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
Tuesday, February 9, 2010
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.
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