Episode 196 - Breech Whisperer: Resigned not Retired
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
Mel:
[0:23] This podcast is completely free to you, the listener, because we have some epic sponsors who help us make this podcast happen. I only accept sponsorship from businesses with high integrity and useful products that I have no shame in recommending if you want to feel prepared for your labor and birth. Poppy Child is a doula and hypnobirth practitioner and the woman behind the birth box, which is a hypnobirthing preparation resource. And it also includes Poppy's signature labor and birth tracks to help you get fully into the zone for your labor and birth. The birth box is being updated and refined all the time and Poppy knows the importance of having your birth team be fully prepared and ready to support you. Poppy has just dropped a new immersive birth partner rehearsal track inside the birth box and it guides couples through practicing contractions together and it includes three vivid scenes to rehearse holding the space, advocacy and navigating unexpected changes. So this is about mental preparation and teamwork not just information. Click the link below in the show notes and have a look at the birth box and the Great Birth Rebellion listeners get 20% off at the cart if you type the word Melanie as a discount code.
Mel:
[1:46] Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today I have a very special guest that I want you all to meet both here on the podcast today, but also you can have the privilege of hearing him live in person at the Convergence of Rebellious Midwives that happens every year. And this year it's happening in July in Melbourne. The details for the conference are in the show notes, but today I welcome Dr. Andrew Bissetts to the podcast for a candid conversation about his career and experiences of the maternity care system over his 40-year obstetric career. You might know Andrew Bissetts as the Breach Whisperer, but his career has been so much more than that. Andrew finished up his clinical practice last year after earning a name for himself as the Breach Whisperer. And when I phoned him to wish him well for his retirement, he said, no, no, Mel, I'm not retiring. I'm resigning. And they felt like fighting words to me. There feels like something behind that. And today we're going to dig in and discover what it is. So welcome to this fly on the wall interview with Dr. Andrew Bissetts. Welcome to the podcast, Andrew.
Andrew:
[3:07] Thanks very much for having me.
Mel:
[3:08] My first question to you is if someone asked you who you are, how would you answer that question?
Andrew:
[3:14] Right, so that is an interesting question because, you know, it's not one that immediately comes to mind. So I have been thinking about it, but this is how I'll put it. I'm many things, right? Not that I'm better than, but when I think about this, I'm many things. First and foremost, I'll just say in two words, I am a believer. That's all I'll say I am a believer Every day that's what I am The next thing that I am I am a husband to my wife I am a father to my children And now clearly a grandfather to my grandchildren I am an obstetrician I am a teacher I am a researcher I've been an administrator and organiser of sorts I'm a musician of sorts.
Mel:
[4:20] Of sorts.
Andrew:
[4:21] Yeah, you know, I am a keen woodworker when I get the moment and I'm a tennis player. I do other things, but, you know, so they're all the things that I'd have to say if you ask me who am I.
Mel:
[4:40] Yeah. That's why I asked this question of who am I, not what do you do, because it sort of draws out some elements of your own identity.
Andrew:
[4:51] Yes, yes, yeah.
Mel:
[4:52] Yeah. And I know you said all you'll say is I'm a believer, but what do you believe in?
Andrew:
[4:58] A lot of things, everything.
Mel:
[5:01] Would you say you're an optimist?
Andrew:
[5:04] Yes, yeah. No, I would say I'm a melancholic optimist.
Mel:
[5:13] Fantastic. In terms of identity, how wrapped up is your work as an obstetrician in that? You know, I think about, gosh, if I didn't call myself a midwife, what would I call myself? Who am I?
Andrew:
[5:28] It was huge.
Mel:
[5:31] Can you give us an overview of your career? What's that been?
Andrew:
[5:36] All right. So I went straight into medicine after I finished school. I went to a boarding school in Bowerall, run by an order of fairly quite humane priests and lay teachers. But anyway, I went into medicine straight away.
Andrew:
[5:59] I was exposed to obstetrics and gynaecology in one term there at the Royal Hospital. Then I graduated as an intern. I planned to do general practice.
Andrew:
[6:13] In the course of that, I did do a stint. So I worked in Victoria for some two years doing various rotations. I then went, I did a stint in ONG. I did a stint in pediatrics. I then went to northwestern India to work with Tibetan refugees for a year. And I realized I was very deficient in maternity care knowledge. I then came back and I decided to do some more time in maternity care, in obstetrics And that's when I grew to Lyca and that's where I've stayed with it So I worked at Fairfield and Liverpool as a non-accredited registrar Which was an excellent experience Then I moved to Newcastle I was in Newcastle for 23 years as a trainee
Andrew:
[7:11] Then, you know, moved into a consultant position. I worked with the university as a lecturer. I was an active clinician. I then moved into administrative positions. I became a staff specialist. I remained teaching with the university. I became a director of obstetrics. And that's where I became fairly involved with aspects of working closely with midwives. And clearly with obstetricians, but I was particularly keen on that setup and that's where we set up, or together we set up the Belmont Birthing Service.
Andrew:
[7:51] And then in 2010, because of perhaps it was a challenge and because of family things, decided to move to Sydney, take up the position of the Royal Hospital of Women. And then I was there as, you know, effectively all those things. I was a very active clinician, I was a teacher, I was a researcher, I was an administrator. Then, of course, last year in June, I stopped the active clinical work. And as you noted correctly, you know that I resigned. I've resigned. I haven't retired. And so that's where I'm at. I'm, you know, now resigned from that position and I'm doing, you know, I'm still teaching and doing quite actively involved in various research initiatives.
Mel:
[8:41] So you've seen, you must have been in your early 20s when you were doing and finishing your medical training.
Andrew:
[8:51] Yes.
Mel:
[8:52] So then the maternity care landscape will have changed significantly from that time. To now, from your perspective, can you take us on a little journey, What's changed? Is there anything that you've seen has gotten better or anything that you've seen has gotten worse, anything that's filled you with heart or made you a bit despondent about the maternity care system as it is?
Andrew:
[9:20] So when I started, it clearly was a very obstetric-dominated maternity care system. That's how it was. That was the culture of obstetric care. It was very much about the obstetrician, midwives had a place, but it wasn't sort of as out there as it is now, right? And that's a good thing, but that's how it was. Mind you, even in that sort of what I'd call slightly subservient state, I learned a lot. I learned most of the valuable insights about birth I learned from midwives even at that time. Now, the other thing was that at that time, evidence wasn't the dominant thing which determined patterns or aspects of care A lot of it was quite authoritarian based on people with particularly obstetrician midwifery experience and so that's totally different now in that we do make appeals to evidence
Andrew:
[10:32] And I don't put any, now that's a good thing but there are aspects to it that I think at times have gone a little bit astray. Now the other thing was that at the time when I started There was starting to be some concerns around the medico-legal side of practice Since that time, it's exponentially got worse
Andrew:
[11:03] And in one sense, that aspect of maternity care has undone, to my mind, a lot of the good things that have developed. Because a lot of the good things that have happened regarding continuity of midwifery care, various approaches, have played second fiddle to medico-legal anxiety.
Andrew:
[11:32] And that has been an unfortunate thing And, you know, now some people get a bit annoyed with me when I emphasize this But I'm telling you, I don't say it in any nasty way You listen to any discussion amongst maternity care professionals And it slips so easily into medico-legal concerns Rather than a focus of, oh, what's the best way to do things, right? So I'm just saying that's a huge shift. Now, the other thing is that clearly from a demographic point of view, women are older and now when they're having their children, they are having fewer children. So that's a huge shift as well because the whole complexion of birth changes when you start to get a predominance of, you know, first-time mothers, primary gravitas. Because that's the image of childbirth. That's that difficult primogravid experience. Whereas in the baby boomers era, the majority of women were multis.
Mel:
[12:43] Right. So you're saying the very fact that we're working with predominantly primips is skewing how we experience labor and birth as clinicians.
Andrew:
[12:56] Yes. Yes, but also for the public. Because they get this idea that labour and birth is this, you know, primogravid experience, that that's it. Whereas previously it would have been, well, yes, the first birth had its challenges, but after that, when you had your second, third, fourth, fifth or sixth like my mother, well, it was much easier. And so that dominated. See, that's a big thing. And you see it really in the hardcore figures that we have. But, you know, culturally that is a big change.
Mel:
[13:35] So when you're talking about the medico-legal issues, are you saying, because there'll be some people listening to this who are like, I don't understand what you mean by medico-legal. Are you saying that as we consider the care of women, In the back or the front of clinicians' mind is, if I get sued for this or if I get in trouble for this, what's it going to look like?
Andrew:
[13:59] Yeah, that's exactly right. They have that breathing down their neck all the time.
Mel:
[14:04] Do you think that comes from hospital management or is that coming from somewhere else?
Andrew:
[14:12] It comes from everywhere.
Mel:
[14:13] Okay.
Andrew:
[14:14] Because, you know, yes, it goes by hospital management. It comes by the medical indemnity organizations. And I'm not saying this is malicious. I'm just describing it to you.
Mel:
[14:25] This is a fact.
Andrew:
[14:26] It's a fact.
Mel:
[14:27] Yeah.
Andrew:
[14:28] But it's huge, right? And it does, you know, the way you put it, you know, in the back of their mind, well, it's often in the front of their mind and it messes with people's reasoning around and thinking around birth.
Mel:
[14:45] Somebody described it to me, you know, And I would... I love being a midwife. I love that I, when things are out of my scope, I can refer on and consult with other people and go, hey, this is really out of my scope. And I always comment to people that, you know, we're referring on and passing these things on to obstetricians. They don't have a next person in line. They have to deal with it. And so to have that responsibility and that role and then also to have the medico-legal pressures, I feel like I understand why decisions are made in that context under that level of pressure.
Andrew:
[15:28] That's true to a certain extent, and that does weigh heavily on people because you would have heard obstetricians who are trying to do their best and they'll say, yes, well, they will say virtually the buck stops here, okay? And then, yeah, that's when that whole, as you say, the medico-legal thing becomes even bigger there because there is a vulnerability there, right? Of course, it doesn't necessarily have to be like that because, you know, say whenever I've, you know, or I'd say midwives said, look, Andrew, what are we going to do here? Well, I've actually never felt alone. And the two reasons I haven't is that I could always ask a colleague. I've always worked with people who are saying Will give me a considered opinion But the other thing is of course I will often go back to the midwife herself And I'll say, this is what I think What do you think? Because often they have more insight about
Andrew:
[16:45] Particular situation, clinical decisions, then they will give themselves credit for. Sure, yeah. And so, you know, there are ways of dealing with this. But the fact is that it's there and, you know, you hear it all the time. And it's just a pity that often in clinical discussions, it reigns supreme. You know, it's when you're trying to sort, you're trying to reflect on a case. You know, someone comes up, well, medico-legally, you know, I think this and this. Well, I've already said, well, let's think like, you know, just think like clinicians and see, well, could things have been done different? Let's forget what goes on in the courts. People have to remember that the whole medico-legal sphere is a different way of thinking.
Mel:
[17:36] Can you think through that? Because there's a clinical way of thinking, decisions that you would make based on clinical outcomes. And you're saying that their medico-legal thinking is different.
Andrew:
[17:48] Yes, that's right. It's different because there you've got particular concerns where someone who feels as though the wrong thing has been done by them is then as a legal advocate. And their task is To win a case So they will take It's whatever it takes it to win that case. Now, that sounds brutal, right? And clearly there is a greater degree of civilization there. But it does involve what I call a lot of throwing of mud at one another. That's the adversarial process. And that's the really harmful thing in it. And the fact that women are made to relive whatever traumatic experiences led to this, that distresses them. And so it's a regrettable process that has nasty fallout.
Mel:
[18:52] So then the two things already you've mentioned is that you've noticed a shift in the authoritarian culture. Maybe it's shifted less away from obstetrics to a more balanced sort of measure.
Andrew:
[19:06] It's very much more a team effort, and that's a good thing.
Mel:
[19:11] I'm glad that you mentioned that because there's midwives coming into their careers now at this point in history feeling like they're still subservient and don't have a lot of sway or, you know, power in the maternity care system that it still feels obstetrically dominated. But from what you're saying is you can see that there has been a shift over time.
Andrew:
[19:36] Definitely, definitely.
Mel:
[19:37] So we're going in the right direction.
Andrew:
[19:40] Yeah, that's right.
Mel:
[19:41] Yeah. So there's that shift. There's the more unfortunate shift of there being the medico-legal. Is there anything else that you've noticed over time?
Andrew:
[19:54] Okay. It's sort of partly to do with that is that because we do have evidence, because we've done a lot of research, Pregnancy has become a minefield of risks, pregnancy and birth. You know, it's not just, you know, we need to be careful about this or that, or I remember the advice I was given when I was an accredited registrar and even it is about eternal vigilance, you know. Now, that's a very nice way to put it, right? But now, everything, you know, there are so many risks that women have to consider. And, in fact, the whole of maternity care is couched. In a culture of risk or, you know, contained in a culture of risk. And again, that just has a huge impact, right? And see, yes, it's not as though that didn't exist previously, but the degree to which it exists today is much more.
Mel:
[21:03] Are you saying perceived risk or actual risk?
Andrew:
[21:07] Well, it's both, all right, in that, you know, yes, you can make a case that there might be a risk of something going wrong and it might occur sort of one in 100, one in 200 times. Then you find something else, you know, that's a concern. That might occur one in 100, one in 200, one in 300 times. And so if you collect enough of these, even though they're infrequent, just because you're having to collect it, you know, consider a number of them, it starts to make it look like a minefield.
Mel:
[21:45] Yes, and they stack up in the eye of the clinician. If you're stacked up four risks next to each other, they don't all lay down next to each other. They actually get higher like a risk tower.
Andrew:
[21:58] Well, and that's particularly for women who are hearing about these things. Yeah. You know, because... Yes, we can define, you know, the ultrasound with all sorts of investigation that there might be a risk of this, but the majority of the time, they're low equivalence risks, and women do need to be reminded that childbirth has never been safer. Uh-huh. Yeah?
Mel:
[22:25] You think it's safer now than it was?
Andrew:
[22:27] Oh, yeah, yeah. Yes, yeah, yeah.
Mel:
[22:30] So do you think the risks are overstated strategically? Particularly why? Why do they overstate the risks, you know?
Andrew:
[22:38] Well, I think the medico-legal pressures, you know, because even if something's a low-prevalence risk, people will say, yes, but if it happens to this person, right, X, Y and Z can, you know, will then follow. The woman will seek compensation. And so the fallout from that risk when it actually happens can be huge.
Mel:
[23:05] Anything else that you noticed?
Andrew:
[23:09] Yeah, I suppose it's this thing of autonomy, right? So when I started, you know, the idea of a woman requesting, and we'll take the example of a cesarean, not that I want to focus too much on that, but the idea that a woman would request a cesarean where there was no indication, or even if there was, say, a slight indication, well, that just didn't happen, okay? Okay. There might have been, but it was quickly, let's say, we dismissed. Whereas now, it's the era of a particular notion of autonomy, that if you're informed about something and you request it, even though it's harmful, well, that's okay, as long as you're considered all the risks.
Mel:
[24:05] Interestingly, though, and I hear what you're saying, you know, that women are expressing their autonomy in things like elective inductions and elective cesarean sections. And even though they pose what, you know, pose a potentially higher risk to the option of waiting in a vaginal birth, they're allowed to make those choices as autonomous women. And interestingly, if they were to go the other way and use their autonomy to choose something that was not aligned with a medical philosophy, for example, breech vaginal birth or a VBAC after two cesareans or twin vaginal birth maybe in a place that doesn't really, isn't facility. So she would potentially get pushback and try and be convinced to accept a different kind of care, whereas if she said, well, I want an elective caesarean, and that was aligned with the philosophy of that clinician or that location, they'd go, sure, no trouble. Of course, we can do that. So her autonomy is still governed by the preferences of the clinician or the facility.
Andrew:
[25:18] Yes, and that's definitely true. There is that paradox that a caesarean, or most people feel very comfortable with caesareans. But when it comes to the possibility of a vaginal bridge birth, and this is not a criticism, the reality is the majority of obstetricians are not comfortable.
Mel:
[25:41] Why, and this is something that you have focused on in your career too, is being comfortable with vaginal breech birth. I love that you're saying this is not a criticism because I think you're just stating, these are just the realities of the maternity. We're not saying it's good or bad. This is just, I mean, this is just how it is. But you built a name for yourself, you know, whether or not you accepted the label or not. But people call you the breech whisperer. Andrew Bissett's the breech whisperer. Why did you welcome vaginal breech births when a lot of your colleagues and the maternity care system was not?
Andrew:
[26:18] Well, first of all, I noticed in the mid-90s that, you know, breech births were going by the by. And I thought to myself, well, does that really need to happen, right? Can we, is there something we can do better, work better with women who are laboring with the breech? So that question arose, but then they planned this term breach trial because everyone was getting very excited about randomized controlled trials being able to give us answers, and fair enough, to a certain extent, they can. They designed this study. Now, I had concerns when it was designed, and in my mind, as it was designed, I thought this is only going to go one way.
Mel:
[27:08] So you could see it straight up before they even did it?
Andrew:
[27:11] Yes, yes. As they were designing, I thought, well, you know, they had to scrape far and wide to get institutions to...
Andrew:
[27:22] Be in it and a lot of the institutions that they had were not confident with vaginal breaches and just remember the places that were didn't partake largely in the in the study so that was one problem and i thought and you know then you know so a hospital not too far from john hunter decided to be part of the study now they hadn't seen a vaginal breach for i don't know two or three years okay so yeah so for that reason you know i was already concerned and of course the results were not good with the study there was a clear difference and i knew why it happened right and it was so it shocked people so much and frightened people so much that people didn't even want to think about it they just said look let's just stop doing breaches they're so dangerous We'll just end up all in the courts if we keep on doing that Whereas I thought, sorry, no, I don't think that's the truth And I've always thought that it's not good for anyone's brain just to work on this principle That if I do X, Y, Z, I'll get sued There are other interests here, right?
Andrew:
[28:43] And clearly I saw, you know, that there are a number of women who said Yes, I appreciate that there might be risks and this study might have shown them But first of all, a woman might say, I'm confident about myself Okay, and you have to work with that
Andrew:
[29:03] And then I'd seen enough breaches to say, well, it can't be as bad as what the term breach trial reported. And a number of people agreed with me. So I thought, all right, well, it's either we keep offering this or we totally lose that sense about, you know, this variation of normal. Because that's what's happened is that, you know, a whole swathe of obstetricians have lost a, and it's not so much about manual skills, it's just a certain sort of presence and ability to work with normal birth. Because, see, that's my big learning from breech births. It's not so much tricky mechanics or manoeuvres. It's actually talking with the woman before the birth and then just watching the birth, paying attention to the birth.
Mel:
[29:59] Well, understanding what's normal, which is so much of the periphery work too, is observing and understanding what's normal and to keep saying to yourself, no, this is normal, this is normal, this is normal, in which case there's nothing to do. And then you attune your skills to go, well, actually, now this is not normal because I am so confident in what normal looks like that I know exactly what happened.
Andrew:
[30:24] Exactly right. Exactly right, yeah. So, and see, the other thing, of course, I did ask myself, well, you know, these places that have kept on doing breaches, like particularly in Scandinavia, French countries or France and Belgium, Holland, is it as bad as what's reported in the term breach trial? And the reality is it's not. And that was particularly shown by the French because they really didn't believe the term breach trial results.
Mel:
[30:56] I think maybe, if anything, the term breach trial showed that an unskilled, frightened clinician is not a good idea at a breach birth.
Andrew:
[31:04] That's exactly, yeah, that was one important learning and that, you know, it's not as though, you know, when they planned this, they had guidelines around breech birth,
Andrew:
[31:19] But clearly they couldn't determine, they had a rough and ready way of determining whether someone would be skilled or not. Well, they ended up having one in five births attended by relatively unskilled people. And they were the problem. So, and all of that arose from the fact that, you know, they had to scrape far and wide to get institutions to participate. And so it would have been different, say, if they, you know, just enrolled the Scandinavian countries or the French countries, but of course they didn't want to be part of it, you know. And I thought it was very important that if we didn't want to lose these skills, if we wanted to further our knowledge or develop our knowledge and insights about breached birth, well They need to keep happening. You know, you talk to women, you consider issues of risk, but also, you know, it was very important to revitalise a very intelligent understanding of the normal, you know, process and mechanics of a breech birth. And that's been one of the, you know, key developments since that study. And so I'm very glad that we, particularly that I and others, persisted.
Andrew:
[32:42] That's been an incredibly rich part of my career.
Mel:
[32:47] So have you seen it now turning? Do you feel like it's turning or are we still just holding on to breach?
Andrew:
[32:54] Just holding on. There are some excellent initiatives. I'd say the Women's in Melbourne is doing a fantastic job. Western Australia has a very championing midwife advocate there who's, you know, just go ahead and things are happening there. So these are good. But by and large, there's still a lot of resistance and fear.
Mel:
[33:19] Yeah. So you operated in that. People knew you, Andrew Bissop's doing breaches. Did you get any, what was the, I mean, there must have been pushback.
Andrew:
[33:30] There was. But a lot of the times it wasn't hostile pushback. Okay. It was just say, well, more or less it was, you know, Well, thank God, Andrew, you're prepared to look after these because more or less some said, I've forgotten how to do breech and others have said, no, I don't want anything to do with that. But there was an appreciation that, all right, as long as we can have some idea, more or less it was implied, Andrew, that you're being responsible, that's good.
Mel:
[34:01] Yeah. So was it like, did you feel like you were fighting to try and give the option of breech birth? Thank you.
Andrew:
[34:09] At times a little bit, yes, at times. But most of the time, you know, people had to say, well, if the woman's informed, see, but that was the thorny issue because the question was, well, Andrew, what are you telling these women, you know?
Mel:
[34:27] Okay.
Andrew:
[34:28] And, of course, you know, that's a tricky issue. What do you tell women? And so there has been sort of, at times they've been sort of critical, Sort of slightly colourful discussions about that But overall there's been an appreciation that You know, well, someone has to Someone has to, you know, take the responsibility here and, you know, so I think more or less there was gratitude several times.
Mel:
[34:57] Well, that's good to hear. I had this vision of you just having to go to work, just battling all day long trying to get...
Andrew:
[35:03] No, no, no. I can never say, you know, there have been times when there's been some, how should I say, muted resistance. And only on a few occasions can I describe, say, the hostility or resentment in it.
Mel:
[35:20] You know, Michel O'Don, the obstetrician, died recently. And after that, I reread all of his books and I did a whole podcast episode on Michel O'Don and his vision for the future. But one of the things that he talks about is authentic midwifery and authentic obstetrics. And his sort of birth utopia, as he described it, would be that the midwives would go about their day caring for well women who had no need for any medical care, and they did all that. And then in the instance where they were out of their scope, They would call on the skilled, what he called authentic obstetrician, who was so capable and so skilled in the complex because they busied themselves with that arena. His belief was that because obstetrics had this attempted kind of domination over pregnancy, birth, and the postpartum period for women, they were busying themselves with the care of well women and were losing the ability to care for complexity because they just were trying to do everything. Do you think at this point now there is the de-skilling of obstetricians?
Andrew:
[36:45] Yes, definitely. Definitely.
Mel:
[36:48] What have they lost?
Andrew:
[36:51] Well, it's what I call this, it's a fairly refined skill. It's that ability to watch and wait in trickier situations. Sure, in a, let's call it a low-risk birth where maybe the woman's having a second or third baby. Yes, that's okay, but it's these ones where the baby's not just popping out. The baby, it might be twins, it might be a V-back. It's that ability to just wait carefully, clearly not over-call it, not under-call it. That's a very refined skill. And I don't agree with this terminology, but I remember, I'll just hark back to what this fairly gruff obstetrician at a hospital that I worked with. But actually, he had a lot of insight. And one time in this fairly gruff voice, he says to one of the obstetricians, where's your obstetric courage, doctor? That's how he said it. Now that stuck with me And I wonder what's he talking about there Well I think he's talking about something Now obstetric courage Sounds you know a bit macho
Andrew:
[38:13] But What I think he was referring to Was that ability just to Sit and watch Even if some things Are a little bit threatening
Andrew:
[38:25] But You know it's also What I think it emphasized was just keeping an eye on the woman herself rather than being bowled over by your own fears. Yeah. And so I would call it more...
Andrew:
[38:45] Let's call it steel. You have to have a certain steel. And I think midwives display this very well. And again, it's not macho. It's just that ability to sort of, when a whole lot of things start to look a bit tricky, you're able to take a step back and say, yeah, how is this really going? How long are we going to wait? How are we going to work together rather than just saying immediately, well, we just need to do this, this, and this.
Mel:
[39:11] So do you think that's what's happening is obstetricians are seeing something that could potentially be an issue and thinking, well, we might as well fix it now before there's… Yeah.
Andrew:
[39:21] That's right. Yeah. So that's the first thing that I think's, you know, the fundamental thing that's been eroded at present. All right? Right. Now, then there's actual skills. All right? And again, skills in obstetrics and in midwifery, I think they are subtle things. It's the way you use your hands. It's the way you talk to someone about a problem. I think particularly when it comes to all the places where we're deemed to be intervening. It's where, you know, your breech birth, it's with a twin birth, it's with an assisted vaginal birth These are very refined skills and therefore it's important that skills maintenance is an important part of even experienced obstetricians Because the occasions to use, to see those things are less these days
Andrew:
[40:27] If we're going to have realistic maintenance of skills, obstetricians have to sit down every now and again, go through a twin birth, go through a breech birth, look at what are newer ways of looking at breech birth so that we're all a bit more calm about it at all levels and you should be doing it together. That's the way it works But that maintenance of skills That was just something that Because everyone assumes Well the obstetrician They're consultants They are trained in these things But the reality is A lot of them haven't seen A lot of them say I haven't seen a breech birth for so long I haven't seen a twin birth for so long Or I've only seen a very few twin births And the registrars are saying So we have to have some meaningful way and it is possible with all the videos and the models that we've got that I think you can maintain skills, but it could be that obstetrics, you know, particularly labour ward obstetrics in conjunction, you know, pregnancy care, might need to be totally separated from gynecology.
Mel:
[41:43] Yeah, sure, because this is what's happening. Obstetrics and gynecology, that's a massive field of study.
Andrew:
[41:49] Yeah, that's right.
Mel:
[41:50] And then if you add to that, that actually also some obstetricians are just caring for well women who have absolutely no need.
Andrew:
[41:59] Yeah, and I think that's really important. That's always the reason I've always, there are many reasons why I've always just been in the public sector. But, you know, my intention was always, you know, what I'm needed for is where there are problems. And as far as lower risk births, well, I have to learn about those and, you know, appreciate them. But, you know, my skill is needed for, you know, where things are deemed not to be normal or are there a bit more complex.
Mel:
[42:33] Yeah, well, that's the delineation, isn't it? And that's how midwives and obstetricians work together is we sort of go, look, this is your scope. You work within that. And then when it's out of your scope, it's time to add another expert to the space who's got a different set of skills. Not the same set of skills. We don't both have the same set of skills. So we're complementary in the care of a woman.
Mel:
[42:56] When you finished your clinical work, I said to you, Andrew, you're retiring. He said, no, no. I'm resigning and I really felt like there was something behind that, you know, that you were kind of like, I'm moving on to this other thing. I'm not stopping. I'm keeping on going. What are you, where's your energy going now that you've resigned but not retired?
Andrew:
[43:25] First of all, you know, it was actually quite hard for me to resign and that aspect of my work, that day-to-day being in labor, Lord, I actually missed that. Now, I expected that, but, you know, it is. But there were reasons for that. So what I decided was that, look, I've had 40 years of experience. I don't want that just now to disappear.
Mel:
[43:47] No, thank you because I do feel.
Andrew:
[43:50] Like a response. Yeah, and so I felt. And responsibly, partly to myself, by the way, but also to everyone else, that, all right, I should maintain various teaching initiatives, and that's particularly with our breech course or with any other aspect of, say, more complex birthing processes, right? That's the first thing, and so that's really important. And at times, that might mean a little bit of, how should I say, on-site clinical work to support that. So there are a number of initiatives around where I'll be doing that then the next thing is research there are a number of research areas which you know when I was very busy I just didn't have the brain space full so you know I want to do that and again that that's for the same reasons you know it just means it would be just would have been just too difficult and a little bit you know almost a waste had I just said right I'm just going to play music Yeah,
Mel:
[44:50] Which you can also do.
Andrew:
[44:52] Yeah, but yes, and that's been really good actually because, you know, there is clear purpose and meaning in that. Yes, you know, it's still almost I'd like to be on a birthing unit, but I'm saying no, this is where I need to be now.
Mel:
[45:09] Yes. Do you mind sharing what instigated the resignation?
Andrew:
[45:16] Well, it was just, it was part of my age. You know, I'll be 70 this year, so... You can try and hang on to, you know, your role, but you've just got to, things change. You do get older. And I think you have to be very careful at our age that, you know, what you were able to put up, you know, with in younger days, you just mightn't be able to. And you don't want to end up in sort of various areas of judgment or bad calls because you're overly tired. or you weren't just quite on the ball. So you just have to face up to that. The other thing is that I think for my wife, I mean, she could probably do with a break from that sort of high-level intensity, although she's always been supportive. Yeah, they were the main reasons.
Mel:
[46:07] I'm already seeing a vision of, you know, Andrew teaching the, you know, the lost skills of obstetric course at university so that we just rekindle all this skill. I actually love that term obstetric courage because I've witnessed it a few times. In circumstances, I'm a private midwife and I often work with obstetricians. My clients require additional care. And I remember phoning an obstetrician once and going, when are you going to do this cesarean section? Because it's been days and days and days of watching this woman and I'm concerned. And she's like, a little bit more, Mel. let's give the babies a little bit more time and and we're watching and it's okay and I thought whoa that would be one example of obstetric courage where I was like you know even in with my own philosophy I'd be like days ago there's something poetic about, beautiful obstetric skill. I can't describe it any other way, but I've had times where I've watched an obstetrician work and I thought that was stunning. How incredibly confident and calm and considered they were with their skill, how little they did for so much impact, even like a great manual rotation.
Mel:
[47:26] I don't see very often because obstetricians are often favoring either of cesarean sections, vacuum forceps or, you know, some other strategy, but just watching a manual rotation with an obstetrician who was just so confident and I just thought, oh, that's real, that's true, authentic obstetrics.
Andrew:
[47:48] Yes, yeah, that's right.
Mel:
[47:50] I've got two more questions for you. The first one is if you were tasked with dismantling the current maternity care system and putting it back together again,
Mel:
[48:01] how would you redefine it, redesign it?
Andrew:
[48:04] The first thing is that I would insist on no-fault compensation.
Mel:
[48:11] That's a medico-legal thing.
Andrew:
[48:13] And so, you know, sure, if there was an adverse event and bad outcome, then there are mechanisms for immediate compensation. You look into the case, you take responsibility for things that didn't go so well And you make sure that either individuals or systems are held to account So I think that's really important And clearly the examples, the templates for that are in the Scandinavian countries Then the next thing is that there has to be private obstetric care there should be we should have a mechanism of limiting that to more complex cases so that obstetricians do what they're trained for. Clearly there needs to be an absolute insistence on continuity. Now The mechanism for that, however, sometimes is very challenging, but there has to be so that women don't feel tossed around amongst various opinions. Then there has to be incentives for vaginal birth and a value has to be placed on vaginal birth. It's not judgmental because currently things are just heading one way.
Mel:
[49:30] Well, because the cesarean section right here is around 40% now.
Andrew:
[49:35] I would say almost 50%.
Mel:
[49:37] Why should we, and I know the answer, but I'd be curious to know, why should we prioritise vaginal birth?
Andrew:
[49:45] Well, mainly because if you let things go and allow things to go the way they are, it's going to, first, there is a genuine public health concern about the longer-term impact of a cesarean.
Mel:
[50:01] Because there are risks. because it's not a risk-free work option.
Andrew:
[50:04] That's right. Well, you know, first of all, it's a harmful procedure, all right? It's like all surgery. It's a well-intended harm. Fundamentally, our role is to do no harm as a first step. So if, you know, you are having this wholesale intervention, then you've also got to realise that longer term for the baby, it is associated with some concerns for longer-term health.
Mel:
[50:33] And for the woman, we need subsequent births. You're pushing the risk up.
Andrew:
[50:38] That's right. And so it does have impacts. So if you have this snowballing cesarean section rate, well, you're going to have fewer maternity care staff being exposed to normal birth and their confidence will be undermined and that will impact both obstetricians and midwives.
Mel:
[51:01] So we're all going to lose the skill. Yes, yeah, that's right. The same with breach is that if the more cesareans we do, the less vaginal births we attend, then you less and less have that skill. And I'll add too that midwives who want to work with women and in continuity of care models are getting increasingly frustrated by what they see in the system and they won't last as long. So not only are we going to increase the intervention rates and caesareans but midwives are going to get despondent. I think I did not, this is not what I came into midwifery for.
Andrew:
[51:35] That's exactly, well, yeah, sadly that is the case. You know, if you're revamping a system, well, you have to counter that And you do have to have, you know, responsible incentives for vaginal birth And you also have to look at, you know, constantly look at better ways of working with normal birth You know, this is something, it's not, you know, this is not a procedure It's got a huge amount of variation And it's understanding that variation, understanding how we work with it And then the important aspects of teamwork, yeah, but that aspect is that it's a collective effort. One of the problems with private practice at present is that the huge sort of difference in earnings creates its own problems, right? So, again, in Scandinavian countries, the differences aren't that huge. Midwifery status is quite high. You know, so the entrance mark for midwifery in Denmark is slightly higher than medicine. Now, I'm not saying that needs to be like that,
Andrew:
[52:42] You have to have something that sort of perhaps just puts them on a similar plane. Now, it doesn't necessarily have to be financial, but actually one of the best templates for this is the also course, which is now called, you know, advances in. See, the teams that deliver that care, they work genuinely, I should say, equal standing colleagues. That's how it's been from the start. And every time I've taught them that, I thought, this is the way we need to work in hospitals.
Mel:
[53:14] Well, what you're observing then as an insider into the culture is that there seems to be a hierarchy in the authority in a maternal care system that the doctors are at the top doing the, I'm using inverted commas, important, expensive, high acuity work, and then midwifery work is not as valued. Where obviously paid less input into kind of the way that the hospitals run and the home maternity care system as a whole. And you're saying in Andrew Bissett's redesign there would be a more horizontal power structure where everybody, it's different roles but no one is more, it is not higher than the other person.
Andrew:
[53:56] Yeah, that's right, yeah, yeah. And the other thing is that as far as ways of talking to women and care that has to be not scripted but it has to be can't be left to chance because you know currently you might have someone trying to explain some piece of evidence and they there's a particular spin on it and then they talk to someone else is a totally different spin on it and we just got to respect that this just drives the women around the bed and you do have to have A system that aims to You know adhere to That principle that first Do no art you know currently It's It just doesn't make sense that there is such a reliance on, you know, the cesarean is solving everything. It doesn't. But, you know, that's one of the issues at present. And regrettably, there's not much from a, so, Department of Health perspective, there's not much interest in it.
Mel:
[55:01] In reducing the cesarean infection rate?
Andrew:
[55:04] Yeah.
Mel:
[55:05] Where do you think the change has to come from? I mean, how are we going to do it?
Andrew:
[55:09] Well, you know, you have to, you can't sort of resurrect towards normal birth, but you can in a, how should I say, in a subtle way.
Mel:
[55:21] Sure.
Andrew:
[55:22] That's what it has to be. And it's looking at, you know, better ways, not controlling normal birth, but better ways of working with it. And, you know, like say the French published this study about spontaneous births where they just observed that if you gave them, you know, the passive second stay, let's say they gave it up to three hours, they had, you know, a very low rate of eventual instrumental births. They had clearly a high number of normal births. And they didn't have many postpartum hemorrhages because the period of active pushing was relatively short. So that, to me, is a prime example of a very intelligent way of saying, well, wait, if we just look at this one thing where we've had this previous formula that after an hour of passive, you get the woman to push, she then pushes for two hours. Well, that prolonged period of active pushing is what predisposes more to the postpartum hemorrhage. So it's that type of thinking. Also, the variation, we are dealing with a normal process. If you're dealing with normal processes, you're dealing with variation. This is not a tumor or some other pathology where there is less variation.
Andrew:
[56:47] This is normality. and normality immediately means a lot of variation that you have to work with.
Mel:
[56:56] And so much clinical reasoning, which is what you're saying maybe is being lost in that skill of waiting.
Andrew:
[57:04] Yes, that's right. Yes, yeah. Well, now, can I just briefly on that? See, again, one of the richest things for me has been the development of, You know, being part of the development of publicly funded home birth services To me, that's a beacon of light Not that I've ever been to a home birth But I know every time the midwives in one of the groups goes to a first-term home birth It's like a mystical experience for them because they think, ah, this is what it can be like.
Mel:
[57:39] I tell you what, I take students out with me as a clinician and I almost feel like I need to warn them that your brain is gone. Once you see the baby come out and you witness physiological birth, your brain is going to change in a way that cannot be reversed and I almost am apologetic because, I'm sorry, You cannot unsee and unexperience this. It's like an inner knowing for a midwife. All this physiology that you've heard about and the way that a woman's body can and does work. A lot of the time in hospitals there's so much boundary on that that we never fully get to see what a woman's body is capable of. We don't give her enough time and we don't ever get to answer the question of what would happen if we just left it alone. And then when midwives or student midwives see this in a home setting where we really do leave it alone until it's clear that we shouldn't any longer, they something changes in their brain you can see it in their eyes they determine and they look at me like what and i'm like that's right there it is your you know your neural pathways just completely reorganize themselves and you can't now imagine birth any other way this is like their new ground zero of this is how birth is i think it makes us realize the work we're supposed to be doing yeah.
Andrew:
[59:09] That's right so one of the things i'm looking into in on the research front is just trying to determine is it the actual home birth environment that sort of makes that difference in the outcomes
Mel:
[59:24] Well this is the question isn't it uh i think if i have my two cents yeah sure i mean my whole career i've never worked in a hospital as a midwife my whole career has been as a home birth midwife, 18 years of watching babies come out at home with what I believe are very good outcomes for my clients and the midwives around me. And I'm not sure that you can scientifically pick apart the reason why home birth works. There's so many elements. There's the relational element, the continuity of care, the fact that the midwives are working with clinical reasoning and not policy. There's no sort of governance behind the midwife that's asking, why didn't you do a vaginal exam at this time? We get an opportunity to fully tap into what does this woman clinically need, not am I going to get in trouble for this, somebody's going to be watching. The mentality of the woman is different. Yeah, I don't know if there's any one way to tease it out. It's this whole package.
Andrew:
[1:00:30] Yeah, but I would look at the best you can do is you say, what does the home birth package, right, which you just described then, Does the home birth package by itself contribute independently? Now, as you said, there are many components to the home birth package. Which of those it is? Well, that's even more difficult. But I'm very interested in that when you consider all the aspects of risk, continuative care, can you say that the home birth package by itself or independently contributes to what looks like better outcomes.
Mel:
[1:01:11] And is it transferable? For example, if you identified some significant elements that when you package them together creates the outcomes that we see in a home birth, and is it transferable? For example, if we added all of those elements right at a hospital, could it still work?
Andrew:
[1:01:30] Yeah, well, and that's a really important question because there have been times, and this is credit to hospitals, there have been initiatives to do bits and pieces like that However, what always happens is that there are other overriding concerns, anxieties in the hospital, which can often undo those initiatives, and particularly when you're looking at some of the initiatives regarding the architecture. Now, that's really important, but if you've got this really nice environment that might look like a home, but you've got this immediate pressure around hospital policy, what you can do, what you can't do, deliver it in a particular way, well, again, it's not malicious, but it can undermine.
Mel:
[1:02:22] Yeah, the paint colour just doesn't change it if the underlying infrastructure.
Andrew:
[1:02:27] Yeah, that's right, yeah.
Mel:
[1:02:28] What are the barriers to positive change in the direction that you would like to see the maternity sickest? What are we battling against?
Andrew:
[1:02:35] Look, I had to bring it up again, but it's the Medico-Legal. That's just a huge wall. And then that drives a particular mentality around risk. Women as, you know, pregnancy and birth is almost viewed as a, perceived as a, you know, swimming in a minefield of risks. Yes, until you can get your head around that. See, on the medical legal front, if, say, there's a lot of medical legal cases boil down to the interpretation of the CTG.
Mel:
[1:03:11] We just spoke to Kirsten Small about the CTG last week.
Andrew:
[1:03:14] Now, if, say, my thing would be that if there is concerns about a CTG that might not have been interpreted correctly by standards, Take it right out of the courts And just say No fault Because those discussions are totally inflated and useless yeah you get this wrangling over a ctg one expert says this one expert says the other and you know i'm afraid look sure if a on a ctg the baby's heart rate drops to 80 and is there for you know an hour and someone doesn't do anything yes all right well that's But most of the time, it's these more subtle changes, which, you know, there can be 10 different opinions on. So, at least you take that out. And I guarantee, say, if you did that, that would immediately change the whole, it would be, that would affect a substantial cultural change.
Mel:
[1:04:22] Wow, simple as that. We'll just take the CTG out, which is what Kirsten Small's been advocating for all these years. And see what happens from there.
Andrew:
[1:04:32] Yeah, yeah. That's right.
Mel:
[1:04:33] I have one more question.
Andrew:
[1:04:35] Yes?
Mel:
[1:04:36] So there's a lot of women who listen to this podcast as well as the midwives and there's a whole raft of people. What do you think they need to know as they are stepping into the maternity care system for their care?
Andrew:
[1:04:48] I think the first thing, and it might surprise, they've got to realise that
Andrew:
[1:04:53] everyone in the maternity care system is on their side, okay? At times it might look like that because, and it's most of the time, it's not because people don't care, it's most of the time because there are so many competing anxieties, I'd call them, and considerations around risk. They've also got to realise that birth, in fact, has never been safer. When you add the sum total of it, right, There are various things that we could do better. But the other thing, I think they've got to insist, they should be on consistency of information and communication about. And that they shouldn't, you know, you often get this line that, well, it depends on who's on duty on the day. No good.
Mel:
[1:05:42] Unacceptable.
Andrew:
[1:05:44] Unacceptable, you know. And if you hear that, they've got to say, well, sorry, Can't you do better than that? And the other thing is they've got to just let their carers know that they, as consumers of maternity care, want to work with the carers, be they obstetrician or midwife. Just that very positive state that I want to work with you. And then the other important thing, I think, is if something is recommended in the form of a test, be it policy or something extra or some intervention, clearly you need a reason for that, you need some of the evidence, but most important, you need to say, how strongly is that recommended? To say, you know, well, so my line was always, You know, say we, if a woman had a placenta previa and, you know, we're saying, well, we advise a cesarean section, I will say, and if I had to say how strongly I advise that, well, it's a 9 out of 10.
Mel:
[1:06:53] Right. So the woman knows we're not just making this up.
Andrew:
[1:06:56] Yeah, that's right.
Mel:
[1:06:57] Just policy. We actually have a concern for you.
Andrew:
[1:07:00] Yeah, whereas, say, if you were to talk about screening for gestational diabetes, all right, what's the recommendation there? Well, it's more like a six or a seven. It's not discouraging the woman. Overall, it's saying yes for these reasons, but you know that a whole lot of women who don't have screening for gestational diabetes are okay.
Mel:
[1:07:26] Yeah, well, and it might even be, look, you're 22. You're not overweight. You're not of an ethnicity that I'm concerned about. You don't have a family history. My concern for you is a one or a two. Alternatively, if you've got a woman who's 43 with a history, my concern for you is, you know, yeah.
Andrew:
[1:07:43] Yeah. But it's, you know, having some idea, well, how strongly is this being recommended, you know? And this business, you know, and the other thing you don't accept is any sort of language that you're not allowed to do this or that, you know, we just can't do that here or...
Mel:
[1:08:01] If a woman's told, you know, we don't do that here or you're not allowed to do that here, what can they say to that?
Andrew:
[1:08:08] Well, they can say, sorry, this is not a boarding school. They need an explanation, you know, that you're telling me that you're anxious about this or that you've got... Can you tell me what the concerns are? And sure, if, you know, the institution says that they can't do it because of these concerns, well, you try and make some arrangement locally or at some other hospital. The other thing is that, all right, there's a ton of evidence out there And the reality is that there are very few cases where evidence gives you a black and white answer. Evidence, you know, mostly gives you some average recommendation, doesn't take into account individual variation. That's the role of, you know, the maternity carer. And so the black and white sort of recommendations based on a black and white understanding of evidence, you know, And this particularly applies to the whole induction of labor issue.
Mel:
[1:09:12] Andrew, is there anything else that you feel like you'd love to add to this conversation?
Andrew:
[1:09:16] One of the questions which you asked me about resilience, all right, it's been hard work. At times, you know, there have been some demanding moments and you asked, well, what helps me in that situation?
Mel:
[1:09:33] Yes, strategies for resilience.
Andrew:
[1:09:36] Well, the first strategy was just having that substantial quantum of positive working relationships at work, right? Any times when, say, something was getting tough, I was very fortunate to be able to go to a number of people and they would just sort of take one look at me and say, what's happened, Andrew? And that was really nice, right? But the other thing there is, you know, when I said I believe, well, that helps me, all right? Because I do. The other thing is clearly my wife is always very good in that she's the type of person, I just relay her, you know, describe the situation, she immediately gets it. She immediately gets the aspect of human interaction, power concerns, you know, and she'll be able to say, yeah, it sounds like this, Andrew, you know, and she's right. And that's really helpful. Music is really helpful. And then, of course, tennis, being able to shout and scream on a tennis court is very helpful.
Mel:
[1:10:48] I can't imagine you shouting and screaming.
Andrew:
[1:10:51] It brings out the worst in me. Let me show you. So, yeah, look, I'm very lucky there that all those things really do help. But it's that even if there's some significant difference, it's always been that the underlying working relationships have always been strong. And so, you know, you do get that genuine mutual support so that, you know, the demands, you know, the inescapable demands and difficulties don't bowl you over.
Mel:
[1:11:24] And the fact that you really wanted to continue going after all those years is a testament to how you set up a system of resilience around, with hobbies, little releasers, colleagues, and what sounds like to be a very, very wise, intuitive wife.
Andrew:
[1:11:45] Yes, that's right. Yes, that's a little bit mildly.
Mel:
[1:11:51] Mildly. I love that. Oh, my gosh, I want to meet her now. Sounds incredible. Well, thank you so much, Andrew. I want to thank you for so many years of commitment and years that you've given to women, that your work around breach birth, your tenacity and resilience, and the fact that you want to keep going is so inspiring. Now, Andrew is going to be with us live at the Convergence of Rebellious Midwives in July, and I've already had some insight into his talk, and I'm so excited about it. So if you want to see Andrew live, come to the Convergence. Otherwise, Andrew, I want to thank you so much for your time and your good pleasure.
Andrew:
[1:12:31] It's very nice to help you, Melanie, and thanks for the questions. That sort of helps me, by the way.
Mel:
[1:12:38] Great. Well, that has been this week's episode of the Great Birth Rebellion podcast, and we will see you in the next episode. To get access to the resources for each podcast episode, join the mailing list at melanethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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