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

Choices Women Make in Childbirth

This is a short blog about a few conversations with several women regarding the choices they made for the birth of their babies....I was  in a shopping center promoting midwifery and chatted to some pregnant women.....  I’m sharing some of these conversations for two reasons; because the choices these women made blew me away and in light of the vigorous homebirth debates after the release of the SA coroner’s report where he suggested that women who have a high risk factors should possibly consider a caesarean section rather than a homebirth or words to that effect...... (which will be my next blog).

I have to note that the women concerned all had private health insurance and wanted to birth in a private hospital. First two women were 35 and 36 weeks respectively, they were having repeat caesarean sections. When I asked how they felt about their impending c/section Mary said “look I have accepted that is my reality”, I asked was she happy to discuss her decision and she said she was happy to share and talk about it.... she went on to say “my first section was an emergency.... when I was pregnant again we saw the same obstetrician and we were told the risk of the scar tearing was high and its best to have another section. I then said I would get another opinion..... You know, I could not find another obstetrician that serviced the private hospital that would do a VBAC.....and besides my husband did not want to take the risk and I have to consider his wishes,” I asked “did she know the risk was really low...as in 0.04%” and she said “yes, but my husband did not want to take that chance, I wanted to have my baby in a private hospital and did not want to go to a public hospital, so I accepted the second section, now its baby number 3 and that’s the choice I’ve made, it would of been nice to birth normally, but that’s the choice I made, I wanted to have my baby in a private hospital”.

Janie who was her friend had a similar story.... except this was her second section...she also knew about the risks involved regarding a VBAC but really did not mind having a section, again her main reason was she wanted to birth in a private hospital as opposed to a public one....

Sally was an older professional woman, 39yrs old first baby and elected to have a caesarean section, currently she was 34 weeks and was not interested in a vaginal birth, she said ‘I never wanted to give birth naturally, I want to protect my pelvic floor and besides it took me longer to get pregnant than I thought, don’t think I could deal with all that unexpected stuff, now I know the date my baby will be born.....’ her mind was made up – we did go to talk about breast-feeding to which she was not interested in, however we did manage to talk about skin to skin at birth for bonding and the possibility of expressing for the first few weeks and bottle feeding with  breast milk as an option.... I asked had she ever spoken with a midwife, her response was ‘I have private health insurance therefore I have a very good obstetrician.... and he does have a midwife I see from time to time....but he makes all the decisions....”

The last woman was 35 weeks booked for her repeat section at a private hospital – first section was an emergency, no VBAC offered and she elected for a section because her husband is a fly –in-fly-out and she wanted to plan his time off for the birth and this was the easiest way....she also did not want to birth in a public hospital....”on no I only go to private hospitals, that’s why I pay for private health insurance...”

Out of the 10 women I spoke to 5 were having elective sections, 3 were booked in secondary hospitals and another two for private hospitals and hoped for a vaginal birth but all knew about the chance of a caesarean section.... “if all goes well, I will have a vaginal birth..... we have discussed if the need arises we might have a section”.....

I must say the aspect that surprised me most was the desire to birth in a private hospital even if it meant having a c/section as opposed to birthing in a public hospital.....that puts a different perspective on some of the issues.....what is it that the majority of women want and is this the expected norm of place of birth?

Again I come back to the point of education and informed choice..... these women wanted to birth in a private hospital and how that happened did not matter, their main issue was the place of birth.....food for thought.

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

Women need to debate if its time for fetal rights:

In doing so it must be remembered that women's autonomy is paramount. For too long men have bludgeoned and pillaged women's autonomy. A woman's autonomy and body is sacrosanct and for her alone to choose what to do with it.
Education, communication and choice about place of birth is the answer...not mandating through legislation what happens to the woman's body.

As Dame Elizabeth Butler-Sloss in Re MB (1977)

A mentally competent patient has an absolute right to refuse consent to medical treatment for any reason, rational or irrational, or for no reason at all, even where that decision might lead to his death. The only situation in which it is lawful for the doctors to intervene is if it was believed that the adult patient lacked the capacity to decide and the treatment was in the patient’s best interests.

’

Also Justice Cardozo on a Patient's "Rights"
"Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages,".

Consent in law is very clear, as is the current status of the fetus - it has no rights until born alive.

As I see it there seems to be two schools of thought - first when in domestic violence or violence against a woman and the fetus is killed at term (37 weeks usually able to survive outside the uterus)in this instance, women have been calling for greater accountability against the perpetrator...and calls for murder / manslaughter for killing the fetus (unborn child).
On the other hand, you have the woman who chooses an unconventional birth mode, in which her fetus (unborn child) dies at term (from 37 weeks) and there is no accountability for the death of the fetus.( This woman usually chooses this option due to the mismanagement of her care through conventional health services and she feels she has been left with no options).

There seems to be a disparity with this argument, there needs to be the same rule for all, we must come to a consensus as to whether the term fetus deserves some rights. The problem will be in affording the term fetus rights, that the woman's autonomy is not compromised.

Whilst discussing fetal rights it seems unfair that the AMA (WA) should be targeting pregnant women with drug and alcohol issues saying there needs to be some sanctions applied to these women. Where will we draw the line.... obesity, working, sport...this is a preposterous argument we will drive women away from health professionals -

Dr David Mountain stated "there should be penalties for some of the "wild extremes" of homebirth/freebirth advocates where misinformation is deliberately given to women about the risk to their unborn child. I was very clear that in this situation it is the purported expert who misleads a mother into endangering their unborn child that should be considered to have recklessly endangered the child"

I would like to know if this extends to the medical profession whose Caesarean section rate is rising at a rate of knots - are the purported experts misleading women into having a c-section (which will then affect the next pregnancy choice) when it is not required.....therefore endangering their unborn child....

Women who choose to homebirth are very well informed and often do most of the research themselves....they are well aware of the risks involved and think they are doing what is best for themselves and their baby.

No where else in health care do we see that a person's autonomy is compromised in such a way....no one makes you donate a part of your body to a dying relative if you did not want to do so..no one takes you to court to make you give a part of your body to that relative... so why are we so intent on undermining women's autonomy?

Yes it is time for society to debate these issues, as the born alive rule was made in the 17th century. I think women need to be debating this issue as it is their bodies that are in question.

Please write to the West Australian in response to Dr David Mountain's comments Friday 2nd March email: letters@wanews.com.au include full address and telephone number. These comments came as a response to this article.
Charge reckless mums: doctors' union

Questions to ponder:
- what do you think about fetal rights?
- Is a term fetus a human being? and does it deserve some rights?
- in what circumstances should a term fetus be awarded rights?
- should a health professional be accountable for the death of a fetus?
- what responsibilities does the mother have when making choices about her fetus?

The Face of Birth

Great inspiration:Homebirth movement in the US took 40 years......

The Face of Birth

Interesting:

Collaborative Maternity Care Agreement - give your feedback

RANZCOG has developed a template for Collaborative Maternity Care Agreement between Eligible Midwife and Specialist Obstetrician or General Practice Obstetrician for use by Specialist Obstetricians or GP Obstetricians and Eligible Midwives.

It is very important to give your Feedback.

It is acknowledged that the template agreement will not be suitable for all settings and that not all Obstetricians will wish to enter into a collaborative arrangement, but all comments will be considered.RANZCOG

Please send feedback to Rupert Sherwood by email to ganderson@ranzcog.edu.au or by fax to +61 3 9419 0672.

Sending your response is important, this is how your voice and numbers count, please be proactive, read the document in its entirety... and give your feedback.

Born Alive Rule - is it time to rethink

A few seconds after birth:

There is much debate over recent months regarding this issue; traditionally in Australia and some other countries a fetus has no rights until “Born Alive”, otherwise considered the “Born Alive Rule”. This rule has been around since the 17th century, at this time viability was considered when the woman could feel the fetus this was generally known as “the quickening”. It is now the 21st century technology is advancing at great speed, ultrasound is very definitive, there is no question now about the viability of a term fetus, is it time to reconsider the rights of the term fetus. An embryo is usually from fertilization, early stages of growth and then a fetus from 12 weeks of pregnancy; The definition of a term fetus is when it is considered that the fetus can survive outside the uterus without any assistance this happens from 37 weeks - 40 weeks. Once born most people refer to the infant as a baby.


When considering the question of fetal rights it is important to consider what is considered a human being? Is the fetus a human being? What or who is a person? Can the fetus survive outside the woman’s body? These questions raise many ethical questions: My masters 10yrs ago was, is it time to re think fetal rights, and I concluded then that a woman’s autonomy was sacrosanct. 10 yrs on I think it is time to open Pandora’s box and debate the issue again.

The born alive rule can be viewed from several perspectives; women - pregnancy – domestic violence – violence against pregnant women – criminal responsibility. I am going to view several circumstances; This blog is not a judgement of anyone, I am expressing a point of view to illicit debate on the issue of does a ‘term fetus’ need rights:

A recent case in WA, Matthew Silvestro who had a history of domestic violence was found guilty of causing grievous bodily harm when he drove his car into another car, causing his pregnant partner Vanessa De Bari serious harm (she spent 8mths in hospital recovering from injuries) including the death of her 8 month fetus. His sentence was a two year driving suspension and $8000.00 fine to which he pleaded he was unemployed and unable to pay this fine he ordered to pay costs of $119.20

South Australia’s coroner has been conducting an inquest into several homebirth deaths of term fetus’s. The issue of “sign of life” and the “Born Alive Rule” has been bought into question and debated. Another issue that has been debated during the SA coronal inquiry is the decision to have a home birth, particularly because it involved twins a higher risk – and that no backup plan was made. One twin was born alive at home and the second suffered brain damage and died later. This is not a judgement, this is about questioning what is a human life? And does a fetus have a right to life? Do we have the right to dictate by our actions whether a term fetus lives or dies? It is time to debate this question further.
Dr McCaul said at the SA coronial inquiry:

"I had a strong sinking feeling because I felt she strongly still wanted to go ahead with a home birth," she said.
"I don't think it's safe to deliver twins at home. I think the risk of complications is high.
"She listened to what I had to say but I didn't feel that it was influencing her. I don't know that frustrated was the right word. I felt a bit powerless I think."

Another case from SA that has a questionable ruling that of Tate Spencer-Koch case in which the coroner states

“Tate had been a perfectly viable fetus until the time of her delivery........the PEA (Pulseless Electrical Activity) that excited in Tate after her birth, acknowledging as I do that it was slow and could not support a mechanical heart beat, and could not be reversed, is to be regarded as the last vestige of her human existence. This last vestige existed at a time after she had been fully delivered. As such it was a sign of life that existed after she had been fully delivered. (1.27)
.......the PEA of 15 beats per minute that was detected in Tate approximately 10 minutes after she was fully delivered was a sign of life for the purposes of the law......all facts of the born alive rule have been satisfied in this case and I find Tate was a person in the eyes of the law and for the purposes of the jurisdictional requirements of the Coroners Act 2003”.(1.28)

This case will change the course of history if this definition of a sign of life remains......it is my opinion that PEA is not a sign of life and that is because at this stage there is no cardiac output, you are essentially dead....there is only an electrical current that runs through your body as the last automatic process of the body....it does not mean you are alive.... It is however interesting to read the process and see how the coroner has come to his conclusions, it is all about words and how they are used and what they mean.

Interestingly in the case of R v Iby a case of an assault that caused the subsequent death of a fetus/child. This case heard that the presence of a heart beat was sufficient to satisfy the born alive rule. It was also found that there was no ‘common law definition of what constitutes ‘life’ for the purposes of the born alive rule (248).

WHO defines live birth as

Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life - e.g. beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles - whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born

.

Fetal rights is a real dichotomy the right of a woman to her own autonomy and her body v the right of a fully formed term fetus who would live if able to be born..... what is the answer...In my mind there is no question that a term fetus is a human being: What is required is that there is community support / structures for midwives who choose to support women who make these choices; one thing is for sure, women have the right to choose where and how to birth – what is required is for hospitals and health professionals to be more flexible.

In 1999 Regina McKnight the first woman in South Carolina was convicted of homicide by child abuse in 2001 after a jury bought scientifically unsupported arguments that her cocaine use caused the stillbirth. Regina suffered the charge for suffering an unintentional stillbirth after having used cocaine during her pregnancy.

McKnight unsuccessfully appealed her conviction in 2002, challenging the constitutionality of using murder statutes to prosecute women who experience stillbirths. But in a split decision, the state Supreme Court upheld her conviction, offering a novel interpretation of the state's homicide laws. The court held that any woman who unintentionally heightens the risk of a stillbirth could be found guilty of homicide with "extreme indifference to human life." Under this doctrine, the court held, any pregnant woman who engages in activity "potentially fatal" to her fetus could be charged with murder.

In 2008, the Supreme Court ruled that McKnight had an unfair trial... McKnight argues that counsel was ineffective in her preparation of her defense through expert testimony and cross-examination...and the court also found that the information given to the jury about the supposed link between McKnight's cocaine use and her stillbirth was not scientifically supported. More importantly this ruling sends a clear message to lawyers as it was found that current research simply does not support the assumption that antenatal exposure to cocaine results in harm to the fetus, and the opinion makes clear that it is certainly ‘no more harmful to a fetus than nicotine use, poor nutrition, lack of antenatal care, or other conditions commonly associated with the lower socio economic group. This ruling will send a clear message to lawyers to get the facts right and not be misguided by medical misinformation.

It is a travesty that Regina McKnight spent 9 years in prison for a crime she did not commit and in South Carolina 90 women have been convicted of drug use during pregnancy, this is not the answer to the problem.

As a midwife sometimes this issue creates a dilemma for me as I firmly believe in the woman’s right to choose what happens to her body. That is under no circumstances should she be forced to accept any treatment she does not want. How do we balance the need to protect the term fetus that is a fully formed human life, but for the fact it has not been born alive it has no rights.... one minute in utero it has no rights, however once born and shows a sign of life you cannot kill it..... this just does not make sense to me........

I do think a term fetus should be afforded some right to life.....but I'm not sure how we can do this without impinging on women's right to autonomy, which must take precedence.


References:
CORONERS ACT, 2003 SOUTH AUSTRALIA RULING OF CORONER
http://www.courts.sa.gov.au/courts/coroner/findings/findings_2010/Spencer-Koch_Tate.pdf
R v Iby (2005) 63 NSWLR 278, 248
http://stopthedrugwar.org/chronicle/2008/may/16/pregnancy_south_carolina_supreme
26484 - McKnight v. State; http://www.sccourts.org/opinions/displayOpinion.cfm?caseNo=26484National Advocates for Pregnant Women: http://www.advocatesforpregnantwomen.org/
Doctor says mother ignored homebirth warning:
http://www.abc.net.au/news/2011-11-17/home-birth-twins-death-coroner/3677156
Pic ref: http://www.solarnavigator.net/animal_kingdom/humans/babies.htm

The challenge of collaboration:

http://www.nhmrc.gov.au/guidelines/publications/cp124

I have written about collaboration in the past and it still seems elusive, however a few of my esteemed colleagues have managed to gain some sort of formal collaboration. The word ‘collaborate’ means ‘to work with another, cooperate’. However so far, the collaboration has been limited to antenatal and postnatal care, and intrapartum care being only provided by the doctor. When it comes to continuity of midwifery care, through all phases of pregnancy the problem arises when the woman goes into labour - the birth is still in the realm of the doctor. The woman goes to hospital and is cared for by the doctor, they still hold onto this part. However I have noted that times and attitudes are changing and maybe given a little more time the doctors will not be so territorial regarding ‘normal low risk’ births.

I would dearly love to see women with the opportunity to have a midwife in their home for the early part of labour, to support, encourage, nurture and be with woman. Keeping the woman in their own environment with a midwife until they are ready to go to hospital in established labour, this could prevent the cascade of intervention and we would have more normal births.

I do wonder whether the threat of things going wrong and not in the doctors control; in other words the threat of litigation is the motivator, together with no real benefit for the doctor to collaborate with the midwife. What is the incentive for the doctor to collaborate? Maybe if we a sign a Medicare no to "collaboration" doctors might do so... Most doctors I have written too are happy to continue as they have for the past years; however the issue is, that women are requesting midwives and continuity of midwifery care, it is time for change.

NHMRC was commissioned by the Dept of Health to develop national guidance on collaborative maternity care as part of the national maternity reforms they produced a whole document about the process of “Collaborative Maternity Care”. This was to encapsulate maternity care collaboration placing the woman at the centre of her own care, whilst supporting the health professionals who care for her. Thus ensuring her cultural, psychological and clinical needs were met. The NHMRC produced a pamphlet for women to help explain collaboration; I have yet to see this document widely distributed.

The pamphlet explains to women that

“Midwives provide care to women during pregnancy – from conception until early parenting in collaboration with other health care providers. Midwives can provide most aspects of ‘low risk’ pregnancy, labour and birth, and postnatal care to women. They may need to refer you to, or talk with, a doctor or other services if you or your baby have or develop problems”

Obstetricians & GP “Provide specialised care for mothers and babies in collaboration with other health care providers. They can look after women with “routine” and “complicated” pregnancies and births, and provide labour and birth care in hospitals.

Pregnancy is a very special time for women and families, it is very important to ensure you are getting quality safe care including informed choice from your service provider, whether it is an obstetrician, midwife or GP Obstetrician. That your choices are being heard and respected, you also have the right to say ‘no’ to treatments you do not want, don’t ever be afraid to ask for a second opinion.

Collaboration is about working in partnerships with each other in order to facilitate the wishes of the woman and her family. Recently I experienced true collaboration with a hospital in facilitating a woman’s birth, what we need is the Determination of July 2010 overturned or amended for midwives to collaborate with a Health Service, rather than an individual doctor.

Here’s to ‘continuity of midwifery care’, every woman having the opportunity to have a midwife and doctors and midwives working in partnership.

What you need to do if you want to be a Private Practice Midwife in WA

Western Australia is unique in many ways, but particularly in the area of Midwifery, it is the only State in Australia where you have to declare your intention to practice midwifery as a private practitioner to the Health Dept. In principle I think it is important for the regulatory body to know who is practicing independently, however I think rules pertaining to this should be National, not state by state. However despite my personal views it remains that for WA you need to register your intention to practice privately (independently).Therefore it is important to take several steps:

1. Ensure you are eligible to practice midwifery
2. Be a registered midwife (NMBA - AHPRA)
3. Review recency of practice standards
4. There are no rules as to how long after registration that you can practice privately(exemption until July 2013)
5. Review Health Act Regulations 1914 Midwives Notification
6. Lodge the form to the Health Dept (your intention to practice) Notification
7. Secure Insurance (VERO or MIGA) all private practice midwives (independent) must have insurance
8. Review guidelines for insurance (NMBA - AHPRA)

Medicare for Midwives: for this you need to be an Eligible midwife (private/independent)

An eligible midwife has completed three years midwifery covering antenatal, intrapartum and postnatal care.

1. Complete Midwifery Practice Review (or equivalent) (ACM)

2. Review the application form for addition of notation as an eligible midwife
3. Currently registered as a midwife, with no restrictions

4. Current competence to provide pregnancy, labour, birth and postnatal care to women and their infants.

5. Midwifery experience that is equivalent to three years full time post initial registration as a midwife.

6. Formal undertaking to complete within 18mths - course for prescribing (course has to be approved by the Board)
7. 20 additional hours per year of continuing professional development relating to the continuum of midwifery care.

That's it, not much to do.....but please remember to register with the Health Dept your intention to practice privately. Also remember there is currently no insurance for Homebirth.
We need more eligible midwives, so please consider taking up the challenge, and offering women continuity of midwifery practice.

No Collaborative Agreements: No equality or justice:

12 months on and I still do not have access or a collaborative agreement:

As a private practice midwife I have not been able to secure a written collaborative agreement or access to hospitals to facilitate the care of my private clients; Unfortunately for the women of WA, there is only one Tertiary hospital and to date this hospital has not supported the role of the 'eligible midwife' or women's choice to be cared for by a private midwife within the tertiary hospital setting. This is totally unacceptable and goes against the governments National Maternity Plan initiative.

There have been many obstacles to try and implement midwifery reform within Australia: To date as far as I am aware there are a handful of collaborative agreements and no credential pathways for access to hospitals for private midwives:

If you remember the National Health Collaborative Determination July 2010 outlines the requirements for private midwives to work within the community; This Determination is clearly not working; for whatever reasons, personal or professional 95% of Obstetricians / GP Obstetricians are not choosing to enter into a formal collaborate agreement with midwives; There has to be a better system in place that does not require midwives to be reliant on Obstetricians who clearly do not want to collaborate -this effectively puts a midwife out of business, and gives women little or no choice. This will not stop women, they will just birth without a midwife.

I have written to over 50 Obstetricians, receiving only 3 responses (negative): the latest response being:

"I do not intend to enter into one of these agreements...... Planned birth at home is clearly associated with higher rates of both perinatal morbidity and mortality and I cannot support it"

.... he went on to wish me well in my venture..... Just how well does he think I am going to do with no hope of getting a collaborative agreement? Maybe that is the plan! This appears to be the general attitude of Obstetricians in WA. The evidence clearly supports homebirth for low risk women, however my request was for continuity of midwifery care not homebirth.

The Determination has to be changed or rescinded to stop the monopoly and control of doctors over midwives, this system is clearly not working;

Just taking a step backwards;

From November 1 2010, women receiving midwifery care could claim a Medicare rebate for services rendered from an eligible midwife:

On 12 November 2010, the National Maternity Services Plan (the Plan) was endorsed by the Australian Health Ministers’ Conference.

The Plan recognises the importance of maternity services within the health system and provides a strategic national framework, as endorsed by state, territory and Commonwealth Governments for the five year period 2010-2015

Within the first 12 months the plan's priority 1 was to:

1.2.1 Australian governments facilitate increased access to midwifery-managed models of care for normal risk women, e.g. midwifery group practice or birthing centres, while maintaining support for choice of, and access to, medically managed
models of care. Australian governments facilitate increased access for public patients to midwifery and medical practitioner continuity of carer programs

1.2.2 Jurisdictions develop consistent approaches to the provision of clinical
privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners

NOT ACHIEVED - the first year has passed and we are no closer to achieving these outcomes;

It is apparent that women are not being offered true choice within maternity services and Health Services are required to be more flexible. The evidence is clear that midwifery continuity of carer affords better outcomes for women; it reduces intervention and provides for improved parenting. This includes homebirth as an option for uncomplicated pregnancies. Therefore it is imperative, to achieve the strict intention of the National Maternity Services Plan, to protect mothers, babies and achieve best outcomes in maternity care, the Australian Health Ministers need to provide PII insurance for Intrapartum care at home for uncomplicated pregnancies, rescind the current Determination requiring written collaborative arrangements with an obstetrician and compel local Health Districts / Services to provide clinical privileges for eligible midwives, as a matter of urgency.

Ref: picture: http://www.ontheissuesmagazine.com/2010summer/2010summer_Ross.phpA Feminist Vision: No Justice-No Equity by Loretta Ross - My mother always asked the question, "Why would I want to be equal to men, when I've been superior to them all my life?"

Head on the chopping block – HOMEBIRTH:

Homebirth the hot topic: combine that with autonomy, women’s choice of place of birth no matter what the risk factor and you have an explosive cocktail and a subject that will divide a nation. There has been much written on this subject and sadly what is bringing it to the forefront again is term foetuses (babies) dying at home, with or without a health professional.

In 2009 there were 30,760 women giving birth in WA and the average age was 29.5yrs, the majority of women (98.8%) gave birth in hospital. Non Hospital births 1.2% including Born Before Arrival (BBA) (0.4%) and babies born at home (0.8%). The caesarean section rate was 33.3% (10,241) of the women recorded as having had a previous caesarean section 87.1% had a repeat section. What we need to be doing is reducing the caesarean section rate and concentrating on is promoting normal birth.

In 2010 WA had 245 homebirths, 203 occurred with the Community Midwifery Program and 42 homebirths with private practice midwives. We have 19 private practice midwives registered with the Health Dept and 5 eligible midwives.

This debate about homebirth revolves around less than 1% of women, not that I am suggesting that their views are not important; however there are 99% of women that need midwifery input to improve their birth experiences. It seems that a disproportionate amount of time is spent on homebirth in relation to the work that needs to be done to improve maternity services for all women.

I will start with my position as a midwife on the subject in the current Australian context;

Do I believe that women have the right to choose where and how to give birth? YES.

Do all women need a midwife throughout the continuum of pregnancy, birth and postnatal period? YES.

Should homebirth be an option for all women? The evidence shows that homebirth is safe for uncomplicated pregnancies.

Should all women have a midwife? YES

Should high risk women birth at home supported by a midwife? This is the six million dollar question; professionally and personally I would answer NO, based on the lack of protection for the midwife to facilitate this choice. However it is not that simple; usually women who are choosing homebirth for high risk pregnancies have experienced some sort of birth trauma, are extremely fearful of hospital and usually have knowledge of the associated risks, each case needs to be evaluated individually. It is unfair to label all these women as zealots or radical. What needs to happen is to listen to what the issues are and find more flexible ways to support these women providing continuity of midwifery care, collaboration with an obstetrician within a safe health system.

What is a problem is if midwives / or de-registered midwives keep supporting high risk homebirth without collaboration and health service support. Recently there have been several high risk homebirth deaths. If the term fetus (babies) keeps dying in the homebirth setting we will be endangering homebirth for uncomplicated pregnancies. Worse still women will lose their autonomy because the term foetus will be afforded more rights similar to what has happened in the USA. Currently in Australia a foetus has no rights under law until born alive, but this concept is being challenged.

What needs to happen is that health services need to be more flexible, by having visiting rights for private practice midwives allowing them to bring their women into hospital and continue to caring for them. When fearful women present they should be facilitated to birth in a low risk setting such as a secondary hospital or birth centre supported by the tertiary hospital. Specialist obstetricians could travel to see the women and support the secondary hospital – it is about being flexible – considering the psycho-social issues of the women. Having all high risk women being herded into a hospital like cattle is giving them no choice or options therefore creating more fear. Remembering there is established legal principle that a mentally competent woman can refuse treatment. It is no wonder that these women choose to birth at home or freebirth. Freebirth is an unsafe and unacceptable practice and Health Services are failing women if this is the only option they feel they have.

We as midwives need some sort of supervision or mentoring system to support us in difficult clinical situations therefore allowing us to support these women. We need legislative changes to protect the midwife to stay with women no matter what the risk and where she chooses to birth, we need health services to be more flexible and supportive. We need women to be demanding that Health Services and Doctors be flexible, it’s about open communication and negotiation.

Three questions:

What do you think about the homebirth debate?
Would you have a high risk birth at home?
Would you freebirth?



Ref: WA Mothers and Babies 27th Annual Report – Midwives Notification System
photo credit: http://offthebroiler.wordpress.com/2006/11/21/death-of-a-turkey/

Confusion reigns.......

A sad state of affairs: it seems that continuity of midwifery care is the last thing on anyone’s political mind:

To say I am confused would be an understatement; two urgent issues: Insurance and the practice role of a midwife: for months I have been asking the question can a Midwife be a support person or advertise as a doula? to me a Midwife is a Midwife is a Midwife, not a doula or support person.....these are all roles within the scope of a midwife...I remember as a registered nurse you could not work as a career I would think the same would apply to midwifery; however due to the recent kerfuffle surrounding private insurance for midwives and the requirements of the regulatory agency... midwives have been looking at different ways of presenting themselves to elevate some of these problems and still support the woman and her choice. I have written twice to NMBA asking for clarification on this issue... Today a colleague highlighted to me that on the AHPRA website under frequently asked questions; ‘Regency of Practice’ gives a definition of what is meant by ‘Practice’ http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ.aspx

Q2. What is meant by ‘Practice’?
A. Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a nurse or midwife. For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care. It also includes working in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery

In effect this means if you are a registered midwife you cannot act as a support person or a doula, because we have the knowledge and skills of a midwife.....this has far reaching repercussions and when you add the recent problem with the MIGA insurance into the picture it gets worse.

The MIGA cover clearly states you are not covered for

“midwifery services which are provided by you to a public patient (even if the public patient is in a private hospital).

This then leads me to the question when you are working in a hospital and you finish your shift and you stay back to support the woman because you choose too...because of the bond you have with your woman...this may be seen as interference as the woman may look to you for a clinical decision... in effect this will not be permitted as you will not be covered by the hospitals vicarious liability insurance because your role is a midwife not a support person.....I may have got the wrong end of the stick, but what’s good for one is good for all....

We as midwives are now backed into a corner... One would think with the Medicare provider number and the maternity reforms midwives would be rejoicing ...however the long arduous road to credentialing / visiting rights to hospitals have created many problems; the process is taking too long; the inability of obstetricians to agree to collaborative arrangements have left the maternity reforms in tatters....and the personal cost to many midwives trying to make this work is enormous; I am paying MIGA for the privilege to be insured only to find that I am not and its good money going out the window, I don’t have money to waist, however it seems that MIGA is profiting very well from this venture. At the end of the day both women and midwives are suffering here and the process are very unclear.... the only time you find out that something is wrong is when you have been reported... this is all unacceptable.

I have had good support from the Minister of Health WA, Office of the Chief Nurse/Midwife and the Chief Medical Officer, however this is not enough, no one can make collaboration happen:
As for collaborative arrangements, I have written over 40 letters to GP Obstetricians and Obstetricians asking for a collaborative agreement and have had one response, politely saying ‘no’. Where does this leave me...absolutely no where?
The other day I went with my client to meet her obstetrician, you know build bridges, be nice etc and he could barley look at me...he never addressed me once, there was no professional courtesy. How are we to move forward when we are met with such resistance.... it is a sad state of affairs. My client employed an independent midwife so that she could have continuity of care with a midwife, she choose a midwife for her knowledge and experience to enable her to facilitate the birth she wants knowing that the midwife would support her through this process.... this now is even a problem.

I also pay premium insurance through MIGA and it seems for nothing: I have no hospital access, no collaborative arrangement; yes I do have women booked, now I am in a quandary what to do; that I cannot be a support person because this may be a reportable offence this leaves us nowhere to move......my only saving grace is that I have access to a hospital as a casual midwife but this is only a temporary solution so one client is safe...as for the others I will have to bare the consequence as I have committed to being a support person... something has to give soon. I may have to look at not booking anyone further until the processes are in place and who knows when that will be...

Please if anyone has any further news on this issue let me know...
Very frustrated and disillusioned eligible midwife:

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Homebirth: A reminder July 2012 is looming

Following on from my previous blog which generated much discussion; lets remember the figures we are talking about: In Australia less than 1% of women homebirth: In the UK 10% of women homebirth and there is a call by doctors to increase that figure and have more 'low risk' birth centres and homebirth: I wish the AMA would say that:

The role of the midwife is clearly defined; anything outside of 'normal' needs collaboration with an obstetrician in partnership with the woman. However we do have some serious issues within maternity services that force women to birth alone (freebirth) which is unacceptable: as I have alluded to before partly due to there being no support or protection for the midwife under the legislation.

The Determination (National Health arrangements for Midwives) of 2010 set out the rules for collaboration which to this date has been difficult to secure. As far as I am aware there are only a few collaborative arrangements in this country, one of them being Melissa Maimann (Eligible Midwife) and Dr Andrew Pecese.

As privately practising midwives in Australia we are in real threat to losing the ability to support women at home for a 'normal' homebirth, so where will that leave HBAC, (homebirth after Cesarean section): HBAC needs to be done in collaboration with an obstetrician; come July 2012 the exemption for private practice midwives / independent midwives (these terms are used interchangeably) will cease to exist. If we or the government cannot secure insurance for Homebirth we will lose this right: and only publicly funded homebirth programs will exist.

As I have said before the consumer must help to take this forward: we saw the result from the Homebirth Rally in Canberra. We all have to work in partnership with , professional bodies and consumers: Women need to be asking their obstetricians for midwifery care: Ask your GP surgery, what is their position regarding Midwives; will they facilitate shared care with a midwife outside a hospital system? we need to focus on the AMA - we need to get them to the table and debate these issues with the consumer groups such as Childbirth Australia.

My real fear is that we will go down the same path as the USA (Pregnant and Miscarry....Do not pass go; Go directly to Jail) and we will lose rights for women and gain more fetal rights; choices for women will be limited due to legislation, we need to act now by working together and find a solution: One solution is for 'continuity of midwifery care'.

There is no quick fix to these issues, this will be a long slow political journey of negotiation to get what we want: which means providing different models of care, such as 'continuity of midwifery care' access to hospitals for privately practising midwives: the right of the midwife to support the informed choice the woman has made: This has to be a united journey not fragmented into separate issues, Homebith v HBAC or 'low risk' v 'high risk'.
We need to move towards 'every woman needs a midwife' and 'continuity of care'.

Homebirths in the news again....

It is interesting that the debate is always around homebirth...is it safe or not.... however should we ban hospital births because babies die there as well. The language used "doctors divided" "the Health Dept" is allowing homebirth to continue... where is the choice factor here for women.. in fact where is the discussion with the women... in what other form of health treatment do you get autonomy so blatantly ignored as in this one...if someone refuses treatment the doctors accept this ...why is it so different in this instance.... Women have the right to choose where and how to birth....a well informed woman will make the right decision for herself and her baby....no where do I see any of these considerations here.

See the full story on 6 minutes Doctors divided over homebirth reports
We all know that statistics can be manipulated.... and the figures don't break down the women who choose to birth at home when they know their baby is going to die through an abnormality.

I would also like to know if BBA (Born before Arrival not planned homebirth) and en route births are registered as a hospital or homebirth.... also we know that statistics can be manipulated to which ever outcome you want....the figures also do not separate the women who choose to have a homebirth whose baby has an abnormality:

The other group of women that are missing from the report are the ones that Freebirth.... this is an unknown entity...we know it happens and these figures would alter the homebirth outcomes.... so really we still don't have a good indication as to the statistical value of the current outcomes.

The more the medical profession demand that women birth where they want them to the more the divide will grow…. It is time to listen to what women want…. The choice to have information and make and informed choice whether it is one the medical profession agrees with or not…... It is called autonomy. Dome doctors are openly hostile about homebirth. It is about communication, trust, building a therapeutic relationship, not based on fear, it is about being flexible and learning new ways of doing and communicating with women about birthing options.

The one thing that’s a reality is that women are being bullied and made to feel guilty, for choosing a homebirth. Their autonomy is being eroded and paternalism reigns supreme. It is time to change this……its about informed choice and autonomy.

Insurance for Midwives:

Now that I have a Medicare Provider number & eligibility it's time to consider my insurance; the options that midwives have are:
A government supported insurance through MIGA (The Medical Insurance Group) or Mediprotect insurance;

The question you have to ask is which insurance do you choose? here is all the information: an important factor to consider is which company offers run-off-cover:

Read MIGA information Booklet:
Frequently asked questions:
Payment options:
Risk Managment workshops:
Maternity Care Plans & Collaboration
Product disclosure Statement:Application form:


Mediprotect - Vero - wording of policy document:
Application form:

As you can see from the summary of information available.. there is more information provided by MIGA than Mediprotect:

The most important factor for me is, I need intrapartum cover when birthing in a hospital as a private practice midwife and run off cover; therefore my choice of insurance will be governed by this; I have therefore applied with MIGA and will see how much my costs will be, although I have a good idea of what it will be.......

I have also sort guidance from my accountant and lawyer.....so that I am fully aware of my requirements.....it is exciting times....

An extraordinary year:

As the end of the year sets and the New Year dawns we often think of the year gone by…at least I do…it seems to me that the years are getting busier and time is flying bye…this could be a reflection that I am getting older however I don’t feel older, but sure as hell my body keeps reminding that I am….

As this has been a humongous year in line with my recent trip to Tanzania I am going to list the 10 highs and lows of the year: it is so handy having a blog to look back on to jog the memory when so much happens in a year.

Top 15 highlights for 2010 – the order is not significant

Meeting the Prime Minister (K Rudd) & Health Minister
Listening to proceedings in Parliament and hearing the words 'midwife' 'midwifery' continuity of care' spoken so many times and in a positive light
Teaching in Singapore / Meeting up with friends in Sydney
Putting in Submissions / politically lobbying
24hr Virtual IMD Celebrations (Sarah Stewart)
Linda’s Holiday – Perth to Carnarvon – (being a Skype Midwife)
Sitting on Uluru….breathing in the atmosphere
Making a decision about my study – starting a new degree
News of a new Grandchild (April 2011)
Medicare Provider Number for Midwives
Gaining Eligibility
Starting Centred Midwifery Group Practice Inc (CeMGP)
My Tanzanian experience
Family, friends & some great work colleagues

The Grandchildren

Jasmine started Yr 1, Dylan Pre-Primary, Jessica Kindy
Talia coming into her own, starting to stand up for herself,
Sam, Isabella and Logan all going through the terrible two’s

Top 11 Disappointments:

The division over collaborative arrangements and the Determination 2010
Homebirth debate / Insurance issues
Miscarriage in the family
Election dirty politics
Factions within Midwifery
Lack of team work and loss of integrity from esteemed colleagues
Bullying issues
Muffin passed away
A better disciplinary process (Hospital) for midwives using their piers
son-in-law having a back operation
Seeking & acting on legal advice for defamation

As you can see the highs thankfully outweigh the disappointments….and my lists are not exactly 10…. See you have to be adaptable in life…best laid plans of mice and men...lol.
Wishing everyone that reads my blog a happy, peaceful, safe and successful 2011: