research

Picture this scene:
Part 1 - Plan A:
A woman having her first baby has laboured spontaneously through the day and the next night.  She has gone to the hospital, and spent a few hours in the water, staying upright and mobile.  At 08:00 hours her cervix has dilated to 4-5cm; her cervix is soft and baby's head is 'high'; and her contractions are less frequent than they were a few hours ago.  She is told that she needs her labour to be augmented: move to 'Plan B'.
[This is a major decision point for a labouring woman.  She can either continue working with her body's natural processes (hormonal, physical, and emotional), or give permission for medical processes to be commenced - all with the goal of a healthy woman giving birth to a healthy baby.]

Part 2 - decision to move to Plan B:
The woman agrees to augmentation of her labour, and after considering pain management options available, requests epidural anaesthesia. 
The hospital staff organise the intervention without delay: and IV line is sited, a pump with a second bag of IV fluids plus oxytocic is prepared, and the anaesthetics doctor introduces herself, asks questions about the woman's health, and explains what she is about to do.  The epidural is commenced, and after a couple of contractions the woman feels less pain and lies down quietly in the bed.  The electronic fetal monitor provides continuous information about the baby's condition, as well as charting the presence of uterine contractions.  After the doctor has checked the level of the anaesthetic block with ice, she goes out of the room.

Part 3 - invitation to participate in research
[and the reason for this post]
Soon after, a person comes into the room and introduces herself as a research midwife. She asks the woman if she would agree to being enlisted in a research trial.  She explains that the purpose of the trial is to reduce unnecessary caesareans.
She explains that, in this trial women who have already elected to have an epidural would be randomly allocated, if the question of whether or not to have a caesarean birth, to a particular test of the baby's blood (lactate), which would be accessed vaginally via a scratch on the baby's scalp.
[I won't tell you what the woman chose.  How would you respond?]

Comments on this research from a scientific, professional point of view:

1. Research is an integral part of professional health care today.  I accept that.  
2. The design of a particular trial - in this case to enlist women in labour after they have had an epidural, means that those who have spontaneous uncomplicated labours and births, or those who have elective surgical births, do not even think about the issues such as a decision to go to caesarean, or to continue in labour.
3. This research seeks to look at those for whom the intervention (intrapartum fetal blood sampling for lactate measurement as an assessment of fetal wellbeing, in the presence of non-reassuring fetal heart rate trace) could be critical in making a decision about the way a baby will be born.
4. The randomisation of all research subjects (labouring women who agree to being enlisted in the trial) into treatment or control groups seeks to prevent bias in decision-making. 
5. Research on human subjects can only be approved if the researchers are able to demonstrate the value of the information to the relevant discipline(s), and strategies that prevent harm (to the mother and/or baby, in this case). 
    
   Comments on this research from a woman's point of view:
6. If I agree to what you are asking, and my baby becomes distressed, do I have any say in what is done?  No - the decision is made according to the randomisation.
7. I feel exhausted after a couple of nights without sleep, and now I am being asked to make a decision about something which I have never thought about before.  How can I know what's going to be best for me and my baby?  That's why the research is being done.  Noone knows what is the best way to proceed.  
8. If I say no, I don't want to be in the research, and a decision needs to be made about whether or not to do a caesarean, how will that happen?   ...

I often argue that there is really only one real choice in childbirth: to do it yourself (Plan A), or to ask someone else to do it for you (Plan B). 

There are no guarantees in birth.  It's a journey, and decisions must be made as events unfold.

Midwives are bound, by definition, to promote normal birth.  A woman whose labour proceeds without complication is in the optimal position to give birth spontaneously, and with good outcomes for herself and her baby.   There will never be a safer or more appropriate way for these women to give birth, than to do it themselves.

Any intervention brings potential benefits and risks.  Augmentation of labour with oxytocic may, in many cases, bring about a more coordinated labour than what was being experienced before the augmentation, and a happy, healthy mother with a happy healthy baby in her arms a few hours later.  However, augmentation of labour can also lead to hyper-stimulation of the uterus, a distressed hypoxic baby, an emergency surgical birth, haemorrhage, ...

When a woman needs/chooses to move from Plan A to Plan B, the presence of a known and skilled midwife who can reassure her, and at times offer guidance, is essential.  Midwifery is not limited to promoting normal birth.  It's about being 'with woman' - a midwife with a woman, in a professional arrangement that enables sharing of information and support that is uniquely tailored to that woman and her baby.  The journey that leads to the birth is not predictable, but each woman's decision making is her own, without pressure or coercion.  This is, in my opinion, the pathway to safe birth through accessing appropriate interventions when indicated.

a pot of tea

my new enamel teapot

I am delighted with my new enamel teapot which my daughter found for me.

Today I would like to make a pot of tea, and talk with you about one of the challenging topics in maternity care: decision-making.

here are some of my questions:

• Who is the decider?
• What choices does a woman have?
• Are there limits to personal autonomy?
• How much information does a midwife (or obstetrician) need to give a woman when a decision needs to be made? 

You:  That's easy, it's my body, my baby, my birth.  I'm the decider.

Me:  Yes, but your decision can only be made from what is on offer at the time, can't it?

You:  What do you mean?

Me:  Let's take a very common decision that has big implications for subsequent events in birth, induction of labour.  Let's assume that you and your baby are well, that your pregnancy has continued a few days past the due date, and you are getting tired of being pregnant, of all the phone calls: "Are you still in one piece?" and waking up in the night with a half-full bladder, and half strength contractions that don't go anywhere.  Someone suggests that you ought to have induction of labour.  How would you decide?

You:  I would ask you as my midwife to tell me the pros and the cons, and I would make my mind up.

Me:  I need to declare a certain bias here.  As a midwife, by definition, I am committed to protecting and promoting the natural process unless there is a valid reason for interruption.  It sounds to me as though you are likely to come into spontaneous labour very soon, with all those runs of pre-labour contractions, and I see no clinical reason to induce labour at present, so I cannot encourage you to consider induction of labour.  I will list off some of the risks that are inherent in this procedure: a cascade of interventions, use of artificial stimulants that can lead to hyperstimulation of your uterus, and reduced blood flow to your baby; to increased perception of pain, and need for medical forms of pain management, possibly increasing the likelihood of assisted vaginal birth or even caesarean; separation of mother and baby at birth; difficulties with bonding and breastfeeding ... do you want more? 

You:  So, my decision is no.  I don't want induction of labour.

Me:  When I check you again in a week's time and you still haven't had your baby, I may want to encourage you to re-consider induction of labour.

You:  But you have convinced me that it's not a good idea.

Me:  That was last week.  We are now 10 days past your due date, and the guideline I am required to follow leads me to advise you to carefully consider induction of labour if you are past 40 weeks + 10 days.  There are pros and cons which you need to consider - some the same and some different from what we discussed last week -  as you make your decision. 

You:  I do want to have my baby, but I don't want to do anything that would hurt my baby.  How can I be sure?

Me:  There are no guarantees.  Each decision point is like a fork in the road: you must take one or the other, and there is no turning back.  I would encourage you to be reviewed at the hospital, where they can use ultrasound to check fluid levels around the baby, and the function of your baby's placenta, and do some monitoring.   If any of these tests result in non-reassuring features, there will be more 'encouragement' to proceed to the birth without delay, which could include surgical induction (breaking the waters - the membrane holding amniotic fluid around the baby), and possibly medical induction (IV syntocinon).  If all the tests are reassuring, I will encourage you to consider waiting for spontaneous onset of labour.

You:  So, although I get to make the decision, I need to trust the information and trust the person who is giving it to me.

Me:  That's right.


Another possible pathway in this scenario is that you, the woman, have made an effort to inform yourself, and decided that under no circumstances will you accept induction of labour.  You want to have your baby naturally, in your home.  You know your rights, and you decline any offer of investigations because you have no intention of being spooked by the medical system.  How much information am I required to give you?  Should I discuss all the possibilities, or should I give you my professional assessment based on my palpation of your abdomen, and my (limited) ability to auscultate and assess?

If there is an adverse outcome, am I culpable because I did not give you enough information?

Decision making is not a one-off choice; it constantly evolves as we move through a childbearing episode. The trump card that a woman has is 'Plan A' - her capacity to do it without assistance or education or coaching or therapies or any outside help. But it's the fine line between Plan A and Plan B, when intervention is likely to lead to better outcomes - that may call for expert and timely professional action.

My concern about naming a 'decider' relates to situations in which I have seen the professional treat decision making as a sort of lottery - "I can do this or I can do that - your choice" without giving sufficient information to help the person understand the choice they are making. It's an ongoing process that demands trust and reciprocity between the woman and the midwife.

Even if 95% of women who come into spontaneous labour could stay in 'Plan A', and go on to an unassisted birth, what happens to the 5%? How does a woman know? 

I hope you have enjoyed your cup of tea.
Your comments and further discussion are welcome.

the importance of trust

I (Joy Johnston, aka villagemidwife - see note at the end of this post) often say to women in my care, "I need to trust you, and you need to trust me."

This sounds reasonable to me, particularly within the context of primary maternity care that spans the pre-, intra- and postnatal periods.  While midwifery is not rocket science, the commitment a woman and her family make to a new baby is perhaps the most far-reaching investment they will ever make.  Trust is something to value: it's not lightly given; it's not easily won; and once won it can be lost.  I can not assume that a woman in my care is trusting me, and she may not know if I am trusting her.  This is the case especially when difficult decisions need to be made: when I am asking the woman to trust my professional judgment and advice in order to protect the wellbeing of the mother or child.

According to contemporary thinking, midwives and women engage in a partnership that is based on reciprocity and trust (a phrase coined, as far as I know, by sociologist-academic Karen Lane.)  It's a two-way relationship.  It's a relationship that builds over time, and is tried and potentially strengthened as each woman and her midwife navigate the unique terrain that each pregnancy-birthing episode offers.

Partnership should not be seen as an idealistic notion: the current internationally accepted definition of the midwife includes:

... The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.... (International Confederation of Midwives)

The stark reality of life is that some people find it difficult to trust anyone, while others give away their trust lightly to anyone who sounds as though they know what they are talking about.  Most people fit somewhere between the two extremes.  The definition of the midwife is looking at the big picture, while the experience many women have with a midwife or midwives may be far removed from any sense of working in partnership.  Similarly, midwives who provide continuity for their own caseload of women may find themselves in situations in which the sense of partnership is sub-optimal.

A young midwife told me she felt that a woman in her care does not trust her because she has had only a few years' midwifery experience.  A couple of comments that the woman made left the midwife wondering if she was able to continue as midwife. 

That discussion prompted me to think a lot about what it means to trust, and the importance of trust in midwifery - in the processes of decision-making that a midwife uses.

I do not, ultimately, trust birth.  Birth, like any other part of life, is able to be complicated by disease and corruption.  The midwife's role in maternity care is to firstly work in harmony with awesome natural processes, and secondly to recognise complication and intervene to prevent loss of life or damage. If I trusted birth there would be no need to work as a midwife.  I would simply accept 'Que sera sera' (what will be will be).

I have reflected on the many women for whom I have provided midwifery services over the years, and wondered if my statement, "I need to trust you, and you need to trust me" is true.

Many women have gone through the birthing process with minimal intrusion or action by me: my job is to be 'with woman': to watch and occasionally give support, then fill out the paperwork.  In almost all of these cases there has been, I believe, a working partnership based on reciprocity and trust.  The woman who is trusting her midwife is able to surrender to the work of her body when the time comes.

Some women have needed more than I have been able to give them in community based midwifery care, and we have transferred care to a hospital maternity service.  I expect that in some of these situations the woman's ability to trust me as her midwife, or to trust herself as the birth-giver, has been less than optimal.  In some, my ability to trust myself as midwife, or the woman as the birth-giver has been compromised.  At times I may have been too weary, or emotionally drained, or fearful, or ...




Spring 2013

Tomorrow is the official start of Spring in the southern hemisphere.  It's exciting to see the tender young leaves on deciduous trees, and flowers on the fruit trees.

Spring 2013: Bonsai Japanese Maple and azalea

The signs of new life are within the natural processes that offer endless wonder and thrill to those who are ready to see.

Midwifery has taught me to respect and work in harmony with the natural processes as much as is possible.

These little bonsai trees have been in my care for several years. 






postscript...
Don't believe everything you see on the internet!
I began today with "I (Joy Johnston, aka villagemidwife...)" because, for some reason Blogger (the program I use to write this and other blogs) thinks I have changed my name. Probably my own fault - I told my sister I would help her get started writing a blog, and somehow Blogger now thinks that I am my sister - Barbara Clark. Everything I have written is now attributed to her, so I need to either find out how to get into my blogger profile and change my 'name', or get used to writing under a pseudonym. I have followed the instructions to go to Blogger profile, but keep getting a message "oops that didn't go well"!

I'm just venting, but if you have a suggestion for fixing it, I'm keen to get it sorted out! XXjoy

pps
Thanks Paul for fixing it.

conversations about breastfeeding

Two recent online Conversation articles, 'Breastfeeding improves IQ – now have we got your attention?' (Hayley Dickinson, 1 August 2013), and ‘Nipple Nazis’ vs overwrought mums: the breastfeeding debate' (Katie Attwell, 9 August 2013) have prompted a great deal of attention and sharing of strong opinions. 

I have read many of these comments with interest; and am surprised at the lack of comment from midwives.  We are the one profession that has more ability to protect, promote and support breastfeeding than any other - simply because we are with woman at the incredibly critical times for breastfeeding: the birth, the hours after the birth, and the early days.  If breastfeeding works for both mother and baby in the first week of life, most of the problems have been sorted.

If, on the other hand, after a couple of sleepless nights and days, both mother and baby exhausted and crying, the mother's nipples bleeding and incredibly painful, and someone tells her that her baby should have some formula because her baby will lose too much weight, and she should express her milk until her nipples heal  ...  It's all uphill, isn't it?

These discussions - they are all there for you to read, and come to your own conclusions.  I will make a few observations.

Having read the IQ article, and a quick succession of responses that questioned everything from the validity of the research conclusions, to the value of breastfeeding, I wrote:

There are many compelling reasons today for health professionals to promote, protect and support breastfeeding. We have a duty of care to do no harm. Promoting breastfeeding is, to my mind, a no-brainer. (and I don't really care if my IQ would have been higher if my mother had breastfed me longer)

Almost everyone in our society accepts that 'breast is best' for babies and their mothers.
The dilemma that midwives face in the brief period of birth and postnatal care in which we are directly responsible for mother and baby is that breastfeeding can be easily disrupted. Midwives, more than any other group of health professionals, can work with mothers and babies in through those early days, and guide and encourage mothers when the going gets tough.

When hospital maternity units work towards becoming 'Baby Friendly', implementing the BFHI global criteria, one of the most challenging steps is to demonstrate that a sufficient proportion of healthy breastfed babies were exclusively breast fed or breast milk fed from birth to discharge from the unit.

Mother-baby pairs who have used formula supplements, or milk from another mother, can be supported in optimising their reliance on mother's own milk, at the same time as being realistic about their particular situation.

Breastfeeding is one of life's big challenges. If it weren't so good, it probably would not be so contested.

 Many of those who posted comments supportive of breastfeeding were challenged by a doctor who claimed, repeatedly, that there was little difference between the health of breastfed and formula fed babies in our (wealthy) society, which has clean water and enough money to purchase formula.  For example:

why are you so resistant to discussion of what the data actually show about the effects of feeding type in our society? Is it because it threatens your ideology? And what, exactly, do you consider the ''risks of formula'' to be (in our wealthy society)?
Families should be encouraged to choose breast feeding and, if they choose it, the mother should be assisted to make it work - so long as the harms of continuing do not become greater than the benefts.

The self-appointed jury panel in this case included mothers, retired persons, university lecturers, a public hospital clinician, a PhD candidate, and others.  The strength and frequency of comment from one leader set the rules.  Nothing was protected, other than mothers who did not breastfeed.  How dare anyone make a connection between the harmful effects of smoking, and the (supposed) harmful effects of not breastfeeding (in a wealthy society)!


A point that I want to record in this context is that no matter how 'wealthy' our society is, no matter how difficult it is to demonstrate through research an advantage for a breastfed child over the non-breastfed child, breast feeding is the biological norm.  No technology or man-made substance has, or will, be developed to replace that norm.  Anything that is developed as a replacement for a mother's own milk, delivered directly to her suckling infant, can only be an inferior substance.

Another point that is clear to me is that, if it is truly dangerous (as we know it is) for a baby in the developing world to be denied his or her mother's milk, the onus is on us, the developed/wealthy world, to set the standard.  Statements that trivialise the life-giving properties of breastmilk in the wealthy world have overtones of colonialism and racism.  Australia is not uniformly wealthy.  Disadvantaged groups of people in Australia today have lower rates of breastfeeding than those in the better postcodes, and poorer health outcomes for babies as well as other age groups.

Here's a true story: A woman who came to Australia with her husband on a 457 work visa told me, with tears, of the birth of their first baby.  He had been born in a hospital in India, was healthy and hungry, and she was shown how to give him formula in a bottle.  She did not receive assistance with breastfeeding, which she tried, unsuccessfully, to initiate.  By the time he was three weeks of age he was refusing the breast, and essentially fully bottle fed.  He died at one month of age.  She asked me to help her give birth to her new baby, and breastfeed him - which she did.  



This brings me to the second article, headed 'Nipple Nazis'.

Again the correlation between social attitudes towards smoking, and not breastfeeding, was drawn.  Again, the cry from the stalls: how dare you!  That's not allowed!

It is true that the quantum of harm is greater with smoking than with not breast feeding.  But the harm of smoking is (usually) to the adult who smokes.  Even if there is only a small amount of harm with not breastfeeding - especially for premature babies who develop necrotising enterocolitis (NEC) and need surgery to remove large portions of dead bowel tissue, and for babies in poorer communities, and for those who receive contaminated feeds when someone in the big business making the formula makes a mistake ...  surely the onus is on the midwives, and the health system, to do all it can to promote, protect and support breastfeeding.  The baby is the innocent recipient of whatever the mother chooses to feed him or her.  I reject any notion that a wealthy society can accept a standard that would put poorer people groups at an increased risk of harm. 

So, dear reader, why are we looking at offensive headings such as 'Nipple Nazis', when considering breastfeeding?  Who is a 'Nipple Nazi'?  The term has been used in maternity and child health services for the midwives, nurses, lactation consultants, and doctors, who seek to promote, protect and support breastfeeding. How is it that the thought police have not stamped out that outrageous and offensive suggestion?  What is it about the work that we do that has ANY relation at all to that horrible and inhumane blot on history?

It seems to me that while our society - at least that section of it who reads the health section of The Conversation - is very protective of the feelings of any mother who finds herself unable to, or chooses to not breast feed for whatever reason - we don't see anything wrong with the implied derision of those who make it their business to work in harmony with the natural processes in breastfeeding.

transferring to hospital

I am reflecting on a few recent situations in which I have made the 'call' that we need to go to hospital.  In my mind there has been no doubt. 

It's fairly clear to me, that when a woman and baby are strong and well, home is ideal.

But ...

when the mother is not well, physically or emotionally, it's not good at home.  Even a mother who has no continuous support in her home - should she be left alone a mere 3 or 4 hours after the birth, when I pack up my gear and go home?


Midwives have a set of guidelines, published by our College (ACM), to set down systems for decision-making about consultation and referral (see previous post).  They do not actually address homebirth, but are a list of the conditions in which a midwife would expect to work collaboratively with an obstetrician or an obstetric unit in providing maternity care - meaning that the woman is in hospital for the birth and any other continuous acute care. 

The ACM Guidelines list hundreds of 'indications' for consultation (with) and referral (to) specialist obstetric or newborn or other medical services.


Rather than focus on 'indications' or medical/obstetric conditions, I prefer to turn the coin to the other side, and ask the questions:
"Is the mother well?",
"Is the baby well?"

If the answer to each is "yes", there is no reason to intervene prior to the onset of labour, so we wait for labour to establish spontaneously.  This is the only woman who, in my opinion, is fit to proceed with home birth. 

If the answer to either is "no", the hospital probably has real advantages.  Homebirth requires strength, and intentionality about wellness.


Many women who plan homebirth have serious concerns about what might happen in hospital.  They know about continuous monitoring in labour, and scheduled vaginal exams, and narcotic analgesia being offered at the time when they are vulnerable to suggestion.  They know about protocols for normal progress; about high rates of inductions and augmentations, and all-time high rates of caesarean births.  They know about babies's cords being cut, and babies being separated from their mothers. 

Yes.

When I say to a woman, who has gone to considerable expense and trouble to plan homebirth, that I want her to go to hospital to give birth to her baby, I know that she may experience difficulties with the system.  Hospitals are not committed to protecting, promoting and supporting natural physiological processes in birthing.  Hospitals are concerned about patient/staff ratios, availability of emergency services, and a hundred and one issues that make hospitals relatively safe places for the majority of patients and staff and visitors.


Transferring care from planned homebirth with a humble midwife, to a hospital with 'teams' of midwives, nurses, and a heirachy of doctors from the new Resident to the obstetric Consultant, can be a daunting process.  I will recommend that transfer if I believe the woman's and her baby's needs are likely to be better served in hospital than at home.   The best is all that I want.


The person who owns the natural processes in birthing (and nurturing of the baby) is the mother.  She is the only one who can give permission for a staff member, or a privately employed midwife, to take her pulse, or listen to her baby's heart beat, or assess her cervical dilation and the station of her baby's presenting part.  The mother owns her body, regardless of where she is intending to give birth.

This ongoing process of decision-making is guided in my practice, not by a 84-page spiral bound guidance manual, but by the two simple questions:
"Is the mother well?",
"Is the baby well?"

What should I say to the students?

Over the years I have spoken to each new intake of midwifery students at Deakin University in Burwood about the midwife in private practice.   I feel privileged to be invited to give this lecture.  I stand before a room full of fresh and eager young women (usually), who want to become midwives.

Yesterday I asked Martina, a young midwife who asked me to mentor her in homebirth and private practice, who had been in that same lecture room a few years ago, what she thought I should focus on.  She was quick to reply: "normal unmedicated birth, physiological third stage, leaving the cord un-clamped - these are basic midwifery, but students may rarely experience them as they complete the practical requirements of the course."  

Yes Martina, I think you are right.  This truly is basic midwifery.  Students may find that their courses emphasise so strongly the complications and illnesses that can devastate a woman in pregnancy and birth, yet undervalue the body of scientific and clinical knowledge around protecting spontaneous normal birth, breastfeeding, and mothering.  Teachers may take it for granted that students will learn how to be 'with woman' when the woman is strong and well and intentional about working with her own body's natural power in childbirth, while they prepare the students for obstetric emergencies, neonatal and maternal resuscitation, and other potentially life-saving measures.

Working in harmony with natural processes in birthing is indeed a wonderful thing.  Midwives sometimes refer to ourselves as 'oxytocin junkies', and anyone who has spent time repeatedly in the zone of healthy spontaneous birthing will know what I mean by that phrase.  We come away from birth with a renewed sense of awe and wonder each time, and we never exhaust its potential. 

Yet I need to balance that fact against the reality that a midwife's place in birth is not a passive one.  If there were no serious professional role for the midwife in a 'natural', spontaneous birth, it would be reasonable for women to be attended by their sisters, friends, or a sub-professional group of birth attendants.  A midwife attending planned homebirth is watching the woman's response to her body's intuitive work, watching the baby's response to the labour, and assessing progress over time.  While an inexperienced midwife might become frustrated when progress is poor, the seasoned midwife seeks an understanding, weighing up what she observes against her knowledge of normal. 


Midwives entering the profession today face a distinct set of challenges:

• Basic midwifery

Mainstream maternity service providers in cities like Melbourne - the employers of the majority of midwives - are pretty good at dealing with the complicated aspects of birth.  They have educational and research arms that impress colleagues around the world.  But, in general, they do not do a good job at 'basic midwifery'.  There are few strategies that protect wellness.  The rates of various interventions, from induction of labour for non-medical reasons, to rates of caesarean, or rates of serious perineal trauma, or rates of admission of babies to neonatal intensive or special care nurseries - all performance indicators - could be improved. 

It is the job of midwives to insist on 'basic midwifery' improvements to the care of women.  We can't expect the obstetric services director - a medically trained specialist in surgery - to champion midwifery which is outside the scope of an obstetrician's expertise.  (Mind you, some obstetricians do understand, and champion, the work of the midwife) 

• increasing medicalisation of life events

This challenge point is linked to the previous one.  Our society has, to a great extent, lost its knowledge of and trust in wellness.   There is a point at which additional medical interventions fail to improve outcomes, and possibly increase the risk of poor outcomes.  Midwives today carry knowledge of protecting and supporting spontaneous birthing processes.  We must value our knowledge and skill.

• increasing bureaucratic red tape

Midwives have lobbied successive governments over many years for equity and fairness in access to public funding for midwifery services.  This challenge continues, even though we are now able to provide Medicare rebates for some midwifery services, and other extensions to practice such as requesting tests and investigations, and prescribing some medications.  There are many bureaucratic requirements attached to these new professional benefits, and only time will tell if we meet the expected standard.


**********
Private midwifery practice in Australia today focuses on homebirth.  Homebirth offers midwives an opportunity to experience 'basic midwifery', because the only way to access the obstetric component of maternity care is to transfer care to a hospital.  

Over the years of my midwifery practice I have become more and more committed to the protection, support, and promotion of the spontaneous natural processes in pregnancy, birth, and breastfeeding, and this has been predominantly through planned homebirth.   It makes sense.  It leads to better outcomes for mother and baby.  Over the years of my midwifery practice I have also valued greatly the appropriate use of medical and surgical interventions.  In situations where the natural process is not likely to lead to good outcomes, we have excellent processes for 'Plan B'.  This is good.

I am happy to encourage the new group of midwifery students to give all they can to this profession, and I believe they may discover that midwifery will satisfy and challenge the most critical mind.

What do we mean by 'professional advice'?

The Australian College of Midwives (ACM) has invited comment and response on its draft position statement on "Midwives working with women who seek care outside of professional advice"

I am working on a response, and would love to hear from other members who have used Appendix A in the past, and who are now including Appendix B in your paperwork (see previous post). 

I have headed this post with the question, "What do we mean by professional advice?"  There seems to me to be an assumption in the draft document that 'professional advice' is a uniform thing. I don't think it is. eg (Draft) Principle "5. Midwives should attempt to understand why women are seeking care outside of professional advice."  (Good idea, but hardly a principle to guide action.  I'll have to come back to that later.)

Sometimes the midwife disagrees with the advice from another professional, while agreeing with what the woman wants.  So is the midwife's advice professional advice?  

I see quite a few women who plan homebirth, for whom I think homebirth is a very reasonable choice, but the professional (obstetric) advice they receive is that they must be cared for in hospital for labour and birth. 

An example would be a woman who has indications from the guidelines, such as having her 6th+ baby, or a woman who has had a previous caesarean, and possibly another indication such as a post partum haemorrhage (pph) at one of her previous births. The Guidelines don't comment on planned place of birth, but out here in the real world, the only option for many women to access primary maternity care from a known midwife - best evidence based care according to many - is to ask the local midwife to attend them for planned homebirth.

In this scenario, the professional advice from me, the midwife, if I had meet this woman in early pregnancy, is that, provided there are no valid reasons to interfere with, or interrupt the spontaneous natural processes in pregnancy, birth, and thereafter, a woman is protecting herself and her baby by seeking out care that protects normal physiological birthing.  The previous caesarean, the previous pph, and the grand multiparity, although each significant factors in planning maternity care, each point to the advisability of spontaneous birthing: spontaneous onset of labour, spontaneous progress in labour, and spontaneous completion of the birthing process.  The professional care provider who is most likely to be expert at providing this package of care is the midwife who has a primary care caseload, regardless of the planned setting for birth (hospital/home).

This same woman may have initially booked with an obstetric managed service, planning birth in a private hospital or a public hospital.  As the chosen model of care becomes apparent to the woman, she may "seek care outside professional advice", and find a midwife who is willing to work in harmony with her natural processes, unless there is a valid reason to refer her for obstetric intervention.  Once again, the midwife is not being asked to do anything outside the usual scope of  a midwife's practice.  The midwife who agrees to provide care for this woman is not stepping outside professional boundaries in any way, even though she is providing care that is quite different from the standard in the mainstream.

Knowing the boundaries of midwifery practice is something that seems quite obvious to me, yet I know that some of my colleagues do not understand these boundaries as I do.

A woman who is planning homebirth, having had a caesarean for her previous birth, asked me if I am supporting her plan.  

I responded that I don't feel that I must support her plan. My duty of care in any birth is to act to protect the safety and wellbeing of the mother and her child.  If there is no reason to go to hospital, homebirth becomes the obvious choice at the time.  At present, prior to onset of labour, the plan is quite reasonable, and there is a good chance that it will continue as a reasonable choice.  I provide primary care, with a planned option for transfer to hospital if needed.  I cannot tie myself in to any commitment of setting for birth.  That is of secondary importance.


It's dinner time now.  Next time I get a chance to write I want to explore the principles that underpin decision making by midwives when women "seek care outside of professional advice"

documenting a 'Record of Understanding'

The National Midwifery Guidelines for Consultation and Referral (ACM Guidelines) are an essential tool for midwifery practice.  They set out, in a systematic way, the situations in which a midwife will initiate a conversation, or a consultation, or a referral of a woman receiving primary maternity care into a specialist level of care.

The third edition (2013) has recently been published (pictured here).  To order a copy, click here.

A new appendix to the new edition is called a 'Record of Understanding', to be used when a woman chooses to act outside the Guidelines or against the advice of her midwife. As I read through the Record of Understanding for the first time, my thoughts went to situations in which I might consider using this tool.  Recent situations in which I have prepared a written record of discussions between myself and a client, when the woman has chosen a pathway that may be at odds with usual professional advice include women who are planning homebirth after a previous caesarean, or women who have had a large number of children.

When using the new Guidelines' Appendix B: Record of Understanding, I will be required to ask the woman to answer, in writing, a series of questions:

1. What information, evidence, or concerns have you considered in your decision to decline the hospital's advice to have an elective caesarean?
2. What questions/ concerns do you have?
3. What is your understanding of the answers you received to your questions or concerns?
4. Did you discuss your maternity care option(s) with your midwife and/or other care providers? Why/why not?
5. What is your understanding of those decisions?
6. What questions do you have about your midwife's recommendations to you?

Decision-making in maternity care is always complex, and ongoing until the completion of the episode of care.  For example, a woman who finds that her baby is presenting as breech near Term is confronted with a whole series of big and small decisions: each one either opening or closing potential pathways.  The one basic choice that a woman has any degree of control over concerns the way the baby will be born: either spontaneously, or with medical management.  My role, as the woman's midwife, is to go with her and provide accurate information as she considers her options.

It seems to me that this 'Record of Understanding' has taken professional documentation to a new level, and this disturbs me.  The matter that I take issue with is the expectation, in the Guidelines, that a woman will provide written answers to these questions.  The unmentioned assumption seems to be that this documentation will be produced in the event of a coronial inquest or other professional inquiry.   I have a duty of care to the woman, and this includes supporting informed decision making.  The woman has no reciprocal duty to provide me with reasons for her choices.  The Australian Medical Association acknowledges this fact in its statement on maternal decision making.  A woman may have her own reasons for declining a recommended course of action in her maternity care, and should not be coerced or placed under pressure to explain that reason. 

The potential value of a written 'Record of Understanding' as it is described in the new Guidelines is that midwives and women will be forced to confront difficult decisions in a way that clearly has not happened in some of the well-known recent cases that have been reported publicly. 

home midwifery in the (legal) spotlight

Melbourne in mid-winter is grey and damp and cold.  The tall concrete buildings block the weak, angled sunlight.

This week I have sat for two days in a tired meeting room in a city hotel that has passed its prime:  not old enough to be interesting; not fresh enough to be attractive.  The plate glass windows in the conference room revealed nothing more than the boarded up windows of a derelict multi-storey building on the other side of Little Collins Street.

The conference provided opportunities for comment on homebirth, and particularly homebirths that have gone wrong.  Lawyers presented papers on topics such as 'Managing the Risks inherent in Women's Choice in Obstetric Care', and 'Practical Obstetric Risk Management: defending your care'.  It sounded simple.    

Human rights in the childbirth process were eloquently discussed by other lawyers who drew from both their knowledge of the law and their personal experience.

'Open Disclosure' was discussed by two speakers, and I concluded that, in order to 'defend' oneself against potential legal or disciplinary action, an adverse event in a hospital is met with what seems to me to be a charade called 'open disclosure' that is not very open, and that doesn't disclose much.  Don't be too literal about the meaning of 'open' or the meaning of 'disclosure'.  A curious conundrum! 

A Coroner delivered, with barely an inflection in his voice, a keynote address on 'Lessons to be learned from the Home Birth Cases in Vic and SA.'  In this presentation, seven cases were reviewed, the common thread being that they had been planned homebirths, with either a registered midwife or a previously registered midwife in attendance.  When considering risk factors such as previous big babies, previous caesarean births, and a twin pregnancy, the conclusion was that most of these cases should not have been planned homebirths; that the midwife had a duty of care to transfer care to an obstetric unit.

In 6/7 cases, the baby deaths were declared by the Coroner to have been potentially preventable.  The Coroner does not attempt to apportion blame, merely to discover the facts, and to make recommendations.  The Coroner's filtering of the information presented at the inquest failed to notice any possible reason that a woman might have had for trying to avoid a medically managed birth; any mention of her desire to hold her baby to her breast within moments of birth; or even any recommendations that maternity hospitals provide pathways for women who want to have a known and trusted midwife providing continuity of care within the hospital.

I want to be perfectly clear here: I cannot speak for either the mothers or the midwives.  I am merely an onlooker, and I have read the Coroner's findings that have been put in the public domain.  I am also shocked at the tragedies that precipitated these cases into the Coroner's court.

The points made by those who spoke about women's rights were either ignored or not understood by those who spoke from the professional duty of care perspective.   The fact is that pregnant women have personal autonomy; that decisions do not have to be approved by, or even understood by, those who attend for birth.

***
The presentation following that by the Coroner was from the Victorian Perinatal Data Collection Unit.  I noted down a point that was briefly made, without any further comment, that, of the approximately 900 perinatal deaths in this State annually, 63% are found to have potentially avoidable factors.

The loss of a baby's life is, thankfully, uncommon in our world.  Yet it is one of the most heart-wrenching experiences imaginable.  Whether the death is linked to homebirth or not, everyone needs to take what lessons are available from the facts of the case.  I ask myself, what lessons have I taken from these seven tragic cases?

***
I believe the huge challenge that lies ahead for midwives and the whole maternity world is to find a balance between providing advice and care that protects the wellbeing and safety of the mother and child, while at the same time respecting the woman's decisions and choices.  This is not going to be easy.  It is an ongoing process, and demands trust and commitment between the midwife-woman, and the midwife-obstetric/hospital system. The paternalistic dictatorial style of hospitals has, in many instances, demanded submission to hospital policies and processes. This needs to change. The misunderstanding of risk in maternity care, as was clearly demonstrated in the cases reviewed, will likely continue to open the door for self-educated, internet-researched women to make the choice of birthing without a midwife in attendance.  This needs to change, to include intelligent dialogue and planning that is specific to the individual woman/pregnancy.  The misunderstood partnership between woman and midwife, as was also clearly demonstrated in the cases reviewed, may from time to time place unreasonable weight on the woman's choice, and devalue the midwife's skill and knowledge.  This also needs to change, enabling midwives to practise more autonomously and accountably.

Women who engage a midwife to attend them at home for birth, having an identified risk profile, such as a previous caesarean, a previous post partum haemorrhage, or multiparity, or any of the other features that are classified as risk - these women, and these midwives, need support rather than being driven underground.  The midwife who is ready to go with her client to the hospital, and continue supporting the woman's informed decision-making process within the hospital, will accompany that woman to the best birth that she can have.

And, we only want the best.



Your comments are welcome.

ps - this link to the story of a maternal death is, sadly, what we will see more of if we don't maintain a midwifery profession that is 'with woman'.

more about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.


Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:

• spontaneous onset of labour, and
• spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.

Midwives and Medicare

For the past 2+ years I have been able to give clients Medicare rebates for antenatal and postnatal midwifery services.  I am looking forward to having a prescriber number in the near future.  This is part of the government's reform measure, More Choice for Women - Expanding Medicare Support for Midwives, introduced in November 2010.

The basic requirement that I must fulfill before a client can claim a Medicare rebate is that there is a collaborative arrangement in place: a letter or statement, signed by a suitable doctor.  As I have no 'agreement' to meet this need, I must seek out an arrangement for each woman.

There are a couple of doctors who have 'collaborated' with me on more than one occasion.  Most of the time it's a one-off.  Most of my clients live within a 1-hour drive radius of my home.  That's a huge metropolitan area, and some out in nearby towns.  In that area there are thousands of doctors.  Very few have met me.  Some have refused to collaborate, saying that they would thereby be liable for anything I did.

Several months ago a woman who has had three previous uncomplicated births in hospital contacted me.  She wants to have her next baby at home.  I explained Medicare and collaboration, and emailed a letter describing the need for a collaborative arrangement with a doctor, to her.  She took the letter to her local doctor.  In her own words, 

I am just writing to advise you of the trouble that I am having getting a GP to write a referral to your services.

After contracting you to get a letter for the referring doctor, I went to my local GP for confirmation of my pregnancy. They were happy to send me for tests and ultrasounds but when I explained that I didn't want to birth my fourth child in a hospital, but rather have midwifery care and plan a homebirth I was met with an almost hostile response. This GP who had seen me throughout 2 of my previous pregnancys pointed out that he would not write me a referral due to the use of the word "collaborative" . He failed to understand where his duty of care ended and the midwife's began. I tried to explain that I didn't need to see him throughout the pregnancy and that I only needed initial blood tests and this letter but he would not listen. He continued to explain that he would not put his reputation on the line for the sake of my Medicare rebate!

Feeling disheartened I searched for a doctor who had a similar outlook on the way birth should be. I felt positive that this woman would give me the referral I needed.

This time the doctor endorsed homebirth, was happy for me to see a private midwife and ordered the appropriate tests to be sent to my chosen care provider but once more would not write the letter. When I asked for an explanation once again there was talk of scaremongering from insurance companies who had advised her that if she wrote this letter and something went wrong at the birth, even if she was 200ks away she would be liable.

I find it extremely frustrating and disheartening that in order to get the birth that is right for me and my family, I am being financially penalised because my doctors of choice don't fully understand what is required of them.

With this woman's permission, I forwarded her letter to the Health Minister, Hon Tan Plibersek, MP.  The letter I have received from the Minister's office, in reply, gives me hope that the wrinkles may be ironed out.

Excerpts from the Minister's letter, dated 27 May 2013:

The More Choice for Women - Expanding Medicare Support for Midwives, introduced on 1 November 2010, expanded the Medicare arrangements to include midwifery care.  This was in recognition that women should have a range of birthing options available to them and be supported in their choice of practitioner.

Recognising midwives as primary maternity care providers under Medicare was also intended to assist in improving service delivery by enabling better use of the existing workforce ...

 ...

Since the measure was introduced, midwives have reported ongoing difficulties with establishing collaborative arrangements with individual medical practitioners.  This has hindered their ability to provide services under Medicare.

In recognition of this, at the Standing Committee on Health (SCoH) meeting of 10 August 2012, the Minister for Health ... agreed to vary the legislation on collaborative arrangements, to enable agreements between midwives and hospitals and health services.

The Department is currently in discussion with the medical, midwifery  and consumer groups to discuss the detail of the proposed changes.

The Minister recognises that the lack of hospital clinical privileging and admitting and practice rights is a fundamental issue for midwives.  This prevents privately practising eligible midwives from working to their full scope of practice, undermines continuity of care and reduces choice for women.  

As such, the Minister has asked Health Ministers to finalise consistent approaches to credentialing for midwives in public hospitals in line with States' and Territories' commitments under the Maternity Services Plan.

The Minister is committed to supporting increased participation by eligible midwives in the Medicare arrangements and to the proposed changes to the collaborative arrangement requirements that would facilitate this.

Thankyou for raising this important issue.  I trust this information is of assistance to you.
Yours sincerely
[&c]

My comment:
A letter like this to an ordinary inquirer like me does not give any new information.  However, I feel encouraged by the tone of the latter part of the letter.

Specifically:

• that midwives need practising rights in public hospitals 
• that the Minister has put pressure on the State and Territory Health Ministers, to get a move on 
• that public hospitals will be expected to support collaborative arrangements with midwives
• that the Minister is committed to this reform measure.

Readers may also share critical thought about the More Choice for Women ... reform measure, such as:

•  the inequity of signed collaborative arrangements, in that the midwife is required to obtain the arrangement, but no doctor is obliged to agree or to sign anything.  The loser, of course, is the woman.  AND the midwife looks pretty useless.
• the lengthy delays (such as since SCoH in August 2012) in making even the promised changes to the Collaboration Determination
• the obstruction by public hospitals throughout the country, with the exception of a few in S-E Qld, to any progress on practising rights for midwives
• with the above point in mind, surely it's unlikely that these hospitals will agree to collaborate with midwives, even after the legislation has been varied as promised 
• and finally, with an election, and probably a change of government in September, will we see ongoing support for More Choice for Women - Expanding Medicare Support for Midwives?

Your comments are welcome