Is midwifery practice controlled by the insurer?

what the stork brought!

Is midwifery practice controlled by the insurer?



If the answer is 'yes', is that a problem?








Recently I wrote about indemnity insurance: who benefits?
The insurance company is a business that can only exist if it protects the interests of its shareholders and employees.  In that article I wrote:

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defense schemes which cost more than some midwives earn.

Today I would like to focus on a case study, published recently by an insurer of midwives, guiding midwives in the potentially difficult scenario of the client who refuses to follow a midwife's advice.


The case study, titled Terminating the midwife/client relationship (April 2014) suggests that midwives can be insured only if there is zero tolerance for departure, by the midwife or the client, from a very narrow compliance pathway.  That in a situation where the client declines advice from the midwife, the midwife will jump ship - terminate the relationship she has with that client.

I think the advice in this case study is wrong, and MIGA needs to withdraw it.

Many readers will know MIGA is the insurance company that provides professional indemnity insurance (PII) for independent midwives, underwritten by Treasury. It's the only option for midwives who have hospital visiting access.  That's a monopoly.

The big issue of concern in this case study is: "The client signed a service agreement with the midwife agreeing to comply with the requests and recommendations of the midwife."
 
???
 
agreeing [UP FRONT] to comply ... !

Is that reasonable?

What's the point of rhetoric like 'informed decision making' in that sort of relationship?
 
There is no legal obligation that I know of (outside of this sort of service agreement that has been made by the risk management/legal team of the insurer) to ask a woman to sign over her rights, particularly the right of refusal, which is a human right. 

Midwives practising privately, who are planning to attend homebirth, are required by NMBA to have a statement signed by the client that she understands there is no PII for homebirth with a midwife.

The relevant provisions of the National Law and the Board’s requirements are:

Section 284(1)(b) informed consent has been given by the woman in relation to whom the midwife is practising private midwifery

Informed consent must be given by the woman who is the client of the midwife who is in private practice.  Informed consent is defined specifically as written consent given by a woman after she has been given a written statement by a midwife that includes:

·        a statement that appropriate PII arrangements will not be in force in relation to the midwife’s practice of private midwifery in attending a homebirth, and

·        any other information required by the Board.

  [Guidelines for professional indemnity insurance arrangements for midwives]

The case study is based on a scenario in which the midwife believes her ability to care safely for the woman and her baby has been irretrievably compromised, because the woman, now ten days past her 'due date', declines consultation with and review by a doctor/ hospital antenatal clinic.

I want to express surprise at this scenario, and I realise that the MIGA team who prepared this case study probably sent it to one of the midwives insured with them for checking and review.  That thought only adds to my sense of concern!  The scenario presented is hardly a decision point that could be the cause of irretrievable compromise to the relationship.  Most privately practising midwives would have experienced this scenario many times.  The clinical scenario described in the case study is certainly a point for discussion and accurate documentation, but in my mind it would be unthinkable to abandon the woman at that point, on such flimsy grounds.

The case study mentions the ACM guidelines which list post-term pregnancy (7.1.22)  as >42 weeks (not 41+3), category B - 'consult' - which may be with another midwife. The guidelines have a guiding principle of informed choice (3.2.2), stating that "The woman is free to accept of reject any procedure or advice".

Notions of a woman's right to decline, and to make informed decisions in any professional care situations are well established.  The midwifery profession cannot provide safe professional services for women if such blatant and uninformed control is delegated to the insurer, whose primary interest may not be the safety and wellbeing of mother and child.  The scenario described in this particular case study could very easily leave a woman feeling that she has no option than to 'free birth', without any professional attendance.
 

supervision, part 2

Beautiful Brisbane, the city of my birth

continuing from yesterday's post, ...

[I have posted these comments on a social media site that might not be accessed by many of my readers, so have copied and expanded it here.]

A blog post by UK midwife-author-teacher Sarah Wickham, questioning the Australian regulation of midwives, provides comment on the UK model of supervision of midwives.

 
I share Sarah Wickham's concern, when midwives are subjected to "vexatious reporting and persecution in a number of ways, simply for supporting women’s choices."
 
Without pointing the finger at any person, and I wasn't at the recent homebirth conference in Brisbane, I think it's likely that Sarah has heard only a fraction of the story.  In my opinion there have been too many cases recently, some on public record, in which midwives have hidden behind a notion of the woman's choice, when in fact there was no discussion of escalation of care and appropriate intervention.  Midwifery partnership can only be achieved when the conversation between the midwife and the woman is ongoing, and informed *decisions* are made rather than choices.

An effective program of professional supervision of midwives could, theoretically at least, support the midwife in real time whose client is making an informed decision that does not follow usual professional advice.  This would apply whether the midwife was in private practice or employed in a hospital or other birthing facility.   The UK model of supervision of midwives is for all midwives.
 
A midwife can't afford to be a true believer, or to 'trust birth' in any idealistic way, even though we act to promote, protect and support normal birth and the physiological adaptation of the newborn to life out of the womb.
 
The setting/place of birth (home/hospital) has become an obstacle in this country to good midwifery practice, because privately practising midwives are restricted to homebirth.  The exclusion of PP midwives from mainstream hospital is not in the interests of wellbeing and safety of mother and baby, and probably contributes in complex (and unaccountable) ways to some adverse outcomes. The midwife's duty of care includes what we do in emergencies, and accessing medical (ie hospital) help in a timely manner. 
 
The introduction of the wonderful www, and social media, and digital communication ... has had a profound impact on some women's access to information about birth, and their choices. Anyone who remembers 20 years ago, when homes didn't have internet access, and mobile phones were great big clunky devices, will know what I mean. Now women tell me they have 'researched' their choices, as though it's done and dusted. The rise and rise of freebirthing is very much an internet phenomenon.
 
Please keep the conversation happening.

supervision?

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

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

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

 


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

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

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

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

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

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


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

 

indemnity insurance: who benefits?

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

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

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

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

An eye for an eye!

The matter is placed in the hands of lawyers.

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

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

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

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

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


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

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

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

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

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

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defence schemes which cost more than some midwives earn.


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

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

That's the top end of the scale. 

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

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

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

It's a self-defeating cycle.

costs progressively rise - 

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

reduced access to private midwifery services for women

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

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

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

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

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

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

Back to the initial question:
Who benefits? 

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

Who benefits?

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

someone else!



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

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

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

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

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

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

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

A midwifery half-truth: doing nothing

A couple of weeks ago I wrote about the myth of choice.

The midwife 'doing nothing' is a similarly misleading notion: not quite a myth, but definitely a half-truth. It's only one side of the coin.  It sets a potentially dangerous precedent, devaluing the expert professional activity of the midwife, being actively 'with woman' in the interest of safety and wellbeing of mother and child, to the point we have today: an epidemic of unattended births ("free births") in the community.  The rationale is like this: "If the midwife does nothing, then we don't need a midwife."



Today I want to critically explore what midwives are doing when we may appear to be 'doing nothing': what happens when I spend time on the couch in an almost dark room in the wee hours, with my eyes closed; what I am doing when I take up some simple knitting or crochet project as I wait for a baby to be born.

Let's consider the pregnant_woman/mother+baby to be central in this discussion.  What does that woman hear from her own intuition, from midwives, from other professional maternity care providers, from family, and from other sources?

There are many voices, and the value that the woman places on each of those messages varies from one to another.  Social media has, for at least the past decade, played an increasingly powerful role, as indeed this blog site offers information and discussion.  The current generation of mothers is the generation who uses online searches to 'research' a question, who follows multiple social media sites, who is prepared to ask questions.  Whereas previous generations had the 'disease of the month' prompted by an article in a publication (such as Reader's Digest), today's generation can search and often self-diagnose - with dubious effectiveness.  Gadgets can be bought: a pregnant woman can set herself up with a fetal heart rate monitoring device, a blood pressure machine, digital scales for the baby, and any number of other potentially useful, potentially useless pieces of equipment.

But I digress.

Back to the assertion I have made, that 'doing nothing' is a half-truth.  Further, I suggest the notion that the midwife does nothing, without taking into consideration the enormous and life promoting role of the midwife in any professional setting, could have negative consequences for idealistic, impressionable, inexperienced midwives, and for women in their care.

A woman who is labouring strongly, who has invited me into her home to attend her for birth, will have spent time with me during the pregnancy, discussing and planning and preparing for this climactic time.

I am in her home; I have moved quietly into her intimate space, and

• I assure myself that mother and baby are well, through observation, active listening, and auscultation of baby's heart sounds after a uterine contraction
• I communicate my assessment and any concerns to the mother, and support her, reassure her if appropriate 
• I prepare the space so that I can maintain my written record 
• I prepare equipment that may be needed, such as the newborn 'bag and mask', and oxytocic for mother
• I recognise any idiosyncratic matters or instructions that are given, such as "don't open the door because the cat might escape"
• I make a mental note of this woman's progress up to this point in time, how she is responding, what professional observations are reasonable, and what I expect to see happening
• I assume a protective role of the space, knowing that interruptions and intrusions and interventions can be disruptive: for example, telephones are not welcome in the birthing room.
• I may sit on a chair or rest on the couch in an almost dark room in the wee hours, with my eyes closed
• I may take up some simple knitting or crochet project as I wait for a baby to be born.

Doing nothing?  No way!

Even if the labour and birth are 'uneventful', even if the baby is born quickly and easily (from an observer's point of view), without any instructions from me, my presence is the essence of my professional action.  I bring the capacity to intervene, when there is a valid reason.  I bring the ability to minimise interruption that may increase anxiety in the labouring woman, so that the woman is free to progress, unaware of what's going on in my mind or in the outside world.

Dear reader, if you know the ICM Definition of the Midwife, and other foundational statements and codes in our profession, you will understand what I am saying. 

"... This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures." (ICM 2011 - emphasis added)

Those who understand the promotion and support of normal, physiological processes in birth will know the masterly inaction of authentic midwifery.  This is not 'doing nothing'!

Midwives need to protect women from an idealistic message that tells only part of the midwifery story, and may confuse those who genuinely need the midwife to act in the interest of wellbeing and safety of mother and/or baby.  If that were not the case there would be no need for a midwife.


Your comments are welcome.

Obstetric violence in Australia today?

This is the definition of obstetric violence, presented by UK obstetrician Dr Amali Lokugamage at RCOG World Congress 2014 in India:

"Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
"It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
"It is also the act of disregarding the emotional needs of mother and baby throughout the whole [childbearing] process" 
Jesusa Ricoy-Olariaga 2014

Today I want to carefully reflect on a couple of births and other maternity experiences that are very close to home.  
I want to carefully measure the maternity culture that I know and participate in, in and around Melbourne today.  
I want to ask in what way I am contributing to obstetric violence.
I want to seek ways by which adverse aspects of a culture can be changed.

[Please note that names and some of the details in the cases have been changed for anonymity]

Case study 1
Bess was a 30 year-old, carrying her third child, planning homebirth.  I have been her midwife for each of her births, and her first and second baby were born at home in my care.

At about 36 weeks, Bess visited her GP, who looked at her abdomen, and said her baby was too small - growth restricted (IUGR).  The GP quickly arranged an ultrasound scan, which appeared to support the diagnosis, and an appointment for Bess at the tertiary hospital.  The GP spoke to me about her concerns, and I wondered if I had missed something.  

.... fast forward to 38 weeks
Bess was advised to go to hospital to have an induction of labour.  She asked me if I thought her baby was too small.  I did not.  However, I told her "If I'm wrong, and there is a valid reason to get this baby born (as she had been advised by the hospital and the GP), you have more to lose than if I'm right."

... fast forward to a couple of days after the birth of her baby (whose weight was well within the normal range).
Bess told me she did not feel traumatised by the experience: rather, she had faced the challenge head on, and accepted the intervention of induction of labour by artificial rupture of the membranes (ARM).  She had progressed unmedicated, and gave birth without assistance to a healthy baby boy.   When she was told, a couple of hours after the ARM, that it was time to commence IV Syntocinon, she declined and was quite definite about not needing further intervention.  She knew from the tone of the contractions she had experienced that her baby was on his way. 

Obstetric violence monitor (using the above definition):
-1  Bess was pressured by (albeit well-meaning) doctors and maternity care system that introduced fear of harm to her baby, when in fact her pregnancy was progressing normally
-1  Spontaneous onset of labour was denied
+1 Bess was able to decline further intervention after the ARM
+1 Bess considered that, despite experiencing pressure to comply with medical plan, her decisions had been respected, and she felt emotionally supported

Score: Pass - Case 1 is not an example of obstetric violence

Comment:  There are many contributing factors in any decision-making.  The choices that a woman has around her maternity care, and the decisions she makes at any time, are not equally weighted.  The support she has, both professional (eg from a known and trusted midwife) and personal (eg from partner, family, friends) will probably influence outcomes, especially if the decision-making pathway is not clear.

Case Study 2.
Deb was a 38-year old mother who had had two caesarean births, both prior to labour.  Deb wanted a VBA2C (vaginal birth after 2 caesareans) for this birth.  She considered herself well informed about making this plan, and made sure that her written birth plan was included in her hospital record.  She had felt cheated in her previous caesareans, and longed for the spontaneity and bonding between mother and baby in normal birth.

Prior to the onset of labour, Deb had some bright bleeding from her vagina.  She went to the hospital, and had some electronic fetal monitoring and other investigations.  The doctor told Deb that her baby did not seem to be distressed, but that he strongly recommended a repeat caesarean immediately.  Deb explained to him that she would accept a caesarean birth, even though it was not what she had so much hoped and planned for, if the hospital would permit her to keep her baby with her, skin to skin, in the operating theatre, in the recovery room, and when they had returned to the postnatal bed.  The doctor went away to make this arrangement, but was told the hospital did not provide staff for that option: that the baby and his/her father would be taken to the postnatal ward, and the mother reunited with them as soon as she was released from the recovery room.

Deb then refused the emergency caesarean.  Deb's baby was, a couple of days later, still born.

Obstetric violence monitor (using the above definition):
-1  The emotional needs of the mother were disregarded
-1  The emotional needs of the baby, as understood by the mother, were disregarded

Score: FAIL - Case 2 IS an example of obstetric violence

Comment:  Deb's case is clearly complex from an obstetric/medical point of view, and I have cherry picked a few facts in coming to my conclusion that this is an example of obstetric violence.  The hospital disregarded the clearly expressed emotional need of this mother, and used inflexible staffing arrangements as the reason for denying her request.



In what ways am I contributing to obstetric violence?
There is no simple tick-box for obstetric violence in maternity care today.  As evidence emerges about the finely orchestrated hormonal processes in birth and nurture of the new born child, the expectations of women will change.  The providers of professional maternity services must also integrate the contemporary knowledge into our care.




One of my own babies was born with a fractured clavicle, and aspirated mucus, as a result of rather rough handling by the doctor.  The mucus was cleared from her lungs using suction and percussion, and the clavicle healed as expected.  But that child became fearful and anxious when ever her throat became inflamed.  She had a definite memory of pain that had been caused by the failure of my accoucheur to permit me to give birth to her spontaneously.  She had experienced obstetric violence.  I did not feel or know that I had been traumatised - the requirement for me to be lying on my back with my feet in stirrups was standard at that time.

At about that same time, in the 1970s, there were dark and horrible secrets in many facilities where children received care.  Predatory sexual activity, and physical and emotional abuse, were tolerated within the system.  A blind eye was turned.  It has taken several decades for the light of public scrutiny to be directed towards those institutions, and for the people who experienced such abuse as children to have an opportunity to tell what they can of their stories.  

In reviewing birth as I know it in Melbourne today, I want to ensure that I and my colleagues are not tolerating - turning the blind eye - situations of abuse and violence against women and babies.


The maternity system as we know it today does not protect, promote and support natural physiological processes in birth and nurture of babies.  It does not follow the standard, that "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

It is possible that future generations will look, aghast, at the way mothers and babies are being treated in the early 21st century, in the same way that we are shocked by revelations of institutional abuse of children in the C20. 

the myth of choice

1983 - working night shifts a the Women's

For a couple of decades now, *choice* has been a pillar of the natural birth movement.

An organisation that I am a member of has the vision, that
"Every woman can choose how, where and with whom she births."

This vision has troubled me for some time.  Today I am attempting to critically explore the notion of choice, and whether it is desirable or imaginable that every woman choose "how, where and with whom she births."


Firstly, some historical considerations:

• The Fortelesa (Fortaleza) Declaration (1985) on appropriate use of technology in birth challenged interventions, from shaves and enemas, to inductions of labour.  This seminal document also declared that "The whole community should be informed about the various procedures in birth care, enable each woman to choose the type of birth care she prefers".  *CHOICE!*
• Changing Childbirth in the UK (early 1990s) declared that women want the 3C's: *choice*, control, and continuity of care.
• A call for *choice* of place of birth (home/hospital) and care provider (such as individual midwife or the maternity system) was clear in the Australian National Maternity Action Plan (2002).

At the same time,  twenty years ago,

• emerging trends in medical research led to the Cochrane Collaboration, defining the reliability of evidence;
•  UNICEF and World Health Organisation introduced the Baby Friendly Hospital Initiative, with a key document being the Innocenti Declaration  of 1990. 
•  various state and territory governments around this country were conducting broad reviews into birthing services, and producing their reports. (eg Having a baby in Victoria 1990)  These reviews sought consumer comment as well as professional.
•  WHO prepared a series of basic publications on maternity care, including Care in Normal Birth: a practical guide (1996).  This document brought a consensus statement that "In normal birth there should be a valid reason to interfere with the natural process"

During the past two decades the world has experienced the digital revolution.  Twenty years ago, in 1994, few households had computers: the world wide web and email had only just been invented.   This phenomenon exploded communication and access to reliable information.  Our home went 'on line' in the early 90s, with a (very slow, and unreliable) dial up connection, and we were leaders in the field.   Prior to that, if I needed to send an email, I would ask my husband Noel to send it from his office at the university.  He kept up with the expansion of knowledge via inservice education, and a very helpful secretary, Jean.  He became the 'IT' expert in our home, until our children absorbed the knowledge and quickly spoke the language, as children do.  (but I have digressed from my topic!)

Twenty years ago, professional peer reviewed scientific publications were held in libraries, and accessed by scholars and the intelligencia.  Today, there is an inexhaustible wealth of knowledge at the tip of our fingers, from our computers, tablets, and phones.

Twenty years ago, information about natural childbirth was passed from teacher to student couples in highly motivated childbirth education.  Today women join social media groups where they share everything from their nausea and indigestion, to ultrasound pictures.  These groups, as well as personal blogs and microblogging, have introduced a degree of sharing of opinions, and introspection ('navel gazing'), that would have been unimaginable when person to person communication was limited to a telephone or over the back fence or a tea room at work.

So, what about choice?

In discussing choice in childbirth with colleagues and other interested folk, I have been a little surprised to observe that the woman's right to decline (a treatment/intervention) is often perceived to be the same as a choice in maternity care.  A woman's autonomy in any care situation (whether it's her toe nails or the birth of her child) is often limited to the little word "No!"

By way of example:

Jill is in hospital, in labour with her first baby.  Jill has been told she needs a Caesarean, because she has been labouring without adequate progress, and the doctor is concerned that her labour is obstructed and her baby is becoming distressed.

Jill does not want a caesarean birth, but she has no other options at this time, other than to do nothing, and that may lead to injury/death to her baby.  She has planned for a natural birth, because she believes that's the best way for her and her baby.  Jill has written in her birth plan/preferences document that if she truly needs a caesarean birth, she wants her baby's umbilical cord to remain uncut, and the placenta delivered intact (known as 'lotus' placenta).  She wants her baby to be placed skin to skin on her chest, and to remain with her in the operating room and in recovery so that breastfeeding can be initiated without delay.  She is aware of 'natural' caesarean births, discussed on her social media forum, and likes the idea. 

Jill communicates her wishes to her doctor.  If that doctor has previously supported women's choices in this way, he/she might be willing to agree.  But Jill is a patient in a public hospital.  The doctor who is performing the surgery is being supervised by the consultant obstetrician, and does not feel able to accommodate such a radical plan.  The hospital's policy is to send the baby and the father to the nursery while mother is in recovery, and Jill is told that the hospital is not able to provide suitable staff to accommodate her choices.  Jill has run out of options.  She needs the help of the hospital to get her baby safely born, and she finds to her surprise that the notion of choice doesn't work in this situation.

 Jill thought, prior to coming into labour, that she had chosen:

how: a natural birth 
where: in the local public hospital
with whom: the hospital staff at the time

'how' Jill gives birth is something that cannot be predicted, whether she chooses a private hospital with the most popular obstetrician according to the online rating system, or the guru homebirth midwife who has amazing skill and, according to social media, can do all sorts of things to make birth work as it's supposed to.  The best Jill can find out when she is choosing her care provider is an approximate rate of spontaneous unmedicated births that person reports for woman in their care.

I (frequently) remind women that they have only one choice in childbirth - to do it themselves, or to ask someone else to take over. This is the case, whether it's avoiding induction, having a vaginal breech birth (vbb), a vaginal birth after caesarean (vbac), a physiological 1st, 2nd or 3rd stage. (Haemorrhage and death are also physiological). 

There's an obvious rationale for the skilled midwife in these equations. A primigravida who wants to have a natural unmedicated birth, booked at Caesar's Palace, in the care of a knife happy OB, may have chosen where and with whom she births, but doesn't have much chance of achieving the 'how'.  

Choice is also dependent on money $$$.

The woman who chooses a caesarean for her own (not clinically indicated) reason can get a private doctor to deliver her baby if she can pay the doctor's fee (Medicare + out of pocket) and the hospital fee. But she has very little say about who else is in the room - her partner is likely to be welcome but may be asked to step outside. 

If we have a vision that every woman should be able to choose how - including elective C/S - do we think our public health $ should be supporting that so that women who can't afford the co-payment are also able to rock up and *choose*?
 
I am very concerned about over-spending of health $.  

The only sustainable policy direction in maternity care is to protect, promote and support the natural processes in birth wherever that is reasonable. The workforce needed as experts in achieving this goal is midwives whose duty of care by definition includes "promote normal birth". This does not remove the woman's right to make an informed decision to decline or accept the plan. Medical and surgical options should of course be available to those for whom they are likely to lead to better outcomes, but that's not a matter of the woman's *choice*.


Your comments are welcome.