Saturday, March 23, 2013

Midwifery under the spotlight at obstetric malpractice conference

The 5th annual obstetric malpractice conference will be held in Melbourne, June 20 and 21 this year.

Key issues to be covered:
  • Developments of the National Disability Insurance and Injury Scheme and National Injury Insurance Scheme and implications for obstetric practice
  • The Coroner's perspective on inquests involving perinatal death
  • Lessons learned from the midwifery indemnity model in New Zealand
  • Practical and legal implications of the Open Disclosure Standard
  • Practical legal measures for when a baby is born with Hypoxic Ischemic Encephalopathy or other unexpected birth outcome
  • Managing the Risks inherent in women's choice in obstetric care
  • Perinatal Review Process
  • Medico-legal risks of female genital mutilation and female elective surgery
  • Race-based pregnancy care. Is that good medicine?
  • Implications of new genetic technologies on prenatal diagnosis
  • Wrongful birth damages - the first detailed damages judgment
  • FACILITATED PANEL DISCUSSION: Awful Lessons I have learned by being an expert witness
  • PANEL DISCUSSION: Medico-legal risks and ethics of female genital mutilation

This list of topics includes several of considerable significance to midwives who practise privately.  However, there is one major hurdle for anyone who may be considering making a booking: the cost!  Even with earlybird discount, $1,700, added to the potential loss of income if a baby in the midwife's caseload needs to be born, and accommodation costs, is a LOT of money in midwifery-land.

The opening address on Day 2 is 'Lessons to be learned from the Home Birth Cases in Vic and SA' - speaker is the coroner Judge Ian Gray. It would seem to me that we need to have midwives who are practising privately in Victoria and South Australia to hear what is said and to respond if appropriate. 

Midwives who face disciplinary hearings or coronial investigations find ourselves, our actions, and our 'outcomes' thrust into the spotlight, within a legal and professional framework that may seem quite foreign to contemporary midwifery philosophies.  Midwifery notions of informed decision making and partnership and choice can be discarded as meaningless by legal experts who rely on guidelines rather than professional clinical decision making. Click here and here for recent examples.

I do not wish to suggest that midwives always get it right - there will always be a need for unbiased outside review of serious morbidity and mortality, or unprofessional conduct in professional health care.
Issues around a woman's right to decline treatments (usually medical) that are considered 'evidence based', or 'best practice' will be reviewed from obstetric, legal, and consumer perspectives.   The management of breech births is a good example, and two consumer presenters, Rhonda Tombros and Ann Catchlove, who are also lawyers, will discuss:

Breech birth: consumers, choice and consent
  • Women with breech presenting babies near term often find themselves with limited birth options. Some change care-providers, hospitals or even travel interstate to access the opportunity to attempt a vaginal breech birth
  • This presentation will explore issues around consumer choice and consent in breech birth with a focus on the legal and ethical issues that arise when women are given no option for birth other than planned caesarean section
  • How can care-providers and hospitals facilitate care that is both safe and respects women's decision-making autonomy?
Both women come with a proven track record, in challenging obstetric dominance of women giving birth.  See Breech Birth Australia and New Zealand, and the breech fb group, and Maternity Coalition.

Midwives discussing this conference via the Eligible Midwives facebook group have called for recordings of the proceedings to be made available after the conference.  I will keep readers informed.

Post script:
Midwives may apply for financial assistance via Government Scholarships (administered through ACN

Wednesday, March 13, 2013

Ireland: No Country for Pregnant Women

Press Release - AIMS Ireland

No Country for Pregnant Women

This past weekend, as the nation celebrated International Women’s Day and Mother’s Day, an Irish Maternity Hospital initiated an invasive procedure on a pregnant woman against her will. ‘Mother A’ was denied patient autonomy and the right to informed refusal when the drastic and unprecedented measure of an emergency High Court sitting was called in order to compel her to undergo a Caesarian section. The risk of uterine rupture was cited as one of the main reasons for the urgency in this case but this risk is widely reported as being 0.1% or 1/1000. This is what Dr. Michael Turner, Obstetrician at the Coombe Hospital has called: “exaggerated, professional scaremongering...and it must stop”. (VBAC Conference, 2012)

State-sanctioned coercion of medical procedures on pregnant women or any other competent adult is not only unacceptable but it is also unlawful in other jurisdictions, such as the USA and the UK (Re AC [1990] & Re S [1998]). ‘Informed consent’ and ‘informed refusal’ abuses are common issues reported to AIMS Ireland by women.

Jene Kelly of AIMS Ireland states: “there is an overwhelming acceptance by the public and some maternity service providers in Ireland that a pregnant woman’s right to informed consent, or informed refusal, is not reliable and that women who exert their rights are selfish. It is this mentality that has allowed atrocities such as symphysiotomies, miscarriage misdiagnoses, unnecessary hysterectomies by Dr Neary and all the other reported assaults against women by our maternity system to continue to go unanswered in Ireland for so long. This is no country for pregnant women. ”

AIMS Ireland reports that women who are bullied into consenting do not fulfill the principles of informed consent and therefore are entitled to sue the doctors for assault. For example, a woman who was forced to have a caesarean section against her wishes in the UK sued the doctors (Ms S v St George's NHS Hospital Trust, 1998) and was awarded £36,000 damages. It is time that Irish women did the same. Threatening women, bringing women to the high court, removing women’s rights and choices - these bullyboy tactics do not promote trust between women and their care providers. How can you trust a system that doesn’t acknowledge your rights? Women are choosing to leave the system as a result.

Annette is one of these women. She is lobbying the HSE for a homebirth following a previous Caesarean section. The HSE currently does not recognize informed choice for homebirth for women who fall outside strict exclusion criteria in site of a European Court of Human Rights ruling recognizing a woman’s right to decide how and where she births. Annette does not meet criteria following her previous Caesarean, despite having subsequent successful vaginal births. Annette asks: “Is it HSE policy to use the High Court as a method of intimidation and coercion, when a patient tries to exercise her right to informed decision making, as laid out by the European Court of Human Rights (Ternovsky v Hungary, Under Article 8)? We are humans, with great intellect. We are capable of informed discussion and decisions regarding our pregnancies and births in the best interests of ourselves, our babies and our families. I feel anger, disappointment and bewilderment. Today as a woman and mother, I grieve.”


AIMS Ireland Press Contacts:
Jene Kelly 087 681 9095
Krysia Lynch 087 754 3751
Barbara Western 086 385 3344

AIMS Ireland is a consumer-led voluntary organisation that was formed in early 2007 by women following their own experiences in the Irish maternity system. Our mission is to highlight normal birth practices, which are supported by evidence-based research and international best practices, and campaign for recognition of maternal autonomy and issues surrounding informed choice and informed refusal for women in all aspects of the maternity services; from Caesarean section to homebirth. AIMSI campaigns on the grounds that birth choice is a basic human right as declared at the International Conference of Human Rights and Childbirth, “It is a fundamental human right for women to choose the circumstances in which they give birth, with whom and where, including a choice between hospital and home birth” and Article 8, European Court of Human Rights

Tuesday, March 5, 2013

Medicare review

The federal government health department has engaged consultants to review the incorporation of Medicare into midwifery practices.  Yesterday the MAMA practice was visited, and focus groups and interviews carried out with midwives and mothers.

I don't know if or when the public (you and I) will see any such reports, but this sort of review is expected a couple of years after major policy and funding changes by our government.

A midwife/maternal and child health nurse asked the reviewers to note that the maternity reform initiative, subsequent to the Maternity Services Review, is notable in its lack of public education or advertising.  The government's response to the Review was a  "$120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives. This Budget package provides Australian women with more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services."

More "choice in maternity care" is not accessible if women don't know about it.  Medicare rebate for midwife-attended births means nothing if midwives can't have visiting access to hospitals.  Yet the rationale for the reforms is more safety and better outcomes for mothers and babies: achieved through continuity of midwifery care.

Any other government health initiative, such as immunisation, or safe sleeping, or smoking cessation or ... is presented to the target audience public with the aid of professionally prepared TV and radio advertising, brochures, posters, and the like.

Midwife primary care with Medicare rebates is the best kept secret in the country. 

Why aren't there posters about continuity of care from a known midwife in places where women of childbearing age will see them? Why haven't we seen letters sent to doctors explaining how they can collaborate with midwives? Why are hospitals working harder than ever to actively prevent midwives from achieving visiting access? 

Your comments are, of course, welcome.