Once upon a time there was a hospital…

This is a piece I wrote about a local hospital in the outer suburbs of Melbourne, Victoria, Australia. I know it’s a sensitive topic to many of my colleagues and friends, but I’m writing it because I’m tired of the way women have been used in the media coverage of this issue and the way staff at this hospital (and others) have been vilified.

 


 

The stories that have unfurled over the past four months regarding Bacchus Marsh Hospital’s maternity services have certainly been concerning. More than expected numbers of unexplained baby deaths were the trigger for the hospital’s board to be sacked and for the Health Minister to announce concerns about the hospital’s obstetric practices and standards of care. But the media’s handling of the issue has been focussed on blame and retribution and an almost voyeuristic preoccupation with personal stories of baby deaths and maternal wound infections. There also seems to have been little concern for the reputation of local health services in general.

There have been numerous television and print media stories about the alleged “horrors” of Bacchus Marsh hospital’s obstetric services. Even a newspaper piece written by one of the litigation lawyers.

Many of the stories in these reports have come from women whose babies have been stillborn or who have themselves personally suffered infections or complications post-birth at the hospital. Very upsetting stories. Of an often very personal nature. Life-changing events for these women and their families.

These stories have been used by the media to argue that particular doctors at the hospital are unfit to practice.

It is not the media’s responsibility to judge the competency of medical staff at this or any other health service and their use of women’s very personal experiences to this end does not honour these mothers or the memory of their babies.

Instead, the stories have been used to create emotional leverage bordering on hysteria, all the while touted as “giving mothers a voice”. Meanwhile these women have shared their heart-wrenching stories with the world – but to what end?

Many media segments have similarly implied that every baby death at every Victorian hospital is the direct result of medical mismanagement. Sadly, there are babies born every single day in Victoria who never take a breath. The perinatal mortality rate for Victoria in 2011 was 10 in 1,000 births. The reasons for these deaths are often a complex combination of macro structural issues and individual management – important factors that need ongoing close and careful examination by people with appropriate experience and training such as the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM).

One newspaper article last year listed the “likelihood” of baby deaths in specific Victorian hospitals. Interesting stats but what do they really mean and to what end?

These are local community hospitals that people rely on for their healthcare.

There is rarely an alternative service for these people to choose. What do locals do when they lose trust in their neighbourhood health service? And what exactly does it mean that babies are 80% more likely to die at your local hospital? There was no attempt to contextualise these statistics.

At what point does the media take responsibility for the impact this kind of reporting has on undermining local trust in health services?

Bacchus Marsh is a local hospital. It has been a great option for women in the area with normal pregnancies to receive maternity care and to birth close to home. The number of women booking  to have their babies there increased exponentially over the last ten years.  Despite departmental concerns, the hospital is still open for business and presumably it’s staff are trying to somehow rebuild some of that local trust they gained as the hospital’s birth rate grew and grew over the last ten years.

From all this it seems that there are really two key issues that need addressing in this situation:

1. the professional regulation of medical and allied health practitioners is currently the responsibility of AHPRA, and its actions are being called into question, especially regarding delays into investigations of practice. No doubt this is a complex issue related to process and structure.

2.The other issue involves systems of management and leadership for hospitals in Victoria to ensure safe practice and good health outcomes in these services. Not exactly a racy media hook, but good structures can improve accountability and importantly,  help to ensure that people trust their health services to provide safe care for them.

So why not focus on investigating these issues rather than fishing around for allegedly shonky operators who are unlikely to be solely responsible for large numbers of baby deaths, or bringing down the names of local health services who may or may not have practice issues related to their statistics?

If a health service is truly dangerous it should be shut down – no question.

But my heart is with those dedicated health professionals still working at Bacchus Marsh – battling every day the fallout from media stories denigrating their work.

It’s also with the women and families who have shared their stories of heartbreak publicly. Maybe their experiences will help us see the human side of the statistics.

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The Roar Behind the Silence: book review

Soo Downe and Sheena Byrom are midwives from the UK with long and illustrious clinical careers in midwifery and also many midwifery research projects and publications to their names.

This year they published an edited collection of brief, sharply edited chapters written by 50 (count ’em) different authors.

The topic that the book deals with is the need for maternity services to be based on a philosophy of kindness and compassion: [back cover blurb]

For many years there has been growing concern about the culture of fear that is penetrating maternity services throughout the world, and that the fear felt by maternity care workers is directly and indirectly being transferred to the women and families they serve.

The consequences of fear include increased risk of defensive practice, where the childbearing woman and her family become potential enemies to those providing her care. In addition, the prevailing risk management and ‘tick box’ culture in maternity services encourages maternity workers to give priority to the records instead of the woman. These factors contribute to the dissatisfaction felt by those using and providing maternity services. There is however increasing evidence that kindness, compassion and mutual respect improve efficiency, effectiveness, experience and staff morale within healthcare settings.

The book is divided into three sections:

1. Stories and perspectives from maternity care.

2. Principles and theories.

3. Making it happen: solutions from around the world.

This is an action manual for creating change.

These are issues that are not only for the UK to be concerned with –  in Australia we have important problems to address with regard to how maternity care is provided, how women are respected within particular models of care and, of course, with regard to rising caesarean section rates and the consequences of this.

The chapters in the book are written by people as diverse as…

Kirsten Uvnäs Moberg:  a medical doctor and author of two books on the physiology of oxytocin. Her take on the impact of intervention on the action of oxytocin should make us reconsider the “safety” of many interventions which effectively block the action of the hormone.

Alison Barrett: an obstetrician who practises in New Zealand, and talks about how motherhood is not valued in western culture, “which is a nice way of saying that our culture (still) hates women” (page 63). She describes how every woman in the maternity system deserves the Best of Care. Every woman. She invites us to examine the barriers in our own minds that prevent us from providing this.

Milli Hill:  is a writer and campaigner and author of a book on water birth. She is the founder of the Positive Birth Movement – a grassroots organisation designed to promote discussion amongst women about positive birth. It emerged as an antidote to the widespread cultural fear of childbirth. As she says: “women in the PBM network consistently report that being treated and spoken to with kindness and respect is at the heart of a positive birth experience” (page 189).

Anna Byrom: is a midwifery lecturer who has used drama through Progress Theatre to explore issues through critical reflection and discussion and debate in maternity and general healthcare services. The chapter, co-written with Adele Stanley, Gemma Boyd and Kirsten Baker, outlines how their methods have enabled understanding of different participants’ experiences in healthcare settings as well as personal development – with a view to providing compassionate care.

Mavis Kirkham:  is a midwifery researcher who has written about and researched midwifery for 40 years. Her work has often focussed on the context of midwifery work and what kind of care this produces. Her chapter argues that  the NHS maternity care system is a powerful shaper of how midwifery care is delivered. We can’t ignore the impact that a system which oppresses midwives has on the way care is given.

Hannah Dahlen: is an Australian midwife researcher and practising midwife who is a professor of midwifery at Western Sydney University. Her research has covered topics such as episiotomy rates, perineal safety during birth and the impacts of place of birth and antenatal care on birth outcomes. Her chapter in the book (co-authored with Kathryn Gutteridge) looks at how the fear of midwives impacts on the experience of women during pregnancy and birth – how models of care based on risk alone take so much away from the the miracle of the
experience…and also the joy of doing midwives’ work.
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Maybe you don’t usually read books about midwifery?

That’s ok.

This is unlike any midwifery text I’ve read – the chapters are readable, understandable, distinctly lacking in researcher or academic jargon, and contain many stories.  They are also SHORT, concise and written in such a way that if you want to find out more about a particular person’s work or point of view, you can easily do so by looking at the reference list for each chapter or googling the organisations and publications referred to.

It is also a great way to find out the names of people who are doing interesting and stimulating work in our profession.

The other amazing thing is that at the end of each chapter there are summaries of key messages, and then a list of action points: what you can do – as a midwife.

I’m excited about this book because it has the potential to enliven and excite our profession towards change – a change that is centred on kindness and compassion for the women and families in our care.

The book is available for purchase online (for less than 20 bucks) via Amazon or Book Depository or locally through Capers: http://www.capersbookstore.com.au

Do yourself a favour.

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Breastfeeding support – what makes it good.

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I’m reading  a lot of research that considers  the best ways to prepare and support women to breastfeed.

Truth is, we really don’t know for certain what’s the most effective way to do it.

One theme that seems to be coming through is that the what isn’t so much of an issue as the how.

When women are asked about what care was helpful to them, they talk about having their feelings acknowledged and being listened to.

Graffy and Taylor (2005) undertook a randomised controlled trial in the UK to measure the outcomes from a particular model of breastfeeding support. As well as this, they asked the women in the trial about what they thought constituted “Good Breastfeeding Support”.

The authors summarised it in 5 points:

1. women wanted good information about the benefits of breastfeeding. This was so they could defend their decision to breastfeed when they were questioned (as they expected to be) by their family and friends (!).*

2. women, as I mentioned above, wanted their feelings acknowledged and wanted to feel listened to.

3.  women wanted practical tips for breastfeeding such as different positions for feeding.

4. they also wanted reassurance and encouragement to breastfeed.

5.  Provision of resources for what to do if they were having trouble – someone to call or make contact with.

Not a bad list.

I would defy any midwife to not know how to provide the elements these women were after.

One of the big points here is that women aren’t expecting a huge amount from their caregivers. Mainly time, patience, a listening ear and some encouragement. You don’t need to solve all their problems….but hey, preventing some would be excellent.

As midwives, we can do this by helping them get to know their new baby – to read the baby’s cues, to offer the breast when the baby is quietly alert, to hold the baby close any time.

To believe them when they say they have tried to feed.

To stay with them when they are going to try.

You don’t need all the answers – you will have seen enough babies to know the range of what is normal – and be amazed by the immense variation in this!

Something I tried to mention to women in clinic when we were talking about breastfeeding at the 26 week visit (probably should have had a chat about it at every single visit…) was: “as midwives we know a lot about lots of different babies …but not so much specifically about yours – you will very quickly become the expert on your baby – you can use us midwives to help along the way with figuring it all out”.

My experience as a volunteer breastfeeding counsellor and then training to be a lactation consultant helped me realise there are more important things than “knowing all the answers” to breastfeeding problems when we are supporting women to breastfeed.

So much more is about walking beside them on the journey.


 

*just by the by…I think this issue needs unpacking (and highlighting) a bit more.  Never mind criticism of the health message “breast is best” – when women are being judged on their decision to breastfeed by their own families!

The issue of skin-to-skin.

photo (3)Atul Gawande  is a general surgeon and researcher from North America. And he writes. And thinks.

I “discovered” him a couple of years ago when I read an article of his in The New Yorker on how medicine takes up new ideas into practice (see links below).

In part of the article he described the efforts of public health workers in India trying to instil the practice of immediate skin-to-skin contact for mothers and babies after birth. The proven power of skin-to-skin contact in reducing infant mortality means it should be a natural activity for birth workers to encourage. And it’s an easy thing to facilitate and encourage in the clinical setting. But still it took time for widespread taking-up of the practice.

Gawande’s conclusion was that people are key in creating change in clinical practice.

Health workers with some clinical skills were employed to visit health care facilities to educate on the importance of the practice and also to make connections with practitioners. Practice is a complicated thing. Clinicians go through many processes in order to change their practice. It is one thing to know what the “evidence” is. It’s another thing to incorporate that into what you do. There may be particular factors which prevent the practice from being carried out, and perhaps most importantly, there may be colleagues who don’t share your priorities.

In the case of skin-to-skin contact, I thought of a few obstructions that might occur in a typical Australian maternity setting:

– the need or expectation that other activities will occur following the birth, such as checking the woman’s perineum, delivering the placenta or checking the baby, which skin-to-skin contact may delay or prevent being carried out.

– the desire of family, friends or health workers to give the mother “a rest” from her baby after what may have been a long and difficult labour.

– the belief that the operating theatre environment is too cold for a newborn baby to be unwrapped.

– the belief that a mother having skin-to-skin contact with her baby on an operating table will interfere with the rest of the caesarean procedure.

– the pressure on labour rooms necessitating the transfer of women who have given birth to postnatal wards as soon as possible.  This might mean that administrative tasks take precedence in the activities following birth.

In fact, many of these obstructions were issues in Indian healthcare facilities too!

Gawande’s conclusion in the Indian situation was that this ongoing person- to- person contact was the most effective means of creating change in practice.  Why?

-It meant that the activity was perceived as a priority (why else have someone dedicated to the task of changing practice?)

-It allowed for the clinician to understand all the reasons for the new activity by discussing it with the health worker.

-It gave local clinicians the opportunity to “own” the activity because they could discuss the particularities of their place of workplace with someone else and adapt their practice in a way that suited their context.

-When the practice was increasingly adopted the results could also be observed by the clinician which then had a positive feedback effect…and so skin-to-skin would become a “standard” feature of post-birth care.

And we haven’t even started to talk about breastfeeding…

 

The New Yorker article: http://www.newyorker.com/magazine/2013/07/29/slow-ideas

Atul Gawande’s website: http://atulgawande.com

Breastfeeding in public. Build a bridge.

I’ve been a subscriber to google alerts for a couple of months now. The topics I am sent include “breastfeeding”, “bottle feeding”, “pregnancy” and “lactation consultants”. I get links to newspaper and magazine articles that the great google machine finds via its keyword searches.

Most days I skim them, some days I read a few and my midwife Facebook friends will know that I often post links that I think are discussion-worthy or particularly interesting.

The breastfeeding posts and links and articles have predominantly been focussed on two things: reported incidents of women breastfeeding who have been asked to cover up or leave the space they’re in. The other topic is how women are unfairly pressured to breastfeed by so-called breastfeeding nazis – a topic I have addressed in another post (More women doing it for longer).

I am coming to think that breastfeeding in public is a key issue for ongoing breastfeeding rates in Western countries. And it’s an issue of human rights…no,dammit, women’s rights.

If a woman is going to have the freedom to leave her home and surrounds with her breastfeeding infant she needs to know that she can feed her baby whenever and wherever she wants to, and more importantly, whenever, wherever and for however long it takes for her baby to feed. With no judgement whatsoever, and even with some encouragement – not a cheer squad, but maybe a nice place to sit and a drink of water.

Women who breastfeed in public are expected to look after the feelings of everyone else who enters that public space. It’s less of an issue that anyone can actually see anything (for example, areola or nipple) and more about the idea that this woman could be breastfeeding.

Breastfeeding women are often being asked to be discreet by the members of the public who see themselves as Reasonable People: “I don’t mind if women breastfeed, but they should be discreet about it”.  These people seem uninformed as to the realities of feeding a live, wriggling child.  And also to how rare sexual exhibitionism is amongst breastfeeding women.

Being a mother of a small baby and toddler can be an isolating experience. A lot of a mother’s time is spent in her own home with her children, attending to her childrens’ needs and running the household. Being able to get out, even if it’s to the shops, is what you need to do every day and sometimes it’s a downright lifeline (please take note shop keepers).

We all expect that when we enter the public sphere we can act as we please, within certain boundaries.

For a breastfeeding mother that means that she will very likely need to breastfeed her child at some point in public.She needs to do that so that she can leave her house, buy food, feel part of a community, stimulate her child, maybe even have a latte…in short, live her life.

Frankly, anyone else’s sensibilities will need to take a back seat if we can agree that, as a member of our society, she has the right to do those things. And breastfeed.

In Australia she has the inalienable legal right to do so.

I know that women’s bodies being displayed in public is a complicated issue in Western society. And breastfeeding is seen as a private activity that shouldn’t (?) be brought into the public sphere. What better way to cut through the hypocrisy around the objectification of women’s bodies than for a mother to carry out a beautiful, physiological activity of love and food with her child?you-can-do-it-breastfeeding