Love to Birth Maternity Services Review Submission

I am posting this submission to the Maternity Services Review on behalf of mummadoula, who is a doula, founder of the Coffs Coast Maternity Group, Bellingen Baby ( a pre and post natal support group) and homeopath. I humbly thank mummadoula for sharing her submission with us.

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Federal review into Maternity Services
Submission written by Mieke Elzer

Executive Summary

Introduction
Here is a little about me, my business and my motivation for wanting to contribute to this process of review.

Doula’s
Following a successful four year pilot program in Chicago for community doula, America has, this year funded community doula programs country wide. So what is a doula, what are the benefits and how can we implement community doulas in Australia.

The Indigenous Solution
A fresh perspective on the issue of ‘Closing the Gap’.

Other idea’s
From getting rid of soft drink dispensers in our public health waiting rooms to increasing the number of placements available to study the Bachelor of Direct Entry Midwifery. Implementing Case load midwifery to publicly funded homebirth. Even how a bath tub can mean the difference between a natural birth and unnecessary caesarean. I have loads of ideas!

Introduction

My name is Mieke. I live in Gleniffer which is a short drive from the inner coastal town of Bellingen on the Mid North Coast, traditional land of the Gumbaynggirri Nation. Me and my husband Emanuel, live with our four children aged 8, 5, 3 and 2. My eldest child was born after the traumatic suicide of her biological father. I know first hand the current maternity health system in this country. From the vibrant successes to the tragic failings. All of my births have been positive experiences with no medical intervention. Three of my children were born at home with the assistance of a lay midwife and one of my children was born in a city birthing centre (due to the exuberant cost of homebirth in our cities). I have always had a passion for life. This translated into my calling to do work in the area of healing and birth. I first completed a diploma of Homoeopathy before I went on to study to become a doula. In 2003 I founded the Coffs Coast Maternity Group which successfully campaigned for a midwifery led pregnancy care clinic at Coffs Harbour Health Campus. I also coordinate the much loved pre and post natal support group, Bellingen Baby (see appendix for more information). I own and operate a business, ‘Love to Birth’. The business provides; Doula packages, professional bellycasting, birthsong singing groups, preconception and postnatal advisory services and homoeopathic consultation. For more information please visit my website http://www.lovetobirth.com.au

The discussion paper outlines that “Australia is one of the safest countries in the world in which to give birth or be born”. Sadly, safety seems to be indicated solely by the decline in maternal and neonatal deaths. Furthermore these decreases are not shared by all Australians. “Most notably, risk factors and health outcomes for rural and Indigenous women and babies are considerably poorer”. The review goes on to say that the rates of intervention during birth in particular caesarian are outside world health organization recommended guidelines, breastfeeding rates are lagging with less than 1 in 5 women still breastfeeding past 6 months, antenatal and postnatal depression rates alarm with an estimated 40,000 women being affected annually and social and emotional responses to pregnancy and birth are a key challenge with women only having variable access to support services especially following miscarriage and stillbirth. Clearly Australia’s safety standards are not inclusive of the wider spectrum of social, emotional and spiritual health and wellbeing.

I am motivated to contribute to this process of creating a better maternity health system because I believe that the quality of a person’s birth directly impacts on the quality of their life. It is also a very pivotal experience for the mother and father and can influence the way in which they go on to parent. Providing the necessary support to mothers and family’s during this time has the potential to heal our past and pave a path to a future that is built on trust, respect and love. I believe that the repercussions of this shift will mean better health and wellbeing for individuals and society on a whole, which makes good economic sense!! I believe that I have some very constructive idea’s to enhance the Maternity Service System in this country and would love to be involved in any further consultation. And yes, I am a “late at night - typing mummy”, as my 5 year old son so eloquently put it. This submission was typed between the hours of 10pm and midnight while my children were safely tucked into sleep!

Doulas

"If a doula were a drug, it would be unethical not to use it." Suzanne Arms, from the film- Giving Birth: Challenges and Choices.

What is a doula?
A doula is someone who is educated in childbirth issues and experienced in labour support. A doula offers non medical support to parents during pregnancy, birth and in the post natal period. Doulas understand the spiritual nature of birth and are able to ‘hold the space’ without judgment. A doulas main role is to help ensure a positive birth experience.

What are the Benefits of ‘Doula Support’?
Doulas take the time to get to know you. Pre and post natal visits last between 1 and 2 hours and are done in the comfort of your own home. Doulas provide nonjudgmental support and a positive outlook on birth. According to research undertaken in the US, Klaus, Kennel and Klaus, authors of “Mothering the Mother” and "How a Doula Can Help You Have a Shorter, Easier and Healthier Birth", have identified these benefits of having a doula at your birth:
50% reduction in caesarean rate
25% shorter labour
60% reduction in epidural requests
40% reduction in oxytocin use
30% reduction in analgesia use
40% reduction in forceps delivery
Improved breastfeeding
Decreased incidence of postpartum depression
Greater maternal satisfaction
Better mother-infant interaction

Publicly funded doula programs in America
Following the success of the Chicago Doula Project (a four year pilot program run by Chicago Health Connection), the US Department of Health and Human Services/Health Resources and Services Administration (HRSA) has now awarded funding to six community based doula programs across the country (2008). Already the outcomes are having a positive effect on infant and maternal health as well as families and communities at large. For more information, have a look at these sites
http://www.raconline.org/funding/funding_details.php
http://www.chicagohealthconnection.org/chw/advo.htm
A film which was instrumental in the campaign for doula funding in the US can be viewed here: http://www.blackpublicmedia.org/catalog/prod/37

Doula Testimonial
The testimonial below is from mothers and fathers who have had doula support throughout their pregnancy, birth and postnatal period. These testimonials have been sourced from http://www.findadoula.com.au

The list is just a small snapshot to show that regardless of the type of birth, doulas ensure a positive birth experience, for mothers and fathers. Imagine if everyone’s birthing experiences were this positive. It is possible!

Today is Monday. It has been 9 days since A's glorious water birth at home and for that I am thankful because today is the day I was "supposed" to have a c/section. Because of the events leading up to her birth and her rapid entry into the world, it has taken me several days to reflect upon and understand the enormity of my achievement. I DID IT!! I had a successful VBAC...and I did it on my own with your incredible support and the support of my family. I trusted my body and my baby. I only have a limited knowledge of childbirth, but I do believe that a baby is affected by how he/she comes into the world even though it is only a fleeting moment when you look at a lifetime. A has a calmness about her and for the most part is very content. I would love to be able to say for certain that it has something to do with her birth. I still can't believe that I did it! I have such a wonderful story to tell A. Even now after having time to think about it, I am having trouble putting into words how much I appreciate your support and positive energy since becoming a part of my VBAC journey. After meeting you I immediately felt more relaxed and secure knowing that you would be there for me during one of my most powerful amazing and intimate life experiences. Claire, there is so much more that I want to say to express my gratitude but I just don't know how. You are a beautiful person and your support is priceless.
Having been through a very traumatic birth experience with my first child, deciding to utilise a Doula this time was immediately reassuring. I had never heard the term until we were considering the issue. I knew Mieke would support my partner during the birth but it was so much more than just that. The prenatal advice and reassurance gave both of us a plan and confidence. Her support to both of us during the labour was a blessing. As the father, knowing that one was not alone on this journey and that one’s partner had the continuum of both physical and emotional care, removed my fear of inadequacy and of even failure to cope. Postnatally, Mieke was able to provide us with

continuing reassurance and advice which was also invaluable. I strongly encourage everyone to consider having a Doula during the birth of their baby and completely endorse Mieke for this role.
My pregnancy was very traumatic. I experienced a situation of domestic violence in which I was hospitalized in the last trimester. I was at a loss to know how I was going to reconcile my family situation in order to give birth to this precious child. I saw both me and my husband as victims in this sad situation and desperately wanted for this experience to be a catalyst for change in our personal lives as well as our relationship. The decision to enlist the help of a trainee doula was probably one of the best decisions I have made in my life thus far. Firstly, being in a low socio-economic situation, having access to a doula free of charge was a blessing (I understand that Doula’s must undergo trainee births free of charge as part of their training). Secondly, our doula was so amazing. She did not look down on me or my husband. She brought great compassion, love and understanding to both of us which I think ultimately led to the rehabilitation of our relationship. Having somebody who believed in our capacity to fix these problems was the support that we needed. Her physical support during the labour was brilliant. And her support for my husband in the hospital setting was so essential. I honestly don’t know if he would have coped without her being there. This was in turn extremely helpful for me because it meant that he was able to support me when I needed it. Postnatally, she made sure that we had the necessary contacts to support services so that we could continue on this path to reconciliation.
When it came to the actual birth, Jen was an angel. She never left my side from when I first started experiencing contractions to Eli's arrival, more than 24 hours later. There were many times during the labour when I didn't think I could go on. Jen's gentle support and encouragement calmed and reassured me.
Belinda was great. Labour still hurt a lot and the intensity was really hard work, but Belinda presents a supportive and positive way to view it. She reminded us that it was all natural and normal, which was very reassuring. She helped us keep focused and positive. Just knowing that she was there and ready to assist made all the difference. Her suggestions for pain relief were wonderful and had so many ideas to ease the discomfort. We couldn’t have come up with them on our own. When things became complicated she helped us get the information we needed. We are very thankful that Belinda was there to support us through the most incredible experience of our lives.
The birth was just the beginning, as your post-birth support has also been fantastic. You are always available and willing to provide wonderful encouragement, information and suggestions on breastfeeding, sleep and settling, and teaching me to trust my instincts. When I think things are getting difficult, that gives me the strength to believe in myself as a mother.
If you're wondering if a Doula is right for you, from my experience with Vickie, the answer is that you would be crazy not to have one. The first time we met Vickie with her gorgeous smile we felt a huge weight lifted as all our fears and concerns just seemed to disappear. Vickie is a wonderful person with a very special gift, she taught me to trust my instincts and having a familiar face turn up on our big day made all the difference to me and my partner. I cannot recommend Vickie highly enough.
I was happy Anna was there to support my husband, to assure him it was normal when I was in distress and explain what the monitors were doing. (And the lollies to keep his energy up!) And my husband was happy Anna was there to support me.
I can genuinely say that having a dedicated trained and experienced doula should be a birth right of every woman giving birth... I cannot express enough how much difference your pre-natal and birthing assistance made in a host of positive ways and having you as my doula for my last birth was the ultimate... You have been so comforting and supportive, both during my pregnancy and at the birth of my baby, even calling to see how we're going since birth... You took the 'burden' of being my main nurturer from the father of the child, which was a great comfort and support to him...
I liked the way you presented information in an unbiased fashion with the intention of educating rather than trying to persuade me with any personal views. I felt I was able to make well informed choices about my pregnancy, labour and birth and felt very much supported, no matter what my decisions about care were... During labour you were very responsive to my needs and adapted to the situation with ease. You kept me focused and I felt safe knowing that you were there to look out for me and ensure that my wishes were respected... Thank you for supporting me on this incredible journey that is birth. I will always look back on Jack's arrival into this world with fond memories.

Why are doulas so effective?
The biggest deciding factor in whether or not a couple feel as though they have had a positive pregnancy, birth and post natal experience comes down to whether or not they feel a sense of control in their experience. Of course the ideal is, a complication free pregnancy, natural birth and a glowing mother and father whose baby sleeps and breastfeeds easily. For whatever reasons, this is not always the case. In the case of a highly intervened birth it is imperative that the couple feel as though they are in control and have choices. When they feel as though they are victims of the circumstance there is a high risk of postnatal distress as well as breastfeeding difficulties and other complications. This feeling of losing control can come in any birthing scenario, though. In my own doula practice I have seen a women experience this lack of control even after a seemingly perfect natural birth. The impetus was on the fact that the mother had felt pressured from her family and society to have a natural birth and to breastfeed when in her heart she really wanted to have an epidural (this women was a victim of sexual abuse, note that it is common for women who have experienced sexual abuse to have a lot of trouble with both birth and breastfeeding). Although I am an avid supporter of breastfeeding and natural birth, my role as her doula was to fully support this woman in her decision to bottle feed. Doulas help couples avoid unnecessary complications and where intervention is necessary; doulas ensure a positive birth experience by helping couples maintain a sense of control. Above all, doulas support women to make informed choices that are right for them. So how do doulas achieve this?

Doulas:
have a thorough understanding of the couple’s birth plan
have formed a relationship with the birthing couple
are non judgmental

are great listeners
have excellent communication skills
are available throughout the entire birth
are trained to provide effective drug free labour support
know what it means to ‘hold the space’
maintain positive relations with medical staff
are up to date with medical procedures and protocols
have long lists of community resources for referral

In conclusion…
I believe that public funding for doulas is essential because doulas meet a need that is not being met in any other sector. It is ideal to say that family members would be able to provide this need but we live in a world where close family members often live great distances away and when they do live close enough to support the birth, they are likely to be too emotionally connected to the family to provide objective support anyway. Objective, non-judgmental support is crucial to the success of a doula. Also, it would be ideal to say that Obstetrician’s and Midwives would be able to provide this kind of personal, non judgmental approach but by nature of the public health system this is neither viable nor realistic. Midwives and Obstetricians provide a medicalised knowledge of birth. They are the reason that our maternal and neonatal mortality rates are so low. It is simply not within their scope of care to get to know each patient. Also, knowledge of the patients ‘dream birth’ may compromise their medical decisions.

A doula provides the necessary mediation between the parent’s ideal and the medical ideal for safe outcomes.

I am a member of the Australian Doula College. For more information regarding doula training and ethical guidelines visit http://www.australiandoulacollege.com.au


The Indigenous Solution

I am not going to go into detail about the gap between indigenous and non indigenous health. It exists, it is unacceptable and it must change. The causes of the problem are complex and so the changes to be made are many. Rather than directly talking about these changes I am going to address the issue from another angle. I am going to talk about the issue in relation to non indigenous people and women in particular. It is hoped that through this shift in perception you will understand that it is more productive to talk about the indigenous solution rather than the indigenous problem.

This is an issue that is close to my heart. Growing up in Australia I have always sensed that something is missing. As a child it was as though I had a connection with something but was unable to touch it, talk to it, and know it. It was only when I walked the path to motherhood that I became aware of what it was. During pregnancy I felt a profound lack of spiritual support from my mother, aunties and sisters. This was in stark contrast to my inner knowing. My parents had instilled in me a love for nature. I felt instinctively that birth was natural and that the spirit of this land held many secrets that would help me on my way. It was then that I began looking for answers. I bean to research koori culture. I was amazed and frustrated with the lack of information that I could find. It is as though there is a void. What I did find though was information with relation to the atrocities that had been committed towards Aboriginal, Men, Women and Children in this country. I felt angry but also sad because it was this history of genocide that had cheated me out of my birth right. That is the right as a woman born and raised in this country to have access to all of the spiritual and cultural wisdom of this country. I am a non indigenous Australian woman and I want reconciliation now so that there is a chance that my daughters will be able to access the rich diversity of Koori culture that I have been denied.

I do believe that Koori culture is the most valuable asset on this planet (infinitely more than our center’s mining industry!). Today’s aboriginal people are decedents from the oldest known civilization on this planet. A civilization that has survived 60,000 years. If we plan to sustain our existence then we are going to need their help. Enriching spiritual wisdom, valuable knowledge of country as well as understanding of complex social and family structural dynamics are some of the mysteries contained in our Aboriginal People. I think it is this new found respect for the solutions that indigenous people offer that will ultimately ‘close the gap’. Without this shift in perception, I predict that no amount of policy changes or positive health initiatives will have a lasting impact on the problems faced by Indigenous Australia.


Other Ideas

There are so many little things that we could do to improve our Maternity Health System. To show you an example, I will start with an anecdote. This is from my own experience.

I am at my local hospital taking my eight year old daughter for a check up at the public dentist. I notice in the dental surgery, there is a poster on the wall, outlining how soft drinks are bad for your teeth. After the dentist we wander up the hall to say hello to the midwives at the pregnancy care clinic and after traveling less than a minute along a beautifully decorated corridor. We are confronted by a big soft drink, chips and chocolate dispensing machine sitting in the waiting area. Sadly, there is a pregnant woman eating a packet of chips while she is waiting to be seen by a midwife.

Now, I am not making a judgment on this woman as I have myself infrequently eaten packet’s of chips (though I do find the multitude of ingredients that I can’t even pronounce and the wasteful packaging and mass produced mentality – quite puts me off my food actually). No, the judgment here is that our health care system should be setting an example of good health. The question I ask myself in these situations is “would this be happening if it was not for the financial incentive?” The answer is, “absolutely not”. Sure, there is perhaps a need to offer food and drink in a waiting room but a basket of locally grown banana’s and kiwi’s (of which Coffs Harbour has an abundance) and a ceramic urn of water would be suffice don’t you think? You know what, you could even employ someone locally to provide this service and not only would our pregnant mother’s and their babes benefit but we would also feel good knowing that our money was being invested into the future of our planet and our community. Is anyone honestly prepared to argue that a diet of soft drink, chips and chocolate is going to improve outcomes for babies and mothers? If so, please, pretty please, let me know. I want to be there. Let us televise this debate… I am prepared!! This brings me to my first idea.

Good Nutrition

Apparently Australia is struggling with its waist line. According to latest studies, Australians are among the most obese on the planet. I believe that nutrition is central to both cause and effect. Lack of good nutrition obviously leads to obesity and poor health ultimately leads to poor food choices. We need to break this cycle of poor nutrition. Ideally, pre conception but pregnancy will do, postnatally, certainly but we absolutely must get our nutritional guidelines right, before the babe starts on solids. Again, I think a community approach to this issue would be much more cost and user effective than a whole bunch of hand outs available through the hospital or baby health clinic or pre school. We need hands on approaches. Cooking classes for young men and women, preconception advisory services as well as cooking workshops for new parents and parents of school kids. It is not complicated or expensive to pack a lunch that is nutritious, delicious, locally produced and with no packaging, people just need to be shown how. And while we are there, schools need to implement no junk, no packaging policies. I trust you are aware of how many rubbish bins are filled each food break at an average sized school. Too many for me to think about right now.

On the topic of nutrition, my mind ponders as to what percentage of Post Natal Distress could be avoided with adequate nutrition in the post partum period. Where I live in Bellingen, we welcome our new mothers with a meal roster. The roster usually lasts around 2 weeks. And in that time the new family receive a lovingly prepared meal every night from one of their friends or extended family. As well as being less stress for mum and dad, the meals are bursting with nutrition and nourishment, love and support.

Community Initiatives and Complimentary Models of Care
I think that we need to be concentrating on Community Initiatives and Complimentary Models of Care. Our current public health system is under extreme strain and I think that this is something that is going to get worse not better if something is not done to reduce the numbers of people reliant on public health services. I propose funding for community initiatives such as the above mentioned meal roster plan, cooking and nutrition classes. As well as funding for Complimentary Models of Care. For example, Acupuncture, Homoeopathy, Naturopathy, Massage, Osteopathy and Counseling services are all well equipped to deal with health issues in pregnancy and post partum. Importantly, we need to remember that each community is different so initiatives and models of care need to be designed by the community. I truly believe that this local approach to problems is more effective than national approaches. National approaches are riddled with waste on the one side and inefficiencies on the other. Local approaches target community needs efficiently and effectively.

Water Birth Facilities
All hospital’s need to be fitted with water birth facilities. If you have ever been in labour and experienced the absolute bliss of stepping into a warm bath, then you will know that it seems to be neglect in the utmost for women to be denied this simple, safe and very effective pain relief method. Women who use a bath during their labour do not necessarily choose to birth in the water but all agree that the relaxing effect of the bath was imperative for the health of their mind and body during labour. For more information visit;
www.waterbirth.org
http://www.bellybelly.com.au/articles/birth/waterbirth-birth-in-water"

Case Load Midwifery
What are we waiting for? This is WHO standards for best practice. In the current system, midwives are under utilized while obstetricians are over worked. Case load will also attract more people to become midwives as it is a much more satisfying model of work for the midwife.

Public funding for Home Birth
Public funding for homebirth will substantially reduce the pressure on our public health system. Home birth is a safe (arguably safer) option for normal pregnancy and it is about time the government included this birth option in its public health system.

More places for Direct Entry Bachelor Midwifery
A lot of people who want to become midwives have little or no interest in studying nursing. More places for Direct Entry Bachelors will undoubtedly increase our midwife numbers. I can think of five people off the top of my head that live locally and would study to become a midwife if Direct Entry was available at out local University (Southern Cross Coffs Harbour).

Mummadoula, there are so many great ideas in here! The new perspective on "Closing the Gap" was thought provoking and inspiring.

Clearly doulas are a key in bringing birth to a more natural, woman centred place.