Thursday, July 21, 2011

Challenging times for women and midwives (HBAC)

Sad and disturbing times for both women and midwives:

As a private practice midwife it is very important to understand the boundaries of my role as a midwife; some are outlined in my previous blog “government paying us lip service”. Many midwives are facing complex ethical dilemmas:
As a UK trained midwife I was used to being able to do a homebirth for a woman who has risk factors and has had collaboration and consultation with an obstetrician through the local Health Authority and has chosen a homebirth despite these risk factors. The difference being that in the UK there is a Supervision system of midwives (supervisor of midwives) that provides midwives with support and backup. Also within the UK system you are protected by legislation that states that only a midwife or a doctor can assist with the birth except for an emergency in which case anyone can help.

S16 (1) A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth: Nurses Midwives and Health Visitors Act 1997(UK)

In the UK a woman’s choice is respected in that she can birth at home and the local Health Authority has to provide a midwife for the homebirth if one is available (National Health Services Act). Also the Royal College of Obstetrics and Gynaecology (RCOG) and Royal College of Midwives have a Joint Statement No.2. -April 2007 supporting homebirth and work together to support this. However here in Australia a major problem is that the AMA categorically opposes Homebirth.

The Nursing and Midwifery Council (NMC) works in the same way as AHPRA in its role to protect the public to ensure that midwives work within their scope of practice which is low risk ‘normal’ and provide a safe environment for birthing women. Independent Midwifery is also under threat in the UK as there is no insurance for private practicing midwives: see Homebirth and the Law reference list:

The Health System is different in Australia; therefore we cannot really compare with the UK except to say that both regulatory authorities work in the same way, in protecting the public and ensuring that midwives provide safe and competent care for the woman.

Legal Advice: I am not a lawyer and not giving legal advice; this is my interpretation of the legal advice given to me)

I have to state that my position as a midwife is that yes I believe in “women having choice in place of birth” and I believe that every woman should have midwifery care. I also have to state that I believe my role as a midwife is dealing with the “normal” and anything that falls outside of the parameters of “normal” I will collaborate with an Obstetrician, working in partnership with the woman to achieve a mutual arrangement and provide midwifery care throughout. I would like to see more liberal / flexibility surrounding place of birth for high risk women instead of always sending women to tertiary centres where they often feel alienated and fearful this would be a step in the right direction.

In light of the recent debate surrounding HBAC, I have sort some legal advice regarding the issue of VBAC (vaginal birth after caesarean) and having a homebirth. I wanted to know where I stood legally when a woman approaches me as a midwife asking for this service, should I decide to book a planned homebirth for H/VBAC – in terms of my responsibilities and my registration/licence: You have to remember that a good lawyer can argue a defence for anything and there is always a defence to be had.

The first question you have to ask is - What does the professional bodies say about HBAC / VBAC?
The professional bodies are the AMA and ACM – (the AMA has 90% membership, do not support homebirth, and is very powerful & political) does this give you an idea of what the answer will be to the first question.

Second question: What does the regulatory body stipulate about HBAC/ VBAC? Here you have to look at the current codes and guidelines that govern midwifery practice; you could compare with the UK, NZ and USA;

Thirdly : Have you provided unbiased informed choice, have you got collaboration (Dr; support) for the H/VBAC is it clearly documented, have you clearly documented the risks associated with HBAC/ VBAC , are you providing a safe environment for the woman; and have you an emergency care plan, are you working within your scope of practice?

There may be a possible defence, how successful this would be is the unknown quantity as it has not been tested yet and I can assure you I am not going to be the first to do this.

Women do have a choice of place of birth; however the choice to have a midwife present in the home environment for a risk associated birth is a limited option due to the legislation and the regulatory authority. However if the midwife chooses to accept the HBAC he/she maybe risking disciplinary action which could mean losing his/her registration and or having restrictions on his/her practice together with a lengthy legal case that will be distressing and costly.

How to move forward:
The answer is to work on changing legislation, to something similar to the UK and gaining support from the AMA to collaborate with midwives in listening to what women want. Helping and facilitating women achieve the kind of birth they want in a safe environment with a health professional to support them, whether that is in hospital or the home. Providing different models of care which include continuity of care no matter what the risk factor is.

It is very clear that the consumer/woman has to lead the impetus for change, the demand must come from them otherwise nothing will change; it is the power of the voter to change legislation.


Pam said...

The actions which are currently going on work against the Government document, National Guidance on Collaborative Maternity Care from the NHMRC. It is clearly stated in that document that,
"when a woman chooses to not follow professional advice she will not be abandoned" there is still a responsibility to provide care

Laura Jane said...

a 'supervisor of midwives' role would be a great step forward for Australia.

Its also important to continue to lobby for better access to midwifery care for ALL women, for a higher profile of the midwife's role, and for SERIOUSLY reducing the CS rate.

Australia is beginning to reap the whirlwind of the escalating CS rate, as these 1/3 women are having their subsequent babies.

Perhaps it is time to turn the tables and fight fire with fire. Report shoddy inductions for no reason. Call out (and report) staff for lying to women and overestimating risks to do with vaginal breech birth, and VBAC.

And ask women (yet again) to send another round of letters to people who can influence and speed change.

Consumers are our greatest allies. And they will be the greatest winners from these changes.

InfoMidwife said...

interesting points made Pam....

InfoMidwife said...

Thanks Laura for dropping by, and yes i think a supervisor role is a step in the right direction: I also think we need to focus on Making birth normal.... and continuity of midwifery care...great access to hosptials for private practicing midwives...

Govind@wbcom said...

And ask women (yet again) to send another round of letters to people who can influence and speed change.

Consumers are our greatest allies. And they will be the greatest winners from these changes.

InfoMidwife said...

Thanks for you comments, I agree the NHMRC says that "women should not be 'abandoned' because of their choice'..and when in labour a woman hopefully would never be abandoned... however I reiterate that currently midwives registered with the regulatory authority in Australia are not covered to work outside their scope of practice: therefore when booking women that fall outside that scope of practice for a homebirth without collaboration will be problematic; until the legislation is changed this will continue to be a problem... we can however work in collaboration to find a solution and women must not be ‘abandoned’. Yes keep writing letters. As I have said before it is the consumer that will make the difference..... not midwives, it must come from women.

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