Choices Women Make in Childbirth

This is a short blog about a few conversations with several women regarding the choices they made for the birth of their babies....I was  in a shopping center promoting midwifery and chatted to some pregnant women.....  I’m sharing some of these conversations for two reasons; because the choices these women made blew me away and in light of the vigorous homebirth debates after the release of the SA coroner’s report where he suggested that women who have a high risk factors should possibly consider a caesarean section rather than a homebirth or words to that effect...... (which will be my next blog).

I have to note that the women concerned all had private health insurance and wanted to birth in a private hospital. First two women were 35 and 36 weeks respectively, they were having repeat caesarean sections. When I asked how they felt about their impending c/section Mary said “look I have accepted that is my reality”, I asked was she happy to discuss her decision and she said she was happy to share and talk about it.... she went on to say “my first section was an emergency.... when I was pregnant again we saw the same obstetrician and we were told the risk of the scar tearing was high and its best to have another section. I then said I would get another opinion..... You know, I could not find another obstetrician that serviced the private hospital that would do a VBAC.....and besides my husband did not want to take the risk and I have to consider his wishes,” I asked “did she know the risk was really low...as in 0.04%” and she said “yes, but my husband did not want to take that chance, I wanted to have my baby in a private hospital and did not want to go to a public hospital, so I accepted the second section, now its baby number 3 and that’s the choice I’ve made, it would of been nice to birth normally, but that’s the choice I made, I wanted to have my baby in a private hospital”.

Janie who was her friend had a similar story.... except this was her second section...she also knew about the risks involved regarding a VBAC but really did not mind having a section, again her main reason was she wanted to birth in a private hospital as opposed to a public one....

Sally was an older professional woman, 39yrs old first baby and elected to have a caesarean section, currently she was 34 weeks and was not interested in a vaginal birth, she said ‘I never wanted to give birth naturally, I want to protect my pelvic floor and besides it took me longer to get pregnant than I thought, don’t think I could deal with all that unexpected stuff, now I know the date my baby will be born.....’ her mind was made up – we did go to talk about breast-feeding to which she was not interested in, however we did manage to talk about skin to skin at birth for bonding and the possibility of expressing for the first few weeks and bottle feeding with  breast milk as an option.... I asked had she ever spoken with a midwife, her response was ‘I have private health insurance therefore I have a very good obstetrician.... and he does have a midwife I see from time to time....but he makes all the decisions....”

The last woman was 35 weeks booked for her repeat section at a private hospital – first section was an emergency, no VBAC offered and she elected for a section because her husband is a fly –in-fly-out and she wanted to plan his time off for the birth and this was the easiest way....she also did not want to birth in a public hospital....”on no I only go to private hospitals, that’s why I pay for private health insurance...”

Out of the 10 women I spoke to 5 were having elective sections, 3 were booked in secondary hospitals and another two for private hospitals and hoped for a vaginal birth but all knew about the chance of a caesarean section.... “if all goes well, I will have a vaginal birth..... we have discussed if the need arises we might have a section”.....

I must say the aspect that surprised me most was the desire to birth in a private hospital even if it meant having a c/section as opposed to birthing in a public hospital.....that puts a different perspective on some of the issues.....what is it that the majority of women want and is this the expected norm of place of birth?

Again I come back to the point of education and informed choice..... these women wanted to birth in a private hospital and how that happened did not matter, their main issue was the place of birth.....food for thought.

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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 Hague...as 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..........................

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.

(Ref pic: http://www.i-choose-self-improvement.com/left-brain-right-brain.html)

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)...as 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 Hague....so 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.

Ref pic: http://www.i-choose-self-improvement.com/left-brain-right-brain.html

Hitting a Brick Wall

The National Health (Collaborative arrangements for Midwives) Determination of 2010 (This instrument determines the collaborative arrangements with the kinds of medical practitioners that an eligible midwife must participate in when providing midwifery treatment in order to satisfy the definition of 'authorised midwife'.). This Determination is clearly not working and needs to be amended or rescinded.

Obstetricians benefit from Eligible Midwives not being able to practice. Is it fair and equitable that this group can monopolise the market? Should the role of a collaborator be given to a Health Service or an independent body rather than a ‘named obstetrician’?

I am an Eligible Midwife and have a Medicare provider number. The government introduced the Maternity Reforms in 2010. With these reforms came the Determination for Midwives 2010. At the time of the Determination the then Minister of Health Nicola Roxon acknowledged that there were issues with the AMA but encouraged us (Midwives) to try and make the determination work. We are almost at the 2 year mark and this determination is not working. There is a multitude of evidence to show that obstetricians do not want to collaborate with midwives.
Here are some comments from Obstetricians

‘ I will do the birth you can do the rest’
‘I will not collaborate, I am happy with the status quo’
‘we do not support homebirth regardless of the risk, therefore I will not collaborate’
’I am very comfortable with the situation as it stands and I am not interested in supporting your model of care’

It seems that there is a condition with an offer to collaborate, which means that as a midwife I cannot work to my full potential. On the other hand, there are some private midwives so frustrated with the current political system, they have rescinded their registration and are working as birth attendants. These birth attendants support and assist women’s birth choices and are not responsible to any regulatory authority and are not insured. I wonder is this the answer?

This piece of legislation is a bad law it needs to be changed urgently to allow the Eligible Midwife to work as they were intended. That is to give women more choice, more continuity of midwifery care and for women to claim a Medicare rebate for those services.
Call or email your local member of Parliament and have you say: Ask for your right to see a Midwife and claim your Medicare rebate:

Women need to debate if its time for fetal rights:

In doing so it must be remembered that women's autonomy is paramount. For too long men have bludgeoned and pillaged women's autonomy. A woman's autonomy and body is sacrosanct and for her alone to choose what to do with it.
Education, communication and choice about place of birth is the answer...not mandating through legislation what happens to the woman's body.

As Dame Elizabeth Butler-Sloss in Re MB (1977)

A mentally competent patient has an absolute right to refuse consent to medical treatment for any reason, rational or irrational, or for no reason at all, even where that decision might lead to his death. The only situation in which it is lawful for the doctors to intervene is if it was believed that the adult patient lacked the capacity to decide and the treatment was in the patient’s best interests.

’

Also Justice Cardozo on a Patient's "Rights"
"Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages,".

Consent in law is very clear, as is the current status of the fetus - it has no rights until born alive.

As I see it there seems to be two schools of thought - first when in domestic violence or violence against a woman and the fetus is killed at term (37 weeks usually able to survive outside the uterus)in this instance, women have been calling for greater accountability against the perpetrator...and calls for murder / manslaughter for killing the fetus (unborn child).
On the other hand, you have the woman who chooses an unconventional birth mode, in which her fetus (unborn child) dies at term (from 37 weeks) and there is no accountability for the death of the fetus.( This woman usually chooses this option due to the mismanagement of her care through conventional health services and she feels she has been left with no options).

There seems to be a disparity with this argument, there needs to be the same rule for all, we must come to a consensus as to whether the term fetus deserves some rights. The problem will be in affording the term fetus rights, that the woman's autonomy is not compromised.

Whilst discussing fetal rights it seems unfair that the AMA (WA) should be targeting pregnant women with drug and alcohol issues saying there needs to be some sanctions applied to these women. Where will we draw the line.... obesity, working, sport...this is a preposterous argument we will drive women away from health professionals -

Dr David Mountain stated "there should be penalties for some of the "wild extremes" of homebirth/freebirth advocates where misinformation is deliberately given to women about the risk to their unborn child. I was very clear that in this situation it is the purported expert who misleads a mother into endangering their unborn child that should be considered to have recklessly endangered the child"

I would like to know if this extends to the medical profession whose Caesarean section rate is rising at a rate of knots - are the purported experts misleading women into having a c-section (which will then affect the next pregnancy choice) when it is not required.....therefore endangering their unborn child....

Women who choose to homebirth are very well informed and often do most of the research themselves....they are well aware of the risks involved and think they are doing what is best for themselves and their baby.

No where else in health care do we see that a person's autonomy is compromised in such a way....no one makes you donate a part of your body to a dying relative if you did not want to do so..no one takes you to court to make you give a part of your body to that relative... so why are we so intent on undermining women's autonomy?

Yes it is time for society to debate these issues, as the born alive rule was made in the 17th century. I think women need to be debating this issue as it is their bodies that are in question.

Please write to the West Australian in response to Dr David Mountain's comments Friday 2nd March email: letters@wanews.com.au include full address and telephone number. These comments came as a response to this article.
Charge reckless mums: doctors' union

Questions to ponder:
- what do you think about fetal rights?
- Is a term fetus a human being? and does it deserve some rights?
- in what circumstances should a term fetus be awarded rights?
- should a health professional be accountable for the death of a fetus?
- what responsibilities does the mother have when making choices about her fetus?

The Face of Birth

Great inspiration:Homebirth movement in the US took 40 years......