Friday, February 07, 2014

collaboration, coercion, and concocted evidence

Today I would like to write about an experience that I have found very difficult, and I know the parents of the baby shared my concerns.

It is not easy for me to write about this.  I'm usually a peace maker.  I'm usually more pragmatic; I don't like being idealistic about birth issues, simply because life is not perfect.

This post follows the previous one, in which I have written about some of the 'carrot and stick' aspects of maternity reform.   One 'stick' is the cost of midwifery services.  While one-to-one primary maternity care by a midwife, and use of hospital facilities only when indicated - the basic best practice model - describes pretty much the scope of private midwifery services, and thousands of dollars are 'saved' by the state for each woman who does not require hospitalisation for birth, the women who choose care from a midwife pay for the privilege.   

The second 'stick' that I want to consider is collaboration

Collaboration, which in theory means that professionals work together so that the consumer/patient receives optimal care, is a requirement for eligible midwives who wish to enable women in our care to claim Medicare rebates (See Collaboration Determination 2010).   I have no problem with collaboration.  BUT, I have a big problem when, instead of collaboration a woman in my care is subjected to coercion, bullying, and fear-mongering with concocted data being presented as evidence.  I have a big problem when a bureautically-defined process that's called collaboration is a requirement for midwives, but no doctor, and no hospital is required to reciprocate.

From time to time as I write at this blog I include stories from my experience.  Today's story of (non-) collaboration, coercion, and concocted evidence goes like this:

Jill and her husband Jack (for want of better names) were expecting their third baby.  Jill is a healthy young woman, and she gave birth without incident to her other two children at home in my care. 
When Jill spoke to me about maternity care for the birth of this baby, I explained that we needed to find a suitable doctor to provide a referral to me for antenatal and postnatal midwifery services, in order to comply with the medicare collaboration rules. 
The local GP who Jill had seen previously agreed to collaborate, and it all looked good.  Jill was happy to see the GP and had routine tests and investigations arranged.  The doctor asked Jill to come back for some checkups during her pregnancy.

>>> fast forward to 36 weeks
I visited Jill and Jack and the children in their home.  I noted that Jill had found the summer heat rather taxing!  We had had a run of four or five very hot days, which is taxing for everyone.  I palpated her abdomen, and thought the baby was not very big.  I remembered that neither of the other two children had been large.  OK, I thought, let's see how this baby looks in a couple of weeks' time.  Jill had been having some troublesome pre-labour contractions, especially in the evening.  I encouraged her to rest, to eat nourishing food, and to keep her baby growing in her womb for a couple more weeks.
A couple of days later Jill's GP saw her, and told her there was a problem: the baby was too small.  An ultrasound to estimate the size of the baby was arranged.  Jill was told her baby was small, and she had too little amniotic fluid.  Jill's GP told her she was to go to the tertiary referral hospital for review.  Jill is a logical thinker, and she tried to discuss her options.  No discussion!  And you had better rethink the plan for homebirth too!
Jill phoned me and told me she was feeling bullied.  She respected the doctor's opinion, and was prepared to accept investigations, but she felt she was being pushed up against a wall.
The next couple of weeks were busy, with visits to the GP, visits to the fetal monitoring unit at the big hospital, arranging family members to care for the children, and arranging time off work for Jack.

>> 38 weeks
Time for another ultrasound growth scan. 
Would you believe it, the baby's not growing as well as we would like!  Estimated weight 2.4 Kilos.
Baby's placenta is fine, but it might not continue to function well.
Advised to have an induction of labour tomorrow.
Jill talked it over with me. 

[I could not help but ask myself, would I have raised the alert about this baby; about this pregnancy?  No, I don't think so.  Had I missed something important?]
Jill was finding the pressure overwhelming.  I reassured her, that she could choose the pathway.  I encouraged her to make the best decision that she could in the situation; that I would work with her at the hospital or at home.
Jill decided to accept the hospital's offer of induction of labour by artificial rupture of membranes.
The labour and birth progressed normally, and five hours after arriving at hospital, Jill gave birth without incident to her healthy baby boy.   I looked down at him and thought, "he's not too little!"  He later weighed in at a healthy 2.8 kilos.

Later that evening, Jack and Jill wanted to take their new baby home.  The doctor from the paediatric department arrived in their room, and told them the hospital required Jill to remain in hospital for 24-48 hours, so that the baby could be observed for the symptoms of early onset group B streptococcus (EOGBS). 
Jill had received an antibiotic in labour to prevent EOGBS, and argued that she was an experienced mother, and would recognise if her baby became ill.  The doctor then presented some concoction of evidence - who knows what she actually said!  What Jack and Jill heard, and told me, was that they were told that 50% of the babies of mothers with positive GBS swabs will die from the disease.  That's scarry!  Jack phoned me and asked me to talk through EOGBS with them, which I did.  They went home.  Baby continued to feed from Jill's breast and thrived.

[For those who are interested, I would like to note here that GBS is a serious infection.  There is a high mortality statistic related to GBS, but it did not apply in any way to Jill's baby.  A baby who develops GBS and is not treated, either in labour or after birth, would have approximately a 50-50 risk of dying from the infection.  That's why we treat infection in labour or after birth so seriously.]
The coercion and concoction of evidence that Jill has experienced in this episode of care is a very distressing phenomenon.  I wish it was an isolated event.  Sadly it's not.  And I regret that Jill and Jack experienced the coercion and bullying as a result of my collaboration.

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