Sunday, November 13, 2011

When women choose maternity options against the recommendations of their midwife

Having written a post on the new ACM Position Statement on Homebirth Services 2011, together with a 'guidance' document and literature review, for the APMA blog yesterday evening, I find that my mind is dwelling on the situations in which women "choose a planned homebirth when this is not recommended by a health care provider."

What are the forces that are exerted within our communities, pulling women, and midwives, toward professionally acceptable standards and actions?

How does a midwife make a clear and timely call, telling the woman who has employed her to provide homebirth services, that homebirth is no longer recommended?

Where is the cut-off, between low- and high-risk? 

The ACM National Midwifery Guidelines for Consultation and Referral (ACM Guidelines 2008 - which are available to download free as a .pdf) set out situations in which a midwife is expected to consult with, and refer a woman to, an appropriate medical/obstetric service provider.  Conditions listed under category C, requiring referral, include chronic hypertension, pre-eclampsia, multiple pregnancy, breech presentation at Term, coagulation disorders, diabetes requiring Insulin treatment, and many other medical and obstetric conditions and complications that may co-exist with the pregnancy, or arise during pregnancy, birth, or the postnatal period.  A woman experiencing these complications requires coordinated maternity care from a team of medical, midwifery, and possibly other disciplines.

Another all-too-common-today situation is a woman who has had caesarean surgery for one or more previous births.  According to the ACM Guidelines (2008), previous caesarean is category B, meaning that the midwife is required to facilitate consultation with a medical or other health care provider.  The ACM Guidelines do not attempt to differentiate between those for whom homebirth is not recommended. 

The South Australian Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 recommendations state clearly that "A previous caesarean section and breech presentation are contraindications for home birth."

As noted at the APMA blog, obstetrician Andrew Pesce has given advice on a way forward for those who want to bring homebirth into mainstream maternity care, with:

"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."

It's clear to me that there are important conversations that the midwife needs to take responsibility for, when complications or new risk factors are identified.  The midwife's professional duty of care requires that the situation, and a plan of action, be clearly outlined and any questions responded to, to the best of the midwife's ability.   The woman's response can be to agree, to disagree, or to explore further.  Simple questions that I encourage women to ask, if at any time someone wants to interrupt the physiological processes are:

  • What do you want to do?
  • Why do you want to do that?
  • What is likely to happen if I say "no"?
The partnership between a midwife and a woman requires honesty and trust both ways.  A woman who fears that her midwife may 'make' her transfer to hospital, for some trivial reason, will not make an informed decision.  Similarly a woman who takes no responsibility for her own decisions, but puts herself meekly in the hands of her midwife, is not making informed decisions.  Trust always has limits.  Midwifery is not a cult; midwives can not ask for blind acquiescence.
As a wise colleague put it,  

"I find the 'trust birth' claim far too naive ... but I think a lot of women in their bubble want to believe it. Perhaps all our easy access to IT - internet/emailgroups/facebook etc has something to do with which women choose homebirth now and why and who and how cult followings get supported, possibly blindly."

I wonder today if some women are misusing maternity care, and abusing the trust of their midwives, in a cult-like way that over-rides partnership, and puts the woman's experience first and foremost. 

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