Andrea’s Diary

The Bangkok Mothers and Babies International (BAMBI) group is celebrating its 20th birthday this week. It was established by a small group of expatriate mothers living in Bangkok who recognised the need for a place where foreign women and children could meet and support each other. These women were often wives of businessmen or diplomats who were not allowed to work themselves and many were in Thailand on contracts that would mean a temporary residence of a few years before returning home or moving on again to another city.

These women often had skilled or professional jobs in their own countries and this brought a huge range of talents to the group. Sub groups were formed to meet specific needs, for example, the BUMPS and BABIES group utilises the skills of midwives, child health nurses and breastfeeding counsellors to offer prenatal classes and post natal breastfeeding counselling. Playgroups in several areas of the city offer a chance for the children to mix and socialise and a Charities Committee collects unwanted toys, children’s clothing and equipment from those no longer needing them and distributes them to orphanages, schools and other deserving institutions around Thailand. Fundraising efforts have supported a wide variety of projects including school buildings for Thailand’s Hill Tribes in the north.

Another interesting service that BAMBI has set up is a link to the Central Blood Register. Negative blood groups don’t exist in Thailand, so anyone requiring a transfusion of negative blood could be in serious trouble. BAMBI asks all it members to be blood donors and most willingly agree - after all it could be them or their children who needed a transfusion. With the caesarean section rate quite high in Thailand there is also a potential need for blood.

The BAMBI Magazine is a very professional publication that carries articles and advertising of interest to members. Here can be found useful tips on living in Bangkok and finding the services that make adapting and settling in easier. It is also a means to welcome new members and share experiences.

A guide for nursery schools has also been produced and there is even a wonderful booklet of clothing designs for pregnant women that can be used as the basis for discussions with local dressmakers. I’ve never seen such an extensive collection of maternity dress ideas!

A new publication “Having your baby in Thailand” is about to be released and this will offer basic information about the health care system and suggestions for finding the kind of pregnancy and birth care that expatriates might want. Compiled by Mel Habanananda (see my previous entries) who, as BAMBI founder, is now the Honorary President, it contains the wisdom and insight of 20 years of living and working in Bangkok - a valuable asset for any newcomer.

Imagine that you were suddenly required to go and live in a very foreign land, with small children and perhaps pregnant again, for a period of a couple of years. BAMBI is just the kind of group you would want to know about to make your stay much more enjoyable. Some High Commissions, many businesses and companies and all the removalists now support BAMBI and make sure that new arrivals know of its existence. It is not only a support group for a section of the Bangkok community but a generous supporter of Thailand in a wider sense.

For more information, check out their website: www.bambi-bangkok.org

Happy birthday BAMBI!

The Childbirth and Breastfeeding Foundation of Thailand (CBFT) is the brainchild of Mel and Tanit Habanananda (see my previous Diary entry). Having spent 20 years working, largely on their own, to get some better birth practices into Thailand they wanted to find away to keep the work going when they decide to retire, probably to their wonderful property outside Chiang Mai in the north. They also wanted to involve the Thais themselves in taking the work forwards, because this is really about cultural change and setting in place programs and visions that will benefit the Thai people at large. A very successful Conference had been held in Chiang Mai in 1997 (”Birth without Borders”) and it was clear from the enthusiasm of the participants from allover the South-East Asian region that change was much needed and leadership would be required.

After much soul searching (and some prodding from me, I have to admit) they decided to form a non-profit Foundation with a Board representing stakeholders in the Thai maternity system. Establishing a Foundation is no easy task and it took some years. Everyone involved had to be scrutinised by the Government and the police to check their backgrounds, worthiness and suitability and an elaborate process for registration exists, ensuring that very few proposed Foundations manage to jump all the hurdles. It took some years, but finally the deed was done and the Foundation began work in 1998.

This is the Mission statement of the Foundation:

“The CBFT is a non-profit networking and resource centre dedicated to ensuring the best possible start in life for our babies. We believe that this can best be achieved through:

Hello from Thailand! Yesterday was a last-minute-getting-ready day and then travelling the 9 hours to Bangkok. I am having a few days here before heading off to the UK for a huge round of workshops (13 on all) and three conference appearances over the next 5 weeks. I’ll keep you posted on the current scene in the UK as I trek about to Scotland (twice), Ireland, Wales and many points in Britain.

During these few days in Bangkok I will have a chance to catch up with my close friends Melanie and Tanist Habanananda. Tanit is a Thai obstetrician and a crusading pioneer in this country for normal birth. Mel is a British childbirth educator who has been a major influence here as well. Together they established the first (and only) Birth Centre in Thailand at the Samitivej Hospital almost 20 years ago and this unit has a proud record of water births, normal births, great breastfeeding rates etc. It has also been a showcase for how birth can be as opposed to the very high rates of interventions that are part of the birth scene everywhere else in this country.

For women in most of South East Asia, births are managed in a very medicalised way, a legacy of old style US birth practice that has never been updated. Virtually 100% of women will experience shaves, enemas, lithotomy and episiotomy, labour alone in a shared room with little or no privacy and give birth in stirrups in a multi bedded 2nd stage area. There is no concept of midwifery care and birth is managed by a team of obstetric nurses who follow the doctors orders. Concepts such as consumerism in health care, choice as part of care, informed consent and woman-centred care are virtually unknown and not part of the culture in these countries.

Dr Tanit had his obstetric education in the UK (many doctors here learned their skills in the US) where he was exposed to quite different ways of doing things. He and Mel also had home births for their children and have read widely and seen many normal births. Many expat women in Bangkok seek our Dr Tanit’s care because he has a low interventions rate (3% caesarean section rate!) and encourages active birth. He is well known amongst medical circles here, often speaking to colleagues, and I’ve seen him demonstrate in their own hospitals with their clients how births can be achieved easily when off the bed.

I first met these wonderful people in the UK when Mel came to a workshop I presented in London in 1996 with a Thai nurse, Supriya Boonyagate, who was interested in birth. They had a great time and invited me to stop over in Bangkok and speak to the obstetricians on my way home. This I did, with success, and after that a very close bond has developed between us all. I have since facilitated many workshops in Thailand and my book Preparing for Birth is about to be released in Thai version. We travelled together to the big Humanisation of Birth Conference in Brazil in 2000 where we were speakers and have holidays together when we can. Mel and Tanit spend part of every year in the UK and the rest in Bangkok - an enviable lifestyle!

I’ll write some more about their work with the Childbirth and Breastfeeding Foundation of Thailand tomorrow, but today I am going to spend time lounging by the pool in the most sensational tropical garden paradise in the heart of Bangkok. An oasis in time and place.

Reading about the various launching events for the NMAP on the ozmid list today has once again illustrated for me that consumers of maternity services have very powerful voices when it comes to achieving change. Of course, I have “come up through the ranks” of consumers myself and now work with maternity care providers, so I have a foot in both camps, so to speak.

When midwives complain that they having trouble getting a policy changed, or some new equipment, or even saving their unit from being closed down, I always ask if they have contacted the women whom they serve and asked them for help. There are many ways that consumers can challenge the system and get changes made from the outside that would be impossible for midwives to undertake from the inside.

Consumers these days also bring a number of potentially useful skills to their cause. With the average age of women having first baby now standing at just under 30 years, it means that these women have more education and life skills, and are also better equipped (i.e. experienced) at tackling authority figures, speaking in public, getting organised, finding resources etc.

Of course, many women don’t know the problems being faced by midwives. Therefore, if you need help you will have to ask and provide background details before they can take up your cause. Multips are often the best bet - they are at home with children and are used to juggling a number of tasks at once. They are often keen to take on an interest outside their homes and they know the importance of good births from their own experiences. Check through the birth register at your hospital - find out who has writing skills, is a journalist, can manage statistics, prepare budgets, lobby politicians, has access to potential funding sources or whatever it is that you need. Make a personal call and ask for their help - very few will refuse and most will be delighted to be asked.

Following a suitable background briefing, you can then let the consumers get on with fighting the cause. Keep in close contact and praise their efforts. You’ll be surprised at the energy they can create and the wonderful supportive atmosphere that develops between women and midwives.

This is how it always was - women needing their midwife for the birth, then the midwife needing the woman for support to enable her to do her job most effectively. These relationships need rediscovering and nurturing.

Well, NMAP is off the launching pad! Here in Sydney we had a good day - first there was the Press Conference which was reasonably well attended by the major TV channels and some other print media. Nicole Christianson (”Keep Birthing in the Mountains”, Fiona Tito (of the famous Tito Report on Professional Indemnity), Lee Rhiannon (NSW Greens) and Arthur Chesterfield-Evans (Democrats) all spoke in support. The hazard of choosing Parliament House was that the press conference would be hijacked by media intent on grabbing a politician for a quote on anything that was breaking news and that did happen in the question time. Chesterfield-Evans was aksed about some corrupt politician’s antics that had hit the headlines earlier that morning, so we were left feeling a little silly while he had his say. However, he thought we went well - and we are hopeful that it will make the local news bulletins this evening.

The Launch event followed and lasted an hour. The speakers were Jo Westley (spearheading the campaign to save Camden Hospital Birth Centre), Hannah Dahlen (NSW Midwives Association), Fiona Tito and Mark Tracy (Father, husband of Sally and Neonatologist). All covered aspects of NMAP and provided great background information. Copies of the report were on hand, other material relating to the NSW Government’s Greater Metropolitan Transition Taskforce’s idiotic plans about rationalising materntiy services in Sydney were given out and various health policy makers and politicians ( a few - most had Caucus meetings to attend) heard more about NMAP.

We heard that Craig Knowles’ (NSW Minister for Health) advisor was to issue the considered response at 3.30 p.m. and Denise Hynd was to wait and see what it contained.

We did manage to doorstop Bob Carr (Premier) and to give him a quick message about NMAP and a copy of the report. He wanted to know about how much it would cost, and when told it would save him money, said he “would look into it”. We were most impressed by his wonderful tan and impeccable suit and decided that he either must have been wearing make-up or else spent a lot of time in a solarium!

An interesting day. It will be great to hear how the launches went in other capitals and how the meetings in Canberra with Meg Lees (Independent) and Helen Coonan (Deputy Treasurer) went.

This is the start - we still have a long way to go. As Fiona Tito said to me over lunch - “why does this stuff have to be so hard? We keep giving them the data and the cost savings and telling them what we want and they just find ways to ignore it”. If she is having difficulty, then we have our work cut out. We won’t let them stop us - our time as mothers and midwives has come.

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It’s been an exciting few days. Over the weekend I have been in Queanbeyan (right next to Canberra) presenting a workshop for the Southern Area Health Service, and it gave me the opportunity to catch up with Barb Vernon and Justine Caines from the Maternity Coalition. We talked about the last minute plans for the launch of NMAP tomorrow and the meetings with the politicians planned for the rest of the week. What a dynamic duo these two are!

The launch is on final countdown and the excitement is building. I’ll be back to you later with some feedback on what could easily be the watershed event for maternity care in this country!

There was an interesting post to the ozmidwifery list recently that described one hospital’s policy about the management of the third stage of labour. It appears that this unit insists that all women will have an actively managed third stage of labour and that any woman who refuses (in advance presumably) will have to seek maternity care elsewhere.

This is an outrageous position on a number of levels. First, the denial of informed choice is surprising, given that hospital managements are usually keen to avoid potential litigious situations. The hospital, however, possibly takes the stand that they inform everyone of this policy in advance, so that anyone not willing to comply has time to find another hospital for the birth, thus enabling the “informed choice” to be make early in the pregnancy. I wonder how many parents would haven even thought about third stage of labour at that point, or knows what the implications are? As the hospital’s name is not revealed it is not known where it is, but I suspect that it is a rural unit and therefore the ability of the parents to go elsewhere may be severely limited. Choice may simply not exist.

Secondly, the evidence for managing the third stage with oxytocics is a contentious issue. If the birth has been normal (that is, no oxytocics for induction or augmentation, no pain medications, no obstetric interventions) there is very little chance of a haemorrhage after the baby is born. Expectant management should be the approach, rather than “just in case” measures. If there have been interventions during the labour and birth, and this will be the case for probably 90%+ of all women giving birth in a hospital setting, then there is an increased risk that she will bleed heavily after the birth, but this is not a certainty. Many women and midwives would still prefer to wait until there is a medical need for intervention, because the giving of oxytocics is not without its own risks.

This is a good example of where midwives often collude with the doctors during labour and birth. Midwives (and doctors) don’t always know how to manage a third stage physiologically; they are often rushed and short staffed and want to get the woman cleaned up and on her way out of labour ward fast; they don’t know the ramifications of giving oxytocics to mothers and the effects it may on the establishment of breastfeeding, for example. They may be unwilling to take a stand on the issue perhaps because they fear a lack of support from their colleagues. It is a shameful state of affairs, and the woman and her baby are the victims of poor professional practice.

These policies need to be challenged. They should be discussed in the pre-natal classes where the parents can be acquainted with strategies to ensure they are not treated in this “conveyer belt” fashion. Parents must know that no-one can lay a hand on them, at any time, without their expressed permission Signing “consent forms” in advance does not lock them into acceptance - they can always change their minds. Informed consent must also be freely given, not extracted under a threat of the withdrawal of services, as is apparently happening in this instance.

Midwives should be challenging their medical colleagues and their management to rethink this policy in the light of the medical evidence and the potential for parent dissatisfaction. Yes, I know that the Cochrane Library suggests that oxytocics should be given routinely, but they do not recommend that they be given against parental wishes. Their recommendations are just that, and should be seen as guidelines, not as hard and fast rules.

The giving of oxytocics for third stage is a classic example of the double standards in maternity care: on the one hand we say “let’s keep birth normal by not interfering with the normal process” and then in the next breathe we say “but you will be given routine syntometrine for third stage as it is our policy in this unit”. Ridiculous! No wonder parents are confused and many are looking for alternatives away from such a crazy and uncaring system.

There was an interesting post to the ozmidwifery list recently that described one hospital’s policy about the management of the third stage of labour. It appears that this unit insists that all women will have an actively managed third stage of labour and that any woman who refuses (in advance presumably) will have to seek maternity care elsewhere.

This is an outrageous position on a number of levels. First, the denial of informed choice is surprising, given that hospital managements are usually keen to avoid potential litigious situations. The hospital, however, possibly takes the stand that they inform everyone of this policy in advance, so that anyone not willing to comply has time to find another hospital for the birth, thus enabling the “informed choice” to be make early in the pregnancy. I wonder how many parents would haven even thought about third stage of labour at that point, or knows what the implications are? As the hospital’s name is not revealed it is not known where it is, but I suspect that it is a rural unit and therefore the ability of the parents to go elsewhere may be severely limited. Choice may simply not exist.

Secondly, the evidence for managing the third stage with oxytocics is a contentious issue. If the birth has been normal (that is, no oxytocics for induction or augmentation, no pain medications, no obstetric interventions) there is very little chance of a haemorrhage after the baby is born. Expectant management should be the approach, rather than “just in case” measures. If there have been interventions during the labour and birth, and this will be the case for probably 90%+ of all women giving birth in a hospital setting, then there is an increased risk that she will bleed heavily after the birth, but this is not a certainty. Many women and midwives would still prefer to wait until there is a medical need for intervention, because the giving of oxytocics is not without its own risks.

This is a good example of where midwives often collude with the doctors during labour and birth. Midwives (and doctors) don’t always know how to manage a third stage physiologically; they are often rushed and short staffed and want to get the woman cleaned up and on her way out of labour ward fast; they don’t know the ramifications of giving oxytocics to mothers and the effects it may on the establishment of breastfeeding, for example. They may be unwilling to take a stand on the issue perhaps because they fear a lack of support from their colleagues. It is a shameful state of affairs, and the woman and her baby are the victims of poor professional practice.

These policies need to be challenged. They should be discussed in the pre-natal classes where the parents can be acquainted with strategies to ensure they are not treated in this “conveyer belt” fashion. Parents must know that no-one can lay a hand on them, at any time, without their expressed permission Signing “consent forms” in advance does not lock them into acceptance - they can always change their minds. Informed consent must also be freely given, not extracted under a threat of the withdrawal of services, as is apparently happening in this instance.

Midwives should be challenging their medical colleagues and their management to rethink this policy in the light of the medical evidence and the potential for parent dissatisfaction. Yes, I know that the Cochrane Library suggests that oxytocics should be given routinely, but they do not recommend that they be given against parental wishes. Their recommendations are just that, and should be seen as guidelines, not as hard and fast rules.

The giving of oxytocics for third stage is a classic example of the double standards in maternity care: on the one hand we say “let’s keep birth normal by not interfering with the normal process” and then in the next breathe we say “but you will be given routine syntometrine for third stage as it is our policy in this unit”. Ridiculous! No wonder parents are confused and many are looking for alternatives away from such a crazy and uncaring system.

Things have been a bit quiet on the Diary entries from me in the last couple of days. Next week I am going back to the UK for a series of workshops and Conference appearances and so I have been working madly trying to make as many pelves as possible before I leave.

Yes, that’s right - making pelves. Most people don’t know that this is what I do in my “spare time”, butl those pelvis models you see in our catalogue are all made by my hands, in the good old “garden shed” equivalent at our office.

It all started 15 years ago, when I was looking for a pelvis to use in my own classes. All the ones I could find has bolts and wingnuts holding them together and I thought they were insulting to women and very distasteful. What do do about it? The answer was - design and make your own.

It was quite a saga. First I had to find someone who could make the moulds (three) and this was surprisingly hard until I discovered a wonderful sculptor who found no difficulty dealing with the complex shape of bones when making the fibreglass cradles and silastic rubber inserts. The task of getting the right polyurethane mix for the casts was a lot of drama as well but eventually the best combination of ingredients was worked out after a lot of trial and error and help from a surf board manufacturer. I wanted just enough “give” to make it possible to show how the joints move, but enough rigidity so that the model was easy to work with. Then there was the glue problem! Polyurethane is notoriously hard to stick together and I still sometimes have trouble with breakages, which I am always happy to fix.

Anyway, thousands of pelves later (I’ve given up counting) I am still at it on a regular basis. As a best selling item, I must make sure that there are enough on hand to supply customers when I am away for extended periods, so for the last three days I have been slaving away getting them done.

You didn’t know that I was so multi-skilled did you? Amazing what a bit of passion will drive you to create!

Many childbirth educators have a copy of my book “Preparing for Birth: Mothers” which they use as a reference for their classes.

From time to time I am asked if some pages can be photocopied for use as handouts for the parents. Invariably, my answer is “no”, not because I don’t want parents to have access to the information, but because I want parents to have all the information in the book, not just some selected pages. There is always a risk that issues seen as “difficult” by educators may be left out of the program, perhaps because of their own discomfort or lack of knowledge or because including them would risk going against “the party line” promoted by their hospital.

Sometimes the expense of buying the books is quoted as a reason. Photocopying and assembling take time (and money) and parents will be handed a sheaf of pages amongst a collection of leaflets. These are likely to be lost and don’t necessarily look very professional (they may be covered with advertising, for example).

My policy has always been to make these booklets available very cheaply when bought in bulk. Many hospitals now order in lots of 100 and some take regular orders of 500 or more. For these larger orders we will negotiate a price that gives an added discount. In this way, we hope that everyone is happy: the educators get a quality product that saves them work, looks good and contains notes on all the information they would include in a normal program. Parents get a concise, well illustrated manual that is user-friendly and jargon free. I am happy because I know that parents are getting the full story and not just an edited version.

I know that some people do make copies. Please respect our copyright laws ……..