AIHW report 2009

The Australian Institute of Health and Welfare (AIHW) has published its statistical report Australia's mothers and babies 2009, released: 21 Dec 2011 author: AIHW (Li Z, McNally L, Hilder L & Sullivan EA)

In 2009, 294,540 women gave birth to 299,220 babies in Australia. The increase in births continued, with 2,295 more births (0.8%) than reported in 2008. The average age of women who gave birth in Australia has increased gradually in recent years, from 29.0 years in 2000 to 30.0 years in 2009.

The full report is available at the AIHW website.

The following excerpts are likely to be of particular interest to readers of the APMA blog.

Homebirths

In 2009, there were 863 planned homebirths, representing 0.3% of all women who gave birth. The highest proportions were in Tasmania (1.4%) (Table 3.14). It is probable that not all homebirths are reported to the perinatal data collections.

The mean age of mothers who gave birth at home was 31.7 years (Table 3.45). The proportion of mothers younger than 20 was 1.6%, and the proportion aged 35 and over was 30.2%.

The proportion of mothers who gave birth at home who identified as being of Aboriginal or Torres Strait Islander origin was 1.7%.

Most women who gave birth at home were living in Major cities (58.6%) (Table 3.45). Of mothers who gave birth at home, one-quarter had their first baby (25.0%), and 75.0% were multiparous. The predominant method of birth for 99.5% of women who gave birth at home was non-instrumental vaginal (Table 3.45).The presentation was vertex for 98.1% of women who gave birth at home. Of babies born at home in 2009, 99.8% were liveborn. The mean birthweight of these liveborn babies was 3,646 grams (Table 3.45). The proportion of liveborn babies of low birthweight born at home was 0.9%, and the proportion of preterm babies born at home was 1.0%.

Private midwives are, and have been for many years, the main providers of homebirth care for Australian women. This report does not seem to distinguish between babies born at home in 'private' or 'public' care.

Method of birth and hospital sector

Method of birth for women who gave birth in hospitals was compared by hospital sector and state and territory (Table 3.40).

Women who gave birth in public hospitals reported higher levels of non-instrumental vaginal birth than those in private hospitals (61.5% compared with 43.4%).

Private hospital patients had higher proportions than public hospital patients of vaginal births requiring forceps (3.6% compared with 3.0%) or vacuum extraction (10.5% compared with 7.1%) (Table 3.40). Of women who gave birth in public hospitals, the highest rate of forceps deliveries was in the Australian Capital Territory (6.1%), and of those in private hospitals, the highest rate of forceps deliveries was in the Northern Territory (6.7%). Vacuum extraction was most common for both public and private hospitals in Western Australia.

Of women who gave birth in hospitals in Australia in 2009, 32.6% had a caesarean section delivery. The caesarean section rate of 42.5% for women in private hospitals was higher than the rate of 28.4% for those in public hospitals. The highest rate of caesarean section deliveries in private hospitals was in Queensland (47.9%), followed by Western Australia (41.8%) and Northern Territory (41.0%) (Table 3.40).

NOTE: Data from Victoria are not final Provisional data were supplied by Victoria for this report and limited to Perinatal NMDS data items. The numbers of mothers and babies in Victoria in Australia may change when the final data are used. Tables will be updated when NPDC data from Victoria are received. Tables in this version of the report are footnoted accordingly.

Sarah Buckley: Is homebirth safe?

Sarah Buckley comments on the question:
Is homebirth safe?

Homebirth has been in the news recently, with reports that homebirth may be unsafe. 

If you read an article that reports this, it is important to note the background of the researcher or commentator, and where the research has been published. As you may be aware, there are many vested interests in the maternity care system, including individuals and institutions who could lose much of their livelihood if homebirth became more popular.

As well as this, many of us enter the caring professions with a strong "need to be needed".

It can be confronting, especially for those with long years of training, to realise that women's bodies are superbly designed for labor and birth (as I describe in my ecstatic birth ebook), and that the vast majority of mothers and babies will birth safely anywhere, without outside assistance. (As my friend, and neonatal resuscitation teacher extraordinaire Karen Strange says, "Birth is designed to work, even if there is no-one else around")

The debate about homebirth safety is not just about home birth. It is the tip of a centuries-old argument that began when medical doctors first entered the birth room: is birth intrinsically safe, or an accident waiting to happen? Can we trust women's bodies or do we need to constantly improve them with monitoring, medicating and otherwise intervening?

This argument continues to rage in other aspects of birth: for example a recent paper argues that routine induction for all women at 39 weeks (as compared to 'expectant management') would be cost-effective and beneficial for all mothers and babies.

However, as my writing and research shows, there are many known safety factors in normal birth, and likely many more that we have not yet discovered. Without a full understanding of these factors, any attempt to 'improve' birth for healthy mothers and babies is unlikely to succeed. For example, we still do not understand the processes that initiate labor, but have identified mechanisms that switch on brain protecting factors. and that do not operate before term in other animals.

You can read more on my website about homebirth safety and benefits (and see an interview with my daughter Emma** ) and my blog post Ten things to love about homebirth.

Midwives and prescribing

Midwives who have achieved eligibility for Medicare (MBS) are required to sign an undertaking:

• That I will undertake, and successfully complete, within 18 months of recognition as an eligible midwife:-

(i) an accredited and approved program of study determined by the Board to develop midwives’ knowledge and skills in prescribing; or

(ii) a program that is substantially equivalent to such an approved program of study, as determined by the Board.

I understand that until I meet the above requirement I will not be able to seek endorsement for scheduled medicines and will therefore not be prescribing medicines.

As there is at present no option (i) 'accredited and approved program of study', option (ii) is being used, and midwives who have completed a course of study in pharmacological management for Nurse Practitioners are required to undertake an exercise in *mapping* their course against the AHPRA guideline and accreditation standard. For more information regarding each section and for greater context please refer to the “Guidelines for Education Requirements for Recognition as Eligible Midwives and Accreditation Standards for programs of study leading to endorsement for scheduled medicines for Eligible Midwives”

Broadening the discussion about home births

An insightful commentary on homebirth by Hannah Dahlen has been published in 'Croakey' blog. Here's a brief excerpt:

The home birth is about more than safety

... The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.  

Home birth also represents starkly the different philosophical frameworks held by midwifery and medicine, and hence the debate over this issue is ideological, contested, longstanding and circumscribed by relationships of power.

ACM Position Statement on Homebirth Services 2011

The Australian College of Midwives (ACM) has released a revised Position Statement on Homebirth Services 2011, together with a 'guidance' document and literature review. To access the .pdf files, click here.

"The following Position Statement on Homebirth Services 2011 has been developed utilising extensive consultation with all submissions being considered by a Review Panel. The Review Panel consisted of nominees from all Branches (eligible midwives, private practising midwives, midwives providing public homebirth services and midwifery academics) and two representatives from the ACM Consumer Advisory Committee. It should be read in conjuntion with the Guidance for midwives regarding homebirth services 2011."

Readers of this and other midwifery blogs will know that an Interim Position Statement on Homebirth, with a guidance document and lit review were released a couple of months ago by ACM. The position statement was endorsed by the Nursing and Midwifery Board of Australia, prior to the documents being circulated in the midwifery profession for comment. The full significance of this rapid endorsement by the regulatory body, of an 'interim' document, prior to consultation with the profession, is not clear.

The new Position Statement presents a clearer position than the previous one.  One of the key stumbling blocks is what to do with women who choose home birth against the midwife's or other health service's advice.  The new statement addresses informed decision-making, informed consent, and the woman's right of refusal, and acknowledges that "some women may choose a planned homebirth when this is not recommended by a health care provider.  Women should continue to have access to midwifery care whatever they choose."

In a Croakey blog (the Crikey health blog), outspoken obstetric spokesman Dr Andrew Pesce states that:

"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."

Dr Pesce's concluding, and tantalising statement is:

"If they [those individuals and groups which advocate for publicly funded home birth] can cross that Rubicon, they might find that they have broader support than they realise."

I say this statement is tantalising, because it appears to be suggesting that obstetricians and mainstream maternity services would, with agreed boundaries, support publicly funded homebirth.  That is happening in a variety of homebirth models, providing homebirth services for a small number of women around Sydney, Melbourne, Adelaide, Perth, Fremantle, Darwin, Alice Springs. 

I wonder if that support would extend to home birth in the care of a privately employed midwife?

Births in South Australia: Summary and recommendations

Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 including the South Australian Protocol for Investigation of Stillbirths

Summary
This is the Twenty-fourth Annual Report of the Maternal, Perinatal and Infant Mortality Committee, for the year 2009:

1. There was one direct, one indirect, and one incidental maternal death in 2009. The maternal mortality ratio for the last four-year period 2006-2009 was 6.5 deaths per 100,000 women who gave birth, which is low by international standards. It is also lower than in the preceding five-year period where there were 9.1 deaths per 100,000 women. The overall number of deaths was small (five in four years
compared with eight in five years).

2. The Committee reviewed the 189 perinatal deaths of babies born in South Australia in 2009. The perinatal mortality rate for all births (stillbirths of at least 400g or 20 weeks gestation and all live births) was 9.5 per 1,000 births. The stillbirth rate was 7.0 per 1,000 births and the neonatal mortality rate 2.5 per 1,000 live births. Over the past years, declines have occurred particularly in the perinatal mortality rate used for international comparison, i.e. stillbirth and death within the first 7 days of life for babies weighing at least 1,000g. The early neonatal death rate for international comparison remained low in 2009 at 0.9 per 1,000 live births.

3 Eighty-three percent of the perinatal deaths occurred in preterm babies (less than 37 weeks gestation). The leading cause of perinatal death in 2009 was again congenital abnormalities, which accounted for 34% of the deaths. Other leading causes were spontaneous preterm birth (11%), specific perinatal conditions (11%) and stillbirth of unknown cause (11%). There were 21 stillbirths of unknown cause, a rate of 1.1 per 1,000 births in 2009. This rate has fallen in recent years, compared with 2.0 per 1,000 births in 1995-1998. The Committee has distributed its protocol for the investigation of stillbirths to all obstetric units (Appendix 8). Twenty-one deaths were attributed to preterm birth. Preterm birth and poor fetal growth (which contributed 9% of deaths) have been associated with smoking during pregnancy. The proportion of women smoking during pregnancy has been declining in the state. However, in 2009 it remained at 16%.

4. Nine babies of Aboriginal mothers died during the perinatal period. The perinatal mortality rate of 14.6 per 1,000 births with Aboriginal mothers in 2009 was the second lowest recorded, but remained higher than that of 9.3 per 1,000 with non-Aboriginal mothers. The rates of preterm, small-for-gestational-age and low birthweight births with Aboriginal mothers also remained higher. The  proportion of Aboriginal women who smoked during pregnancy was 52% compared with 16% for non-Aboriginal women.

5. The Committee also reviewed the 23 post-neonatal deaths in 2009 of babies born in South Australia, two of which were the babies of Aboriginal mothers. The postneonatal mortality rate remained very low at 1.2 per 1,000 live births. Congenital abnormalities accounted for 11 (48%) post-neonatal deaths. There were 10 ‘Sudden Unexpected Deaths in Infancy’ (SUDIs). Three subcategories of the SUDI deaths can be difficult to distinguish: ‘SIDS’, ‘accidental asphyxiation’ and ‘undetermined cause’. In total, six deaths, including one SIDS death, were attributed to these three subcategories.

6. The infant mortality rate in 2009 was 3.6 per 1,000 live births. The infant mortality rate for babies of Aboriginal mothers of 4.9 per 1,000 live births was the lowest recorded but remained higher than that of 3.6 for babies of non-Aboriginal mothers.

7. From the review of maternal, perinatal and post-neonatal deaths, the Committee makes the following recommendations:

General
>> NEW - There should be further development and evaluation of culturally appropriate programs to enhance access to, and uptake of antenatal, birthing and postnatal care in Aboriginal communities.

Antenatal
>> Caring for pregnant women should be undertaken in a setting which is appropriate for the level of risk the pregnancy presents for the mother and/or the baby.
>>Women with current or previous serious medical conditions should be reviewed by a physician early in pregnancy.
>> Pregnant women travelling in motor vehicles need to wear seat belts at all times for safety.
>> Pregnant women with a Body Mass Index (BMI) greater than 35 kg/m2 are at higher risk from anaesthesia. A timely referral for an anaesthetic consultation should be considered for women with a high BMI. South Australia is developing a policy for care of bariatric patients.
>> Effective strategies should be pursued to reduce smoking in pregnancy, including culturally appropriate smoking cessation interventions for Aboriginal women.
>> Testing the antibody status of Rhesus D negative women before the first administration of Anti-D is important. A measurable titre of Anti-D antibodies is an indicator of potential alloimmunisation and always requires investigation and a specialist opinion.
>> Early ultrasound determination of chorionicity is advised for twin pregnancies, followed by further surveillance for twin-twin transfusion in monochorionic pregnancies.
>> It is satisfying that the decline in deaths attributed to fetal growth restriction has continued from 7.9% of deaths in 2008 to 7.4% in 2009, compared with 11.2% in 2007. Vigilance to ensure that fetal growth restriction is not missed remains warranted.
>> The institution of streamlined arrangements between rural/level 4 hospitals and their regional level 5/6 maternity service in situations where there is a lack of on-site CTG expertise; this includes easier access of rural practitioners to the consultant on call.

Labour and birth>> NEW - All home births should be conducted in accordance with the ‘Policy for Planned Birth at Home in South Australia’; specifically that the mother should be transferred for hospital care when a planned home birth is complicated by the presence of meconium stained liquor.
>> A previous caesarean section and breech presentation are contraindications for home birth.
>>When induction of labour is deemed necessary in the presence of a uterine scar and an unripe cervix, careful consideration should be given to alternative options such as postponing the induction or caesarean section.
>> Once a decision to perform an emergency caesarean section has been made, it is recommended that fetal monitoring should continue until the commencement of surgery.
>>When feto-maternal haemorrhage is suspected, flow cytometry should be considered to estimate the volume as it is more precise than the Kleihauer test.
>> Carriers of Group B Streptococcus and women with risk factors such as prolonged rupture of membranes require appropriate screening and antibiotic treatment.

Postnatal>> NEW - Where a woman presents with serious medical complications early in the post partum period she should be reviewed by a physician with an interest in obstetrics, if available, as well as by an obstetrician, together with other medical specialists as appropriate.
>> If a diagnosis of pre-eclampsia has been made, the blood pressure should be monitored until it has settled and any abnormalities of renal or liver function or blood counts have been appropriately managed.
>> Non-steroidal anti-inflammatory drugs should be avoided post-partum and post-operatively in women with pre-eclampsia. Low dose aspirin, especially when commenced early in pregnancy, remains an effective drug for prevention of pre-eclampsia.
>> Use of the recently-revised protocol for investigating stillbirths, which has been sent to all maternity units in South Australia (Appendix 8).
>> Seeking parental permission for autopsy, which may provide information most valuable in the counselling of parents and in the management of future pregnancies. The State Perinatal Autopsy Service (telephone 08-8161-7333) is available at no cost to the parents, including those in country areas. Certain categories of death have to be reported to the State Coroner (see page 40).
>> Sending placentas for histological examination with all relevant clinical information in all cases of perinatal death (see Appendix 9).

Professional
>> Appropriate training and maintenance of competence in cardiotocograph (CTG) interpretation for all levels of medical and midwifery staff.
>> Ongoing development and implementation of statewide perinatal protocols is recommended (www.health.sa.gov.au/ppg).

Infant
>> An effective system of appropriate and ongoing support, supervision and referral should be offered to families with known risk factors for adverse child outcome, such as substance abuse, psychiatric illness, extreme youth of the mother or violence in the household. This should be continued at least throughout the first year of life, if not for a longer period of time.
>> Monitoring growth in children, which can be undertaken using the weight percentiles in the child’s Personal Health Record (Blue Book), and investigating why a child is not thriving.
>> Immunisation of children to prevent infectious disease.
>> Vigilance to ensure that potential hazards in the home are removed from the infant’s environment.
>> Vigilance to ensure safe feeding in children under four years of age. Foods that can break off into pieces should not be given, as accidental asphyxiation may occur.
>> Consideration should be given to better ways of identifying serious underlying illness in children presenting to clinicians, for example, Medic Alert bracelets.
>> Systems to facilitate referral by community nurses of high-risk children to paediatricians or tertiary hospitals for urgent appointments need to be considered.
>> Hospitals with high paediatric throughput need provision of 24 hour paediatric expertise.

midwifery in Australia

The Annual Report 2010-2011 of the regulation agency AHPRA and the National Boards reporting on the National Registration and Accreditation Scheme has been released.  The annual report marks the first ever release of comprehensive national data on health practitioner regulation, including state and territory information, and profession-specific data.

At the time of the Report there were 97 [Medicare-] eligible midwives, listed as coming from:

• 13 NSW 
• 53 QLD 
• 5 SA 
• 4 Tas 
• 16 Vic 
• 6 WA 

Here are a few selected quotes from the report and linked documents:

Midwifery was the most female-dominated of the regulated professions, with the largest group of midwives aged 40 to 44 years and practising in Victoria.

Important information for the nursing and midwifery professions in the report includes: –

•  On 30 June 2011, there were 332,185 nurses and midwives registered to practise in Australia, with nursing and midwifery representing 63% of the total group of registered health practitioners
• Of these, 1,789 practitioners held midwifery registration only, 290,072 nursing registration only, and 40,324 held dual nursing and midwifery registration
• New South Wales was nominated as the principal place of practice by the largest cohort of nursing and midwifery registrants
• Of all nurses and midwives, the largest group was aged 50 to 54 years (51,998 or almost 18% of the profession)
• 83% (274,228) of the total number of registered and enrolled nurses and dual nursing midwifery registrants are female; and 99.67% (1,783) of midwives are female
• There were 1,466 nursing and midwifery practitioners in Australia with an endorsement on registration: 624 nurse practitioners; 744 endorsed for scheduled medicines; one midwife practitioner and 97 eligible midwives
• There were ... 2,483 students of midwifery registered from April 2011, ... 2.5% of registered students across all regulated professions
• There were 8,139 notifications received about health practitioners in 2010-11, including 1,300 about nurses and midwives. This means between 0.1% and 0.3% of Australia’s 332,185 nursing and midwifery practitioners were subject to a notification relating to either health, performance and/or conduct of the nurse or midwife
• The Board took immediate action in relation to 115 nursing and midwifery practitioners after receiving a notification about the practitioner’s health, performance and/or conduct. As a result, the Board took no further action in 24 cases, imposed conditions on the registration of 26 practitioners suspended the registration of 36 practitioners; noted four practitioners surrendered their registration and accepted undertakings from 26 practitioners
• There were 254 mandatory notifications about nurses and midwives in 2010-11, representing just over 58% of all mandatory notifications received across the 10 professions

Medicare and eligible midwives

click to enlarge

This is the new schedule of fees and rebates that have been increased by 2% as part of annual indexation of Medicare items, effective from 1 November.  The item descriptions can be viewed in full at www.health.gov.au/mbsonline

Obstetric items and referrals

Requesting diagnostic services

social networking

In this post we draw attention to social networking sites, such as Facebook. This topic is addressed at the UK Nursing and Midwifery Council (NMC) 'Advice by topic' site. Reference was made to this advice in the September 2011 issue of the Victorian health department's Maternity and Newborn Clinical Network Newsletter. From the UK NMC:

MUMS MATTER!

Announcing APMA's on-line campaign: Mums Matter!

Maternity reform

Reform Basket case: Roxon forces midwives to collaborate, now they face regulatory action if they do
NEW: Press release

Position Statement on Home Birth

Midwives and other interested parties are preparing critiques and responses to the ACM ‘Interim’ homebirth documents .   The College is inviting comments on the documents, which are an interim position statement, guidance for privately practising midwives providing midwifery care for planned homebirth, and a literature review.  None of these documents have undergone academic peer review.  The closing date for submissions is 23rd September 2011.

The Nursing and Midwifery Board of Australia has "endorsed the Australian College of Midwives position statement on Homebirth." The full significance of this rapid endorsement by the regulatory body, of an 'interim' document, prior to consultation with the profession, is not clear. 

We refer readers to the International Confederation of Midwives' (ICM) Position statement on homebirth

It states, after a brief introduction:

POSITION:

The ICM supports the right of women to make an informed decision to give birth at home. The midwife who elects to provide professional services for women in their homes should be able to do so within a nation’s health service. The ICM recognises that not all nations have the legislation or health service structure which supports home birth, and urges national governments to review the scientific literature on the subject and progress to a maternity service which includes it as an option for women giving birth. 

GUIDING STATEMENT TO MEMBER ASSOCIATIONS: 

Member Associations based in countries where women do not have access to a full range of options as to where they can safely give birth, are encouraged to negotiate with their governments for this to occur. 

The Australian College of Midwives (ACM) is a member association of ICM. Any position statement of the ACM should usually be consistent with, and reflect, the Position Statement of the ICM. The professional College for midwives in Australia is expected to negotiate with our government to provide a full range of options, including homebirth, where women in this country can safely give birth. Please remind the College of this ICM position and guiding statement in your submissions.

insurance and private midwives

All regulated health professionals have been required, since 1 November 2010 when the new National Health Practitioner Regulation law came into effect, to have professional indemnity insurance.

There is no insurance product that covers homebirth, which is the mainstay of private midwifery practice. An exemption from indemnity insurance for homebirth has amended the requirement for insurance, and this is in effect until 30 June 2013.

Midwives who practise privately have the choice of two insurance products. One of these, from MIGA, is the only one that will provide intra-partum cover for Medicare-eligible midwives to attend certain hospital births, as it has government backing. The other product, from Vero Mediprotect insures midwives for provision of private prenatal and postnatal services and education, but excludes birth. [These links are included for information only, and this statement should not be construed in any way to direct midwives to one particular product.]

Recent developments with regard to insurance have been outlined at the MiPP blog, since we learned that a 'mandatory reporting' notification was made of a midwife who was considered to be practising without insurance. We understand that this midwife was in a public hospital with a woman who had planned homebirth. After transfer of care to the hospital, the midwife continued in a supportive role with the woman: the usual practice in Australia when women transfer from planned home birth to hospital care.

There seems a small window for those with MIGA insurance if the woman is admitted ‘private’. The MIGA-insured midwife then may be covered. Most hospital backup booking arrangements that are made by or for women who are planning homebirth are with public hospitals. The possible pathway that is being looked at is that the woman is admitted as a 'private' patient in the public hospital. Some larger hospitals have 'in house' obstetricians. In this case the obstetrician on call at the time of admission will assume responsibility for the care of the woman and baby. Other hospitals have local obstetricians, paediatricians, and obstetrically qualified GP's on roster, to be called in for public as well as private patients. 

ACM Position Statement on Homebirth, "endorsed"

From the AHPRA website

“The Nursing and Midwifery Board of Australia has endorsed the Australian College of Midwives position statement on Homebirth. The College is inviting comments on the position statement; the closing date for submissions is 23rd September 2011. The position statement is available from the Australian College of Midwives website.”

totally flawed research

Listed as a top article in today's Age, readers are confronted with the question: 'Caesarean births a better option for mothers? ' The article tells us that "Dr Stephen Robson, an associate professor of obstetrics at Australian National University, is recruiting 1000 pregnant women to test the long-held view that vaginal deliveries are better than caesareans for healthy women with uncomplicated pregnancies."

This 'study' requires well women who are expecting their first child, of whom 500 choose a caesarean (for no medical reason) and 500 plan a vaginal birth, and will look at "psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates."

"Good luck!" I say. Good luck to the mothers and babies - they will need it.

This research is not good science - whatever results are achieved will not come anywhere near testing the safety of vaginal vs surgical births for healthy women with uncomplicated pregnancies.

What sort of ethics committee would give approval to this research? Anyone who has studied basic health science will know that the numbers in this study are so small that confounding variables will make the data useless.

Of the 500 women planning vaginal birth, assuming that they are standard pregnant women who receive standard maternity care, at least 30%, and possibly up to 50% will experience a Caesarean birth. That leaves the vaginal birth cohort of 250-350. Many of these women will receive powerful narcotic drugs either by injection or epidural; drugs that are kept locked up in the 'dangerous drugs' cupboard. A considerable number of the 'vaginal birth' cohort will have their labours stimulated artificially with synthetic prostaglandins and oxytocin; and many will be 'assisted' to give birth by obstetricians wielding forceps or ventouse caps. All of these interventions carry potentials for harm to the mothers and babies, with a potential to influence depression and breastfeeding rates.

Of the 500 women planning elective pre-labour Caesarean, there will be other variables. A few may even labour spontaneously and quickly, and give birth vaginally! A considerable number of the surgically delivered babies will experience difficulties with breathing, and require special care for the first day or so. A few of these babies may be very ill.

A few mothers in the elective Caesarean cohort will develop wound infection, and many will develop internal adhesions that may complicate future births. A few may experience serious iatrogenic complications of the surgery, including accidental surgical damage to uterus, bladder, ureters, or bowel; drug administration errors; harm resulting from spinal anaesthesia; and haemorrhage. Subesquent pregnancies for these women also bring the potential for abnormal placenta formation, with placenta accreta and percreta placing a woman at great risk of serious haemorrhage requiring urgent hysterectomy as a life-saving measure.

In 1996, World Health Organisation made the profound statement that "In normal birth there should be a valid reason to interfere with the natural process." (in Care in Normal Birth: a practical guide, p4)  It's a no-brainer.

Today, Australian women are being enlisted into research that pretends to address the question of which is better, vaginal birth or abdominal surgery. It's a stupid question. If the safety of vaginal birth for the primigravid well woman is considered anywhere near the risk of a Caesarean, it's an indigtment on what happens to women planning vaginal birth.   The researchers need to find ways to protect and promote the natural processes in birth, while reserving surgical intervention for those who have a 'valid reason'.

I hope there are midwives and doctors whose critical thinking alarm bells start sounding when they are asked to enlist women in this study, and I hope the women who are approached tell the researchers what they can do with their trial.

This is a personal opinion, and is not a policy statement for Australian Private Midwives Association.

Your comments are welcome.

News for privately practising midwives and women planning homebirth

from
Australian Health Ministers’ Conference
COMMUNIQUÉ
5 August 2011

Professional Indemnity Insurance Exemption for Independent Privately Practising Midwives
"Ministers agreed to a further 12 month extension of the exemption to 1 July 2013 while further options are explored with a report back to the next Health Ministers meeting."

Your comments are, of course, welcome.

MotherBaby Childbirth Initiative

[click image to enlarge]

In 1996 the Coalition for Improving Maternity Services (CIMS) created the Mother-Friendly Childbirth Initiative (MFCI): 10 Steps to Mother-Friendly Hospitals. Although designed specifically for the U.S, the MFCI had global impact. In response to strong international pressure, the CIMS International Committee was formed with the goal of creating an international initiative that would be applicable in all countries and settings. It became the International MotherBaby Childbirth Organization (IMBCO) in 2007. In collaboration with grass-roots representatives from every world region and an international Technical Advisory Group (consisting of representatives from WHO, UNICEF, ICM, FIGO, Lamaze International, and many others), IMBCO created the International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal MotherBaby Maternity Services and launched it in 2008.

The purpose of the IMBCI is to call global attention to the importance of the quality of the mother’s birth experience and its impact on the outcome, the risks to mother and baby from inappropriate medical interventions and lack of access to appropriate emergency care, and the scientific evidence showing the benefits of optimal MotherBaby care based on the normal physiology of pregnancy, birth, and breastfeeding. The IMBCI 10 Steps set the gold standard for excellence and superior outcomes in maternity care. The IMBCI has been translated into over 20 languages and is being put to many uses in the developed and developing worlds. Its 10 Steps are currently being implemented in 3 pilot/demonstration sites--hospitals in Quebec, Brazil, and Austria. This presentation will describe the IMBCI and the multiple ways in which it is being put to work around the world. A critical component of the IMBCI is that it highlights the fact that “women’s and children’s rights are human rights” and that “access to humane and effective health care is a basic human right.”

The Asia-Pacific Regional Representative of the International MotherBaby Childbirth Organization is midwife Rachael Austin, dnraustin[at]bigpond.com from Theodore, Queensland.

Collaborative arrangements

Midwives providing services eligible for Medicare rebates are required to have evidence of a collaborative arrangement with a specified medical practitioner for each woman in their care. In essence, the midwife is required to have written records of:
(a) the name of at least one collaborating medical practitioner;
(b) that the midwife has told the woman ["patient"] about the arrangement;
(c) acknowledgement by a named medical practitioner that the practitioner will be collaborating in the woman’s care;
(d) plans for the circumstances in which the midwife will consult, refer, or transfer care to that medical practitioner.

Midwives who have contacted the Department of Health and Ageing (DoHA) have given examples of situations in which collaborative arrangements have been difficult to obtain. The hurdle that is proving particularly difficult is (c) acknowledgement by the doctor that he/she will be collaborating. Doctors who have for many years worked collaboratively alongside midwives have baulked at the idea of putting their signature on a collaboration document.

Many midwives attending homebirths privately have for many years had good collaborative arrangements with public maternity hospitals. If a woman or baby in the midwife’s care requires transfer to hospital, or referral for specialist assessment in pregnancy, the process of consultation, referral and transfer is straight-forward, which is in the interest of the wellbeing of mother and baby.

For example, when the woman and midwife have completed the hospital booking-in process, the hospital gives the woman paperwork with the woman’s name on it, clearly marked ‘HOMEBIRTH BACK-UP’. This is evidence of the collaborative arrangement, but at present this sort of arrangement cannot be used as evidence of collaboration for the purposes of Medicare rebates.


In response to midwives' letters to the DoHA, Rosemary Bryant (Chief Nurse and Midwife) wrote:

The Australian Government, through this Department is continuing to monitor these difficulties through a range of activities including monitoring correspondence received- including your email, calls to our hotline and data from Medicare. We will also be undertaking surveys of midwives, obstetricians and GP obstetricians in the coming months to ascertain what is working, what is not working and then we’ll develop responsive action accordingly. Through our evaluation activity we’ll also be talking to pregnant women, women planning pregnancy and their families, about their experiences and awareness of the reforms to maternity services more generally.

I can assure you that the Government is committed to increasing choice of and access to maternity services in Australia, and maintaining our high standards of safety and quality through supports for workforce and infrastructure.

With reference to reports that doctors are reluctant to enter collaborative arrangements with midwives because of indemnity insurance concerns, Ms Bryant stated:

The Government has put in place arrangements that allow eligible midwives to obtain solid and affordable professional indemnity insurance cover that provides peace of mind for midwives and their clients. The Commonwealth-supported cover, which is provided through insurer MIGA (www.miga.com.au) is, in effect, unlimited. It covers eligible midwives for their full scope of practice, except intrapartum services in relation to planned home births. Obstetricians, GPs who provide obstetric services and hospitals can be confident that the Commonwealth-supported MIGA product provides strong, reliable professional indemnity cover for privately practising midwives. Therefore, from an insurance perspective, collaborating with a midwife who has the benefit of Commonwealth-supported cover is no different from collaborating with another medical practitioner who holds their own medical indemnity insurance cover.

Comments are welcome

Do women have a right to choose natural birth?

It's a simple question. Do we?

We know that most women are able to give birth under natural, physiological conditions, and we know that for most women and babies there is no safer way than via that natural physiological process.

How is the private midwifery profession faring?

Midwives have had six months since the federal government's Medicare reforms became effective (1 November 2010). Midwives, and the women who employ us, have a mere thirteen months before the exemption from professional indemnity for attending births in homes expires (1 July 2012). It's a good time to take stock of our situation.

Senate Inquiry into AHPRA, the day before International Midwives' Day

Press Release:
Australian Private Midwives Association and Midwives in Private Practice


Midwives will present at a Senate Hearing into the national regulator – AHPRA - on Wednesday 4th May, the day before Midwives Day is celebrated around the world.

Marie Heath, National President of the Australian Private Midwives Association, today indicated that many unfounded complaints/notifications against midwives would be raised in a move that many see as part of an international war against homebirth.

Join the global webinar to celebrate International Midwives' Day 5 May

Plans are set for the Virtual International Day of the Midwife on May 5th. The program, which spans the 24-hour period, with speakers from the various continents, has now been finalised, and it looks to be a very interesting and diverse program: http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011

APMA submission to Senate Inquiry

APMA has made a joint submission with Midwives in Private Practice (MIPP) to the Senate Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA). To access the submissions, click here.

The three matters that our submission has focused on are
1. AHPRA’s administration of the registration process for Medicare benefits
2. Concerns around the administration by AHPRA of complaints against privately practising midwives
3. Professional Indemnity Insurance for midwives practising privately.

INFOSHEET: The Third Stage of Labour

This is the second in the current review of the INFOSHEET series. To download this, and other INFOSHEETs, click here.

The revised INFOSHEET - click to enlarge

This INFOSHEET deals primarily with natural physiological Third Stage, the time from the spontaneous, unmedicated birth of the baby to the spontaneous birth of the placenta. It may seem like stating the obvious, but remember that physiological Third Stage can only be considered when the rest of labour, the first and second stages have been physiological and uncomplicated, and mother and baby are well.

In today's maternity care world, relying heavily and often unnecessarily on medical interventions including pain medications, anaesthesia, continuous fetal monitoring, and surgical measures, the proportion of women who proceed through their births in harmony with normal physiological processes is small. Likewise, midwives and doctors in mainstream maternity care have become progressively deskilled in their care of women for whom physiological birth is a realistic option.

A midwifery student who will graduate as a midwife in a few months wrote:

"I have been at X[health network] as a mid student since Feb 2010, I have seen one attempted physiological third stage where the mum had enough after a while and we discontinued and went for active managment. I have not had any other women request physiological management. For those who are not aware it is also worth noting that women who chose to birth in X's homebirth program must sign a contract stating they agree to active 3rd stage managment at home, as physiological third stage is not offered in the [hospital's] homebirth program."

This is a common scenario in midwifery education, and in maninstream maternity care today. In reviewing the Third Stage INFOSHEET, the working group will need to address the issue of evidence relied upon in support of active management, and what the current guidelines around active management advise.

I believe it is important that we take an assertive position, now that the Cochrane review (2010) has concluded that, for women at low risk of bleeding,
“there was no significant difference identified for severe haemorrhage.”



The revised INFOSHEET will address debate internationally around the risk vs benefit of active management in resource-rich settings.

Also, as has been noted in the reviewed INFOSHEET on Baby's Transition, there is more debate now than a few years ago around time of clamping of the cord. The Women’s Clinical Practice Guidelines requires ‘early’ clamping of the cord 2-3 minutes after birth, rather than depriving the baby of the placental blood. Guidelines from another major Level 5 hospital requires injection of oxytocic as the anterior shoulder is delivered, or within one minute of the birth of the baby, followed by:

"Clamp and cut the umbilical cord.
In the preterm, If maternal /neonatal condition allows, in collaboration with the neonatal resuscitation team, consider delaying clamping the cord for up to 2 minutes. Delayed cord clamping has been shown to diminish the risks for the pre term baby of needing a transfusion, being hypotensive or having an interventricular haemorrhage." (Southern Health cp-ma42)

Readers will understand that there is an imperative that those midwives who seek to work in harmony with the natural physiological processes, and promote normal birth when ever possible, establish clear statements about physiological Third Stage.

For further reading, go to
The ICM page on post partum haemorrhage
.
The FIGO-ICM Joint statement (2006) 

Thankyou for comments and discussion on this important topic.

Senate Inquiry into AHPRA

Link here to the Senate Inquiry into AHPRA.

Submissions should be received by 14 April 2011.

All midwives in this country are registered and regulated through Australian Health Practitioners Regulation Agency (AHPRA).

The federal Opposition Health spokesman Peter Dutton MP has called for a Senate enquiry into the workings of AHPRA.

Many midwives, and women who employ us privately, are concerned about the process that has been implemented by AHPRA for midwives applying for notation on the Register as eligibile for Medicare provider numbers - a reform that was implemented by the government in November 2010. Submissions by midwives' organisations, individual midwives, and women who want midwives to attend them privately, will address the excessive and repeated delays in processing applications.

Women whose midwives are waiting for their notations of eligibility are, understandably, distressed. Clients of midwives who have Medicare Provider numbers are able to claim substantial rebate - estimated up to $1000 in total, on prenatal and postnatal care provided by the midwife. The failure of a midwife to achieve eligibility means that this amount of money, to which the women/clients are entitled, cannot be accessed.


Please note that there are Procedures to be observed by Senate Committees for the protection of witnesses.

Your comments here are welcome, as are your submissions to the Senate inquiry.

Revision of INFOSHEET

Revised INFOSHEET, A baby's transition from the womb to the outside world.
If you would like a .pdf copy of this INFOSHEET, please send an email request to Joy Johnston joy[at]aitex.com.au
Thankyou for your comments.

INFOSHEET: A BABY’S TRANSITION FROM THE WOMB TO THE OUTSIDE WORLD

Please read through this INFOSHEET, and post any comments about the statements made, the evidence to support those statements, and the usefulness of the information.

A BABY’S TRANSITION FROM THE WOMB TO THE OUTSIDE WORLD

Review of INFOSHEETS

Blog readers are invited to download INFOSHEETS, in preparation for their review.

The current set of INFOSHEETS were a project of Maternity Coaliton, to present reliable consumer information on key maternity topics. The INFOSHEETS project was led by midwife Joy Johnston (the editor of this blog and several others).

The INFOSHEETS series are designed to assist women to question and communicate with their care-givers, and make informed decisions about their maternity care, promoting care that is appropriate for the individual woman.

The current INFOSHEET topics are:

Congratulations Justine Caines!

Today's Australia Day honors list included the Medal of the Order of Australia (OAM) being awarded to Justine Maree CAINES, who is well known to APMA as a maternity consumer activist.

Justine Caines, OAM

Citation: For service to the community, particularly in the area of women's health, maternity care and education.

September 2009, Canberra - more than 2000 people protest the government's maternity reforms, which threatened to deny Australian women the right to homebirth with a private midwife.