Andrea’s Diary

The Managing Midwifery workshop was a huge success. The workshop activities around dealing with complex organisations, goal setting, solution based approaches to resolving problems, writing proposals for midwifery projects and the coaching were particularly popular. Much fun was had by all, as we worked hard in small groups, laughed over lunch and shared many success stories (and disappointments) along the way.

The idea of including coaching as a topic was new for most of the group. These are important skills for managers to develop, especially if they want to motivate and support staff as they move into new ways of working. It is a different concept from mentoring, which is a hierarchical model, and as Michael Cavanagh, the facilitator of this session put it succinctly “A coach is the guide on the side not the sage on the stage”. The idea of supporting and assisting someone through a coaching relationship as they move through their life, work and various challenges, is a concept we need to develop further for midwives. The hierarchical structures that have existed for so long in nursing and midwifery are underlying factors in the bullying that goes on, and we need positive ways of tackling this endemic problem.

We are going to explore some innovative ways of developing these skills in midwives for future programs. Managing Midwifery will certainly we on again next year and it will be hard to resist the temptation to make it 3 (or more!) days instead of the current two. There is so much to be shared and learned!

What an exciting day I have had today! It has been the first day of the Managing Midwifery program and we have a great mix of managers from all over the country - Darwin, Alice Springs, Brisbane, Perth, Melbourne, Adelaide, Sydney and several rural areas of NSW and Queensland. Their commitment and energy to improving midwifery is inspiring and many spoke of the new directions they were already implementing in the maternity services in their area.

Half of today’s program was devoted to exploring the workings of a number of different models of midwifery care that have proven successful. The rest of the day (and most of tomorrow) will focus on developing team work and people management skills. Specific issues such motivating others, finding solutions for problems, working within complex organisations and getting the best from people are also on the agenda, as is dealing with bullying and horizontal violence in the workplace.

I have the strong feeling that while we may be able to achieve some modest goals for the individuals in the group (given the limited time we have), this workshop will prove that ongoing work in these areas is sorely needed, not just for these and other managers, but for midwives more generally.

I am going to investigate developing a new series of one day workshops that we can make available across the country that will build on these themes. I feel sure that a one day program that enables, for example, the rebuilding of dysfunctional teams in a unit would be beneficial. I will check this out tomorrow as part of our wrap up….

Another long weekend - this time to celebrate ANZAC Day (possibly the most important day in our National Calendar).

Over the weekend, and the past few weeks, I have had the opportunity to cuddle/observe a number of babies in the 4 - 8 month age range. I’ve noticed that few of these babies seem to be sitting up as mine and most others did when they were around 6 months of age. Some were not even rolling over at 6 months.

I wonder if it is the current advice to sleep babies on the their backs that is the cause. It seems that parents are unwilling to let babies lie on their stomachs at all these days, yet they need to lie prone to strengthen their back and neck muscles - a necessary precursor for being able to sit unsupported.

Of course, sitting up early may not be all that important in the overall scheme of things, but it certainly makes self feeding easier for the baby (and they are often eager to put things in their mouth around that age) and it also encourages mobilisation.

Just a thought….

Another long weekend - this time to celebrate ANZAC Day (possibly the most important day in our National Calendar).

Over the weekend, and the past few weeks, I have had the opportunity to cuddle/observe a number of babies in the 4 - 8 month age range. I’ve noticed that few of these babies seem to be sitting up as mine and most others did when they were around 6 months of age. Some were not even rolling over at 6 months.

I wonder if it is the current advice to sleep babies on the their backs that is the cause. It seems that parents are unwilling to let babies lie on their stomachs at all these days, yet they need to lie prone to strengthen their back and neck muscles - a necessary precursor for being able to sit unsupported.

Of course, sitting up early may not be all that important in the overall scheme of things, but it certainly makes self feeding easier for the baby (and they are often eager to put things in their mouth around that age) and it also encourages mobilisation.

Just a thought….

For the last two days I have been presenting an Active Birth workshop at Selangor Private Hospital in Nambour, Queensland. This private hospital is an outstanding example of what can be achieved when a dedicated midwife (in this case, Lynne Staff) sets out to create a new maternity unit where women will be central focus of the care, rather than the system and the clinicians.

I have written about it before, and frequently mention it in my workshops. From time to time I have great pleasure in co-presenting workshop programs with Lynne, for example the Essential Midwifery series of events http://www.birthinternational.com/event/essential/index.html scheduled for early June in the UK. Her experience and sensitivity in enabling labouring women to have the best experience possible regardless of the kind of birth that eventuates, is remarkable, and as an educator of note, she has a gift for getting this message across to others. For this event she will be utilising participation, problem solving, story telling and research evidence to facilitate an interactive program on dealing with complexity during labour and birth - the women who have had previous poor obstetric outcomes, caesarean births, medical complications or just variations on the theme such as posterior positioned babies that cause so much angst for a woman during labour.

At Selangor they have a water birth rate of 30%, a VBAC rate around 90%, and regularly manage twins and breech birth vaginally. Lynne has successfully “re-educated” the private obstetricians to be respectful of women’s needs and wishes and they are reaping the benefits of this approach, with women travelling many miles to obtain this kind of care. It is one of the best success stories in Australia and as soon as their “virtual reality” tour is up on their website, I will post the URL for you to check out.

Meanwhile, those of you in the UK should consider coming to the Essential Midwifery program - it will be an excellent next step from my Active Birth workshop and an informative and practical study day. Look forward to seeing you there!

Back to work today after the Easter break. Over the weekend I had a chance to catch up with one of my pregnant neighbours (there are 4 couples expecting babies soon in my small block of apartments) and I was able to answer the questions she had regarding her birth plan. She and her husband had completed the 7 week prenatal course at my local hospital (the Royal Prince Alfred Women’s and Babies Unit) and she had some interesting feedback on the way that course had been conducted.

The educator had managed to alienate the fathers on the first week by making flippant comments such as “you guys won’t be doing much - you’ll just be there to observe”, which angered this father, as he has every intention of being very much involved. Several couples did not return for the rest of the classes and I wondered if the educator followed up to find out why - perhaps her pitch was unappealing?

The main thrust of the course, according to my friends, was to prepare the parents for the hospital policies that will be applied to them when they come in during labour. It was stated that “you will have a 30 minute CTG trace done” and when they challenged the necessity of this, it was grudgingly acknowledged that this could be circumvented or done by hand using a sonicaid, but it was emphasised that “this was hospital policy”. Other issues such as routine Vitamin K injection for the baby and routine oxytocics for third stage management were also stated as necessary policies. The whole tenor of the discussion (lecture?) was to set parents up for the procedures that would be applied to them. There was no real exploration of the issues nor information given that would enable parents to make an informed choice. If this couple had not continually asked questions and challenged the sweeping statements, the other participants would have had no idea there were other ways the birth could be managed.

Having spent a whole week listening te Mavis Kirkham during the Future Birth tour talking about “the rhetoric of choice and the reality of coercion” it was obvious that this was the practice here in Sydney, as it is in most parts of the western world. My friends could certainly relate to this statement when they recalled the program they had just attended. Needless to say, they have sought broader information elsewhere and have crafted a careful birth plan which they will be presenting to their private obstetrician and the midwives in the Birth Centre when the time comes.

I have assured them that the Birth Centre midwives will listen carefully to their desires and not perform any routine procedures ( I hope I am right!), and certainly not without clear permission. My neighbours found it ironical that if something is so important that it must be regarded as a necessary routine in the Labour Ward (such as an on-admission CTG trace) that it could be safely overlooked in the Birth Centre. This is indeed another wonderful example of the double standards that exist in maternity care!

I am continually amazed that hospital administrators, clinicians and educators fail to grasp the basics of risk management: good communication and full disclosure of all facts so that informed consent can be assured for clinical procedures. When they with hold information (especially deliberately) they leave themselves open legally and it must just be a matter of time before someone takes them on in a court of law, for acting against express wishes that resulted in an unwanted outcome. I say, roll on this day….. perhaps this will be the only way they will learn.

Meanwhile, my friends reported that there was one woman in this prenatal program that said not one word through the whole seven weeks, even when invited to speak. Finally, as part of the closing exercise, when each person was asked to give one word about how they were feeling about the program, she volunteered her word - “scarey”. A sad indictment of this program and its inability to meet her needs.

Easter. For most people this means a holiday (at least in Australia) and a time to take a rest from the usual busy round. I am going to try and fall into line with everyone else on this score, so the next Diary entry will be in a few days.

Happy holidays to you all….!

The Future Birth tour is over for another two years. Caroline Flint and Mavis Kirkham are returning to the UK this afternoon and I will begin the wrap up and evaluation of the whole series. What have been the highlights?

First, the chance to work with a very talented and committed team of speakers who have offered wonderful insights into midwifery as it is and as it could be.

The message that Mavis gave us was not always cheerful because midwifery in the UK (where her research has been based) has not taken advantage of the political and professional support it has to develop a really vibrant and woman centred system of care. Midwives are stressed, disorganised, poorly lead and in need of better management. The new impetus towards developing Birth Centres (a re-naming of midwifery led units and GP units of the past) holds out some hope provided enough midwives can be found to staff and promote them. Home birth is really the best answer to the increasing fragmentation of midwifery care as this at least restores the basic unit of midwife/mother to its rightful place at the centre of the system.

Tracy Reibel explained how we in Australia are approaching improving care here through the development and implementation of the Australian Midwifery Action Plan (NMAP). This is a very exciting proposal that holds out the best hope of reform that we have had for many years. Each State will evolve their own version of NMAP that fits best with their conditions and the NSW and Victorian plans are well under way. Tracy’s energy and commitment also demonstrated that non-midwives also care about the way that maternity services are provided and that they are prepared to join with midwives to collectively fight for better births.

Vanessa Owen is an amazing woman and a wonderful ambassador for the Australian College of Midwives. Her presentation outlined the way that the College is working for its members and for women. It was an eye-opener for many in our audiences, who tend to think that “someone” must be doing something, but just what that may be is a complete mystery. The fact that all the office bearers in the ACMI work in a voluntary capacity was also well noted and many were inspired to join the College to add their weight to their increasing numbers - this was very heartening.

Caroline Flint debunked a lot of the myths surrounding working as a caseload carrying midwife in a very entertaining and presentation. Using a variety of aids, slides and overheads, Caroline showed that while living with a bleep may be a pest at times, provided you take care to fit your work in and around your social life (rather than the other way around), a full and rounded life is very possible. I think many midwives in the audience came to realise that caseloading is a great way of working and of course, this will be an essential component of the new midwifery that NMAP proposes.

All in all, a great program. The evaluations were glowing and enthusiastic and we all enjoyed reading them. All the speakers commented that they had learned much from the audience as well, which was a bonus. After all, women and midwives talking together about our mutual concerns is a basic need that underpins everything we do in maternity care.

Have to start thinking about next year’s program now….. if anyone has any suggestions for the on-going series of midwifery workshops that we present in the year between Future Birth events, please let me know…..

The Brisbane Future Birth event is on today. Everyone is having a wonderful time and for me, one of the best aspects is having time to chew over various birth related issues with the speakers as we travel from place to place. Yesterday, during a long day getting from Tasmania to Brisbane we had time to talk about a number of issues.

The ACTOBAC trial was one of them. This is a proposed multi-centre, based in Adelaide, that is currently before the National Health and Medical Research Centre for funding approval. The hypothesis to be tested is that babies born via elective caesarean do just as well as babies born vaginally when the mother has previously had one caesarean section. The trial will recruit women who have had one caesarean, whose current pregnancy is uncomplicated and who could be considered good candidates for a vaginal birth after caesarean (VBAC). They will be randomly allocated either to a VBAC or to an elective caesarean and the outcomes for the babies will be recorded.

This is a completely unethical trial, and considerable opposition to its funding is gathering. The trial does not propose to consider the outcomes for the women who may end up with unnecessary major surgery, and assumes that this kind of surgery is a viable, affordable (and apparently safe) option for healthy women. Sufficient research already exists to show that women with a previous caesarean and an uncomplicated subsequent pregnancy have an excellent chance (up to 80%) of having a normal vaginal birth. The Cochrane Library supports this view.

This trial is a blatant attempt by obstetricians to try and prove that a caesarean is a safe way for a baby to be born so they can justify increasing the rate of surgical birth. We’ve been down this road before with the term breech trial that, despite its poor quality, has been used to coerce women into routine surgery for breech births. Like the breech trial, the way the labour is conducted (e.g. the support available to women from midwives during labour, the use of epidurals, inductions etc), appear to be variables that will not be considered. The term breech trial proved that women with breech babies, who give birth in a hospital, with an obstetrician in charge, have better outcomes if a caesarean is performed. It proved that doctors have few skills in facilitating vaginal breech births and that they are only really capable of performing surgical procedures. This is reassuring for those rare times when surgery will save a baby’s life, but is a dismal prospect when so many women are relying on an obstetrician for a normal birth.

This ACTOBAC trial will probably prove the same thing: if a woman has had a caesarean birth in the past, and a doctor is involved in the subsequent pregnancy, your baby may be better off if you have surgery. This trial may once again prove just how inept obstetricians can be with normal birth, and that women should seek alternatives to stay well and healthy.

Meanwhile, while the trial is under way, many healthy women will be denied a normal vaginal birth and may suffer the well known effects of caesarean surgery. Home birth with a midwife may well be the safest way to go if you want a VBAC.

Let’s hope that the NH&MRC see sense and refuse to fund this shonky research.

Melbourne yesterday and another Future Birth event - wonderful day!

Launceston in Tasmania is today’s venue. This state is the only one in Australia where the Nurses Registration Board (who are responsible for registering midwives) do an audit of each registration to ensure that the midwife is actually working. Many midwives retain their registration even though they are not employed in midwifery and this has been one of the confounding variables that has made determining workforce numbers in Australia difficult. In Tasmania, before they started doing these audits, the workforce here was apparently about 1800. After the first audit, this number dropped to around 800 which is a much more realistic figure.

If all Australian Registration Boards undertook similar audits we would have a much better idea of the actual numbers of working midwives across the country. At present there are around 70,000 midwives on the books, yet probably only around 8,000 actually working. Forward planning estimates, compiled through detailed studies of workforce needs have concluded that we need between 12,000 and 14,000 midwives to staff our maternity services properly. However, whenever midwives complain that there are not enough to adequately fill the workforce needs, they are often told that “you have 70,000 registered midwives available - all you need to do is get them all back to work”. An accurate picture is therefore desperately needed. The Tasmanians can teach the rest of us a thing ir two about how to go about this urgent task.