Coming Under The Knife

I have moved house and had no Internet for a while, also having the usual issues with authorities and this has put me off posting for a while. Also 13 births since new year has kept me on my toes.

There has been a whole lot of something and nothing happening in the progress of the legislation.

There is a school of thought that the government just wont do this to us. We keep concentrating on just one area at a time, things look up for a while then we realise that they have smoke screens that keep us from the real drama.

Recently it’s been about a written collaborative agreement. Around the country there have been meetings to discuss the national frame work and insurance for private midwives. It is in Adelaide at the beginning of March. a Few independent midwives were asked, others requested to go and were told NO. How can this be?

In Adelaide the talks are split up. Clinical managers from the big hospitals, clinical networks group, consumers, midwives and Obs.

I wrote to the health department expressing my concern that there should be an Independent midwife (as the discussion is about us) in every meeting. I was told “No Way.” Why would the 3 head of Obstetrics have any input into independent midwives framework? I was told they were major stake holders. In what? I would love the health department to have the courage to ring me and explain exactly what is going to happen. I know they read this. Could you imagine a framework for Doctors where the midwives have a direct input as major stake holders?

Consumers at the frame work meeting in Victoria were told that there would be no breech, no vbac and no twins at home. We can also assume they mean, no previous pph, no grandmultips, no blue eyes, nobody too fat or too thin. Mmm, starting to sound like every other government homebirth policy.

While we are all busy concentrating on this, there is small print on the quality and safety framework saying that we have to be eligible for medicare. So even if they take a signed collaborative agreement out of the quality and safety frame work we have to be eligible midwives first. Sneaky!!!

Meanwhile, out of the main public glare is the latest report of surgical deaths from Victoria. This has been handled in a very interesting manner. The report audited 718 deaths and decided that only 5, ( 0.6%) were a problem. Due do confidentiality these can’t be discussed described or talked about and of course the AMA have assured us that this is such a tiny number that we needn’t worry about it.

Why is it that VBAC rupture rate is 0.4% and the AMA say the risk is massive, but you have a greater chance of dying in surgery but it’s dismissed as nothing?

How is it that homebirth is hung drawn and quartered and midwives vilified by their own board at the beck and call of the medical fraternity but the same medical fraternity hide and collude to protect any quack practitioner with an MD?

19 responses to “Coming Under The Knife”

  1. shortfriction

    Could I point out that 0.6% is the percentage of surgical deaths that were considered to be contributed to by the surgeon's care. It tells you nothing about the chance of dying in surgery. In another way of looking at it you could say, "If you die in surgery, in 0.6% of cases you could blame the surgeon." Which is not the same as saying "Surgeons cause the death of 0.6% of their patients." Unless 100% of surgeries ended in death, based on these figures the risk of your surgeon causing your death is something less than 0.6%. Probably quite a lot less.

    That doesn't mean I agree with legislating against homebirth. But I think there is maybe less of a conspiracy against independent midwifes than you might feel. As an allied health professional with National Registration also on my horizon, I'm at least vaguely familiar with what you are going through. Keep up your campaigning and I reckon the outcome may be more favourable than you dare to hope.

  2. WiseWoman

    Physician’s groups like to paint a picture for the government that somehow they know what they are doing in the field of obstetrics. The statistics speak for themselves. When the cesarean rate is 30 per cent, it mean the obstetric model is broken.

    Every doctor in Australia should have to have the approval of a midwife before they are allowed to be involved with the birth of a baby, not the other way around.

    Just as a dentist can give dental care to a pregnant woman on her/his own professional merits, so can a midwife give care in her own professional capacity. If a dentist needs to involve a physician in the care of a patient, she/he can do so easily—just pick up the phone and call a cab.

    The government of Australia needs to allocate an amount of money per birth and give each adult pregnant women the birth coverage of her choice—including her right to birth her baby all by herself and keep the money. Ultimately, the state has no place in the bedrooms of the nation. Making complicated laws that can’t be enforced has never served the public.
    Gloria Lemay, Vancouver BC Canada

  3. Lisa Barrett

    Shortfriction I didn't actually say that surgeons cause 0.6% of their patients to die, intentionally.

    There is no doubt the AMA would love to get rid of IM's along with many other health practitioners that don't fit the medical model.

    I was comparing the stats to show that wording is everything with the same set of results.

    Just like saying 0.4% of VBAC will have a ruptured uterus tells you nothing about your chance of actually having one.

    I hope you are right about the favourable outcome. Fingers crossed.

  4. Anonymous

    Is anyone checking to see how many complaints the OBs who are involved in the committees/legislation have against them????

  5. Anonymous

    Unverified account of AMA president speaking to first year med. students recently at Canberra's ANU, citing the recent AMA homebirth study *proving* that homebirth is far more dangerous for babies.

    How will midwives be able to find OB backup in years to come if med. students are being brainwashed with a misleading study from the get-go?

  6. Rebecca

    Tsk Tsk Lisa – Have you forgotten your place?? Dr are Gods, don't ya know, therefore how dare we pathetic mortals even DARE to question their supreme powers?? They Know All! We are here only to serve and lick their Almighty Feet!

  7. Andrew Pesce

    In reply to anonymous,
    I recently addressed the 1st year intake of medical students at ANU. During my address, I made no mention what soever of home birth, midwives, or in fact maternity services. It was a general address on medicine as a vocation, and the responsibilities of medical students to uphold the highest professional standards.
    After the address, an individual student approached me, and asked about the recently published home birth study which he had heard some midwives condemn as unscientific. I privately informed him I believed the study was scientifically valid, and demonstrated a significantly increased risk of intrpartum perinatal nortality in otherwise healthy full term babies in planned home birth compared to hospital birth. I enquired whether or not the student had a background in statistical methods, and he said he did. I invited him to read the MJA study, and the accompanying editorial, and come to his own conclusions.
    I hope this addresses the concerns of anonymous
    Andrew Pesce

  8. Lisa Barrett

    Dear Andrew, I don't think the study is unscientific as it is just a retrospective look at birth in SA. However some of the commentary is misleading, the figures inside the study definitely speak for themselves.

    I am interested to see that of all the information on this blog you would chose to comment on an unsubstantiated report from anonymous.

  9. Kat Williams

    Dr Pesce, How interesting that you would comment on Lisa's blog. The SA homebirth study showed the total perinatal mortality rate was higher in planned hospital births – what were these babies dying from? I find it appalling that you defamed homebirth when the study actually proved it is a safe option. You can continue with your dirty tactics but homebirth will continue – my body births well without you and your colleagues having any part in it.

  10. Di

    Welcome to the discussion Andrew. im sure many of Lisa's readers will be keen to have a lively discussion with you!
    The report (hardly a 'study'!) is clearly lacking in power and thus the sensationalist conclusions are seriously skewed. Im no statistician, but i can clearly see that these claims are a long stretch of the truth!

  11. Tiff

    Mr Pesce,

    I hope that you then directed the student to the Hutton et al. retrospective cohort study (2009) and de Jonge et al. 2009 study published in BJOG.

    Surely 529 688 births are statistically significant sample size to show that homebirth is indeed a safe option.

    The evidence supports homebirth.

    But after all its not REALLY about safety is it Mr Pesce… its about eliminating the competition in the private birthing market.

  12. Anonymous

    The scientific validity of the study and the arguments for and against are well covered in Melissa Sweet's Crokey debate
    I don't expect to be able to add to that debate
    I thought however I should correct an erroneos comment by anonymous

    Andrew Pesce

  13. Lisa Barrett

    Thanks for the link. It is always hard to add to your own debate in any way. I agree that erroneos comments can be damaging and irritating.

    By way of an invitation I would love you to get in touch and attend a birth at home as an observer, I have many lovely clients who would consider it an important event. Even Marsden Wagner didn't understand until he had embraced the experience. At least then you would be able to comment from a position of knowledge instead of a position of power and prejudice.

  14. shortfriction

    Sorry Lisa, I think you still don't quite understand the difference in statistics. A VBAC rupture rate of 0.4% means that a woman having a vaginal birth after cesarean has a roughly 0.4% chance of rupture. The 0.6% you cite for surgery, though, is not the percentage of all surgeries that end in death. Let's say 1 in 100 people die in surgery, and 0.6% of those deaths were because of an error made by the surgeon. that makes 6 in 1,000 of the 1 in 100, which is 6 in 100,000 deaths that are because of errors by the surgeon. That's 0.006% compared to the 0.4% rupture rate for VBAC. Of course, I just pulled 1 in 100 out of the air. It all depends on what percentage of people die in surgery.

  15. Lisa Barrett

    Thank you shortification I certainly do understand the difference in statistics.

    COLIN RUSSELL: Out of the 718 audited cases there were 33 that were classified as adverse events. Now of these only five of these was it felt that what the, what had occurred may have contributed to the likelihood of death. So that's in fact 0.6 per cent.

    Here is a quote from Colin Russell which is in the article linked.
    Maybe he should have said 0.0006% if that is what he meant. Would have sounded so much better.

    Maybe you have misunderstood what was being said.

  16. Anonymous

    Dr. Amy at SOB slams the AMA's homebirth study!

    Can this get any zanier Mr. Pesce?

    Andrew Pesce, president of the Australian Medical Association, has emphasized that his opposition to homebirth is based on the scientific evidence.

    The paper, Planned home and hospital births in South Australia, 1991–2006: differences in outcomes by Kennare et al., was published this week and if Dr. Pesce is hanging his case against homebirth on this paper, he better head back to the drawing board. The paper does not show that homebirth increases the risk of neonatal death. In fact, the paper is so poorly done that it doesn't show much of anything.

    The groups should be created by "intention to treat." In other words, it does not matter where the patient ultimately delivered. The most important criterion is where the patient intended to deliver at the start of labor.

    Right away there is a problem. The groups were not defined by intention to treat at the start of labor, but rather by intention to treat at the start of prenatal care. So any woman who developed complications during pregnancy and was appropriately transferred to hospital care long before labor began was included in the homebirth group.

    Moreover, instead of comparing the homebirth group to comparable risk women who gave birth in the hospital, the authors compared the homebirth group to all women who gave birth in the hospital including premature births, and those with serious complications.

    What did they find?

    The rate of neonatal death in the homebirth group was 7.9 per 1000 births, compared with 8.2 per 1000 births for planned hospital births. In other words, there was NO difference between the planned homebirth group and the planned hospital group. Oops! That wasn't what the authors were hoping to find.

    So the authors take a different tack:
    One third of deaths (3 of 9) among planned home births were due to intrapartum asphyxia compared with 3.6% among planned hospital births. Both intrapartum deaths and deaths attributed to intrapartum asphyxia were considerably more frequent in the home birth group than in the hospital birth group.

    And proudly conclude:

    In our study of births and perinatal deaths in SA during the period 1991–2006, planned home births had a perinatal mortality rate similar to that of planned hospital births, but had a sevenfold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia.

    To which I say: So what? Dead is dead. It it hardly a ringing endorsement of hospital birth to claim that all the dead babies died AFTER birth instead of during birth.

    So the study does not show that homebirth increases the risk of neonatal death. What does it show? In my judgment, it doesn't show anything because it is poorly done. The authors should go back and reanalyze their data. First they should create the groups by intention to treat at the start of labor. Second, they should remove high risk women from the hospital group. Only then is there a chance of obtaining valid, useful results.

    If the intention of the authors was to bolster the case against homebirth, it has certainly back fired. Instead, they've given Australian homebirth advocates a gift. Homebirth advocates be able to point to this study as showing that homebirth doesn't increase the risk of neonatal death. Perhaps more importantly, though, homebirth advocates will be able to point to this study as evidence that opponents of homebirth disingenuously sliced and diced the data to make hospital birth look good on at least one criterion. And that criterion, the fact that the homebirth babies died during labor instead of after labor, is absurd.

  17. Kayte

    Firstly I want to say I enjoy your blog very much Lisa. Telling the truth, the facts and working hard with women who want the only continuity of care available for women in Australia.

    Secondly, I have to say it pisses me off when all that is talked about amongst media, doctors ec is stats.
    It would seem the stats are kept as the main focus to draw away from what truly is the crux of all of this, Women being treated poorly and with no regard to what is truly best for them all as individuals.

    Women do not care about stats. They care about being treated with respect and as a human being who is informed and can make decisions that are best for her and her baby.

    Homebirth vs hospital will never stop, just like breast vs bottle.
    The only fact that is true is that there will always be those for and against wherever a mother wants to birth.

    Can we all get back to the mother and foocus on what she wants and needs.

    My neighbour wanted an Ob and a private Hospital. Great, have it.

    I wanted a Midwife and homebirth. Nup, too late, the only Independent Midwives near me were already booked solid.

    My neighbour had done no research into birth at all, not one book read. She just wanted what she felt was best for her.Fair enough, it's her choice.

    I researched, read books, studies, watched videos, talked to mums. Then decided what I felt was best for me. But still could not access that care.

    I should have the right to choose just like my neighbour.
    It is about us mothers, what is best for US.

    The fact that independent midwives are booked so quickly surely tells us all how much in demand they are!
    Women are the ones in power, we are the ones who get to say what we want. Not someone who will never see us, our babies or families affected by decisions that can strip us of our bodily right to choose where, with who and how we birth our children.

    No one has the best interests of a bay more than the mother.

  18. Stitch Sista

    I just have to say hear hear to Kayte.

    Yes homebirth is safe BUT EVEN IF IT WASNT it is still my choice whether or not to have one!

  19. Ries

    Go Kayte!
    Dear Andrew P. i am 42, have just had my 3rd child of six at home with my independant midwife, I had well managed gestational diabetes, a 15 year history of thyroid disease and a supposedly ancient, overused uterus. My husband and I have discussed it, and despite having finished at six children, would welcome the opportunity to concieive again with the EXPLICIT purpose of having you join us for a home birth that is perfectly safe, led by myself, and our independant midwife. wether it is legal or not, since it is such concern to you that I and my child are in safe hands, will you condsider attending as a friend? you can even hold the camera, play with the other babies or bake a cake with us. good food, good company and a surprise guest, what more could you want. say yes!
    Please state whatever you want about stats, but remember that a woman's birthing history has a lot to contribute, as does her attitude towards birth. the attitude of the birth attendant can adversly affect care and therefore outcome. it's not all about what's between my legs, but my brain and my heart. so enter into homebirth-land to see what we are REALLY all throwing away before it is gone… PLUUULEASE!