Andrea’s Diary

One of the interesting aspects of moving our office this week was the interest shown by many of the men who helped us, in the work that we do and in birth in particular.

The removalist that we hired was the same one we used last time (I had forgotten this) but he remembered especially because his partner is pregnant and he was intending to call by and get some information on how to assist her with a good birth. We talked about Birth Centres and as it happened, Jan Robinson, an independent midwife in Sydney, was in the office at the time and knew of a Japanese midwife who would be willing to talk to his partner, who was also Japanese. Email addresses were exchanged and another small birth education class took place in between sorting out our removal needs.

When I ordered some new furniture, the man taking my order asked me for advice about whether they should engage an obstetrician or use the birth centre for their next birth in a few months time. We talked about the statistical outcomes for obstetric care versus midwifery care and I suggested that they go with their first inclination to the birth centre and the public health system.

When removal day came, the guys who actually moved the dozens of boxes were highly amused by some of their contents - a whole box of model breasts!!!

The man who delivered some new office furniture was also expecting to be a father again soon and he was seeking some particular information. He had been to classes and wanted to know about avoiding episiotomy, but the educator has talked in “official language” (his words) and when he asked specific questions about the vagina, she was too acutely embarrassed to answer him directly! I soon had his query sorted out. Interestingly, he had also heard about the importance of labour hormones to the well being of the newborn and so I pointed him to our web site where I have written about this extensively. He also commented that he thought not enough was being done to encourage women to have natural births, which was an exciting view from a young man. Meanwhile he assembled our desks and then went off happy!

I even had a short conversation with the plumber and carpet layer about children and babies. The plumber knew all about children and the carpet layer was dubious. As I pointed out, these days you can make a conscious decision about whether you have children or not - a vast improvement on our parent’s lives.

All of these helpers were men and all were interested in birth and babies. I noted that they knew about midwifery care, that they felt that birth should not be interfered with, and that medical carers were not usually necessary. I was very encouraged by all this and it once again demonstrated that we must include the men much more in what we are doing. I’ve done my bit for childbirth education this week, in between heaving boxes, packing and unpacking. I have always said that childbirth education can be done in a variety of ways….

Today (Wednesday August 27) is moving day for Birth International’s Sydney headquarters.
After today, our contact details will change:

Street address: 87 Percival Road, Stanmore, NSW Australia 2048. Stanmore is a suburb of Sydney, close to the city centre, on a main train line and bus routes.

Postal address remains the same: PO Box 366 Camperdown NSW Australia 1450.

Telephone numbers (during business hours, Eastern Australian time) : +61 (0)2 9564 2322

Fax number (any time) +61 (0)2 9564 2388.

Of course, all our email addresses are the same as before: info@birthinternational.com or
if you want to contact me directly: andrea@birthinternational.com

We hope this will be our last move for many years - this office space is really comfortable, and even has a garden in which I can exercise my (sort of) green thumbs.

Our United Kingdom office details remain the same as ever:

PO Box 173 Sevenoaks, Kent, TN14 5ZT

Phone: +44 (0)1959 524 622

Fax: +44 (0)1959 525 800

Email: uk@birthinternational.com or ukinfo@birthinternational.com

As the pressure builds to reform maternity services in Australia, there seem to be an increasing number of media stories that try to paint the obstetricians as the victims of fickle women and unsympathetic Governments. Their lobbyists have always had good access to the media, and whenever a question is raised or a report released that challenges, even gently, the status quo, the media trot out a “poor me” story about some struggling obstetrician who is just “trying to save babies” in the face of hostility and political ill-will.

Of course, what is really going on is that the doctors are starting to feel the blow-torch of public scrutiny over their management styles which invariably result in over-servicing of pregnant women and high rates of intervention in birth. The reports that have been released in recent years and the excellent research that has revealed the truth have made this abundantly clear.

In today’s major Australian weekend newspaper, the Sydney Morning Herald, is yet another such media beat up. This story, once again about doctors leaving the private health care system, places the blame on long hours and being on-call 24 hours each day. Whilst this is a genuine concern for many obstetricians, especially the women who have chosen this profession, the regular complaints about insurance are once again cited as a reason. The most interesting part of the report are the figures, which must be read in the contact of an annual birthrate in Australia of 250,000 babies:

‘Almost half the country’s obstetricians are planning to abandon private practice in the next five years, affecting the delivery of up to 17,000 babies by 2008. Some will enter the public hospital system and others will practise gynaecology and related specialties.

Doctors are also warning that the public hospital system will be increasingly struggling to meet the demand created by the exodus of private obstetricians.

“If we get another 16,800 babies in the public hospital system, which is the amount of births we would expect to handle in the next few years, there will be strain,” Dr Child said.

Specialist obstetricians are also quitting public hospitals. The survey found 100 intended to quit the system in the next five years. Of the 1162 specialists practising obstetrics and gynaecology around the country, less than half practise obstetrics and only 300 are in private practice only. Already, 150 specialists have quit private practice in the past three years, and 55 said they intended to stop private practice in 2003, the survey found. Over the next five years, another 150 will cease practice.

While medical indemnity was not nominated as the main reason for leaving the profession, 10 per cent of those surveyed reported paying premiums of more than $98,000 in 2001-02.

“One issue is the affordability, but there is also the ogre of this hanging around in the background, whatever you do,” Dr Child said. Ultimately, it meant it was increasingly difficult to get a private practitioner, with rural areas suffering most, he said.’

I feel sure our public health care system can easily cope with another 16,800 babies being born in our public hospitals. With a change in Government policy these women’s maternity needs could easily be catered for by independent midwives!

I have always believed that the obstetricians would eventually price themselves out of private obstetric practice one way or another. Despite their protestations of other reasons, I think this si starting to happen, and rather more quickly than many of us had hoped.

Yesterday I spent a wonderful couple of hours with my colleague Sally Tracy. She has just completed her doctorate in midwifery (Australia’s first) and in the process produced some magnificent research papers that have been enormously useful in pushing the case for autonomous midwifery care in Australia.

Sally has been appointed as Associate Professor of Midwifery Practice Development for the Northern Area Health Service and the University of Technology, Sydney, and in that role she is overseeing the development (at last) of innovative midwifery programs in the northern suburbs of Sydney.

This geographical area has always been the affluent part of Sydney, and consequently it has had a plethora of privately practising obstetricians and private hospitals. It is the only health region that has steadfastly refused to modernise by building birth centres or establishing midwifery services, and a year ago there was an attempt to close three smaller maternity units in the name of developing a “centre of excellence” at Royal North Shore Hospital. This would have meant that women would have had to travel some distance in labour, something that the planners has decided women would tolerate (but they didn’t actually ask them, they just made this assumption). When the blueprint was revealed, amid much fanfare and in the lead up to a State election, there was an outcry and this part of the plan was dropped.

Sally has been appointed to get things moving and she is off to a running start. After a few months in the post she has already flagged that things will be changing and the doctors, used to making decisions without consultation or citing any evidence, are being challenged - an unfamiliar process, but one they will have to adjust too quickly.

One of the smaller units in the area, Ryde hospital, has indicated they are willing to explore setting up an autonomous midwifery model of care. As the operational and staffing details are being finalised, it is possible that women in Ryde will have access to the first truly autonomous midwifery service in Sydney. Once this is in place, it will serve as a model for others and it is expected that other hospitals will follow suit.

One advantage that Sally brings to the task of establishing these types of services is her experience of working in New Zealand, where she regularly lectures and works as an occasional locum (her “sanity time”, as she would say). She know these systems work well, for midwives and women and she is just the person to push reform through the maze of bureaucracy and professional obfuscation that the health system specialises in.

We are lucky to have her working in the field and I, of one, hope that she will stay in a practice setting rather than submerging herself in academia and research.

I have received notification that another midwifery service, this time the Elizabeth Seaton Childbirth Centre, the only free standing birth centre in New York City, is to close by September 1, another casualty of the insurance crisis.

There is not much that I can do about this, as I live in Sydney, Australia, but I can give it some publicity, at least amongst the readers of this Diary. If you want to know more, they have full details of the centre and the issues surrounding the closure - please email them at:

elanit@att.net

This is not th first time that free standing birth centres in the US have been forced to close - the last time, which was some years ago now, an insurance company who would underwrite the malpractice insurance was found at the last minute. It is to be hoped that another company will come forward so that this Centre and many others, will not be forced to close.

It seems that independence (in many respects) is now a condition under severe threat. In the end, the only way for birth centres to exist may be as part of the regular services offered by hospitals (this is the way they operate in the UK and Australia). This can be viewed as both positive and negative. On the plus side, parents get easy access to a birth centre environment, at no cost, making it an option that is truly available to the whole community. The midwives who staff these centres are covered by the hospital insurance and have their working conditions covered by employment laws.

On the minus side, there is the possibility that hospital administrators will curtail or place limitations on the kind of clients that can use the Centre and the services that can be offered (no vaginal breech birth, twins or perhaps VBACs, for example) thus effectively curtailing the Centre’s availability to the whole community. This would also mean that limitations were placed on the midwives’ scope of practice, a situation that would not apply to the doctors who use the hospital.

Is the demise of independent birth centres such a bad thing? I believe that these centres offer models of care that “keep the bastards honest” (to use a well-known Aussie political phrase) and that without them we, as a community, run the risk of being completely dominated by hospital based medical practices. Choice is an important measure of a democracy and in a small way, the maintaining of independent practitioners and birth centres is a measure of our tolerance and sense of fair play.

The fact that insurance companies are not willing to accept the safe outcomes provided by these birth centres and independent midwives is an indictment of the power they are exerting over us in these litigious times. In Australia, we are getting much closer to convincing the Government that they can support independent practice by underwriting the necessary insurance themselves and that this measure will ultimately save them money in a number of ways, whilst producing safer outcomes for mothers and babies

I doubt that this route for gaining support will be available in the US, where a universal public health care system does not exist. I can offer no suggestions or strategies for keeping them open at the present time. I suspect that only a complete turnaround by the politicians who run the US and a complete shake up in the health sector will ensure freedom of choice for all US citizens and true choices for birth. And changes of this magnitude are a very long way off.

I have received notification that another midwifery service, this time the Elizabeth Seaton Childbirth Centre, the only free standing birth centre in New York City, is to close by September 1, another casualty of the insurance crisis.

There is not much that I can do about this, as I live in Sydney, Australia, but I can give it some publicity, at least amongst the readers of this Diary. If you want to know more, they have full details of the centre and the issues surrounding the closure - please email them at:

elanit@att.net

This is not th first time that free standing birth centres in the US have been forced to close - the last time, which was some years ago now, an insurance company who would underwrite the malpractice insurance was found at the last minute. It is to be hoped that another company will come forward so that this Centre and many others, will not be forced to close.

It seems that independence (in many respects) is now a condition under severe threat. In the end, the only way for birth centres to exist may be as part of the regular services offered by hospitals (this is the way they operate in the UK and Australia). This can be viewed as both positive and negative. On the plus side, parents get easy access to a birth centre environment, at no cost, making it an option that is truly available to the whole community. The midwives who staff these centres are covered by the hospital insurance and have their working conditions covered by employment laws.

On the minus side, there is the possibility that hospital administrators will curtail or place limitations on the kind of clients that can use the Centre and the services that can be offered (no vaginal breech birth, twins or perhaps VBACs, for example) thus effectively curtailing the Centre’s availability to the whole community. This would also mean that limitations were placed on the midwives’ scope of practice, a situation that would not apply to the doctors who use the hospital.

Is the demise of independent birth centres such a bad thing? I believe that these centres offer models of care that “keep the bastards honest” (to use a well-known Aussie political phrase) and that without them we, as a community, run the risk of being completely dominated by hospital based medical practices. Choice is an important measure of a democracy and in a small way, the maintaining of independent practitioners and birth centres is a measure of our tolerance and sense of fair play.

The fact that insurance companies are not willing to accept the safe outcomes provided by these birth centres and independent midwives is an indictment of the power they are exerting over us in these litigious times. In Australia, we are getting much closer to convincing the Government that they can support independent practice by underwriting the necessary insurance themselves and that this measure will ultimately save them money in a number of ways, whilst producing safer outcomes for mothers and babies

I doubt that this route for gaining support will be available in the US, where a universal public health care system does not exist. I can offer no suggestions or strategies for keeping them open at the present time. I suspect that only a complete turnaround by the politicians who run the US and a complete shake up in the health sector will ensure freedom of choice for all US citizens and true choices for birth. And changes of this magnitude are a very long way off.

Diary entries have been a bit erratic this week - our Web site domain host experienced technical difficulties all week, perhaps as a result of the Blaster worm that is doing the rounds.

Those of us in Australia (and elsewhere) who use the ozmidwifery mailing list to stay in touch, found that our lifeline was down and for almost a week. Dozens of emails flowed in from subscribers asking where their beloved list was - it was nice to know that it was missed. This list was one of the first of this kind and has been going for over 5 years. It has an archive service too, so that people who want to check what was discussed earlier on a topic can track it down. One day it will be used for research - especially for someone who want to track the history of midwifery innovation in this country. If you are interested in joining us for a while, the instructions on joining can be found here. We have a number of international readers - the world is such a small place!

After a chaotic week with the Internet, it seems that all is back to normal. Ten years ago we hardly knew what the internet was all about and now we have come to reply on it almost completely for quick communication, information and resources. Some of us have even managed to leave technophobia behind (sometimes after a bit of a struggle)!

An email arrived to day with sad news for midwives in the US. The message came from Norma Swenson, from the Harvard School of Public Health and it has been sent to various childbirth activists around the world. Here is the main text of the message:

“It is with a heavy heart that we inform our midwifery colleagues that the University of Chicago has decided to eliminate the Nurse Midwifery Practice.

Established in 1985 we have been the only private CNM practice on the South side of Chicago. The current philosophy of The University of Chicago, is to make OB/Gyne a state of the art high risk facility, with focus on filling the new Comer Children’s hospital NICU (promising 1000 more babies/year for the NICU).

It appears there is no place for women to choose normal birth or to utilize the services of a CNM. We have consistently been cited for high patient satisfaction and optimal outcomes. But as we have been told this is not about patient satisfaction and choice, but all about money and power. We put together a plan with 4 different options that we felt would allow us to be fiscally responsible and continue our practice. All options were declined by Dr. Haney, the new Chair of OB/Gyne at U of C. His letter to the faculty today blamed the malpractice rates (departmental increase of 100%) as his reason for terminating our practice.”

The midwives have co-ordinated a campaign as best they can within the hospital system and they have had a lot of local support. If any of you would also like to register your concern with this loss of freedom of choice in Chicago, you can email the midwifery team at:

midwives@babies.bsd.uchicago.edu

The struggle to establish and maintain midwifery services is a world wide effort. We always think that our local conditions are less than ideal and are far from perfect, yet somewhere in the world there are always women worse off than we are, both having babies and working as midwives. As I said in an earlier posting on the state of birth in the USA - there are not many examples in that country that we would want to be emulating!

An email arrived to day with sad news for midwives in the US. The message came from Norma Swenson, from the Harvard School of Public Health and it has been sent to various childbirth activists around the world. Here is the main text of the message:

“It is with a heavy heart that we inform our midwifery colleagues that the University of Chicago has decided to eliminate the Nurse Midwifery Practice.

Established in 1985 we have been the only private CNM practice on the South side of Chicago. The current philosophy of The University of Chicago, is to make OB/Gyne a state of the art high risk facility, with focus on filling the new Comer Children’s hospital NICU (promising 1000 more babies/year for the NICU).

It appears there is no place for women to choose normal birth or to utilize the services of a CNM. We have consistently been cited for high patient satisfaction and optimal outcomes. But as we have been told this is not about patient satisfaction and choice, but all about money and power. We put together a plan with 4 different options that we felt would allow us to be fiscally responsible and continue our practice. All options were declined by Dr. Haney, the new Chair of OB/Gyne at U of C. His letter to the faculty today blamed the malpractice rates (departmental increase of 100%) as his reason for terminating our practice.”

The midwives have co-ordinated a campaign as best they can within the hospital system and they have had a lot of local support. If any of you would also like to register your concern with this loss of freedom of choice in Chicago, you can email the midwifery team at:

midwives@babies.bsd.uchicago.edu

The struggle to establish and maintain midwifery services is a world wide effort. We always think that our local conditions are less than ideal and are far from perfect, yet somewhere in the world there are always women worse off than we are, both having babies and working as midwives. As I said in an earlier posting on the state of birth in the USA - there are not many examples in that country that we would want to be emulating!

In three weeks we will be relocating our office, and in preparation for the move, we are having a big clean out of old papers, files and accumulated detritus that tends to mount up in any office. It is amazing what we have kept, thinking it might be useful “one day”.

Our very first ACE Graphics catalogue came to light, revealing that some of the products we stocked in the early days are still popular. Back in 1986, the pelvis and fetal doll model were our main items. We began to add books, and early titles included Birth Reborn by Michel Odent and Active Birth by Janet Balaskas.

By 1990 we had produced our first set of “Positions for an Active Birth” charts following the success of our Anatomy and Physiology charts. The first videos in our range were “Ella’s Birthday” and “Birth of our Second Child”, and “Active Birthing”, all from New Zealand and “Under her own steam” and “With both feet on the ground” from The Netherlands. It is funny to think that the babies being born in these videos are now young adults! The Dutch videos are still available and are amongst my personal favourites - they show no sign of ageing.

In 1991 we had added the Breast Model and Knitted Uterus to the ever expanding list and had located a local manufacturer for Newborn dolls, making them cheaper than the American imports that were the only alternative.

Looking at our huge range of products now, I am proud that we have maintained our high standards whilst continuing to support our basic goals of protecting, promoting and supporting midwifery. We are aware that is what our customers expect, together with a high standard of customer service. It won’t be long until we are celebrating our 20th anniversary!