The Foundation has begun its first projects and to establish its credentials. Workshops have been held in a number of hospitals and a tour of major centres with Marsden Wagner, Gabrielle Palmer (author of The Politics of Breastfeeding) and myself as speakers took place in 1999. Links have been forged with UNICEF and the Department of Health and various publications are in the pipeline. As an Advisor to CBFT, I have given then permission to translate Preparing for Birth as a basic manual for parents and a means of raising funds through sales, and this is about to be printed.

Getting things done in Thailand takes time. The Thais are lovely, gentle, warm people with a very proud background and a strong sense of self as a nation. Their ways of doing things are unique, and at times very frustrating. They are known for their smiles, but these can hide a range of emotions making it impossible to “read” their reactions. Their concept of time and deadlines is very relaxed and causes angst for those used to westernised time-driven ways of working and getting things done.

I know that the Foundation is very much needed here and holds the promise of improved birth and parenting for the Thai people. I also see the effect that lack of action and slow progress is having on my dear friends and I hope they can hang in there to see their dream emerge and develop.

More about Thailand tomorrow.

Posted by andrea at 12:13 PM | Comments (4)

Birth in Bangkok

Hello from Thailand! Yesterday was a last-minute-getting-ready day and then travelling the 9 hours to Bangkok. I am having a few days here before heading off to the UK for a huge round of workshops (13 on all) and three conference appearances over the next 5 weeks. I’ll keep you posted on the current scene in the UK as I trek about to Scotland (twice), Ireland, Wales and many points in Britain.

During these few days in Bangkok I will have a chance to catch up with my close friends Melanie and Tanist Habanananda. Tanit is a Thai obstetrician and a crusading pioneer in this country for normal birth. Mel is a British childbirth educator who has been a major influence here as well. Together they established the first (and only) Birth Centre in Thailand at the Samitivej Hospital almost 20 years ago and this unit has a proud record of water births, normal births, great breastfeeding rates etc. It has also been a showcase for how birth can be as opposed to the very high rates of interventions that are part of the birth scene everywhere else in this country.

For women in most of South East Asia, births are managed in a very medicalised way, a legacy of old style US birth practice that has never been updated. Virtually 100% of women will experience shaves, enemas, lithotomy and episiotomy, labour alone in a shared room with little or no privacy and give birth in stirrups in a multi bedded 2nd stage area. There is no concept of midwifery care and birth is managed by a team of obstetric nurses who follow the doctors orders. Concepts such as consumerism in health care, choice as part of care, informed consent and woman-centred care are virtually unknown and not part of the culture in these countries.

Dr Tanit had his obstetric education in the UK (many doctors here learned their skills in the US) where he was exposed to quite different ways of doing things. He and Mel also had home births for their children and have read widely and seen many normal births. Many expat women in Bangkok seek our Dr Tanit’s care because he has a low interventions rate (3% caesarean section rate!) and encourages active birth. He is well known amongst medical circles here, often speaking to colleagues, and I’ve seen him demonstrate in their own hospitals with their clients how births can be achieved easily when off the bed.

I first met these wonderful people in the UK when Mel came to a workshop I presented in London in 1996 with a Thai nurse, Supriya Boonyagate, who was interested in birth. They had a great time and invited me to stop over in Bangkok and speak to the obstetricians on my way home. This I did, with success, and after that a very close bond has developed between us all. I have since facilitated many workshops in Thailand and my book Preparing for Birth is about to be released in Thai version. We travelled together to the big Humanisation of Birth Conference in Brazil in 2000 where we were speakers and have holidays together when we can. Mel and Tanit spend part of every year in the UK and the rest in Bangkok - an enviable lifestyle!

I’ll write some more about their work with the Childbirth and Breastfeeding Foundation of Thailand tomorrow, but today I am going to spend time lounging by the pool in the most sensational tropical garden paradise in the heart of Bangkok. An oasis in time and place.

Posted by andrea at 02:38 PM | Comments (2)

Using consumer power!

Reading about the various launching events for the NMAP on the ozmid list today has once again illustrated for me that consumers of maternity services have very powerful voices when it comes to achieving change. Of course, I have "come up through the ranks" of consumers myself and now work with maternity care providers, so I have a foot in both camps, so to speak.

When midwives complain that they having trouble getting a policy changed, or some new equipment, or even saving their unit from being closed down, I always ask if they have contacted the women whom they serve and asked them for help. There are many ways that consumers can challenge the system and get changes made from the outside that would be impossible for midwives to undertake from the inside.

Consumers these days also bring a number of potentially useful skills to their cause. With the average age of women having first baby now standing at just under 30 years, it means that these women have more education and life skills, and are also better equipped (i.e. experienced) at tackling authority figures, speaking in public, getting organised, finding resources etc.

Of course, many women don't know the problems being faced by midwives. Therefore, if you need help you will have to ask and provide background details before they can take up your cause. Multips are often the best bet - they are at home with children and are used to juggling a number of tasks at once. They are often keen to take on an interest outside their homes and they know the importance of good births from their own experiences. Check through the birth register at your hospital - find out who has writing skills, is a journalist, can manage statistics, prepare budgets, lobby politicians, has access to potential funding sources or whatever it is that you need. Make a personal call and ask for their help - very few will refuse and most will be delighted to be asked.

Following a suitable background briefing, you can then let the consumers get on with fighting the cause. Keep in close contact and praise their efforts. You'll be surprised at the energy they can create and the wonderful supportive atmosphere that develops between women and midwives.

This is how it always was - women needing their midwife for the birth, then the midwife needing the woman for support to enable her to do her job most effectively. These relationships need rediscovering and nurturing. BTW - does any have a better word we can use to replace "consumer" in this context? I have tried out just calling these women "users" of maternity services but that doesn't seem quite right either. Ideas anyone?

Posted by andrea at 02:52 PM | Comments (4)

NMAP takes off

Well, NMAP is off the launching pad! Here in Sydney we had a good day - first there was the Press Conference which was reasonably well attended by the major TV channels and some other print media. Nicole Christianson ("Keep Birthing in the Mountains", Fiona Tito (of the famous Tito Report on Professional Indemnity), Lee Rhiannon (NSW Greens) and Arthur Chesterfield-Evans (Democrats) all spoke in support. The hazard of choosing Parliament House was that the press conference would be hijacked by media intent on grabbing a politician for a quote on anything that was breaking news and that did happen in the question time. Chesterfield-Evans was aksed about some corrupt politician's antics that had hit the headlines earlier that morning, so we were left feeling a little silly while he had his say. However, he thought we went well - and we are hopeful that it will make the local news bulletins this evening.

The Launch event followed and lasted an hour. The speakers were Jo Westley (spearheading the campaign to save Camden Hospital Birth Centre), Hannah Dahlen (NSW Midwives Association), Fiona Tito and Mark Tracy (Father, husband of Sally and Neonatologist). All covered aspects of NMAP and provided great background information. Copies of the report were on hand, other material relating to the NSW Government's Greater Metropolitan Transition Taskforce's idiotic plans about rationalising materntiy services in Sydney were given out and various health policy makers and politicians ( a few - most had Caucus meetings to attend) heard more about NMAP.

We heard that Craig Knowles' (NSW Minister for Health) advisor was to issue the considered response at 3.30 p.m. and Denise Hynd was to wait and see what it contained.

We did manage to doorstop Bob Carr (Premier) and to give him a quick message about NMAP and a copy of the report. He wanted to know about how much it would cost, and when told it would save him money, said he "would look into it". We were most impressed by his wonderful tan and impeccable suit and decided that he either must have been wearing make-up or else spent a lot of time in a solarium!

An interesting day. It will be great to hear how the launches went in other capitals and how the meetings in Canberra with Meg Lees (Independent) and Helen Coonan (Deputy Treasurer) went.

This is the start - we still have a long way to go. As Fiona Tito said to me over lunch - "why does this stuff have to be so hard? We keep giving them the data and the cost savings and telling them what we want and they just find ways to ignore it". If she is having difficulty, then we have our work cut out. We won't let them stop us - our time as mothers and midwives has come.

Posted by andrea at 04:47 PM | Comments (4)

NMAP Launch

It's been an exciting few days. Over the weekend I have been in Queanbeyan (right next to Canberra) presenting a workshop for the Southern Area Health Service, and it gave me the opportunity to catch up with Barb Vernon and Justine Caines from the Maternity Coalition. We talked about the last minute plans for the launch of NMAP tomorrow and the meetings with the politicians planned for the rest of the week. What a dynamic duo these two are!

The launch is on final countdown and the excitement is building. I'll be back to you later with some feedback on what could easily be the watershed event for maternity care in this country!

Posted by andrea at 02:51 PM | Comments (2)

Managing the third stageof labour

There was an interesting post to the ozmidwifery list recently that described one hospital’s policy about the management of the third stage of labour. It appears that this unit insists that all women will have an actively managed third stage of labour and that any woman who refuses (in advance presumably) will have to seek maternity care elsewhere.

This is an outrageous position on a number of levels. First, the denial of informed choice is surprising, given that hospital managements are usually keen to avoid potential litigious situations. The hospital, however, possibly takes the stand that they inform everyone of this policy in advance, so that anyone not willing to comply has time to find another hospital for the birth, thus enabling the “informed choice” to be make early in the pregnancy. I wonder how many parents would haven even thought about third stage of labour at that point, or knows what the implications are? As the hospital’s name is not revealed it is not known where it is, but I suspect that it is a rural unit and therefore the ability of the parents to go elsewhere may be severely limited. Choice may simply not exist.

Secondly, the evidence for managing the third stage with oxytocics is a contentious issue. If the birth has been normal (that is, no oxytocics for induction or augmentation, no pain medications, no obstetric interventions) there is very little chance of a haemorrhage after the baby is born. Expectant management should be the approach, rather than “just in case” measures. If there have been interventions during the labour and birth, and this will be the case for probably 90%+ of all women giving birth in a hospital setting, then there is an increased risk that she will bleed heavily after the birth, but this is not a certainty. Many women and midwives would still prefer to wait until there is a medical need for intervention, because the giving of oxytocics is not without its own risks.

This is a good example of where midwives often collude with the doctors during labour and birth. Midwives (and doctors) don’t always know how to manage a third stage physiologically; they are often rushed and short staffed and want to get the woman cleaned up and on her way out of labour ward fast; they don’t know the ramifications of giving oxytocics to mothers and the effects it may on the establishment of breastfeeding, for example. They may be unwilling to take a stand on the issue perhaps because they fear a lack of support from their colleagues. It is a shameful state of affairs, and the woman and her baby are the victims of poor professional practice.

These policies need to be challenged. They should be discussed in the pre-natal classes where the parents can be acquainted with strategies to ensure they are not treated in this “conveyer belt” fashion. Parents must know that no-one can lay a hand on them, at any time, without their expressed permission Signing “consent forms” in advance does not lock them into acceptance - they can always change their minds. Informed consent must also be freely given, not extracted under a threat of the withdrawal of services, as is apparently happening in this instance.

Midwives should be challenging their medical colleagues and their management to rethink this policy in the light of the medical evidence and the potential for parent dissatisfaction. Yes, I know that the Cochrane Library suggests that oxytocics should be given routinely, but they do not recommend that they be given against parental wishes. Their recommendations are just that, and should be seen as guidelines, not as hard and fast rules.

The giving of oxytocics for third stage is a classic example of the double standards in maternity care: on the one hand we say “let’s keep birth normal by not interfering with the normal process” and then in the next breathe we say “but you will be given routine syntometrine for third stage as it is our policy in this unit”. Ridiculous! No wonder parents are confused and many are looking for alternatives away from such a crazy and uncaring system.

Posted by andrea at 08:05 AM | Comments (3)

Third Stage of Labour

There was an interesting post to the ozmidwifery list recently that described one hospital’s policy about the management of the third stage of labour. It appears that this unit insists that all women will have an actively managed third stage of labour and that any woman who refuses (in advance presumably) will have to seek maternity care elsewhere.

This is an outrageous position on a number of levels. First, the denial of informed choice is surprising, given that hospital managements are usually keen to avoid potential litigious situations. The hospital, however, possibly takes the stand that they inform everyone of this policy in advance, so that anyone not willing to comply has time to find another hospital for the birth, thus enabling the “informed choice” to be make early in the pregnancy. I wonder how many parents would haven even thought about third stage of labour at that point, or knows what the implications are? As the hospital’s name is not revealed it is not known where it is, but I suspect that it is a rural unit and therefore the ability of the parents to go elsewhere may be severely limited. Choice may simply not exist.

Secondly, the evidence for managing the third stage with oxytocics is a contentious issue. If the birth has been normal (that is, no oxytocics for induction or augmentation, no pain medications, no obstetric interventions) there is very little chance of a haemorrhage after the baby is born. Expectant management should be the approach, rather than “just in case” measures. If there have been interventions during the labour and birth, and this will be the case for probably 90%+ of all women giving birth in a hospital setting, then there is an increased risk that she will bleed heavily after the birth, but this is not a certainty. Many women and midwives would still prefer to wait until there is a medical need for intervention, because the giving of oxytocics is not without its own risks.

This is a good example of where midwives often collude with the doctors during labour and birth. Midwives (and doctors) don’t always know how to manage a third stage physiologically; they are often rushed and short staffed and want to get the woman cleaned up and on her way out of labour ward fast; they don’t know the ramifications of giving oxytocics to mothers and the effects it may on the establishment of breastfeeding, for example. They may be unwilling to take a stand on the issue perhaps because they fear a lack of support from their colleagues. It is a shameful state of affairs, and the woman and her baby are the victims of poor professional practice.

These policies need to be challenged. They should be discussed in the pre-natal classes where the parents can be acquainted with strategies to ensure they are not treated in this “conveyer belt” fashion. Parents must know that no-one can lay a hand on them, at any time, without their expressed permission Signing “consent forms” in advance does not lock them into acceptance - they can always change their minds. Informed consent must also be freely given, not extracted under a threat of the withdrawal of services, as is apparently happening in this instance.

Midwives should be challenging their medical colleagues and their management to rethink this policy in the light of the medical evidence and the potential for parent dissatisfaction. Yes, I know that the Cochrane Library suggests that oxytocics should be given routinely, but they do not recommend that they be given against parental wishes. Their recommendations are just that, and should be seen as guidelines, not as hard and fast rules.

The giving of oxytocics for third stage is a classic example of the double standards in maternity care: on the one hand we say “let’s keep birth normal by not interfering with the normal process” and then in the next breathe we say “but you will be given routine syntometrine for third stage as it is our policy in this unit”. Ridiculous! No wonder parents are confused and many are looking for alternatives away from such a crazy and uncaring system.

Posted by andrea at 08:00 AM | Comments (2)

Making pelvis models

Things have been a bit quiet on the Diary entries from me in the last couple of days. Next week I am going back to the UK for a series of workshops and Conference appearances and so I have been working madly trying to make as many pelves as possible before I leave.

Yes, that’s right - making pelves. Most people don’t know that this is what I do in my “spare time”, butl those pelvis models you see in our catalogue are all made by my hands, in the good old “garden shed” equivalent at our office.

It all started 15 years ago, when I was looking for a pelvis to use in my own classes. All the ones I could find has bolts and wingnuts holding them together and I thought they were insulting to women and very distasteful. What do do about it? The answer was - design and make your own.

It was quite a saga. First I had to find someone who could make the moulds (three) and this was surprisingly hard until I discovered a wonderful sculptor who found no difficulty dealing with the complex shape of bones when making the fibreglass cradles and silastic rubber inserts. The task of getting the right polyurethane mix for the casts was a lot of drama as well but eventually the best combination of ingredients was worked out after a lot of trial and error and help from a surf board manufacturer. I wanted just enough “give“ to make it possible to show how the joints move, but enough rigidity so that the model was easy to work with. Then there was the glue problem! Polyurethane is notoriously hard to stick together and I still sometimes have trouble with breakages, which I am always happy to fix.

Anyway, thousands of pelves later (I’ve given up counting) I am still at it on a regular basis. As a best selling item, I must make sure that there are enough on hand to supply customers when I am away for extended periods, so for the last three days I have been slaving away getting them done.

You didn’t know that I was so multi-skilled did you? Amazing what a bit of passion will drive you to create!

Posted by andrea at 02:56 PM | Comments (4)

Copyright and "Preparing for Birth"

Many childbirth educators have a copy of my book “Preparing for Birth: Mothers” which they use as a reference for their classes.

From time to time I am asked if some pages can be photocopied for use as handouts for the parents. Invariably, my answer is “no”, not because I don’t want parents to have access to the information, but because I want parents to have all the information in the book, not just some selected pages. There is always a risk that issues seen as “difficult” by educators may be left out of the program, perhaps because of their own discomfort or lack of knowledge or because including them would risk going against “the party line” promoted by their hospital.

Sometimes the expense of buying the books is quoted as a reason. Photocopying and assembling take time (and money) and parents will be handed a sheaf of pages amongst a collection of leaflets. These are likely to be lost and don’t necessarily look very professional (they may be covered with advertising, for example).

My policy has always been to make these booklets available very cheaply when bought in bulk. Many hospitals now order in lots of 100 and some take regular orders of 500 or more. For these larger orders we will negotiate a price that gives an added discount. In this way, we hope that everyone is happy: the educators get a quality product that saves them work, looks good and contains notes on all the information they would include in a normal program. Parents get a concise, well illustrated manual that is user-friendly and jargon free. I am happy because I know that parents are getting the full story and not just an edited version.

I know that some people do make copies. Please respect our copyright laws ........

Posted by andrea at 05:18 PM | Comments (3)

Male midwives ?

I have been contacted by a Spanish language midwifery magazine, Ob Stare, for a comment about male midwives. It seems they are canvassing opinion about whether men should be able to work in the field of midwifery.

This is a question that has come up occasionally in my workshops. I am acquainted with a number of male midwives in both the UK and Australia, and although there are very few of them, they seem to be well liked by the women and by most of their colleagues.

This is the comment I have sent to Ob Stare:.

Surely the most important qualities for a birth attendant of any kind are sensitivity, faith in the birth process and trust that women can give birth successfully. With this in mind, and provided that the person has the necessary professional skills, the gender of the attendant is not of primary concern. I am acqainted with a number of male midwives, whom I have found impressive and a good deal more compassionate and understanding than some of the more "medically orientated" female midwives I have met. At the end of the day, it is the woman who should choose the attendant to care for her during pregnacy and birth - only she will know who feels "right" during this most intimate and demanding time of her life. Choosing a caregiver is "the woman's business".

It will be interesting to see what the other respondents write. I will have to ask my Spanish speaking staff member,Larissa, to translate for me!

Posted by andrea at 05:33 PM | Comments (19)

Childbirth Education elective

It looks as though the proposal we put to Monash University (Gippsland, Victoria Campus) for Birth International to offer an elective on childbirth education into their Graduate Diploma in Midwifery has been successful and we will be going ahead with the program in late Janaury 2003.

The program will involve 40 hours of workshop sessions over 5 days followed by an assessment task that has to be completed within the following 4 weeks. The University is likely to open the program up to non Grad Dip Mid midwives in the area who would like to participate in an intensive course close to home.

I am really excited by this initiative. For the first time, midwifery students will get the opportunity to really get some skills in education for expectantparents and the chance to dovetail this work with their regular midwifery work. The idea came from the students as well - augers well for the future when we have students willing to go out and get what they want in their courses!

Those who complete this elective will also have it recognised as prior learning should they wish to enrol in our Graduate Diploma in Childbirth Education at a later stage. With this neat overlap, students will get both Grad Dips in a shorter time, if they wish!

Posted by andrea at 05:53 PM | Comments (7)

Another perspective on doulas

Michel Odent is now involved with the doula movement in the UK. Athough he and I still argue about the concept of "support" in labour, he has decided that there is a place for doulas post natally and even does some workshops for them. He has a chapter in his new book The Farmer and the Obstetrician on the topic of doulas.

You can read more on his new wesbite.

Posted by andrea at 05:49 PM | Comments (2)

More on Doulas

I am really glad that so many poeple have responded to my comments on doulas. I was going to add some feedback to the comments already posted, but since there are a number of things I wanted to say, I will put them in this new Diary entry.

Karen, Pip and Jaqueline - thank you for your thoughts. I agree that we are all striving for the same things, I guess my concern is how we go about it. See my comments below.

Tina, yes, we need to be careful that lactation consultants and childbirth educators are also not co-opted into the system. The place and role of lactation consultants is another interesting development and I will write about it another day. It seems these specialities develop in medical systems that are dehumanised and social systems that are fractured...... but more about this later.

Childbirth educators have a different function, as I see it, and that is to provide social settings in which parents can explore their experiences together. I ahve always seen this facilitation role as the most important reason for prenatal groups of all kinds. The giving of information is of secondary importance to my mind. Again, when health professionals (e.g. midwives employed by a hospital) take on this role, they are often coming from a different angle and see the information they give as the primary function of their programs. As a result, parents end up in huge classes with didactic teaching that revolves around the theme of "what will happen when you come in to have your baby in our unit". Choice is explained as "the services we offer (tolerate) here. I could go on, but let's leave this to another day as well.

Marilyn, thank you for your insights, especially about the system in the US, where my experience has been limited to facilitating workshops for a mixtureof midwives/nurses. I agree that if the system was perfect we wouldn't need doulas because there would be enough sensitive midwives (as opposed to burnt out or frustrated midwives) who could fulfil that role. Several years ago I was the keynote speaker at the Midwives Alliance of North America (MANA) Conference, whose theme was "Midwifery in the Mainstream". My message was to take the skills that the participants at this conference clearly had (most work in either independent practice or in birth centres) and get them into hospitals, so that the vast majority of women, and not just the priviledged few, could get better births. I was astounded to discover that in reality, MANA members didn't want to have anything to do with hospitals and that instead of being "mainstream" they wanted to stay on the fringes. I am not blaming them for taking that position, because they've been hounded by the system as it is, but I was surprised that they didn't see that this stance was elitist and that all women should have the right to midwifery care. They didn't know what to make of me - for a start I was wearing my "corporate type clothes" even though I sounded like one of them!

Beth, I think you have misunderstood me (or perhaps I haven't made my self clear). I would never question that women want to be suported by women at birth, it is very defintiely "women's business". If you have read what I have written in my books, you would know that most of what I know about birth has come from labouring women, those I have been honoured to support as a companion. Some of these were friends but most were women I met though my prenatal sessions and that I had come to know. I think there is an "art" to being a good support person - and that revolves around being invisible. The woman should not be aware of your presence and at the end of the day believes she did it all by herself. I am concerned that some women may choose to be a doula because it gives them a profile and they "need to be needed" - that's why I say you have to look at your own motives and innermost feelings before you take this role on.

In summary, I would say I have these major concerns about doulas:

1. The potential for undermining midwifery and midwives, especially when the system is under stress.

2. The commercialisation of social support. This is something you do because you care and not because you will be paid.

3. Friends and family should always be invited first, and openly, into the labour wards. We've been doing this readily in Australia for 20 years as part of our Active Birth approach and thus I question the need for an organised system of doulas.

4. Claims are being made for the necessity/usefulness of doulas on the basis of questionable research, sometimes as part of selling training courses etc.

Being present at the birth of another woman's baby is the most special thing in the world and something anyone would do, if asked, without hesitation. Let's keep it at the level of community service and not turn it into another business or allow it to be cooted by the health care system.

Posted by andrea at 06:08 PM | Comments (5)

Drug addiction references

The discussion about doulas is still going on and I want to say some more about this on another day. However, let's change the subject for now!

Had a phone call from a staff person at the Drug and Alcohol Committee of the Royal Children's Hospital in Melbourne. She was chasing up some references she had been asked to track down ...... I immediately knew what she would be asking for next, and I was right.

In Preparing for Birth: Mothers in the section on Drugs in Labour (page 43) and also in The Midwife Companion, I list the potential risk that babies exposed to opiate drugs during birth may develop a lateraddiction to opiate drugs, or to amphetamines if exposed to nitrous oxide during labour. I regularly get requests for the references to back these statements and I am always happy to pass on the list of studies. In fact, I have now included them in an article in the Essential Parent pages of this web site to make them easier for everyone to access.

The interesting thing about this call was that this person was very defensive about this information and was adamant that I should reference these statements int he book itself. I pointed out that the book clearly says on the cover that it contains "Background notes for prenatal classes" and on the inside cover is suggests parents ask their educator if they want references or more information on any topic included in the publication. The book was designed like this to encourage parents to talk to their educator about issues that are concerning them and also to avoid the book becoming 'heavy' with a lot of technical references. I wanted it to be as "user friendly" and non-threateneing as possible, like a woman's magazine. My caller obviously didn't have a copy of the book to hand but my explanation didn't mollify her at all - she was clearly upset that I had included this information in the first place and that the Drug and Alcohol Committee didn't know about this research.

It is interesting how people react to this issue of drug addiction. I've been talking about it for 10 years now, at every class, workshop and training course I have presented, and it always raises anxieties. As a result, people often say that parents should be protected from this info because "we don't want to make them anxious, or guilty of they choose to use these drugs during labour".

I have found that parents often take a different view. If they have never had a baby they don't understand (yet) that the decisions they make in the heat of labour are often different from those they might choose in the calm of the pregnancy. As a result, when these thorny issues of predisposing their unborn baby to the potential for a later addiction to drugs (and it must be stressed that it is not cause and effect, just an increased risk) are raised during the pregnancy, parents are often glad to have the information. In fact, if it was withheld, there would be a risk that later they might get angry if it was discovered that they had been misled, or patronised by the educator.

It is a tricky one, and an issue I have written about elsewhere. In the meantime, I hope that the Drug and Alcohol Committee at the Royal Children's Hospital might investigate these links further. We need more research in these vital areas - I am convinced that one day the connection between exposure to drugs and medical procedures during labour and birth and the effect of their imprinted memories on the unborn baby will be shown to be a major factor in some teenagers developing life threatening behaviours later. It is a topic that health professionals find very threatening, especially if they have offered women drugs during labour, but one they must face squarely.

Posted by andrea at 05:49 PM | Comments (2)

More on doulas

It is very good to see the debate/discussion about doulas, both in response to my Diary entry and also on the ozmidwifery list. This is an important issue that needs wide consideration and I am happy to kick that off, and in this Diary entry, to keep it going, through raising some new points.

Let’s consider some of the claimed benefits for doulas. It has been stated that the presence of a doula can improve birth outcomes by lowering the need for interventions, even to the extend of reducing the need for a caesarean by 60% (this statement appears in Suzanne Arms’ video Giving Birth Challenges and Choices”). However, it is well proven that it is the attitudes, practices and philosophy of the primary care giver that shape the birth experience for a woman and it is this care giver who has the greatest influence on the outcome of the birth. It is hard to see how the presence of a doula could make any difference to the outcome of the birth, given that they have no say in the management of the case. If research can show that the presence of the doula causes the care giver to act differently, then it may be possible to change the course of management, but this seems a stretch to me.

Again, let me go back to the US scene. I have just read in my copy of Birth - Issues in Perinatal Care that the rate for caesarean sections in the US, having been 24.7 % in 1988, then dropping to 20.8% in 1995, has risen again and now stands at 24.4% in 2001. VBAC rates have dropped from 36.5% in 2000 to 16.5% in 2001 (a drop of a massive 20%). I can’t imagine the presence of a doula making much of an inroad in this climate. In countries with much higher rates of caesareans (Brazil and South Africa, for example) all that a doula can hope to do is to make the wait until the caesar occurs a little more humane and comfortable. While this is an important and valuable goal in itself, it will not contribute much to improving the final outcomes.

In the developed world, where midwives already exist in numbers, the way to get better outcomes is to strengthen their role and provide opportunities for them within the system (this is where NMAP comes in). Doulas may be useful to supplement the role of the midwife and to replace absent friends or family but they are perhaps best described as an “extra” at a birth, not an essential member of the “team”. I prefer to put my energy into energising and uplifting the resources we have - the midwives - rather than work on an alternative that might actually (if unintentionally) undermine midwifery. I also believe that almost every woman could find a close friend, if not a family member, to be with her during birth, and that we should encourage this every time, as a way of strengthening family and community bonds.

In the developing world, there is an added risk that some women will be lucky to get a companion and other will miss out, because it would be difficult to provide enough doulas to meet every woman’s needs. Therefore, if change is to occur for the greatest benefit to all, then the system has to change from the top, that is, the doctors and nurses that are already in place must be encouraged to change their views, attitudes and practices. This is a very tall order, and will take a lot of time, good will and re-education, but it has the greatest potential for doing the greatest good. Perhaps that’s where the energies and resources should be directed, rather than on some new “fad” as the doula approach may come to be seen.

Another issue of importance in developing countries, is that women acting as doulas will need to be paid for their work. This is an important way of giving many woman an income that is much needed, but even that carries risks. People who are paid have a vested interest in keeping themselves in work and are not necessarily interested in political agendas for changing the system that feeds them.

The research into the benefits of doulas has mostly been carried out in developing countries and for that reason perhaps much of the findings are relevant and applicable to those maternity care systems. However, I haven’t seen much research carried out in US hospitals, for example, that shows that the presence of a doula improved birth outcomes and lowered intervention rates. Yet the claims being made in western countries for the usefulness of doulas are being based on results obtained from studies carried out in very different circumstances. Research from the dev eloping world is being co-opted to make a case for a “commercial” venture in the US.

Doulas may, in the long run, get dispirited and burnt out if they go into this work thinking they will be able to change the system and make birth better for women. They need to be very clear about their own goals and expectations for this work, and so do all the health professionals that they encounter. At the end of the day, it may be the money to be made as a doula that enables them to justify their work in their own mind.

There are other points to make about this issue (as I say, it is a weighty one) but I will save them for another day, and see what people think of these ideas first. I am sure you’ll have an opinion on what I’ve said here.......

Posted by andrea at 06:18 PM | Comments (10)

The "doula" craze

Another Americanism is threatening to undermine the movement towards humanized birth - this time it is the “doula” phenomenon. This movement, begun in the 1990's, has now become another money-making venture and introduced a whole new level of health professional to the labouring woman’s bedside. Its origins lie in the medicalised way of birth in the US, where women are routinely confined to bed during labour with IVs and monitors strapped on, cared for by obstetric nurses who check the technology and assist the doctor, who will invariably be there to manage the birth. The father may be present, but other support people have been discouraged or banned form attending. Midwives, as we know them in the UK, Australia and Europe, are not employed in hospitals who rely instead on the obstetric nurse (handmaiden to the doctor). It is a very medical, caregiver centred, institutionalised setting for birth.

Enter the doula. Her role is to “mother the mother” as their advertising states. She offers physical and support, emotional understanding and practical hands-on comfort, as needed. She has been hired by he parents during the pregnancy and will have visited with them a few times to “get to know them”. She stays for the labour and does some post-natal follow up. She will be well paid for these services, and thus has a vested interest in promoting the need for her services.

In the US there are several organisations that offer “doula training”. They appeal to women who have had babies, love birth, have a need to help others and who don’t want to undertake more formal education to become midwives or nurses. The work is attractive - you get the warm glow of being able to help, you get to hold newborns and it can be fitted in around your family commitments, while adding to the family’s finances. To be effective, the doula needs to be able to answer a pregnant woman’s questions and interact with caregivers, hence the need for some training in the basics of birth. They are bit like nannies, only this time the baby is not yet born.

With their usual flair for self promotion, the Americans are now exporting their practices again onto an unsuspecting public around the world. I have heard of doula training programs in Australia and have had intending doulas in my workshops. Their intentions may be noble and high minded, but what are the messages they are sending to our population? That our midwives are not able to provide this kind of care? That women in Australia have no-one who could help them during birth? That buying services (and the obligations that come from such a contract) is better than relying on friends and family to fulfil these traditional roles?

What is also needed is the re-education of obstetric nurses to take on the philosophy and model of care enshrined in midwifery. This is particularly important is those areas where midwives are scarce and births are medicalised. In developing countries where no midwifery exists in hospitals, the need to encourage birth companions is very necessary, but let’s not see these people as needing special training. Let’s first just open the labour wards to the family and friends of the labouring woman. If we only allow a trained doula to be present, then we have medicalised social support and once again robbed women of their right to a humanised birth within the family circle.

Birth is certainly women’s business, and a spare pair of hands (often a woman’s) has been encouraged here for many years. Let’s not add another layer of “health professionals” into our already institutionalised birth system.

Posted by andrea at 09:32 AM | Comments (41)

Inequalities between Nurses and Midwives

It’s just been announced that in NSW a new nursing qualification has been created: that of Nurse Practitioner. These nurses, often with Masters degrees and many thousands of hours of advanced nursing experience will be able to undertake many of the tasks traditionally done by doctors. The rate of pay will be the same as for hospital Registrars.

There are already Nurse Practitioners working in rural areas, especially where doctors are scarce and they have proven very successful. It’s the extension of this approach to city based hospitals that is new, and initially these nurses will work in areas such as accident and emergency and mental health.

Of course, the Australian Medical Association is sounding the alarm bells in a very predictable and well-worn fashion - “who will supervise these nurses?” “who will carry the ultimate responsibility?” and the inevitable “patient safety is being put at risk!” I’ll bet you’ve heard these bleated complaints before.....

The real issue, as I see it, is where midwifery sits in this scheme of things. Midwives have traditionally had the education and skills to work as independent practitioners at this level, yet at present they are the only group of health professionals being barred from working in this way, primarily from a lack of recognition and professional indemnity insurance.

How can the Government support Nurse Practitioners and not support midwives in the same way? This is a question that will no doubt be raised as part of the campaign surrounding the launch of NMAP and the commitment of the Government to equity and access for midwives (as well as for women) will be under close scrutiny. Things are hotting up!

The only certainty is that the AMA will no doubt trot out the same statements regarding midwifery models of care as they have done for Nurse Practitioners. Australian might be a nation of gamblers, but this is one bet I wouldn’t want to take on!

Posted by andrea at 08:39 PM | Comments (2)

Suicide amongst teenagers

Michel Odent has sent me his Summer 2002 Primal Health Research Newsletter, with the intriguing title of “The Future of Suicide”.

He describes the contrast between two visits to China, the first in 1977 and the second in 2001. There were many differences to note, but he focuses on the the extremely high rates of suicide that are now occurring in China - 44% of all suicides and 56% of all female suicides in the world. The rate is highest amongst teenagers and young adults and accounts for 19% of all deaths in the age group of 15 - 34 years.

He theorises that this incredible statistic may have its roots in the way Chinese babies are now born, with very medicalised births and 40% caesarean section rates. Unusually, the suicide rates for women are 25% higher for woman than men, when in every other country male suicides out number females by 3:1.

Odent also refers to the work of Lee Salk and Bertil Jacobson, who have investigated the underlying causes and manner of teenage suicides and related them to birth experiences. The newsletter is full of interesting references covering an area that deserves more attention from us all.

To find out more go to The Primal Health web site and do a search using the word ‘suicide’. You will also find details there on how to get the newsletter yourself. It seems that Michel Odent is the only person interested in making these connections between intrauterine conditions for the baby and later life consequences. Fascinating stuff!

Posted by andrea at 07:00 PM | Comments (2)

UK Midwives lose their Professional Indemnity Insurance

Received an email today from Virginia Howes, an independent midwife in the UK. She explains the current situation regarding PI insurance for independent midwives in the UK: diabolical! Here are some of the details she included (the comments in italics are mine):

"The regulatory body for midwives, the Nursing and Midwifery Council (NMC), formerly known as the UKCC, wants to introduce a clause into the Code of Professional Conduct, making it mandatory for all nurses and midwives to hold professional indemnity insurance (PII).

Prior to 1994, independent midwives had PII as part of their membership to the Royal College of Midwives but then this was stopped. [The members were asked to vote to increase the annual membership fee by just of £3.00 but this was rejected by the members at large]

From 1994 until March this year it has been possible for independent midwives to purchase some form of PII, but it has become more expensive year on year until reaching £18,000 - £20,000 a year/midwife (more than many independent midwives earn) and few companies [are] offering it. This left midwives with the choice of giving up independent practise or practising without insurance.

From March this year no PII has been available in the UK, at any cost, as insurers all around the world have pulled out of the market. This means that all midwives who practise independently now have no choice but to practise without PII.

If the NMC makes it mandatory for midwives to have PII, independent midwives will be forced to cease practising in the UK. This will instantly remove the option for women to choose this form of maternity care. The Independent Midwives Association (IMA) is seeking a QC legal opinion on the legality of the introduction of such a clause.

The IMA believes that the NHS are also struggling with the cost of insurance/litigation and will soon be unable to afford it as it consumes ever increasing amounts of the NHS resources. The only possible solution we can see is some form of ‘no fault medical accident compensation scheme’ to be introduced and remove insurance from the equation."

I'll bet this sounds very familiar to Australian midwives ! Midwives in the UK are now gearing up for a fight similar to that going on here, and they have until Sepember 30 to state their case before the consultation period set by the NMC closes

I am not a believer in conspiracy theories, but sometimes there seems to be more than coincidence at work. Of all the professionals working in midwifery care, why are midwives being singled out for this harsh treatment? Is this a final attempt to put midwives firmly in their perceived place - working in hospitals under medically determined policies ? And what of the women and the notion of freedom of choice?

Posted by andrea at 01:55 PM | Comments (3)

Communications from ACMI

In recent days, there has been quite a bit of comment on the ozmidwifery mailing list regarding the apparent lack of action by the Australian College of Midwives Inc (ACMI) around the issues of current concern to midwives: the professional indemnity insurance issue, the NMAP launch, registration issues for direct entry students etc. It seems that members have equated the lack of feedback and comment on this list to a lack of action generally, and if this is the case, then this needs to be rectified.

I have contacted Vanessa Owen ( President, ACMI) and suggested that someone on the executive be tasked with making regular contributions to the ozmidwifery list so that the wider population knows what they are doing. She tells me that a decision had been made by the Executive not to use the ozmid list for official communications. I appreciate the need for official communication channels, such as their newsletters and journals, but I think that if ACMI is to attract more members and get itself better known, then reaching out to prospective members, students, consumers etc is important. Using the ozmid list to disseminate information and increase their profile is an obvious way to do it. I would think that the majority of people who read the list are not members of ACMI, yet they may feel more like joining if they knew what ACMI was doing, even on their behalf.

Lists like the ozmidwifery mailing list is a simple way of reaching hundreds (and thousands) of midwives and others with vested interests in midwifery. Vanessa says she will raise this again with the executive of ACMI to see if someone will volunteer to be their spokesperson. I hope they realise the enormous PR advantage of being seen to be taking action and that we can look forward to regular contributions from now on.

Posted by andrea at 06:44 PM | Comments (4)