MIPP Peer Review

Midwives working independently within the MiPP collective meet a couple of times each year for what we call Peer Review. This is, for us, an informal process based loosely on the New Zealand model of professional standards review.

"The concept that the individual midwife continues to develop and grow throughout her professional life forms the basis of [Peer Review]. By participating in a review, a midwife is demonstrating her commitment to her own ongoing professional development. Reflection on practice … provides the opportunity for midwives to learn from their own actions, and from the feedback they receive from clients. … Reflection with the members of the [Review] panel enables the midwife to explore her own practice issues in a supportive and confidential atmosphere. The fact that the midwife participates in a forum with peers (the profession) and consumer representatives (the public) demonstrates accountability for practice." (NZCOM 2001. Midwifery Standards Review)

Due to our small numbers, and our inability to commit to a particular time because we may be called to attend a birth, our Peer Review meetings follow a less structured path than is currently followed in New Zealand, or in the Australian College of Midwives' Midwifery Practice Review (MPR). The MPR encourages midwives to undergo a detailed self-assessment and self-reflection exercise; a face to face review discussion with a specially prepared midwife and consumer; and receive guidance and support in developing a personal Professional Development Plan.

In summary, Peer Review:

• Is voluntary
• Is confidential. The summary data provided contains no features identifying clients or other professionals or institutions. Members participating in a peer review agree to maintain confidence about the midwife, and the information discussed.
• Supports the individual midwife's professional development.

World Breastfeeding Week 1-7 August 2008

Mother support: going for the gold
http://www.worldbreastfeedingweek.org/

Health professionals today like to use the term 'evidence based'.
Mother support is truly an evidence based intervention in health promotion through breastfeeding. WABA 2008 states:
Mother Support: Evidence that it Works
"The recent Cochrane Review evaluated 34 trials from 14 countries for effects on the duration of any breastfeeding (both partial and exclusive) and exclusive breastfeeding alone. The review found that all forms of support, professional and lay, analysed together, significantly extended the duration of any breastfeeding, and had an even greater effect on the duration of exclusive breastfeeding." Read more at http://www.waba.org.my/

Review of ACM Guidelines

The Australian College of Midwives (ACM) has published a draft of the revised National Midwifery Guidelines for Consultation and Referral (Guidelines) http://www.midwives.org.au/ForMidwives/PracticeGuidelines/tabid/308/Default.aspx

Individuals and groups have been responding to ACM, and there has been discussion amongst midwives on email lists. In accepting the need for a systematic set of Guidelines, there is a hope that the professional identity of midwives will be enhanced, and that collegial relationships with other providers of maternity and newborn care (including doctors, nurses, midwives, and allied health), will be effective in providing the best options for each mother and baby. The need for Guidelines that deal with consultation and referral, and possibly transfer of care from a midwife led model to a collaborative, multidisciplinary team that is obstetrician led is clear in ensuring a seamless process for the woman and her baby when the need arises.

Anyone reading this blog will probably already realise that independent midwives are an endangered species. Midwifery in Australia is restricted to the point of near suffocation, and midwives who come to this country after working in other developed countries (incl UK, Canada, Netherlands, Denmark, NZ) are shocked at the lack of professional recognition in such basic matters as arranging routine blood tests, and access to oxytocic drugs. We face social and financial and professional exclusion. We can't get professional indemnity insurance. Although we are fully recognised as providers of maternity care, women who use our services have no public funding when a midwife provides the same service as doctors and hospitals provide. No equal pay for equal work!

Many midwives are paralysed by fear. It's not fear of adverse events in birth - it's a fear of what our colleagues may do if we dare to step outside the usual authoritarian system. It's a fear of being regulated and reviewed by people whose expertise is in nursing, not in midwifery. It's a fear of being misunderstood, and possibly losing our right to practice; our livelihood, over trivial disagreements with those who have power.

Our profession will never thrive until midwives are proud of our identity and our authority. The title 'midwife' is protected by law in all States and Territories in this country, meaning that a person who has not achieved and maintained a recognised midwifery qualification cannot call themself a midwife. Yet midwives themselves easily give away their unique identity, as the primary care provider who works in partnership with each woman, promoting normal birth, health and wellness for the woman and her family.

The following points have been made by a group of independent midwives, including several Victorian MiPPs, in our submission to the ACM.

• We accept the Guidelines, with further ongoing refinement, as being a statement that guides midwives in decision making, particularly in the interface between primary maternity care, and collaborative care within a multidisciplinary team.
• We accept the Guidelines as being a useful risk management tool for maternity service providers.
• We express our concern at the potential for misuse of the Guidelines, affecting some models of midwife-led care. Midwives who are regulated and employed within authoritarian, medically dominated systems have experienced punitive action, apparently with the support of ACM Guidelines. We recommend that a statement be included in the revised Guidelines to protect the scope of practice of the midwife in all settings.
• Although the revised Guidelines quote the ICM Definition of the Midwife (2005), we recommend that the Guidelines draw attention to the fact that the midwife’s duty of care now includes, since 2005, “the promotion of normal birth”. This change in the Definition is potentially useful to midwives who may consider that, in a particular professional situation, their advice and actions are consistent with the promotion of normal birth rather than strict adherence to a professional guideline.
• We recommend that the phrase ‘evidence based’ be deleted, except where specific reliable evidence is quoted.
• We recommend that the reference list be limited to papers or documents referred to directly in the document, and to current literature reviews that inform the midwife’s decision to consult or refer. If a paper is considered important enough to be included in the references, a referencing system such as footnote could be used to identify the reference, as in the Preamble.
• We recommended that the word ‘support’ or ‘support person’ be removed from any ACM documentation referring to midwives as it devalues the midwife’s title which is protected by law throughout Australia.

[We welcome your comments on these points and recommendations. We will be meeting with ACM later this month to discuss our recommendations. Joy Johnston)

The Women's

[Photo: Independent midwives and Shared Care Coordinators in the lobby at the Women's]

Thismorning a group of independent midwives met with the Shared Care coordinators at the Women's for morning tea and a tour of the new hospital. We asked a security guard to take a group photo, so when that is available, it will be added here.

For some years now the Women's has provided an excellent hospital backup booking arrangement for women planning homebirth. Midwives are able to fax or mail a booking referral form, and if medical review is needed in pregnancy, or during labour, or after the birth, the woman is welcomed.

We hope that in the near future all public hospitals will offer similar backup arrangements for women planning to give birth in the care of a midwife at home. A recommendation to achieve this change has been made to the Maternity Services Advisory Committee, who advise the Minister for Health. The collaboration between midwives who provide primary maternity care, and the hospitals with specialist obstetric, paediatric, and other medical, midwifery and nursing services is consistent with the professional duty of care to act in the interest of the mother and her baby.
We also hope that in the near future many public hospitals in Victoria will be offering homebirth services, and supporting midwives who want to upskill to work with women in the community. This would make a lot of practical sense in the current birthing environment, where virtually every maternity hospital is stretched beyond its capacity, and the birth rate is at an all time high.
The South Australian government has recently introduced a process by which women can give birth at home, within funded public health arrangements. The information brochure is at http://www.health.sa.gov.au/PPG/Portals/0/planned_home_birth_brochure_SA.pdf
Publicly funded homebirth is also available in WA through the Community Midwifery Program http://www.cmwa.net.au/ in Alice Springs and Darwin through the NT government, and potentially in NSW, although we have been told that baby's experiencing a difficult birth due to a lot of red tape. [If anyone reading this has up to date information on homebirth accessibility, particularly with public funding, we would love to hear from you. JJ]


On a practical note, the new hospital can be accessed from the West on Flemington Road, or after turning into Flemington Road from Grattan Street. Car parking is underground, and fees are similar to other public car parks in the city. For details of the new hospital go to http://www.thewomens.org.au/OurNewHospital

Hearing into an independent midwife's practice

The following case study has been published in Nexus, the newsletter of the Nurses Board of Victoria (July 2008 Vol16:1, p7), reporting on the outcome of a formal hearing by the Board. The newsletter Nexus is distributed to all nurses and midwives registered in Victoria. The article has been copied to this blog to inform our readers.

Midwife fails to provide safe and competent post natal care
The parents of baby JK complained to the Board that the nurse who had assisted in JK's birth as an independent midwife failed to provide safe and competent post natal care and assessment for the infant after a home birth in 2005.
The complaint alleged that, despite JK having severe jaundice on day two, the midwife failed to properly assess and advise the parents to seek further medical assessment. It was not until day four that the mother was advised to take JK to hospital for treatment. When JK's total serum bilirubin was eventually assessed it peaked at 782 micromoles per litre, nearly five times the upper limit of the reference range.
JK also had at least one or two major risk factors for developing hyperbilirubinaemia given that she was jaundiced within the first 48 hours of birth.
At the formal hearing, the nurse admitted to the allegations and demonstrated insight into her mistake. The nurse also indicated she would not be taking part in home births in the future.
Findings
Whilst the nurse had acknowledged the mistake, the panel heard she had not undergone annual credentialing to consolidate her neonatal skills and knowledge. The panel found the nurse had engaged in unprofessional conduct of a serious nature.
Determination
The panel reprimanded the midwife and imposed conditions and further education as part of her registration.
[Please note the NBV's website is www.nbv.org.au]

Safe motherhood in a safe country

I am sure I am not alone when I admit to being overwhelmed when I hear of the lack of safety for mothers and their little children in many of the poorest communities in this world. The tragedy of loss of the life of a baby is heartbreaking, while the loss of a mother cannot be comprehended.

Here I am, a midwife in Melbourne, Australia. Any time I am concerned about a woman in my care I can make a telephone call to a large, well equipped maternity hospital, and refer the woman for complex investigations, or for skilled management of whatever the problem is. Women can travel by car or, if needed, by ambulance, at any time of the day or night. Although there are no guarantees in this or any other life event I have no reason to fear. I can certainly find fault with the mainstream public hospital system, and I believe it could be improved particularly in providing services for well women, but it is pretty good when women or babies are ill, or develop complications. Most of the women in my care give birth to healthy babies at home, without drugs to stimulate labour or to relieve pain, and with very little or no help from me.

A story in the World section of today's newspaper describes a woman in Peru, pregnant with her seventh child, who hiked for hours through the Andes mountains to a health clinic where she gave birth. The clinic's notable difference from hospital maternity care is that women are encouraged to give birth standing up. (Sunday Age, July 13 2008, p11) The program described in this article encourages mothers who had previously given birth at home to go to the health clinics in an effort to reduce Peru's awful maternal death rate of185 per 100,000 births. This compares with around 10 women per 100,000 births in Australia (http://www.aihw.gov.au/publications).

A call has recently gone out from World Health Organisation and other leading organisations to the G8 leaders to address maternal and child health. "We don't need a new cure to save the lives of 6 million women and children. What we need is political leadership and investment. The Partnership has issued a Global Call asking G8 Leaders to fund basic health services for women, newborns and children." http://www.who.int/pmnch/en/ This call is in concert with the UN Millennium Development Goals, particularly #4 and #5 http://www.un.org/millenniumgoals/
The Countdown to 2015 http://www.countdown2015mnch.org/ has been set up "to track progress made towards the achievement of the United Nations Millennium Development Goals 1, 4 and 5 and promote evidence-based information for better health investments and decisions by policy-makers regarding health needs at the country level."

The message I have heard, and that I want to send out to any readers of this blog is that "we don't need a new cure to save the lives of 6 million women and children." We need midwives who work at the primary care or basic level in all communities. For the majority of women we need to protect normal birth. That may be, as in Peru, saying it's OK to stand up to give birth. But you can't stand up to give birth if you are loaded with narcotics or if you are numbed by epidural. You can only stand up and give birth actively, or kneel, or choose to lie down, if your mind and body are strong and working in harmony with your God-given birthing power.
For the minority of women and babies who experience complications or illness we need health clinics and referral hospitals that are accessible when they are needed.

Joy Johnston http://villagemidwife.blogspot.com/

"Global Call to G8 Leaders to Champion Maternal, Newborn & Child Health"

http://www.countdown2015mnch.org/g8/
We do not need a new cure to save the lives of 6 million women and children. What we need is political leadership and investment. Sign up to the Global Call - asking G8 Leaders to fund basic health services for women, newborns and children. As well, we urge you to pass this "Global Call to G8 Leaders" to your friends and colleagues. An additional $US10.2 billion is needed yearly to provide basic health services for women, newborns and children in developing countries: That is what the world spends every 2.5 days on military expenditures. The "Global Call to Leaders" has been developed by the Partnership for Maternal, Newborn and Child Health, in collaboration with its 250 member organizations around the world. "Play your part" by visiting our website to sign on to the "Global Call":

• Click here and sign the Global Call;
• Forward this e-mail to like minded people and organizations to do the same;
• Join the "Global Call" Campaign by posting a Banner and Campaign link on YOUR website:
  

Link: Click here and sign the Global Call; (http://www.countdown2015mnch.org/g8/)

• Download the Campaign Banners from our website.
  

You may also keep track of our Partner G8 Actions--from their perspectives and in the news-- on The Partnership website in our special section "G8 WATCH" . Remember to Share your action as well! Our best regards The Partnership for Maternal, Newborn & Child Health Secretariat: Hosted by the World Health Organization 20 Avenue Appia- 1211 Geneva 27, Switzerland tel: + 41 22 791 2595 - fax: + 41 22 791 5854 Please sign up for our regular Partnership Update. www.pmnch.org This message has been sent to our members, contacts and e-Communities. We apologize for any duplicate messages.

Twin Homebirth

Wendy Buckland

Was it 'undiagnosed' or just 'denial'? I still wonder.

Darling Sandy has 4 year old twins born in hospital, managed relatively unscathed, born vaginally without medication. She then went on to birth a very chubby singleton girl who is now two and a half, at home.

Sandy employed me to care for her in this her 3rd and last pregnancy. All the way along she suspected twins but I reassured her I could just feel one and she measured the right size for one. She dreamed of twins, I did once too. Sandy never wanted an ultrasound. As the pregnancy advance I began to suspect an unstable lie, one week breach, the next head down, lots of movement and activity.

I was fully prepared for my first breech homebirth and said I was happy with that and to just wait until she went into labour and we would trust and surrender to whatever came. The second midwife and I joked about being prepared for twins. I said I can’t promise what is coming first or how many.

Sandy rang me at 2am Sunday to say she had ruptured her membranes and there was lots of liquor. Labour started a few hours later and I arrived just after 8am. The palpation was still confusing to do. I could feel a head I thought in the fundus, and only confirm one back, or was that a head deep deep in the pelvis and this was another large baby. I waited for the second midwife and she thought twins but we couldn't be sure. In the end we said we cant 100% say its not twins but that she was in labour!

I don­t usually do VE's in home birth unless a need and Sandy agreed it would be useful in this case to determine what was coming first. She didn't want to know dilatation. She was 7-8 cm with definitely a head coming first. We waited for a second sonic aid to be delivered to the home to try and differentiate 2 heart beats. We could definitely find it in 2 distinct places but the rate was the same and impossible to state definitive if it was one or two babies.

Sandy decided to get into the birth pool. I decided to stop analysing everything. I asked her if she was still happy, comfortable and feeling safe to birth at home, I would support her no matter what and she said yes. So we stayed.

There was a 3 hour latent phase where labour almost stopped between Sandy being fully and pushing. She had lots of emotional issues to process. I eventually asked her. "How are you feeling about having another baby in the house?" which opened a floodgate of tears. She felt she was burdening her husband, wasn't sure if she had the support for a babymoon and to manage 3 toddlers as well... CRY CRY CRY! It was great, she got back into the pool, time to birth now. We all sat in silence, and then a friend started singing to her. It was amazing. Picture if you will, Sandy and her family live 50 km form the nearest town (and hospital) in a tiny shed as they build their straw bale home, no power, just a long drop, sitting outside under a lemon scented gum tree Sandy in a plastic grape bin as a birth pool singing. Midwife still wondering how many babies were coming BUT NO FEAR! I was never afraid or worried.

After about an hour of singing and pushing Sandy felt the head born and her husband reached in and pulled their daughter up. Short Cord. I immediately knew something was holding her back, Sandy had to kneel up out of the water to keep baby above the waterline. I reached down to her tummy, felt twin 2. I got eye contact with her and asked her to put her hand down on mine. "Are you ready for this Sandy?" "What is it?" ... "It­s another baby darling?"... "Twins?" ... I kissed her "Yes, it is twins" ... Sandy needed twin 1 removed so we clamped and cut the cord after explaining to baby mummy needed her to do this (she was a bit cross and screamed at us in protest) and handed her to her daddy. I tried to listen to twin 2's heart rate but Sandy got a contraction so I gave up. Another contraction and she could feel a bottom "It­s a boy!" she whispered to me. Another push the whole body was out. I reached down into the water to check no arms were stuck up around his neck but of course all was perfect and just one push later Sandy birthed her breech son into her own hands 12 minutes after his sister. An hour later she calmly and easily birthed the two placentas, walked back inside and hopped into bed with the two babies. Then it was time to weigh the babies and check them out, feed everyone, laugh and cry with joy. The first few hours flew by then at about 8pm Lisa and I were dismissed! We left the property but needed to debrief. Standing at our cars we looked at each other in silence and decided a stiff drink was in order so drove to the Whitfield Pub. When we got there we were still in a daze, got out of our cars and I said to Lisa "What the @#&%,just happened?!"

Of Course it was twins! Sandy subconsciously knew it; part of me prepared for it during the labour, so why couldn't I diagnose it with conviction? Sandy and Christos say they didn't want to know, it would have opened up a dilemma for them that may have led them to considering transferring in labour. Part of me wanted to manage this, whatever was coming; my uncertainty but most of me just trusted the process, trusted Sandy. What an amazing birth, an amazing woman and an amazing birth team.

A note to any critics.......

Countless time I have gone over this birth and there is not one thing I would change. I have read and re-read my notes, sought independent counsel and spoken to the other people present at the birth. Sure hindsight is wonderful, but even knowing what I do now I would not change a thing. Questioning Sandy or her decisions was never on my mind. The choice for her to birth at home was never mine it was always Sandy's. My role was, and always is, to support the birthing woman's choice. My duty of care is to support birthing women, even when choices are made that I don't agree with. Every single day working in hospital I am expected to support women's choices that I strongly disagree with. When I do this, within the mainstream system I am a "good" midwife. Even if I had disagreed with Sandy's informed choice, which by the way I never did, I would not have withdrawn my care and abandoned her.

Unless you are actually present at a birth you cannot pass judgement on what happened. Unless you are a witness or participant, aware of the lead up to the event, involved in the interactions or decision making, how can you really know what happened? I could write pages and pages explaining the full story in minute detail and still it would be impossible to share the full essence of this birth. Unless you were actually there how could you possibly judge, yet judged I have been.

The ramifications and repercussions of this birth have been very interesting for me. I have been overtly and covertly criticized, bullied and harassed by people who were not there. My professional judgement and integrity have been questioned. My critics should now stand warned I am stronger than ever in my conviction to support women's choice to birth at home. My thanks go to those professionals who have supported me, particularly other Midwives in Private Practice and most especially Lisa Chapman. My heartfelt love and thanks to Sandy and Christos for inviting me to be their midwife and allowing me to bear witness to the birth of Zoe and Emilio.

[Sandy's account of her birth was published in Birth Matters Winter 2008]