Sunday, September 21, 2014

possibly postmature

Possibly postmature
and
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 
  • the date of the first day of the last period
  • the normality of the last period
  • the date of quickening
And, if ultrasound is used, there are additional pieces to add to the puzzle.


Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.


A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.


A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?

Why?

          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?


With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 



There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.




No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable. 

Wednesday, August 20, 2014

Risk and maternity care

Discussion about risk in maternity care may be met with the full range of responses, from the hands over the ears "hear no evil", through to scary stories about the "disaster waiting to happen".  A midwife needs to understand risk, recognise progression into complications, and appropriate response to change in a woman's or baby's status, without being fearful.  A midwife is guided by principles such as
"In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: A practical guide.)

The usual model of care offered by midwives who practise privately is primary maternity care, with a strong emphasis on continuity of carer and the promotion, protection and support of the natural physiological processes in childbearing: spontaneous unmedicated birth, facilitating strong mother-baby bonding, and exclusive breastfeeding. This emphasis is consistent with best standards of midwifery practice and health promotion globally, and is to be applauded and supported in the interests of public wellbeing and safety. 

Today I want to look at practice issues for midwives in private practice, from a risk based approach.  Not just risk of complications or illness in the mother or baby, but also the risk that a midwife's practice may not be of the standard expected by the profession or the community.

The statutory regulator for health professionals, AHPRA, has established a set of regulatory principles which require the Boards to establish a responsive, risk based approach to addressing practice issues. (http://www.nursingmidwiferyboard.gov.au/News/Media-Releases.aspx )


It has been recognised for many years that systems of maternity care which rely on risk assessment will place a disproportionately high number of women in the "at risk" categories, leading to an increased likelihood that these women will be subjected to a higher level of intervention in the birth.  This process might be seen as necessary, in ensuring the best outcomes, but it often fails to do that!  No amount of bureaucratic micromanagement through laws or practice guidelines will ensure safety.  Many women for whom no risk categories apply will develop complications that require expert obstetric intervention, while many of the women in the "at risk" categories will, with appropriate care, proceed to an uncomplicated, spontaneous birth of a healthy baby.


Within the broad scope of midwifery, issues of special note in private practice, when there may well be an increased risk to women and babies in the care of midwives include:
• Education of midwives, registration, and transition to private practice
• Notifications, investigations, and hearings into professional conduct
• Lack of professional indemnity insurance for homebirth
• Notation as an eligible midwife [including Medicare, endorsement for prescribing, hospital visiting access]

Here are a few of the risks, all of which could contribute to poor outcomes for the mother and baby:

  1. Risk of unrealistic, idealistic notions of midwifery practice and natural birth, 
  2. Risk of inexperience, and lack of appropriate education and preparation for autonomous practice.
  3. Risk of professional isolation, and stunted growth of a midwife's professional identity.
  4. Risk of bias in the regulatory body against private midwifery practice.
  5. Risk of bias in mainstream hospital maternity services against private midwifery practice. 
  6. Risk of discouraged, disheartened midwives leaving the profession and being unable to find suitable employment.
  7. Risk to the public of being prevented from accessing the options for midwife-led maternity care, introduced through legislative reform in 2010. 
  8. Risk that women are being prevented from accessing the potential for excellent outcomes that are seen in midwife-led care.
  9. Risk of obstruction of trade for midwives.
  10. Risk of the rise of 'free birth' and births attended by unqualified or lay midwives.

There is a separate, and different category of risk that needs to be included in any discussion about private midwifery practice in Australia.  Midwives are unable to purchase professional indemnity insurance (PII) for homebirth - the core ingredient of most midwives practices.

It is unreasonable that Australian midwives' homebirth practices should continue to be excluded from the PII that is currently available.  Eligible midwives are able to buy insurance for every aspect of their practice, except homebirth.  This needs to be changed.  Insurance, per se, does not make birth safer or less safe; does not ensure good outcomes.  Insurance seeks to protect the financial interest of the players, rather than the health interests.


Tomorrow I am meeting with other representatives of professional organisations, and the NMBA, to discuss midwifery practice issues and regulation.  The points I have noted in this blog are contained in a discussion paper that I have written for this meeting.

Your comments are welcome.




Monday, July 21, 2014

mothering

The mother of a two-and-a-bit year old commented wistfully, "I had no idea of what I was committing to when I became a mummy."


That's so true.

In fact, I don't think it's possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.
Thanks to Miriam and Amelie


This mother who, for whatever reasons, started her family in her mid- to late-thirties has probably experienced a great deal of freedom and responsibility in her personal and professional life.  She has experienced leaving home, and becoming independent of parental influences.  She has possibly experienced promotions and increases in her work earnings.  She may have enjoyed overseas travel or achieved success in the personal pursuits that she has chosen.

...

And now, at about 40 years of age, she has her two-year old constantly in her care, and is preparing for the arrival of a sister or brother.


The day begins with "I very hungry now mummy", and continues as she seeks to meet each of the needs of the child. Multiple meals and snacks, nappy changes, library, play group, walks to the playground, playing hide-and-seek, art work at the kitchen table, music, visits to friends, daytime sleeps, melt downs because the little one didn't get all the sleep she needed, sweeping up crumbs and food scraps under the table for the n-th time, and thinking about upping her dinner menu to something special tonight.  These are just a few of the day's challenges, along with shopping for groceries, mountains of washing, drying, folding and putting away the clothes, getting to appointments on time, and much more.

There is no suggestion of complaint in this mother's musings.  Most of the time she patiently accepts the work of caring for one small person; valuing her own role as mother above all other options at this time of her life.  University education and professional standing cannot compete with the status that is simply and profoundly accessed under the title 'mother'. 


Am I being idealistic?   Am I seeing only what I choose, through the filter of many years; forgetting the reality of sleep-deprivation, and the constant and unrelenting need of the little one for attention? 


I don't think so.  I see a great mystery, something timeless and inexplicable, in the ability of a mother to care for her children.  I accept that many aspects of mothering call for a commitment that goes far beyond our usual limits, and that it's not possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.

The mystery of the mother is our birth-right; contained within the wonderous bodies that God created in his own image, and that God said "is good".  Mothering is part of the natural physiological process that can happen automatically in a woman's person during pregnancy and after the birth of her baby.  It's the same normal physiological process that I as a midwife have sought to protect, promote and support, unless there is a valid reason to take another, more medical, pathway.

Yet the ability of a mother to give, and give again, is not to be taken lightly.  The presence or absence of loving support and encouragement from husband, family, friends and within the community can make a huge difference.


I recognise that mothers today are expected to return to paid employment after their babies have reached one year, or even six months, with children being placed in day care.  I cannot accept this as being in the child's or the family's interests.  In the end Australian families will be paying a high price for this social experiment that interferes with the basic building blocks of love and attachment between mothers and their babies. 

Mothers who are willing and able to nurture their own babies should be supported to do so. 

Monday, July 14, 2014

conversations on *choice*

I would like to bring some thoughts about maternity choices from the relative safety of a closed social media group to the openness and exposure of this blog, which does not restrict access.  This is not the first time I have written about choice.  A simple search of this blog brings up posts each year since 2007.

The current conversations have been prompted, in my mind at least, by my awareness of the movement that promotes a person's right to self-determination in health care, and particularly a woman's right to autonomy over her own body in the highly contested terrain of maternity care.

Here are a few real examples of that evasive entity, *choice*:

  1. Jenny is pregnant with her sixth child.  She is a healthy 38-year old, who had a caesarean birth for her first, and has had uncomplicated births of her babies since then.  She would really like to give birth at home, in water, but the (free - publicly funded) homebirth program from a nearby public hospital will not agree to homebirth because she is considered high risk (previous caesarean, multiparity >5). 

    Jenny inquires about private homebirth services, and thinks that the cost of $5,000+ is prohibitive, even with Medicare rebate of approximately $1,000.  The midwives are also concerned that her risk status might put them at risk of mandatory notification to the regulatory Board.

    Jenny inquires at the local public hospital, where she could receive free maternity care.  She is told that she would not be permitted to use water immersion in labour, be managed as 'high risk', have continuous fetal monitoring in active labour, have IV access established in labour, and immediate active management of third stage after the baby was born.

    Jenny feels she has no real choice.  The system (public or private) simply does not support her choice to proceed naturally, and does not respect her desire to avoid what she considers to be unnecessary medical interference that could quickly lead to complications.
  2. Jean is pregnant with her second child.  Her first baby was born three years ago, weighing 4 kilograms, and she had an epidural and forceps, and a large third degree perineal tear which took a long time to heal.  Jean feels traumatised by her experiences in her first birth, and she feels that her marriage relationship has suffered, because she does not enjoy intimate contact, and tries to avoid sexual intercourse.   She considers herself healthy, but she is over weight, and she has 'failed' the glucose tolerance test.  The hospital advises that she needs a series of ultrasound assessments of her baby's growth, and possible induction at 38 weeks if the baby seems large. 

    Jean is now 34 weeks along in this pregnancy.  Jean's preference is for natural birth, and she discusses this with the hospital midwife. 

    Jean feels that she has no real choice.  She could opt for an elective caesarean, or for an induction of labour, but the system does not have a pathway for her that supports and protects unmedicated natural birth. 
  3. Jo is pregnant with her first child, and everything was 'normal' until the 35 week check when she was told that her baby was presenting breech - bottom first.  She was told by her (private) doctor that she would be booked for elective caesarean at 40 weeks, unless her baby turned. 
    Jo has quickly checked out websites that address breech births, and joined social media groups, got hold of moxa sticks, and started positioning herself crawling on the floor with her bum higher that her shoulders to help the baby turn.  She finds that there are a couple of obstetricians in town who are 'pro' vaginal breech birth, and a couple of public hospitals that support the option. 

    Jo feels that she has no real choice.  Decisions will need to be made as she progresses along the road to the birth of her baby.  Those decisions may be limited by the services available, the service providers, and the status of her baby as far as position, progress, and wellness are concerned.
  4. Jazz is pregnant with her third child, and is planning homebirth with the publicly funded hospital homebirth program. 

    Jazz understands that she has one choice, 'plan A': to proceed naturally without medication or other medical intervention, at home.  If she needs to move to 'plan B' for any reason, her midwife will go with her to hospital, and Jazz will be able to make what she considers to be the best decisions from options available at the time.

A midwife has a clear duty, by definition and best practice, to support and protect normal physiological processes in birth, unless there is a valid reason to offer medical intervention(s).  This is the DEFAULT position, that protects the safety and wellbeing of mother and child. 

'Plan A' does not deny the woman's right to decline any treatment that is offered.  But that is the woman's prerogative; not the midwife's.  The pathway to good maternity services comes with respect for both the woman's voice, and the midwife's.  There is no partnership if either the woman, or the midwife, feels unable to contribute honestly to the decision-making.


The midwife who does not apply health promotion/ best practice principles to their advice and protect that *Plan A* default position will probably contribute to the society's loss of professional skill required to work in harmony with the unique natural physiological processes in pregnancy, birth, and nurture of the infant. Once that skill is diminished or lost, the mother will find her *choice* has been seriously restricted to the medical options. eg professional de-skilling in breech vaginal births.

I have seen midwives overwhelmed by their desire to support a woman's choice, and ignoring or missing signs that a potentially life-saving intervention needs to be taken.    

[A note to those who read this post.  If you think I am referring to you, it's possible that I am.]

Saturday, June 21, 2014

Supervision, again ...

My thoughts are returning to the supervision topic, as I prepare to attend more meetings in preparation for the introduction of some model of supervision for privately practising midwives.  This additional regulatory process is clearly intended to identify and manage midwives whose practice does not conform with accepted standards.

Becoming a mother is a quintisentially profound moment in a woman's life, regardless of her people group, education, wealth, or any other variable.   A midwife holds knowledge and skill of working in a way that protects, promotes, and supports wellness in the childbearing process and adjustment to motherhood. 
A greeting card that captures some of the wonder of becoming a mother.

The regulation of midwifery, and other health professions, is the process by which a society can have confidence in the profession, ensuring high standards of education and practice, and a reliable process of investigation and calling to account any midwife who is involved in care that leads to adverse outcomes, or allegations of professional misconduct.


In its Request for Tender – Privately practicing midwives models of supervision, the NMBA (2013) has stated that supervision is: “a critical mechanism in the training, support and ongoing safe practice of midwifery. It incorporates elements of direction and guidance through a process of professional support and learning which enables a practitioner to develop knowledge and competence, assume responsibility for their own practice and enhance public protection and safety.”


The Australian College of Midwives (ACM) has encouraged members to communicate the following points to the reviewers, either in the consultative process of focus groups, or via the online survey.  ACM states that:
  • Supervision should be a supportive, mentoring and advisory process, not a management or punitive process; 
  • There should be one supervision process for all midwives 
  • If supervision is mandated by the NMBA, the model should be developed, implemented and regulated by midwives, not other professions 
  • Supervision is not an inter-professional clinical review process 
  • The importance of current practices in Australia such as the ACM Midwifery Practice Review (MPR) program, should not be overlooked. 
  • The projects should also be mindful of other review and consultation processes currently happening, and that supervision should not been seen in isolation:
    • ACM evaluation of MPR

    • NMBA review of the Quality and Safety Framework

    • NMBA review of registration standards for both midwives and eligible midwives

    • ANMAC’s review of standards for prescribing programs and peer review programs

    Many midwives using social media have been quick to express their frustration and dismay at *yet another* level of regulatory control.  Questions asked include: 
    • Why are private practice midwives being subjected to supervision?
    • Haven't we jumped through enough hoops with eligibility, insurance, MPR, QSF, and all the codes and guidelines we have to follow?
    • The UK Health Ombudsman found their supervision system has problems - "Supervision is a statutory responsibility...the dual role of a Supervisor, providing support but also a regulatory function, allows for an inherent conflict of interest." Why are we introducing supervision if it is not working in the UK?
    • Who pays for supervision?
    • The UK review also found  "There is a weak evidence base in terms of risk for the continuation of an additional tier of regulation for midwives."
    •  What if the woman doesn't want a supervisor involved in her care? 
    •  Is the supervision remote or ... direct observation? 
    • How are the supervisors trained? Who trains them? 
    • Can a non-eligible midwife supervise an eligible midwife? 
    • What Body does the supervisor report to?
     
It appears to me that AHPRA has decided it needs to provide additional levels of regulation for some midwives (and they can, whether we like it or not).  The current investigation is seeking models of supervision, and from the NMBA (2013) request for tender (referenced above) I gather that the primary focus of supervision of privately practising midwives is to be those midwives who are entering private practice, ensuring that they develop "... knowledge and competence, assume responsibility for their own practice and enhance public protection and safety"  A large number of midwives have recently left hospital jobs, attracted by the possibilities of primary midwifery practice in their communities.  There has been no standard pathway for this exodus: each midwife has found her own way, achieved notation as an eligible midwife, and endorsement to prescribe, and hung up their shingle or joined a group practice.

In concluding this log, I would like to put my thoughts on the record.

Anything that comes from the NMBA needs to be of a regulatory nature, and that regulation needs to be transparent about what it is seeking to achieve, and properly managed and funded to maintain the integrity of the process.   This sort of regulatory professional supervision could be applied to all midwives who move into private practice, for a period, such as up to five years, with standards against which the midwife and the supervisor are able to assess performance.  Midwives who have had some years of experience in midwifery may be able to demonstrate their "knowledge, competence, and responsibility" over a shorter period of time (eg 1 year), while new graduates of a B Mid course, or midwives who are under Board investigation, may remain under supervision for the full five years, or more.

In developing my position on professional supervision, I must assume that any regulatory requirement must be funded, for the preparation and payment of supervisors, and the ongoing development of the program.

I do not agree with a process that attempts to integrate the regulatory surveillance role with a support role.  Mentoring and support are valuable elements of professional development, but are different, and should be separate from supervision. 


Your comments here, or in the facebook villagemidwife group, are welcome. 

Wednesday, June 04, 2014

Midwives: improving Women's Health Globally

This week the world's midwives are meeting in Prague, for the 30th International Confederation of Midwives' triennial congress.  Many Australian midwives have gone, and will be visible with  distinctive red Akubras (hats) and pashminas.

I am 'following' (to use social media language) from my desk, via twitter 
I am a twitter newcomer, and haven't yet come to appreciate or enjoy the tiny grabs of information and links that come up.  But, I have joined, and I'm ready to learn from the experience.

The theme for the 2014 Congress is ‘Midwives: Improving Women’s Health Globally’, a theme which reflects Millennium Development Goal  (MDG) 5: 'To improve maternal health.'  Governments and global health organisations have recognized that midwives are an essential workforce to achieve MDGs 4&5 by 2015.

Midwives: Improving Women's Health Globally

Midwives save lives

There is sound logic in this statement.  Midwives work to promote health and wellness in the mother and baby, during and after pregnancy, and during the climax of birth, as well as to provide and access appropriate emergency assistance when the need arises.

It is estimated that almost 90% (87% to be precise - see IMPACT poster above) of the essential maternity care for women and newborns can be provided by midwives.  These statements seem hollow in Melbourne, Australia, where the majority midwives have no idea of how to practise their profession outside a hospital, with high rates of every intervention being the norm.  I live within 30 minutes drive of three tertiary hospitals (Women's, Monash, and Mercy), and several slightly smaller public hospitals which provide emergency obstetric services (Box Hill, Angliss, Dandenong), as well as a gaggle of private maternity services.

Most midwives in Australia would run in the opposite direction if they were asked to be responsible for 87% of the essential maternity care in their communities.   Most midwives in Australia have no concept of health promotion. 

Even the (growing) group of midwives who are eligible to provide (publicly funded) Medicare-rebated services, and who have authority to prescribe medicines, are required, by law and strict regulation, to 'collaborate' with the medical profession, whether the woman in our care needs it or not.   We are forced into a pattern of over-servicing of those who least need it.

@@@

The poorest outcomes in pregnancy and birth occur in parts of this world where women do not have access, firstly to midwives and then to other basic maternity services: particularly parts of Africa and Asia.  These are communities where the burden of disease, such as anaemia, linked to poverty, malnutrition, intestinal parasites, malaria, ... place women at higher risk of poor outcomes.  A friend of mine who has worked with MSF in several poverty-stricken war-torn locations told me she has never before seen so much blood, or so many dead mothers!




There is little or no acknowledgment in the Australian mainstream hospital models of maternity care, of the extra-medical (the part unknown to the medical community) contribution of midwifery to maternity care, and health promotion.  The hospital protocols are dictated by the medical/obstetric faculty, in close collaboration with the insurer.  These protocols are not wrong!   Hospital insurers report costly payouts:
  • when babies suffer hypoxic brain injury that is linked to induction of labour with synthetic oxytocin, leading to hyperstimulation of the mother's womb
  • when continuous electronic fetal monitoring (CTG) is mis-understood by the midwives caring for the women, or 
  • when appropriate action is not taken in response to changes in the CTG, or 
  • when perineal tears or cuts are poorly repaired 
The insurer of Victorian public hospitals, VMIA, reports that although obstetric claims account for only 16% of claims processed, they are responsible for 33% of the costs incurred (statistics given at a VMIA webinar on Litigation, 3/6/2014).   [I have been writing at this site recently about maternity care dictated by the insurer, and it's easy to understand why it's in the insurer's interest to minimise potential litigation.]


In this context, I consider that biggest problem in hospitals is the failure to protect pregnancy, birth and the nurture of the newborn as precious, natural processes.    The fact that never ceases to amaze me is that our bodies are so wonderfully made.

Pregnancy, birth, and the nurture of children are processes driven by an incredibly powerful orchestration of hormones and physical features that support and interact whether we understand the processes or not.

Midwives work to improve women's health firstly by
protecting,
promoting,
and supporting
the natural, healthy processes of women's and babies' bodies.  This is the non-medical, non-interventionist, non-therapist side of midwifery.  Yes, there is an aspect of midwifery that demands timely and effective intervention when indicated.  It's the other side of the same coin.

'In normal birth there should be a valid reason to interfere with the natural process.' (WHO 1996)

The phrase 'protecting, promoting, and supporting ...' has been used many times in the past 2 decades with reference to the Baby Friendly Hospital Initiative (BFHI), introduced around the world by WHO and UNICEF. 

This is good.

But, the protection, promotion and support of breastfeeding does not begin when the newborn baby is taken into the mother's arms and cradled at her breast.  The response of a newborn child to the stimuli during and after birth depend on many other aspects including mother's health and nutrition, and the presence of inhibitory substances such as narcotics and regional anaesthesia that causes temporary paralysis.  The response of a woman to her newborn child is also changed by physical and chemical changes that over-ride of obliterate the mother's feelings and reactions in birth.  These medical procedures and substances need to be restricted, for use only when indicated, and with extreme caution.

I am blown away by the statistic quoted earlier in this post, that
It is estimated that almost 90% of the essential maternity care for women and newborns can be provided by midwives.
From my sphere of knowledge and influence, in Melbourne's middle class, leafy Eastern suburbs, I find it difficult to believe, yet I know that this statistic has been made on reliable information.

!!!

Welcome to our newest grandchild, born this week!

In concluding today's post, I want to acknowledge and thank God for a wonderful young mother, Anna, and her husband Josh, who this week have welcomed our newest grandchild: a healthy baby born at Term, spontaneously, into the loving arms of a strong, healthy mother.






Monday, May 26, 2014

Is midwifery practice controlled by the insurer?

what the stork brought!


Is midwifery practice controlled by the insurer?



If the answer is 'yes', is that a problem?








Recently I wrote about indemnity insurance: who benefits?
The insurance company is a business that can only exist if it protects the interests of its shareholders and employees.  In that article I wrote:
It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defense schemes which cost more than some midwives earn.

Today I would like to focus on a case study, published recently by an insurer of midwives, guiding midwives in the potentially difficult scenario of the client who refuses to follow a midwife's advice.


The case study, titled Terminating the midwife/client relationship (April 2014) suggests that midwives can be insured only if there is zero tolerance for departure, by the midwife or the client, from a very narrow compliance pathway.  That in a situation where the client declines advice from the midwife, the midwife will jump ship - terminate the relationship she has with that client.

I think the advice in this case study is wrong, and MIGA needs to withdraw it.

Many readers will know MIGA is the insurance company that provides professional indemnity insurance (PII) for independent midwives, underwritten by Treasury. It's the only option for midwives who have hospital visiting access.  That's a monopoly.

The big issue of concern in this case study is: "The client signed a service agreement with the midwife agreeing to comply with the requests and recommendations of the midwife."
 

???
 

agreeing [UP FRONT] to comply ... !

Is that reasonable?

What's the point of rhetoric like 'informed decision making' in that sort of relationship?
 

There is no legal obligation that I know of (outside of this sort of service agreement that has been made by the risk management/legal team of the insurer) to ask a woman to sign over her rights, particularly the right of refusal, which is a human right. 

Midwives practising privately, who are planning to attend homebirth, are required by NMBA to have a statement signed by the client that she understands there is no PII for homebirth with a midwife.

The relevant provisions of the National Law and the Board’s requirements are:
Section 284(1)(b) informed consent has been given by the woman in relation to whom the midwife is practising private midwifery
Informed consent must be given by the woman who is the client of the midwife who is in private practice.  Informed consent is defined specifically as written consent given by a woman after she has been given a written statement by a midwife that includes:
·        a statement that appropriate PII arrangements will not be in force in relation to the midwife’s practice of private midwifery in attending a homebirth, and
·        any other information required by the Board.
  [Guidelines for professional indemnity insurance arrangements for midwives]

The case study is based on a scenario in which the midwife believes her ability to care safely for the woman and her baby has been irretrievably compromised, because the woman, now ten days past her 'due date', declines consultation with and review by a doctor/ hospital antenatal clinic.

I want to express surprise at this scenario, and I realise that the MIGA team who prepared this case study probably sent it to one of the midwives insured with them for checking and review.  That thought only adds to my sense of concern!  The scenario presented is hardly a decision point that could be the cause of irretrievable compromise to the relationship.  Most privately practising midwives would have experienced this scenario many times.  The clinical scenario described in the case study is certainly a point for discussion and accurate documentation, but in my mind it would be unthinkable to abandon the woman at that point, on such flimsy grounds.

The case study mentions the ACM guidelines which list post-term pregnancy (7.1.22)  as >42 weeks (not 41+3), category B - 'consult' - which may be with another midwife. The guidelines have a guiding principle of informed choice (3.2.2), stating that "The woman is free to accept of reject any procedure or advice".

Notions of a woman's right to decline, and to make informed decisions in any professional care situations are well established.  The midwifery profession cannot provide safe professional services for women if such blatant and uninformed control is delegated to the insurer, whose primary interest may not be the safety and wellbeing of mother and child.  The scenario described in this particular case study could very easily leave a woman feeling that she has no option than to 'free birth', without any professional attendance.