Virtual IMD reflection

Virtual IDM reflection: this was taken from listening to Dr Amali Lokugamage present, it was an excellent presentation, food for thought. This is my understanding of the presentation.
Also a big thank you to Sarah Stewart who organised the Virtual International Day of the Midwife a wonderful event. If you want to listen to Dr Lokugamage presentation just follow this link.

(Ref pic: http://www.i-choose-self-improvement.com/left-brain-right-brain.html)

Dr Amali Lokugamage “Why doctors fear homebirth”
Amali started by sharing she had a homebirth – an obstetrician who has had a homebirth – this was fantastic news, it was so inspirational to hear her talk about her experiences and try to explain the position of the obstetrician. Not that I never considered the position of an obstetrician before, but Amali made it so clear for me. She went on to say that prior to her own homebirth she did not understand why anyone would have a homebirth. She describes her homebirth as a profound experience so empowering. Which led her to write the article “Why doctors fear homebirth”. Amali described that her pregnancy changed her views, she had an intuitive connection with her son, she talked about her connection...this led her to writing her book “ The heart in the Womb”. ...which I must order.....She contributed her fear of childbirth to her lack of knowledge in this area, and her medical education, lack of knowledge leads to mass cultural blindness on normal birth and the basics of physiology of birth.
Litigation is on the increase, therefore defensive practice is prevalent – obstetricians fear preventable bad outcomes. Doctors worry, will I survive litigation, they are fearful of it and try to avoid it at all costs, you can understand why they are fearful as this is their lively hood and sustains there family and lifestyle.

Interestingly Brittan does not have an issue with homebirth – as they largely have a public system and homebirth is provided within the healthcare system and provided for in legislation. Where as when you look at countries where health care is privatised, a greater private sector, she talks about a war on money – how true is this; I firmly believe part of our problem in Australia is that a large percentage of women have private health insurance, and GP’s refer directly to obstetricians, they do not offer midwifery led models of care...and often women think having obstetric care equates to high quality care.....

Dr Amali made another interesting point about the politics of homebirth by looking at how the Obstetric Colleges support or do not support homebirth – the only one I know off that supports homebirth and works together with midwives is the UK RCOG. (RCOG v AMA, ACOG) this might reflect the culture of the country. She went on to say Doctors want to fix, solve, not considering autonomy, because it’s about fixing the problem for what they perceive as the best. They are taught the importance of Maternal Mortality – 358,00 women die in childbirth each year – mostly in developing countries -, therefore they want to make things better......she also discussed, The three delays model – delays which lead to trouble pregnancy complications, delay transport, receiving g adequate care one transferred (“The “three delays” as a framework for examining maternal mortality in Haiti” Barnes-Josiah D, Myntti C, Augustin A, Soc Sci Med. 1998 Apr:46(8):981-93).

This next point was most revealing was that there was an audit conducted of the Evidence in O&G practice, the audit found only 1/3 of the recommendations put forward by the ACOG was based on good and consistent scientific evidence, that is grade A. This is appalling considering that ACOG is most aggressive about homebirth and women’s right to autonomy. (Obstet Gynecol. 2011 Sep:118(3);505-12. Scientific evidence underlying the American College of Obstetricians and Gynecologists practice bulletins. Wrigh JD, Pawar, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ.)
Also discussed was Homebirth evidence, we know the – two largest homebirth studies; de Jonge, 2009 low-risk planned home and hospital births – low risk equivalent to birth in hospital. BJOG: An International Journal of Obstetrics & Gynaecology, 116, 1177-1184 . Birthplace in England Collaborative Group. 2011. Perinatal and maternal outcomes by planned place of birth...BMJ. 2011 Nov 23;343;d7400; for multiparous women low risk is safe at home. Birth place in England - last study to say it was cheaper to have birth at home – and we all know this... it seems that the evidence is only used to discredit home birth and not when it is showing the benefits.

It was refreshing to hear an Obstetrician talk about - 'Obstetric latrogenesis' (that is problems caused by the hospital / health professional) – increasing - induction, epidurals, surgical delivery, reduces bonding, reduces chances of reducing breast feeding; Normal birth leads to adaptive physiological function in the baby, endocrine, immune system thyroid function, respiration promotes high breast feeding rate, greater bonding.
Clearly you can see – healing is viewed differently between the – midwifery model v medical model. I have heard this argument presented before that, Obstetricians only look at a snap shot of the woman's life – intellectual technical knowledge of birth as opposed to wisdom, feeling of birth. Obstetrics dominated by the left brain as opposed to midwives who use both sides of the brain.
I liked the idea that Amali talked about how oxytocins may affect us – fight and flight, so low oxytocins for obstetricians as opposed to high levels of oxytocins calm, considered composed = midwives; this is a very interesting concept, she also says that it is possible that obstetricians and midwives are physiologically different...certainly food for thought, I liken it to Men are from Mars and Women are from Venus.....

I was  surprised to hear the number of specialist doctors that have had successful homebirth (but I guess they are in the UK) – Dr Amali gave no answers to how to resolve the issues of the power imbalance, she thought that it would be almost impossible to convert them from left brain thinking...."it is difficult", maybe showing more video’s such as orgasmic birth"....

Dr Amali closed with that a possible solution maybe that Birth is a Human Rights issue.. as human rights will over rule obstetricians...maybe this is the way forward.... for me this will be a whole separate blog (as this is not as simple as it sounds and takes a long time)...as I would like to go through the case of Ternovsky v Hungry, a woman’s right to choose homebirth whether low or high risk ....

At the end of this month there will be a Human Rights conference in the Hague....so watch this space.
Thank you Dr Amali Lokugamage for an inspiring presentation, I will try to view the 'Obstetrician' from a more left brain angle rather than just being paternalistic and disregarding a woman’s autonomy.

Ref pic: http://www.i-choose-self-improvement.com/left-brain-right-brain.html

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The government is paying us lip service:

There are three burning issues for me currently: Mandatory reporting, women’s choice to birth where and how they want and ‘continuity of midwifery care’; each deserves a separate blog.

I have refrained from blogging recently because things have been politically difficult and I have been trying to keep a low profile, but it hasn’t worked, so I might as well just carry on and express my opinions.

I am in a real quandary as with many midwives, there is a fine line we walk and I have erred on the side of caution and to no avail. What keeps me on the straight and narrow is the fact that I value my registration. That is not to say I don’t value the woman’s choice, but if that choice compromises my registration I will think very carefully about the consequences before making a decision.

Up until recent times this has not presented a problem, however since the introduction of the new legislation namely the Health Practitioner Regulation National Law (WA) 2010. With this legislation came mandatory reporting, if I had known the implications of this piece of legislation I would have fought harder to see it changed. I had no idea until it started happening, that is the reporting of midwives. This is not about pitting midwife against midwife; this legislation is about ‘mandatory reporting’ the same as ‘mandatory reporting’ for child abuse...... it is the law and if you don’t there are consequences for not doing so ( it is noted that there are no penalties prescribed under the National Law for practitioners who fail to notify, but you may be subject to conduct or performance action)....Most reports have been made by Health Services or Medical Practitioners, however it is interesting to note that it seems that only midwives are being reported using this clause: s140(d)
s.140 of the National Law defines ‘notable conduct’ as where a practitioner has; (a).., (b).., (c)..., (d) placed the public at risk of harm because the practitioner has practised the profession in a way that constitutes a significant departure from accepted professional standards.’
The explanation given in the AHPRA document Guidelines for mandatory notifications (p4)
The term ‘accepted professional standards’ requires knowledge of the professional standards that are accepted within the health profession and a judgement about whether there has been a significant departure from them.
The notifiable conduct of the practitioner must have placed the public at risk of harm as well as being a significant departure from accepted professional standards before a notification is required. However, the risk of harm just needs to be present - it does not need to be a substantial risk, as long as the practitioner’s practice involved a significant departure from accepted professional standards. For example, a clear breach of the health profession’s code of conduct which placed the public at risk of harm would be enough.

Maybe we should start reporting doctors for placing the public at risk by overzealous reasons for caesarean sections, or rupturing membranes when it’s not required, or induction of labour for social reasons. I am sure there are many reasons doctors give that are unfounded and put the public at risk. Why are health services or midwives not reporting doctors for unsafe practice or out of scope practice as readily as they are reporting midwives, there seems to be a real disparity in the reporting mechanism.
If hospitals are going to use this piece of legislation then use it fairly on all health practitioners not just midwives, this is paramount to a witch-hunt we have moved back 20yrs, why not just burn us at the stake.

Our problem lies with the legislation, it is the law and this is what needs to be addressed to resolve some of these issues. Australia currently has no protection for midwives who choose to support the woman's choice of care which falls outside of the recommended standard of care - a midwives role is "normal" - I can hear all the rhetoric.

Choice:
It seems that women do not have choice; choice seems to be relative to the situation or dependent on certain conditions – if your BMI remains normal, if your glucose level stays low, if you don’t have a scar on your uterus etc etc,. Working within frameworks is not something new for midwives and balancing the woman’s autonomy against these frameworks can be difficult and often puts the midwife in a stressful position which may lead to an inquiry and threats of negligence.

Informed choice is a fundamental issue, autonomy the right to self determination – not when it comes to health and perceived risk. Mavis Kirkham states that ‘in our own culture, obstetric ideology is particularly coercive. The medical definition of safety and risk means that while minor choices exist, conceptual choices cannot.’
“.......You can have your baby any way you like as long as you understand that I must step in when the safety of you and the baby is involved’ (Shelley Romalis 1985 p 190). How many times have you heard this?

The women the consumer must stand up and demand what is rightfully theirs, the right to birth where and how they want and protection for the midwife who cares for that woman’s choice.

The gloves are off, because I think the government is paying us as midwives lip service. Since November 1 2010, we have seen many changes, Medicare rebates, eligibility and insurance for midwives; however the maternity reforms certainly in WA are lacking in substance and commitment from the State government.



ref:Informed Choice in maternity care: Edited by Mavis Kirkham (2004)