Showing posts with label continuity of carer. Show all posts
Showing posts with label continuity of carer. Show all posts
Saturday, April 19, 2014
The costs of institutional births
I would like to share this youtube video https://www.youtube.com/watch?v=7eZJqMhxD00 The Costs of Institutional Births: a wake-up call for obstetricians, presented by Dr Amali Lokugamage at the recent RCOG conference in India.
It's an excellent summary of the (growing) body of knowledge around birth place, the physiology of birth, birth ecology, sociology, economics, continuity of midwifery care, ... and quotes some of the great Australian research on these matters.
Please take a moment to watch the presentation, and share it with others who are committed to improving maternity care for mothers and babies.
Saturday, January 18, 2014
A new vision for maternity care
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| ARM 2013 - click to enlarge |
"central to maternity care: the midwife caring for the mother and providing a safe space in which she can develop confidence in her own ability to give birth and mother her baby." (ARM 2013, p3)
Last year, 2013, the UK Association for Radical Midwives (ARM) published its New Vision for Maternity Care.
The basic principles are copied in this post. The Vision document is only 16 pages, and well worth the read. In the Conclusion, ARM states:
"This is our New Vision for the maternity services of the future. We wish to change the perceptions of the general public about birth and about midwives so that we can practise the profession for which we have been trained. Organisational change and financial and educational input is needed to start the process. Once women know other women who have experienced birth with continuity of care and real autonomy, whether at home or in hospital, this care will be expected. This new standard of care will bring about improved clinical outcomes for mother and baby, substantial savings for the NHS and positive cultural change within maternity services and the wider public. Babies whose mothers have a more confident start to motherhood will have a happier and healthier start to life.
Midwives are unique in their combination of skill, sensitivity and training to be 'with woman' through one of life's landmark experiences which has long-term effects on the individual, the family and society as a whole. We must generate a new respect for both motherhood and midwifery. We owe it to ourselves and to future generations."
Monday, November 11, 2013
'private in public' midwifery
A message today from Katy Fielding, Manager Acute Programs, Victorian Department of Health
Midwives who have Medicare numbers, and Prescriber numbers (ie achieved notation on their registrations as 'eligible', and endorsement as authorised to prescribe scheduled medicines) are well positioned to move into the new models, in cooperation and collaboration with mainstream public maternity hospitals.
How many midwives are we talking about?
Registration data published by the NMBA for June 2013 noted that 48 (of 212 nationally) midwives in Victoria had notation as eligible midwives, and 8 (of 22 nationally) had endorsement to prescribe scheduled medicines. Those numbers are out of date, and we know that they are increasing each week. For example, a social media group set up for eligible midwives (nationally) has more than 200 members, and another group recently set up for midwife prescribers has 100 members.
The conclusion I must draw is that there are many midwives who are ready to move out of employed models into private midwifery practice, as private practice has been redefined by the last federal government. I believe as midwives leave the mainstream system, it will become increasingly difficult for hospitals to staff their maternity units within the old fashioned shift work models. They will need to employ core staff only, and have midwives provide the basic care for their own clients, especially in labour, with early discharge wherever possible. Hospitals will become more and more restricted to providing acute care only.
What will 'private in public' midwifery look like?
From the woman's point of view, it will be similar to the option that some women have, by which they have a private doctor within a public hospital. Only this way they will have a private midwife who oversees and coordinates their care while they're admitted to a public hospital.
From the midwife's point of view, the care provided will be similar to the option that some midwives have, by which they work in a caseload/continuity of care/'know your midwife' model. Midwifery practices will make their own decisions as to how they provide 24/7 midwifery cover - whether in a simple 'one to one' model, or having a named midwife on call covering a particular period, then off call at other times. All midwives providing this 'private in public' midwifery option will be notated as eligible, will have government supported professional indemnity insurance covering intrapartum midwifery services in hospital, and will be credentialed by the hospital for clinical access.
From the hospital's point of view, the specified medical practitioner who will act as the collaborating consultant obstetrician at any time when a visiting midwife seeks discussion, consultation, or referral of women under the 'private in public' agreement will be the doctor authorised by the hospital to do so.
When will the new 'private in public' midwifery options be available?
Good question. The short answer is that we don't know. However, the release of this framework document is an important step in the right direction. Midwives who seek visiting access are making appointments to meet with hospital administrators. Mothers who would like to use the 'public in private' midwifery options would do well to write to their local hospitals and request information.
Where do homebirths fit in?
Prior to the introduction of the federal government's maternity reforms, the only setting for private practice was the community, and the only place a privately practising midwife had professional autonomy was the home. This has changed.
Private midwifery is no longer synonymous with homebirth.
However, unless the 'private in public' midwifery options are facilitated quickly, many midwives will have no choice but to get into homebirth if they want to practise privately.
The 'private in public' midwifery framework seems obsessed with distancing itself from homebirth. I hope midwives can negotiate agreements with the public hospitals to cover the care we provide for homebirths, but I have no idea how amenable the hospitals will be.
When midwives attend women for planned homebirth one of the most significant decisions that can be made is to transfer from home to hospital. The way this needs to happen, when it does happen, is without delay, in a seamless and professionally accountable way. The writers of the reform legislation and the linked documents seem to believe - against all the evidence - that homebirth is dirty. A lawyer commented on social media: "The more they try to integrate private midwives into the hospital system, the more homebirth becomes isolated and tied up in endless red tape which it becomes more and more impossible for midwives to satisfy."
Homebirth is not going to go away. In a maternity world of machines that go 'ping', many women and midwives know that there is no better way to give birth than within the woman's own normal physiology, and that this can be achieved within the privacy and safety of the woman's own home, unless a valid reason exists to interrupt the natural process.
Opinions expressed are those of the author, Joy Johnston, and are not necessarily shared by all members of Midwives in Private Practice.
Your comments are welcome.
Dear colleaguesI would like to inform you that the Minister for Health has recently approved the release of Eligible midwives and collaborative arrangements:You will recall that the framework aims to assist public health services to assess how private midwifery services can operate at their service. As the “private in public midwifery” service model is relatively new in Victoria, the framework provides direction for public health services wishing to establish collaborative arrangements with eligible midwives. The Department plans to evaluate the framework once this new model of care has been in operation for a sufficient period of time.A hard copy of the framework has been distributed to CEOs of public health services and is available on-line at www.health.vic.gov.au/maternitycareI am grateful to all of you for your valuable contribution to the development of this framework and welcome any feedback you may have. ...
Midwives who have Medicare numbers, and Prescriber numbers (ie achieved notation on their registrations as 'eligible', and endorsement as authorised to prescribe scheduled medicines) are well positioned to move into the new models, in cooperation and collaboration with mainstream public maternity hospitals.
How many midwives are we talking about?
Registration data published by the NMBA for June 2013 noted that 48 (of 212 nationally) midwives in Victoria had notation as eligible midwives, and 8 (of 22 nationally) had endorsement to prescribe scheduled medicines. Those numbers are out of date, and we know that they are increasing each week. For example, a social media group set up for eligible midwives (nationally) has more than 200 members, and another group recently set up for midwife prescribers has 100 members.
The conclusion I must draw is that there are many midwives who are ready to move out of employed models into private midwifery practice, as private practice has been redefined by the last federal government. I believe as midwives leave the mainstream system, it will become increasingly difficult for hospitals to staff their maternity units within the old fashioned shift work models. They will need to employ core staff only, and have midwives provide the basic care for their own clients, especially in labour, with early discharge wherever possible. Hospitals will become more and more restricted to providing acute care only.
What will 'private in public' midwifery look like?
From the woman's point of view, it will be similar to the option that some women have, by which they have a private doctor within a public hospital. Only this way they will have a private midwife who oversees and coordinates their care while they're admitted to a public hospital.
From the midwife's point of view, the care provided will be similar to the option that some midwives have, by which they work in a caseload/continuity of care/'know your midwife' model. Midwifery practices will make their own decisions as to how they provide 24/7 midwifery cover - whether in a simple 'one to one' model, or having a named midwife on call covering a particular period, then off call at other times. All midwives providing this 'private in public' midwifery option will be notated as eligible, will have government supported professional indemnity insurance covering intrapartum midwifery services in hospital, and will be credentialed by the hospital for clinical access.
From the hospital's point of view, the specified medical practitioner who will act as the collaborating consultant obstetrician at any time when a visiting midwife seeks discussion, consultation, or referral of women under the 'private in public' agreement will be the doctor authorised by the hospital to do so.
When will the new 'private in public' midwifery options be available?
Good question. The short answer is that we don't know. However, the release of this framework document is an important step in the right direction. Midwives who seek visiting access are making appointments to meet with hospital administrators. Mothers who would like to use the 'public in private' midwifery options would do well to write to their local hospitals and request information.
Where do homebirths fit in?
Prior to the introduction of the federal government's maternity reforms, the only setting for private practice was the community, and the only place a privately practising midwife had professional autonomy was the home. This has changed.
Private midwifery is no longer synonymous with homebirth.
However, unless the 'private in public' midwifery options are facilitated quickly, many midwives will have no choice but to get into homebirth if they want to practise privately.
The 'private in public' midwifery framework seems obsessed with distancing itself from homebirth. I hope midwives can negotiate agreements with the public hospitals to cover the care we provide for homebirths, but I have no idea how amenable the hospitals will be.
When midwives attend women for planned homebirth one of the most significant decisions that can be made is to transfer from home to hospital. The way this needs to happen, when it does happen, is without delay, in a seamless and professionally accountable way. The writers of the reform legislation and the linked documents seem to believe - against all the evidence - that homebirth is dirty. A lawyer commented on social media: "The more they try to integrate private midwives into the hospital system, the more homebirth becomes isolated and tied up in endless red tape which it becomes more and more impossible for midwives to satisfy."
Homebirth is not going to go away. In a maternity world of machines that go 'ping', many women and midwives know that there is no better way to give birth than within the woman's own normal physiology, and that this can be achieved within the privacy and safety of the woman's own home, unless a valid reason exists to interrupt the natural process.
Opinions expressed are those of the author, Joy Johnston, and are not necessarily shared by all members of Midwives in Private Practice.
Your comments are welcome.
Monday, March 5, 2012
choice of home birth: a human right?
This heading 'choice of home birth: a human right?' refers to the woman, not the midwife. Is it a woman's right to choose home birth?
Many would argue that the choice of home birth is a human right. As recently as 2010, the European court ruled that the choice of home birth is a European human right (please read on to the end of this post for the source of that piece of information).
Whatever the woman's right in choosing to give birth in her own home, that 'right' is at best meaningless if the woman is not able to access professional midwifery services. In the absence of a suitably skilled midwife, the woman who hopes to exercise her 'right' to home birth must either give up the notion of home birth, or proceed without professional midwifery care.
In this brief essay I am seeking to apply the notion of a woman's right to choose to give birth in her home, to current Australian situations in which midwives may feel that they are notable allowed to attend certain women: those who have risk factors, such as post maturity, a previous caesarean or other obstetric complicated birth, a multiple pregnancy, or a baby in breech presentation.
Midwives who attend home births independently are facing increasing pressure to conform to external professional protocols which seek to define who is, and who is not 'suitable' to be in the care of a midwife. Such documents become instruments of a society's expectation on women giving birth, effectively forcing conformity on the midwife, and indirectly on the woman.
The current protocols (also referred to as guidelines and position statements) in relation to a midwife attending a woman for planned home birth, include:
AHPRA Safety and Quality Framework for Privately Practising Midwives attending homebirths
ACM Position Statement on Homebirth Services 2011
ACM Guidance for Midwives regarding Homebirth Services 2011
Other codes and professional documents, such as the ACM National Midwifery Guidelines for Consultation and Referral (Second Edition 2008) that apply to all midwives can also be used to restrict the scope of the midwife's practice.
The broad principles underpinning contemporary midwifery are defined by the International Confederation of Midwives in the Definition of the Midwife (2005 – it was revised 2011), which stated
This definition is a core statement in Australian midwifery codes, eg the Codes of Ethics and Professional Conduct for Midwives in Australia.
Midwives around the world, in all levels of socio-economic and health status, grapple with the home birth issue. In recent generations in developed countries, the professionalisation of midwifery has progressed hand in hand with the medicalisation of birth. Australian midwifery education and regulation is a good example of this phenomenon. Under current laws, midwives are the like poor cousins of nurses in the professional regulatory scene. It may be difficult for midwives to have complaints against them investigated and heard by professional peers who have any recent midwifery practice experience. Determinations by investigators in cases of professional conduct may have little relevance to the real world in which the midwife works. The focus of the medicalised midwifery on risk factors and mainstream 'broad brush' risk management in hospitals can easily overshadow any acknowledgement of the woman's informed decisions. The well known Monte Python skit, 'The Meaning of Life' applies: the woman on the bed calls out "Can I do anything?" and is told without delay "No, you're not qualified!"
It is worth noting that the ICM Position Statement on Home Birth emphasises the social/family aspect of birth, as distinct from a medical condition.
[For more detail on the European Court decision, click here]
The woman who, notwithstanding her knowledge of her own particular 'risk' status, asks a midwife to work with her to protect and promote normal physiological birthing in her home, is as entitled to professional midwifery care as the woman who chooses care in a birth centre or hospital. The conversation between the midwife and the woman will address the woman's plans as to how she hopes to give birth to her baby, and what will happen if her midwife advises transfer of care to an obstetric unit. This is not new or unusual in midwifery. Every woman who comes into spontaneous labour has to make decisions about when to go to hospital, or when to ask the midwife to attend, if home birth is planned.
In conclusion, I do not want to seem to encourage midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or BAC, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.
The midwife is also enabled to fulfill her duty of care to the woman, without exposing herself unnecessarily to potential investigations for professional misconduct.
Many would argue that the choice of home birth is a human right. As recently as 2010, the European court ruled that the choice of home birth is a European human right (please read on to the end of this post for the source of that piece of information).
Whatever the woman's right in choosing to give birth in her own home, that 'right' is at best meaningless if the woman is not able to access professional midwifery services. In the absence of a suitably skilled midwife, the woman who hopes to exercise her 'right' to home birth must either give up the notion of home birth, or proceed without professional midwifery care.
In this brief essay I am seeking to apply the notion of a woman's right to choose to give birth in her home, to current Australian situations in which midwives may feel that they are not
Midwives who attend home births independently are facing increasing pressure to conform to external professional protocols which seek to define who is, and who is not 'suitable' to be in the care of a midwife. Such documents become instruments of a society's expectation on women giving birth, effectively forcing conformity on the midwife, and indirectly on the woman.
The current protocols (also referred to as guidelines and position statements) in relation to a midwife attending a woman for planned home birth, include:
AHPRA Safety and Quality Framework for Privately Practising Midwives attending homebirths
ACM Position Statement on Homebirth Services 2011
ACM Guidance for Midwives regarding Homebirth Services 2011
Other codes and professional documents, such as the ACM National Midwifery Guidelines for Consultation and Referral (Second Edition 2008) that apply to all midwives can also be used to restrict the scope of the midwife's practice.
The broad principles underpinning contemporary midwifery are defined by the International Confederation of Midwives in the Definition of the Midwife (2005 – it was revised 2011), which stated
“The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. ... A midwife may practise in any setting including the home, community, hospitals, clinics or health units.” [Note that this paragraph is unchanged in the revised (2011) ICM Definition of the Midwife.]
This definition is a core statement in Australian midwifery codes, eg the Codes of Ethics and Professional Conduct for Midwives in Australia.
Midwives around the world, in all levels of socio-economic and health status, grapple with the home birth issue. In recent generations in developed countries, the professionalisation of midwifery has progressed hand in hand with the medicalisation of birth. Australian midwifery education and regulation is a good example of this phenomenon. Under current laws, midwives are the like poor cousins of nurses in the professional regulatory scene. It may be difficult for midwives to have complaints against them investigated and heard by professional peers who have any recent midwifery practice experience. Determinations by investigators in cases of professional conduct may have little relevance to the real world in which the midwife works. The focus of the medicalised midwifery on risk factors and mainstream 'broad brush' risk management in hospitals can easily overshadow any acknowledgement of the woman's informed decisions. The well known Monte Python skit, 'The Meaning of Life' applies: the woman on the bed calls out "Can I do anything?" and is told without delay "No, you're not qualified!"
It is worth noting that the ICM Position Statement on Home Birth emphasises the social/family aspect of birth, as distinct from a medical condition.
“Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs. There is a consequent need and demand for care that is close to where and how people live, close to their birthing culture, and at the same time safe. The World Health Report 2005 states that ‘There is a value in the rituals surrounding birth, and in keeping these as a central feature of family life. The setting for birth may therefore be the woman’s home, a local health facility or, if medical or surgical care is likely to be needed, a hospital. Furthermore a recent (2010) the European court judgement declared that the choice of home birth is a European human right.”
[For more detail on the European Court decision, click here]
The woman who, notwithstanding her knowledge of her own particular 'risk' status, asks a midwife to work with her to protect and promote normal physiological birthing in her home, is as entitled to professional midwifery care as the woman who chooses care in a birth centre or hospital. The conversation between the midwife and the woman will address the woman's plans as to how she hopes to give birth to her baby, and what will happen if her midwife advises transfer of care to an obstetric unit. This is not new or unusual in midwifery. Every woman who comes into spontaneous labour has to make decisions about when to go to hospital, or when to ask the midwife to attend, if home birth is planned.
In conclusion, I do not want to seem to encourage midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or BAC, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.
The midwife is also enabled to fulfill her duty of care to the woman, without exposing herself unnecessarily to potential investigations for professional misconduct.
Thursday, January 19, 2012
hospital access for Medicare-eligible midwives
A few months ago I reported on the work of a reference group set up by the Victorian Health Department to develop consistent approaches to the provision of clinical privileges for midwives within public maternity services, to enable admitting and practice rights for eligible midwives, and a new option for women who seek maternity care that protects continuity between the woman and her midwife.
Midwives in Private Practice (MIPP) was represented at the three meetings of the expert reference group. The 'deliverable' of this initial consultation process, which has been managed by the 3Centres Collaboration, is a draft document which provides a framework, and templates for paperwork and various records. This document will progress through careful checking by the Health Department, before it is able to be released. It is hoped that this document will provide a reliable process whereby public maternity hospitals in Victoria will be able to proceed with making arrangements whereby midwives are able to attend women privately for birth and other maternity care in the hospitals.
Readers may wonder how many women would want to be attended privately for birth in public hospitals? How many midwives would apply for visiting privileges, and what number of private clients/births would they be able to expect in a year? It is not known how many women in Victoria employ a midwife privately to attend them in labour in a public hospital. An estimate would be 100-200. Many more employ unregulated birth support people. Some midwives would attend 10-20 planned hospital births each year; others only occasionally.
For many years the predominant focus of private midwifery practice throughout Australia has been homebirth. However, since the introduction of notation as a Medicare-eligible midwife, the options for private midwifery practice have been extended. Some midwives who have achieved their Medicare notation/provider numbers have no experience in, and no intention of attending home births. Their plan is to provide continuity of care (and carer) for women giving birth in hospital. This suggests that as the number of Medicare-eligible midwives increases, the demand for hospital admitting and practice rights will also increase. If 10 newly eligible midwives were each taking 40 caseload bookings for planned hospital births, the estimated 100-200 per year could be 500-600. It's still a tiny proportion of the State's annual number of births, but it's a potential growth area.
In order for a midwife, or doctor, or anyone, to be allowed to practise in a hospital facility, there are basic instructional and policy matters that need to be communicated. Routine fire evacuation plans and other emergency procedures are essential for safety of patients and staff and all concerned. Everyone needs to be skilled in use of the hospital's computer systems, entry of data, admission and discharge, reporting of incidents, ... just to name a few examples.
A midwife who is employed in a hospital, who also has a private practice, or who has recently moved from hospital employment to private practice, would be able to quickly meet the requirements for emergency procedures, IT processes, &c. This midwife would be ideally situated to take up admitting and practice rights. The hospital knows the midwife, and the midwife knows the hospital. The process might be more challenging for a midwife who has not practised recently in the hospital.
It is important to remember that there is a woman and a child behind every episode of maternity care. Private midwifery care for birth is a model that focuses on the woman and her baby, not on the care provider or the facility. MIPP members look forward to the day when the options and arrangements for maternity care will truly value the woman, and thereby promote healthy outcomes.
Midwives in Private Practice (MIPP) was represented at the three meetings of the expert reference group. The 'deliverable' of this initial consultation process, which has been managed by the 3Centres Collaboration, is a draft document which provides a framework, and templates for paperwork and various records. This document will progress through careful checking by the Health Department, before it is able to be released. It is hoped that this document will provide a reliable process whereby public maternity hospitals in Victoria will be able to proceed with making arrangements whereby midwives are able to attend women privately for birth and other maternity care in the hospitals.
Readers may wonder how many women would want to be attended privately for birth in public hospitals? How many midwives would apply for visiting privileges, and what number of private clients/births would they be able to expect in a year? It is not known how many women in Victoria employ a midwife privately to attend them in labour in a public hospital. An estimate would be 100-200. Many more employ unregulated birth support people. Some midwives would attend 10-20 planned hospital births each year; others only occasionally.
For many years the predominant focus of private midwifery practice throughout Australia has been homebirth. However, since the introduction of notation as a Medicare-eligible midwife, the options for private midwifery practice have been extended. Some midwives who have achieved their Medicare notation/provider numbers have no experience in, and no intention of attending home births. Their plan is to provide continuity of care (and carer) for women giving birth in hospital. This suggests that as the number of Medicare-eligible midwives increases, the demand for hospital admitting and practice rights will also increase. If 10 newly eligible midwives were each taking 40 caseload bookings for planned hospital births, the estimated 100-200 per year could be 500-600. It's still a tiny proportion of the State's annual number of births, but it's a potential growth area.
In order for a midwife, or doctor, or anyone, to be allowed to practise in a hospital facility, there are basic instructional and policy matters that need to be communicated. Routine fire evacuation plans and other emergency procedures are essential for safety of patients and staff and all concerned. Everyone needs to be skilled in use of the hospital's computer systems, entry of data, admission and discharge, reporting of incidents, ... just to name a few examples.
A midwife who is employed in a hospital, who also has a private practice, or who has recently moved from hospital employment to private practice, would be able to quickly meet the requirements for emergency procedures, IT processes, &c. This midwife would be ideally situated to take up admitting and practice rights. The hospital knows the midwife, and the midwife knows the hospital. The process might be more challenging for a midwife who has not practised recently in the hospital.
It is important to remember that there is a woman and a child behind every episode of maternity care. Private midwifery care for birth is a model that focuses on the woman and her baby, not on the care provider or the facility. MIPP members look forward to the day when the options and arrangements for maternity care will truly value the woman, and thereby promote healthy outcomes.
Sunday, November 7, 2010
What the women said ...
... in their submissions to the Maternity Services Review
The website at which the submissions are posted has a statement:
Today I have taken the opportunity to look at just a few of those personal accounts from individuals, and separated out into themes (not in any particular order). Today's theme is Caesarean births and VBAC. Here are some direct quotes. Women's descriptions of their own feelings have been highlighted. The number noted in square brackets [n] denotes the reference number for the submission.
Theme 1: Caesarean births and VBAC
1.1 Cascade of interventions in primiparous woman at a birth centre [515]
1.2 Caesarean followed by a feeling of disconnectedness and a profound sense of grief [538]
1.4 Emergency Caesarean followed by VBAC [516]
These four accounts speak eloquently for themselves.
Recommendations of the Report of the Maternity Services Review (The Report) include:
"2. That the Australian Government, in consultation with states and territories and
key stakeholders, initiate targeted research aimed at improving the quality and
safety of maternity services in select key priority areas, such as evidence around
interventions, particularly caesarean sections, and maternal experience and
outcomes, including from postnatal care."
The Report trivialised homebirth and stated that "Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28" The Report ignored the many submissions by women who called for greater access to home birth and private midwifery services.
Comments from readers are welcome.
The website at which the submissions are posted has a statement:
We have received many personal accounts from individuals. These provide a valuable insight into people's experience of maternity care in Australia and were considered by the Review Team in preparing the Review Report for the Minister.
Today I have taken the opportunity to look at just a few of those personal accounts from individuals, and separated out into themes (not in any particular order). Today's theme is Caesarean births and VBAC. Here are some direct quotes. Women's descriptions of their own feelings have been highlighted. The number noted in square brackets [n] denotes the reference number for the submission.
Theme 1: Caesarean births and VBAC
1.1 Cascade of interventions in primiparous woman at a birth centre [515]
For my first child, I was 25 and healthy, considered “low-risk”. I booked into the local Birth Centre at the public hospital (it sounds easy but in reality I was put on a ballot, missed out, then made it in when some poor unfortunate woman was shunted out for whatever reason). I attended antenatal appointments with the same midwife, who I thought was on the same page as me regarding birth. I wanted a drug free, intervention free birth. I was well-informed and well-educated.
However during labour my midwife told me she had to perform several interventions which I had been led to believe weren’t routine in the Birth Centre. These included vaginal exams (VEs), the premature rupturing of my waters, and coached pushing (when I was actually not fully dilated and not wanting to push yet as it didn’t feel right).
It is hard to stand up for yourself during labour, so I did not protest any of these interventions, yet they caused, in a cascade of interventions, my cervix to swell and my progress went backwards. My midwife said I needed an epidural and syntocinon to speed things up, even though that was the last thing I wanted, but quite disheartened I agreed. After getting me set up she then left to go home, which I saw as abandonment. My continuity of care ended there. After a few hours I was at the same point, having apparently progressed no further, and the obstetrician suggested a caesarean. Quite defeated and wanting the whole sorry ordeal over I consented to a caesarean that would have been completely unnecessary had my midwife kept her hands to herself.
1.2 Caesarean followed by a feeling of disconnectedness and a profound sense of grief [538]
I had my first baby by emergency caesarean section in a public hospital after a planned home birth. My main care provider for this pregnancy was a community midwife with the Community Midwifery Program here in Perth. During the pregnancy I felt supported by my midwife in any decisions I made about my pregnancy and birth options (Routine ultrasound, strep B testing, water birth etc), and despite the resulting caesarean section, I felt the continuity of care was extremely valuable in making my pregnancy an exciting event for my family, as were able to create a caring and professional relationship with my midwife, leading to feeling secure as my birth approached.1.3 VBA2C [404]
During the birth I experienced great care at home from my primary and back up midwife, however once we transferred to hospital, their role as my primary care providers was not recognized by the hospital, and subsequently I lost faith in my body’s ability to birth as I received fragmented care from a number of different midwives and at least 3 different obstetricians, all of whom I had never met, and who did not take the time to discuss the progress of my labour with me. My resultant Caesarean section was a traumatic experience, and I was not able to hold my son immediately, leading to a feeling of ‘disconnectedness’ from him which sadly lasted well into his first year.
After the birth I experienced symptoms similar to those which I now believe similar to Post Traumatic Stress Disorder, with an inability to sleep, flashbacks of the anesthesia and caesarean procedure itself, and a profound sense of grief that my experience of meeting my first born child had not been the joyous occasion I had hoped it would be.
Our first baby was born in private hospital by emergency caesarean after a failed induction. My husband and I were left to ourselves in the delivery room for long periods. When we did see someone they were total strangers, people we had never before met, who came and went as shifts changed. Minimal help with breastfeeding was provided until 4 days later I had a wonderful agency nurse who spent an hour in the middle of the night giving me the support I so desperately needed. The whole experience was very frightening and traumatic. I was subsequently diagnosed with postnatal depression.
During my second and third pregnancies we paid for our own private midwife who was with me during the pregnancy, labour and post birth. Although our second child was also born by emergency caesarean, I had the continuity of care that made all the difference to the experience. She was with me throughout labour, then in theatre, and afterwards she helped me in recovery where she enabled my baby to stay with me and ensured I received all the help I needed with establishing breastfeeding.
Finally, with the support of my own midwife I was able to birth our third child vaginally, without intervention and will never forget the hormonal high and feelings of self respect, dignity and peace that contrasted so starkly with the terror, grief and despair I felt when my first child was born.
1.4 Emergency Caesarean followed by VBAC [516]
I had my first baby in a public hospital. He was born by emergency caesarean because he was brow presentation. ... I had assumed that my care at the hospital would be in keeping with basic tenets of human rights- that I would be treated with dignity and respect during birth. This was not my experience.
During the 13 hours of labour prior to the emergency caesarean I experienced a shift change of midwives and felt that the second midwife wasn’t confident to guide me. I felt that she gave up on me. I remember her telling me that she had recently had a caesarean and that it wasn’t that bad. I had painful internal examinations during contractions. The bright lights and the public nature of the environment made me feel violated. This fragmented care with people moving in and out of the birthing room upset the flow of events.
Once the wave of interventions had begun I felt there was no any other option in that environment than to do what I was told and to be a ‘good girl’. Several professionals told me that I would be risking my baby to try anything different. I was frightened, I felt coerced and patronised by the midwives and the obstetrician. I demanded that I try every other monitoring option prior to the surgery which was my most feared scenario. As a way of trying to reclaim some sense my own power in the birthing process I wanted to have my baby remain with me and I wanted somebody to stay with me in recovery. I was denied both of these. Post surgery I lay on a bed for an hour shivering alone, without my baby. I felt exposed and ashamed. This deeply impacted my confidence and the crucial bonding with my baby and set the conditions for what I now recognise as Post Traumatic Stress after the birth. I believe this was caused by a combination of factors namely a restrictive birth environment. I suffered a deep sense of failure and grief which has only been resolved with my second birth.
I approached the second birth very differently and chose a homebirth. My partner was also very enthusiastic that we try this after the previous hospital experience. In spite of the fear mongering about VBAC and the dangers of uterine rupture my second baby boy was born peacefully at home in the water. My main care provider was a midwife in private practice. During the pregnancy I experienced great support to make my own choices. During the birth I had no internal examinations. There was no sense of time constraints during the nine hour labour. It was on my own terms and I felt comfortable and safe in my home environment. I felt that my midwife trusted in my innate ability to birth and believe this had a very powerful effect on the birthing outcome.
After the birth I felt great satisfaction and reclamation of my own dignity. I believe this was due to the wonderful support provided by my carer and the continuity of care I experienced.
These four accounts speak eloquently for themselves.
Recommendations of the Report of the Maternity Services Review (The Report) include:
"2. That the Australian Government, in consultation with states and territories and
key stakeholders, initiate targeted research aimed at improving the quality and
safety of maternity services in select key priority areas, such as evidence around
interventions, particularly caesarean sections, and maternal experience and
outcomes, including from postnatal care."
The Report trivialised homebirth and stated that "Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28" The Report ignored the many submissions by women who called for greater access to home birth and private midwifery services.
Comments from readers are welcome.
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