Saturday, August 27, 2011

Where is the woman?

Today's SMH and Age newspapers carry reports around the insurance debacle that has been unfolding this past week. I have written about it here and at the other blogs - you can click on the links at the right hand side of this page if you haven't already read them.

Where is the woman?
... the pregnant-labouring-childbearing woman in this whole dog's breakfast of red tape?

Wednesday, August 24, 2011

changes in my world

Today the sky is blue, there is a soft, warm breeze, and signs of Spring are everywhere. I haven't thrown open the doors and windows of the house yet, but I would love to be outside, enjoying the sunshine, allowing my skin to drink in that life-affirming warmth, going for a walk, or pottering in the garden.

But I need to work on supporting other midwives who are feeling threatened, and letting the world know what is happening here in Australia.

There is another change in my world, and only time will tell what it means to midwives and to the women who value our services.

Midwives have been told that a midwife colleague has been 'reported' to the regulatory authority for being with a woman in hospital, after transferring that woman to the hospital from planned home birth.

Under the new 'mandatory reporting' rules, a notification must be made if, in the course of professional practice, another regulated health professional "form[s] reasonable belief that a [midwife] has placed the public at risk of substantial harm due to practising their profession in a way tha constitutes a significant departure from accepted professional standards." (ANF Vic 2010)

In the case of an independent midwife transferring care of a woman from home birth to hospital, and continuing to support the woman in hospital: the standard practice of homebirth midwives for many years - that midwife is not covered by any professional indemnity insurance. The 'significant departure' from 'accepted professional standards' is that the midwife is 'practising' without insurance.

Until yesterday, midwives and hospitals accepted the presence of the midwife in a hospital birth suite in a non-clinical, non-decision-making role, as being outside the requirement for insurance. As recently as this past Saturday, I was with woman in a hospital birth suite. The woman had planned homebirth, in my care. I believe the 'risk of substantial harm' in that case would be greater if I abandoned that woman, rather than continuing with her in a supportive and caring role.  I am a midwife, with woman, and my practice must be centred on the woman, not on the setting or model of care, or even the availability of insurance.

However, a new, extremely narrow definition of 'Practice' has emerged, covering any situation in which a midwife uses her skills and knowledge as a midwife.

I will write about what this means as I get opportunities today.

Thankyou, readers, for your interest.

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.

Saturday, August 06, 2011

News for privately practising midwives and women planning homebirth

Australian Health Ministers’ Conference

5 August 2011

Professional Indemnity Insurance Exemption for Independent Privately Practising Midwives
"Ministers agreed to a further 12 month extension of the exemption to 1 July 2013 while further options are explored with a report back to the next Health Ministers meeting."

My comment:
I don't have time to write much today, as I have a primip in labour, and Saturday morning chores to do in the house. This extension to the Exemption is good news - we can continue planning homebirth until June 2013 at least!

Your commets are very welcome.

Monday, August 01, 2011

"Women have the right to ..."

What right or rights do women have? What special rights do childbearing women have? What rights do mothers and babies have?

This question has played in my mind recently. Readers who have read the previous post may have noticed the statement:
"Women have the right to self determination and to be supported and encouraged to get on with ..."
Do they? Really?

What does 'self determination' look like? How does it work when difficult decisions need to be made in maternity situations? How does it work when the woman is frightened by the power of her labour? What support and encouragement is appropriate ...? Isn't that the time when the "best laid plans" come undone?

We know that in modern societies all competent persons (female or male), in the context of health care, have the right of refusal. The woman in maternity care has this right, even when her refusal may result in what most would consider to be adverse consequences for herself and her baby.

'Refusal' is very different from 'self determination'.

Consider this scenario:
Midwife: "Jane, I am advising you to go to hospital and have an induction of labour, for the following reasons [eg post 42 weeks' gestation] ..."
Jane: "I understand that you advise induction of labour. Would you please tell me what is likely to happen if I refuse your advice."
Midwife: "As your midwife I would continue to check you and your baby, and tell you if I detect any changes. I would also advise obstetric review at XX hospital. The tests that are usually carried out at this time are fetal monitoring, ultrasound studies that check blood flow to your baby, and measurement of your baby's amniotic fluid level. These investigations, which can be repeated as time passes, may detect subtle changes in baby's condition, or may reassure us that your baby is well."
Jane: "I have always planned to wait for spontaneous onset of labour, unless there is a valid reason to interrupt my natural process. I don't think 42 weeks gestation alone is sufficient reason. Therefore I will refuse induction today, and wait for labour to begin. I am willing to make an appointment for specialist obstetric review."

This conversation, in which the midwife gives professional advice (for whatever reason), and the client/consumer makes a decision, based on her understanding of principles of appropriate maternity care, and the information given to her, to refuse that advice, is what I call 'informed refusal', or 'informed decision making'.

A very different conversation would be something like:
Midwife to Jane: "You're 42 weeks. What do you want to do now? Induction or wait for labour?" [ie self-determination]

Since the early 1990s, midwives and maternity consumers have quoted the reports of the British government's inquiries into maternity care, that women want the 'THREE C's' choice, control, and continuity of care. Since the early 1990s I have worked with Australian women and midwives, and have often used the THREE C's as a guide in the uncharted terrain of birth reform.  However, this little mantra should not be seen as a statement of women's birthing rights.

I have seen situations in which a woman's choice, or her sense of control [self determination], have led to what I see as disastrous outcomes - loss of life, and potentially preventable harm.  In these situations 'continuity of care' has been 'continuity' [same person] without the 'care' from a professionally skilled person who has the duty and ability to act in the interests of mother and baby at all times.  The care has been confused, fragmented, and ineffective.   A midwife or doctor who says "What would you like to do now?", when the only responsible statement is, for example, "I must advise you that your baby needs to be born now ..." is forgetting their professional duty to that woman.

When a woman has effective continuity of care, with a midwife who she (the woman) respects, and who respects her, there will be no doubt about the differences between a woman's rights, a woman's choices, and the midwife's duty of care.