The Face of Birth

Interesting:

Collaborative Maternity Care Agreement - give your feedback

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

It is very important to give your Feedback.

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

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

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

Born Alive Rule - is it time to rethink

A few seconds after birth:

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


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

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

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

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

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

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

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

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

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

WHO defines live birth as

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

.

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

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

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

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

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

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

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


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

The 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/

The challenge of collaboration:

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

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

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

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

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

The pamphlet explains to women that

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

No Collaborative Agreements: No equality or justice:

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

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

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

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

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

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

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

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

Just taking a step backwards;

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

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

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

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

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

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

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

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

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