Head on the chopping block – HOMEBIRTH:

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

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

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

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

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

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

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

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

Should all women have a midwife? YES

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

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

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

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

Three questions:

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



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

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:

ACM Interim Homebirth Position Statement and Guidance for Private Practice Midwives

It is long overdue, a position statement on Homebirth for Australia from the ACM, well done: since 1987 RANZCOG has had an endorsed position statement that opposes homebirth: Since 2007 there has been a joint statement from the RCM & RCOG supporting homebirth for low risk women:

Now the ACM has an interim position statement that supports homebirth for the woman who has a 'low risk'; which is in line with the current Australian Legislation: The ACM cannot contradict the regulatory authority which created the Quality and Safety Framework.

This brings me to the Introduction of the Statement; yes 'women have the right to choose where and how they wish to give birth'..... as I have discussed before in previous blogs...women always have this choice...what they don't have is the right to a midwife to support that choice...because of how the legislation is set-up here.... for women that are in a 'risk category' a midwife needs to consult and collaborate with an obstetrician and this does not happen.... certainly not in WA....this is not from a lack of trying from private practice midwives / independent midwives to collaborate with doctors; As a privately practising midwife I have tried to no avail to get doctors to collaborate; they do not answer emails, letters phone calls. I have had some success with one doctor however the doctor is reluctant to put anything in writing.
A midwife owes the woman a duty of care to provide a safe environment and work within the defined scope of practice...very few obstetricians will support a homebirth for any risk category....and here we have a quandary; unlike the UK that supports midwives to support women in whatever choices they make.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG) does not endorse Home Birth.
In Australia about 0.2% of women deliver their babies at home. However this may be an underestimate, as it is unlikely that all babies born at home are recorded in perinatal data collection statistics.
Whilst mindful of a women’s right to personal autonomy and decision making, RANZCOG
cannot support the practice of Home Birth due to its inherent risks and the ready availability of safer birthing practices. Where a woman chooses to pursue Home Birth, it is important that this is an informed choice, considering all the benefits and possible adverse outcomes.

RCOG and Royal College of Midwives joint statement
The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.

The ACM is the professional body for midwives and I urge midwives to comment on the Position statement: contact the college and express your point of view, do you agree with it? How would you change it? give a balanced view:
Send submissions by email to info@midwives.org.au or by post to PO Box 87, Deakin West ACT 2600. Only submissions with identified senders and a return address will be considered, you have until 23rd September 2011.

As for me I've read lots of comments on the Statement and the guidance document, one comment that keeps appearing is that a scarred uterus is a 'new concept' or 'new rule'.... this is nothing new.... a scarred uterus has always been considered 'high risk' I suppose what is new is the terminology of a scarred uterus...but the concept is old...

My objection with the Guidance Document is the fact that as a private practising midwife we are required to consult with an obstetrician prior to or at booking-in: this is an unrealistic expectation; I am usually booking a woman at anywhere from 8-12 weeks: I would prefer a booking visit with the obstetrician at 20 weeks to discuss the plan of care: The Woman is encouraged to attend this appointment with her midwife and create a plan of care...if the woman chooses a different pathway this also needs to be discussed and a plan made to facilitate this choice: this is clearly documented and all parties sign the document understanding all the risks associated with it: however I am not sure that this will be enough to protect the midwife in a court of law: What we need to be working towards is a continuity of care model...supporting high risk women to birth in hospital with her private midwife having visiting rights to all hospitals.

Remember please to send your comments to: info@midwives.org.au

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.

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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'.