Issue 114

WELCOME, TENA KOUTOU KATOA, KIA ORANA, TALOFA LAVA, MALO LELEI, FAKAALOFA ATU

Physiological birth in AotearoaNZ appears to have become an endangered “species”. MSCC has been vociferous in our continued support for access to midwifery continuity of care and the importance of access to primary birthing options for all women. We assumed that midwifery care throughout the maternity experience would support physiological pregnancy, labour, birth and breastfeeding, and reduce the rate of interventions experienced by birthing mamas. In this edition, we compare local (National Women’s Health and Birthcare) and national Report on Maternity, statistics to see if our assumptions are correct. At our time when midwifery shortages threaten women’s access to midwifery continuity of care, we share women’s experiences of continuity of care from the joint maternity consumer survey (July 2018).

People living in developed countries have actively or tacitly chosen to accept an interventionist maternity culture. Japanese Dr Tadashi Yoshimura, has shown that when women take responsibility for their health, are determined to birth naturally and are supported by caregivers who trust them to do so, birth works! In this edition we include a review of his inspiring, and somewhat controversial, book in which he describes the underlying philosophy that has led to his dedication to natural birth and the maternity care provided to women and their families at his clinic.

MSCC recognizes that each woman’s childbearing experience is unique so we don’t expect that our readers will necessarily agree with everything we write. We do hope, however, that the content of our newsletter will stimulate thought, discussion and hopefully changes in the way women, whanau and their maternity care providers view and experience the maternity services.

MSCC WELCOMES input, feedback and suggestions: Email [email protected]

We also INVITE any women who are interested in maternity related issues to participate in our monthly Steering Group meetings. If you would like to observe, add your voice or contribute your skills to our organization, please phone 022 421 6008 to arrange to meet us.

Continuity of Midwifery Care

A Brief Herstory of Midwifery Continuity of Care in AotearoaNZ

The Nurses Amendment Act 1990 not only gave midwives the right to practice autonomously, without the supervision of a medical practitioner, it also gave women access to the possibility of continuity of care throughout her maternity experience.

Prior to 1990, most women in AotearoaNZ received pregnancy care from their GP, labour care from staff midwives in the maternity facility in which they birthed with their GP often in attendance for part of the second stage, and in patient postnatal care in the postnatal wards. The duration of postnatal stay gradually reduced from 2 weeks in the postwar baby boom period when the majority of women gave birth in a local maternity hospital, to 6 -10 days in the 1970s, (when a falling national birthrate combined with a policy of regionalization of obstetric services resulted in both the start of gradual closure of small maternity hospitals and a gradual increase in the rate of obstetric interventions in labour and birth). The duration of inpatient postnatal stays continued to reduce throughout the 1980s with women being discharged between 2-5 days. After discharge few mothers and babies received any midwifery care. Home-based postnatal care was provided by a combination of District Nurse and Plunket Nurses with a final visit to the family GP at 6-weeks.

From the early 1970s a tiny percentage of women received continuity of midwifery care by choosing to birth at home. The “supervising” GP still provided most of the antenatal care but women also received up to 3 antenatal home visits from their domiciliary midwife, who also provided care during labour and birth (“supervised” by the GP in the second stage) and who then visited the mother and baby at home 12 times in the first 14 days postnatally.

In the 1980s, politically active homebirthers from throughout AotearoaNZ actively supported lobbying efforts to bring about legislative change that would given midwives the right to practice autonomously and enable women to access continuity of midwifery care whatever their choice of birthplace.

The Area Health Board Act (1983) required these Boards to consult with consumers in their areas but didn’t mandate a process for doing this. In the late 1980s in Auckland, a handful of maternity consumer organisations were approached by Auckland Area Health Board (AAHB) maternity managers and asked for input into a community consultation process. A group of Auckland based, politically active consumers, determined that women should have a strong voice in the planning and provision of maternity services in Auckland, suggested that an umbrella consumer council be formed that would disseminate information from the AAHB to interested consumer organisations and, collate and feedback information and concerns from consumers to the AAHB. There was resistance from, but also a few champions within the AAHB, and by April 1990, the MSCC, with a membership of 80+ other organisations who had an interest in maternal and child health, was formed.

The Nurses Amendment Bill (September 1990), gave midwives autonomous practitioner status, but obstacles delayed the availability of continuity of care for most women for a few years. e.g managers at a number of maternity hospitals, were resistant to giving midwives the “Access Agreements” needed for midwives to be able to book women into, and provide labour and birth care for their clients, in maternity facilities.

MSCC Research Supports and Promotes Midwifery Continuity of Care as a Maternity Quality Indicator

In 1992, the Northern Regional Health Authority contracted the MSCC to undertake a consumer consultation project to find out what consumers believed constituted maternity service quality indicators. MSCC consulted with all our, then, 78 member groups to establish consumer defined Maternity Quality Indicators.

Fifty-three of our member groups responded, and two of the most frequently identified indicators of a quality maternity service were:-

(1) Continuity of Care from a chosen maternity provider (with midwives being identified as the most appropriate maternity care provider for the majority of women)

(2) A wellness model that sees service design and provision take into account the physical, emotional, psychological and spiritual needs of individual women. A service that is grounded on the fact that, for the majority of women, pregnancy, birth and parenting are normal life processes. Medical interventions are therefore, only recommended/offered when appropriate, rather than as a routine.

MSCC firmly believed that these two indicators would be mutually supportive, that continuity of midwifery care would reinforce pregnancy and childbirth as normal life processes and put the brakes on the increasing use of medical interventions that had accompanied the regionalization of maternity services in the 1970s and 80s. Obstetric control of maternity service provision had resulted in the closure of local primary level maternity units, and directed women into Level 2 or 3 obstetric hospitals where maternity care was led and overseen by obstetricians.

25 years on, more than 90% of women in Aotearoa NZ now have a midwife as their Lead Maternity Carer, but primary birthing units are underutilized, the national homebirth rate has remained static and the numbers and rates of medical interventions have continued to rise in hospitals throughout the country.

Recently Published Research Shows Benefits of – Midwifery Continuity of Care

Internationally there is growing concern about the steadily rising c-section rate. The major cause for this concern is cost but many providers and researchers are also becoming concerned about the potential for (and costs of) longer term morbidity associated with c-section for both mother and baby. A recently published Australian meta-analysis, reviewed articles that described and evaluated organisational interventions that had the primary aim of reducing planned and unplanned c-section rates.^[1] The results indicated that women who received continuity of midwifery care were less likely to have a c-section than women allocated to usual care (i.e. a combination of obstetric, midwifery and often nursing care). This review also showed that women receiving midwifery continuity of care, who birthed vaginally, were less likely to have an episiotomy. Having a formal process of audit and feedback for c-section or a policy of mandatory second opinion prior to c-section, were interventions that also showed potential to reduce c-section rates.

Midwifery Continuity of Care and intervention rates in AotearoaNZ?

The following statistics are taken from the Ministry of Health’s Annual Reports on Maternity for the years stated and shows that nationally, intervention rates remained high or increased, despite a high percentage of women receiving midwifery continuity of care.

	2000	2010	2017
LMC at birth
Midwife	70.8%	91.6%	86.9%
GP	13.4%	1.7%	0.2%
Obstetrician	15.8%	6.6%	5.1%
Not Registered with LMC	Not included	Not included	7.7%
Birth Location
Primary	15.12%	10.8%	10.0%
Secondary	41.89%	40.7%	41.1%
Tertiary	42.86%	44.7%	45.6%
Home birth	Not stated	3.2%	3.4%
Not stated	0.13%	0.6%	0%
Type of Birth
SVB	68.4%	62.1%	62.7%
Home Birth	Not stated	3.2%	3.4%
Emergency C-section	13.6%	13.0%	15.2%
Elective C-section	7.2%	10.7%	2.6%
Operative vaginal	10.8%	8.9%	9.3%
Not Stated	0%	2.1%	0%
Interventions ( excludes women who had an elective c-section)
Induction of Labour	20.7%	19.8%	25.5%
Augmentation of Labour	Not Stated	28.6%	22.8%
Epidural	25.3%	24.6%	26.5%
Episiotomy	11.6%	12.5%	15.9%
Vaginal Breech	0.9%	0.3%	0.4%

Outcomes of Midwifery Continuity of Care in Auckland

The recently published National Women’s Health Annual Clinical Report for 2018 supports the primary finding of the Chapman et al research^[2] that, continuity of midwifery care reduces the elective c-section rate and has a small positive impact on the emergency c-section rate. A higher percentage of women birthing at Auckland City Hospital, are registered with an LMC obstetrician than in any other part of the country. The growing shortage of LMC midwives resulted in only 42.7% of women being registered with an LMC midwife while 30.2% were registered with a private obstetrician. Private obstetrician intervention rates are alarmingly high. While the intervention rates for women with an LMC midwife are lower than for other provider types, they are still very high when one considers that birth is a normal physiological function.

	National Womens Health 2018
Intervention	LMC midwife*	Private Obstetrician*	NWH Community Team*	Labour started at Birth care
Induction of Labour	35.0%	36.4%	39.2%	0%
Elective c-section	11.8%	36.8%	16.4%	0%
Emergency c-section @ term	23.5%	32.2%	26.61%	4.8%
Induction>Emergency c-section	47.24%	72.6%	56.3%	0%
Forceps (fullterm babies)	7.6%	7.7%	8.1%	8.2%
Ventouse (fullterm babies)	19.4%	12.8%	18.1%
Episiotomy (Total Vaginal Births)	33.27%	45.96%	?	12.54%
Intact Perineum (Total Vaginal Births)	17.09%	13.22%	?	24.78%
Episiotomy (Total Nullipara)	54.1%	62.5%	40.3%	?
Episiotomy (Total Multipara)	13.6%	27.6%	8.8%	?
Epidural in labour (Nullipara)	66.4%	83.5%	68.5%	?
Referral for ECV for breech presn.	66.0%	28.0%	43.%	?

NB – *The percentages are calculated as the percentage of the total number of women registered with each LMC type, not as a percentage of the total number of women.

Primary Birthing at Birthcare in Auckland

The data published in this Annual Clinical Report for women who commenced labour at Birthcare is sparse, but does show that Continuity of Midwifery Care results in much lower levels of intervention for women who choose to birth in a primary setting, (even when they subsequently need to transfer to hospital).

	Total (352 women commenced birth at BC)	Birthed at BC 275 (78.13%)	In Labour transfer to birth @NWH 77 (21.88%)
Nullipara (1st time mother)	179	113 (63.13%)	66 (36.87%)
Multipara (second or successive baby)	173	162 (93.64%)	11 (6.36%)
Spontaneous Vaginal Birth	306 (86.93%)	275 (78.13.%)	31 (8.81%)
Forceps/Ventouse	29	0	29 (8.2%)
Emergency c-section	17	0	17 (4.8%)
Episiotomy (% vaginal births)	42 (12.54%)	9 (2.69%)	33 (9.3%)
Intact Perineum (% vaginal births)	83 (24.78%)	70 (20.9%)	13 (3.88%)

Standard Primipara

A Standard primipara is a woman who has never previously given birth; is aged 20 – 34 years; who has a singleton baby that is assessed as being of average weight, has no known anomalies and is in a head down position during labour that occurs between 37 – 41 weeks gestation. The Standard Primip has no medical disease or infection and no pregnancy related health issues e.g. gestational diabetes, hypertension etc.

Tertiary hospitals like National Women’s (and some private obstetricians), frequently justify their intervention statistics by claiming that they provide care for a higher percentage of women who have a higher level of complexity. However, 511 of the women giving birth for the first time, at NWH in 2018 were low risk (and probably a much larger number of multiparous women). The outcomes for this group of healthy women transitioning through a normal life stage, suggests that the culture of birth at NWH has as much impact on intervention rates as the risk status of mothers and babies. Low risk women would be well advised to avoid giving birth at NWH. Why are the intervention rates for low risk first time mothers, who received continuity of midwifery care at NWH, so much higher than for the low-risk women who birthed at Birthcare? It is unfortunate that the intervention rates for primips/nulliparous women who commenced birth at Birthcare aren’t recorded separately, but what we see from the statistics above, is that, 63.13% of low risk, first time mothers birthing at Birthcare had a spontaneous vaginal birth compared with only 52.8% low risk, first time mothers, at NWH.

Standard Primip Data NWH 2017	LMC Midwife	Private Obstetrician	NWH Community Team
Total number of Women	511	340	204
Spontaneous Vaginal	52.8%	28.2%	48.5%
Induction of Labour	This data was not available by maternity care provider, but the total IOL rate, for the Standard Primip at NWH, was 11.3%
Forceps	9.0%	9.4%	15.3%
Ventouse	16.8%	15.3	18.6%
Elective c-section	1.6%	16.2%	4.9%
Emergency c-section	19.8%	30.9%	21.6%

Cochrane Review of Midwifery Continuity of Care

In 2016, the Cochrane Database undertook a review of 15 randomized controlled trials from the UK, Ireland, Canada and Australia, that included, 17,674 women with low- or mixed- risk pregnancies, to find out if outcomes are better for women and babies who receive midwifery continuity of care compared with other models of maternity care provision.^[3] (Home birth was not offered in any of the trials.) Women who received midwife-led continuity of care were less likely to have an epidural or forceps/ventouse assisted birth and were also less likely to experience preterm birth at < 37 weeks and fetal loss < 24 weeks gestation. The duration of labour was more likely to be longer for women receiving midwifery continuity of care and was more likely to culminate in a spontaneous vaginal birth. This review found, no difference between the women receiving midwifery continuity of care compared with medical led or shared care, for a number of other outcomes, including induction of labour; augmentation with synthetic oxytocin; caesarean section; intact perineum; perineal laceration requiring suturing; postpartum haemorrhage; initiation of breastfeeding or; admission of baby to NICU or SCBU.

The majority of included studies reported greater maternal satisfaction with midwifery continuity of care models compared with other models. The authors also reported a trend toward midwifery continuity of care being cheaper than medical-led care. The evidence for all the primary outcomes in this review was graded as high quality, indicating a high level of confidence in the validity of the findings.

2018 Maternity Consumer Survey

The joint online maternity consumer survey initiated by Women’s Health Action and circulated by MAMA Maternity, Maternity Services Consumer Council and La Leche League, corroborated the finding of the Cochrane review with regard to maternal satisfaction. 83.96% of all respondents were satisfied or very satisfied with the care they received. 84.92% of respondents received midwifery continuity of care. Hundreds of women volunteered comments praising the skills and thanking the dedication of their LMC midwives and expressing their gratitude for the availability of the current maternity model that provides access to midwifery continuity of care in AotearoaNZ.

What were the BEST (or most satisfying) things about your (or your partner’s) maternity care during pregnancy and after baby was born/the pregnancy ended?

“First baby born in Ireland so this pregnancy was a transformative experience. Being cared for by a LMC midwife – so much personal growth and felt so empowered that I had a homebirth.”

“Great having the same midwife the entire pregnancy who got to know us well and knew how we wanted to bring our baby into the world. Great service at local birth centre and great to have visits at home after birth.”

“Having a known LMC who was my care provider throughout pregnancy, birth and postnatal has been invaluable. Particularly that for 3:4 of my babies it has been the same midwife. This takes continuity of carer to the next level!” (2018)

“Having the same person throughout the whole experience to build a trusting relationship with. There are some wonderful midwives out there who make the whole experience so much better.”

“I had the best experience I could ever ask for with my midwife for both births (used the same midwife for both). Was always available to answer any calls or texts re concerns that I had during pregnancy and afterwards, no matter what time it was. She made sure I had good care in the hospital…With my second she was amazing, kept me calm through labour and had faith in me that I could do it naturally because my first was long, hard and a little traumatic. After birth for both kids she provided every information I needed. I was 100% satisfied with the care I received.”

“I love the special bond you develop with your midwives, it is empowering to know you have such support throughout the whole process, including breastfeeding.”

“The continuity of care from my amazing midwife, not only throughout this pregnancy, but the 3 before it too. It is the best thing to have someone there for you on your Journey who knows your history as well as you do. She provided the information to allow me to make all the decisions regarding my care and supported me every step of the way. I don’t know what I’d have done without her!”

“The midwifery care from the start of pregnancy to when bubs was 6 weeks old was great. I wouldn’t be the confident mum I am today without the midwives.”

“Continuity of care- the same midwife throughout pregnancy, birth and postnatal (in conjunction with her backup who we met a number of times). The ability to choose where we wanted to birth. Free care.”

Grateful

“Amazing outstanding professional midwife. Great continuity of care from midwife, so lucky to have such a great maternity system in NZ.”

“As an American living in New Zealand I feel very fortunate to have been able to access the continuity of care model. We must keep it here for the good of future New Zealanders.”

“I had my first and third baby in NZ, my second baby was born in Australia. New Zealand maternity care is absolutely amazing. Australian mothers would not believe how wonderful the midwife system is in NZ.”

“I love having options of where to birth in New Zealand 🙂 that we have one midwife follow us throughout our entire pregnancy. I love how the whole process is free 🙂 the stories I have heard about the care in Australia compared to here in New Zealand, make me so grateful for our system in new Zealand.”

“Loved having my midwife go through the whole journey with me, from near the beginning of my pregnancy until 6 weeks post birth. I also loved the fact that she was able to come in to hospital with me and continue with me there, even though I ended up having caesarian section.”

Continuity of Midwifery Care in Aotearoa New Zealand

Partnership in Action

In the foreword to this recently published NZCOM produced booklet, editors Lesley Dixon and Karen Guilliland state, “We hope this publication provides a comprehensive explanation of midwives globally as to how the New Zealand system of continuity of midwifery care works, for both the woman and the midwife.”

MSCC believes that the issues discussed in Chapter 2, The Midwifery Partnership Model: The foundation of continuity of care, are particularly relevant. In this chapter the principles of the midwifery partnership are defined.

• Equity – This section starts by stating that, “Having a baby is not a disease process. It is a life event…The role of the midwife is to facilitate an experience which optimises the outcome for the woman, her baby and family, and supports on-going confidence in parenting.”

• Reciprocity – “…the midwife and woman enjoy an equitable relationship, both mutually gain from the experience… A healthy functional partnership can bring joy and reward for both mother and midwife. An unhealthy partnership is also reciprocal and can be difficult for either party.”

• Informed Choice – “the concepts of informed decision making and informed consent …provide an important mechanism for empowerment for women and midwives.”

• Shared decision-making and responsibility – “The midwife is responsible for providing relevant up-to-date and research-informed evidence and for making this information accessible for each woman… Continuity of care is important for informed decision-making because it provides the necessary time for discussion, understanding and negotiation, as well as building confidence for both women and midwives about the decisions being made.”

Some women responding to the consumer survey reported that these principles are being undermined by both the midwifery shortage and the process available for meeting a midwife. These factors leave many women feeling that they have to register with the first midwife they meet. A number of women also commented that their midwives seemed overcommitted, leading to “rushed” appointments that provided too little time for true partnership to develop.

“… because so many midwives are booked out so early, choice is not really an option and you have to go with one quick or risk not finding one, even if you don’t quite gel with that midwife. With my first, I found out so late that I had a hospital midwife as lmc and I had no choice at all.”

“2015 when we had our son, it wasn’t a very good experience but we put it down to selecting a midwife we didn’t click with… now we are expecting again and can’t find a single midwife who will respond to emails and calls to arrange to meet due to the shortages” (2018)

“I felt our visits with midwife were very rushed including our postnatal care, and felt overlooked and not heard/listened to. I feel as women who know our bodies we need to be heard and listened to. This is especially important for the safety of our babies and our own mental health, prenatal and postnatal which have lasting effects.” (2018)

“It would have been better had I had a choice in my midwife, because of the area I was stuck with who I got.”

“There was a real lack of midwives available to me when I had to unexpectedly change because of changing cities so that added a lot of stress calling/checking availability and I thought I was going to have to birth without a midwife.” (Christchurch 2017)

“Didn’t meet midwife during first and second trimester, only got to see her frequently enough during third and at that stage was too late to change…it was a good experience in that the midwife came to my house after baby was born. Other than that, I can’t really think of much that was satisfying about my midwife. To be honest, I didn’t have much of a relationship with her, didn’t feel she was approachable or feel as though I could confide in her…”

“I love the system NZ has. It’s a shame you have to phone a midwife the second you take the pregnancy test to get the midwife you want or end up in an uncomfortable situation with another you don’t click with. You think you can change but you can’t as they are all full.”

Inspite of the constraints imposed by midwife shortages and a payment schedule that neither matches nor adequately remunerates midwives for the services they provide, many midwives continue to provide care that fully meets the partnership principles and leads to a high level of satisfaction and gratitude from women and their whanau.

“Friendly midwife who I got to choose and who was on board with how we wanted the pregnancy and birth to go. The whole experience was laid back and intuitive. Support after the birth was again excellent and laid back. I felt reassured in my decisions as a mother and my baby’s development. She asked the right questions in the right way to gain a picture of how we were doing. Never pushy or dismissive. I think the care we receive from midwives in this country is fantastic.” (2018)

“I received excellent care from an excellent midwife who made me feel very comfortable safe and respected. Having the option to choose a midwife who has the same opinions about pregnancy and birth as I do was very important and special to me. Having the option to birth at home was very special also. Aftercare was fantastic.” (2018)

“I was incredibly impressed with the midwives that helped us all through the pregnancy, birth, and post-birth. We were so well supported as a new family. Our midwives truly listened to us and our desires to have a home birth, they advocated for us every step of the way, and answered every question professionally and with great care. During the birth, they ensured I was safe but also completely let me do my own thing, allowing us to have the birth we’d hoped for. Afterwards, we had so much attention and care shown to us, ensuring our breastfeeding journey got off to a good start. I am worried that we won’t be able to access the excellent level of care with had this time, if we have more children, given that so many midwives are leaving the profession due to poor remuneration and conditions….”

“Midwife was an amazing support before during and after. She was always available and made the transition into parenthood a bit easier! During pregnancy she was always very open and honest. She didn’t sugar coat potential issues and discussed options which suited me well. During labour with both our kids, she always offered options and only gave her opinion when asked. She didn’t push her view but spoke up when it was time to change things up. With second birth we even had a laugh mid contraction!! After bubs were born she was always available any time if I needed her. Nothing was ever too much…”

“My midwife formed a very close genuine relationship with me and my family. She was always available and confident and experienced. She answered all my questions and put all my fears to rest leading to an incredibly empowered birth and very happy postnatal period. Her continuity of care, experience and caring nature were fundamental to our family’s very positive birth experience and positive postnatal period.” (2018)

“My midwife was amazing and visited me throughout pregnancy, stayed through the birth and came to see us for the 6+ weeks after birth without fail. I realise that I am in the minority with the quality care that I received, mainly because of how overstretched and overworked most midwives are. My self-employed midwife only takes a certain amount of clients so that she is able to provide quality care and fortunately doesn’t have to rely on her wages alone to cover her living costs…If only all mothers could have experiences like mine with their midwives!” (2017)

“My midwife was amazing. The care before birth was brilliant. During my labour she was amazing and her aftercare was fantastic. I was very sad when our 6 weeks were up. The experience I had with my midwife makes me happy, excited and looking forward to when I have another baby.” (2018)

The culture of birth in the 21^st century

The partnership principles are frequently undermined by what is the third party in the midwife:woman relationship, i.e. the culture of birth in the 21^st century. Maternity intervention statistics show that access to, and acceptance of, interventions throughout the maternity experience, by both women and their caregivers, while minimising the risk of death for baby or mother, has undermined confidence in pregnancy and childbirth – normal physiological processes that have ensured the survival of our species. Pregnancy has become peppered with tests to “confirm” that the mother’s body is coping, that her pregnancy is progressing normally and that she is growing a genetically perfect baby, who is exactly the right size etc. This culture of dependence on the use of technology to test, monitor and measure, has eroded women’s confidence in their inherent (NB in-her–ent) ability to grow, birth and nurture their babies.

The culture of birth in the 21^st century does not trust women or their bodies. It alienates women from their own physiology and their intuitive connection with their growing babies, making them anxious, fearful and dependent on their care providers and the perceived ability of medical technology and procedures to manage and control the process. Although women are legally able to make informed choices about their maternity care, the options they are offered generally come from the beliefs and values of the medical model. A model based on reductionist, empirical science that separates the wellbeing of mothers and babies, promotes control and has focused maternity care on the single outcome of, delivery of a live baby and a live mother. The normalization of interventions into the maternity experience shapes most women’s choices; technology quantifies the risks and tells women (and their care providers) what the “right” choices are; what to eat, how to sleep, where to birth, when to birth, how to birth etc etc. Women “choose” intervention because they are afraid and our maternity culture has persuaded them that intervention can control what it presents as, the unpredictable, risk laden and painful process of reproduction, by monitoring, medicating and assisting with instruments and surgery. Fear sees the majority of women choosing to birth in a hospital, “just in case”; an increasing number of women, choosing induction of labour, apparently believing that their bodies can’t be trusted to initiate the onset of labour at the optimum time and; more women choosing to avoid labour altogether by opting for elective c-section. Women have surrendered their maternal instincts and power and sacrificed their bodily integrity, (and often their emotional and psychological wellbeing as well), to the medical model of interventionist childbirth.

There are women and midwives who instinctively understand that pregnancy, birth and mothering are the fundamental wholistic experiences in life; that mother and fetus are one enitity, what is good for the mother is good for her baby, that a woman’s body knows how to grow, birth and nurture her baby. There are midwives who know that encouraging, empowering and supporting women to trust their bodies and their instincts will produce the best outcomes for mother and baby. Many women reported that it was continuity of midwifery care based on the principles of partnership that empowered and enabled mother and midwife to challenge both, proponents of the medical model of childbirth and the use of unnecessary medical intervention.

BEST “Midwifery support of my choice to homebirth after a previous c-section. Recommended back-up consult at the hospital could have involved more shared decision making and less bullying.”

“Having obstetricians who work more collaboratively would have improved my experience. They were very pushy and keen to speed up my induction instead of letting my body work its magic. I opted for the least invasive induction process first (foley catheter) and it worked. Obstetricians definitely have room for improvement around respecting the birthing person’s autonomy. The conflict between the medical model and the midwifery model was frustrating.”(Christchurch 2017)

“Hospital doctors and midwives should respect a woman’s right to make choices and not be disrespectful and hold them to ransom that you have to do everything their way if you want any help from them. I still feel so angry and upset at my treatment and things I felt forced into and it was over 2 years ago. Hospital staff breached so many of the Code of Rights and think they have the right to.” (Auckland 2016)

“I changed midwives at 39 weeks (baby born at 39+3). I had been basically scared into thinking that my baby would get stuck because it was 97th centile. I changed midwives, such a breath of fresh air, encouraging that I could birth my baby (was #3) naturally. Baby was only 8lb 7oz. Midwives need to encourage and empower women. My aftercare has been great.” (Birthed in PBU 2018)

“I had a fantastic midwife who thankfully knew my history with large babies and got me a referral to ob with my current newborn as she was measuring quite large. I had to really push my case for induction to reduce the risk of tearing. They finally let me be induced on my due date. Baby was born measuring 10lb 14oz and my midwife did a wonderful job of delivering and I only ended up with small 2 degree tear. After 4 babies it would be great if ob’s had a little more understanding/faith that I know my pregnancies and my body and believe you, I felt i really had to push to be induced which Is wrong for my own health etc. Thank God for a great midwife.” (2018)

“I loved the continuity of care from beginning of pregnancy to postnatal care. Having a midwife who listened to my needs and was very supportive of my wanting minimal intervention even including monitoring and didn’t make me feel pressured into making choices for care I didn’t want.”

“I wanted a VBA2C and I got it. Ended up having my back up midwife for labour, who I hadn’t met. She knew what I wanted and did everything to help me reach my goal without compromising our health.”

“I was devastated when my midwife told me that I had to go straight to hospital when my waters broke and there was meconium through them – my dream was a home birth and hospital was my absolute last resort…The only reason I held it together before and after labour was because of my fabulous Midwife…she knew me so well and did everything she could to give me the closest we could get to the experience she knew I so wanted. We still miss her 4 months on!!!

“I would like the medical fraternity to be more supportive of women’s choices, (including moving away from offering caesareans when unnecessary). I was 3 weeks over ESTIMATE (not overdue) and would have liked more support in my decision to wait (based on the good health of my unborn child) rather than pressure to induce (NOT from my midwife – from other supporting services in the medical sector).”

“LMC Midwife, amazing advocate, and provided great care and support. Obstetrician – saw him twice but he took into account what the midwife had to say and my wishes as well. Gestational diabetes nurse – awful she told me my baby would die if I didn’t go on insulin, I was only 0.1 over the blood sugar level that classed me as having gestational diabetes so I felt that insulin would do more harm. I managed with diet and oral meds and delivered a healthy baby with no blood sugar issues. If I had of gone on insulin, I would have been induced and she would of had to go into the NICU. Listen to the parents more and respect their choices.” (2017)

“Midwife and her other midwives she worked with were all amazing. They kept me well informed, made me feel supported and in control throughout my pregnancy, labour and until I was discharged. I had a few appointments with an obstetrician due to having factor v Leiden. He was very pushy about wanting to induce me early for a supposedly large baby (3440g at birth-40+2). My midwife was really supportive and helped me push back in a way that felt really empowering but still respectful. It was a tricky situation and she guided me through it well.” (2017)

“Midwifery care was exceptional. The emotional support to navigate difficult decisions when facing essential interventions due to pre-eclampsia was appreciated. From planning a home birth to requiring an induction was quite sad for me. In the end because I was able to negotiate every step of the way and my birth was a positive experience.” (2017)

“Midwives need more support and not to be ignored by some hospital staff. My midwife and I had 8 months to build a relationship and to have my opinion ignored and then her ignored when she tried to back me up was horrible.”(2018)

“My choice not to induce was respected and supported by my midwife and had my baby at home 42+3.”

“My midwife saw birth as a physiological process not a medical condition. This made a world of difference in my confidence in her caring for us. I needed to feel safe knowing I wouldn’t be pushed into anything I didn’t want while I was so vulnerable. This was the opposite to my first midwife (over 10 years ago) who encouraged medical interventions/pain relief over natural alternatives such as position changes or water. My midwife supported my decision to give birth at home and the last minute change to hospital when I went into labour while moving house. Everything about the care from my midwife was exemplary!”(2018)

“My midwife was ultimately the reason my situation didn’t end I suicide. She fought against the system with me where I was being pressured into induction and unnecessary intervention. She’s one of the good ones and should seriously have a medal. My midwife protected me against the pressures of intervention.”

“My mw trusted my own feelings and fully supported all of my decisions while also keeping me informed. I trusted her guidance and felt that both my baby and I were safe and cared for at all times. We discussed pros and cons of natural birth vs early induction vs cesarean due to previous shoulder dystocia. After also talking to the obgyn we decided natural birth. My mw made sure everyone at the hospital was prepared for possible shoulder dystocia…”

“Our LMC was confident in supporting our family’s health philosophy which is lifestyle based and not screening tests and pharmaceutical drugs. Having the option of homebirth and choice of antenatal care, which test we wanted to use and which not was amazing and empowering. It set us up for a parenting journey where we take responsibility for our health and wellbeing!”

“The attitude of obstetricians and hospital midwives – in general, I felt that even asserting a low level of informed choice was dismissed and I was made to feel like a problem.” (Dunedin 2016)

“The best thing was the autonomy facilitated by the midwifery care, unlike at Christchurch Women’s where I experienced an inability of other health professionals to see birth as normal until proven otherwise” (2017)

“The doctors in the hospital need to realise that birth is not a medical thing. The doctor at the hospital made me feel like I had to be induced, which I didn’t, and she made me feel bad for refusing.” (North Shore 2016)

“Very angry about the hospital care and outdated policies. My baby was breech. I planned a home birth but ended up having to go to hospital for lack of breech birth experience with midwives. The hospital doctors were not open minded. They continued to quote the term breech trial which is outdated and known to be bullshit. They struggled to support my want for a vaginal breech birth. (North Shore 2017)

Does continuity of midwifery care reduce intervention rates?

The answer is that it can. If more midwives and and women: forge a true partnership that respects and supports women’s innate ability to grow, birth and nurture their babies; reject the disempowering, fear-based medical maternity model that tells women from the beginning of pregnancy (sometimes pre-pregnancy) that their bodies are potentially defective and puts more trust in external information provided by tests and monitoring than in women’s instinctive knowledge; and reclaim primary birthing options as the safest and most appropriate place of birth for most mothers and babies

Book Review

Joyous Childbirth Changes the World by Dr Tadashi Yoshimura.

Published April 8th 2014 by Seven Stories Press Copyright 2008 Tadashi Yoshimura

Dr. Tadashi Yoshimura is a Japanese obstetrician and natural birth advocate. He became an “accidental” obstetrician over 50 years ago when, aged 28, he inherited the Yoshimura Maternity clinic from his ailing father. During his first twelve years of practice, the clinic practice was based on the medical model, but as happens, a number of mother:baby pairs defied convention and birthed naturally, allowing him to witness some spontaneous births. “Through these experiences, I gradually came to believe that the fewer the medical interventions the better the childbirth… I began to seek ways to make a transition from medical childbirth to natural childbirth.”

Yoshimura was in his 70s when he wrote this book. Many women will be exasperated, by its naively paternalistic tone and old-fashioned ideas about women’s place in society. However, as, Ina May Gaskin says in her forward, “A true scientist is one who, on observing behavior and phenomena that do not conform to the received wisdom of his profession, is open-minded and brave enough to adapt his thought and practice to the deeper reality that he has perceived. Dr Yoshimura is such a scientist and as a result of his observations, he has created both a physical clinic and, a culture of practice that supports the innate ability of women to give birth.

Yoshimura’s observations led him to believe that almost all problems encountered during labour and birth are due either to doctors intervening unnecessarily or because pregnant women are “vegging out, pigging out and freaking out” during their pregnancies. In his opinion all pregnant women need is to remain physically active, eat ‘natural’ foods and stay calm to achieve natural birth and the essential mother:baby bond. He believes that modern techno-industrial lifestyles have robbed women of vitality and have become fearful and less confident in both their need and their ability to, birth physiologically.

Dr. Yoshimura has virtually stopped using any interventions or placing any time restrictions on women’s labours. There are no inductions for postdates or prolonged latent stage (walking and chopping wood are prescribed) or prelabour rupture of membranes (“Obstetric textbooks also say that rupture of the membranes (is) a situation which demands the doctor give the mother antibiotics to prevent infections. In my early days, I would often use antibiotics…I reduced the usage of antibiotics little by little and at last I stopped it completely and we have not seen any infection since then. Textbooks are full of lies!”); no time limits on the total duration of labour (“Once we had a case that took ten days from the first contraction to eventual delivery.”); no augmentation (“Even when the contractions are not progressing, we don’t use drugs to augment them. We continue to observe the condition of the fetus and the mother, and if both are normal, we wait until the natural birthing process continues.”); no time limits on the second stage (“I know that obstetric textbooks define the failure of delivery within two hours of the cervix being fully dilated as “abnormal labor”…who decided this time limit?”) Women who have been told they need interventions because of risk factors like, breech babies (including footling breech), advanced maternal age, babies diagnosed with congenital anomalies, women wanting a VBAC, women with a history of premature labour are all supported to birth naturally. Yoshimura does not share many statistics from his practice but states that the clinic c-section rate is 3.4%, forceps assisted birth-0% and ventouse assisted birth 0.5%.

Yoshimura has observed that natural childbirth is transformational; it prepares mother and baby for the next stage of their lives, it is joyous and has the potential to change the world. He believes that a lifestyle and philosophy that supports natural conception, pregnancy, labour, birth, breastfeeding etc, has the potential to “save” humanity from the current epidemic of anxiety and depression, and the need for money, power and possessions that has enslaved us and is causing environmental devastation.

This book is a quick read but would have benefited from some editing to delete repetitions. It contains many gems of wisdom that inspire confidence in the birth rights of mothers and babies and the power of birth to transform the way we live. Some readers will take exception at some of Yoshimura’s ideas about how women (and men) should live, but his oft-professed love for women and his belief that, “Natural childbirth is not merely an alternative to medically controlled delivery…It is an inherent right that all women deserve to enjoy.” shines through.