Wednesday, September 1, 2010

The Homebirth debate: I want to pull my hair out!

Some arguments presented; I am working through some thoughts and decided to blog it!

I will start with the role and scope of a midwife; the midwife is the specialist in dealing with the 'normal' pregnancy & birth and recognising when things become abnormal and then refer to an obstetrician. All medium and high risk pregnancy should be seen by an obstetrician, you could have shared care or good collaborative care so that the woman can have continuity of care with her midwife whilst seeing the obstetrician.

I can see some independent/private midwives totally disagreeing with my definition of what a midwife's role or scope of practice is. However this is determined by the ANMC competency standards / Ethics / Conduct and the ANMC decision making framework. The scope of practice for a midwife is clear; that is dealing with what is 'normal'. The ACM referral guidelines are also used to guide midwives in private practice - there are recommended conditions of which women should be referred (evidenced based) and when to refer women. this document protects the midwife if followed.

The government funds a small percentage of homebirths through the CMPWA programme, therefore women can claim through medicare - this is for approx 450 women per year. The program accepts healthy low risk women and the demand is greater than what is available.

As far as I am aware there are no Midwifery Group practices in WA, which really is a tragedy, as most other states have several MGP both private a publicly funded.
I do wonder if the women who choose independent midwives know the scope of practice of a midwife and to what extent she/he can practice? and do independent midwives ever say to the women this is out of my scope of practice I am not qualified to do this? however I will support you in the hospital setting?

There are a number of independent/private midwives who practice in WA, these are separate from the government funded midwives. Independent/private midwives will have a fee for service for which women cannot currently claim through medicare. This can be limiting for women and expensive.

Interestingly like private obstetricians private midwives are not required to follow public/government policy because they are privately employed. However they are responsible to the regulatory body which for midwives is the Nursing and Midwifery Board of Australia (from October for WA).

I do understand and empathise with the woman that has been so traumatised that she just cannot face going to hospital or even seeing a doctor due to her mis-treatment, this is very real and happens all too often. Recently this was evident in the 750 submissions made by women/men when asked about maternity services in Australia. Who cares for these women? The women are so fearful they would rather freebirth.... this is a terrible reflection of the state of maternity care in Australia. We are letting these women down.

I am frustrated with the homebirth debate; on one hand you have the independent midwife who at all costs will defend the right to support a woman of her "choice" to birth at home whether she is medium or high risk (and rightly so otherwise who looks after them). They believe that the woman has the right to choose homebirth because she is well informed and knows all the associated risks with birthing at home with a risk factor, therefore has the right to self determination and the right to refuse treatment. There are health professionals who do believe the midwife should walk away from this woman in other words abandon her in labour because your registration is at risk. There are obstetricians who believe that women do not have the right to choice when they are high risk......that it is the obstetricians professional right to make the correct decision in the 'best interest of the woman and baby'.

The law in Australia does not protect this midwife when she/he works outside of the scope of practice. Unlike the UK where the midwife is protected by legislation and is not allowed to abandoned the woman..... We need this type of protection in Australia for the midwife. Currently the independent midwife works out on a limb and is not supported and alienated by the hospital system.

The problem I have with the above scenario is that the midwife is not qualified to care for the high risk woman she/he would be working out of the scope of practice, because this is not within the role of the midwife and this worries me. I am not saying our role as a midwife is not to support this high risk woman, it is to support and provide collaborative care for the risk factor associated with the pregnancy, however often doctors will not collaborate unless the woman does as the doctor suggests.......this is a lose - lose situation.

The trouble as I see it is that fundamentally women are not being heard by health professionals, they feel pressured, bullied and are often scared into submission by the health professional, therefore choose an alternative model of care this may include freebirthing (birthing without a trained health professional present). Hospitals are not flexible, they are rigid and not prepared to meet the woman half way.... it appears that's its the hospital way or the highway...and women will choose the highway.

So what is the answer?
If I sound frustrated I am?
Please tell me how we move forward?
How do we stop women from feeling alienated and force independent midwives to work outside their scope of practice?


Anonymous said...

Perhaps its time to reorientate discussion for midwives to focus outwards? Rights also bring responsibility and accountability-considering this triad as a professional may help the decision making process "Am I fighting for my midwifery rights here or the best interests of this woman, at this time in these circumstances

Melissa Maimann said...

The answer is to change the legal system to one of no-fault liability. While ever a practitioner's insurance company has a say in clnical practice / decision making, there will be restrictions on women's birthing options. Hospitals don't want bad outcomes pasted on the front page of the newspapers so they will not support anything that is not hospital policy. This includes meeting women half way.

Private midwives are not covered for "inapprpriate practice" and if insurance does not cover part of our practice, we are outside the conditions of registration to attend the woman. The only answer is to get rid of insurance and the legal system that forces women to sue - and prove negligence - in the event of a bad outcome. In its place, we need no fault liability and disciplinary action for health practitioners whose practice falls below an accepted standard of care.

InfoMidwife said...

Dear Anonymous and Melissa,

thank you for droping by and leaving a comment.... I am still no closer to an answer...I would like to see midwives clearly protected by legislation in this in the UK...imagine if you had this to protect you "Whilst an employed midwife has a contractual duty to their employer, she also has a professional duty to provide midwifery care for women. A midwife would be professionally accountable for any decision to leave a woman in labour at home unattended, thus placing her at risk at a time when competent midwifery care is essential".Homebirth guidelines UK

Anonymous said...

I think the system which supports women and midwives in the UK is so completely different that we cannot compare and perhaps its not helpful to try?

Lisa Barrett said...

The ANMC does not define midwifery practice, there is an international definition of the midwife.
Perhaps it's time to focus on women's rights. The right to birth with whom she wants and where she wants. This isn't a debate of venue but of human rights. As long as midwives are married to the registration board, the insurance, the college of midwives, the right to be seen as a professional blah blah we will never have resolve.
A private ob/Gp etc doesn't face this sort of debate or criticism of their own profession by others who either will not or cannot bring themselves to be with women. Surely there is room for everyone here. If there isn't we leave women vulnerable to birthing alone out of necessity instead of choice.
So the first thing to change must be the attitude of the midwife community, supporting each other instead of casting stones at those who support women that you wouldn't is the greatest change we must make.

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