Saturday, January 31, 2009

'protecting the public'

In recent weeks I have had discussions with several midwives who are concerned about complaints that have been made to their registration authority, about them. This is a difficult and potentially distressing time for a midwife. While it would be unwise of me to mention anything that could link this entry to the particular midwives, I would like to explore the general matter of regulation by law, 'protecting the public', as it applies to midwifery.

Midwives who are self employed, who practise midwifery independently, or in private practice, may feel that we come under more scrutiny now than we did when we were employed as midwives in hospitals. While I don't have figures on the number of complaints received by the registration boards about self employed midwives compared with the rest, it's likely that there is a huge proportionate disparity.

A midwife employed in a hospital or health service can expect to be called to the manager's or director's office for a chat, and even given warnings, if she is thought to be practising at a less than expected standard. As an employee there are routine appraisals and other processes to help improve staff performance. Hospitals want to retain their staff, and internal processes are constantly being used to maintain the standard of compliance with the agreed standard. Procedures and protocols are in place as a risk management strategy, and the staff are required to apply the hospital's protocols. I don't want to denigrate the hospitals - that's the way risks are managed, and insurers provide cover. The broad brush approach sees conditions and interventions rather than what we refer to as a woman centred approach.

An independent midwife cannot ignore current practices. We confront this from time to time if a woman in our care has twins, or her baby is presenting as a breech at Term. While a woman may refuse any intervention that is offered in maternity care, the midwife will be judged differently, especially when a complication arises that professional peers consider could have been avoided, had the care been 'managed' differently.

For example, a woman who has had a previous caesarean experienced release of the baby's fluids (ruptured membranes) at 40 weeks, and did not come into labour. The woman agreed to regular monitoring, and blood tests, but refused a repeat caesarean or an induction of labour. The pregnancy continued, without infection or other complication, until 14 days later when she laboured and proudly birthed a healthy beautiful baby in her own good time.

I don't expect there will be any complaint about any midwife or doctor involved in that woman's care. It was the woman who had informed herself of her rights, and who checked from time to time with a trusted midwife. She kept to 'plan A' because she had no reason to accept 'plan B'. Efforts to stimulate labour 'naturally' - walking, nipple stimulation, intercourse, castor oil, stuff from the naturopath, acupuncture, ... - only gave her wind.


If any person makes a written complaint to the midwife's registration board or council, the board is required by law to investigate the complaint. The board's officers make an initial inquiry, and advise the appointed members of the board on the severity of the complaint, and what action should be taken. If a complaint is found to be without substance, or is vexatious, or a waste of time, the decision may be to not investigate. A serious, well substantiated complaint may lead to immediate suspension of the midwife's qualification and right to practice, while the investigation proceeds. In this way the laws are designed to 'protect the public'. The more serious investigations into professional misconduct or unprofessional conduct are usually highlighted in the public media. Most of us would agree that a rogue professional whose unethical or incompetent actions are likely to hurt people who trust them should not be allowed to practise.

When it's a self employed midwife in the spotlight, it's possible that the issues are more subtle. A midwife who supports a woman who wants vaginal birth after caesarean(s), and in the process challenges the hospital culture that she believes might have made the woman more likely to have the surgical births in the first place, may be seen as overstepping professional boundaries. A midwife who transfers a newborn baby to hospital after homebirth, and continues to support the mother's desire to exclusively breastfeed her baby during the hospital stay, may be accused of interference by the nursery staff. The midwife may feel confident that she has acted professionally, but if a complaint is lodged, she will need to argue her case, under the legally authorised system under which she is registered.

In a little more than a year from now a new process will be implemented across Australia for national registration and regulation of health professionals. The intergovernmental agreement covers all states and territories, and is set to become effective 1 July 2010. Professions included in the agreement are physiotherapy, optometry, nursing and midwifery, chiropractic care, pharmacy, dental care (dentists, dental hygienists, dental prosthetists and dental therapists), medicine, psychology and osteopathy.

Despite these changes, the jobs that are currently managed by the state and territory nursing and midwifery boards and councils will more or less continue. The first objective of the national scheme (point 5.3 of the agreement) "to be set out in the legislation, [is] to:
(a) provide for the protection of the public by ensuring that only practitioners who are suitably trained and qualified to practise in a competent and ethical manner are registered;"

What can independent midwives do to ensure that we are practising in a competent and ethical manner?
We don't have managers or directors, but midwives can support one another, and be accountable to one another, with peer discussion and reflective learning. The requirement for proof of ongoing professional development activities is to be implemented with the new national health regulation. The MidPLUS portfolio, set up by the Australian College of Midwives, provides a system of recording and accounting for professional development.
Independent midwives are usually well represented at educational events. Many independent midwives demonstrate excellence in their professional activities.

I don't have an easy way out for a midwife who is required to answer questions about her practice. But if we always practise with professional integrity, assuming that everything we do could be seen and judged by others, then we should be proud to undergo peer review or investigation. We have chosen to practise independently, which means we are in a select minority within our profession. We can expect that we will be noticed, and, unfortunately in the land that cuts down the tall poppy, sometimes we will be an easy target for anyone who wants to take a pot shot at us. (mixing metaphors, but I hope you get the point)

I welcome any comments that you may like to make, either on this blog or by email to

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