Principles of accountability and transparency must be applied to professional practice. When something goes wrong in birth, our society wants to know, and has a right to know what happened. It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear? How must I act when a woman in my care understands her personal risk differently from the mainstream?
A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain. The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity. So, when I read in the SA Coroner's report that
"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?
The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.
This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:
- if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);
- if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean;
- if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean)
I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result. The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation. She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]
Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive. The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives. The emergency code had been rehearsed, prepared for, and was called into action. Perhaps that group of midwives will be more ready and competent when it really is called for???
In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety. I cannot control another person's actions. I also cannot use these experiences as a reason to stay out of hospital in future situations. The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.
I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
The Coroner's recommendations are listed at the end of the 106-page report. In this blog I am attempting to summarise the recommendations, for future reference:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."