Andrea’s Diary

There was small paragraph in the Bangkok Post Newspaper that caught my eye the other day. It was reporting the low rates of breastfeeding in Thailand and the Ministry of Health’s concern that only 5.4% of babies are being exclusively breastfed at 6 months of age.

This low rate probably reflects the growing need for mothers to return to work after the birth of their babies, and perhaps other factors as well, and is probably not very different fro the situation in many other countries.

What attracted my attention was the proposed solution for improving these figures: a publicity campaign to be headed up by a “Miss Breast Milk” (!). My mind immediately wandered to the possible images that might accompany such a campaign…..

The formation of a political party to focus on specific issues relating to childbirth is a momentous event. The coming Federal election in Australia (due in October or November 2007) has been the catalyst for Justine Caines, former national President of the Maternity Coalition to launch a campaign that will put midwifery care into the spotlight.

What Women Want is the new force on the block - dedicated primarily to getting Medicare rebates for midwifery services in Australia. In this country, midwives are the only group of recognised health professionals that are not included in the Medicare system, and this situation has reduced choices for women across the country, escalated the cost of maternity care enormously and contributed to the shocking rates of intervention in childbirth that are occurring.

Despite many reports in maternity services (almost 40 Government and industry enquiries have investigated maternity services in Australia in the last 30 years) recommending that midwives be given a greater role in the provision of care, the medical lobby has worked hard to maintain their monopoly on birth services. Several landmark population based studies have proven that reliance on obstetricians as the primary care professionals for pregnancy and birth has given us poor outcomes (amongst the worst birth results in the western world), cost us millions of unnecessary dollars and reduced options for women.

The new political party will be highlighting these issues, amongst others, during the coming election campaign. They are actively recruiting members at present, prior to registering the party and planning the details of their policies. I encourage everyone in Australia who wants to see better births, more equitable and sustainable maternity services and long overdue recognition of midwifery to get involved. Their website outlined their aims and plans - check it out for more information and join up today.

I’ve heard a string of stories today from midwives in the Huddersfield/Halifax area that illustrate the terrible state of the NHS in the UK.

Despite the Government’s many initiatives, policies, legislation and regulations that support midwifery across the UK, the enormous hole in the budgets in many NHS Trusts has meant that many programs are being cut or scaled back and restrictions on staffing are putting labouring women and their midwives at risk.

One of the midwives in my group ducked into the Labour Ward at the first break to grab a cup of coffee and discovered that the Manager was frantically phoning around trying to find some staff for the night shift this evening. The midwife was made to feel that she should be on duty or else her colleagues would be struggling and working under duress. She had to leave the workshop so she could get sleep and organise her child care in preparation for turning up for the night shift.

This was described as a typical problem in this area (and I suspect, many others). A full complement of staff cannot be found for many shifts and those on duty find they are having to work in conditions that are clearly unsafe for women. It was suggested that several incidents (one that ended in tragedy) were exacerbated by the extreme stress of midwives who were doing their best, but working way under safe working conditions.

Several midwives mentioned that even basic equipment, such as Sonicaids, was in short supply and that even CTG machines, often vital when a baby is in trouble during labour, were sometimes hard to find. There is a new Birth Centre being constructed in this area, but there is concern that its facilities and equipment may be limited by the stringent budgets in place.

The midwives in this group are committed and dedicated, wanting to practice their skills as they know how. Many are totally frustrated and angry with the way the NHS is taking advantage of their willingness to do the best for the women in their care. One wonders how much worse it will all get before improvements finally arrive.

I hope tomorrow to give them practical measures they can implement within their own scope of practice. When things are bad within the system at large, perhaps this is the time to think local rather than global: working with each women, one at a time, and making her experience the best it can be, so a midwife can gain some personal rewards for her work.

Addressing the issues at the broader level will take group action, commitment, and strong political action. The midwives here have good leaders, willing to support and encourage change so I hope they see the potential of a collective approach and work as a unified group to achieve what they want as midwives.

This morning I heard a report on the radio that the Australian Competition and Consumer Commission had set up a new code of conduct to oversee the relationship between drug companies and doctors, in particular the way the companies offer freebies and kick backs (my words) as part of their advertising campaigns. The Government feels that this widespread practice needs to be made more transparent, so that patients are aware of what is going on and why certain drugs may be promoted by their doctors over other alternatives.

The schmoozing and massage of the doctors by drug companies (and no doubt equipment manufacturers as well) is outrageous. Incentives to attend conferences, free samples, free publications etc are all widely offered and received. The doctors need to keep up to date with rapidly changing developments in the medical field, which may not be so easy in a busy professional life. However, the requirement to keep updated comes with the territory and is a requirement for maintaining registration.

In addition, subscriptions to professional journals, registration fees for Conferences and seminars and other strategies that can be proven to be important for the maintenance of professional competence are all tax deductable. Doctors earn huge amounts of money (despite their protestations, no-one has ever met an impoverished doctor in Australia) and I would have thought that a few handy tax deductions might be useful.

At a recent workshop I presented, the midwives’ attendance was subsidised by the taxpayers, through a special purpose grant. Midwives earn very modest salaries and often get no help with seminar or Conference fees, and have to fund their registration, travel and accommodation from their own pockets. However, the doctors (GPs) who attended this workshop were paid to attend, the princely sum of $1500 for each day. The cost of the workshop to the taxpayers would have worked out at around $100 per day for each of the midwives, so the doctors did very well. In addition, two of them didn’t stay the whole time, dashing in and out to attend patients, for whom they would have received payment as well. Not bad - being paid handsomely to be in two places at once!

Knowing about this rort of the system left me feeling less than charitable (hence this whinge) when I also heard a comment from the Australian Medical Association spokesperson, in response to the report on the radio, that any changes made to the current system, “were unnecessary”, and might discourage drug companies from telling doctors about new treatments. Perhaps he was thinking about the added costs to his own pocket if all the freebies dry up.

You can read more about this interesting development on the ABC’s Newsradio website.

It was heartening to read the latest News Release from the Australian College of Midwives announcing that the NSW Department of Health has released a Policy Directive that supports and encourages the setting up of home birth services through the State’s Area Health Services.

Politicians often pay lip service to programs they think will win them friends and votes, yet often fail to follow up with appropriate legislation or regulations that enable services to be set up. In the case of home birth, the midwives and women of NSW have been lobbying hard for many years at both the national and State level to have home births made available on our national health service (Medicare). Privately, the NSW Department of Health has been muttering encouragingly, and now finally they have issued a directive that is binding on all Area Health Services in NSW. The full text is available on their website, but here is an excerpt:

Date of Publication 29 June 2006

Summary

This Policy Directive has been developed to reflect current evidence about the provision of homebirth. Area Health Services (AHSs), when providing public homebirth services, must comply with the standards set out in this document. Clinicians providing public homebirth services must be employees of, or have clinical privileges with, AHSs.

This document applies to: Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, Public Health Units, Public Hospitals.

Now that this Policy Directive is in place, it will be easier for Area Health services to set up appropriate home birth services for women. The South Eastern Sydney Area Health Service already offers home births as an extension of their Birth Centre Program at both St George Hospital and the Royal Hospital for Women, Randwick. It is hoped that home births will soon be available through Camden and Belmont Hospitals to extend theircurrent caseload midwifery services.

Although a welcome development, the Policy Directive does not help independent midwives, as it does not address their lack of professional indemnity insurance. As the Directive states, midwives offering home birth will have to be employed by or have been granted visiting rights at the AHS. This means that independent midwives are still excluded as they had their visiting rights at hospitals withdrawn when their indemnity insurance was withdrawn some years ago. This is a critical issue that still needs urgent resolution. Until a means is found to resolve the insurance issue, independent midwives will be reluctant to offer their services and women will be denied access to their care. This situation is discriminatory both for pregnant women and also independent midwives.

The Policy Directive is a good start. How many Area Health Services will heed this policy and set up a service for homebirths? That will be the final proof that home birth is on the map.

The BBC News this morning had considerable coverage of the latest National Institutes of Clinical Excellence (NICE) draft guidelines regarding home births. NICE is the advisory body that establishes “best practice” guidelines for the NHS and they have made a number of recommendations regarding aspects of childbirth and its management.

In their view, women should have more choice regarding the place of birth and home births should be more widely supported. Although Government policy supports home birth, only 2% of women in the UK choose this option, although this figure varies widely across the country - some areas have 12% and there are pockets where 20% choose birth at home.

Beverley Beech, Chair of AIMS was interviewed and stated that choice was a myth and that women were often unable to get a home birth due to local hospital policy. She also said that the practice of sending two midwives to a home birth was unnecessary and not supported by research. She claimed that this practice had been established when it was discovered that home births were cheaper than hospital births, so two midwives were to attend at home to keep the costs artificially high. This was something I had not heard before - I have often questioned the necessity for two midwives at a home birth as it certainly adds to the costs.

The shortage of midwives was raised with the Obstetrician and NICE representative who were interviewed, as well as the old hoary arguments about safety of home births. The Obstetrician was from University College Hospital said he thought that their “home from home” centre was the best compromise (but women who want a home birth want to be at home, not in a birth centre).

Whilst stating that birth at home resulted in less intervention in birth, the safety issue is still unresolved, according to the NICE spokesperson, and they will be “keeping an eye on it”. Given the massive shortage of midwives and the chronic low morale in the UK maternity services, it will take more than these new draft guidelines to turn things around. Even with the very public support for home birth at all levels of Government, they still can’t get their rates up, possibly because of the fear factor in both women and midwives. Women in the country have simply been scared off.

If you want to read about these draft NICE guidelines, which will be finalised next year, you can view them here.

I am back in the UK at present, with several workshops planned for this short trip. Just before I left Australia there was quite a bit of discussion about the rapid rise in our birthrate and also the timing of many of these births.

For some years now, Australia has been doing very well economically. Very low inflation, low unemployment, affluent lifestyles and high levels of education have encouraged many women to work on their careers and as a result many are delaying having babies until they are in their 30s (other western countries have similar trends). Our relatively low birthrate has also been flagged as a possible problem for the future - who will support the ageing population in years to come?

Our Treasurer came up with a plan to solve this problem. The Government brought in a “baby bonus” of $3,000 that was to be paid for every baby born after June 1, 2004. The Treasurer then began exhorting women to have three babies - “one for you, one for your partner and one for the country”. The incentive of a cash payment, no strings attached, seems to have done the trick and we are experiencing a large jump in the birth rate - another baby boom.

Interestingly, a new report has revealed that in order to be eligible for this “baby bonus” many women delayed the births of their babies by two or more weeks. Holding off until after June 1, 2004 was a good move worth money to many families. Most of these women were planning caesareans or else were refusing inductions before their due dates. There was a suggestion from the Australian Medical Association that some women might have delayed too long and put their babies’ lives at risk!

On July1 this year, the baby bonus will be increasing to $4,000 per birth. The question being asked this week is, how many women this time around are going to put of their caesarean or induction in order to make more money? July 1 also falls on a Saturday in 2006, a traditional day for obstetricians to be playing golf (or whatever) but this year might see them hard at work in the operating theatres, valiantly supervising births that have been delayed an extra week or two. I wonder if they will charge extra for this “after hours” service and if this will be paid for out of the extra baby bonus?

Another busy week draws to a close - where does the time go?

The workshop at Campbelltown on Monday and Tuesday gave me the chance to catch up with developments in that area. The Hospital at Campbelltown and the Birth Centre at Camden (about 17 kms away) are part of the same Area Health Service. This AHS has been under a cloud due to many problems, and some deaths, which have been attributed to a number of factors. Some administrators have gone, some staff have left and the situation is improving, however, it has left moral amongst staff at a low point and a degree of suspicion and distrust as well.

Camden has a lovely Birth Centre, which is currently closed. The obstetricians in the area have refused to cover for births at Camden, forcing women to travel and give birth in the larger Hospital at Campbelltown. When the Birth Centre was closed, there were two very noisy protest marches of mothers and babies which received extensive media coverage and as a result, the State Government, under a lot of pressure to provide better services in the area, has promised Camden will re-open as a midwifery only unit. For the women of the area this is good news, but many have heard it all before, and are sceptical that it will ever happen.

Into this scene has come two top midwifery administrators to sort out the mess, clear away the blocks and get the service running. A caseload model is the preferred option, and is close to being implemented, once the annualised salary issues are resolved. The midwives in the area who have been patiently waiting for 5 years, are close to giving up and are beginning to doubt the promises. While their frustrations are understandable, this is the very time that a final concerted effort (push?) is needed to get this baby born.

Until Camden Birth Centre re-opens, the midwives from that Unit will be providing pre and post natal care on that site and bringing the women to Campbelltown for the births. This is far from ideal, but at least does offer the midwives in Campbelltown the chance to witness the working of this model and to learn from some very experienced midwives. Eventually it is to be hoped that the midwifery services across both hospitals will be similar so that women can be assured of having midwifery style (not obstetrically influenced) care wherever they choose to give birth.

Managing major changes of this nature are hard on everyone. Improvements and new developments never happen fast enough and usually take longer to negotiate than planned. An additional pressure comes from the fact that these new midwifery-only hospitals are a new concept that is being gradually introduced, amid a flurry of angst from the doctors and considerable political pressure from various stakeholders. The midwives in these new units must feel they are being watched like fish in a tank, with hungry predators waiting to pounce!

The medical model of obstetric care is a robust and almost unshakable system that is very hard to shift. However, the realities of high costs, over-servicing (30% caesarean rates), unjustifiable restrictions on women and lack of choice are forcing a re-think of the way birth is managed in this State. Camden could be one of the leading lights in this process and given a chance, I feel sure that it will succeed, just as other midwifery unit have done in the recent past.

The issue of doulas came up again today, this time with the group in Nuneaton. These are experienced midwives from a number of hospitals, very well versed with active birth and familiar with homebirth and midwife led units. As I commented at the end of the first session - this may be one of the easiest programs I have ever facilitated!

One midwife raised the issue of doulas after we had viewed a video that includes comments from an American doula. Her feeling was that if the doula movement becomes established in the UK, then midwives will lose out, as the care offered by a doula was traditionally part of the midwife’s role and that if this is relinquished to a doula then the midwife will end up being little more than an obstetric nurse. There was general acceptance of this view within this group, although when I explained about the service being established in Hull, they readily agreement that this was a different situation altogether and was a very promising development for those in genuine need.

It seems that some women today feel that paying for personal care during labour could be seen as a status symbol - “look what I can afford”. Employing someone to pamper and attend to personal needs during labour is a statement about wealth, in much the same way as employing a servant. This may not be the overt intention, but may be a factor in the decision to engage a paid person rather than calling on friends and family, as has been the traditional way. I know that many women will say they have no family on which they can rely and that friends are too busy to help and that may be the case - we live in affluent times that enable us to travel, move easily and find work far from our childhood roots.

I also know that many women need a friend, someone with a genuine and long lasting interest in their well being. I am not sure that buying the services of a doula for a few weeks or even months will meet that need completely, but then some families will hire a nanny or place the children in child care and return to work, where friends abound, as the next step.

The role of the doula is a thorny and complex issue. These are a few random thoughts, amongst many mixed feelings. I can appreciate the sensitivities of midwives who feel supplanted by doulas and I understand that for some women, paying for social services and practical help is part of their approach to life. I will always promote the idea that babies are born into an extended family, and that finding ways of drawing in their ongoing support and experience is essential in building communities and a stable, caring society. I expect that others will hold different views, and so be it……..

This weekend I am visiting friends who spend their time between Bangkok and Britain. They told me that they had been contacted by a woman in Bangkok who was wanting to ensure that if she had a caesarean birth in the private hospital where she has booked, her husband can be with her in the theatre.

This request has caused some mayhem, it seems. The hospital’s response was to quote a recent policy change that husbands could not now accompany their wives to theatre for the birth of their baby by caesarean. This woman then contacted the rival private hospital, to be told that they had an “open door ” policy. When this information was conveyed to the first hospital they reconsidered their position.

The need for secrecy about what goes on in hospitals is becoming more of a problem. The usual reason given (perhaps indirectly) is that if you have family members in the theatre (or extra people in the labour ward) then they may become concerned about what is going on, and sue the hospital. Hospital administrators reason, apparently, that if you keep the people in the dark, they won’t become alarmed and will take on trust what they are told about events that occur during hospital stays.

An alternative way of looking at this would be to encourage the partner into the theatre, or the extra family and friends into the labour ward, so they would be witness to everything and could see for themselves what was done to save the mother and baby from harm. It could be argued that being open and forthcoming heads off potential law suits, because it is clear that there is nothing to hide and that every effort has been made to achieve a good outcome in an emergency situation.

Of course, sometimes people will make mistakes and the system won’t work as well as it should - that’s life. Being honest and open, however, may help those involved to come to terms with these events better than trying to cover them up and obfuscate under questioning.

As far as I know, most hospitals in Australia (and probably Britain) do enable fathers to be in the theatre when their baby is born via caesarean, unless there is a true emergency with no time to equip him being in the theatre. This is something I will ask midwives about during workshops, because it may be another reason why men are so often traumatised by the drama of the caesarean and subsequently encourage their partners to accept an elective caesarean for future births. Being present for a surgical procedure must carry the potential for trauma for the uninitiated, but surely excluding people and thus creating mystery could contribute as well.