Friday, December 11, 2009

Report on Stakeholder Forum

MiPP was represented at the meeting in Canberra yesterday, as a stakeholder providing input to the National Health and Medical Research Council (NHMRC) in its task of developing multidisciplinary guidance for collaborative maternity care arrangements.

The 'guidance' is to support the new legislation enabling midwives to access MBS and PBS in November 2010. I am not sure what's the difference between guidance and guidelines.

Questions put to the invited stakeholders were:
1. How does collaboration work now?
2. What does/can collaborative maternity care mean?
3. What are the essentials?
4. How do you create and maintain collaboration?
5. What are the opportunities to review and monitor collaboration?

This meeting was funded by the taxpayer through NHMRC. Celebrity host Norman Swan acted as facilitator. The 'guidance' that will be produced as an outcome of this meeting will not have any power in the laws governing midwifery practice.

Participants were seated at round tables. Places had obviously been carefully appointed. Midwives, consumers, obstetricians, academics, GPs, paediatricians, and bureaucrats were mixed and matched in an interesting way. I was positioned next to a previous head of RANZCOG, and a young female GP Obstetrician from Tasmania. Also at my table were a couple of very articulate consumers, one of whom had a delightful baby with her, the CEO of the Commission on Safety and Quality in Health Care, and a privately practising midwife from Sydney. Ann Catchlove, who was representing Maternity Coalition Victorian Branch was placed next to Dr Andrew Pesce, also known as Mr 3am.

Many conversations ensued about the questions of the forum, as well as other issues. Although the 'h' word, 'Homebirth' was not the topic of the day, it was mentioned frequently. So many people giving their time to discuss a matter that affects a tiny proportion of midwives and births.

A large Discussion Paper had been distributed for pre-reading. This document attempted to tease out the arguments, and referred to its review of the literature, without quoting references, and its 'consultation comments' some of which could have come from the DoHA tea room or corridor.

An attempt was made to identify principles that define collaboration in maternity services. The principles, which will probably be further refined, include (not necessarily in order of importance):
[comments and discussion are welcome]
1. Care must be woman-centred, culturally responsible, acknowledging a woman's right to autonomy, as well as the rights of professionals, and be coordinated according to the woman's clinical need.
2. evidence informed care appropriate to the local environment.
3. enable women to make informed decisions by providing evidence-based information, agreed to and endorsed by professional and consumer groups.
4. communication strategy
5. safety and quality framework to support all clinicians in it, including data monitoring, regular multidisciplinary audit (a process inclusive of consumers) and public reporting.
6. requires participants to respect and value each others' roles, provide support to each other in their work and provide education to meet those ends.
7. committed to joint education, trainign and ideally research focussed on improving outcomes.
8. provide to women continuity of care through pregnancy , birth and the early postnatal period as well as clear description of the roles and responsibilities of the person they identify as their primary maternity care coordinatior.

Some statements in the discussion documents were, in my opinion, plain group-speak eg "... the overarching principle that pregnancy, birth and the postantal period are normal physiological processes ..."

In many cases birth particularly, and subsequently the postnatal period, are not at all physiological. In fact, physiological births are not common in our world. The statement would have been more acceptable if "can be" replaced "are", and the document acknowledged the importance of the physiological process for health and wellbeing of mother and child. World Health Organisation (1996) states "In normal birth there should be a valid reason to interfere with the natural process."

A suggested draft definition of collaborative care is (in the discussion document)
"Collaborative maternity care involves collaboration with the woman and for the woman ..."
I disagreed with this statement. The relationship of a professional with a client, in this case, a midwife or other maternity care provider with a woman, is not collaboration. The midwife needs to collaborate with other professionals, while acting in a professional partnership with the woman. The woman has the right to disagree with the individual or collective wisdom of professional care providers, and the care providers have responsibilities to accept and respect the woman's decision. This is woman centred care. We can't place the woman as part of a collaboration with professional care providers, then place the collaboration at the centre of the care. There is no equality either in position or power in that relationship. The woman's rights and responsibilities are separate from professional collaborations.

There was no mention of the RANZCOG position that the obstetrician is the ‘designated clinical leader’ in all collaborations. The heirarchial nature of the obstetric model appeared to be overruled by the group, with the phrase "primary maternity care coordinator" being applied to the one professional person who provides care for the woman throughout the episode of maternity care, and who the woman identifies as her leading carer.

Discussion took place about the ACM National Midwifery Guidelines for Consultation and Referral, particularly with reference to the RANZCOG refusal to adopt these Guidelines. It was indicated that RANZCOG objected to what it considered a lack of consultation in the development of the guidelines, rather than the guidelines themselves. Interesting!

There was too much idealism, and too little factual reality in the room. In the discussion on continuity of carer it seemed that everyone wanted to jump on the bandwagon. Someone suggested that obstetricians, registrars, residents and even medical students would like to get to know the pregnant woman. Never mind what that would mean to the woman! How many prenatal visits would she need? Would everyone then commit to being with her when her time came to give birth, and also commit to working in harmony with her natural intuitive processes, unless there was a valid reason to intervene? I don't think so.

The facilitator had no idea of the extent to which midwives collaborate, nor did he seem interested in knowing what happened. He had an agenda - to get this mob to collaborate. And he was 'gunna' make it happen 'by hook or by crook'.

In this reform process a meeting like this one can be used as evidence of consultation with stakeholders. It can also be a box ticking exercise - yes, stakeholders have been consulted.

A further comment on insurance and practice issues can be found at Joy Johnston's blog.

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