Andrea’s Diary

I am in Thailand at present, staying with my good friends Dr Tanit Habanananda and his wife Mel, who is one of our Graduate Diploma in CBE Supervisors (amongst other things!). The Habananandas are the driving force behind the Childbirth and Breastfeeding Foundation of Thailand which they set up to promote natural birth.

We have been discussing the slow progress towards changing the medicalised birth scene here. The doctors and nurses (there are no midwives as such) are often keen on the ideas and are willing attendees at lectures and workshops, but translating this into results in the maternity units just doesn’t seem to happen.

This situation is not unique to Thailand, as I pointed out to them. It is very hard to change the practice habits of professionals everywhere and this is a constant problem I have encountered everywhere. It seems to me that the only way that professionals will change is if they see natural births and then are able to be mentored as they try making changes themselves. Close observation of the new techniques followed by supervised practice might be the answer.

Here in Thailand, this approach may be reasonably easy to set up in the public system. Dr Habanananda is well known as a specialist and given his status and position, he can often “take over” a case for demonstration purposes. I have seen this happen, when he was able to step in and facilitate a birth in a teaching hospital. The woman was encouraged to adopt a comfortable position on the floor and very quickly gave birth to her baby, with a group of awe-struck nurses watching from the side.

This kind of demonstration brings the theory to life and enables care givers to see how it works. We discussed the possibility of setting up some intimate workshops for small groups of doctors and nurses that utilised this kind of demonstration, followed by a theory session to de-brief what they saw, then supervised practice with appropriate support and feedback.

There is a major hospital in Khon Kaen (a regional city in the north of Thailand) who are keen to implement change. They will be the first hospital to have the benefit o this approach and it will be interesting to see how it goes.

The Foundation has prepared a wonderful set of teaching notes and workbook exercises called the Better Babies Initiative and this will be used to lay the basic underpinning research evidence for changing the way birth is handled now. If this can be followed up with small group intensive training sessions using actual birthing women, there is a good chance that some of the techniques that have been discussed in theory can actually be translated into practice. I hope this works well for the Foundation, because without some tangible signs of progress, my good friends may just decide that 25 years of struggle is not worth it any more and that retirement is a better option. Thailand would be losing two of their greatest innovators, if this happens.

I happened to be listening to the radio today and heard a very interesting discussion with Dr. Karl Kruszelnicki, Julius Sumner Miller Fellow, School of Physics, University of Sydney. Dr Karl is a very popular media figure and his brief for the School of Physics to make science into a popular subject for the community. He is one of those irrepressible characters, always full of weird tales, amazing facts and exciting scientific discoveries, and he has a big following in television, print and radio media.

I remember him from 15 years ago, when her and his wife came to my prenatal classes before the birth of their first child (they now have three). At that time he was a resident doctor at the Children’s Hospital and he delighted in arriving at class, straight from the hospital wearing wild clothes designed to amuse and reassure frightened and sick children. I well remember the huge woolly slippers designed as bear feet that he plonked down in the middle of the circle as we settled to discuss weighty issues around birth!

The conversation today was about water and Dr Karl was explaining that what we needed to purify water (saving water is a hot topic in Australia today) was a machine like the kidney, his third most favourite organ and the world’s best filtration system.

After exploring this issue for a while, the interviewer asked him what his first and second most favourite organs were and surprisingly he answered “the uterus and the placenta”! He then went into raptures about how clever the uterus was and how well designed it was to carry a baby and give birth. The placenta got a great wrap-up as well for its ability to sustain life. It was a witty and erudite discussion and there was no doubt about his genuine admiration for these two female organs. I couldn’t help feeling that I was hearing something special - women’s bodies are usually dismissed in tones that suggest mild defectiveness.

Onya Dr Karl! (Pardon the Aussie-ism)

The overnight flight from Perth to Sydney is a killer - while it takes 5 hours to get to Perth it only takes 3 ½ hours to get back because of prevailing winds, so getting any sleep on such a short leg is impossible. However, it does mean that I get a few precious hours in the office rather than spending most of a day travelling back, even if I am feeling rather jaded from only having one hour’s sleep!

I am getting ready for my next trip overseas at the moment. This next excursion will take in Thailand, Northern Ireland, Britain (several cities), Guernsey in the Channel Islands, Valencia in Spain and Massa in Italy. This will be a trip of major contrasts and new experiences and I will keep you posted on my discoveries through this Diary. There is a lot to do in this next month!

The Western Australian newspaper ran a supplement today - “Spring Baby and Maternity liftout”. Eagerly I scanned the pages to see what was on offer in WA maternity care and very quickly I was disappointed. It turned out to be just advertising with some advertorials, and the only options included were the private hospitals in Perth and some baby and maternity clothes businesses.

The ads for the hospitals were interesting. Much emphasis on the decor, facilities and “highly skilled obstetric and midwifery staff” who would ensure an “experience to remember”. Rather ironic really, given the high rates of intervention in these hospitals. If parents choose their care based on this kind of information, they are in for a rude shock, unless they are aware of the medicalised nature of the care they offer and are keen for a caesarean birth.

Meanwhile, the WA Government is still fluffing about over the funding for the Community Midwifery Program (CMP), which is one of Australia’s showpiece midwifery services. The midwives working for this outstanding program are all on three month contracts, which is very unfair and stressful. It is the issue of insurance that is causing the problem - at present they midwives are covered by the Government’s own insurance policies but this is far from a certainty and is being challenged, hence the short term contracts.

Earlier this year Tracy Reibel, who managed the CMP for several years, explained the background for this program and the way it operates, when she spoke on the Future Birth program that toured Australia. Everyone was very impressed with this excellent model and it is hard to imagine that such a good example of cost-effective, popular and safe maternity care could ever be under a threat of closure. A big rally is planned for the end of the month to draw attention to its plight and to ensure the politicians take note of the community’s concerns. I wish them the best for their efforts and ultimate success.

The midwives in Geraldton are planning how they want their new maternity unit to be equipped. The whole hospital here is to be rebuilt in the next few years, and efforts are being made to get the facilities right in the labour ward.

The starting point is not wonderful - they are having their bed numbers reduced from 12 to 8, even though their numbers of births are steady and may even rise, if more women start choosing public care over expensive private hospital cover. However, they have been promised a bath (hopefully one for each labour room) which will be a big improvement. During the workshop, we talked about the little things that make a big difference, such as dimmer switches for the lighting in the toilet and bathroom areas. Locating the drain for the shower in the corner rather than the centre of the floor is also important to avoid flooding if sitting on a birth ball will cover the floor drain.

The midwives had hoped they could have a birth centre rather than the standard hospital set up, and they are still considering how they might achieve this. I suggested using the community to apply pressure in the appropriate places - this has been done successfully a other towns and cities. Since they know all the women who have given birth in their hospital, it shouldn’t be difficult to locate some community leaders and women with useful skills who could throw their weight behind such a project, to form a core team who can push for the necessary reforms.

It has been a great weekend in Geraldton, and now I am in Perth, ready for another group that will no doubt be more diverse, but just as interesting.

This weekend I am in Geraldton, a town on the west coast of Australia an hour’s flying time north of Perth. They have two maternity units, one in the public system and one in the private hospital and the GPs do most of the obstetric care in the town, along with the obstetrician.

The energy amongst the midwives here is very exciting. They have been working hard to keep birth normal and have managed t keep the caesarean rate at 19% (almost 10% less than the state average). The obstetrician is supportive of vaginal birth and they have an 80% vaginal birth after caesarean (VBAC) rate. Their next challenge is to get the induction rate down and to find a way of establishing a midwifery service - they hope they can get a midwives clinic going.

Although midwives working in these rural areas often feel they are rather cut off from the action in the big cities, they have many advantages to celebrate. With fewer staff it is easier to establish close working relationships and to share ideas and plans. Making changes is often easier because there are fewer people to convince and management is not as remote as it can be in a large hospital. The women often know the midwives and the community spirit is easier to tap into when support is needed from those quarters.

The GPs do wield extraordinary power, however, in a small town. The community is anxious to keep them happy in case they decide to move to greener pastures and the hospitals rely on them for many of their services, including minor surgery and some anaesthetics. For a General Practitioner, providing birthing services is often a pleasant aspect to their work, although the current pressure from high insurance premiums required for obstetric services is taking much of the gloss off. The time will come when the GPs decide that the costs outweigh the benefits and they may withdraw their birthing services. This will be crunch time for the midwives, who will have a wonderful opportunity to step in and set up a midwifery service at the hospital. It will mean that some women may have to be shipped out to larger units some distance away when there are complications, but with midwives as primary care givers, the statistics show that the numbers of women with complications usually falls. As long as the midwives don’t lose their cool and support each other as they rediscover their skills, it can work very well.

I get a strong feeling that here in Geraldton, the future is very bright for the midwives, even if it takes some time for them to achieve their goals. They have a vision, strong leadership and a strong commitment to improving birth for the women in this town. I am pleased to be playing a small part in their plans through presenting this workshop for their midwives.

As I write this, the External Review Panel for the re-accreditation of our Graduate Diploma is meeting in the next room. This process, a requirement of the Vocational Education and Training Accreditation Board (VETAB), is designed to make sure the Course is reviewed by appropriate people in the field who are qualified to determine that it accords with the National Accreditation Principles.

To adhere to these Principles, a Course must:

• Meet an identified industry, enterprise or community training need

• Complies with the Australian Qualifications Framework (e.g. the definition of a Graduate Diploma)

• Not unnecessarily limit access or participation (e.g. does not discriminate against applicants and encompasses access and equity principles)

• Provides credit transfer to other qualifications

• Can be customised if necessary or required to meet the needs of clients

• Has assessment methods that are consistent with any nationally endorsed competency standards and are consistent with the National Assessment Principles

• Includes monitoring and evaluation processes that are used to maintain the relevance of the Course.

It is an arduous process, bound up in bureaucracy, which requires reams of paperwork and struggle with acronyms, jargon and issues that have nothing at all to do with the content of the Course itself. One thing it does ensure is that submission writing skills get dusted off, patience and tolerance get a working over and staff time is eaten up in large chunks. Thank heavens it only comes up every five years!

I was asked recently about my views on hypnobirthing, a technique that trains women to labour in a way that is claimed will result in a pain-free birth.. As I understand it, the original ideas stemmed from the work of Grantly Dick-Read, a British doctor who first described the fear-pain-tension cycle that still underpins much of our understanding of pain in labour. His idea was that if women could be encouraged into a relaxed state they would not, or need not, feel pain in labour and his theory formed the foundation of the first childbirth classes in the UK and the introduction of the “breathing” into these programs.

The modern interpretation of his work has evolved into “hypnobirthing” which attempts to use autosuggestion and relaxation techniques learned in the pregnancy as aids to a pain free labour. It has been developed in the US and I have come across practitioners in both Britain and Australia, who have been trained in the methods.

I must admit to a definite scepticism about this approach, for two main reasons. There is no evidence that a pain free labour is a normal labour, and indeed the essential and necessary feedback mechanism from the contractions (often experienced or described as pain) is important for a safe, natural birth. I have noted that those who most vehemently defend hypnobirthing’s claims are male promoters of this technique and I am afraid I would have to question their credibility when it comes to labour pain.

My second, and more important reason to challenge hypnobirthing stems from this practice of teaching women to overcome fears by reprogramming their thought processes. Meddling with people’s minds is a very serious and potentially dangerous exercise, particularly in the hands of the non-professional and semi-skilled practitioner. If women have deep seated fears about labour pain (or any other aspect of birth) then these need to be dealt with by fully qualified psychologists, experienced in cognitive therapy or similar techniques which have proven merit. We all carry a lot of baggage in our subconscious minds and delving into these depths can have unexpected or even debilitating results. Even seemingly simple techniques such as visualisations have the potential to trigger memories and trauma, and using these, especially in prenatal classes, should only be considered when there is a qualified counsellor or psychologist available to deal with any aftermath.

Apart from these concerns, I also question why women are being encouraged to disassociate themselves from their labours through utilising any distraction technique. The endorphins produced in a natural birth encourage the inwards focussing of women on their bodies so they can react appropriately to get the baby born safely. Encouraging her to place her attention elsewhere could mean that she misses important signals and raises the risk she may not fully engage with her baby and body during birth.

Hypnobirthing, it seems to me, is pseudoscience being applied to vulnerable women who are at risk of being exploited at an emotional time in their lives.

There is an interesting discussion being aired on the ozmidwifery list in response to a question from a midwife: “Is it possible to have an active birth in a public hospital?”

For those readers who are unfamiliar with the concepts of an active birth, I suggest you check the quiz on our website - if you can answer “:yes” to these questions, you are undoubtedly practising in a woman-centred, holistic, physiologic fashion that many would identify as central to an “active birth”.

In answer to the question posed on the list, this is what I replied….

I think it is possible to have an active birth in a hospital, but it is difficult in the larger units for a number of reasons:

• A lack of skills (and sometimes motivation) amongst midwives. As epidurals take hold, midwives forget how to get a woman through transition, how to do observations with her off the bed and certainly how to support her in an upright labour and birth, to name a few examples.

• The perception that active birth is “old hat” when it is just as fresh and vital as every woman that will give birth today and tomorrow. I feel that midwives should be reminded regularly of the basics and underpinning philosophy because it is so easy for standards to slip and “tricks of the trade” to be forgotten.

• A lack of support from experienced midwives, who could show the students and graduates how it is done. Every student I have ever had in a workshop over the years has said that they were not taught the basics in their training, so it is imperative that the necessary knowledge and practical skills be passed on my midwives on the job.

• The chronic shortage of staff (often a problem in non woman or midwife - friendly workplaces) puts additional pressure on the midwives left to face the daily struggle. It may seem easier to just fill the labouring woman up with an epidural, plug in the electronic baby-sitter (CTG) and get on with the paperwork. Interventions add to the midwives’ workload, not reduce it.

• The inability (unwillingness?) of midwifery managers to rid the maternity staff of “dinosaur” midwives who are resistant to change and block innovations, improved services and supportive practices. This would never happen in other areas of medicine, where staff who did not keep up with evidence based care and demonstrate best practice would be asked to leave pronto. These undermining midwives are not necessarily the older staff, but are often nervous, insecure, timid and scared practitioners who need support, re-education, and understanding. If this doesn’t help, then it would do everyone, including them, a favour if they left the profession that clearly is not for them.

I could have gone on, but have left it here, to see what others contribute on this topic. It is an issue that I constantly grapple with, having been the primary promoter of active birth in Australia for the last 20 years. At times I feel we are getting somewhere and maternity services and improving, but then, when I reflect on the progress that has been made over this time, it seems we have such a long way to go, especially as so much backsliding is going on, often amongst midwives themselves. Being of a positive nature I will keep plugging on, but I do wish midwives would take time out to regularly update and hone their skills, before our hospitals are staffed solely by obstetric nurses.

The group today in Sydney were a very diverse. Some had years of midwifery experience and others were relative newcomers to the profession. We have childbirth educators and doulas as well - an interesting mix that is always a strength of these Active Birth workshops.

We talked about the new developments in midwifery and the need for midwives to retain and develop their skills. There were the usual mix of stories about working as a midwife in our hospitals - some terrific, many ridiculous. The prize for “silliness” goes to one of our largest public teaching hospitals in Sydney who have just moved into a brand new facility. Even though they knew they would need to update the skills of their staff so they could assist at water births in the new baths, this was not done, and so a compromise has been put in place. If a woman using a bath during labour develops a problem, the midwife must call for lifting equipment so that he hapless woman can be removed, without endangering the staff. Imagine levering a woman in advanced labour into a lifting contraption! Of course, it is assumed she is completely unable to help herself! By the time the lifting gear is in place and the removal has been completed, who knows how the baby and mother might be faring?
It would have been so much easier to train up the staff, given that managing a water birth is so simple and easy for a midwife.

Several of the participants are from private hospitals, where the caesarean rates are sky high. Obstetricians, fearing litigation, are adopting “slash and burn” tactics to scare women into thinking that the care of a doctor is essential for the well being of their baby. One of the childbirth educators told me that parents int her classes are insisting the “only this doctor could have saved the baby”, obviously parroting information they have been given by the doctor himself. This educator thinks that doctors are taking acting lessons to “ham up” the gravity or seriousness of a situation so that they can justify what they see as their pivotal role in the ensuring the safety of birth. She might have something there….. I have certainly been at a birth (many years ago now) where, after a particularly heavy handed, and quite possibly unnecessary forceps birth, the obstetrician (the Medical Superintendent of the hospital at the time) leaned forward over the exhausted and battered woman, held up his gloved hands and pronounced “these hands have saved your baby”! I was too shocked to even feel sick, but the woman was very grateful and showered thanks over him. These guys give the caring and empathetic doctors a bad name and most (but not all) have now disappeared into retirement. Good riddance.