Professor, chief and midwife

Lesley Barclay is a respected researcher and a professor of health services development. She is also a chief of a small Samoan village.

It is an honour that was bestowed upon her in 1996 in recognition of her contribution to the country's nursing and midwifery services.

“It was conveyed with due ceremony... I was dressed in a fine woven palm mat with feathers stitched around the bottom... I had feathers in my hair and stripes of ash from the fire on my face. The ceremony is run by the male chiefs of the village and it is a traditional title that is attached to a particular village on the north coast, so it has not been affected by the tsunami... It was a great honour and whenever I go to Samoa I am referred to by my chiefly title, Utumuu.”

Part of the work Professor Barclay was doing in Samoa was investigating a birth model she believes is unique in the world. Traditional birth assistants, that is women who are culturally designated the role of a midwife but have not been through any formal training, work alongside Western trained nurses and midwives.

In a new book called Birth Models That Work Lesley compares the experiences in Samoa with other countries she in which has worked including Papua New Guinea, India, China and Jordon.

“Data we have collected from traditional and professional midwives shows the experience in Samoa paints a much more positive picture and demonstrates a successful transformation from colonised birthing models,” she says in the book. “(Samoa) is more advanced in integrating social systems and practitioners with the advantages of professional health care than many others.”

By contrast her research in a remote region of China found that women were overwhelmingly rejecting the well meaning, but culturally insensitive attempts to get them to birth in hospital.

“They expose you, they shave you, they cut you, they stick needles in you, they give you nothing to eat or drink, they leave you alone and don't come when you call, they won't let your relatives in to be with you and when you complain, they yell at you and slap you,” one woman is quoted as saying in the book.

Lesley has been a strong advocate for homebirth for 30 or 40 years and, given the situation in Australia at the moment where independent homebirth midwives fear being forced underground because they are unable to get indemnity insurance, it is interesting to hear her thoughts on what is happening.

“I'm worried that we are losing sight of the fact that almost all midwives in Australia are employed within the hospital system... In three states (SA, WA and the NT) you can have homebirths with salaried midwives (who work within the hospital system)... We have very good evidence that homebirth is safe when it's properly conducted. It reduces pressure on the hospital system and in fact the UK is working extraordinarily hard to increase homebirth levels for exactly that reason...We need a number of models... Individual private practitioners need to be there, but my intuition is that they are not going to grow a large amount because we have had a similar number of midwives in private practice for 30 or 40 years and it's a very small percentage. Most midwives appear to prefer to work in a salaried system, but most who work within that system, like mothers, need lots of flexibility.”

She suggested the model used at Mullumbimby is one of the best in the NSW public health system. Women who are assessed to be low risk and see an approved obstetrician in the lead up to the birth are able to have their baby in a private birthing suite with the assistance of a midwife. The partner is also able to stay with the mother the entire time she is in the hospital. They also have the advantage of having the obstetrician on call if needed and the ability to be moved to a larger hospital as a last resort.

“The models that work are the models that put the woman and the family at the centre,” she said. “The ones that don't work are the ones that prioritise the facility or the professional.”

She believes the greatest failing of childbirth practice in Australia has been the increase in medical intervention.

“About 30% of women now are having an operation to give birth (and) operations have risks attached.

“The reasons are complex but one of the contributing factors in this country has been requiring young, healthy women to take out private health insurance. If you have private health insurance and you think you should be buying private obstetric care, you have then increased the risk of intervention...One of the good things about private obstetric care is it gives you continuity of care... so if the choice is buying a familiar face and all the hospital is offering is a different face every time you go in, then a private obstetrician is a much better option. But associated with that has been a shocking increase in operative birth which is now two to three times higher than it should be, and it is much higher in private hospitals than in public hospitals. That's one of the real failures of our system. Not just because it increases the risks for mothers and babies, and those risks are serious risks, it also reduces the quality of social outcomes. It makes breast feeding harder. The likelihood of becoming depressed or anxious is higher because you are recovering from major surgery and that's really difficult on mums and on families. So it's much better to give birth vaginally if it's possible. If it's not possible, and that's probably for about 10% of women, we are very fortunate in that we have got high quality surgical care available to us.”

Lesley is currently the Director of the Northern Rivers University Department of Rural Health in Lismore and began her career as a nurse, working in a small South Australian hospital before realising she wanted to study midwifery.

“Once I did midwifery I didn't really want to go back to nursing... I worked on and off for 8-10 years around the birth of my own children as a clinician and realised I couldn't influence the quality of care people were getting sufficiently as a clinician. So I taught midwifery for about six years and at the same time did an undergraduate degree and a masters degree. I decided then that I wasn't able to revolutionise the system as a teacher so I'll become a researcher. Along the way, whilst doing a PhD, I also worked in primary health care, community development and system transformation and in 1991 was appointed as the first health service funded Professor of Nursing and Midwifery in Australia.”

In the last 10 years she has supervised 26 PhD students and 12 of those are now also Professors of Midwifery around Australia and the UK.

“So I couldn't change things as a practitioner, I couldn't change them enough as an educator and I personally won't change them enough through my research, but the people who I have educated will!” she said with a laugh.

Prior to moving to the North Coast Lesley worked in the Northern Territory as the first Professor of Health Services Development. She has also worked extensively for the World Health Organisation and AUSAID in places like India, Indonesia, Papua New Guinea and China running development projects in primary health care and maternity care, as well educating nurses, midwives and community health workers.

“When I got to the Northern Territory there was no post graduate education for nurses, midwives or aboriginal health workers. We set up a school and a graduate diploma in child and family health because there was nothing in the NT, where children's health is the worst in the country. So we set education systems in train and prepared some more PhDs who have a remote, rural primary health care focus.”

She says the rural health system we have in Australia at the moment needs to be brought into the modern age.

“What's fascinating here (in the Northern Rivers) is the juxtaposition of small towns and how you design a health service that provides the best possible care for rural populations... At the moment we've got this view in our heads that you've either got a small hospital or you've got the regional hospital (and) we're having to shift our understanding in the community that's it's not about one or the other, it's about the best possible blend of both.

“Towns here were set up a day's horse ride from each other. (They) had to be self contained. You needed your own GP, you needed your own hospital, there was nowhere else to go. So we've got a health system that is historically logical, that's based on the horse and based on the fact you had GPs come in their 20s and stay for the rest of their lives. You had young growing populations and a vibrant farming industry that was not struggling to maintain rural populations. And there were young people coming and young people growing up and staying, not older people coming to retire. So we've still got a health service that essentially reflects that historical priority that was logical and made sense, but now with great ambulance services and good communications with the capacity to link with motor vehicle transport so quick and easy, we haven't caught up in our thinking and we're in transition.”

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