Wednesday, June 24, 2009

Outcomes for births booked under an independent midwife in the UK

Readers of this blog may be interested in a new paper from the BMJ:
Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study

Authors: Andrew Symon, Clare Winter, Melanie Inkster, Peter T Donnan

To access the full paper and citation, click here.

<<Conclusions: Healthcare policy tries to direct patient choice towards clinically appropriate and practicable options; nevertheless, pregnant women are free to make decisions about birth preferences, including place of delivery and staff in attendance. While clinical outcomes across a range of variables were significantly better for women accessing an independent midwife, the significantly higher perinatal mortality rates for high risk cases in this group indicate an urgent need for a review of these cases. The significantly higher prematurity and admission rates to intensive care in the NHS cohort also indicate an urgent need for review.>>

Comment by Joy Johnston:
This paper adds to the significant body of literature supporting homebirth as a safe and reasonable option for well women who are assessed to be at low risk of complications. It also identifies a higher rate of death of babies born at home to mothers in higher risk categories, when compared with births in hospital.

In general the *low risk* woman is in good health; her pregnancy continues without medical complication to Term; she has one fetus who is lying longitudinally and whose presentation is cephalic; she comes into spontaneous labour and progresses to giving birth unassisted to a live healthy baby, without requiring uterine stimulants or pain relieving agents.

Many independent midwives in both UK and Australia would agree to attend a woman who would not meet hospital risk management criteria for low risk. While in the UK the principle of informed choice is a key aspect of government policy for maternity care, Autralian women are increasingly finding that they have little choice. For example, women who have had one or more caesarean births, and who want to plan a vaginal birth, often experience strong pressure to the point of bullying by midwives and doctors who attempt to enforce compliance with the plan of management considered 'best' by the maternity service providers.

Health is not black and white - there's always the possibility of shades of grey.

Independent midwives in Australia, and women who want homebirth, face enormous challenges as the changes to legislation regulating midwifery practice are implemented next year from 1 July. The women in 'grey' zones of risk - women who have had caesareans, or the grand multis - those who have given birth to six or more children, or the older or very young women, or those whose pregnancies are continuing beyond 41 weeks - these are the women for whom the independent midwife provides an invaluable personally refined service, whether they choose to give birth in hospital or at home. These are the women for whom the promotion of normal birth, working in partnership with a trusted and skilled midwife, becomes the key to protecting good outcomes. These are the women who will be most affected by the banning of independent midwives from professional practice.


Midwife Flora said...

"Healthcare policy tries to direct patient choice towards clinically appropriate and practicable options; nevertheless, pregnant women are free to make decisions about birth preferences..."

The "directing" that goes on in some hospitals is plain coersion and bullying. Many hospital midwives and doctors do not even understand the simple concept of informed consent and refusal. Yesterday afternoon in handover the midwife in charge (very experienced) was discussing the details of a woman who had come in at term with her 4th baby, her previous babies had been born vaginally with no complications. The woman's membranes had ruptured earlier in the day and the vaginal swab taken at 36 weeks had shown GBS bacteria present in her vagina. Normal procedure would have been to administer prophelactic IV antibiotics but this mother delined to recieve them. The midwife then went to on to ask her why she was saying no, had she ever seen a baby sick with GBS infection and then threaten her with getting a Dr in to explain the risks further. I was the only staff member there to say "She is ALLOWED to say no!". The midwife in charge actually disagreed, saying "if something happens to that baby it will be our fault." The rest of the staff then corrected the midwife and the woman ended up going home as she wasn't in labour. How can such a basic and fundamental right as that of consent and refusal have become so lost in the arse-covering and fear of being sued?

I am about to print out the Public Hospital Patient Charter to post up in the tea room which includes the right to refuse treatment.

Joy Johnston said...

But many midwives and doctors and women I have encountered in mainstream maternity care are oblivious to the reality of refusal. Sometimes we can defuse the situation by suggesting that a note could be made that antibiotics were offered, and declined; that the woman understands her decision, and a plan has been discussed ...