Newcastle obstetrician Andrew Bisits has a reputation for taking on the cases that others shy away from. Admirers say his approach is refreshing but the specialist tells Neil Jameson it?s only natural.
In September this year, when Townsville?s Tammy Forster learned her baby was comfortably breech, she almost resigned herself to having a caesarean section. ?I was on the net researching caesars and different options and getting really depressed about the whole thing,? she tells Weekender.
It was when she changed her search from ?caesareans? to ?vaginal births? that she stumbled upon the John Hunter Hospital and its director of obstetrics and gynaecology Dr Andrew Bisits, a practitioner willing to take on breech deliveries.
In recent times Bisits, as one of a rapidly dwindling number of obstetricians who will do breech deliveries, has become a go-to guy for helping mothers achieve natural birth in spite of difficulties. And the frequency with which his name appears in online maternity forums suggests others are following Tammy Forster?s path to his door.
The international Term Breech Study of 2000 reported that planned caesarean section was safer for the baby than attempting vaginal birth. The study has since been the subject of much debate and criticism but its legacy has been a worldwide reluctance to deliver breech babies vaginally and a decline in skills among obstetricians.
Forster, the first-born of six, had been a breech baby herself and, like her mother, felt strongly about women exercising a choice in childbirth. Her experience typifi es the process that is bringing increasing numbers of mothers-to-be to the John Hunter unit. At 36 weeks, she had visited the Townsville Hospital for a routine check-up.
?I began discussing the possibility of a vaginal breech birth with the doctor. I was told that as the Townsville Hospital was ?public? they would be forced to follow my request,? she says.
?My knowledge about the risks of breech deliveries was tested and questioned. I was told that a meeting would need to be held with all obstetricians at the Townsville Hospital to discuss my decision, and all obstetricians would have to agree to deliver our baby because any doctor ? including doctors with little to no experience with breech deliveries ? could be on duty at the time of my delivery. I was told that they would rather I delivered our baby in Newcastle.?
At 38 weeks, Tammy and her husband, Adam, arrived at John Hunter to meet Bisits. ?We instantly felt confident and proud of our decision to come to Newcastle,? Tammy later noted.
A week later, on October 28, Liam Heath Forster, weighing 3.78 kilograms, arrived feet first into the world. A few days later the Forsters flew home with their baby.
As Andrew Bisits attests, the whole of pregnancy is characterised by a series of risk hoops. But where the statistics cause other practitioners to shy away from ?difficult births? such as breech or where a mother has had a previous caesarean section and is seeking a vaginal birth, he is willing to acknowledge the rights of the woman.
Justine Caines delivered her seventh baby this year. Having a newborn on her breast didn?t prevent the Scone-based maternity advocate travelling to Canberra to contribute to the Maternity Services Review. She is a strong supporter of the Bisits attitude to birthing. ?He is pretty much the most progressive obstetrician in Australia,? she says.
When Caines was pregnant with twins three years ago, she chose Bisits for her consultation. ?I have never heard of a male obstetrician remove themselves so much from the equation and acknowledge the intrinsic right of women to make decisions about their bodies and babies,? says the former national president of the Maternity Coalition.
Few callings are as subject to gender politics as obstetrics, with its historical profile of male leadership. And few are as potentially litigious. When an expectant mother from outside the Hunter finds her way to Bisits?s door he refers to her as having arrived from ?St Elsewhere?. As word spreads, especially via the internet, more and more St Elsewhere clients are arriving at John Hunter.
Carolyn Boyd was a St Elsewhere arrival in March 2007 when she gave birth to breech baby Finn. Last month, Boyd and partner Matt Shepherd had their second. Baby Millie arrived in Sydney via a natural birth after an incident-free labour lasting just 11/2 hours.
It?s fair to say that the groundwork for that joyously smooth event was laid some 20 months prior when the first-time mum had gone to considerable lengths to give birth naturally to Finn.
Had Boyd accepted the initial prognosis and settled for having her son delivered via caesarean section, it would have almost certainly pre-ordained the birth process of Millie and ensuing babies. In the risk-focused world of ante-natal care, obstetricians are reluctant to offer a VBAC (vaginal birth after caesarean).
Nursing week-old Millie at home in the inner-Sydney suburb of Alexandria, Boyd tells Weekender that the smooth nature of her new baby?s arrival delivered ?a good end to the story?.
?In a way it was a vindication of our decision to have Finn naturally,? she says.
In February 2007, a fortnight before Finn?s arrival, Carolyn and Matt had headed for Newcastle where they had leased a house in the East End close to the beach. Boyd had been told that her breech-positioned baby meant Sydney?s Royal Hospital for Women couldn?t guarantee her a vaginal birth.
?Officially, they thought it would be OK, but they couldn?t guarantee staffing,? she recalls. In plain speak, it was unlikely that an obstetrician would be available to attend the birth. The only option was an elective caesarean before the onset of labour.
But Carolyn Boyd was determined to make an informed choice. She went home, did her homework and packed for Newcastle. The proximity of the beach to their rented terrace was a bonus but the real attraction lay out at John Hunter Hospital.
?It was a 12-hour labour but I was motivated for it and I had done my research,? Boyd recalls. ?We couldn?t have been happier with the result.?
?Outside the square? is a phrase you will hear often when Andrew Bisits talks about the birthing business.
In offering women the possibility of a birth of their choice he has often placed himself at odds with the prevailing view, driven as it is by statistics and the reduction of risk.
The square, in this case, is the shrinking space left by a decline in resources and the process of health authorities and insurers seeking to reduce birth complications (and potential damages).
?There are a number of particular intermediate hospitals where there are problems with staffing, so the easiest way to run the system is to make sure you have people on the ground who can do a caesarean,? Bisits says.
Consequently, Australia has developed one of the highest rates of caesarean births with 31 per cent of babies delivered this way. Bisits fears the legacy will leave a scar on the quality of care.
?Ante-natal care has degenerated to antenatal scare,? he says.
?There has been far too much focus on the worst-case scenario to the point where our thinking has become distorted and we?ve lost sight of normality.?
He says that rather than merely talking about the frequency of an occurrence, everything is regarded as a risk.
?Risk is a very powerful word. Everything that can occur is called ?a risk?,? he says. And Bisits should know. He became a voracious consumer of statistics, particularly as they applied to risk.
?I would sit in the bathtub reading books on statistics,? he confesses. The degree of risk is gauged in part by the gamut of tests women are obliged to run almost from the onset of pregnancy. These tests have created what Bisits terms a ?a new environment for pregnancy?.
?Everyone is potentially normal until proven abnormal by a certain risk factor. Today, we?re so ambitious we want to detect everyone with a problem. It creates a new way of relating to the baby which is already centred around, ?Is there something wrong, is my baby perfect?? ? Rather than succumbing to this climate, Bisits says we need reminding that risk-taking is a vital part of life.
The extreme end of the fear obsession plays out in what maternity forums have tagged the ?hair salon? syndrome where women are influenced by tabloid accounts of Hollywood stars adopting children and thereby evading the entire maternity process with all the challenges and risks it poses.
?The truth is that it has never been safer to have a baby normally,? Bisits assures. ?Yes, pregnant women may be older and heavier, but they have never been more healthy.? Bisits agrees that social factors are leaving the greatest impression on mothers-to-be. The components, he says, are the legal phenomenon underscoring risk and a lack of confi dence among many women.
As director of the John Hunter unit, Bisits is vibrantly aware that there are elements of a major hospital that play into the concerns of pregnant women. Unlike most patients, expectant mothers are neither injured nor ill, but they arrive at a facility where the climate of concern creates a certain tension.
?I have never heard of a male obstetrician remove themselves so much from the equation and acknowledge the intrinsic right of women to make decisions about their bodies and babies.?
?It?s a busy place with lots of problems and we do our best to shield the women from that,? he says. ?That can be unsettling because as they get closer to the time of having a baby they experience an increasing sensitivity.? That?s why, he says, some women make the decision to have a home birth with the condition that if there are complications they can go to a hospital. In spite of all his training and the sophisticated elements on offer at a major hospital, Bisits accepts such a decision is reasonable.
?There are provisos,? he says. ?It must be a well-informed decision. It must be more than ?I just don?t feel safe going to a hospital?.? Abashed to learn online discussions refer to him as the Breech Catcher, Bisits acknowledges the collaborative effort that has contributed to his unit?s success with breech births.
?We have developed a system whereby women are motivated and educated. We talk about it and we get them to watch a video.? Usually, the video shown is that shot by Carolyn Boyd?s partner, Matt Shepherd, during the 12-hour labour that brought Finn into the world.
In recent times, the John Hunter unit has delivered 50 breech babies a year but that is certain to rise. In handling the growing traffic flow, Bisits refers to the ?quorum of confidence? that the John Hunter unit has developed around breech birth.
?There is any number of midwives I can call on. They give the women the midwifery perspective rather than my bland description of how it?s done. Then the midwife sits with them through the video and arranges continuity of care.?
Bisits is a powerful advocate for the role of midwives, knowing that many of his peers may not agree.
?The culture of practice in Australia has been dominated by doctors,? he says. ?Up to about 15 years ago it was predominantly males. Today, we have many more women, but it?s still doctors in charge. ?So, the idea of midwives having a primary role threatens that concept of ?We know best?.?
That attitude, Bisits suggests, is driven by the perception that Australia?s comparatively good perinatal mortality rate is a situation best left alone.
?The view is that if you have a system where midwives have a bit more power, that?s going to lead to worse outcomes. That?s the bottom line,? he says.
Maternity advocate Justine Caines is optimistic the soon-to-be-released Maternity Services Review will overturn that thinking by establishing a national funding arrangement for Australian midwives.
Meanwhile, Bisits observes that midwives are highly motivated by women choosing a natural birth.
?These [birthing] women are just ecstatic,? he says. ?I know it sounds cliched but it is the only word I can use. Because labour is portrayed as all pain and suffering, people don?t perceive that ecstasy is also a component.
?In my middle-aged maleness I cannot put myself in their position ? I am not a woman ? but I do know what they?re saying: They are not saying ?I?m petrified?; they?re saying ?I want a labour?.?
Carolyn Boyd, who is at pains to point out that women who do choose to have a caesarean section are making a very legitimate decision, says she and her partner wanted to capture Finn?s birth and show other parents that a choice does exist.
?Our advice is do your research,? Boyd suggests. ?You wouldn?t want to have a breech birth with an obstetrician who doesn?t have the skills.?
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