Articles by Month: May 2006

Another birth centre closure in the UK

It seems the struggle to provide woman-centred midwifery care will never end. Just as we are inching closer towards midwifery only maternity hospitals and caseload midwifery care across the board in Australia, we hear that many similar units in the UK are under threat of closure, despite Government policy that clearly voices support for this option of care.

One lesson that was learned the hard way in Australia some years ago, is that if these units are funded separately, and especially though a special purpose grant, then they are vulnerable to closure because they appear as a separate line item in the maternity budget of a hospital. When finances are tight and the accountants are looking for services to cut, a separate line item for midwifery care is very obvious and presents and easy target. Bitter experience with the sudden closure of a wonderful program in one of our regional areas due to a whole hospital over-spend taught midwives that these programs must be funded within the existing budget if they are to survive the hard times.

In the UK, each small Trust or PCT (and there are dozens of them) controls the purse strings for all the services in its area and centralised policies (such as the Government’s public commitment to midwifery services) can be ignored if the local managers want to provide other services as the expense of midwifery care.

Here is an extract from the press release issued by Mary Newburn of the National Childbirth Trust in the UK in response to the latest assault on services for women:

The National Childbirth Trust (NCT) has today expressed its dismay over the proposed closure of the third largest midwife-led maternity unit in the UK. Stroud Maternity Hospital has been told that it will be closed within the year due to the financial constraints of Cotswold and Vale PCT.

Mary Newburn, Head of Policy Research at the NCT said:

'Government policy states that the NHS should provide choice over place of birth and specifically highlights midwife-led units and birth centres to be available as an option.

'If the Government is to fulfil its pledge to ensure women have a range of maternity choices available to them then action must be taken to halt the closure of midwife-led units and birth centres. Stroud Maternity Unit is the latest in a long line of birth centres and midwife-led units that have been closed - temporarily or permanently - or that are facing closure. The proposed closure of Stroud is therefore yet another example of how Government policy is failing to be implemented.

'Closing birth centres rarely saves money so should not be targeted when action is taken to correct an over-spend. We'd like the Secretary of State to issue a clear statement that maternity services should not be cut back when other hospital departments fail to keep to budget. The major cost of providing maternity care is the cost of midwives' salaries, estimated to be around 85%, and midwives are needed to provide one-to-one care whether the women uses a birth centre or a hospital unit.

'In addition, we'd like to see the midwife-led units and birth centres that have been closed in the past three years reopened.'

The NCT believes that more than 13 birth centres and midwife-led units in England and Wales are currently either closed (temporarily or permanently) or are facing closure. Five units in Scotland are also under threat including Aboyne Community Midwifery Unit in the Grampians. This is despite the Scottish Executive's Framework for Maternity Services, which states that 'women have the right to choose how and where they give birth.'

I will be back in the UK in 2 weeks and I will no doubt hear more of these problems when I am there. The frustration level amongst midwives in the UK must be at al all-time high (and probably rising!).

Posted by andrea at 11:22 AM

Midwifery in East Timor

Margaret Aggar is a midwife from the Central Coast in NSW (just north of Sydney). About two years ago she visited East Timor and discovered their enormous need for midwifery training and assistance, supplies, equipment and know how.

East Timor, as many of you will know, is a former province of Indonesia that achieved independence a few years ago, following a long struggle with separatist and rebel forces. The UN stepped in, achieved peace and then organised democratic elections where the people voted to established their own independent State. As East Timor is only a couple of hours flying time from Darwin, Australia played a large role in the peacekeeping forces and has continued to support the struggling country to get on its feet and this process continues.

Margaret decided to organise another visit to Dili (the capital city) and this time to take some supplies with her. The purpose of the trip was to train the local midwives and to give them some basic equipment to help them carry out their work. She has been there about 4 weeks now, and has been sending back regular accounts of her adventures, with many photos of the local midwives, women and general scene.

Over the past few days hostilities have again broken out, with gangs of armed youths rampaging through the city, attacking the armed forces, looting and burning houses and public buildings. Once again the UN has been called in and Australian troops are again on the ground, restoring order and disarming the gangs. Many foreigners have been evacuated to Darwin along with a number of refugees. Margaret is still there, and reports that she is safe and well protected. She is going about her midwifery as usual, supporting the women who visit the clinic and also many of the staff, whose homes have been vandalised or burned.

It took quite some time for all the supplies that Margaret had organised to be cleared through customs. The red tape was extensive and in the end they “liberated” the goods themselves from the containers at the airport. The birth packs are now being put to good use as part of the training program that Margaret has begun.

One of the midwives was herself pregnant with twins and worked right up until going into labour herself at the clinic, where she had assisted at a birth only hours before. Her babies arrived very safely and are doing very well.

Some months ago Margaret had approached Birth International for some help with this project. We receive many requests of this kind and try to do what we can. In this case we were able to donate dolls and a pelvis and Margaret has been using them to teach the midwives how to manage a shoulder dystocia (amongst other topics).

I’ll include some photos of her work for you. Hats off to Margaret for her huge voluntary effort and her dedication and commitment to the women of East Timor. It shows what a difference one person can make, when they set their minds to a project.

“Liberating” the 12 cartons of materials.

Unpacking some of the boxes at the Clinic.

Margaret with the twins, born to her midwifery colleague Marcelina, at the Clinic.

An educational session using the donated Birth International models.

Posted by andrea at 05:36 PM

Another exploitation of women's bodies

When I was in Israel last year, I was impressed by the openness of the Israelis to new ideas and their ability to get moving with new projects. The Birth Centre at Tel Hashomer Hospital was one innovation that was nearing completion when I paid a visit and I know that under Debby Gedal-Beer’s direction they have been enjoying great success.

I recently received the following letter that Debby sent to the Midwifery Today E-Bulletin and as it is now dong the rounds of the various email lists, I am reproducing it here to make sure that the message reaches as many people as possible. I am sure that she would be happy to hear from you, if you wanted to contact her, so I have left her contact details at the bottom of the letter. We must all be vigilant when it comes to the exploitation of women’s bodies, and this blatant example deserves to be stopped in its tracks.

"A high tech company called Barnev (www.barnev.co.il/) is currently manufacturing a product called a computerized labor monitoring system. This product works by placing two clips with electrodes on a laboring woman's cervix and a scalp electrode on the fetus and using ultrasound waves to measure cervical dilation and height (descent) of the fetal head. I am aware of this product because of clinical trials were held at the hospital with which I am affiliated. In spite of the midwives' opposition to using this mechanical device on women, we were not able to totally block its use (although some changes were made in the informed consent, and many women did not agree to participate due to midwives' explaining to them what was involved). The trials were moved to other hospitals where the midwives were not as vocal in their opposition, and now the company is promoting use in Europe and the US. I understand that they have received or will be receiving Food and Drug Administration (FDA) approval. The product is being promoted as a means to assess women's progress in labor without a manual vaginal examination.

I believe that this product takes advantage of and potentially harms women and their babies in labor, all for the purpose of economically profiting a biotech company. I believe that steps need to be taken at a higher level regarding the ethical considerations.

How do E-News readers suggest that I carry on from here? Can you offer any support/ideas? I feel that this issue is not only within the midwifery realm, but takes advantage of women's rights and of women's bodies for research purposes under the guise of medical treatment. You can contact me at: Debby.Gedal-Beer@sheba.health.gov.il".

Debby Gedal-Beer, CNM, MSc.
Coordinator of Women's Health and Midwifery Education
Sheba Academic School of Nursing
Tel Hashomer, Israel

Posted by andrea at 05:54 PM

The value of prenatal education

During my conversation with Fran Gallwey in our UK office last night, we were discussing the forthcoming Preparing for Birth and Parenthood Conference (naturally!). Some people like to register by phone and this gives Fran a chance to chat to them about what is happening in their area.

One educator told her yesterday that where she works near Manchester, the parent education program has been cut back to one session! I wonder how they have justified taking this action when there are so many compelling reasons why they should be expanding, not contracting these services? Have they considered that:

These are the first thoughts that spring to my mind when I hear that parent education programs are being slashed. Short sighted decisions such as these deserve to be questioned. The parents in our communities deserve better treatment than being fobbed off with one class.

Posted by andrea at 04:31 PM

Credentialling midwives

The credentialling process is now available for midwives in NSW. Intended primarily for midwives who will be working in caseload or other autonomous midwifery positions, the process is designed to ensure that midwives are safe practitioners, have the necessary skills to facilitate births on their responsibility and have a clear woman-centred midwifery philosophy. However, it would be a useful step for all midwives to undertake, wherever they work, and this is the ultimate aim.

The process has been set up by the NSW Midwives Association for the NSW Department of Health, who wanted to ensure that the midwives who would be staffing he new midwifery hospitals and birth centres were sufficiently experienced and competent to run the services safely. This will provide assurances for the women using these services and also the doubters (the doctors?) who are sceptical of the safety of these new maternity services.

To be credentialled, the midwife needs to go through a process of self-evaluation that involves reflecting on her skills and practise and identifying any areas where she feels further development would be useful. Having compiled a portfolio of her educational and practise development qualifications and her statistics, she also needs to select case studies that illustrate her capabilities. The portfolio is submitted to a review panel, who then interview her and assess her skills in managing complications.

Each panel is made up of two midwives and a consumer representative. One midwife supervises a skills assessment workstation and the other two conduct the interview. This “conversation” is designed to give the midwife an opportunity to explain her practise and the reflect on her achievements, strengths and future plans for professional development. The discussion is conducted in a caring, supportive atmosphere that is intended to encourage the midwife to explore her potential. It will also give her a chance to review difficult cases and to receive further guidance and ideas, or perhaps another perspective that will enable her to grow and develop.

I have been invited to be a consumer representative on these panels and yesterday was my first attendance at credentialling interviews. It was a most interesting and informative few hours for me and I came away deeply impressed by the system that has been developed, the commitment to the process that was evident and the sheer skill of the midwives whom we credentialled on the day.

This is a wonderful system that will give midwives the opportunity to show what they can do and to have this recognised and supported. I hope that many will take this path as part of their own personal growth - it will give them status and confidence and tangible proof of their midwifery qualities.

Posted by andrea at 08:20 AM

Birth in Water

Using warm water (in various forms) during labour had been around a long time and has a proven record in enabling women to manage labour pain effectively and safely. Water birth has also long been a reality, since Michel Odent first tried this technique in the early 1980's in France. Most home births these days involve water, either for easing pain or the birth itself, and many hospitals have also adopted the idea, installing baths or pools for women to use during labour if they want.

Some hospitals, however, have been reluctant to provide water options, fearing that water birth requires special training of staff and presents special risks for care givers (bad backs, infection). The reality is that water births are very easy for staff - they need to do very little during the labour and birth, apart from regularly checking the baby’s heartbeat. It is the woman who does the work and gives birth unaided, into the water. The caregiver then helps her to lift the baby to the surface.

A beautiful new DVD, “Birth In Water”, shows how this can be achieved in a big public hospital. Dr Andrew Davidson has long seen the potential for warm water immersion during labour and birth under water and has actively encouraged its use st John Flynn Hospital in Queensland. Now he has made a video explaining the techniques and offering practical suggestions about implementing this approach, based on the experience of his team. There are several water births shown (not all at his hospital) and the women and midwives share their experiences as well. The story told by one midwife of her first water birth is amazing and amusing, and shows what can be done if one is prepared to watch and wait and let nature take its course.

This video adds to the growing number of films on this theme. This one, intended primarily for parents, will also be valuable for professionals who want to know more about this gentle option for birth can be implemented in their own hospitals.

Posted by andrea at 09:38 AM

Nitrous oxide - potential dangers for midwives

The article that I wrote about the hazards of nitrous oxide to midwives and women in labour wards was published in the March issue of MIDIRS.

I have now added it to our website so that it can be read more widely. The exposure of midwives and other staff to high levels of nitrous oxide in labour wards is a health and safety tissue that has been largely overlooked. It is especially important in the UK, where this gas is almost routinely used at labours, even during waterbirths and home births. Few other countries use it in the same way, and in countries like Australia, where most labour wards are air conditioned (and therefore have actively circulating ventilation) there should be less of a problem if the gas is used.

Just the other day I mentioned this issue at a workshop and a midwife said to me that she had just been diagnosed with a Vitamin B12 deficiency (which can lead to pernicious anaemia). She was now wondering if her long exposure to nitrous oxide in her workplace might be a factor underlying her problem. Her maternity unit was old and the gas has been used freely for many years. She took a copy of the article and was going to take it up with her employers.

If this article alerts other midwives to the possible health hazards of this gas, then it will have served its purpose. Although the gas can be safely used in conditions that are similar to operating theatres, perhaps it is time to consider other less invasive means of easing women through the later stages of labour, when nitrous oxide has been the traditional standby. Alternatives such as water and heat combination (showers, hot wet towels etc), verbal encouragement, positioning and movement are cheaper and more readily available.

Women too should be aware of the potential problem if they are giving birth in unventilated, enclosed spaces where the gas has been used for previous births. There are suggestions that the chronic fatigue experienced by some midwives (and perhaps women postnatally) may also be linked to exposure to nitrous oxide.

This issue is a good example of how “traditional” practices can often be taken for granted and assumed to be safe when proper analysis and investigation may prove otherwise.

Posted by andrea at 10:05 AM