Countdown - 3 months

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

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

The big milestones will be:


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


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

Some midwives will seek to continue private practice without public funding.  The reasons they will give for taking this approach include

• too many bureaucratic hoops to jump through
• professional decision making being constrained by impersonal guidelines
• excessive paperwork anticipated
• fear of ... 

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


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

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

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


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

This is woman-centred care.

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


Enough from me for now!
Joy

controversy about breech births

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


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

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

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


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

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

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

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

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

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

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


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

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

Maternity reform hijacked

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

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

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

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

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

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

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

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

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

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

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

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