Andrea’s Diary

Here is a wonderful piece of marketing! The Queensland State Government inAustralia has sponsored the Australian Breastfeeding Association to in a campaign of displaying large pro-breastfeeding posters in bus shelters across the State. The posters will go on display from July 24 - August 7 .

This is clever and delightful. You can download a copy of the poster for yourself here. How about printing some up and putting them up on notice boards in your local area?

This morning I heard a report on the radio that the Australian Competition and Consumer Commission had set up a new code of conduct to oversee the relationship between drug companies and doctors, in particular the way the companies offer freebies and kick backs (my words) as part of their advertising campaigns. The Government feels that this widespread practice needs to be made more transparent, so that patients are aware of what is going on and why certain drugs may be promoted by their doctors over other alternatives.

The schmoozing and massage of the doctors by drug companies (and no doubt equipment manufacturers as well) is outrageous. Incentives to attend conferences, free samples, free publications etc are all widely offered and received. The doctors need to keep up to date with rapidly changing developments in the medical field, which may not be so easy in a busy professional life. However, the requirement to keep updated comes with the territory and is a requirement for maintaining registration.

In addition, subscriptions to professional journals, registration fees for Conferences and seminars and other strategies that can be proven to be important for the maintenance of professional competence are all tax deductable. Doctors earn huge amounts of money (despite their protestations, no-one has ever met an impoverished doctor in Australia) and I would have thought that a few handy tax deductions might be useful.

At a recent workshop I presented, the midwives’ attendance was subsidised by the taxpayers, through a special purpose grant. Midwives earn very modest salaries and often get no help with seminar or Conference fees, and have to fund their registration, travel and accommodation from their own pockets. However, the doctors (GPs) who attended this workshop were paid to attend, the princely sum of $1500 for each day. The cost of the workshop to the taxpayers would have worked out at around $100 per day for each of the midwives, so the doctors did very well. In addition, two of them didn’t stay the whole time, dashing in and out to attend patients, for whom they would have received payment as well. Not bad - being paid handsomely to be in two places at once!

Knowing about this rort of the system left me feeling less than charitable (hence this whinge) when I also heard a comment from the Australian Medical Association spokesperson, in response to the report on the radio, that any changes made to the current system, “were unnecessary”, and might discourage drug companies from telling doctors about new treatments. Perhaps he was thinking about the added costs to his own pocket if all the freebies dry up.

You can read more about this interesting development on the ABC’s Newsradio website.

Last week there was an interesting program shown on SBS Television in Sydney. It was the story of a woman who was born with two wombs, two cervix and two vaginas, who conceived in each uterus at the same time.

Being born with two complete reproductive systems is extremely rare and is often associated with infertility. However, despite the odds, this mother became pregnant, with one baby a girl and the other a boy. The pregnancy was carefully monitored by her obstetrician (this was in the UK), because each uterus was about half the normal size and there was concern that this may hamper the baby’s growth and development.

The film followed the mother through her pregnancy, interviewing her and her husband, the obstetrician and her mother. There were several scares when ultrasound scans suggested there may be problems (once it was the shape of one baby’s head) but these proved to be false, and the babies grew well. The plan was to maintain the pregnancy as long as possible, with a caesarean birth scheduled around 36 weeks.

By 34 weeks, the scans were being done every two weeks to determine growth. At the 34 week visit, the obstetrician announced that the fluid surrounding one baby was reduced and he scheduled an immediate caesarean, for later that day. The poor mother was very upset, and not at all emotionally ready to give birth, however she agreed for the sake of her babies. Given that very few cases of a double pregnancy like this have ever been recorded, and none had produced two live babies, it is easy to see how everyone was trying to achieve a positive outcome in this case.

The scene after the caesarean was heartbreaking. The mother was shown in a bed, sobbing because she had not seen her babies. They had been whisked away in theatre to be cared for in intensive care as both had respiratory distress (a typical problem of premature births) and after two days, she had still not seen her children. She was bereft and clearly distressed by this separation, which had started suddenly, out of the blue on a day when she thought she was going to have a routine check-up.

Finally, after a long wait, she was taken in a wheelchair to the ICU where she was helped to cuddle her babies against her skin, while a midwife helped with all the tubes etc. The change in her was dramatic - at last she held her precious bundles and expressed the joy of holding her child and what it meant to her.

While this was an interesting story, and no doubt one of great historical interest, I felt it showed some glaring inadequacies in the system at the hospital in Exeter. Why was the mother left for two days without even seeing her babies? She was quite well and there was no apparent reason why she couldn’t have been taken immediately she left recovery, to at least see her babies. To deprive a mother, especially in her special circumstances, of the opportunity to affirm her babies were OK, after all the concern raised by this complex pregnancy, seems cruel and unusual punishment.

A caesarean birth is not one that most women anticipate, yet sometimes they are necessary. When a caesarean is indicated, especially in an emergency, why can’t basic humanity prevail and steps be taken to minimise the trauma that will accompany such an event? There are many things that can be done to ensure the emotional and psychological well being of the mother and her family at that time: holding the baby in theatre, having skin to skin contact while in the recovery area (and early breastfeeding), unrestricted access to the neonatal intensive care unit and help with expressing colostrum for the baby. The needs of the father must also be considered as he is often traumatised as well, and he needs unrestricted access to his partner and baby too.

On another note, I was surprised that the obstetrician made the snap decision for an immediate caesarean based on one reading of a scan that suggested some reduction in the amniotic fluid surrounding one baby. Surely the appropriate course would have been to monitor the situation, taking readings every two days to ensure that the fluid was decreasing. A single interpretation of a scan may have been incorrect, or it may have indicated reduced fluid that was stable and not a cause for concern. I couldn’t help wondering if his rushed decision had something to do with the theatre schedule, and the presence of the TV crew that day. The babies were as well as could be expected at 34 weeks and respiratory distress (the result of being born too soon) was reported as their only problem. Why couldn’t they have stay safely inside until both they and their mother were ready to take the next step into the world?

The Essential Educator Kit has been launched in the UK with a very successful event in Wales. Having worked constantly on this huge project for the last six months I have been so close to it all that I was a little nervous about how others would receive it. I need not have worried - the group of midwives, University Lecturers and childbirth educators who came to the free demonstration were bowled over!

One asked me how long it had taken me to write, produce and assemble the Kit and when I said “six months” another person added “and the last 30 years!”, which is not exaggeration as I have poured all my experience of childbirth and parenting education into this project. Several commented that the cost was extremely reasonable, given what the Kit contained and the quality of the products. The diversity, scope and innovation of the inclusions was praised and also the flexible way it can be used in either existing programs or to launch a new educator into the field.

Those who purchase a Kit are entitled to a free place in a one-day workshop that will help them get the most from their Kit and provide extra training in group management and presentation. These workshops are being scheduled for Australia in late August and for the UK in September, with more to follow in early 2007. The first one on the UK will be inwales, to follow on from last week’s event. The dates will be added to the website in the coming weeks.

I am very proud of this Kit and hope that others will find it practical, useful and very professional. You can find out more about The Essential Educator on our website where the full details are now displayed. I am looking forward to feedback from the first Kits to go out to those who have already purchased - I’ll be talking to them when I get home.

It’s back to Australia today, after a very interesting and useful time in the UK. Lots awaiting me as usual but as ever, it will be good to be home.

This week I presented a workshop at Queen Charlotte’s in London. This famous hospital relocated a few years ago to a new site, with a new building and all mod cons. The plans had been on the drawing board for some years and by the time the service was established, it was realised that the number of births in the area had grown and they needed extra capacity. It was decided that the extra births (around 1000 per year) could be accommodated if a Birth Centre was established, so part of the adjoining Hammersmith Hospital was converted for this purpose.

The Birth Centre at Queen Charlottes is a very well appointed service. The rooms are spacious and well equipped with large floor mats, huge bean bags, birth balls and birth stools and each has an en-suite bathroom and a large tub. The small regular bed sits in the corner and has a pull-out trundle bed for the father if he wishes to stay after the birth. One room has a hammock-like sling hung from the ceiling that women can use for support during labour or to hold onto for the birth.

The midwives who work there are carefully chosen for their experience and skills with normal birth and the outcomes, as you would expect, indicate that the midwifery model of care is very effective for keeping intervention rates down (the caesarean rate in the main part of the hospital is 36%).

The participants in the workshop were from several hospitals and all were involved with either caseload midwifery (one-to-one) care or were employed in a birth centre. It was stimulating to have such a group of experienced midwives to work with - all were familiar with home births and all were deeply committed to providing woman centred care.

Yet even so there were issues that we needed to explore. Two of the midwives were Italian and both had provided home births in Italy. Given the lack of opportunity for this approach in Italy, they had decided to come to England - “the home of midwifery” - so they could work freely as midwives. They discovered that in England, even amongst midwives, birth is often medicalised. They were shocked at the regulations and rules that are all pervasive in the maternity services, often stifling midwifery practise and forcing women and their midwives to fit into predetermined moulds. Both worked in a birth centre and were able to facilitate normal births, but declined to use Entonox and TENS, for example, which are both “very British” inventions and almost unknown outside the UK.

We also discussed the language issue at length. One of this group talked about “confinements” to the surprise of the others and all were very fond of the “delivery” word. Since they had identified communication with women as a theme they wanted to explore during the program, we talked about the way words impact on women’s impressions and emotions, especially during labour and how a few well chosen words can confirm the faith and trust of the midwife and build a woman’s confidence in her ability to give birth well.

Two of the group are involved in the setting up of a new birth centre service in the Mayday Hospital in Croydon just outside London, and we talked about the impact that the language can have in creating the right impressions in both the staff’s and the women’s minds. I encouraged them to think about designing paperwork that used the “birth” word rather than “delivery” as a starting point and gave them a copy of an article ai have written on the subject of language to stimulate further thinking around this subject.

Queen Charlotte’s Birth Centres uses an adaptation of the All Wales Pathway for Normal Birth to record labour progress, which I was delighted to hear. More about this wonderful tool later - I am off to Wales today to give a short presentation and will be talking to the creators of this outstanding midwifery innovation this evening. I’ll write it up further in a later Diary entry.

It was heartening to read the latest News Release from the Australian College of Midwives announcing that the NSW Department of Health has released a Policy Directive that supports and encourages the setting up of home birth services through the State’s Area Health Services.

Politicians often pay lip service to programs they think will win them friends and votes, yet often fail to follow up with appropriate legislation or regulations that enable services to be set up. In the case of home birth, the midwives and women of NSW have been lobbying hard for many years at both the national and State level to have home births made available on our national health service (Medicare). Privately, the NSW Department of Health has been muttering encouragingly, and now finally they have issued a directive that is binding on all Area Health Services in NSW. The full text is available on their website, but here is an excerpt:

Date of Publication 29 June 2006

Summary

This Policy Directive has been developed to reflect current evidence about the provision of homebirth. Area Health Services (AHSs), when providing public homebirth services, must comply with the standards set out in this document. Clinicians providing public homebirth services must be employees of, or have clinical privileges with, AHSs.

This document applies to: Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, Public Health Units, Public Hospitals.

Now that this Policy Directive is in place, it will be easier for Area Health services to set up appropriate home birth services for women. The South Eastern Sydney Area Health Service already offers home births as an extension of their Birth Centre Program at both St George Hospital and the Royal Hospital for Women, Randwick. It is hoped that home births will soon be available through Camden and Belmont Hospitals to extend theircurrent caseload midwifery services.

Although a welcome development, the Policy Directive does not help independent midwives, as it does not address their lack of professional indemnity insurance. As the Directive states, midwives offering home birth will have to be employed by or have been granted visiting rights at the AHS. This means that independent midwives are still excluded as they had their visiting rights at hospitals withdrawn when their indemnity insurance was withdrawn some years ago. This is a critical issue that still needs urgent resolution. Until a means is found to resolve the insurance issue, independent midwives will be reluctant to offer their services and women will be denied access to their care. This situation is discriminatory both for pregnant women and also independent midwives.

The Policy Directive is a good start. How many Area Health Services will heed this policy and set up a service for homebirths? That will be the final proof that home birth is on the map.