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

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'.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Court ordered medical treatment for pregnant woman in the US

Informed consent and right of refusal are accepted legal concepts. The woman has the right to make informed decisions, including consent or refusal of any aspect of her care. The courts have consistently affirmed that the autonomy of the individual prevails, even when a patient refuses to consent to life-saving treatment.

Autonomy; Even when his or her own life depends on receiving medical treatment an adult of sound mind is entitled to refuse it. This reflects the autonomy of individuals and the right to self determination........as you will read from Judge Butler-Sloss in the St George’s Healthcare NHS Trust case where a woman was forced by a court order to have a caesarean section against her will...... You could liken this to the current issues surrounding women making a choice to have a ‘Homebirth’..... and doctors applying pressure and creating a ‘fear’ culture to ensure that women choose hospital as opposed to homebirth.....

Judge Butler-Sloss in St George’s Healthcare NHS Trust v S (1999) “...while pregnancy increases the personal responsibilities of a woman it does not diminish her entitlement to decide whether or not to undergo medical treatment. Although human and protected by the law in a number of different ways..., an unborn child is not a separate person from its mother. Its need for medial assistance does not prevail over her rights. She is entitled not to be forced to submit to an invasion of her body against her will, whether her own life or that of her unborn child depends on it. Her right is not reduced or diminished merely because her decision to exercise it may appear morally repugnant.,....”.

Now in the US where the fetus has arguably had more rights than its mother in some states, which in my opinion is outrageous the State of Florida has recently ruled that a woman who refused medical treatment was ordered to comply with her doctor’s orders. The woman a mother of two who was experiencing complications during her pregnancy was ordered to hospital, made to receive medical treatment and have a caesarean delivery.

“The trial court ruled that the woman's refusal of medical treatment placed her pregnancy at high-risk and created a "substantial and unacceptable" risk to her fetus. The trial court said the state's interests in protecting the fetus superseded the woman's privacy interests, and she was ordered to comply with her doctor's orders. The woman submitted to hospitalization, medical treatment and a caesarean delivery, although the fetus was delivered stillborn.”

The case went to appeal and the decision was overturned......

“In its ruling, the appeals court said the state's interest in the life of the fetus becomes compelling only when the fetus reaches viability, as outlined in the 1973 U.S. Supreme Court ruling on Roe v. Wade. The court added that there was no indication of viability when the trial court ordered medical treatment and that even if viability were shown, the trial court applied the wrong legal test. The "test to overcome a woman's right to refuse medical intervention in her pregnancy is whether the state's compelling interest is sufficient to override the pregnant woman's constitutional right to the control of her person, including her right to refuse medical treatment," the court said in its ruling. It added that the state also must show that its method of pursuing the compelling state interest is narrowly tailored to protect the woman's rights”.

However for this woman her rights have been totally obliterated..... mind you this case now becomes another precedent and hopefully some other woman does not have to go through the same ordeal. We have to remember that women have the right to self determination; because they are pregnant they do not lose that right.

We in Australia have to be mindful that this does not happen here, that women’s right to self determination is not eroded such as this.

“The American Civil Liberties Union, which filed a friend-of-the-court brief in support of the woman, said in a statement that the ruling is "an important decision for the right of women to make their own medical choices." Diana Kasdan, a staff attorney with the ACLU Reproductive Freedom Project, said that women "do not relinquish their right to determine their own medical care when they become pregnant."

Ref:.http://www.medicalnewstoday.com/articles/197902.php

St George’s Healthcare NHS Trust v S [1999] Fam, 26’ [1998] 3 All ER 673

Homebirth hits the news again.

The other morning I woke to the news of "Danni Minogue is rushed to hospital for a Cesarean section, doctors save mother and baby in a Nick of time...Homebirth emergency",I was incensed. This was complete sensationalism by the media....Again today the headlines read: Minogue ditches home birth over safety fears .....it's a way of grabbing headlines and selling newspapers again without having complete facts.....in this current climate of Homebirth being the focus of news and the government not providing private practice midwives insurance cover. It almost seems like we will take any opportunity to bash Homebirth.
There was no mention of the good professional care that Danni received.... that the midwife is a professional who provides continuity of care and collaborates with other professionals, this includes knowing when to safely transfer care to a teritary unit...this is good midwifery care and excellent collaborative care.....ah but no, the media and some doctors decide to jump on the bandwagon and start to knock the woman's choice and demand that Homebirth is unsafe.....what was unsafe about what occurred....Danni would most likely have had the same outcome in a hospital birth.... women have the right to choose Homebirth and this case shows good collaborative care with the woman being the centre of care and focus.

The Australian today published a comment made by Dr Barry Walters WA who said "DANNII Minogue is better at judging performers than she is in making choices about childbirth".
...

Many studies show maternal complications and stillbirths are more common in women who deliver at home. The decision to try homebirth is based on ideology, not on concern for the baby. Most women will experience a wonderful and fulfilling event, assisted by caring midwives, when they deliver their baby in hospital. Don't play Russian roulette with a baby. Babies don't care where they are born.

This comment by the good doctor is arrogance at its best, negating women's right to choose and insulting their intelligence because it is not his choice. Danni Minogue has every right to make an informed choice and based on the evidence Homebirth is not playing Russian Roulette.
Clearly this Doctor has not read the recent studies on Homebirth: In the private and public sector the evidence has shown a strong safety for homebirth. Women want more control around the birth of their baby. Control provides greater satisfaction especially psychologically. Studies also show that 30% of women found that their hospital birth was traumatic. Women want continuity of care by a known midwife and this happens at home and can happen in a hospital.
Congratulations Danni & Kris and the birth of your son Ethan:the joys of parenthood begin enjoy the journey.

Celebrating International Midwives Day - Happy Day

Working at Watford Birth Centre 2001

Happy Midwives day to all midwives and women.....why am I a midwife.... because I love women and wanted women to have informed choice, information that enables them to birth how they choose. I was fortunate to complete my midwifery course in the United Kingdom where midwives work truly autonomously and they are respected by both the consumer and health professionals.

My vision is to see Midwives work autonomously in Australia with women.... for every pregnant woman to have a midwife....for women to be able to book in to see there midwife and have continuity of care with a named midwife.....and for this to be accepted practice....not for a select few.....this is the fundamental right for every woman....childbirth does not have to be a medical event...... childbirth is normal for a large percentage of women....women need informed choices about birth so this will enable them to make their own decisions about how they would like to birth their baby.

Becoming Conscious: "When we expand our thinking and belief, our love flows freely. When we contract, we shut ourselves off" Louise Hay.

Allowing women to make their own decisions......

Here is the follow up to the Empowering women - not as easy as you think scenario

....the woman is GBS positive with query ruptured membranes....she has commenced IV antibiotics, the advice given to her by the doctor is to be induced immediately 1700hrs....as the doctor feels she will not go into labour on her own...she is currently contracting 1:10 mildly. After being given all her options by the midwife....

The woman chooses not to be induced until the morning and goes against the medical advice given (this is all clearly documented).... she does choose to stay in hospital and wait until the morning.... her hope is to go into normal labour.... the outcome of this scenario is that the woman continued to walk around, eat, drink and no monitoring, until in established labour.... she progressed into normal labour and birthed at 0739hrs that morning....an assisted birth....

This was a good outcome by a woman who knew what she wanted and was willing to standby that decision despite the advice given by the doctor....she determined the risks and made her mind up with the information given... together with what she had anticipated for her birth (her birth plan was a natural normal birth) and an induction of labour was not in that plan (as it meant, restrictive movement, monitoring) however she made the best compromise she knew how..... to achieve what she wanted..... well done... congratulations......

Empowering women - not as easy as you think

Thoughts to ponder on!

There are times it is difficult empowering women.... there is a fine line that you walk and the only way I find to walk it is to be true to yourself, let go of your ego and just state the facts and what you see.

As any midwife knows there are always two sides to a treatment and this is where the fundamental problem arises, because you can have several responses from the woman, and you as the midwife have to know which way the woman wants to go.....and often you will sense that...

Often women only get one side of the treatment, often a paternalistic point of view. Not that a doctor consciously chooses that, it is what the doctor feels is in the best interest of the woman... now how he puts across that treatment option is often to sway or dis empower the woman to his way of thinking rather than giving the woman the complete facts and allowing her to make that decision. Now why is that?

The second option of course is that the woman does get the compete treatment option from the doctor and then says "I don't know what to do, you make the decision"? now I understand this option and I can live with this option.... it is the first option I have problems with...here is an example....

A woman comes in with a query rupture of membranes...40/40 (she is due) not a convincing history of her waters breaking...she was lying in bed, knowing she wants to go to the loo.... gets up and feels a gush of fluid but she is unsure her waters have broken.... she waits several hours.. and then calls the hospital.... she is asked to put on a sanitary pad to see if any water leaks and come in to be assessed. She arrives several hours later, her pad is slightly wet so she is asked to lay down for 20 mins to see if any water is leaking (amniotic fluid)... the woman has an assessment...the fetal position is LOA, presentation-longitudinal, position-cephalic (head down) head ?3-4/5 palpable..(a high head) and a speculum examination is performed to see if there is any water pooling.... there is none...she then has a real time scan (ultrasound) which shows reduced amniotic fluid.... and on reviewing her notes it is noted that she is GBS positive... which means she needs IV antibiotics in labour... the woman is contracting irregularly 1:10..it is now 9 hours since query rupture of membranes....and early evening... the doctor recommends induction of labour (IOL)due to GBS positive, high head, and irregular contractions..... the woman is unconvinced... but her questions are dismissed by the doctor.....when the midwife attends the woman and asks what are we doing for you this evening... the woman is hesitate about the upcoming procedure... when she is asked to explain what is going to occur...she states "the doctor wants me to have the drip"...language is very important... if you are listening to women you hear the unspoken question or the resentment....the next question needs to be... "is that what you want?" she replies " what are my options, I would prefer to wait until the morning to see if I can go into normal labour", she was asked, did you discuss this with the doctor....she said yes.... but he said this is the best option, "you will not go into labour with the baby's head so high".....I would still like to wait said the woman... the midwife discussed it with the doctor and he repeated, his reasons as already stated..... now here is where the conflict lies..... how far do you push for the woman? yes I hear you say all the way.... but how many times do you do this and then the doctor walks in and speaks to the woman and she says to him ok do it......

In this instance the midwife sat and spoke to the woman asking what did she really want and why? and gave the woman the pros and cons for having the IOL now or waiting until the morning.....presenting all the evidence including information about her GBS status & ruptured membranes including the option not to accept (refuse the treatment option) the doctors treatment option and that all this information will be documented in her progress notes. The midwife left the woman to discuss her options with her family, the woman then made the decision to wait until the morning before having the drip. The doctor was notified and the information was documented in the clients progress notes. The woman had some dinner, was happy with her decision and went walking around the hospital for the next two hours.... when she returned she was contracting every 6 minutes... and they were lasting about 45 seconds... it was great......everyone was happy..... the woman went on to labour all night and birth in the morning... it was a vacuum extraction.... there was no induction....in this instance it all worked out well.... the empowering of the woman was because she was given all the information and the woman made her own choice knowing all the risks... she just wanted to wait until the morning..... it really was not a lot to ask... she was being monitored.... that is, pulse, temperature, IV antibiotics 4/24,she did not want to go home... just wait until the morning... to have her baby the way she had planned....

Sometimes I think as a midwife you need to choose the battle.... read the woman's Birth Plan, and most importantly listen to what the woman wants......

picture ref:http://mdean.tripod.com/justice.html

Mother of all rallies:

As you may be aware if you have been reading my blog that on Monday in Canberra was the Homebirth rally.
I was excited to participate by having a virtual placard present, which I think is a fantastic idea. It was good to see the sea of virtual placards in attendance of the people who could not physically get there.


Women, babies, families and Midwives from all over Australia attended the rally to show support for Homebirth – the choice for women to have a homebirth, as from 2010 due to National Registration and legislation independent midwives would not be allowed to register to practice as a midwife if they did not have indemnity insurance.



What was exceptionally disappointing was there was very little media coverage about the rally. I rushed home after work to watch the news and subsequent current affairs programs and no one reported on the rally, not one channel – how unfair is that!
This is big news, over 2000 women, babies and families attended to show how they felt and no one picked up the story, my question is why?
This story made page 16 in the West Australian on Tuesday, bottom right hand corner, that’s just not good enough, who is listening to our voices?

Is it that we are women / midwives and the story is not big enough, do we not matter?

I do find it interesting that when the AMA has anything to say or protest about any issue it is always reported in the news, why is that?
What do you think?

The photos were supplied by a colleague midwife who attended the rally.

If you wish to read about what the rally was like from someone who attended visit Lisa Barrett's blog - rally thoughts!

watch this space!

Homebirth rally! Canberra September 7th 2009

In my last blog, I forgot to add the Homebirth website (Homebirth Australia) for the Rally in Canberra when is it:

WHEN: Sept 7th @ 11.30am
WHERE: outside Parliament House, Canberra

You can register your commitment to attend on face book
http://www.facebook.com/profile.php?id=1641140582&v=feed&story_fbid=9419...


Unfortunately I can not attend, however you can be part of this rally by being a Virtual Rallier what a great idea!

Be a ‘virtual rallier’. For every person who is unable to attend we are organising a virtual rally in conjunction with our ‘live’ rally. Pledge $25, send us a head shot, your name and location and 25 words or less that you want the politicians to hear. We will mount your head shot onto a cardboard pregnant belly with your message, which will be attached to bamboo and will be placed in the ground outside Parliament House. Your pledge will go towards the cost of your cut and our continuing campaign.

see you all at the Homebirth rally, virtual or real.

The Homebirth debate!

I'm a homebirth baby and I am not happy if my mummy does not have choice about my birth!



There is much debate around Australia amongst midwives and women, what’s it about? Homebirth! Now what brings about this discussion, yes it's National Registration: which means by 2010 all midwives in order to be registered with the Nurses and Midwives Board need to have indemnity insurance to conduct a homebirth.
It is interesting to note that within the profession of Midwifery there are many differing views on this subject. Historically nursing has been fractured and governed by the medical model; therefore this has carried forward into midwifery. You have midwives that consider themselves nurses as well as midwives who still follow a medical model. Then you have the midwives who consider themselves purely as a midwife. I do believe that the Bachelor of Midwifery will help change this perception within Australia. Try as it may midwifery battles with the medical model regarding health issues. We as a Nation hold a very medical model mentality; this is another reason why so many women choose obstetricians as opposed to midwives. However now with the proposed changes being made by the government which allows for midwives to have a Medicare provider number this is a huge step in the right direction. The introduction of the Nurses and Midwives Act 2006, further confirms the separating of the two professions, Nursing and Midwifery. Of course with every carrot there is a price to pay and in this case it is that the government will not provide indemnity insurance for private practice midwives (independent).

Midwives are highly skilled autonomous practitioners; however they may work in different ways. There are those who practice midwifery in every aspect, which is working with the women, antenatal, intrapartum and postnatal. You have midwives that only work in one area, so they choose either labour/birth suite or a ward area and only specialise in that area however they do know all aspects of midwifery care. When working within a hospital system (medical model) midwives can practice within a team model which is midwifery led care, referring to the medical model when a problem arises. Also midwives work providing high risk care in consultation with the obstetrician. Midwives always endeavour to keep labour as normal as possible for the woman. Even though midwives work within a hospital system there is also low risk normal labours and births with midwifery led care and without intervention.

As a midwife you can work in a birth centre and within the Community Midwifery Program which provides midwifery led care for low risk women. The only provision for Homebirth is in the community midwifery program. These midwives will be provided with indemnity insurance because they are attached to a health service. All other care is covered by Medicare or private health insurance.

Private Practice midwives (independent midwives) provide a homebirth service in which they will charge the women a fee approximately $4500.00. This fee will vary between midwives and is a reasonable fee as opposed to our medical doctors who charge much more, however the woman can claim this from her private insurance or Medicare.
Private practice midwives provide all facets of midwifery care and would refer to an obstetrician if there was a medical problem. The ideal is for private practice midwives to look after normal healthy women without any medical problems, therefore considered low risk. The Australian College of Midwives (ACM) provides National guidelines for midwives to assist them in which conditions are considered high risk. Remembering the definition of a midwife is to deal with the normal, anything abnormal is referred to an obstetrician for advice.
This is where some midwives differ in opinion; there are some who believe that all births should be in a hospital setting and those who believe anything goes. The most important point to remember is that it is the woman's choice as to where she wants to birth.
The conflict arises when a woman chooses to birth outside what is considered the ‘normal’ which is stated in the guidelines (AMC). A private practice midwife can choose to accept a woman even though she may be considered high risk. As long as the woman is well informed and has consulted an obstetrician for a medical opinion. The midwife needs to clearly document her discussion, care and plan of action; it is after all the woman's choice. However, the woman and midwife must accept the consequences of this action. The midwife has to remember to continue to work within his/her scope of practice as legislated by law. Fringe or radical midwives, whatever term you would like to call these midwives might accept any woman with what is considered a high risk pregnancy and this is where the problem lies. This is not an easy choice, because there are women that would go it alone rather than go to hospital. The question is who protects these midwives who choose to work with high risk women who are well informed and do not want medical intervention? Because the choice is that these women will go it alone.
I am pleased to work as a private practice midwife however I would not work outside the realm of 'normal' 'low risk' because that is what I consider the role of a midwife to be, anything that is abnormal is not considered for midwifery care within the home environment. There are midwives and women that would consider me to be conservative and not being ‘with woman’ because I choose only to take low risk women. I am happy to facilitate and care for a high risk woman within the boundaries of a hospital making her experience as much normal as possible.
I am sure that some women do not really understand the scope of practice of a midwife and that we are governed by legislation as to how we can work (Nurses & Midwives Act 2006). The big question is if the government does not provide indemnity insurance for private practice midwives, homebirths will no longer be allowed. This will surely push homebirth underground and more women will free-birth. This in fact will take us back to the dark ages, more women and babies will die. This is the last thing the government and society wants.
Change is slow - and maybe we need to take a step back to enable two steps forward. Medicare provider numbers are a step in the right direction; this will increase the visibility of the midwife and allow women to claim for the care provided by the midwife. Hospitals will give visiting rights to private practice midwives to birth women in the hospital under the care of the midwife and allow these women to go home a few hours later, continuing the care at home. Eventually the powers to be will see the value of birthing at home? 'It’s a nice dream'
I personally want to see women’s choice for homebirth being an option - by 2010 this may not be an option.


please contact your local politician and have your say!

Limited choice for rural areas - Homebirth refused

A NSW hospital refused a woman the right to have a homebirth, despite the local obstetrician agreeing to the woman's request. The obstetrician was willing to send a hospital midwife to the homebirth, however the request was rejected by the hospital.
The woman only found out by chance that her request was rejected - she states

They knew that at 37 weeks you can't fight,"Ms Caines said.

This woman who has been a maternity advocate in the region for eight years, said she was upset that women in the Upper Hunter were given fewer choices when it came to delivering their babies than elsewhere in the region.

she said.

"As a leading advocate I hold dear the fact that there needs to be benchmark of safety and quality,"

It's birth by postcode

The outcome is that this woman has now employed a private midwife for the birth, but not all women have have this option or resources to do this.
The reason the hospital gave for not allowing the homebirth was

...did not meet the criteria for a home birth because she did not have a GP who would support her and she needed to have a midwife from the Upper Hunter area.

There was no medical reason stated for the refusal of this woman's request, in fact she did have the support of an obstetrician and it made no difference to her case. This is a tragedy for women's choice.

Ref: http://www.theherald.com.au/news/local/news/general/muswellbrook-hospital-rejects-home-birth/1251837.aspx

The questions I am posing is; do our hospitals have the right to do this? and as a result of this, will the hospitals be forcing our women to "freebirth" or birth in a way that may not be safe and go it alone?

Would it not be better to find a compromise to suite all parties rather than a straight out "no"? do they think in doing this they can control women?

If we constantly refuse women their choices, women will find a way to do it? where does this leave us as a society and our duty of care?

What happened to informed choice and women taking responsibility for their own choices?
Why do we not allow women to make these choices? or are we just a paternalistic society?

Paternalism manifests in the making of decisions on behalf of clients/patients, where doctor knows best - that is the culture of our health care system - a culture which is hard to change.