Monday, August 30, 2010

Families


In the past week or so my mind has been drawn into a family-related project that I call 'Pictures and memories from long ago'.

With a strong sense of purpose, I have scanned pictures and documents, and copied accounts of the lives of some of my forebears. These fragments of memories have been drawn together, as I have remembered people and stories from the past.

The two women pictured in this post are truly wonderful women, from whom I have learnt values and been inspired to follow their guidance. The stately old lady is Jane Eliza Harriet White, aged 95 when this picture was taken, I think. My Grandma lived in the old homestead overlooking the bay at Redland Bay, Queensland. The tall palm trees made the house visible from a mile or so away as we headed towards School of Arts Road. Grandma had given birth to, and cared for her eight children, through terrible times or war and the Great Depression.

The beautiful younger woman, with two little girls, is my mother, Ella White. Mum's story includes missionary work in China, where she met and married my father. She gave birth to, and cared for her seven children, through the 50s and 60s. I have written about my mother in this blog in the past, especially as I waited for my own daughter to give birth.

Both Mum and Grandma included twins amongst their children. Mum had trained as a triple certificate nurse: nurse, midwife, and infant welfare sister. Grandma had done lady-like preparation for life in the early 20th century, including learning to paint landscapes. These two women have given me my two passions that go beyond family: midwifery and art.

My work of collecting and collating pictures and stories has been inspired by my enjoyment of digital technology. A simple e-book format that I used for my first book, Midwifery from my heart, has been readily adapted to the job at hand. I am bringing out the old albums, scanning the pictures, and presenting them in a way that tells a very special story.

My children and grandchildren are not very interested in their heritage at present. They have busy lives. But one day they may find, as I have, great pleasure in remembering and adding to my memories.

Monday, August 23, 2010

IS HOMEBIRTH SAFE?

and,

IS THAT A VALID QUESTION?

I am not wanting to write at length about this very significant question today, but would like to direct readers to Amy Romano's comment and debate at the Lamaze blog.

In what appears to be a global race to discredit homebirth, people who should know better have shamelessly manipulated retrospective data from planned homebirth, and come up with conflicting and often confusing results that have been published in peer-reviewed literature.

Note in this context the critiques of the Australian Medical Association's publication of the Kennare et al (2010) Planned home and hospital births in South Australia, 1991-2006: differences in outcomes. The wild claims of increased risk of perinatal death or morbidity are just that: wild claims made on deeply flawed research.

Amy Romano writes:
The (in)famous Wax home birth meta-analysis hit the scene over a month ago. But the buzz doesn’t seem to be dying down. In the weeks since the original pre-publication and press release, editors at The Lancet and BMJ have both weighed in, and there’s a steady stream of media attention. While all of the media have dutifully quoted midwives in leadership positions saying the meta-analysis is flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier post – did we need a meta-analysis to establish the neonatal outcomes of planned home birth? We had, after all, a very large, methodologically rigorous study on home birth safety involving over a half million women that was published less than 2 years ago. Won’t that suffice? ... (continued)

Thursday, August 12, 2010

Collaborative arrangements for midwives

photo: Mizz with Josh
Readers who have been following the political developments in the world of midwifery will know that the Australian government has signed into law a requirement for midwives to have 'collaborative arrangements' in order to entitle their clients to claim Medicare rebates on their charges. Midwives may become eligible for Medicare provider numbers after 1 November this year, if all goes to plan.

Midwives have known since early in the maternity reform process that the Health Minister is committed to collaborative arrangements. Midwives and childbirth advocates have repeatedly lobbied the Health Minister and her bureaucrats about the fact that the requirement for collaborative arrangements for midwives, without any matching requirement that doctors should engage in such arrangements, was an effective veto of private midwifery practice. There is no incentive, no reason why any doctor would consider signing a collaborative arrangement with a midwife in private practice, who is, in a small way, competing with the doctor for business.

Press releases and discussion about the Gillard government's action in progressing the small piece of legislation, 'National Health (Collaborative arrangements for midwives) Determination 2010' under subsection 84(1) of the National Helath Act 1953 can be reviewed at recent posts to the MiPP blog.

My intention in commenting here on this matter is to work through a scenario that I, and a woman who sought my services, would encounter if we tried to comply with the requirement for collaborative arrangements as laid down in this piece of legislation.

Section 7 requires that (1) an eligible midwife must record the following for a patient in the midwife's written records:
(a) the name of at least 1 specified medical practitioner who is, or will be, collaborating with the midwife in the patient's care (a named medical practitioner);
(b) that the midwife has told the patient that the midwife will be providing midwifery services to the patient in collaboration with 1 or more specified medical practitioners in accordance with this section;
(c) acknowledgment by a named medical practitioner that the practitioner will be collaborating in the patient's care;
(d) plans for the circumstances in which the midwife will do any of the following:
(i) consult with an obstetric specified medical practitioner
(ii) refer the patient to a specified medical practitioner;
(iii) transfer the patient's care to an obstetric specified medical practitioner.

Under this section, the woman who is my 'patient' requires a named medical practitioner (a) of whom the woman has been informed (b), and who agrees in writing to be the collaborating doctor (c).

I don't know where to start looking for this doctor (or doctors). My clients at present come from as far away as Epping in the North, Point Cook in the S-W, and the Yarra Ranges in the East - from 20-50K in each direction. I do not know the local doctors. Most of my clients are healthy women who take good care of their bodies and their families, and who don't have much need for doctors.

I have no idea how the named medical practitioner of this section is going to make him/herself available 24/7. Midwives take small caseloads so that we can respond at any time, day or night. Critical decision making in maternity care, particularly when the midwife is committed to protecting, promoting and supporting the natural physiological processes, is not something that happens in office hours. Most doctors have work hours; many medical practices are closed out of hours. Is this doctor going to give me his/her private contact details, and engage with the midwife at any time, under this collaborative arrangement?

I can only imagine how the insurance company of the named medical practitioner of this section will respond to any potential claims. The indemnity issue alone will probably be off-putting enough for even those most supportive of midwifery practice.

The requrement (d), plans for consultation and referral and transfer of care are not a problem at present. A midwife, by definition, arranges medical referral when and if required.


The legislation continues:
(2) The midwife must also record the following in the midwife's written records:
(a) any consultations or other communications ...
(b) any referral ...
(c) any transfer ...
(d) when the midwife gives a copy of the hospital booking letter for the patient to the named medical practitioner - acknowledgment [signed -received]
(e) when the midwife gives a copy of the patient's maternity care plan to the named medical practitioner - acknowledgment [signed - received]
(f) if the midwife requests diagnostic imaging &c for the patient - when the midwife gives the results to the named medical practitioner - acknowledgment [signed - received]
(g) that the midwife has given a discharge summary to the named medical practitioner and the GP - acknowledgment [signed - received]


Reading this section makes me wonder how I would be able to comply with all the complexities of this system.  I don't have a secretary sitting at a desk and organising my letters and paperwork. I wonder if this doctor is going to be happy with faxes, or with results sent by mail from the pathology lab?

My conclusion is that the future looks unpromising for midwives who are hoping to set up Medicare - supported practices.



In the Radio National's Life Matters program today, midwife Liz Wilkes and obstetrician Ted Weaver spoke on "collaborative arrangements".

For those who'd like to hear the online audio, download the podcast, or make comment, the website is:
http://www.abc.net.au/rn/lifematters/

Liz spoke well. Ted Weaver has his head in the sand. He reckons doctors haven’t been asked if they would sign a collaborative arrangement so that a midwife’s clients can access Medicare. He suggested obstetricians will agree to increase their clinical load without being paid – he used the term altruism!

Midwives are regulated practitioners in our own right.  Yet the Medicare reforms put us not only at the mercy of the medical profession, but also asking for their generosity.  There is really no sense, from a doctor's point of view, in supporting someone in competition for business.

Sunday, August 01, 2010

RANZCOG on trial

The new Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) C-Obs 38, issued July 2010 by the College of Obstetricians and Gynaecologists, RANZCOG, requires critical review.

Yesterday I commented in another blog on the 'risk' picture presented in this Statement.

The ultimate statistic:
RANZCOG notes an "extremely low but clinically important frequency of adverse outcomes", notably maternal death, for women who have elective repeat caesarean surgery (ERCS). However, RANZCOG deftly attributes the reason for the "apparent association" to "women with complex medical and obstetric problems [who] are much more likely to feature in the ERCS". This statement is dishonest and misleading. Women with no medical or obstetric problems have added to maternal mortality and serious morbidity statistics after caesarean surgery that has been undertaken for non-medical reasons, or after a cascade of interventions that began with medical interference in an otherwise uncomplicated pregnancy.

Homebirth for VBAC
While the 'H' word is not prominent in the RANZCOG statement on VBAC, it is understood from a previous College Statement (C-Obs 2) that RANZCOG "does not endorse home birth". This position has been clear since 1987, and has effectively prevented any useful dialogue on home birth between midwives and most obstetricians.  It's a matter of joining the dots.

Having declared its standard for antenatal preparation; intrapartum care; contraindications to Trial of Labour (TOL), and TOL in risk-prone circumstances, the RANZCOG statement on VBAC has defined the option of "TOL" in "risk-prone circumstances" as "sub-standard care" [emphasis added].
"A TOL may become particularly risk-prone where: there is a lack of services for safe provision of emergency care (eg a TOL conducted at home, birth centre or centre without ready access to obstetric, anaesthetic and paediatric support); there is a failure to provide or accept adequate intrapartum maternal and fetal surveillance; and there are clinical circumstances such as outlined above (eg more than one previous caesarean section)"

It is pretty clear to me that RANZCOG's TOL is unlikely to proceed to a spontaneous vaginal birth, with a healthy mother and baby. This statement exposes the lack of recognition of childbirth as a physiological process that is normal and good; a process that is in delicate hormonal balance. Throughout the document the reader is reminded repeatedly of the risk of rupture. It comes up like an advertisement: "remember you might need an obstetrician".

How often is the risk of rupture likely to result in catastrophic outcomes?

About 1 in 2000 labours for planned vbac.

*****

There are many factors to be considered by women who have had one or more previous caesarean births. The Births after Caesarean INFOSHEET, available at the Maternity Coalition website, summarises the choices that these women may face.

Midwives who agree to provide primary care for women planning VBAC, whether the birth is planned for home or hospital, face potential criticism based on the RANZCOG Statement. The Statement advises that before a midwife agrees to "administer care in risk-prone circumstances, that the women agree to counselling by a senior obstetrician who should ... [read on, there's a real sting in the tail of this one! That selfish woman needs to know that she is potentially imposing "considerable demands on the limited resources of the health team, with potential adverse consequences not just for her and her baby, but also for other women and their babies"]

Feeling guilty now?

Why don't you just roll over?

*****

In this RANZCOG Statement on Planned Vaginal Birth after Caesarean Section I have found material for all the bullying and manipulation that is needed to force women into submission to the medical system. While acknowledging a woman's right to make choices, the Statement sets the stage to shackle those who have the ability and skill to recognise and address complications early if they occur, while working in harmony with the natural physiological processes that lead to safe and joyous birthing.  Under this Statement the rate of Caesarean births, and all the related complications, is likely to continue to rise in Australia and New Zealand.