Midwifery Council Forum Dunedin

Having just completed the first audit of my practice by Midwifery Council I have decided there is some value in continuing to reflect in my blog, making it easier to pull some reflection together for standards review and audit. I will not reflect in my blog about actual midwifery practice and will save that for a closed activity as I am acutely aware of the issues of confidentiality. If a woman particularly told me she was happy for me to write in my blog I would do so and would also make it clear that I had permission to post on my blog from the woman and her family.





Image from Luxmart's photos on Flickr.com

The purpose of this post is to reflect on the Midwifery Council forum in Dunedin, which I attended today.

It was great to get together with many friends and colleagues, some of whom I had not seen for a long time. It was also nice to meet midwives I had not met before, for example Andrea Vincent, who is a new member of midwifery council. I was sad to learn that Sue Bree's term of office on midwifery council has ended. Sue is a wonderful and inspiring woman and I have enormous admiration for her.

It was also good to meet up with Ruth Martis, my colleague from Christchurch Polytechnic and arrange to meet up with her in October for a day brainstorming the Midwifery Practice Skills course for 2011.

During the forum we had a brainstorming session establishing what midwives wanted for the next three year cycle of Technical Skills workshops. Everyone was adamant the day on complex skills should remain. There were quite few other topics that the room came up with for the other Technical Skills workshop day. Amongst the topics discussed were Pharmacology and Prescribing and Newborn assessment. Courses on these topics are available as part of the overseas midwives competency programme and are available too for New Zealand midwives who wish to do them. Antenatal screening was another topic, there is a course available through the National Screening unit for midwives to complete at no cost. Other topics discussed were postdates care, keeping birth normal, postnatal care, preventing burnout and complex care. This was a useful session and it will be for Midwifery Council to decide what the components of the next technical skills workshop will be.If you are a midwife do you have any ideas about topics that should be in the Technical skills workshops of available as continuing education for midwives. The advantage of having a topic in the technical skills workshops is that all midwives must do it, however if it is just available as a course only those who choose to will do it.

In the forum we looked at the proposed new code of conduct for midwives and also the new cultural competence guidelines for midwives. We were able to feedback some thoughts on these proposed requirements for midwifery practice. These will provide good guidance to midwives but we need to be careful what we regulate. For example there is a clause in the proposed code of conduct which states that midwives should not have an emotional or sexual relationship with clients. Many at the forum saw this as a problem as many midwives provide care to family members and also there is an emotional connection with families when you have been the midwife with that family for several births. What do you think? Should midwives be able to care for family members, or should they only be able to be a support person in this situation?

Council also explained there move into and electronic format for the midwifery recertification and payment and issuing practicing certificates.

At the end we had an open session where issues such as the timing of midwifery standards review were discussed, some were interested in moving this to a three yearly component but the consensus and midwifery council position was to leave this as a biennial requirement. Do you think that biennial standards review is a good time spacing or should it be annual or three yearly?

It was quite a long day and I picked up some fried chicken on the way home on request of my husband. Not my favourite meal but saves coming home to cook.

Protecting, supporting and promoting normal birth in New Zealand

In New Zealand we have a National Strategic Plan of Action for Breastfeeding. At the same time intervention rates in birth are skyrocketing, as they are internationally. Breastfeeding is an important health issue for women and their babies, and it is right that we should do all in our power to support breastfeeding in our communities. There is however general lack of acknowledgement of the health risks of birth intervention to women and their babies. Caesarean section is accompanied by significant morbidity to women and to neonates. It also siginificantly increases risks for future pregnancies. This is an issue of concern for me, as it is for many midwives.

I have taken the first couple of pages of the Action Plan for breastfeeding and have substituted Normal Birth for the word breastfeeding. One or two sentences needed to be removed as they were not relevant to normal birth. I would be interested to know what you think of this. If only we could inspire a movement to protect, promote and support normal birth. Is there any way that you think that we could make this happen?

So read on::
The vision for the National Strategic Plan of Action for Normal Birth

Aotearoa New Zealand is a country in which Normal Birth is valued, protected, promoted and supported by the whole of society.
The statements on this page set out the achievements that will show that the vision has been realised in New Zealand.

Women and their wha¯nau/family have the information they need to make confident and informed decisions about Normal Birth, and live and work in an environment that enables and supports their decisions. Women and families have access to support to help them gain, practise and pass on knowledge of Normal Birth to family, friends, and successive generations. Communities, along with health and social services, provide accessible, consistent and knowledgeable support to women and families who need it. Normal Birth rates show a significant improvement across all population groups, and there are no longer any significant differences between the Normal Birth rates of different ethnic, socioeconomic or geographic communities. There are accessible and appropriate Normal Birth education and support services for all eligible women, fathers/partners, families and wha¯nau from all cultural and ethnic groups, and for migrant communities, low-income families and young mothers. Government planning, policy and service delivery decisions are thought through with a view to actively protecting, promoting and supporting Normal Birth. This occurs across all relevant government agencies in ways that fully involve and respond to communities. Where it is necessary, legislation actively and explicitly protects, promotes and supports Normal Birth.
1.1 Priority areas for action for the short term: 2008–2010
The Committee has identified a group of issues that need to be addressed in order to make demonstrable progress in improving Normal Birth rates in New Zealand. The priority areas are listed below:
Government
• Objective 1.1(a): The Ministry of Health provides the leadership for Normal Birth strategy and policy.
• Objective 1.2(a): The Ministry of Health continues to strengthen the accuracy and completeness of the existing dataset on Normal Birth.
• Objective 1.3(a): Identification of New Zealand-specific Normal Birth research needs.
• Objective 1.4(b) The Ministry of Health supports a programme of research into intervention in the normal birth process. National Strategic Plan of Action for Normal Birth 2008–2012 page


Family and community
• Objective 2.1(b): The Ministry of Health works with District Health Boards (DHBs) to assess and plan for improving access to ante-natal education.
• Objective 2.2(b): Communities work with DHBs and other providers to establish new or support existing peer support programmes for Normal Birth.
• Objective 2.3(a): the second phase of the national Normal Birth social marketing campaign promotes positive attitudes to Normal Birth in the community and public places.

Health services
• Objective 3.1(a): All DHBs achieve and maintain Normal Birth Friendly Hospital accreditation.
• Objective 3.2(b): DHBs are aware of and act on the Normal Birth support needs of their Māori, Pacific and other ethnic communities.

Workplace childcare and early childhood education
• Objective 4.1(a): The Ministry of Health continues to link with other agencies (for example the Families Commission, Department of Labour) to support the development of a policy framework for options for extending current paid parental leave entitlements.

1.2 The need for the National Strategic Plan of Action on Normal Birth
Normal Birth is important for the physical, social, emotional and mental health and wellbeing of infants, mothers, fathers/partners and families. There are risks identified with intervention in birth. Normal Birth is important to the health of individuals and communities. [We] now require[s] DHBs to actively work towards improving Normal Birth rates as one way of improving the health status of communities. Concern over declining Normal Birth rates is not unique to New Zealand.

Routine epidural denied. Is this a problem?

A news item today discusses women in the UK being denied epidurals because of a lack of anaesthetists. Epidurals are a local anaesthetic injected into the epidural space in the spine near to the spinal cord, which provides numbing and therefore relief of pain in labour. This emotive article quotes the Vice President of the Royal college of Obstetricians saying that epidurals should be routine in birth.

There are clear associations between epidural anaesthetic and the need for other interventions in labour, such as instrumental birth with forceps or ventouse(suction cap applied to the babies head)or caesarean section.

The article sites the Cumberland Royal Infirmary as being particularly affected by this inability to provide epidural. It is not so strange then that the Cumberland Royal Infirmary has a lower level of intervention in childbirth compared with other local hospitals. Cumberland Infirmary has a 50% normal vaginal birth rate, Cresswell maternity has a 30.8% normal birth rate and Furness has a 44.4% normal birth rate. Normal vaginal birth leads to lower incidence of complications in the postnatal period for both mother and child. There are also fewer complications with following pregnancies. Do women want pain free birth at this price? What do women think about 'routine' epidural? How do staff support women to birth normally and without intervention if they expect every woman to have a epidural? How do they walk alongside women through the triumphant process of normal and natural labour and birth?

Do you have any thoughts or comments about this? Are women told enough about what to expect in childbirth and the effects of interventions such as Epidural?

Lovely wee birth video

Just had to share this one. I love the commentary.Thanks to the health-nut family.
A lovely water birth.

The business of being born in Dunedin

At last, after a long wait, I have finally had the opportunity to see this documentary.

On the worst night of the year, wintery showers of sleet and hail we went to Logan Park High school to view this film. There was a fairly small group of us, not surprising due to the weather. None the less enough hardy souls made the effort to cover the costs for the Otago region of the College of Midwives. It was a mixed group with good number of student midwives and midwives from Queen Mary maternity center. A few independent midwives and sprinkling of consumers.

I had a fairly good idea of what to expect from the online discussion that has been generated. I will not go into the details of the film, others have done that much better than I could. I have to say it is very similar to "Giving birth: Challenges and choices" produced by Suzanne Arms in 1998. Marsden Wagner features in both of these films with a very similar message. This new film is longer and more in depth, it is also significantly longer at 1 hour 30 mins as opposed to 35 mins for the Suzanne Arms film. It has more births and stronger historical overview of how America lost midwifery in the first place. Overall the material and the information was not something that is new to me. The benefits of being upright and mobile in labour were highlighted. The importance for no restriction on the pelvic joints was mentioned and the ability of the woman to move through out the birth. The benefit of water was highlighted.

Overall it is a good film but I think for those, like me, who have been involved in the business of birth for a while the information was not new. It has been around for a long time. I think that obstetricians and midwives have heard this all before and they either agree or disagree with the arguments. None the less it is a good to reiterate, and clearly in America the message desperately needs to be heard. The real value in this film is to women who are thinking about birth. It is a shame therefore that there were not more consumers in the audience. It would have been good to have some sort of debate scheduled for the completion of the film to allow us to talk about how this might impact on us and our situation in Dunedin. To talk about what, if any, relevance it had for us. It is also a shame that the film is not more available so that midwives could show it to women. The arguments are valid and well presented, why is it so protected? I understand that the marketing of the film has stimulated interested and created a whole culture around it which I beleive has been having an impact in America, which is great.

The question that remains to be asked is how does this apply for us in New Zealand. We have the most supportive legislation for midwifery care in the world. All women can choose midwifery care for normal birth. One would think that all choices should be available to all women. Any woman should be able to birth at home if she wishes. The benefits of birthing outside of the hospital should be explained to women. All women should be able to birth in water. The benefits of birthing in water should be explained to them. All women should be able to decline obstetric intervention in the absence of clear and apparent medical risks. Most women should be able to birth in the care of a midwife without ever having to see a doctor. If this is the case why is our caesarean section rate so appallingly high, 22.7% in 2002
, (the last available statistic) and would appear to be much higher than this now. What do others think about this. As reported by Paul Kruger in response to the screening of this video in Sydney Australia "The Royal Australian and New Zealand College of Obstetricians and Gynaecologists says there are a range of complex factors to explain the high caesarean rate, including the older age at which women are giving birth, and litigation against doctors". What do you think about this? Does this video have any relevance for us? Or is it only important for women in America?

Two very different birth videos

In this post I want to highlight the very different experiences women can have with what might be called a 'normal vaginal birth'.

In this first video a young woman gives birth to her child in water. In contrast to the video posted on my friend Sarah's blog, this baby is taken from the water quite quickly. I wonder if, given a little more time, the mother might have reached down and picked up the baby herself. Obviously all the labour has gone before this and this is just the birth of the baby. It appears a relaxed and loving birth experience. Both mother and child seem to take a moment or two to realise what has just happened.



In this second video a young woman is giving birth in a hospital. We do not see the whole birth. She is fully draped in sterile drapes, with many gowned and masked health professionals and others buzzing around. The doctor at the foot of the bed is ready to catch the baby. He does not seem to be using any instruments so it would seem safe to assume that this is a 'normal vaginal birth'. A friend or family member is taking this video. The language used is Spanish I think, but the body language clearly indicates that the doctor is not pleased to be videoed. I wonder why? The doctor does not seem to engage with the woman at all. His focus is entirely on the woman's vulva. A shame we do not see the rest of this video.


I welcome your thoughts on the contrast between these two birth experiences. All over the world, and I think New Zealand is no exception to this, women can experience birth in the way these two young women do, and many variations in between.

How might these different birth experiences affect women as they start on their journey of motherhood?

VBAC homebirth

This is a wonderful story of a woman who had two previous hospital births resulting in caesarean birth who chose to birth at home for her third child. She tells her story very eloquently in this video. She understands that she needed to be upright and mobile and to have faith in her own bodies ability and in the care and support of her midwife. This is the story of her personal journey.

If you are considering a VBAC it is important that you understand why you needed a caesarean previously. You need to be well informed of the risks of all your birth options before you decide what is best for you and your baby. You might need to talk to more than one care giver before you can truly make an informed decision. Check out the Childbirth Connections information about the risks associated with various birth options.

Information for mothers and would be mothers

Are you worried and confused about birth? The Childbirth Connection web site offers really good unbiased evidence based information to help you to get a better understanding of some of the things that might be confusing you. They have produced a booklet, which is free online entitled "What every woman needs to know about cesarean section". You have to register with the site to be able to download but registration does not cost you anything and does not seem to come with any extras that you might not want. Well worth having a look. Whether you are planning to have a cesarean section or not this is important information that you do need to know.

Homebirth video

I have just read a posting and watched a video of this midwife's own birth. Rather than putting the video in here I am posting a link to the entry in her blog. It is her story and her video and needs to be seen as such. Please go and look and read.

She talks of the birth as a difficult struggle. I doubt that it would have been less of a struggle in a hospital setting and may not have ended as happily. She is a brave woman to share her true feelings about this birth and I applaud her for doing so. Do you want to share your thoughts about this?

elective caesarean increases breathing difficulties for babies

A recent TV One Health news item speaks of the increased risks of breathing difficulties for babies with elective caesarean sections. Particularly when these are performed early, that is before 39 weeks.
This is information gathered from a large Danish study. They found a nearly fourfold increased risk of breathing difficulties in caesarean babies delivered at 37 weeks, a threefold increase at 38 weeks and a doubled risk at 39 weeks. Babies who have breathing difficulties usually need to be transferred to a special baby unit and are monitored in incubators with oxygen provided. This is another risk which has been identified for women who are choosing or being advised to have an elective caesarean section.

A French study published recently "Postpartum Maternal Mortality and Cesarean Delivery" reported that caesarean section increased the risk of the mother dying after having a baby more than threefold.

This growing evidence of the increased risks to mother and child of having a caesarean section as opposed to a vaginal birth are very concerning as rates of caesarean section continue to rise. Recently published figures from the United States report a 30% national rate of caesarean births. The most recently published national rate in New Zealand was 27% but it is very likely that it too is now 30% or higher.

Can we as a society afford this level of intervention in childbirth.Is this an issue for sustainability? Think of the resources that are involved in this level of intervention/

I am not suggesting that any mother or child be put at risk by withholding necessary medical care and intervention, but where does it stop. Clearly we are not reducing risks for women and children by increasing medical intervention. Instead we are raising risks to the health and wellbeing of the mother and her child.

Can we turn this around? Midwives we need to help and support women to have confidence in their bodies and ability to birth. We need to provide sensitive caring support and information to women. We need to have faith ourselves in the process of birth and to share our faith with women and those who will be supporting them during the birth of the child.

Where to birth and how long to wait before going home.

Where to birth? At home, in a primary birthing unit or in a hospital this is a question that many women have to consider during pregnancy. If choosing to birth in a facility, primary birthing unit or hospital, how long can they or should they stay before going home?

Photo from Sadalit's photostream http://www.flickr.com/photos/sadalit/123737076/


Research does little to help women decide when it is best to go home from a facility after birth. There has been quite a bit of research into early discharge, but the problem is that definition for early discharge varies so much. For some it means 2-3 hours after the birth of the baby and for others it means 1 or 2 days after birth of the baby. A Cochrane review of this topic found that the evidence was inconclusive but found that there was no evidence of adverse outcomes for the mother or baby with early discharge from a facility (Brown, Small, Faber, Krastev & Davis, 2002). If considering a home birth again the Cochrane review of this topic was inconclusive although they could find no evidence to state whether home or hospital was better for low risk women (Olsen & Jewell, 2007). A large American study found that there was less intervention when women planned to birth at home without any increased risks to the mother or her baby (Johnson & Daviss, 2005).

So what does this mean for women? If they have no health issues during pregnancy then women are less likely to have interference in the birth process if they plan to birth at home. Women have expressed increased satisfaction with birth when there is no intervention so it would tend to follow that satisfaction would also be greater with homebirth. The same is true if they birth in a unit which deals only with low risk births, (a primary birthing unit0. Of course if any problems arose then the woman would need to go to the hospital. Discharging from the hospital within hours of the birth also does not increase problems for women or their babies who are otherwise well.

There are two main issues here. One is being prepared for being at home, either early discharge or homebirth and the other is having the necessary support to be able to achieve this. One of the advantages of planning to birth at home is getting the support you will need prepared beforehand for this event. This might mean preparing meals before the baby is born so that there is no need to cook after or it might mean that a relative moves in with the new family. The woman will have prepared herself for early baby care, her midwife will cover the knowledge the woman and her partner need for those early days well before the baby is born. The home is ready for the new baby.

With hospital birth women often plan to stay in hospital for two or three days to learn how to care for baby and then go home. Many women seem to think that they will then pick up life as it was before, but this is not the case. They still need support as they learn how to become mothers and care for the new baby. It is not an instant process. We need to think of the first month after the baby is born as a continuation of the pregnancy-labour-birth process. It is a time when the woman's body is making enormous changes as well as the psychological adaption to new motherhood. The baby too is adapting to life outside the uterus and needs loving attention during this time. For the mother to be able to provide this to her baby she needs to be cared for and supported herself. Enormous changes and adaption occurs in the first month but there are those who would say that this continues, to a lesser degree, for at least first three months of the babies life. As a society we need to embrace the concept of mothering the new mother as she takes on her new role. It is an enormous life changing event and women need to be supported and nurtured as they adapt to this new identity.


Brown S, Small R, Faber B, Krastev A, Davis P. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD002958. DOI: 10.1002/14651858.CD002958

Johnson KC. Daviss B. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ. 2005 Jun 18; 330(7505): 1416-9.

Olsen O. Jewell MD. Home versus hospital birth. [Journal Article, Research, Systematic Review] Cochrane Database of Systematic Reviews. 2007;(4): (CD000352)

Fear, risk and supporting normal birth in midwifery practice.

I am writing this in response to a posting by Sarah Stewart. She has written an honest and insightful posting on how midwives cope with fear and risk. She considers the impact on practice when other midwives are involved in litigation. It seems to be especially difficult at these times to support women, or to maintain a midwifery identity considering birth as a normal and empowering life event. I am sure many midwives will identify with the situations she describes.

I too have struggled and debated the concept of risk and how we as midwives can promote normal childbirth and support women to birth without intervention, as we know the majority of women are able to do. Spiraling caesarean section rates force all midwives to look at their practice and consider what their contribution is to this phenomenon. For me, when I am considering risk, I try to turn it around. I consider the fact that almost always, no matter what the risk, it is much more likely that everything will be fine than the possibility that the risk, whatever it is, will eventuate and result in an adverse outcome. Sometimes the risks are so high that there is no question about the need for intervention, for example, placenta praevia or transverse or oblique lie at term. At other times the risks are very low, for example the risk of uterine rupture following previous caesarean when labour is spontaneous. Conflicting evidence about the chance of adverse outcomes makes decisions difficult for women and midwives need to support them to understand and make rationale decisions. If we approach risk in this way I believe women are more likely to have confidence in themselves and in us. Confident that they can birth their babies without intervention, but also confident that we will be watchful and will advise them if things are deviating from the expected path.
Our job, as midwives, is to acknowledge risk but not get it out of proportion. We need to assure women that we are aware of and vigilant to the possibilities of problems occurring which may require intervention. This is after all why women need the care midwives. We not only need to support women and assure them that all is well and that they can succeed in birthing a baby, we also need to be aware of what can go wrong and have the ability to deal with the situation in an emergency situation, or refer on to specialists when there is a necessity to do so. If this were not so women would birth without any support at all.