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

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

Virtual IMD reflection

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

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

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

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

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

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

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

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

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

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

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

Women need to debate if its time for fetal rights:

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

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

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

’

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

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

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

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

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

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

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

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

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

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

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

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

The Face of Birth

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

Collaborative Maternity Care Agreement - give your feedback

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

It is very important to give your Feedback.

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

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

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

Born Alive Rule - is it time to rethink

A few seconds after birth:

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


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

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

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

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

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

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

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

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

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

WHO defines live birth as

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

.

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

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

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

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

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

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

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


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

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?"

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Homebirth: A reminder July 2012 is looming

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

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

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

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

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

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

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

Challenging times for women and midwives (HBAC)

Sad and disturbing times for both women and midwives:

As a private practice midwife it is very important to understand the boundaries of my role as a midwife; some are outlined in my previous blog “government paying us lip service”. Many midwives are facing complex ethical dilemmas:
As a UK trained midwife I was used to being able to do a homebirth for a woman who has risk factors and has had collaboration and consultation with an obstetrician through the local Health Authority and has chosen a homebirth despite these risk factors. The difference being that in the UK there is a Supervision system of midwives (supervisor of midwives) that provides midwives with support and backup. Also within the UK system you are protected by legislation that states that only a midwife or a doctor can assist with the birth except for an emergency in which case anyone can help.

S16 (1) A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth: Nurses Midwives and Health Visitors Act 1997(UK)

In the UK a woman’s choice is respected in that she can birth at home and the local Health Authority has to provide a midwife for the homebirth if one is available (National Health Services Act). Also the Royal College of Obstetrics and Gynaecology (RCOG) and Royal College of Midwives have a Joint Statement No.2. -April 2007 supporting homebirth and work together to support this. However here in Australia a major problem is that the AMA categorically opposes Homebirth.

The Nursing and Midwifery Council (NMC) works in the same way as AHPRA in its role to protect the public to ensure that midwives work within their scope of practice which is low risk ‘normal’ and provide a safe environment for birthing women. Independent Midwifery is also under threat in the UK as there is no insurance for private practicing midwives: see Homebirth and the Law reference list: http://www.homebirth.org.uk/law.htm

The Health System is different in Australia; therefore we cannot really compare with the UK except to say that both regulatory authorities work in the same way, in protecting the public and ensuring that midwives provide safe and competent care for the woman.

Legal Advice: I am not a lawyer and not giving legal advice; this is my interpretation of the legal advice given to me)

I have to state that my position as a midwife is that yes I believe in “women having choice in place of birth” and I believe that every woman should have midwifery care. I also have to state that I believe my role as a midwife is dealing with the “normal” and anything that falls outside of the parameters of “normal” I will collaborate with an Obstetrician, working in partnership with the woman to achieve a mutual arrangement and provide midwifery care throughout. I would like to see more liberal / flexibility surrounding place of birth for high risk women instead of always sending women to tertiary centres where they often feel alienated and fearful this would be a step in the right direction.

In light of the recent debate surrounding HBAC, I have sort some legal advice regarding the issue of VBAC (vaginal birth after caesarean) and having a homebirth. I wanted to know where I stood legally when a woman approaches me as a midwife asking for this service, should I decide to book a planned homebirth for H/VBAC – in terms of my responsibilities and my registration/licence: You have to remember that a good lawyer can argue a defence for anything and there is always a defence to be had.

The first question you have to ask is - What does the professional bodies say about HBAC / VBAC?
The professional bodies are the AMA and ACM – (the AMA has 90% membership, do not support homebirth, and is very powerful & political) does this give you an idea of what the answer will be to the first question.

Second question: What does the regulatory body stipulate about HBAC/ VBAC? Here you have to look at the current codes and guidelines that govern midwifery practice; you could compare with the UK, NZ and USA;

Thirdly : Have you provided unbiased informed choice, have you got collaboration (Dr; support) for the H/VBAC is it clearly documented, have you clearly documented the risks associated with HBAC/ VBAC , are you providing a safe environment for the woman; and have you an emergency care plan, are you working within your scope of practice?

There may be a possible defence, how successful this would be is the unknown quantity as it has not been tested yet and I can assure you I am not going to be the first to do this.

Women do have a choice of place of birth; however the choice to have a midwife present in the home environment for a risk associated birth is a limited option due to the legislation and the regulatory authority. However if the midwife chooses to accept the HBAC he/she maybe risking disciplinary action which could mean losing his/her registration and or having restrictions on his/her practice together with a lengthy legal case that will be distressing and costly.

How to move forward:
The answer is to work on changing legislation, to something similar to the UK and gaining support from the AMA to collaborate with midwives in listening to what women want. Helping and facilitating women achieve the kind of birth they want in a safe environment with a health professional to support them, whether that is in hospital or the home. Providing different models of care which include continuity of care no matter what the risk factor is.

It is very clear that the consumer/woman has to lead the impetus for change, the demand must come from them otherwise nothing will change; it is the power of the voter to change legislation.

The government is paying us lip service:

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

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

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

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

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

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

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

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

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

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



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

It’s been a while since I blogged.... life in the fast lane

Canberra - Autumn

I have really missed blogging even felt guilty about not writing and sorry to my faithful readers for the lack of updates, but as usual the build up towards the end of semester (marking, studying, and meetings) takes its toll on my time to blog....

Let’s see where I got up to.... sorting out collaborative agreements... progressing with CeMGP “the practice”.... writing copious letters and getting limited responses....working three days a week at Uni.....my commitments to the College continue...picking up three units in my study this semester was not a wise move...note to self “don’t do that again”, no more than 1 or 2 units or drop something else... almost forgot I was sick....feeling better now... the mediation continues.... it really keeps me sane I do notice my anxiety levels rise when I don’t meditate... Thank God on Saturday I get an injection of super duper all day retreat... that should centre me again.


Jasmine - I think mummy ate all that chocolate

On the grandchildren front the birthday season for this year has begun, as they get older they are harder to buy for.... Jasmine is now 7, Dylan (June) 6yrs & Jessica (Aug) 6 yrs, Talia (June) 4, Sam (July), Isabella (July) and Logan (Oct) will be 3yrs old and off course our newest one Tayla is 7weeks old.... by far the greatest pleasure I get is from the grandies...they are truly delightful and the light of my life.....


Talia's party:

As the semester comes to a close and the marking is complete, its time to read a book or novel.... today as I was buying birthday pressies for family and friends I spied a couple of books that leapt off the shelf into my bag via the cashier.... I wanted them all...but alas some are for gifts, however I will keep and read “The Wish” it did appeal to me.... so will give some feedback once I’ve read it.... I think I am back in the swing for my blog... will update on the political agenda for midwifery in my next entry:
Ciao!

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.....

Privacy Act: patient consent to collect and disclose information:

This is a gentle reminder for all privately practicing midwives to get patient / client consent to collect and disclose information, especially now that there are eligible midwives: something else we have to set up for the practice........

All organisations that provide a health service are covered by the Privacy Act (whether or not they are small businesses). Organisations providing a health service include:
traditional health service providers such as private hospitals and day surgeries, doctors and specialists
• pharmacists
• allied health professionals such as psychologists
• complementary therapists like naturopaths and chiropractors and
• in some cases other services like gyms, fitness services and weight loss clinics, child care and schools (if they provide a health service and hold health information).

The National Privacy Principles set out how organisations should collect, use, keep, secure and disclose personal information. They cover collection, use and disclosure date quality
Further information on the new privacy legislation can be obtained from the Australian Privacy Commissioner’s web site http://www.privacy.gov.au/

Don’t leave Privacy to chance:

10 steps to protecting other people’s Personal Information:

1. Collect only the information your require
2. Don’t gather personal information just because you can and just in case you require it
3. Tell people what you are doing with the personal information you are collecting
4. Consider whether you should be using personal information for a particular reason
5. Think about whether you need to divulge the information
6. If people ask, give them access to the personal information you hold about them
7. Keep personal information secure
8. Don’t keep information longer than you need to
9. Keep information accurate and up to date
10. Consider making someone in your organisation or agency responsible for privacy

Use and Disclose example: with my consent, the practice staff will use and disclose your information for purposes such as:
- account keeping and billing purposes
- referral to another medical practitioner or health care provider
- sending of specimens for analysis
- referral to a hospital for treatment and or advice
- advice on treatment options
- the management of our practice

Ensure that you gain the clients consent (best to have written consent) for the practice or midwife to collect, use and disclose personal information as outlined and I understand that I may withdraw my consent as to use and disclosure of my personal information......

ref pic:http://health-link.com.au/PrivacyPolicy.aspx