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 joy@aitex.com.au

Wednesday, January 28, 2009

Inquiry into Public Hospital Performance Data

I became aware of this inquiry last week, and initially thought it could slip by without requiring my input. However, it occurred to me that it was unlikely that anyone else would inform the committee of the need for public hospitals to provide back-up for planned homebirths. Therefore, I realised, I had better get to work on a submission.

There are three areas, under the general topic of public hospital performance data, that the committee has asked for comment on:
To inquire into and report on
1. the capacity of hospitals to meet demand, standards and quality of care,
2. resourcing and access levels, and
3. the accuracy and completeness of performance data
for Victorian public hospitals.

Background on homebirths
Birth in the home is unusual in Australia, with only 0.2% of births being recorded as homebirths in 2005 (AIHW 2007), and a similar number being unplanned out of hospital births, known as ‘born before arrival’ or ‘bba’ births.

Most planned homebirths in Australia are attended by self employed midwives, with a fee-for-service arrangement between the woman and the midwife. The State with the highest rate of homebirths is WA, at 0.6% of births (155 births) in 2005 (AIHW 2007). In WA, a publicly funded homebirth program has been operating in Perth and Fremantle through Community Midwifery (CMWA) (http://www.cmwa.net.au ) since 1997.

Reports produced by the Victorian Government’s Perinatal Data Statistics Unit (PDCU), including the annual Hospital Profile of Perinatal Data - Homebirth Report, and the Births in Victoria Report, provide accurate and reliable epidemiological data for planned homebirths that are attended by midwives, and planned homebirths for which transfer of care to hospital took place.

A review of 440 planned homebirths in Victoria 1995-1998 (Parratt and Johnston 2001) reported that:
• Spontaneous labour rate was 96.4%
• Spontaneous cephalic birth rate 91.6%
• Transfer to hospital rate 20%
• No perineal trauma in 64.2%
• Post partum haemorrhage 5.5%
• Retained placenta 1.1%
• Four perinatal deaths in this cohort were unrelated to their risk status or place of birth.

A woman planning homebirth faces certain requirements before homebirth becomes a possibility: she needs to come into spontaneous labour at term, and progress in labour without analgesics or stimulants, so that she can give birth spontaneously. The midwife works in a way that protects the mother’s wellness, and her baby’s transition from the womb to the outside world, and has the capacity to intervene when required to protect mother and baby, in the same way as she would attend a spontaneous birth in a hospital or birth centre. Homebirth midwifery is not remarkably different from hospital midwifery for well women in spontaneous labour. The midwife’s competencies are the same. The consideration by midwives to attend homebirths is a logical step after caseloads in establishing autonomous practice.

Developed countries in which midwives attend homebirth within the usual scope of midwifery practice include the Netherlands, UK, Canada, New Zealand, and other parts of Europe and USA.

Although the number of women who plan homebirth in Victoria is small, they are a significant group, and should not be ignored.

[This post has been condensed from my submission to the inquiry. Joy]

Wednesday, January 21, 2009

Angelina



In a simple timber home near the North Pine River, in the Colony of Queensland, Angelina gave birth to her little boy, who she named Ben. Her friend Mrs Fogg, whose husband owned the general store in Petrie town had come to help her; the older children were being cared for by a neighbour. It was mid-December, and the frequent storms and hot, humid weather had sapped her of her energy. She had felt the pressure of this pregnancy for many weeks now, as her body sagged under the strain of too many babies.

Mrs Fogg was not a midwife, but was a sensible woman who was trusted in the district. Her own child had died very young, and she had had several miscarriages, years ago. There was a midwife and even a doctor in Caboolture, or Redcliffe, but the distances were too great for most ordinary folks to contemplate.

For a couple of days after the birth Angelina had rested in bed, waiting for her strength to return. Mrs Fogg stayed with her, and brought food, and helped her wash. The baby was often fretful, and Angelina patiently nursed him at her breast. She remembered the early days after each of her births, as the babies eagerly took what they could. Then the milk came in, and a peaceful hush settled on the child and the home.

A few more days passed, and rather than feeling stronger Angelina became feverish, and was in pain. Her lochia had developed an offensive odour, obvious to anyone entering the room. The milk that had come in, dried up, and baby Ben became more demanding and unsettled. It was thought best that he be nursed by a young mother from the Church, whose own baby was a few months old. Angelina had encouraged her as she had faced her own challenges, and she was more than willing to do what she could.

By seven days Angelina was barely aware of what anyone said. Her husband James knew they faced a critical situation, and his heart was heavy as he went about his work on the farm each day, with the help of the older boys. He had watched this woman, his beloved wife of sixteen years, and had admired her strength and wisdom. He saddled his horse and rode several hours to find the doctor, who gave him some powders for the fever and pain, and promised to come as soon as he could.

It was Christmas eve, two weeks after the birth, when Angelina experienced a severe secondary haemorrhage. In her already weakened state, her gentle face was listless and ghostly pale. They had tried all the remedies and treatments available. As each minute, each hour passed, those who knew her prayed for her recovery. Two days later, as she ceased to breathe, her stricken husband gathered the children around him, and committed her spirit to their loving Heavenly father.

The Reverend C Clarke from the Presbyterian Church officiated at Angelina's burial the next day at the North Pine Cemetery. Other witnesses are recorded as John Todd, Archibald Hamilton, and Joseph Slater.

Several weeks later James again saddled his horse and returned to Caboolture with the documents, so that he could register her death. The cause of death was recorded as 'in child bed'. 'None' was recorded against the question 'Medical attendant by whom certified'.

Angelina's children's names are listed on her death certificate, and their ages: 14, 12, 11, 10, 8, 6, 5, 4, 2, 1 and 16 days. My grandfather, Frank White, was her four-year old son.

We don't know much about Angelina - most of the detail in this brief note is from her death certificate. It seems right to record the names of those who shared this journey with my great grandfather, my grandfather, and his brothers and sister. I don't know who attended to Angelina's needs in her last days: the role Mrs Fogg played is fictional.

The only photo we have of Angelina shows a strong young woman, dressed handsomely, next to a piano. Angelina, who was born to Samuel and Elizabeth Smith in London, probably came with her family to Queensland in the early 1860s.

In telling Angelina's story I want to value her as a mother; and as one whose mother-love and strength of character was passed on to her children's children, in spite of her too-early death.

Tuesday, January 13, 2009

A MIDWIFE'S HOUSEKEEPING

Today I was able to spend time doing office work - the 'housekeeping' for my midwifery practice. This is a time for critical reflection, and learning. It's a real privilege to provide primary care for women who choose me as their midwife. But with privilege comes responsibility, and I am constantly reminded that these families have entrusted me with some of the most lasting and memorable times in their lives.

I have checked through my active folders; filed away those that are complete; and checked that all payments are entered properly in my QuickBooks accounting program, ready for the next BAS (Business Activity Statement) to the Tax Office next month. I have tallied my births for 2009, and looked at any challenging situations that I needed to address.

I find myself reviewing carefully the couple of births in which our plans changed.

One mother, a primip, was in very early labour when her membranes ruptured spontaneously, revealing meconium in the liquor. I listened to the baby, who did not seem distressed. We decided to go to the hospital, and in spite of the continuous fetal monitoring, the labour progressed well, and we experienced a physiologically normal birth. The hospital was very busy (there is a baby boom at present), and the midwife allocated to care for my client was happy to manage the paperwork and watch, while I knelt on the floor beside the young woman and guided with my voice and her hands as she received her baby from her body.

Another mother who transferred from home to hospital, in labour with her second child, had called me to her home. She was progressing nicely, late at night, when we heard the distinctive sound of cracking, breaking, and falling as a huge branch of a large gum tree next to the house fell. It was a frightening sound, and I was immediately concerned for the safety of my client and her baby. It was dark, and we couldn't see if anything had been damaged. I felt it best that we go to hospital, and the parents agreed. About 30 minutes after we arrived at the hospital, the mother gave birth to a bonny, healthy baby boy. Later we looked at the tree, and found that the branch which had broken off had become caught in the fork of another branch, and was suspended above a parked car, next to the house. Had it fallen all the way, the car would have been squashed, and some of the house would probably have been damaged.

Another transfer to hospital was for a mother who was not progressing well, with her second baby. This can be a very difficult call for a midwife, and the woman, to make. When is the mother needing to accept the pain, and when does she need to ask for medical help? When is pain unbearable, intolerable? When does the lack of progress indicate a problem? As time passes the baby becomes tired, and is less able to tolerate contractions.

When transferring to hospital in a situation like this, we ask the hospital staff to work with us, using all the skill and resources that are available in achieving the best birth we can for that mother and baby. In the case I am reflecting on, the birth was caesarean. Not what we had planned for, yet the best on offer in that situation, that night.

I had a few planned hospital births too. I am a plain midwife, and if a woman wants to be in hospital I go with her, despite the restrictions that hospital have placed on me and my kind. Birth can proceed well in hospital or at home. One mother had a beautiful vba2c in a private hospital. Her two previous births had been caesareans because the babies had, for some reason which she did not understand, been distressed in early labour. This labour took some time to establish, but the baby held in there beautifully. That mother's face, as she took the wet and beautiful newborn child to her breast, declared a moment of utter triumph.

Another mother gave birth to her twins, just eight minutes apart, without any medical intervention. We had arrived at the hospital in good labour. Without having planned to do so, I happened to 'catch' both babies, while the hospital midwives worked alongside me. This is unusual - most hospitals will tell an independent midwife that she is not to carry out any clinical care. I am not keen to challenge the system when I am 'with woman'. I seek to collaborate with the hospital colleagues, knowing that the woman and I have a special partnership which cannot be over-ridden by protocols or rules. But really, I don't think anyone could insist that receiving a baby who is being born spontaneously is an exclusive professional act. The mother is giving birth! As they say, it's not rocket science.

My 'housekeeping' today also helps me prepare for the births I will attend as the weeks and months of this year unfold. Each consultation, both before and after the birthings, and each birth, is a time when I must give my full focus to the individual woman. I cannot guarantee a particular outcome: what I can do is offer to accompany her through the amazing journey she has begun.

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