Andrea’s Diary

This weekend I am presenting an Active Birth workshop for the Corangamite Managed Clinical Care Network, in Timboon, Victoria.

This is an interesting two year project, initiated by the GPs who cover the three hospitals in this area: Camperdown, Timboon and Terang. These three small rural units have about 150 births per year between them. The GPs have Obstetric Diplomas and also are able to do anaesthetics and they see all the pregnant women for pregnant and intrapartum care.

The Managed Clinical Care Network is an initiative funded by a rural health grant and was established to encourage good communication, education and learning opportunities for the GPs and midwives in the region. The Co-ordinator is responsible for administering the program and arranging the educational events and meetings.

The workshop is well attended with two of the GPs and midwives from the local hospitals and Warrnambool, which is the tertiary referral centre, not far away. There are also two midwives who have travelled over 900 kms from Cooma to attend!

It is clear that there is much interest in promoting natural birth and in developing good working relationships between all the staff. The easy camaraderie and sharing has been notable and new ideas have been thoughtfully considered. As with many hospitals, there is a shortage of midwifery staff and this is an issue that the network is tackling, looking at ways of attracting and retaining new midwives so that the hospitals can remain open. Without midwifery staff, the GPs will not be able to continue offering maternity care.

All the midwives work as nurses, dividing their time according to the needs of the hospital to cover the inpatient cases. This presents a further problem for the future, as the new midwives graduating are all “direct entry” and will not be able to provide nursing care. From what I have seen so far in this area, the set up of the three hospitals (they are all relatively close together) provides the perfect opportunity to establish case loading midwifery care. This is being considered, but many of the midwives are reluctant to give up their nursing and many have also expressed concern about the commitment and changed working practises that will be required.

One big problem is that because the GPs attend the births, the midwives have lost some clinical skills and therefore lack confidence (and perhaps competence). Up-skilling the current midwives, or attracting midwives from elsewhere who are able to practise autonomously will be important if case loading is to work.

The project is about half way through its two year term. It is to be hoped that their plans for re-vamping the system will be completed and in place with enough time to evaluate and report on the outcomes. It could be a very useful model for other small rural units, who are often under threat of closure.

The WHO Reproductive Health Library is an alternative source of information to the Cochrane Library. It focuses on all areas of reproductive health in a multimedia format, from fertility regulation, through pregnancy and childbirth, HIV/Aids, newborn care, infertility and more. The April 2006 release includes new editorials, commentaries and systematic reviews, as well as a new practical video demonstrating how to do a vaginal breech delivery (which unfortunately has the labouring woman lying on her back).

The RHL is prepared by an editorial team based in the WHO Department of Reproductive Health and Research and was established in 1997 in collaboration with other agencies worldwide.

The website is easy to use and well laid out. I think it is more user-friendly than the Cochrane Library and because it has other input apart from the randomised controlled trials, is more geared to the practical application of the research.

For more information and to subscribe (from as little as £47 per year) click here. There is also a free trial service and a demonstration that explains what is in the Library and how to use the various sections. Subscriptions are subsidised for those in developing countries.

This is another very useful source of information for midwives, educators and others keen to see better maternity services worldwide. You will want to bookmark this site in your browser.

While I was in the UK, I had an opportunity to get together with the artist whom we have commissioned to produce a wonderful new set of pregnancy charts. This series will replace several sets of charts we currently stock and be more useful for educators, who won’t have to buy so many separate chart series. It will also have no words, making it useful for educators who work in languages other than English.

The charts will be part of the next release in “The Essential Educator” series. The first two packages in this unique series will be available next month and the third set, on the theme of Pregnancy, will be released in July. The Pregnancy Charts are the centrepiece of this package and will offer a wonderful visual aid to help women understand fetal growth, the changes in their body from conception to birth, and the development of twins.

Meeting with Joanne Acty, the artist who also drew the “Giving Birth” chart series, was terrific and we discussed the finer details of the project. She had some of preliminary work to show me and it is looking fabulous. Instead of using coloured pencils to painstakingly create layers of colour as she did for the “Giving Birth” series, this time she is using the computer and some special techniques to develop images that are similar to drawings but easier to replicate.

She is a very talented artist and runs her own art school where she works with adults and children to enable them to develop their creativity. Joanne has had home births herself, so she is very familiar with the philosophy that underpins everything we do at Birth International and it is a pleasure to work with her. Can’t wait to get my hands on the finished product…….

Its hard to know where reform of the maternity services In Iran might begin. On the second day of the workshop, the group spent some time thinking about how women could be made more comfortable and less fearful when labouring in the hospital. There is little that can be done about the physical facilities as the pictures below reveal.

Women arriving in labour are first taken into a small assessment room, where the baby’s heart will be monitored and basic checks undertaken. If there is any irregularity detected at this point, the women will go straight to theatre, otherwise she will then be moved into the main labour ward.

This is the first stage area where women labour in this hospital (which is typical of most in Iran). Moveable screens were added recently and I was told that curtains have been ordered for around each bed. There were two women in labour in this six bed room when I visited - both were alone, lying on the bed and had drips in place.

There was a group of medical students in attendance, shown here consulting together around the bed of one woman. All the births are managed by the doctors (or students) and the midwives are there to carry out their instructions.

One full dilatation is achieved, the woman is then moved into this delivery room. Three beds here, with no privacy whatsoever. I was told it is unusual for three women to be giving birth at the same time, but two was not uncommon. The green plastic sheet is covered with a sterile sheet before the woman is lifted onto the bed and into the stirrups. The women will have sterile leggings applied she will be draped with sterile sheets for receiving the baby.

Once born, the baby’s the cord will be immediately clamped, the baby shown briefly to the mother, then taken to the resuscitaire for checking before going immediately to the nursery, where it will stay for at least 2 hours. The woman will be stitched after the mandatory episiotomy then moved again, to a recovery room where she will wait until the two hours are up and she can be moved to the ward and reunited with her baby.

If any problem is detected during labour, the solution will be an immediate caesarean, under general anaesthetic - the theatre is next door to the first stage area. In this hospital, 50% of births are by caesarean.

Where can change begin in such a system? The doctors are all powerful, completely dictating the management of every birth and seemingly oblivious of evidence based care, midwifery skills, mother’s wishes or anything else that might impact on their practise. They have the “once a caesarean always a caesarean” rule firmly in place, so it is no wonder that surgical birth rates are rocketing.

Midwives have little voice, power or status within the system. They learn about normal physiology but it is an academic knowledge as they have little chance of seeing it in action and gaining confidence through practise is virtually impossible.

Some of the questions I was asked indicated that the information they were giving students was from obstetric texts - it seems that Williams Obstetrics is the main reference manual. One belief they voiced was that precipitate labours have a very high risk of post partum haemorrhage - where do they get such ideas? They also have very definite views that many kinds of perineums just won’t stretch and that is why routine episiotomy is performed.

Although we talked about all kinds of things, such reducing V.E’s, giving women drinks in labour rather than routine IV hydration, not shaving the perineum, abandoning enemas and not separating mothers from their newborns, I am not at all confidence that they believed me when I stated many of their routine procedures were outdated and even dangerous. These midwives, mostly from academic institutions were aware of The Cochrane Library and other good sources of research, but seemed unable to translate the theory into any kind of practical application. It is sad that most have never seen a normal birth (by my definition - not just a vaginal birth, which is what they normal). A pilot Birth Centre is on the drawing boards at the Ministry of Health, but how this could function without skilled midwives is a mystery to me.

I will be making some suggestions in my post visit report on how midwifery might be strengthened. It will be interesting to see how they tackle the problem…..

Meanwhile, they were a terrific bunch of women, keen, warm and very hospitable. I have had an eye-opening time, and I think they did as well!

The group at work

Having lunch together

All in together

I have returned from Iran and can now post several articles and some photos about my experiences in Iran. This is the first report.

Today was the first day of the workshop I am facilitating in Iran. They (the Ministry of Health, the UN Population Fund and the Hospital that is hosting the event have gone to endless trouble to make everything as comfortable as possible and they are being wonderful hosts - I am embarrassed by all the attention I am receiving.

The group is made up of some policy makers from the Department of Health (who are midwives and doctors), Midwifery educators from a number of Universities (many of whom are also practising midwives), some Obstetricians (who only stayed for a few hours), some students and other key midwives. They have been forthcoming and interested, asking many questions!

After the formal opening speeches, we got down to work. First I asked the group to tell me about birth in Iran. After some consultation with colleagues in small groups, they described the typical care pattern for pregnant women, noting that there are variations between city and rural areas. It seems that pregnant women have the following routine:

If a caesarean birth is indicated (and this happens up to 75% of the time in some hospitals) it will be done under general anaesthetic - epidurals are not routinely offered for surgical births. Few forceps or vacuums are offered, and caesarean is the preferred method used whenever there is a problem in labour.

Doctors perform almost all of the births in both the public and private system, with the midwives acting as assistants. Midwives usually care for 5 woman at a time during labour.

There is no organised system for prenatal education for women at all - whatever they learn will be picked up during the 5 minute midwifery consultations during pregnancy.

This is a brief outline of what I learned today. It is not a pretty picture but is typical of birth in developing countries. It seems they have learned their birth management techniques from the Americans 40 years ago and haven’t shifted since - there is a long way to go.

We touched on evidence based care, informed consent, defensive practice and litigation today and will explore these in depth later on. I spent most of my day fielding basic questions that reflected almost total disbelief that birth could happen in any other way. Certainly some in the group have experience of physiological births, some because they were practising many years ago, before birth had become so centralised in large hospitals. The midwifery educators have knowledge of the evidence but are struggling to convey it to their students who are unlikely to see any of it in practise. I was told at one point that much midwifery education is based on medical texts not midwifery tests, with Williams Obstetrics being the basic text for both midwives and doctors.

It is hard to know where to start with all this. We’ve done the pelvis exercise an explored how they can use the pelvis to resolve difficulties during birth. There is a perception that I am going to teach them “the method” for training women and this is going to be hard to debunk, given that they are used to telling women what to do and expecting them to conform. All I can do is show them another way and leave them with evidence and ideas. Perhaps on the next visit (yes, they are already talking about that!) we can go further, but my first task will be to try and shift some attitudes towards birth and get them thinking.

Tonight I am heading off to Iran, to present a three day workshop for the Ministry of Health. This trip has taken quite a while to organise, involving joining the United National Consultants list, negotiating the program and then obtaining the necessary Visa (which has taken some doing!).

The plan is to provide some in-service training for those making decisions about maternity care in Iran. I have asked for the group to be primarily midwives, as the primary goal is to encourage the development of skills that may assist in lowering the caesarean section rate. Obstetricians are not much help in this regard, as they are usually behind the rising rates of surgical births and are often very reluctant to change. I have requested that the group consist of midwives, policy makers and midwifery educators and it will be interesting to learn who is in the group and how they work in the Iranian maternity services.

I haven’t much idea of what is happening in the Iranian birth scene, but tomorrow I will visit one of the hospitals, so that should be illuminating. I am hoping I can take some pictures, that I can share with my readers when I get home.

My global roaming facility for the internet is not set up for Iran, so there will be no email or Diary entries from me until I get home to Sydney at Easter. By then I hope to have accumulated a number of entries and I will upload them all, along with some pictures, for you to read.

I have been feeling a bit nervous about travelling to Iran, because I know so little about it, but now I am getting quietly excited, and anticipating an extremely interesting week.

The last two days have been spent with a bunch of midwives and educators from all over Cornwall, exploring teaching skills for prenatal programs, and tomorrow I am Iran, exploring birth in a very foreign land. The wonders of modern travel!

Last night I had dinner with the leaders who are involved in the Hull Sure Start Doula program. They told me that since my last visit, all the doulas in the first intake have been assigned to women and have been supporting them through their pregnancies. A number of the women have already given birth, and all the births so far have been “active” and very rewarding for all concerned. One woman, a drug addict, gave birth well, needing no medication and this was a wonderful outcome for a woman who clearly needed good support (and her doula) .

This is a very inspiring service and one that other Sure Starts might like to think about establishing. It will be a few months before this new crop of volunteer doulas are ready to be teamed up with women in the local community. Each woman who is selected for inclusion in the program will have a primary doula and a back up doula, and can expect close contact with a volunteer who will provide friendship and practical assistance. I am most impressed with this service and am sure that it is peer support aspect that makes the difference. We know it works with breastfeeding and it makes sense that good social support can also result in better births as well.

I am back in Hull today, to present an Active Birth workshop for the Sure Start Doula program. Once again I have a group of volunteer doulas who are undergoing their training in preparation for working with needy women during their pregnancy, birth and postnatal period. There are some other Sure Start people in the group and a number of midwives from the Hull area and further afield.

This is a very different group from the one I worked with in Mansfield on the weekend. That group was mainly older, experienced midwives, who felt that had already established an excellent midwifery service. Some of the feedback from them indicated some dissatisfaction with the workshop and I suspect they misunderstood some of the teaching strategies that I used. I wondered if, at times, they felt a little uncomfortable being challenged to think again about the services they were offering. I have still to find a unit anywhere in the UK that has managed to be completely “woman-friendly”.

This group in Hull are fresh-faced and young. Many have said they would like to become midwives and a number of the doulas are working towards gaining university entry and a place in a midwifery course in the near future. We’ve had a fun day exploring the physiological basis for natural birth and tomorrow we’ll tackle how to enable normal birth to unfold. Almost everyone in the group has had children as well, which always adds an extra element to the discussions. I think we’ve managed to explain why some of the events in labour occurred for several of these women, which will perhaps help them to resolve some of their feelings. Tomorrow will be another good day, I am sure.