Saturday, October 04, 2008

Thinking about choice

The maternity reform movement has for many years now used 'choice' as a key demand. Women want choice. My body, my baby, my choice!

Today, I encourage women to avoid what I call the supermarket attitude to choice in maternity care: "I want that, and I don't want that, and I'll have a pink one of that, and two of that ..." Choice is still a key demand, but it's a limited choice.

There is really only one choice at any time in maternity care: either you do it yourself, or you ask someone else to do it for you. While you can proceed under natural, intuitive processes, you are free to decline all other offers of help if you so choose. However, once you choose an unnatural pathway, whether it's speeding up the labour, or taking away the pain, or surgical birth, you relinquish your right to choice. How strange it would be if you were asked would you prefer a 14 or 16 gauge cannula in your vein! Or into which intervertebral space would you like the epidural anaesthetic to be administered?

The midwife's commitment is to work in a way the promotes normal birth. The partnership between a woman and her midwife supports the woman who chooses to work in harmony with her natural processes.

About seven years ago I worked with a group of committed consumers and midwives in Maternity to produce and publish the National Materntiy Action Plan (2002) which included the key demand that women have the right to choose a midwife as their leading or primary materntiy carer.

"The National Maternity Action Plan is a blueprint for reform of Australia's maternity services.
It has been put together by pregnant women and mothers who are committed to seeing women have the choice of a known midwife to care for them throughout pregnancy, birth and the first few weeks after the birth.
The right to choose a midwife as her lead carer is available to women in many other OECD countries, but not to women in Australia. It is based on scientific evidence that shows women and babies have very good outcomes from midwife-led care. The National Maternity Action Plan explains why reform of our maternity services is needed and how women and babies will benefit.
It calls on governments to respond as a matter of priority."

It is encouraging to note that the current national Review of Maternity Services quotes the National Maternity Action Plan in the call for "urgent reform to promote access to community midwives, including funding, legislation, standards of care, and indemnity arrangements." (from the Introduction)

I am thinking about choice, as it applies to maternity care today.

In the early 1970s I was amongst the outspoken young women who demanded that our husbands be allowed into the birth room. As a recently graduated midwife, and obviously pregnant, I proudly and somewhat naiively told the hospital matron about my choice. She looked icily at me as she said "Mark my words, Sister, there can only be trouble from that. Men don't belong in the delivery room." I quickly dismissed her warning - how could she understand my choice?

In the '80s the wonder of ultrasound became available, and I and many others presented in early pregnancy, holding on to a full bladder, and took home the grey polaroid image of a fetus. My choice, no questions asked.

In the early 90s there was a government report in the UK which identified 'choice, continuity and control' as what women want. At that time I was beginning to identify strongly with the birth reform movement, and I embraced those demands. Anything about midwifery in the UK, where midwives could be real midwives, had to be so much better than what we have. I bowed uncritically to a higher authority, and went about integrating the notion of 'choice' for women into my midwifery identity.

By the early years of this century, with the State and National caesarean birth rates rising by about 2% each year, word got out that women were increasingly choosing caesarean. These were said to be sensible, organised women, who wanted to be able to schedule the birth of a child into the other important matters of their lives, like work and maternity leave. These included women who were averse to the unpredictable nature of natural childbirth; who wanted to keep their "honeymoon vagina" and were "too posh to push". Their choice. And they found doctors who would respect their choice without question.


I do not want to suggest that choice should not continue to be a key demand of the birth reform movement. Yet when the 'choice' for costly and possibly harmful interventions into birthing is made for no reason other than preference, I object. I do not think it is reasonable for hospitals, doctors, and all the other staff to be distracted from their ongoing professionally valid work in order to provide a consumer items and interventions at public expense, unless those interventions are likely to improve the outcomes for the mother or her child. The items to which I refer come from a long list, including induction of labour, continuous electronic fetal monitoring, narcotic pain killers and epidural anaesthesia, and caesarean surgery.

A mother who was particularly anxious about her healthy newborn baby is not able to 'choose' to place the child in a high dependency special care nursery. That would be ridiculous. The mother does need help to develop skills and confidence in caring for the newborn, and that support can be provided by a midwife or sister or friend. Yet the 'choice' of epidural or caesarean on demand is not dissimilar. With good support that mother can learn how to work with her labour, and make truly informed decisions as the labour progresses. Having an epidural or a caesarean is not a failure, or in any way wrong in itself, when the decision is made carefully. But a system that allows women to choose such major and potentially harmful options, without first exploring less harmful alternatives, is failing in its duty of care to the woman and her child.

Someone might say that they are choosing carefully, and they choose an elective caesarean. At present that's not difficult to do, particularly in the private maternity system. The same public funding is applied through hospital funding arrangements, and Medicare, and the Medicare Safety Net, and the Private Health Insurance tax incentives, as would apply for caesarean surgery on medical grounds. That is, in my opinion, an abuse of public funding.

Midwives have choice too. We can choose to get alongside women, establish partnerships based on trust, and organise ourselves so that our services are available and we minimise the risk of burnout. Or we can choose to be obstetric technicians, managing the monitoring and surveillance of women in birth, and making sure that the paperwork is up to date.

I don't think many midwives can, in the present maternity terrain, choose to be self employed. The stresses of irregular bookings, and unreliable income, and unpredictable work hours are too much for many to take on. But changes are occurring throughout the public hospital materntiy system, particularly in places like Sunshine, Geelong, Casey, and the COSMOS trial at the Women's. I am watching these places, and others, with keen interest.

1 comment:

state_ur_worth said...

Thank you for your considered words Joy. I agree that the 'choices' available in maternity services are not as simple to navigate as it might first appear.

It fits very well with some things I have been musing on since chatting to a close friend recently. When she last saw the midwife at antenatal clinic at around 28 weeks it was suggested she might think about her birth plan. When she queried what it was that she was supposed to prepare the midwife answered that she could CHOOSE to prepare one, or she could CHOOSE to just 'go with the flow'. My friend said she felt more comfortable not thinking too much about it. I was horrified by the idea that she could approach this momentous occasion with less thought than her and I have spent preparing for a night on the town. This is a mature, intelligent & educated woman. One who usually owns her decisions, but I don't get the impression that she is engaging as the decision maker in this situation. It also made me consider the 'blame game' between women, midwives, OB's and maternity services. If a women doesn't take responsibility for her choices, then is she not handing over control for the choices to the care giver who must then shoulder that responsibility?

Becoming informed about the normality, the processes and the variations of pregnancy and delivery is something that all women should be CHOOSING. It is only through this choice that we can hope to see clearly the other choices that will be presented along the journey.