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Melanie Jackson is mother of two, Midwife in private practice, PhD graduate, part-time blogger, obsessed veggie patch owner and even more obsessed crocheter

Sunday, 20 March 2011

Risk is in the Eye of the Beholder

For this past year I have been researching what motivates and influences mothers to choose a free-birth or ‘high-risk’ homebirth as part of my PhD thesis ‘birthing outside the system’. It has become dramatically obvious that women who make choices that are seemingly against the system have a very different perception of risk than our medically minded counterparts.

                The concept of risk is just that, a concept, one that can be perceived and understood differently by everyone based on their previous experiences, research and influences throughout life. Obstetrics argues that their definition or perception of risk is ‘right’ and authoritative (Murphy-Lawless 1998 p.22) and touts their management and intervention as the best and most sure way of reducing the risk of childbirth. Medicalised management of birth is a hallmark of mainstream birth services; these services perceive their management of birth to be the only ‘right’, ‘best’ and ‘safe’ way to birth, dismissing all other options as ‘dangerous’, ‘irresponsible’, ‘risky’ and ‘wrong’, but, what if medical management of birth is ‘wrong’? What if they unequivocally have it wrong? This is certainly the question asked by the highly intelligent, critical and knowledgeable women who have shared their stories for my research. 

                For mothers who choose to birth at home, medical interventions and interruptions in the birth process are seen as ‘dangerous’ and ‘risky’. They feel that the risk of something going wrong at their birth proliferates the more they part-take in or make themselves vulnerable to the medical management of birth. One woman explains, ‘I look at interference a bit like risk, every time someone new comes across you or does something, that’s a risk that something goes wrong, every time you get a medication there is a risk it’s the wrong one, every time they do something there’s a risk that flows onto something else, so if no-one is doing anything to you or performing any unnecessary tests, then there is no risk there’- (homebirth mother). This is in dramatic conflict with the medical message that interventions are designed and employed in order to reduce risk.

                The medical use of risk language alongside birthing generates fear around the process of labour and birth and if birth is marketed as risky, then it will be perceived as scary. By the use of risk language, obstetrics has perpetuated the myth that childbirth is to be feared and thus throughout history convinced mothers to conform to their birth management in order to avoid something going wrong (Murphy-Lawless 1998, p.18). The medicalisation of birth has allowed obstetrics to redefine what is considered ‘normal’ and ‘abnormal’. By developing a conceptual difference between abnormal and normal the medical profession have secured a large and growing market for their services in perpetuity by the creation of false needs and then catering to these newly perceived needs (Ballard & Elston, 2005, p.230). By the social process of medicalising birth, modern obstetrics can justify managing labour and birth by intervening to make each individual labour and birth conform to the obstetric definition of normal. By defining what is constituted as normal birth, obstetricians have monopolised control over events which occur outside the norm under the guise of ‘risk management’.

Women who remain unconvinced by the obstetric definition of ‘risk’ see no reason in accepting medical interventions and therefore see no reason to enter hospitals. The very place they are most at risk of being subjected to interruption and intervention while they are trying to give birth is at hospital. Home birthing women see intervention as risky and thus will not be convinced to accept them as a way of avoiding adverse outcomes; in fact, they believe that the risk of adverse outcomes at birth is increased by unnecessary intervention. One mother comments, ‘I don’t see induction now as the safe way out, actually having an induction now is the risk to me, that is tempting fate, not carrying a well baby to full term and comfortably to post-dates, that’s not the risk, it’s the unnecessary induction’ (homebirth mother). Another mother also comments, ‘they interfere so that’s why things happen, they end up with forceps or vacuum or caesarean because they put up drips (to speed labour) and they just stuff women up’ (homebirth mother).

The question must be asked, how can it be that modern medicine believes they can make birth safer by interfering, to avoid complications and minimise risk when a home birth mother believes interventions make her birth more dangerous, will cause complications and increase her risk? Is it possible that both are right? if not- who is wrong? The answer lies in what women have described to me as ‘medically indicated intervention’ and ‘necessary intervention’. The women who have contributed to my study saw the absolute necessary place of obstetrics in emergency care for birth complications; we can all agree that when a caesarean is legitimately needed we want a skilled obstetrician (not a midwife) to perform the surgery, but where the bone of contention exists is- who defines necessary?

Just like modern obstetrics and home birthing women have different perceptions of ‘risk’ they also have different definitions of necessary. Women who birth their babies at home see ‘necessary intervention’ as one that is ‘medically indicated’ and a response to a real threat to the mother and baby, one that is truly required because the mother and baby are at risk of death or damage. One mother was asked during her interview if she think thought there was a right place for intervention, she replied, ‘yeah, if there is a problem, if there is a risk, there’s something possible that’s going to affect the mother or the baby and that’s their only way of getting out a healthy baby then yeah, that’s the advantage of living in today’s society’ (home birth mother).

You might ask, why else would an intervention be performed if not for the safety of the mother and baby? The answer not only lies in the findings from my study but also my personal experience working in the hospital system. Deviating from the medically defined norm of time in pregnancy will find you shafted into an induction, not because you and your baby are at risk, but because the hospital policy says so. Not dilating at the medically defined speed will see you augmented with medication, which will see you strapped to the medically defined ‘best’ way of monitoring your baby, which will see you in much greater pain then if you had free movement, which would increase the ‘risk’ of you needing pain medication, which would increase the ‘risk’ that your baby will need to be pulled out with forceps and need intervention to breathe, which will increase the ‘risk’ of breastfeeding being unsuccessful.  Digressing from medical definitions of normal and hospital policy will see you managed with intervention, not to decrease your risk, but to increase your conformity to the medically defined boundaries of normal- which may or may not be right. 
Risk is in the eye of the beholder, every day we make decisions about the risks we are willing to take. You take a risk getting in your car, buying sushi, having sex, taking a panadol, going for a jog, drinking hot coffee and gardening on a hot day, I took the risk today of aggravating my repetitive strain injury while typing, but it was a risk I was willing to take. The medical system and home birthing women perceive risk differently and are willing to take different risks based on different motives, but while each ones perception is different, it is not less or wrong, just different. What is ‘right’ and ‘best’ can only be determined by each individual and where the conflict lies is in who defines what is ‘best’ and which risks are ‘right’ to take.   
If you would like to, or know someonw who you think would like to participate in this research please e-mail mkjackson@live.com.au. For more information on accessing a homebirth midwife visit http://www.ellamaycentre.com/

with love
Mel xo

Thursday, 10 March 2011

The hormones of love and birth

Michel Odent
on the hormones of love and birth
After re-watching ‘The business of being born’ the other day I felt inspired by Michel Odent’s comments on the role of love hormones in maternal bonding. I remembered that on my shelf I have a copy of his book, ‘The Scientification of Love’ and set about reading it with much gusto- often calling out to the ever-understanding and patient Dan, ‘whoa man, you should hear this!’. It reminded me of the very simple ingredients and low-key basic necessities of the birthing woman that facilitate a physiological labour, birth, breastfeeding, bonding and parenting experience. Every woman, midwife, doctor and doula should heed the words in this book – they will enlighten you as to how and why birth works given the right carers and setting. The simplicity and logic of his arguments are astounding and so refreshing in a world where birth is portrayed as complex, dangerous and unpredictable.

To give you just a taste I have included a small excerpt from ‘The scientification of love’ which was a timely reminder of the delicate and basic needs of a birthing woman and the midwives role in protecting these needs.

‘To give birth a woman needs to release a certain cocktail of hormones... The crucial thing is to realise that they all originate in the same gland- the brain. Today the traditional perceived separation between the nervous system and the endocrine system is obsolete. There is only one network and the brain is also an endocrine gland. But it is not the whole brain which is active as an endocrine gland, only its deepest part. We might say that when a woman is in labour the most active part of her body is her primitive brain- those very old structures of the brain (the hypothalamus, pituitary gland etc) that we share with all other mammals. Modern scientific language can also explain that when there are inhibitions during the birth process (or any sexual experience) they originate in that other brain, the new brain, the part of the brain which is so highly developed among humans- the neocortex.

Physiologists might also interpret a phenomenon which is familiar to midwives and some mothers- or at least to those who have had the experience of unmanaged and un-medicated birth. During the birth process there is a period when the mother behaves as if she were ‘on another planet’, cutting herself off from our everyday world and going on a sort of inner trip. This change in her level of consciousness can be interpreted as a reduction in neocortical activity. Birth attendants who understand this essential aspect of the physiology of labour and delivery would not make the mistake of trying to ‘bring her back to her senses’. They would readily appreciate that any neocortical stimulation in general and any stimulation of the intellect in particular, can interfere with the process of labour. From a practical point of view, it is useful to review the well-known factors which can stimulate the human neocortex: language, particularly rational language is one such factor’

‘when considering the birth process from the perspective of physiologists, it is clear that a labouring woman needs to first feel secure and that a midwife is originally a protector, a mother-figure, the mother being the prototype of the sort of person with whom one feels secure’ p.28-31

I will be speaking at the Capers conference in Brisbane in May 2011 and so will Michel Odent ; I can’t wait to hear what he has to say and feel privileged to be sharing a podium with the likes of him. On that note... I highly recommend this book and am going to read the rest of it right now... and I recommend you do the same.

For more information visit www.ellamaycentre.com
With love
Mel xo

Tuesday, 1 March 2011

Midwives @ Sydney and Beyond - Trail blazing with evidence based models of maternity care

a creative way of rolling with the punches

At the end of 2010 the legislative changes imposed on privately practicing midwives and allied health professionals alike meant that we had to obtain personal indemnity insurance in order to maintain our professional registration. Two packages were offered to midwives and for the first time since 2001 privately practicing midwives had insurance to practice. As with all good things- there is a catch, with insurance and registration come regulation and then professionalisation of the midwifery industry.

This regulation does not impact hospital based midwives severely but has meant that privately practicing midwives are held more accountable for their practice and must maintain transparency more than ever. Access to insurance also paved the way for medicare and PBS numbers for midwives who choose to be 'eligible' for these benefits which allow clients to get some of the out-of-pocket cost of hiring a private midwife back and also allows eligible midwives to refer their clients for antenatal testing and screening without first consulting a GP.

This arrangement is all theoretically good news for the profession of midwifery and women alike who can now access the care of their own midwife regardless of birth setting or 'risk' status. Attached to 'eligibility' and medicare is the requirement to work collaboratively with other maternity care providers, this theoretically improves continuity of care for women who choose to hire a privately practicing midwife to birth in hospital or require specialist care if complications arise during pregnancy or birth. It all sounds very complicated, and it is- and still being ironed out, like all new government policy. The changes to the face of privately practicing midwifery are inevitable and regulation of the profession has happened whether we choose to acknowledge it or not.

Midwives @ Sydney and Beyond was born out of the need to 'roll with the punches' of these changes. Melanie Jackson, Jane Palmer, Robyn Dempsey and Hannah Dahlen got together with the agreed aim of forming a private midwifery group practice to provide midwifery care to our client’s where ever they choose to birth. The Quality and safety framework under which we work allows the women 'right of refusal' and the midwife has a 'duty of care'- this clause within the framework allows mothers choice and midwives freedom to support women in this choice. We embrace and help inform a woman’s choice during pregnancy, birth and beyond and are dedicated to providing women with continuity of care, one-to-one attention and an uninterrupted physiological birth and baby-feeding experience. This concept of a group midwifery model of care is somewhat new to the private midwifery sector and we are very much feeling our way through the legislative changes as we adapt to the new world order - the benefit is that we get to do it together!.

Midwifery models of care are highly researched and supported by rigorous evidence and provide gold standard outcomes to women who choose this option for their pregnancy, birth and baby feeding experience.

Below is an excerpt from the Cochrane database of systematic reviews on midwifery models of care:

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a
service through a team of midwives sharing a caseload, often called ’team’ midwifery. Another model is ’caseload midwifery’, where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner.

All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers. By contrast, medical-ledmodels of care are where an obstetrician or family physician
is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates.

Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks’ gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.

The review concluded thatmost women should be offeredmidwife-ledmodels of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women.Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

It is important to know your needs, desires and philosophy about pregnancy, birth and baby-feeding and ensure your carer and place of birth match these desires to ensure the greatest success and satisfaction in your parenting journey  

with love
Melanie xo

for more information on Midwives @ Sydney and Beyond visit http://www.ellamaycentre.com/