Monday, January 05, 2009

DUTY OF CARE?

A midwife friend has recently posed this question:
How many health professionals involved in midwifery, obstetrics, anaesthetics and paediatrics are breaching a duty of care?

I questioned what she meant by midwives 'breaching duty of care':
A: "the collaboration in the system induces midwives not to inform women properly especially in the private system and they participate in medical delivered care often without question. ... All professionals have a duty of care, to do no harm. Informing women about the effects of opioids and other drugs is avoiding harm when we know from the research the effects on the foetus via the placenta and the newborn via breast milk."

This is a serious accusation. 'Duty of care' is "a legal obligation imposed on an individual requiring that they adhere to a reasonable standard of care while performing any acts that could foreseeably harm others." (Wikipedia)

This midwife is stating a belief that is clear enough to those who know midwifery, but I don’t think the general public, or even most midwives, would understand. Most women who receive dangerous drugs commonly used in labour, such as Pethidine or Morphine by intramuscular injection, or similar opioid drugs in epidural cocktails, would have a vague understanding that these are powerful substances, and many who receive them would have commenced labour with a birth plan of some kind stating that they wanted to avoid such drugs. It's a good/bad, "yes I want what's good /no I don't want what's bad" plan. But by the time she agrees to the offer of an injection to 'help' with the pain, the level of distress the woman is experiencing is intolerable, and any warning that the substances given may harm the unborn child or impair the child's ability to breast feed effectively will seem irrelevant. "What's the point if this is killing me anyway?" The woman who cannot find a way to work with her labour becomes effectively trapped in an unrelenting barrage of pain. Her feelings of entrapment can lead to fear, with vomiting, dehydration, and emotional distress accompanying a failure to progress.

I have at times been present when a woman who had planned unmedicated birth requests medical pain management - usually an epidural. The anaesthetic doctors are usually very careful to inform that woman that although the procedure is considered appropriate, and they are willing to proceed with it, she needs to understand that there is a small risk of certain complications including infection, nerve damage, ongoing pain, and even paralysis and death. The doctor waits for the woman to give consent, before proceeding.

Midwives seek alternatives that are less intrusive, less 'medical', and we believe, less likely to harm either mother or baby. We have promoted active birthing, danced and climbed stairs, loved water emersion, massage, and words of gentle assurance. Although it's difficult to 'prove', the research evidence seems to indicate that women are less likely to request medical forms of pain management/relief if they are being cared for in labour by a known midwife. The trusting partnership between a woman and her midwife, and vice versa, is of great value.

Women who have the constant company of a lay birth attendant (or doula) in labour seem to be more able to accept the work of labour, and are less likely to ask for medical alternatives, if their professional care providers support their desire for normal birth. The birth attendant does not have any agenda other than to provide the labouring woman with company and physical assistance. The birth attendant does not have any responsibility to achieve particular outcomes, and should not be guiding or 'coaching' the woman.

However, regardless of the skill or other characteristics of those in attendance, there will be women for whom medical pain relief and medical/surgical procedures are the safest way for both mother and baby to negotiate the birthing journey. How many women, you ask? It may be 5% or it may be 15% - that doesn't really matter. If it's you, you will be thankful that appropriate emergency obstetric care can be accessed. No woman can consider that her birthing will be free of complications. It's not a matter of choice or planning.


I have formed an opinion that a midwife has a particular duty of care, which is more specific than standing in the way of the possible evils of a system which relies too heavily on medical management of birth. That duty of care is to be a midwife, all that contemporary midwifery entails, in an effort to achieve optimal birthing outcomes for both mother and baby. Unfortunately the maternity care system as we know it leads midwives to be submissive to the more powerful medical model, rather than to act within a midwifery framework and attempt to not only prevent unwarranted interference, but to work in harmony with the woman’s natural process.

I know a midwife in a public hospital who refused to put up Syntocinon to augment a labour, because she, the midwife, assessed progress to be satisfactory. The midwife had a complaint against her and had to defend her action to her employer. Another midwife recently supported a woman’s wish to have a waterbirth in a private hospital – that midwife has received a ‘first and final warning’ from her employer. The mother in that case is very pleased with the midwife's actions in attending her, and enabling a safe and intimate birth that happened to be in water. When the midwife asked her managers about the woman's choice, they laughed at her, and said that in an institution we can't afford to be led by what patients want. That midwife may be more careful, and perhaps less supportive, the next time a woman wants to do something outside the hospital's usual process.

So although some midwives understand our 'duty of care' to promote normal birth, it will not become an acceptable ‘duty of care’ to be applied across the profession until the broader professional and lay community agree. That is a long way from where we are today. It would probably take a midwife to have a serious complaint made against her, that she as a midwife failed to promote normal birth (or other midwifery imperative) by taking a certain action, and that complaint would be a test case before the registration body. At present if a complaint like that was received, I expect it may be considered vexatious or frivolous, and therefore no action taken.

To any midwives who read this blog, I want to encourage you to take seriously your professional commitment, call it a duty of care if you like, to learn to work in harmony with natural processes, and promote physiologically normal birth whenever you can. Only when there is a valid reason to interfere with the natural process can we make decisions about the most appropriate medical or surgical intervention, whether it's induction of labour, augmentation, painkilling drugs, anaesthesia, or surgically managed birth.

To mothers and mothers to be who read this blog, I want to encourage you to choose a model of care that will support your choice to give birth under your own power (Plan A), unless there is a valid reason to move to 'Plan B'. It is likely that the experience of birth, particularly with your first child, will take you way beyond your expectations, and out of your comfort level. Your midwife is able to be present, with you, and reassure you that all is well.

This has been a long post. I hope it contains valuable insights for readers.
Joy Johnston

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