PRIVATE MIDWIFERY SERVICES

making birth safer

2012-02-04T15:45:00.000+11:00

... for the mother and her baby.

All maternity professionals are expected to act in a way that protects the wellbeing and safety of mother and baby. That's a reasonable expectation of any society. Midwives have guidelines and codes of practice and decision-making frameworks that are all structured around principles of safety and quality.

The tragic death of a woman, Caroline Lovell, after giving birth at home in a Melbourne suburb, has thrust homebirth midwifery into the media spotlight. I have written about the breaking news at the MIPP blog. One comment summed up the situation,

"A tragic event is made sadder by the tendency of traditional media to suggest a causal link between the setting for this birth and the poor mother's passing before the facts have come to light."

I do not have information about the facts of this case, and I therefore cannot form an opinion. I have heard the TV reports, read the newspaper reports and online commentators, and had conversations with other midwives and members of the community who have heard rumors. A TV reporter who spoke to me before recording an interview told me that a leading legal person in Victoria had commented that she considered homebirth midwives to be "cultish". I reject this notion. There is nothing at all cultish in professional midwifery as described in international and Australian definitions and standards: the standards against which all midwives are judged.

I am hoping that whatever tests are done, the autopsy, coroner's inquiry and report, and the investigations by the Nursing and Midwifery Board of Australia will satisfy my need, as a member of this community, to be confident that in this case, there was no professional negligence or unprofessional conduct. I would have this expectation regardless of where the death occurred.

Many women have contacted their midwives with messages of love and support. Women have also told their midwives that they are being questioned by concerned family members about their plan for homebirth.

The decision to give birth at home is made by the mother, with professional advice from her midwife. If the labour is not progressing well, it's crucial that decisions about transferring care to hospital are made in a timely fashion. This is the midwife's responsibility - not the woman's choice. A labouring woman cannot be expected to monitor her own progress. A mother and baby have limited reserves. When the demands of the birthing process become more than the mother or baby can be reasonably expected to cope with under natural situations, the best option is to transfer care to a hospital which provides emergency obstetric care. There can be no guarantees of particular outcomes.

Dear reader, I have only touched on these deep and potentially unsettling issues. The intense media interest in this case passed quickly. However, midwives who are ready to learn from each situation will not forget.

The reports by Coroners are placed on the public record. For example, a baby death in hospital from perinatal asphyxia.

Thankyou for your comments

'Coming out' of the hospital

2012-02-01T22:39:00.001+11:00

A colleague who is in the process of establishing a private midwifery practice wrote: "I am feeling very disillusioned with the whole hospital system at the moment. ... Women do not have choice in hospitals."

My colleague went on to describe a couple of instances in which women who she accompanied to hospital experienced intimidation and bullying which led them to accepting interferences that they did not want, and were, understandably, unhappy with their experiences.

This midwife is a skilled, competent midwife with years of experience in hospital-based midwifery. She asked me if I think the solution to her dilemmas is to guide women into planning homebirth. I said no, I don't think that's the answer,

Understanding normal physiological birth (Plan A) from the woman's and baby's perspective is, I believe, the key to working as a midwife, 'with woman', and without fear of the hospital. I'm not suggesting that an experienced midwife does not understand normal birth, but what I am saying is that having become acclimatised to hospital processes and rituals can diminish the midwife's focus on the woman, as she has always previously been required to work according to the service's guidelines and protocols. As the midwife 'comes out' of the hospital, and shifts her focus from the service to the woman who knows and trusts her individually, she will become strong in her identity as a professional midwife.

Whether it's a first baby, third baby, or a vaginal birth after caesarean (VBAC), or any other situation in which the woman intends to labour spontaneously, once everyone accepts the process of spontaneous onset of labour and getting established in labour, not interfering without a valid reason, it’s usually not difficult to go to hospital and complete the birthing there. Plan A all the way, if that's possible at the time.

I recently wrote about vbac at the mipp blog so won’t repeat that here. Many midwives feel disillusioned with the hospital system, and they have experienced no alternative so they quickly start to feel trapped. I think the thinking of the disillusioned midwife (or student) may be too much in the framework of being part of the system in the way they want the doctors and the other midwives to work with them, such as in respecting women's 'choice'.

'Choice' is a concept that is misunderstood in maternity care. Midwives talk about 'informed choice', and become frustrated when a woman who wants spontaneous unmedicated birth is quickly put on the managed care conveyor belt, and ends up with augmentation, epidural, 'and the lot'.

A midwife who has become independent of the system, and independent in her thought processes actually has a new way of looking critically at birth and learning how to adapt her knowledge to suit the individual woman in her care. The focus of the midwife changes subtly, and she learns how to work effectively so that the wellbeing of mother and child is always first in her mind, at the same time as she uses knowledge and skill to work in harmony with, and protect, delicate natural processes. The private midwife's role takes into account the standard responses that are part of mainstream obstetric managed care, and the midwife expertly protects and guides the woman to understand how she can accept what she needs and decline, without becoming anxious or defensive, what she doesn’t.

For example, I spoke Linda (not her real name) who had achieved vbac for her last baby by just refusing everything and I mean everything – she is very (wonderfully) stubborn! Understandably Linda wants to have an unmedicated spontaneous birth for this baby too. I spoke to Linda about the various interventions that are considered standard practice in the hospital for vbac, and asked her to tell me how she felt about each one.

When we got to having intravenous (IV) access, Linda could only think about it getting in the way and being annoyingly painful when she moved her hand. Linda was interested that the IV cannula could be sited at her wrist, and she could have full movement of her hand. She came around to an understanding that it could be to her advantage, if "they" were happy for her to get on with her labour. She knows that her veins are difficult to access at the best of times, and siting the IV cannula might be something that can be taken care of in early labour rather than being a major source of interruption in the most demanding time.

Does Linda have choice in hospital? Yes. She can choose to refuse the intervention. Or, she can make an informed decision to accept an IV cannula that is positioned carefully so as not to impede her activity or movement.

This is a very simple example of how a midwife and woman work in partnership. The midwife knows and understands the system, and at strategic points gives the woman guidance that assists her in making informed decisions, and feeling she has authority for her natural birthing process. The midwife has 'come out' of the system/hospital and is learning how to use the system to benefit her client.

Thankyou for your comments

on a personal note

2012-01-27T10:45:00.000+11:00

Picture taken yesterday, at the home of friends

Today Noel and I are celebrating 39 years of marriage. Thirty-nine years of shared life is worth noting, and I thank God for this man!

I'm not going to try to delve deeply into personal matters, but I do want to draw attention to the importance of a stable and supportive home base. A midwife who intends to provide primary care for women across the childbearing continuum, including the occasional disruption and uncertainty that come with spontaneous birthing, needs security and stability within her home and family life. Of course this can't be guaranteed - situations can change in an instant.

Most of the women who call our home phone to speak to me get the opportunity to speak with Noel. He's my gatekeeper when I have been out all night, and need a sleep. He's my receptionist when I'm out, or when I'm having a shower. When a mother and baby come for the 6 week postnatal 'show and tell' visit, he usually manages to say hello, and offer congratualtions on the new baby.

Noel's qualifications are in Veterinary science. His Masters and PhD work at Michigan State University in the 1970s investigated the protective effect of colostrum for the newborn calf. He demonstrated that a calf who received colostrum in the first days of life was protected against 'scours' - the term used for gastroenteritis in the dairy, responsible for high rates of death of calves. At that time, newborn dairy calves were removed from the cows immediately after birth, and fed with 'milk replacer' - a substitute milk similar to the formula milks made up for human babies. Noel's research also demonstrated the phenomenon of 'gut closure': the brief time immediately after birth when macro molecules are able to pass across the intestinal wall directly into the blood. The time and significance of gut closure in human infants is still unknown.

I believe I have benefited a great deal from Noel's studies and academic work. The principle that the natural physiological processes across the childbearing continuum are truly awesome, and truly worth protecting, has strong foundation in my mind. Those who remember the 1960s and 70s will recall the infatuation in health care with what they saw as science - that science could provide smart alternatives to anything natural, from clothing fabrics to human milk. Women were being told they no longer needed to be burdened with tedious natural tasks such as breast feeding. Women could control when they had babies, and what they did for the babies they bore. Intellectual theorists of the 60s and 70s hailed female-male equality as the new societal standard.

The reality that was ignored in attempts to free women from the burden of nourishing their babies was that being a mother can be GOOD! That maternal instinct is a strong force, under hormonal direction, that enables a woman to want to stay with her baby; to respond to the baby in a loving and nurturing way; to give the baby access to her breast whenever and wherever the baby is hungry or needs comfort. Interruptions in physiological processes inevitably interfere with hormonal states, leading to non-physiological and often adverse outcomes.

I had not learnt about maternal instinct in the midwifery course that I had completed just months before the birth of my first child. The midwifery teachers were older single women, as were most of midwives in senior positions in the hospital.

I am looking forward to continued learning about the beauty and desirability of hormonally-mediated maternal behavioural patterns.

Thankyou for your comments

Breastfeeding well from the start

2012-01-14T13:23:00.001+11:00

1977, with my son Paul

Breastfeeding is PLAN A.

Breastfeeding is what a woman's body expects to be doing, whether her mind agrees or not, and it's what a baby expects to be doing, from the start. Anything else is a variation from the biological, hormonally determined, norm. Anything else is a compromise, as far as the natural physiological processes are concerned.

Although breastfeeding is 'natural', it's not simple. For many women and babies, it's not easy. For many women, alternatives appear attractive.

Today I want to focus on breastfeeding well from the start. This is not possible for all mothers and babies, but it is possible for most. As with 'Plan A' in birth, 'Plan A' breastfeeding can best be achieved when the mother, the midwife, and all involved, accept and work in harmony with sensitive natural processes. As with 'Plan A' birth, 'Plan A' breastfeeding can be interferred with by a well-intentioned but misinformed person, resulting in distress for all and possibly long-term consequences.

The midwife who understands these truths will protect the mother-baby pair during pregnancy, labour and birth, anticipating the wonders and challenges that lie ahead; will support the woman and baby as they learn about and explore each other from the moment of birth; and guard the bond between mother and baby after birth, guiding and instructing the new mother only when the need arises.

The title of this post, 'breastfeeding well from the start', puts breastfeeding into the context of a continuum. Breastfeeding is a relationship, not an act. The same word, 'breastfeeding' describes what the baby is doing, and what the mother is doing. Yet the actions taken by the two participants are very different.

Consider the breastfeeding continuum within the series of firsts:
. the first moment
... the first hour
..... the first day
....... the first week
......... the first month
.......... the first year

Breastfeeding well from the start is, like any other natural phenomenon, most likely to continue on the right track if it starts on the right track. By this I mean, the mother and baby who are well at the onset of labour; who proceed spontaneously, without medical stimulants or emotional coaching or analgesia or anaesthesia to a normal birth; who experience the wonder of falling in love in the moments after birth, bringing with it a huge surge of the love hormone, oxytocin; enabling the mother to release her baby's placenta without excess blood loss, and enabling the baby to use his senses of sight, smell, taste and touch to search for the breast and achieve a deep attachment; suckle, and swallow the sweet, precious colostrum. This is usually happening in the first hour after birth, before anyone else has held the newborn.

The first hour quickly passes, and the first day unfolds. Mother may pass the precious little person to the father, or another trusted family member, so that she is able to empty her bladder, and wash herself. She needs to eat and drink, and rest. Each time baby is alert, the instinctive actions of both mother and baby culminate in breastfeeding. Baby goes to sleep, and mother can't because she is too high!

2011. Bec and James (18mo)

The first day opens out into the first week. Baby works strongly and confidently at the breast, and soon the breasts are swelling and producing a bountiful flow. Baby's feeding and sleeping pattern changes, as does the colour of his stool. Mother sleeps well between breastfeeds at night, and is quickly returning to strength. She accepts the closeness of the relationship between herself and her child. Someone asks "Do you feed your baby on demand?" and she has to think what that might mean. Not really - her baby has never learnt to demand a feed. She looks at her baby, or her baby looks at her, makes a sound or a movement of his mouth, and together they proceed with the most satisfying and beautiful work that either knows about.

And so it goes, through the first month, and the first year, or two, or ...

Thankyou for your comments

Looking forward

2012-01-07T09:20:00.005+11:00

From time to time I have taken the opportunity on this blog to write about the complex and often challenging position I and other midwives have found ourselves in as we work through and apply government 'reforms' and changes to our practices.

Now, at the end of the first week of January 2012, I want to summarise my position as a midwife, attending individual women for birth and associated prenatal and postnatal care, and what developments I expect and hope for in the coming year.

Firstly, on the positive side of the ledger:

Babies are being born, and thriving - beautifully.
Women are being transformed in the process of giving birth. That's a wonderful thing to witness.
Collaborative arrangements are being set up with a couple of supportive GP-obstetricians, who are happy to give women referrals for the midwifery services they choose.
Collaborative arrangements are being set up occasionally with obstetricians, after the woman and baby have been discharged from hospital, enabling one-to-one postnatal care for the woman.
Medicare rebates are being paid to women who use the services of participating midwives.
I am happy to bulk bill additional antenatal and postnatal visits, which continue until the baby is 6-7 weeks old.

On the negative side of the ledger:

Some public hospitals at which women make homebirth back-up bookings are refusing to acknowledge the collaboration in the way that has been spelt out in the legislative determination, in that there is, for example, no provision for a 'specified medical practitioner', who is "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.", or any acknowledgment "when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy" ...
Midwives eligible for Medicare are required to sign an undertaking to complete a course in pharmacology within 18 months, yet there is no such course accredited.
No midwives have access arrangements to privately attend women admitted in hospitals. This means that women who choose to give birth in hospital, with their private midwife in attendance, must accept the hospital's employed midwife as the leading midwife at the time of the birth. This situation can lead to unnecessary conflict.
There is no insurance product to indemnify midwives attending women privately for home birth. The government has exempted midwives from the requirement until 2013, and we don't know what (if?) plans are afoot to rectify the situation.

Logically, indemnity insurance does not change outcomes - it simply provides a pot of money that can be fought over in the law courts, should there be an adverse outcome. I consider the only solution to the insurance problem is to set up a no-fault compensation scheme, to which all health professionals contribute, which provides a suitable level of financial support to those who suffer disability or loss, separate completely from the apportioning of blame.

Midwives who face regulatory or coroner's inquiries into incidents in which they were involved are being advised to obtain legal representation. While ideally a professional should be investigated by peers, it seems that the process of investigation into conduct is becoming increasingly formalised, with inherent costs and isolation of the practitioners.

I have recently accepted a role as Vice President in Australian Private Midwives Association (APMA), which represents private midwives nationally. I have been a member of this organisation, and have written and edited the APMA blog for the past couple of years. It is a privilege for me to work alongside the President Marie Heath and the other committee members. Keep an eye on that blog if you are interested in the national private midwifery scene.

I continue my involvement in Midwives in Private Practice (MIPP), which represents midwives practising privately mainly in Victoria. See the MIPP blog. MIPP is a participating organisation in Maternity Coalition (MC). The concept of partnership between the woman and the midwife is carried through into the relationship between MC and MIPP.

There are plenty of challenges to keep me busy in the midwifery profession broadly, as long as I have the (physical, mental, spiritual) strength to continue my practice. I enjoy consulting with women and attending them professionally in their homes, mentoring other midwives, giving lectures to midwifery students at Deakin University School of Nursing and Midwifery, and my involvement in the Professional Development Unit at Deakin.

Family and home responsibilities keep me busy, and my beautiful grand-children remind me of the every-changing needs of our most precious resource.

Thankyou for your comments

Simple pleasure

2011-12-26T11:44:00.004+11:00

My life as a midwife brings the personal and the professional into an unpredictable, ever-changing mix. As long as I have mothers and babies on my books, I am conscious of the possibility that I may be called out at any time. This is particularly important to me at Christmas time.

Today is Boxing Day, and I am reflecting on our family's Christmas celebration. I want to record here a few of the simple pleasures that I experienced this Christmas. I call them simple, because they happen without any fanfare or note, but actually these pleasures are part of a wonderfully complex natural order that is ours to enjoy.

I treasure the births of two babies in recent days, with all the struggles and challenges birth brings. The knowledge that a young mother can confidently nourish and nurture her child, with loving support from the baby's father, gives me great pleasure.
I treasure the singing of carols, reading of the scriptures, and reflecting on the reason for the celebrations.
I treasure the feasting: meals with family and close friends, sharing good food and fellowship.
I treasure being able to take food from our garden and include it in the festive meals: eggs, herbs, peas, spinach, broccoli, leek, spring onion.
I treasure the special festive foods that we make and eat: the stuffed turkey, the pudding in a cloth, the big fruit cake, the decorated gingerbread house
I treasure the special family gatherings: this year we had a memorable performance of the Owl and the Pussycat from our seven-year old Poppy, who has realised that she can read even nonsense words like 'runcible'.

There are many more simple pleasures that come to mind. Yet I know, dear reader, that this time of year also brings its share of pain and sorrow for many people. Families with fractured relationships, and people suffering illness. The experience of loneliness and loss will often destroy pleasure and suck hope out of life. There is no simple answer, no easy fix, when sadness and fear threaten to overwhelm us.

With this in mind, whether times are easy or difficult, I am reminded that the principles for a life of integrity are, "to act with justice, to love kindness (mercy), and to walk humbly with our God." (Micah6:8)

Thankyou for your comments

Hospital back-up for planned homebirth

2011-12-12T16:41:00.000+11:00

This post is a continuation from the MIPP midwivesVictoria blog

Midwives in this part of the world use the public maternity hospitals to make backup arrangements when we are planning homebirth. As a general rule, we plan to use the hospital nearest to the woman's home, that has the capacity to provide emergency obstetric services at any time of the day or night.

My home is situated about 20K East of the Melbourne CBD - about 30 minutes' drive from the Women's Hospital in Parkville. It takes approximately the same amount of time for me to get to either of the other two major 'tertiary' referral centres: the Mercy in Heidelberg, and Monash in Clayton. Box Hill hospital's Birralee Maternity Unit is about 15 minutes' drive from my home; the Angliss in Ferntree Gully is about 30 minutes.

I am happy to attend any hospital, either when my client requires transfer from planned homebirth to obstetric/hospital care, or when a woman in my care chooses to give birth at that hospital. The focus of a midwife's care is the *woman* - not the planned place of birth. I have often said to other midwives, and to women in my care, that *homebirth* is not an outcome. It's a location - a setting for birth.

The importance of having a plan for transfer to hospital from planned homebirth has been highlighted since the new regulatory authority AHPRA has been set up, with a long list of codes, guidelines, and statements that define a midwife's practice. The NMBA Safety and Quality Framework for Privately Practising Midwives attending homebirths has a requirement for "Clearly articulated referral pathways for referral and /or consultation in accordance with ACM Consultation and Referral Guidelines."

Homebirth is the unique domain of women who intend to give birth without medical intervention, establishing labour spontaneously at Term, and progressing to birth without the need for medical or surgical assistance. Babies born under such conditions are usually well, and require little or no assistance to make the transition from the womb to the outside world.

The midwife's role in planned homebirth is to determine when, and if, complications arise. At that point the decision may need to be made to transfer to hospital. Such a decision cannot be made at the time of booking, or even at Term prior to the onset of labour. The decision-making process is an ongoing, dynamic one, which must take into account all the related factors at that point in time.

Your comments are welcome.

a womb-baby's heart

2011-12-02T20:14:00.001+11:00

A couple of weeks ago I reflected briefly upon some of the uncertainties that parents face, especially when an abnormality is detected in their womb-baby. I linked to the evolving story, as told by Petrina and Dave on their blog, whose womb-baby's heart was in distress; whose little body was distended with fluid that the wee heart was failing to direct through the tiny body.

We are a family who believe in the power of prayer, and we are asking GOD to protect this unborn child and mother; to guide the minds and hands of the professional care providers, and to bring blessing through this difficult time.

Some years ago a young couple spoke to me about their womb-baby, who had been diagnosed with a serious heart defect at the 19 week anomaly scan. They had been anticipating the wonder and joy of the birth of their first child. Instead they experienced unutterable shock. They had been advised to abort the baby. They quickly and confidently declined the offer.

Our faith community at that time united in prayer for the young couple, and for their womb-baby. We prayed for him each time he had surgery, and we have watched him grow.

This week his story has been told in a Herald Sun newspaper article.

IN Melbourne's eastern suburbs on Friday, a boy called Kush will join classmates at a graduation dinner celebrating the end of his primary school years. Last year, he qualified for his school's cross-country competition and he plays cricket every weekend.
He's a kid who was never expected to live long enough to even start primary school, let alone finish it. This little chap functions on only three heart chambers. He's cheeky and smart and he has a mile-wide smile.
He has endured four open-heart surgeries - the first was when he was just five weeks old.
At 19 weeks gestation, medics discovered he had a serious congenital heart defect. They recommended termination because of the likelihood he would die early and painfully.
But his parents would not consider abortion.

In reflecting about our young friend Kush, and about Petrina and Dave and their womb-baby, I want to encourage midwives to remember that the life of a baby in the womb, even a womb-baby who has an imperfect heart, is a gift from God to that family. As they learn to do whatever is possible to promote health and wellness, they also learn to accept the possibility of loss of a child - a journey that one would never choose. These are life lessons, and are the lessons our parents and grandparents had to learn, in a different time, when the possibilities of restorative medical and surgical interventions were vastly less than they are today.

I am sure it has been difficult for Petrina and Dave to share their journey, often not knowing what the next day will bring, with an open audience. Yet I sense that they and others will be helped, as a little network forms around a tiny and less than perfectly functioning womb-baby's heart, knowing that they are not alone.

In a society which pretty well assumes that it's *best* that a baby who may not survive birth should be aborted - terminated - I honor parents who stand against the prevailing trend, and treasure the life of that womb-child.

Thankyou for your comments

HYPOGLYCAEMIA and newborn babies

2011-11-27T17:41:00.001+11:00

From time to time I have an opportunity to participate in a Baby Friendly Health Initiative (BFHI) assessment of a maternity hospital. I have participated in BFHI since the early 1990s. Today I am reflecting on one such recent assessment, and the importance of protecting, promoting and supporting breastfeeding.

BFHI is a global initiative of WHO and UNICEF. Hospitals implement infant feeding policies consistent with the 'Ten Steps to Successful Breastfeeding', and ethical marketing practices for the distribution of artificial milk formulas for babies.

Hypoglycaemia (low blood sugar) is the *diagnosis* under which many breastfed babies in Australian hospitals receive formula feeds in the first hours of their lives. Babies of mothers with poorly managed diabetes - that is, mothers whose blood sugar levels are abnormally high - can become very ill very quickly when their sugar supply is abruptly cut off at birth. Please refer to the Women's hospital CPG on infant management of Hypoglycaemia1. for further review of definition and management guidelines. The brief comments I wish to make in this post will be made with consideration of that CPG as a statement of the way I understand contemporary practice.

Definition of terms

Hypoglycaemia: There is a lack of consensus on a definition of neonatal hypoglycaemia. It is recommended that clinical practice be guided by operational thresholds (i.e. blood glucose levels at which clinical interventions should be considered).Clinical signs which suggest clinically significant hypoglycaemia are non-specific and include jitteriness, irritability, high pitched cry, cyanotic episodes, apnoea, seizures, lethargy, hypotonia or poor feeding.

When BFHI assessors visit a hospital, we have a series of questionnaires that are designed to gauge the hospital's compliance with the global BFHI criteria. Midwives, doctors, and other staff who advise women on breastfeeding are asked to state three acceptable medical reasons for use of breastmilk substitutes. The usual response includes 'hypoglycaemia'. The assessor is required to explore the meaning of 'hypoglycaemia' further to check if the staff member is confident of what is an acceptable reason.

The BFHI acceptable medical reasons include

newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age, or who have experienced significant hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic) if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.

Usually the hospital's own clinical practice guidelines will be quoted. The assessor is able to then check the hospital's guideline on management of babies with hypoglycaemia.

Why is this important?

The short answer: Diabetes.

A longer (incomplete) answer:
'Hypoglycaemia' is one of the main reasons for breastfed babies in hospital receiving formula feeds. Diabetes and hypoglycaemia are closely linked, and breastfeeding may prevent the development of diabetes later in the child's life.

A hospital that has a breastfeeding policy consistent with the BFHI '10 Steps to successful breastfeeding' is required to implement management guidelines for hypoglycaemia that are consistent with the breastfeeding policy. The 'steps' in which a hospital's management of suspected hypoglycaemia has a potential to interfere with the establishment of breastfeeding are:

Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff

"exclusive breastfeeding in the first six months of life
protects against chronic conditions in the future such as type-1 diabetes, ulcerative colitis and Chron's disease
Breastfeeding during infancy is associated with
... lower prevalence of type-2 diabetes, overweight and obesity during adolescence and adult life
..." [from BFHI Australia Booklet 1, p16]

Step 2: Train all healthcare staff in skills necessary to implement this policy

Protecting, promoting and supporting the natural physiological processes in birth and nurture of a baby requires skill and commitment by all care providers.

Step 3: Inform all pregnant women about the benefits and management of breastfeeding

Women who are well informed will be able to make informed decisions about any interventions that are recommended in the care of themselves or their babies. Those who know they are at risk of having babies who develop hypoglycaemia are able to take some measures to avert the need for breastmilk substitutes, including careful dietary measures and avoidance of sugary foods.

Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.

The hospital's definition of 'medically indicated' must be consistent with the BFHI acceptable medical reasons. Also, note the need for true blood sugar level to confirm hypoglycaemia.

Step 7: Practise rooming-in - allow mothers and infants to remain together 24 hours a day

Babies identified as 'at risk' who are asymptomatic should stay close to their mothers and breastfeed normally.

infant with risk factors for hypoglycaemia but no clinical signs - blood sugar level < 2.0 mmol/L [Women's CPG]

Step 8: Encourage breastfeeding on demand

Step 9: Give no artificial teats or dummies to breastfeeding infants

The hospital policy and guidelines need to be reviewed critically at regular intervals, by people who are well informed and who are skilled at asking good questions.

The protection of breastfeeding in potentially complex clinical situations is not a yes-no, black or white situation. Guidelines can, and often do, help us to avoid unnecessary and potentially harmful interventions into normal physiological breastfeeding situations.

For example, a baby weighing 4 Kg at birth may in some cases be at risk of hypoglycaemia, and in other cases be healthy, consistent with the size of his or her parents and siblings. In the latter case a clinical judgment would be made by the midwife, not to measure blood glucose levels as this baby is judged to be a well, term infant.

Thankyou for your comments

A letter to obstetricians

2011-11-18T15:23:00.001+11:00

I have sent letters to obstetricians practising in my area.

Re: Medicare rebates for private midwifery services

Dear Dr XXXX
I am writing to inform you of my current private midwifery practice since obtaining notation as a Medicare ‘eligible’ midwife.

Examples of the services I am able to provide are:
• a part of the woman’s care such as postnatal only (after discharge from hospital)

• antenatal care that is shared with an obstetrician or hospital,
• primary maternity care for the whole episode of care, whether the woman is planning to give birth at hospital or in the home.
[Note: At present midwives do not have visiting access/clinical privileges in hospitals. However, this is a goal to which public hospitals are working, through the Three Centres group project on ‘Collaborative arrangements with eligible midwives for Victorian public hospitals’. I am a member of the Expert Reference Group for this project, and am keen to see privately practising midwives able to obtain visiting access in hospitals.]

Medicare scheduled fees and rebates for private midwifery services are listed on the attached document Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011.

Since becoming eligible for Medicare, I have found that some women appreciate more postnatal visits in their homes, with Medicare rebates making the service more affordable, than was previously the case. Rebates are available for postnatal consultations in the six weeks following the birth, and for a 6-7 week review. I am now able to write referrals to obstetricians and paediatricians, and request tests and investigations related to childbirth. I do not yet have PBS authorisation, and Victorian law is yet to be amended to enable midwives to prescribe.

In order for women to claim Medicare rebate on fees for antenatal and postnatal visits the participating midwife is required to document a collaborative arrangement, by which a specified medical practitioner is identified as the person to whom the woman will be referred if indicated. Referral is one type of collaborative arrangement, described in Section 5(1) that the “patient is referred, in writing, to the midwife for midwifery treatment”, in this case antenatal and/or postnatal services, and that [Section 5 (2)]:“For subsection (1), the arrangement must provide for: (a) consultation between the midwife and an obstetric specified medical practitioner; and (b) referral of a patient to a specified medical practitioner; and (c) transfer of a patient’s care to an obstetric specified medical practitioner.”

That is, the collaborative arrangement to be entered into is that I, the midwife, will provide midwifery services (treatment), with consultation and referral to you when/if indicated. Under such collaborative arrangement, I am required to send you (the named medical practitioner) a Maternity Care Plan (proforma attached), results of any tests and investigations, and referrals.

Also I am required to send a discharge summary to you and the patient’s GP.

I would appreciate your support through referral or other collaborative arrangements. I am happy to make an appointment to meet with you and discuss this with you further if you wish.

There is a small number of midwives in Victoria who now have Medicare provider numbers, and others who are waiting for their applications to be processed. I anticipate gradual expansion of private midwifery services in response to the government’s maternity reforms.

Thankyou for considering this request.
With best regards
Joy Johnston

Attachments:
Health Insurance (Midwife and Nurse Practitioner) Determination 2010
Maternity Care Plan proforma

When women choose maternity options against the recommendations of their midwife

2011-11-13T19:33:00.001+11:00

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 'trustbirth' claim far too naive ... but I think a lot of women in their bubble wantto believe it. Perhaps all our easy access to IT -internet/emailgroups/facebook etc has something to do with which women choosehomebirth now and why and who and how cult followings get supported, possiblyblindly."

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.

Thankyou for your comments

Learning Medicare

2011-11-08T13:28:00.000+11:00

My mind has been challenged recently as I have attempted to learn the technology associated with Medicare rebates.

I decided that a portable EFTPOS machine would be the best means of processing bulk billing and client rebates through Medicare. This process requires a lot of technical support - well beyond my skill. The bank sent the machine, and set it up for me.

The next step was for Kirsty, a lovely lady who works for Medicare, to enter my provider number, and the item numbers for my work. Kirsty worked through it with me, and I watched her process one claim, then did one myself. Those payments have now shown up on the bank account statement.

Yesterday I took the machine to a postnatal visit, and attempted to process the bulk bill payment on the spot. It didn't work. I obtained a signed authorisation from the client, determined to work it out.

Today I opened the manual, followed multiple instruction steps, and identified the point at which I had been stumped. I was able to complete the transaction. YAY!

Medicare has offered me the immediate opportunity to do more postnatal work for my clients. This is great. I am thankful.

what are the boundaries for homebirth midwifery practice?

2011-10-25T18:05:00.001+11:00

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!

2011-10-24T11:05:00.000+11:00

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?

2011-10-16T19:08:00.002+11:00

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

Notation on the Register

2011-09-25T17:44:00.000+10:00

The notation on my registration states:

Mrs Joyce Johnston is an eligible midwife competent to provide pregnancy, labour, birth and postnatal care and qualified to provide the associated services and order diagnostic investigations required for midwifery practice, in accordance with the relevant State and Territory legislation. Eligible midwife, but NOT qualified to obtain endorsement under section 94 to prescribe Schedule 2, 3, 4 & 5 medicines required for midwifery practice in accordance with State & Territory legislation.

I had applied for this eligible status last December, so it is with a considerable sigh of relief that I acknowledge this achievement.

Anyone reading this post who is not familiar with current maternity care in Australia may question the wording of the notation. I am now an 'eligible midwife'. I am now "competent to provide pregnancy, labour, birth and postnatal care" - care that I have been providing on my own authority, independenty, for most of the past 20 years.

So what's new?

The main new feature of my practice is that some women in my care will, as a result of this notation on the Register, be able to claim rebate from Medicare on my fees: women who have Medicare cards, and for whom I am able to set up sutiable collaborative arrangements with a doctor. As soon as I can organise the software and other technology, I hope to be able to process Medicare rebates from my office directly to a woman's nominated bank account.

Another new feature is, as the notation states, that I am now able to order diagnostic investigations required for midwifery practice. In the past I have asked women to have routine blood tests and any other investigations requested by their GPs.

I am not yet able to prescribe medication. I have signed an undertaking to complete a medication course for midwives , within 18 months of being recognised as an eligible midwife. However, to date the Board has not approved a program of study in prescribing, so I am waiting for that approved course to be announced.

Another feature of the government's midwifery reform package that is yet to be realised is the ability for midwives to attend women privately in hospitals. At present, when a midwife goes to hospital with a woman for whom she has provided prenatal care, the midwife's status is a sort of support person who has no professional role, and who can be seen as persona non grata. Midwives' ability to provide professional intrapartum care in hospitals is part of the government's Midwife Professional Indemnity Scheme.

In the 2009-10 Budget, the Government announced the 'Improving Maternity Services Package'. The package provides for the introduction of Medicare supported services to provide greater choice for women during pregnancy, birthing and postnatal maternity care, including the provision of professional indemnity for midwives.The Midwife Professional Indemnity Scheme (MPIS) includes a Commonwealth contribution initiative designed to assist with claims made against eligible midwives and encourage the provision of indemnity insurance policies for private independent midwives.The Midwife Professional Indemnity Scheme provides financial assistance to eligible Insurers who provide indemnity to eligible midwives.

There are now a handful of Medicare-authorised midwives. In Victoria, you can get Medicare rebates for private midwifery from a midwife in Echuca, and from a few midwives in Melbourne. There is no Medicare rebate, or indemnity insurance for home birth. Midwives are exempt from being required to have insurance for homebirth until the end of June 2013.

You can search for a midwife on Google, or go to Midwives Australia.

Thankyou for your comments

continuity of carer

2011-09-02T16:14:00.003+10:00

Pic: Ash labouring in hospital - used with permission

A mother-to-be who I will call Jenny came to my office for a pre-natal check. Jenny is planning to give birth to her first baby in hospital, and I am providing shared antenatal care*, and planning to be with her in labour, birth, and continuing the care after her baby has been born, and visiting her at home.

Jenny has read the blogs I have written in the past week or so, and newspaper reports, about the emerging situation when a midwife is with woman in a hospital. Jenny asked me for more information about these matters. Jenny's questions were particularly focused on how the insurance/ reporting issues would affect my plan to be with her as her known and trusted midwife. Jenny reiterated, without any prompting from me, that the reason she wants her own midwife to be with her in labour is her need for continuity.

Continuity of carer refers to “a model of care providing relational continuity between each woman and midwife by continuity of midwifery carer throughout the full process of pregnancy, birth and the postnatal period, responsive to the needs and preferences of the individual woman." (Fontein 2007, p37- see full reference below)

In an ideal world that midwife would be the responsible, accountable primary care provider, who attends and 'conducts' uncomplicated births in the setting of the mother's choice, and refers to and collaborates with specialist obstetric and nursing providers when and if the need arises, all the time maintaing a unique professional relationship with the woman, regardless of the level of complexity or simplicity encountered. We clearly don't live in the ideal world, but we try to make the best of what we have.

If women were to lose the right to continuity and not be able to access personal support and interaction with their own midwife in hospital; the midwife with whom they have formed a special relationship - dare I say friendship - over a substantial period of time, those women will be the ones most adversely affected. The old-fashioned word 'confinement' which used to be applied to childbirth is an apt description of such a situation, bringing with it the loss of liberty in personal association, and loss of freedom to choose. It sounds like the other type of confinement, imprisonment.

But the important point to remember here is that the concept of "offering continuity of care, and where possible carer, as a key element of quality care": a key principle agreed upon by federal and state health ministers, and published in a 2008 statement by Australian Health Ministers Advisory Council (AHMAC), Primary Maternity Services in Australia - A Framework for Implementation. These key principles for primary maternity services have been carried through into current regulatory documentation for midwives, such as the Safety and Quality Framework for Privately Practising Midwives attending homebirths, which can be downloaded as a .pdf at the NMBA website.

STOP PRESS: 4pm, 2/9/11
A statement has just been circulated by the Nursing and Midwifery Board of Australia, concerning the role of the midwife who supports a woman admitted to a public hospital. If you would like the full statement contact me joy[at]aitex.com.au

... The midwife may choose to withdraw when the care of the woman is assigned to the health facility’s health care professionals. However, should the woman request it, the midwife may choose to remain as a support person to the woman either as paid or unpaid as agreed between them. The Board recognises that the midwife has no obligation to stay with the woman and that it is an individual decision for the midwife.

If the midwife chooses to stay with the woman - and therefore take on a support person role - the midwife must articulate the change in role to the woman, who should then consent to the midwife’s involvement as a support person only. The midwife should also clarify her change in role from midwife to support person with the health service.

The decision by the midwife to remain as a support person is linked to the woman’s right to choose the person(s) whom she wishes to be with her during birth. ...

*Note: (Shared antenatal care means that Jenny has a few key reviews at the hospital, and that I provide the other antenatal checks.)

Reference:Fontein Y, 2007. Making the transition from ‘being delivered’ to ‘giving birth’. A literature review and reflections on the potential for introducing the UK model of ‘caseload midwifery’ to the Netherlands. MIDIRS Midwifery Digest, vol17, no1, March 2007, pp35-40.

A message to women and midwives

2011-08-24T16:35:00.000+10:00

Dear Reader
If you have read the other blogs that I write, you will know that midwives are worried about being reported when we go with our clients to hospital.

I would like to reassure you that I, and midwives with whom I work, are continuing to practise in a way that we believe is consistent with contemporary evidence and best practice.

Please take strength from the message of Spring. These little Bonsai trees bring great encouragement. There is new life and hope.
Joy

"Needy" mothers

2011-08-13T16:28:00.002+10:00

A colleague who works in a hospital midwifery unit made a comment something like this:"Continuity of care sometimes makes the mothers more needy."

The thought of the 'needy' mother - the woman who needs a lot of help/care/attention/support - caused me to reflect and question my own assumptions and beliefs about women, particularly those in my care.

A further layer of this reflection was my questioning, "Does continuity of care every make mothers more needy?"

In theory,

Midwifery care is woman-centred.
Centred on the woman, the mother-baby unit, who is like the heart of the flower.
Each woman, regardless of her situation, her beliefs, her culture, her wellness, her illness, her wishes ... the petals, stem and roots of the flower.
Each woman, regardless of her neediness - the external and internal threats that are like pests and disease to the flower.

Maternity care that is centred on the woman seeks to enable that woman to be as well as she can be, to use whatever strength and ability she has, as she traverses the pregnancy-birthing terrain that is often unpredictable, at times challenging, and sometimes devastating.

Maternity care that is centred on the woman seeks to provide the best available and most timely intervention for those women who experience complications and needs that present a real threat to their wellbeing or their babies' wellbeing.

Maternity care that is centred on the woman seeks to promote physical and emotional resilience within individuals and within families.

Maternity care that is centred on the woman seeks to provide a trusted partner - a midwife - who accompanies that woman through the maternity experience, and who has the expert knowledge and skill to promote, protect and support the natural processes, and to identify complications.

As a result of this reflective journey I have concluded that continuity of midwifery care/ caseload/ known midwife does not make a woman more needy. However, the woman who is feeling needy/ vulnerable/ unsupported may turn to her known and trusted midwife for more support than she may have sought from a midwife who is a stranger to her.

Thankyou for your comments

In the first few days of life ...

2011-07-30T15:37:00.001+10:00

In the first few days of life ...

I have been visiting a mother and her baby - her first child - daily since the birth on Wednesday afternoon. "What's news-worthy about that?" you may ask. That's what midwives do.

This young woman and her little one are making good progress in all the developments and transitions that are normal and necessary for the continued wellbeing of each, and of the two of them as a little team.

This young woman, and her husband, felt exhausted after a sleepless night in early labour. They are still exhausted after three more nights in which the little chap has worked strongly at his mummy's breast to get the wonderful colostrum into his stomach. They tell me they haven't had much sleep. But they look wonderful! Less than 3 days after giving birth, this young woman and her infant have pretty well mastered the complex art of breastfeeding. Baby is taking his fill of milk, settling down to sleep, and waking up a couple of hours later to do it all again. Baby is strong, and that's good!

Breastfeeding is a huge challenge for a new mother-baby pair. Nurture, nourishment, bonding, wellbeing and contentment are all inextricably linked to that basic mother-skill of putting a baby to the breast, and that basic baby-skill of drawing milk from the breast.

This little one spent the first hour or so of life skin to skin, resting on his mother's chest. He made brief attempts at breastfeeding during that period, but didn't achieve much active sucking. He was born at home, and after a few hours I left him in the care of his parents. I gave the mother the standard advice, that she should feed him when ever he was awake and interested.

The next day I visited in the morning, and was told that attempts at breastfeeding had not been very successful. The little one was eagerly sucking on his lower lip and tongue. The instinct to suck was strong - he just hadn't worked out what he was meant to be sucking. With a little assistance he took the breast and stayed there, sucking strongly and consistently.

Over the next two days both mother and baby learnt from each other. The powerful intuitive forces that exist in the minds of both baby and mother brought these two together, and they worked it out. My visits brought encouragement and reassurance, but I could see that the wonderful natural processes were working well.

This is one of the great moments in midwifery - to realise that they are doing it themselves, and doing it well.

Thankyou for your comments

Birth Plan and Birth Preparation checklist

2011-07-16T14:11:00.003+10:00

[This is the checklist that I review with women in my care at our Birth Preparation meeting at about 36 weeks]

BIRTH PLAN

A BIRTH PLAN is a guide for those who are with you when decisions need to be made.

A simple Birth Plan has two components, A and B.

PLAN A: “I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.”

PLAN B: “If medical intervention is recommended in order to achieve the best outcomes for myself and my baby, I need to be given the following information in order to make an informed decision:
• What do you want to do? [procedure, test, intervention, advice …]
• Why do you want to do that?
• What is likely to happen if I say 'no' - if I don't allow you to do IT?”
With this decision-making process you will only allow interventions that you believe are best for you and your baby.

BIRTH PREPARATION

(This list is only a guide – Please raise with your midwife any issues that you consider to be important)

LABOUR AND BIRTH:
1. Planned place of birth?
2. Backup hospital (for planned homebirth)?
3. Do you have a written birth plan?
4. Who do you want with you in labour and birth?
5. Information about complications.
6. Ruptured membranes and the risk of infection.
7. Options/preferences for pain management/relief.
8. Immediate contact with the baby.
9. Cutting the baby’s cord.
10. Blood loss, oxytocics.
11. Third Stage, caring for the placenta.

AFTER BABY HAS BEEN BORN
1. How long does my midwife stay?
2. Midwife’s involvement if hospital birth.
3. Assistance with baby care and breastfeeding.
4. Milk supply, meeting baby’s needs, breast fullness, expressing milk.
5. Blood loss, after pains, involution of the womb.
6. Healing of perineal tear, regaining muscle tone.
7. Vitamin K?
8. Newborn screening test?
9. Hepatitis B vaccine for baby?
10. Support at home – meals, cleaning, other children ...
11. Maternal and Child Health services? Community services and support groups.
12. Sexuality and contraception after having a baby.

Access to medical services

2011-07-04T09:58:00.003+10:00

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

Why I chose homebirth

2011-06-13T16:16:00.002+10:00

This guest post was written by Miranda Davies.

Almost 3 weeks ago, I gave birth to my second child at home, a gorgeous little boy, in the bath at home, with my husband and two midwives present. It was an amazing experience that I will cherish forever.

I cannot describe how wonderful it is to be able to give birth in the comfort of your own home, at your own pace without people trying to interfere or tell you what to do. I came to understand what it meant for ‘me’ to be in charge of giving birth, no one would do it for me, which is so far removed from the concept of the Dr. or midwife ‘delivering’ the baby. Yet I was also well aware that I was in good hands if something was so come up, which meant I felt very safe.

When I first became pregnant I could not have imagined ending up having my baby at home. Homebirth sounded like an ideal situation, but we don’t have much exposure to it in our society. It is assumed that you see a Doctor and have your baby in hospital. Towards the end of my first pregnancy I watched ‘The business of being born’. It immediately clicked with me. My husband and I both thought that having a homebirth just made sense, not this time around, but in the future. The birth of my first child went reasonably smoothly with only a relatively small amount of intervention.

When we got pregnant again for the second time, we once again discussed the idea of homebirth, but were not 100% sure. We knew that we wanted midwife care; I firmly believe that for healthy pregnancies an obstetrician is overkill, pregnancy is not an illness. I also knew that the rates of intervention are significantly lower with a midwife. In 2008 a Cochrane review was published examining the outcomes of midwife compared to other models of care http://www2.cochrane.org/reviews/en/ab004667.html if you are interested.

It was only because a friend also became pregnant at the same time and was certain she would have a homebirth that it suddenly did not seem such a far-fetched idea. Given my job (as an epidemiologist) I became very interested in looking up original research papers that looked at the outcomes of planned homebirths, reasons for complications and risk factors etc. The more I read the more confident I felt about the safety side of having a homebirth.

It also became very apparent to me that many of the things that are ‘standard care’ in hospital were not things I necessarily wanted or had good evidence for doing them. I became aware that I would most likely have a battle on my hands, which really isn’t conducive to good birthing!

It was suggested that I read ‘Ina May's guide to childbirth’. I finished the birth stories section and realised I wanted my birth to be like those in the book! And if I wanted that I really needed to have a homebirth with a midwife that believed that 95% of the time pregnancy and childbirth are totally natural processes.

But how to pick a midwife? Given my background/job my main concern was a midwife who was a bit too ‘hippy’. I wanted to know that if I really did need to go to hospital the call would be made and early on. It was probably a bit of a silly concern as no midwife would put a mother or baby in harms way to maintain ‘natural childbirth’. I now attribute this thought to the media portrayal of homebirth midwives. The deal sealer for me was a connection with a girl I went to school with. Joy had been present at the birth of her daughter and also her sister’s child at home. I emailed Joy that same day and arranged to meet. As soon as we started chatting I was certain this was perfect for us, lucky for me my husband agreed!

I had my first antenatal appointment at 24weeks. It was in stark contrast to any appointment I had had in hospital. Firstly it was about an hour long and in the comfort of Joy’s home. I didn’t wait for an hour with 30 other pregnant women just to be rushed through with a quick ‘how are you feeling?’, blood pressure check, measure and heart rate check. My appointments weren’t filled with comments about me being either ‘too big’ or ‘too small’. They were a time where Joy and I got to know each other, we chatted about all manner of things, feelings, fears, statistics, certain protocols and philosophies. These are the things that are important, yet are things that are now lost. Busy Obstetricians and midwives don’t have the time to sit and really get to know you and what you want, there is only time to tick all the necessary questions and tests off the list.

Choosing an independent midwife and homebirth really are no brainers. You get the continuity of care through your pregnancy, labour and post-natal period. Having experienced both sides of it, I can tell you the level of care is far superior. You have someone who comes to your house when you are in labour, brings all the medical gear for if something crops up and more importantly has the experience and knowledge to let you know its all going fine and that you can stay at home or that maybe something isn’t going as expected and it is time to go to the hospital. There are no strangers and no shift changes. There is no pressure to ‘deliver’ a certain way, to get out of the pool, to have your waters broken or that IV put in. No one is telling you ‘your baby is not in an optimal position’ or you are ‘ONLY 3 cm’ neither of which are helpful. A wonderful thing that Joy said to me was ‘if you make it an issue it will become one’ very wise words that in many ways can bear weight to the high intervention outcomes of childbirth we see today.

I am not a crazy hippy, I did not have a terrible first birth, and I’m not anti the medical establishment. I went to university and have a PhD epidemiology and biostatistics. I like to research the choices I make in life and like things to be backed up with strong evidence. I feel like I am one of the few that know a secret. Being able to give birth your way, at your pace, free of inhibitions so you can get into your ‘labour song’ (as Janie called it), in a location you feel safe in, with people you already know and trust, is probably the most amazing and empowering thing a woman (and her partner) can ever do.

If even a small part of you thinks you might like care from an independent midwife and/or a homebirth, I say go for it, you wont be disappointed.

Thankyou for your comments

Action on maternal mortality in developing countries

2011-06-07T15:43:00.001+10:00

Talk point: Maternal health - can MDG5 be achieved by 2015?

A global shortage of midwives is reducing the chances of countries hitting millennium development goal 5 to reduce by three-quarters the maternal mortality rate. Tell us what you think about maternal and child health, and the progress of the MDGs

Click on this link to guardian.co.uk for an insightful series of videos addressing maternal death rates and maternity care in Africa and Nepal.

A midwife from Melbourne, who is working with MSF in the African country of South Sudan, wrote recently:

"In the short time I had been in Aweil, I had seen more miscarriages, more stillbirths, more premature births resulting in death than in my 8 years as a midwife in Australia. I was faced with doing things that caused me so much distress and heartache. To balance this somewhat, I have seen more twin births (nearly all of them vaginal) here than in Melbourne – it seems to be a norm in Africa, maybe to balance all the other babies who die. It is difficult here – for all who live here – and part of the work is to try to get women to the hospital sooner so that their bodies, which are already so depleted in so many ways, are not left recovering with no baby, as they have stayed away too long. This is all too familiar a story. They are in labour for 3-4 days at home, they come to us with a baby that’s already dead. There are also many who come with their babies still alive but then they seem to give up right at the end and we can’t resuscitate them. It is normal for there to be meconium stained liquor. Too many dead babies…The women have many pregnancies, and their bodies don’t often have time to recover before they’re expected to be pregnant again. So, we are also looking to do education in antenatal clinics, trying to encourage women to come earlier to the hospital."

Thankyou for your comments

Transfer from home to hospital

2011-05-29T15:57:00.001+10:00

A transfer from planned home birth, to hospital, can bring challenges to both the mother and the midwife, testing the partnership and trust between them.

From time to time, and at times unexpectedly, I need to arrange transfer to hospital. Being able to transfer care, without anxiety, from midwife-led primary care in the woman's home, to medically supervised specialist care in hospital is one of the most basic 'acts' that a midwife must be able to carry out in protecting the wellbeing of mother and baby.

Midwives working in hospital-based homebirth programs, and even birth centres, have a strict set of rules to follow. Any clinical finding that could be interpreted as an unacceptable 'risk' (such as previous caesarean surgery) or an escalation in 'risk' for mother or baby (such as meconium stained liquor) means that the midwife has no choice other than to follow the risk management process set down by the hospital.

Midwives working independently, in a private employment relationship with each woman, are able to consider the situation more broadly. This does not mean that midwives practising privately are unconcerned about risk. But it can allow a more holistic (whole-person) assessment of the situation, often meaning that the woman who is considered unacceptable for 'low risk' hospital-managed models (homebirth or birth centre) is able to proceed without any complication to giving birth to a healthy baby in her home, in the care of a midwife.

A publication that has guided and informed my practice in a significant way since the mid-1990s is the World Health Organisation (WHO)'s Care in Normal Birth: A Practical Guide (1996).

This paper does not primarily deal with the issue of 'home birth' or 'hospital birth': it focuses on 'normal birth'. That's a really important point. If birth is normal, the place of birth is of little consequence as long as the mother's and baby's needs are met. The midwife is fully able to attend such a birth, providing appropriate care.

The WHO (1996) paper provides a clear discussion of the 'Risk approach in Maternity Care' (p3), stating that

"An assessment of need and of what might be called "birthing potential" is the foundation for good decision making for birth, the beginning of good care. What is known as the "risk approach" has dominated decisions about birth, its place, its type and the caregiver for decades now (Enkin 1994). The problem with many such systems is that they have resulted in a disproportionately high number of women being categorised as "at risk", with a concominant risk of having a high level of intervention in the birth. A further problem is that, despite scrupulous categorisation, the risk approach fails signally to identify many of the women who will in fact need care for complications in childbirth. By the same token, many women identified as "high risk" go on to have perfectly normal, uneventful births."

The picture of the process of ongoing decision making in the birth process is described in some detail, including this series of highlighted paragraphs:

"Risk assessment is not a once-only measure, but a procedure continuing throughout pregnancy and labour. At any moment early complications may become apparent and may induce the decision to refer a woman to a higher level of care." (p3)

"We define normal birth as: spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. The infant born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.
However, as the labour and delivery of many high-risk pregnant women have a norml course, a number of recommendations in this papeer also apply ot the care of these women." (p4)

"In normal birth there should be a valid reason to interfere with the natural process." (p4)

In recent years I have perceived a strong movement by the birthing consumer movement in this country, whereby a woman's 'choice' has become the guiding principle in calls for better maternity care. Choice that is not balanced by the critical judgment of a skilled midwife or other professional can be more dangerous than Russian roulette. A midwife cannot provide optimal maternity care if the woman's choice is more important than any other factor.

A woman giving birth has only one real choice: to either do it herself, or to submit to the medical care available. If there is a valid reason to interfere in the natural process, the midwife is bound to advise that intervention, even when it clearly goes against the woman's 'choice' or wishes.

This is often the situation when a midwife recommends transfer from home to hospital.

One of the key principles articulated by midwives in practising privately for planned home birth addresses the time of transfer:

"We support seamless and reliable processes by which midwives are able to make hospital bookings for women planning homebirth, and arrange transfer to the hospital in a timely way when needed."

[APMA Position Statement on Planned Home Births with a Midwife]

Thankyou for your comments

A new book from Michel Odent - part 2

2011-05-19T08:22:00.000+10:00

[Continuing on from the previous post]

Having now finished, and enjoyed this book, there's one additional point I would like to explore. It's a small detail.

In the epilogue, Odent indulges in some fanciful thoughts about childbirth in the land of Utopia, January 2031. [That's only 20 years from now, and my grandchildren may be having babies at that time!]

This chapter has appeared previously in Odent's newsletter, and republished with permission at the midwivesVictoria blog in 2009.

My interest in this utopian dream was piqued by a question "What if the prerequisite to be qualified as an obstetrician would also be to have a personal experience of giving birth without any medical intervention and to consider birth as a positive experience?"

... at which time the participants in this utopian scenario all shouted "Eureka!"

Odent has previously proposed this prerequesite for the authentic midwife. It's idealistic, but fascinating.

My response, which may be influenced by personal bias, culture, and anything else, is to immediately say "no way!" as far as obstetricians are concerned.

Obstetricians should perhaps be required to have major abdominal surgery after 36 hours of sleepless activity, then be required to tend to a little creature who needs all that a newborn baby needs. Even that would not start to mimic the emotional/hormonal cocktail that a new mother experiences.

A midwife is 'with woman', bringing a special partnership to the childbearing event that allows the woman to proceed under natural physiological influences without fear. This allows her body to do whatever it needs in the growing and birthing and nurturing of a baby.

There is no similar concept of 'partnership' in medical/obstetric ethics or standards. The doctor/obstetrician is required to be an independent thinker, who brings special surgical skill to births that would not do well under natural physiological processes. The doctor is not there to be 'with' the woman.

For this reason I reject any suggestion that the obstetrician in the utopian setting would be someone with "a personal experience of giving birth without any medical intervention and to consider birth as a positive experience." Indeed, if an obstetrician had that level of experience, I would suggest that obstetrican could also be admitted to the profession of midwifery.

Thankyou for your comments

A new book from Michel Odent

2011-05-07T17:12:00.001+10:00

I am, once more, enjoying a book written by Michel Odent, the French doctor who has contributed an enormous amount to my understanding of the physiology of normal birth.

Last week I sat in a workshop and listened to Michel speak, without notes or anything remotely modern, such as a data projector, for three hours. It required a lot of concentration to understand his accent, which seems more 'French' than it was a few years ago, the last time I heard him speak. There was also a problem with the microphone, which didn't help. I chatted with him at lunch time, and he autographed my copy of his new book.

This octogenarian champion of birth physiology is not going to please many of his readers all the time. For instance, he has come down hard on the natural childbirth movement, for its penchant for birth videos, its teachings about 'support', its masculinization of the birth room, and much much more. You will have to read the book to get the full picture. Here is a brief quote from p47-48:

Language is a specifically human stimulant of the [neo]cortex. This implies that in situations associated with intense activity of archaic brain structures, such as giving birth, exposure to language should be avoided. ... Of course, after thousands of years of culturally controlled childbirth, silence as a basic need cannot be accepted overnight. It is all the more difficult today since many theories that are at the root of 'natural childbirth' movements have reinforced a deep-rooted cultural conditioning and have introduced to the birthing place a guide (a 'coach') who does not hesitate to use language.

There are statements that will not please midwife intellectuals and researchers, particularly his apparent uncritical acceptance of recent publications such as the meta analysis by Wax et al (2010) which report increased adverse outcomes for women at low risk who plan home birth (see p60). This study has been strongly criticised for its methodology and conclusions.

When reading this book I detect an idealism that seems to suggest that all women will be fine if only they can progress within an appropriate setting that is silent, unstimulating, free of husband and other onlookers, free of language, and with a midwife who is knitting in the corner. There seems to be an avoidance of recognition of the midwife's role in detecting complications and accessing appropriate specialis care when progress is abnormal. I am willing to understand this apparent bias as an assumption that readers already know about such matters.

There is a very interesting discussion around the phenomen of two midwives attending a birth together. This practice is widely promoted in Melbourne by hospitals and independent midwives: indeed some of my colleagues have told me that they consider it unwise and possibly unsafe for me to attend a birth as a solo midwife. Don't I know there could be two people needing my attention at once?

Another obstacle is a deep-rooted tendency to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. In many societies one of the women around plays the role of the midwife, often accompanied by relatives or neighbours. Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or SOuth America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: When there are two midwives, the baby's head is crooked". (p63)

A further comment in the context of people who have been introduced into the birthing room:

"The doula phenomenon is such a sudden international phenomenon that it must be analysed and interpreted in the context of the twenty-first century." (p 63),

and

As long as the studies [about doulas] were conducted in low-income Hispanic populations [in the US], the statistical results clearly confirmed the positive effects of the presence of a doula. The findings were different in the context of middle-class American populations, ... where the presence of a doula had no impact on the rates of caesarean deliverise and other operative deliveries." (p64)

I have not yet finished reading 'Childbirth in the age of plastics', but wanted to get these comments up on the blog pronto!

Thankyou for your comments

Vernix

2011-04-16T15:12:00.001+10:00

Vernix covering the face of a precious newborn baby

After every birth I find something of value upon which to reflect. It may be something unexpected, or it may have been the ordinary-ness of the whole event. Ordinary, yet extra-ordinary. It may have been something about myself, and my personal ability to fulfil the role of midwife. And my reflective review may take place at several different levels.

I love returning to homes as midwife for the second time, and more. It's a wonderfully privileged place for me. The mother knows me, and I know her, in a deeper way than the first time 'round.

The picture in my mind now is a mother whose second baby is nursing contentedly, naked against her warm, naked breast. It's a mild autumn day outside, with some light rain, and occasional sunshine. We are in the bright, airy room that is a closed-in verandah at the rear of the house. The setup is very much the same as it was three years ago when this mother gave birth for the first time.

I had been called out a few hours earlier, and had worked with the mother; my few words and actions being carefully chosen to act in hamony with the wonderful natural process that was progressing and unfolding. But that's another story. Today I am thinking about vernix. The little one of today's reflection was born with thick slathers of the white creamy substance on her back, and sizeable globs of it in the water of the birthing pool.

I know I'm not the only midwife who is fascinated by, and has a special love for, vernix. Not the vernix on the baby's skin. That stays there, and has often disappeared, apparently absorbed by the baby's and mother's skin, when we take another look at the baby after a couple of hours. Water birth has made the vernix that has separated from the baby more accessible than it used to be. The vernix in waterbirth floats to the surface of the water, while in conventional births this vernix ends up on the absorbant under-sheet with amniotic fluid, blood, and anything else that issued from the mother's body at the time of birth.

I don't know if it's an old wives' tale, but I heard a long time ago that midwives in France would collect vernix for use in the cosmetic industry. A blob of vernix is, to me, an attractive little bonus to glean when all the hard work of birthing has been done. I scoop up a bit of it, and apply it, usually to my arms. A few years ago I was conscious of a small scaly patch of skin that had been for some time on my forehead, and I rubbed vernix into it. Having grown up in the Queensland sub-tropics, sun exposure has left my skin with some damage. The skin healed over soon after.

It's likely that any readers who are interested enough to read a post about vernix will also use an internet search engine and see what comes up. That's how I came upon a very interesting, comprehensive paper:

Vernix Caseosa: The Ultimate Natural Cosmetic?
By: Johann W. Wiechers, PhD, JW Solutions; and Bernard Gabard, PhD, Iderma
Posted: August 31, 2009, from the September 2009 issue of Cosmetics & Toiletries.

The authors of this paper also state that "rumor has it that midwives apply some of the vernix caseosa they remove to their own hands, rendering them soft and well-hydrated."

Your comments are, as always, welcome.

Midwife-blogger

2011-03-27T17:45:00.001+11:00

Midwife-blogger is the title of my presentation to be given at the global 24-hour Virtual International Midwives Day webinar, Thursday 5th May, hosted by midwife Sarah Stewart in New Zealand.

I have been maintaining midwifery blogs since 2006, with the aim of recording and sharing midwifery skill and knowledge, promotion of normal birth, and making critical comment on current issues in maternity care.

In the mid-1990s, as I was establishing my private midwifery practice, I kept a hand-written journal with photographs and other mementos from many of the births I attended. This journal became the source for the chapters of ‘The Midwife’s Journal’, which has been a section of my website since 1997. The Midwife’s Journal was my first attempt to use electronic media. I sought to write about my personal journey through the terrain of childbearing, rather than make a record of birth stories.

Blogs and web-based books such as The Midwife’s Journal are readily translated into e-books. My two midwifery e-books are Midwifery from my heart, published in 2010, and Mother Daughter and Midwife, published in 2011. I have more e-books planned.

I would like to encourage midwives to use reflective writing as an aid to developing a strong midwife identity, and in processing both the joys and challenges and sadnesses that we face on a daily basis. A blog can be set up with open access, or to be accessed only by those who the owner permits. Privacy issues must be considered, of course.

Today I have received a very special email message from a young woman in London. This is what she wrote:

I wanted to send you an email and whilst searching for your address I came across the beautiful birth story you wrote about me in your journal (Homebirth Far From Home). I am so grateful you did that as it brings back such wonderful memories, and makes me so proud. Thank you.

The reason I wanted to email you was to let you know that I have just completed my midwifery training and will be starting a job at Kings College Hospital in London in June. I chose to apply KCH because of their 7% home birth rate (one of the highest in the UK) and the strong philosophy that permeates their care in keeping birth normal.

I know I have said it before but I wanted to let you know what an inspiration and role model you have been to me on this journey. Although we live on opposite sides of the planet, and [her son's] birth was over 12 years ago I still feel that you have played a strong part in my success at starting and completing the rewarding but often challenging training involved. You have also influenced my every day practice and my belief in the power of women to birth their babies as they choose.

With much love and respect,
[name]

Dear reader, can you imagine how wonderful it is to receive this letter?

I have just now gone back to the account of 'Homebirth Far From Home', and my eyes are moist as I recall that beautiful young woman giving birth confidently to her strong and healthy child. I feel totally privileged to know that my brief role with her more than 12 years ago has contributed to the development of a new midwife who is about to set out on her professional career.

As women give birth to their babies, midwives beget baby midwives.

Midwives who are reading this, let me encourage you now to treasure every experience you have when being 'with woman'. One of those women may, with your support, begin or progress in the journey towards becoming a midwife herself.

Thankyou, dear reader, for your comments.

Shared antenatal care at the Women's

2011-03-09T14:30:00.000+11:00

Changes that are being implemented in midwives' practices, with the availablity of Medicare funding (I am still being patient - I have not yet received notation as eligible for Medicare), have led me and some colleagues to apply to be recognised as Shared Care affiliates at public hospitals. I have recently received my certificate from the Women's. Click here for more detail on Shared Maternity Care.

General practice doctors who have qualifications in obstetrics (GP-Obs) are usually the providers of Shared Care at public hospitals. The Shared Care Affiliate provides regular check-ups, and orders blood tests and other investigations for women who are planning to give birth at the hospital. The Shared Care Affiliate does not usually have any involvement in the acute care, from onset of labour to discharge of mother and baby.

Shared Care with a midwife at the Women's is available for women who live in the catchment area. It is possible that, with Medicare rebates for antenatal and post natal care, some women will choose to have their antenatal and postnatal visits with a midwife, without having the expectation that the midwife will also attend them in labour. However, midwives who provide primary care are, by definition, committed to working with a woman through the continuum or pre, intra, and postnatal care. When a midwife is a Shared Care affiliate at a hospital, she is also able to provide midwifery care during labour at home, to attend hospital and be 'with woman' through the birth, and support the amazing transitions that a mother and her baby go through in the early days and weeks after birth.

Thankyou for your comments

Homebirth, freebirth, and doulas ... a broken maternity system

2011-02-27T14:47:00.003+11:00

The latest issue of Women and Birth, the journal of the Australian College of Midwives, contains a paper by midwife academic Hannah Dahlen and two colleagues, M Jackson and J Stevens, titled:
Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system.
Read more »

First MOTHERBABY group gathering for 2011

2011-02-22T17:03:00.003+11:00

We sat around the table thismorning with cups of tea and glasses of water and listened to each other. What a delight it is to welcome a new baby into our world, and today we welcomed three into our little group. Arwen, Matthew, and Scarlett are pictured here with their mothers.

Reflecting on midwifery practice

2011-01-22T10:37:00.003+11:00

Matilda is on the ball! (it's never too early to prepare for good birthing)

In preparing for my recent professional practice review, I was able to identify several incidents in which I believed it was important for me as the midwife to act within my professional skill to ensure the safety and wellbeing of the mother and/or baby. In other incidents I engaged collaboratively with specialist maternity care providers, also with the goal of ensuring safety and wellbeing.

Read more »

'hands-off'?

2010-12-31T18:03:00.004+11:00

I don't know who first came up with the idea of the 'hands-off' midwife: the midwife who has a good set of hands and knows how to sit on them.

Midwives are not universally 'hands-off' when we should be, nor are we always 'hands-on' when we ought to be. That latter point is what I am attempting to write about today.
Read more »

Reviewing the past couple of years

2010-12-21T14:35:00.004+11:00

To Daddy

A couple of years ago the federal Health Minister announced a Maternity Services Review, declaring that the government intended to provide “More Choice in Maternity Care – Access to Medicare [funding] and PBS [prescribing] for Midwives”. The monopoly of government funding for maternity care being available only for services provided by doctors and hospitals was to be broken.
Read more »

Midwifery exam, 1973

2010-11-25T12:03:00.006+11:00

click to enlarge

I found this exam paper when going through an old file.
I read through the questions, and this is what I noticed:

Questions on breech presentation: diagnosis, ECV, indications for Caesarean section, and foetal risks associated with [vaginal] breech delivery.
A question on [vaginal] delivery of the second twin.
Questions on anaemia, fundus not equal to dates, varicose veins, onset of second stage, increasing parity, indications for forceps, polyhydramnios, placenta succenturiata, inversion of the uterus, and infants with sticky eyes, thrush, physiological jaundice, and cephalhaematoma.

Global Forum, Day 6

2010-11-13T16:52:00.003+11:00

Spring roses in our garden

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question: Over the weekend we would like you to continue to discuss the question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 5

2010-11-12T20:32:00.002+11:00

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 4

2010-11-11T14:22:00.003+11:00

For the online discussion, click here. The forum community is continuing to grow with 624 members from 86 countries!
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:
Today we will continue to discuss the role of the lay health workers. However, we would like you to elaborate more on the specific issues below:
- What wider social roles, such as promoting female empowerment, should lay health workers take on in communities?
- What approaches that have been used in different settings to motivate and retain lay health workers, to improve the quality of the services they deliver and to promote the delivery of high priority services for maternal and newborn health?
Read more »

Global Forum, Day 3

2010-11-10T10:51:00.003+11:00

Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum

Today's question:

Community or lay health workers are health care providers who have no formal professional or paraprofessional tertiary education but are usually provided with job-related training.They can be involved in either paid or voluntary care. The term 'lay health worker' is therefore very broad in scope and includes, for example, village health workers, promotoras, treatment supporters and lay counsellors. Lay health workers may take on a wide range of different health-related tasks including giving help and advice about child health, child illnesses, pregnancy and medicine taking. In some studies, lay health workers also treat or refer people for particular health problems.

Global forum, Day 2

2010-11-09T14:40:00.003+11:00

The forum leaders have written:

Today we continue to discuss Day 1's question on:
"What practices or tasks should be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?"

Reducing maternal and newborn mortality and morbidity at the primary health care level

2010-11-08T10:22:00.003+11:00

Today's discussion topic in the Global Forum is:
What practices or tasks can be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?

My quick response is to ask the same question differently, placing the focus on the woman-baby unit, rather than the tasks:

What needs do mothers and babies have that can be addressed at the primary health care level by health care providers other than medical doctors, and how will the addressing of these needs accellerate the reduction of maternal and newborn mortality and morbidity?

Global forum: optimising the effectiveness of Health Workers to achieve MDG's 4 and 5

2010-11-01T17:24:00.004+11:00

The WHO Guidance Global Network invites you to join a NEW online discussion forum.
8-16 November 2010
The World Health Organisation and partners are developing global guidance on enhancing the effectiveness of different cadres of health workers through evidence-based practice to improve maternal and newborn health care.

Theme: Crossing professional boundaries to define what safe and effective practices can be delivered by different cadres of health workers at the primary and community level to improve maternal and newborn health.

Register: to participate and receive a daily discussion digest, click here.

Reminder
MDG 4: Child health
MDG 5: Maternal health
To review the eight UN Millennium Development Goals, click here.

2010-10-19T19:48:00.003+11:00

Spring roses in the front garden

“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."

~ C.S. Lewis

Women may 'go it alone' on home births Ireland

2010-10-17T19:58:00.002+11:00

[Posted: Fri 15/10/2010 by Niall Hunter, Editor - www.irishhealth.com]

A campaign group has warned that some women may opt for home births without professional care as a result of problems with indemnity insurance for qualified home-birth midwives.

The Association for Improvements in the Maternity Services-Ireland (AIMS) says proposed new midwifery legislation will in effect make it illegal for a home birth midwife to provide antenatal and birth care if the pregnant woman's circumstances do not meet criteria set in a current memorandum of understanding which midwives have to sign with the HSE.

Krysia Lynch of AIMS told irishhealth.com said the memorandum, which will be used in the legislation, outlines the criteria for State indemnity insurance cover for midwives in home births but these criteria were too restrictive.

She claims they are based on a misinterpretation by the HSE of evidence-based guidelines for home births and claims the HSE is attempting to restrict home birth and midwife-led services.

AIMS says the restrictive criteria could lead to midwives becoming uninsured in the middle of a home birth should the mother's clinical circumstances change.

Midwives attending women having home births could face could face fines or imprisonment or both if they are found in breach of the new legislation, which is expected to be passed by the Oireachtas before the end of the year, AIMS says.

It adds that a growing number of women who do not want to attend maternity hospitals are saying that if professional midwife-led home birth services are not available to them, they will "go it alone" with their home birth without professional care providers.

Ms Lynch said this type of "underground home birth movement" has already taken root in other countries where home birth services are restricted.

AIMS says it understands a group of lay midwives without medical training are now offering their services to women who have difficulty in finding professionally-registered midwives.

The organisation is calling for revisions to be made to the Nurses and Midwives Bill in order to change the professional indemnity criteria for home births.

It is organising a petition calling for a changes in the proposed legislation.

Further details on this issue, and a petition to sign, are available here

I have signed the petition - signer #873:

Ireland's Home Birth Services: MOU and Nurses and Midwives Bill 2010.

The Australian Government's current effort to reform maternity services is also likely to have this negative effect of directing women with known 'risks' into the underground home birth movement. Midwives are faced with real and imagined restrictions when providing care for women who have had previous caesareans, or whose pregnancies continue beyond Term, or who are over weight, or ... These women would likely benefit greatly from a known midwife primary carer.

Understanding statistics

2010-10-07T10:24:00.000+11:00

Those who want homebirth to be, if not outlawed, at least so marginalised and dirty that noone with any sense would go near it, are able to use statistics to coerce their listeners into compliance, and to assure authorities that they are acting 'in the public interest'. There have been a couple of outstanding examples of this phenomenon in the past year.

Firstly, remember the Australian Medical Journal's publication of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), using shameless distortion of facts gathered in the research. I wrote about it and set up links to the paper at the MiPP blog in January this year. Alarm bells sounded, and media picked up the story from the abstract: X7 higher risk of intrapartum death and X27-fold higher risk of death from intrapartum asphyxia in the planned home births group.

The second doozie [for readers who are unfamiliar with this word, it's Australian slang - not sure what it really means, but it seems to fit here] is the Wax et al 2010 paper on maternal and newborn outcomes for homebirths in North America.

Various reliable midwifery organisations have critiqued this paper for its methodology and conclusions. The Medscape "Attention-Grabbing No Doubt, But Uninformative" comment by Andrew Vickers, copied in full (below) is worth reading.

Midwives can also understand statistics.

"Home Birth Triples the Neonatal Death Rate": Attention-Grabbing No Doubt, But Uninformative
Andrew J. Vickers, PhD

Posted: 09/27/2010

Home birth, according to a position statement from the American College of Obstetricians and Gynecologists, is "trendy" and "fashionable." Moreover, women who choose to deliver a baby at home "place the process of giving birth over the goal of having a healthy baby."[1] Interesting thoughts, I guess, but hardly evidence-based. Has anyone actually interviewed home-birthing parents to determine, for example, that they rate having a healthy baby at, say, 5 out of 10, whereas being allowed to listen to druid chanting during the second stage of labor is rated an 8? And with respect to being fashionable, have researchers really evaluated the wardrobes of home-birthers compared with those choosing to labor in the hospital, finding in the former a higher proportion of Marc Jacobs and Manolo Blahnik?

So it is nice to finally see some data that quantify the relative benefits and harms of home birth. Joseph R. Wax and colleagues conducted a meta-analysis, combining data from 12 studies including more than a half million deliveries, in order to report on a wide variety of outcomes, including process (eg, use of epidural), maternal morbidity (eg, vaginal laceration), neonatal morbidity (eg, prematurity), and mortality (of both mother and child).[2] What isn't so nice is the spin. The study authors themselves, who are from a department of obstetrics, report a highly alarming statistic -- that home birth is associated with a triple the risk for neonatal death. The American College of Nurse-Midwives, predictably enough, finds fault with the methodology of the study and cautions against overinterpretation of the findings.[3]

I am sympathetic toward the critiques. A meta-analysis is only as good as the studies that are entered, and it is somewhat disconcerting to see a mixture of prospective and retrospective observational studies all mixed in with a single randomized trial. (On which point, it is even more disconcerting to find that the paper referenced for the randomized trial was a discussion piece, not a trial report.) But for the sake of argument, let's assume that the paper is perfect and accurately represents the true outcomes of home and hospital delivery.

First off, how should we interpret a "tripling of death rates"? This is what statisticians call a relative risk, and it is widely known to be problematic for decision-making. As a simple example,[4] would you buy a pair of slippers if I told you that they were 90% off? Well, no, you would want to know how much they cost. It is the same with risk; it is the absolute amount that matters. The classic example is the contraceptive pill and breast cancer. One estimate is that the pill raises the risk for early breast cancer by 50%. This sounds pretty scary until you realize that most women's risk is so low that this translates to about 1 woman with breast cancer for every 10,000 on the pill. Most women would feel that is a risk worth taking, given the benefits of the pill and the possible harms of the alternative: pregnancy, which after all, has dangers of its own.

In place of a "tripling in death rate," the more informative statistic is the absolute increase in neonatal death associated with home birth. On the basis of the results tables, it is possible to calculate that this turns out to be 1 neonatal death per 1000 women who choose home birth. However, the results tables show that those women would also experience some benefits, including 40 fewer premature labors, 45 fewer cesarean sections, 140 fewer vaginal lacerations, and 140 fewer epidurals. This type of cost-benefit analysis -- trading off neonatal mortality against maternal morbidity -- can seem sort of cold-blooded. But if the only thing we cared about was a healthy baby, then we'd do cesareans on all pregnant women at 38 weeks (as well as insist that all women conceive once they turned 21). We implicitly trade off risks and benefits anytime we consider a medical procedure. Let's do it explicitly rather than implicitly, on the basis of decision-analytic statistics such as absolute risk, rather than headline-grabbing statistics such as a "tripling of the death rate."

References
1. American College of Obstetrics and Gynecologists. ACOG statement on home births. Medscape OB/GYN and Women's Health. 2010.Available at: http://ww.medscape.com/viewarticle/725383 Accessed September 9, 2010.
2. Wax JR, Lucas FL, Lamont M, Pinette MG, Carlin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol. 2010;203:e1-e8.
3. American College of Nurse Midwives. The American College of Nurse Midwives expresses concerns with recent ACOG statement on home births. Medscape OB/GYN and Women's Health. 2010. Available at: http://ww.medscape.com/viewarticle/725382 Accessed September 9, 2010.
4. Vickers AJ. Top scientific papers vs. furry green slippers: which should you trust? Medscape Business of Medicine, 2010. Available at: http://ww.medscape.com/viewarticle/722723 Accessed September 9, 2010.

The current state of private midwifery practice

2010-10-02T11:09:00.001+10:00

This is a brief summary - more detailed information can be sourced, of course.

Private midwifery practice for planned homebirth
Midwives continue to practise as we have for many years, providing the full scope of pre-, intra- and postnatal services for women who want to give birth at home, working without medical interference, without drugs to stimulate labour or relieve pain, and in harmony with natural physiological processes.

Midwives continue to provide statistical data to the government data collection agencies, as we have done for many years.

Midwives inform our clients that we are not able to purchase professional indemnity insurance for homebirth, and that the government has provided a 2-year exemption from this requirement, until June 2012. We don't know what will happen after that date.

The Nursing and Midwifery Board (NMBA) is preparing a Safety and Quality Framework document which (according to the most recent draft) is:

"consistent with the principles underpinning provision of primary maternity care (Attachment 1) and
"recognises the full scope of midwifery practice.
"recognises that women will make the final choice about their care and birthing choices in most circumstances [MOST circumstances ???]

"It is incumbent upon privately practising midwives (PPMs) to provide balanced and contemporary clinical advice to ensure that informed decisions are able to be made."

The Framework also relies heavily on the ACM National Midwifery Guidelines for Consultation and Referral (2008). A further 'guidance' document on collaboration is being prepared under the auspices of the National Health and Medical Research Council (NHMRC) - we have not seen drafts of that yet.

Private Midwifery practice for planned hospital birth
Many women who intend to give birth in hospital employ a midwife to attend them for birth, and provide continuity of care through the pregnancy to the postnatal period. Although private midwives do not have visiting access arrangements with hospitals, the partnership between the labouring woman and her known and trusted midwife is able to transcend most situations in which a hospital protocol might derail normal birth. The woman and her private midwife make decisions about when to travel to hospital, as the midwife uses her knowledge and skill to protect the natural processes in birth and early parenting.

This aspect of private midwifery practice goes unrecognised in Australian birth reports. The woman who plans homebirth, then transfers her care to hospital can be tracked statistically, but not the woman whose plans include a private midwife for planned hospital birth. The position of the private midwife in hospital has not been mentioned in all the so-called 'reform' that we are engaged in at present.

Private midwifery practice and Medicare-eligible midwives
This is the aspect of private midwifery practice that is set to emerge from 1 November, less than one month away. There are more questions at present than answers.

The Medicare-eligible midwife who I will refer to as the 'MEDI-WIFE' will be a very different person from the ordinary privately practising midwife. The MEDI-WIFE will:

have a close working relationship with a group of obstetricians (no doctors work 24/7 these days
provide prenatal checks in the community, possibly in 'rooms' shared with obstetricians or other doctors
attend births in private hospitals where she has visiting access, and where the 'senior' member of the professional team is always the obstetrician
be able to order basic tests and prescribe basic drugs, such as oxytocics
provide postnatal services for mothers and babies in hospital, and possibly at home.

The Australian Medical Association has published Collaborative arrangements: what you need to know, in preparation for the birth of the MEDI-WIFE.

A great deal of discussion is taking place in the world of midwifery about the signed collaborative agreements that have been required, under law, for a midwife to be eligible for Medicare &c. Go to the MiPP blog for more information.

Midwives are now being asked to record examples of our efforts to comply with the requirements of the Determination, so that the implementation of the government's maternity 'reform' can be reviewed over time.

What is the position and/or importance of independent midwives as an option for pregnant women?

2010-09-24T17:07:00.000+10:00

This is a question put to me by a lawyer representing a midwife who is answering charges of unprofessional conduct with the regulatory board. I will express my opinion on the position and/or importance of independent midwives as an option for pregnant women, and provide statistical information as to the current status of independent midwifery practice in Victoria.

My report is based on my midwifery qualification and more than 30 years’ experience in midwifery, including teaching, writing, professional and regulatory work.

It is my opinion that midwives are capable of practising privately and independently as primary maternity care providers, ensuring safety and wellbeing for the mother and child, and effectiveness of the service provided. Some current statistical information will be provided below.

The Definition of the midwife (ICM 2005) (the Definition), which is accepted in Australian midwifery education and professional codes of practice, states that “The midwife is recognised as a responsible and accountable professional ... to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”

The Definition does not comment on issues of employment by an agency, or self-employment. Although most Australian midwives work as employees of maternity hospitals, the option of being self employed has existed historically. The midwife who practises privately enters an agreement with the individual woman (client) who pays the midwife’s fee. There is no government funding for privately employed midwives, which compares with free hospital based maternity services.

The Definition states that “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.” The independent midwife is the only provider of home birth services in most communities. The current exceptions in Victoria are publicly funded home birth programs based at Sunshine and Casey hospitals.

The question of the importance of independent midwives as an option for pregnant women is a personal one. Childbirth is not a medical condition, and many women who choose home birth object to what they perceive to be excessive and unnecessary use of medical intervention in hospital births.

A woman planning to give birth at home understands that the midwife does not use drugs to stimulate labour or to take away pain, as is commonly available in hospital.

The Definition addresses situations in which transfer from home to hospital may be advised: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”

The ACM (2008) National Midwifery Guidelines for Consultation and Referral (Guidelines) are also used by midwives in the provision of primary maternity care. These guidelines are not designed to be prescriptive, and are to be used within the context of informed decision making by the individual woman.

When a complication such as non-cephalic presentation is detected, the midwife will usually seek to arrange consultation with a specialist medical practitioner (obstetrician). The woman is able to make decisions based on the advice she receives. Transfer of care from planned home birth to a hospital or private obstetrician will only occur if the woman chooses that option.

When transfer of care occurs, the independent midwife usually continues to provide private midwifery care within the context of the new care plan.

There are occasions when, after a midwife has advised and referred a woman for specialist medical consultation, the woman chooses to continue with a plan for spontaneous labour and birth. This may be against medical advice. The woman makes an informed decision as a competent person.

The number of women who give birth at home is small, approximately 0.2% of all births in Australia (Laws and Sullivan 2009, p21).

There is controversy about the safety of planned homebirth in Australia, particularly since the publication in the Medical Journal of Australia of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), in which all births recorded as planned homebirths over a 16-year period were reviewed retrospectively. Many questions have been asked about statistical method and conclusions drawn. There are probably only two women in the study whose babies died who started labour at home planning a homebirth. The others whose babies died had all transferred before the onset of labour, which means that the management of the labour was in the hands of the hospital, not the independent midwife.

Annual reports on perinatal data are published in Victoria by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, within the Department of Human Services. The most recent published report refers to births in 2007 (CCOPMM 2009). Of the 253 women whose births were coded as planned home births, seven babies were admitted to hospital nurseries. This is a similar rate of admission to the group of babies born at small hospitals with less than 100 births annually. (CCOPMM 2009, page 30). I am not able to draw conclusions about these births.

There is a degree of uncertainty in all births.

[If you would like the references quoted above, please contact me joy@aitex.com.au to request them, or leave a comment with your email address)

RCM Campaign for normal birth

2010-09-18T22:01:00.002+10:00

The Royal College of Midwives (RCM), the professional body for midwives in the United Kingdom, has a Campaign for normal birth.

The protection of normal birth will, without doubt, save lives of mothers and babies and reduce morbidity in both developed and developing countries.

The promotion of normal birth is a message that must be a top priority for all midwives and other maternity care providers in an age that embraces gadgets, quick fixes and technology, and ignores the sensitive intuitive processes that are essential to human life.

The support of normal birth is contingent on the undeniable fact that the safest and most wonderous way for a baby to be brought into this world is, in most cases, in harmony with natural physiological processes.

The midwife holds the key to protecting, promoting, and supporting normal birth. The midwife has the skill and duty to be 'with woman' as the first level (primary) care provider, and to engage and work with other specialist providers when and if the individual woman or her baby need specialist intervention.

It seems to me that 'normal birth' is perceived to be the default position in midwifery care: if there are no complications, 'normal birth' will ensue. In fact, nothing could be further from the truth.

Having practised independently for the last 15+ years, I have learnt, mainly through refelctive learning, that the practice of promoting, protecting and supporting normal birth is in fact the most demanding, engaging professional challenge that I have ever known.

Here is an example of the very useful links featured at the Campaign for normal birth site:
Latest news
* Cathy Warwick comments on the Lancet editorial which criticises homebirth and midwife-led care
* Promoting normal birth key to cost savings
* Midwifery Care and Normal Birth - Recent Policy statement by Canadian Association of Midwives
* Specialist preparation pre-pregnancy produces no measurable outcome benefits
* Giving birth at home is as safe as doing so in hospital with a midwife

Readers of this and related blogs will be aware of the enormous threats that are at present being experienced by midwives who practise privately in Australia. Government 'reform' of maternity services threatens to restrict midwifery with excessive bureaucracy and rules that ignore women's basic human rights and autonomy in choosing their care provider and place of birth. Rather than focusing on the dog's breakfast of 'guidelines', 'frameworks' and regulations, I call on all midwives to shift our focus to a campaign for normal birth.

Breastfeeding babies exclusively

2010-09-08T18:42:00.000+10:00

These two mothers breastfed their babies at a rally outside the Health Minister's office. Well done!

Exclusive breastfeeding for the first six months of life, followed by continued breastfeeding as well as a diet made up of nutritious family foods to the age of two years and beyond is the gold standard in infant nutrition.

Far too few babies in our world get past the first week exclusively breastfed, which sets them up for subesquent feeding difficulties.

I won't try to explain why exclusive breastfeeding is so important to both mother and baby. Sufficient to say that the principle "In normal birth there should be a valid reason to interfere with the natural process" applies as much to the establishment of breastfeeding as it does to progress in labour. Interferences will likely interrupt natural physiological processes, including mother-baby attachment, bonding, onset of lactogenesis 2, baby's ability to suckle, baby's gut flora, jaundice, and a mother's acceptance of the maternal role, just to mention a few.

A baby who is born at home, whose mother takes the baby to her breasts and who is able to initiate breastfeeding without interruption in the next hour or so is very unlikely to ingest anything other than his own mother's milk in the first week of life. It's a busy week, with baby eagerly taking the breast frequently through the day and night, and often with both parents facing endurance challenges. Some mothers and babies face some of the not uncommon difficulties with flat nipples or very large breasts or whatever. But by about day 4 or 5 there is an abundance of wonderful milk, a baby who sleeps blissfully after spending time at the breast, and there's light at the end of the tunnel.

The over-medicalisation of birth has led to many babies experiencing non-physiological challenges at birth, and this leads on to wasting of the baby's energy resources, painful surgical wounds in the mother, and separation of mother and baby. The end result is that babies are given artificial formula feeds to 'supplement', 'top up', or 'complement' what the baby is able to get from the breast.

Where the natural provision for a baby is ideally suited to the baby's physiological needs, of small volumes of colostrum that coats the digestive tract and supports cell proliferation and colonisation of the gut with the normal bacterial flora, the baby who is given, at 2 hours of age, 30ml of the white chemical concoction that is called infant formula has the whole process interrupted and interfered with. While that baby's energy needs may be met a whole lot of other needs are being denied.

A midwife recently told me that she was concerned about her client giving birth in a particular hospital because any baby born over 4 kilos was immediately treated as if at high risk of hypoglycaemia. The baby would be taken to the nursery, separated from the mother soon after birth, and blood glucose levels tested. With interruption to the first breastfeed, and separation, it's likely that a 'negative' result - blood sugar level lower than the required amount - would be obtained. That baby would then be given a formula feed, and the whole process repeated in a couple of hours. A mother who objects to the infant formula will be given information about the horror of hypoglycaemic brain damage, and only someone who is well informed knows that she has another option - to breastfeed effectively.

With approximately one in three babies in hospitals being born by caesarean surgery. The usual post operative pain management regime in hospitals in Melbourne maternity hospitals is Endone (a narcotic, dangerous drug that comes with the warning, "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child."), Panadol and Voltaren. I have written about Endone at my villagemidwife blog

Anyone who takes exclusive breastfeeding seriously knows it's an uphill battle in most hospitals. Even the Baby Friendly hospitals. It has been 15 years since the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was produced and adopted. The Declaration, adopted by all WHO and UNICEF Member States, has been a key strategy on improving health of infants and young children through optimal nutrition. [for more information go to Innocenti + 15]

Maternity care today is so wedded to infant formula use that it will take a major reformation to change the trend. The community must demand protection of the infant's right of access to the breast. We must also demand that human infants are given only human milk: that milk banks should be available for any additional requirements of breastfed babies.

VBAC - assessing safety and success

2010-08-26T21:49:00.000+10:00

This Reference will be of interest to readers who seek to understand vbac.

Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success.

Cahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones GA.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA. cahilla@wustl.edu

Comment in:

* BJOG. 2010 Jul;117(8):1034; author reply 1034-5.

Abstract

OBJECTIVE: To estimate the rate of success and risk of maternal morbidities in women with three or more prior caesareans who attempt vaginal birth after caesarean (VBAC).

DESIGN: Retrospective cohort design.

SETTING: Multicentre, from 1996 to 2000, including 17 tertiary and community delivery centres in north-eastern USA.

POPULATION: A total of 25 005 women who had had at least one prior caesarean delivery.

METHODS: Women who attempted VBAC with three or more prior caesareans were compared with those who attempted after one and two prior caesareans. Univariable and stratified analyses were used to select factors for multivariable analyses for maternal morbidity. Maternal characteristics were compared using a Student's t test, Mann-Whitney U test, chi-square test or Fisher's exact test, as appropriate.

MAIN OUTCOME MEASURES: The primary outcome was composite maternal morbidity, defined as at least one of the following: uterine rupture, bladder or bowel injury, or uterine artery laceration. Secondary outcomes were VBAC success, blood transfusion and fever.

RESULTS: Of 25 005 women, 860 had three or more prior caesarean deliveries: 89 attempted VBAC and 771 elected for repeat caesarean. Of the 89 who attempted VBAC, there were no cases of composite maternal morbidity. They were also as likely to have a successful VBAC as women with one prior caesarean (79.8% versus 75.5%, adjusted OR 1.4, 95% CI 0.81-2.41, P = 0.22).

CONCLUSION: Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.

more on risk management

2010-08-21T17:42:00.001+10:00

In a previous post I explored the presentation of 'risk' by a doctor to a woman who was planning for vaginal birth of her second child after a caesarean birth of her first.

We live in an information era. Our challenge, as midwives, is to understand reliable information and to present it in a way that enables our clients to make good decisions. A good decision is, literally, a decision that leads to good outcomes for that mother and her baby.

Managing risk is a difficult topic to write about, and can be even more difficult if you are confronted with decisions needing to be made. The pendulum of risk-managed maternity care has swung a long way from the centre, to the point where any identified increase in risk is immediately considered a valid reason to interfere with the natural process.

When research has been carried out on a group of 'patients' in a way that quantifies a particular risk, the practitioner has a duty to inform the client about the research. This is obvious. Yet, in my mind, the prevailing risk-averse culture in maternity care today robs women of any semblance of informed decision making. Instead, by even mentioning risk of death (known as 'shroud waving'), maternity services ensure a high level of compliance with the prevailing culture of intervention, and devaluing the spontaneous physiological birth process.

Recently I was with a woman who was advised to have an induction of labour a couple of days after 41 weeks' gestation. The reason given was that the volume of amniotic fluid (AFI) around her baby was less than the normal range (AFI 5-25) - a feature that was identified coincidentally when untrasound examination was carried out for another reason. The fetus was active, and there were no other unreassuring features identified.

The doctor who presented induction of labour as the planned course of action explained that there was an increased and unacceptable risk of death of the baby. In quantifying 'risk' he stated that at 41 weeks there was a risk of 1 in 1000; while if the AFI was reduced the risk was 3 in 1000, or 1 in 333. Furthermore, the doctor stated, induction of labour at 41 weeks does not increase the 'risk' or likelihood that a baby will need to be born by caesarean.

The numerator in the equation is death of a baby at or around the time of birth. The denominator is all births with that particular set of features.

Most women who hear words such as "we need to induce labour because there is an unacceptable risk to the baby if we don't induce labour" will be frightened, and immediately agree to whatever plan is presented to them. They cannot contemplate the thought of losing this precious baby. They cannot ask questions that enable careful consideration, because that makes them feel as though they are willing to place their baby's life at risk.

Words such as 'unacceptable risk' are used deliberately. The argument by the doctor is that he or she would be taking an 'unacceptable risk', from an indemnity point of view, if he or she did not recommend action to get the baby born without unreasonable delay.

The pathway to healthy, normal, physiological birth begins long before labour, including:
* a healthy mother, who cares for her body and the child she carries
* a fetus who has grown normally
* a fetal head whose position inside the maternal pelvis, in relation to the internal os of the cervix is able to bring about normal onset of labour

We don't know what gets human labour started in nature. Not 'knowing' makes waiting for spontaneous onset of labour an 'unacceptable' delay in many situations where an increased risk has been identified.

Logically an increase of 2 in 1000 births is not a big risk. As I have discussed previously, there is a background risk for death of a baby of about 1 in 100 for all births. Many of the babies who die have increased risk because of abnormality, prematurity, or illness of the mother. That means that the real risk to a healthy woman with a healthy baby is greatly reduced.

The question I am placing to myself, and to other midwives who may face this dilemma, is:
at what point does it become unreasonable to wait for spontaneous onset of labour,
or,
at what point does it become important to move out of Plan A?

A midwife's decision-making is a constant process, and it continues throughout the episode of care. The woman whose baby has not been born by 41 weeks, and who has been told by a doctor that she needs induction of labour, may look to her midwife to help her unpack the issues so that she can understand the situation well enough to make a wise decision. The informed woman who accepts induction of labour, or any other departure from 'Plan A', does so because she believes it is the best course of action for her and her baby at that time.

A midwife in the situation described here would be unwise to insist in a blinkered way that 'natural is best' - yet she could also be challenged if she supported the plan for immediate induction of labour.

The midwife has to see beyond the risk of a perinatal death, and evaluate all the other reasons for promoting, protecting and supporting physiological processes in the childbearing continuum. The birth of a baby, although hugely significant, is not the 'end point'. It's only a beginning. The ability of a mother to accept her baby, to form lifelong bonds, to nurture the child, to feel well physically and emotionally in herself: to get along in life, cannot be trivialised. Similarly, the ability of the baby to make those huge natural transitions from the womb to the outside world, to search for and take life-giving milk from the mother's breast, and to become resillient and grow strong: these are all matters of immense value to the mother and her child, and the midwife.

I have written enough for today. I have a big pot of soup on the stove, and am looking forward to enjoying a bowl with my family. I hope that today's discussion supports other midwives and women who have to confront risk management in their daily lives.

VBAC statement from RANZCOG

2010-07-31T23:14:00.003+10:00

A new College Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) has been issued (July 2010) by the College of O's and G's, RANZCOG.

Midwives who are monitoring the current state of maternity reform in Australia are aware of increasing pressure on both women and midwives to comply with RANZCOG's professional guidelines.

In this statement RANZCOG has summarised its statement of risks to mother and baby, of both 'Trial of labour' and repeat elective caesarean surgery, and its recommended plans of care.

Recently I was with a woman who was planning vbac at home in my care, as an obstetrician was reviewing my client whose pregnancy had progressed to 11 days past 40 weeks. The doctor listened with empathy as the young woman explained that she felt severely traumatised by the caesarean birth after induction of labour for her first baby. The doctor considered that a trial of labour was a good plan, but was adamant in objecting to the plan for home birth.

The doctor's explanation of risk was:
"One in 200 women who attempt vbac will experience uterine rupture.
"One in 10 of those who have uterine rupture will experience serious consequences - either serious (maternal) haemorrhage or still birth."

These risk figures are consistent with the references quoted in the College Statement on Planned VBAC. Multiply 200X10, and according to this doctor there is a risk of 1 in 2000 that an attempted vbac will have an adverse outcome.

The doctor did not mention to my client that elective repeat caesarean increases the risk to her, particularly in her chance of serious haemorrhage, leading to hysterectomy, and even death. Her risk of abnormal placenta implantation (previa and accreta) was increased in subsequent pregnancies.

Pregnant women are often faced with many risk calculations. In early pregnancy when they have screening for Down Syndrome they are greeted with risk ratios that would be more familiar to bookmakers than to most mothers-to-be. Many feel bullied by the use of statistical reckonings that seem to have been pulled out of thin air.

Here are a few other statistics to consider:

Despite impressive advances in technology and treatments Australian parents experience the tragedy of loss of a baby in approximately 10 in 1000, or 1 in 100 births (perinatal mortality rate in 2006, from the National Perinatal Statistics Unit).

The rate of babies born with Apgar scores less than 7 at 5 minutes in 1.5 in 100 births or 15 in 1000 births (PDCU 2007) in Victoria.

Women giving birth in hospitals have approximately a 30%, or 30 in 100 chance of caesarean birth. Women having their FIRST baby in certain private hospitals have a 50%, or 50 in 100 chance of caesarean birth.

Comparing these risks with the 1 in 2000 risk of adverse outcomes for vbac makes vbac sound relatively safe.

Midwives advising women who are intending to give birth physiologically will encourage minimal interference as labour establishes and progresses. If their plan is to go to hospital for the birth, the transfer will usually occur after the labour has established. Key features of midwife care for planned vbac include:
.trust: the woman and midwife establish a partnership based on reciprocity and trust
.the woman calls the midwife to be with her at her home when her labour has established
.the midwife carries out basic assessments of fetal and maternal wellbeing, and progress, in an unobtrusive way
.the woman is able to proceed to home birth vbac, or to make an informed decision to go to hospital when and if needed

The RANZCOG College Statement sets out advice on TOL (trial of labour), including:
.admission to hospital relatively early in labour
.intensive maternal and fetal surveillance intrapartum, including continuous electronic fetal monitoring.

Clearly there is a huge difference in the way independent midwives and obstetricians approach vbac. There is no evidence of poor or worse outcomes when women plan vbac at home. Some go to hospital; some proceed to vaginal births in hospital and some proceed to another caesarean birth.

Reviewing July 2010

2010-07-28T16:16:00.002+10:00

In a world that is constantly changing, one thing stays the same: babies are conceived and grown, in the bodies of their mothers, and the time comes for every one when she or he must be born. The physiological, natural process is the standard way, just as breathing is usually done without drugs or machines.

In the past few weeks Australia has seen its first female Prime Minister, Julia Gillard, take over the reins of government, and a federal election has been scheduled in August.

The polls tell us that women are preferring Ms Gillard. Is she worthy of our trust?

Julia Gillard was the Opposition health spokesperson in the leadup to the last federal election. She was instrumental in assuring women that maternity reform was a high priority for the Labor Party.

The Australian people elected the Rudd Labor government, and Julia Gillard became the Deputy PM. The Health portfolio was passed to Nicola Roxon; the Maternity Services Review and various offshoot inquiries were held; and the government meekly followed the directions laid down by the medical lobby.

That's all on the record.

Birth IS important to women, and to their midwives.
Birth IS NOT an illness - to be managed, treated, and cured.

Decisions made by any woman going through any natural physiological process, such as pregnancy and birth ARE of profound significance to that person and her family. The mother not only (literally) takes the baby home; she takes her body and mind home. Many new mothers do not make the adjustments well; many suffer depression and post traumatic stress for years after what should have been a satisfying time of personal growth and development.

A group of mothers and midwives in Brisbane, under the Maternity Coalition banner, rallied yesterday as the PM and the Health Minister announced funding for mental health initiatives.

“We welcome Julia Gillard’s announcement about increased funding for mental health. Suicide is the leading non-direct cause of death for new mothers. We know that good quality maternity care, including from a known midwife, is likely to be protective against post-natal depression”, said Melissa Fox, West End mother of two and Vice President of consumer group Maternity Coalition’s Queensland Branch.

We know that rates of depression can be reduced when women receive primary care, with appropriate social support, from a known and trusted midwife. As it happens, primary maternity care from a midwife is THE very issue that the Australian health care system refuses to support.

Why?

Simply because the medical profession considers it in the public interest that all maternity care be carried out under medical supervision and strict medical protocols.

Ms Fox noted “The Government has committed $120m to Medicare for midwives. We call on the Government to remove the legislative barrier to enable the reforms to work. No action on the part of the Government would result in no improved access for women to midwifery models care ”.

In a similar press release, birth activist Justine Caines claims that:

"Women’s Rights Removed under Female PM - Sometimes it does Matter that the PM is a Woman.
The new Gillard Government has removed the basic rights of women in childbirth, with legislation that requires medical permission for all elements of [maternity] care.

"These moves mean that a doctor not a woman will decide. Most women seeking private midwifery care have gone out of their way to seek this option" Ms Caines added

"The Gillard government has just annihilated those choices, giving doctor the say over women's bodies and births."

“Minister Roxon’s total mismanagement of the Medicare for Midwives initiative will have far reaching consequences across the health sector. Childbirth accounts for the greatest number of hospital bed stays and yet we have a Health Minister putting doctors hip pockets over whole of maternity reform.”

Links:
Maternity Coalition Queensland blog
Maternity Coalition website
Homebirth Australia

post script:
The world of private midwifery practice for women planning homebirth is not very different today than it was prior to the last election. The substantive difference is that midwives now must:

have indemnity insurance to cover all pre- and postnatal work, with homebirth being exempt
obtain consent from women that they wish to proceed in the care of an uninsured midwife if they give birth at home.

The current status of access to homebirth midwives will have changed in some communities, particularly in rural areas. A number of midwives who had previously attended a small number of homebirths each year have withdrawn from homebirth practice. Many midwives are confused about the indemnity insurance rules and products. The information and links at the MiPP blog is up to date. A disproportionate number of midwives in private practice are currently under investigation by the regulatory authority, and one Victorian MiPP has had her licence to practice suspended.
Some MiPPs are preparing to be eligible for Medicare, hospital visiting access, and other extensions to practice (prescribing and ordering tests), which is scheduled to be in effect in November this year. There are many unanswered questions in this arena - pregnant women whose babies are due in November and subsequently should not hold your breath for Medicare rebates for your midwife's fees, or for your chosen midwife to attend you privately in a public maternity hospital.

A year in review -part 2

2010-06-27T15:00:00.007+10:00

It is just one year since the formation of Aitex Private Midwifery Services (APMS), and I am reflecting on the question, "How has APMS performed in the past 12 months?"

[The business model I had prior to 2009 was that I was self-employed. The difference with the APMS business model is that I now employ other midwives, as well as personally being employed by APMS]

The goals for the year 2009-2010 were:
APMS intends to establish a robust business model for achieving its purposes. Prior to July 2010, APMS aims to:
• provide primary maternity care for (x) women
• employ and mentor two midwives as primary maternity care providers, and as ‘second midwife’ for planned homebirths
After 1 July 2010, with changes in legislative arrangements for midwives, APMS aims to
• find ways of providing ongoing private midwifery services
• provide support for women and midwives affected by the legislative changes
Long term goals include midwife education in caseload primary maternity care practice and homebirth; consumer education; and mother to mother peer support.

The following notes are condensed from the APMS Annual Report.

1. The business model has been developed.

2. Midwives employed by APMS have signed employment agreements, submitted time sheets for hours worked, and are paid by APMS. Superannuation has been paid when midwives have earned $450 or more in a month.

3. Clients have been receiving primary maternity care through their pre, intra, and postnatal episode.

4. The three midwives have been employed and mentored.

5. Plans for AFTER 1 July: One midwife has indicated her interest in continuing as a midwife in private practice, and has agreed to working as the first APMA 'partner'. Another midwife has spoken to me about coming under a mentorship agreement.

6. Midwives in private practice are required to have professional indemnity insurance to cover prenatal and postnatal services after 1 July 2010. Homebirth is exempt. All APMS midwives will confirm that they have appropriate indemnity insurance.

7. At present two insurance products are available [see MiPP blog]. The APMS fee for primary care has been increased by $100 to pass on that extra cost to the clients.

8. Midwives who attend women for homebirth are required to inform their clients of the lack of indemnity insurance for homebirth. An agreement form which clients and midwife sign acknowledging the lack of insurance has been developed.

APMS employment model
Since a midwife in private practice works with individual women, the APMS employment model links the midwives to the women who engage us for private midwifery services.

This model enables midwives to be employed either as a partner/colleague, or at an agreed rate of pay that compares favourably with the rate that midwife would be paid as a casual employee in a hospital, but is the same regardless of weekends or public holidays.

Vision for the future
I envisage growth in APMS, with increasing numbers of women receiving maternity care, and increasing numbers of midwives being supported and mentored through this practice.
I envisage good birthing outcomes in the care of APMS midwives.
I envisage a robust midwifery workforce, developing strong midwife identities, engaging in ongoing learning and professional development, and reflective, critical practices.
I envisage midwives who are located distant from Melbourne coming under the APMS employment and mentoring model.
I envisage expanded opportunities for peer support by mothers and midwives through APMS
I envisage midwife partners mentoring others, as part of their roles in this practice.

Note: Part 1 of this review is at the villagemidwife blog

what midwives will NOT accept

2010-06-14T11:51:00.002+10:00

The obstacle that has been obvious to midwives throughout the maternity reform process is to do with the requirement for a 'collaboration' agreement between a doctor and the midwife.

OF COURSE midwives want collaboration. We do it all the time.

BUT we will not agree to another professional (a doctor or anyone else) being given authority to sign off on a midwife's professional decisions. That is not collaboration, it's control.

In recent weeks an announcement has been made by the Health Minister Nicola Roxon that a government-supported insurance policy is now available for midwives to purchase. This MIGA policy, as it stands, does not meet the needs of private midwifery practice, and is unacceptable.

Professional Indemnity insurance, which is not available for homebirth, is mandatory from 1 July this year - with an exemption for homebirth. Midwives whose field of practice centres on women who intend to give birth at home, employing a midwife privately to provide a professional service, do not want an insurance that covers birth in hospital. Hospital visiting access is simply not available for midwives, so why would they want to buy an expensive insurance product that covers hospital birth, if they have no opportunity to attend their private clients in hospital?
For more discussion go to the MiPP blog.

The Australian College of Midwives (ACM) has issued a press release supportive of the MIGA insurance, and hospital birth attended privately by a midwife. ACM spokeswoman, midwife Tina Pettigrew states that:
“To be able to look after a woman throughout her pregnancy, follow her into the hospital to have her baby and follow her home again afterwards to help her settle into being a new mother is what I’ve always wanted to do. Now I can to do all this with full indemnity cover”
ACM also claims that:
"The provision of insurance cover for private midwives is one of the necessary precursors to midwives gaining access to Medicare funding for their care from 1 November this year.
"Medicare funded midwives will be able to work in practices in the community, with other midwives, with doctors and with allied health professionals as well as in hospitals to offer more women the choice of having one-to-one care from a known midwife throughout their pregnancy, labour, birth and early parenting."

The deadline, 1 July, is approaching. Many midwives in private practice have indicated in discussion that we we plan to buy the cheapest insurance product that meets the requirements of the new national registration and accreditation legislation.

Insurance does not protect the mother and baby in our care. Good midwifery practice, and promotion of health in pregnancy, birth, and mothering does. As I wrote in August last year, the insurance debate is more about smoke and mirrors than safety.
It's more about business at the top end of town than protecting the little person.

Until our government provides a no-fault insurance product that deals equitably and fairly with all consumers who suffer loss or disability in health care, the insurance industry, and the law industry, will be the only ones who benefit.

"not for the faint-hearted"

2010-06-07T16:46:00.000+10:00

Private midwifery practice is reaching a watershed. Many midwives who have in the past practised privately, providing a vital professional service for women who want to protect and work in harmony with their bodies' natural processes in birthing, are quitting.

Midwives who are continuing are arranging insurance policies that will comply with the new laws (NRAS). The cost of insurance will be passed on to the consumers. Midwives are likely soon to be less available and more expensive.

This may sound pessimistic when the spin from the Health department is that "Private midwives to be covered by insurance".

Health Minister Roxon is reported as saying "This will make a real difference to expectant mums, who can now elect to see a private midwife who will have government-subsidised insurance and, from November 1, have the cost of those services covered by Medicare," Health Minister Nicola Roxon said.

The government-subsidised insurance covers midwives attending birth privately in a hospital. At present we know of no hospital that is willing to extend visiting access to midwives. We will be interested to know of developments in this direction.

Details of the government-subsidised insurance, and links, are at the mipp blog.

The second insurance option, called 'Mediprotect' and available through insurance agency VERO, provides cover for private midwifery services in pregnancy and postnatally, EXCLUDING birth.

A letter from the Victorian branch of the nurses and midwives union, ANF, received by a member today, informs us that the ANF Vic members insurance policy is also with VERO. VERY interesting. To date ANF Vic has responded negatively to requests from members to find an insurance policy that also covers private midwifery services in pregnancy and postnatally, EXCLUDING birth.

Back to the title of this post, "Not for the faint-hearted."

There are a number of midwives in private practice who are currently awaiting formal hearings by the statutory body, into complaints about their professional practices. One well known midwife in a rural Victorian setting has, a couple of days ago, had her registration suspended pending a hearing.

It appears that there is an escalation in the number of complaints that are being made about private midwives.

The mandatory reporting requirements of the new NRAS define notifiable conduct as (the usual impairments, sexual misconduct, ...) and
"(d) placed the public at risk of harm because the practitioner has practiced the profession in a way that constitutes a significant departure from accepted professional standards."

We midwives must be prepared to gather credible evidence and define accepted professional standards. It doesn't say "in the local hospital" or even "according to the professional body".

Midwives in private practice stand out like sore thumbs, and can expect to be reported.

We can also report. Can our community accept midwifery that results in 50% of primipara having caesarean surgery, with the subsequent increased risk to the mother and future children?

There is a huge theory-practice gap. Everyone involved in education knows that. We have to use that theory-practice gap to declare what is acceptable, and what's not. We have to be prepared to question what we see and hear, gather information, and write reports to the Board. Even if they are dismissed, the concerns that we all talk about need to be put on the record.

Reflecting on a hospital transfer

2010-05-28T20:54:00.004+10:00

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

1: TRANSFER
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.

2: DECISION MAKING
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.

3: RESPECT
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.

continuing the countdown - May

2010-05-15T10:01:00.001+10:00

We midwives have now received the draft (13 May) 'Safety and Quality Framework for Privately Practising Midwives attending homebirths' (SQF).

Readers of this and linked blogs (such as midwivesvictoria) will be aware of concerns that the government's reform of maternity services would in fact put extreme limitations on the ability of midwives to provide primary care in the community, and particularly homebirth.

The first draft of the SQF confirmed our fears. A set of 'mandatory requirements' would effectively double-regulate midwives in private practice, as if private midwifery were a different profession from midwifery in mainstream hospital employment. In the MiPP response to the first draft, I wrote:

". ... MiPP recommends that broad inclusion factors be applied to midwives' eligibility for the exemption, rather than the fairly narrow approach that is outlined in the draft. We recommend that all midwives who are currently in private practice should be eligible for the exemption ... The only mandatory requirement should be that the midwife is registered by the National Nursing and Midwifery Board to practise midwifery without restriction."

It appears from the new draft that this recommendation has been accepted:
"This framework will be provided to the NMBA (Nursing and Midwifery Board) with the intent that it is placed in a code or guideline. ... The exemption applies [for all midwives] even without a NMBA approved code or guideline providing guidance for a quality and safety framework."

Countdown - 6 weeks...

2010-05-12T15:13:00.004+10:00

... til 1 July.

Today I was with a colleague in a cafe in Middle Camberwell when a doctor who is well known for his ongoing support of homebirth came up to our table to say hello. He asked us, "What should I tell these women who are wondering if they will be able to have a homebirth later this year?"

My colleague and I were happy to reassure him that independent midwives would be continuing to offer home birth privately after 1 July.

We had just come from a MiPP (Midwives in Private Practice) meeting. A colleague presented current information about the United Nations Convention on the Elimination of all forms of Discrimination Against Women CEDAW, and developments in the response of key women's groups to our government's maternity 'reforms'.

In recent years many midwives and birth activists have attempted, apparently in vain, to argue the midwife's right to carry out our professional business on a level playing field under Competition Policy. It now appears that the human rights aspects of home birth need to be investigated and promoted.

Is there a human rights argument in the choice of place of birth?

Is our government failing in its human rights commitments, as a signatory to conventions such as CEDAW, by maintaining the state-sanctioned discrimination against women who plan to give birth in their home?

Can you think of any other natural, physiological function of the human body for which we experience discrimination that seeks to force all to follow government-mandated management in hospital? What would our society do if similar discrimination was enacted for a uniquely MALE function?

In a previous post I reflected on the suggestion "that the Austrlian constitution has clauses that can be used in defence of women's rights to homebirth as a "natural law right".

The legislation denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing.

The only requirement for physiological birth is that the woman is able to proceed without medical or surgical assistance. Since pregnancy and birth are truly natural states, and are not, per se, reliant on outside management, it is reasonable to protect the woman’s natural law right to maintain personal control over such decisions, including if and when she goes to hospital.

I want to stress the distinction between physiological birth, and managed maternity care. I would not argue that there is any natural law right to induction of labour, or to medical analgesia or anaesthesia, or to surgical birth or any of the other items that are common in maternity services in this country and throughout the developed world. These are no more our 'right' than is dental care or surgery to remove an inflamed appendix. The only requirement for physiological birth is that the woman is intentional about doing the work of labour and birthing herself.

Midwife led maternity care

2010-04-20T17:11:00.001+10:00

It's easy to rattle off phrases such as 'woman centred care' or 'continuity of care' or 'continuity of carer' or 'evidence based care' because that's the politically correct language (from a maternity care point of view) of our day. These words are popping up repeatedly in the documents that are being prepared by government agencies in preparation for the implementation of the government's maternity reform packages. We should all feel very confident, shouldn't we?

There is one evidence based care option that has largely been avoided in the process; 'midwife led maternity care'. It's not PC in Australian maternity circles to talk about anyone leading care. We are being told that we need to talk about 'collaborative' care.

Quoting from the NHMRC Draft National Guidance on Collaborative Maternity Care,
"Principles of maternity care collaboration:
1. Maternity care collaboration places the woman at the centre of her own care, while supporting the professionals who are caring for her (her carers). Such care is coordinated according to the woman’s needs, including her cultural, emotional, psychosocial and clinical needs.
2. Collaboration empowers women to choose care that is based on the best evidence and is appropriate for themselves and for their local environment.
3. Collaboration enables women to make informed decisions by ensuring that they are given information about all of their options. This information should be based on the best evidence, and agreed to and endorsed by professional and consumer groups.
...
9. Collaboration aims to maximise a woman’s continuity of carer by providing a clear description of roles and responsibilities to support the person that a woman nominates to coordinate her care (her ‘maternity care coordinator’)."
[you can read it all here]

It sounds excellent: the woman nominates her 'maternity care coordinator'. Those who want a midwife can arrange midwife led care. Right?

Not really. I will try to explain.

Some who want a midwife as maternity care coordinator will, hopefully, be able to have a midwife who is employed within public hospital birthing programs similar to those that already exist. The midwife will be able to coordinate the care, but only within the hospital's protocols, as is the case in many midwife care models today. That's where there may be a problem. These protocols are strictly controlled by the hospital's medical authorities.

This is not midwife led care.

It's a hybrid that restricts midwives, and is unlikely to make much difference to outcomes when compared with the standard care in those hospitals.

Examples of restrictions experienced by midwives working under hospital protocols are already emerging. A mother who has had previous home births, and who is booked in a hospital homebirth program (one of the Victorian government's 'pilot' homebirth sites) has been told she will NOT be permitted to have a physiological third stage. The midwife is REQUIRED to inject an oxytocic, actively managing third stage. Another mother who has had previous home births has been told she is not permitted to give birth at home under the 'pilot' because one of her previous births was a caesarean. She has been told that a pilot program is very closely watched, and her presence in the pilot would skew the figures.

A recent Lamaze blog post by Amy Romano, titled
What’s Behind the Cochrane? (or…, “The Good News About Midwives Gets Better!”) explores 'gold standard' research in maternity care. When we look at the best research evidence into models of maternity care, we can conclude that optimal care is midwife led care. That means a woman has a known midwife who not only provides the primary service throughout the pregnancy, birthing, and postnatal phases; who is the responsible professional in attendance at birth; and who accesses/ refers to specialist services when and if required.

Amy Romano warns:
"Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies."

At present there are very few options of midwife led maternity care in mainstream Australian public hospitals. (There are none in private hospitals).

What we don't know yet

2010-04-13T13:38:00.003+10:00

The big changes facing midwives who provide private midwifery services and attend homebirths will be implemented from 1 July - only two and a half months away!
Most professional planning, particularly in the field of primary maternity care, is done many months before the date. We know that we will be required to have professional indemnity insurance that covers everything we do professionally, excluding homebirth.
What we don't know yet includes:

Who will provide the indemnity insurance?

What that insurance will cost?

What 'excluding homebirth' means, precisely. When does homebirth begin and end, for the purposes of this insurance?

What will we be required to do to access the exclusion for homebirth?

We have been informed that the Quality and Safety Framework [see the MiPP blog], for which national consultations with stakeholders have been held, will be released next Monday 19 April.

As I have written previously on this blog, I am confident that private midwifery practice will continue past 1 July. We expect to be able to buy private indemnity insurance products that 'cover' all aspects of our practices, except homebirth, and to meet the other requirements that are yet to be finalised.

As far as I know, insurance brokers who are looking into providing this special insurance product for midwives' private practices have not yet put any offers on the table publicly. The Australian College of Midwives has informed members that it has a product which will be available for a fee in addition to membership fees. The Australian Nursing Federation (Victorian Branch) has informed members that it is also negotiating a product suitable for members who are independent midwives.

Midwifery group practices or business (such as the business linked to this blog, Aitex Private Midwifery Services) which employ midwives for private services will also need to access professional indemnity insurance to cover the services provided by their employees.

Questions about professional indemnity insurance for midwives

2010-04-08T17:21:00.002+10:00

Questions asked in the Senate Community Affairs Committee in February by Senator Rachel Siewert have shone some light on the changes midwives are facing as a result of the federal government's maternity reform. The complete Hansard is available. I have selected excerpts below (in italics) for comment.

Under the maternity reform package that has now passed both houses of Parliament, midwives will be required to have collaborative arrangements with doctors in order to be eligible for the government's insurance product which will be linked to Medicare, prescribing and ordering tests.

The doctors are not *required* to reciprocate. The logical question that arises is, will the requirement of collaborative arrangements with doctors allow the doctors to control or veto midwifery practice?

This is not a far-fetched notion. Even today, before any of these reforms come into effect, some doctors refuse to provide services, such as ordering blood tests, if they know a woman is planning homebirth attended by a private midwife. Women have been told by their GPs that the GP is not willing to accept the 'risk', from an indemnity point of view, of collaboration with a midwife. Midwives who try to make collaborative arrangements with local hospitals, establishing transparent and seamless processes for referral and transfer to hospital care when appropriate often face barriers and difficulties.

The questions asked by Senator Siewert, and the responses by the Department of Health and Ageing (DOHA) are very useful for those midwives who are trying to understand how these reforms will impact on our ability to practise midwifery, and what changes we may be incorporating into our professional lives in the coming year.

It is clear from the Hansard excerpts below that some insurance providers would refuse to cover obstetricians or GPs whose collaborative arrangements with uninsured or 'underinsured' (ie no cover for homebirth) midwives. This is fairly logical, and will potentially put a stop to the midwife's efforts to comply with the law.
Reforms that give with one hand and take away with the other are of no use to anyone.

The actuarial advice to the Department is interesting, being based on "the historical data relating to claims experience of obstetricians in Australia." Perhaps they could think of no better comparison. But it would be similar to comparing the risk associated with employing a swimming instructor to guide your child in developing skill in the water, with the risk of major surgery on the child.

Hansard Page: CA 118

Senator Siewert asked:

When the Department asked medical indemnity insurers whether an insured doctor would remain insured if they have a collaborative arrangement with a midwife, even if the midwife is not insured for home births, can you give us the process that you have used, the questions that you asked and their response.

Answer:

Prior to Ms Huxtable’s letter to the Committee Secretary on 21 January 2010, the Department had spoken to four of the five medical indemnity insurers in Australia who insure doctors. The Department has since received written advice from all five insurers that a doctor collaborating with a midwife will not result in a doctor's medical indemnity policy becoming 'void'.

The five medical indemnity insurers were asked to respond to three questions.

1. Would a medical indemnity policy issued by your insurer to a member/insured respond on behalf of the insured in the event of a claim against the insured in relation to an incident that involved collaboration with a midwife?
All insurers responded "Yes"; with most noting that this would be to the extent that their insured was liable and was acting within the scope of practice covered by the policy.

2. Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an uninsured midwife? If so, what is the reason for the policy not responding?
Four of the five insurers responded "No". The fifth has responded to two member queries. The insurer’s answer is at Attachment A.

3. Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an underinsured health professional (including an underinsured medical practitioner)? [Note: 'underinsured' refers to a situation where an insured is not insured for the full scope of his/her practice, and where the insured actually provides services in relation to his/her full scope of practice during the period of cover.]
Four of the five insurers responded "No."

The fifth responded as follows:
“Members are certainly advised that they must select the appropriate practice category, retroactive date, make accurate declarations of risk history etc. Members who are acting as supervisors/trainers are advised that they must have the appropriate qualifications/training and experience for the nature of their practice and select the appropriate practice category for the training/supervision they are providing. Trainees providing health services under the supervision of a trainer rely on the indemnity of the trainer and are advised of the expectation that their trainer/supervisor must have the appropriate qualifications, training and experience and indemnity for that role. That advice is provided because if not then they are in effect “underinsured”. The situation of anticipating underinsurance however does not normally arise (and hasn’t previously to my knowledge) because underinsurance is not usually known until after the event and usually at the time the claim is made.

That is not the situation here as it is now understood that midwives currently do not have any medical indemnity insurance for home births.”
Attachment A
Response from an insurer to questions about doctors collaborating with midwives

Question 2

Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an uninsured midwife? If so, what is the reason for the policy not responding?
I understand that the insurer has been contacted by 2 members in relation to midwife queries.

The first contact (some months ago) concerned a hypothetical situation requesting the insurer’s views on the scenario and the level of cover afforded by the Insurance Medical Indemnity Insurance Policy in such a situation.

The Underwriting Committee reviewed the scenario and in response to the questions asked advised that;

 There is a general requirement that members have the appropriate recognised qualifications, training and experience for the health services they provide.

 The insurer’s Constitution at 1.2 details Objects of the Company and states at 1.2(c) “to promote honourable and to discourage irregular practice”.

 The medical indemnity insurance policy does not cover independent contractors and in the event of a claim in relation to the actions of an uninsured health service provider, any associated/related health practitioner could also be named in proceedings even if due only to the fact that they held indemnity insurance.
Consequently, it was the view of the Committee that the scenario put forward (where an injured mother or baby may not have access to compensation) did not meet the insurer’s requirements under its Constitution. The Committee observed that on this basis it would not seem appropriate for a member to be involved. The Committee also observed that there was no appropriate practice category for the nature of practice proposed (which was not shared care as defined and not obstetric practice).

The Committee stated that based on the scenario presented that if a member notified the insurer that they were to become involved in such practice (such notice being a requirement under 5.1.5 of the Insurance Policy), that it is likely that the insurer would give notice in accordance with 12.2.2 of the Insurance Policy (where the insurer asks the policyholder to cease a practice and if they do not do so, cover will cease for that practice after 14 days).

The Committee observed that the above would not apply to actual good Samaritan or emergency matters where there is no expectation/anticipation of a member’s involvement in the care of the patient.

Member contact 2 (this week). In summary the member held a “General Practice - consultations and office procedures (non-procedural) practice category. GP’s in that practice category who meet the general requirements of appropriate recognised qualifications, training and experience are permitted to provide shared ante-natal care. As required under shared care the member had referred the pregnant patient early to hospital to book in and had continued to provide care appropriate for shared ante-natal care on that understanding.

The member wrote to us because it had subsequently come to their attention that the patient had not presented the referral/booked-in to hospital and apparently intended to have a midwife assisted homebirth.

The member was advised that;
 their current practice category was no longer appropriate (as they were no longer providing shared-care as defined)
 if there was an intention to continue to provide ante-natal care outside of the shared-care requirements permitted under their current practice category
 that they needed to provide the insurer with documentation showing that they had the appropriate recognised qualifications, training and experience for any expanded ante-natal role and

 members who met the qualification, training and experience requirements for management of pregnancy outside of shared-care arrangements normally selected an Obstetrics category.”

Hansard Page: CA 119

Senator Siewert asked:

Could you provide us with the data on which the actuarial assessment was based that assisted the Department to work out the cost of the Commonwealth supporting indemnity insurance for midwives, particularly midwives who are practising in hospitals and the numbers of births and dangers thereof. Also tell us if state by state is relevant information.

Answer:

The assessment by the Australian Government Actuary was based on the historical data relating to claims experience of obstetricians in Australia. Other matters were factored in, including the key assumptions listed below.

The Actuary’s analysis assesses actuarial and financial risk, rather than the clinical risk of dangers of birth. The actuarial analysis was prepared at a national level and the Actuary was not asked to undertake state by state analysis, as the small number of midwives would not have led to meaningful analysis.

Key assumptions were:

Number of eligible midwives 196 midwives in 2010-11, rising to 712 midwives in 2013-14
Average claim size $227,000
Percentage of claims over $1 million 7%
Number of claims per 1,000 births 1.1 claims
Full time caseload of each midwife 40 births per annum
Claim inflation rate 6%
Claim discount rate 6%

Countdown - 3 months

2010-03-23T12:20:00.005+11:00

A midwife's life follows the progression of time as babies in their mothers' wombs develop. I have a calendar on the wall of my office with the names of women in my care written at the time their babies are due. These names are ticked after the baby has been born.

The other gestation that we are watching carefully is the progression towards broad reforms of midwifery regulation in this country, that will remake the face of maternity care.

The big milestones will be:

#1 1 July 2010, when legislation mandates indemnity insurance for all registered health practitioners, with a 2-year exemption for certain midwives attending home birth.
#2 1 November 2010, when eligible midwives will be able to provide services that attract public funding via Medicare rebates. Prescribing medications and ordering pathology tests will also be part of this reform.
#3 1 July 2012, when the 2-year indemnity exemption for homebirth expires.

I am confident that private midwifery practice will continue past #1, 1 July. We expect to be able to buy private indemnity insurance products that 'cover' all aspects of our practices, except homebirth, and to meet the other requirements that are yet to be finalised.
I am also becoming more confident that a means will be found whereby some established independent midwives will be able to incorporate #2, the Medicare and related reforms into their practices.

Some midwives will seek to continue private practice without public funding. The reasons they will give for taking this approach include
too many bureaucratic hoops to jump through
professional decision making being constrained by impersonal guidelines
excessive paperwork anticipated
fear of ...

The requirement for 'collaboration' by midwives has been written into various levels of the new regulation. The picture that has been erroneously painted is that independent midwives set ourselves up as a 'one-stop shop', avoiding collaboration with the medical profession. This is untrue. This is fear-mongering by those who do not want midwives recognised in Australia as professionals with a discreet body of knowledge and scope of practice.

Under the legislative reforms, midwives will be REQUIRED to have collaborative arrangements with doctors.
Doctors will not be required to return the favour.

I have concluded that the most obvious meaning of the verb 'collaborate' - to co-labour or to work together - is not understood.

Last week I attended a meeting hosted by the National Health and Medical Research Council (NHMRC), in which stakeholders were given an opportunity to comment on a draft document 'National Guidance on Collaborative Maternity Care'. This is an extensive document that has a lot of good midwifery stuff in it. A great deal of government funded work has gone into fixing a problem that doesn't exist.

When we move the focus of maternity care from the providers (midwives/doctors/hospitals/health services) to the individual pregnant/birthing woman (+child), the needs of the recipient(s) of care direct the service, rather than the service directing the recipients.

This is woman-centred care.

A woman who is well, and progressing without complication through pregnancy and birth, in the care of a midwife does not need to be seen by an obstetrician, a GP, a neurosurgeon or any other doctor. Collaborative arrangements are in place, without being enacted for that episode of care. But a woman who develops severe headaches in pregnancy may access specialist care (not necessarily healing or wellness, unfortunately) when the midwife coordinating her care advises her to consult with an obstetrician, who may refer her on to a brain specialist.

Enough from me for now!
Joy

controversy about breech births

2010-03-15T15:06:00.004+11:00

Breech Birth Woman-Wise, published in 1998 by NZ midwife Maggie Banks, is an excellent and very useful resource for midwives and for women considering the need to give birth to a breech baby.

*****
Tomorrow the first year medical students at Monash University will be exposed to some of the contorversy that exists around breech births. The class is Sociology. Most of these students are bright young school leavers whose almost perfect scores in their VCE exams have allowed them to take their first step into the privileged world of medicine.

The course seeks to expose the students to the views of a range of participants, including women who have had a breech baby, midwives in private practice, private obstetricians, and lay birth support people. I have participated in this class for several years now. It would be easy in this debate to present a black and white, 'medical/surgical' versus 'midwifery/holistic' scenario, but that would not be truthful. I hope to demonstrate informed decision making that occurs within a professional relationship between mother and her known midwife.

The aim of the class, and subsequent tutorial discussion, is to ensure that the students understand that people have divergent views on professional bodies of knowledge that inform decision making in maternity care, and develop some understanding of the roles of individuals within maternity care.

Four instances of breech birth come to mind. By telling the stories of these mothers and their babies, I hope to share my knowledge in a way that will be useful to others.

We will call the four women A, B, C, and D.

They were all well women at Term, and the reason they are appearing in this account is that their babies were all presenting bottom-first, breech. This presentation occurs naturally in approximately 3-5% of babies at Term.

Mother A was pregnant with her first baby. At 37 weeks' gestation, after abdominal palpation and auscultation (listening to baby's heart sounds) the midwife was confident that A's baby was breech. After discussion A decided to request external cephalic version (ECV). However the obstetrician who performs ECVs disagreed with this plan, as ultrasound showed that the level of amniotic fluid aroung A's baby was less than normal. The obstetrician recommended elective caesarean surgery. A's choice was breech vaginal birth, against medical advice, or elective caesarean. She chose caesarean.

Mother B, pregnant with her second baby, was planning homebirth with an independent midwife. At 38 weeks' gestation, B told her midwife that she thought her baby was presenting as breech, as she was aware of a hard round lump (her baby's head) just under her ribs. B went to the hospital and requested ECV. Her request was denied, and she was told she would be scheduled for caesarean surgery. B went home and arranged acupuncture and moxibustion from her traditional Chinese medicine practitioner, without the desired effect. After several subsequent conversations with hospital staff, B was able to arrange a consultation with the obstetrician. B convinced the obstetrician to attempt ECV, having informed the doctor that she intended to proceed with vaginal birth whether the baby had turned or not. The ECV was successful, and B gave birth at home the next day.

Mother C, pregnant with her second baby, was booked to give birth at a suburban private hospital. C's doctor was happy with her condition when he checked her at 38 weeks. At 39 weeks' gestation C's labourb began spontaneously. C arrived at hospital in strong labour, and shortly thereafter her membranes ruptured. The presence of unmixed meconium in the amniotic fluid suggested undiagnosed breech, and with the next contraction the baby's feet were visible. The hospital midwives called the doctor urgently, and he said he was on his way. The midwives prepared C for 'delivery' - lying on her back on the bed, with her legs in stirrups. About 10 minutes after the waters had broken, the baby's body was visible up to the shoulders. There was a small bright bleed, and the baby became pale. The umbilical cord stopped pulsing. The doctor arrived only a few minutes later and delivered the baby's head, and proceeded with resuscitation of the baby - artificially stimulating heart beats and breating. The baby was taken to special care nursery, and although he survived, he was later diagnosed with cerebral palsy which was thought to have resulted from the hypoxia at the time of his birth.

Mother D, pregnant with her fourth baby, was planning homebirth with an independent midwife. At 35 weeks, the midwife and D both suspected twins, and D had an ultrasound which confirmed the suspicion. The leading twin was breech. The midwife advised obstetric review, and agreed to support D in her plan for vaginal birth unless there was a clear reason why this would not be safe, and D wanted to change her plan. The obstetricians who D consulted were strongly opposed to any plan for vaginal birth. The midwife then contacted another hospital, where a couple of obstetricians were known to support vaginal breech births, and vaginal twin births (not necessarily at the same time). These doctors also strongly advised D to accept caesarean surgery, and once again, D refused. D was confident that she would be able to give birth spontaneously. She agreed to plan hospital birth in case emergency surgery was needed. D came into spontaneous labour one morning, and proceeded to give birth to her first twin (breech) at 10.30am, her second twin (cephalic) at 11.30 am, and they all went home that afternoon.

Mothers today have many choices, especially in childbirth. A mother who is informed about the options is able to weigh up the potential positive and negative aspects of any choice that she considers, and reach her own conclusion.

There was no 'informed choice' for mother C. Undiagnosed breech is a phenomenon that is likely to continue occurring as long as babies are being born. The point is that midwives and many doctors have been de-skilled in breech vaginal births. As in this case, the baby needed to be born immediately, and the few minutes delay in waiting for the doctor to arrive may have cost dearly. In this instance the position of the mother, supine rather than upright, may even have delayed the baby from being born spontaneously. It's a true story - we will never know what would have happened if.

Maternity reform hijacked

2010-03-05T16:17:00.005+11:00

With the passing of the federal government's national health practitioner regulation legislation, and subsequent legislative amendments in states and territories, changes which are claimed will improve maternity care options for women have been made to the regulation of midwives.

Midwives in Australia, and particularly in Victoria, can not at the present time work to their full professional capacity. This package of reform had the opportunity to
• disable anti-competitive restrictions to midwifery,
• leading to improved maternity outcomes for mothers and babies,
• increased choice for consumers and access to midwife led models of care both in the community and in hospitals, and
• better career options for midwives
• with the potential for less attrition from an already stressed workforce.

However, this legislation [Statute Law Amendment (National Health Practitioner Regulation) Bill 2010] and linked bills nationally do nothing to address the current state of affairs for midwives. While other comparable OECD countries (eg UK, Netherlands, Canada, NZ) recognise the midwife's scope of practice as a primary health care professional, with responsibility to work on her/his own authority, midwives in Victoria will continue under this legislation to be unreasonably restricted, effectively fulfilling a role of obstetrician's assistant, doing what the doctor orders.

Whether you look at this so called reform from a consumer choice angle, or from a competition policy - Trade Practices Act (ref Hilmer report) perspective, or from a professional's right to practise in that profession without interference from another profession, this package is a prime example of socialist health policy being selectively applied to a section of the community, at the direction of the medical profession which has a clear interest in keeping midwifery in the status quo and preventing increased competition. This, and other health related reforms are examples of the federal Labor government's extreme style of bungling bureaucratic micromanagement, as is now progressing with reforms to the management of public hospitals. The roof insulation debacle, led to tragedy and loss, and yes, we believe this reform could also result in avoidable deaths and loss

Background
Until as recently as 1995, midwives in Victoria practised under an archaic set of rules, the Midwives Regulations 1985. These regulations included the requirement that midwives
• must wear clean clothes of a washable material
• must act under the supervision of a doctor
• must not perform a vaginal examination without a doctor's permission.
[Whose vagina? one might ask.]

The midwife of that set of regulations more resembled the gin-sodden crone who Charles Dickens called Sairey Gamp, than the well educated professional midwife who was practising in Victoria in the 1990s, and who may still be attending births today.

The Midwives Regulations 1985 sunsetted in 1995, and were not renewed. Under the new Nurses Act 1993 there was no Register of midwives: midwife became an 'additional qualification' noted on the nurses register. The apparent 'trade off' for midwives was the expectation of professional self-regulation.

With the expectation that the Midwives Regulations would sunset, the new Nurses Board of Victoria called together stakeholders with an interest in midwifery, and in 1996, published a Code of Practice for Midwives in Victoria. This Code of Practice was based on the International Confederation of Midwives' Definition of the Midwife, which had been endorsed by the international Obstetrics and Gynaecologists' professional organisation (FIGO), and World Health Organisation.

The Code of Practice promoted the principles of woman-centred care, partnership between the midwife and the woman, competence of the midwife, and collaboration between the midwife and other providers of maternity services. These principles were, and are still today, in harmony with best practice standards in midwifery. The Code of Practice was acclaimed as world class, and ushered in significant changes in mainstream midwifery practice in this State.

At the same time, other countries such as New Zealand and Canada had introduced legislation which significantly reformed midwifery and the maternity care terrain. Midwives in New Zealand were able to be the LMC, the leading maternity carer, or primary maternity care provider, for women throughout the pregnancy-birth episode of care. Women were able to choose their own LMC.

Midwives gained the entitlement to equal pay with doctors when providing equal services in maternity care, visiting rights to practise in hospitals, and other reforms such as prescribing and ordering tests. Midwives in Australia do not have these rights, and the federal government's reforms around Medicare and prescribing for midwives are a dog's breakfast of uninformed bureaucracy, which is likely to make eligibility beyond the reach or interest of most skilled midwives.

For more comment on this topic, go to
Part 2 Consumer choice, and Competition Considerations
Part 3 Professional Indemnity Insurance, and Collaborative Arrangements

Continuing the countdown ... February

2010-02-09T11:09:00.003+11:00

As we progress toward 1 July, just over 4 months away, independent midwives continue to have many questions, and no answers, as to what the regulation of our professional activity will look like after that date. Many of these questions are linked to the 'exemption' from indemnity insurance for midwives attending homebirth. I have written about that at the MiPP blog. Only those midwives who have been granted the exemption will be able to attend homebirths lawfully.

Questions midwives are asking include:

Will all midwives who are currently attending homebirths be granted the exemption, and thereby be permitted to continue providing this service for the coming two years?

Will I be able to continue to earn my living lawfully as a midwife? If not, what will I do? [join the dole queue?]

What will the women who are planning homebirth do?

We have no answers yet to these questions.

Some midwives have already declared that they are not accepting bookings post 1 July. Others (including me) are informing women who inquire that there is a degree of uncertainty, yet we are optimistic that a way will be found through the uncharted terrain. Many midwives are distressed and angry.

The Victorian consultations around the national Quality and Safety Framework for the exemption from profession indemnity insurance for homebirth are booked for next Thursday 18 February. The consultation team, appointed by the Victorian health minister, will listen to presentations in capital cities, and will come up with a set of rules that all midwives who are given the exemption will be expected to follow. The process for governance, or policing of compliance will also be decided.

There is a pessimist in me that says it's likely those rules have already been written - that we are giving the health department the opportunity to tick the box that they have 'consulted' with stakeholders.

Yet I am holding on to enough optimism and belief in the value of authentic midwifery, that if enough people speak the truth, it might get through.

Private or independent midwifery should not, in my opinion, focus exclusively or even primarily on home birth. The midwife's commitment is to the woman and her child, not to the setting in which the care is provided. Home is a very wonderful and reasonable choice for most women, but is not the ultimate.

Midwives provide primary maternity care that is tailored to each woman's personal needs and choices, as well as being based on best standards of contemporary midwifery practice. Studies have shown that women who receive care from the same midwife or small group of midwives throughout pregnancy and birth have improved outcomes and greater satisfaction than those who do not receive continuity of carer.

Midwives providing private midwifery services:

· seek to establish a one-to-one partnership with each woman

· limit the number of clients booked so that we can provide a personal, reliable service

· commit to being with each woman as her personal professional carer throughout the episode of care. This sort of midwifery practice is often referred to as ‘caseload’ midwifery

· commit to being with each woman in the setting she chooses for her birth, either home or hospital, and with the personal support team that she chooses

· If you give birth at home your midwife will give you the paperwork required for registering the birth, claiming the ‘Baby Bonus’, adding your baby’s name to your Medicare card, …

· If some unforseen circumstance prevents your midwife from attending you, a colleague will usually be able to stand in for her.

A midwife’s unique skill in providing primary maternity services is her ability to work in harmony with natural processes, to promote health, and to enhance wellness in both mother and baby. In situations where a mother or baby experience illness or complications the midwife continues to provide the personal midwifery care, while collaborating with medical services and specialists as we seek to provide appropriate care.

The main choice a woman has to make in primary maternity care is a very basic choice: to proceed without intervention/interference/interruption, or not. Provided there is no valid reason to interfere with the natural processes in birthing, midwives recommend, and support women to work in harmony with their own wonderful bodies, rather than relying on drugs and other medical or surgical processes, which all have side effects and a potential to cause harm.

Sometimes it’s not clear, and there are choices that a mother needs to make about a course of action. A midwife will seek to provide information, and answer questions, so that the client can make an informed decision.

We look forward to accompanying each woman on her wonderful, personal journey, as she brings a new life into her family and community.

Joy Johnston

Do midwives ignore science?

2010-02-06T16:31:00.003+11:00

This week I was interviewed by the producer of Channel 7's Today Tonight program. The questions were about the safety of homebirth, in response to the paper published recently in the Medical Journal of Austraila, 'Planned home and hospital births in SA, 1991-2006: differences in outcomes'.

For more detail about this publication, and links, go to the MiPP blog.

This is important topic, and I am pleased to be asked to comment.

The producer quizzed me several times about safety.
How can I, a (mere) midwife, disagree with the conclusions published in a scientific journal?
Didn't I know that doctors go to university for 8 or more years?
Didn't I know that animals die out there in the wild?

I pointed out that no matter how educated they are, doctors don't practise midwifery. Midwives do.

I hope I answered in a useful way, and I hope the little part of the recording that ever reaches the television screen will be true and helpful. When I reflected on the questions later in the day, I wondered if the producer knows about statistics: that they can be manipulated and used to deceive.

The paper, written by leading epidemiologists in South Australia, makes claims that perinatal death and particularly death from asphyxia are more likely to happen in the group of planned home births - those babies whose mothers planned to give birth at home - compared with those babies whose mothers planned to give birth in the hospital. I do not question their findings.

It's the conclusions that are drawn that I question.

Note the emphasis on 'planned' home births. These are not actual home births. Many of these deaths happened in hospital despite the interventions and monitoring carried out in the hospital.

Does anyone turn the spotlight in the same way on the outcomes for women who planned to give birth in the big private hospital in Melbourne, known in the trade as 'Caesar's Palace'? Of course not. That would be bad for business.

The authors themselves have given enough information that a fair minded person using the intra-occular statistical test (it hits you between the eyes) would conclude that there is a great deal of safety in the planned homebirth model of care. In the body of the paper, the authors state that "in the 16-year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth, or timing of transfer to hospital might have made a difference to the outcome." (p79) An amazingly significant statement. Just think about it!

The focus that this paper, and indeed the focus our society places on 'planned' place of birth places an unrealistic, and in my opinion, undue emphasis on the planned setting for birth. Noone can predict outcomes, regardless of the model of care.

The best standard of care available for any well woman with an uncomplicated pregnancy is primary care from a known and trusted midwife, who has the skill to work in harmony with natural processes in birth, and who is able to move seamlessly from home to hospital if required. The woman is able to come into labour spontaneously, to progress without undue interruption or interference, and to make decisions about obtaining medical/hospital referral if the need arises.

The paper appears to trivialise the outcomes for women who want to give birth vaginally after a previous caesarean, stating in the Discussion that "several women accepted for home birth also had previous caesarean sections." (p79) Elsewhere in the same paper it is stated that "From 1998-2006, 56 of 635 women (8.8%) with a previous caesarean section planned a home birth, of whom 32 (57%) gave birth at home." (p77) That's a few more than "several"!
There is no evidence given of poor outcomes for these women, yet women who have had a previous caesarean birth are amongst those considered to have risk factors which some would consider require the greater fetal surveillance that is practised for births after caesarean in hospital. The State government's Policy for Planned Home Birth in South Australia, which is used in government funded homebirth programs, does not permit women who have had a previous caesarean to plan home birth:

"Contraindications:

...

6.4 The following conditions preclude a woman giving birth at home.

Obstetric history—previous:

�� caesarean section;" (p7)

I, and my midwifery colleagues, do not lightly discount a paper such as this one. Our first concern is the wellbeing and safety of mother and baby. I find that midwives and homebirth mothers/parents are very cognisant of the scientific literature. A retrospective study such as the SA one must be understood in context of its own limitations, and put next to other reliable sources of information.

In fact the SA study gives considerable evidence of the safety of home birth for those who actually give birth at home, in the care of a midwife.

MOTHERBABY SUPPORT GROUP

2010-01-28T11:18:00.002+11:00

Mothers with babies in their first year,
and pregnant women
are invited to join our

Motherbaby Support Group

The group meets fortnightly through the school term, providing

· Mother to mother peer support

· interactive adult learning for mothers,
with midwives, in a setting that
promotes and protects wellness in birth and mothering

· responsiveness to issues raised
and experiences encountered, and much more

For more information, call Joy Johnston
04111 90448 - 03 9808 9614
or email joy@aitex.com.au

http://privatemidwiferyservices.blogspot.com/

http://villagemidwife.blogspot.com/

Birth and Breastfeeding

2010-01-26T15:50:00.001+11:00

My holiday reading this year has been Michel Odent's Birth and Breastfeeding (First published in French 1990, in English 2003, Reprinted 2007).
Not that I have had many days to devote to reading!

Dr Odent's writings have been familiar terrain for me for many years, and I am indebted to this man for his persistent efforts to describe and explain the natural physiological processes in everything to do with childbearing. The subject keeps me attentive for new information, as well as on the lookout for anything I find implausable, and need to think more critically about. I do not want to be a gullible 'true believer' in my understanding of these topics. Birth and Breastfeeding did not disappoint.

There are several questions posed in a postscript, and I copy three of them here for further refection:

What if maternal qualities become the main criterion for the selection of aspiring midwives? The need to feel safe without feeling observed or judged is satisfied by the proximity of a mother-figure.
What if obstetrics becomes a medical discipline at the service of women and midwives?
What if the Caesarean section recovers its status of a wonderful rescue operation, while obstetric forceps find their place only in the museums?

continuing the countdown

2010-01-12T11:59:00.000+11:00

The context of writing this post is that it's hot outside. Melbourne has sweltered yesterday and last night, and I am thankful for air conditioners in houses and cars. My thoughts go out to all mothers with new babies.

I have no new news since my last entry on this blog.

A couple of draft documents that will have an impact on the way midwives practise privately after 1 July this year have been circulated, and I am doing what I can to prepare responses. Other midwives and birth activists are also committing precious time to writing responses.

The most significant matter at the moment (from where I sit) is the exemption of birth from indemnity insurance. See the MiPP blog for the current news.

The big question is, Which midwives will be allowed to access the exemption from indemnity insurance?

The draft framework document once again raises the idea of mandatory
". evidence of formal arrangements for professional and medical backup as demonstrated by signed letter from collaboration partners"

This requirement itself would exclude most midwives from access to the exemption, unless the government also provided, at considerable cost, a bureaucratic system that established a process to tick the box - a silly notion. Even though I respect and from time to time work with various obstetricians, I don't have obstetricians who I could ask to give me a signed letter of collaboration. I and others will be arguing this in our submissions to the inquiry, and we believe we can use a letter from Health Minister Roxon in preventing this particular requirement from being adopted into regulatory processes.

I believe every midwife should be free to choose to work in a private, self employed capacity, practising midwifery. Therefore every midwife should be able to claim the exemption from indemnity insurance for attending birth, either in the woman's home or in hospital. Midwifery is a discreet scope of practice that limits what a midwife can, and cannot do.

Secondary regulation, which this draft framework is, can not be used to replace or preempt the basic regulation of the midwifery profession. There can be only one gatekeeper into the midwifery profession in a jurisdiction, and the body with that responsibility is the regulatory Board, which has the authority to investigate, take disciplinary action, and in extreme cases, remove or restrict the practice of a midwife. This grave responsibility cannot be delegated to insurance providers or other regulatory panels.

I think we, independent midwives, have to approach this framework as positively as we can. We are the privately practising midwives of Australia; we are legally registered to practise midwifery. We have already argued to the Health Minister and the Senate hearing why it is unreasonable to mandate the signed collaborative agreement, and those arguments, which appear to have achieved some significant changes, can be aired again. Midwives are able to produce evidence of collaborative practice (however it is defined). We draw the line on having double jeopardy at the hands of a competing profession, obstricians.

There continues to be a degree of uncertainty about how private midwifery will look after 1 July, when the government's reforms will come into effect. I am hopeful that there will continue to be a place for every midwife to attend women who choose their care, whether it's through publicly funded programs or privately.

Countdown to July 2010

2009-12-11T11:51:00.010+11:00

Over past months I have been recording events and my comments as we progress through uncharted waters of what is supposed to be maternity reform. There have been confusing and sometimes distressing messages, from a privately practising midwife's point of view. I can only imagine how women who value private midwifery service are feeling about it all. A blog is a good repository of information, and from time to time I scroll down through this and other blogs to be reminded and to get my facts straight.

Yesterday I attended a Stakeholders Forum in Canberra, auspiced by (and funded by) the National Health & Medical Research Council on Developing National Guidance on Collaborative Maternity Care. I attended as a representative of Midwives in Private Practice, and plan to write a report on the MiPP blog. It was a big day; I was up before 5 to get to the airport at 6.30.

In summary, the big issues at the moment are a midwife's insurance and our right to practice.

Insurance
We know that every midwife in Australia will be required by law to be insured in order to practise after 1 July next year.

We know that an exemption on this requirement will apply for 2 years to homebirth. The exemption is limited to the birth only.

We have been told, but are yet to see documentation, that an affordable insurance product will be available for midwives to purchase before 1 July, to cover their private midwifery practices (excluding birth).

Right to practice
This indicates that all midwives will be able to continue their private practices lawfully, as long as they have an indemnity insurance.

Rosemary Bryant, who is the health minister's Chief Nurse, confirmed this verbally to me yesterday. This reassurance is somewhat 'reassuring', but I will wait until I have seen the fine print. On face value it appears that midwives will be able to continue practising privately next year, IF ...!

My confidence has been jaded this year by the repeated episodes of this government adding new rules, new hoops to jump through - the most recent being the 'collaboration' amendment to the midwifery legislation. The amendment adds the condition that a midwife must have a "collaborative arrangement". The Health Minister told the parliament "These bills will mean that eligible midwives working in collaborative arrangements with obstetricians or GP obstetricians will be able to access the new government supported professional indemnity scheme."

What we don’t know yet is what this collaborative arrangement will look like. Doctors are not required to have collaborative arrangements with midwives. That sets up the likelihood that some midwives may not be able to practise because they are unable to get a doctor to give them the gold star of approval.

Noone has defined collaboration as it appears in this law.

Noone knows if the doctor’s insurer will support that doctor’s arrangement with midwives; if any legal action against the midwife will imply liability on the doctor’s part.

The point that the Minister, and her advisers, have not acknowledged is that midwives constantly collaborate with doctors, nurses, and other health professionals. It's written into our definition.

Witch hunts and midwives are sadly intertwined in our history. A writer to a midwives email list has proposed that the current attempt at micromanagement of all midwives who attend homebirths is another attempt to control and suppress women. By attempting to remove all midwives who are prepared to focus their attention on women, the system is tidying up that small but embarrassingly indominatable group (reminiscent of a certain fictional Gaulish village).

Midwives who are willing to be independent in their thought and reflective in their learning are also willing to stand their ground because they know that what they have to offer their community must not be relinquished.

COLLABORATION IN MATERNITY CARE

2009-11-26T15:35:00.005+11:00

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.

Medical dominance in birth

2009-11-25T15:35:00.003+11:00

Society and cultural beliefs may not always agree with or understand the ‘promotion of normal birth’ which is, by definition, the duty of every midwife (ICM 2005). Many midwives who may have only practised under medical supervision, may not understand or have any skill in the promotion of normal birth. Regardless of the fashion of the day, and a midwife who does not possess skill in promoting normal birth should be challenged and supported in achieving competence, in the same way as a midwife is required to have competence in newborn resuscitation or any other basic midwifery skill.

In a discussion on ‘Birth Territory: a theory for midwifery practice’ (Fahy and Parratt 2006) the authors postulate that “when midwives create and maintain ideal environmental conditions maximum support is provided to the woman and fetus in labour and birth which results in an increased likelihood that the woman will give birth under her own power, be more satisfied with the experience and adapt with ease in the post-birth period.” (p49)

Are midwives really able to create and maintain ideal environmental conditions for good births? If so, should midwives accept responsiblity, at least in part, for the inability of women in our society to give birth in a spontaneous, physiological way, and to make the adjustments to mothering successfully?

It is not fashionable for midwives to take responsibility for the high caesarean rate in Australia. After all, that's the doctors' domain. Yet surely the national caesarean rate of approximately 30% (and growing) points as much to poor midwifery as it does to interventionist, knife-happy obstetrics.

Midwives who practise as independent primary carers demonstrate excellent outcomes, both locally and internationally. The woman's own home is uniquely suitable for her to engage in a sensitive and demanding physiological process, and the midwife is uniquely skilled at enabling that process.

In commenting on conflicts and tensions between midwifery and obstetric professional groups, Karen Lane (2005) presents the argument that midwives need to “resist the terms of their own professional subordination. In other words, the complexity of midwifery identities will variously position each midwife to accept, resist or just remain ambivalent about the causes and forms of their own oppression.” (p2)

In its submission to the Maternity Services Review (2008), the National Association of Specialist Obstetricians and Gynaecologists (NASOG) state that it “believes that it is preferable that a single individual carer take overall responsibility for care of a woman in labour and the obstetrician is the most appropriate choice for such a role.” (p5) It is clear from this and several other obstetric submissions that the concept of the midwife as the primary or leading professional carer is not understood by the writers of the submissions. NASOG asserts “That current excellent obstetric outcomes are due to a high quality overall maternity service which has historically been medically led.” (p6), and strongly discourages the government from making the reforms foreshadowed in the review’s Discussion Paper.

It can be argued that medical dominance in birth, and devaluing of normal birth in western societies falls within ‘Modernity’ – “a narrow canal through which the vast majority of contemporary cultures have passed or are passing. … Thus in modernising societies, traditional systems of healing, including midwifery, have become increasingly regarded by members of the growing middle and upper classes as ‘pre-modern vestiges’ of a more backward time that must necessarily vanish as modernisation/biomedicalisation progresses.” (Davis-Floyd, 2005 p32)

While it makes sense to class the midwife as a traditional system of healing in a society that understands birth within a medical mindset, it may not be helpful. The modern authentic midwife is not a therapist, not one of the myriad of ‘healing’ modalities that have little evidence and require amazing faith: simply because birth is not an illness, so there is essentially nothing to be healed or ‘therapied’. The midwife’s role is to work in harmony with, and to support and protect the individual woman’s own ability to give birth.

While pre-modern midwives were confronted with the full spectrum of the woman’s challenges in reproduction, the modern midwife is not a one-stop-shop when complications arise. The midwife of today is able to detect “complications in mother and child” and access “medical care or other appropriate assistance” (ICM 2005). The midwife primary carer is able to fulfil this role, with the woman-baby dyad at the centre of care, and effective collaboration that seeks to protect the wellness of mother and child.

Melbourne academic Kerreen Reiger (2006) considers that “In Australia, although governments traditionally promoted medical dominance of birth, recent policy initiatives in several states are encouraging significant change in the mainstream public hospital system.” (p331) The current Victorian policy states that “Ensuring continuity of carer and providing choice thus underpin the new framework for maternity services.” (DHS 2004, p1) These two elements, ‘continuity of carer’ and ‘choice’ would appear to ensure a strong future for caseload midwifery in Victoria. As time passes we will be more able to judge whether ‘ensuring continuity of carer and providing choice’ are indeed established in maternity services.

As the maternity reform process that was ushered in by the Maternity Services Review (2008) has progressed, the reality of medical dominance in birth has become progressively more foreboding. The hope for changes based on evidence coming into mainstream maternity care has been replaced by an unprecedented level of medical control that is being systematically written into the laws of this country. Even the level of access to private midwifery care that women 'enjoy' at present will expire 30 June next year.

It appears to me that Australia's socialist government's efforts to reform public hospital maternity care have entrenched a two-tier health system, reducing the public system to a processing line, while protecting the pockets and privilege of the obstetric/medical class. The small degree of choice that has been provided by private midwives who have carefully worked to "create and maintain ideal environmental conditions" for physiological birth and adaptation to mothering, is being extinguished.

[Note: References have not been given in full. That would encourage students to copy! jj]

Update - less than eight months to 1 July

2009-11-12T14:08:00.004+11:00

[Pic: a card by curly girl design]

As the countdown progresses relentlessly in the same way that the sands pass through the constriction in an hour-glass, midwives continue to ask what will our lives, our practices look like, in less than eight months' time.

Remember that the rationale for the current package of reform was to *improve* health care, *in the public interest*, across the range of regulated health professions. A decision was made in the rarified air of health bureaucracy that the system needed to mandate professional indemnity insurance for all registered health professionals. Even the vocal maternity consumer groups, Maternity Coalition and Homebirth Australia, and professional groups chimed in with calls for mandatory indemnity insurance as a condition of registration.

The rationale was that they were demanding equity. If the government provides subsidised indemnity insurance for doctors, let's demand it for midwives as well. That sounded reasonable enough to ordinary folk.

Few seemed to stop and ask in whose interest indemnity insurance was, and noone was listening to them anyway. The groupthink was that everyone needs it, so that's that.

I recently received a letter from the Victorian Health Minister, Daniel Andrews, in response to some of my correspondence to him. I was amazed to read in that letter, a statement that professional indemnity insurance “goes to the very cornerstone of the scheme which is public safety.”

This is an example of spin that is simply indefensible. Statutory regulation must be in the public interest, to enhance public safety, but there is no evidence of a connection between public safety and the mandating of professional indemnity insurance, nor is there any logic in that statement.

From the start in this ‘reform’ it was delegation of the regulation of midwives to the insurance companies, now with the amendment it will be double regulation again, this time by a doctor. The logical question is “which doctor?” [My lateral thinking says the Minister would then be obliged to provide a doctor for private midwives, in that if a regulation is written into the Act, surely the government must provide the means for it to be carried out. I WISH!] Can anyone imagine the legal ramifications for the doctor who does enter a collaborative arrangement with a privately practising midwife???

The Department of Health and Ageing is very concerned about cost blowouts as a result of their reforms. Good grief, if they would only do their sums they would see that the government could save buckets of money if maternity care was managed consistently with the evidence, following basic principles, in stead of the current ‘anything-goes-as-long-as-the-doctor-says-so’

As it looks today I doubt that any midwives will be able to do any private practice lawfully, although we will be on the register of midwives after 1 July. But I encourage everyone to discuss the situation as openly as you can with women who contact you for bookings. If they are scared off, that’s a shame, but if they want to book us knowing the facts, then we are bound by our duty of care as midwives to give them the best we can.

Perhaps there will be mass complaints to the health ombudsmen, perhaps even some brave law firm will work probono for a group claim. ??? (just musing!)

things are looking grim for midwives

2009-11-06T10:57:00.003+11:00

As I write, things are looking grim for midwives. We have talked a lot about the outrageous restriction on a midwife's ability to practise privately and autonomously, but it's worse than that. Our federal government is making laws that will completely redefine midwifery.

A new amendment in the Health Legislation Amendment (Midwife and Nurse Practitioner) bill will require eligible midwives to have a “collaborative arrangement” with a doctor in place at all times.

Midwives have always had collaborative arrangements, in that we consult with medical professionals and refer when we suspect illness or complication. We encourage women to make a booking at a hospital as back up, to access services if and when required.

However, the 'collaborative arrangement' foreshadowed in this legislation appears to be the mandating of a formally agreed relationship that covers every single episode of care provided by the midwife. This is the opposite of autonomous professional practice; it is external supervision of the midwife's practice - a medical veto over care.

No doctor in their right mind will agree to any arrangement that gives the midwife any responsibility in decision making. I don't know any doctor who I could ask to enter such a relationship with me.

In recent months several women coming to me for care have said their local GP was reluctant to be involved (by ordering blood tests) when they said they wanted to plan homebirth. They said the doctors thought they were not allowed to. This is likely to become more acute in coming months.

ALL MIDWIVES in Australia stand to lose if this legislation is passed. The person the Health Minister is concocting is a handmaiden, and obstetric assistant. Not a midwife, but this person will have the title midwife, and we midwives who have served our communities safey and effectively for generations will be made illegal.

Due Date: July 2010

2009-10-30T19:09:00.002+11:00

A woman who has missed her period this past week will probably be due to give birth in the first week of July 2010, when the new national registration of midwives and other health professionals comes into effect.

What sort of maternity care will be available for this woman, and any others who become pregnant in the coming weeks and months?

There won't be much change to the medical-hospital maternity models that cater for the majority of women. The government's 'reforms' that will provide Medicare rebate on prenatal and postnatal care provided by as yet undefined 'eligible' midwives will not be in effect until at the earliest November 2010.

Only those women who are interested in private midwifery care will have concerns about their choices of carer and place of birth.

We really don't know what sort of maternity care will be possible after 1 July for women who want homebirth with a privately employed midwife. All midwives who are currently on the state and territory registers will automatically be included in the new national register. But the mandating of professional indemnity insurance will make any private midwifery services unlawful, except for the birth, during the exemption period of 2 years. The boundaries and rules around the exemption have yet to be announced.

The overarching principle that must be kept in mind is that birth is not an intervention or a drug, to be manipulated and managed like stock in a grocery store. The significance of birth in each little person's life; to the mother who gives birth; and to the family into which the baby is brought is a profound element in an extremely complex social order. People who are willing to defy ridiculous restrictions in order to promote normal birth, and to protect wellness and wholeness in birthing, will encounter such action because the alternative is simply unacceptable.

More on the exemption

2009-10-22T21:13:00.003+11:00

We have recently had clarification (from a reliable source) about the 2-year exemption for midwives from the requirement for indemnity insurance. According to a senior official in the National Registration and Accreditation Scheme, the legal interpretation of the exemption has now been completely imbedded into legislation. What this means is that all registered midwives will have to have indemnity insurance to cover antenatal and postnatal care of all women, including those wanting to birth at home. The exemption from the requirement for indemnity insurance covers birth in the home only. Midwives will only be exempt for the actual birth for women birthing at home.

Midwives and mothers who want homebirth need to consider what that actually means. If the government is redefining childbirth and midwifery, two can play at that game. Pregnancy and birth are not an illness. Under this new system I can envisage a midwife in private practice charging a fee for attending the actual birth at home, and having social contact (the ‘cup of tea’) with women instead of what’s now called prenatal and postnatal ‘care’, but achieving the same end. I say this sadly – it’s madness isn’t it!

The Medicare model simply does not fit what we as midwives know as ordinary midwifery care. As Andrew Laming said “Bad policy in two years is still bad policy.” The slogan ‘medicare for midwives’ sounded catchy, but as they say, the devil is in the detail, and we have been had.

It looks to me as though there will be plenty of essential political activity for generations of midwives and women into the future in this country.

In summary, from 1 July 2010:

All midwives will be required to have indemnity insurance for professional practice, except (for 2 years) when they are attending a woman for homebirth.

We don’t know yet what midwives will have to do to get the indemnity product that we expect will be available under government tender. We don't know the costs or conditions that will be attached to that product.

Monthly update

2009-10-13T19:25:00.004+11:00

My purpose in writing a monthly update is to draw my own thoughts together, as much as to inform others. The terrain of private midwifery practice in Australia is going through great changes at the hands of our government, with varying degrees of input from professional and consumer bodies who have a seat at the discussion tables.

Here are links to the August and September updates.

Meetings have been convened this week in Canberra by the Health Department, with working groups on 'eligibility' and Medicare arrangements for midwives. Considerable discussion has circulated amongst independent midwives about the issue of a suitable 'framework' under which the eligible midwife will practise in the new maternity era that will be ushered in 1 July next year. From what I have read I am not sure that anyone knows what is meant by 'framework'. My concern is that any structure for midwifery must be consistent with the ICM Definition of the midwife (2005) - see earlier blog.

An attempt at micromanagement of midwifery that is mis-named 'framework', dictating detail in an effort to appease competing interest groups, rather than declaring the agreed principles under which midwives practise, will simply not work.

The Australian College of Midwives (ACM) hosted a meeting today in their offices in Canberra. Other organisations invited to the meeting are Australian Private Midwives Assn (APMA), Homebirth Australia, and Maternity Coalition.

Today I am no more confident that authentic midwifery will survive this period of legislative reform than I was a few months ago. Midwives who have practised safely in their communities for many years, and who are highly respected by their clients as well as other professionals, are still wondering what hurdles will be in place in the near future, and whether they will be able to continue providing the basic primary maternity care midwifery services that they are expert in.

When a decision about who to trust must be made

2009-10-12T20:19:00.003+11:00

The young mother who I will call Jenny had booked a private midwife as well as being booked at a public hospital birth centre in Melbourne. As the pregnancy progressed, Jenny's plan for homebirth became clearer in her mind, and she retained her booking at the hospital as a backup arrangement.

A couple of days after reaching 37 weeks' gestation Jenny found that her waters had broken. It was a small trickle of clear fluid initially, and it continued to flow. Jenny called her private midwife. Labour had not commenced; Jenny was well; and her baby gave plenty of reassuring kicks, so there was no cause for concern. She had an appointment scheduled at the birth centre that day, and presented at the desk. The midwife who she spoke to was busy and distracted, and asked Jenny if she would perhaps like to come back later.

"Well actually my waters have broken", Jenny said.
"Oh, well you'll need to go and have monitoring" was the reply. Jenny was given instructions on where she needed to go.

A midwife applied the straps of the CTG monitor around Jenny's belly, and was walking away when Jenny asked, "Could you please tell me what this is about?"

"Oh sure!" (as though it was unusual that a woman would want to understand what was being done to her)

...

Jenny then went back to the birth centre with a report that her baby was happy, and a strip of monitor paper to prove it.

"This is your first baby, and you're not in labour. You've got 24 hours (to use the birth centre). After that you will be moved around to the delivery room for an induction of labour. If you're not in labour by 7 tomorrow morning you will be induced. And here's an antibiotic tablet to take at midnight. It might stop you from getting infected."

The midwife's tone was dismissive, fatalistic. Jenny felt gutted, and alone. Her partner had not been able to go with her to the birth centre, and she really missed him at that point. The implied message, as far as she was concerned, was that she had already been written off. There was no discussion of options, of evidence supporting this course of action, or even of anything Jenny could do to encourage the onset of labour.

...

It was after 4pm when Jenny returned to her home and phoned her private midwife.

"You need to decide now who to trust, Jenny. Me, or the hospital. I am going to offer you an alternative plan, which is quite different from the plan that has been offered by the hospital."

Jenny's midwife reassured her that spontaneous onset of labour was very possible; that homebirth was a very real option.

"I want you to go for a walk with your partner when he comes home. I want you to try to let go of all the anxiety and fear. Have a good dinner, and get yourselves off to bed. You will need plenty of energy for the work ahead of you. Call me in the morning and we'll talk about the next step. Call me at any time if you are worried, or if your labour is strong," her midwife explained. "And I don't want you to take that antibiotic. I don't want to mask any signs of infection, if that were happening, which is very unlikely," she added.

Jenny was awake and working hard by three, in good labour, and her midwife was asked to come at about 6am. At 7am her partner called the birth centre to let them know that Jenny would not be wanting an induction of labour. Their beautiful baby was in her arms later that morning.

To download a review of current evidence and guidance on Pre-labour Rupture of Membranes, go to Maternity Coalition's INFOSHEETS.

A framework for private midwifery practice

2009-10-04T22:08:00.009+11:00

There has been a lot of talk in midwifery circles lately about a *framework* that will enable eligible midwives to practise privately within the new environment promised under the government's package of midwifery reform. We have been informed that an "advanced midwifery credentialing framework" will be required for eligible midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors".

Midwives who continue practising privately without insurance in the 2-year period (2010-2012) have been told we will be required to participate "in a quality and safety framework which will be developed ..."

I am very concerned about the misuse of the concept of a regulatory framework, which seems to be interpreted by the government as redefining what midwifery is (to suit vested interests), rather than embracing a wonderful profession. Our professional College, ACM needs to be strong in demanding that the principles of midwifery be used at the foundation of any statements about midwifery in this country.

What is meant by a *framework*?
Google took me straight to Wikipedia,
A framework is a basic conceptual structure used to solve or address complex issues. This very broad definition has allowed the term to be used as a buzzword, especially in a software context.
Framework can also refer to mechanical structures, such as scaffolding.

[and if you are unsure of what a *buzzword* is, Wikipedia can help out there too!]

As time passes I am becoming increasingly more confused as to what is actually meant by our Federal Health Minister, and all who are collaborating with her in bringing about maternity reforms, when they refer to a *framework*.

The challenge in my mind has been to prepare a statement which is a "basic conceptual structure used to solve or address complex issues", that is, midwifery practice.

I found the answer to my quest - the conceptual structure ... in the Definition of the Midwife (2005), a Core Document [ie no buzzwords here] of the International Confederation of Midwives (ICM).

The ICM Definition is foundational to all midwifery practice, including homebirth. Education and Codes of Practice and other guiding documentation of all member organisations, including the Australian College of Midwives, are expected to be consistent with this definition.

The ICM Definition of the Midwife establishes the following principles:
.1 The principle of ‘partnership’: “The midwife … works in partnership with women …”
.2 The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
.3 The principle of continuity of carer (‘caseload’) – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
.4 The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
.5 The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
.6 The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
.7 The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
.8 The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”

Simple logic tells me from the principles of midwifery, that basic midwifery includes, by definition, consultation with and referral to a doctor when appropriate. And, for that matter, referral to a dentist when appropriate. Doctors and dentists don't do midwifery, and vice versa.

So when midwives are told that we are going to be required to undertake "advanced midwifery credentialing framework" in order to be 'eligible' midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors", we are confused.

The only way this makes any sense is to accept the Wikipedia broad definition of *framework*, as a no more than buzzword. Until any framework applied to midwifery practice or credentialling or teaching actually confirms the principles that undergird midwifery, any attempt to describe midwifery's position will flounder.

Who is responsible? - Debunking the myth of doctor liability.

2009-09-26T10:04:00.004+10:00

Midwives in Australia as well as other countries face varying degrees of regulation and restriction. Some of this control is enshrined in law, some by monopoly of funding and access to services, while much is the accepted status quo. People don't challenge what they don't recognise as having potential to change.

Historically doctors have taken the leading and thereby controlling hand in health care. This is especially so in maternity care, and midwives around the world have in recent decades strongly resisted medical supervision of midwifery. Most Australian midwives don't recognise this fact, as they work in hospitals and their scope of practice is defined by hospital protocols. Midwives who practise privately, and autonomously, develop a midwife identity that is informed by the partnerships we develop with individual women, and that is consistent with the contemporary international definition of the midwife. Midwives who practise privately know that we are responsible for all decisions, advice, actions, and lack of action in our interactions with women who employ us as their midwives. We consult, refer, and occasionally transfer care to medical colleagues when the situation a woman in our care faces is outside our scope of practice.

The question of 'who is responsible?' with reference to the relationship between doctors and nurses is explored in a paper from the Royal College of Nursing, Australia. The arguments posed in this paper can be applied to midwifery.

Ultimate doctor liability: A myth of ignorance or myth of control?
Author: Andrew Cashin and others
Reference: Collegian Volume 16 • Number 3 • July/September 2009, Royal College of Nursing, Australia

Summary
Ultimate medical doctor responsibility for the care delivered to patients by all professionals is a myth. Legally Lord Denning dismissed the myth in the mid-20th century in England. The assumption that a medical doctor is responsible for the care delivered by nurses has not existed in English and Australian law since that time, and it has been actively refuted. Yet it is a myth that continues to circulate influencing health service, state and federal health policy. For some it is a myth of ignorance and for others it is a means of control. This paper outlines the relevant case law to debunk the myth of ultimate medical doctor control.
________________________________________

The current government's effort to reform maternity service provision in Australia has brought to light the reality that the myth of ultimate doctor responsibility in maternity care is alive and well in this country.

Birth Plan for twins

2009-09-18T08:54:00.001+10:00

Readers may have seen recent posts on my villagemidwife blog about complex negotiations that have gone into planning for birth of twins, and a summary from the birth.

My purpose in telling this story publicly, with the support of the mother, is to highlight basic midwifery knowledge, that even in complex situations, the physiologically normal processes in birth can be, and often is, the best. The only way to reach physiological birthing in today's world is for the mother to have the confidence to refuse all offers to actively manage the birth. When a midwife and a woman have established a partnership based on trust, respect, and reciprocity, the midwife is able to support the woman as she negotiates complex and unpredictable decision-making.

In this particular case the mother had initially planned homebirth, but on my recommendation, after the twin pregnancy was diagnosed, agreed to change that plan to hospital birth. The mother was pressured and coerced in an attempt by the hospital to achieve compliance and agree to elective caesarean. She listened and discussed what was on offer, yet she believed that the safest way for her to proceed was to wait for spontaneous onset of labour, and to proceed without surgery or anaesthesia. This is what she did.

In this blog we are sharing the framework of a birth plan. This birth plan was prepared at about 36 weeks' gestation. Ultrasound scanning gave no indication of any specific reason which may have swayed the balance towards surgically managed birth, other than the fact that the first twin (A) was presenting as Breech. Size of babies and amniotic fluid around the babies were unremarkable.

BIRTH PLAN
Include statements such as:
• “I plan to give birth to my babies spontaneously unless there is a reason for me to change this plan.”
• “I understand that I have the right to refuse any intervention.”
• “I believe that my birth plan is the best way for me to ensure the safety of my babies and to protect my own health”.
• "I ask that all care providers respect my need for privacy in labour and birth. Please do not interrupt me without good reason. Please minimise the number of people who come into my room, and keep equipment brought into my room to a minimum."
• "If an intervention is recommended, please explain to me the reason and I will consider it, and discuss it with my husband and my midwife so that I can make an informed decision."

DECISION POINTS IN SPONTANEOUS BIRTH FOR BREECH AND TWIN BABIES
Include:
• Onset of labour – may be regular contractions, or breaking of water or both. [Contact midwife]
• Going to hospital – as labour becomes established. Usually labour for the first twin proceeds in a similar way to previous labours. [Discuss with midwife]
• Established labour – check babies are coping well with labour. [midwives will be watching for normal progress over time.]
• Birth of Twin A:
• Urge to push – find upright position
• If membranes have not ruptured when visible at the vaginal opening, midwife will break the sac
• As baby’s body emerges, allow it to hang, assisted by gravity
• No forceful manipulation of the body
• No touching unless absolutely necessary until neck is visible
• Gentle support as face is born
• Clamp and cut cord soon after birth to prevent the possibility of twin-twin transfusion
• Baby to mother, skin to skin, as soon as baby’s condition is good
• Mother rest and enjoy Baby A, while midwife checks condition of Twin B.
• Baby A to breast if mother wishes
• Mother may need to stand and walk, to bring Twin B into to the birth canal
• When contractions return, and mother needs to focus on the birth of Twin B, pass Baby A to father, who stays close by. As long as Twin B's condition is good, there is no reason to speed up the birth by breaking the baby's waters.
• Birth of Twin B:
• Second labour will usually progress quickly once baby is presenting well, as the cervix has been dilated.
• Third Stage: After pulsation of the cord for Baby B has ceased, proceed with administration of oxytocic and controlled cord traction.

[Thanks to English midwife Mary Cronk, for sharing her guidelines for the care of a woman expecting twins. These guidelines have informed me in advising several twin mothers over the past few years.]

Monthly review

2009-09-14T09:43:00.003+10:00

Last month I began a countdown to 1 July 2010. I hope to summarise and review progress over the past month, for my own sake as well as for others who are following events as they unfold. If you don't understand something I have written, or think I have got it wrong, please let me know.

We can be confident that a baby who is conceived this week will be born before 1 July.

A woman whose menstrual period starts this week and conceives when she becomes fertile a couple of weeks from now will attain 42 weeks' gestation in the first week of July.

If you are that woman, and are planning homebirth with a privately practising midwife, you will need to work closely with your midwife, keep a clear mind, and remember your personal rights and responsibilities in giving birth to your child.

In summary

# Health Ministers have agreed to a transitional clause in the current draft National Registration and Accreditation Scheme legislation which provides a two year exemption until June 2012 from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth. (AHMC Communique 4 September 2009)

Although this sounds like a useful reprieve at face value, I see it as a meaningless political gesture to get the pressure off the Health Minister and the government that is presiding over reform that is a dog's breakfast before it's even enacted. Curiously the two-year exemption was announced at 4pm on the last business day before the big rally!

# The Department of Health and Ageing is seeking tenders from insurance companies to provide indemnity for eligible privately practising midwives.

This could potentially make private midwifery technically lawful, while making it so expensive that it becomes more marginal and unaffordable than it is now.

# The Maternity Service Advisory Group, with hugely disproportionate obstetric and medical representation, has been set up by the (federal) Health Minister.

# Key players have been invited to send a representative to three technical working groups to be convened 24 September and 12 October, as a component of the national maternity reform process. The working groups will consider PBS (pharmaceuticals), MBS (Medicare), and eligibility (credentialing).

Australian Private Midwives Assn (APMA) and ACM have been invited to send one representative each. Maternity Coalition have been invited to send two representatives. I don't know who else is to be represented.

My comment:
I will be satisfied that we are moving in the right direction if there can be agreement on broad principles underpinning midwifery practice and primary maternity care.

These principles are well articulated in the ICM Definition of the midwife.

As long as the advisors to the Health Minister are ignorant of the principles underpinning midwifery, and are able to be swayed by interest groups who advocate for midwifery to be a support service to obstetrics, these principles including partnership between a woman and her midwife, promotion of normal birth, and professional competence will not be respected in any of the outputs from working groups and advisory committees.

Call for tenders to provide professional indemnity for midwives

2009-09-13T18:44:00.003+10:00

From the Business section of The Australian newspaper yesterday:

"The Department of Health and Ageing is seeking tenders from capable and experienced individuals or organisations to provide insurance (in compliance with Australian insurnce legislation) to eligible privately practising midwives.

"The successful tenderer must offer professional indemnity insurance, in the form of a contract with each individual eligible privately practicing midwife who seeks such cover to provide cover for their midwifery services in a manner that is efficient, equitable and timely with effect from July 1 2010 for a total of three years. The successful tenderer must manage all claims during the contract period and certain run off claims after the expiry of the contract and must collect and provide data on incident notifications and claims to Medicare Australia. "

RFT 014/0910
REQUEST FOR TENDER
Professional Indemnity Insurance for eligible privately practising midwives
Tenders close October 8th 2009
If you have been talking to an insurer, please make sure they know about this call.

What will Medicare rebates mean?

2009-09-10T16:56:00.004+10:00

A guest editorial 'Medicare rebates for midwives: An analysis of the 2009/2010 Federal Budget' appears in the September issue of the Journal of the Australian College of Midwives (ACM) (Women and Birth 2009, Volume 22 Issue 3). The authors are Liz Wilkes, Bruce Teakle, and Jenny Gamble - Queenslanders who are well known in maternity and midwifery activism. Liz is a privately practising midwife; Bruce is a homebirth dad and birth activist; and Jenny is a midwife academic.

This editorial explores some of the initial concerns that many midwives have expressed, both publicly and privately, about the wisdom and application of the government's 'reform' plans. The legislation sets conditions for midwife eligibility, including that the midwife be "appropriately qualified and experienced"; "working in collaboration with doctors"; under an "advanced midwifery credentialing framework".

The authors rightly note that the normal "full scope" of midwifery practice - which, incidentally, everyone who graduates with a midwifery qualification is supposed to be competent in - has been redefined as "advanced practice". They note that no other profession is required to be "working in collaboration" with another professional group as a separate requirement to their professional codes and competencies. And what does 'collaboration' mean? Watch this space - the definition has not been written yet. Likewise the meaning of "appropriately qualified and experienced", or the "advanced midwifery credentialing framework".

While initially midwives expressed delight at the bravery of the Health Minister to open a pathway for publicly funded private midwifery practice, the draft legislation does not look good on closer scrutiny. It lacks attention to detail, and lacks understanding of the foundations of midwifery. In a bumbling effort to prevent "polarising the professions", the legislation has managed to discard all private midwifery practice as it currently exists, considering it 'controversial'.

I consider the best option at present would be to send it all back to the drawing board.

I have been involved in the call for reform of maternity services since the mid-1990s. 'Medicare for Midwives' has been a catchy slogan that many have taken up eagerly.

I have not supported 'Medicare for Midwives'. My argument has been that the Medicare system as we know it is NOT a suitable funding system for primary maternity care. Medicare fragments care into 'items' - fragments a woman into prenatal, intrapartum, and postnatal care, as most Australian women today experience. Medicare causes buck-passing between federal and state health departments. The federal health funding covers prenatal care through Medicare rebates to doctors, and the Medicare Safety Net. State and Territory health funding covers acute care for birth and the early postnatal days. This is the domain of the hospitals. The recipient of materntiy care is pushed from pillar to post - "that's not my problem, it's theirs'"!

Holistic primary maternity care by comparison is woman-centred, meaning that the pregnant woman/mother-baby dyad are central throughout the continuum of care. Midwives providing woman-centred care work with caseloads, or at the very least in small group practices. Notions of partnership between a woman and her known midwife, promotion of normal birth, and preventative measures - all of which are fundamental elements in the international definition of the midwife (ICM 2005), are nigh impossible in fragmented models of MEDI-care.

My objections to Medicare for basic maternity have not been allayed in any way since the draft legislation has been available. It is nonsensical to imagine that midwives will be able to set up private practices that are modeled on medical practice. Noone has even attempted to describe how a midwife will practice within this Medicare-funded fragmented scheme.

Reform, like any structure, cannot work without reliable foundations. The structural framework required for reform of midwifery is to agree firstly on the principles that define midwifery. This is not a matter for a committee of interest groups, dominated by medicine, under the direction of the Health Minister. Midwifery has been defined, and the definition has been refined and updated regularly by the International Confederation of Midwives.

I do not want to see the group of reform bills pass in their current form. They fail at the very foundational level. Australian women deserve a funded maternity system that works for them and their babies.

What does the 2-year exemption mean?

2009-09-08T09:20:00.003+10:00

What does it mean for privately practising midwives?

What does it mean for women who want to plan homebirth with a private midwife, as distinct from those who plan homebirth under a publicly funded scheme?

The general response by midwives to the announcement of the temporary reprieve is guarded. As I wrote last Friday, we have no reason to trust those who are advising the government, or the government itself. The woeful lack of consultation with midwives in this whole sorry saga, making us pawns that can easily be sacrificed by health ministers in their point-scoring and dodging of responsibility, has forced us to defend ourselves in a way that most midwives have never imagined we would need to do. We are not just talking about our livelihoods; which are in and of themselves legitimate and worth protecting. We are also talking about the safety and wellbeing of a group of mothers and babies whom midwives have served consistently since the beginning of human existence.

Midwives are waiting to see what hoops we will be required to jump through in order to "access the exemption".

One argument private midwives in Victoria have used in our submissions to government authorities and inquiries is the homebirth data that the Victorian government's Perinatal Data Collection Unit collects and analyses each year. It seems that no amount of evidence to the contrary can convince those at the helm of the ship of state that private midwifery practice, even with all the unreasonable restrictions that we face, is safe.

I have made an application to the Perinatal Data Collection Unit to make a Performance Indicator analysis of de-identified data for the past five years, from both homebirths and those who planned homebirth and transferred to hospital. [Here's a link to the 07-08 Performance Indicators You won't find 'Homebirth' in the publications, as our data is included in the Private Hospital aggregate data, because we provide private maternity services. There's a conundrum to consider!]

Two-year exemption from indemnity insurance announced today

2009-09-04T15:35:00.003+10:00

A reprieve has been announced, giving more time to resolve the impasse caused by the intersection of Bill B (which makes indemnity insurance mandatory) and other bills which are designed to reform maternity services in this country.

Australian Health Ministers’ Conference

JOINT COMMUNIQUE

4 September 2009

Australian Health Ministers met in Canberra today to discuss a range of issues affecting the national health system. The meeting was chaired by ACT Minister for Health, Katy Gallagher.
...

Homebirth

Health Ministers agreed to a transitional clause in the current draft National Registration and Accreditation Scheme legislation which provides a two year exemption until June 2012 from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth.

Additional requirements to access the exemption will include;

- A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.

- Reporting each homebirth

- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.

These provisions will only apply to midwives working in jurisdictions which do not prohibit such practice as at the date of the implementation of the scheme.

...
Other matters referred to in the communique include Health and Hospitals Reform, H1N1 Influenza, Fourth National Mental Health Plan, BreastScreen Australia Evaluation, and Health Workforce Australia.

Comments are welcome on this and other midwifery blogs.
My initial comment centres on the requirements:
A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.

This is not a problem. It's not as though we have been pretending that we have had indemnity insurance all these years! I wonder what 'they' think we tell our clients now?

- Reporting each homebirth
Also, not an issue in Victoria, as it seems that the only homebirths that don't get 'reported' to the government's perinatal data collection unit are the intentionally unattended births.

- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.
This is a totally unknown entity. We will have to look at it when it happens. Past experience has included a woeful absence of consultation by government entities with privately practising midwives, so the stated commitment to consultation is something we will be looking out for!
Joy Johnston

a message from the Victorian Health Minister

2009-09-02T19:55:00.004+10:00

The Minister for Health, Hon Daniel Andrews, informed a large group of midwives at the ANF (Vic Branch) conference today that midwives in private practice "need to have dialogue with us [the Department] about what would need to be included in pilot schemes [for hospital auspiced homebirth] for MIPPs to be part of them." There were three or four MIPPs in the gathering of over 150.

Minister Andrews was giving the opening address at the midwifery conference. Much of what he had to say was the same spin we had heard previously. He stressed the importance of his government's plan to introduce hospital-auspiced homebirth, and strongly reiterated his previous statements that he would not be providing any support for independent midwives to obtain indemnity insurance.

He stated that exemptions [from indemnity] would compromise the integrity of the scheme. He avoided the fact that the pilot homebirth programs are no more than a vague plan - not a reality. He said they will be up and running in 2010. [we will see!]

It was clear to me that the health minister is more interested in neat systems and schemes, putting people into boxes, than in respecting the individual woman's autonomy in primary care options, or the individual midwife's right to hang up a shingle and provide this very basic level of care in communities. This is socialist health policy on steroids - restrictions and bureaucratic systems taking precedence over the individual's right to choose who provides the most intimate care in bringing children into the world.

Andrews was dismissive of women who seek private midwifery care. He declared that homebirth is not an important option to most Victorian women. The numbers of women and midwives are too small to matter. His 'hospital in the home' style of homebirth will provide choice for "a lot of women" - tick the choice box! Too bad that most of the women in the State who will be seeking private midwifery services for births after i July next year will not be in the vacinity of the two hospital-auspiced homebirth programs. They will have to make the best choice from what's available to them. They can choose primary care from a private (specialist) obstetrician who may or may not be around if they labour spontaneously, and for that matter who has no skill in the midwife's terrain of physiological birth; or they can choose whatever fragmented model of maternity care is available via the local hospital and general practitioners, with a 'lucky dip' option of midwife allocation in the hospital when midwifery services are most needed. Or, of course, they can choose to DIY - stay at home without a midwife.

Women must stand strongly against the arrogance and rudeness of politicians who refuse to listen. Women who want a midwife to provide primary care - whether the birth is at home or hospital - actually want to avoid costly medicalisation of their births. They want the skill a known midwife brings to their birthing, enabling and protecting normal birth in most cases. Surely this is not too much to ask?

responsibilities of the homebirth midwife

2009-08-31T19:58:00.002+10:00

This week I have been invited to speak briefly at an Australian Nursing Federation (ANF) Victorian Branch midwifery conference. My topic is THE LEGAL AND PROFESSIONAL RESPONSIBILITIES OF A HOME BIRTH MIDWIFE – the buck stops with you!

I plan to make my presentation a tribute to homebirth and private midwifery practice as we know it. I will be using a brief slide presentation about the home-water-birth of a baby girl named Lila, about a year ago. The BMid student who was undertaking one of her follow-through journeys took the photos. Lila’s mother has kindly given me permission to share these intimate images with fellow midwives.

A focus on homebirth, rather than focusing on the woman, sets an unhelpful basis for this discussion. The place of birth, either home or hospital, is a choice that a well woman has if her midwife is competent in attending a physiologically normal birth in any setting. The picture of partnership between a woman and her midwife, who is primary care provider throughout the episode of care, is the key. The midwife is committed to the woman, not to the place of birth.