Insurance: a pot of gold at the end of the rainbow

A pot of gold at the end of the rainbow?
A mirage?
The emperor's new clothes?
[My question is, when will we - the maternity community including midwives, hospitals, and consumers - wake up and come to terms with reality?]


Here's a thumbnail sketch of the insurance problem:

Professional indemnity insurance (PII) for all Australian health professionals became mandatory five years ago.
... BUT midwives who attend homebirth privately cannot purchase PII
... SO the exemption was introduced by the government, to enable midwives to continue being midwives.

Until recently, privately practising midwives who provide clinical midwifery services (pre-, intra-, and post-natal professional care) have purchased PII to cover pre- and post-natal services, and have, with certain conditions set down by the Nursing and Midwifery Board, come under the exemption for attending women in labour, birth, and the immediate postnatal period.  There were two insurance companies MIGA and Vero.  MIGA insurance is restricted to Medicare-eligible midwives, and includes cover for birth in hospital when the midwife has clinical privileges.  Vero, on the other hand, has provided an insurance product for midwives regardless of their eligibility for Medicare funding, and offers no cover for intranatal midwifery services.


Now, Vero has notified midwives that:

"It is with deep regret that we inform you that as of the 2nd April, 2015 Vero and Medisure will no longer be able to provide a Professional Indemnity Insurance policy to Private Practicing Midwives who are providing any home birthing or home birthing related services.

There are a number of factors that have impacted on this difficult decision, including:
• the high cost of claims that have resulted in the past 4 years
• the lack of government funding or assistance (for claims or premium costs), and
• the ability to offer an affordable policy to Private Practicing Midwives who are providing any home birthing related activities.

..."

The Vero insurance product was the only PII option available to non-eligible midwives, and was seen by some eligible midwives as more affordable, and adequate to meet the requirements of registration.

I am not surprised that Vero has come to this decision.  The wonder to my mind was that someone thought it would be do-able!  The 'number of factors' dot points listed in the Vero letter are not surprising:

• the high cost of claims that have resulted in the past 4 years

Yes, legal defence is costly.  That's what insurance is about.

• the lack of government funding or assistance (for claims or premium costs), 

This is not new.  The product has never had government assistance

• the ability to offer an affordable policy ...

This is not new either!


It has been clear to me, since privately practising midwives lost our insurance in 2001, that the private midwifery 'industry' cannot provide the sort of $$ required to insure birth.  Our annual earnings are of a similar quantum to the insurance premiums paid by obstetricians.  At that time I argued (unsuccessfully) in the then Nurses Board of Victoria that if insurance was to be mandated, there was an onus on the regulator/government to ensure that a suitable product was available and affordable.  If not, the regulator was effectively delegating its responsibility for protection of public interest through regulation of the midwifery profession to the insurer.

The purpose of statutory regulation of the health professions is protection of the public.  The insurer does not exist to protect public interest - in this case ensure safety for mothers and babies.  The insurer is a profit-making enterprise, and exists to protect the financial interests of its people - in this case midwives - and shareholders. 

When is the Australian government, the statutory regulator, and the whole maternity community going to stop chasing the pot of gold at the end of the rainbow?  When are they/we going to recognise the mirage of insurance, that in almost every case it makes no difference to any outcome for the client?





Readers who are interested in the back story and further discussion may check out these links:

Midwife Rachel Reed has recently updated her Midwife Thinking blog post on the Future of Midwifery and Homebirth in Australia.

Maternity Choices Australia (formerly Maternity Coalition) has documents and links at its website, and discussion at its facebook pages.

in two minds: why 'choice' is often a mirage

Today I am looking at (the woman's) choice, decision-making (whether it can be called 'informed' or not), and the midwife's challenge which, by definition, includes the protection, promotion and support of healthy natural processes in birth and nurture of the baby. 

From time to time a book or an article promoting women's *rights* in pregnancy and childbirth comes to my attention.  A recent feminist blog is headed with a big question "Why is it still controversial to say that women should make the decisions about childbirth?"

The group Maternity Choices Australia, which emerged out of Maternity Coalition (an organisation in which I was active for a couple of decades) has placed strong emphasis on a woman's own choices in the maternity terrain.


Who is *in two minds*?  
The woman herself. 

What are the two minds?
The woman's intellectual mind and the intuitive mind.  The same brain has separate parts that are used differently.

Why is 'choice' often a mirage?
Choices that are made (using the intellectual mind) prior to the time at which the intuitive mind takes the lead (particularly in labour and bonding) can be irrelevant, but can trap the woman. 


Although I am critical of a great deal of the maternity choice campaign as I see it today, my criticism is based on my understanding of the physiology of birth, which describes the two minds and their interaction with each other; not on feminist arguments of women's rights or fetal personhood.

The person missing from the current arguments about a woman's own choice is the midwife.  Not the generic midwife, whoever is given the task of providing midwifery services at a given moment; the one midwife who is acting as the unique professional, dedicated to working alongside and in partnership with that individual woman through the pregnancy, birth, and postnatal.

I am ready here for someone to tell me that I am being idealistic.  How can health services provide a one-to-one partnership between each woman and a committed midwife whose skill and knowledge the woman is able to trust at any decision-point?

Yes, I know it's not easy.  I have recently ceased providing this level of midwifery care, because I have become too old; too weary.  I can no longer offer to stay awake past my bedtime, or get up in the wee hours; to put aside my own needs hour after hour for the sake of what I believe to be optimal care in birth.   I still see that as optimal, even though I can no longer offer it. 

The only way I can see a maternity world that protects women's ability to make decisions about childbirth is when systematic changes are made so that midwives and women can honestly explore any choices that are presented as time progresses.  When the woman, using her intellectual mind, can explore and grasp the complexity of decision-making in labour, and can trust her midwife-partner to interrupt her from her intuitive state only if she needs to bring a matter of importance to her (intellectual) attention.  

I want to caution here, that without effective partnership, midwives and maternity services, as well as mothers, can err in over-reliance on 'natural' birth.  A UK report highlights the need for caution.  Anecdotes are common and some lead tragically to coroner's reports.


A midwife who delegates decision-making completely to the woman is foolish, lazy, incompetent, unprofessional!
For example:

Midwife A says she believes the woman is free to make any choice she wants about how long to stay in a birth pool after giving birth. 

The woman B has progressed in harmony with amazing natural, physiological forces in her body to give birth unmedicated and unassisted to her baby.  This was just what the new mother B had wanted, and she had (in her intellectual mind) chosen this pathway as having real advantages for herself and her baby.   Midwife A had supported B's plan. 

In the minutes after the birth, B stayed in the birth pool, hormonally awash in the beauty of her newborn and the afterglow of her ecstatic experience.  Midwife A was confident that all was well, and said nothing about getting out of the water.  Baby C did what healthy unmedicated babies do: she found her mother's breast.

Mother B experienced painful uterine contractions, and about 30 minutes after the birth B experienced a gush of blood, and midwife A reassured her that her placenta was about to be born.  Nothing was said about getting out of the water.

More minutes passed, with further after-pains, further bleeding, but no expulsion of the placenta.  Nothing was said about getting out of the water.

Why?

Because Midwife A believed B would know when she needed to get out of the water.

Midwife A was wrong.  Mother B was using her intuitive mind as she nurtured and bonded with her baby C.  She had no idea of time, or any other aspect of expected progress that her intellectual mind had considered prior to the birth.  The only intuition about moving out of the birth pool came much later, when B became faint.  I don't need to spell out the consequences of this error in delegation of 'choice'.



In conclusion, I can say that it is still controversial to say that women should make decisions in childbirth.  The big challenge is that midwives and women are enabled to work together, in deep respect, and with freedom to find the best course as time passes.  Neither can do it alone.

A question

Hello!

Having moved from our home of 30 years in Melbourne's leafy Eastern suburbs to a beautiful semi-rural 'lifestyle' block in central Victoria (link), Noel and I are getting used to our new way of life.  For most of the past month we have not had a reliable internet connection to our home, so have been using the free service at the Kyneton library, and other processes in an attempt to keep in touch with the outside world.

We now have the new year 2015, and an old challenge.  I have been thinking about this question, and hope I can record here something of the current situation in Australian maternity care.  This question was posted by a midwife, to a large international group that discusses human rights in childbirth.  

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have safe cesareans if they need one? 

I am quite disturbed and shocked at this question.  Why, I ask, would there be a need for passion and activism to advocate for the right of women and their babies to have safe maternity care?   

Perhaps the question is irrelevant to Australia?  Perhaps this is an issue in developing countries, or somewhere else?  

Yes, women can get relatively safe caesarean births here if they have a valid reason.  Those who can afford it, or who work out how to manipulate the public health system, can also get caesareans without needing it.  This surgery might meet all the required hospital safety protocols, but the risks of major abdominal surgery add a new dimension to the safety equation.  Infection, haemorrhage, drug errors, adverse drug interactions, issues of pain management, separation of mother and baby, interference with bonding and establishment of breastfeeding, and additional risks of catastrophic birth outcomes in a subsequent pregnancy are just a few of the additional risk factors in surgical birth when compared with spontaneous, unmedicated uncomplicated vaginal birth.

I would suggest that the big question in a modern Western society such as Australia is 

Can we find passion and activism in the middle ground, that ground that advocates for the right of women to have skilled professional services that will protect the mother's capacity to give birth to a healthy baby spontaneously?

Indeed, do we as a society value a mother's ability to give birth?  Do we value the midwife's duty of care which includes the protection of normal birth?   

No, we don't.

Maternity care in Australia is a dog's breakfast that pays more attention to a woman's ability to pay a fee for service than anything else.  It includes obstetrician-managed 'private' care for women who have no clinical need for a specialist; it includes public hospital maternity services that fail to communicate plans and tests done antenatally with the staff who provide intrapartum care; it includes midwife-led private care for planned homebirth, with no provision for the midwife to continue as the responsible professional if the decision is made to go to hospital for the birth; and it includes a fringe of women who proceed with free-birth, with what care there is directed by doulas and unregulated birth workers.

Advocacy in this country around birth is more focused on the woman's right to 'choose' than protecting and promoting natural healthy processes.  Yes, some women 'choose' just that, and make choices about their care that they believe will enhance the process.  But much 'choice' focuses more on whether or not to use painkilling drugs in labour; whether or not to induce or augment labour; planning a waterbirth, or delayed cord clamping, or vaginal breech birth, or some other aspect of care which may be very important in itself but which cannot be addressed separately from the bigger picture. 

Midwives are the only group who have (or should have) the skill and capacity to improve birth outcomes working in harmony with natural processes.  Mothers can't do it on their own.  Physiological birth requires a woman to minimise neocortical activity - thinking.  Childbirth educators, doulas, or well meaning family or friends can't do it.  They don't have the midwife's unique skill. There is plenty of evidence supporting this contention, which requires a care-partnership between woman and her trusted midwife, who is present as the leading or primary professional carer at the time when decisions are being made.  Yet many Australian midwives approach pregnancy and birth as though their role is inconsequential.  They work from an obstetric-managed philosophy of care, relying more on tests and investigations that detect abnormalities than any authentic midwifery philosophy of firstly protecting, promoting and supporting physiological processes in birth, balanced with a commitment to accessing appropriate emergency obstetric services when indicated.

So, is there a place for ' passion and activism in the middle ground, ...'?

I hope so!

That middle ground where women are valued and respected for their capacity as birth-givers; where we seek first to achieve unmedicated, healthy mothers and babies, and place restrictions on the professionals and the consumers as far as frivolous or unfounded interventions are concerned; where midwives are valued for their ability to protect and support the natural processes. 
 
This is worth being passionate about.

changes

Dear reader

Over many years I have enjoyed writing as villagemidwife, and I know that there are many people who read my posts.  Much of my writing is an outpouring of thought and emotion that has been directly linked to my practice.  I am hoping to continue writing for a long time, but it's likely that that will change, as my life's pathway moves on.

I have attended the last birth in my caseload.  I am continuing to practise, particularly in sorting out breastfeeding problems and other postnatal care, but I have decided to act my age, and to leave the births to the younger midwives.  My decision to cease attending births was supported by the fact that in the past 3+ years, since the government's maternity reforms, the number of privately practising midwives in and around Melbourne has increased exponentially, while the number of women who wish to engage a midwife for homebirth, or hospital support, is increasing only steadily.  That means many midwives are under-employed, and there is huge competition for 'business'.

[aside] This sort of language may be unpalatable to some readers.  Birthing is about women and their beautiful babies.  Yes!  Surely midwives who practise independently do so because we have made personal commitments to the protection, promotion and support of natural birthing in a way that we are not likely to be able to practise in mainstream maternity services?  Yes!

But these wonderful possibilities can only be sustained if the midwife is free to focus on the woman and her child, and that means maintaining a reasonable caseload and being paid a reasonable amount of money. 

We have sold our house in the leafy Eastern suburbs, and bought a beautiful (smaller) house on five acres in Kyneton.  If you want to search, the address is 121 Rosa Court, Kyneton Victoria 3444.

If you enjoy reading this blog, you may also enjoy OLD midWIVES' TALES.
Also a fac_book site of the same name.  You are welcome there too - just go to the site and send me a membership request.
So far I am the only writer, but I would love to have other midwives record something of their wisdom, experiences, and learnings.

With best wishes
Joy Johnston

more on DANGEROUS DRUGS

(by Poppy)

Several years ago, in 2010, I posted Dangerous Drugs, in which I explored my thoughts and concerns about the adverse effect of opiate drugs on a baby's ability to function normally in the first few days of life.  In that post the narcotic (opiate) drug endone came under the spotlight, as it was being (and still is) used liberally in early postnatal settings, particularly after caesarean births or when women complain of perineal pain.



[Note to readers:  If you would like to check the information about any drug, you can search the myDr medicines site.  For example, Endone tablets. ]


In 2012 I completed an accredited course in Pharmacology, the Graduate Certificate in Midwifery at Flinders University, and subsequently received endorsement of my registration as a midwife prescriber, and obtained my own prescription pads.  I and many other Australian midwives have used social media for discussion of prescribing issues, in the Midwife Prescriber group.


Any medicine that contains opiates (including over the counter medicines such as panadeine [paracetamol+codeine]) is metabolised into morphine as well as other substances, and has a similar analgesic action to endone for the mother, and is transmitted via breast milk to the baby.  There is a great deal of variability in the way an individual metabolises opiate medicines, transferring the substances from the stomach, via the liver, to the blood stream, and to pain receptor sites.  The existence of ultra-rapid metabolizers of codeine should be noted by any midwife or doctor or pharmacist who prescribes or recommends oral opiates for women who are breastfeeding, and the medicine should not be used if the baby appears affected (excessively sleepy/lethargic) after being fed with mother's milk.  (??? aren't babies supposed to be sleepy after breastfeeding?  Yes - not lethargic though.)


Pethidine (meperidine)
After that rather lengthy introduction, today I would like to focus on another opiate, pethidine, or meperidine (Demarol) in some countries.

Peer reviewed medical literature has for more than a decade drawn attention to the neurotoxic effect of metabolites of pethidine, in both the adult and in the breastfed infant.  In 2006, the New Zealand Medical Journal published a paper by Shipton, stating that "Pethidine is no longer considered a first-line analgesic. ... Clinicians around the World recommend its removal from health systems
or restriction of its use." (p1)

Anderson published A Review of Systemic Opioids Commonly Used for Labor Pain Relief (Journal of Midwifery and Women's Health, 2011), and stated that,
"Meperidine [Pethidine] and its metabolites accumulate in colostrum and breast milk and may be associated with newborn neurobehavioral alterations and unfavorable effects on developing breastfeeding behaviors. Wittels et al43 conducted a prospective, randomized study of breastfeeding women who underwent cesarean births and compared intravenous PCA administration of meperidine to intravenous PCA administration of morphine. Meperidine was associated with significantly more neurobehavioral depression in breastfeeding newborns on the third and fourth days of life when compared with the behavior of the newborns in the morphine cohort (P .05), despite similar overall doses of morphine and meperidine." (page 227)


A question posted at the Midwife Prescriber site a week ago indicated that pethidine is currently used liberally in labour and postnatally, except in public hospitals in New South Wales, where I understand its use has been restricted.  Old habits die hard!


Here's a recent case (true story) -

A woman who is a well informed registered professional, having her second baby by elective caesarean for transverse lie, at a public teaching hospital in Melbourne:

• requested that the IV be inserted in a vein on her left arm rather than the back of her hand, because she wanted freedom to hold and feed her baby after the birth.
• was surprised that the young anaesthetic doctor was very reluctant to do this - had to insist - and eventually got what she requested
• asked not to be given pethidine which is the standard in that hospital, preferred morphine via a PCA, as she was aware of concerns about metabolisation of pethidine, and transfer to colostrum, and felt she could have more control over the amount of drug in her system this way
• once again found that she had to argue with the anaesthetic doctor in order to achieve this preference. No valid reason was given for the hospital's preference of pethidine. The doctor said that "the midwives don't like PCA and don't know how to manage it" (which I think is nonsense)
• and after this doctor had (albeit reluctantly) complied with the woman's wishes, said to the woman. "You're right you know, we don't like using pethidine. It's a 'dirty drug'. And not siting the IV on the back of your hand is a no brainer."

This story illustrates unprofessional behaviours, particularly by the anaesthetic doctor, who was probably doing exactly what she or he had been told to do.  As a teaching hospital, one would expect evidence to be critically examined and applied.  If pethidine is not the best available medicine, it should not be used.  Passing the blame to the midwives is outrageous.  Most of the midwives working in hospitals have not studied pharmacology, and do not have authorisation to prescribe.  The person who signs the medications chart is the person who takes responsibility for the prescription.  If there are problems with the equipment, sort that out.


Drugs such as pethidine, morphine, endone, OxyContin, and others are DANGEROUS DRUGS.  They are kept in the DANGEROUS DRUG cupboard in hospital wards, and protocols must be followed to ensure that these medicines are signed out and administered correctly.  They are called DANGEROUS DRUGS because they are DANGEROUS!

The challenge is that when a dangerous drug is required, such as after major surgery, what is the least dangerous option for the mother and her new baby?

possibly postmature

Possibly postmature
and
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 

• the date of the first day of the last period
• the normality of the last period
• the date of quickening

And, if ultrasound is used, there are additional pieces to add to the puzzle.


Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.


A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.


A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?

Why?

          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?


With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 



There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.

No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable. 

Risk and maternity care

Discussion about risk in maternity care may be met with the full range of responses, from the hands over the ears "hear no evil", through to scary stories about the "disaster waiting to happen".  A midwife needs to understand risk, recognise progression into complications, and appropriate response to change in a woman's or baby's status, without being fearful.  A midwife is guided by principles such as
"In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: A practical guide.)

The usual model of care offered by midwives who practise privately is primary maternity care, with a strong emphasis on continuity of carer and the promotion, protection and support of the natural physiological processes in childbearing: spontaneous unmedicated birth, facilitating strong mother-baby bonding, and exclusive breastfeeding. This emphasis is consistent with best standards of midwifery practice and health promotion globally, and is to be applauded and supported in the interests of public wellbeing and safety. 

Today I want to look at practice issues for midwives in private practice, from a risk based approach.  Not just risk of complications or illness in the mother or baby, but also the risk that a midwife's practice may not be of the standard expected by the profession or the community.

The statutory regulator for health professionals, AHPRA, has established a set of regulatory principles which require the Boards to establish a responsive, risk based approach to addressing practice issues. (http://www.nursingmidwiferyboard.gov.au/News/Media-Releases.aspx )


It has been recognised for many years that systems of maternity care which rely on risk assessment will place a disproportionately high number of women in the "at risk" categories, leading to an increased likelihood that these women will be subjected to a higher level of intervention in the birth.  This process might be seen as necessary, in ensuring the best outcomes, but it often fails to do that!  No amount of bureaucratic micromanagement through laws or practice guidelines will ensure safety.  Many women for whom no risk categories apply will develop complications that require expert obstetric intervention, while many of the women in the "at risk" categories will, with appropriate care, proceed to an uncomplicated, spontaneous birth of a healthy baby.


Within the broad scope of midwifery, issues of special note in private practice, when there may well be an increased risk to women and babies in the care of midwives include:
• Education of midwives, registration, and transition to private practice
• Notifications, investigations, and hearings into professional conduct
• Lack of professional indemnity insurance for homebirth
• Notation as an eligible midwife [including Medicare, endorsement for prescribing, hospital visiting access]

Here are a few of the risks, all of which could contribute to poor outcomes for the mother and baby:

1. Risk of unrealistic, idealistic notions of midwifery practice and natural birth, 
2. Risk of inexperience, and lack of appropriate education and preparation for autonomous practice.
3. Risk of professional isolation, and stunted growth of a midwife's professional identity.
4. Risk of bias in the regulatory body against private midwifery practice.
5. Risk of bias in mainstream hospital maternity services against private midwifery practice. 
6. Risk of discouraged, disheartened midwives leaving the profession and being unable to find suitable employment.
7. Risk to the public of being prevented from accessing the options for midwife-led maternity care, introduced through legislative reform in 2010. 
8. Risk that women are being prevented from accessing the potential for excellent outcomes that are seen in midwife-led care.
9. Risk of obstruction of trade for midwives.
10. Risk of the rise of 'free birth' and births attended by unqualified or lay midwives.

There is a separate, and different category of risk that needs to be included in any discussion about private midwifery practice in Australia.  Midwives are unable to purchase professional indemnity insurance (PII) for homebirth - the core ingredient of most midwives practices.

It is unreasonable that Australian midwives' homebirth practices should continue to be excluded from the PII that is currently available.  Eligible midwives are able to buy insurance for every aspect of their practice, except homebirth.  This needs to be changed.  Insurance, per se, does not make birth safer or less safe; does not ensure good outcomes.  Insurance seeks to protect the financial interest of the players, rather than the health interests.


Tomorrow I am meeting with other representatives of professional organisations, and the NMBA, to discuss midwifery practice issues and regulation.  The points I have noted in this blog are contained in a discussion paper that I have written for this meeting.

Your comments are welcome.

mothering

The mother of a two-and-a-bit year old commented wistfully, "I had no idea of what I was committing to when I became a mummy."


That's so true.

In fact, I don't think it's possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.

Thanks to Miriam and Amelie

This mother who, for whatever reasons, started her family in her mid- to late-thirties has probably experienced a great deal of freedom and responsibility in her personal and professional life.  She has experienced leaving home, and becoming independent of parental influences.  She has possibly experienced promotions and increases in her work earnings.  She may have enjoyed overseas travel or achieved success in the personal pursuits that she has chosen.

...

And now, at about 40 years of age, she has her two-year old constantly in her care, and is preparing for the arrival of a sister or brother.


The day begins with "I very hungry now mummy", and continues as she seeks to meet each of the needs of the child. Multiple meals and snacks, nappy changes, library, play group, walks to the playground, playing hide-and-seek, art work at the kitchen table, music, visits to friends, daytime sleeps, melt downs because the little one didn't get all the sleep she needed, sweeping up crumbs and food scraps under the table for the n-th time, and thinking about upping her dinner menu to something special tonight.  These are just a few of the day's challenges, along with shopping for groceries, mountains of washing, drying, folding and putting away the clothes, getting to appointments on time, and much more.

There is no suggestion of complaint in this mother's musings.  Most of the time she patiently accepts the work of caring for one small person; valuing her own role as mother above all other options at this time of her life.  University education and professional standing cannot compete with the status that is simply and profoundly accessed under the title 'mother'. 


Am I being idealistic?   Am I seeing only what I choose, through the filter of many years; forgetting the reality of sleep-deprivation, and the constant and unrelenting need of the little one for attention? 


I don't think so.  I see a great mystery, something timeless and inexplicable, in the ability of a mother to care for her children.  I accept that many aspects of mothering call for a commitment that goes far beyond our usual limits, and that it's not possible, prior to the experience, to understand something as absolute as the basic, intuitive, hormonally mediated changes that occur in a woman's life when she takes her child into her arms and puts that child to her breast.

The mystery of the mother is our birth-right; contained within the wonderous bodies that God created in his own image, and that God said "is good".  Mothering is part of the natural physiological process that can happen automatically in a woman's person during pregnancy and after the birth of her baby.  It's the same normal physiological process that I as a midwife have sought to protect, promote and support, unless there is a valid reason to take another, more medical, pathway.

Yet the ability of a mother to give, and give again, is not to be taken lightly.  The presence or absence of loving support and encouragement from husband, family, friends and within the community can make a huge difference.


I recognise that mothers today are expected to return to paid employment after their babies have reached one year, or even six months, with children being placed in day care.  I cannot accept this as being in the child's or the family's interests.  In the end Australian families will be paying a high price for this social experiment that interferes with the basic building blocks of love and attachment between mothers and their babies. 

Mothers who are willing and able to nurture their own babies should be supported to do so. 

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.]

Supervision, again ...

My thoughts are returning to the supervision topic, as I prepare to attend more meetings in preparation for the introduction of some model of supervision for privately practising midwives.  This additional regulatory process is clearly intended to identify and manage midwives whose practice does not conform with accepted standards.

Becoming a mother is a quintisentially profound moment in a woman's life, regardless of her people group, education, wealth, or any other variable.   A midwife holds knowledge and skill of working in a way that protects, promotes, and supports wellness in the childbearing process and adjustment to motherhood. 

A greeting card that captures some of the wonder of becoming a mother.

The regulation of midwifery, and other health professions, is the process by which a society can have confidence in the profession, ensuring high standards of education and practice, and a reliable process of investigation and calling to account any midwife who is involved in care that leads to adverse outcomes, or allegations of professional misconduct.


In its Request for Tender – Privately practicing midwives models of supervision, the NMBA (2013) has stated that supervision is: “a critical mechanism in the training, support and ongoing safe practice of midwifery. It incorporates elements of direction and guidance through a process of professional support and learning which enables a practitioner to develop knowledge and competence, assume responsibility for their own practice and enhance public protection and safety.”


The Australian College of Midwives (ACM) has encouraged members to communicate the following points to the reviewers, either in the consultative process of focus groups, or via the online survey.  ACM states that:

• Supervision should be a supportive, mentoring and advisory process, not a management or punitive process; 
• There should be one supervision process for all midwives 
• If supervision is mandated by the NMBA, the model should be developed, implemented and regulated by midwives, not other professions 
• Supervision is not an inter-professional clinical review process 
• The importance of current practices in Australia such as the ACM Midwifery Practice Review (MPR) program, should not be overlooked. 
• The projects should also be mindful of other review and consultation processes currently happening, and that supervision should not been seen in isolation:

• • ACM evaluation of MPR

  
  

  • NMBA review of the Quality and Safety Framework

  
  

  • NMBA review of registration standards for both midwives and eligible midwives

  
  

  • ANMAC’s review of standards for prescribing programs and peer review programs

  
  Many midwives using social media have been quick to express their frustration and dismay at *yet another* level of regulatory control.  Questions asked include: 
  
  • Why are private practice midwives being subjected to supervision?
  • Haven't we jumped through enough hoops with eligibility, insurance, MPR, QSF, and all the codes and guidelines we have to follow?
  • The UK Health Ombudsman found their supervision system has problems - "Supervision is a statutory responsibility...the dual role of a Supervisor, providing support but also a regulatory function, allows for an inherent conflict of interest." Why are we introducing supervision if it is not working in the UK?
  • Who pays for supervision?
  • The UK review also found  "There is a weak evidence base in terms of risk for the continuation of an additional tier of regulation for midwives."
  •  What if the woman doesn't want a supervisor involved in her care? 
  •  Is the supervision remote or ... direct observation? 
  • How are the supervisors trained? Who trains them? 
  • Can a non-eligible midwife supervise an eligible midwife? 
  • What Body does the supervisor report to?
   

It appears to me that AHPRA has decided it needs to provide additional levels of regulation for some midwives (and they can, whether we like it or not).  The current investigation is seeking models of supervision, and from the NMBA (2013) request for tender (referenced above) I gather that the primary focus of supervision of privately practising midwives is to be those midwives who are entering private practice, ensuring that they develop "... knowledge and competence, assume responsibility for their own practice and enhance public protection and safety"  A large number of midwives have recently left hospital jobs, attracted by the possibilities of primary midwifery practice in their communities.  There has been no standard pathway for this exodus: each midwife has found her own way, achieved notation as an eligible midwife, and endorsement to prescribe, and hung up their shingle or joined a group practice.

In concluding this log, I would like to put my thoughts on the record.

Anything that comes from the NMBA needs to be of a regulatory nature, and that regulation needs to be transparent about what it is seeking to achieve, and properly managed and funded to maintain the integrity of the process.   This sort of regulatory professional supervision could be applied to all midwives who move into private practice, for a period, such as up to five years, with standards against which the midwife and the supervisor are able to assess performance.  Midwives who have had some years of experience in midwifery may be able to demonstrate their "knowledge, competence, and responsibility" over a shorter period of time (eg 1 year), while new graduates of a B Mid course, or midwives who are under Board investigation, may remain under supervision for the full five years, or more.

In developing my position on professional supervision, I must assume that any regulatory requirement must be funded, for the preparation and payment of supervisors, and the ongoing development of the program.

I do not agree with a process that attempts to integrate the regulatory surveillance role with a support role.  Mentoring and support are valuable elements of professional development, but are different, and should be separate from supervision. 


Your comments here, or in the facebook villagemidwife group, are welcome. 

Midwives: improving Women's Health Globally

This week the world's midwives are meeting in Prague, for the 30th International Confederation of Midwives' triennial congress.  Many Australian midwives have gone, and will be visible with  distinctive red Akubras (hats) and pashminas.

I am 'following' (to use social media language) from my desk, via twitter  ICM @world_midwives
I am a twitter newcomer, and haven't yet come to appreciate or enjoy the tiny grabs of information and links that come up.  But, I have joined, and I'm ready to learn from the experience.

The theme for the 2014 Congress is ‘Midwives: Improving Women’s Health Globally’, a theme which reflects Millennium Development Goal  (MDG) 5: 'To improve maternal health.'  Governments and global health organisations have recognized that midwives are an essential workforce to achieve MDGs 4&5 by 2015.

Midwives: Improving Women's Health Globally

Midwives save lives

There is sound logic in this statement.  Midwives work to promote health and wellness in the mother and baby, during and after pregnancy, and during the climax of birth, as well as to provide and access appropriate emergency assistance when the need arises.

It is estimated that almost 90% (87% to be precise - see IMPACT poster above) of the essential maternity care for women and newborns can be provided by midwives.  These statements seem hollow in Melbourne, Australia, where the majority midwives have no idea of how to practise their profession outside a hospital, with high rates of every intervention being the norm.  I live within 30 minutes drive of three tertiary hospitals (Women's, Monash, and Mercy), and several slightly smaller public hospitals which provide emergency obstetric services (Box Hill, Angliss, Dandenong), as well as a gaggle of private maternity services.

Most midwives in Australia would run in the opposite direction if they were asked to be responsible for 87% of the essential maternity care in their communities.   Most midwives in Australia have no concept of health promotion. 

Even the (growing) group of midwives who are eligible to provide (publicly funded) Medicare-rebated services, and who have authority to prescribe medicines, are required, by law and strict regulation, to 'collaborate' with the medical profession, whether the woman in our care needs it or not.   We are forced into a pattern of over-servicing of those who least need it.

@@@

The poorest outcomes in pregnancy and birth occur in parts of this world where women do not have access, firstly to midwives and then to other basic maternity services: particularly parts of Africa and Asia.  These are communities where the burden of disease, such as anaemia, linked to poverty, malnutrition, intestinal parasites, malaria, ... place women at higher risk of poor outcomes.  A friend of mine who has worked with MSF in several poverty-stricken war-torn locations told me she has never before seen so much blood, or so many dead mothers!

There is little or no acknowledgment in the Australian mainstream hospital models of maternity care, of the extra-medical (the part unknown to the medical community) contribution of midwifery to maternity care, and health promotion.  The hospital protocols are dictated by the medical/obstetric faculty, in close collaboration with the insurer.  These protocols are not wrong!   Hospital insurers report costly payouts:

• when babies suffer hypoxic brain injury that is linked to induction of labour with synthetic oxytocin, leading to hyperstimulation of the mother's womb
• when continuous electronic fetal monitoring (CTG) is mis-understood by the midwives caring for the women, or 
• when appropriate action is not taken in response to changes in the CTG, or 
• when perineal tears or cuts are poorly repaired 

The insurer of Victorian public hospitals, VMIA, reports that although obstetric claims account for only 16% of claims processed, they are responsible for 33% of the costs incurred (statistics given at a VMIA webinar on Litigation, 3/6/2014).   [I have been writing at this site recently about maternity care dictated by the insurer, and it's easy to understand why it's in the insurer's interest to minimise potential litigation.]


In this context, I consider that biggest problem in hospitals is the failure to protect pregnancy, birth and the nurture of the newborn as precious, natural processes.    The fact that never ceases to amaze me is that our bodies are so wonderfully made.

Pregnancy, birth, and the nurture of children are processes driven by an incredibly powerful orchestration of hormones and physical features that support and interact whether we understand the processes or not.

Midwives work to improve women's health firstly by
protecting,

promoting,

and supporting

the natural, healthy processes of women's and babies' bodies.  This is the non-medical, non-interventionist, non-therapist side of midwifery.  Yes, there is an aspect of midwifery that demands timely and effective intervention when indicated.  It's the other side of the same coin.

'In normal birth there should be a valid reason to interfere with the natural process.' (WHO 1996)

The phrase 'protecting, promoting, and supporting ...' has been used many times in the past 2 decades with reference to the Baby Friendly Hospital Initiative (BFHI), introduced around the world by WHO and UNICEF. 

This is good.

But, the protection, promotion and support of breastfeeding does not begin when the newborn baby is taken into the mother's arms and cradled at her breast.  The response of a newborn child to the stimuli during and after birth depend on many other aspects including mother's health and nutrition, and the presence of inhibitory substances such as narcotics and regional anaesthesia that causes temporary paralysis.  The response of a woman to her newborn child is also changed by physical and chemical changes that over-ride of obliterate the mother's feelings and reactions in birth.  These medical procedures and substances need to be restricted, for use only when indicated, and with extreme caution.

I am blown away by the statistic quoted earlier in this post, that

It is estimated that almost 90% of the essential maternity care for women and newborns can be provided by midwives.

From my sphere of knowledge and influence, in Melbourne's middle class, leafy Eastern suburbs, I find it difficult to believe, yet I know that this statistic has been made on reliable information.

!!!

Welcome to our newest grandchild, born this week!

In concluding today's post, I want to acknowledge and thank God for a wonderful young mother, Anna, and her husband Josh, who this week have welcomed our newest grandchild: a healthy baby born at Term, spontaneously, into the loving arms of a strong, healthy mother.