Maggie banks home birth in new zealand - challenges and choices - yesteryear and today

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  • 1. Home Birth in New Zealand: Choices and Challenges, Yesteryear and Today Well-behaved women rarely make history Laurel Thatcher UlrichThe title of this conference is about the present and future, and focuses on how today’s choicesinfluence tomorrow’s parenting. I am going to start my talk by drawing a little on my doctoralresearch 1 which was an herstorical work on the midwives of the Domiciliary Midwives Society ofNew Zealand (Incorporated). This society was formed by the midwives primarily so they, rather thanthe New Zealand Nurses Association, could lobby and represent themselves in pay negotiations, butit also had an educative and support role for domiciliary midwives. Domiciliary midwives practised inhome birth before the return of midwifery autonomy in 1990. Those of us who work only in homebirth are known now as home birth midwives.So, I will condense 7 years of work into a few paragraphs to give a very brief overview of home birthin Aotearoa New Zealand to start with. My reason for doing that is that looking back at what hasinfluenced us up till this point gives a context for where we are today and can help us make sense oftoday’s world and, perhaps, may help us deal with that which will exist in the future. 1After that I will go on to look at a couple of the many challenges that exist for women birthing inNew Zealand, and I will finish up with a story that speaks to the power home birthing has to changethe culture of birthing and parenting in families.This paper will be on the Home Birth Aotearoa ( and Birthspirit( websites next week if you want to follow up on the sources of informationthat I have used.So where did it all begin?It can be difficult to imagine in 2011 but approximately 5 generations ago, all women birthed athome and almost all were attended by goodly or kind neighbours rather than midwives, doctors ornurses. This was the case until the early 1900s when midwives of the St Helens hospitals or midwivesfrom some hospital boards provided services for what they called ‘outdoor cases’ or ‘homeconfinements’. These services continued to be provided at least until the late 1930s but theattendance primarily revolved around birth with minimal antenatal and postnatal care.2In 1938, the passing of the Social Security Act introduced what is known as our ‘from cradle to grave’welfare system, part of which provided for all women to have their babies in hospital withoutcharge. The services were now funded through taxes. One of the many benefits supporting that A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 2. welfare system now provided payment for midwives (and medical practitioners) to providedomiciliary confinement or home birth.The then governing body of all health services was known as the Board of Health. As it had predictedand intended, the already dropping number of home births decreased further and by 1973 homebirth numbers were at an all time low of thirteen births for the whole country.3 The number ofdomiciliary midwives had also declined progressively and, by 1973, there were only eight throughoutthe whole country and these mainly provided only postnatal services.However, this period of the early 1970s was the beginning of a time of tremendous social changewith the rise of the feminist movement. Women were starting to take hold of their right to governtheir own bodies. By 1974, the women’s movement was starting to focus on health issues andhospital midwives were being challenged to “change their attitudes…from a hospital/sicknessorientation and…play a large part in humanising maternity services”.4 Women started to demand tobe treated respectfully in childbirth as they were no longer prepared to accept the humiliation thatmany were been subjected to in the hospital system.1974 would mark the start of the home birth resurgence as one Christchurch midwife (Ursula Helem)and two Auckland midwives (Carolyn Young and Joan Donley) commenced full domiciliary practice 5to meet the demands of women.By the 1977 United Women’s Convention, delegates were urged to consider themselves ‘consumers’rather than clients or patients. Home birth was, as Joan Donley, the mother of modern home birth,said, “an idea whose time had come”.6 2In 1978 the first Home Birth Association and a Home Birth Support Group were formed in Aucklandand Christchurch, respectively, and the consumer movement would grow over the next decade tohave branches throughout New Zealand. Today the home birth movement is supported by HomeBirth Aotearoa as the national organisation representing the many local associations throughout thecountry.Home birth numbers climbed and in 1986 these had grown to number 534 for the year.7 However,the number of domiciliary midwives grew more slowly – there were 17 by 1980 attending births inthe greater Auckland area, Hamilton, Palmerston North, Wellington, Lower Hutt, Nelson andChristchurch.8 The reason for this slow grow was financial - domiciliary midwives could not afford topractice. For a 40 hour week, domiciliary midwives received less than half of that which one wouldreceive through the Unemployment Benefit.9 They would continue to earn much less income thanhospital-employed midwives until the change to the Nurses Act which happened in 1990. If it hadnot been for the families of the home birth movement who dropped off boxes of vegetables, kepttheir cars on the road, provided child care and paid for them to go to conferences (and many otherthings), many domiciliary midwives would not have been able to continue to practice prior to 1990.So what was home birth all about then and now?Home birth philosophy was, and is, simple – it centres around the fact that when well women whoare lovingly supported in their own healthy homes by family, friends, and known and trustedcaregivers, the act of giving birth seldom requires medical intervention or hospitalisation. For the A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 3. home birth midwife it is about promoting, supporting and protecting the continuum of a healthy lifeevent rather than using the interventionist practices and drugs common in New Zealand’s hospitals.For the woman it is about having a nutritious diet, a healthy life style and breastfeeding the baby,and about exercising her rights of responsibility for herself and her baby. Simplistic as it sounds, thisis the core of home birth – health, wellbeing and women taking control of what happens to them,and midwives supporting them to do so.Home birth is every woman’s choice - however, not all women are informed of that choice as theyare guided to birth in hospitals with their first babies.If there is one thing that I would like you to take away from this address it is that planning to birthat home with your first baby if you and your baby are well, is an essential step to avoid themedicalisation of birth that persists in New Zealand.We can see that heavy impact on women and babies through a continuously escalating Caesareansection rate.Caesarean sectionIn 2004, the overall Caesarean rate was nearly 24 percent (23.7). Just over 61 percent (61.13) ofwomen birthing for the first time in New Zealand birthed normally 10 - and this ‘normal’ birth figureincludes all the well women with a normal length pregnancy (up to 42 weeks gestation) whoreceived the common interventions that medicalised birth attendants regularly use, such as, using 3drugs to induce or speed up labour, breaking the waters, administering ‘gas’, narcotics and epiduralanaesthetics (all of which enter the system of the baby), and cutting the perineum – just to mentiona few things.While we don’t know what the so-called ‘normal’ birth rate is for first time mothers for 2010, therate for all women is just under 65 percent (64.8), and the Caesarean rate has risen to 25 percent(15,145 women).11What is clear in New Zealand is the Caesarean rate has, for the last 12 years at least, remained overtwice that which the World Health Organisation recommends as appropriate, and is between 8 and10 times higher than midwives embedded in home birth practice cite of their statistics (2-5 percent).Home birth in hospitalThere is no such thing as ‘home birth in hospital’. The environment for birthing needs to be anenvironment of privacy, intimacy and familiarity, the very same intimate space and atmosphereconducive to lovemaking, as the hormonal interplay of labour and birthing is exactly the same asthat of lovemaking. For those who promote home birth in hospital, I would suggest they try to makelove in a hospital. I am sure the lack of locks on the doors, the ever-present potential for a strangerto enter the room, the clinical obstetric bed, the antiseptic smells and the sound of emergency bellsringing out will dampen the strongest ardour. A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 4. Home birth supportHome birth is supported today by the Ministry of Health and the New Zealand College of Midwives.It is not supported by the professional body of obstetricians.12 Fortunately, that doesn’t matter asmuch today as it did in yesteryear. While it has always been a woman’s decision to make, today herright to control her health care is supported by the Health & Disability Commissioner’s Code ofRights, and midwives do not need permission from doctors to provide home birth services as theydid from 1971-1990. But it is disturbing to see robust scientific evidence continues to be ignored andpoor quality evidence continues to be cited by RANZCOG as its rationale for opposing home birth.Ongoing medicalisation of childbearingWomen who plan to birth at home can still be exposed to the progressive medicalisation ofchildbearing as they go through the hoops of various test choices. Probably the most common ofthese is ultrasound scanning in pregnancy.In 1974 there were only 2 ultrasound machines in New Zealand – one in Auckland and the other inChristchurch. This procedure was seen by the then Department of Health’s senior obstetric advisorto be of value in only very few pregnancies.13The Ministry of Health’s most up-to-date Report on Maternity from 2004 tells us that only 9 percentof women go through pregnancy without scanning and that over one third of women will have 3 or 4more ultrasound examinations; this data excludes those who have scans in hospital or who pay forthem themselves.14 It also excludes those who have scans each time they see their obstetrician LeadMaternity Carer.This escalation of scanning over the last years is not about increasing unwellness. It is being used asa tool to identify the imperfect baby with recommendations for surgical abortion (politely named,termination of pregnancy). This culling of babies is not based on an acceptance of diversity but iscentred on the health dollar and resource allocation. While a 2010 Cochrane review15 appears tonegate the idea that scans have a detrimental effect on childrens physical or intellectualdevelopment, the machinery used is progressively more powerful and used more penetratingly.Investigations as to whether higher and repetitive exposure creates the same cellular disturbance inunborn babies that occurs in experimental animals 16 are lacking, and the ‘safe’ maximum of thetemperature elevations that occur during the procedure have yet to be determined.17 I have gearedmy ‘Challenge’ for discussion later around the use of ultrasound, specifically the use of Dopplers tolisten to baby’s heart beat in pregnancy and labour so this issue is explored more.To finish my address I would like to tell you a simple story about the power home birth has to bridgehearts, homes and generations. It is about a woman I will call Adele. A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 5. Adele’s storyAdele came to home birth when she was pregnant with her 6th baby. She had experienced 4 of those‘normal’ births that I spoke of previously – waters broken artificially, episiotomies, babies’ umbilicalcords clamped and cut immediately and injections to make the afterbirths come. With her secondbaby, forceps were also used to turn and pull out her 6lb 5oz (2481gm) baby. During one of thetimes that Adele’s placenta was being pulled out, the cord was pulled off and she was transferredfrom the rural birthing unit to the obstetric hospital where her placenta was scraped off the wall ofher uterus by the obstetrician’s hand once Adele was put to sleep with a general anaesthetic.She was philosophical about these births; she had trusted her caregiver (a General Practitioner) tonot intervene unnecessarily but this trust had not been honoured.Adele was valued in her church community and, as an elder, she would be called upon to talk to theyoung women of the church about birthing and mothering.Adele had discovered La Leche League and she was a committed breastfeeder. Over time she beganto question the impact on breastfeeding of the interventions – all of which prevented immediatelatching and in-arms mothering, and the effects of the drugs on her baby made early breastfeedingdifficult.According to the obstetric thinking of the Referral Criteria, she was too old, had too many children,and she had a history of retained placenta, all of which meant that she was supposed to birth in theobstetric hospital for any other births. 5I would be Adele’s midwife for the next 5 planned home births and I was happy to support herknowing she would avoid the problems which her previous caregivers had bestowed upon her.Adele’s children were always present for labour and birth.For one of these births I was called to Adele’s place in the early evening as she was in labour. Afterhaving stowed my gear in the wash house, I was ushered into the kitchen where there was a flurry ofwashing being folded, a small wet child was being tickled as he was dried and dressed, and Adelewas dishing up the dinner. She gave me a quick smile and an instruction to sit up at the table; it wastime for dinner. Adele’s labour was almost imperceptible but clearly her hawk-eye gaze over thefamily proceedings was not as it normally was as she missed the sliding of numerous peas onto myplate by one of the two little boys between whom I was sandwiched. While I had a clearunderstanding of what a midwife’s role is during labour, this little boy also saw that it includedmaking this most hated vegetable disappear, and to do so without complaint. My wink assured himhe had an ally.Following the dinner, some people did dishes, others ushered the remaining small children into theshower and the birth pool was filled. One of the older children was tasked with keeping the youngerones from falling into the pool as they strained to splash and swirl in the deepening water.There was a point where Adele disappeared and this was my cue that, having seen to all outstandingfamily matters of the day, and having started the viewing in the lounge of a video rented for theoccasion, she was now into the business of birthing in the back room. A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 6. Adele and her husband Syd were in the birth pool. Over the next little while, Adele’s labour builtuntil her urge to push saw her bearing down. Syd, in front of her, was in the prime position to lift herbaby out of the water and into her arms which he did after Adele’s minimal pushing. In those lastfew moments before the birth, a call went out for all the children to gather around to witness thebirth of their sibling, and they stampeded into the room. Tanya, a daughter in law, was individuallysummoned by Adele; as Adele said, “she needs to know how babies should be born so she can do itherself”.The birth was greeted with great joy and the baby was examined from head to toe by his siblings.The movie soon beckoned, and all the children drifted back to the lounge.The placenta was born and left to float in an ice cream bucket on the surface of the water until theumbilical cord was clamped and cut by Syd before Adele left the pool. The baby, who remainedcontinuously in arms, was put to the breast and commenced breastfeeding, nourishment that wouldbe ongoing for some years.The exposure of these children to birth at home did not take the family by storm; after the first, itwas their family norm. The births of further siblings became the interlude between the scenes of ahigh adventure movie that was rented for each birth.But it did have a profound effect on the choices that this extended family made as 4 of thesechildren (now adults), or their partners, have since planned home births for their collective (to date)9 children. In each case the choices made were different from those that their parents had madewhen they themselves were being born. One of these births in particular speaks volumes about how 6home birth can shape parenting – one which gave birth to a father.David appeared at my home one evening saying he wanted me to meet his fiancé, asking me what Iwas doing in eight months time. (I had come to recognise this question as an announcement of apregnancy and that it was intended that I would be the midwife.) It was actually a re-meeting of hispartner as I had attended her mother some years previously.The understanding that this teenaged couple brought to pregnancy, birthing and parenting beliedtheir youth, none more so than David’s preparedness for the birth and the early days ofbreastfeeding. On entering the home when called in labour I was met by the warmth of the house,my birth pool all ready for use, towels over an airing rack above a heater ready to flip into action,many tempting morsels for his partner in labour, sipper bottle to the fore and offered regularly, andthe dishes were being done.As the labour progressed, he helped his partner into the pool, getting in himself to receive their babywhen the birth was imminent. After he had caught their baby and placed her in her mother’s arms,he was onto his next activity. The towels were warmed, a snack was made for his partner and thebed was straightened up ready for use. As the midwife, my role was one of patient and quiet vigil –or as an unknowing observer might interpret – I did nothing but listen a few times to the baby.David’s support of his partner continued to ensure that over the first week of her babymoon she didnothing but rest, eat and care for herself and their newborn. In the second week he supported her to A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 7. gradually take on the running of the home in preparation for his return to work. These things thisboy-man had learnt came through home birthing.In closingHome birth is not just about place of birth and avoiding all the routine interventions of medicalisedenvironments and practitioners. It is also about creating or recreating families who are strong andknowledgeable who are then able to hand down that knowledge to their children.Some of us gain that knowledge by our own birthing, and others, like myself, do so through thewomen we attend and, importantly, also hand it on to our children.The American birth activist Suzanne Arms once said (and I paraphrase): if we want to create a nonviolent world then we must start with the way babies are born.My experiences as a home birth midwife over more than two decades have repeatedly shown methat birth can be gentle and that home is the birth space for bridging hearts and humanity.Thank you.References 7 1. Maggie Banks, ‘Out on a limb: The personal mandate to practise midwifery by midwives of the Domiciliary Midwives Society of New Zealand (Incorporated), 1974-1986.’ [PhD thesis]. Victoria University of Wellington, Wellington, 2007. Available at 2. Adelheid Wassner, Labour of Love: Childbirth at Dunedin Hospital, 1862-1972, Adelheid Wassner, Dunedin, 1999, p. 47. A register of ‘Outdoor Cases’ of the Batchelor Hospital in Dunedin documents 200 cases up until August 1934. The last birth on the register was recorded as ‘Case no. 1499’; New Zealand Nurses Association, Report on Community Health Nursing in New Zealand, Wellington, New Zealand Nurses Association, 1980, p. 3. 3. ‘Number of home delivery figures by health district and year’, Table, c.1978, in Department of Health, ‘Self-employed midwives (domiciliary): the Department’s responsibilities’, Paper, March 1979, DoH, ‘Board of Health – Maternity Services Committee, 1978-1979’, ABQU 632 W4550, 29/21 (49879). Held at Archives New Zealand, Wellington. 4. Maureen Marshall, ‘Women as Healers’ in Women 74: Proceedings of the University Extension Seminar, 14-15 September 1974, Hamilton, University of Waikato, 1975, p. 96. 5. ‘Home delivery and post natal care by Health District…’, Table, c.1978, in Department of Heath, ‘Self-employed midwives (domiciliary): the Department’s responsibilities’, Paper, March 1979, DoH, ‘Board of Health – Maternity Services Committee, 1978-1979’, ABQU 632 W4550, 29/21 (49879). Held at Archives New Zealand, Wellington. 6. Joan Donley, Herstory of the NZ Home Birth Association, Joan Donley, Auckland, 1992, p. 3. A paper presented by Maggie Banks (PhD, RM, RGON) Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011
  • 8. 7. ‘Home birth statistics 1987’, c.1987, DMS, ‘Home birth statistics, DMS/00 11’. Held at Wise Woman Archives Trust, Hamilton.8. Data source: ‘Numbers of (A) Home Confinements and (B) Domiciliary Midwives in Each Health Area, 1977-1980’, in Maureen Laws to Tony Cochrane, Letter, 10 June 1981, DoH, ‘Board of Health – Maternity Services Committee, 1982-1983’, ABQU 632 W4415, 29/21 (54816). Held at Archives New Zealand, Wellington.9. Allison Livingstone to Dr Claudia Scott, Chairperson, Health Benefits Review Team, Submission, 28 May 1986, DMS, ‘Correspondence, re Maternity Benefits, DMS/00 4/18’. Held at Wise Woman Archives Trust, Hamilton.10. Ministry of Health, Report on Maternity 2004, Ministry of Health, Wellington, 2007, p. 33.11. Ministry of Health, Maternity Snapshot 2010, Ministry of Health, Wellington, 2011. Available at Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Home births (C-Obs 2), 2009. Available at Professor JL Wright, ‘Standards of ante-natal care’, Therapeutic Notes No. 137, Department of Health, 30 September 1974.14. Ministry of Health, Report on Maternity 2004, Ministry of Health, Wellington, 2007, p. 25.15. M Whitworth, L Bricker, JP Neilson, Dowswell T, ‘Ultrasound for fetal assessment in early pregnancy’, Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD007058. 8 DOI: 10.1002/14651858.CD007058.pub2.16. NI Vykhodtseva, K Hynynen, C Damianou, ‘Histologic effects of high intensity pulsed ultrasound exposure with subharmonic emission in rabbit brain in vivo.’ Ultrasound in Medicine & Biology, 1995, 21(7), pp. 969-979.17. Charles C Church, Morton W Miller, ‘Quantification of risk from fetal exposure to diagnostic ultrasound’, Progress in Biophysics and Molecular Biology 2007,Volume 93, Issues 1-3, pp. 331-353. A paper presented by Maggie Banks (PhD, RM, RGON)Home Birth Aotearoa Conference: Todays Choices, Tomorrows Parents - bridging hearts, homes and humanity. Okurukuru Winery, New Plymouth, 28-30 October 2011