Andrea’s Diary

Irish maternity (or should I say Obstetric) services are under the microscope at the moment. For many women in Ireland, having a private obstetrician’s care for pregnancy and birth has been regarded as synonymous with status, prestige and excellent medical care. That may be under challenge now that a report into the shameful behaviour of one obstetrician has been released.

The story began some years ago, when a consultant at the Our Lady of Lourdes Hospital in Drogheda began exercising his own form of retribution on young, unmarried women giving birth. He began performing hysterectomies on these women following caesarean sections, without their consent. These unfortunate women would wake up from their anaesthetic to be told that they had lost their uterus and, in often patronising and demeaning terms, be told they should now go home and care for their baby as it would be the only one they would ever bear. The ultimate irony was that these women were primarily his private clients - those women in the public system but under his care, largely escaped his sadistic surgery, because hospital staff, who knew what was going on, were better able to protect the women from harm.

The whistle was finally blown by a midwife, who could not in all conscience, stand by and watch him remove another uterus without consent, just because the young unmarried woman had become pregnant. The complaint reached the Medical Council, who eventually struck him from the medical register and the doctor, having re-organised his finances so that he would be protected from potential lawsuits, escaped to Spain where he now lives.

The Government set up a public enquiry, headed by a Judge and it is his report that was released last week. The fallout has been inevitable: the case has attracted considerable media attention and the Department of Health is under pressure to make sure that policies and procedures are changed to protect women from such assault in the future.

All maternity hospitals have been sent a document that sets out a number of changes to be immediately implemented. Practice audits of are to be carried out on a regular basis; policies are to be reviewed and updated, and collaboration between doctors and midwives on all committees etc is to become standard. Outcomes will have to be justified and rigorous checks made to ensure that some transparency will finally enter the system as a whole.

These changes have been sorely needed in Ireland for a long time. For too long the midwives and women have been ruled by a tight knit obstetric fraternity, led by “the Masters” of the main maternity hospitals in Dublin. Just the existence of a person who is referred to only as “The Master” says it all really - such a situation would not be tolerated in any place outside Ireland. Perhaps a change of title will be one change that will result form the sweeping overviews that is now being demanded by the Government.

Meanwhile, the women of Ireland are getting a wake-up call. In the past, I suspect that Irish women would have tended to protect and defend their obstetricians when a scandal such as this one broke. Modern women may not be so inclined to be charitable, given that they are more worldly wise and more demanding of value for money.

It will be interesting to see how the ripple effects of the shocking revelations play out. Will midwives seize the day and demand support and recognition so they can protect women from unnecessary surgery and medical meddling? Will the women rise up and demand more choice in maternity services? Will the Government set in place genuine reforms that guarantee some transparency of the services the taxpayers are underwriting, so that, for example, all birth outcomes are published and freely available for public scrutiny? Will midwives et up their own College, breaking away from the Nurses Association to create their own autonomous professional organisation? Will the doctors start treating midwives as professional equals and work happily in collaborative ways to ensure clinical excellence for women and babies?

None of these issues are being discussed amongst midwives on their Irish Midwifery Mailing list, so it seems they have either not been registered on midwives’s radar (which I would find hard to believe), or else the topic is too “hot” to handle or broach publicly. This could be the greatest rallying point that midwives in Ireland have ever had. I hope they see the potential and get their acts together. Midwifery in Ireland could finally come of age as a result of this terrible tragedy where dozens of women’s reproductive lives were sacrificed for one doctor’s desire to play God. It would be some small consolation for their terrible losses.

Today I am leaving for another trip to the UK. My first stop will be in Ireland where I will be once again presenting an Active Birth workshop for the midwifery students in Limerick (and others). This is my fourth visit to Limerick and talking to students there has become a regular event. The first workshop in Limerick happened as a result of a request from Kiwi student, who wanted some input on normal birth in her training. She finished her course, and after some months consolidation in Ireland, has now moved, with her family, to Derby in Western Australia. I can’t think of a greater contrast - from green Ireland to dry, dusty Derby! I am sure that she will get wonderful all round midwifery experience in Derby as it is in one of the most remote parts of this country.

After Ireland, I have workshops in a number of places in the UK. They are all listed here and promise to be an interesting series of events.

On the way home from this trip I will be detouring to take in Iran, where I will be presenting a three day workshop for the Iran Ministry of Health and the United Nations. They are concerned about their rising caesarean section rate (just like the rest of the world) and are looking for ways to keep birth normal. Working with the Iranians will be a challenge and also very exciting. I have been reading about this ancient land and am looking forward to meeting the people and learning a little about their culture and lifestyle. I’ll post some pictures when I get home.

It’s been quite a while since I wrote up My Diary. I have never been busier than I have over these past two months, mostly with writing projects, so finding a moment to update here has been in the “too hard basket”. However, things are settling down now and I can get back to recording what’s going on more regularly.

There have been two major projects taking my attention. The first is a new initiative that is a world first - “The Essential Educator“. This is a teaching kit for parent educators that provides everything they need for facilitating effective parent education programs. It is in production at the moment and will be available in May. There are details of this comprehensive teaching kits on the website, so click on the link to find out more. As the project gathers pace, we’ll add more specific information about the component parts.

The other project has been the first Birth International Conference for Childbirth Education to be held in Sydney. This event was last weekend at Sydney University and we had a wonderful time, with 160 people participating in Plenary sessions and workshops on a variety of topics. The program has two international guest presenters - Mary Nolan from the UK and Sherokee Ilse from the US and both were sensational. I am delighted that they will both be appearing on our similar program in the UK in July - those who attend are in for a real treat.

We had many other presenters at the Conference, most of whom have been involved in our Graduate Diploma in Childbirth Education. They offered a host of practical teaching tips and activities that the participants can incorporate into their own classes and all the workshops were lively affairs.

Some of the Plenary papers will be available on our website in the next few days and I will let you know when you can access them. The workshops, being based on experiential learning, don’t lend themselves to written outlines that make much sense - you have to be there to understand what they are all about.

A number of the speakers on the Sydney program will be part of the presentation team at the preparing for Birth and Parenthood Conference at Reading University in July. The “Core of Life” team have a wonderful workshop on working with pregnant teens that was highly praised and Julie Clarke will be facilitating several workshops on small groups work.

Bronny Handfield will be showing her fabulous hour long DVD on the media’s interpretation of birth. These clips, taken from many well known television shows explain how women form their views about childbirth (often making it very hard for educators to debunk various myths). Some of it was quite shocking (remember that terrible episode of “ER”?) and a lot of it was very funny - it is a marvellous mix that was entertaining and also illuminating about where community attitudes are formed. I am sure it will be resonate with British audiences as well.

Full details of the UK Conference are now on the web site and I recommend early registration to make sure you get your workshop choices. We already have a long list of people waiting for the details to be posted so they can register, so as they say, “first in, first served”.

The highlight of my visits to Japanese birth facilities was the Fureai Hospital in Yokohama, a city of 4 million people adjacent to Tokyo. The early immigrants to Japan settled in Yokohama because it was the entrance port to Japan and it has a reputation for a more cosmopolitan atmosphere (not all that readily apparent to the untrained eye!). However, it is seen locally as more progressive in many ways and this hospital is a good example.

The hospital is a converted modern hotel and offers a range of medical services along with a small birth unit which is located on the 8th floor. There was no hint of “hospital” in the lobby area downstairs and as I stepped out of the lift to visit the maternity unit, I could have still been in a hotel. Pastel shades of wallpaper, pretty dados, not a single poster or sign on the wall (”wash your hands!” etc) - just an airy light atmosphere and a pervading sense of peace.

The unit is the brainchild of Dr Tomoko Saotome, an obstetrician who specialises in women’s health and sexuality. She is a wonderful woman, with a sensitivity and insight that has no doubt been influenced by spending time in the West and the birth of her own two children. She has created the best maternity unit I have ever seen.

There are the usual birth rooms, which are large and sun-filled and women stay in the same room for labour and birth (unusual for Japan). The postnatal rooms on the same floor are also very low key and homelike, with warm colours and comfortable furniture. A small nursery (now used as a storage area!) and bathrooms complete the picture.

The most striking feature of this unit is the area to one side, where they have set up a birth room in what was thought to be the traditional Japanese restaurant area of the former hotel. A series of interconnecting small rooms, complete with tatami matting, sliding paper screens and bamboo walls and ceilings have been left untouched, and in place of the tables and seating, futons and cushions offer a comfortable space for labour and birth. A small room once used for Tea Ceremonies is also sometimes used for birth and this room has a wonderful view through sliding screens onto a well established Japanese roof garden, complete with trees, a stream and numerous plants and shrubs. Access to this garden is also possible through a small passageway with stepping stones set in gravel in the traditional manner.

On the morning of our visit there were three futons set out in the birth room and a breastfeeding clinic was about to get underway. Women with breastfeeding babies could visit and seek advice from a midwife or just meet and socialise with other breastfeeding mothers. One new mum was having her breasts massaged as she fed her baby, and other babies happily crawled around. The midwife who was in attendance is in independent practice nearby, and offers home births, her midwife house for births and postnatal clinics in this hospital.

The maternity unit caters for a limited number of clients to ensure that each woman receives the best of care and is able to achieve a peaceful birth. Around 30 women each month give birth there, under the supervision of the midwives and Dr Saotome. This small number has become a problem because the hospital’s owners want to make more money by making the facilities available to more women. Dr Tomako is insistent that if this happens the special nature of this unit will change and she is fighting to save it as it is.

Most hospitals that I visit have a sameness about them and a predictable arrangement of medical equipment and clutter that all scream “hospital”. This maternity unit was completely different and an outstanding example of what can be achieved when a person of vision has the chance to follow through in all aspects. It should be used as a showcase for others in Japan to follow and Dr Saotome deserves wide recognition for her achievements. The managers of this Hospital perhaps don’t yet realise what a public relations bonanza they have on their doorstep!

I’ll include some pictures in the Photo Gallery at the end of these articles on Japan.

Next March, the Chichester Homebirth group is presenting one of their special Conferences, this time in Bristol, UK. These are a very popular event and offer an opportunity for midwives, parents and others interested in home birth to gather and share ideas.

Next year’s event is titled “Home Birth: A new concept?” and all the details are now on a web site, that has information about past events and a down-loadable registration form for this coming Conference.

The main speakers will be Mavis Kirkham, Mary Cronk, Jonathan Montgomery, Lynne Leyshon and myself. We’ll be tackling a variety of topics related to home birth and I have been asked to address: “Have women changed?” An interesting challenge!

Providing home birth options is Government policy in the UK, yet its availability depends on the attitudes and capacity of the various Area Health trusts and PCTs to implement. This has been successful in some areas and a failure in others - the lack of staff to provide the service being the most often quoted problem. I am sure these issues will come up next March and that there will be lively discussion on how to make the home a more often chosen birth place by women.

Will I see you there?

The Effective Pre-natal Education workshop is proving most enjoyable. With such a diversity of people in the group, there is lots to discover and share, quite apart from the useful work we are doing on how to organise and present dynamic education programs for expectant parents.

We have two from New Zealand, for example, both midwives. They were surprised to discover that in Australia, women don’t have a known midwife for their pregnancy and birth. Here, women will meet the midwife usually when they arrive at hospital in labour, and they have to take pot luck that this midwife will follow their wishes. In New Zealand, every woman must choose her own caregiver once she is pregnant, and so she has that wonderful continuity that everyone else around the world strives for.

The educator from Finland described how one hospital there (and perhaps more) have fitted each labour room with a bank of monitors that enables the midwife to keep track of the CTG trace coming from all the woman in labour ward at the time. She said that the fathers often watch this bank of monitors: “Look how well the labour is going in Room X. You’re not doing much by comparison”. We were all horrified at this breach of patient confidentiality, apart from the concept of spying on women in this way. I’ve never heard of such a system anywhere else, but perhaps it exists. What away to reduce the intimacy of giving birth to a minimalist set of data! And voyeuristic too - a bit like a camera being set up in the foyer of a brothel so guests could check on progress being made in the various rooms of the establishment…..

The difference between country and city hospitals in Australia has also become apparent from various anecdotes and personal experiences shared by some of the Australian group members. There is no doubt that in country maternity units, largely as a result of the lack of obstetricians or GPs willing to offer maternity care, women have a better chance of receiving midwifery care. Sometimes this can backfire if the midwives are unwilling to try “new” ideas such as waterbirth, or giving birth on a mat on the floor, but generally midwives are flexible and willing to help.

Today we will be tackling program planning and I will be encouraging the group to think outside the traditional models of parent education to explore other program structures that might better meet the needs of parents.

These past few days I have been preparing my presentation for a trip to Japan that will take place in early December. It’s been eight years since I last visited Japan (the time just flies!) and I am looking forward to discovering what had changed in the Japanese birth scene since my last visit.

I remember being impressed last time by the lack of concern about the length of labour, as long as all was well and some progress was being made (partograms were not much in use), and of course, the stoical Japanese attitude to labour pain. Dealing with pain of all sorts, without complaint, has been a hallmark of Japanese culture for centuries, and noisemaking in labour has been frowned upon as an outward show of not being about to cope, and therefore a display of weakness.

I gather, from the information that my hosts have sent me that the epidural is now being promoted for use in labour. I don’t as yet know how widespread it is it, or what local attitudes to it are, but I will be investigating this as soon as I arrive. Japan has always had very low perinatal mortality statistics and low rates for caesarean birth too, and I wonder if these are being influenced by the more aggressive medical approach that I understand is taking hold.

I will be present a one-day training course for educators, another day long workshop for midwives and doctors and then participating in a forum for parents with a group of obstetricians and midwives. Three very different programs that will give me a chance to learn a lot about their country, as I explain what is happening in the west and how we can “keep birth normal”. More later.

It’s my last day in the UK for this trip. In reflecting on this visit, as I try to do each time, it is interesting to see what the big issues have been and what I have learned from the many midwives I have met and the many hospitals I have visited.

While I have been travelling about, I have been enjoying a book “Watching the English - the hidden rules of English behaviour” by Kate Fox. This is a delightful book, written by a social anthropologist, in which she explains why the English behave as they do.

The core characteristic she describes is “social dis-ease”, the chronic inhibition that underlies all social interaction, leading to “embarrassment, insularity, awkwardness, emotional constipation, fear of intimacy and general inability to engage in a normal and straightforward fashion with other human beings.” This may sound rather harsh, but it in fact leads to a very polite society, an obsession with privacy and a multitude of coping strategies that are familiar, such as “don’t make a fuss”, “mind your own business”, “don’t draw attention to yourself” etc.

Kate Fox also explains many other cultural habits that define Englishness such as their wonderful use of humour, their addiction to moderation, class consciousness, courtesy and sense of fair play. I recommend this book to anyone who ever travels or works in England - it will enable you to understand and appreciate what makes this country so interesting and different.

The book also explained some of my frustration, at times, in working with the midwives here. They know so little about what goes on in other parts of the country, even towns or cities close as a few miles away, and seem reluctant to try new ideas or strategies. I can see now that this is in part the English “drawbridge” strategy of retreating into the familiar home or workplace to avoid social contact and potential embarrassment.

Moaning is a national pastime, and often forms the basis of conversation. It is not acecptable to boast or promote oneself and constant complaining is much referred. It is therapeutic and part of the bonding process and is usually humorous in tone and seen as an enjoyable pastime. The down side is that when people write about a new service, such as a Birth Centre, or a caseloading midwifery practice, other perhaps interpret this as “showing off” or being too earnest about their successes - a definite no-no in this country. Moaning about a lack of services etc is much more acceptable, and absolves the complainer from having to do anything about improving them.

There is also the “keeping up with the Jones” element, a manifestation of the class system that pervades British society. A NHS Trust may not want to know what is happening in the next Trust area in case it shows up some deficiency that would put them in a bad light. It almost as if they say “if we don’t know what others are doing, and everyone keeps to themselves, we won’t be embarrassed by scrutiny of our service provisions”. There is certainly little consistency in either services, standards or quality from one NHS Trust to another, even if they are just a few miles apart. It is called the “postcode lottery” here and affects all areas of health care. It can mean that a woman on one side of the street, in one Trust area, can have a home birth, whereas her neighbour over the road, in another Trust area, has no homebirth service available to her.

The “social dis-ease” that Fox describes is also apparent in my workshops. I regularly broach embarrassing topics (the sexuality of childbirth for example) or ask participants to engage in uncomfortable activities (such as introduction games) to show that these things can be done, usually with humour and fun, and that once we overcome their discomfort, much useful interaction can occur.

I understand where they are coming from, and have many of the same English characteristics myself (being an Australian of English descent). However if we are to move forward and get better maternity services for women, some of these natural inhibitions will need to be challenged. It will mean “making a fuss” and “drawing attention” to new and notable programs, lowering the drawbridge to let in new ideas and seeking valuable conversations and interaction with colleagues in other places.

It’s been an interesting month, and I have learned much, as usual. There are many good things happening here with maternity care, but they need trumpeting, celebrating and publicising, so they can be embraced by others and not ignored or sidelined. Perhaps that is my main role in criss-crossing the UK on seemingly endless train and plane journeys - to be the messenger, mediator and communicator that helps to link these groups and individuals up. My next attempt at this feat will not be until March 2006. Meanwhile, I have a huge workload awaiting me in Sydney, where I will land in 2 days time.

I’ve been learning more about the Hull Volunteer Doula Project, which has just been launched. The program will train volunteer doulas who will be buddied up with vulnerable women in need of friendly support through their pregnancy, birth and post-partum period.

There is a high level of need for a service sch as this in Hull, and the impetus for setting it up has come from women and midwives in the area. It is co-ordinated through Sure Start, but will also work closely with the local maternity hospital and the community midwives in Hull.

To recruit the doulas, an advertisement was placed in the local newspaper. Free training, on-going support and the satisfaction of volunteer work was the carrot, and over 60 people applied for the first 10 positions. The final number in the first intake ended up as 11, and they had their first meeting last week.

The training will take place over two months, with my Active Birth workshop and 8 two hour sessions to follow. The doulas will be given training in pregnancy support, labour assistance and post-natal care. Once the training is complete and they have been assessed, they will be allocated to chosen women who are around six months pregnant, to follow them through for the rest of their pregnancies and then on into the early months with the new baby.

A second intake is planned for March next year, with both groups fully funded through Sure Start. It is an ambitious project and it will be interesting to see how it works. These doulas will not be paid for their work - it is a fully voluntary program, aimed at those who need support and have few financial resources. In this respect it is unique - all the other doula programs in the UK are geared for those who can pay for this service. These Hull doulas are also receiving more training that other doulas, which will be important as the women they will work with will have considerable needs.

Supporting other women during pregnancy and birth was always a traditional role for women in the village and it is good to see that these concepts are being resurrected, especially in an age when paying for services has become the norm. I hope this project is very successful and will make a difference to the women who receive the support as well as the doulas themselves.

I have received the following letter from Zeshi Fisher in South Australia, and she has given me permission to reprint it here, so that others may learn of the humanitarian work being done in Africa.

“I am a 3yr bachelor of midwifery student in my final year at the Flinders University of South Australia. Over the summer period December 2004 - February 2005, I was involved in the creation and development of a health post and education centre in the northern desert regions of Ethiopia, known as the Afar. Four friends and I initiated the project and completed it with the help of financial support through private donations and other small-scale fundraising activities.

The Afar is a place of extreme need in all aspects of health and education. It was our hope to provide a place from where a women’s extension worker (WEW), and/or community health worker (CHW) could provide basic health care and education to the nomadic communities who live in the region. The health of Afar women is especially fragile. Female genital cutting (FGC) is performed on almost every young girl, causing her to suffer multifaceted implications for the rest of her life. The maternal and infant morbidity and mortality is devastating, with each woman facing a 1 in 7 chance of dying in childbirth. These women predominantly birth in their villages accompanied by traditional birth attendants (TBAs) or relatives, and receive no or very little care before and after the birth.

An Australian midwife, Valerie Browning, has been working to improve the well-being of Afar women for many years. She has founded an NGO called Afar Pastoralist Development Assn. (APDA), which is instrumental in the development of health and education strategies for the Afar people, particularly through their work with women as a central aspect of functional and healthy communities.

One important aspect of APDA’s work is the training of WEWs and TBAs from the community to enable them to take skills and travel with their nomadic families. In order to provide the birth attendants with an understanding of the birth processes, I would like to take 15-20 foetal model dolls (dark brown) and pelvises to Ethiopia to give to APDA for the purpose of enhancing their training programs. At present they have little if any educational tools with which to work.

I am hoping to raise the money needed to purchase these dolls, and I am aware that Birth International sells model pelvis & foetal doll sets for AUS$175. It is my hope that Birth International may be able to provide me with a reduction of price if not a donation for the purpose of this cause. It would be enormously appreciated not only by myself, but also by the birth attendants and birthing women of the Afar Region of Ethiopia who will subsequently be able to enjoy improved care and birthing outcomes as a result of this education”.

Of course Birth International will help her with this project, as we have with others of this nature. When you look at the conditions in which women and babies have to live in many parts of the world, it seems the very least that we can do. It is especially uplifting that our midwifery students are involved in projects of this kind - a mighty effort, given their study workloads.