Thursday, May 31, 2012

Women need midwives and midwives need more autonomy

Firstly I should be studying not writing this blog...... way to procrastinate.....Life has been very busy as usual for me  especially with hubby not being well .. the garden is in disrepair, months of ironing waiting to be done and as for the dusting... forget it.... but life must go on.... most importantly I have to make time for my beautiful grandchildren.....
I have currently just completed a Human Rights assignment and this got me thinking even more about the dilemma in Australia particularly in WA with Medical dominance, the strength and power of the AMA and the deliberate non engagement with private midwives for collaboration. It seems that the obstetricians are happy with the status-quo that is monopolizing childbirth - remembering in WA the uptake of private health insurance is approx 40%, (people think if they have private health insurance they get better care and value for money) and 99% of women want to birth in a hospital. WA has less than 1% of women who are choosing homebirth - with these small numbers and the high uptake of private health insurance, together with the failure of GP's to refer women to midwives, as they only refer to obstetricians..... it seems the only way forward for both women and midwives may be a Human Rights approach.

Continuity of midwifery care is almost absent in WA. The lack of autonomy for midwives whether they work in a hospital or as a private midwife in Australia is shameful. Even worse is the denigration of women's right to choose place of birth no matter what the risk and be afforded the right to have a midwife support that choice is non existent. Clearly the midwife would need some support if it was  'high risk' as this would be outside the scope of practice - this is where a supervision model would be beneficial similar to the UK. But instead women are pushed to the brink and birth alone without a health professional present. The question is who will protect the midwife who chooses to support the woman when she chooses outside of the recommended boundaries? Next question is who protects the fetus when things go wrong.... yes I know the fetus has no rights until born alive, but this rule is being challenged each time there is an adverse outcome.... watch this space.... This brings me to the first ever Human Rights in Childbirth Conference being held in the I write this blog....I have paid to be part of the webinar but alas it is not working.... will have to do a blog on it when I finally get to listen to it. This conference is going to debate and discuss all the issues surrounding place of birth, maternal fetal conflicts and rights - how fascinating... I truly wished I could attend.

As I have stated before there is no legislation in Australia that will protect the midwife if she chooses to support the 'high risk' woman at home. The midwife would more than likely be reported under the current Health Practitioners Regulation National Law Act 2010, be disciplined, which could mean a fine, restrictions on his/her practice or de-registered.

I am hoping that out of the Hague conference will come some true discussion from the lawyers, midwives, academics, doulas and who ever else is contributing to the conference about the maternal / fetal debate and the right of women to choose where and how they want to birth - and what happens in the countries where true choice is not valued. Here's hoping..........................

Monday, May 7, 2012

Virtual IMD reflection

Virtual IDM reflection: this was taken from listening to Dr Amali Lokugamage present, it was an excellent presentation, food for thought. This is my understanding of the presentation.
Also a big thank you to Sarah Stewart who organised the Virtual International Day of the Midwife a wonderful event. If you want to listen to Dr Lokugamage presentation just follow this link.

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Dr Amali Lokugamage “Why doctors fear homebirth”
Amali started by sharing she had a homebirth – an obstetrician who has had a homebirth – this was fantastic news, it was so inspirational to hear her talk about her experiences and try to explain the position of the obstetrician. Not that I never considered the position of an obstetrician before, but Amali made it so clear for me. She went on to say that prior to her own homebirth she did not understand why anyone would have a homebirth. She describes her homebirth as a profound experience so empowering. Which led her to write the article “Why doctors fear homebirth”. Amali described that her pregnancy changed her views, she had an intuitive connection with her son, she talked about her connection...this led her to writing her book “ The heart in the Womb”. ...which I must order.....She contributed her fear of childbirth to her lack of knowledge in this area, and her medical education, lack of knowledge leads to mass cultural blindness on normal birth and the basics of physiology of birth.
Litigation is on the increase, therefore defensive practice is prevalent – obstetricians fear preventable bad outcomes. Doctors worry, will I survive litigation, they are fearful of it and try to avoid it at all costs, you can understand why they are fearful as this is their lively hood and sustains there family and lifestyle.

Interestingly Brittan does not have an issue with homebirth – as they largely have a public system and homebirth is provided within the healthcare system and provided for in legislation. Where as when you look at countries where health care is privatised, a greater private sector, she talks about a war on money – how true is this; I firmly believe part of our problem in Australia is that a large percentage of women have private health insurance, and GP’s refer directly to obstetricians, they do not offer midwifery led models of care...and often women think having obstetric care equates to high quality care.....

Dr Amali made another interesting point about the politics of homebirth by looking at how the Obstetric Colleges support or do not support homebirth – the only one I know off that supports homebirth and works together with midwives is the UK RCOG. (RCOG v AMA, ACOG) this might reflect the culture of the country. She went on to say Doctors want to fix, solve, not considering autonomy, because it’s about fixing the problem for what they perceive as the best. They are taught the importance of Maternal Mortality – 358,00 women die in childbirth each year – mostly in developing countries -, therefore they want to make things better......she also discussed, The three delays model – delays which lead to trouble pregnancy complications, delay transport, receiving g adequate care one transferred (“The “three delays” as a framework for examining maternal mortality in Haiti” Barnes-Josiah D, Myntti C, Augustin A, Soc Sci Med. 1998 Apr:46(8):981-93).

This next point was most revealing was that there was an audit conducted of the Evidence in O&G practice, the audit found only 1/3 of the recommendations put forward by the ACOG was based on good and consistent scientific evidence, that is grade A. This is appalling considering that ACOG is most aggressive about homebirth and women’s right to autonomy. (Obstet Gynecol. 2011 Sep:118(3);505-12. Scientific evidence underlying the American College of Obstetricians and Gynecologists practice bulletins. Wrigh JD, Pawar, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ.)
Also discussed was Homebirth evidence, we know the – two largest homebirth studies; de Jonge, 2009 low-risk planned home and hospital births – low risk equivalent to birth in hospital. BJOG: An International Journal of Obstetrics & Gynaecology, 116, 1177-1184 . Birthplace in England Collaborative Group. 2011. Perinatal and maternal outcomes by planned place of birth...BMJ. 2011 Nov 23;343;d7400; for multiparous women low risk is safe at home. Birth place in England - last study to say it was cheaper to have birth at home – and we all know this... it seems that the evidence is only used to discredit home birth and not when it is showing the benefits.

It was refreshing to hear an Obstetrician talk about - 'Obstetric latrogenesis' (that is problems caused by the hospital / health professional) – increasing - induction, epidurals, surgical delivery, reduces bonding, reduces chances of reducing breast feeding; Normal birth leads to adaptive physiological function in the baby, endocrine, immune system thyroid function, respiration promotes high breast feeding rate, greater bonding.
Clearly you can see – healing is viewed differently between the – midwifery model v medical model. I have heard this argument presented before that, Obstetricians only look at a snap shot of the woman's life – intellectual technical knowledge of birth as opposed to wisdom, feeling of birth. Obstetrics dominated by the left brain as opposed to midwives who use both sides of the brain.
I liked the idea that Amali talked about how oxytocins may affect us – fight and flight, so low oxytocins for obstetricians as opposed to high levels of oxytocins calm, considered composed = midwives; this is a very interesting concept, she also says that it is possible that obstetricians and midwives are physiologically different...certainly food for thought, I liken it to Men are from Mars and Women are from Venus.....

I was  surprised to hear the number of specialist doctors that have had successful homebirth (but I guess they are in the UK) – Dr Amali gave no answers to how to resolve the issues of the power imbalance, she thought that it would be almost impossible to convert them from left brain thinking...."it is difficult", maybe showing more video’s such as orgasmic birth"....

Dr Amali closed with that a possible solution maybe that Birth is a Human Rights issue.. as human rights will over rule obstetricians...maybe this is the way forward.... for me this will be a whole separate blog (as this is not as simple as it sounds and takes a long time) I would like to go through the case of Ternovsky v Hungry, a woman’s right to choose homebirth whether low or high risk ....

At the end of this month there will be a Human Rights conference in the watch this space.
Thank you Dr Amali Lokugamage for an inspiring presentation, I will try to view the 'Obstetrician' from a more left brain angle rather than just being paternalistic and disregarding a woman’s autonomy.

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