother’s and baby’s health.

Unless this situation is acknowledged and discussed, appropriate care is made available that redues the risk of PTSD, and systems are developed to deal with its aftermath when it does occur, we are going to be hearing a lot more “horror stories” in our classes, our new mother’s groups, post-natal reunions and the community at large. All these stories are fuelling the fear women have of giving birth these days.

Those who promote medical management of birth may think they are saving lives, but at what personal, emotional and psychological cost to their clients?

I have just returned from another mission to Iran, where I am working on a project to improve the childbirth practices for women and babies for the Ministry of Health and Medical Education. This has been my third trip, funded through the UNFPA, and it is pleasing to see that some improvements are now in place and that efforts are being made to take these further.

The main effort has focused on the establishment of eight centres where normal births can occur. These are located in Tehran (2 centres) and 6 in regional cities around the country, including Mashad, Gorgon and Tabriz. Each has been provided with some basic equipment that would be found in a typical birth centre such as a bath, access to a toilet and shower, floor mats and birth balls, some privacy and more space.

In Iran, obstetricians are totally in charge of childbirth and midwives play a subservient role, acting as obstetric nurses. It was encouraging to have several obstetricians tell me of the great success they are having with physiologic birth in these new centres. It certainly helps that virtually all obstetricians are women in this Muslim country, but also sad that many have chosen caesarean births for themselves, due to the inhuman conditions that prevail in most hospitals.

One of the main goals of this visit was to help set up a program for training childbirth educators in Iran. I feel this aspect of my visit has been less successful than I hoped, for a variety of reasons. It is clear that there is no concept of how a training course should be established and the role of the educator is not clearly defined or even understood. There is a fledgling program in place but this needs to be completely re-vamped so that it reflects adult education principles, incorporates appropriate subject matter and enables educators to develop presentation, communication and counselling skills.

Each of the new centres had set up a program of prenatal education for pregnant women. This is a first - until recently there had been no formal education available for expectant parents. The program that is in place covers the basics of pregnancy and post natal care but is very inadequate when it comes to labour and birth. Women are still not being given any information about the many interventions and medical procedures they will be routinely subjected to in hospital. There are no detailed discussions on shaving, enemas, rupture of membranes, oxytocic drips, forceps, vacuum, episiotomy and caesarean birth. Discussion about the other routines that are carried out, such as no access for a companion, restriction of fluids in labour, hourly vaginal examinations, labouring on the bed, the use of pethidine and nitrous oxide for pain and the routine separation of mother and baby following birth also need to be included.

For many women, giving birth in Iran represents a horrific experience where their human rights are disregarded and they are routinely subjected to humiliating, embarrassing and unnecessary procedure. Many will opt for caesarean birth to avoid these indignities. The Ministry of Health is keen to change this, but it will take a concerted effort on several fronts to improve the birth experiences for women.

I’ve been asked to make a number of recommendations.

First, I have suggested that those hospitals and obstetricians who have embraced normal physiologic birth should be publicised as widely as possible, in recognition of their work and also to alert women that alternatives are now starting to appear.

Secondly, I have recommended that a new course be developed that focuses solely on midwifery. At present the basic nursing course and the subsequent midwifery degrees are too broad, requiring graduates to be competent in areas outside the accepted scope of midwifery such as paediatrics, gynaecology and women’s health. Many of the midwifery courses are taught in part by obstetricians and a standard obstetric text is the basic reference. This is unsatisfactory and has left midwives feeling unable (and unwilling) to take responsibility for the care of women during pregnancy and birth.

The whole area of childbirth education needs a re-think. A clear vision of its purpose, objectives and structure needs to be prepared and a program developed that is separate from mainstream midwifery, preferably administered by a dedicated team of master trainers. I’ll be working with they key personnel within the Ministry of Health on these issues.

Overall, this has been an interesting mission. I was left feeling frustrated by the educator’s workshop I presented, but heartened by my program for the obstetricians. The midwives workshop was mixed - they need a lot of support and encouragement to fully embrace their role as primary health care professionals.

As ever, the Iranians have been generous and gracious hosts. I have been very well cared for (through boundless hospitality) and I feel I have made some very dear friends over the past few years. I hope that I can continue to work with these people as they make further progress in the future.

I have written a number of times about the Doula project run by the Goodwin Centre in Hull. They have recently been awarded for their efforts - this is an outstanding community based program and very worthy of this recognition. Here is an extract from the Press Release I received today:

Date: 8 July 2008

Doulas Delight at Parliamentary Awards

Goodwin Volunteer Doula Project and Hull and East Yorkshire Hospitals NHS Trust and have been honoured with an award at the All-Party Parliamentary Group on Maternity (APPGM) summer reception. The awards acknowledged several maternity units’ inspiring work in improving local maternity services.

Based on four key themes, the Goodwin Volunteer Doula Project and Hull and East Yorkshire Hospitals NHS Trust received their award for developing inclusive services for disadvantaged groups and communities.

‘Heather Barnes, Project Manager for The Goodwin Volunteer Doula Project said “The day was a great celebration for the volunteers and staff who have been involved in the development of this innovative project across Hull. The award recognizes the effort put in by all the volunteer doulas over the past three years, as well as the great team work across the city by all agencies, ensuring isolated pregnant women get the support they need throughout their pregnancy and birth”

Health Minister Ann Keen MP and Emily Thornberry MP, Chair of the All-Party Parliamentary Group on Maternity (APPGM), presented the awards at the Atrium Restaurant, Millbank on Monday.

The APPGM, which is serviced by the NCT charity, highlights maternity issues within Parliament and brings together health professionals and service users with politicians.

The reception was attended by nearly 200 politicians, leading health professionals and user representatives from the maternity services across the UK.

Emily Thornberry MP, Chair of the APPGM, said; “It is a great privilege to present these awards to such deserving and exemplary maternity units. All the entries were very impressive. The winning units are doing innovative work which will act as an inspiration to other Trusts.”

Mary Newburn, Head of Policy Research at the NCT charity said, “We are celebrating the success of these awards as excellent examples of the good work that happens in local Trusts. ”

The Goodwin Volunteer Doula project, developed by Goodwin Development Trust, focuses on listening to the needs of local women from disadvantaged communities to ensure their needs are being met. This pioneering project recruits, trains and matches up volunteer Doulas with pregnant women who need support at what can be a lonely and difficult time. A Doula is a trained and experienced partner who accompanies a woman through pregnancy and childbirth and the first few weeks of family life. The volunteers are trained in child protection, domestic violence awareness, hospital tours, antenatal and postnatal roles, health and safety and breastfeeding.

There were a number of other midwifery projects that also received awards. They are all worthy recipients, and it is wonderful to be able to share these good news stories. I hope you find these inspiring.

Developing inclusive services for disadvantaged groups and communities:

Joint winners

Hull and East Yorkshire Hospitals NHS Trust/Goodwin Volunteer Doula project which focuses on listening to the needs of local women from disadvantaged communities to ensure their needs are being met. The volunteers are trained in child protection, domestic violence awareness, hospital tours, antenatal and postnatal roles, health and safety and breastfeeding.

Ashford and St Peters Hospitals NHS Trust developed maternity services within HM Bronzefield Prison. This includes specialist midwifery care, obstetric ultrasound and high risk obstetric consultant care. Prior to this service, pregnant women within the prison received little or sporadic antenatal care and, in some case, none at all. Since the prison opened in 2004, the Head of Midwifery and the prison directors had regular meetings to discuss the care pathway for pregnant women in prison, and funding was finally obtained in April 2007.

Highly Commended

Pennine Acute Hospitals Trust for employing an ethnic health worker in an area where there is a high percentage of mothers from Pakistani and Bangladeshi communities; she is trained in breastfeeding support, smoking cessation and providing advice on co-sleeping, nutrition and welfare benefits.

Barking, Havering and Redbridge Hospitals NHS Trust where the teenage pregnancy midwifery team has worked closely with young parents and other professionals and community groups to determine what is needed to provide a high standard of holistic care to pregnant teenagers, encompassing continuity of care and support.

The normality of childbirth

Winner

Royal Wolverhampton NHS Trust - in particular New Cross Maternity for the range of measures to introduce and promote a new water birth service, with the aim of increasing normal birth. Over 85% of midwives have been trained and previous waterbirth parents now provide feedback to prospective parents who may want to use the birth pool. They have also provided specific sessions for teenagers and have organised interpreting services for women who wish to attend the preparation classes.

Highly Commended

Shrewsbury and Telford NHS Trust have developed a new midwifery module focussed on promoting and facilitating normal birth. It provides other midwives within the West Midlands the opportunity to address the rising trend in caesarean section rates and raise awareness and understanding on how to promote normal birth within their Trusts.

Responsive, woman-centred, family focussed postnatal care

Winner

Burton Hospitals NHS Trust for the bereavement support service aimed at ensuring those who have lost a baby are treated with sensitivity. An extensive training programme was developed to target all staff who came into contact with bereaved parents and special bereavement care suites have been developed, with ensuites and sleeping facilities for the partner, to ensure parents do not have to receive care in the labour ward.

Highly Commended

Pennine Acute NHS Trust for their production of a light-hearted book which challenges the myths of breastfeeding. ‘Saggy boobs’ aims to raise awareness of the facts about breastfeeding amongst the public and professional bodies.

Involvement of women in providing local maternity services

Winner

Calderdale and Huddersfield Foundation NHS Trust who, despite grassroots opposition to a birth centre, saw the opening of the Huddersfield Birth Centre and Midwifery Led Unit. The key to its success was user involvement and ensuring the Trust listened to what women would value in a local facility through focus groups. A set of evidence based pathways were developed by the consultant midwife to build awareness and confidence in the birth centre concept for the public and local midwives.

Highly Commended

East Sussex Hospitals NHS Trust for its women’s focus group. The group of user volunteers meet monthly to support their local maternity services and work in partnership with the maternity services staff to contribute to the service development within the maternity department.

Portsmouth Hospitals NHS Trust who were nominated for involving women and families in the improvement of maternity services in Petersfield by reopening the Grange Maternity Centre twenty-four hours a day, seven days a week. The Trust was particularly responsive to calls from local families and actively encouraged user involvement in the development of the Centre by asking users to sit on the Maternity Development Group

Mindy Levy is a remarkable midwife in Israel, who has established a birth centre in the north of the country near Nazareth, and who also offers a home birth service. She was one of the driving forces behind both of my visits to Israel. On my last visit, she offered to arrange a workshop for Palestinian midwives, which took place in East Jerusalem in June 2005. This was a wonderful event, if somewhat disjointed due to the langauge difficultlies and the haphazard arrival of midwives due to the onerous checkpoint formalities at the border of the West Bank. The midwives from Gaza had been unable to attend because the border has been closed completely for 4 days by the Israelis.

However, we had an interesting day and Mindy said she would like to follow up wirh another meeting between Israeli and Palestinian midwives. Today I received the following email from her - she has achieved her goals at last.

Dear All,

The last 2 days were big ones- the culmination of months of work and years of planning and dreaming. Sponsored by COHI, nine Israeli midwives and nine Palestinian midwives spent 2 days together at my birth center in Beit Lechem Haglilit talking about women, babies, birth, midwifery and mothering in the Middle East.

It was a party. The atmosphere was festive, loving, hopeful, and professional. We learned much about midwifery on “the other side” and had many opportunitied to explore the differences and similarities, the strengths and weaknesses of each health system.

We understood very quickly that midwives are midwives, regardless of their religion and nationality. Our passion about our profession is universal as are the warmth and love that eminate from our bodies and souls. Midwives are midwives are midwives.

We fell in love with each other instantly. We forgot that there had been a time when we were wary about this first meeting, when we felt fearful of meeting the “enemy” and encountering our own prejudices. There was no fear. There was trust, openness to reveal weaknesses and difficulties, a lot of curiosity, and a great willingness to share and to listen.

We are now planning the continuation of this connection and the sky seems to be the limit. When we parted ways this afternoon, we spoke of when we will meet again, not IF we will meet again.

I feel as if I had given birth- happy, exhausted and overwhelmed. And indeed a birth has occurred- the birth of this incredible project. Now we need to hold it, get to know it, nurture it and some day teach it to walk.

When the birth center emptied I could still feel the energy buzzing in the building- the presence of these midwives was a true blessing for the birth center. I am thankful that I had the honor to host this birth.

In the concluding circle one of the midwives raised the possibility that the end to the violence in our region could be begin by eliminating violence in birth. We all agreed that we really do have the power to change the world, one birth at a time. This might sound a bit much to the non-midwives among you, but this is one of the things that gets us through the pain, blood, sweat and guts of birth, knowing that what we do does makes a difference. Birth is important for both women and babies.

Anyone who feels motivated to support this project financially is encouraged to do so through the COHI website or directly to me.

Mindy

Midwifery in Thailand (as opposed to obstetric nursing) has received a boost with the availability of a new course at Burapha University in Chonburi. Until recently, all nursing courses included six months of obstetrics and this has formed the basic qualification of those wanting to specialise in midwifery.

Burapha University has introduced a new post graduate course that will focus solely on midwifery, providing an avenue for those who want to upgrade their basic nursing skills and develop a midwifery philosophy rather than an obstetric orientation in their practise. This is exciting news and will eventually mean more options for birthing women, who will be able to choose midwifery rather than obstetric care for their pregnancy.

Other Universities may follow Burapha’s lead - this course is proving very popular with many applicants for its limited places. Perhaps the next step will be a professional organisation for midwives, that enables them to develop a real identity and voice as health care providers. Knowing about the slow pace of change in Thailand, I won’t hold my breath waiting for that development, but this new course is a very definite step in the right direction.

The birth scene in Thailand is at last changing from one dominated by private obstetrics to one where alternatives, and especially midwifery care, is becoming more available.

I’ve spent the weekend catching up with my friends in Bangkok and learning of the latest developments with the Childbirth and Breastfeeding Foundation of Thailand. This group has been working for some years to promote natural birth and better breastfeeding rates, and although often frustrated by the slow rate of change in this country, they are pleased that their message is being heeded in some hospitals, with outstanding results.

As in most countries, there are two levels of maternity care - the private system and the public health system. In the private sector, the outcome of the birth will depend almost entirely on the practises and attitudes of the chosen obstetrician. With a supportive obstetrician, natural birth is possible, or at least many of the routine obstetric interventions can be avoided. From the information I have gathered this weekend it seems that women wanting to negotiate natural birth options in Bangkok will have the best chance at Rajvithe Hospital in Bangkok (Dr Ekachai), Bangkok Phuket Hospital in Phuket (Dr Suppakit) and at the Samitivej Sukumvit Hospital, also in Bangkok,(Dr Yawaluk, who is a woman doctor).

I have written about the Samitivej Hospital before in My Diary as they have the only Birth Centre in Thailand, but their recent statistics show that support for water birth and physiological management is decreasing, which is both disappointing and alarming. This is probably due to reduced support for normal births from several of their doctors, and it seems that Dr Yawaluk is offering the most flexible approach at present.

In the public sector, there is encouraging news. Smaller community hospitals in rural areas are having great success with upright births (squatting, kneeling etc on floor mats) and mobilisation during first stage. Fathers or other companions are being encouraged to attend and their midwives are very pleased with the good outcomes they are achieving. I have heard great stories about natural births at the Bangnampreo Hospital (in Chachongsao Province, 1 ½ hours east of Bangkok), Somdej-na-Sriracha Hospital (in Sriracha, Cholburi), and Bangtarad Hospital (in Kalasin, in the north east). As often happens, smaller units that are not teaching facilities and where staff have more freedom often produce great results. If a pregnant woman in Bangkok was not able to obtain the care she needed from her private obstetrician, she might want to consider travelling a few hours to get quality midwifery care and the opportunity for a better birth.

The facilities in these small community hospitals may be very basic, with none of the pretty decorations and gleaming technology found in the private city hospitals, but in the final analysis, women in labour are less worried about the decor than the attitude and philosophy of the caregiver who is assisting them. As women discover the benefits of midwifery care over routine obstetrics, and as the successes in these community hospitals become known more widely, it will help drive change elsewhere in Thailand.

I have just left the UK after a brief (for me) visit of 10 days during which I presented some workshops and had a short break with friends in Wales. I also spent time with Caroline Flint in London enabling me to catch up with her successful midwifery practice based around The Birth Centre in Tooting.

This Birth Centre was the first one ever established in the UK and has provided a lovely birth place for many babies over the years. As a model for midwifery care it is unequalled - being independent of the NHS system offers women complete freedom to have the birth and care they want without any of the restrictions that must be applied to those birth centres attached to maternity hospitals. It is just a shame that more centres like Caroline’s have not been established elsewhere and crazy that her achievements as a pioneer of the birth centre philosophy in the UK is rarely acknowledged by her peers. The “tall poppy” syndrome that we are so familiar with in Australia seems to have taken hold in the UK as well.

My impressions of UK midwifery, formed on this visit, is that is seems in the doldrums. The midwives I met this time talked about the chronic staff shortages, which have been going on for some time, but this time there seems to be a feeling that the problems will never be fixed. With the mass resignations looming as the average age of midwives advances, many were gloomy about the prospects for midwifery in the future and fear that births will become concentrated in the large hospitals as the only practical way of staffing maternity care. Too many doctors working in obstetrics are having a big influence on the way births are managed and the imposition of strict rules and guidelines (formulated by doctor dominated bodies like the National Institutes for Clinical Excellence - NICE) are overriding the expertise of midwives in facilitating normal births, leading to more and more caesareans. The once proud record of natural births that was the hallmark of British maternity services is under serious threat and the only way to escape the increasing production line approach seems to be having a home birth (if a woman is lucky enough to live in an area that will provide this mandated option).

More dynamic leadership of the Royal College of Midwives might also help. With morale amongst midwives at a very low point, the RCM has a big task ahead if it is to lift the spirits of midwives and take the strong political role needed to get the working conditions improved to attract and retain midwives in the system. What is needed is not just pay rises for midwives, but assertive efforts to have the voice of midwives heard equally with their medical colleagues as policies are formulated and services are planned and implemented. The RCM could also take the lead in establishing strong supportive structures to stamp out the horizontal violence that is endemic in many hospitals. I understand that the leadership of the RCM is about to change and that (gasp!) a man is even being considered for this post. What a refreshing change that might be - will the College be bold enough to take this idea on? The Australian College of Midwives employed a non-midwife as its CEO several years ago and it revolutionised their organisation, giving it new energy, a strong lobbying voice and better internal systems. Will the RCM look “outside the square” on this occasion?

I have received an email from Ruth Malik, my contact in India, who is setting up a new childbirth education service for Indian women. She has mounted a legal case to challenge the management of the birth of her second child, which she considers was an unnecessary caesarean birth. She has asked that I circulate the following petition that she has submitted to the Indian authorities, to provide information, support and encouragement for other women in India who may also feel their births were mismanaged. It is an interesting story, and one that will resonate with women in many countries, not just India.

MAY IT PLEASE THIS HON’BLE FORUM TO ACCEPT MY PLAINT AS UNDER:

This Complaint is against the Medical negligence/ Malpractice of the Respondent Doctor and the Hospital as a result of lack of due care, abrupt decision making in carrying out childbirth leading to Emergency Cesarean Section of the Complainant on 24th March 2006.

FACTS OF THE CASE

1. I am a foreign national married to an Indian. I have a 5 years old male child born by caesarean section.
2. . I consulted Respondent No 1 for my second pregnancy and expressed my strong desire for a normal vaginal delivery. She gave me full support for the same.
3. . On my due date (17.03.06) she examined me cursorily per abdomen and declared that I had a lazy uterus and my previous scar was paper thin and thus I was unlikely to be a suitable candidate for normal delivery. I was not satisfied by her statements so I approached another doctor at …… Healthcare Centre for second opinion ( Annexure A) regarding my chances of having normal child birth. They carried out Ultrasonography (Annexure B) and NST ( Non Stress Test) and assured me that all is well so I stayed home waiting for Labour.
4. . On 24.03.06, Respondent No 2 carried out CTG (cardiotopography) for which I had to lie on my back. A belt was tied around my abdomen to check baby’s heart rate. I felt uneasiness and incredible heat, they said after a few seconds that I would be taken up for surgery.
5. . Though I signed the informed consent for emergency Cesarean section, I was not convinced with the indication verbally given by the attending staff at Respondent No 2. They admitted me at 2.54pm and at 3.05 (Annexure C) I was in the operation theater for a surgery by Respondent No 1.
6. . In the operation theater, Respondent No 1 told me of being misinformed and the doctors who gave me second opinion as QUACK. This further added to my doubt regarding her decision for Cesarean section , but I was helpless for myself by that time.
7. . I had a baby girl, who was pink and healthy when shown to me in the operation theater. I could not relate her to the emergency scene I was shown to be suffering from.
8. . I was discharged from the hospital on 27.03.06, feeling confused and cheated.
9. . I went back to Respondent No 1 after ten months to clear my confusion and to find out what really had happened. She told me that I had rupture of membranes and fluid was leaking out. I pulled my discharge card (Annexure D) and asked her why it was not mentioned there. She grabbed it from me and quickly scribbled scar dehiscence in the mid portion of scar with herniation of membranes.
10. . Respondent No1 again tried to satisfy me by stating that I was lucky that I came in as soon as labour started. I was stunned and told her that I have never had been in labour. She was silent on this. By this time, the mental strain and agony was unbearable.
11. . I applied for and got my indoor case papers and discovered questionable discrepancies, evident of deficiencies of services suffered from both the Respondents as a consumer / an Expectant Mother and at last a Deceived Mother.
12. . What I inferred from my research was that I was wrongly stamped as an emergency cesarean section, what I really needed was careful support and monitoring for a few more days, which (duty of due care) was denied to me by both the Respondents.
13. . An evaluation of Respondent 1’s series of actions demonstrates that she intended the birth to consist of an emergency Caesarean section before I was given to chance to commence natural labour. I must conclude that the surgery was pre-planned by Respondent No 1.
14. . Childbirth is the Reproductive right of a woman. Normal childbirth has a more positive impact on the body, in establishing breast feeding and thus providing good growth parameters for the baby. Researches have further laid down the safety criteria of reproductive organs after normal deliveries. The humane bond between child and mother is being weakened by these increasing rates of intervention i. e. cesarean section. The modern medical technology aims at providing qualitative health care but what I experienced as a woman as well as a mother at Respondent No 2’s care, of being violated, deliberately abused by the doctors on whom I trusted for seeking help of experiencing a normal childbirth which was deserved in my case.
15. .I made a complete inquiry of my case and decided to raise my voice because it concerns the reproductive rights of so many women who have suffered from this deliberate negligence and left confused or misinformed by their gynecologists. When I compared this fact with other countries, I found that it is easy to see the standards for practice of major hospital abroad on the internet but impossible to get an ideal of practice of Gynaec/ Obstetrics in India. I wondered what human care and which standard of medical services is provided to a dependant consumer called “Patient” in these corporate hospitals.

THE MAIN DEFICIENCIES OF SERVICE I SUFFERED:

During my pre-delivery care.

1. . My doctor and I never had time to talk to each other which is highly unethical, and extremely dangerous for the patient. I felt I was a burden to my doctor rather than a woman paying a huge amount as a consumer for availing her medical services.
2. . My mother had all three children delivered normally ten days overdue. As a literate woman I assume that my post maturity may be because of this genetic factor. I mentioned this every time to my doctor during my regular ( Ante Natal Care) checkup in expecting a rational and scientific explanation from a qualified Medical professional What I got was as answer was, her silence.
3. . She was under professional obligation of satisfying my queries. But I was left confused. It was my right to know my status as an expectant mother and then only I would have been in a position to exercise my options about my baby’s birth. Respondent No 1 has totally neglected her duties as a medical professional.
4. . Because of this deliberate negligence of Respondent No 1, I had to seek second opinions from other professionals expending more time and money in my last few stressful days of pregnancy.

   During my stay at Hospital

5. . Respondent No 2 had supported Respondent No 1 in carrying out an unethical surgery, in interest of revenue generation.
6. . When I was admitted on 24.03.06 at 2.54pm at Respondent No 2, I was not having any pain, fluid leaking from vagina or decreased foetal movements etc. As a routine practice, a detailed history and complete checkup ( external and internal) has to carried out, but the attending doctor ( Registrar Gynecology) at Respondent No 2 did not examined me internally ( that is per vaginally). In her notes (Examination per Abdomen in Annexure C) my uterus was found to be relaxed (that means not in Labour) but in the consent form for surgery, I was stated to be in labour (that is Rhythmic contractions of uterus). Can this be possible or acceptable to man of rational thinking?
7. . It was a pre planned surgery on part of Respondent No 1. Respondent No 2 ( also being a healthcare professional) did not bother to inquire and justify the consultant’s decision and thus supported her in this deliberately planned act of negligence and money generating Malpractice.
8. . At the time of taking consent for the surgery, the reason given to me was postdated pregnancy overdue by 7 days. I was with 41 weeks gestational age on 24.03.07 I was not convinced this to be the reason for emergency cesarean but the hype was deliberately created by both the Respondent so as to avoid me in making decision about my surgery. They put me on the Operation table on 3.05pm. Is this brief time period with so many misinformation, can allow an expectant mother to understand the so called informed consent and assent to it?

   I was made to sign the consent under undue influence

9. . In the operation theater, when Respondent No2 labeled the second opinion giver professional as QUACK, I was surprised to see the dirty politics of medical fraternity, (in which ultimately innocent patients are being victimized.)
10. . Because of her abrupt decision about my cesarean section, I was prevented from experiencing the natural bliss of being a mother, left with an unnecessary scar on my abdomen and a feeling of guilt. I suffered a lot of mental agony and stress from this incident which is supposed to be a wonderful and blessed part of every woman’s life.
11. . Now I already have two unnecessary cesarean which had further reduced my chances of having normal delivery in future. My reproductive rights had been deliberately violated.
12. . I was denied by both Respondents the duty to care (careful monitoring of maternal and foetal well being) for at least few days, owed by me. So I would have equally exercised my choice in the process of decision making about child birth , signed the Informed consent with consensus, not with confusion . At last I may have achieved a normal vaginal birth and enjoyed the motherhood more healthier both physically and emotionally.
13. . Respondent No 1 failed in her obligation to reasonably pursue the option of a VBAC birth as we had previously discussed and agreed upon. By confusing me with unsound medical information she failed to serve my best interest as her patient and failed to provide appropriate services to me as a consumer of health care.

After the excitement of the obstetricians workshop and the first waterbirth in the new birth centre came a change of pace for me as I facilitated a workshop with the midwives. A group of 50 had assembled and it was great to meet many of the midwives who had been in my previous group 18 month ago. There were lots of hugs and stories to be told and I spent much of the day having my photo taken (these new mobile phones make it easy!) with old and new friends.

The workshop itself was great. I had decided that the theme would be pre-natal education, as midwives have a major role to play in this area. Since my last visit, a number of programs have been launched to begin addressing the lack of prenatal education in Iran, which is very encouraging. During the day we explored the various kinds of programs that might be suitable, their location, format and content. We also had some fun trying a number of interactive activities that could be included in a program.

This group were very animated and the level of interaction and discussion was high. They were happy trying new games and were full of ideas for improving and extending the programs they had started.

Towards the end of the day, I received a message form one of the obstetricians in the previous group - she had returned home and already started using the new ideas we had presented. In the previous 24 hours she had assisted at two births - one a primip and the other expecting her 3rd baby. Both births were spontaneous, with no oxytocin used and intact perineums in both cases. She was ecstatic and so was Kirsten when I told her the good news. The final activity in the obstetrician’s group asked them to consider how they could make changes:

It seems that natural birth is Iran is getting started at long last. Tomorrow we have a meeting with UNFPA and the Ministry of Health to map out the next steps and explore ways of keeping this momentum going.

We’ve just completed our second workshop for obstetricians in Iran. This group was terrific and we have had many animated discussion about a whole variety of birth related issues. I think the absence of a cameraman in the room has helped - Iranian women feel very uncomfortable when men are around in situations like these and are unable to fully relax when a man is present.

Once again we were hoping that a woman would come into labour at the right time and we could provide a first hand experience for this group. Luck (or Allah) was on our side and when we arrived this morning for the final day, we were greeted with the news that a woman expecting her second baby was in labour and willing to try a normal physiological birth.

Dr Kirsten Small who is travelling with me was able to assist her in the new birth room. Here is Kirsten’s account of this exciting event:

What a day it turned out to be! There was a noticeable drop in numbers given the holiday today, but the obstetricians who were there were real keen. Not long after we started into the morning word came through that a woman had arrived in labour who would be suitable for me to care for during her birth. I’m not entirely sure, but I believe that this is Tehran’s first water birth outside of a research trial.

Here is her birth story -

Her name is Maryam and this is her second child. Her first child is a daughter and the scan says this is a boy. Her husband has just finished a night shift at a factory making knitted winter clothing. It is almost winter so they are working longer hours than usual.

Her last birth was - by Iranian standards - straight forward, a vaginal birth with an episiotomy in lithotomy position. Her pregnancy has been uncomplicated, she is at term, she started contracting at 7:30 am, and her membranes ruptured spontaneously at home. She arrived at the hospital soon after and had an admission VE (standard Iranian practice) revealing that she was 8 cm dilated. She was moved to the Birth Centre area and I came and met her, while Andrea brought the group to the room with the video screen to watch the events unfold. She was obviously in transition - making the noises women make in transition. Fataneh (Obstetrician who was in the first workshop) came with me, as did an obstetrician from Shiraz who has not done the workshop, and the same midwife that we had in the previous attempt. Fataneh told me that Maryam way saying “Please Allah don’t inflict this pain on one of your creatures” or words to that effect - much the same as the Australian version of “Jesus Christ this is f&*(ing ridiculous!”.

I started by sitting her backwards on a chair and rubbing her back, sitting behind her. She was bothered that she couldn’t see me and asked them to bring a mirror so she could keep an eye on what I was up to back there! I didn’t realize what was going on until the mirror was produced and it was explained so I moved to another chair and sat beside her. That didn’t last long as she was very restless and was soon on her feet rocking her hips and clutching at us for support. Fataneh was impressed that everything we had said about transition behavior was playing out in front of her eyes.

We heard involuntary pushing at the height of some of the contractions, and she said she felt like going to the toilet. We let her try without success, but I was keen to get her back from the toilet quickly. I didn’t want our demo birth to result in the child diving head first into the toilet bowl! Her toes were now curling and I showed Fataneh the legendary “red line” - which is of course dark brown in an Iranian woman.

We had been running the bath - which was tediously slow - and as it got to about 3 inches deep she climbed in - night dress and all. She rolled onto her knees and leaned on the edge of the bath. The bath is just a bit too shallow as with it up to maximum the water level was under her introitus. So we broke one of the rules and asked her to move for our convenience - into left lateral so that all the important bits were submerged. The pushing started to get more serious, but was a perfect demonstration of physiological pushing with a fair bit of open glottis pushing (aka screaming!) and a few short grunts in between. We had a few bath “floaters” and I had to try to explain what a strainer was and how to use it for this, and in the meantime we pretended they weren’t there. We also discussed using a mirror and a torch to make easier for the observer.

After about 20 minutes in the room the head came onto view, and it was basically about 5 contractions from then to birth. The shoulders were a little slow coming with the next contraction so I reached under to the posterior shoulder (which mostly delivers first underwater in my experience), to discover the babies hand emerging beside the head. I wiggled it free and WHOOSH - we had a baby, and the promised boy emerged at 9:55 am. He was bright and alert and breathed quickly. He went straight to his mother’s arms and we covered him with a warm wet towel. There had been absolutely no bleeding into the bath so I was pretty confident that the perineum was intact.

The Shirazi obstetrician was very quickly by my side with cord clamps and scissors and was a little confused when I said no to her kind offer. After about 5 minutes I asked Maryam if she would like to move and she said she would like to lie down on the bed. I took the blasted stirrups off the bed and tried to hide them where they couldn’t find them again (I don’t think I was very effective though). I took the baby in a small wrap and helped her to the bed. The group were getting restless so Andrea took them upstairs again for morning tea.

Once on the bed I checked the cord, which had stopped pulsating so it was clamped and cut. Farah (midwife and chief hospital childbirth educator) knows that we have fathers in our birth rooms all the time, so she went and grabbed Dad and the mother’s sister who where waiting in the always crowded reception area for news, and brought them in. Dad was pretty pleased and I told him that he had a very strong wife who gives birth easily, which made them both pretty happy. They had some questions for me - where was I from, why was I here, did I have children and so on, and whether the baby’s testicles were normal (just like an Australian father would!). At one point they expressed some concern as they didn’t think that they could afford to pay the foreign doctors fee for the birth (even in the public hospital there is a fee for care). I explained that the only payment I wanted was to be able to take her picture, which was met with much graciousness.

After 20 minutes there were no signs that the placenta was imminent (physiological third stage of course). I suspected that the presence of the father was inhibiting this, as the baby was feeding well, so we asked him to step out. I had a feel of her fundus and could feel that the placenta had separated and a gentle tug revealed easy cord lengthening, so I asked her to push again and we had a placenta. There was about 10 mls of blood loss (seriously!) and of course she was completely intact. Dad was returned to the room.

I have to say I was pretty relieved, and pleased with myself and Allah that it went according to plan so perfectly. Fataneh was impressed and I think we have changed her view of birth forever today. I wrote up some notes which will be translated into Farsi for her record, and returned to join Andrea and the group to report back. It would have been good to also simultaneously have been in the room with the group to see their reactions.

At lunchtime I took a photo of my own children and my camera to the postnatal ward. Mother and baby (who is named Amir-Mahdi) were resting quietly together. You can see them together in the photo. He weighed 3650 g and was 50 cm long - quite large by Iranian standards (did I mention the intact perineum?). I asked her if this was an easy birth and she said it was. So I asked her to tell her sister and all her friends that this is the hospital to come to if you want a great birth!

While this wonderful birth was unfolding, the rest of the group was in a room across the corridor, watching the event through a video link. We were joined by various other staff who had heard that something different was happening that was worth watching. It was fascinating to observe the group’s reaction to this event. There was concern that the birth was taking its time (30 minutes in second stage is quite normal, but these obstetricians are used to going in fast, using directed pushing and fundal pressure to speed the birth, cutting an episiotomy and pulling the baby out without delay, followed by immediate cord cutting and timely stitching. Sitting and patiently waiting is a skill they will need to learn if normal births are to occur. This birth was a revelation to many of them and will hopefully encourage them to try some of these techniques themselves.

It was an amazing day for us all!