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.
Saturday, August 21, 2010
Saturday, July 31, 2010
VBAC statement from RANZCOG
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.
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.
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.
Wednesday, July 28, 2010
Reviewing July 2010
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:
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.
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.
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.
Sunday, June 27, 2010
A year in review -part 2
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
[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
Monday, June 14, 2010
what midwives will NOT accept
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.
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.
Monday, June 7, 2010
"not for the faint-hearted"
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.
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.
Friday, May 28, 2010
Reflecting on a hospital transfer
I have recently reflected on the experience of transfer of a labouring woman from her home to the local public hospital. It's a regional city hospital, with contemporary obstetric, paediatric and anaesthetic services, and the machines that go 'ping'.
As usually happens in a transfer, a midwife takes away complex and multi-layered issues to reflect upon. In this brief record I want to highlight three points:
* the importance of seamless transfer from planned homebirth to an appropriately capable hospital
* the importance of careful decision making at each decision point
* the importance of respect by the hospital for the midwives attending the woman
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.
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.
Saturday, May 15, 2010
continuing the countdown - May
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."
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."
Wednesday, May 12, 2010
Countdown - 6 weeks...
... 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.
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.
Tuesday, April 20, 2010
Midwife led maternity care
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).
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).
Tuesday, April 13, 2010
What we don't know yet
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.
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:
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.
Thursday, April 8, 2010
Questions about professional indemnity insurance for midwives
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%
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%
Tuesday, March 23, 2010
Countdown - 3 months
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
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
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
Monday, March 15, 2010
controversy about breech births
*****
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.
Friday, March 5, 2010
Maternity reform hijacked
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
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
Tuesday, February 9, 2010
Continuing the countdown ... February
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
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
Saturday, February 6, 2010
Do midwives ignore science?
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:
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.
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)
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.
Thursday, January 28, 2010
MOTHERBABY SUPPORT GROUP
Mothers with babies in their first year,
and pregnant women
are invited to join our
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
with midwives, in a setting that
promotes and protects wellness in birth and mothering
· responsiveness to issues raised
and experiences encountered, and much more
and experiences encountered, and much more
For more information, call Joy Johnston
04111 90448 - 03 9808 9614
or email joy@aitex.com.au
04111 90448 - 03 9808 9614
or email joy@aitex.com.au
http://privatemidwiferyservices.blogspot.com/
http://villagemidwife.blogspot.com/
Tuesday, January 26, 2010
Birth and Breastfeeding
Not that I have had many days to devote to reading!
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?
Tuesday, January 12, 2010
continuing the countdown
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.
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.
Subscribe to:
Posts (Atom)