Maternity Services Review

The date for submissions to the Maternity Services Review Discussion Paper has now past. I received the email below today to say my submission has been accepted. I now am waiting excitedly with the hope that real changes are going to occur such as midwives receiving Medicare rebates, professional indemnity insurance and that we'll have the ability order diagnostic tests and have prescribing rights.

Dear Jane

Thank you for your submission in response to the Maternity Services Review Discussion Paper, “Improving Maternity Services in Australia: A Discussion Paper from the Australian Government”.

Your submission, along with all other submissions and information, research and expertise assembled from other sources will be used by the Department of Health and Ageing in the development of a report to the Minister for Health and Ageing, the Hon Nicola Roxon, MP.

Thank you again for your contribution to this important process.

Yours sincerely




Rosemary Bryant
Chief Nurse and Midwifery Officer

Midwife-led versus other models of care for childbearing women

A friend has just emailed a link to this review from the Cochrane Collaboration (published October 2008) - I thought you might be interested:

Midwife-led versus other models of care for childbearing women
Hatem M, Sandall J, Devane D, Soltani H, Gates S.

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 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. By contrast, medical-led models 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 reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced 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. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks. The review concluded that all women should be offered midwife-led models of care.

To read more visit: http://cochrane.org/reviews/en/ab004667.html

Proverb Translated from the Tao Te Ching

You are a midwife, assisting at someone else's birth. Do good without show or fuss.

Facilitate what is happening rather than what you think ought to be happening.

If you must take the lead, lead so that the mother is helped, yet still free and in charge.

When the baby is born, the mother will rightly say: "We did it ourselves!"

from The Tao Te Ching

Greater Roll for Midwives

Midwifery is on the national agenda today. There has been wide coverage on television and newspapers. Finally we are seeing a shift by the government towards midwifery care. This is long overdue. My fingers are crossed the government is serious about implementing the planned changes.

Here is the report in today's Sydney Morning Herald (on the front page).

Mark Metherell - September 10, 2008

Midwives would be given doctor-style responsibilities such as being able to order diagnostic tests and prescribe drugs under proposals being considered by the Federal Government.

With a shortage of nurses and doctors straining maternity services at a time of near-record birth rates, the Minister for Health, Nicola Roxon, will release a discussion paper today proposing a boost in the role of Australia's 12,000 midwives.

The paper cites fragmented services, professional restrictions, funding problems and a lack of affordable indemnity insurance as barriers to greater use of midwives. Australia's use of independent midwives compares poorly to other developed countries, including New Zealand and Britain.

To provide a comprehensive service similar to that of general practitioner obstetricians, the discussion paper says, midwives require rights in hospitals to enable them to visit and refer their patients to specialists, to order diagnostic tests, prescribe drugs and have access to Medicare payments for the work they do.

The proposals are likely to encounter resistance from the Australian Medical Association, which has previously raised concerns about patient safety - claims that have been rejected by the Australian College of Midwives.

The discussion paper is part of a comprehensive review of maternity services being led by the Chief Nurse and Midwifery Officer, Rosemary Bryant, to be completed by the end of the year.

The review will cover issues including support for a greater role for midwives; opportunities for women to have more birth-care options, including home births; the shortage of maternity staff and services, particularly in rural and remote areas; and rising levels of post-natal depression.

The paper says that as there is no Medicare benefit payable to midwives for management of labour and delivery, there is only limited support for midwifery services through private health insurance.

In most cases, mothers choosing to have their babies outside hospital pay the full cost of midwife services, which is typically more than $1000.

A key issue was expanding the scope within both the public and private sectors for women "to achieve greater choice and increased continuity of care.

The report states that Australian women often had a range of different health-care providers during pregnancy.

This was despite international studies which had consistently demonstrated that continuity of carers improved satisfaction for both patient and carer, and improved health outcomes.

Shellharbour Hospital gets new home birth service

Some exciting news has just published by ABC News. This adds to the growing trend of publicly funded homebirth programs in New South Wales.

New South Wales Health Minister Reba Meagher has announced a new home birthing service and family care centre for Shellharbour Hospital.

The family care centre will offer prenatal services and post-discharge midwifery support, such as help with breast feeding and sleep management.

The home birthing service will see publicly funded midwives offer continuity of care through a pregnant mother's labour, birth and postnatal care.

Ms Meagher says the new centre will add to the range of choices available to women in the Shellharbour region.

"This will mean those women who want to give birth at home will be able to do that with the support of a specially trained midwife. Increasingly women are choosing to have children at home," she said.

The home birth announcement has been welcomed by the New South Wales Midwives Association.

To read the complete article go to www.abc.net.au/news/stories/2008/06/13/2273925.htm

National Health and Hospital Reforms Commission

On 25 February 2008, the Prime Minister and the Minister for Health and Ageing announced the establishment of the National Health and Hospitals Reform Commission. The commission will provide a blue print for tackling future challenges in the Australian health system. Out of the blue I received an invitation to attend a focus group, which was one of many groups facilitated by the commissioners across Australia. They brought together a diverse group of front line health care providers such as midwives, physiotherapists, ambulance officers, dieticians, nurses, doctors, prison health care workers (and quite a few other professions). It was a very interesting few hours. We sat randomly at round tables and worked as a group to discuss what we wanted to see changed in the health care system. We each had the opportunity to present two changes. Then together as a group developed three changes for the future. Each table presented their ideas (there were five tables in all). Out of all the ideas collected we had to all agree on five changes. Then a table was assigned one of these changes and we had develop ideas on how to achieve these changes. It was a fascinating process and easy to contribute to. As health professionals I found we all have similar ideas of what was needed for the future. I had the opportunity to speak for improvements in maternity care and have some of my ideas included into the submissions to the commissioners. I spoke for the right of women to have publicly funded homebirths, for the care of well pregnant women to be available in the community (rather than by the hospitals), to change from an illness focus to a wellness focus in maternity care and for the need of midwives to have professional indemnity insurance. While I was only one voice - I did feel that I was listened to. I do commend the government for this initiative. However I hope the Australia Government doesn't just produced a blue print for the future, I hope they choose to act on it rather than filing it in the bottom draw. To find out more visit the National Health and Hospital Reforms Commission Website.

Belmont Birthing Service

While being an independent midwife has it's struggles and I often feel like the birthing services are getting worse instead of better, - there are many people working behind the scenes to improve the care women and their families receive. Belmont Birthing Services is a fantastic example of what can be achieved with the right support. The following information is written (and reproduced with permission) by Carolyn Hastie

Hi all, thought I'd write and give you all an update on what's happening at Belmont Birthing Service (BBS) on the shores of the beautiful Lake Macquaire near Newcastle, NSW.

To remind you about BBS, we are a stand alone, women centered, midwifery managed maternity service, situated with in Belmont Hospital. We are a public health service, part of the maternity services offered through John Hunter Hospital. There are 8 of us, seven midwives and one manager. We care for women throughout pregnancy, birth and the postnatal period for two to three weeks. Our service commenced on the 4th July 2005, so we are almost three years old.

We have now cared for 651 women through the birth of their babies and beyond.
72% are having their babies on site at Belmont.

The normal birth rate, even for those women who are transferred to the tertiary referral hospital, either in labour or before is > 95%

Reasons for transfer are predominately post dates for induction of labour and slow progress in labour - either requiring pain relief or augmentation. Interestingly, there were far more transfers in the first two years of our service than there are now. That is due to several factors including the fact that in the first year, women who were Group B Strep positive were transferred for antibiotic cover. Since then, all the midwives have been credentialled as immunisers, so can give IV antibiotics without medical presence. Chlorhexidine douches are very popular and effective for GBS prophylaxis and most women choose to use that as they are not keen on antibiotics.

Other stats you may find interesting include:

• most of the women choose to birth their babies through the water - the baths at BBS are wonderful.
• most of the women choose undisturbed labour, including third stage and so the physiological third stage rate is very high blood loss rates are very normal, postpartum haemorrhage is exceedingly rare there have been only two women with elevated blood pressure (no actual Preclampsia) prenatally and one postnatally.
• there have been five premature births and those babies were one at 32 weeks, the rest at 34-36 weeks.
• Four women have had breech babies and given birth at the tertiary referral hospital.

We are very blessed to have great midwifery and medical management and our health executive are fantastic, very supportive of our service and other innovative ways of caring for the health needs of their population.

Other great items include:

• Hunter New England Health has an area wide homebirth policy based on the wonderful NSWHealth Homebirth policy and we are now able to provide homebirth for those women who choose that option. Our first homebirth occurred on Christmas Day 2007. We have a virtual ward and virtual nursery for these births and babies.
• Intradermal water injections are used as needed and have been very beneficial to the women who have used them.
• The midwives have admitting rights and now women are admitted with the midwife's name as care provider.
• Across the health service, routine birthing medications, such as syntocinon, N2O, Konakion and Hep B, Priorix are now midwife initiated medications, so no doctor's signature is necessary for their administration.

It's all very exciting and wonderful to see the way that everyone in the health service is supportive of enabling women and midwives to work together to keep birth normal and rewarding for everyone.

love, Carolyn Hastie
Midwifery Manager
Belmont Birthing Service
0428112786

To download a flyer on Belmont Birthing Service (PDF Document)

Save Independent Midwifery

Since 2003 Independent Midwives in Australia have been unable to obtain professional indemnity insurance. Insurance companies felt that the number of independent midwives is extremely small and that one claim would wipe out any premiums they'd obtain - making independent midwives an uneconomical group to support. As far as we can ascertain there have been no major claims against independent midwives (or none that the insurance companies have let us know about). This had a big impact on my independent midwifery practice. I'd enjoyed a wonderful working relationship with Prince Alfred Hospital at Camperdown - I had visiting rights as an independent midwife which enabled me to support women as their primary caregiver in the birth centre and also enabled me to continue care for women who required a transfer after a planned homebirth. In NSW the Nurses and Midwives Registration board does state that we are supposed to carry Professional Indemnity insurance but does not enforce it.

It seems that Independent Midwifery in the UK is not so fortunate. The government is proposing that all health professionals carry professional indemnity insurance - which effectively will make it illegal for independent midwives to continue practicing. I cannot believe that such problems face my sisters in the UK. If you wish to read more go to http://www.saveindependentmidwifery.org/

Dangers of Prenatal Testing

Channel 9's Sunday program has a very interesting video footage on the "Dangers of Prenatal Testing"

An ultrasound screening test at 12 weeks is now considered a routine part of pregnancy, but an eminent British Radiologist claims the test, designed to pick up chromosomal abnormalities like Down syndrome, is highly inaccurate.

In a controversial interview with the Sunday program, Dr Hylton Meire claims that the screening test known as a Nuchal Translucency, has a false positive rate of 95%, and that healthy babies are put at risk of miscarriage from more invasive tests to confirm or deny the original suspicion. He argues up to three healthy babies die for every one Downs syndrome baby that goes to term. Read On...

Scared for Life

The Sydney Morning Herald recently put Caesarean Birth's as a major headline for more than a week. As the caesarean rate fast approaches 1:3 births - it was a timely response from a major newspaper. If you happened to miss the headlines you can read about them on Sydney Morning Herald's Website. They have also uploaded a very powerful video interview with two women who's caesarean births went very wrong.

Awesome VBAC story

I was reading my emails this morning and was sent a link to the site One True Media - which I wasn't aware off. It is similar to YouTube so I thought I'd check it out. The link was to a short video of Theresa's journey to a successful vaginal birth after three caesareans - it is one of the most powerful birth stories I've come across - so I thought I'd share it with you.

Make video montages at www.OneTrueMedia.com

The worst intervention in the birth room ...

My recent experience working as a midwife in the hospital system has fastened my belief that the worse intervention in the birth room is the clock. When working with women in the community - there is no clock, there is no pressure and there is no unnecessary intervention. The events of labour unfold as nature intended. This is in stark contrast with birth in hospital. Every aspect of labour is MANAGED according to the clock. For example a women's membranes break the clock starts ticking. Often times she may be offered an induction of labour straight away or alternatively allowed 12 to 24 hours to establish labour or then have the induction of labour (and all it's associated problems).

A women's progress in labour is managed by the clock - the expected dilatation is 1cm per hour or her labour is considered abnormal and her labour sped up with Syntocinon. There is no quality evidence that supports a woman must dilate at a certain rate and in fact speeding up a labour unnecessary is quite harmful. Syntocinon causes the uterus to contract more painfully than a natural labour - increasing the use of pain medications (and their inherent effects). Syntocinon often causes too frequent contractions - depriving the baby of oxygen causing unnecessary fetal distress. One of the most catastrophic problems syntocinon causes in an increase in postpartum haemorrhage and the associated morbidity and occasionally mortality that a haemorrhage can cause.

While Syntocinon, in a few causes, will assist a woman to achieve a vaginal birth where her labour is truly prolonged. In most cases it is used unnecessary, causing a cascade of intervention.

Get rid of the clock in the birth room and allow women to labour under their own steam.

First Post for 2008

I can't believe I've left it this long to add to my blog. I must say that it was exhausting organizing the screening of The Business of Being Born - there was more work than I'd anticipated. The feedback from the screening was very positive - I'd love to make the documentary more widely available. It looks like the DVD will be released in March 2008 - which is great news. I'll keep you posted.

Christmas was fantastic, I enjoyed time with my family doing Christmas activities (like taking my younger children into the city - they are seen in this photo riding Santa's train).

I continue to work at the local hospital in the birth unit. It is challenging as intervention rate is unnecessarily high. The system has lost sight of what normal birth is and complication rate is high. It is rewarding though as I feel like I make a difference and I have access to lots of education programs.