Wednesday, August 20, 2014

Risk and maternity care

Discussion about risk in maternity care may be met with the full range of responses, from the hands over the ears "hear no evil", through to scary stories about the "disaster waiting to happen".  A midwife needs to understand risk, recognise progression into complications, and appropriate response to change in a woman's or baby's status, without being fearful.  A midwife is guided by principles such as
"In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: A practical guide.)

The usual model of care offered by midwives who practise privately is primary maternity care, with a strong emphasis on continuity of carer and the promotion, protection and support of the natural physiological processes in childbearing: spontaneous unmedicated birth, facilitating strong mother-baby bonding, and exclusive breastfeeding. This emphasis is consistent with best standards of midwifery practice and health promotion globally, and is to be applauded and supported in the interests of public wellbeing and safety. 

Today I want to look at practice issues for midwives in private practice, from a risk based approach.  Not just risk of complications or illness in the mother or baby, but also the risk that a midwife's practice may not be of the standard expected by the profession or the community.

The statutory regulator for health professionals, AHPRA, has established a set of regulatory principles which require the Boards to establish a responsive, risk based approach to addressing practice issues. (http://www.nursingmidwiferyboard.gov.au/News/Media-Releases.aspx )


It has been recognised for many years that systems of maternity care which rely on risk assessment will place a disproportionately high number of women in the "at risk" categories, leading to an increased likelihood that these women will be subjected to a higher level of intervention in the birth.  This process might be seen as necessary, in ensuring the best outcomes, but it often fails to do that!  No amount of bureaucratic micromanagement through laws or practice guidelines will ensure safety.  Many women for whom no risk categories apply will develop complications that require expert obstetric intervention, while many of the women in the "at risk" categories will, with appropriate care, proceed to an uncomplicated, spontaneous birth of a healthy baby.


Within the broad scope of midwifery, issues of special note in private practice, when there may well be an increased risk to women and babies in the care of midwives include:
• Education of midwives, registration, and transition to private practice
• Notifications, investigations, and hearings into professional conduct
• Lack of professional indemnity insurance for homebirth
• Notation as an eligible midwife [including Medicare, endorsement for prescribing, hospital visiting access]

Here are a few of the risks, all of which could contribute to poor outcomes for the mother and baby:

  1. Risk of unrealistic, idealistic notions of midwifery practice and natural birth, 
  2. Risk of inexperience, and lack of appropriate education and preparation for autonomous practice.
  3. Risk of professional isolation, and stunted growth of a midwife's professional identity.
  4. Risk of bias in the regulatory body against private midwifery practice.
  5. Risk of bias in mainstream hospital maternity services against private midwifery practice. 
  6. Risk of discouraged, disheartened midwives leaving the profession and being unable to find suitable employment.
  7. Risk to the public of being prevented from accessing the options for midwife-led maternity care, introduced through legislative reform in 2010. 
  8. Risk that women are being prevented from accessing the potential for excellent outcomes that are seen in midwife-led care.
  9. Risk of obstruction of trade for midwives.
  10. Risk of the rise of 'free birth' and births attended by unqualified or lay midwives.

There is a separate, and different category of risk that needs to be included in any discussion about private midwifery practice in Australia.  Midwives are unable to purchase professional indemnity insurance (PII) for homebirth - the core ingredient of most midwives practices.

It is unreasonable that Australian midwives' homebirth practices should continue to be excluded from the PII that is currently available.  Eligible midwives are able to buy insurance for every aspect of their practice, except homebirth.  This needs to be changed.  Insurance, per se, does not make birth safer or less safe; does not ensure good outcomes.  Insurance seeks to protect the financial interest of the players, rather than the health interests.


Tomorrow I am meeting with other representatives of professional organisations, and the NMBA, to discuss midwifery practice issues and regulation.  The points I have noted in this blog are contained in a discussion paper that I have written for this meeting.

Your comments are welcome.