Saturday, June 22, 2013

home midwifery in the (legal) spotlight

Melbourne in mid-winter is grey and damp and cold.  The tall concrete buildings block the weak, angled sunlight.

This week I have sat for two days in a tired meeting room in a city hotel that has passed its prime:  not old enough to be interesting; not fresh enough to be attractive.  The plate glass windows in the conference room revealed nothing more than the boarded up windows of a derelict multi-storey building on the other side of Little Collins Street.

The conference provided opportunities for comment on homebirth, and particularly homebirths that have gone wrong.  Lawyers presented papers on topics such as 'Managing the Risks inherent in Women's Choice in Obstetric Care', and 'Practical Obstetric Risk Management: defending your care'.  It sounded simple.    

Human rights in the childbirth process were eloquently discussed by other lawyers who drew from both their knowledge of the law and their personal experience.

'Open Disclosure' was discussed by two speakers, and I concluded that, in order to 'defend' oneself against potential legal or disciplinary action, an adverse event in a hospital is met with what seems to me to be a charade called 'open disclosure' that is not very open, and that doesn't disclose much.  Don't be too literal about the meaning of 'open' or the meaning of 'disclosure'.  A curious conundrum! 

A Coroner delivered, with barely an inflection in his voice, a keynote address on 'Lessons to be learned from the Home Birth Cases in Vic and SA.'  In this presentation, seven cases were reviewed, the common thread being that they had been planned homebirths, with either a registered midwife or a previously registered midwife in attendance.  When considering risk factors such as previous big babies, previous caesarean births, and a twin pregnancy, the conclusion was that most of these cases should not have been planned homebirths; that the midwife had a duty of care to transfer care to an obstetric unit.

In 6/7 cases, the baby deaths were declared by the Coroner to have been potentially preventable.  The Coroner does not attempt to apportion blame, merely to discover the facts, and to make recommendations.  The Coroner's filtering of the information presented at the inquest failed to notice any possible reason that a woman might have had for trying to avoid a medically managed birth; any mention of her desire to hold her baby to her breast within moments of birth; or even any recommendations that maternity hospitals provide pathways for women who want to have a known and trusted midwife providing continuity of care within the hospital.

I want to be perfectly clear here: I cannot speak for either the mothers or the midwives.  I am merely an onlooker, and I have read the Coroner's findings that have been put in the public domain.  I am also shocked at the tragedies that precipitated these cases into the Coroner's court.

The points made by those who spoke about women's rights were either ignored or not understood by those who spoke from the professional duty of care perspective.   The fact is that pregnant women have personal autonomy; that decisions do not have to be approved by, or even understood by, those who attend for birth.

The presentation following that by the Coroner was from the Victorian Perinatal Data Collection Unit.  I noted down a point that was briefly made, without any further comment, that, of the approximately 900 perinatal deaths in this State annually, 63% are found to have potentially avoidable factors.

The loss of a baby's life is, thankfully, uncommon in our world.  Yet it is one of the most heart-wrenching experiences imaginable.  Whether the death is linked to homebirth or not, everyone needs to take what lessons are available from the facts of the case.  I ask myself, what lessons have I taken from these seven tragic cases?

I believe the huge challenge that lies ahead for midwives and the whole maternity world is to find a balance between providing advice and care that protects the wellbeing and safety of the mother and child, while at the same time respecting the woman's decisions and choices.  This is not going to be easy.  It is an ongoing process, and demands trust and commitment between the midwife-woman, and the midwife-obstetric/hospital system. The paternalistic dictatorial style of hospitals has, in many instances, demanded submission to hospital policies and processes. This needs to change. The misunderstanding of risk in maternity care, as was clearly demonstrated in the cases reviewed, will likely continue to open the door for self-educated, internet-researched women to make the choice of birthing without a midwife in attendance.  This needs to change, to include intelligent dialogue and planning that is specific to the individual woman/pregnancy.  The misunderstood partnership between woman and midwife, as was also clearly demonstrated in the cases reviewed, may from time to time place unreasonable weight on the woman's choice, and devalue the midwife's skill and knowledge.  This also needs to change, enabling midwives to practise more autonomously and accountably.

Women who engage a midwife to attend them at home for birth, having an identified risk profile, such as a previous caesarean, a previous post partum haemorrhage, or multiparity, or any of the other features that are classified as risk - these women, and these midwives, need support rather than being driven underground.  The midwife who is ready to go with her client to the hospital, and continue supporting the woman's informed decision-making process within the hospital, will accompany that woman to the best birth that she can have.

And, we only want the best.

Your comments are welcome.

ps - this link to the story of a maternal death is, sadly, what we will see more of if we don't maintain a midwifery profession that is 'with woman'.

Sunday, June 16, 2013

more about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.

Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:
"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."
Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:
  • spontaneous onset of labour, and
  • spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.

Saturday, June 01, 2013

Midwives and Medicare

For the past 2+ years I have been able to give clients Medicare rebates for antenatal and postnatal midwifery services.  I am looking forward to having a prescriber number in the near future.  This is part of the government's reform measure, More Choice for Women - Expanding Medicare Support for Midwives, introduced in November 2010.

The basic requirement that I must fulfill before a client can claim a Medicare rebate is that there is a collaborative arrangement in place: a letter or statement, signed by a suitable doctor.  As I have no 'agreement' to meet this need, I must seek out an arrangement for each woman.

There are a couple of doctors who have 'collaborated' with me on more than one occasion.  Most of the time it's a one-off.  Most of my clients live within a 1-hour drive radius of my home.  That's a huge metropolitan area, and some out in nearby towns.  In that area there are thousands of doctors.  Very few have met me.  Some have refused to collaborate, saying that they would thereby be liable for anything I did.

Several months ago a woman who has had three previous uncomplicated births in hospital contacted me.  She wants to have her next baby at home.  I explained Medicare and collaboration, and emailed a letter describing the need for a collaborative arrangement with a doctor, to her.  She took the letter to her local doctor.  In her own words, 

I am just writing to advise you of the trouble that I am having getting a GP to write a referral to your services.
After contracting you to get a letter for the referring doctor, I went to my local GP for confirmation of my pregnancy. They were happy to send me for tests and ultrasounds but when I explained that I didn't want to birth my fourth child in a hospital, but rather have midwifery care and plan a homebirth I was met with an almost hostile response. This GP who had seen me throughout 2 of my previous pregnancys pointed out that he would not write me a referral due to the use of the word "collaborative" . He failed to understand where his duty of care ended and the midwife's began. I tried to explain that I didn't need to see him throughout the pregnancy and that I only needed initial blood tests and this letter but he would not listen. He continued to explain that he would not put his reputation on the line for the sake of my Medicare rebate!
Feeling disheartened I searched for a doctor who had a similar outlook on the way birth should be. I felt positive that this woman would give me the referral I needed.
This time the doctor endorsed homebirth, was happy for me to see a private midwife and ordered the appropriate tests to be sent to my chosen care provider but once more would not write the letter. When I asked for an explanation once again there was talk of scaremongering from insurance companies who had advised her that if she wrote this letter and something went wrong at the birth, even if she was 200ks away she would be liable.
I find it extremely frustrating and disheartening that in order to get the birth that is right for me and my family, I am being financially penalised because my doctors of choice don't fully understand what is required of them.

With this woman's permission, I forwarded her letter to the Health Minister, Hon Tan Plibersek, MP.  The letter I have received from the Minister's office, in reply, gives me hope that the wrinkles may be ironed out.

Excerpts from the Minister's letter, dated 27 May 2013:

The More Choice for Women - Expanding Medicare Support for Midwives, introduced on 1 November 2010, expanded the Medicare arrangements to include midwifery care.  This was in recognition that women should have a range of birthing options available to them and be supported in their choice of practitioner.

Recognising midwives as primary maternity care providers under Medicare was also intended to assist in improving service delivery by enabling better use of the existing workforce ...
Since the measure was introduced, midwives have reported ongoing difficulties with establishing collaborative arrangements with individual medical practitioners.  This has hindered their ability to provide services under Medicare.

In recognition of this, at the Standing Committee on Health (SCoH) meeting of 10 August 2012, the Minister for Health ... agreed to vary the legislation on collaborative arrangements, to enable agreements between midwives and hospitals and health services.

The Department is currently in discussion with the medical, midwifery  and consumer groups to discuss the detail of the proposed changes.

The Minister recognises that the lack of hospital clinical privileging and admitting and practice rights is a fundamental issue for midwives.  This prevents privately practising eligible midwives from working to their full scope of practice, undermines continuity of care and reduces choice for women.  

As such, the Minister has asked Health Ministers to finalise consistent approaches to credentialing for midwives in public hospitals in line with States' and Territories' commitments under the Maternity Services Plan.

The Minister is committed to supporting increased participation by eligible midwives in the Medicare arrangements and to the proposed changes to the collaborative arrangement requirements that would facilitate this.

Thankyou for raising this important issue.  I trust this information is of assistance to you.
Yours sincerely

My comment:
A letter like this to an ordinary inquirer like me does not give any new information.  However, I feel encouraged by the tone of the latter part of the letter.

  • that midwives need practising rights in public hospitals 
  • that the Minister has put pressure on the State and Territory Health Ministers, to get a move on 
  • that public hospitals will be expected to support collaborative arrangements with midwives
  • that the Minister is committed to this reform measure.
Readers may also share critical thought about the More Choice for Women ... reform measure, such as:
  •  the inequity of signed collaborative arrangements, in that the midwife is required to obtain the arrangement, but no doctor is obliged to agree or to sign anything.  The loser, of course, is the woman.  AND the midwife looks pretty useless.
  • the lengthy delays (such as since SCoH in August 2012) in making even the promised changes to the Collaboration Determination
  • the obstruction by public hospitals throughout the country, with the exception of a few in S-E Qld, to any progress on practising rights for midwives
  • with the above point in mind, surely it's unlikely that these hospitals will agree to collaborate with midwives, even after the legislation has been varied as promised 
  • and finally, with an election, and probably a change of government in September, will we see ongoing support for More Choice for Women - Expanding Medicare Support for Midwives?

Your comments are welcome