Thursday, November 29, 2012

questions ...


"Do you [the midwife] consider that after you have informed the woman of risk, such as twins, that it is appropriate for you to agree to homebirth?"

"In your opinion, what is more important: the right of the woman to have informed choice, or the safety of the mother and baby or babies?"

"If a woman who was having quadruplets told you she wanted to give birth at home, and you informed her of the risk, would you agree to attend her for homebirth?" 

"Isn't the reality that if the midwife says 'Yes, I'll come to your homebirth of quads, isn't the midwife giving the green light to the woman's wishes?"

Continuing from the previous post, I want to further record and begin to explore lines of questioning that have been pursued by the barrister acting for AHPRA, in a formal hearing into the professional conduct of a midwife who attended births for two women classified as risk categories C and/or B in the ACM National Midwifery Guidelines for Consultation and Referral - in this case the 2004 version of that document.  In both cases there was a transfer of care to hospital; mothers and babies are well.  

The legal expert's job in the hearing is to prove allegations that the midwife acted in an unprofessional manner when she attended these births privately at the homes of the women.  The case relies heavily on the categorisation of risk in the ACM Guidelines.

The midwife has retained the services of a barrister to defend her.  The costs have accumulated to in excess of $20,000.

The panel of three, appointed by AHPRA to hear the case, includes one person who is a nurse academic, who lists RM (registered midwife) in her cv that is available online.  This person has published in her field, but there is no mention of midwifery or maternity in the titles listed.  This person has listed memberships in professional organisations, and there is no mention of any midwifery or maternity related organisation.   The other two members of the panel are a lawyer, and a nurse whose specialty area is psychiatry.

I am recording this point because there is an expectation in hearings into professional conduct that the evidence will be heard by peers.  The panel in this case was totally lacking in peers, and the one member who listed RM should perhaps reconsider her use of the title RM.  Midwives continue to be judged by nurses, as nurses, despite the reforms that have restored the register of midwives.

The pursuit of information by the Board's barrister, who acted like a blood hound, included many questions about choice and risk and safety.  The complexities of informed decision-making over time, and within that woman's real world, were barely acknowledged.  The relationship between 'risk' and 'safety' was not explored.  If the 'guidelines' identify 'risk' ... it's *obviously* unsafe, and not suitable for a midwife to be providing primary care in the home.

The midwife expert witness called by the defense barrister brought some clarity and sense to the hearing, with her consistent and persistent assertion that safety can only be achieved when a mother's right to informed decision making is protected and upheld.

Midwives and others who promote humane maternity care around the world have been alerted to the criminal case against Hungarian midwife-obstetrician Ágnes Geréb.  For an update on this case, click here.

Tuesday, November 27, 2012

Questioning a midwife about women and risk

I am reluctant to make any broad statements about privately practising midwives and the way each one approaches a professional situation in which the woman has risk factors.  Each midwife, and each woman, is unique.  In fact, that's what the often repeated phrase 'woman centred care' points to: that the care for each woman is approached by her midwife from an individual perspective.

A midwife whose practice is under the regulatory spotlight for events that led to allegations that she has engaged in unprofessional conduct when she agreed to provide homebirth care for women in a risk category* is on the stand, under oath, and quizzed by the Barrister acting on behalf of the statutory body.  Here are a selection of the questions that this midwife may be required to answer.  Perhaps other midwives will take a moment to reflect on how we would answer these questions.

* The 'risk' profile could include, for example, postmaturity, prematurity, birth after caesarean, multiple pregnancy, breech presentation.  

With reference to a woman who wishes to give birth at home, the midwife is asked:
"Do you accept that you have a professional responsibility to inform the woman of risks?"
"Do you consider that after you have informed the woman of risk, such as post maturity, or previous caesarean, that it is appropriate for you to agree to homebirth?"
"Do you accept that homebirth after caesarean (hbac) entails higher risk than homebirth without previous surgery?"
"Do you agree that risks in a vaginal birth after caesarean (vbac) birth are better managed in hospital if they occur?"
"If as you say there are some risks for the vbac at home, why did you not record this in your notes?"
"What evidence do you rely upon for permitting vbac at home?"
"What special preparations did you make for a high risk birth at home?"
"Did the mother lead the decisions about homebirth, or did you give her the green light?"
"Did you consider saying no to homebirth, and sending the woman to a doctor?"
"In your midwifery practice, do you follow the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (ACM Guidelines)?"
"Do you accept that the ACM Guidelines state that the pathway for birth after caesarean is to at least consider referral and transfer to obstetric care?"
"Do you accept the first guiding principle of the ACM Guidelines, that 'As a primary caregiver, the midwife, together with the woman, is responsible for decision making.'?"
"Do you as midwife accept that you and the woman are jointly responsible for the decision to give birth at home?"
"On reflection, with the wisdom of hindsight, do you agree that you made a poor decision in providing home birth care in this situation?"
"Are you able to give the panel the assurance that if you were faced with a similar situation again, you would act differently?"
"Don't you think that a woman who is more than 10 days postmature, and unable to give birth in a small hospital, is too high risk for homebirth, where there are even fewer resources on hand than at a small hospital?"

The main 'requirement' for homebirth is that the woman is able to labour spontaneously without medical stimulation of labour or pain relief.  Midwives attending homebirth use no drugs to stimulate labour or to ease pain.  The only stimulation of labour available for homebirth is natural processes, such as walking, nipple stimulation, sexual intercourse, and perhaps a special meal.  If a woman who has had a previous caesarean, or whose baby is in a breech presentation, intends to give birth spontaneously, she usually accepts the requirement for spontaneous onset and good unmedicated progress in labour. 

The polarisation of midwifery care into 'planned homebirth with a private midwife' and 'standard hospital care for birth' is in itself unreasonable.

Physiological birth is a basic function of the female of the species.  In our world today we have the opportunity to interrupt physiological processes if we think they are progressing in a way that would lead to poor outcomes.

Consider any other physiological process: breathing, for example.
I breathe because that's what my body does.
I continue to breathe whether I am conscious of the fact or not.
If breathing becomes difficult, this can be a warning sign that prompts me to seek medical attention.

In the same way, a physiological labour will proceed because that's what the woman's body does.
She will continue to labour whether she is paying attention to it or not.
If labour becomes difficult, this can be a warning sign that can prompt transfer to another level of care.

Planned homebirth is 'Plan A'.  The midwife checks the fetal heart, or records signs of progress, or monitors the woman's vital signs in preparation for intervention if that becomes necessary.  The midwife has (or should have) no intention to interrupt the natural processes without a valid reason.  A transfer to hospital, 'Plan B,' is a change in the plan.   There are different rules in operation under 'Plan B' than 'Plan A'.

Effective decision making in labour requires a shared responsibility for the decisions that are made.  The midwife has a certain body of knowledge, and familiarity with the processes, and the woman has other knowledge about herself, her values, and her life direction.  Together they are able to navigate the often unpredictable journey of bringing a baby into the world.  A midwife is not a hired help, employed to facilitate a certain preferred option.  Active participation in decision making protects the wellbeing and safety of mother, baby(ies), and the future of the midwife.

Birth is a highly contested zone.  Our society takes a paternalistic attitude towards birth, through the regulation of the midwifery and medical professions, and the oversight of institutions such as hospitals.  This is good - to a degree.

However, the one who is literally 'holding the baby' at the end of the day is the mother, and she is usually within an immediate family and broader community.  Unless the mother-family-community relationships are broken down beyond repair, the best place for a child to be cared for and to grow is within that network.  A midwife works in partnership with the woman, for the childbearing period, promoting health, protecting wellness, and supporting the development of healthy families.

There will always be aspects of risk that either exist prior to the onset of labour, or that develop during labour.  The midwife who recognises and acts appropriately in the care relationship, and the woman who engages in an intelligent way in decision-making, will have a high level of safety built into their care plan.  There is no safer way than Plan A for a well woman to approach birth.  When complications are present the care decisions become more complex, and the need for medical attention becomes more urgent.  A midwife and woman working together in a trusting relationship bring strength and confidence to the decision making process.

Your comments are welcome.

Wednesday, November 21, 2012

Homebirth backup arrangements

Melbourne's MIPPs were invited to meet with midwifery management at the Women's Hospital today, to hear about changes that will be implemented to the hospital's homebirth backup arrangements from 1 January 2013.

The Women's has, for many years, provided a 'booking' process by which midwives have made a backup arrangement with the hospital for women planning homebirth.  This arrangement will be ceased from 1 January.  Women for whom midwives are providing private care will be seen in the Emergency department, and admitted without having previously made a booking.

The hospital has reached this position after reviewing its processes.  The 'booking' was of a clerical nature only - the hospital has had no professional clinical review of the paperwork, including results of blood test and other investigations, until or if the woman has actually been admitted. 

The Women's is a busy, complex place: there were more than 7,300 births in the past 12 months.  The number of women who present without having had prior care from the hospital antenatal services is small.

How does this change impact on private midwifery care in the community?  

  • A woman whose midwife refers her to the Women's is able to expect appropriate maternity care.  
  • The midwife who is caring for the woman privately in the community is able to phone the hospital Emergency department, and provide verbal and written handover at the initial triage, and after admission.  Sometimes midwives who phone the hospital have reported difficulty, when the phone is not picked up within what seems a reasonable period of time.  The advice is always to put the woman's and baby's needs first, and to present at the hospital without calling if needed.

How does this change impact on collaboration between private midwives and public hospitals?
  • It doesn't.
  • The hospital is not under any obligation to accept collaborative arrangements with midwives, even though, under the federal government's Medicare reforms, there is a legislative/ bureaucratic expectation that midwives who provide Medicare rebates for women will establish collaborative arrangements with hospitals [Click here].
What does the National Health law require in terms of collaboration between a midwife and a hospital?
  • The National Health law appears to envisage hospital births: a setting for which no midwife in Victoria, or in most of the nation, is able to have clinical privileges.  The issue of hospital backup for homebirth is not specifically addressed.  Rather the law requires arrangements that cover consultation, referral and transfer of care: the very process that backup arrangements cover.
  • The National Health (Collaborative arrangements for Midwives) Determination 2010 states:

         (1)   For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:
                (a)    the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;
               (b)    a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;
                (c)    an agreement mentioned in section 6 for the midwife;
               (d)    an arrangement mentioned in section 7 for the midwife.
         (2)   For subsection (1), the arrangement must provide for:
                (a)    consultation between the midwife and an obstetric specified medical practitioner; and
               (b)    referral of a patient to a specified medical practitioner; and
                (c)    transfer of a patient’s care to an obstetric specified medical practitioner.
         (3)   A collaborative arrangement, other than an arrangement mentioned in section 7, may apply to more than 1 patient.
         (4)   However, an acknowledgement mentioned in paragraph 7 (1) (c) may apply for more than 1 patient.

         (1)   An agreement may be made between:
                (a)    an eligible midwife; and
               (b)    1 or more specified medical practitioners.
         (2)   The agreement must be in writing and signed by the eligible midwife and the other parties mentioned in paragraph (1) (b).

In practice, a woman who books for homebirth with a Medicare-authorised midwife, is advised by her midwife on steps they need to take in order to fulfill the requirements collaborative arrangements.  For example, a referral to the midwife, signed by an specified medical practitioner (defined in section 4) for provision of antenatal and postnatal midwifery services, covers the part of the care that attracts Medicare rebate.  The arrangement includes hospital backup, should consultation, referral or transfer of care be indicated. 

There is a big black hole in the National Health law as far as birth at home is concerned, and the hospitals are understandably going about the job of tightening up their processes. 

Enough from me for today.   Your comments are very welcome.