conversations on *choice*

I would like to bring some thoughts about maternity choices from the relative safety of a closed social media group to the openness and exposure of this blog, which does not restrict access.  This is not the first time I have written about choice.  A simple search of this blog brings up posts each year since 2007.

The current conversations have been prompted, in my mind at least, by my awareness of the movement that promotes a person's right to self-determination in health care, and particularly a woman's right to autonomy over her own body in the highly contested terrain of maternity care.

Here are a few real examples of that evasive entity, *choice*:

1. Jenny is pregnant with her sixth child.  She is a healthy 38-year old, who had a caesarean birth for her first, and has had uncomplicated births of her babies since then.  She would really like to give birth at home, in water, but the (free - publicly funded) homebirth program from a nearby public hospital will not agree to homebirth because she is considered high risk (previous caesarean, multiparity >5). 
   
   Jenny inquires about private homebirth services, and thinks that the cost of $5,000+ is prohibitive, even with Medicare rebate of approximately $1,000.  The midwives are also concerned that her risk status might put them at risk of mandatory notification to the regulatory Board.
   
   Jenny inquires at the local public hospital, where she could receive free maternity care.  She is told that she would not be permitted to use water immersion in labour, be managed as 'high risk', have continuous fetal monitoring in active labour, have IV access established in labour, and immediate active management of third stage after the baby was born.
   
   Jenny feels she has no real choice.  The system (public or private) simply does not support her choice to proceed naturally, and does not respect her desire to avoid what she considers to be unnecessary medical interference that could quickly lead to complications.
2. Jean is pregnant with her second child.  Her first baby was born three years ago, weighing 4 kilograms, and she had an epidural and forceps, and a large third degree perineal tear which took a long time to heal.  Jean feels traumatised by her experiences in her first birth, and she feels that her marriage relationship has suffered, because she does not enjoy intimate contact, and tries to avoid sexual intercourse.   She considers herself healthy, but she is over weight, and she has 'failed' the glucose tolerance test.  The hospital advises that she needs a series of ultrasound assessments of her baby's growth, and possible induction at 38 weeks if the baby seems large. 
   
   Jean is now 34 weeks along in this pregnancy.  Jean's preference is for natural birth, and she discusses this with the hospital midwife. 
   
   Jean feels that she has no real choice.  She could opt for an elective caesarean, or for an induction of labour, but the system does not have a pathway for her that supports and protects unmedicated natural birth. 
3. Jo is pregnant with her first child, and everything was 'normal' until the 35 week check when she was told that her baby was presenting breech - bottom first.  She was told by her (private) doctor that she would be booked for elective caesarean at 40 weeks, unless her baby turned. 
   Jo has quickly checked out websites that address breech births, and joined social media groups, got hold of moxa sticks, and started positioning herself crawling on the floor with her bum higher that her shoulders to help the baby turn.  She finds that there are a couple of obstetricians in town who are 'pro' vaginal breech birth, and a couple of public hospitals that support the option. 
   
   Jo feels that she has no real choice.  Decisions will need to be made as she progresses along the road to the birth of her baby.  Those decisions may be limited by the services available, the service providers, and the status of her baby as far as position, progress, and wellness are concerned.
4. Jazz is pregnant with her third child, and is planning homebirth with the publicly funded hospital homebirth program. 
   
   Jazz understands that she has one choice, 'plan A': to proceed naturally without medication or other medical intervention, at home.  If she needs to move to 'plan B' for any reason, her midwife will go with her to hospital, and Jazz will be able to make what she considers to be the best decisions from options available at the time.

A midwife has a clear duty, by definition and best practice, to support and protect normal physiological processes in birth, unless there is a valid reason to offer medical intervention(s).  This is the DEFAULT position, that protects the safety and wellbeing of mother and child. 

'Plan A' does not deny the woman's right to decline any treatment that is offered.  But that is the woman's prerogative; not the midwife's.  The pathway to good maternity services comes with respect for both the woman's voice, and the midwife's.  There is no partnership if either the woman, or the midwife, feels unable to contribute honestly to the decision-making.

The midwife who does not apply health promotion/ best practice principles to their advice and protect that *Plan A* default position will probably contribute to the society's loss of professional skill required to work in harmony with the unique natural physiological processes in pregnancy, birth, and nurture of the infant. Once that skill is diminished or lost, the mother will find her *choice* has been seriously restricted to the medical options. eg professional de-skilling in breech vaginal births.

I have seen midwives overwhelmed by their desire to support a woman's choice, and ignoring or missing signs that a potentially life-saving intervention needs to be taken.    

[A note to those who read this post.  If you think I am referring to you, it's possible that I am.]

Is midwifery practice controlled by the insurer?

what the stork brought!

Is midwifery practice controlled by the insurer?



If the answer is 'yes', is that a problem?








Recently I wrote about indemnity insurance: who benefits?
The insurance company is a business that can only exist if it protects the interests of its shareholders and employees.  In that article I wrote:

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defense schemes which cost more than some midwives earn.

Today I would like to focus on a case study, published recently by an insurer of midwives, guiding midwives in the potentially difficult scenario of the client who refuses to follow a midwife's advice.


The case study, titled Terminating the midwife/client relationship (April 2014) suggests that midwives can be insured only if there is zero tolerance for departure, by the midwife or the client, from a very narrow compliance pathway.  That in a situation where the client declines advice from the midwife, the midwife will jump ship - terminate the relationship she has with that client.

I think the advice in this case study is wrong, and MIGA needs to withdraw it.

Many readers will know MIGA is the insurance company that provides professional indemnity insurance (PII) for independent midwives, underwritten by Treasury. It's the only option for midwives who have hospital visiting access.  That's a monopoly.

The big issue of concern in this case study is: "The client signed a service agreement with the midwife agreeing to comply with the requests and recommendations of the midwife."
 
???
 
agreeing [UP FRONT] to comply ... !

Is that reasonable?

What's the point of rhetoric like 'informed decision making' in that sort of relationship?
 
There is no legal obligation that I know of (outside of this sort of service agreement that has been made by the risk management/legal team of the insurer) to ask a woman to sign over her rights, particularly the right of refusal, which is a human right. 

Midwives practising privately, who are planning to attend homebirth, are required by NMBA to have a statement signed by the client that she understands there is no PII for homebirth with a midwife.

The relevant provisions of the National Law and the Board’s requirements are:

Section 284(1)(b) informed consent has been given by the woman in relation to whom the midwife is practising private midwifery

Informed consent must be given by the woman who is the client of the midwife who is in private practice.  Informed consent is defined specifically as written consent given by a woman after she has been given a written statement by a midwife that includes:

·        a statement that appropriate PII arrangements will not be in force in relation to the midwife’s practice of private midwifery in attending a homebirth, and

·        any other information required by the Board.

  [Guidelines for professional indemnity insurance arrangements for midwives]

The case study is based on a scenario in which the midwife believes her ability to care safely for the woman and her baby has been irretrievably compromised, because the woman, now ten days past her 'due date', declines consultation with and review by a doctor/ hospital antenatal clinic.

I want to express surprise at this scenario, and I realise that the MIGA team who prepared this case study probably sent it to one of the midwives insured with them for checking and review.  That thought only adds to my sense of concern!  The scenario presented is hardly a decision point that could be the cause of irretrievable compromise to the relationship.  Most privately practising midwives would have experienced this scenario many times.  The clinical scenario described in the case study is certainly a point for discussion and accurate documentation, but in my mind it would be unthinkable to abandon the woman at that point, on such flimsy grounds.

The case study mentions the ACM guidelines which list post-term pregnancy (7.1.22)  as >42 weeks (not 41+3), category B - 'consult' - which may be with another midwife. The guidelines have a guiding principle of informed choice (3.2.2), stating that "The woman is free to accept of reject any procedure or advice".

Notions of a woman's right to decline, and to make informed decisions in any professional care situations are well established.  The midwifery profession cannot provide safe professional services for women if such blatant and uninformed control is delegated to the insurer, whose primary interest may not be the safety and wellbeing of mother and child.  The scenario described in this particular case study could very easily leave a woman feeling that she has no option than to 'free birth', without any professional attendance.
 

Birth statistics

Source: Victorian Health Department 2009

I expect readers will find the trend in the number of women achieving planned home birth (Table 33)  interesting.  (click on picture to enlarge)

To access the full Victorian Consultative Council on Obstetric and Paediatric Mortality & Morbidity (CCOPMM) Annual Report for the year 2009, click here.
[This is the most recent of the annual reports]

Midwives are the only professionals who attend women for planned home birth these days.  In years past there were a few GPs, but time and cost of insurance has caught up with them.  Midwives are attending homebirths privately without professional indemnity insurance, under a special exemption that is in place until June 2015.


I note:

• the gradual increase in homebirths as a percentage of all confinements*, from 0.2 in 1985, to 0.4 in 2009 (Table 33).
• Table 34 indicates the type of birth for all women who were recorded at the onset of labour as 'planned' homebirth.  Women planning homebirth in 2009 had 90% 'unassisted vaginal' birth (the overwhelming majority of these being spontaneous, unmedicated); 6% caesarean birth, and the rest forceps, vacuum, or unknown.  
• This compares with only 38.6% of all women in 2009 coming into spontaneous labour without augmentation (same report, p61), and 54.6% having unassisted vaginal births (p64).

AIHW 2010 - click to enlarge

We do not yet have a 'Births in Victoria' report for 2010 or subsequent years.
 
This 2010 national report is from the Australian government's Mothers and Babies publications site.

I note:

• In Table 3.18 (shown here), the number of babies born at home in Victoria has increased from 300 in 2009 (PDCU) to 567 in 2010. 
• This is the actual place of birth, including those who planned to give birth in hospital, and the baby beat them to it, and those who intentionally gave birth unattended ('free birth')
• The AIHW 2010 data does not report on home birth by intended place of birth in Victoria (Table 3.19, p29)
• 2010 was the year that the two public hospital homebirth trials commenced at Sunshine and Casey.  The number of homebirths births through those hospitals was small (40)
• 2010 was also the year that the federal government's maternity reform package was implemented, with midwives becoming eligible to provide Medicare-rebated antenatal and postnatal services from November 2010.

AIHW 2011 click to enlarge

 The 2011 national report from AIHW provides more information on home births in Victoria, as it includes the breakdown of those women who gave birth at home, having planned (intended to) give birth at home.

I note:

• The number of planned homebirths in 2011, in Victoria,  was 432, accounting for 0.6% of the State's births.  
• Looking back at Table 33 (above), the increase from 300 in 2009, 0.4%, is substantial.
• Midwives in Victoria quickly accessed eligibility for Medicare, and promoted primary maternity care options for women.
• The only place in Victoria where a midwife can practise privately is in the community, for planned homebirth.
• No Victorian hospital has yet established processes whereby midwives can apply for clinical privileges and attend their clients in the hospital
• Since 2010, a number of experienced midwives have resigned from mainstream Victorian hospital and birth centre employment and joined the ranks of midwives offering homebirth.

The following excerpt from AIHW 2011 provides interesting comment:

Homebirths 
In 2011, there were 1,267 women who gave birth at home, representing 0.4% of all women who gave birth. The highest proportions were in Victoria and Western Australia (0.8%) (Table 3.18). It is probable that not all homebirths are reported to the perinatal data collections.

The mean age of mothers who gave birth at home was 31.7 years (Table 3.49). The proportion of mothers younger than 20 was 1.3%, and the proportion aged 35 and over was 29.8%.

The proportion of mothers who gave birth at home who identified as being of Aboriginal and Torres Strait Islander origin was 1.1%.

Most women who gave birth at home were living in Major cities (70.8%) (Table 3.49). Of mothers who gave birth at home, about one-quarter had their first baby (22.3%), and 77.4% were multiparous.

The predominant method of birth for 99.3% of women who gave birth at home was non-instrumental vaginal (Table 3.49). The presentation was vertex for 97.6% of women who gave birth at home.

Of babies born at home in 2011, 99.2% were liveborn. The mean birthweight of these liveborn babies was 3,614 grams (Table 3.49). The proportion of liveborn babies of low birthweight born at home was 1.6%, and the proportion of preterm babies born at home was 1.3%. (AIHW 2011, pages 65-66)

I note:

• There were 10 babies of the 1,301 homebirths in 2011 recorded as fetal deaths.  These data do not provide detail as to how or why those deaths occurred.
• The midwife is duty bound to promote the wellbeing and safety of the mother and baby in her care, above preference for place of birth, or other factors.

*The word 'confinements' is used in these reports, as a tally of the number of women who have given birth, rather than the number of births, which includes multiples.  Readers might like to suggest a better word!

The bigger picture

Grand-daughter's photography - you can see that I love her!

I have a lull in my bookings at the moment, and have set myself the challenge to consider the bigger picture.

Questions of birth/maternity care/midwifery that comprise the bigger picture are along this line:

• How well does Australia measure up against global midwifery?
• What is being done in Australia to protect sustainability in the midwifery profession?
• What can a woman in Australia anticipate as she carries, births, and nurtures a baby?

It would be easy for me personally to be dismissive about the bigger picture.  Leave that to the younger generation!  I have enjoyed my career, have had many incredibly beautiful experiences with women who have given me their trust, and have invited me into their lives at their most intimate moments.  I have written many of my stories down in journals and blogs and argued my point in articles and published papers.


How well does Australia measure up against global midwifery?
The home of global midwifery is the International Confederation of Midwives (ICM).  The Australian College of Midwives (ACM) is a member organisation of ICM, and Australian codes and standards are based on the ICM Definition of the Midwife (2011).

ICM lists the following key concepts.  I will use them as a basis for my assessment of Australian midwifery as I know it, and give each point a score out of 10. I will not attempt to justify or give references, since this is a statement of opinion.  However, my opinion is based on careful reading of midwifery literature, and careful reflection on a lifetime of midwifery practice.  If the reader considers that I have made a statement that is wrong, or unsupportable, please tell me why.

ICM Key midwifery concepts that define the unique role of midwives:

• partnership with women to promote self-care and the health of mothers, infants, and families;
• respect for human dignity and for women as persons with full human rights;
• advocacy for women so that their voices are heard;
• cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
• a focus on health promotion and disease prevention that views pregnancy as a normal life event.

1. partnership with women to promote self-care and the health of mothers, infants, and families:
Promoting self-care and health of mothers, infants and families is a wonderful, big picture statement. 

I would suggest that we look at rates of spontaneous unmedicated birth as an initial measure of health promotion, self care, and wellness of mothers and babies.   Spontaneous unmedicated birth will be most likely to proceed when the midwife is practising as an authentic midwife, establishing a partnership with the woman based on reciprocity and trust.   WHO (1996) stated that "In normal birth there should be a valid reason to interfere with the natural process."  Achieving spontaneous unmedicated birth is a measure of the capability of the midwife as much as the mother.  There is no safer or better way, in most instances, than for the midwife and the woman to work in harmony with natural processes.  The midwife acts in a way that minimises disturbance, disruption, interference, interruption, while observing and assessing progress and wellness.  The woman learns to minimise neocortical activity, and access her amazing supply of natural opiates.  Her oxytocin and adrelanine peak as she gives birth, providing for her baby the ideal transition to life outside the womb, and giving herself the ability to contract her womb strongly and expel the secundines (an old fashioned word meaning the afterbirth) without excessive bleeding.

In Australia more than 30% of women have caesarean births, completely by-passing these physiological states. Only about 25% of women have no analgesia for birth.  Only a tiny minority of the women receiving maternity care in Australia are cared for in labour by a known midwife - one of the evidence-based measures by which we can anticipate improved outcomes for mother and baby.  There is much room for improvement!

SCORE 4/10

2. respect for human dignity and for women as persons with full human rights
What measure is there for respect of human dignity?  I don't know.
There are many cultures in Australia, and it's not possible to generalise.  The planned homebirth 'culture' is quite exceptional.  These women are  usually not wealthy, but find the money so that they can have private midwifery care.  They value their personal dignity, within their own homes.  They accept the work of childbearing, as their own job, and give it their best. 
On the other hand, I consider the educated, relatively wealthy segment of our population, whether they are cared for in private or public hospitals, there are many examples and anecdotes of a lack of respect, an expectation by the midwives and doctors in the hospitals that they will submit to the superior training and knowledge of the medical practitioner who is most senior at the time.
My conclusion is that in Australian mainstream maternity care, there is a lack of respect for the human dignity of women as persons with full human rights, and this is backed up by the Australian Medical Association Position Statement on maternal decision making  (2013)

1. A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.
   
2. A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.
3. Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies. ...

There is, again, much room for improvement!

 SCORE: 5/10

 

3. advocacy for women so that their voices are heard

Australian women have for many years attempted to have their voices heard, and organisations such as Maternity Coalition have advocated on behalf of women.  I and many of my midwife colleagues have been in the thick of it.  Many of the stories since about 2007 can be found on this, and linked blogs.  Here are a couple of pictures that describe advocacy for women:

Mothers, babies, and midwives outside a politician's office in Melbourne

more than 2000 rallied in the rain, on the lawns of Parliament House in Canberra

In response to advocacy, the government of the day (2008) announced a Review of Maternity Services, and asked the public to tell them what they wanted.  Thousands of ordinary people, mostly childbearing women, sent submissions.  Many of them asked for choice - that they could choose where they had their babies, and with whom.  Many told their stories about wonderful empowerment in giving birth at home, with their own midwife. Yet, when the report of the Maternity Services Review was published, homebirth was excluded from the reform package.  

Midwives now have indemnity insurance, but not for homebirth!  We now have Medicare, but not for homebirth!  We now have the processes so that hospitals can award clinical privileges to midwives, but except for a few in the S-E corner of Queensland, this just is not happening.

There is, again, much room for improvement!

SCORE: 3/10

4.  cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies.
It would be politically correct for me to launch into discussion of the plight of Australia's aboriginal peoples in addressing this topic.  There is a great need for such work, and for improvement in all sorts of health outcomes and health promotion.  But I do not see many indigenous people, and in my years of practice have cared for only a handful.   Not many women with indigenous heritage will seek out the services of an independent midwife.

Painting by Odetta Moore (Copyright).  "This is our baby boy waiting to be born.  That's him in the middle.  The circles round him are me, holding him and protecting him.  The tortoises in the corners are his protectors."

There is another vulnerable cultural group that we midwives are seeing, and for whom we need to improve care.  Women who are in this country on work visas, either for themselves or their husbands.  Many come from India and Pakistan, some from Africa.

The visas that these women use do not entitle them to publicly funded health care under Medicare.  The visas require health insurance, but the insurance policy usually does not cover childbirth.  These women enquire at public hospitals, and are told that they will be required to pay $11,000-$15,000 upfront for maternity care.  Some have no prenatal maternity care, and present at a public hospital in labour.  Some are choosing homebirth, as the cheaper option.  Many are Moslem women, fully covered when outside the home, and it's common to see very low levels of Vitamin D, and iron deficiency anaemia.

What can we do to improve the health outcomes for these women and their babies?

SCORE: 5/10

5. a focus on health promotion and disease prevention that views pregnancy as a normal life event.
Health promotion in maternity care in Australia relates to initiatives such as smoking cessation, obesity, family violence, and baby sleeping arrangements.  There is little recognition of the fact that pregnancy is a normal life event; that health outcomes are best when technology and medicine and surgery are used sparingly; and that health outcomes are best when exclusive breastfeeding is initiated at birth.

Pregnancy is seen, in mainstream maternity care, as a minefield; a disaster waiting to happen.  Women are investigated, tested, and explored - in expectation of something awful.  Concepts of informed decision making are poorly understood, and even more poorly followed.  Women report being bullied if they question a plan of action, or try to decline an offered treatment.

Australian maternity services are medically driven, with obstetric hierarchy dominating most services and decisions.  The RANZCOG College Statement on Homebirths, while attempting to support personal autonomy and informed decision making, leaves little room for discussion, and a great deal of room for coercion:

"... While supportive of the principle of personal autonomy in decision making, RANZCOG cannot support the practice of planned homebirth due to its inherent risks and the ready availability of safer options for labour and delivery in Australia and New Zealand. Where a woman chooses to pursue planned homebirth, it is important that reasons for this are explored and that her decision represents an informed choice, considering all the possible benefits and potential adverse maternal and perinatal outcomes. ..."

There is, in my opinion, ample evidence supporting planned homebirth, with plans for transfer of care to hospital in a timely manner when indicated.

There is, again, much room for improvement!

SCORE: 3/10

TOTAL SCORE: 20/50

40%

FAIL!

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:

Background:

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.

Cultutal heritage in need of urgent safeguarding

Recently my attention was drawn to the UNESCO cultural project to develop a list of Intangible Cultural Heritage in Need of Urgent Safeguarding.

Intangible cultural heritage is knowledge and skill that, unlike monuments or collections of clay pots, cannot be touched.  The UNESCO list includes a fascinating range of human activities, from Mongolian calligraphy, to Watertight-bulkhead technology of Chinese junks, to many examples of traditional music and singing.

Readers of this blog may already have joined the dots, and wondered if some aspect of 'midwifery', or 'spontaneous, unmedicated *normal* birth' (or both) could be considered an under intangible cultural heritage in need of urgent safeguarding?

Is the reality of normal (natural unmedicated physiological) birth something that can be called a cultural heritage, and something worth protecting? I say "YES".

transferring to hospital

I am reflecting on a few recent situations in which I have made the 'call' that we need to go to hospital.  In my mind there has been no doubt. 

It's fairly clear to me, that when a woman and baby are strong and well, home is ideal.

But ...

when the mother is not well, physically or emotionally, it's not good at home.  Even a mother who has no continuous support in her home - should she be left alone a mere 3 or 4 hours after the birth, when I pack up my gear and go home?


Midwives have a set of guidelines, published by our College (ACM), to set down systems for decision-making about consultation and referral (see previous post).  They do not actually address homebirth, but are a list of the conditions in which a midwife would expect to work collaboratively with an obstetrician or an obstetric unit in providing maternity care - meaning that the woman is in hospital for the birth and any other continuous acute care. 

The ACM Guidelines list hundreds of 'indications' for consultation (with) and referral (to) specialist obstetric or newborn or other medical services.


Rather than focus on 'indications' or medical/obstetric conditions, I prefer to turn the coin to the other side, and ask the questions:
"Is the mother well?",
"Is the baby well?"

If the answer to each is "yes", there is no reason to intervene prior to the onset of labour, so we wait for labour to establish spontaneously.  This is the only woman who, in my opinion, is fit to proceed with home birth. 

If the answer to either is "no", the hospital probably has real advantages.  Homebirth requires strength, and intentionality about wellness.


Many women who plan homebirth have serious concerns about what might happen in hospital.  They know about continuous monitoring in labour, and scheduled vaginal exams, and narcotic analgesia being offered at the time when they are vulnerable to suggestion.  They know about protocols for normal progress; about high rates of inductions and augmentations, and all-time high rates of caesarean births.  They know about babies's cords being cut, and babies being separated from their mothers. 

Yes.

When I say to a woman, who has gone to considerable expense and trouble to plan homebirth, that I want her to go to hospital to give birth to her baby, I know that she may experience difficulties with the system.  Hospitals are not committed to protecting, promoting and supporting natural physiological processes in birthing.  Hospitals are concerned about patient/staff ratios, availability of emergency services, and a hundred and one issues that make hospitals relatively safe places for the majority of patients and staff and visitors.


Transferring care from planned homebirth with a humble midwife, to a hospital with 'teams' of midwives, nurses, and a heirachy of doctors from the new Resident to the obstetric Consultant, can be a daunting process.  I will recommend that transfer if I believe the woman's and her baby's needs are likely to be better served in hospital than at home.   The best is all that I want.


The person who owns the natural processes in birthing (and nurturing of the baby) is the mother.  She is the only one who can give permission for a staff member, or a privately employed midwife, to take her pulse, or listen to her baby's heart beat, or assess her cervical dilation and the station of her baby's presenting part.  The mother owns her body, regardless of where she is intending to give birth.

This ongoing process of decision-making is guided in my practice, not by a 84-page spiral bound guidance manual, but by the two simple questions:
"Is the mother well?",
"Is the baby well?"

What should I say to the students?

Over the years I have spoken to each new intake of midwifery students at Deakin University in Burwood about the midwife in private practice.   I feel privileged to be invited to give this lecture.  I stand before a room full of fresh and eager young women (usually), who want to become midwives.

Yesterday I asked Martina, a young midwife who asked me to mentor her in homebirth and private practice, who had been in that same lecture room a few years ago, what she thought I should focus on.  She was quick to reply: "normal unmedicated birth, physiological third stage, leaving the cord un-clamped - these are basic midwifery, but students may rarely experience them as they complete the practical requirements of the course."  

Yes Martina, I think you are right.  This truly is basic midwifery.  Students may find that their courses emphasise so strongly the complications and illnesses that can devastate a woman in pregnancy and birth, yet undervalue the body of scientific and clinical knowledge around protecting spontaneous normal birth, breastfeeding, and mothering.  Teachers may take it for granted that students will learn how to be 'with woman' when the woman is strong and well and intentional about working with her own body's natural power in childbirth, while they prepare the students for obstetric emergencies, neonatal and maternal resuscitation, and other potentially life-saving measures.

Working in harmony with natural processes in birthing is indeed a wonderful thing.  Midwives sometimes refer to ourselves as 'oxytocin junkies', and anyone who has spent time repeatedly in the zone of healthy spontaneous birthing will know what I mean by that phrase.  We come away from birth with a renewed sense of awe and wonder each time, and we never exhaust its potential. 

Yet I need to balance that fact against the reality that a midwife's place in birth is not a passive one.  If there were no serious professional role for the midwife in a 'natural', spontaneous birth, it would be reasonable for women to be attended by their sisters, friends, or a sub-professional group of birth attendants.  A midwife attending planned homebirth is watching the woman's response to her body's intuitive work, watching the baby's response to the labour, and assessing progress over time.  While an inexperienced midwife might become frustrated when progress is poor, the seasoned midwife seeks an understanding, weighing up what she observes against her knowledge of normal. 


Midwives entering the profession today face a distinct set of challenges:

• Basic midwifery

Mainstream maternity service providers in cities like Melbourne - the employers of the majority of midwives - are pretty good at dealing with the complicated aspects of birth.  They have educational and research arms that impress colleagues around the world.  But, in general, they do not do a good job at 'basic midwifery'.  There are few strategies that protect wellness.  The rates of various interventions, from induction of labour for non-medical reasons, to rates of caesarean, or rates of serious perineal trauma, or rates of admission of babies to neonatal intensive or special care nurseries - all performance indicators - could be improved. 

It is the job of midwives to insist on 'basic midwifery' improvements to the care of women.  We can't expect the obstetric services director - a medically trained specialist in surgery - to champion midwifery which is outside the scope of an obstetrician's expertise.  (Mind you, some obstetricians do understand, and champion, the work of the midwife) 

• increasing medicalisation of life events

This challenge point is linked to the previous one.  Our society has, to a great extent, lost its knowledge of and trust in wellness.   There is a point at which additional medical interventions fail to improve outcomes, and possibly increase the risk of poor outcomes.  Midwives today carry knowledge of protecting and supporting spontaneous birthing processes.  We must value our knowledge and skill.

• increasing bureaucratic red tape

Midwives have lobbied successive governments over many years for equity and fairness in access to public funding for midwifery services.  This challenge continues, even though we are now able to provide Medicare rebates for some midwifery services, and other extensions to practice such as requesting tests and investigations, and prescribing some medications.  There are many bureaucratic requirements attached to these new professional benefits, and only time will tell if we meet the expected standard.


**********
Private midwifery practice in Australia today focuses on homebirth.  Homebirth offers midwives an opportunity to experience 'basic midwifery', because the only way to access the obstetric component of maternity care is to transfer care to a hospital.  

Over the years of my midwifery practice I have become more and more committed to the protection, support, and promotion of the spontaneous natural processes in pregnancy, birth, and breastfeeding, and this has been predominantly through planned homebirth.   It makes sense.  It leads to better outcomes for mother and baby.  Over the years of my midwifery practice I have also valued greatly the appropriate use of medical and surgical interventions.  In situations where the natural process is not likely to lead to good outcomes, we have excellent processes for 'Plan B'.  This is good.

I am happy to encourage the new group of midwifery students to give all they can to this profession, and I believe they may discover that midwifery will satisfy and challenge the most critical mind.

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"

Baby Bonus gone

The federal treasurer's announcement in the Budget 2013 that there is to be no Baby Bonus from early 2014 is, in my opinion, a sad legacy of the present government, and an equally lamentable commentary on the opposition's lack of support for those who need it most. 

It sometimes takes a cartoon to speak truthfully about political situations.  Thanks, Australian.

Mothers who stay at home with their young children, particularly in the pre-school years; mothers who do not benefit from paid parental leave because they do not have employment out of the home; families who live on one income - these are the ones who will miss the baby bonus most.  And, as it happens, many in this sub-group of modern Australian communities are the ones who also value wellness and protection of health in pregnancy, birth, and nurture of their babies - and who employ a midwife privately.  Many mothers have 'afforded' homebirth, knowing that they will be entitled to the baby bonus.  So, in that sense, I must declare that my interest in the baby bonus is, in part, linked to my need to earn a living as a midwife.

I don't have time thismorning to write any more, but will get to it as soon as I can, and add to this post.  Any comments from readers will be appreciated, either in the comments section here, or by email.

later...
Responses received in 4 our so hours since I wrote include:

Cancelling the baby bonus demonstrates ...

"undervaluing of the role of a parent"

Yes, the current social pressure to have children of all ages cared for by specially designated child care businesses does ignore the very real intuitive and personal roles of parents in caring for, guiding, and teaching their own children.

"full time parenting is not recognised as gainful or important.  ... the role of a stay at home mum has been labelled 'for the chronically unambitious'."

Outrageous!

"I think this really will have an impact of breastfeeding and extended breastfeeding rates."

No doubt!

...

Then, there are those who have seen what they consider to be abuse of the government's over-generous middle class welfare, new parents who have boasted of purchasing the flat screen TV, state of the art coffee machine, new sofa or a trip to Bali.

or, as a midwife notes, 

"the women in [low socio-economic area/suburb] who come back and have a new baby each year, and can't wait to get the Centrelink forms filled out so that they can get their payments."

Yes, any social welfare scheme can be abused.  We Australians have many supports provided by government at the time when our babies are being born and nurtured, including family tax benefit, parenting payment, as well as the child care benefit and child care rebate for children in approved care facilities.  For more detail, click here.

A quick review of media around the scrapping of the baby bonus informs me that there will be an end to the current baby boom, that teenage pregnancies will be discouraged, and that families will no longer have 'one for the country', as proposed by Peter Costello in 2004.  The consensus amongst thinking people seems to be that the baby bonus is better relegated to the wastebin of bad economic management.

Here's a story.  Once upon a time ...

There were two men in a certain city.  One was very rich, and he had properties and flocks and herds and many possessions.  The other was very poor, and lived near the rich man.  He owned just one ewe lamb, which the poor man had bought.  The poor man and his family loved that lamb, and it ate their food, and drank from the same cup, and slept in the poor man's arms.  Now one day a traveler arrived at the rich man's house, and he invited the traveler to stay for dinner.  The rich man did not take a lamb from his own flock, but in stead took the lamb from the poor man, killed it and had it prepared for his meal.

[This story is based on the one in 2 Samuel 12.]

I see the cancellation of the Baby Bonus as the rich man taking from those who are weakest and least able to defend their own interests in the political arena.

When (then Treasurer) Peter Costello introduced the Baby Bonus reform legislation in 2002, he stated that:

"The Baby Bonus recognises that one of the hardest times for families, financially, follows the birth of a first child. A family could lose one of its two incomes for a period of time as the mother, or father, gives up or reduces paid employment to care for the child." [click here for more]

The need for support when one parent gives up or reduces paid employment to care for a child is an ongoing need.  By all means, the provision of the baby bonus should be refined and managed in a way that minimises abuse.  In the current financial situation, I believe it would have been prudent for the opposition to hold to the long-term support of this program, rather than supporting the government's plan to use the ewe lamb owned by the poor man to feed the rich man's guest.

Making the bed

I drove through crisp Autumn air, under blue sky, to visit the mother and her baby boy who was just 24 hours old.

Within minutes of laying eyes on them, and without touching either, I was satisfied that all was as it should be.  With early morning light filtering onto the bed, I noticed that the baby was sleeping quietly in his mother's arms; that his skin was a healthy pink; that his mother had a confident, oxytocin-induced smile.  A few questions confirmed my assessment: mother's blood loss was minimal; she was eating and drinking well; passing urine without difficulty; she had slept a little, and her baby was eagerly taking the breast.

It's difficult to describe the deep thankfulness that I feel as I witness the normality of birth.  Much of the preparation and discussion prior to the birth focus on what would happen if complications or difficulties arise in labour, or if the baby's condition at birth is not good.  The equipment and supplies I bring to the birth require skill and competence in assessment, resuscitation, and midwifery management of sometimes unpredictable, rare events.

Although the assessment was made with the confidence that comes from years of professional learning, at this postnatal visit I did not need to take any professional action.  I asked the mother if she had had breakfast yet, would she like a cup of tea?  Yes.  So the midwifery student went to the kitchen to prepare it.  We reflected on the exhaustion a mother feels after even an 'uneventful' spontaneous birth.  We laughed at the though that the father is often more spent!  We pondered the help given by the warm water in the birth pool; that the softness of the pool's inflated sides gave the mother a lovely soft surface upon which to drape her upper body in the most demanding part of the labour.  We chatted about the responses of the baby's brother and sister, building up a set of unique and very personal memories of this unique and very personal event.

I had noticed a small splatter of blood on the bed sheet.  "Would you like us to make the bed for you, with clean sheets?" I asked.

And while mother ate her toast and drank the hot herbal brew, we changed the sheets.

Making beds happens each morning in hospital, and it's not something that I would write about in a midwifery context.  Yet as we went away from this beautiful homeborn baby and his beautiful mother, I thought that making the bed was the main professional act that we had accomplished in that visit.

I wonder if he reflected on what he said?

Today I want to look at the words of an obstetrician who was interviewed for an ABC TV story 'Call for wider availability of home birthing' on the 7:30 report last night.


The professional body representing obstetricians, RANZCOG, strenuously opposes homebirth, and appears to have no interest in opening pathways for midwives to have visiting access for clinical privileges in hospitals - public or private.  The midwife's place is working in hierarchical maternity care models in hospitals.  The obstetric dominated maternity care has no place for the sort of midwifery that I have practised for the past 2 decades: private midwifery practice in which I have a small caseload of 2-4 births per month.  Most of the mothers in my care are planning homebirth.  Others are planning to give birth at the hospital, and I become the primary carer working within a larger team, and a sort of 'event manager' during the hospital stay.

Back to the 7:30 report.

Two obstetricians were interviewed.  Euan Wallace is director of obstetrics at Southern Health, the large network that covers Monash Medical Centre, as well as Casey, Dandenong, and Sandringham hospital maternity units.  Dr Wallace spoke of the (publicly funded) homebirth program within Southern Health as "one of the jewels" in the program.  He compared the relative rarity of homebirth in Australia, less than 0.5% of all births, with the UK: that in Australia homebirth seems to have a "wackyness" about it!   His heavy Scots accent suggests that his life experience is less insular than many of his obstetric colleagues.  He called homebirth an appropriate choice for certain women, and a choice that women should have, wherever they live in Victoria.

The other obstetrician, Michael Permezel, spoke on behalf of RANZCOG.  It is his comments that have left me wondering if he has reflected on what he said.  In short, he said women can't be given the responsibility to make a choice about homebirth.

Patronising? Definitely. 

RANZCOG does not support homebirth because, he said, there are a few nasty things that can happen at home that would be better managed in hospital.  By some amazing stroke of [un-]logic, it follows that if homebirth was offered, women would get a false message about the safety of homebirth.  That it would somehow give out a wrong message, leading women to imagine that availability of the program implied safety.  [This is not a verbatum quote, but it's very close.]

Readers of this blog are probably mostly people who have heard all this before, and who do not think that women who choose homebirth are deluded or intellectually impaired.

In a brief response to the RANZCOG position as stated by Prof Permezel, I acknowledge that there are occasions when unpredictable events can quickly escalate into the need for emergency obstetric or neonatal medical treatment.  This is not a homebirth issue: it's a life issue.   It's something that maternity hospitals face every night when their operating theatre staff go home.  Even the big tertiary centres face the possibility of doctors and midwives being unskilled when a woman presents in spontaneous labour with a breech baby.


Women who sit down in my office to discuss homebirth are not ignorant; are not holding onto false notions about the safety of homebirth.  They are usually very well informed, and are making plans that give them the best options that are available to them.  These women, and I, the midwife, are deeply offended by the suggestion of this obstetrician that they somehow don't have the capacity to weigh the risks against the benefits of different options.

Dueling Experts

This week, at the MIPP blog, I have recorded some of the questions asked in the course of a formal hearing into the conduct of a midwife.  The scene was a room in the County Court in Melbourne: formal, foreboding, and unfamiliar territory to the midwife whose actions in two particular cases were allegedly unprofessional.  The panel appointed to hear the case did not have anyone who could be called a peer.  Those three women also appeared to be in very unfamiliar territory.

Although formal hearings are open to the public, I have not identified the midwife or the witnesses who spoke for the Board or in the midwife's defense.  The name of the person who made the notifications (complaints) is suppressed by law, and the names of the women who received care from the midwife, leading to the complaints are also not allowed to be published.

In his opening address the lawyer acting for the Board ( Nursing and Midwifery Board of Australia ) commented that this case will probably come down to 'dueling experts'.  The second time he used that phrase it sounded more like 'drooling experts'!  Whether it was intended as a joke or not, it's difficult to see the funny side when a colleague is having to undergo such grueling questions about births that took place more than 6 years ago.

There were two experts called to answer the questions put to them by the two lawyers.  Both experts are Professors of midwifery: highly respected women who have impressive academic credentials.   The arguments become polarised between risk and the woman's choice.

Expert 1 told the panel hearing the case that the risk of a twin birth, or a postmature birth, was too great to be managed in the woman's home by midwives. 'Risk' and 'safety' appeared to be synonymous.
 
Expert 2 told the panel that safety can only be achieved when the woman's right to choose is upheld and supported - even if the woman is giving birth to twins, or the pregnancy is postmature.

Have you ever listened to dueling banjos?  Take a moment to listen to this one from Youtube, played by John O'Connell with James Meall.

That's the image that came to me when the barrister said we faced dueling experts.
They start out slowly, deliberately.
One makes a statement.
The second answers.
Another statement, slightly more complicated.
Another answer.
And it continues until they are in full swing, and I think one or both must surely be lost.  I do not understand how one or the other 'wins' the duel - I think banjo players must have some rules about that. 

And so it is for midwives.

Is a midwife *allowed* to agree to homebirth when one or more risk factors have been identified?
Is a woman *allowed* to plan homebirth when one or more risk factors have been identified?

This is the question, ultimately, that this panel are required to answer.  The NMBA has a two-fold statutory role, to protect the public and to guide the profession.  The protection of the public, in this case, is about putting limits on midwives, and thereby putting limits on the women who engage our professional services.  The guidance of the profession is, in this case, about attempting to define the boundaries of a midwife's practice.

I have come away from this episode of dueling experts without any solution.
I agree with the second expert, who strongly asserted that safety can only be achieved when a mother's right to informed decision making is protected and upheld.
Yet I know well that midwives will continue to be challenged if they agree to operate 'on the fringe'.