supervision?

This is an amazing old piece of stitching. 
But, I don't think it is meant to represent a ruptured uterus!

Recently, the Nurses and Midwives Board of Australia (NMBA, or Board) has invited midwives to participate in a series of focus groups and consultations that will lead to a process of supervision for privately practising midwives.  I and a number of other midwives and stakeholders have been invited to participate in three expert consultations with the law firm, Pricewaterhouse Coopers (PwC) that has been engaged to oversee the project, and advise on potential models.

This midwife supervision project is all about the statutory duty (of the NMBA) to provide a level of protection for the public through regulation and support of the midwifery profession.  Whether or not they introduce supervision for PPMs, or for all midwives, and what it will look like (how supervision will work) is unknown.  Note that the Board has recently replaced its ‘Safety and quality framework for midwives attending homebirths’ with a SQF for all midwives http://www.nursingmidwiferyboard.gov.au/News/2014-04-30-safety-and-quality-framework.aspx

 


If you are a midwife who has worked in the United Kingdom, you will know that all midwives there have a supervisor, who answers to the local regulatory authorities, who in turn answer to the national regulator.  The process is at present being reviewed.  [See Parliamentary and Health Services Ombudsman's Conclusions and Recommendations -added to this post 19/6/14]

The current model of supervision, in the UK context, is a "means of promoting excellence in midwifery care, by supporting midwives to practise with confidence ...", and  a means of protection of "women and babies by actively promoting a safe standard of practice." (NMC 2009.  Modern Supervision in Action: a practical guide for Midwives, p3)

That two-sided goal, to protect mothers and babies, at the same time as supporting midwives, is what statutory regulation seeks to provide.  A process that is focused solely on weeding out those midwives who may have performed poorly in a particular situation is unbalanced and probably unnecessarily punitive.  A process that is focused solely on supporting midwives, and ignores the need for careful correction and improvement, is also unbalanced and may lead to tragic, preventable outcomes for the consumer, and loss of that midwife to the workforce. 

At present in this country any midwife is able to elect to work in a self-employed capacity, or employed privately by a midwifery group practice.  A small number of midwives have chosen one of these pathways, with very little, or no postgraduate experience working in the more structured, and more supervised, environment: mainstream hospital maternity wards.  Within hospital employment models a midwife who has recently graduated will be given support and a process of structured performance reviews over time.  A midwife whose practice does not meet the standard expected within the unit may be asked to agree to a performance contract that includes measurable outcomes.

Midwives who are practising privately form a very small proportion of the profession.  Yet, we are an easy target for bureaucratic control.  In the past few years we have jumped through amazing hoops in order to achieve eligibility for Medicare, and notation on the register as midwife prescribers.  We are instructed and guided by the Board, the insurers, Medicare, and professional bodies, and the list of codes, guidelines and instructions grows constantly.  In my opinion, there is no need for a professional supervision program for all privately practising midwives.  It would be an enormous waste of resources, for very little gain.

I would like to urge the NMBA to establish a targeted professional supervision program, with a strong focus on adult learning through peer discussion and reflection, directed at those midwives who have recently commenced private practice, as well as those who have had complaints or notifications made about their private practice.  The midwife may be required to comply with a program of professional supervision for a period of time, such as 5 years, or a number of episodes of care (eg 50) in which the woman is receiving primary maternity care from that midwife.  The midwife supervisor would need to be a respected and experienced member of the profession, who has demonstrated her/his ability to practise midwifery in the private practice context.  At the end of the supervision period, the supervisor would advise the NMBA of the midwife's successful completion, or recommend an extension.  If at some time the supervisor forms the opinion that the midwife's practice does not meet the Board's standard, there may be restrictions to practice imposed, and the process of notification, investigation, and a hearing would need to be initiated.   The Board has supportive processes like this available for nurses and midwives who seek help in dealing with mental health issues, or alcohol or other substance addiction. 


The opinions shared and explored here are my own.  I would be very happy to discuss this matter further with midwives or others, either through the comment function on this blog, or at my villagemidwife facebook site.

 

Social Media and midwives

Two of my precious grand-daughters, Poppy and Amelie

I want to declare my interest in the use of social media by midwives.

This blog site provides ample evidence of my commitment to and fascination with openly available websites. This blog is a notice board; a library; a magazine; an ongoing journal of my opinions and comments about midwifery and about life.   It is also an ongoing record of special people in my life, such as the two precious little girls pictured today.

I began this blog in 2006, and it sat, unused and dormant, until mid-2007. At that time I felt a strong need to communicate with young women, particularly those who searched the internet for information in preparation for the births of their babies, and I realised I could do this as a blogger. From time to time over the years I had received emails, usually from women in other countries, thanking me for The Midwife's Journal, which they had found on my old website. A woman from Holland referred to The Midwife's Journal, which had been written at least 10 years prior (ie before the word blog existed in my vocabulary, at least), as a 'blog'.

It occurred to me then that I could continue The Midwife's Journal as villagemidwife, the blogger.

These are the headings from that new beginning [link]:

• Natural birthing in Australia today 
• The culture of birthing 
• Vaginal breech birth 
• Who let the dads in? 
• Nurture and nourishment of the newborn baby 
• Paternal behaviours 
• Mother-infant bonding, and maternal instincts 
• Giving birth 
• The life of the unborn child in the womb, and imprinting at birth 
• Commenting on some of life's big moments 
• Midwife for Christ’s birth 
• You are free, my dove 
• The homeborn newborn: how do mothers manage breastfeeding when there's noone to show them what to do? 
• Protecting normal birth 
• Why protect normal birth? 
• Birth Trauma 

The regulator for health professionals in this country has announced a review of its social media policy:

The National Boards will consult publicly on social media policy in coming months The National Boards in the National Registration and Accreditation Scheme (National Scheme) will release a consultation paper on a social media policy in October/November 2012.

A draft of the social media policy has been released as a preliminary consultation paper to targeted stakeholders for initial feedback, ahead of a wider public release. The preliminary consultation process aims to ‘road test’ the initial draft to weigh operational impact, issues or initial concerns. We are pleased that this early draft is generating a lot of interest, especially on social media. National Boards are monitoring feedback closely and will take the issues raised into account when refining the draft social media policy before it is released for public consultation on the National Boards’ websites.

If you would like to contribute feedback on the preliminary draft social media policy, please email your considerations to socialmediaconsult@ahpra.gov.au by close of business 14 September 2012. When the formal public consultation process opens, the National Boards encourage feedback from registered health practitioners and members of the community on the draft social media policy. The National Boards will publish the public consultation document on their websites, and will encourage wider distribution to seek extensive feedback.

Until then, visit the News section of the National Board websites (via www.ahpra.gov.au) for updates on past and current consultations, general communiqués from National Boards, media releases and more.

I have read the draft policy, which reminds health practitioners that in using social media, we must comply with the National Law, Advertising Guidelines and the code of conduct.


Midwives who in recent years had published testimonials at their websites have found themselves being directed to the law that prohibits the use of testimonials.  Birth Stories, on the other hand, seem to be permitted.

There will be times when I have used experience from real life in my writings, and it is possible that some of those who read my accounts may at times recognise the woman, even if I have been careful not to identify her. Whether this could, in a narrowly defined mindset, be seen as a breach of privacy, is yet to be seen.

There is nothing sinister about blogging, or any other aspect of social media, per se.  The medium is neither good nor bad: it's simply a medium.  The content is what can be anything from wholesome and useful, to trivial navel gazing self absorption, to defamatory and destructive.   The author has the ability to communicate in a way that is useful, or not.  I hope to continue writing in this medium, and I hope there are readers who value the material posted and thoughts expressed.


Your comments are, as always, welcome.

safer and better systems of care

with my first baby 1973

Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.

Caring about professional conduct

The topic of this post is one that is unlikely to attract acolades for the writer. It's one of those aspects of professional practice that implies a risk to the recipients of care, and that sometimes difficult judgments need to be made in order to maintain a professional standard.

There are people in every walk of life who develop conditions that may impair their judgment or conduct, people whose thoughts and actions are adversely influenced by alcohol or other substances, and people who fail to meet the community's standard in terms of professional misconduct and abuse of their position of trust. There are also people whose actions as professionals are significantly different from accepted professional standards. While tolerance and acceptance of difference are values many of us hold dear, we must all take seriously our duty of care, and act to protect others at times when we observe conduct that is of concern.