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.]

indemnity insurance: who benefits?

It's a simple question.  Who benefits from indemnity insurance?

We're all familiar with insurance: home and contents insurance, vehicle and third party property insurance, health insurance, travel insurance ...  Some are mandatory; some are not.  

Narrowing the field a little ...
... to mandatory indemnity insurance for midwives as regulated health professionals.  Who benefits from that?

The obvious answer is that the consumer - the mother+baby who receive professional care from the midwife - are potential beneficiaries.  When/if a mother or her baby experience adverse outcomes that may have been avoided under professional care that may have been done differently, that mother or baby are able to sue the midwife for the loss they claim to have suffered.

An eye for an eye!

The matter is placed in the hands of lawyers.

If the midwife has indemnity insurance, the insurer advises and supports the midwife.  The insurance policy may have exemptions and limits that are taken into consideration.

Sometimes a settlement is reached without going to court.  Money is paid to the person who suffered loss, and that's the end of it.

Or the case is scheduled to be heard in the appropriate law court.

If the court agrees that the midwife was culpable, an order is made that a sum of money be paid to the person who suffered loss in the care of the midwife.

Who benefits?
[simple!]
The person who was harmed.


The complication is the availability/affordability of indemnity insurance.  This is a global problem.  No-where in the world is there an indemnity insurance product for individual midwives that provides assurance of sufficient funds to pay out for the life-long health needs of a baby who is severely disabled by hypoxia at the time of birth. 

It's not a new problem.  I have been attending births without indemnity insurance since it became unavailable in 2001.   I (and others in this country) have been permitted to continue practising without insurance for births, while our government agencies attempt to solve the problem.  Midwives in oz are at present exempt from having indemnity insurance for privately attended homebirth, because it's not available. This exemption will be reviewed by June 2015.

Australia's national regulatory board published a research report on professional indemnity insurance for midwives in December 2013.

The UK Department of Health has rejected a proposal by Independent Midwives UK, concluding that government funding of midwives' insurance will not give patients protection (DoH News story 6 March 2014).

German midwives and mothers have been holding huge public rallies - see hebammenblog and scroll down to 13 March (and use translation if, like me, you don't understand German)

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 defence schemes which cost more than some midwives earn.


I am considering this threat to private midwifery practice from as many perspectives as I can.  Readers may consider my concerns to be tainted by self-interest, because I practise midwifery privately.  But, as I am close to retirement from attending births, I see myself as a commentator who knows the terrain well.

From a professional perspective, the cost of indemnity insurance demands consideration.  Midwives who are taking a full caseload (40+ births per year as primary carer, as well as other midwifery services) are paying between approximately $2,000 to $7,500 annually.  Neither of the policies on offer covers homebirth; the more expensive policy covers birth attendance in a public hospital at which the midwife has been credentialed and awarded clinical privileges.  The number of women planning homebirth with a privately practising midwife is small - less than 0.5% of the birthing population.  Midwives who take too many bookings burn out quickly, and women lose faith with their private one-to-one midwife if she is not available to attend their births. 

That's the top end of the scale. 

Midwives who have a very small caseload; perhaps only a few bookings for primary care per year, are also required to have indemnity insurance, and the minimal cost is approximately $2,000.  Those midwives, possibly living in rural towns or properties, may work part time as employees in the local hospital, and see their small 'private practice' as an expensive hobby.   

From a professional business perspective, there is clearly a point at which the cost of private practice outweighs any perceived benefit.   

As fees for indemnity insurance increase, and the cost is passed on to the client, some midwives will not be able to earn enough to afford meaningful PII, unless they charge high fees that make their services unaffordable to the majority of women.

It's a self-defeating cycle.

costs progressively rise - 

midwives burn out or fail to attract enough business to continue offering their professional services - 

reduced access to private midwifery services for women

However, the bigger issue (imho) is the myth that mandatory indemnity insurance is somehow in the public interest, when the vast majority of cases of cerebral palsy, for example, cannot be linked to an action or omission by any professional care provider (hospital or home), and there's no claim on anyone's insurance.
 
From a social perspective, does our society think that midwives should be free to provide services privately (independently) to women, in a way that is affordable and accessible? 

Or the other side of the same coin, that women should be free to engage a midwife privately? 

Most women in our society like to be able to control who provides other personal, intimate services such as hair cutting, or beauty services for removal of unwanted hair, so why would they not want to have a say in who attends them for the most intimate of professional services?

But most women in our society have no idea of the scope of a midwife's practice, or indeed of their own birth-right: to give birth safely and triumphantly under amazing natural forces.
 
The midwife's ability to protect, promote and support normal birth is limited by the professional/regulatory control: a state's duty to protect the public through the regulation of the profession.

The UK government article that I referenced above suggests that midwives should be able to form 'social enterprise' businesses that purchase insurance for members. To me (I do enjoy the one-to-one relationship between me and the woman for whom I provide primary maternity care) this sounds like layers of unhelpful nanny state control that provides only a mirage of safety.

The indemnity insurance situation for midwives in Germany is different from that in Australia or UK.  A German midwife informed me that "Our "independent" midwives do not practice "privately" or "outside" the system.  Here their service are still covered by national healthcare and their "extinction date" has just been pushed back another year as the insurers will offer indemnity insurance for another year to come (with another raise of 20% and limited for another 12 months and the sum covered cut down to half of what it covered before…)" 

Back to the initial question:
Who benefits? 

• when a midwife's indemnity insurance does not cover what midwives do?
• when the increasing costs of providing midwifery services prevents some midwives from offering their professional services, thereby reducing access of women in the community to midwives?
• when the increasing pressures associated with providing midwifery services lead to burn-out and break-down and unsustainable commitments being made
• when the increasing costs of providing midwifery services leads to business models that focus on risk management and the bottom line $$ rather than the woman-midwife partnership?

Who benefits?

• Not the consumer/client/woman+baby
• Not the midwife
• Not the community

someone else!



Dear reader, today I have only touched on these matters.  What solutions can we propose?
 
In the present climate I see reports of cases before the coroner that are likely to have had good outcomes if they had been managed differently.  I read reports of midwives taking extreme positions on management of women with known risk. 

I have phone calls from women who think they would like homebirth because they don't like hospital.   

The solution is not to be found in ever-tightening rules being imposed on midwives.

The solution is not to be found in governments throwing money at the insurance industry.

One aspect of the solution, as I understand birth, must be that a midwife can arrange to provide care for women in hospital as well as home.  

I would like to see the 'villagemidwife' concept available in any town or community where a midwife chooses to work in a professional capacity, providing primary maternity care for individual women.  The setting for births in this midwife's practice must be determined by the woman's and baby's needs at the time of birth.

A society that provides regulation of midwifery must also ensure the ability of the midwife to practise midwifery.  That is the only way to protect the public.  A society that makes midwifery unaffordable, inaccessible, or restricted to homebirth, is depriving its mothers and babies of one of the most basic health promotion services that human existence has ever known.

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.

TWO YEARS LATER

It's two years since November 2010, when the Australian government announced sweeping maternity reforms that promised to give women a better deal in their maternity care.  The Report of the Maternity Services Review acknowledged that:

"... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care."

There are several posts on this site addressing the 2008 Review, and the subsequent recommendations and legislative reform.  For example, go to March 2010 Maternity Reform Hijacked, parts 1, 2, and 3; and the September 2010 one on Medicare funding: carrot or poisoned chalice.

Many midwives around this country have accepted the challenge, jumped through all the hoops, and achieved notation as Medicare eligible.  Our invoices for antenatal and postnatal midwifery services include the Medicare item numbers, and women are able to obtain Medicare rebate.  Some midwives are offering certain services at the Medicare bulk bill rate, which involves the swipe of a Medicare card in a little EFTPOS machine; the entry of a few details using the numbers on the machine, and the bulk bill payment shows up in the midwife's nominated bank account the next day.

The other major change that was brought about by the reform package was the ability of midwives to prescribe certain scheduled drugs: drugs that at present only a doctor can prescribe.  The first group of students in the Graduate Diploma of Midwifery from Flinders University are soon to receive their final scores for the Pharmacology exam paper, which we sat last Thursday, and which accounts for 50% of the mark.  For my journal as a student, go to this and subsequent entries.

On the positive side of the 2-year report of the 'reform' process we can record Medicare.  For example, Item number 82115, with a scheduled fee of $313.05 is

Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks,...

[Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162

]
The Medicare statistics website reveals that, in the 12 months October 2011 to October 2012, a total of $325,005 was paid out by Medicare for Item #82115.
The breakdown of amounts is (in order of magnitude):

Queensland $114,010
Victoria $63,944
South Australia $55,081
NSW $44,308
WA $40,720
ACT $3,241
Tas $2,912
NT $788

This is only one item number.  Other reports can be generated at the Medicare Item Reports site.


On the negative side of the leger, there are several points to note.  This list is my personal one, made from my experience.

1. Medicare Collaboration:
   It is becoming increasingly difficult in some areas to obtain collaborative arrangements that meet the requirements for midwives to provide Medicare rebates for women.
   
2. Access to practising in public hospitals: Despite expert multi-disciplinary committees and meetings and reports, it's clear that public hospitals do not welcome the idea of midwives practising privately within their confines.
3.  Access to practising in private hospitals: Are you kidding?
4. The homebirth problem: Midwives attending homebirth are doing so without indemnity insurance.  Surely the time of birth, regardless of place, is the very time when insurance may be useful. 
5. The future of private midwifery practice: I believe it is becoming more difficult over time to sustain private midwifery practice.  I believe some (probably well meaning) captains of the industry have an agenda to rid our society of homebirth.

Two years on, and the private midwifery profession is more restricted than it was previously.  There has been no expansion of the "range of models of maternity care" - the stated purpose of the maternity reforms.

*****

In conclusion, today I sat in a court room in Melbourne, as the case of complaints into the professional practice of a colleague was commenced by AHPRA.  The law under which the complaints are being heard prevents publication of the name of the complainant, and in this case the names of the women who employed the midwife have also been suppressed.

The legal inquiries and arguments will proceed over the coming days, and the midwife will eventually be told what findings have been made against her, and what conditions may be placed on her ability to practise her profession. [see MidwivesVictoria]

The issue that will, I believe, be at the centre of the case is whether a midwife is *allowed* to attend birth at home for a woman who has recognised risk factors.  The other side of that same coin is whether a woman who has risk factors, such as post maturity, previous caesarean, or twins, is *allowed* to give birth at home.  I have written *allowed* this way to highlight the statutory process that is being employed here, using the regulation of the profession to either permit or prevent certain activities, that are seen - rightly or wrongly - as 'operating on the fringe'.

I am not able in a blog to explore these issues fully.  I would like to make a clear statement that I consider the duty of care of the midwife who agrees to provide primary care for any woman, regardless of the risk status of that woman, to include the promotion of the wellbeing of mother and child, and where reasonable, the protection of spontaneous natural life processes.  The woman is the one who has the final choice on accepting or refusing any intervention.

The midwife practising privately brings skill and knowledge that may not be accessible or reliable in the hospital, where ad-hoc staffing issues often take precedence over the interests of the individual woman.

What progress have we made in the two years since the Maternity reform package was enacted?  Very little.  The only place most midwives are able to practise is the home.  The only way a woman can rely on a midwife is if she plans home birth.

WHY I DISAGREE WITH THE CORONER'S RECOMMENDATIONS

Having written last week about some of the complexities of the decisions made by women about their birth-giving, and the roles of midwives, I would like today to briefly explore why I disagree with (most of) the South Australian Coroner's recommendations in the recent case.

I have summarised the recommendations as:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

Rather than starting with #1 and plodding through this minefield, I will start with what I see as easier, and pick my way through the minefield, trying to state my opinions clearly. (And, dear reader, I must warn you that I often delete a great deal of what I write, so that you see the heavily edited version)

6) education for public distribution on homebirths and risks 

This is not a bad idea. My only hesitation relates to what sort of education, and who writes it, and who defines the risks, and ...

 5) "establishment of alternative birthing centres" 

Also not a bad idea - for the 1980s, that is. Midwifery theorists proposed that hospital rooms dressed as 'home-like' settings would help women to feel OK about birth.  Some women did well, while many were excluded by risk protocols, and moved into standard (the alternative to 'alternative') obstetric care.  I gave birth to my fourth child at the Women's Birth Centre in 1980, and that experience helped me come out of medically managed and dominated midwifery.  I know many other midwives who have learnt to work in harmony with physiology in unmedicated birth, and to trust their midwifery knowledge when detecting and acting upon complications, during their time working or giving birth in a birth centre.  Perhaps that's a good reason to establish birthing centres.

4) "establishment of a position known as the Supervisor of Midwives"

I need to sit on the fence for this one.  The role of Supervisor of Midwives is one that I don't fully understand.  How would these people be appointed?  What would their role entail?  Would all midwives be supervised, or only certain midwives?    The UK-style Supervisor of Midwives is different from the New Zealand system.  Psychologists work under a system of professional supervision.  I believe a thorough exploration of this proposal needs to be had by midwives, ethicists, psychologists, lawyers, and maternity consumer spokespeople, and some agreement reached, before yet another regulatory control be imposed on the profession.

1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"

NO!
Australia does not need to outlaw unregulated midwifery services.
Australia needs to protect and support the midwifery profession, so that midwives can provide midwifery services in homes and hospitals; so that women will feel safe in the professional care of midwives as primary carers, who are able to work seamlessly with specialist services when indicated.
Modern societies, and the legislators and coroners and others in positions of authority need to recognise that spontaneous labour and birth is a fact of nature, not something that a midwife controls or gives permission for, and that women under natural law are able to use the professional services provided in their community, or not.  It's their choice.

2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"

NO!
Midwives who understand the ethical and moral duties of our profession, who by definition work 'in partnership' with a woman, will REFUSE to report women on the grounds of a plan for homebirth.  My own practice for many years has been to encourage women to see the choice of place of birth as a decision they make as labour becomes established, and not before.  I believe this is best practice, as the midwife is committed to the woman, not to the planned setting for birth.

8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

HOW would this work?  Will that woman be arrested and forced to listen to 'appropriate advice' being delivered?

I have not tried to tease out which risk factors the Coroner thinks would be used to initiate reports or the giving of advice.  There are few absolutes in midwifery.  Regardless of what risk factors may be attending a particular situation, physiological birth always starts with spontaneous onset of labour, and spontaneous onset of labour happens in the woman's own time, in her own world, in her own body.  The woman has to make a decision to call a midwife, or not; to go to hospital, or not.  This decision cannot be taken from her.

This set of recommendations exhibits a shallow and linear view of life, risk, and decision-making.  The question that the Coroner seemed to avoid is:

"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and

"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"



Australia is a society which supports a wide range of freedoms for the individual.  I don't have the words to describe the legal and ethical framework that this is built upon, but I know that when a State (government-sanctioned authorities) is given power to control the most intimate relationships between a woman and her child, that comes with a great loss of basic freedom.

Civil disobedience by midwives has been recorded many times, when the midwives believed that the lives or wellbeing of the mother and/or her baby were at risk.  The Hebrew midwives, Shiphrah and Puah, who were prepared to disobey and deceive the autocratic, absolute authority of Pharoah, are our model.

The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, "When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.  But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live.  So the king of Egypt summoned the midwives and said to them, "Why have you done this, and allowed the boys to live?"  The midwives said to Pharoah, "Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwives come to them."  So God dealt well with the midwives; and the people multiplied and became very strong,.  And because the midwives feared God, he gave them families. (Exodus 1: 15-21, From the New Revised Standard Version (1989) of the Bible)

Reflection on practice

Today I am using Gibbs' reflective process in reviewing an experience I have had recently, attending a woman, who I will call Linda (not her real name), giving birth in hospital. I do not want to approach this from an idealistic standpoint, or to 'deamonise' the hospital. Birth, as with the rest of life, is full of unpredictable moments when those who are present are called upon to do their best.

Alena welcomes her baby brother, Christopher

I want to assure readers that mother and baby are well.  However, I am left with some difficult questions. I question my own actions as well as those of colleagues in the hospital.

1. What happened?
Linda was treated unnecessarily (imho) and aggressively for obstetric haemorrhage.

2. Feelings: What was I thinking and feeling?
I was shocked, surprised, and bewildered when I realised that there was a full-scale emergency 'code' being performed, with not only active management of the Third Stage, but additional oxytocic drugs intramuscular Syntometrine, intravenous Syntocinon (40 IU in 1 litre of fluid) administered urgently.

3. Evaluation: What was good and bad about the experience?
What was good? Having experienced respectful care from the doctors and midwives through the pregnancy, and engaged in carefully informed decision-making up to the moment of birth, this incident was an over-reaction to Linda's known risk factors (including multiparity, and a previous caesarean birth)
What was bad: I realised that I had facilitated this chain of events, because I encouraged Linda to agree in early labour to having the IV cannula sited in her arm.

4. Analysis: What sense can I make of the situation?
I can understand why this incident happened, because I know about other very difficult incidents that this group of midwives were dealing with.

5. Conclusion: What else could I have done?
At present a midwife practising privately is not able to have visiting access for clinical privileges in hospitals in Victoria. I cannot over-ride the clinical decision of another midwife, and when an emergency code has been called, I would be foolish to interfere. My long term hope is that I will be able to have clinical practice rights in public hospitals, and in this case I would be able to take responsibility for my own clients.

6. Action Plan: If it arose again, what will I do? 

As I noted in #3 above, I had encouraged Linda to agree to the hospital's policy and have an IV cannula sited in preparation for an incident such as a post partum haemorrhage (pph). I believe Linda would have declined the offer if I had not spoken to her about it. In this case I think it was the fact that the cannula was in situ, and the hospital midwife was basically 'set up' for a pph, that somehow set the pathway.

In another similar situation, I will be careful to inform the mother that once a cannula has been sited, it is easier for staff who may be on edge for totally unrelated reasons, to 'jump the gun' and treat her as though she is in an emergency, when this is not the case.

Risk aversion

Midwives who attend women for homebirths have often been portrayed as having an affinity or fondness for risk, accepting and even encouraging situations that would not be considered suitable for midwife-led care in hospital.