Thursday, November 28, 2013

relationships between independent midwives and public hospitals

Midwives who work independently, who are employed directly by the woman and her family to provide midwifery services in pregnancy, birth, and postnatally, are at the front of efforts to reduce unnecessary medicalisation of birth, and to protect, promote and support the natural processes in birth when ever this is reasonable.

It would be simplistic and untrue to paint a black/white, bad/good picture of the medicalised birthing world (hospitals) compared with the holistic, woman-centred world of private midwifery and homebirth.  Unfortunately, many of the stories of disempowered mothers who found themselves experiencing a cascade of medical interventions carried out by strangers, without their informed consent, are stories from hospitals.

Equally lamentable are the stories that become public knowledge after coronial investigations into deaths, when midwives were providing care for planned homebirth.  Any evidence of delay in advice by the midwife that the care should be transferred to hospital places a cloud over independent midwifery and homebirth.

Readers of this blog will know that one of the federal government's 2010 maternity reform promises has been the option of private midwifery care for birth in a public hospital.  Here's how it would work:

The eligible midwife who has a Medicare provider number, and an endorsement to prescribe certain medicines; who is insured with the government-backed professional indemnity insurance product - this midwife is theoretically able to apply to public maternity hospitals, and request the right to admit her clients to the hospital for intrapartum care.  The hospital is expected to be able to authorise doctors to enter into an agreement with the midwife (or midwives) so that any consultation or referral during the episode of care is smooth, timely, and transparent, and in the interests of the wellbeing of mother and child.  A midwife with admitting privileges would work within the hospital's protocols and risk management processes.

The purists in the natural birthing community are not supportive of the plan for midwives to provide birthing services in public hospitals.  The arguments might include:
  • that the very act of leaving the safety and familiarity of one's own home could interrupt the sensitive hormonal processes of labour and natural birth.  
  • that the ready availability of pain-relieving narcotic drugs and regional anaesthesia (epidural/spinal) would surely increase the likelihood of use, when compared with labouring at home.  
  • that the easy access to the machine that goes 'ping', and other medical gadgets that are not available when a woman is labouring at home - surely there will be an increased reliance on these medical devices in hospital!  

The current situation for independent midwives is that public hospitals do not want to throw their doors open to us.  As was recently discussed on this site, there is a significant number of eligible midwives, and this number is likely to continue growing.  Each eligible midwife is potentially eager to take up hospital admitting privileges as soon as they are offered.  A number of midwives who were employed in hospital maternity units until they achieved Medicare eligibility have now set up private practice, and have, in the past three years, quickly transitioned to homebirth practice. These midwives are up to date with all hospital competency requirements, and familiar with hospital processes, and could quickly take up the 'private midwifery in public hospital' option. Other midwives who have practised independently in the community for many years would require support to transition into the new model of maternity care.

A midwife cannot afford to take an idealistic view of setting, or place of birth.  Regardless of how much we endorse homebirth as a safe and wonderful place for most women to give birth, we need flexibility for those who choose or who need care that is beyond the scope of midwifery.   The focus or centre of all midwifery care is the mother [woman+baby], and the midwife acts professionally to ensure the wellbeing and safety of her clients.   There is no simple guideline that can predict those who may need specialist medical obstetric or paediatric care - the flexibility of the model must support access to emergency obstetric services when and if indicated.

In bringing this post to a conclusion, I want to stress the importance of access to appropriately staffed and equipped hospitals for all women in their childbearing, and for all midwives who are suitably credentialled to provide professional services. 

The relationship between independent midwives and public hospitals needs a lot of work.  Trust and respect are lacking.  The hospitals have learnt to trust other health professionals who are not directly employed by the hospital - doctors, dentists, physiotherapists, pharmacists, and many others.  There should be no difference for midwives.

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