'hands-off'?

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

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

Reviewing the past couple of years

To Daddy

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

Midwifery exam, 1973

click to enlarge

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

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

Global Forum, Day 6

Spring roses in our garden

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

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

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

Global Forum, Day 5

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

Today's question:

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

Global Forum, Day 4

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

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

Global Forum, Day 3

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

Today's question:

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

Global forum, Day 2

The forum leaders have written:

Today we continue to discuss Day 1's question on:

"What practices or tasks should be undertaken by health care providers other than medical doctors at the primary health care level to accelerate the reduction of maternal and newborn mortality and morbidity?"

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

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

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

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

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

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

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

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

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

Spring roses in the front garden

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

~ C.S. Lewis

Women may 'go it alone' on home births Ireland

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

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

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

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

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

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

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

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

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

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

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

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

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

I have signed the petition - signer #873:

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

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

Understanding statistics

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

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


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

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

Midwives can also understand statistics.

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

Posted: 09/27/2010

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

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

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

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

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

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

The current state of private midwifery practice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There is a degree of uncertainty in all births.

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

RCM Campaign for normal birth

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

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

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

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

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

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

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


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



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

Breastfeeding babies exclusively

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

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

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

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

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

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

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

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

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



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

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

VBAC - assessing safety and success

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

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

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

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

Comment in:

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

Abstract

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

DESIGN: Retrospective cohort design.

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

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

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

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

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

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

more on risk management

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

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

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

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


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

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

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

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

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


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

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

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


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


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

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

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


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

VBAC statement from RANZCOG

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

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

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


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

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

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


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


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

Here are a few other statistics to consider:

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

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

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

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

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

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

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

Reviewing July 2010

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

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

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

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

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

That's all on the record.

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

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


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

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

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

Why?

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

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


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

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

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

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

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

Links:
Maternity Coalition Queensland blog
Maternity Coalition website
Homebirth Australia

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

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

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

A year in review -part 2

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

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

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

The following notes are condensed from the APMS Annual Report.

1. The business model has been developed.

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

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

4. The three midwives have been employed and mentored.

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

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

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

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


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

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


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


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

what midwives will NOT accept

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

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

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


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

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

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


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

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

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

"not for the faint-hearted"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reflecting on a hospital transfer

I have recently reflected on the experience of transfer of a labouring woman from her home to the local public hospital. It's a regional city hospital, with contemporary obstetric, paediatric and anaesthetic services, and the machines that go 'ping'.

As usually happens in a transfer, a midwife takes away complex and multi-layered issues to reflect upon. In this brief record I want to highlight three points:
* the importance of seamless transfer from planned homebirth to an appropriately capable hospital
* the importance of careful decision making at each decision point
* the importance of respect by the hospital for the midwives attending the woman

1: TRANSFER
The ability to transfer from planned homebirth to hospital in a timely manner, without any sense of shame or failure by either the woman or her midwife, is an essential part of professional midwifery in the community. Much has been written in recent months about the Australian private midwife's need to *collaborate* appropriately.

2: DECISION MAKING
The process of decision making is constant and vital as labour progresses. As each observation is made a decision point is reached: the decision will be either to continue in 'Plan A', or to consider 'Plan B'. 'Plan A' is that the mother is able and willing to continue in the spontaneous natural process, with the expectation that this will lead to the best outcomes for her baby and herself, continuing in the care of her midwife(ves). Alternately, moving to 'Plan B' involves the decision that in this particular situation, intervention will be sought from specialist service providers.

3: RESPECT
The woman who transfers from planned home birth to hospital does so in a belief that she needs what the hospital is able to provide.

The woman has a right to expect a range of services within the capacity of that hospital. She also deserves respect for her choice of her private professional midwives, and the model of care.

My experience when entering some Victorian hospitals is an uneasy, awkward response from the midwives and doctors with whom I seek to collaborate. It's as though they would like to pretend that I (and midwives like me) don't have any place in the care of the woman I am attending. There is often a lack of respect for my scope of practice, and for the woman's choice of me as her care provider.


Private midwifery in Victoria, and in most of Australia, faces many challenges.  Inter-professional jealousy, with the effect of excluding or threating the private midwife's right to practice, is common.  Here are a couple of examples:

* A midwife attached to the regional hospital referred to above told me that the staff have been instructed to refuse to leave the room of the labouring woman when the hospital's advice is being discussed between the private midwife, the labouring woman and her partner. In an effort to ensure compliance, the woman's right to private conversation with whoever she chooses is being threatened.

* Midwives in private practice have experienced complaints to the statutory authority, complaining about their professional conduct during transfer from home to hospital. In material collected in the investigations, there appears to be a targeted trawling through records of previous cases involving the midwife under investigation and even other midwives associated with the midwife under investigation.

* Women who ask a GP doctor to order prenatal blood screening, and inform the doctor that they are planning homebirth in the care of a private midwife are increasingly being told by the doctor that he/she is unwilling/unable to provide that service; that their insurance would be jeopardised if they were seen to support homebirth.

The lack of acceptance and respect for midwives in private practice, and for the women who employ us, is a potential threat to the safety and wellbeing of the mothers and babies in our care. Midwives who fear reprisal and retribution when they need to arrange a transfer of a mother or baby to hospital may delay when the best course of action is the transfer of care.

continuing the countdown - May

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

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

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

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

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

Countdown - 6 weeks...

... til 1 July.

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

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

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

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

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

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

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

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

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

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


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

Midwife led maternity care

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

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

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

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

Not really. I will try to explain.

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

This is not midwife led care.

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

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


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

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


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

What we don't know yet

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

Who will provide the indemnity insurance?

What that insurance will cost?

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

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

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

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

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

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

Questions about professional indemnity insurance for midwives

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%