Wednesday, August 12, 2009

Midwifery framework

In my last blog entry I referred to the 'framework' under which midwives may be required to work after 1 July next year.

What exactly is meant by this term 'framework'?

I don't know if anyone has carefully defined 'framework' as it applies to contemporary midwifery practice, but from a simple understanding of the term, most people would understand 'framework' to mean the underlying principles that put shape and boundaries to our work, in the same way that the frame of a house defines the shape and boundaries of the house. The framework is not usually visible, but it is none the less essential.

Framework is not new. Midwifery already has a strong framework. For many years midwives in Australia have attempted to allign our framework with the international definition, codes, standards and competencies for midwifery. In many ways this constantly evolving, internationally agreed framework has supported our calls for reform of Australian maternity services, resisting medical dominance supported by anticompetitive government funding arrangements. The International Confederation of Midwives has dilligently collaborated with FIGO (Federation Internationale de Gynecologists et Obstetricians [pardon my anglicised French!]), WHO (World Health Organisation) and other key international bodies in defining and developing a strong midwifery profession.

Independent midwife Lisa Barrett has commented on the expected framework for midwifery in her blog: "In real terms this means restrictions. This is where it gets muddled. Are the restrictions to keep midwives safe or to limit the right of women to chose?"

This statement appears to me to indicate fear that some freedoms that exist at present will be lost. It suggests muddled thinking. Of course there will be restrictions: we already work under restrictions. BUT, the right of a woman to choose is a totally separate issue from the professional boundaries that the midwife works in.

A week ago a client who had booked me for homebirth asked me if I would attend her breech birth at home. Without hesitation I reassured her that it is her choice to give birth spontaneously, working in harmony with her own physical and physiological abilities, in the setting of her choice. And that as her midwife I would be with her. But I also recommended a path of action that included referral to obstetric services for consideration of external cephalic version. I work within a responsible midwifery framework. Had I ignored the need for collaboration when an abnormal presentation is detected I would have been denying this woman the right to an informed decision making process, and restricting her options to the non-intervention model under which a midwife primary carer practises.

Another woman phoned me to tell me she has just discovered that she has twins, and is looking for midwives who will support her choice of homebirth. I encouraged her to make choices that she knows are best for her babies and herself; choices that cannot be made months in advance of the birth. Her right to choose is apart from the midwife's professional framework. If, after having considered carefully all her options, this woman is labouring and intending to give birth at home, I will do all I can to provide whatever professional private midwifery services she wants from me.

The question Lisa asked is "Are the restrictions to keep midwives safe ...?" I don't think so. Any 'restrictions' we experience within a professional midwifery framework are really structure, shape, and boundaries to midwifery practice. Without integrity in the framework the whole structure will collapse. Framework does not keep midwives safe; the safety of midwifery practice is complexly and beautifully dependent on the awesome natural processes that God created, and authentic midwives know how to work in harmony with.

Framework does not conflict with a woman's right to choose between physiological and medical processes.


Stitch Sista said...

So does that mean you would or wouldn't provide prenatal care to the woman carrying twins??

What bothers me is this idea that anyone - bet it the dr or the midwife is the 'keeper' or solely responsible for the birthing woman and her child. Indeed the birthing woman needs to take responsibility for her choices, after the midwife gives her all the information she needs to make the best choice.

Joy Johnston said...

Thanks for asking this question, stitchsista. I suppose it seems that I'm being wishy washy, but I have to say, yes, and no.

Yes, I would provide prenatal care, as a midwife, at the 'primary care' end of things. But I would be expected (under the basic midwifery framework that is understood world-wide) to refer the woman to a specialist, either within a public maternity hospital or a private obstetrician - and she would have to make informed decisions about any choices that come out of that care. Most women with twins would not consider midwifery care sufficient: they would want ultrasound, and possibly some other forms of monitoring. These are technologies that I do not manage, and in normal uncomplicated birth I am happy to work without them.

Does this mean that the midwife or doctor become the 'keeper'. I don't think so.

I see midwives as guardians or keepers of normal birth, but not of the women and their babies.

Stitch Sista said...

Oh sorry I wasn't clear...I wasn't suggesting that you were purporting to be the keeper of the woman and child, but that's the way it is often portrayed. Like when I chose to homebirth one of the most common things I was asked was "are you allowed to do that?" or "will the dr let you do that?"

I find it very sad that people do not understand their basic human rights to seek the care they desire, and to also refuse interventions etc if they wish.

Lisa Barrett said...

Joy, under current midwifery understanding you wouldn't be expected to refer a woman with twins you would be expected to give her all information for her to decide for herself. making not necessarily what we consider the best choice as we see it but the best choice for herself.

Under new government proposed framework (although difficult to discuss as homebirth isn't included at the moment) you would be expected to refer the woman and she would have to have due process for her right to refuse.

This is why there is a question over keeping midwives safe and the womans right to chose.

They are muddled because a midwifery framework will restrict a womans right to chose if she can't find a midwife who will work outside a given framework.
A framework and guides ARE there to ensure safe behaviour of a midwife and it IS assumed with these that the midwife is the keeper of birth.

We can rationalise anything to make it appear that we are woman focused but any over regulation is not in the womans best interest or in the midwives best interest to provide absolute individualised care.

Joy Johnston said...

Lisa I do appreciate your comment, as I think this sort of discussion throws light on the subject.
You say that "under current midwifery understanding you wouldn't be expected to refer a woman with twins ... [and she makes] the best choice for herself."
I agree that she is responsible to make the choice, but I consider that the best way she can do this is by hearing her options from those who provide the options, rather than by me giving my version of what I think the doctor will or will not 'let' her do. I have always practised midwifery in this way.

Lisa Barrett said...

I see what you mean and for the women who are open to that its great.
Even better for me is if they have already done the research and spoken to the medical establishment and then decided to make contact. That way there is no possibility of confusion on the care offered or the research available. This would be ideal if it were readily available.
I have a client expecting twins who came to me in this way. Makes antenatal decisions for her much clearer.