what are the boundaries for homebirth midwifery practice?

The short answer:

"I don't know."

The midwife purist answer:

"I am 'with woman', not 'with' or committed to a setting for birth or a model of care. The midwife is able to provide primary maternity care throughout the continuum for any woman who proceeds spontaneously through pregnancy, birth, and the postnatal period, and to advise on potential complications and refer the woman to specialist services if the need arises."

The midwife pessimist answer:

"I must restrict my practice to 'low risk' women, or I am likely to face complaints and even suspension of my registration, and loss of my ability to earn a living while complaints are investigated."

My answer:

"I'm not prepared to define boundaries. I am willing to explore possibilities with any woman who asks me."

For example:

"I am starting the process of looking for support for a home birth. My first two children were born via c-sections (breech, then a failed hospital VBAC). I am wondering if HBA2C something that you can support?"

Similarly, a colleague midwife called me to discuss her client whose pregnancy has now gone past 42 weeks. Is it 'safe' (for the mother, the baby, and the midwife), to proceed with a plan for homebirth after 42 weeks?

Am I being evasive, even dishonest, in saying that I do not want to give a yes or no?  I don't think so.

Here's what I hope to achieve:

• Optimal outcomes, and the best level of care possible for each mother and baby.  I surely do not want any adverse outcomes. 
• Each mother feeling safe, and confident in making decisions as her pregnancy-birthing journey unfolds.
• Each mother feeling respected, even when and if the journey leads her on a pathway that she would not have chosen.

I acknowledge that the only place where I can act as the responsible professional care giver is, at present, the woman's own home.  Hospital visiting access for midwives is 'in the pipeline', so to speak, but I'm not holding my breath. 

I have attended many women in labour after Caesarean birth.  Some have given birth spontaneously at home, while others have transferred to hospital for the birth.  Some of the hospital births have been spontaneous, and some assisted medically, physically, or surgically. 

The confidence I need to have in each woman and baby, as they progress in pregnancy and labour, and in the crucial moments and hours after birth, is "Are you well?"  "Is the mother well; is the baby well?"

When the answer is "Yes", I can be confident to continue under natural, physiological processes.

When the answer is "No", or "possibly not" or even "I'm not sure", I must move into a new state of alertness and planning, and inform the mother as to my recommended plan of action.  That's the only way a mother can make an informed decision.  I can't make the decision for her.  Her husband can't either, although of course there is often a shared decision-making process entered into willingly by the woman.

Midwives have often said that we sit on our hands.  We refrain from all unnecessary interruption, interference, and intervention, as we observe a labouring woman.  Our skill is in enabling and encouraging the woman to continue working with her own body.  However, a capable midwife also recognises when intervention is required, and acts confidently and appropriately.  The non-interventionist intention of a midwife must always be balanced by skill and knowledge, and an ability to act in the interests of mother and baby when indicated.


Returing to the question: "I am wondering if HBA2C something that you can support?"
Yes, it is.  My role as a midwife is to be 'with woman'.  If that woman makes an informed decision to plan homebirth, and asks me to be with her, I can support her plan.  However, in accepting the role as midwife to that woman, I am not committing to home birth, or even to natural birth.  Those decisions are yet to be made, and will be made by the woman as events unfold.

And the other question, "Is it 'safe' to proceed with a plan for homebirth after 42 weeks?"

For some women it is, and for some women, definitely not.  I must advise the woman on her own position, to the best of my ability.  I encourage the woman to listen to other voices of expert advice: the doctor at the hospital where she has a booking, for instance.  The woman must make the decision that she considers best at that point in time.

Thankyou for your comments

WOW!

In the previous post on this blog I reflected briefly on newspaper reports about 'ex-midwife' Lisa Barrett (for want of a better description of Lisa).

Thismorning I have been repeatedly shocked and challenged as I have read Lisa's blog 'Free for all', and its screeds of comments in the day or so since the account was posted.

The struggle to protect an Australian woman's right to choose the maternity care she receives, and her right to plan homebirth, has continued over many years. I have participated in that movement for the past 20 years. I have seen colleagues in the press limelight briefly; I have seen organisations take a lead in efforts at political lobbying. In recent years I have witnessed changes under a socialist health policy, offering hope (the carrot) of better maternity services for all, that have introduced a level of bureaucracratic control (the stick) that has not previously been imagined by independent midwives.

As I said in my previous post, it is not possible to judge a case when we have only fragments of information. It is also not possible to obtain consistent information, or judge the reliablility of information, through blogs and the media.

Yet the big issue that I am seeing as I read Lisa's blog, and the linked comments, concerns the rights of parents to keep and protect their newborn babies. The case study that Lisa has presented exemplifies the harsh reality that the State can, and apparently in some circumstances will, exercise protective custody of a newborn baby when and if it chooses. This is a statutory right in developed societies, set up to protect innocent lives. Its misuse, which is what this chilling account clearly suggests, will surely instill fear into the hearts of midwives and caring parents.

Many independent midwives, including yours truly, have chosen a less confrontational pathway through the current maternity reform process, than the one Lisa Barrett has - very publicly - taken.  BUT the scenario presented in this case: a mother giving birth in hospital to a well baby, after planned homebirth, going home with their baby hours after birth, and making an apparently informed decision that this is better than staying in hospital ...

I could name women in my practice who have signed themselves and their babies out of hospital care in very similar circumstances.  Occasionally over the years, women have been reminded that they could be reported to child protection services.  It's the trump card that can be pulled out to force non-complient mothers into line.  Once initiated, there's a legal minefield ahead.

Your comments are very welcome.

a preventable death?

Whenever I hear of the intrapartum death of a baby, or other major morbidity or mortality around birth, I wonder what actually happened: was it preventable?

What were the critical decisions leading up to the adverse outcome?

Speculation is not helpful. When my sources are limited to media reports, blogs, and email discussions, I am unlikely to ever know the detail, or be able to form an opinion, on a particular case. However, there is great value in critical reflection on my own experiences, considering what happened, why it happened, how I responded, and how I might respond in the future if faced with a similar situation.

Readers of this blog are probably aware of the Coroner's inquiry that has been proceeding in Adelaide, into the homebirth deaths of two babies, and the well-known homebirth advocate Lisa Barrett who was in attendance at these births. Now Lisa has again been mentioned in a newspaper report, of "the death last week of a newborn twin".

An American blogger who is definite and unrelenting in her anti-homebirth position, Dr Amy Tuteur, has informed her audience of this newspaper report.

The key point of difference between those who support homebirth is whether the choice to plan homebirth can be made by the woman, or if that is a matter requiring professional 'duty of care' in declaring whether or not homebirth is considered a 'safe' option. Can a woman be allowed to make an informed decision? 

The International Confederation of Midwives' (ICM) position is that

“The ICM supports the right of women to make an informed decision to give birth at home.”

Australian Private Midwives Association (APMA)’s ‘position’ is

“We support home birth with a midwife in attendance for women who have uncomplicated labours.”

I don’t think anyone would argue that a twin birth can be called uncomplicated prior to the birth. But the big question is what the midwife does when a woman who knows she has twins on board makes what she considers to be an informed decision to give birth at home.

I’m not wanting to put my head in the sand; to shift the blame from the midwife to the woman. A decision to plan to give birth at home requires a whole series of conversations, during which the midwife and the woman consider the situation, and the woman decides whether to stick with 'Plan A', the natural, physiological process, or to move to 'Plan B'.

A woman who thinks she has made an 'informed' decision  can be horribly ill-informed, whether the decision related to home birth or to medically managed birth in hospital. For the record, here's a recent example:

A woman who has a young baby believes she made an informed decision for the birth and nurture of her child. The woman has been treated by a specialist psychiatrist for depression. The psychiatrist *informed* the woman that her depression could become worse if she was sleep deprived, and encouraged her to suppress lactation and artificially feed her baby - to prevent sleep deprivation. The obstetrician supported this plan, and furthermore encouraged the woman to undergo elective Caesarean surgery - also in order to keep everything well controlled. The *informed decision* that was reached, in consultation with both doctors, was that a Caesarean operation would be performed without labour; that the baby would not go skin to skin on the mother's breast; that the mother would receive medication to suppress lactation; and that the baby would be separated from the mother, and cared for in the hospital's nursery for most of the mother's hospital stay.

This scenario leaves me wondering. 

Thankyou for your comments