Articles by Month: January 2005

Epidural use in NSW

Browsing amongst the statistics in the NSW Mothers and Babies 2003 report makes rather sad reading. It seems that women today are opting for epidurals more and more and that the use of drugs for labour is still very high. Very few babies will be born with no exposure to drugs and I wonder what impact this might have on their future health.

There is the usual variation in rates for drug use amongst city and rural areas, district and teaching hospitals, smaller units and larger ones, private and public hospitals. The best results are in the country areas, where Queanbeyan enabled 28.1% of women to labour without drugs and Muswellbrook achieved a 26.7% drug free labour rate. In this report, smaller units with fewer than 200 births per year are grouped in each region, and in the North Coast Region, (this takes in the trendy areas of Coffs Harbour, Bellingen, Byron Bay, Mullumbimby) the smaller hospitals achieved the most outstanding result : 34.6% of women giving birth in these hospitals used no drugs during labour. These hospitals will have few facilities for epidurals, often only GP care (no obstetrician), the midwives are known to the women (small country towns) and often have very experienced staff - they are therefore often better placed to practice midwifery, rather than obstetric care.

The city hospitals do predictably worse. The private hospitals are incredible: only 2.3% of women at the Mater Private, 3.0% at Sydney Southwest Private, 2.7% at North Shore Private and 3.3% at the Sydney Adventist Hospital gave birth without drugs for pain. Perhaps this is the “too posh to push” brigade or just the results of clever selling of epidurals to vulnerable women with money in their pockets. It makes you wonder, when 4.3% of the women in Fairfield, 7.3% of women giving birth in Bankstown and 7.1% of women at Hawkesbury Hospital need an epidural, compared to the affluent areas of the city, where 64.5% of women at Kareena Hospital, 60.5% at the Mater Private and 64.8% at Hurstville Community can’t manage labour without one.

A woman came into our office the other day to buy an EPI-NO. She wanted to avoid stiches and was prepared to use this device to reduce the risk of needing an episiotomy. I spoke briefly to her and gave her some hints for keeping an intact perineum: staying upright, not pushing too much, taking time etc. She explained that she had already booked her epidural (she is going to the regular labour ward of a bit city teaching hospital) and that upright birth might be difficult. I pointed out that she had a 50% chance of either forceps or vacuum with an epidural (and forceps will require an episiotomy) and she said she knew this. It was her obstetrician who had recommended the EPI- NO and I was surprised, because with an epidural (which I’ll bet he didn’t discourage) he would know that she was more likely to end up with intervention. He is having her on, I thought?

No wonder epidural rates are so high - women give up even before they give themselves a chance. Do they realise what they are taking on with these levels of interference in labour? Have they given any thought to the risks an epidural, or other drugs, poses for their babies? This is information that is usually lacking in prenatal classes and the women I saw last week said her classes were “pretty useless” (her words). I know that at that hospital, the talk on epidurals is given by the anaesthetists.... !

Posted by andrea at 06:44 AM

Birth outcomes in NSW

A closer look at the birth outcome statistics for New South Wales (2003) reveal some interesting facts and confirm what has been proven by previous analyses. In simple terms, if you want to have a great birth with a minimum of interference, choose a country hospital and use the public health system. Avoid a city hospital, especially if it is a teaching hospital and don’t choose private care at a private hospital unless you are prepared to pay for it, with your dollars and also your body. A few figures will explain these statements.

The best hospital for normal natural birth in 2003 was Wyong, just north of Sydney. This unit is run by midwives and some selection criteria apply, but once accepted you have a 92.1% chance of a straightforward, uncomplicated birth. It could be argued that this outcome would be expected under these conditions, and that any other result would be unacceptable, but it does prove that the majority of women, when cared for by midwives, do well during labour.

Other hospitals, without the ability toscreen their clients, have also done well. Armidale Hospital (77% normal birth rate) and Kempsey (77.6%) stand out but smaller hospitals in the Northern Region also achieved high rates of almost 80% uncomplicated births.

Some city hospitals did well too. The western suburbs of Sydney, an area where many migrants and poorer people live stood out: Fairfield (71.6%) Canterbury (71.4%) , Auburn (78.8%) and Camden, which is again under threat of closure, had a normal birth rate of 85%. All of these hospitals can handle emergency caesareans and all, except Camden, are teaching hospitals. There will be very little private obstetric care in these units and they are good indicators of a public system that is working well.

At the other end of the scale are the private hospitals. These places should hang their heads in shame - their clients are from the wealthy end of town, well nourished, healthy and with few underlying health problems. Yet they achieve deplorable birth outcomes: Hurstville Community Hospital (43.8%) and Kareena Private Hospital (38.5%) take top honours here, with the majority of their clients (44% at Kareena and 37.4% at Hurstville Community) having a caesarean birth. This is outrageous and gives a good indication of the risks that come from choosing obstetric care - only an obstetrician can do a caesarean!

The larger Regional referral hospitals don’t do so well either, but they will have a higher than average number of women with problems, especially if the system is working as it should and those with complications are referred for specialised care. The figures from Bathurst Base Hospital (59.6% normal births and 34.2% caesareans) and Goulburn Base Hospital (53.4% normal births and 28.4% caesareans) illustrate this point. These figures for caesareans are still high, according to the WHO, who say that even if all the women admitted to the hospital had complicated pregnancies the caesarean rate should be no more than 15%. I suspect it is once again the presence of obstetricians in these centralised referral units that tip the balance towards surgical birth, even when it may not be absolutely necessary. Next, I’ll have a closer look at the rates for epidural and drug use in labour.

Posted by andrea at 07:08 AM

Australia Day

Happy Australia Day to all my colleagues around the country! This is a big day in Australia, as we celebrate the founding of our nation and take time out to party. Lots of people are awarded special Australian Honours for service to the community ( a bit like the system in Britain where some people get Knighted or made Dames etc) and also it is a day when many people take out Australian Citizenship at special ceremonies around the country.

There are no midwives amongst the recipients of special awards this year, as far as I know, but that’s not for want of trying. Midwives here keep the struggle for better births and alive, and for many the best form of recognition would be the underwriting of a free home birth service and community based midwifery by each State Government. Every year this goal gets closer and perhaps 2005 will see the first programs firmly in place. I am ever the optimist!

I was talking to Dr Barbara Vernon, the Executive Officer of the Australian College of Midwives and she told me that this year, a priority is to establish a link between registration as a midwife and on-going professional education. This will encourage midwives to undertake further education to develop their skills and to have their efforts recognised when they do. The Registration Boards in each State are in favour of such a scheme , and it is a matter of setting up the necessary infrastructure to award credits or points for courses, events, studies etc undertaken by midwives each year. This is a development that is sorely needed in Australia, where a midwife can qualify and then attend nothing during her entire career while still continuing to practice. At present there is no need for her to demonstrate any efforts to maintain her competence, knowledge or specific skills and this is a major weakness in our system. I hope that the Australian College of Midwives succeeds in its plans for rectifying this gap in our maternity services and I wish them every success.

Posted by andrea at 05:48 PM

Birth outcomes in NSW Australia

The New South Wales Mothers and Babies 2003 Report is full of fascinating details about the maternity services in this State. It is the most comprehensive report released in the country and offers 117 pages of packed tables and statistics that cover every aspect of the service, from pregnancy care to intrapartum, postnatal, neonatal intensive care and perinatal deaths. The outcomes for various sectors of the community are also broken down, by nationality, place of residence, age and parity. The report is so detailed, it would be possible to discover the likely outcome for a young Turkish woman, with a pre-existing health condition, married, living in a rural town, having her first baby as a public patient in a district hospital!

With so much to read, the Executive Summary at the beginning makes a useful snapshot. The figures here indicate that the demographics continue to change: teenage pregnancy rate have fallen again to a low of 4.0% of all mothers in 2003 and the number of women having their first baby over the age of 35 has risen once more to 19.3% of all births.

The normal vaginal birth rate continues to fall slowly and is now at 62.6% of all births. Women choosing private, obstetric care don’t do so well - only 52.4% have a vaginal birth, and 32.2% of them will have caesarean surgery. Women who chose the public health system have a much better chance of avoiding surgery, and only 20.9% of them will find themselves in theatre (still way too high).

One disappointing fact to emerge is that the number of women who are choosing a birth centre for their care fell slightly in 2003, to just 3.7%. The number of homebirths also fell to just 132, out of a total of 86,414 births. This will be partly a reflection of the lack of midwives due to the insurance crisis, but will also be due to the lack understanding about home birth in the wider community.

There are more fascinating figures to reveal and next time I will look at specific hospitals and their outcomes.

Posted by andrea at 06:48 AM

A hectic week

This has been a very hectic week. We have interviewed and appointed a new Administration Assistant/PA to help us all out, and finalised the Birth International catalogue, which will go to press early next week. The new products are all ready to be uploaded onto the website (you’ll want to check this out at the end of next week). All the main workshops for the year have been finalised so their details could be included in the catalogue and website as well, and we have been processing dozens of individual and group bookings for our Future Birth tour around Australia in March.

The NSW Mothers and Babies Report from our Department of Health arrived on my desk yesterday and these are interesting figures, some of which I will share with you in a forthcoming Diary entry. Birth in NSW seems to have polarised, with women having stark choices: a high degree of success with natural births in rural areas or a caesarean section in the cities. This is a simplistic view, I know, but the figures tell the story. More later.

There have also been developments with our Graduate Diploma in Childbirth Education and I will detail these in the next Diary entry.

Posted by andrea at 02:59 PM

Monologues from the Labour Room

Last year I visited Israel and met some wonderful midwives. Many had come from other countries to settle in Israel and it was a truly international group that attended the workshops that I presented.

One of the midwives, Leslie Wolff, mentioned that she had made a film about the experiences of midwives working in hospitals. She said it was a play, performed by four women and that they had presented it, to great acclaim, at the Midwifery Today Conference that had recently been held in Germany. Naturally I was curious, so she offered to send me a copy on DVD.

This arrived during my holiday break and I have now had a moment to view it. Called “Working under restraint: Monologues from the Delivery Room” it is a series of short scenes, spoken as monologues by midwives and mothers about birth in hospitals. Two of the actors are midwives and two are “real” actors, who play a variety of roles. All the familiar feelings of midwives are included: their beliefs in women; prayers for lovely natural births; desires to be able to practice true midwifery; frustrations with the system; constraints on their practice and lack of appreciation by the hospital administration. There are wonderful snatches dealing with doctors and their unreasonable demands, stifling protocols, and the dreaded epidural. Towards the end there is a wonderful birth story, acted out with a truth and honesty that will resonate with women and midwives everywhere. The segment on “Eyes” I found particularly moving - the descriptions of what can be read in the various people’s eyes around a labouring woman is revealing and full of insight.

These women tell an universal story. Midwives and women everywhere know these lines, have heard them, sometimes on a daily basis where they work. Women have been told these things in labour, in countless delivery rooms across the world.

This film will be a wonderful talking point for midwives, a great discussion starter and invaluable in preparing students for the realities of hospital life. I loved it and am delighted that we can bring it to a wider audience. It will be in the next catalogue, due out in 3 weeks. It will also be available on-line through our extensive mail-order range. I’ll keep you posted.

Posted by andrea at 12:32 PM

EPI-NO for avoiding perineal trauma

My goodness, we seem to be selling a lot of EPI-NOs these days! There must be some information about them in the Parents magazines that has generated the enquiries, and women seem to be keen on using them to prepare for birth (although they also have a role post birth as a perineal muscle exerciser). One obstetrician did call me recently to request some pamphlets about it that he could hand to his clients.

Women’s bodies are designed to stretch well during birth and if the second stage of labour is not rushed so that tissues have time to stretch naturally, and there is sensitive management (read: no handling) of the perineum as the baby emerges, there should be minimal, if any damage to the vaginal tissues. Midwives know that women value an intact perineum and most midwives try hard to maintain the integrity of muscles and skin around the vaginal opening.

Not all doctors have understood women’s sensitivity towards stitches and many lack the skills and patience to stand back an allow the baby to emerge slowly. These doctors want to stretch the tissues manually, or massage the area, or just make an episiotomy as a means of speeding up the birth process. Time is their main problem - they don’t want to wait and “do nothing”.

Women too, have lost a lot of confidence in their capacity to give birth well. In today’s technological, “quick-fix” society, the appeal of this gadget may be in its claims, backed by research, to reduce the incidence of perineal trauma. For some women, choosing an appropriate caregiver (e.g. a midwife) would be a better way of reducing the risk of tearing during birth, but many women may not be able to make such a choice, or are unaware of the significance of midwifery skills. .

The position of the woman as she gives birth is also a potential problem. In an upright position the vagina has more even pressure applied on all sides, encouraging better stretch. If the mother is recumbent, or even worse, flat on her back, there is considerable pressure on the area between the vagina and anus, and the whole perineum tends to be thinned and over- extended by the pressure of the baby’s head. This is much more likely to lead to an unnecessary episiotomy if the caregiver believes that a nice clean cut (episiotomy) is better than a tear - a situation prevalent in many hospitals where evidence based care is not the norm.

Women who use an EPI-NO are sending a signal to their caregiver that they care about intact tissues and are prepared to use this equipment during pregnancy to improve flexibility and stretchiness of their vaginas. Perhaps this is one reason why the research, especially the studies done in Israel where episiotomy is almost 100%, shows that intact perineal rates can be significantly improved when women use an EPI-NO during the last weeks of their pregnancy.

If buying and using this gadget is what it takes to avoid an episiotomy then that’s OK by me. Not all women can count on having a caring midwife to facilitate the gentle arrival of the baby and a caregiver who knows that a woman have taken a lot of trouble to avoid tearing or an episiotomy may be better prepared to wait.

Posted by andrea at 01:36 PM

Midwifery in Kenya

During the break I received a lovely letter from a midwife in Kenya. She had written to me before and this letter was an update on her work. I will share some of its contents with you, as I am sure she would be pleased for others to know a little more about midwifery in Kenya.

“When I first approached you for information I was working in a project which was located in a maternity ward with 15 beds. My role was a research midwife, I was overwhelmed by the numbers of maternal deaths and the many problems facing the mothers I encountered. I, most of the time, shed tears, and I felt a need to look for information of any kind which could help me and the other midwives deal with those situations better. Thank you for the journals, but I think if I could manage attending a workshop this would have been most appropriate.

Then I left maternity and worked in a High Dependency Unit (paediatrics) within the district hospital. My attention to midwifery issues was also disrupted......

From the beginning of December 2004 I am in a project which has a component in MCH and in a maternity ward, immunising newborns. This is now a modern maternity newly built with 36 beds, 2 spacious nurseries with 2 incubators, a spacious labour ward covering a whole width on one end of the building, with 4 delivery beds, well spaced, a baby resuscitator and about 150 deliveries per month.

Lastly, is to say that I would like to build myself up on the research experiences I have had within the midwifery field, and since I feel I may not be able to attend the workshop [the Preparing for birth Conference in the UK ] due to financial constraints, I would request if I can be sent something to read on topics such as “involving fathers’ “about pain” and “2nd stage issues”.

I will be sending her a package of reprints and articles and hope they will help her in her work. The tsunami crisis in South East Asia has highlighted the need for us all to work as one world towards bettering the life of others, and we can all play a small role in this. In this instance it is a midwife from Kenya who wants help......

Posted by andrea at 07:13 AM

Preparing for Birth

Today we took delivery of 15,000 “Preparing for Birth” books, enough to see us through the next few months. These books have been in print, in several editions, since 1987 and must be the all time most popular book on childbirth in Australia. Almost 300,000 copies have been sold.

There is still no other simple format and concise book like it on the market, as far as I know, especially at the price (cheap!). There are several imitations and many much longer books, but where they usually fall down is in the area of information on the effects of drugs and obstetric interventions on the mother and baby. Most books gloss over these, sometimes giving the impression that women should be protected from details that may make them anxious, especially if an intervention becomes necessary or medication is chosen in labour.

Preparing for Birth: Mothers takes a different approach - setting out the vital details on the impact of intervening in birth in a clear, unbiassed and simple fashion, using dot points and simple line drawings. Women will find information here on the effects on the baby, often overlooked when the comfort of the labouring woman is the chief focus of labour these days.

I have deliberately left the references for this information out of the publication, to keep it “user friendly” and uncomplicated. The educator presenting the classes should be able to provide this information, but if not, the references can be found on our website.

Everyone who registers for the forthcoming Preparing for Birth - new strategies for parent education conference in the UK will be receiving a free copy of “Preparing for Birth: Mothers and Preparing for Birth: Fathers. We hope they will find it useful for their own programs and the parents with whom they are working during pregnancy.

Posted by andrea at 06:58 AM

Happy New Year

Happy New Year!

This is my first Diary entry for 2005 and already is seems that we are off to a busy start. Our Sydney office has re-opened today after the Christmas holiday break, although our UK office has been in full swing for almost a week.

We have a large pile of orders to process today and no doubt the phone will be running hot as well. Over the break, I have taken time to undertake a number of administrative tasks in readiness for the new year, including reviewing our plans for future development and putting some new systems in place. A holiday period is a good time to do this kind of thinking - no phones, emails or other distractions to impede the thought processes!

The first priority will be to finalise the January 2005 catalogue, ready for printing and distribution. This issue will be bigger than ever, as we have a number of new and exciting products to add to our ever growing list. Twenty one new books, new charts, videos and DVDs plus some innovative teaching aids for parent educators are amongst the collection. If you don’t already receive this full colour catalogue, click here to go to the website area where you can order a paper copy. Although many people choose to view products and order on-line these days, a paper copy can be more convenient for sharing with colleagues or showing the boss.

While you are on the website, check out the big events for this year. Future Birth: With woman, with child is the major tour in Australia this year and early registrations (before January 31) are available at significant discounts.

Preparing for Birth: New strategies for parent education is the title of the major conference we are presenting in the UK in April. This innovative program features a number of international speakers and promises to be a practical, skills enhancing program for everyone who works in prenatal education. Full details can be obtained by clicking here, including the early registration special offers, which close on February 18.

We have two other exciting tours with international speakers planned for 2005 and details will be on the website soon. I will let you know when the information is available.

Posted by andrea at 06:49 AM