Monday, August 08, 2011

Refining and redefining a midwife's boundaries

The release by the Australian College of Midwives (ACM) of an Interim Homebirth Position Statement and guidance document has prompted discussion and debate amongst those of us who are interested in the boundaries of a midwife's practice. Of immediate concern is the statement in the guidance that:
"There are some contraindications to a planned homebirth which women should be informed of at booking. These are: • Multiple pregnancy • Abnormal presentation (including breech presentation) • Preterm labour prior to 37 completed weeks of pregnancy • Post term pregnancy of more than 42 completed weeks • Scarred uterus"
[I have written about the 'Scarred uterus' at the MIPP blog]

The word 'contraindication' means 'NO!'.

There is little room for movement in the word ‘contraindication’ which in any medical setting means that there is a reason to avoid using a particular treatment. For example, Penicillin is contraindicated when a person has an allergy to penicillin. Many specific drugs are contraindicated in pregnancy because they may adversely affect the fetus.

When I spoke about this concern to a respected colleague she told me not to worry, that it just means we have to initiate ‘Appendix A’ [in the ACM National Midwifery Guidelines for Consultation and Referral (ACM 2008)]. Appendix A gives a process for the midwife to follow 'When a woman chooses care outside the recommended ACM National Midwifery Guidelines ...' . My colleague argued that once a midwife has signed off on Appendix A for whatever reason, the midwife just continues to provide care, confident that the woman is making an informed decision. "Put it to the woman when she inquires about homebirth that her previous caesarean means that you are not able to support homebirth because the guidelines say so, but if she still wants homebirth she can sign a statement ..."

As has been pointed out by a consumer activist, the ACM has generously speculated in the guidance document on the possibility that “In the event of a woman making her own decision/s ...” This statement made me stop and think – a woman making her own decision/s – isn’t that what usually happens??? Oh dear!

What ever happened to all the notions of woman-centred care, informed decision making, partnership, cultural safety, reciprocity, trust? Is ACM trying to protect midwives from those women who make their own decisions? I think that's the only sort of woman I can provide midwifery for!

I have been a member of ACM continuously since the 1980's when it was the Midwives Association of Victoria Inc, and I proudly received Fellowship (FACM) from the College in 1997. Professional bodies attempt to describe and define boundaries of that profession, and members must either go with the change or resist it.  In this matter, I am resisting.

The ACM has been funded in this project by the federal government, which has initiated major reforms across health, to refine and redefine the midwife's boundaries, especially in the context of private practice. The Australian people elected a Labor government. We are now experiencing centrally controlled social health policy that restricts the individual (consumer and practitioner) while claiming to bring benefits for everyone? That's how a socialist health policy works.  Why are we surprised?

Enough from me.
Your comments are very welcome.

1 comment:

Joy Johnston said...

More discussion can be found at