the end of summer

A Japanese Maple bonsai tree in my garden

Readers may have read in previous posts that I am planning my retirement from attending births in the coming year, and eventually from the practice of midwifery.  I can't ignore the sadness that comes to my mind as I contemplate this huge step.  Midwifery has been my passion; to a great extent my identity, for many years now. 

Yet, just as I celebrate the changes of seasons, and tend my little garden, and look forward to the autumn colours on this little bonsai tree that I have tended for the past five years, since it was just a seedling, I am also choosing to celebrate the passing of time in my life.  I am also looking forward to the new freedoms and opportunities that will present when I am no longer 'on call'.  I am coming to the end of the 'summer' of my life: the time of productivity and strength.  I have the autumn and winter ahead.

I have, in the past couple of months, informed my colleagues and potential clients of my intention to retire.  I do not have any particular reason to retire, other than age.  I am in good health, and I think I am in possession of all my faculties.



In the past few years I have witnessed major changes in the midwifery profession in this country.  Many of these changes have been related to the legislation governing the practice of midwifery, and I have written at length on this and other sites.

In the past few years I have also witnessed a migration of midwives, from mainstream hospital employment, to private practice.  Of the twenty-or-so midwives practising privately in the Melbourne area, about ten have been part of the exodus from hospital jobs, since 2010.

This phenomenon, by which the number of midwives practising privately in Victoria has doubled in only three years, has translated into a decrease in the demand for my services as a midwife.  There are plenty of midwives looking for work.  New midwifery practices and businesses are working hard to promote their services, and to compete for clients.  I am content that the Melbourne (and surrounding areas) women who are seeking private midwifery services, either for planned home birth, or hospital support, will have midwives willing to work with them when I have called it a day.

Some of the garden produce this year: figs, peaches,tomatoes ...

A midwife’s scope of practice is not related to the business model under which she or he works.  This means that any midwife, except those who have specific restrictions imposed by the regulatory body on their registration, is able to practise midwifery without supervision, in the way that they choose. 

Mainstream maternity care is within hospitals and health services.  When a person applies for employment in a hospital or health service, the application will be reviewed by experienced peers, and processes will be followed to confirm that the skill and experience levels are suitable for the position.  This aspect of due diligence is expected of employers.

In private practice there may be no employer, other than the woman.  The onus falls on the individual midwife to ensure that they are competent for the work they undertake.  The main setting for private midwifery practice in Victoria today is planned homebirth.  Midwives who have practised in hospital maternity units in this country, whether for a graduate year, or for many years, may have had very little experience of caseload practice or homebirth.  They may have idealised notions about the women who employ midwives privately, and about what happens in homebirths.  

Midwives who have achieved Medicare eligibility and set up private practice have, in the past three years, quickly transitioned to homebirth practice.  This can be seen as a positive step: attending homebirth is, after all, basic midwifery practice.  Yet we need to proceed with caution: there is a body of knowledge and a set of skills that are specific to homebirth and caseload midwifery practice.  As some wise person said: “you can take the midwife out of the hospital, but can you take the hospital out of the midwife?” 

Until hospitals are willing to set up collaborative agreements, and support eligible midwives for the full scope of midwifery services, including attending births in the hospital, this will continue to be the case.  It cannot be assumed that the good outcomes that have been demonstrated in homebirth in Victoria for the past couple of decades will continue.  Midwives need support as they extend and develop their private practices.  This is not happening.

As I move into the autumn of my life, handing births over to younger midwives has to happen.  I hope these midwives are reflecting on their own practices, speaking honestly to colleagues, and reading widely in midwifery literature - even places like this.  And I hope many are writing their stories.  I don't see much evidence of that - it seems to be the exception rather than the rule, to have midwives who are not academics committing their practice to writing.

I know that this blog has only a few regular readers.  I don't know who you are.  I hope something I have written is meaningful and useful to you.

Many more visit the other midwifery blogs that I write: villagemidwife and midwivesVictoria.



Thankyou for your comments

conversation on cord clamping

This week an article Are we cutting umbilical cords too soon? by Sydney midwife, Professor Hannah Dahlen, appeared in The Conversation.

I posted the following comment:

...
I would like to make a point here that the normal physiology of the third stage relies on spontaneous unmedicated progress through the preceding stages of labour. The processes of separation and expulsion of the placenta and cessation of bleeding are finely orchestrated when relying on the mother's hormonal activity.
In the world of spontaneous unmedicated birth, the midwife acts to support the natural physiological processes, and one of the key points is to maintain an intact umbilical cord as the baby is being born. If immediate resuscitation is required, the midwife may instruct the mother to kneel and place her baby on a clean towel on the floor in front of her. The midwife kneels next to the baby, and proceeds with whatever is needed - tactile stimulation, and blowing on the baby's face is often sufficient while assessing heart rate and respiratory effort, but the process may include suction of airways, bag and mask respiratory support, and external cardiac stimulation. As such a baby recovers, the pulsing of the cord is an early sign of resuscitation, ensuring an immediate surge of oxygenated placental blood (with a dash of adrenaline) is delivered with the aid of gravity, to the baby. Then the mother can take her baby to her breast, and wait for the natural completion of the third stage.

My submission attracted a strongly worded response from a person who is identified as a 'public hospital clinician' (presumably a doctor), who considered that I was incorrect in the statement that "the pulsing of the cord is an early sign of resuscitation, ...".  She stated that:

If the midwife conducting resuscitation does not understand newborn physiology, including placental circulation, the baby may well be in better hands in hospital.

I have not tried to defend myself in The Conversation, but will make some comments here here.

I consider the criticism of my statement to indicate a mis-reading of what I have written. In stating that the baby receives oxygenated placental blood, I did not differentiate between arterial and venous blood.

Pulsation of the umbilical cord is in response to the baby's heart action.  The umbilical veins bring blood from the placenta to the baby.  

I can only assume that this criticism came from someone who objects strongly to the very idea of homebirth, and has used criticism of what she understands to be the midwife's knowledge to justify her objection.   She provides further objection to homebirth with the claim that homebirth results "in three times excess mortality for the babies of low risk mothers (compared with birth in hospital)."  This is an unsupportable statistic that has been quoted from time to time, which I think is based on a retrospective report of homebirths in South Australia, published in 2010.  Click here for more discussion and links.

The safety of homebirth is difficult to explain using logic or science.  It makes sense that quick access to all the machines and highly skilled people, if something 'goes wrong', should result in overall better outcomes than being in the woman's home.  Although a midwife is ready and skilled to intervene, and provide neonatal resuscitation, or other life-protecting measures for the baby or mother, the safety of homebirth is not in the interventions: it's in the woman's and baby's own abilities to proceed through the amazing transitions in birth, and the midwife's skill to work with, and not against, those natural physiological processes.

The umbilical cord does not pulse by accident after birth.  It pulses because the link from the newborn baby's heart is open.  This opening will quickly close as breathing becomes established, and the baby's body becomes independent of the mother. 

A recently published (2013) Cochrane Review of 'Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes' states that:

There were, however, some potentially important advantages of delayed cord clamping in healthy term infants, such as higher birthweight, early haemoglobin concentration, and increased iron reserves up to six months after birth.

Those who have seen births in hospitals will know that there is often a great flurry of activity by the accoucheur immediately after the birth of the baby, and that the cutting of the cord and passing the baby to a second person (doctor/midwife) who proceeds with the rituals of drying, and 'resuscitating' the baby, happens very quickly.  These practices need to change. 

I am often the only midwife present at home births.  There is noone to pass the baby to, other than the baby's own mother - cord intact. The woman in her own home is free to choose the place where she gives birth, and the body position she adopts to give birth.  She may be kneeling, lunging, sitting, standing, squatting, or lying.  The baby may be born in water or into air.  My response as the moment of birth approaches is to be ready to take action if required, or to simply be there and witness the wonder of creation in the birth of a child.



Thankyou for your comments

Journal: Week 2

GDM: a disputed diagnosis

Screening for GDM
Women in mainstream maternity care are routinely tested for gestational diabetes mellitus (GDM) at 24-28 weeks pregnant.  The screening tests that are used are the oral glucose challenge test (GCT), or the glucose tolerance test (GTT).  If the fasting or 1-hour blood glucose level for GCT is higher than the reference level, a GTT will be performed on another day.

This sounds quite rational, and reasonable, since diabetes in any of its manifestations is a serious medical condition. The reason for the dispute in the diagnosis is the reference range at which blood glucose is classified normal, or abnormal.   The setting of the reference range has historically been the outcome of expert opinion, rather than any rigorous scientific evidence.

The test involves drinking a solution containing a certain amount of glucose, usually 75 g or 100 g, and drawing blood to measure glucose levels at the start and on set time intervals thereafter.

From Wikipedia:

Oral glucose tolerance test
The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes.^[33]

The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:

• Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
• 1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
• 2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
• 3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)

An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify fewer women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test.^[34]

Note the phrase "with ... no compelling evidence of improved perinatal outcomes".

"First, do no harm"
 A pregnant woman who is given a diagnosis of GDM may be instructed on dietary modification, or may be treated with insulin.  The aim of the treatment is to prevent adverse effects such as macrosomia and neonatal hypoglycaemia in the baby.

The baby of a mother with the GDM diagnosis is tested in the early hours, and will, in most hospitals, be given artificial formula milk as the first line treatment if baby's blood glucose level is low.   The interference with a baby's initiation and establishment of breastfeeding is crucial in the early neonatal hours, and significant harm to baby and mother can be attributed to failure to establish exclusive breastfeeding.

When the reference range for GDM includes those who are less hyperglycaemic, a large number of mother-baby pairs will be captured in the 'net' for whom the treatment is likely to do more harm than good. 

"Treating a larger number of 'less hyperglycaemic' women may very well reach a tipping point where therapy may turn out to be useless, or worse, harmful.  Realistic concerns include maternal hypoglycaemia, poor fetal growth, and earlier and more frequent induced deliveries."  Long H. Diabetologica  (2011) 54:2211-2213.

Validity
The validity of a test is not just its sensitivity (identifying those with the condition), but also its specificity (identifying only those who do not have the condition, or, conversely, not wrongly labeling a person as having the condition).  In the case of testing for GDM, many questions can be asked about specificity.  The cost of identifying as many as possible who may have the condition, is the rate of false negatives - giving the GDM tag to women who do not have GDM, and whose pregnancies are thereby medicalised unnecessarily.

My experience
The issues around testing for GDM first came to my attention when I was pregnant with my fourth child, in 1980, and booked at the Women's hospital birth centre.  The doctor who looked at my notes informed me that since my previous children had weighed over 4 kilograms, I would be required to have a glucose tolerance test.  This experience was a challenge to my (previously) very submissive-to-medical-authority attitude.

In deciding to decline the GTT, I rejected the notion that there was anything abnormal about the weights of my first three children.  Yes, they were in the 'above 90th percentile' range for weight, length, and head circumference.  I am also in that range, and have been from birth.  My babies showed no signs of hypoglycaemia in the hours after birth, and all thrived, exclusively breast fed until they began to put other foods into their mouths around 5 months of age. 

The doctor seemed a little surprised at my statement that I did not intend to submit to the GTT.  He said something like "Well, yes, we are giving women in the birth centre more say in their care these days."  That was it.

My practice
Women in my care will often also decline the glucose screening.  I discuss it with them.  I am more interested in promoting health through good diet, activity, and emotional stability than following patterns of 'broad brush' screening for disease. In my years of private practice, attending homebirths on my own authority, I have not once needed to intervene for hypoglycaemia in the newborn.

Babies born spontaneously at home go into their mother's arms, and remain skin to skin at her breast for the first couple of hours.  They are not passed to anyone else; they are not weighed, or any other checks, until after they have had a good breastfeed.  Their cords are not cut until the placenta has been birthed.

The blood that a baby is deprived of with early cord clamping is a significant amount: 54-160ml, of the total 300-350ml blood volume in a newborn (source: Sarah Buckley 2005, Gentle Birth, Gentle Mothering. p191.)  Baby blood includes a multitude of cells, which are specific to the baby, and nutrients, including glucose, from the mother's blood stream.  The protective effect of physiological birth on both the baby and the mother is upheld in homebirth.

"In normal birth there should be a valid reason to interfere with the natural process."  (WHO 1996. Care in Normal Birth)

Thankyou for your comments

decision-making for breech births

In recent months I have been very impressed by the work of a consumer-led group, Breech Birth Australia and New Zealand (BBANZ).  This site has a great deal of useful information and birth stories.  Readers who are interested in being part of the social media discussion on breech births can apply to join the facebook group.


In this context, I have been drafting an information sheet on the decision-points for a woman who has a baby in a breech presentation:

Decision Point #1:      DIAGNOSIS of breech presentation at or near Term

Your midwife or doctor may diagnose breech presentation by palpation, and recommend further investigations such as ultrasound.  Your decision—yes or no—will lead to the next Decision Point.

 Decision Point #2:      ATTEMPT ECV

IF your baby’s breech presentation is confirmed, then you may consider attempt(s) at external cephalic version (ECV). 

After ECV, your baby may be presenting cephalic (head first), or the breech presentation may persist.  In either case, if there is no valid reason to interfere with the natural process, await spontaneous onset of labour.

 Decision Point #3:      PLAN for VBB

Consider the capacity for vaginal breech birth (VBB) at your intended place of birth; the skill and willingness of your primary maternity care team to proceed with VBB; and access to emergency obstetric and neonatal care if required.  Consider the possibility of changing to another maternity service that is more able to support VBB.

Decision Point #4:    Onset of labour

Your midwife or doctor will advise you of recommended ‘boundaries’, such as gestational age of your baby, spontaneous pre-labour rupture of membranes, and changes in your own and your baby's condition. 

Decision Point #5:    Progress in labour

Your midwife or doctor will monitor your progress, and your baby’s wellbeing, as labour becomes established.

NOTE: The wellbeing and safety of mother and baby guide all maternity care.

This list makes it all sound very straight forward, and it should be. 

UK midwife Mary Cronk MBE wrote in 1998: 

These are the points which midwives should bear in mind when facilitating a vaginal breech birth:

• Don't push a breech through a pelvis with oxytocic drugs
• No inductions, no augmentations
• If the labour does not progress - caesarean operation
• Don't pull a breech down through the pelvis - no breech extractions
• Breech by propulsion, not traction
• If it isn't coming down - caesarean operation
• Keep your hands off - sit on them if necessary
• Be ready to bag and mask. (AIMS Journal)

In that article, Mary Cronk outlined the features of a breech birth (as distinct from a breech delivery):

Breech birth

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

It's clear to me, from a midwife's perspective, that in the journey of decision-making for spontaneous breech births, there are several points at which caesarean surgery would be the next step.  Many colleagues would say, what's the point? 

We will never know if a vaginal breech birth (VBB) is possible unless we proceed down this mystery pathway.  We will never know if labour is able to progress normally if an elective caesarean is performed at 39 weeks.  The avoidance of unnecessary caesarean surgery is of great benefit to the mother and baby, and subsequent children.

A breech birth requires skill, patience, and courage on the part of the woman, the midwife, and the support team.  A breech birth also requires the willingness of the woman to engage in decision-making over time, as the process unfolds, rather than being attached to an inflexible plan for vaginal birth.

A breech birth relies heavily on the ability of the woman's body to intuitively progress through spontaneous onset of labour, and progress in the first and second stages of labour.  There is no room for induction or augmentation of labour, which might mask the natural reluctance of the woman's body to proceed with the birth of a disproportionately large or poorly positioned baby.  There is no room for mind-numbing narcotics which distance the woman from her ability to make a natural response to her labour, and which inhibit the baby's ability to breathe in the moments after birth.  The maneuvers that a midwife may undertake in the moments before the birth, such as gentle turning to release a nuchal arm, or support to flex the head, require confidence in the mechanisms of breech birth and the midwife's skill.

DIFFICULTIES in achieving VBB
A dilemma we face today when approached by a woman who plans to give birth vaginally to a breech baby is the lack of understanding and skill in spontaneous breech birth in most hospitals.  It's almost a lost art.  Even hospitals where the obstetrics team have indicated 'support' for VBB (more accurately, breech delivery or extraction), the requirement is usually that the woman is in lithotomy position once the presenting part is on view, and that the obstetrician manages the birth.  The baby's cord is clamped and cut soon after birth, and the baby is passed to the paediatric team for resuscitation. 

This scenario contrasts with spontaneous VBB birth: in second stage the woman adopts an upright position (such as 'all fours', kneeling, or supported squat) and her baby is born with minimal touch and without any pulling by the midwife.  The integrity of the cord is maintained, and if initial resuscitation is needed baby is placed on a flat surface, continuing to receive the oxygen-rich placental transfusion from the mother, while the baby's independent breathing is being established.

A second dilemma that midwives face is the discussion on place of birth.  Midwives who understand the advantages to mother in baby in spontaneous breech births are often strongly in favour of home birth.  Yet the implications for the baby particularly, if urgent caesarean birth becomes the birth of choice, mean that there is a real advantage to being in hospital for the latter part of first stage, and second stage labour.  The other matter for midwives to consider is the 'unprofessional conduct' notification that would almost certainly follow a transfer of a breech baby or mother to hospital.  Never mind the woman's choices: midwives are expected to refer women with breech babies to a higher power (Category C in ACM National Midwifery Guidelines, 2008.

In conclusion:
I believe that the process of decision-making in breech births is all about getting the best possible birth for that mother and that baby.  It's not about vaginal birth or caesarean, no matter how much the spontaneous physiologic birth is the preferred option.  If a caesarean is required, then it would be tragic if a caesarean was not available.  



Thankyou for your comments

Journal: collaboration

Activity: Establish a working relationship with a doctor 
There is currently much grief and anger surrounding the term “collaboration” when used in the maternity care setting in Australia at present. ... discuss the following issues –
• What actually is collaboration?
• What would the best model of how women and their babies can have their needs met in pregnancy, birth and the postnatal period, including midwives AND doctors, look like?
• Discuss your own individual situations where you presently work, or intend to work.
• What ways are you currently able to work with local doctors?
• What works well?
• What doesn’t work well? Why? Is there scope to change this? ...

I have reflected a great deal on collaboration, especially in the past few years, with the rules demanding a formal and pedantic process that is called a collaborative arrangement, for each woman in my care, in order for that woman to access Medicare rebate.

Collaboration is, in my mind, simply working together 'co'+'labor'.  One person can't collaborate.  It takes two.  In maternity care, the woman+baby unit is at the centre of the care, and a midwife+/- others work together to provide the maternity care. 

+/-?

This is the point at which disagreement arises.

For maternity care at its most basic level, the midwife is able to provide the entire episode of care, on her/his own responsibility, provided the woman and her baby are well and progress through pregnancy, labour, birth and the puerperium without complication.

Collaboration is added to the care mix if the woman or her baby need care that is outside the scope of the midwife's practice: whether it's collaboration with a dentist, obstetrician, physiotherapist, or paediatrician.


When I read the heading for this activity, "Establish a working relationship with a doctor", I asked myself, "which doctor?"

I have initiated collaborative arrangements with about 30 doctors in the past 18 months.  Most are GPs; a couple are obstetricians.  On a couple of occasions the same doctor has provided collaboration for more than one woman.  Most of these doctors I have never met or spoken to.  One of these doctors has given birth at home in my care.  Another doctor knows a woman for whom I have been midwife.

My understanding of good collaboration in maternity care is summarised in the letter that I send to a doctor when a woman asks me to be her midwife. (If the doctor is an obstetrician, and the woman is planning birth in a private hospital, the wording is slightly different.  Most of my work is with women planning birth at home, or in a public hospital)

"The plan is basically to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. We plan to go to the [X] hospital without delay for urgent obstetric concerns, or [the woman] would be referred to you for non-urgent medical indications."

Collaboration for midwives who are participating in Medicare has been set out in the National heath (collaborative arrangements for midwives) determination 2010
In the real world these rules present midwives with a difficult, though not impossible, situation.  I don't have energy to waste on resisting.  I hope that when my turn comes to be audited, my processes and records will be acceptable.
Thankyou for your comments

The hospital problem

It's two years since our federal government's maternity reforms have provided significant new support for private midwifery practice.

Since November 2010, midwives have been able to provide taxpayer subsidised services to patients outside of the public system.  A search of Medicare statistics for the financial year July 2011 to June 2012 reveals that there were 16,474 'Midwife services' rebated, accounting for more that one million dollars of taxpayer's funds. 

A key component of the reform agenda was hospital access for births: that midwives would be able to deliver maternity care, including antenatal and postnatal care in the community, and, as the then Health Minister Nicola Roxon announced, "undertake deliveries in a hospital."  

Access for midwives to maternity hospitals has turned out to be problematic.  Except for Queensland Health, which has established processes for midwives to have access to public hospitals in Toowoomba, Ipswich, and Gold Coast, midwife-attended births in hospitals have not become a reality.

In fact, I have observed a gradual increase in resistance to midwives attending our clients privately in hospitals in Melbourne over the past two years.  I am trying to understand why this is happening.  Here are a few pieces of the puzzle:

• Private in public:  Melbourne's large tertiary maternity hospitals (Women's, Monash, and Mercy) employ specialist obstetricians rather than the visiting consultant who, in return, is able to use the service for his or her private patients.  The director of obstetrics at one of these hospitals has told me that 'private in public' is the major obstacle to midwives being granted clinical privileges.  
• Credentialling for clinical privileges: Smaller metropolitan and regional hospitals rely on doctors to provide consultancy services for obstetrics, anaesthetics, paediatrics, and other specialties, as well as GPs who provide primary care that includes basic maternity services.  The processes for credentialling of these doctors for clinical privileges in public hospitals are managed by each hospital, guided by the Health Department and the VMIA (public hospital insurer).  This process was expected to be extended to provide for credentialling of midwives, and meetings of key stakeholders were convened in 2011.  I attended these meetings, as representative of Midwives in Private Practice (MiPP)   A report was given at a conference in May, but since then there appears to have been no progress and the report has not yet been made public.
• 'Support person':  At present when a midwife in private practice attends a private client in a hospital (private or public), either with a woman who intended to give birth at the hospital, or when transferring from planned homebirth, we may be called a 'support person'.  This is a head in the sand mentality on the part of hospital employees: we are midwives, are accountable for all our actions, and have a real duty of care to those who employ us as midwives.  

Here are a couple of examples of the increasing resistance to midwives by Melbourne's public hospitals:

Recently I visited a mother and baby the day after the birth: the mother had experienced a complex and life threatening labour, and had been delivered by caesarean.  I introduced myself at the desk and asked if I could visit my client.  The nurse in charge told me somewhat grudgingly that she would let me in, but that I was not to discuss clinical matters with the patient.  I must have looked shocked (which I was).  "Why?  Is something wrong?" I asked.  "No, but you must not interfere with the hospital's care of patients", was the reply.  I informed the nurse that I had no intention to interfere; that I was there for the woman and I would discuss anything the woman wanted to discuss!  I reminded the nurse that 'patients' are not prisoners: that they are free to discuss anything with anyone. [see comment after this post]

Another private midwife was invited to meet with a senior member of the midwifery staff to discuss complaints about her behaviour in the hospital. A midwife in the birth suite had complained that she could not work with women who had this private midwife with them, because the women looked to their midwife for guidance and support!  (And this is a hospital where research has demonstrated a range of improved outcomes for mothers and babies when the woman is attended by a known midwife who has a personal caseload!  It's no secret that women value a trusting relationship with their own midwife.)


What should we be doing about hospitals?

Some Medicare-participating midwives have negotiated casual employment arrangements with a hospital, so that when their clients are admitted in labour, the private midwife becomes an employee of the hospital, and provides midwifery care for that woman.  The midwife is paid by the hospital for the hours of employment.   I do not see this as a solution - it's a temporary filler at best.  The Medicare provisions for midwife attendance in labour and birth cannot be applied: Item #82120, Scheduled Fee $739.25

Management of confinement for up to 12 hours, including delivery (if undertaken), if:

(a) the patient is an admitted patient of a hospital; and

(b) the attendance is by a participating midwife who: (i) provided the patient’s antenatal care; or (ii) is a member of a practice that provided the patient’s antenatal care

(Includes all attendances related to the confinement by the participating midwife)

[Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011]



Earlier this week I wrote about women's rights in childbearing, and quoted from the recently updated Cochrane review of planned hospital birth compared with planned home birth for low-risk pregnant women, in which the authors commented:

"It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications."

If maternity services are serious about basing practice on evidence; if the government is serious about providing maternity services that are appropriate and in the interests of safety and wellbeing of mother and baby, then the option of homebirth MUST be seriously addressed across the board.  As long as there are disincentives and professional biases that prevent the majority of women from accessing homebirth, and that prevent midwives from offering affordable private midwifery services in all communities, we will continue to see the cascade of interventions fast-tracking women and babies into medical emergencies.


Thankyou for your comments