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!

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'.