Home Birth Aotearoa were invited to present at the 2015 Maternity Conference hosted by the Ministry of Health. This event is a great opportunity to connect with a broad range of maternity caregivers and policy makers. This was a great opportunity for Home Birth Aotearoa, one of our core goals is to have a voice in policy around maternity and maternal health.
We asked Carla Sargent (author of Where the Heart is and the Birth Trauma Report) to represent us at the event. She held space for our kaupapa beautifully.
Below is the speech she made, we thank Carla for standing strong with her home birth heart and ‘telling it like it is’.
Kia ora koutou. My name is Carla Sargent. I used to be an independent midwife in Tauranga many years ago. I now live in Hamilton with my husband and three children, and run a birth trauma support organisation called Voice for Parents. Today though, I am very honoured to be representing HBA in this important panel discussion.
How to increase primary birthing… It’s interesting isn’t it, that there is a wealth of research which has demonstrated the safety of low risk women giving birth at home or in a primary birthing unit, yet the vast majority of women still opt to give birth in hospital. We know that maternal and infant rates of morbidity and mortality are very similar when we compare primary birthing locations with secondary and tertiary ones. We know that rates of physiological birthing are higher for women who plan to birth in primary care settings and that rates of medical interventions and surgical birth are higher for women who plan to birth in hospital settings. We know that primary birthing is a hell of a lot less taxing on the government’s maternity bill. We know that women express greater satisfaction with their births and birth care when they give birth at home or in a primary birthing unit compared with those who choose a hospital birth. The research is clear… to improve birth outcomes we need to keep low-risk birthing women out of the hospital. This will be a big challenge as there still exists the widely held public perception that hospital is the safest place to give birth.
Negative media coverage of midwives in general and home birth midwives in particular has been unreasonably harsh and has undoubtedly skewed societal views on the safety of birthing in primary settings. HBA challenges our Ministry of Health take a similar approach to that that the NHS has in terms of nationwide promotion of primary birth settings being the most suitable option for healthy women. This would require a Ministry or DHB funded media campaign and the development of guidelines to ensure that all GPs, practice nurses and LMCs who are first in contact with pregnant women, are providing the same evidence-based information for women to contemplate their choices around. We need to send a clear message to the public that physiological birth is best achieved in primary care settings and that hospital birth ought to be reserved for those with obstetric need. Where else do we see public health care being paid for where there’s no medical necessity for such care?
However, if we are to carry out such a campaign, we need to also ensure that women have access to the sorts of services we are acknowledging are most suited to them. Currently, dependent upon where women live, home birth midwifery care and primary birthing units are not necessarily available. While we can feel proud of the envied maternity care system we have here in NZ – one that entitles women to choose where and with whom they give birth, and one where continuity of care is enabled – we still fail a significant proportion of our birthing population by implying they have choices when actually those options don’t always exist. We need more midwives who are confident and skilled in practicing home birth midwifery. Currently, there are many NZ midwives who feel uncomfortable to support women to give birth at home… which begs the question, what are we teaching our student midwives? And what sorts of experiences are they being exposed to, or not being exposed to in their training? If home birth is to be a valid choice for NZ women, it is our midwives who need to be promoting it, offering it, supporting it and ensuring its continuity – midwives, after all, are our guardians of normal birth. And I hazard a guess that, like I did, many students formulate their own midwifery philosophy of practice based on the birth care they witness during their training.
This week I heard from a new midwifery graduate who said that not only had she had absolutely zero home birth experience during her three years of training, but that the vast majority of her practical experience was very medicalised. This is how she spoke of her training: “You can’t do more than two placements with the same midwife – so you can see different types of midwifery practice. But that’s not that effective as there are HEAPS of midwives who practice more to the medical model. Put it this way – I didn’t see a physiological third stage till the end of year 2, then didn’t see it again till the middle of year 3. If that gives perspective. I WISH so bad I had been exposed to more normal birth at tech.” It seems almost inconceivable that being able to support women to give birth at home is such an important part of the NZ midwifery service, yet there is no requirement for even one of the 40 births that a student midwife must attend, to be a home birth. Not one. Even trainee Childbirth Educators are expected to attend one home birth. How can we claim that our midwives are the experts in primary birth care, that they know best how to facilitate the natural birth process when there are so few opportunities for them to witness physiological birthing during their training? The medicalisation of birth is rife, demonstrating a widespread mistrust in, or misunderstanding of, the normal birth process. Midwives are not immune to the culture of fear that envelops much of maternity care, something that we need to ensure our midwifery students are viewing with eyes wide open. The best way for them to gain an appreciation for this is to show them what intervention-free births look like… the skill of a midwife to NOT intervene in birth unless there is good reason to do so, is just as important and possibly as challenging as the skill of a midwife to act proficiently when necessary.
Which brings me to our second proposal; HBA would like to encourage our Midwifery Council to ensure that all student midwives are being exposed to home birth experiences during their training. Our midwifery graduates ought to feel confident and competent to provide home birth midwifery care regardless of whether or not they choose to do so upon graduating. If students are unable to gain the valuable learning involved in attending home births, then a feasible alternative is to have community representatives share their stories with students. Given that there are very limited opportunities for students to do placements alongside home birth midwives, we propose that midwifery schools be required to hold regular workshops run by home birth women, home birth midwives and regional Home Birth Association representatives. The use of narratives is a powerful learning tool that, although it doesn’t provide quite the opportunities that practical experiences do, still gives much insight into home birth philosophy and practice. A couple of years ago I published a book of NZ home birth stories called Where the Heart Is. The intention for the book was to provide readers with an appreciation for, and understanding of, the natural birth process, an inspirational and informative tool for pregnant women and midwives. Without wanting to come across as a pushy salesperson, I believe Where the Heart Is should be on the required reading list for all midwifery students.
We, at Home Birth Aotearoa, also acknowledge that many midwives may grow less comfortable with supporting home births over time, especially if they are working within a hospital setting where medicalised birth inevitably becomes the norm. As the skills required of midwives are different in different birth settings, HBA suggests that there should be ongoing regular PD for midwives to remain up-to-date on research and information surrounding home birthing and home birth midwifery care. A number of HBA representatives attended Dr Sarah Buckley’s Conference earlier this year. We were somewhat surprised and disappointed that there were so few midwives in attendance. It’s those sorts of Conferences that we feel ought to be required PD for practicing midwives.
Dr Sarah Buckley’s work focuses on the hormonal orchestration that enables physiological birthing and how various interventions interrupt this important pathway. She provides a scientific basis for the higher degree of positive outcomes associated with physiological birthing – things such as less PPH, and increased rates of successful breastfeeding and bonding. Women are entitled to choose where they give birth and what interventions they are willing to consent to, but their decisions are only as good as the information they are basing them on, information that is provided primarily by their LMC. Although our midwives have access to compelling research from for example the Birthplace study in the UK, we at Home Birth Aotearoa recognise the importance of collecting national statistics on birth interventions and outcomes relating to all of the available birth settings, including therefore, statistics on home birth. We propose that well-defined data is consistently collected and analysed across all regions of NZ and that such data is used to paint a clear picture of various outcomes for our spectrum of birth place options. With regards to collection of home birth statistics, this has, in the past been carried out in an ad hoc manner without, for example, distinguishing between planned home births and unplanned, perhaps unassisted, home births. Perhaps we could involve consumer representatives in the planning stages of such data collection. That way we are able to collect information that is relevant to birthing women. I, for one, am concerned about the flippant use of the word “safety” to describe birth outcomes. For example, we use maternal and infant morbidity and mortality statistics to determine that birth in primary settings is as “safe” as birth in hospital settings for low risk women. But what of the emotional and mental health consequences of various birth experiences? Has a woman who feels traumatised by her birth and struggles to bond with her baby really experienced a safe birth?…I kept hearing yesterday that maternal mental health needs need to be a priority, I couldn’t agree more.
To sum up, the three key actions that HBA would like implemented within the next year are:
- nationwide promotion, via a Ministry funded media campaign, of primary settings being the most suitable birth place for low risk women. This would also involve the development of guidelines to ensure that all GPs, practice nurses and LMCs who are first in contact with pregnant women, are consistently providing the same evidence-based information.
- for midwifery students to learn about and grow confident in home birth midwifery practice. We would like to see all students attend home births during their training, and for regular workshops to be run in the midwifery schools by home birth women, midwives and Association representatives. In a similar vein, we propose that compulsory attendance at workshops on physiological birthing, such as those run by Sarah Buckley, be a part of midwives ongoing education. And 3
- We call for standardised nationwide collection and analysis of data on interventions and birth outcomes relating to all birth locations, including of course, home.
Thank you for this opportunity to speak on behalf of HBA on what is undoubtedly a topic that is very close to our hearts.