Friday, May 28, 2010

Reflecting on a hospital transfer

I have recently reflected on the experience of transfer of a labouring woman from her home to the local public hospital. It's a regional city hospital, with contemporary obstetric, paediatric and anaesthetic services, and the machines that go 'ping'.

As usually happens in a transfer, a midwife takes away complex and multi-layered issues to reflect upon. In this brief record I want to highlight three points:
* the importance of seamless transfer from planned homebirth to an appropriately capable hospital
* the importance of careful decision making at each decision point
* the importance of respect by the hospital for the midwives attending the woman

The ability to transfer from planned homebirth to hospital in a timely manner, without any sense of shame or failure by either the woman or her midwife, is an essential part of professional midwifery in the community. Much has been written in recent months about the Australian private midwife's need to *collaborate* appropriately.

The process of decision making is constant and vital as labour progresses. As each observation is made a decision point is reached: the decision will be either to continue in 'Plan A', or to consider 'Plan B'. 'Plan A' is that the mother is able and willing to continue in the spontaneous natural process, with the expectation that this will lead to the best outcomes for her baby and herself, continuing in the care of her midwife(ves). Alternately, moving to 'Plan B' involves the decision that in this particular situation, intervention will be sought from specialist service providers.

The woman who transfers from planned home birth to hospital does so in a belief that she needs what the hospital is able to provide.

The woman has a right to expect a range of services within the capacity of that hospital. She also deserves respect for her choice of her private professional midwives, and the model of care.

My experience when entering some Victorian hospitals is an uneasy, awkward response from the midwives and doctors with whom I seek to collaborate. It's as though they would like to pretend that I (and midwives like me) don't have any place in the care of the woman I am attending. There is often a lack of respect for my scope of practice, and for the woman's choice of me as her care provider.

Private midwifery in Victoria, and in most of Australia, faces many challenges.  Inter-professional jealousy, with the effect of excluding or threating the private midwife's right to practice, is common.  Here are a couple of examples:

* A midwife attached to the regional hospital referred to above told me that the staff have been instructed to refuse to leave the room of the labouring woman when the hospital's advice is being discussed between the private midwife, the labouring woman and her partner. In an effort to ensure compliance, the woman's right to private conversation with whoever she chooses is being threatened.

* Midwives in private practice have experienced complaints to the statutory authority, complaining about their professional conduct during transfer from home to hospital. In material collected in the investigations, there appears to be a targeted trawling through records of previous cases involving the midwife under investigation and even other midwives associated with the midwife under investigation.

* Women who ask a GP doctor to order prenatal blood screening, and inform the doctor that they are planning homebirth in the care of a private midwife are increasingly being told by the doctor that he/she is unwilling/unable to provide that service; that their insurance would be jeopardised if they were seen to support homebirth.

The lack of acceptance and respect for midwives in private practice, and for the women who employ us, is a potential threat to the safety and wellbeing of the mothers and babies in our care. Midwives who fear reprisal and retribution when they need to arrange a transfer of a mother or baby to hospital may delay when the best course of action is the transfer of care.

1 comment:

  1. I think one of the greatest issues in transfer situations is the hospitals' respect for the woman's choice of care provider and place of birth. Some transfers work really well - where there's respect and a genuine concern to see that the woman's needs are met (including respect for her birth plan). Other situations are simply awful with a great deal of mistrust and suspicion. Not a healthy environment for a woman.


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