The politics of birth for the private midwife: A minefield from all directions

Being a private midwife can be a minefield, you never know what action will set of an explosion. We all know minefields are designed to destroy or disable.  This means you can have a varying degree of damage from slight, mediocre or catastrophic. Clearing minefields is a long, slow, time-consuming process, and there is no room for error, a bit like the life of a private midwife. There is no clear pathway every woman (case) presents another set of issues often a new battle or the same one revisited but it is the same minefield, you just pray that you don’t step on one and get damaged. You have to select your path carefully.

What is so infuriating; the level of bureaucracy that is required…. let me share a story or two…..you have a so called ‘low risk’ woman who wants a homebirth, she needs to be booked into hospital as a backup – this is required by several governing bodies, however the hospitals play ping pong with you – Hospital ‘A’ says ‘No’ this woman is ‘low risk’ she needs to birth in hospital ‘B’. Hospital ‘B’ tells you No ‘we don’t have the infrastructure’ to support a homebirth go to hospital ‘A’ and whilst this toing and froing is going on….. The woman is progressing through her pregnancy…..God help you if you have a problem…because everyone wants to pass the buck.... And in the meantime the Director General has resigned; there is a State election so the Minister of Health does nothing to assist you and no one in the dept. responds to your urgent requests for help……What is the private midwife to do? However if the private midwife is found to be lacking in some capacity the hammer falls very quickly and very hard…... There is just no equity in this at all…it seems that progress is ever so slow: however I am grateful for the help I do get from some corners  and without that this journey would not be worth it….  I am also thankful for the women for without them we would not be midwives and the breaking of new ground would not be possible.

On the other hand the minefield is the choice some women make: they choose for whatever reason to go outside any boundary the midwife has…outside of the scope of practice the midwife has, and each midwife has their own limits….. now the midwife can choose to accept that woman’s sole choice at her own personal risk… as there is nothing to protect that midwife when she works outside the boundary of the so called ‘low risk’, accept her documentation and sometimes that is not even enough – the woman is only wanting what she considers is in her best interest. However the midwife ends up having to defend themselves and this means $$$$$ in legal fees, even if the midwife did everything within her power. Who looks after the midwives best interest? Not the regulatory body, not the government and certainly not the AMA - The Midwife has too….because no one else will…. This is sad reflection of Midwifery practice in Australia – I for one am not prepared to risk my registration and pay out $$$$ in legal fees…. until the midwife is afforded protection as her counterparts in the UK and NZ the Australian private midwife is becoming are rare commodity and will become extinct.

I will end by saying I have had some wonderful experiences with women along this journey and every single one has taught me something about myself and pushed a boundary – I reflect on every experience and say ‘how can I make the next one better’. The major drawback is the political battle that each case brings in access to hospital, collaboration and the support required…. The burden of collaboration is tremendous….it is a one sided affair….every now and then you step on a landmine and you get damaged….. And you contemplate when will the damage be catastrophic and you pray it won’t be you and it won’t be today.

picture ref: http://www.smh.com.au/it-pro/innovation/blogs/smoke--mirrors/patent-battles-are-a-worry-for-developers-20120831-254fo.html

Where to find some Evidence - pregnancy

This is a great Blog - have a look at the video regarding Evidence Based Birth Tutorial - very informative, shows you how to find the best evidence - you can then discuss this with your health professional - see what they say - to have knowledge is to be forearmed....for all those pregnant mums...check it out: Evidenced Based Birth Tutorial:

Communication, pregnancy & labour - women

The way we communicate with women:

I was saddened today by again listening to a woman retell her traumatic first birth from two years ago: it is really disheartening that our health system is letting these women down by not providing the right care. Something really needs to change about the culture and language used within maternity services and the paternalistic attitudes of our midwives and obstetricians; It really is all in the way that messages are communicated to the women:

I am sure we all have a story to share, I recently experienced this first hand as an observer: the woman attends hospital and is 6cm dilated on arrival, she requests an epidural. 

Doctor “I want to do a vaginal examination first”

Woman “I really want the epidural first, then you can do an internal examination”

Doctor “I must do a vaginal examination first, now, you might be fully dilated”

Woman “I don’t care I want an epidural now please”

Doctor “but don’t you understand it is important for me to do one now”

Woman’s husband in a cross tone “did you not hear my wife she wants an epidural first then you can do your examination”

Doctor “alright then I will call the anesthetist but he may not come for an hour or so”

This process had already taken an hour; this woman did not get her epidural for an hour and a half.

After a long labour, now fully dilated and a failed vacuum it was determined by the doctor that a caesarean section was required. There was no fetal distress – he had called another more senior obstetrician for trial forceps in theatre.  When the senior obstetrician arrived the woman was upset, she had worked damn hard, she was tired now crying and when the obstetrician introduced himself to her, she looked at him and pleaded..she said ....

“Please try everything before having to do a caesarean section; it really is the last thing I want’. 

The doctors response was “I will do whatever I need to do, that will be best for the baby, and if that means a caesarean section, well, so be it”. He then went on to say “ a friend of mine did a small research study on women who are fully dilated after failed vacuum and the outcome is much better for the baby if you go straight to c/section’. ‘Now let’s get on with this to theatre now’.

The woman and husband were shattered on so many levels; they surrendered to what was to come:

My point is not whether the woman required a caesarean section or not, it was the manner in which the obstetrician had spoken to her.  There was no explanation, no informed choice, there was no empathy, and there was no consideration for what she was feeling, it was pure unadulterated power pure and simple. 

The obstetrician could have said “I am so sorry that this has been such a long hard journey; I will do my best to assist you, however I must let you know that a caesarean section is quite possibly on the cards, but I will assess the situation in theatre and keep you fully informed, explaining the situation to you and we can make the decision when I know the full picture”.

More consideration is needed when communicating with women that enables informed decision making – clear explanations as to the clinical picture therefore empowering women and their partners: More often than not when the clinical picture is spelt out in clear simple language, women will do what is necessary because they understand the situation and they are making the decision.

As health professionals we need to constantly think about the way we communicate with women.... think about the language you use, don’t be paternalistic be empowering – give an accurate explanation of the clinical picture and accept the decision that is given, not the one you want:

Remember the old saying ‘you get more flies with honey than vinegar’ – so true

 Ref pic: http://www.abc.net.au/talkitup/chalkitup/communication.htm

An action packed 2012

It always amazes me when I get to the end of a year and look back, so much has been achieved. My intention each year is clear, I make a list and by the middle of the year it has doubled and by then end of the year much more than I planned is achieved… how does that happen? One thing was for certain my work load was vast…. From 300 plus students, my private practice and my study not including family and friends…..

2012 started with various College activities and takes me through the whole year as this is an important part of my professional life as a midwife.  Then comes my usual trip to Singapore and my 140 students, my usual local students another 150 plus, as well as whatever extra your workload includes. Our private practice was steady… and my usual two units of my personal study and whatever extra summer/winter intensive units I could include. Most importantly there was the family, 6 children and 8 grandchildren to fit into my life….. You might well ask how it all happen…. It just does.

Highlights for the year included: Major decision about changing my work place – I was asked to review my study plan and consider switching to a PhD – this was a major turning point in my academic work life and chose not to commence a PhD at this time in my life as I was already committed….half way through my Law degree and did not want to change at this stage. This gave me the opportunity to re-evaluate where I was in terms of my study and my working life and made a decision to reduce my work hours therefore my workload….by far the hardest part of my work was the marking component, it always coincided with my own study and made this time of the year extremely stressful for me…and therefor my husband and made me unbearable to live with. So began the process of changing my job.

Our holiday to Thailand was a brief respite, it gave Ian and I time together just sitting on the beach, reading I read all three 50 shades books and found them brilliant…. Good light-hearted reading. We did some sightseeing; dining, walking and just general fun… the only problem was it was so brief….
The midwifery private practice is steadily growing however the political struggles continue; we still do not have visiting or credentialing rights to government hospitals….each woman brings with her a new challenge…. And we have been rejected from more hospitals than I care to think about…. But we continue to serve the women who employ us and continue to take the issues up with both the Health Minister and the Hospital directors….. Interestingly the Director General Kim Snowball resigned due to pressure of the job…now there was a surprise… NOT.

My study, I usually take two units a semester, and a winter and summer intensive… I really enjoyed Bioethical and Medical law… a brilliant unit as well as Occupational Safety and Health Law… they were my highlights. I also committed to the Flinders Graduate Certificate of Midwifery, two units pharmacology and diagnostics…..the two worst units ever… disorganised, time consuming over assessed and inconsistent with the marking of assessments….. Thank God I passed and will be an endorsed midwife able to prescribe……Worst law unit was evidence…. It just about broke me…. but have a good handle on it.... I must learn not to show what I am thinking on my face....

Change of job midyear as another major step…. Moved to half time (.5) as a senior lecturer… this reduced my work load significantly… and allowed me more time to complete the extra units for my midwifery prescribing …..this job has been challenging in a different way…the private sector is always different..... new courses are always difficult and have teething problems….but most of them have been overcome….watch this space.

With so much study and work, sadly my blogging has taken a back step…. But I hope that I will have more time to do more of this in 2013…. As I do enjoy blogging… I am always thinking of blogs...but finding the time to write and post them is difficult....

My diet has been fantastic....very hard work....I just did not realise I was as fat as I was.... sometimes I think I am mad deciding to diet when my life is so busy...there is never a good time.... you just have to do it..... it has been well worth it.... have lost now 18kgs.... would like to lose another 10kg.... I always think you never see a fat lawyer..... a  shallow reason for losing weight...but it has worked for me....I feel really good for the weight loss.

The family is all good…. I am so blessed.. I had some personal struggles with a decision made… I guess this is normal, the challenge is to give your opinion and then stand back and watch how it all plays out…when it doesn’t go your way….it is about letting go… continuing to love & support and deal with how you feel in your own way… and that is not always easy…. And sometimes you find you don’t even like each other for the decisions made…time does heal…. the trick is to accept and move on…and that was the biggest lesson I learned in 2012.

The grandchildren are the delight of my life… Christmas is always my favourite time of the year…. I love watching them open their presents….. and it is the time of year in which I can spend some quality time with them……watching them all growing … wow… Jasmine is 8 now… Talia 6, Sam 4, Dylan 7, Isabella 4, Jessica 7, Logan 4 and Tayla 18mths…. And a new one due in April……one of the grandchildren has just been diagnosed with Dyslexia…. Which will bring us some new challenges… the highlight for the year was the family portrait with nanna and pops… I didn’t think it was going to be as hard as it was to get all 8 in  a picture, between Sam having a sad, Talia falling of the fence, Tayla teething and off course Isabella deciding not enough attention is being paid to her…. But the photos were a great success… can’t wait to receive them, they were overpriced and the copyright annoys me…but they will be well worth it…

2013 will bring many new changes for me…as I am going to work towards my career change… not that I want to leave midwifery… but I really want to see some changes from a political stance….our practice will be busier…. Three of the grandchildren will be in kindy…and the rest will be in year 1,2,3,4. My study will continue and hopefully my plan is to be finished by the end of this year…..Wow!
Wishing everyone a happy, successful and healthy 2013.....go forth and reap the benefits of life you only live once.... and don't forget to play: