Monday, June 13, 2016

Are we nearing the end of the villagemidwife era?

Dear reader
In seeking to answer this question, are we nearing the end of the villagemidwife era?, I would like to take you today on a reflective journey.  Please come with me along memory lane - not just our memories, but including our mothers' and grandmothers', and more.  If you would like to leave comment at this blogpage, please do so, and thankyou.

What do you know about your own birth?  If you have given birth, how does that compare with your mother's experience of giving birth?

In my lifetime, and within the broad scope of my culture, the person called midwife has progressed from a midwifery nurse, whose language included 'confinement' and the 'lying in' period, and who was required to work under medical supervision, to a highly regulated modern professional who has endorsement that enables access to public funding, hospitals, and prescribing certain medicines.  My generation of midwives experienced a movement to claim midwifery as a profession distinct from nursing.  This can be seen in the two documents pictured below, both from 1973.  The graduation certificate, from the Royal Women's Hospital in Melbourne, states boldly that I have graduated as a midwife from the hospital's School of Midwifery.  In contrast, the Certificate of Registration, issued by the Nurses Board of Victoria in the same year, declared that I was a MIDWIFERY NURSE. 

Graduation as a midwife 1973

Registration as a midwifery nurse 1973

My mother was also a midwife.  In her lifetime Penicillin was discovered, and surgical interventions in birth became safer than they had been.  My mother's generation of midwives taught young women to scald cow's milk, and add sugar and water, making it a tolerable food to replace the mother's own milk - something that became all too easy!

My grandmothers were not midwives, but they gave birth to their babies in the care of midwives who attended them at home or in a private 'nursing home', strictly enforcing requirements for bed rest, and stayed for a couple of weeks afterwards.

One of my great grand-mothers, Angelina White, died 'in childbed'.  Her death was two weeks after the birth of her child, probably from sepsis and haemorrhage: the sort of illness that I would treat with antibiotics.  My grandfather was only four years old when his mother died.

So, what do I mean by the villagemidwife era?

In the beginning, some women learnt that unique and life-affirming skill of accompanying women through their childbearing event.  Those women learnt to work in harmony with amazing, hormonally mediated natural processes; learnt how to teach others enough to prepare well, without becoming overwhelmed; learnt how to reduce and minimise fear and anxiety, so that the labouring woman accepted the work of labour; learnt how to support without interrupting the processes of mother-baby attachment, ensuring strong bonds and resilient families.  The image in my mind is that of a midwife who was known and recognised by her community as being the guardian of the next generation of mothers and babies.

I discovered the villagemidwife model soon after I set up my private midwifery practice in the early 1990s.   I was providing clinical support to a group of RMIT midwifery students at Box Hill Hospital at the time.  A midwife at the hospital asked a student "What would the villagemidwife do?", when faced with a particular challenge.

The villagemidwife then, as now, is known and recognised by her community as being the guardian of the next generation of mothers and babies. 

It was an absolute privilege for me to, over the years, return to families as their known and trusted midwife.   I also felt deeply privileged to guide women in their first birthing - a significant challenge.  And to support - and dare I say 'help' - women who felt violated in their previous birth.

Yet I need to also tell you about the other side of this coin.

There were many frustrations.   My 'village' had no boundaries.  Working with a caseload, on call 24/7 is the big commitment made by a midwife, but it is not easy.  Some of the births I committed to required me to travel one or two hours, often driving through the night.  One morning as I made my way home along Burwood Highway after a birth in the Dandenongs I realised with only moments to spare that I was heading for a tree.  A micro-second of sleep had almost robbed me of life.   I had learnt over the years of hospital night shifts to eat an apple slowly as I traveled home, giving a steady supply of sugar to my weary brain.  I could usually make an apple last the distance.  But my 'stay awake' strategies were not perfect!

I would not take a long distance booking if the mother could find a midwife who was closer.  Not only was the travel costly on my time and energy, but it meant I might not be able to provide as much postnatal care as I would have wished.  

There was a reality that I had to face - my 'village' needed to give me enough work to pay the bills.  There were times when I accepted bookings that required distance travel, or that put several women due in the same week.   There was no way of predicting when babies would be born.  Many times I would look at the calendar - two due this week, one due the following week, and one the week after that.  Then, all of a sudden, four babies would be born within a couple of days.   Add to that the travel from one side of Melbourne to the other, with crowded suburban roads to cross: not the ideal!

The commitment I made to the women in my care meant that my children had to get on without me, sometimes at special times in their lives.  I missed a couple of Paul's birthdays - to the same mother who gave birth to two of her children on that day several years apart!   There were a few occasions when I had to ask another midwife to cover for me, but the very thought of not being able to keep my commitment to that mother caused me deep sorrow.  One birth I missed when I needed to travel to Brisbane when my Dad was dying.  The fact is that the caseload commitment of a midwife is a very difficult commitment to make.

Last month I decided not to renew my midwife registration. More than a year ago I decided not to renew my professional indemnity insurance, so although I was registered I was not able to practise midwifery. During the past 18 months I have lived quietly, gradually recovering from the physical and emotional burnout that developed gradually over several years. I have been enjoying the beautiful grandchildren (and their parents) that God has sent into our care, the change of the seasons, the garden, and many simple life challenges.

It's ten years since I began writing the villagemidwife blog, telling stories and making comment on midwifery issues. It's about 20 years since I wrote what I called The Midwife's Journal These stories were initially written by hand in a book, often while I could still smell the amniotic fluid on my arms, and while the oxytocin and other wonderful hormones of life soared in my body, and I added precious photos - in the pre-digital camera days. 

During these years of writing and reflecting, I have felt that I am in a position of guardianship, recording and discussing life from the midwife's perspective. I am thankful that advances in computer technology in my lifetime have made it easy for me to do this in a systematic and retrievable way.
Although I am no longer able to do the work of the villagemidwife, I do not think I have lost the ability to think about life from this unique perspective.

I have not yet answered the question at the head of this post.  Perhaps that's for another day! 

I would appreciate comment from anyone who reads this post. Thankyou.

Saturday, April 30, 2016

thoughts on motherhood

Women contemplating motherhood face enormous challenges.  Pregnancy and childbirth are just the beginning.

Many Australian women tell me that they are angry when the 'system' dictates what they can and can't do.
"It's my body; my baby", they say.
"Surely I know what's best for myself and my baby!"
"Surely you're not allowed to not allow me?"

Women also tell me that they have deep sadness as they remember and reflect upon their experiences in birth.  "I know I needed a repeat caesarean.  But I felt like a piece of meat on a slab.  My baby was taken to the Nursery, while I was in Recovery.  I didn't see him for a couple of hours, and that still makes me sad.  I was afraid for him, and wanted him with me.  If I could have had a natural birth, I would have."

Natural birth has become the ultimate, longed-for experience in childbirth.

Unmedicated, physiological birth; uninterrupted, ecstatic, even orgasmic.
No clamping of the umbilical cord.  No separation of mother and baby - at all!  Not just the first hour, but as long as it takes.

Achieved by only a few.

Who wouldn't want to join that exclusive club?

Not only does the mother appreciate the physical, emotional and hormonal bonuses of working in harmony with amazing natural processes in birth, but the baby also joins in, without any prompting, in this unique primal dance.  

The point I am trying to make, and the main reason I am writing this post, is that there's a problem - women can't pick and choose their maternity journey.  My comments may seem predictable.  How many times have I written this sort of thing, since I started blogging in 2006?  

  • The choices or decisions in maternity are quite simple - to intervene or not.  The biological processes in pregnancy, birth and lactation will continue as time passes.  
  • Once interventions have occurred it may be difficult to return to the natural, healthy process.
  • Undesired outcomes including death may occur, with or without medical or surgical interventions.

I have heard childbirth educators who teach that women who really want natural birth need to surround themselves with a team of supporters who will not waver in their support.  "The chain is only as strong as its weakest link," they say.  "If your supporters (including friends, husband, photographer, carer for children, doula, midwives) stop believing in you, they will cause you to give up just when you should be strong!"

This sort of advice is appalling.

Noone can predict a childbearing journey.  Natural birth is not something that can be ordered like a saleable commodity.  Women can't pick and choose.  A woman's pain in labour may be an indication of serious complication which, if nothing is done to relieve it, has catastrophic consequences.  A woman who shuts down her own responses to pain, and blocks the empathy and care of her supporters is ignoring natural processes at her peril.  A midwife who is disengaged, and sits on her hands rather than guide a woman on in labour, or, make the call to escalate care, is negligent or incompetent.  This might be as 'simple' as, without words, guiding a labouring woman to change her position, thereby moving from the transition to the second stage.  It may be as profound as telling the woman that you are now advising medical intervention, with all that that means.

Advice on childbirth has multiplied in recent years, with social media and internet communications.  A childbirth blog that has (literally) thousands of 'like's, tells us that "The legal authority in childbirth lies with the woman giving birth, not the providers ..." [link]

That's nonsense. 

There is a legal and ethical 'duty of care' that providers (midwife or doctor or other health care providers) are required to take very seriously.   It's an ongoing responsibility that the care provider carries as long as they are in attendance or other relationship such as in phone contact with the recipient of care.

This doesn't mean that all advice or decisions by providers are necessarily 'best practice' or acceptable to the woman.  Some providers maintain practices that are out of date, and believe they should intervene when others consider the progress to be uncomplicated and not requiring intervention.  Some providers (midwives and doctors) take large caseloads that result in cutting corners and burnout.  Human error is a constant threat.  These factors are balanced, to a degree, by the legal right of a competent woman to decline any intervention on herself (but not necessarily on her baby after birth).

We can talk about the legal and ethical standard for informed consent, but the hospitals/doctors/midwives know that they are much more likely to be defending their actions to their indemnity provider or the coroner or AHPRA.  

And there's the uneven playing field. The provider does *it* many times every day, while the woman is doing it for the first (or whatever) time - and takes the 'outcomes' (including pelvic floor damage, surgical wounds, infection, and many other types of morbidity, not to mention mortality) home.

Becoming a mother - bearing and nurturing a child - is an awesome and privileged position for any woman to be in.  Our bodies are wonderfully made.  

But, we can't pick and choose what happens in our maternity journeys.

The most healthy and 'low risk' pregnancy can suddenly and unpredictably be subject to life-threatening complications.  Alternatively, a woman with recognised risk factors can proceed without any complication.

Decision-making in the childbearing continuum is an ongoing process.  The woman who can trust her care provider enough to challenge or seek further discussion when any decision point has been reached is, I believe, in the best position.  The woman who believes she is alone, and has to be strong  and resist intervention or professional advice 'no matter what', is likely to be overwhelmed with fear and may make decisions that are not in her best interest.

Wednesday, December 16, 2015

The death of a baby

Today I would like to comment on a case in which the baby died after induction of labour in a tertiary level obstetric hospital. 

It's a well staffed, well equipped modern facility, with all the bells and whistles.   It's a hospital where doctors and midwives and nurses are  being taught their professions, where evidence based practice is treated seriously.

This death was reported to the Victorian Coroner, who carried out an inquest and has recently published her findings.  The baby's name is Kylie.  I would like to refer to her by her name, as she is at the centre of the picture.  Other people will be referred to by their role.

I am writing about this sad case because it has a number of features are important in understanding an unexpected adverse event.  Please note that I don't have any inside knowledge.  I don't know any of the midwives or doctors who cared for Kylie or her mother, and I don't know anyone who knows Kylie's parents or family.  My source is the Coroner's report which has been placed on the public record. 

A layperson reading the report may well ask how was this allowed to happen?  Why was no action taken until (obviously, with the benefit of hindsight) too late, to hasten the birth of baby Kylie?  What's the point of having continuous CTG monitoring if the plan is to press on, even when the most basic understanding of cardio tocography indicates that baby Kylie was distressed? 

That's the big question

Although birth is not an illness, the process carries potential for damage and death.  In birth there is a finite point after which the baby will not do well, but it's impossible to predict where that point is.  Midwives have to accept and embrace this uncertainty, as we work in harmony with natural physiological processes which usually lead to spontaneous birth.  The decisions we make in the clinical setting take unpredictable and sometimes quick changes into account.

The language used to describe a CTG trace, such as 'non-reassuring', is, I think, deliberately vague.  We are all confident when we see a CTG trace that ticks all the boxes.  'Reassuring'!   It's the non-reassuring ones, placed in context with all the other clinical features, that challenge decision-making.  A normal trace now can not predict the condition of the baby in 2 hours' time, or 10 minutes, or any time in the future.

I found the record of the evidence of the obstetric experts very interesting (#70 onwards). Some hospitals/obstetricians have a low tolerance for non-reassuring traces.  Historically the CTG machine has become the catalyst for high rates of caesarean births, and many babies come out pink and complaining about the whole process, suggesting that the surgery was not really necessary.  The ability of the midwives and doctors who are providing professional care to know which mother-baby pair is progressing well, and who needs surgical intervention is a skill that cannot be overvalued.  The big teaching hospitals such as this one set up their guidelines that the staff are bound to follow with this in mind.
The idea of a chronically compromised fetus who may not have done well even if the baby had been delivered earlier is worth thinking about.  

Will this death, and the related report, lead to an even greater rate of elective surgery to avoid the possibility of low fetal reserves?  How many mothers will be operated on without valid reason, giving them and their children the increased life-long consequences of caesarean surgery?  More importantly, will the lives of babies like little Kylie be protected as they make their transition from mother's womb to our world? 

My response to this report is from a midwife perspective. For 20 or so years until my retirement last year I have been attending homebirths, without access to CTG at the primary care level. A midwife attending homebirth will usually listen to the fetal heart sounds using a doppler sonicaid machine after a contraction, and consider that observation within the context of other clinical features. If there are 'non-reassuring' features of that auscultation, such as a deceleration, it's a decision point that can have profound consequences.

Wednesday, December 09, 2015

searching for confidence

A young mother whose second pregnancy is at about 30 weeks phoned me, and we chatted for a while.   As I listened to her story, I felt enormous sympathy for her in her search for confidence. 

I have pondered the predicament of this young woman, who I will call Bea, and others in similar situations many times.  So, dear reader, I will share the story with you, and hope that those readers who are also searching for confidence as you approach your time to give birth will be given some useful tools.   If you think you know Bea, please read any of the more critical comments that I make as criticism of the system that leaves women dangling and lacking in confidence, rather than a criticism of any person.

Bea is booked to have her baby in a hospital, under the care of a team of doctors and midwives.  Bea is hoping to find someone who will palpate her abdomen (See RCM How to perform an abdominal examination) and tell her how her baby is growing, and whether she will be suitable for VBAC (vaginal birth after Caesarean).

Bea experienced an emergency Caesarean birth after a long and painful labour for her first child.  She felt traumatised, disappointed, confused, depressed; at times blaming herself and at times numb towards herself, her child, the child's father, and the world.

In preparing herself for this next birth, and in an effort to come to terms with her memories, Bea has had counselling.  One of the outcomes of that counselling is that Bea recognises a lack of confidence in the (nameless) people who will provide care for her in labour and birth.  Midwives, doctors, others: all with a role in the system that produces babies, yet Bea has no confidence in that system.

Bea is an intelligent woman who is used to researching every aspect of life, from the energy efficiency of white goods in her home, to the source of the food she buys.   She wants to know about pregnancy and birth specifically as it relates to her.  She reads posts from other mothers on social media.

Bea is particularly concerned about the size of her baby; whether he or she will 'fit'.  That's a big question.  It's a question that exercises the mind of every midwife.

Bea would like me to palpate her abdomen and (hopefully) tell her that her baby will fit through her birth canal.  I can palpate her abodmen, feel the fetal poles and hold her baby between my hands.  That gives me a good idea of the size of the baby - it's not much different holding a baby who is still in the womb to holding the baby in my arms.  But I can't tell if the baby will 'fit'! The only times when I would advise against progressing naturally and spontaneously into labour are when a complication presents - when the natural process would be likely to lead to damage or death.

Many times I have attended little women who have big babies.  Many of them have given birth spontaneously and quickly.  I have never tried to be a prophet, predicting events in the future.   The decision making processes in midwifery require the midwife to understand and work in harmony with the natural physiological processes, and only interfere if there is a valid reason to do so. 

Bea told me she has at least three birth plans: a vaginal birth; a caesarean after labouring; and an elective caesarean.

I told Bea that she should have only one birth plan: to do her best. 

You need to take ownership of your own natural processes which are essential if natural birth is to progress well. make the best decision you can at any point when a choice or decision needs to be made.  Here are a few examples:
  • The doctor tells you at 38 weeks that he assesses the baby to be large and advises an elective caesarean (without labour) at 40 weeks.  Do you think the best decision at this point is to say yes, to say no, or to make a decision closer to 40 weeks?
  • It's a few days before (or after) that magical 40 weeks.  You think you are coming into labour - it's midnight and you woke up with a contraction, and felt baby make a few big moves.  Waters have not broken.   Do you get all excited and ring your support team, and ring the hospital, and wake your husband?  Or do you tell that baby to go back to sleep - you have a big day ahead if labour does begin, so you need to get some shut-eye!
  • Later ... You think you are really in labour now.  Memories flood back each time your womb contracts, and you remember the early part of your first labour.  You remember using the labour ap on your phone to track the contractions.  You know you need to get organised - little Johnny will go to his granny after breakfast, DH will stay home from work, and the birth support friends will need to make arrangements for their families and work.  Contractions are coming every 10 minutes, and feel good.  You need to walk and rock through them.   Do you ask your team to come now, or to wait for another call?  Do you call the hospital now?

These 'decision points' might seem insignificant, but I say they are some of the most important decisions you will make.  Each decision is a fork in the road.  If you take one, you cannot take the other.  There is no turning back.  Can you feel confident about these decisions?  If you have that confidence, and you establish labour without any outside (medical or psychological) assistance, I know that you are well on the way to successful and healthy VBAC.   

Monday, November 23, 2015

Natural: is it good, bad, neither, or both?

It has been months since I put (virtual) pen to (also virtual) paper in this blog.

I have needed time to reset my body clock; to recover from the exhaustion and burnout after many years of midwifery and related professional activism.  I don't know if I have fully recovered yet.  The reality of ageing gives much to ponder; a relentless march towards exhaustion.

In recent months, with no midwifery to absorb time and energy, I have taken up some new challenges.  These photos show the performance of the 'Human Knitting Machine' at the Kyneton Show.

performance of the 'Human Knitting Machine'

The finished product

I am enjoying our new home, and the rural Central Victorian lifestyle.  The daily patterns of weather; the sun and clouds and wind; the subtle changes in the seasons; the growth and change in the garden - these natural life factors add wonder as well as sometimes concern to our days.

We are often delighted, and sometimes concerned, by the little members of our family and friendship circle, as they proceed through their developmental milestones.  This is all part of natural processes: sometimes good, sometimes bad, sometimes neither, and sometimes both.

Just as with retirement from attending births my life has changed, so has my capacity for writing.  Blogging has, for me, been closely linked with practice.  In the past, as I pondered the events of my professional life, the thoughts that surfaced became seeds for comment in this blog.

I now find that I need to shift my point of view from that of a midwife who was intimately involved in the day by day decisions related to maternity care and the lives of mothers and babies, to a more distant view.  As a retired midwife, my view is that of guardianship of birthing within the bigger picture of living.  I care deeply about what my society does to mothers and babies.  My right to comment continues as in the past.  Readers will need to decide whether my thoughts are valid and useful, or not.

Today I would like to consider *natural* in the maternity context.  Previously I wrote:

Giving birth spontaneously is, in my mind, a woman's *natural right* (not a legal right), just as we have a natural right to breathe, or walk, or perform any other natural function of our bodies.  Women do have a natural right to birth their babies.  Midwives are in the unique position to protect and work with that natural process, giving the mother confidence as she navigates the most challenging terrain.  The only way we can achieve our natural right to birth is if we stay on that natural pathway, and for the majority of women, this is a wonderful and rewarding phenomenon, working with the amazing hormonal cocktail that sets up powerful maternal instincts and bonding/attachment for mother and baby. 

I know of no better way for birth than to proceed under the spontaneous, hormonally mediated natural process from conception to birth, and beyond to nurture and mothering of the infant - MOST of the time.

Natural pregnancy, birth, and nurture of our children is good - MOST of the time.  Regardless of race, wealth, or other social factors, our bodies and minds are set to the 'default' that whatever is natural will be, unless something is done to redirect the course of events.

Whether we apply this principle to maternity issues, or any other ordinary life event, *natural* can be awfully unpredictable, and unmanageable.  There is no therapy that can make it work better, or reign in the unpredictability.  There is no drug that will 'fix it'.  Modern Western medical management of maternity care seeks to minimise 'risk', and in so doing reduce the impact of the spontaneous natural process: to remove the 'MOST' element, and make maternity just another predictable, manageable medical event that complies with medical guidelines and protocols.

For the midwife who is committed to working in harmony with natural processes, except when there is a valid reason to interfere, the big challenge is to know when the natural process is likely to result in harm; when medical and other interventions are likely to lead to improved outcomes.  This requires clear thinking by the midwife or other primary care professional, and independent clear thinking by the woman who receives the advice that a process other than the natural one is being recommended.

I want to emphasize the need for independent thinking by the woman.  The first decision to interrupt the natural birthing process is profound, and the woman must take responsibility for it as her own decision.  It doesn't matter how much trust there is between the woman and her midwife, or doctor for that matter.  The first intervention, which can quickly cascade into a whole bunch of subsequent interventions, can be a life and death decision point.  As can the decision not to intervene!

I started this post by saying that
I know of no better way for birth than to proceed under the spontaneous, hormonally mediated natural process from conception to birth, and beyond to nurture and mothering of the infant - MOST of the time.

During the past couple of decades I have experienced progressive increases in reliance on medical intervention in maternity decisions, paralleled by loss by women in their ownership of their commitment to natural, spontaneous, unmedicated birth.  In Australia today, the woman's ability to make her own consumer choices has eclipsed any valuing of or protecting physiology.  This has made maternity decisions more like walking down the aisle in the supermarket and making selections based on price, packaging, or some other possibly insignificant factor.

I'm not wanting to suggest that I think maternity care was better 20 years ago, when I was busy with midwifery and maternity activism; or 40 years ago, when I was having my own babies; or even 60 years ago, when as a young child I learnt much about mothering from my own mother.

Twenty years ago we were working to demand that midwives be called midwives, not nurses, in hospitals.  We had supported the release of a Code of Practice for Midwives in Victoria.  We were promoting the Baby Friendly Hospital Initiative, through which maternity hospitals were supported in the protection, promotion and support of breastfeeding as the health promoting natural resource of mothers and their new babies.

As time has passed the indicator of reliance on medical rather than natural processes has been the consistently increasing rate of caesarean births in otherwise healthy pregnancies. 

Women don't, on the whole, choose caesarean surgery.  They enter systems of care that sets up the cascade of interventions, so that there is no safe alternative but to bring it all to a conclusion, and when that happens the most rational and helpful option is surgery.  Women, midwives and doctors play games that set up a mirage of choice as the prize, when in reality there is no choice.

Natural birthing can be very good, or very bad.  It can be neither good nor bad.  It can be both good and bad.  Society will either benefit or pay the price for its reliance on the natural physiological processes in maternity decisions.

Wednesday, June 03, 2015

legal rights in childbirth?

Bec and Lucinda
For some years I have been troubled by apparently common misunderstandings of a woman's *rights* in maternity care.   I have pondered these questions publicly on this and other blogs; questions of choice and informed decision making. 

Consider these statements:
You [a competent adult] have the *right* to bodily autonomy.  This means that noone is permitted to do anything to you without your permission.

In any health care situation, including maternity care, you [a competent adult] have the *right* to decline a treatment or intervention.

These legal rights are well established, and I am not going to spend time discussing them. 

Now consider the following statement, which appeared this week in a news article titled Risky underground homebirths: freebirths tipped to rise:

"Women have the legal *right* to birth how they want to"
A legal right? 

Surely not!

Even in the most ideal maternity care situations there will be some women who, in order to protect the life and wellbeing of the mother and her baby, will be advised to undergo surgery.   What happened to these women's legal rights to birth how they want to?

Maternity care in the developing world is often far from ideal.  Women whose health has been compromised by war, social exclusion, poverty, poor nutrition, disease, and other preventable conditions give birth to babies often in shocking conditions, with high rates of mortality and morbidity.  Do these women have a legal right to birth how they want to?  No!

Giving birth is a natural, spontaneous phenomenon, if a woman's body is left to its own devices.
Babies will be born naturally whether someone is monitoring progress or not.   
The sort of birth that the mother wants, which according to the quote above is her legal *right*, may be very different from the natural outcome.  

Giving birth spontaneously is, in my mind, a woman's *natural right* (not a legal right), just as we have a natural right to breathe, or walk, or perform any other natural function of our bodies.  Women do have a natural right to birth their babies.  Midwives are in the unique position to protect and work with that natural process, giving the mother confidence as she navigates the most challenging terrain.  The only way we can achieve our natural right to birth is if we stay on that natural pathway, and for the majority of women, this is a wonderful and rewarding phenomenon, working with the amazing hormonal cocktail that sets up powerful maternal instincts and bonding/attachment for mother and baby.
Those who have access to modern hospitals are not bound to use their natural right: they can obtain medical management and intervention, which is provided in modern societies along with other medical services.   We are privileged to have this access, and even a degree of choice in planning the way babies are born.  But, access to choice in the way a baby is born is not a simple matter.  It's not a legal right. 

I think it would be silly to argue that women have any legal right to a particular medically managed pathway in childbirth.

So, with great respect, I would like to suggest that midwives and maternity activists stop saying that women have a legal right to birth how they want to. It's nonsense.

Why am I so concerned about this question?

I have read coroner's findings, acted as an expert witness, and discussed cases with peers, and the recurrent theme has been this distorted belief, on the part of the midwives, that women should be able to choose the sort of birth they want, and that the midwife should facilitate this choice.  Midwives working under this belief have forgotten the harsh reality that preventable death and disability is often not far away.

The mother who wants an 'undisturbed' birth, and tells the midwife that she does not want any monitoring of her own vital signs or her baby's.  Yes, she gives birth, and usually the baby's condition is good.   ...

The mother who has various medical conditions including unmanaged gestational diabetes, wants a VBA2C, and who decides that there is too much negative energy in the hospital, so she finds an independent midwife who commits to homebirth.  ...

The mother who feels that she suffered trauma in her previous birth, in which labour was augmented, and a forceps birth resulted in severe perineal tearing which was repaired.  She does not know what she should do.  Should she request an elective caesarean birth? ...

These mothers may not be claiming any legal right to the sort of birth they want.  But they are looking for competent professional care.  A midwife can proceed on life's path with the woman, and provide information, support, expert advice, and sometimes guidance.

The midwife can support the woman's natural right to spontaneous birth, in the setting that is considered most appropriate at the time. 

In relation to human rights and birth at home, the judgment of the European Court of Human Rights in the case of Ternovski v Hungary (2010) is significant.

Friday, April 24, 2015

Insurance: a pot of gold at the end of the rainbow

A pot of gold at the end of the rainbow?
A mirage?
The emperor's new clothes?
[My question is, when will we - the maternity community including midwives, hospitals, and consumers - wake up and come to terms with reality?]

Here's a thumbnail sketch of the insurance problem:

Professional indemnity insurance (PII) for all Australian health professionals became mandatory five years ago.
... BUT midwives who attend homebirth privately cannot purchase PII
... SO the exemption was introduced by the government, to enable midwives to continue being midwives.

Until recently, privately practising midwives who provide clinical midwifery services (pre-, intra-, and post-natal professional care) have purchased PII to cover pre- and post-natal services, and have, with certain conditions set down by the Nursing and Midwifery Board, come under the exemption for attending women in labour, birth, and the immediate postnatal period.  There were two insurance companies MIGA and Vero.  MIGA insurance is restricted to Medicare-eligible midwives, and includes cover for birth in hospital when the midwife has clinical privileges.  Vero, on the other hand, has provided an insurance product for midwives regardless of their eligibility for Medicare funding, and offers no cover for intranatal midwifery services.

Now, Vero has notified midwives that:
"It is with deep regret that we inform you that as of the 2nd April, 2015 Vero and Medisure will no longer be able to provide a Professional Indemnity Insurance policy to Private Practicing Midwives who are providing any home birthing or home birthing related services.

There are a number of factors that have impacted on this difficult decision, including:
• the high cost of claims that have resulted in the past 4 years
• the lack of government funding or assistance (for claims or premium costs), and
• the ability to offer an affordable policy to Private Practicing Midwives who are providing any home birthing related activities.

The Vero insurance product was the only PII option available to non-eligible midwives, and was seen by some eligible midwives as more affordable, and adequate to meet the requirements of registration.

I am not surprised that Vero has come to this decision.  The wonder to my mind was that someone thought it would be do-able!  The 'number of factors' dot points listed in the Vero letter are not surprising:
  • the high cost of claims that have resulted in the past 4 years
Yes, legal defence is costly.  That's what insurance is about.

  • the lack of government funding or assistance (for claims or premium costs), 
This is not new.  The product has never had government assistance

  • the ability to offer an affordable policy ...
This is not new either!

It has been clear to me, since privately practising midwives lost our insurance in 2001, that the private midwifery 'industry' cannot provide the sort of $$ required to insure birth.  Our annual earnings are of a similar quantum to the insurance premiums paid by obstetricians.  At that time I argued (unsuccessfully) in the then Nurses Board of Victoria that if insurance was to be mandated, there was an onus on the regulator/government to ensure that a suitable product was available and affordable.  If not, the regulator was effectively delegating its responsibility for protection of public interest through regulation of the midwifery profession to the insurer.

The purpose of statutory regulation of the health professions is protection of the public.  The insurer does not exist to protect public interest - in this case ensure safety for mothers and babies.  The insurer is a profit-making enterprise, and exists to protect the financial interests of its people - in this case midwives - and shareholders. 

When is the Australian government, the statutory regulator, and the whole maternity community going to stop chasing the pot of gold at the end of the rainbow?  When are they/we going to recognise the mirage of insurance, that in almost every case it makes no difference to any outcome for the client?

Readers who are interested in the back story and further discussion may check out these links:

Midwife Rachel Reed has recently updated her Midwife Thinking blog post on the Future of Midwifery and Homebirth in Australia.

Maternity Choices Australia (formerly Maternity Coalition) has documents and links at its website, and discussion at its facebook pages.