Saturday, August 16, 2008

Looking for a homebirth midwife

[Photo: MIPPs meeting with Shared Care coordinators at the Women's]

We received an email from a mother who I will call Tammy (not her real name), who was trying to find a midwife who would attend a homebirth from 35 weeks gestation. Tammy explained that her first child was born at about 35 weeks, weighing 2.3 kilos, after spontaneous onset of labour. The baby had no difficulty breathing, and fed well at the breast, and maintained body temperature well (three of the possible challenges that premature babies face). The only treatment the baby required while in hospital was phototherapy for jaundice, with "lots of love and care from mummy in nursing __'s poor bruised heels from all the blood tests".

I expect that anyone who reads this blog will recognise that the accepted range for 'Term' or maturity is 37 to 42 weeks. A baby born at 35 weeks is 'premature'.

Midwives who ignore well established standards do so at their own (professional) risk, and are possibly also putting the mother and baby at extra risk. The safety of homebirth internationally has been established in the normal birthing population. If homebirth midwives are holding themselves out as being practitioners in prematurity, twins, breech, and other clearly complicated births we are on very thin ice. A baby born spontaneously at 35 weeks may actually be mature, and this will be recognised soon after the birth. But even an apparently minor intervention such as blood tests and phototherapy for bilirubin are in many of these little babies considered essential for the baby's wellbeing.

By definition the midwife's duty of care includes "preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical or other approtpriate assistance and the carrying out of emergency measures." (ICM 2005

The Australian College of Midwives has recently undertaken a review of its National Midwifery Guidelines for Consultation and Referral (see blog posting 20 July 08). We (MIPP) have engaged in that review, in seeking to achieve a document that
will enable "the midwife to integrate evidence with experience (clinical judgment) in providing midwifery care; and to assist midwives in their discussions with women." (from the draft)

Following Tammy's email several MIPPs replied, seeking the opinion of their peers on this matter. The clear consensus from those who replied to the group was that we state that from 37 weeks is the usual time after which we are happy to attend birth in the home, and would consider the individual situation in the 36-37 weeks period. Of course in this instance the midwife could say yes now, knowing that it's likely that this baby will not be born pre-term. They may even have to have the discussion about postmaturity!

There is no fixed protocol for independent midwives in attending homebirth. We are independent in professional decision-making, and we are accountable for all decisions we make.

The ACM Guidelines are a guide, but should not be seen as prescriptive. Some independent midwives will agree to plan homebirth that carries a degree of potential complication with the belief that the woman will be better attended than unattended, or forced into a potentially harmful situation. That level of decision making requires an understanding of the responsiblities and rights of both the mother and the midwife. It is not a simple matter of booking a midwife who will agree to a particular issue, such as homebirth for a premature baby.

The midwife's selection criteria and guidelines for referral do not prevent the woman from making an informed decision, for her own reasons, which contradicts the midwife's advice. That's a very different situation from the one in this instance, when the mother is seeking a midwife who will agree from the start to working outside standard guidelines.

A wise midwife will encourage Tammy to talk about what she wants, and will use the discussion as an opportunity to explore informed decision making, personal autonomy, and the responsibilities of the midwife. Independent midwives may have greater scope than those employed by hospitals to work in a partnership with each woman, but a midwife cannot simply ignore basic guidelines or professional standards.

Joy Johnston


Lisa Barrett said...

It is also a wise midwife who will give the woman ALL the information and as long as she makes a totally informed decision support her whatever her choices. As a midwife I totally believe in the woman's right to choose and be supported.

gaye demanuele said...

Well said Lisa.
This woman's story has been posted without her permission. Yes, a pseudonym was used, however, many reading this post will have recognised the story and may even know this woman. Can you imagine how she may feel upon reading it? Humiliation comes to mind. She may wonder if any midwife in Victoria is able to be approached. Surely compassion is the appropriate response. This woman had a genuine question, she needed a genuine and compassionate response rather than having "rules" thrown at her. Midwifery is about being with each woman and listening to her unique needs.

FiestyKel said...

I know the woman in your post, I am almost certain. I am quite horrified that she has been made an example of in your blog, and her story shared without her permission. You speak of professionalism, but this is certainly the very opposite. A disappointing read in every way.

Anonymous said...

I believe there has been unesecarily harsh criticism of this post. From what has been written, the woman in question has not had ongoing care from a midwife and had that relationship and trust broken. From what has been written, she emailed an initial enquiry asking if the midwife would consider taking her on or not.

We all know full well that the internet is not private. Being under the delusion that it is so, is not being realistic. And sending an email to a stranger with a general enquiry,is even less reason to expect her request to be kept private, particularly if she did not make the request that the email be kept private (and if that request had been made I'm sure it would have been honoured).

I had emailed Joy a question today, and as part of her answer she sent me to this blog. My question was about whether she would support my care if I chose to freebirth.

If Joy chooses to write a blog about me, and change my name, and discuss freebirthing, then she is certainly entitled to do so. Why in the world would I choose to be offended, hurt or humiliated at that?!

Joy has not called the woman an idiot. She has not disrespected her. She has talked about guidelines that midwives have to adhere to as far as gestation. Any informed woman homebirthing in victoria knows that 37 weeks onwards is the standard at which most women are recomended to homebirth. that is the standard advice. Of course the woman being discussed can question or dispute that, and can choose her own path and her own beliefs. Joy’s blog did not indicate she did not have the freedom to do so. The birthing woman is entitle to her own beliefs, and the midwife is also entitled to agree to support her, or not. I personally see no issue with the blog that has been written, and think intelligent discussion is always a good idea, whether I agree with the midwife's opinion or not is irrelevent.

If it were me in question looking to birth a preterm, I would have to question myself as to whether I felt 35 weeks was safe. It would be a journey of learning for me to find my own truth in the matter. But I think making out that it is perfectly safe to have a baby be born at home at 35 weeks, would be irresponsible for any midwife. When normal gestation is 40 weeks, even 42-43 weeks, who can know whether any baby which might be born at 35 weeks, is actually cooked enough for that baby, or whether in-fact there is a risk that baby is actually maybe even 7 weeks early. There is a wide variation, and surely any discussion or musing on the topic can only be good.