some of the carrots and sticks of maternity reform

A few weeks ago I wrote:

Regulatory pressures that have increased since the previous government's maternity reform package was implemented in 2010 are like the carrot and the stick.  The 'eligible midwife' carrot is that certain midwives earn special privileges:  Medicare rebates, clinical access to hospitals, and prescriber authority.  The 'eligible midwife' stick is the linked requirements and cost of professional indemnity insurance, collaborative arrangements with obstetricians, and getting over increased bureaucratic hurdles such as the midwifery practice review.  There is no reliable evidence that this approach will make birth safer for mothers and babies, or eliminate the fear of a rogue element in midwifery. ...

Today I would like to look closer at an example of what I mean by the 'stick'.

• One-to-one midwifery is accessible only to the relatively wealthy, who can afford to pay, and the lucky, who are accepted into public hospital caseload programs,

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"