Articles by Month: June 2006

Nitrous oxide again

It seems that one of the main ways that the Letterkenny midwives ease women through labour is through the liberal use of nitrous oxide and oxygen. I was told that probably 90% of women use this gas during labour, many for almost their whole labour. This may be the way that women manage labouring in shared rooms with others - all are busy puffing away on their gas!

I was disturbed, however, to find that this shared labour room was not ventilated at all. The gas dispensers have now been fitted with scavenger units but may not be enough to keep the air clear of expelled gas, and this poses a significant health and safety issue for the midwives. I will be discussing this in detail with this group today, and encouraging them to read the article on nitrous oxide that was published in MIDIRS in March. The full text is on our website and is should be read by all midwives who work in units where this gas is used.

Midwives in the UK (and Ireland too, it seems) are unaware that the use of nitrous oxide for labour is unheard of in most western countries and much of the rest of the world. It has never been used in the USA for example, and is unknown in European countries. Given that there are so many other ways that midwives can increase women’s comfort during labour (movement, massage, heat, water etc) it is a shame that they so often resort to offering drugs. Using drugs for labour pain is a symptom of the medical model of care and I would hope that midwives were more aware of their role and suitably skilled in alternative ideas.

My book “The Midwife Companion - the art of support during birth” was written specifically for UK midwives who seemed to lack ideas for easing labour pain without drugs. It is packed full of self help strategies and is written as an illustrated manual for ease of use. Many midwives have told me that it is “their Bible”when it comes to being “with women” which is heartening.

I will be sharing some of the se ideas with the midwives in Letterkenny today in an effort to give them some alternatives to the liberal se of the gas, which may well be compromising their own health as well as that of the women they serve.

Posted by andrea at 05:04 PM

Giving birth in Letterkenny, Eire

I am presently in Letterkenny, Donegal in the north of Ireland. It is a beautiful part of the country and an area I have wanted to visit for quite some time.

The group I am working with are all from the local hospital, which has about 1700 births each year. As we introduced ourselves, it was clear that these women had wide experience of many hospitals and almost all had trained elsewhere (often in the UK) and often worked abroad too, before returning to this area to settle.

They offer a midwifery model of care here for those women not under the care of private obstetricians, which is very different from much of Ireland. Last year I had met some midwives from Letterkenny in a workshop I presented in Dublin and it was clear then that their approach here was (thankfully) out of step with the more rigid approaches in most other Irish maternity units.

I am told that they have a midwife shortage and this is hampering their plans for expanding their midwifery care. A new section of single labour and birth rooms has been built but cannot be opened because of these staff shortages and its location away from the current unit. This is a great shame because right now in this is the only hospital women are labouring in shared four bedded rooms before being moved to the second stage room. The lack of privacy in the shared first stage area means restrictions on the number of support people who can be with the labouring woman and everyone knows this is far from ideal.

However, despite their less than ideal physical set up, they have achieved low caesarean rates and low intervention rates generally. It reminds me of “the olden days” when shared facilities were very common and midwives felt that women spurred each other on as they laboured together. It will be interesting to see what these midwives offer in response to the group work exercise they did yesterday on ways of making the labour room feel “safe” during labour. If women feel protected and safe then their adrenaline levels will be low and labour will be shorter and more comfortable. I am wondering how they can achieve this when they have to work in these outdated facilities.

I have an inkling of how they achieve this from some comments about drug use in labour but I will wait to see what they offer. I certainly hope they can recruit some more staff - they are offering a great service already and will do even better if their new unit can open.

Posted by andrea at 05:41 PM

The Belmont Birthing Service

Following from my previous Diary entry, here is some more information about the Belmont Birthing Service near Newcastle, NSW. This is taken from an email written by Carolyn Hastie, the Manager of the Unit. I will post the statistical outcomes when they are available.

”The midwives have provided comprehensive 1-2-1 care for 187 women since we started a year ago. We also have over a 100 women who are currently booked with our service.

Many of the women who book with us were/are considered 'unsuitable' (ACMI Guidelines for referral and consultation) for birthing at Belmont, which is completely 'stand alone' in that there are no doctors on site and no core staff. If, according to the ACMI guidelines, the women are considered safer at the tertiary referral hospital for birth, the midwives provide all antenatal care with appropriate referral and consultation with the obstetricians at John Hunter and then accompany the women in labour to birth at JHH. The midwives then followed up those women at home for three weeks, just the same as if the birth had occured at Belmont.

Education and information sharing is ongoing. Births through water are popular as the women love our big baths! All babies and mothers for both groups of women are well and healthy. Breastfeeding initiation and continuation rates are high. Skin to Skin for mothers and babies at birth and beyond is explained, promoted and encouraged. We have a weekly discussion group, weekly lullaby group, weekly parenting education sessions and breastfeeding information and education sessions every two months. The midwives don't see the third day blues (which is also really interesting), women are happy and babies are calm. Women are very satisfied with their experience and their care. We will release a full year of stats and information as soon as the year is up.

In the interim, you may like to know that the stats are wonderful for both 'low risk' and 'high risk' women. Low low caesarian and instrumental delivery rate (<10%), low low PPH rate (< 5%); three premature babies; one person with antenatal preeclampsia (which I think is really interesting).

Testimony to women, birth and great midwives - the power of love. The team is fantastic. The families are wonderful too, very supportive.

The fact that BBS exists is very much due to the power of Maternity Coaltion and the absolutely indefatigable efforts and energy of Carol Chapman and Justine Caines without whom none of this would have happened.”

This wonderful service is certainly testament to the power of women when they get organised as a group and keep lobbying/ fighting. I look forward to seeing pictures of their first birthday party with the Minister for Health being feted once again by mothers and babies.

Posted by andrea at 05:38 AM

Midwifery news improving in Australia

The midwifery news from Australia has been good this week. The Belmont Birth Service near Newcastle NSW has had its 100th birth (this is a midwifery only maternity hospital) and the outcomes, as expected, have been terrific. There was a lot of doubt expressed about the safety and necessity for such a service when it opened and the midwives in the area fought hard for a long time to get it established. They have been proven right, and now the NSW State Government is making noises that this kind of midwifery care should be available to all women, not just the lucky few.

This has been the goal of birth activists and midwives in NSW and across the country for many years. The only practical way for it to happen is for the Government to provide the service under Medicare with the insurance for the midwives covered through the Government. We all know that such a program would save the taxpayers millions over time and provide healthier starts for mothers and babies.

I listened to a replay today of the interviews on BBC Radio 2 last week that featured midwife Caroline Flint, a home birth mother and a representative from NICE, talking about the new guidelines on choice of birthplace for women in the UK. I had been amused to read a newspaper report over the weekend from Ireland that stressed the potential dangers of a home birth (well they don’t want home births in Ireland, do they?), so it was good that the problem of linking home birth and safety together and the resultant tendency to make women more scared of the home birth option was canvassed on the BBC interview.

The NICE representative had prefaced her remarks with the comment that birth in the UK had never been safer, and I couldn’t help thinking that they could be safer still if women generally avoided hospitals and birth centres for maternity care. The statistics certainly support the safety of homebirth, even for women who have a moderate “obstetric history” such as being overdue, minor complications in a previous pregnancy, VBAC etc.

I feel sure that one of the reasons that morale amongst midwives in the UK is so low right now is because despite years of struggle, copious Government reports, supportive professional guidelines and statements (such as NICE), money being thrown into projects such as midwifery led units and lots of publicity, women are still being scared into choosing a hospital birth. Once a healthy woman enters the front door of the hospital her chances of coming out in a healthy state are quite small and there is a 40% chance she will have had major abdominal surgery (caesarean birth). It is almost certain that she will have been given drugs whether she wanted or needed them or not and it is likely that her baby will not be breastfed. Such appalling outcomes are enough to sap midwives’ morale and do nothing to build their confidence in natural birth either.

Mary Murphy, a wonderful midwife on the ozmidwifery list discussion group, contributed these suggestions to a midwifery student nervously contemplating her own home birth after witnessing a traumatic hospital birth:

“We make our own reality, so prepare for this birth by using techniques which calm the mind and tone the body. Employ a midwife you trust and then “get on with it”.

Wise words indeed!

Posted by andrea at 06:33 PM

Home birth guidelines

The BBC News this morning had considerable coverage of the latest National Institutes of Clinical Excellence (NICE) draft guidelines regarding home births. NICE is the advisory body that establishes “best practice” guidelines for the NHS and they have made a number of recommendations regarding aspects of childbirth and its management.

In their view, women should have more choice regarding the place of birth and home births should be more widely supported. Although Government policy supports home birth, only 2% of women in the UK choose this option, although this figure varies widely across the country - some areas have 12% and there are pockets where 20% choose birth at home.

Beverley Beech, Chair of AIMS was interviewed and stated that choice was a myth and that women were often unable to get a home birth due to local hospital policy. She also said that the practice of sending two midwives to a home birth was unnecessary and not supported by research. She claimed that this practice had been established when it was discovered that home births were cheaper than hospital births, so two midwives were to attend at home to keep the costs artificially high. This was something I had not heard before - I have often questioned the necessity for two midwives at a home birth as it certainly adds to the costs.

The shortage of midwives was raised with the Obstetrician and NICE representative who were interviewed, as well as the old hoary arguments about safety of home births. The Obstetrician was from University College Hospital said he thought that their “home from home” centre was the best compromise (but women who want a home birth want to be at home, not in a birth centre).

Whilst stating that birth at home resulted in less intervention in birth, the safety issue is still unresolved, according to the NICE spokesperson, and they will be “keeping an eye on it”. Given the massive shortage of midwives and the chronic low morale in the UK maternity services, it will take more than these new draft guidelines to turn things around. Even with the very public support for home birth at all levels of Government, they still can’t get their rates up, possibly because of the fear factor in both women and midwives. Women in the country have simply been scared off.

If you want to read about these draft NICE guidelines, which will be finalised next year, you can view them here.

Posted by andrea at 05:43 PM

How to increase the birth rate

I am back in the UK at present, with several workshops planned for this short trip. Just before I left Australia there was quite a bit of discussion about the rapid rise in our birthrate and also the timing of many of these births.

For some years now, Australia has been doing very well economically. Very low inflation, low unemployment, affluent lifestyles and high levels of education have encouraged many women to work on their careers and as a result many are delaying having babies until they are in their 30s (other western countries have similar trends). Our relatively low birthrate has also been flagged as a possible problem for the future – who will support the ageing population in years to come?

Our Treasurer came up with a plan to solve this problem. The Government brought in a “baby bonus” of $3,000 that was to be paid for every baby born after June 1, 2004. The Treasurer then began exhorting women to have three babies – “one for you, one for your partner and one for the country”. The incentive of a cash payment, no strings attached, seems to have done the trick and we are experiencing a large jump in the birth rate – another baby boom.

Interestingly, a new report has revealed that in order to be eligible for this “baby bonus” many women delayed the births of their babies by two or more weeks. Holding off until after June 1, 2004 was a good move worth money to many families. Most of these women were planning caesareans or else were refusing inductions before their due dates. There was a suggestion from the Australian Medical Association that some women might have delayed too long and put their babies’ lives at risk!

On July1 this year, the baby bonus will be increasing to $4,000 per birth. The question being asked this week is, how many women this time around are going to put of their caesarean or induction in order to make more money? July 1 also falls on a Saturday in 2006, a traditional day for obstetricians to be playing golf (or whatever) but this year might see them hard at work in the operating theatres, valiantly supervising births that have been delayed an extra week or two. I wonder if they will charge extra for this “after hours” service and if this will be paid for out of the extra baby bonus?

Posted by andrea at 11:22 PM

Future Birth 2007

Here we go again with the most popular program for midwives in Australia! This will be our 8th event in this biennial series and once more we have assembled some impressive speakers from overseas for your enjoyment and enlightenment.

Polly Ferguson is the Chief Midwife from Wales where they have used a simple and effective “Pathway” to keep birth normal and reduce caesarean birth rates. Designed and developed by midwives, it empowers them to keep birth normal and resist intervention unless necessary The simple documentation reduces paperwork to a minimum and clearly demonstrates the normality of most labours. It is a tool I think we could useful employ in Australia, and I want everyone to know about it.

Sarah Buckley is well known to many in this country for her writing and presentations on keeping birth normal. There are not many medical voices out there supporting the midwifery model and Sarah is outstanding in her support of natural births. She is an enthusiastic supporter of home births, water births and reducing medical interventions and everyone will enjoy her warm and caring approach.

Marcos Dias is from Brazil, where he is a Consultant to the Ministry of Health on the project being implemented to humanise birth in Brazil. He has worked as an obstetrician in midwifery style clinics and is fervently (as only the Brazilians can be) about improving birth for women, who frequently end up with caesarean births. He was an organiser of the wonderful Conference in Fortaliza a few years ago when 2000 health professionals turned up - it was one of the best events I have ever been involved with. He also facilitated my last visit to Brazil when I presented workshops in Rio de Janiero and Sao Paulo. You’ll love meeting Marcos!

Sandy Kirkman is coming again - what a find surprise she was on the last Future Birth tour! Everyone wanted more, ans though this time you will know what to expectI am sure that you will enjoy her presentation on the theme: “Obstetricians are from Mars - Midwives are from Venus”.

The program will follow its usual format, starting in Perth and finishing in Sydney, from March 20 to March 27. We’ll be including Tasmania this time.

Full details will be mailed out later in the year and of course will appear soon on our website. Looking forward to seeing you all again next year.

Posted by andrea at 05:53 PM

Midwifery practice development tool

A very useful new tool has been developed in Australia to assist midwives assess their capabilities and preparedness for practising autonomously in either a Birth Centre setting, a caseload practise or independently. Called the Practice Development Resource, it has just been released by the Australian College of Midwives, following extensive consultation and testing with midwives in a number of setting across the country.

It is an A4 sized workbook that sets out the list of midwifery skills, knowledge and experience considered essential for midwives working on their own. It is divided into several sections: General Skills, Skills for Antenatal Care, Skills for intra partum care and Skills for postnatal care. Following reflection and self assessment, the midwife rates herself as confident or needing more work and there is space to record the strategy she will use to develop her practise to feel confident, where this is lacking.

It is intended for personal use, and will no doubt be used by midwives who are working towards being credentialled (see my Diary entry for May 11 for details of this process). It is a simple, easy to use, practical guide that would be helpful midwives working anywhere in the world. The skills required by midwives are the same the world over, especially in those countries that embrace the ICM’s International Definition of a Midwife. I can see a useful role for this tool in the UK, for example, where many midwives would like to work in a midwifery led unit and need a way of assessing their readiness for undertaking this move.

We’ve included it in our product range because we want to give it wider exposure than just the Australian scene. I hope midwives elsewhere will use it too.

Posted by andrea at 09:00 AM