A new vision for maternity care

ARM 2013 - click to enlarge

The mother-midwife relationship:
"central to maternity care: the midwife caring for the mother and providing a safe space in which she can develop confidence in her own ability to give birth and mother her baby."  (ARM 2013, p3)





Last year, 2013, the UK Association for Radical Midwives (ARM) published its New Vision for Maternity Care.

The basic principles are copied in this post.  The Vision document is only 16 pages, and well worth the read.  In the Conclusion, ARM states:

"This is our New Vision for the maternity services of the future.  We wish to change the perceptions of the general public about birth and about midwives so that we can practise the profession for which we have been trained.  Organisational change and financial and educational input is needed to start the process.  Once women know other women who have experienced birth with continuity of care and real autonomy, whether at home or in hospital, this care will be expected.  This new standard of care will bring about improved clinical outcomes for mother and baby, substantial savings for the NHS and positive cultural change within maternity services and the wider public.  Babies whose mothers have a more confident start to motherhood will have a happier and healthier start to life.

Midwives are unique in their combination of skill, sensitivity and training to be 'with woman' through one of life's landmark experiences which has long-term effects on the individual, the family and society as a whole.  We must generate a new respect for both motherhood and midwifery.  We owe it to ourselves and to future generations."

human rights and childbirth

A number of Australian midwives and birth activists are watching with interest the campaign demanding human rights in childbirth, particularly in European countries where midwives may face criminal proceedings when they attend women for homebirth.

For information on this movement, and details of the next conference, click the hyperlink:

Birth Rights in the European Union: Mobilizing Change
Monday November 4th 2013
in Blankenberge, Belgium

Rights .... choices



The meaning of phrase 'human rights and childbirth' may be debated at length. Notions of individual freedom, fairness, equality, respect ... - such ideals are often at odds with what happens in the real world.

Human rights in the European Union should not be very different from those in resource-rich Australia, or developing countries such as Papua New Guinea where national maternal morbidity and mortality rates are among the highest in the world.  Yet the choices that are available for women in childbirth vary enormously from place to place, and between socio-economic groups, as variable as differences in outcomes.

What are the intrinsic *rights* of any (human) woman in her childbirth experience?

Let's consider this question: Does a woman have the right to demand the type of birth she considers best?   

Does a woman have a *right* to a birth that requires expert medical, midwifery, and nursing services, and a host of related ancillary services, in order to achieve her chosen birth: induction of labour, regional anaesthesia (spinal/epidural), or even elective caesarean?  I am not asking if a woman can access these elements of her choice - ability and right are two different matters.  And many readers may claim that it's easier in Australia today to access elective caesarean on demand than to access a maternity service that has a good track record with spontaneous, unmedicated, (garden-variety-natural) birth.

I would suggest that there is no human rights imperative in medically managed birth.  In modern maternity services there are professional/legal duties of care, to help and not to harm, but the access to surgical intervention or medical treatment is limited by factors such as availability of the necessary resources, and professional willingness to support the woman's individual choice. 


Which brings me to the other side of the question, Does a woman have the right to demand the type of birth she considers best?

Does a woman have a *right* to a birth that avoids medical intervention and optimises her chance of working in harmony with natural physiological processes?

Not really.  Perhaps there is more of a right in this situation than in the former, because the woman is the only person able to give birth spontaneously, and she does have the right to refuse any 'help'.  But in essence the woman's ability to proceed along the natural pathway, and give birth to a healthy baby without complication, is not about human rights.  It's about a finely tuned process that relies on physical, hormonal and emotional elements that can be either supported and protected by those who are with the labouring woman, or terribly messed up, to the detriment of the mother and her baby.  Even if 95% of women who received optimal support and care (whatever that looks like) through their childbearing experience were able to proceed naturally and spontaneously to great births, the other 5% of women who wanted natural births would miss out.  It's not a right unless it can be applied to all.

Effective maternity services are ones that provide the 'best practice' options for all women, placing the individual woman at the centre of the package of care that is available for her.  In most cases, it is not possible to plan or choose the outcomes.  Careful decision making throughout the journey enables the woman to access the best care, and thereby expect the best outcomes. 


Decision-making

Decision making is a process that constantly evolves as we move through a childbearing episode.  The trump card that a woman has is 'Plan A' - her capacity to do it without assistance or education or coaching or therapies or any outside help*. But it's the fine line between Plan A and Plan B, when intervention is likely to lead to better outcomes - that may call for expert and timely professional action.

There are times when the best option is not clear, when doing one thing may avoid one potential risk, but for some increase another.  This question of risk-utility analysis in decisions around childbirth is huge, and will, I hope, continue to occupy the minds of each generation of mothers and their professional care providers (whoever they are) for as long as childbearing continues.

I fought/aggitated for the rights of women to have their husband/partner present in hospital births in the early 1970s. I gave birth to my fourth child in a birth centre in 1980 - my personal statement of ownership of my birthing potential, and moving out of medicalised childbirth. I mention this because I have seen and experienced the changes in maternity care over 40 years in 2 continents, and am now nearing the end of my period of usefulness as a midwife.

The physiology of the birthing process requires a woman to minimise the activity of her neocortex - her thinking brain - and work with her intuitive brain as she progresses towards the climax of giving birth. This is where the authentic midwife is able to be guardian of the space, so that the woman is free to do the primal, hormonally driven (rather than intellectually driven) work of giving birth. The reality in my mind is that this is not a matter of empowerment or conscious choice - or of any sort of legal *rights*.

A woman's body will do the work of birth if it can, whether she likes it or not, because we are wonderfully made.  On the other hand, decisions about interventions which are designed to protect the wellbeing of mother and/or baby, when obstetric complications arise, are influenced by wealth and availability of /funding for maternity services.


*Note that I am not advocating for 'free' birth: Giving birth under 'Plan A' is an option regardless of place of birth or professional services available.  A woman can give birth without assistance or education or coaching or therapies or any outside help in the care of a midwife, a doctor, a hospital or any other service.

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 http://www.acn.edu.au/sites/default/files/nahsss_continuing_professional_development.pdf).

'free birth'

Birth is, and probably always will be, a contested territory.

An unknown number of women have made the choice to 'free birth': to give birth without professional attendance.  This phenomenon is happening in Australian communities, at the same time as the independent/homebirth midwifery profession is undergoing increasingly demanding levels of regulation from statutory bodies and by way of professional expectations set by our peers. 

While any competent individual has autonomy for their own actions and their own bodies, the issue becomes more complex when that body is a woman's body, which is carrying an unborn child.  And although courts in various countries have upheld the right of a woman to refuse, for example, caesarean surgery that is intended to protect the life of the child, there are many subtle forces that direct a woman in to compliance with social norms.  

Why 'free birth'?
... access? 
Women who proceed with a plan for 'free birth' are not necessarily unable to access a midwife privately to attend homebirth, although this is sometimes the case. 
... cost?
the cost of private midwifery services for homebirth may be prohibitive.
... belief?
the woman who has formed a strong belief that the presence of any qualified person (ie midwife) will inhibit her ability to proceed naturally with birth, considers that she is better off without any professional attendant.
... objection?
A woman may object to some practice, such as listening to the fetal heart sounds, that a midwife may consider to be a basic requirement for safe practice.
... substitution?
an unregulated birth attendant may be willing to act in supporting the woman, and guiding her through her birth, effectively substituting for the midwife.

Whatever the reason, each woman / each situation, is unique.

Here is a hypothetical example.

Ms A and her partner have had two children previously.  Baby #1 was born in hospital, after a long and painful labour, in which Ms A had augmentation of labour, an epidural, and a forceps birth. 

Ms A felt traumatised after that birth, and in her second pregnancy decided that she wanted homebirth.  The midwives who attended her in labour were unhappy with her progress, and recommended that she transfer in labour to hospital.  Baby #2 was born in hospital: a big baby; and another difficult birth. 

Ms A reflected on her experience, and believed that the midwives were fearful, and that she would have been better off without them.  She therefore chose 'free birth' for her third child, and invited two friends who worked as doulas to be with her to support her for the birth.

Ms A's complex process in choosing 'free birth' included her belief that the presence of midwives for baby #2 had inhibited her progress, and the availability of a substitute for professional attendants.

In recording this hypothetical example, I would like to be very clear that I understand that Ms A made choices and decisions that she believed would be in the best interests of herself and her baby. 


The issue of 'free birth' was addressed in a Victorian ABC TV story 7.30 report last Friday.

Several of the people interviewed for this story were asked if they supported the recent recommendation by the South Australian Coroner that it should be an offense for a person to attend birth without having the qualification of midwife or doctor.  The response from Hannah Dahlen, on behalf of the Australian College of Midwives, included a statement that the answer to 'free birth' is not to be found in cracking down, to 'exterminate' its practitioners, as it will only be driven underground.

I concur with this.  Although the events that led to the recommendation by the SA Deputy State Coroner are tragic, I do not consider that legislation to protect midwifery practice in South Australia would or could achieve the desired aim of improved public safety.

The choice that some women make, to give birth to their babies at home, takes into account individual social preferences and reasons. Since birth at home is the outcome of a spontaneous physiological natural process, there is no legislation that can control who a woman consults in pregnancy, or who is with, or not with, a woman who is labouring or giving birth spontaneously.

A woman’s right to self-determination in making decisions such as where she gives birth, and with whom, will not be controlled or altered by legislation designed to protect midwifery practice.

It is my belief that the government’s support for the regulated midwifery profession, with funding for homebirth programs, protection of the full scope of private midwifery practice including hospital visiting access, and education for the public in maternity choices, will result in greater protection of public interest than the proposal to protect midwifery practice.

Joy Johnston

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.


ps
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.