Andrea’s Diary

I have had an irate email message from an anaesthetist challenging some of the statements that I have made in “Preparing for Birth: Mothers”. Without being at all specific he demands to know my references for my “highly contentious statements without mention of conflicting evidence”.

I love these queries - and love the moral indignation that seeps through the message (which he has also copied to a whole pile of his colleagues). I have given him the list of references I have used, such as “A Guide to Effective Care in Pregnancy and Childbirth” , “Pursuing the Birth Machine” and The Cochrane Library and also threw in the list of references regarding teenage addiction following exposure to opiates or nitrous oxide during labour. He didn’t ask for these addiction references but I figured they might as well have them!

Since my correspondent seems to think I am lacking background information, I have invited him to send me copies of any research that he has that contradicts the very simple and basic information that I have included in my book. There is very little quality research on epidurals, for example, and few randomised controlled trials have been carried out. Anaesthetists have been quoted as saying that doing such research these days would be unethical because it would mean that some women would have to forego an epidural so they could make up a control group. This is a very convenient way of dodging the issue of providing evidence for the use of these techniques!

I am sure that this conversation will continue and I will report the next instalment in my Diary. What is it that has got them so steamed up? What research will they proffer to support their concerns? I will let you know the answers…….

Our Graduate Diploma Six Day workshop is over. What a week! The last day was spent with the participants doing their presentations, which is usually viewed by them as the hardest part of the program. This year we included video feedback - we wanted everyone to see how useful this can be and that seeing oneself on the video screen is not as bad as you might think.

Each participant was required to prepare a 15 minute session on a given topic (one that is usually included in the prenatal program). They have to formulate their learner outcomes and devise a teaching activity that will appeal to a variety of learning styles whilst enabling the other group members to achieve the stated outcome. As well as this, they must deal with the group’s interactions and responses, using the principles of adult learning and the group work skills that were explored earlier in the week. It is a tall order, and one they all tackled with a great deal of commitment.

There were many laughs along the way and some very valuable learning occurred as we viewed the tapes and gave each other feedback on the various performances. So much of the effectiveness of prenatal education is tied up in the ability of the group leader (educator) to handle the needs of the group members, whilst effectively covering the information is clear, concise and non-threatening ways. These are skills that come with practice, built on a foundation of awareness of their importance, and I hope that these participants have now grasped some of these essential basics. The day was a most successful and capped a very stimulating and exciting week. A long rest will be next on the agenda for us all, to let the lessons learned sink in and to give everyone a chance to catch our breaths.

For Cassandra McBurnie, my co-presenter, and myself, next week we start preparing for our next week long workshop in a similar vein - this time for the Bachelor of Midwifery students at Monash University, for whom we are providing a full elective on Childbirth Education. This workshop is in January, and we are looking forward to this next challenge with gusto.

Our Malaysian students had a wonderful time on the weekend. Their visit to the Royal Hospital for Women in Randwick, Sydney, was a great success. As luck would have it, they were able to sit in on two prenatal classes facilitated by Julie Clarke, a very experienced educator who is about to join our Graduate Diploma faculty as a Supervisor. Julie has a special gift for involving fathers in her program and our two students were fascinated to see how this can be done so very effectively with two different groups of parents. Julie has developed a particular activity called “Fatherhood” that enables open and honest discussion about a range of issues selected by the men. (I’ve suggested that we market this through Birth International so watch this space!).

In between the two prenatal sessions our students were able to explore the hospital and they visited the Birth Centre, Labour Ward and the Intensive Care Unit. They really appreciated the chance to observe an approach that is entirely different from the one they are familiar with in Malaysia.

Cross cultural visits are very valuable to everyone involved and we are enjoying having these students in our midst - they constantly provide a challenge to our ways of doing things and help raise our awareness of differences we must take into account with our own class groups.

Tomorrow we tackle ways of presenting labour and birth to expectant parents. I anticipate lively discussion on several topics, particularly around medications during labour and the whole issue of pain in labour. It will be two days before I can report on the outcomes for this group, as I have other commitments tomorrow and won’t be able to prepare a Diary entry, but by the time I am able to do my next Diary entry, the workshop will be over and I will be able to reflect on the whole intensive six days.

This week we began the Six Day workshop module of the Graduate Diploma in Childbirth Education. This program runs from a Wednesday to a Wednesday with the weekend free (rest and recuperation!) and comes at the end of the first year of the Course.

The group is small this year (a number of students did not complete the required study units in time) but is a varied and interesting bunch. There are two students from Malaysia and others from interstate. Because the number of our students was small we were able to open up the program to others who just want an intensive workshop without the added study required for a qualification and this has brought us participants from Western Australia and Tasmania.

Having participants from a completely different culture (Malaysia) has put everyone on their toes. The way Australian interacts, share ideas, speak all the time (!) and generally get stuck into group work has been a real eye-opener for them, as this is a complete contrast to their way of learning. In Malaysia, as they explained, it is most normal for the teacher to do the talking, the group to listen politely and answer with a single short sentence when asked. They would not normally add further thoughts or share in a conversational way between members of the group. If the teacher doesn’t “teach” then they are considered a “bad” role model.

We discussed some of these differences on the first day of the program because I wanted to make sure they felt comfortable and knew that we understood they had a different way of relating to the group. The contrast by day three has been remarkable - they are chipping in, adding comments and generally getting involved just like everyone else and they are obviously enjoying this different way of doing things. Give women a chance to talk, no matter where they are from, and they will be hard to stop!

This weekend they are out observing Birth Centres and prenatal classes run by an independent educator in a hospital setting - more learning opportunities! The whole concept of “active birth” is unknown in Malaysia and they are keen to learn as much as they can while they are here. There are still some home births in rural areas of their country (supervised by traditional birth attendants) but birth in the hospitals is very regimented with the doctor in complete charge. Concepts of informed choice, consumerism and options for birth care are very foreign notions and are a long way off in Malaysia. They were asked if they thought these ideas may surface in time, and they felt that they might, because of the growing worldliness of the population and the fact that many young people have a foreign education and have travelled.

It takes a long time to overcome entrenched attitudes and beliefs (as we know from efforts in Australia to change the birth culture) however change is inevitable, even if slow. I hope they enjoy their visits to our hospitals this weekend and I am looking forward to hearing of their adventures when the group meets again on Monday morning.

Why are rates for vaginal birth after caesarean section (VBAC) so low in our hospitals? This question has come up in workshops quite frequently and has also featured on the ozmidwifery list as part of a discussion around fear and its effect on labour.

As I see it, there are two main reasons why VBAC rates are hovering around 30% (or worse) when they should be around 80% according to the evidence.

The first reason is that women are left with many emotional and psychological scars after an unexpected caesarean and these are rarely dealt with adequately so they can be resolved. A woman who has been told that her body didn’t work well, that it was “too small” or “too slow to dilate” or “failed” in some way will have had a severe dent put in her perceptions of herself as a woman. Birth is the central pivotal point around whish a woman’s whole notion of herself as a sexual being revolves. If she is judged to be inadequate or a “poor performer” in this area she may well be unwilling to give a vaginal birth a try next time, because of the impact a further “failure” may have on her psyche. It may be emotionally safer to opt for an elective caesarean which is planned and predictable than to risk the potential for further psychological trauma.

A second factor is the caregiver. It is well known that it is the attitudes, practices and beliefs of the caregiver that shape a woman’s birth experience. In the case of a VBAC there are many vested interests at work : the doctor’s desire for an ordered life; the hospital’s need for scheduling and throughput of clients; the money to be made from surgery, epidurals, drugs, equipment etc. Most doctors also lack the skills and willingness to sit with women in a supportive, positive way while they labour naturally. Time is money and a caesarean takes little time in contrast to vaginal birth.

Another factor, often overlooked, is the fear and grief experienced by fathers who have been caught up in a dramatic caesarean birth. They are rarely counselled or de-briefed afterwards, and their unresolved trauma may cause them to pressure their partner for an elective caesarean the next time.

All of these issues could be dealt with in a useful way through special pre-natal programs for potential VBAC parents. Small groups, with both parents, under the leadership of a skilled facilitator could explore these and other important issues associated with caesarean births and VBAC. I am convinced we need a lot of these programs around the country and they may be a key factor in lowering the ever-climbing caesarean birth rate.

A useful resource on these kinds of classes is The VBAC Source book and Teaching Kit - an excellent outline for such a program packed with teaching strategies and factual information.

Now that I am back in Sydney, I am catching up with the very exciting developments that are happening around midwifery in New South Wales. There is much going on!

The Maternity Coalition have compiled a wonderful document that outlines how autonomous midwifery can be implemented in NSW within 3 years. It forms a companion piece to the National Maternity Action Plan (NMAP) that was launched in September and is designed to show that they have not just come up with a great idea, but also have worked out the means to implement it (an essential strategy if NMAP is to succeed, because if left to the politicians/bureaucrats to implement we would be waiting forever).

There will be an election in NSW before the end of March 2003, so the time is right for getting maternity services reform onto the political agenda. The Greens and Democrats have already endorsed NMAP and will incorporate it into their election platform, so the pressure is already starting to mount on Labour, who have been in power for many years and are due for a shake up.

Premier Bob Carr was effectively ambushed at the recent opening of a new hospital in Camden where the media chose to focus not on the new hospital, but on the brand spanking new Birth Centre that was not allowed to have any births because the obstetricians would not co-operate. The very vocal and colourful collection of mothers and babies demanding better services were a heady mix for the media. Apart from putting the Health Minister, Craig Knowles, firmly on the spot for this silly bureaucratic bungle, it also highlighted the general dissatisfaction at the lack on consultation with maternity care users over the broader plans for hospital closures and reorganisations across Sydney. The moves to close several smaller maternity units were immediately scrapped and the Health Minister who has been reluctant to consider midwifery up until now, is about to consult with the Maternity Coalition about their implementation plan for comprehensive one-to-one midwifery across the whole State.

Justine Caines, Sally Tracey, Denise Hynd, Barb Vernon, Jan Robinson and a host of others have all contributed mightily to this effort. They are amazing women and they have every right to expect that their efforts will succeed. Hats off to them!

Yesterday I filmed my first birth. Bronte Fenwick , weighing 3.9 Kg arrived, face to pubes, at 6.50 a.m. after a 2 hour labour. Tracey, her mother was amazing - lots of back pain but a really fast labour, no doubt assisted by being her third baby. This was the first girl born into her father, Stuart’s, family for 85 years, so she will be especially treasured.

Videotaping this birth is the first step in producing some new birth videos for use in midwifery education. I have a number of potential topics in mind, but will have to see what I can videotape before deciding which issues to tackle first. The wonderful staff at the Birth Centre in St George Hospital, Kogarah, are helping by canvassing women for me and I am really enjoying working with this dedicated team.

It was rather special to have a baby born posterior for my first effort! This is not all that common and to have a completely natural birth, with no medications and an intact perineum was a treat. I hope to tape some more births over the next three months, when I am mainly in Sydney, and therefore available. Whilst I have no experience of videotaping, I do have a “fool proof” camera and one which will record in the dark if necessary. I hope to be an “invisible” as possible during the birth to keep the intrusion of the camera to a minimum. The hardest part was not getting involved with Tracey and Stuart. Not saying anything was OK but keeping my hands off her aching back was hard!

I wonder what the next one will be like?

It’s been a catch up day today. This time of year means putting the final touches together for our program for the first 6 months of the next year and planning the broad outline of the remaining months of 2003. I keep saying that I “will cut down a bit” and “take a holiday” but it never seems to happen - there is so much to be done!

The timetable is shaping up well for the first half of the year:

January

Childbirth Education module for the Monash University Graduate Diploma in Midwifery students (and others) in Traralgon, Victoria - 5 days plus assessments

February

Active Birth workshops

NACE Conference in Sydney

March

UK visit - 10 two-day workshops in various parts of the country

April

Future Birth tour around Australia

Active Birth workshops

Managing Midwifery workshop (Sydney) - a new program for this popular event

May

Active Birth workshops around Australia

June

UK visit - 6 Active Birth workshops (including one in Spain)

Essential Midwifery tour in the UK - 6 events around the country

All this is just for starters…….

Later in the year there will be more workshops in the UK (October) another Conference presentation in Barcelona, Spain and a series of Dynamic Education workshops in Australia. We also have plans to offer the Childbirth Education elective for other University midwifery programs in several states.

All the details of these events are on our website, so have a browse around - I would love to meet you all for a catch up somewhere next year.

Back in Sydney, at last. There is always an interesting pile of material in my in-tray after I have been away and this time I have information about the Nepal Midwives Initiative and the work that midwife Beatrice Carla is doing to introduce Birth Centres into Nepal.

She has been volunteering her services for the past eighteen months and has generated much interest and enthusiasm for natural birth. Her newsletters describe the current scene where maternity services are largely managed by Traditional Birth Attendants in rural areas or by obstetricians in private clinics. As in many developing countries, maternity services have been modelled on early ideas from the west (American, sadly) but because of a lack of funds, further training and updating has not been possible. Women are subjected to antiquated practices that are now discredited, such as routine episiotomies, enemas, confinement to bed, lithotomy and routine suctioning of newborns.

Beatrice has set up the Nepal Midwives Initiative, with these aims:

to raise awareness about the potential hazards of western-introduced but now outdated birth practices

to demonstrate the safety of a less prescriptive and interventionist approach to birth care

to share our current knowledge and experience with Nepali colleagues

to support Nepali colleagues’ efforts to organise as midwives.

If you want to know more about this wonderful initiative, or better still, could send her a donation of money or resources, she can be contacted at:

Beatrice Carla, Nepal Midwives Fund, c/- 7 (Gf1) Rossie Place, Edinburgh EH7 5SF

In his response to my Diary entry about Unmotivated Educators, John Lee asks if we should be teaching parents about options that are unavailable. This is an interesting question and one that often comes up in Teaching Skills workshops.

The issue boils down to: do we teach for compliance or do we teach for informed choice? Many educators take the position that if a service is not available in their unit (e.g. water birth) or Trust area ( e.g. homebirth) that there is little point in alerting parents to these options because they won’t be able to get them. Others believe that if the options exist, then parents should know of them, even if it will be difficult or impossible to get them in their area.

The changes that have come about in maternity care over the years have been consumer driven - think of fathers in the labour ward, rooming in, water birth and birth centres. None of these would have been introduced by the obstetricians or hospital administrations (although they have been able to introduce widespread use of CTGs and epidurals!) and it has been dogged perseverance by parents that has forced these services to be provided. They heard about these options from various sources - their own reading, from other parents and from childbirth educators.

If parents know of a service that is not available where they live, but could be obtained elsewhere (perhaps even in the next Trust area) then they have a right to request the same level of care. If the health service is not asked to provide a service they may conclude that nobody wants it. Therefore, as drivers of change, parents and educators play vital roles in improving services and pushing reforms through.

I believe that educators have a duty of care to explain all possible options to parents. It is up to the parents to find out what is available and to take the necessary steps to get what they want (even if this involves some inconvenience). Teaching for compliance may make life easier for the hospital staff, but goes completely against the basic principles of informed choice. But that is a myth anyway, isn’t it?