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.

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 art of listening and compromising with women

As a midwife the art of listening is imperative, not only listening but hearing what the woman is saying and wanting. This in its self comes with its own inherent problems because as a midwife you know what a woman wants, however this can be like walking a tightrope as a midwife is bound by rules and regulations, therefore it is about the language you use and the compromising you can implement to satisfy both the woman and the institution.

Language is commanding, it is all in the way it is presented; an example would be; you are having trouble monitoring(cardiotocograph (CTG) a woman and she is having a syntocinon (a synthetic form of a hormone oxytocin) infusion for an induction of labour (IOL). It is important to monitor the baby’s heart rate through this procedure as sometimes babies have a negative reaction to the drug and it needs to be stopped. The policy states that a woman having a syntocinon infusion needs to be on a CTG –however in this instance you cannot effectively monitor the woman. What is the midwife to do? The midwife reports to the doctor, the instructions are “the woman must be monitored, put a fetal scalp electrode on”. The procedure is explained to the woman, a small, tiny hook is put on the scalp of the baby, so we can monitor the baby – the woman flatly refuses this option, a definite “NO”. Next: the woman is told, “If you don’t have the scalp electrode and we cannot monitor you, our policy states we must do this. Therefore we will stop the drug and you can walk around for an hour, and if you don’t have contractions, we will start the drug again and you HAVE to have the scalp electrode attached”.

There is something profoundly wrong with this statement: the language is authoritarian, demanding, controlling, there is no compromising, no listening, no discussion, and it creates fear and rebellion and backs the woman into a corner. There has to be a better way of walking the tight rope without losing our balance and falling off. It may be sometimes possible to hold the monitor in place enabling a good CTG reading, thereby giving a good outcome, however I acknowledge that this can be difficult.

What do you do if a woman is refusing best practice, policy, or guidelines?

The answer, discuss the issues in a non-threatening way; give the reasons / evidence why it is important to do whatever it is you want; get the doctor to discuss the issues with the woman; clearly document all discussions and the reasons why the woman is refusing the treatment, however ensure that the woman understands the implications for her decision. It is also a good idea to read back your notes to the woman so that she clearly understands the implications of the discussions and it is how she sees the situation.

At the end of the day the decision will lie with the woman, if she is of sound mind, she is able to consent to treatment or equally refuse treatment. Part of our job is to give her balanced information to enable women to make an informed choice.

A policy is usually best practice and is to be followed. A guideline is as it suggests a guideline that usually outlines how the policy works; both are usually well referenced and evidenced based. In a legal proceeding the policy and guidelines of the time are called to guide the current practice at the time and the expected care to be provided.

Midwives are not and should not be expected to be doctor’s messengers; if doctors have these sorts of explicit instructions, they should be discussing this directly with the client/woman and not expecting midwives to pass on these instructions. The ANMC Competency standards, code of ethics and code of conduct all state that collaboration is essential with health professionals, this means discussing and sharing finding the middle ground, not just regurgitate doctors sentiments, doctors need to be building this relationship with the woman to also find a way to compromise. Midwives need to be mindful of the issue of “failing to obey a doctor’s order” this is a whole separate blog which I will be doing very soon. Working within a system you could face disciplinary action or be sacked for “Gross misconduct”…. Watch this space.

It must be remembered that the woman is the consumer, with her own freely chosen subjective preferences and desires. Doctors tend to practice paternalism – thinking that they know best. Paternalism in medicine is defined as acting for the welfare of the woman, often interfering with or disregarding the woman’s autonomy. Doctors need to find the middle ground.

Autonomy means ‘self-rule’, to act autonomously a woman needs liberty and independence from controlling influences, it is the right to hold your own views. As a midwife we walk a tightrope, balancing the woman’s needs, the requirements of the regulatory bodies and doctors recommendations…….the bottom line remains if a woman is of sound mind, well informed of her choices, she can refuse any treatment, however she needs to clearly articulate these choices together with the possible implications of her choice.

ref pic: http://lukespad.wordpress.com/

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?"

Inspired.....

It's been a difficult week and I am sure next week the news will be all about Homebirth and midwives... so brace yourselves: Today I rekindled my passion, after a hard week.

“Courage is going from failure to failure without losing enthusiasm.” – Winston Churchill

I was delighted when I was asked to talk to a group of midwives who wanted more information about becoming a eligible midwife, we certainly need more: I was greeted by approximately 10 wonderful midwives and a consumer, all keen to learn more about setting up their own business and eligibility: we spent the next two hours discussing the current issues for midwives and some of the difficulties that we are facing as a profession. Whilst I acknowledged that we have some difficulties, I do think that we need to continue to put pressure on the government to follow through on the Maternity reforms; issues such as visiting rights for eligible midwives, so that continuity of midwifery care is an option for all women.
What I found fantastic about today was the interest and that it was younger midwives who traditionally have worked in a hospital who are embracing these new challenges and thinking about working in a different model of care, being more autonomous and wanting to work in the community...which is best for women, and what we all strive for...they were looking for ways of making it work within their current settings....it was really exciting to work with them to suggest the best ways forward for change... it is very important to have change agents spread out to inspire and encourage these changes; change is about knowing people, its about being passionate.... change sticks when people embrace it..and that is what we have to do... I see such potential in midwives being able to set up antenatal clinics....working side by side with Obstetricians, shared care - and six weeks postnatal care that we can provide in the woman's home, how brilliant is that? once a few people start doing it...the knock on effect will be phenomenal.... the issue is that the doctors are fearful of losing control ...and we all know when people are fearful they do things they would not normally do:

Yes we are currently experiencing some issues and that's because this whole concept is new, there is much change and not just small changes they are all huge... National Registration, new Act, insurance, Medicare provider numbers: no wonder we are all reeling with fear.... these are catastrophic changes - independent midwifery has never been so regulated... and this all creates an atmosphere of mistrust: we have to work together...

I found it refreshing today to meet so many midwives that were keen to begin to think about working within a different model of care and this gave me great hope for the future...we need to embrace the changes and work together to implement different models of care...and challenge the medical model, with this comes a word of caution.... the consumer demand has to be present; women need to want 'continuity of midwifery care'.

We still have some major hurdles to overcome with the maternity reforms: collaboration, indemnity insurance, visiting rights and more midwives to take up eligibility.

“The greatest barrier to success is the fear of failure.” – Sven Goran Eriksson

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:

Report concerns or risks......

Mandatory reporting is not only in Australia.... the UK is calling for more health professionals to blow the whistle...
NHS staff told to 'report concerns or risk investigation'

Health regulators should warn nurses, doctors and midwives they may be investigated if they fail to report concerns about colleagues, MPs say.

The General Medical Council (GMC), which regulates doctors, said it was committed to doing more in this area.

It is interesting that not many doctors report each other, the old school boy tie mentality is alive and well.... this is evident by the following statement;

The GMC is currently investigating doctors at Stafford Hospital whose own work was blameless, but who allegedly failed to report colleagues.

It seems though no one has a problem about reporting nurses and midwives.....
maybe the culture will change and there will be fairness about reporting all unsafe health practitioners or health practitioners that put the public at risk....

We have to remember it is about professional responsibility, being aware of professional codes and guidelines and aware of what is good and poor clinical practice. It is also about employers being open and transparent about what occurs within its institution and taking appropriate steps to rectify any untoward activities and not turning a blind eye. Clients have to be protected and advocated for by the health professional, not bullied or manipulated into receiving treatments they do not understand or want.

Fantastic new project: One World Birth

Sign up to One World Birth with Sheila Kitzinger, Michel Odent, Ina May Gaskin, Elizabeth Davis, Cathy Warick and more.......

One World Birth is also building a community of birth professionals to connect, inspire and to help deliver change, to make birth better and safer everywhere.

Click on this link to sign up
One World Birth.com

Waiting patiently for grandchild no 8.....

The art of patience I think is disappearing, we are always in a rush for things to happen or to be done, we want everything yesterday...sadly this is a reflection of the times.

Pregnancy traditionally is anywhere from 37 - 42 weeks, which is nine months and one week. More than 90% of babies do not arrive by the predicted date. So it is not unusual for a mother not to go into spontaneous labour just because its her due date. Technically you are not overdue until 42 weeks, but alas you see women are being offered inductions of labour (IOL) from 37 weeks.

Some mums battle with health professionals consistently about this issue..why is it that once you get to about 38/39 weeks you are offered and IOL, it seems like we are trying to change the boundaries of normal gestation times: Fair enough if there is a medical reason for an induction: as in the fetus (baby) is at risk or the mother, but not because you look uncomfortable or because we can.... IOL can lead to a cascade of intervention and we all know where that ends up. We need to let nature take its course, it stands to reason if you have reached 40-42 weeks and you have not gone into labour your body is clearly not ready....and you have to wonder have we got the dates right? This can already be disheartening for the mother who is eagerly awaiting her new arrival and can sometimes be annoying after so much of anticipation and excitement and pressure from family and friends.

Sadly it is not just health professionals that put pressure on mums, it is society that is friends, family, acquaintances, all saying when is this baby coming.... why don't you just get induced and have it over and done with....it seems everyone is in a hurry....sometimes too this is born out of fear, fear that something may go wrong and we as midwives need to be constantly reassuring about the normal processes of birth.

Then off course comes the advice about how to be induced naturally...and believe me everyone has a story about this one.... (some women have tried it all and none of it worked, like wise some women have tried one or two and it has worked....you never know your luck until you try)
Some of the traditional ways are:
Walking, housework, spicy food (curry) raspberry leaf tea, nipple stimulation and if you are really game clitoral stimulation; intercourse (love making) which releases the hormone Oxytocin which is called the love hormone... this then gets the contractions started; essential oils such as lavender and clary sage; membrane sweep; acupressure and most importantly be calm and think positively..... but like anything it is practice that makes perfect.... doing it just once or twice is not going to make it happen... it is something that you are going to consistently do over a few days or so...ensuring that everyone is safe and you can feel the fetus moving...

Formal Induction of labour: starts with prostin gel or Foley Catheter; artificial rupture of membranes, Syntocinon drip.....epidural? however this needs to be a blog all on its own....

We are waiting for contractions to begin....passing of a mucous plug, waters breaking.... all signs of the beginning.....the deadline is looming...

Lamenting about the lost art of nursing care:

This is a plastic slipper-pan....mine was papermache...even more lightweight...

I have recently been in hospital, nothing serious but none the less needing/requiring some nursing care: There is nothing like a bit of firsthand experience to relay to nursing and midwifery students the importance of a caring attitude..... I also say that people generally complain about staff that are rude and give the impression of not caring ...that is a distinct difference to the nurse who just doesn’t give a shit.

I do have to say that I find being a patient extremely difficult because I do not want to relinquish any sort of control of my life.....to someone else particularly someone who really doesn’t care. On the whole my care was good..... However it is always the little things that make life all the more difficult..... like your tray being placed out of reach and you can’t move....emmm a little difficult.... and ringing the call bell to use...yes the dreaded bedpan... and it takes 20mins for the nurse to appear....then a further 15mins before you get the slipper pan.... oh no..... you can just feel your bladder is about to burst...and then you have this ridiculous looking slipper pan and you know it’s just not going to happen....at this point I wished I had a penis...it would be so much easier....but alas no we take a deep breath and ask to be left alone to contemplate emptying your bladder lying flat on your back and trying not to be in any pain.... it seems a fate worse than death...trying to pee in these conditions.... remembering you have done this all about 4hours ago and wet the bed in the process...then you have to go through the embarrassment and the changing of the bottom sheet.......anyway about half an hour later I think yes... I’m done.... ring the bell... by now the slipper pan is well and truly stuck to my buttocks... the nurse comes in “are you finished” yes thank you... Ok let’s get it out then.... lift up.... tummy muscles work frantically and lift.... as the nurse manoeuvres the pan out .... oops yes you guessed it.... a spillage...but of course... how can this flimsy product hold several litres of fluid without having a mishap......oh did I mention it is the middle of the night....the nurse says “oh that’s good....it didn’t spill did it?” emm... I lament and say...” I think that the bed is wet”....no says the nurse it’s your perspiration... it will dry very quickly....and slips out the room very quickly carrying her overladen slipper pan.... and me... well she doesn’t know that I am a nurse / midwife educator and am totally blown away by this blatant lack of insight into poor care....now here I am the patient....at this stage a not well patient who has pain, now lying in a wet bed and wondering is it worth the trouble to ring the bell wait another 20mins and complain about my care , have the sheet changed creating more pain or shall I just lay here and hope that I fall asleep as I am still affected from the anaesthetic... to which I do just that (I have to say this only happened once, not all the staff were like this).

I should think it is equally as difficult for a man to pee lying down.....

In the next bed was an elderly frail lady whom I had not met but could hear through the curtains that she had some sort of facial surgery and could only swallow. I came to this conclusion because I could hear her trying to swallow her drinks and her meals came in a bowl, she had hardly any visitors and was very quiet. It is interesting trying to assess someone you have not seen by the care she received from the nursing staff. Some nurses would come in very chirpy “Good morning, I have some pills for you, oh your poor darling, that looks uncomfortable let me crush your pills”....to, hello here are you pills.... Patient “oh I find it hard to swallow can you crush them” nurse – just try; patient; ok..... Cough; splutter; splutter; tears........oh Ok I will be back...... surprisingly it was the younger nurses that showed less caring....this occurred at least 4 times a day all with differing responses.... On the second day when the nurse came in and said “here are your pills and asked her to swallow them after the patient had asked for them to be crushed...... I could not bear to hear the patient again try to swallow....that I yelled through the curtains..if I could have got up without causing myself pain I would off.... why don’t you just crush or give her dissolvable paracetamol......the nurse scurried out the room and came back with dissolvable pills.... I know there is nothing worse than a busy body not minding their own business..... but it just had to be done...later when I got up ...the elderly lady said thank you to me for asking the nurse to crush her pills...and explained she had two sons lived away and it was difficult for them to visit...but they would say something if they knew.... and said I don’t know why some of the nurses won’t crush my pills.....she became teary and wondered whether it was all worthwhile.... I sat with her talking about life and I was saddened that none of the nurses found time to spend any time with this frail lonely woman who has had some remarkable facial surgery and how any nurse could possibly ask someone to attempt to swallow when visibly it was obvious that this was an onerous task for the elderly woman....

I know we all use the excuse that we as nurses and midwives are overworked, but please, caring and compassion is what we are about... it is a basic human need.....everyone is so busy with the task that there was absolutely no caring or compassion ......

My dilemma as an academic is how we teach our students to be caring and compassionate in a world that demands tasks to be completed in unrealistic timeframes.... and why are we producing young nurses that do not have a caring philosophy.....

Tip to nurses.... you never really know who the person you are looking after.... therefore be kind, caring and professional to all.... treat your patients like you would like to be treated yourself... and if you are having a bad day stay home..... don't inflict it on your patients.....

The lost art of letter writing: Etiquette:

I come from an era of when someone sends you a letter, remembering that a letter is in place of the spoken word..... It is polite to respond particularly in business; it was accepted etiquette to respond and say thank you for your letter, we will respond shortly or whatever the reasons are.....this is not the case anymore. Not responding is tantamount to rudeness, being uncivil as if to ignore a person who is talking to you.

Question: Do we put emails into the same category as a letter?

The end of February I sent a letter to our Private Health Fund with a query of an overpayment, this was a substantial over payment and we were keen to find out whether our fortnightly payments were going to be reduced and a refund of the overpayment. Up until last week I had not heard anything, so I rang them to ask had they received my letter. The Health Fund, said, yes we are processing your claim. When I asked “why did you not respond in writing”, their response was “oh we don’t do that, it’s not our policy”...... I asked how am I to know you received the query then... “emm” she said... “I guess you have to wait or call to confirm it has been received” as you can imagine I was less than happy with that response... the outcome was that the young lady assured me she would ring back when the claim had been assessed and completed..... I find this disgraceful business etiquette..... the Health Fund rang today to confirm that they were going to credit our membership... they did not ask if we wanted a refund.... and they were not going to send a statement to show how they came to their conclusions, even when it was asked for they said ‘it is not the way we do business” WHAT!... again not how I thought business should be run.... where is the accountability? what I do know is that if we owed them money...we would be receiving an account on a weekly basis....

Over the last 6 months I have written many letters and emails, mainly business orientated; I have come to notice that I have not had any responses to my letters. I wonder why this is. I have written to politicians, hospitals, GP’s with very little response not even the common courtesy to say thank you for your letter and we wish you well.....or we are looking into your enquiry and will inform you of the outcome. But alas no responses..... There could be several reasons for this.... one they don’t want to know about what I am asking.... or is letter writing just an out dated exercise... maybe I should twitter, or Facebook.... only joking:
Writing letters is about keeping in touch, building relationships and politeness ...it’s about presenting your business and responding shows good etiquette even if you do not want the product.....or service:

I do think as a society we are losing the art of letter writing on a personal level because communication via the internet has exponentially grown and therefore letter writing is not really necessary. Although I do think it is an art worth keeping..... but very few people do it anymore, which is a sad reflection of the times.


picture ref:http://www.pubarticles.com/article-letter-writing-write-formal-informal-letters-notes-1244769964.html

Rules of engagement and Facebook:

Firstly I want you to think about why do you engage in Facebook (FB)? What is your primary focus?...this question is very important as you will read further into this blog. For me it is about connecting with people, friends, associates, overseas family, local family, it’s about linking, networking and disseminating information.... FB is one of the fastest growing social mediums in the world...it is changing the way we communicate.... I see it as a fantastic way to get information out to the cyber world..... and remember it stays there forever:

A recent study shows that 54% of Australians use FB.........

Recently a friend described and instance where she was reprimanded in her work place over a Facebook (FB) comment, in fact she did not write the comment she ‘liked’ the comment; I thought that the reprimand was a rather excessive step, so I delved into the possible legal implications of such an activity and have decided that there are some specific rules that you need to consider when engaging on FB.... in fact we all know the rules I think that often people believe the comments they are making are so ambiguous, insipid or insidious that it won’t be connected to them or their work place..... Think again.

The term ‘friend’ on FB is a false term it lures you into a artificial sense of security; come on think about it.... how many of us really have 200-300 friends in real life?.... when I was growing up they use to say “if you are lucky, you will be able to count your true friends on one hand”..... In FB the people I allow in yes are called ‘friends’ and some truly are but the majority are valued colleagues, acquaintances, ex students, friends of friends...etc... not what I consider true ‘friends’, I have to say I like them otherwise I would not invite or accept them..... but in the true sense of the word friends.... most of them are not.... please don’t misunderstand this.... but it is a fact of life: Therefore I go back to the question Why do you engage in FB? You have to really consider who you let into your FB world and what you publish. Keep work and FB separate.

After doing a web search regarding some legal issues on FB... I have come up with a list of rules that might help you keep out of trouble in the work place or anywhere else relating to FB.

Rule 1: really consider carefully who you are letting into your FB as a ‘friend’, if you allow mangers, work colleagues/associates this means you let your work into your private life. Ensure you have a closed privacy setting.

Rule 2: Do not mention anything to do with your work place no matter how insignificant you think it is... if you can be connected to your work by your comment you probably break the golden rules of ‘confidentially’ and ‘Code of Conduct’.

Rule 3: Be mindful of the photos of yourself you allow on FB, these photos become the property of FB and if you are acting in an unbecoming manner this could come back to bite you later. Don’t allow people to take your photo without asking you and letting you know if it is going on FB.

Rule 4: Do not write on FB when you are angry or under the influence of alcohol once the information is in cyber space it stays there: Internet Defamation is the fastest growing litigation ....so don’t write anything derogatory about anyone.

Rule 5: People seem to believe what you do outside of work does not affect your work life....WRONG....this is dependent on what it is and if you have you bought your profession/company/school into disrepute? Just think of our footballers .....there is a prime example of unbecoming behavior.

Rule 6: Social responsibility: this is like a duty of care to society, a reciprocal duty: we owe society and society owes us a mutually beneficial obligation. Be kind to each other.

The bottom line FB is on your employers radar; remember be careful who you invite in your world, don’t talk about work, don’t say anything derogatory and be mindful of the photos you let FB have:

Have a read.. How to use FB without loosing your job over it.....
Happy Facebooking!!!!!!!

A Festschrift to celebrate the careers of two remarkable women:

I was privileged today to find myself sitting amongst many wonderful people and some great academics, I heard many wonderful stories of two amazing women who have had diverse and awe-inspiring careers which has had tremendous impact on the midwifery profession and will do for many years to come, Pat Brodie & Nicky Leap.



Until today I did not know what a “Festchrift” was, I meant to look it up on the internet….but just did not get round to it…. So was relieved today when I heard lots of people had no idea what it was…..and that it actually means “a living book of your life” a celebration of your career by others on the occasion of retirement, what a fantastic idea, just brilliant….. Someone likened it to being at your own funeral, except you are there to enjoy it….. but then Pat said it would be a very long funeral” ….. to me it really is a bit like “this is your life”.



There was opportunity for great networking….. Too many wonderful people to name them all …. Besides you all know who you all are…great to see you and have a chat…. The energy and inspiration goes a long way to maintaining your enthusiasm for when you get home… and need to carry on the task of change and ensuring women have choice and midwifery care…….



For me it was an inspirational day, the room was filled with liveliness….. my soul was rejoicing at the many possibilities for midwifery…..if only we had this sort of leadership everywhere in Australia….some places are truly isolated and continue to have an uphill battle…..we need to spread the talent….

Key take home messages that resonated for me ……

“Square peg in around hole” - midwives
“The less you do the more you give” – care in labour
“Every woman needs a midwife and sometimes a doctor too” - collaboration
“Community based continuity of care for all risk categories of women” – private practice
“The key is good collaboration”
“Morbidity of women during childbirth is only going to increase due to repeat caesarean sections and the obesity crisis…..” – Obstetrician
“Midwives are essential for primary care”
“Address the equalities of women and birth”
"From little things big things grow - Group practice

A truely wonderful time in Sydney..... the only downside was that I didn't stay an extra day or two do some shopping.....not that I have money for shopping...lol

The question is do you use a partograph or not?

The partograph or partogram graphically represents key events in labor and provides an early warning system for the health professional caring for the woman. Until recently I had not given this much thought, I just accepted as part of my practice. I would use a partograph as part of my normal care in labour. I do notice when I go to different hospitals how they all vary slightly. Some are just cumbersome, some not practical and some just down right difficult to use......... and as for that action line....that is a different question all together... I would happily use a partograph without the action line...because part of my normal practice is to know that if the woman is at 4cm and contracting well (3-4:10) then her cervix is dilating and I would make a mental note that in 6 hours I would expect to being seeing signs of being fully dilated.

I understand possibly the need for a partogram in the hospital setting when you have several people looking at the notes; therefore there needs to be a quick review process. However in a home setting you are the only person as well as your partner midwife looking at the notes...so I question the value of using a partogram:

As I was doing a search on the web looking for a partograph template, I found lots of literature supporting the use of the partograph and the action line in preventing or recognising obstructed labour. In fact The World Health Organization partographs are the best known partographs in low resource settings. Some people argue the partograph is essential for good decision making.....and therefore is considered best practice...

A midwife is legally bound to document to clearly / comprehensively all our care, recognise / interpret /act / inform on abnormalities found in a timely fashion however does this mean she/he has to use a partogram to do this?

I am thinking that it is not necessary to use a partogram in the home setting if your documentation clearly tells the story.

What do you think?

can you write your notes in a fashion that does not need a visual expression of what is occurring? and does it make a difference using a partogram?

please leave me a comment on what you think?

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....

My Road to Meditation:

I dabbled in meditation back in the nineties and met the Dalai Lama when he came to Perth…. I subsequently read his autobiography and thought that if I was to have my time over again I would be a Buddhist. I continued to be a part time practicing Catholic and turned more to being spiritual rather than religious. I read books about quantum time (physics), Road less travelled, You Can Heal Your Life, My Mother Myself, A Course in Miracles and many more…..trying to find a sense of spirituality… life got busier and busier and both religion and spirituality took a back seat…. Never leaving… always at the back of my mind but never that priority.

My recent trip to Tanzania I was touched by the strength of the ordinary Tanzanian, the courage in the face of adversity…. The pain that people suffered and accepted as part of their life….what was unbearable for me was to see children suffering in hospital… from the baby that was crying and needed comforting and no staff to do this, his nappy changing and there was no nappy…. Or the toddler that was screaming because he was being bathed in Potassium permanganate dissolved in warm water to come up with a nice pink colored solution, having his burns debrided with no pain relief, it brought tears to my eyes…… I was both humbled and frustrated…. The disparity between rich and poor was at times palpable. The health issues seemed so insurmountable, that I need a way to stop my mind from churning…… I realized that my spirituality was missing… it was not even dormant it had gone……

Last year was very busy and stressful particularly then end of the year was even more so, after I came back from Canberra, I was at breaking point and realized I needed to stop….. I had decided to either go back to church on Sundays or start meditating….I usually go to midnight mass, have for the last 30 yrs… there was a new Parish priest at the church I usually go to… and it was the worst service I have been to for a very long time….no inspiration…… there was nothing….I was like a stranger, I came away knowing I was not going back….


I did an Internet search for a Buddhist retreat starting in January…and would you believe it one was starting on the 2nd January…. I booked in for the week and I have not looked back since then….. I felt like I had found my way home……very strange…. Time will tell how I go….. I feel calmer…. My mind is less chaotic and I now have strategies to slow it down…..I have set myself some boundaries as far as work is concerned…. And am working on my discipline to continue with my meditation on a daily basis with a quarterly retreat to keep me focused…I found a meditation centre here in Singapore and went this afternoon, which was a great end to my teaching weekend……watch this space...


Happy Chinese New Year "Rabbit" Happiness and Prosperity to all....