Andrea’s Diary

It’s been a frustrating couple of days. I went to Wagga Wagga to facilitate a workshop and found that I had left my laptop power cable behind, so I was unable to do much except answer a few emails, and hence, no Diary entries for a few days. It is amazing how dependent we’ve become on this technology - how did we ever manage without email and the web?

There is a lot of action hotting up, on various fronts. The final plans for the national launch of the National Maternity Action Plan on September 24 are being slotted into place, and this week I will be forming part of a delegation putting the NMAP case to various politicians in the NSW Parliament. These promise to be very interesting meetings and I will keep you posted about their outcomes.

Some politicians have already been lobbied especially by Barb Vernon, Justine Caines and Sally Tracy, on a recent visit to Canberra. Meg Lees (former Democrat and now Independent Senator) was the most enthusiastic and she has taken on the issue of midwifery and NMAP as a major platform for her term. She will be making it the central theme of the Adjournment Debate in Parliament at the end of September, which will guarantee that these issues are recorded in Hansard. Kay Patterson, the Minister for Health, was completely disinterested when approached and her staffers (all bright young women) were very uncomfortable with Justine’s 5 week old baby being breastfed as they talked around the table about midwifery!

The Greater Metropolitan Transition Taskforce (GMTT) in Sydney is generating a lot of angst amongst consumers who have not, as yet, been consulted on key issues, such as the closure of smaller maternity units around Sydney. A campaign to publicise this issue, especially in the marginal seat of Campbelltown is being mounted and John Brogden, the Liberal Leader of the Opposition, has already visited the threatened maternity units in the Campbelltown/Camden area to see for himself what these proposals mean for families, and especially women. Camden has a fully fledged Birth Centre that no-one is allowed to use - it sits there in glory, completely untouched - the result of local medical politics.

A number of documents, including those covering the issue of the GMTT , and the Maternity Coalitions’s statement on Professional Indemnity Insurance have been prepared as part of these campaigns and I have had then added to our web site for easy access by concerned parties.

It will be a busy week!

I am off to Wagga Wagga again tonight to present a workshop on “Dynamic Pre-natal Education” for the Regional Community Health Service. Once again it has got me thinking about the overall scene that surrounds parent education programs…….

Why do hospital administrations believe that anyone can present prenatal programs, without any specific training first? There seems to be a very widespread view that anyone who is a midwife is well qualified to teach classes, and that anyone who may be available can be rostered to undertake the classes, sometimes at very short notice.

I

Is this fair to parents and presenters? Have these administrators actually considered what results may flow from these decisions?

Let’s consider the recipients of this education first, especially as they are undertaking the greatest risks. Expectant parents who attend these prenatal education programs, they believe that the leader will be competent and skilled, knowledgeable about their subject and able to facilitate effective learning. These are the qualities they will expect the teachers in their children’s school to possess - it is unimaginable that school principals would recruit casual passers-by to teach maths to 10 year olds. Yet this is exactly what happens in the education department in maternity units!

Hospitals have a duty of care to ensure that the programs they offer fulfil their promise. Perhaps they feel that because they usually don’t charge for their classes, parents can’t expect much; yet this is not they way that parents are likely to view it. Where fees are charged for classes, such as in some private hospitals, the need for qualified educators is even more acute, since the hospital is advertising their programs as part of their maternity packages. “Truth in advertising” might be reasonably argued to be a pertinent issue here!

Another issue is the stress that performing complex tasks without any training places on the staff involved. Leading adult education groups requires a variety of skills and proven competence. To throw inexperienced staff into this field could be seen as an occupational health and safety issue, given that the stress that may result to staff could have been avoided if the necessary training had been provided in advanced.

The importance of prenatal education cannot be denied: it is the best opportunity available in the general community to instil some basic parenting skills into parents; it generates a captive audience for health promotion strategies; it is a prime example of preventive medicine in action. It could be argued that if health administrators were serious in spending their limited budgets wisely that this is one area that holds significant potential for wide spending. Although there is scant evidence that prenatal education produces improved outcomes in either birth or parenting, the qualifications of the educator running the programs being used for these studies is rarely stated. Perhaps if they had been better educated and had clearly defined aims and objectives for their program, effective evaluation might be possible. Perhaps the wrong outcomes were being measures in the first place - an issue worth considering as well.

I am appalled at the quality of most prenatal programs for expectant parents. Educators are often required to “toe the party line” and advertise the services of the hospital and avoid discussion of services and options that the hospital would prefer not to provide. The notion of “informed choice:” is a myth, and parents are gently lead into accepting often substandard care (in terms of birth outcomes) in our hospitals. I believe that hospitals must accept the responsibility of providing quality education for pregnant parents and that this rests largely on their acceptance of the need for appropriate education and support of their educators. Many are struggling to do the best they can, under sometimes impossible conditions. When are hospital administrators going to really look at what they are doing in this area?

Way back when I started getting involved in consumer action around birth issues (and we are talking 25+ years ago!) those who were outspoken on social and political issues were often labelled perjoratively as “radicals”.

It was supposed to be a “put down” , but I’ve always regarded being labelled a “radical” as a huge compliment - after all, it seems it’s these people who often get things moving and raise issues everyone finally accepts as mainstream, given time.

This test of one’s position on the political/humanist spectrum is very interesting and well worth a look. I’ll tell you where I stood if you ask me, after you’ve done the test tyourself!

Over the years, I have had a number of people tell me how attending an Active Birth workshop has helped them in their professional life, and sometimes in their personal life as well. It is not uncommon for pregnant midwives to come to the workshop as it serves as a kind of “intensive pre-natal program” for them.

When I received this story I was overwhelmed. This is what it means to give birth normally, and this is what it feels like for a midwife to give birth normally. I want every midwife to take a moment or two to read this reflection and to consider what it is saying. Powerful messages like this are precious and can inspire and strengthen resolve.

You can do it, as a midwife and you can do it, as a woman. Trust and faith is what it takes.

I’ve been reading Michel Odent’s new book, The Farmer and the Obstetrician, and it offers an interesting examination of how the medicalised approach to birth is having the same effect on people as industrialised farming is having on the environment. The environmental debate is again in the news here and the current Australian Government’s unwillingness to sign the Kyoto Agreement on reducing greenhouse gas emissions seem to mimic the Government’s unwillingness to tackle the pollution of birth by medical maniacs. How do we get them to see reason?

I intend to contemplate all this from the peace and tranquility of Norfolk Island for a few days, where I am sure I will have the chance to see nature at its best while I take a much needed break.

Next week it will be head long into the National Maternity Action Plan launch preparations and more workshops. But, feet up time first!

Whenever Marsden Wagner speaks at an event, he likes to have the local statistics on birth outcomes available so he can make his presentation relevant to the local audience. I remember his last visit for the Future Birth events (1997) and the effort that was required to obtain these statistics for him.

It was easy in NSW - all our figures for public and private hospitals are published annually and are freely available (now via a website) and there were also good figures available from Western Australia and South Australia. Even the Northern Territory was forthcoming with useful data. Victoria had limited figures which were really useless as they contained no individual hospital data. The real fun began when we tried to find out what was happening in Queensland.

Every State compiles perinatal data, using the Midwives Data Collection that is common to all. In Queensland, the only data available for public consumption was for the public hospitals, and this could only be obtained by paying a fee of $120.00. We were told that the private system was just that…. no on-one could scrutinize their figures, as it was “commercial in confidence”!

Having paid the fee we then had to nominate exactly which hospitals and which specific data we wanted. A spread of hospitals was selected to try and get a representative sample of types of units across the State. Then, just at the last minute, a mysterious bundle “fell off the back of a truck” and suddenly we had vital statistics for birth outcomes at some of the leading private hospitals. No wonder they were hiding them - even then the operative birth rate (caesareans, plus forceps and vacuum) were around 75% in some of them!

This situation is disgraceful on a number of counts: taxpayers have a right to know how their money is being spent; the private system is partly taxpayer funded and should therefore be accountable; women have a right to know their chances of birth being normal (we now know this as well for NSW) and health professionals should know how their institution measures up against others that are similar.

As we get ready to launch the National Maternity Action Plan, these figures are important for underlining our message that midwifery care is better, cheaper, safer and more popular than standard medicalised birth. Our Queensland colleagues are now grappling with that State’s reluctance to part with their perinatal data, and no doubt will mount a campaign to expose the rorts going on (they must be, or they wouldn’t be hiding anything, would they?).

Good luck to our colleagues in Queensland, and to all the other birth activists lining up ready to do battle to have the NMAP accepted as national policy. The old saying seems appropriate here: “Hell hath no fury like a woman scorned” - we are angry about delays in implementing maternity reforms and we want action!

Today I’ve been giving some thought to a new edition of The Midwife Companion - the art of support during birth. I’ve been spurred into action because of a comment made to me by Elaine Dietsch, one of the faculty on our Graduate Diploma in Childbirth Education. One of Elaine’s “hats” involves her in midwifery education at the University in Wagga Wagga, where she lives. We had dinner recently when I was in Wagga Wagga to present a workshop and she mentioned that my book, although highly valued by students, was nevertheless on the ” Of historical Interest” list rather than “Required reading list” for their midwifery course. Apparently it is considered “dated” because of a University policy that anything over 3 years old is “out of date”, even though it may contain material that is timeless. I was horrified, especially as students frequently tell me it is their “bible”(of course the Bible would never be on a required reading list at a University either, for the same reasons as my book!).

Protesting to Elaine that I thought this was a rather “elitist” attitude to adopt as a general principle (although I could see its merits for texts based on hard research, for example) she said that the solution was simple - prepare a second edition.

Since we are almost out of stock and a reprint will be necessary before the end of the year, the opportunity is there to write a new edition. That of course, raises the question - what would I change/expand/add/revise? Some answers are obvious, such as changing the resources lists and contact details. However, there is little to change in the text itself, although I may well expand it. Birth balls, for example were not really much in use when I wrote the book and they have become very popular, especially when the hygiene aspects of bean bags started to be questioned by the occupational health and safety “police”. Perhaps I will seek suggestions from my ozmidwifery list colleagues on what they would like included.

I originally wrote the book for British midwives who seemed to have few ideas about how to make women comfortable in labour beyond giving them Entonox or pethidine and I drew on all the ideas that I had used myself when supporting women during labour as my starting point. It seems however, that midwives everywhere have taken the ideas on board and I have had thank-you’s from midwives from all over the world who have found the suggestions helpful. I am always amazed that these ideas, simple in nature and to me, very much common sense, need to be spelled out in detail in this way.

But then, .common sense is such a rare commodity these days!

There is a very interesting article in the Sydney Monring Herald today written by Dr Norman Swan. He explores the powerful influence of the placebo effect (and the even more powerful Nocebo effect) on people’s health, and looks at the reasons why many treatments are no more useful than placebos in improving outcomes for patients.

No where could this be more true than in labour and birth. These are not even illness conditions, yet they are treated as though they were, and women are offered various remedies, medications and even surgery, to “ease” or “relieve” their symptoms. If a positive result occurs, it will be attributed to the medication, treatment or gadget even though it may well have been the placebo effect of thinking something was helping that did the trick. Emphasising the effectiveness of the treatment and downplaying the woman’s own role is a sure way to undermine her confidence and maintain her compliance and submissiveness to the medical message.

A great example of this is the TENS machine. This gadget, hugely popular in Britain, had been adopted by midwives, even childbirth organisations, as a “safe” alternative to drugs for managing pain in labour. It is enthusiastically promoted in pregnancy magazines, Boots the Chemist shops, by childbirth educators who hire out the equipment and even midwives. It is a prop for those with no firm belief in women’s innate abilities to give bith without “help” and who want to be seen as rescuers; it makes people feel good to be doing or offering something; and it makes money for the manufacturers and the retailers.

How have women been so effectively duped into buying these gadgets? Clever advertising, that’s how, by claiming that TENS machine raises endorphin levels during labour. There is no evidence that this is the case and no studies have been undertaken on labouring women. Perhaps natural levels of endorphins are raised, but it this due to the machine, or the placebo effect resulting from a belief that one’s endorphin levels are being raised during labour by the machine? Does it matter if it is the machine itself or the placebo effect that is working here?

Yes! If the woman places her faith in the machine and believes that it was the TENS that got her through, then she completely discounts her own natural abilities, and this can undermine her faith in her own strength. As a result we are at risk of producing women who believe they are weak and incapable instead of strong and resilient. Of course, women with little confidence in themselves will be easily manipulated, more readily coerced, and more dependent on others. It becomes a circular problem - next time women will say “I needed the TENS last time and will need a bit of help again this time…” - music to the ears of the health professional who is ever willing to take over and “help out”.

Given the power of the placebo, this is the time to use it to great effect - women need tobe told “you can do it!” and all those other positive messages that true midwives use to encourage women to give birth by themselves.

Norman Swann also talks about the “nocebo” effect, another fascinating influence on the way we deal with health problems, but that will have to be the subject of a diary entry for another day. In the meantime, check his article out : ” Doctor feelgood”.

http://www.smh.com.au/articles/2002/08/16/1029114012780.html

I’ve just finished putting together a package for a Victorian University that requested we develop an elective in childbirth education for their students doing their Graduate Diploma in Midwifery.

It seems that the electives they are currently offering their students were not seen as very relevant or exciting by the students, who were looking for an opportunity to gain skills in an area that would be of more benefit for them when they graduate.

The elective we will offer in fact is part of our Graduate Diploma in Childbirth Education that we offer as a stand alone postgraduate program for anyone and everyone who wants accredited qualifications in this field. The elective will involve 5 days of experiential workshop sessions and two assessment tasks, that are practical in nature and will involve (amongst other tasks) facilitating a session for expectant parents. We will also make the elective available at the University and it will probably be offered as a summer school subject later this year.

This is an exciting development for us. I have often been dismayed that the undergraduate education programs for midwives include very little about education for parents, yet this is an area that will involve all midwives at some point in their careers. Offering this elective will at least give some students the chance to obtain some real skills in facilitating adult educaton groups and will hopefully enable them to see the huge potential of working with parents during pregnancy. There is no doubt in my mind that parents who have had the opportunity to explore the benefits and practicalities of normal birth are more open to working with the midwifery model of care during labour. Fulfilling your dreams as a mdiwife rests on women being open to exploring their own instincts and innate capabilities, rather than just accepting the medical model without question. Awakening parents to their potential should be a major goal of the pre-natal educator.

Parents don’t learn how to get involved with the experience of birth by listening to the didactic lectures (often called “discussions”) that form the basis of many parenthood education programs. They need need to be part of a well managed adult learning group that sets its own agenda and works to solve its own problems. We hope to show at least one bunch of midwifery students how to do this through this participating in this elective. We are looking forward to working with them!

Today I have been reviewing resources for the article on drugs for pain in labour that I am preparing for the Essential Parent pages of this web site. It is really quite frightening to think about how little we know of the effects these drugs have on the unborn child - very little research has been done on this topic. This lack of evidence is often used as the reason caregivers say things like “epidurals are safe” when in fact they are not. Just because there is no research does not mean there is no problem, it just means there is no research.

You might like to check out this web site - it is powerful stuff and if you have any belief in the right of parents to make informed choices, you need to be well informed yourself!

http://www.nwhalliance.org/

This site has been put together by Doris Haire - a champion for better birth if ever there was one!