Andrea’s Diary

As we toured around Australia recently with the Future Birth program, the subject of the huge cost of obstetric care to the Australian public came up several times. Apart from the 30% subsidy that all taxpayers give to those who choose to take out private health care (which I consider to be a gross misuse of my money), the Federal Government has established a “safety net” designed to ensure that no-one is disadvantaged by being unable to afford the high cost of medical care (with both GP and specialists) when fees are charged over the basic scheduled Medicare rates that cover all Australians

The “safety net” was part of the Federal Governments platform for re-election last year. Those with private health cover are also included in this safety net, because private insurance cover does not cover all additional medical expenses and people find themselves paying for the extra charges, on top of their insurance premiums.

The obstetricians have been the big winners from this arrangement. They charge way above the scheduled fees for their services, and insurance cover still leaves a large gap to be funded by expectant parents. A neat story in the latest edition of “Birth Maters”, the journal of the Maternity Coalition, illustrates this well:

A Melbourne woman who was considering making a booking with a private obstetrician phoned his office to ask for the details of his charges, and exactly what the safety net covers. This is what she was told:

” I pay him $3600.00 and the safety net picks up $1600. Apparently the safety net picks up 80% of out of pocket expenses which are incurred over $700.00 in any one year.”

Here is a simple calculation: If 30% of all women giving birth in one year (250,000 x 30% = 75,000) give birth in private hospitals, under the care of obstetricians, who each charge $3,600 for their services, Medicare is rebating $1600.00 x 75,000 = $120,000,000 via the safety net alone. There is also the ordinary Medicate rebate”.

No wonder this marvellous safety net scheme is so loved by the doctors. It is already known that the blow out in the funding for the scheme is hundreds of millions of dollars (and we haven’t yet reached the end of the first year of operation) and it seems that the obstetricians may be the main cause of this. Rumour has it that the Australian Medical Association (AMA) is aware of the way the obstetricians are using this scheme to make money for themselves and can see that this rorting of the system is giving doctors as a whole a bad image. It will be interesting to see if the AMA decides to take action internally to rectify this, or whether the obstetricians (who have a long history of going it alone within the medical fraternity) decide to tough it out with their colleagues until they are forced to change their ways by the Government.

Meanwhile, us poor taxpayers are again footing the bill for those extra little luxuries enjoyed by the obstetricians.

Finding time to catch up with Diary entries is again a problem - I just seem to be getting busier and busier!

We had a visit from a midwife working in Tanzania the other day. She called in to stock up on some books and materials that she could use in educating the midwives and traditional birth attendants, who care for most women giving birth in Tanzania. We began chatting about what was happening there and she explained that although she has been living there for 3 years she is only now seeking registration as a midwife. Most births occur in hospitals and the women aspire to being flat on their backs on a bed for birth - the “western” way of doing things.

This sounded very much like birth in other parts of Africa that I have visited. While we strive to encourage western women back to their roots and traditional ways of birthing in active, upright positions, those in developing nations try to emulate the affluent western women - they long to have a clean sheet on a bed! At least the use of drugs for pain is very limited in Tanzania and the women accept that pain is a normal part of labour.

One of the biggest problems in Tanzania is the lack of transport and extreme poverty. Many women labour for a long time, unable to get to help. Perhaps eventually they are able to get a ride to a hospital, but often by then they have suffered extreme damage of the pelvic floor muscles, perhaps resulting in terrible fistulas that will ruin their reproductive lives forever. This is a particular problem amongst young girls, who often begin having babies before they are fully grown themselves. The damage caused by trying to give birth to a baby that is clearly too large for the immature pelvis may mean a life of exclusion and ostracism from her family and certainly her husband. The midwife I spoke to told me about the programs that some pioneering doctors have set up to repair some of this damage so that these young women can lead productive lives again.

When you look at th excesses of western medical interference in birth - the unnecessary surgery (caesareans and episiotomy), over use of drugs, necessity for forceps or vacuum extraction of babies, the hospital acquired infections, and the traumatic psychological damage caused to women by all this, it is hard to justify, especially when so many of the world’s women just struggle for the very basics. It would be wonderful if western women could return to some of the simple basics of birth and the women in Africa and other poverty stricken areas could have just a little of the medical care that is overabundant in our communities. Whoa….. watch out for the flying pigs…..!

I waived farewell to the last of our Future Birth speakers on Thursday and we began the wrap up of this fantastic series of seminars. There is no doubt that it was the best we have ever presented - there was not one complaint about the speakers amongst the almost 900 evaluations that we received. Some comments were made about Michel Odent’s French accent being hard to understand, but everyone was enthralled by his message that we should return to the physiological roots of childbirth to make it safer and easier for women and babies.

Susanne Houd’s incredible pictures of her work in three countries (Nunavik in Northern Canada, Eritrea and the eastern coast of Greenland) illustrated her passion for developing programs that enable babies to be born on their own homeland, not shipped away to large impersonal hospitals for birth. There were many lessons in her presentation that could be applied to our indigenous Aboriginal population and this point was highlighted by many in the various audiences.

Sally Tracy presented the research that is about the be published in a top medical journal, showing that small maternity units are safe places for birth. She presented convincing arguments for maintaining these small hospitals, especially in rural areas where they are under constant threat. Her figures were drawn from a study group of 750,000 births in Australia - the entire population of birthing women for 3 years. Hard to argue with a study pf that size! She followed up with the outcomes for the first 100 births in the Ryde Hospital in Sydney - the first unit of its kind in a city area to be established as completely midwifery led. Needless to say, the outcomes were as expected - outstanding.

Sandy Kirkman lifted our spirits and energised us at the end of the day with a wonderful presentation highlighting the difference that just one person can make in changing maternity care practises. Drawing on some well known and some anonymous or almost forgotten people, she explained how their concern at outdated or unkind practises could be changed through simple research or just plain obstinacy. This was a very lively hour, and we were all weak from laughter by the end. A fitting conclusion to the program and one that was welcomed by everyone.

Much of the feedback was repetitous: “inspiring” was the most common remark, “amazing”, “interesting”, “informative”, “fantastic”, “exceptional” “outstanding” appeared often as well.

There were some notable comments as well:

One person described Sally’s statistics as “boring as batshit” but also a great achievement!

Another thought that Michel would “be bigger” (whatever that means!). She also commented that Sandy was “entertaining - can we order you in a jar?”

One summed up the day like this “Enjoyed the seminar incredibly - every second - the feeling of solidarity, the tears”. She also felt that hearing Michel was “a dream come true”.

One grandmother, doing research on an aspect of birth, wrote “The day has been really moving for me - I’ve been trembling with feeling and on the edge of tears a good part of the day”.

One enthusiastic midwife wrote ” [Michel] is worth his weight in love hormones” and praised Sandy for her “joyous content”.

Many midwives wanted to travel with Susanne or even work with her and there was much praise for her passion, achievements and fantastic commitment to women.

Sally received numerous requests to come and “sort out” their local hospital. One midwife said that “we need a few more work-horses like you around the country” and her dedication to the cause and ability to get things done were admired and envied by many people.

Sandy, having asked everyone to think of people who deserved a prize for their unsung achievements, was told firmly by one midwife “you are a shaker and a mover and an inspiration”.

The whole day was summed up by another who said “Wonderful - I could come back again tomorrow”. It was certainly a day we will all remember with great affection. As speakers, we all felt that there was a huge groundswell happening across the country, with midwifery poised to make a giant leap forward into the mainstream as primary carers for childbearing women. The enthusiasm and excitement was palpable, and the commitment, afer so many years of constant struggle, was still as strong as ever.

If this Future Birth program has been able to bolster our midwives to take that final step towards autonomous practise then I will be very pleased. This was my intention, and together with a great team of presenters (and my dedicated staff, behind the scenes) I feel we have been able to make a difference. The next event will be early in 2007 …..

We had a huge crowd of midwives in Perth and many of them were the “up and coming” generation - students and recent graduates. It was such a buzz to feel the energy in the room, and their excitement at the possibilities being suggested for midwifery in WA, both from the speakers on the Future Birth program and also from colleagues within the audience.

I was given a copy of a new document prepared by the Western Australian branch of the Maternity Coalition, titled “Implementing the National Maternity Action Plan in Western Australia”. It is a call for the introduction of caseload midwifery options within the WA public health system and outlines firstly the benefits of caseload practise for pregnant women, then presents feasible means and professional guidelines for implementing such a service.

It is a powerful document, carefully written and factually supported with relevant data. The history of the many enquiries and Government reports that have already been prepared in WA and their relevance to this new proposal is also included, with the conclusion that it is now time for action, not more reports.

The momentum gathering in the eastern states of Australia towards universal cover for homebirths within the public health system will add strength to their case here. It is unthinkable that discrimination between states, within the universal health care system in Australia would be either tolerated or acceptable.

The Maternity Coalition, a group of passionate women and midwives across the country, have had a huge impact on the way birth is viewed in Government circles and policy making units of health services. This latest report is a further example of their attention to detail and well though out proposals and eminently sensible suggestions for improving the lot of birthing women in Australia. They deserve much more support that they get and more recognition for their vision and hard work.

The first event in the Future birth tour of Darwin went very well - the feedback was overwhelmingly positive for the speakers and the event as a whole. The four speakers dovetailed well, their messages reinforcing and strengthening the overall theme of “with woman, with child” and showing in practical ways how this could be achieved.

There was a lot of discussion about the plight of the Aboriginal women in the Territory (and other States) who are forced to leave their homes and travel, often huge distances, to large city hospitals to give birth. The disruption to their family lives, the dislocation of their social networks and the cultural insensitivity inherent in these policies is shameful state of affairs. The wonderful examples provided by the Innuit and Greenlandic women, beautifully described by Susanne Houd in her presentation, highlighted the appalling conditions we inflict on our indigenous people.

We know we treat our Aboriginal women badly in this regard and that reform of the health care system is desperately needed. There are those who are championing their cause at Government levels and there are resources and funding that can be made available. What is needed, as a first step, is to hear from the Aboriginal women themselves - they need to tell us what they want and to get involved in making sure that the services they want are provided. Without this input, new programs may fail, or be implemented in inappropriate ways, as has happened in the past.

We can learn a lot from the strong, resourceful Innuit women of Canada and the women of Greenland. They clearly announced what they wanted and set about finding ways it could be achieved: giving birth in their own homes and towns, no matter how remote; being cared for by their own people and training their own midwives. The results have been spectacular, and show how safe birth can be, when there are competent midwives, no doctors, no anaesthetics (epidurals), no hope of an intrapartum transfer.

It would indeed be a wonderful day when we can say the same services and outcomes exist for our own indigenous peoples. It would be one practical step in reconciliation that would would say “sorry” for the havoc our western medical practises have wreaked on women who quite capable of managing birth themselves.

The “Future Birth: With woman, with child” begins to day in Darwin. Our speakers have assembled from around the world: Susanne Houd from Greenland via Copenhagen, Michel Odent from London, Sandy Kirkman from Wales and Sally Tracy from Sydney. I know that this is going to be a fabulous program and everyone on the team is eager to start.

Darwin is a small city and very remote with Australia, yet 54 midwives have registered! There won’t be too many left to attend to the needs of the women in this town today.

From here we will be travelling to Perth, where a huge contingent awaits us. It will be good to start slowly with a more intimate group as we explore a number of issues that have particular relevance to this part of the country: meeting the childbearing needs of remote, indigenous populations and how woman-centred services can be provided within the public health system.

The first publicly funded home birth service in Sydney has just been announced by the NSW Minister for Health and the staff at St George Hospital. This is a major breakthrough - for the first time, women in Sydney who want a home birth will have access to a free domiciliary midwifery care as part of our public health system.

The service will operate initially through St George Hospital, where the caseload carrying midwives who are now attached to their Birth Centre will be able to extend their care to assist women give birth at home. As employees of the Hospital, their professional indemnity insurance is covered - the lack of insurance for independently practising midwives has been the major sticking point so far in being able to offer greater access to home birth as an option for families.

The Hospital suggests that up to 11 home births per month could be handled by their midwives. It will be interesting to see how the service is taken up and how popular it becomes. There is also the possibility of extending the geographical range of the service to take in both The Royal Hospital for Women at Randwick and also Sutherland Hospital - all are in the same Area Health Service.

The availability of this new service is timely and necessary. Births in hospitals are always at risk of becoming medicalised, and although there will be very strict criteria for acceptance into this new program, at least the option of avoiding the hospital setting for birth altogether will be a reality for women in Sydney’s south-eastern suburbs. No doubt there will be many people watching this new development with interest, and I feel sure they will be surprised and heartened by the outcomes it should produce. I hope it enjoys every success and proves a model program that is eagerly adopted by other Area Health Services.

Congratulations to everyone who has worked so hard, and for so long, to get this service in place. History has been made…..

The first day of the workshop in New Zealand was very interesting. These midwives, all very experienced, are mostly working in the “Know Your Own Midwife” scheme at the Hospital, although there are also independently practising midwives in the group as well. Some have come from other centres some distance away - the usual kind of mix that attend these programs.

To hear them talking of the way they practise was very heartening. The big focus in NZ midwifery is the woman, and everything they do revolves around the needs of the woman - her needs are paramount. Having said this however, as usually happens in a hospital based system, the needs of the institution also are considered and some conflicts can inevitably arise.

The big difference between Australia and NZ maternity services is the lack of private obstetrics in NZ. Obstetricians are only involved in complex cases in NZ, and readily back away from anything that is “normal” - quite the opposite of the way obstetricians behave in OZ. Midwives manage 70% of all the births in NZ, making referrals as necessary but otherwise carrying out all aspects of the woman’s care. Midwives here are justifiably proud of their system and it is a model that is envied by many overseas.

To hear about the rising rates of intervention, given these circumstance, was worrying. Epidurals are being requested by women and as they are the centre of attention, these requests are being fulfilled. Inevitably, the rate of caesarean births is rising, as are forceps and vacuum births, and this trend has the potential to undermine the quality of midwifery care. We talked at length about how to curtail these trends, the consensus being that better education is necessary. We also focussed on the role that midwives can play in discouraging women from demanding medication during labour, by building their confidence through well chosen words and positive feedback. There will be more focus on this aspect today, as we explore practical measures for keeping women off the beds…..

I have often talked about New Zealand as being possibly the best place in which to practise midwifery. The changes brought about in the early 90s established a system where midwives work autonomously, either as independent practitioners or within the hospitals. They have prescribing rights, visiting rights to hospitals and rates of pay that equal the doctors. Women in New Zealand have the right to nominate their chosen caregiver, who is then paid a fixed fee by the Government for the total care of that woman. It is an egalitarian, fair and sensible system, and the envy of midwives around the world.

It also offers very woman-centred care, founded on the well-woman model of midwifery and is very popular. Following its introduction, there were notable improvements in health indicators, with a steady fall in maternal mortality and morbidity for a number of years and increasing rates of breastfeeding across the board. The full story is told in the article by Karen Guilliland on this website - click here to read all about it.

This week I am in New Zealand, to present my first Active Birth workshop here in many years. Given the opportunities for midwives to practice their craft, I have felt they “have their acts together” and have concentrated my efforts in other directions. The invitation to work with a group of hospital based midwives here came as a surprise, but one I was glad to accept, and I will be very interested to discover what is happening in this area at the top of the South Island.

Initial enquiries suggest that although most women in this area see their own midwife through the hospital clinic for their entire childbearing episode, the rates of epidurals during labour is around 60% , the caesarean section rate is also high and even episiotomies are higher than would normally be expected. I gather that although the obstetrician and GPs are only consulted when problems arise, their practises are influencing the midwives, who are increasingly taking on the medical model of care. The aim of my program will be to reverse this trend and toencourage these midwives to rediscover their skills in facilitating normal births.

I am looking forward to this challenge. I must admit I was alarmed to learn of these trends - if midwifery skills are being lost in a wonderful practise setting such as New Zealand, then what hope is there for the rest of the world? I will be doing my best to alert them to what is happening in this corner of their beautiful country.