Midwifery is catching

As part of my most recent placement, I was in an antenatal clinic.

• As a brief aside, how clinic works is a little like a cattle yard. You get pregnant, you call a number. Based on your area code, you’re allocated to a hospital for antenatal care. You call up to make an appointment for a "booking visit". Based on the day you chose for your next appointment, you are put in a clinic to see midwives at a certain time on a certain day for the rest of your pregnancy. Free? Yes. Antenatal care? Indeed. Thorough? Yes - perhaps too thorough. Personalised, one-to-one care? Heck no. But I digress.

Part of the hour-long first appointment (ugh, may I say - boring as crap, far too much information to absorb, and entirely unpersonal care from someone they will never see again) is to talk to the woman about screening for Downs Syndrome, Trisomy 18 and neural tube defects, referred to as the MMS (multiple maternal screening). The screening is a blood test in the 2nd trimester (free in public hospitals), or a blood test and nuchal fold measurement by ultrasound (free if you’re over 35, at own expense if not). These tests screen for these conditions, rather than diagnosing them. If you have a high risk (less than 1:300) then you’re offered a further test (amniocentesis or chorion sampling) to diagnose anything definitively. The latter is a karyotype test so is definitive, while the former is a screening test alone. The latter also has a 1:300 chance of causing in itself a miscarriage.

So - how do you explain:

1. What the test options are
2. What the conditions are
3. What the idea of "risk" is, and how it’s calculated, and that you may still be that 1 in x,xxx because there’s still going to be someone affected by it
4. What the difference between "screening" and "diagnostic" is
5. That these conditions are not treatable
6. That the tests do not tell the magnitude of affect, just that the conditions exist (and they are spectrums, rather than yes/no conditions)
7. That you’re then offered an abortion
8. That there is no clear pathway for accessing support for these conditions

to anyone, let alone someone who has only finished maybe year 10, or doesn’t speak English, or has her husband in the room, or is devoutly religious so wouldn’t consider an abortion but now terrified of the possibility, or to someone who desperately wants a child at 38, or had an accident but is delighted that what she thought was menopause is actually the first trimester but she’s 42 and it’s life changing and great, or someone who would never have an amnio because of the risk of miscarriage… and the examples could go on.

I don’t feel that most people understand these tests. I also wonder about the point of the screening for diseases that are fairly rare, when the education on how to minimise the risk is lost on many people, or the risk is otherwise unavoidable because it’s age-related.

I wonder at the point of screening for diseases that are untreatable (but manageable) and so hugely stigmatised that if someone had the test, had a 1:small.number risk, had an amnio, found that it was definite and then opted for an abortion, the stigma of doing that would be near to or possibly more than the social challenges of having a disabled child.

• It’s a really hard place to be in. My personal opinions here don’t matter, because I’m just exploring how difficult this part of the antenatal process is for me as a student midwife. But I should say here that my nephew was that 1:big.number for one of these conditions, and he is the light of my SIL’s life and I wouldn’t trade him for the world as a nephew, or a baby, or a person. The challenges come from not getting support financially from the government, not knowing what the future holds for children, and the reaction of a lot of people to people like my nephew. 

This came up in my heart and mind because of a case that happened in Melbourne a few years ago. A fetus was aborted at 32 weeks because the mother had been told her baby would be a dwarf. Details are now emerging about this case in the press because one of the doctors recently applied for the right to speak out (I’ve not found a decent reference so as yet have not added one here) but there are questions about informed consent, whether a screening test was used for this decision, and whether such a late term abortion was warranted or legal. The moral discussion also rears its ugly head here - while not as passionate or public as in the USA, abortion rights is a very hot topic with everyone here. Having worked in a place that offers family planning and access to abortions, I have a new-found respect for anyone having to take that choice in their life, but for me the idea of aborting a baby that would otherwise have a good chance of survivial is repugnent.

Right where was I going with this? Oh that’s right - the point of screening tests. What is the point if people don’t understand them? What is the point if the solution to a diagnosis is either keeping a baby that is afflicted with something that will need lifelong management, or terminating the pregnancy? How is all of this explained to people? And why do some midwives insist on badgering women until they consent to the test, rather than listening to their decision to decline and reassuring them that they have made the right decision for them?

This could turn into an exploration of the midwife’s role in contraception and abortion, but I’ll leave that for another night.

I was going to post this morning that I love a woman that I am following through her pregnancy because she has been a rock of calm and patience through out her pregnancy.

I was also going to tell you that she was faced with pressure from a midwife this week to be induced because her blood sugars were slightly up (despite having a lovely little person on board, and not having any other signs of suffering any ill effects from gestational diabetes), and I had encouraged her to wait until Thursday when her midwife returned from leave.

Instead, I’m here to lament. 

Said lovely woman called me at 6am this morning to say she was in labour, and I got up and dressed and ready for the day because she sounded like she was working hard on the phone. At 8am the hospital called me to say she had arrived, was in labour and had gone up to the delivery ward.

In half an hour I was there. In 25 minutes, baby had entered the world after one push, before mum could get comfortable or even get her knickers off, and while the back up midwife was across the room! I missed the birth and I’m sad for that, mostly because the lovely mother looked lost that both I and her midwife had missed the birth.

In my gut I knew I wouldn’t make it when I got the call at 8am. The actual midwife turned up about 1/2 hour later having gotten stuck in traffic. Both of us gave the slightly shocked mother a bit of grief and encouraged her to look like she’d at least had a baby because she didn’t even have a hair out of place .

Today I learnt a lesson though - women truly don’t need us to birth. They love us to be there but they don’t need us. Missing a birth doesn’t change the fact that I’ve watched a lovely person bring another soul into the world and am watching the birth of a new family. I also learnt good things from the midwife about being there in person for the important stuff, not just the birth.  

It also reminds me that I need to trust my gut about my women and if I think they’re going to be fast, then I need to go to them and not be hogtied by the system.