Thursday, November 26, 2009


Collaboration, according to Wikipedia, is
"a recursive process where two or more people or organizations work together in an intersection of common goals — for example, an intellectual endeavor[1] [2] that is creative in nature[3]—by sharing knowledge, learning and building consensus. Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group.[4]..."

Anyone applying this description to the fact of collaboration between a midwife and other professionals in maternity care would be likely to have no difficulty. There is self-evident logic in collaboration.

From the woman's perspective, there is an expectation that any professional care will be effective, safe, and centred on the needs of the woman and her baby. Obviously a woman expects the various professionals to work together. BUT the unique and often forgotten reality in maternity care is that BIRTH IS NOT AN ILLNESS. Only the women who experience illness or medical/obstetric complications come within the scope of requiring medical attention. The women who are well throughout pregnancy and birth, and who intend to give birth spontaneouly without medical stimulants or pain relieving agents will only need to be referred for medical attention if something happens to change this plan.

A midwife who provides primary maternity care for a woman in the childbearing continuum, pregnancy-labour-birth-post birth, is able to consult with and refer to specialist care providers and services if and when needed. This is no different from a dentist who refers you to an oral surgeon if you need surgery in your mouth that is outside the scope of the dentist's scope of practice.

"Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group."

This statement is worth considering when applied to Collaboration in maternity care. The professional leadership in any maternity care collaboration is the primary carer; ideally the known midwife who attends the woman throughout the episode of care. The midwife who has a limited number of women to whom she is committed (referred to as a 'caseload'), and who intentionally establishes a partnership with each woman in her care. New Zealand has defined the 'Lead maternity carer' (LMC), who is identified for each woman receiving maternity care, and can be either a midwife or a doctor.

That's woman-centred care. The woman/baby dyad is positioned at the centre of all decision making. All care is tailored to meet the specific needs of the individual woman and her child.

Unfortunately the woman is not the centre of care in the statements of RANZCOG, the powerful professional body which represents obstetricians in Australia and New Zealand. RANZCOG agrees with Wikipedia that "collaboration requires leadership" but it denies the midwife any role as primary, or 'lead' carer. The RANZCOG form of leadership is heirachical, and not "social within a decentralized and egalitarian group."

The RANZCOG statements make it clear that the obstetrician is the ‘designated clinical leader’ in all collaborations. This is from RANZCOG Guideline:
Suitability Criteria for Models of Care and Indications for Referral within & between Models of Care (2009)

<2.1. All Models of Care are Collaborative

Clear decision making processes are required within the collaborating team, recognising both the knowledge, skills and experience brought by each team member and the imperative of a designated clinical leader.>

The new legislation that is currently passing through Federal and State parliaments will require midwives to have a written collaborative arrangement in place for all midwifery practice, signed off by a Medical Practitioner and a midwife. It is unclear whether the collaboration would be able to occur with a public hospital, as is currently the case for many women and their midwives. It is likely that the hospital's insurers would deny this option.

Doctors are not required to have collaborative arrangements with midwives. Can you imagine a doctor providing intrapartum and postnatal care for his or her 'women' if there were not a band of helpful midwives in attendance? That would be quite unAustralian.

I will leave it at this point. I am preparing for a Stakeholder forum in Canberra, organised by NHMRC, on Developing National Guidance on Collaborative Maternity Care.

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