What do we mean by 'professional advice'?

The Australian College of Midwives (ACM) has invited comment and response on its draft position statement on "Midwives working with women who seek care outside of professional advice"

I am working on a response, and would love to hear from other members who have used Appendix A in the past, and who are now including Appendix B in your paperwork (see previous post). 

I have headed this post with the question, "What do we mean by professional advice?"  There seems to me to be an assumption in the draft document that 'professional advice' is a uniform thing. I don't think it is. eg (Draft) Principle "5. Midwives should attempt to understand why women are seeking care outside of professional advice."  (Good idea, but hardly a principle to guide action.  I'll have to come back to that later.)

Sometimes the midwife disagrees with the advice from another professional, while agreeing with what the woman wants.  So is the midwife's advice professional advice?  

I see quite a few women who plan homebirth, for whom I think homebirth is a very reasonable choice, but the professional (obstetric) advice they receive is that they must be cared for in hospital for labour and birth. 

An example would be a woman who has indications from the guidelines, such as having her 6th+ baby, or a woman who has had a previous caesarean, and possibly another indication such as a post partum haemorrhage (pph) at one of her previous births. The Guidelines don't comment on planned place of birth, but out here in the real world, the only option for many women to access primary maternity care from a known midwife - best evidence based care according to many - is to ask the local midwife to attend them for planned homebirth.

In this scenario, the professional advice from me, the midwife, if I had meet this woman in early pregnancy, is that, provided there are no valid reasons to interfere with, or interrupt the spontaneous natural processes in pregnancy, birth, and thereafter, a woman is protecting herself and her baby by seeking out care that protects normal physiological birthing.  The previous caesarean, the previous pph, and the grand multiparity, although each significant factors in planning maternity care, each point to the advisability of spontaneous birthing: spontaneous onset of labour, spontaneous progress in labour, and spontaneous completion of the birthing process.  The professional care provider who is most likely to be expert at providing this package of care is the midwife who has a primary care caseload, regardless of the planned setting for birth (hospital/home).

This same woman may have initially booked with an obstetric managed service, planning birth in a private hospital or a public hospital.  As the chosen model of care becomes apparent to the woman, she may "seek care outside professional advice", and find a midwife who is willing to work in harmony with her natural processes, unless there is a valid reason to refer her for obstetric intervention.  Once again, the midwife is not being asked to do anything outside the usual scope of  a midwife's practice.  The midwife who agrees to provide care for this woman is not stepping outside professional boundaries in any way, even though she is providing care that is quite different from the standard in the mainstream.

Knowing the boundaries of midwifery practice is something that seems quite obvious to me, yet I know that some of my colleagues do not understand these boundaries as I do.

A woman who is planning homebirth, having had a caesarean for her previous birth, asked me if I am supporting her plan.  

I responded that I don't feel that I must support her plan. My duty of care in any birth is to act to protect the safety and wellbeing of the mother and her child.  If there is no reason to go to hospital, homebirth becomes the obvious choice at the time.  At present, prior to onset of labour, the plan is quite reasonable, and there is a good chance that it will continue as a reasonable choice.  I provide primary care, with a planned option for transfer to hospital if needed.  I cannot tie myself in to any commitment of setting for birth.  That is of secondary importance.


It's dinner time now.  Next time I get a chance to write I want to explore the principles that underpin decision making by midwives when women "seek care outside of professional advice"

H+BAC=?

TROUBLE!
[H+BAC stands for Home + Birth After Caesarean]

I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].

Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.

Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.

Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.

Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.

Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.

Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.

Q. And progressing without medical assistance - that happens best at home?
A. Correct.

Q. And that's where the midwife is experienced and competent?
 A. Correct.

Q. So, why is homebirth contraindicated?

[But there's a hole in the bucket, dear Eliza ...]

Of course this little Q&A sequence is overly simplistic.

But the point I am trying to make is that 'home' is not the key issue.  The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby.  The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.

Achieving vaginal BAC is core business of midwifery.  It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.

Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.

Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices.  Either we continue to attend women with scarred uteruses professionally, or we refuse to do so.  The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.

The central issue is not about the big 'H' - homebirth.  The central issue is the midwife's right to engage in professional practice.  A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions.  In some cases that may mean going to hospital; in others it means staying at home.  At all times the wellbeing and safety of mother and baby guide the midwife's professional advice.  Home is only a setting.  Healthy mothers and babies are the outcome we desire.

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.
Joy