Andrea’s Diary

Midwifery students are starting to call us to order the textbooks they will need for the start of the academic year in February 2005. Next year will see the start of the first Bachelor of Midwifery course at the University of Technology in Sydney and for the first time in NSW, aspiring midwives will not have to study nursing before they can enrol in a postgraduate program to gain their midwifery skills.

It has taken a long time to get this program running, but the wait will have been worth it. Some of the delay, towards the end, came about because the University was unwilling to enrol students whose registration as midwives at the conclusion of their course might not be automatic. The passing of the NSW Nurses and Midwives Act, which recognised the separate professionals of nursing and midwifery ensures that graduates can be registered as one or the other, depending on their undergraduate study program. There are now separate registers for nurses and midwives, which simplifies the process of getting a “work permit”.

Meanwhile, in Victoria and South Australia, the first students in their direct entry courses have just finished their final year and are ready to graduate. These women, pioneers of a new system, have had to endure the teething troubles of all new courses and will face new challenges as midwives without nursing qualifications. The initial intake was drawn from a huge pool of passionate women, many of whom had worked in childbirth related areas, such as consumer activism or childbirth education while they waited their chance to enrol in a direct entry midwifery program. Many of these new midwives will be our future leaders, and they are an inspiring group.

The Course at UTS has drawn on experience learned from the interstate courses, and from the input of the many overseas consultants that offered ideas. Every aspect of the program is “woman centred” and the normalcy of labour and birth is a strong theme throughout the curriculum. I have no doubt that in three years, the first graduates of this new course will also take leadership roles, hopefully in a changing culture around childbirth that recognises the skills and necessity of midwifery as the primary force in keeping birth safe for mothers and babies.

The latest figures on birth outcomes in the State of New South Wales (2003) have just been released. This State is the only one in Australia that makes all the figures, for both public and private hospitals, freely available to the public and it is a goldmine of information.

Once again it underlines what we already know is happening: the caesarean section rate has risen from 19% in 1993 to 27% in 2003 and most of this rise is concentrated in the private sector, where the obstetricians rule the roost and the women have the money to pay them.

At the other end of the scale, this report has the figures on the first midwifery led units, and the Birth Centres, listed separately. Women who choose this kind of care have a 95% normal birth rate, which is impressive, but then this is to be expected as they work with a carefully selected low risk population. If the figures were any worse than this, there would be questions to ask.

The vaginal birth after previous caesarean (VBAC) rates are shocking. Only 20% of women in NSW achieve a normal vaginal birth after a previous surgical birth. The research on VBAC clearly indicates that a normal vaginal birth should be possible for up to 80% of all women and that this option should be encouraged and supported. Some of our births centres will accept women into their programs so they can have a VBAC, which is as it should be, given the research. However, it is clear from the statistics that most women are still being labelled “high risk” and being shunted off to obstetric care, which almost inevitably leads to another caesarean. It is so easy (and convenient) for a doctor to find a “reason” why surgery is to be preferred, and women are very vulnerable to scare stories and have no way of refuting or challenging dubious medical claims, such as a high incidence of uterine rupture if a normal birth is attempted.

There is a lot of work to be done by us childbirth educators, in all spheres, not just with expectant parents.

The issue of what is appropriate sponsorship for events has come up, in relation to a group seeking help to fund an event I may be involved with. I asked this group if they would be careful when seeking funding and advised that I would not be prepared to attend any event where baby formula (or its gadgetry) would be advertised.

Some years ago now, I was caught out on this issue in the UK. A Branch of the Royal College of Midwives had arranged an Active Birth study day and when I arrived, I found to my horror, that beside the registration desk was a large display and handouts about a specific brand of baby formula. There were similar tables of advertising material from other companies in the entrance area as well.

I took the organiser aside and explained my dilemma: although I had come a long way to present the program, and the participants were similarly well travelled, I would never have been involved at all had I known that such sponsorship would be used to underwrite the event. The organiser was very surprised. She explained the RCM often used such companies to help defray costs and this was an “acceptable practice” as far as she knew.

She was a midwife herself, but was not familiar with the WHO Code. When I pointed out that it was the bottle feeding women who ultimately would be paying for the company’s largesse and the midwives’ refreshments, she said that she had never thought about this bigger picture, and was surprised by it.

On that occasion there was little I could do but compromise. I stated to the group that I did not support the products being advertised, nor the position of the RCM in inviting such involvement from these companies. I also stayed well away from their tables, but made sure that they heard the conversation that I had with the organiser.

I suspect that the midwives in the group were not bothered - breastfeeding rates in the UK are the worst in Europe and I think the group members were just happy to have had a cheaper program and free refreshments. The bigger picture and the motivations of multinational corporations in co-opting health professionals is an issue that is often overlooked as a matter of expediency.

The end of the year is rapidly approaching and for me this means finalising all the plans for next year (at least the first six months) and reviewing the programs we are developing at Birth International in readiness for their implementation in the New Year. It is also the time we decide on the new products we will be including in our range next year and get our catalogue ready for publication.

The main events on the horizon at the “Future Birth: With woman with child” tour that will travel around Australia in March and the “Preparing for Birth - new approaches in antenatal education” Conference in the UK in April. The full details of both of these major events are on the web site, along with the details of how to register and how to save money by registering as a group, or early (or both). We also have special student rates. Click on the titles to take you to the appropriate information.

The workshops that I will be offering are also being finalised. Some will be available in February in Australia, but most will be in the UK or Europe in April, Australia in May and in the UK again in June/July. There are a few dates for UK/Europe programs in the mid year round still available and if anyone is interested in hosting such a program, they can find the details on how to do this by clicking here.

I have had a lot of fun reviewing the new products for our extensive mail order range. There is a large number of new items, from books, CDs, DVDs Educational packages, charts and of course videos that you will be able to choose from. There will be something for everyone in this collection, which will be announced at the end of January when the catalogue is released. If you would like to receive a paper copy, click here, to send us your details.

Meanwhile, we have our office Christmas “party” tonight and this year we are going to the theatre for a night of laughs and fun at a brilliant satirical show featuring politicians and larger than life Aussie characters. We’ll all enjoy this I am sure - the show has been widely praised and there are never enough laughs in life……

For once there has been a number of positive birth stories of one kind or another in our major newspaper.

I read with delight a report written by woman who finally achieved a vaginal birth after three previous caesarean sections. Each of the caesareans had been performed for medical reasons, and each time she had planned to labour in ways normally designed to reduce the risk of intervention becoming necessary, that is, in a birth centre or at home, with midwives, using no drugs etc. The first three times, a sudden problem appeared that meant a caesarean was necessary for the baby’s sake.

Finally, with the full support of an obstetrician, she booked into a midwifery program, was able to have continuity of midwifery care and gave birth, in hospital to a 4.1 kg baby in about 4 hours. She was over the moon and felt an incredible sense of achievement.

One of the best things about this story was that she was able to tell it herself and there was no “comment” from an obstetrician. So often, a doctor’s comments are added “for balance” and their often unfounded, non-evidence based throw away lines completely undermine the thrust of the story and feed into people’s fears. This woman’s achievement was allowed to stand unsullied by ill-informed medical commentary and I applaud the Sydney Morning Herald for making that possible.

If only more women could get the support they needed to have this kind of life-shaping and affirming experience, against all odds…….

Last week there was another interesting report in our major newspaper. The Health and Science supplement carried a full page story about prenatal classes being held in a pub in Sydney. Begun by two enterprising doulas, they offer a group get together in a room in a hotel, where they can talk about issues surrounding the pregnancy while they have dinner.

They decided on this format because they wanted to find a location that would appeal to the men in particular and where everyone would feel comfortable. Given that few working couples these days seem to cook during the week, and eating out is relatively cheap in Sydney, this novel approach was almost bound to succeed.

It is an idea that childbirth educators should take on board. Traditional meeting places don’t always feel as comfortable as they could and some lateral thinking might prove more popular, especially with expectant parents who are not used to hospital settings, for example.

The doulas in this article were careful to state that they were not offering prenatal classes. They would not be attempting to involve parents in the many and varied activities usually incorporated into a regular prenatal program, in such a setting as a pub. My guess is that they are concentrating on the social aspects of parent education and giving the parents a chance to talk through their concerns with their peers in a semi-structured way. This is an important aspect of classes and one that is often overlooked.

Of course, the other noteworthy point is that this novel approach is set in the affluent area of Sydney where parents are quite able to pay $35.00 each for a night out, including a meal. Not all parents would be able to afford nights such as these, but it might work well for a Saturday or Sunday session when more could be covered, making further sessions less necessary.

Good on these facilitators for coming up with this idea - I hope that it continues to work well and that others will think about similar ideas for all or part of their own parents education program.

This weekend there are reports in the media of a study on the long term safety of ultrasound in pregnancy. Several years ago, Dr John Newnham, of the King Edward Memorial Hospital in Perth WA, undertook a study to determine the safety for the baby of ultrasound. He used two groups of pregnant women, one group had one ultrasound in their pregnancy, the other 5 scans. When analysing the results, he discovered that quite unexpectedly, the babies who were exposed to more ultrasounds were slightly smaller at birth, by about 30 grams, than the babies who had been exposed to one scan.

At the time, these results attracted much media attention, as they were unexpected and alarming. Many doctors responded by reducing the number of scans ordered in pregnancy and women were advised to limit the exposure of their baby to ultrasound.

Now Newnham has released the results of a study that followed these children for 8 years. His findings now suggest that there are no long term problems for babies exposed to multiple ultrasound scans in pregnancy, news which will reassure many women.

I haven’t yet seen the paper itself and am just reporting here the main gist of the media stories. However, no doubt these reports will encourage the increased use of ultrasound, which certainly has its uses. The research will also have the potential to make practitioners and manufacturers very rich through boosting the number of scans being ordered, and to cost the public health system a lot of money. A review in Australia some years showed that more money was spent on ultrasound scans for pregnant women than on all other prenatal testing procedures put together. This prompted the Federal Government to place a limit of two scans that would be covered by Medicare in our public health system. If women want more, they have to pay for them out of their own pocket, or hope that their private health insurance will cover the costs.

Newnham’s study, published in the Lancet, will make interesting reading. One caution he did make was that the ultrasound machines in use today are far more powerful that those available when he did his research, so we still don’t know what levels of actual exposure are safe for the unborn baby. It is the level of exposure that is the critical factor, and given that babies also receive ultrasound from hand held dopplers (used to listen to the baby’s heartbeat) and from electronic fetal monitoring (CTGs) during labour, the total dose a baby received could be quite high.

Until these factors can be quantified, it seems to me that the only safe way to proceed is to limit the number of ultrasound scans in pregnancy (and the use of sonicaids and CTGs) to the absolute minimum, especially with the higher powered equipment that is now in use. If any of this equipment is found, perhaps many years later, to have cause untoward effects for the baby, then many parents will be looking for compensation. Better to be safe than sorry, I believe, especially as there are perfectly good alternatives available, such as Pinard stethoscopes, that can be used when no specific problems need closer scrutiny.