Andrea’s Diary

This week I have been in Victoria, presenting an Active Birth workshop in Ballarat and a Dynamic Prenatal Education program in Bendigo. Both have been very enjoyable and we’ve had a lot of fun.

The group in Ballarat were mostly either students or recent graduates, with a few more experienced midwives amongst them. Although the group were from a number of hospitals in the district, their limited experience of various workplaces was obvious and I encouraged them to look beyond their current places of employment to find out more about home birth and maternity services elsewhere. Working in other units can really broaden one’s view of birth and help to build confidence.

There were some sad/funny moments, especially when discussing the local obstetricians. One group of midwives work with an obstetrician who sets up a large lamp, shining on the labouring woman’s perineum, then calls to the baby to “come to the light”! It was hard to believe this, but they insisted it happens with this man every time - how do the midwives keep a straight face?

Other midwives described the repressive antics of their local obstetrician, a man clearly frightened of birth, who insists that women come to hospital as early as possible in labour, where he augments their labour ruthlessly and very closely monitors everything. He manages second stage with fundal pressure, heavy handed perineal guarding and sweeping of the vaginal tissues as the baby crowns. All this without any consent or concept of informed choice. This man has come from overseas, and is used to being in total charge of births. The midwives know that his practices are dangerous and that a disaster will occur, but their managers are concerned that unless they co-operate with the doctor, he may move on and the unit would have to close because there would be no obstetric cover.

I mentioned that these midwives could report this behaviour to the Consumer Complaints Commission in Victoria - they will record complaints from any member of the public or any health professional and investigate whilst maintaining complete confidentiality for the person making the report. These kinds of abuses against women must not be allowed to continue, and midwives can play an important role in making it stop.

Next week I am back in the office for a few days before preparing for my next trip back to Europe.

Continuing the story from Croatia, as emailed to me by Vedrana:

Concerning birth, in more detail, we organized the petition entitled “My Childbirth, My Body, My Choice” in 2002, with which we tried to improve conditions in Croatian maternity hospitals and to bring the standard procedures performed in normal birth closer to the WHO recommendations.

This petition demanded from the Croatian Ministry of Health that:

* All women in Croatian maternity hospitals be allowed to be accompanied by a close person during normal labour.

* Routine shaving and enema be abandoned and be performed only at the woman’s request.

* Guidelines for normal birth be made, which would accept the WHO recommendations stated in “Care in normal birth: a practical guide”.

* Statistical reports about medical interventions and conditions in different maternity hospitals be publicly available, so that pregnant women can choose the hospital in which they want to give birth.

These requirements were made according to the WHO document “Care in Normal Birth: a practical guide”. A total of 8931 people have signed the petition. There was some correspondence with WHO and FIGO, and FIGO recommended that Parents in Action (RODA) go into a discussion with our local health authorities, i.e. HDPM (Croatian Association for Perinatal Medicine). We did so, and in May 2003 a working group was formed, including members of HDPM, Ministry of Health and RODA. We were very happy with what promised to be a fruitful co-operation. The goals of this working group, agreed by all parties, were:

* to prepare a questionnaire for women, which they would fill in after the birth. The intent of this questionnaire was to gather information about childbirth conditions in Croatia, including the quality of preparing for birth, the support during and after birth, and the satisfaction with the medical staff and conditions in the maternity hospital. Information was to be used as the basis for various activities for humanizing birth in Croatia,

* to prepare a standardized birth plan, customized to conditions in Croatia. The recommendation was that women fill it in during their last trimester, with help from their gynaecologists, if needed, and

* to create guidelines for normal birth.

Six meetings of the working group were held in over one year and, by March 2004, the working group had prepared a birth plan and the questionnaire. The birth plan takes into consideration the specifics of the Croatian health system, encourages women to seek information and encourages co-operation with the gynaecologist. The questionnaire that the working group prepared was taken for an analysis to an agency for market research, which confirmed that it is professionally made and that it assures qualitative research on this segment. Concerning guidelines for normal birth, it was agreed that they will be based on the WHO document “Care in Normal Birth: A Practical Guide” and adapted to conditions in Croatia.

The working group reported about its work to the managing board of HDPM in March 2004, in order to get an approval on the work accomplished, before going on to creating guidelines for normal birth. The only agreement made after the report was filed was that the managing board would discuss the birth plan and the questionnaire at their next meeting. All official correspondence ceased after that. We have officially requested information on the status of the matter, but have received no response. We have been waiting for more than nine months now for HDPM’s official statement about those documents.

We have tried to change this completely inadequate routine treatment and create a freedom-of-choice atmosphere with our petition and, later, with our co-operation with HDPM, but very few changes have taken place since 2002. Those changes that did take place were mostly because of individual initiatives of a few gynaecologists and neonatologists in hospitals in which they work. The co-operation with HDPM is now stalled and practically non-existent. The co-operation with the organization of midwives is great, but they do not have much influence and are, in many cases, afraid to speak up because they are afraid that they might lose their jobs. The perinatal mortality rate of 6.3 per thousand births in Croatia (for 2003) proves that care in complicated births is of high quality, given the circumstances, but the problem of care in normal birth remains and it has proved to be extremely hard to accomplish improvements in that area.

Much of what Vedrana has written will be familiar to readers - her struggle is similar to many that are going on around the world. If anyone would like to contact Vedrana, please email me and I will pass on you message. I can be reached at: andrea@birthinternational.com.

I have received the following email from Vedrana Valcic of “RODA” a group of parents and midwives who have banded together to try and bring about reform of maternity services in Croatia. She had agreed to her email being included in this Diary, and I will reproduce it in two parts, as t is very long. This first section describes the current scene in Croation maternity hospitals and the next installment will cover the actions that RODA are taking to encourage some changes.

“I am a keen reader of your diary and the Birth International web pages. I am writing to you from Croatia, a country where birth is very medicalised, run by obstetricians, midwives only have secondary education, patients’ rights are ignored in most cases when it comes to birth, breastfeeding rates are pretty low (around 30% of exclusively breastfed children at 6 months), a situation which is pretty close to the one in Italy, which is our neighbouring country. I should also mention that the International Code of Marketing Breastfeeding Substitutes is being violated in the whole country. I am also a member of an NGO called “RODA”, which is short for “Parents in Action” (”RODitelji u Akciji” in Croatian), which has been fighting (among other things) for a possibility of birth without interventions, as well as lobbying for higher education for midwives. RODA is also a member of IBFAN. We have a good cooperation with the organization of midwives, whose web site we helped to build (www.udrugaprimalja.hr). You might also want to check our web site at www.roda.hr. Both sites are mostly in Croatian, I’m afraid.

This is the situation today in the majority of Croatian maternity hospitals. Women are still routinely shaved in normal births and given enema. In the first stage of normal labour, there is constant electronic fetal monitoring and women spend this time bedridden in most hospitals. Delivery is mostly in the supine position. It is practically impossible for a woman in labour to refuse these and other procedures. Non-pharmacological methods of pain relief, such as showering, massage, relaxation and breathing methods are rarely used. In addition, early amniotomy and oxytocin infusion are a common routine. Episiotomy rate is slightly reduced, but only in few of the hospitals, and overall it is still between 50% and 60%. There is usually an attempt to accelerate the normal birth process using all of these procedures, including fundal pressure during the second stage of labour. It is extremely hard for women giving normal birth in Croatia to make decisions about their labour because they are being denied their right to an informed choice. Even when women have presented a birth plan, their decisions and wishes are neglected or it is hard to get the medical personnel to comply with them, even when the labour is progressing normally.

This negative atmosphere for women who wish to have expectant management of their labour is even more emphasized with the fact that in 17 of total 36 maternity hospitals the women are still not allowed to be accompanied by a close person. Out of the 19 maternity hospitals which allow the attendance of a close person, in five there is a prerequisite of attending an educational course while in another four an approval of a physician in charge is required. Furthermore, it is an exception, more than a rule, that a baby is with her mother in the critical period after birth - they are usually separated for at least two hours after birth and bonding is rarely encouraged”.

In my next entry I will include the actions that RODA are undertaking. Vedrana is looking for ideas and input from other around the world and is keen to network with other groups and midwives who might have ideas for her. I have already given her some ideas and we are talking about various possibilities for improving education and networking. I have suggested that she join the ozmidwifery email list and read what other midwives/women are doing not only for ideas but also to gain some support.

There has been a fascinating debate amongst midwives on the ozmidwifery list around the tasks that midwives are asked to perform during labour and whether this constitutes stepping over the line to become obstetric nurses.

It began with a request for hospital policies on the topping up of epidurals, which prompted a spirited response that this was not a midwifery task but a medical one, and should therefore be performed by an anaesthetist. This raised the point that epidurals are also used post caesarean and that anaesthetists are not always on site - should midwives let women suffer because an anaesthetist wasn’t available?

The discussion then extended to other clinical tasks such as cannulation and the giving of antibiotics in labour (usually for the treatment of Step B infection in labouring women - GBS). Some midwives felt that this was well within the scope of practise of a midwife and others felt that it was perilously close to a medical treatment and that by performing these tasks, midwives risked becoming “doctor’s handmaidens”.

Another contributor raised the point that if an intervention was required, such as an ARM, or even a vaginal examination (which could be seen as an intervention in some situations) then it would be better done by a midwife, who was often a lot more gentle than some doctors or residents. The idea of protecting the woman from unnecessary discomfort or disruption to her labour was an important issue in this midwife’s mind.

Midwives in rural areas pointed out that they regularly carry out these treatments in other areas of the hospital where they work as nurses when not required in the maternity unit. To refuse to use these skills in the labour ward would severely limit their employability in remote areas.

Then a discussion arose around the condition of GBS, and whether women who carry this normally harmless bacteria are in fact sick (and requiring medical care) or well, and therefore suitable for midwifery care, which may result in the siting of a drip and the giving of antibiotics in labour. This discussion is on-going, with various points of view being aired.

Describing the role and scope of midwifery is a tricky exercise. I find myself agreeing, in one way or another, with most of the correspondents as the discussion swirls around in a very energetic fashion. I do think that midwives need to guard against performing tasks ordered by the doctors when they are not necessary, such as inductions, vaginal examinations, and rupturing membranes. Taking care of a woman’s comfort in labour is also very important, and if a necessary task, such as topping up an epidural (if the more satisfactory continuous infusion is not available) is required in the absence of medical help, then common sense may suggest the midwife should help.

Email discussion lists are such a useful forum for airing views and canvassing help and opinion. If you would like to follow these threads, please feel free to join the list - we have members from allover the world taking part by now! Click here for details on how to link yourself in…..

It is amazing how the subject of breastfeeding, when discussed amongst women, becomes very personal, even when seemingly simple issues of management are being reviewed. This has been a “hot topic” on the ozmidwifery email list for the past week, and it began with an articles in one of the newspapers last weekend that put the “Pros and cons of breastfeeding” forward.

This article had been an exercise in damning breastfeeding with faint praise, mainly because it was being careful not to upset any women readers who might not have been successful in nursing their babies - the aim was clearly to try and not engender any guilt for apparent “failure”.

The debate has raged all week, not between breast and bottle feeders, but between breastfeeding mothers themselves, many of whom had experienced problems and who felt the level of care and advice they received from the professionals was unhelpful or unsupportive. Most of those joining the debate were midwives, but there were a number of women too, and some who complained of the “nipple nazis” or even “breast bitches”.

I should say that in Australia, where there is strong adherence to the International Code of Marketing of Breastmilk Substitutes, we have high rates of breastfeeding overall with about 50% of women still breastfeeding their babies at 6 months of age This figure might be even higher if more women were able to stay home and not return to work, but it is still a much higher rate than most other developed countries.

One aspect of the debate about how midwives support breastfeeding that hasn’t been mentioned is the innate sexuality of breastfeeding. One correspondent mentioned that women who were not successful with breastfeeding often felt similar guilt to women who had unexpected caesarean births. Pregnancy, birth and breastfeeding are all integral elements of a woman’s sexuality and it is no wonder than any messages a person receives (in any form) that casts doubt on an aspect of their sexuality or capacity for sexual expression, could be seen as threatening and likely to produce a range of emotions, including guilt.

Many years ago, when I first became interested in the whole birth scene, I got started by counselling women with breastfeeding problems. Mostly this was over the phone, but sometimes I visited them as well. It quickly became clear to me that the reason women were finding breastfeeding difficult was not because of their own shortcomings, but because in one way to another, the way the birth was handled had upset their hormonal system or created barriers to the successful initiation of lactation. Most of the labour management strategies in use have this potential capacity: drugs given to the mother can affect the baby; oxytocic drips can disturb the delicate hormonal balance in the new mother for many hours and cause jaundice on the new baby; Forceps or vacuum could give the baby a headache; the list goes on.

Soon after I began putting these factors together, I was lucky enough to meet Walter Whittlestone, a very eminent lactational physiologist from New Zealand whose work on oxytocin was world renowned. He stated clearly that lactation was the most reliable of all the body’s systems - more reliable than respiration, circulation or digestion, for example. This was important because the survival of the next generation depended on a regular and plentiful supply of food.

I believe that the reason women have difficulties with breastfeeding is because the health care system interferes with the hormones and natural behaviours that are necessary for success. Women should stop blaming themselves and turn their attention to finding ways of getting better care during labour and birth. It is not the women who have failed, it is the system that has failed them, and jeopardised the health of their babies through making breastfeeding difficult. All the attention on ensuring “correct latching” (almost an Olympic sport these days) has come about because babies are drugged at birth, their reflexes may be depressed and women are often in no state to interact in a spontaneous and nurturing way with their newborns. The medicalisation of birth has spawned the medicalisation of breastfeeding, with experts, special clinics, and endless advice that puts pressure on women to “get it right”. No wonder some women struggle and finally give up.

This sad state of affairs has provided a reason for a whole new layer of health professionals (lactation consultants) to get themselves established. If more effort was put into helping women make the link between birth interventions and later issues with breastfeeding, perhaps some would stop blaming themselves when their have milk supply problems and recognise that if they had taken fewer opiate drugs in labour, for example, either as pethidine or in the epidural mix, they may have avoided this kind of situation developing.

Years ago, I realised that the key to better breastfeeding lay in enabling women to have natural, undisturbed births. That’s why I turned my attention away from breastfeeding counselling and have put my energies into supporting ways of achieving better midwifery services that will benefit mothers and babies. I think tackling these links is an important key in increasing breastfeeding rates around the world.

The crisis in rural health, especially in the provision of maternity care has become a critical issue, for those who live in the country in Australia and also for service providers.

Although almost all of Australia’s population live within 100 kilometres of the oceans that surround us, there are still many people that live in remote areas, often many hundred of kilometres from the nearest large town. For these people, getting medical help may mean a long drive over dirt roads or else reliance on the Flying Doctor Service who provide emergency care and some regular clinics in small townships in rural areas. For pregnant women, the need to attend check-ups during their pregnancy may mean several long round trips by road to the nearest hospital, and a journey in labour that may end with an unexpected birth on the side of the road.

Service providers face the problem of attracting and retaining staff in rural areas. The long hours required to cover staff shortages, the need to provide schooling for their own children, and the lack of locums to allow time off are some of the issues that make living and working in country areas less attractive in the long term. Obstetricians are in short supply - most prefer to work in the cities where access to the latest equipment, a group of colleagues and wealthy women, make private practice more lucrative and comfortable. For hospital based doctors, there is the prospect of a wide variety of patient problems and conditions that are useful for honing skills.

Last December a meeting was convened in Canberra by the National Rural Health Alliance to discuss these issues and to explore the issues inherent in “Birthing in the Bush”. The group was widely representative of all stakeholders and they worked together to address these issues: women’s birth experience; safety and quality; workforce shortages; job satisfaction; and education and training. Of particular concern was how the varying needs of pregnant women could be addressed - from those who want to stay close to their families when giving birth to those who want access to all forms of technology and the private health care they expect, having paid for private health insurance.

A proposal was formulated that will go some way to meeting the needs of parents and of care givers. In essence, it involves the development of “triage-type” teams operating out of Regional Maternity Services Divisions that would

The papers from the Future Birth tour around Australia in March are now available on our web site. Of particular interest, given the current concern about birth in rural areas, is the paper by Sally Tracy on the new midwifery unit at Ryde and the results of her research into the safety of small maternity units. Click here to read her paper.

Susanne Houd’s excellent presentation on the way maternity care has been returned to women in the isolated areas of Nunavit, northern Canada, and Greenland is of great interest. Here is an example of how enabling women to give birth in small, isolated communities can give better results than birth in larger, more technologically advanced hospitals. It is the midwives who make the difference and the education of local women to become the midwives for their own community is a shining example of primary health care at its best. There is much to learn from these examples, and programs based on these models would serve our Aboriginal women well. Giving birth “with a home”, as Susanne describes it, is as important to Aboriginal women in Australia as it is to the Inuit of Canada. Click here to read more.

One of Sandy Kirkman’s greatest gifts is her ability to make us laugh - at ourselves, our situation and our work. The seemingly endless stories she told of midwives, students, Irish Nuns, and hapless parents were funny, but also carried powerful messages. She encouraged us to celebrate the unsung heroes of improved maternity care and provided a number of examples of pivotal research that changed birth services forever. Click here for these references are all now on the website, along with the poetry she shared with us on the day. I can’t give you the twinkle in her eye or the rubber-faced expressions that had us in stitches - you’ll have to imagine those!

The tsunami disaster in South-East Asia touched everyone in some way and has led to a massive outpouring of aid for the devastated people of the region. An email reached me today from a reader of this Diary who wanted to locate an orphanage in Thailand as she had two cartons of children’s shoes from Clarks that she wanted to give to children in need in the area. As an ex-school teacher she also had time available, if anyone needed help.

I have replied to her privately, because at the moment I am unable to offer the “comments” facility on My Diary because of problems with spam, and this woman had found me through our general feedback section on the website.

I have given her the contact details for Bangkok Mothers and Babies International (BAMBI), a group for expatriate women with young families from all countries. This group has been meeting and supporting each other in Thailand for almost 25 years, providing not only assistance to each other, but support for several local charities, including schools. I know they have been actively involved in providing tsunami relief in the south of Thailand as well.

If any of you have a comment to make on anything that I write, please email me privately for the time being: andrea@birthinternational.com. Messages sent to info@birthinternational.com or via the Webmaster button on the home page will also eventually reach me, via my Sydney staff.

News this morning that another small maternity unit, this time in Mareeba, Queensland, is to close because the only obstetrician in town has decided to turn to private obstetrics and won’t now support the public hospital maternity service.

Mareeba, which is in far north Queensland, just inland from the very popular tourist spot of Cairns, has had an excellent maternity unit for many years, offering very woman centred care, excellent outcomes and a wonderful midwifery philosophy. The obstetrician has been very supportive of the model of care they have developed over time and is very midwife-friendly in the past. Although the midwives have been told they can continue to offer pre and post natal care at the Hospital, this is not satisfactory. Women will be forced to drive down from the tablelands when they are in labour to give birth at the Cairns Base Hospital, which is already struggling to meet demand from surrounding areas. The chances of babies being born on the side of the road is very real.

Th sudden announcement to suspend birth services at Mareeba, made with no warning and no consultation, does offer a great opportunity. This may be the catalyst for the opening of the first midwifery maternity service in Queensland, along the lines of the very successful Ryde Hospital service in Sydney. I understand that the lobbying and politicking has already begun and no doubt there will be much activity both locally and across the State, supported by evidence gathered from other parts of Australia.

The report of the Queensland Government enquiry into Maternity Services has not yet been tabled in Parliament. It is hoped that this enquiry will have exposed the lack of options for women giving birth in Queensland and provide the impetus for the development of more woman and midwifery-friendly services across the State. This debacle in Mareeba may be the tipping point for better birth options in a State that has, for years, lagged behind the rest of the country in terms of birthing services.

The developments in Mareeba will be watched with great interest by everyone.

Contrasts in obstetric care are in my thoughts this morning, as I head to Heathrow for the long trip home to Sydney today.

First I have been in Ireland, where obstetricians rule the roost and women clamour for private consultant care so they can get their private room in a hospital for three days following the birth. Irish women seem quite happy to accept the high levels of birth intervention they and their babies will suffer during labour, the added costs they must pay, and the potential for long term health problems (of which they have probably been told nothing) just as long as they can be moved into a private room in the crowded maternity hospitals for a few days of “hospital pampering”. Private health insurance is a status symbol and women talk proudly of “their consultant”.

Next, I read in the Sydney Morning Herald (which I access online each day) of the problems facing pregnant women in rural NSW. As a result of the close down of small rural maternity units due to the reluctant of doctors to attend births, women in labour are being forced to drive hundreds of kilometres to the nearest regional centre. A recent report of a baby being born outside a pub with the aid of a publican’s wife (an Irish nurse, as it happens!) during a drive of over 150 kms to get to hospital has raised the issue.

Meanwhile, the Australian Government has decided to try and curb the excessive amounts of money being spent through Medicare on IVF as a way to ease the blow-out in the safety net funding arrangements. This has caused a stir because some women feel they have the right to IVF so they can have a baby, and that this should be funded by the public purse. The fact that the obstetricians charge so much for the procedure, knowing that us taxpayers will pick up the tab is not openly acknowledged, but is the root cause of the high price of IVF.

Here is London, obstetricians are apparently diversifying. Not content with the huge boom in caesareans and IVF, they are now adding colo-rectal surgery to the services they are offering. Using the ploy of encouraging women to get “their private parts tidied up” up after giving birth, some are now offering to re-fashion perineums and vaginas so that the “body beautiful” can be preserved. It won’t be long before the need to preserve the “honeymoon vagina” creeps up the list of reasons for caesarean birth in Britain, as it has in places like Brazil, where obstetricians routinely perform this surgery and are proud of their 100% caesarean rates.

Not that Brazil is alone in having obstetricians who boast of their surgical skills. In Brisbane, Queensland, there are at least two obstetricians who will only perform caesarean sections and they too have 100% surgical birth rates. One of these is a staunch and vocal supporter of private obstetric care and is scathing in his criticism of midwives and normal birth. As a spokesperson for the Australian Medical Association he gets lots of publicity and he is no doubt one reason why people are coming to regard some doctors, and especially some obstetricians, as money hungry self publicists.

I wonder what exploitation of women’s bodies obstetricians will come up with next, to maintain their bank balances?