Saturday, April 10, 2010

Scope of practice

The midwife's scope of practice is a topic that has become central in many discussions as we approach the introduction of the government's reforms into maternity care. I have written a lot about the countdown to 1 July in another blog.

Midwifery requires skill and wisdom - knowing how to work in harmony with normal physiological processes in pregnancy and birthing. The midwife who works independently, as the professionally responsible primary maternity care provider for a group of women and their babies, has the opportunity to work to the extent of her scope of practice. There are boundaries, and defining these boundaries also requires skill and wisdom.

It's no secret that a midwife is confident and delighted when a birth proceeds without incident, and a strong mother takes her baby joyfully to her breast. This birth is truly within the midwife's scope of practice.

But what about the birth that has some complexity? Is a breech birth, or twin birth, or even a birth at 36 weeks' gestation, or birth to a woman who has had previous caesarean surgery ... - are these within a midwife's scope of practice? Does that midwife, and that woman, have the *right* to choose the setting for the birth: the woman's own home? Or is there some line over which the midwife must not step?

I would be foolish to try to define a midwife's scope of practice in this blog. My hope is that by raising the issue, readers will reflect and learn in the way that is most useful to them.

The Australian College of Midwives has, since 2004, published National Midwifery Guidelines for consultation and referral (which can be downloaded as a .pdf file). The Guidelines claim to be "internationally comparable and based on the latest available research evidence at the time of publication."  The Guidelines cannot, in themselves, set boundaries for a midwife's scope of practice.

The uniqueness of birth, and of midwifery, is that BIRTH IS NOT AN ILLNESS.

Birth is not an illness.

Certainly there are illnesses that can complicate birth: anything from a chest cold to life threatening diabetes or heart disease can and do result in risk to the mother's and her baby's ability to successfully and safely negotiate the birthing journey.  No midwife has a guarantee of wellness or safety.  Safety is achieved by enabling health and refraining from interfering in sensitive hormonally mediated processes, at the same time as being able to access relevant specialist medical services in a timely and effective way when appropriate.

What we do as midwives is different from any other health profession - even obstetrics. The key is the woman's desire to give birth under physiological conditions, which is what a midwife's scope of practice is able to offer, rather than a medically managed birth, which is effectively the only way the doctor knows.

Midwives who work in medical settings are often prevented by service protocols from working to their scope of practice, sometimes to a degree of restriction that is ridiculous and not based on any evidence. I have been told that midwives providing homebirth services under a new pilot scheme for a hospital in Melbourne's outer suburbs have been told that they will be dismissed if they do not abide by the 'rules'. An example is the management of the third stage. The hospital's protocol requires the midwife to undertake active management of the third stage. Women are informed that if they do not agree to active management, they will not be allowed to proceed in the homebirth group. There is no discussion.

When a midwife and woman are working in a partnership based on trust and reciprocity, and there is an aspect of the care for which the midwife's scope of practice may be broader than that which falls under a set of guidelines, it's an opportunity for decision making. The woman needs to know where she fits within the ACM guidelines, and any other contemporary standards - written or assumed. She needs to know what her midwife can offer.  She may need to investigate what the alternative model of care to which she may be referred can offer, and weigh up the potential and perceived benefits against the costs and risks.  She needs to know this so that she can make her own decisions.

Decision points that arise at any time in the professional relationship can be addressed in this way.

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