Monday, July 4, 2011

Access to medical services

Midwives working in modern cities have excellent access to medical services when and if they are needed. The catchment in which most of my clients live is well serviced by public hospitals that are leaders in complex obstetrics and neonatal care. I live within a 20 kilometer radius of Melbourne's three 'tertiary' (now called Level 5) hospitals: the Women's, Monash Clayton, and the Mercy. I am also close to Box Hill and the Angliss. Within about an hour's drive I can expand my access to medical services to include Dandenong, Casey, Frankston, Sandringham, Mercy Werribee, Sunshine, and Northern. [click here for map]

In reflecting on this level of access, I am thinking of my friend and colleague Jacinta, who is working as a midwife with MSF in a very remote town in central Africa. If you click to her blog, you will read that at present the service has
"no OBS/GYN and no surgeon, so there is no-one in Aweil who can do a caesarean section. One of the other MSF OCs has a surgeon in Gogrial, a very bumpy 2-3 hr drive away, so we can transfer there BUT only between the hours of 7 AM – 3 PM due to curfews in place for security reasons."

I plan to reflect more on access to medical services, and write about it here, after I have done the postnatal visits today.

[some days later]

I have had a few attempts at composing the rest of this post, and deleted them. The reality in my world is a different reality from that of previous generations of my family, and from that of remote places in Australia, Africa, or the frozen Canadian wilderness.

If a woman in my care needs medical intervention, it's available 24/7; it's considered to be at the level of world best practice; and if there are adverse outcomes, everyone involved expects questions to be asked by peers and regulaory authorities.

Australian privately practising midwives are coming under serious scrutiny even when outcomes are good, as in the recent case of a midwife who attended a woman for VBAC (vaginal birth after caesarean) at home. That midwife has been denied the right to continue her private practice while the case is being investigated. See the post on HBAC at Homebirth Australia's FB site.
Other midwives have experienced lengthy periods of suspension or restrictions to their practices, when in the minds of their peers they have provided excellent midwifery care.

Women who are looking for a midwife in Melbourne today often ask lots of questions, “what would you do if ... (breech, twins, post maturity &c)” Those who have experienced Caesarean birth may ask the midwife under what conditions she will agree to attend HBAC.

My answer is that I don’t have a fixed answer. Decision making is an ongoing process, rather than a concept of ‘choice’. The safety and wellbeing of mother and baby are the guiding principles for every midwife. The midwife's duty of care is a different issue from the mother's autonomy over her own body. Sometimes the midwife and the mother will disagree on the best course of action – we have to live with that.

Modern society has become accustomed to Caesarean births. The national rate of Caeareans in this country is approximately 30%. There is a small but significant number of women who are strongly motivated to planning VBAC in their own homes, and their desire is to find a midwife who has the skill and the willingness to work with that plan.

The Australian College of Midwives (ACM) position on homebirth is that:
"Women have the right to choose where and how they wish to give birth. ... Whatever place of birth a woman chooses, a women and her family have the right to expect that the care she receives is provided by appropriately skilled attendants and is safe."

The difference of opinion between competing care providers for births after Caesarean is mainly in an assessment of risk. See MidwivesVictoria blog for a midwifery perspective that considers the woman and her baby to be at low risk, and midwifery care in the home to be optimal, provided the pregnancy and labour progress without complication.

Medical/obstetric care, which includes care provided in most hospital settings, considers the risk of harm to mother and baby in births after caesarean to be such that requires continuous electronic monitoring in labour. This intervention is intended to give the best possible level of surveillance, with the intention that if the baby shows signs of distress there is the option of emergency caesarean surgery. Midwives working in the home do not have continuous electronic monitoring, and rely other methods of monitoring progress and wellbeing of both mother and baby.

For more discussion on VBAC and risk, go to the posts on this blog in July and August 2010, for example, here.

With an estimated risk of 1 in 2000 for catastrophic harm (discussed here), such as death or serious brain injury to the baby from hypoxia, and death or serious haemorrhage of the mother, any midwife or doctor providing care in planned vbac must be conscious of the possibility of an escalation of complications.

Thankyou for your comments


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