AMA position statement on Maternal decision-making

Maternal Decision-Making - 2013

Source: Australian Medical Association (AMA) 28/03/2013

1. A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.
   
2. A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.
3. Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies. ...

[Please click here to read the 10 points of the position statement.]

Position Statements often seem dry and meticulous, but they actually carry considerable weight.  It may seem strange that the AMA feels the need to declare that a competent woman has the right to make her own decisions - isn't that generally understood?

An article by Health Reporter, Melissa Davey, in today's Sydney Morning Herald newspaper noted the new Position Statement, and observed that "Previously, more emphasis was placed on on how maternal behaviours may damage a foetus, rather than the autonomy of a woman's decision."

[Read more: http://www.smh.com.au/national/health/trauma-pushes-mothers-to-home-birth-20130420-2i6wu.html#ixzz2R4VWeejx

In other words, in the past doctors were expected to take action that 'prevented' mothers from making foolish decisions, that may have led to adverse outcomes for their babies.  It's called 'shroud waving', and it usually works.


More discussion at villagemidwife.

Letter to the Sunday Age

[In response to the front page article, 'Patient power troubles GPs', Sunday Age, 30/12/12]

I find it troubling that some doctors are not happy with the concept of independent experts who support a patient’s decision making in medical care. 

The statements by Dr Hambleton of the AMA suggest that he is attempting to protect the old ‘doctor knows best’ position of privilege in our society – perhaps that’s part of his job description?

I also take exception to Dr Hambleton’s questioning of “the need for private midwives to be escorting women during hospital births.”

I am one of those private midwives, and I would like to explain briefly why I provide primary maternity care, and attend birth, whether it occurs in hospital or the woman’s home.   

A midwife’s unique skill is the ability to work in harmony with the natural processes through pregnancy, birth, and the postnatal period.  Birth is not an illness.  The midwife’s duty includes promoting health, supporting wellness, and protecting the woman’s ability to do the work of bearing and nurturing her children.  Only when and if complications or illness are present does the midwife need to collaborate with medical and/or hospital systems, and only then with the woman’s informed consent.  Most women trust the midwife’s guidance, but there are grey areas in maternity care, just as there are in the world of GP doctors. 

The planned setting for birth is not set in concrete.  Many women who plan hospital births experience the ‘coming ready or not’ baby who arrives in all sorts of places, including the bathroom at home, the back seat of the family car, or the hospital carpark or lift.  Some women who plan homebirth need to change their plan and move to hospital, for all sorts of reasons.   

Midwives who practise privately, independent of the hospital system, are able to offer personal continuity throughout the episode of care and be with the woman in labour wherever she is.  Privately employed midwives seek to establish a partnership with each woman in our care, at a level that simply cannot be achieved without significant investment of time prior to the birth.  Privately employed midwives offer a distinct professional care package to each woman.  The women who employ us usually intend to give birth spontaneously,  without relying on medical pain management strategies, or artificial augmentation of the birth process, unless there is a valid reason at the time for such a decision to be made.

When private midwives ‘escort’ women to hospital, we have usually provided significant professional services for that woman through the prenatal period.  Several Medicare items give rebate for services such as the initial consultation, long or short antenatal checks, and the development of an individual maternity care plan.  The woman may have laboured at home, in the care of her private midwife, prior to traveling to hospital.  The woman knows her private midwife’s voice, and touch, and is able to be confident within the care plan.  The care plan includes the ongoing process of  informed decision making, with the wellbeing and safety of mother and child being the guiding principle. 

Postnatally the private midwife continues to provide expert professional services, within the primary maternity care relationship.  Postnatal Medicare items are available until the seventh week after the birth.

Dr Hambleton’s attempt to trivialise the private midwife’s role as “so someone can hold their hand” is offensive to me.  If I hold the hand of a labouring woman, it is a significant act of professional support for which that woman has employed me.

Joy Johnston

25 Eley Rd, Blackburn South Vic 3130

03 9808 9614

http://villagemidwife.blogspot.com.au/

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.