‘The birth of a child is the most important event in life for most Kiwis’ … Jonathan Coleman Minister of Health comment at NZCOM conference 2016
What do the words ‘most important’ mean? Dictionary definition …
- Of much or great significance or consequence.
- Mattering much.
- Entitled to more than ordinary consideration
Everyone KNOWS that birth and death are the most significant events in people’s lives without a doubt. Jonathan’s statement is profound. He’s nailed it but how does this statement align with the issues facing childbirth today?
A ‘most important event’ can be either positive or negative. A ‘most important event’ can never be neutral.
We have to ask this question: Who is responsible to make every effort to make this most important event as positive as possible as well as reduce or prevent some of the negative?
- Obstetricians … believe a healthy baby and mother is what makes the most positive impact on this most important event. Obstetricians use standards of care as well as high-level skills to achieve that goal. Do obstetricians care whether women ‘feel’ positive about this most important event? Obstetricians would claim they do. Midwives and natural birth advocates might feel differently. What the majority of women feel about obstetricians is unknown.
- Midwives … also believe a healthy baby and mother is what makes the most positive impact on this most important event. However midwives care very much about a woman’s subjective experience. Midwives use recognized standards of care to achieve the health and wellbeing of both mother and baby. Midwives also established a Partnership Model that supports Women’s choices as the foundation to achieve a positive subjective experience. Midwives also have a clear and stated ‘non-medical’ approach to birth as a pathway toward both of these values … a healthy mother and baby and a positive subjective experience. It’s unclear whether midwives value the subjective experience for women who have very medical births.
- Families … certainly believe a healthy baby and mother is what makes the most positive impact on this most important event. Yet every woman wants a positive subjective experience. Presently families use the pathway of ‘choice/Birth Plans’ in order to achieve the most positive subjective experience possible
How’s birth working in New Zealand now?
Presently 3 articles have been published: North South (Oct 2016), The Listener and The Spin-off.
QUOTES FROM NORTH SOUTH ‘Is Caesarean safer? The evidence for and against natural birth
‘Fear of childbirth plays a ‘huge’ part of that … fear of pain, fear of the outcome for the baby. Women have a lessening faith in their own bodies that they’re able to birth normally’. Michelle Wise OB
‘While the initial fall in maternal and infant death has stsabilized, caesarean rates are still rising … despite efforts by district health boards to reverse that trend because of the pressure it places on strained resources, from theatre capacity to hospital beds needed for longer post-natal stays.’
‘Whether all pregnant women should be offered a caesarean, says Wise, is ‘a complex issue for society to debate’. Personally I don’t think that’s the way to go. At the end of the day, the safest thing for the mother and her baby is a vaginal birth.
‘New Scientist reported in July that doctors in the UK are now considering whether pregnant women should be officially warned about the danger of leaving it all up to nature.’
‘Medical evidence is on their side’ the magazine claimed, “planned c-sections are the safest option for the baby, because they avoid any chance of brain damage from a vaginal birth and the not-insignificant risk of stillborn after 39 weeks. A planned c-section is also the only guaranteed way to avoid a risky emergency c-section. And they are cheaper in the ong run once the costs of caring for injured mothers and children are taken into account … sometimes medicalization is best:.
‘Elective c-section says women aged 35 years + having their first baby should be routinely offered.
‘The older someone is at first birth, the likelihood of just about every complication in the book goes up says Peter Dietz Uro-gynaeologist. He goes on to explain the higher risks when women get older and there is an acknowledged reality that women are having their first baby later in life compared to two generations ago. He also goes on to say older women are more likely to risk an emergency c-section, associated with increased risks. He feels women aren’t being given information about the risks and cannot exercise ‘informed consent’.
Jenn Hopper, founder of Action to Improve Maternity in NZ supports families whose baby has been injured by ‘poor birth care’. She says:
We’re told over and over about the benefits of vaginal birth and the risks of caesareans and nothing of the opposite for both. I’ve yet to meet a family unnecessarily harmed by a caesarean but there are those who could have benefited from one.’
Prof. Neena Modi says: ‘How can we impose this really quite major change in the way babies are born and not study it scientifically.’
There are a number of creative ways that the medical profession is looking at making an elective c-section as beneficial as possible. There is absolutely no creative or imaginative suggestions coming from the midwifery community.
Statistics in 2014.
- 1 in 3 women have a ‘normal’ birth … a spontaneous delivery without interventions.
- 1 in 2 had at least one intervention…induction 24% ..augmentation 26%, epidural 27% or episiotomy 15%
- 1 in 2 are obese
- 1 in 4 had caesarean. More common 35 years older.
- Almost half caesareans were elective
- Average age 30-34 years old
- Midwives lead maternity carers for 85%
- 4% homebirth
Smallbridge .. .’It might be that you have a birth plan and if all goes well … but it shouldn’t be a vaginal birth at all costs’.
The way a vaginal delivery is managed can also dramatically lower the risks of long-term damage to the pelvic floor.
Annabel Farry says you can’t compare a caesarean with vaginal birth without considering the context and whether it was a fully informed decision. Involved in international research looking at fear of childbirth prior to pregnancy.
90% of women intend to give birth vaginally (not naturally my comment) but ‘if current trends continue, fewer than half of them will end up achieving that’.
She’d rather money spent on free standing midwifery led birthing units rather than non-medical elective casesareans.
Sarah Ballard belives the progression of labour and the natural timing of birth may be far more important than many people think, involving an intricate interaction of maternal and fetal hormones that ensure both mother and baby are physically and psychologically ready.
Adrienne Priday works with clients where the community sees childbirth as normal and healthy.
Sue Belgrave says: ‘most women who request a caesarean are motivatd by the fear of losing control and uncertainty around the outcome of natural childbirth.
Michelle Wise says: ‘We’ve seen the rate (c-section) go up every single year. And with the number of women coming back for repeat caesareans, it will suddenly feel like everyone’s having one. There’s no doubt at some point the whole system as to rejig’.
The Listener:
Wernham study … ‘babies delivered by midwives are 55% more likely to have oxygen deprivation during delivery, have a 39% higher chance of neonatal encephalopathy (abnormal brain function associated with asphyxia at birth) and have a 48% higher incidence of low Apgar scores’
Study looked at 240,00 birth outcomes between 2008-2012 (91.5% of women under continuity of care midwife)
Study acknowledged that there were ‘many positive aspects’ of midwifery care including patient satisfaction and lower interventions rates.
She goes on to say: ‘the midwifery philosophy has always focused on the normal and that care should be provided in a primary care setting … in order to really understand that something si normal, you have to have a good understanding of what is not normal’. (and here lies the problem … everything is ‘normal’ if not easy, straightforward, good outcome. The focus stays on normal vs not normal instead of realizing that women and men can use skills in both circumstances and having skills can make more ‘normals’ and still make challenging births empowered)
OB John Tait said … ‘although some people said ‘I told you so’ we have a safe maternity system’. (I told them so too. This was obviously going to happen when there was no curiosity that skilled women took more responsibility for the health and well being of themselves and babies as well as had a behavioral option in response to fear of birth or that skills could reduce or prevent some of the common problems that lead to more interventions. The question is how can I explain this?)
Tait goes on to say that the system works well and that NZ cannot go back but this really gives us a good opportunity to get some decent research done to see why this is happening. But his solution is very ‘end game’ to look at who intervenes when there is a problem rather than look at how ordinary women (like people with diabetes, heart problems and obesity) can reduce the need for more medical care.
Tait says there are a lot of Obs involved now because we have a 30% c-section rate and 12% forceps.
College of midwives thinks it’s a resourcing problem. Their approach is to sue the government for more money for continuity of care providers. District health boards say that’s not the issue. Some OBs think that GPs were excluded and shouldn’t have been.
Bev Lawton did a study looking at births between 2005-08 and 30% more babies were at risk under first year midwives. College of midwives sued her and lost. She believes there’s a mismatch between midwifery training and the patient group (older first time mothers) … (in reality the mismatch is that midwives care for all pregnant women with their philosophy that birth is innately natural)
Pelvin who is a midwife and the Ministry of Health’s senior adviser for maternity system says: ‘Our whole system is predicate on ‘choice’ (She has been one of the midwives who has resisted the concept for growing a skilled birthing population)
Wernham says that she was always aware of the philosophical conflict between midwives and medicine. ‘I’ve always thought it was unfortunate. It’s important for both professions to keep in mind we are aiming for the same end goal, the best outcome for mothers and babies and the inter-professional conflict only gets in the way of that’. (It’s all about ‘delivery of service’ and ‘outcome’)
From Spin-off article/Jess Berentson-Shaw
A so-called ‘normal’ birth in New Zealand is what we call a ‘spontaneous vaginal delivery’ without medical interventions. These births have the least impact on women and the health system. So labour is not induced, goes OK (though frankly that feeble little word pain does not even get close to encapsulating the appalling trial by fire that is labour), with no epidural, and ends with an intact baby and mother, a nicely delivered placenta yada yada. Awesome.
Guess how many women have this birth in New Zealand? Oh, only about 34% (fewer for a first birth). Perhaps someone really needs to rethink the use of that word ‘normal’?
So there are four things the Ministry of Health can do right now
- Pay for the above research to be done, and done well.
- Compare the optimal models from the existing research on models of care with what we are delivering in New Zealand right now.
- Compare the care factors in births that went wrong and those that went right.
- Ask some hard questions about how system is arranged. Here are some (many) for a start
- Is the current payment system set up to create disincentives for optimal shared care?
- Are we putting the right amount of money and support in the right way into midwifery services?
- Are we putting the right amount into specialist provision?
- Are midwives getting the optimum training and support following training?
- Are obstetricians being trained in the context of how care is delivered in New Zealand? i.e. “shared care” not “doctors are the boss” care.
- Could we use GPs more effectively especially for those women who are harder to reach and at greater risk?
- What can be done to break down hierarchies, improve communications, and address the issues that exacerbate hierarchies?
- Most importantly what can be done to address the massive inequalities in outcomes between different women and babies?
The takeaway message for parents
Having a baby in New Zealand is safe no matter what model of care you choose, compared to other countries just like us. The rate of perinatal death (babies dying before, during, and after birth) has been on a steady decline for many years. Women dying in birth is such a rare event that it is hard to create statistics on it.
But birth is not risk free and it is a massive life event; being mentally prepared and feeling supported is important. If you feel uncomfortable with the care you are getting then do not hesitate to change – it is your legal right. Continuity of care is important but that can also come from a support person, friend, mother, or relative that travels your journey with you. So draw on your support network if your maternity carer needs to change.
The research tells us that midwifery care is just fine for babies, and obstetrician care just fine for women under optimum conditions. If you feel conditions are not optimal, then find someone who can advocate for you. Offer to be an advocate for those who cannot advocate for themselves. Demand better of the system. Demand that Government support all clinicians in the system to deliver optimal care and all women and babies to receive it.
(Once again there is no curiosity or imagination that women can do anything for themselves)
From the North/South and Listener articles it’s clear that something isn’t working for any of the three stake-holders … obstetricians, midwives and families. Are the three stakeholders satisfied?
There is more shame, blame, guilt, disappointment and anger about birth since I’ve been involved with birth for 45 years. In New Zealand the vast majority of women love their continuity of care midwife but loving a care provider and having ‘choice’ is still leaving too many families feeling birth is less positive than they had hoped for and even planned. In a Midwifery led maternity system the c-section rate has continued to rise at the same level as obstetrical led maternity systems globally. Fear of birth and lifetime damage to too many women’s bodies, play a significant part in the increase in Caesareans, more medically assisted births and less subjectively positive experiences.
There seems to be little curiosity or imagination as to how to change things around as I’ve discovered since I arrived in the mid1990s and the issues were beginning to arise at that time. As shown by Andrea’s statistics, implementing a skills-based approach alongside a choice-based approach adds a huge positive element to this most important event. Because doing so requires a simple protocol that all midwives can implement that takes very little effort without increased work for already overloaded midwives.
Briefly, the North South articles points out the two reasons women/health providers seek elective c-sects: fear of birth, damage to crotch … both can be reduced or prevented with skills. There are a number of creative assessments/solutions offered in the article by the medical community but absolutely no mention of ‘skills’, the role of parents within the acknowledged ‘partnership’ or even curiosity or imagination coming from the midwifery profession.
Can preparing our body for birth reduce or prevent damage to the soft tissue of our vagina? Of course, that makes common sense really. Can learning to create space in our pelvis help some babies to move down, through and out more easily? Of course.
Can learning and using birth and birth-coaching skills help women cope, manage, deal with, work through, stay on top of and in control of labour pains EVEN if they are afraid and hate it? Absolutely … a no brainer really.
Why is there no imagination or curiosity about what families can, should and able to do to help themselves? For goodness sake people with obesity, diabetes and heart problems are now expected to help take care of themselves and not just rely on the ‘delivery of service’. There are public service messages everywhere about this. Not every follows it and not every family will become skilled but heaps will!
The Listener is all about a study done that shows poorer outcomes under midwifery care and all about ‘delivery of service’ and whether GPs, midwives or Obs are best. No maternity carer has any expectation of families beyond their ‘choices’. How can this be?
Childbirth can so easily change. The partnership is set up. Midwives/Obs can tell all their clients they need skills and direct them to resources and make a monthly notation in the ‘notes’ about which skills were learned and then refer to those notes during every birth and encourage families to use skills. How can Andrea’s stats not be seriously regarded? What does she need to do to get her profession to wake up that others can replicate this success! Her clients success is not insignificant statistically but rather dramatic!
There are lots of people mentioned in both articles. I just feel I need to figure out how to reach out to someone and try to get a 2 year grant to run a trial. I talked to my local MP who didn’t think Coleman would have any interest at all!
How can I become more public and heard? The College is focused (Listener) on getting more staffing! Who will listen to me and Andrea? I just feel so sad. I’ve tried for so many years to prevent midwifery and childbirth from heading down a path that would only lead to being perceived of as failing. I’ve been shut out at every effort. My goodness The Listener’s title for their article was ‘Birth … where the revolution went wrong. The dangers of midwives in charge’.
This is so easy to turn around.