Hannah Dahlen - The renowned midwifery advocate discusses her career, medical interventions in births, home births, and relationship-based care.

Karen:  Welcome to Episode 3 of the Health Times podcast. I’m your host, Karen Keast. Today we’re speaking with renowned midwifery advocate, Hanna Dahlen, a privately practicing midwife and Professor of Midwifery at Western Sydney University. Hannah has 25 years’ experience in midwifery and has caught thousands of babies. Hannah, what prompted you to become a midwife?

Hannah:  Midwifery you would have to say has been in my blood, and if there’s any kind of genetic inheritability around midwifery I probably have it because my mum was a midwife. I was actually born in Yemen and my mum was a midwife out there, and my very earliest memories as a child were actually being kind of cornered in a playpen in the corner of the clinic while she attended to women. My early memories are of these beautifully decorated and hennaed hands coming over the crib to tug at my hair because I am very blonde and they’d never seen a blonde, blue-eyed child before and they used to shriek with laughter and call me an old woman. My kind of earliest play things were spatulas and kidney dishes, and it was just in my blood. I actually do not remember ever not wanting to be a midwife and I kept begging…I used to go and spend time in the clinic with all the nurses and midwives and I used to help clean out the burn wounds and basically anything I could do that was getting me engaged I’d do.

I finally convinced them at the age of 10 that I was big enough to go in and be part of a birth. I remember seeing that birth and being really bewildered because for some reason the woman was up on the table and it all seemed, kind of not how I’d imagined birth was going to be. Then when I was 12 my next door neighbour had her third little girl, and I was involved all through her pregnancy with my best friend who lived next door, and I got to go over and help the local midwife catch this third little baby who was called Hannah, after me. I will never forget, she turned her head away and said, “Oh, not another girl.” Because in that culture boys were highly valued. And I remember taking this baby over to the window and the dawn was coming up over the Middle East and the Minarets were sounding the Call to Prayer. And I just remember, here I was on the brink of womanhood myself but just being absolutely struck by what other profession on earth could be greater than being at the beginning and watching women’s power and seeing life made, and to me it was just - it was a no-brainer; I was always going to be a midwife.

I then came back to Australia when I was 15 and at that time you had to do nursing before you did midwifery, so I kind of reluctantly went through my nursing training, and as soon as I was done I shot over to the UK to follow in my mum’s footsteps; she was a UK-trained midwife. I did my midwifery in the UK, and it’s 26 years this year and I have not looked back, and I still think I am working in the best profession on earth.

Karen:  Well, tell us a bit more about your midwifery career; where have you worked and how did you make the move to become a privately practicing midwife?

Hannah:  Yes, very good question. I did my training in the UK and I spent a couple of years there and then I came back and I worked at all public hospitals; I worked at Auburn Hospital for three years and that was absolutely wonderful. That’s where I say I became a midwife because my skills were honed. It was midwife-run. We had lots of wonderful, supportive normal birth practices going on and I really stepped into my own and my confidence there. And then, I was young and ambitious and I thought “Well, now I need to go to a big city hospital and experience sort of high-risk and complex.” And I went across to King George V at the time, which is now RPA, I became the Midwifery Educator, and I did that for a few years before becoming the Midwifery Consultant at Canterbury and RPA. I had some babies in the midst of all of this, so life had been in and out, and I’d undertaken an Honours and a Masters and I was on my way through a PhD.

I’ll never forget the day when I was working and a woman walked down the corridor in the delivery ward and she came down with her husband, and she was this small, little Asian woman and her husband was a sort of big, strappy man beside her, and I, to my great shame, thought, before she reached the desk, you know, “Oh, it’s going to be a long, hard labour and it’s a big baby, it’s going to be awful, forceps, and then it’s going to be Cerebral Palsy and there’s going to be a legal case.” And when she reached my desk I had gone through all that thinking in such split seconds and I thought “I have to get out of here. This is terrible. What am I doing to women that the fear that has really started to seep into my soul is now going to be impacting on the way I care for women?” So, I left and, amazingly, I got offered an Associate Professor position at Western Sydney, which I took up. But I missed clinical terribly because I always say, “I’m a clinical academic not an academic purely.”

Then I was President of the Australian College of Midwives at the time when all the reforms were coming in and I was part of all the Senate Inquiries and the rallies and the lobbying and all of the interviews, and it was such an amazing time. When we look back at a moment in history, midwives came into their own in 2010. We got the ability to get Medicare prescribing numbers and be able to order and prescribe medications and get insurance to set up our own practices, and I thought, my whole life began watching my mum in that very autonomous - almost like a private practicing midwife, but obviously in the Middle East that’s a very different concept. I realised I needed to kind of ‘come home’ to where I think I’d always been journeying.

At the time - and these are the interesting kind of collisions of history that happen - I had a wonderful student who was a researcher for me and then became my PhD student and she was desperate to set up private practice, and she said, “Well, what do you think?” And I said, “Great. I don’t want to ever work in isolation.” And we contacted two other long-term private midwives and said, “Would you consider working with us?” They said yes and in 2010 we formed Midwives at Sydney and Beyond and we then brought in two more midwives; Emma and Janine joined Robyn, Jane, Mel and I.It’s now six years that we’ve been providing caseload midwifery from the moment the blue line appears on the stick, all the way through where we attend their births and then we do postnatal care for six weeks after the birth, and the majority of our births are homebirths. So, for me, I feel like I’ve come full-circle. And when I look at where I am now - and I think I’m in a really privileged position to be able to say this - I think I have the perfect job. I love my work, I love what I do. I have my research, which keeps my researcher academic brain alive, I teach student midwives, I still am very strongly engaged in politics but I practice. And I think when you put those kind of four scaffolding bits together that I feel like I have a really well-rounded, both enjoyable but also very well-rounded perspective.

Karen:  You’ve long held concerns about escalating rates of medical intervention in births. How big an issue is this in Australia and what impact does this have on women and their babies?

Hannah:  Yes, that’s probably become the major focus of my work. I’ve now published over 120 papers and book chapters and spoken at many, many conferences, and most of my work now is really focused in around “How can we support women to have normal births?”
Not just normal as in “the baby comes out of the vagina” that’s not the definition of “normal” but also very satisfying births. “How can they feel empowered? How can they feel cherished, looked after, respected?” I want to see women come out of birth and be tigresses. I want them to come out of birth and feel like Amazonian women, not destroyed psychologically.

So, a lot of my work is around “How do we make pregnancy care safe psychologically for women but also safe physically?” And Australia does pretty badly in the world; we’re one of the worst in the OECD countries for our Caesarean-section rate; one in three women now have major abdominal surgery to have a baby. The World Health Organisation still came out only again last year and said, “There is no evidence of a rate beyond 10 to 15 per cent,” so we’re double what we should be. We know we can do it better because we know in continuity midwifery care models, and certainly in our group practice, it’s way under 10 per cent. But you can get those rates. But yeah, we have very high rates.

And one of the major issues we have in this country, which doesn’t exist in the UK where I trained - and in Scandinavia where we see some of the best outcomes in the world not only in terms of safety for mothers and babies but also in the very high rates of normal birth - one of the things we have different in this country is a very high private sector, which has private obstetricians basically caring for low-risk women, and inevitably the medical paradigm is influencing the way that they care for those women. We’ve published several papers looking at low-risk women having a baby in a private or public hospital, and clearly the intervention rates are much, much higher under a medical model of care.

Unfortunately in this country we subsidise and supplement and advocate a model of care that does not necessarily lead to best outcomes for mothers and babies. In New Zealand, over 90 per cent of care is led by midwives. In the Netherlands you only get to see a doctor if there are problems. In Scandinavia it’s all led by midwives until there’s an issue and then a doctor is called in. In this country we still have one-third of women who are healthy and well going to highly-trained surgeons and then we wonder why our rates are what they are.

Karen:  Okay. What are the benefits of the continuity of care model and how widespread is this model in Australia?

Hannah:  Right. That’s a really good question. Continuity of midwifery care is now, through a systematic review published in Cochrane, certainly around most controlled trials, - thousands and thousands of women in several countries, randomised, having a midwife through the pregnancy, birth and postnatal period compared to all other kinds of models; so, several models have been trialled as the control group in these studies. And actually the results are so stunning you could consider it almost unethical for a woman not to be given a midwife that they can have a relationship with and provide their care and in a continuity care model. They have less intervention, they have higher satisfaction, they have better breastfeeding rates, they have less babies going to Special Care Nursery, they have less babies dying under the continuity of midwifery care. But even more stunningly - and this is what is so extraordinary - is they have 24 per cent less pre-term birth. Now, pre-term birth is the biggest contributor to morbidity and mortality when it comes to babies. It costs less, women love it; there is nothing that we can find that is a negative.

And yet, in this country, we’re trying to get better at gathering the data but we think around perhaps five per cent of women have it. And when I say that five per cent of women, they will have to be located in the big metropolitan centres; there is very few continuity midwifery care models out in country, in rural and remote Australia. So, when you think we have the gold standard with the highest scientific evidence, - basically if this were a medication it would be mandated that every woman should be given it because it’s so powerful in effect, yet only five per cent of women can access these models; they’re heavily booked out. If women don’t book the moment they have the blue line on the stick they’ve almost got no chance; there are waiting lists. And it’s completely unethical that in this country we still do not provide evidence-based Best Practice.

Karen:  Another issue is homebirths, which in Australia have been sort of steeped in controversy. How many homebirths have you attended in your career and what do homebirths have to offer women and their families?

Hannah:  Yeah, that’s a very good question, and if you just fly in a plane, 17, 20 hours and land in the Netherlands nobody blinks an eye at homebirth and 20 per cent of the women have one. If you go to the UK, and you go to Wales, over 10 per cent of women are having homebirths and the government is promoting it and has public policy around the fact that more women should give birth away from the hospital. Yet in Australia there is this kind of very parochial, very conservative view around homebirth, which is strongly driven by the medical paradigm. And homebirths in Australia, it’s about .3 percent, so it’s a very small number; it’s about 1000 a year. In our group practice we probably now catch over half of the homebirths in New South Wales; that’s kind of how small it is.

But the difference is unbelievably stunning. When you see a woman labour in her own environment you have to almost relearn everything you have thought you were an expert about before because women in their own environment, they labour differently. You don’t see pain like you see in hospital. You see women in labour, you see incredibly powerful births, and with good care and proper strategic -, making sure that low-risk women access homebirth, not women with significant risk factors, you can have excellent outcomes and we know that from the data. But there is a very strong hostility in this country to it and that’s a pity, because this is our research we’re doing, but there are more and more women choosing to birth without a midwife because they can’t access them because we’ve made it so kind of horrible out there for midwives in homebirth practice. So, I would say now, looking at the data that we’ve got, and we’ve done a couple of really big nationwide surveys, more women are now having their babies at home unattended by any health professional than are having them as planned attended homebirths.

Karen:  So, that’s what we call free-birthing. What concerns do you have about free-birthing?

Hannah:  Look, it’s not ideal, and when I first started looking at this - and I’ve had several PhD students now doing different aspects of this study - I was like “Why would anyone do that? You know, just get a midwife.” And boy, my eyes have been opened. Firstly, many women can’t access a midwife. Secondly, many women can’t afford the between $3000-6000 that they have to pay to access a midwife. Third, some women have been so traumatised by their care in hospital - and this is the number one reason why women seem to choose free birth - that they don’t even trust midwives anymore; they have such a negative, abusive obstetric violence experience in their first birth that they cannot even darken the doors of the hospital.

We’ve interviewed women who are physically sick if they see a hospital sign. They just couldn’t get themselves in there; they’ve got Post Traumatic Stress Disorder. And so, they can be caught between a rock and a hard place. If you can’t afford a midwife, you can’t find a midwife, or you are so scared the midwives are part of the problem, you kind of go “Well, I’m going to die if I go into hospital because psychologically this is not going to be tolerable. I’ll take the risk of potentially not dying if I have the baby at home.” So, we criticise and demonise these women and yet I always say they’re the refugees from mainstream maternity care and we, the health provider, need to look at what we’re doing to damage these women to make them feel so unsafe with us that they feel this is their only option.

I’m very concerned where we’re headed. We’ve just undertaken a survey of over 1800 women who are either planning or having homebirths in Australia and when we ask them the question “What would happen, with all the increased regulation happening with private midwives, if you couldn’t access a midwife for a homebirth what would you choose to do? Would you go to a birth centre, go to a hospital?”  More than 70 per cent of them said they would choose to free birth. And that’s a real worry. You will not stop women having homebirths. What we need to do is put in place a system that’s safe and respectful so that we end up with the best outcomes, not forcing women into making choices that are not necessarily in the best interests for themselves or their babies and families.

Karen:  Well, where do we go from here? How do we get the balance right between hospital-based medical care and midwifery?

Hannah:  Now, it’s an incredibly good question, and I do not think the answer is homebirth - and I’m saying that as a midwife who attends homebirths. The answer is much better continuity and more midwifery models of care  available within the system. We need more stand-alone midwife units that are not attached to hospitals but have easy access to hospitals. We need groups of midwives setting up in private practice to provide a really viable option. And then out of that, what you find in most countries, is where you get established a physiological paradigm, a midwifery-led paradigm, homebirth is a natural evolution from it. So, I’m a great advocate in not beginning with “Okay, let’s get more homebirths.” Let’s get more normal birth in the 98 per cent of the population that have a baby in hospital, and you know homebirth will be a natural consequence.

So, really, there has to be political will. We’ve had every obstacle possible put in our way. I cannot tell you, as someone with so many degrees and a PhD, I’ve had to jump through every conceivable loophole. I’ve had to undertake further education; I’ve had to go through rigorous processes of getting eligibility just to be able to call myself a midwife who privately practices. We don’t put doctors through this and we shouldn’t be making it so, so difficult. We need insurance for private practicing midwives that covers homebirth; currently it doesn’t. We need to have the government actually look at different funding models where we don’t actually fund the provider based on what they do to women but we fund the women, like in New Zealand, to…In New Zealand they give the women a package of money divided into different sort of trimesters and say, “You go out and purchase who you want with that money. You can go pick your provider.” In this country we don’t do that; we don’t give women true choice. So, if we actually put the money into the hands of the provider we would revolutionise the system tomorrow, but there’s a very strong medical incentive not to do that because they sense, and they know from the New Zealand example, how much women, when they experience it, love midwifery care.

Karen:  When it comes to midwives what are the biggest challenges that face midwives for those practicing in hospitals and for those privately practicing?

Hannah:  Look, that’s another interesting question and we’ve done a lot of research into that as well and I write about this; this is another area I’m so interested in because it ties in with normal birth as well. There’s a lot of midwives working who are really despondent and are really frightened and are constantly looking over their shoulder and feeling that if anything goes wrong everybody comes down on them like a tonne of bricks.All the things that they have been taught and the evidence-based practice they know that they should be delivering is being usurped and regulated by a completely risk-obsesses system. We have a name and blame and shame system in this country. When something goes wrong we absolutely crucify the people involved instead of doing exactly what we should be doing, which is learning the lessons, improving the systems, understanding people are in the systems; they’re not lone rangers on the whole out there. They didn’t get up in the morning to do a bad job; most of us are very ethical and principles.

I just went and saw the movie “Sully” on the weekend about the pilot, Sully, who landed the plane on the Hudson, and there were just so many parallels for me about what happens in maternity care with the way we blame midwives for when things go wrong, and the way midwives are running scared, and then when midwives are running scared they start to intervene more and they burnout. So, sadly, there’s a lot of despondency out there and there’s desperation for change. And I think sometimes in life you almost have to get to a breaking point to realise that you need to do something different and you need to turn everything on its head and fix the system.

Karen:  Do you have any advice for midwives; how can they excel in their careers?

Hannah:  Be brave. I’ve learned to do things and ask forgiveness later. I’ve learned to just say, “Well, isn’t this what we all do?” and make people doubt themselves rather than doubt myself. I think we have to be brave. But I’d also say, first of all, “Where is your allegiance?” I think midwives have been pulled away from their allegiance to women and I think many midwives are what I call “With system” and they are thinking all the time about “Well, what should I do according to what I’ll get in trouble for? And have I done all of the checklist stuff?” And they’re so obsessed with that they’re not thinking “This woman is the only woman on earth that exists that’s like her. What does she want? What are her dreams? What are her hopes? How can I be a midwife that meets her needs?”
I’ve got a PhD student doing a wonderful study filming the interactions between women and midwives when they know each other and when they don’t, and it’s just blindingly obvious that where there’s a relationship midwives change their language, they speak less, the woman speaks more, the woman and the midwife tell more stories to each other, the relationship, the way the information is given is just so much more organic and useful. So, I think we’ve got to seriously look at relationship-based care because I honestly think we’re currently trying to put Band-Aids on a bleeding artery, and if we went back to relationship-based care where women are the centre, all these other issues would be fixed.

Karen:  Hannah, darling, thanks for your time. And thanks for listening to the third episode of the Health Times Podcast. We’ll be back with more podcasts. You can subscribe to the Health Times Podcasts on iTunes. And don’t forget to check out the range of jobs, articles, and other resources on the Health Times Website by visiting Healthtimes.com.au.