Maternity Services Turf Wars

Justine Caines has written a Croakey blog 'Maternity Services Turf Wars have not helped women'.
While agreeing with the main points in the essay, I have posted a comment in which I argue that there is no turf war.

Joy Johnston
Monday, 29 September 2008 3:12:44 PM
We all refer to it as a *turf war*, but really, there is no war. Many years of health policy from both parties, and a submissive attitude from generations of Aussie mothers have put maternity services into the capable and trustworthy hands of the medical profession. Almost totally.

If it really was a turf war, there would have to be 2 sides battling it out. Obstetricians and midwives, you say. We do see the odd little skirmish between a midwife and an organisation representing obstetricians, or the medical association, but it's like the ant standing on the elephant's toe.

If there really was a turf war, there would have to be something that you could call 'turf' - a playing field of sorts. The pregnant woman? That's a finite number of people, for a particular period of time - should be the sort of sums that the public health bean counters are very happy with. But maternity care in this country is not provided as a package based on the individual woman/pregnancy. It's provided on Medicare schedules, each for fragments of the whole care, and state government funding arrangements with hospitals. The individual woman is not really part of the equation. Medicare excludes midwives because they aren't doctors. Hospitals employ midwives, but once again, to provide fragments of care.

Midwives who work privately with individual women are not able to provide that service in hospitals, as we don't have visiting access, or insurance. We can provide it in the home, and the woman can pay. We have become experts in home birth. Our care includes health promotion in pregnancy, protection of normal birth, protection and support of breastfeeding and bonding and early nurture. If a complication requiring medical attention arises we arrange a referral and collaborate with those who are expert in complicated birth. It's win-win.

But it has nothing to do with a turf war. The care is provided outside the 'system' - on the woman's and the midwife's own turf.

Gloria Lemay

Here's the blog for childbirth activist Gloria Lemay http://www.glorialemay.com/blog/
Gloria has been a prominent activist for normal birth in Canada for many years. Glria is a contributing editor of Midwifery Today Magazine, an Advisory Board member of the International Cesarean Awareness Network (ICAN).

High caesarean rates in this country

I heard the Life Matters Maternity Teamwork interview of Dr Jolyon Ford, one of the keynote speakers at the ACM 'Breathing new life' conference (see next page in this blog). He had a lot to say about emergency obstetrics. I was disappointed with the interview, as the focus ignored the real issue in maternity care, and in reducing rates of caesarean, which is promoting normal birth.

The focus was on older, fatter mothers failing to progress, and distressed babies, and taking scalp blood samples from the babies. The age or size of a mother is not a clear predictor of her outcomes in childbirth. We have evidence that inductions of labour increase the likelihood of caesareans; we know that augmenting labour with oxytocics can cause distress in the baby; we know that continuity of midwife carer reduces a woman's likelihood of requesting dangerous drugs to deal with the pain of labour.

It may interest readers to know that in Victoria 37% of the mothers who gave birth at home in 2006 (the most recent published record) were aged 35 or over - a percentage slightly higher than the private hospital rate (36.3%) and considerably higher than the public hospital rate (19.2%). Giving birth at home means no inductions or augmentations, and no dangerous drugs or epidurals - they do it themselves. Bravo to the older women giving birth!
Joy Johnston

(a version of this comment appears on the guestbook of the Life Matters program)

Time to normalise birth in the 21st century

Press release from Australian College of Midwives

Breathing New Life into Maternity Care Conference
(Gold Coast, Holiday Inn, September 18th-20th 2008)

A multidisciplinary conference – Breathing New Life into Maternity Care – will bring together maternity care providers and consumers to discuss ways in which to reduce the skyrocketing caesarean section rate and improve care for women, their babies and families.

“This comes hot on the heels of the Commonwealth discussion paper on Improving Maternity Services in Australia and the Primary Maternity Services in Australia Framework”, said Professor Brodie, President of the Australian College of Midwives. “It gives us a wonderful opportunity in this country to put women at the centre of our maternity service planning and to collaborate with each other to achieve this end.”

Dr Andrew Kotaska, a Clinical Director of Obstetrics and Gynaecology in Canada and a keynote speaker at the conference, has called for “normalising birth in the 21st Century”. He said, “with skyrocketing rates of intervention during birth in modern industrialized countries we need a clear definition of normal birth. To empower women and caregivers to embrace normal birth will require a critical examination of our overestimation of common obstetrical risks and our risk-based culture in general. Current caesarean section rates of 30% are not justified to ensure safety and can be reduced.”

Henci Gore another keynote speaker at the conference and author of the widely acclaimed books The Thinking Woman’s Guide to a Better Birth and Obstetric Myths Versus Research Realities said, "It isn't a matter of figuring out what approach and practices produce safe, effective, satisfying, and cost-effective maternity care. We already know. Every group everywhere that has ever come together to make this determination has come up with essentially the same recommendations. The time has come for the government and health care providers to live up to their obligation to the childbearing women.”

Melissa Fox, Vice-President of Maternity Coalition, Australia’s umbrella maternity consumer organisation said, “mums and babies deserve the best start to life. This is the foundation for future health. Strong babies and Mums mean stronger families and healthier communities. Governments and carers need to re-orient maternity services, keeping mothers and families at the centre. We believe the best way to ensure this is to have consumers making decisions alongside care providers to make strong and effective policy and new models of care where there is collaboration and respect between all.”

Professor Brodie said, “With over 250 midwives, doctors, consumers and policy makers in one room, this conference is set to be one of the most exciting and powerful events we have seen in over a decade of maternity care. The key to the future is effective relationships between the health professionals and systems that support the skills of the health professionals in a networked seamless environment that is so important for the provision of safe, satisfying care.”

Contact:
Media Spokesperson, Australian College of Midwives, Assoc Professor Hannah Dahlen 0407 643 943.
President, Australian College of Midwives, Professor Pat Brodie 0417 544 824.
Executive Officer, Australian College of Midwives, Dr Barbara Vernon 0438 855 529.

Questions for Maternity Services Review

The following questions have been posed by the Maternity Services Review, in the Discussion Paper from the Australian Government, Improving Maternity Services in Australia. Responses need to be submitted by 31st October 2008.
MiPP members are preparing a written response, and we would appreciate any comments from our blog readers. Please use the 'comments' function of the blog, or contact us by email. You are also encouraged to send your own responses, so that your voice counts in this review.

QUESTIONS:
(see Discussion Paper for more information)

• What models for maternity services for rural and remote communities are working well?
• What are the key elements to applying such models more broadly?
• What aspects of the Australian context are driving high intervention rates?
• What actions are required to address this?
• What, if any, are key support services, including peer support which warrant national coverage?
• What is required to ensure the quality and consistency of key support services?
• How is current Commonwealth funding targeted?
• What are the key professional development needs for the maternity workforce?
• How will models of workforce support vary in rural and urban settings?
• What are the potential areas for change to expand midwife-led care across antenatal, birthing and postnatal services?
• What are the existing effective models for midwife-led maternity services?
• What are the key workforce barriers to integrated models of care?
• What key infrastructure is needed?
• Are there any other issues the Review should consider?
  

From Carolyn Hastie

I've created a mind movie visualisation tool for pregnant women. I would love to have your feedback about it.

http://au.youtube.com/watch?v=uHdP_sATb-s

It is a great way to get important information out there to women. One woman has commented

"that was very nice. I made my decision not to have kids when I was a young teenager when I found out about the pain of birthing. If I had something like this back then my decision may have been different."

If you can comment and rate the video on YouTube, that would be fantastic.

For those of you who don't know me, I'm a midwife manager of a stand alone birth centre/service at Belmont, NSW Australia. We just won the 'best health care unit' at the Quality Awards last Thursday. We have been in operation for 3 years and our statistics are fantastic!

best wishes, Carolyn Hastie

"Gratitude is not only the greatest of virtues, it is the parent of all the others"
Cicero

A midwife's struggle

A midwife who has ceased her private practice wrote this letter, which is shared on this blog with the writer's permission:
"I have been wanting to become more involved but have absolutely no energy, can't even think very straight at present and consider that I am in some part burnt out, whether by life in general, or the experience of my foray into homebirth or both - I really don't know. I believe very strongly though that I will recover and have the energy and passion once again to be a force for women, babies and families. At present, I ache with the pain of the daily abuses I see being condoned in the name of safety. I am getting along in the postnatal wards, and take some small measure of satisfaction from the response I have to being kind, compassionate and patient with the women that I see there.
"I feel I want to weep most of the time, but the reality is that I need to continue to provide for MY family and this is my profession. Sounds like martyrdom when I think about it, but I really do get a lot out of being able to let families know that it doesn't have to be this way and that they have rights."

This story is not unusual. Many midwives are longing to be part of a more humane, woman-centred midwifery care structure, but the realities of their lives and current maternity services are like a restrictive fence that they can see through but not pass through. I want to thank the midwives and others who are working to reform maternity care for all women. I would also like to honor and encourage the midwives who have given it a go, but not been able to find a place for their dream yet. Keep your dream. Keep your midwife identity. Be ready to be 'with woman' when the opportunity presents, even when that opportunity is a shift in the postnatal ward of a hospital in which 50% of the women are post caesarean.

Remember the Bible story of Noah and the great flood. We are told that after the rain had stopped and the waters began to recede, Noah sent first a raven, then a dove out of the ark, and they came back, not being able to find a place to nest. After seven days Noah sent the dove again, and it came back with a freshly plucked olive leaf. After another seven days Noah sent the dove a third time, and this time it did not return.
The midwife who tries to offer a better maternity service for women, and is unable to sustain it, is like the dove who returned with the sprig of the living olive tree. She can see the possibilities, but is not quite ready. The time will come when that dove leaves and is able to set up her own nest.
Joy Johnston

Meeting with Patrice

A recent meeting of MIPPs with Patrice Hickey, who is the Victorian President of the Australian College of Midwives

The following brief notes reflect some of the discussion at the meeting

• Midwives’ right to make a living. Note that national regulation of health professionals will be in place July 2010. This will bring a lot of change nationally, as well as to the regulatory bodies for each profession.
• Community midwifery. The 3 Tertiary units (Womens, Mercy, and Monash) are being progressively restricted in whose bookings they can take. Womens and Monash provide booking services for transfers from planned homebirth.
• PERS Perinatal Emergency Retrieval Service. Headed by Dr Jackie Smith. Discuss hospital options particularly when there is a possibility that newborn intensive care services will be required.
• ACM Midwifery Practice Review. Patrice encouraged all MIPPs to undergo the MPR on 3-yearly cycles, and for some to become reviewers. Meeting planned by ACM Thursday 2 October.
• Consultation. Independent midwives need to consult with hospital registrars and senior medical and midwifery staff. The ACM National Midwifery Guidelines are a guide, but are not able to be used in a prescriptive or punitive way.
• Federal government. Health Minister Nicola Roxon has established a maternity advisory committee.
• Nurses Board. ACM will seek assurance that the Board will engage with ACM when midwives are under investigation, and that a midwife with relevant experience will be part of any investigation or hearing into a midwife’s practice.
• Prescribing and Ordering for midwives. Qld health department is making progress in this area.
• Access to public maternity hospitals. All public hospitals are required to accept all patients for whom they are equipped to provide services. Women who are planning homebirth and need emergency admission to a local hospital should be admitted unbooked. Sunshine Hospital is happy to make homebirth backup bookings.
• Some midwives report that GPs refuse to order blood tests and investigations for women who plan homebirth. This is not acceptable.

Any unacceptable behaviour towards independent midwives or our clients by public hospitals, or by other health professionals, should be addressed in a professional manner. There is a lot of positive change in the system, and we need to move with it.

Maternity Services Review

From the Federal Government's announcement of the Maternity Services Review
The Review is the first step in developing a comprehensive plan for maternity services into the future.

The Review will:

o canvass a wide range of issues relevant to maternity services, including antenatal services, birthing options, postnatal services up to six weeks after birth, and peer and social support for women in the perinatal period;
o ensure that all interested parties have an opportunity to participate; and
o inform the development of a National Maternity Services Plan.

go to http://www.health.gov.au/maternityservicesreview

midwifery debate

The following responses were sent to the Editor of newspapers which published a small article 'Doctors Attack Midwives Proposal'

The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.

Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.

I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.

Joy Johnston
(most of this was published in Letters to the Editor 12 September)

Sirs

Dr Capolingua knows full well that the Maternity Services Review is not about homebirths but about increasing choices for women in maternity services.

In terms of her comments about the safety of homebirth, readers should be aware that last year the WA Health Dept commissioned a review of evidence relating to issues of maternity care. This review was carried out by the Women and Infant Research Foundation at King Edward Memorial Hospital in Perth. This review entitled: “Models of Maternity Care: A Review of the Evidence” 3 includes an Evidence Summary Point on page 16. The summary states:

“Planned homebirth with a qualified home birth practitioner is a safe alternative for women determined to be at low obstetric risk by established screening criteria.”

The WA Maternity Services Framework launched last year supports the provision of midwifery-led care for women in WA not only for homebirths but for women who choose to birth in hospital: which is what women in WA want. Support for this at a Federal level is to be welcomed.

Reform in maternity services in Australia is urgently required and, at last, both State and Federal governments have woken up to the fact.

For the sake of women and their families could the AMA not work collaboratively with the government, midwives and consumers to provide maternity services that work rather than seeking to protect their patch?

Debbie Slater

Perth, WA

It is to be expected that the AMA as a medical trade union would attack any discussion on midwives’ roles in the health system (Doctors Attack Midwives Proposal September 11th). We must, however, challenge the inaccuracies used in their response.

Firstly, the Maternity Services Review is not about homebirth but about facilitating women's choice in a safe, informed environment. The majority of women will have their babies in hospital and the majority of midwives will work in hospitals.

Secondly, the rhetoric about doctors needing to 'supervise' midwives is unhelpful. We need to all work together as respectful professionals, knowing when and where to access the expertise of the other.

Thirdly, the current model does not work well, as is asserted by the AMA, when we have: unacceptable outcomes for Indigenous mothers and babies; high rates of unnecessary medical intervention; lack of access to continuity of care by midwives despite evidence supporting its benefits, safety and cost effectiveness; lack of postnatal care; closure of around 120 rural maternity services in the past 10 years; a midwifery workforce shortage (1,800) due to workplace stress and lack of opportunities; rising birth costs affecting government, insurance funds and women; low rates of breastfeeding at six months (34%); increasing rates of perinatal depression and maternal suicide; lack of insurance for midwives.

Finally, it is time to stop the war and start working together to address these issues. It can no longer be about ‘us’ it must be about women.

Dr Hannah Dahlen

Spokesperson for the Australian College of Midwives

Midwifery debate

The following responses were sent to the Editor of newspapers which published a small article 'Doctors Attack Midwives Proposal'


The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.

Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.

I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.

Joy Johnston

It is to be expected that the AMA as a medical trade union would attack any discussion on midwives’ roles in the health system (Doctors Attack Midwives Proposal September 11th). We must, however, challenge the inaccuracies used in their response.

Firstly, the Maternity Services Review is not about homebirth but about facilitating women's choice in a safe, informed environment. The majority of women will have their babies in hospital and the majority of midwives will work in hospitals.

Secondly, the rhetoric about doctors needing to 'supervise' midwives is unhelpful. We need to all work together as respectful professionals, knowing when and where to access the expertise of the other.

Thirdly, the current model does not work well, as is asserted by the AMA, when we have: unacceptable outcomes for Indigenous mothers and babies; high rates of unnecessary medical intervention; lack of access to continuity of care by midwives despite evidence supporting its benefits, safety and cost effectiveness; lack of postnatal care; closure of around 120 rural maternity services in the past 10 years; a midwifery workforce shortage (1,800) due to workplace stress and lack of opportunities; rising birth costs affecting government, insurance funds and women; low rates of breastfeeding at six months (34%); increasing rates of perinatal depression and maternal suicide; lack of insurance for midwives.

Finally, it is time to stop the war and start working together to address these issues. It can no longer be about ‘us’ it must be about women.

Dr Hannah Dahlen

Spokesperson for the Australian College of Midwives


Sirs

Dr Capolingua knows full well that the Maternity Services Review is not about homebirths but about increasing choices for women in maternity services.

In terms of her comments about the safety of homebirth, readers should be aware that last year the WA Health Dept commissioned a review of evidence relating to issues of maternity care. This review was carried out by the Women and Infant Research Foundation at King Edward Memorial Hospital in Perth. This review entitled: “Models of Maternity Care: A Review of the Evidence” 3 includes an Evidence Summary Point on page 16. The summary states:

“Planned homebirth with a qualified home birth practitioner is a safe alternative for women determined to be at low obstetric risk by established screening criteria.”

The WA Maternity Services Framework launched last year supports the provision of midwifery-led care for women in WA not only for homebirths but for women who choose to birth in hospital: which is what women in WA want. Support for this at a Federal level is to be welcomed.

Reform in maternity services in Australia is urgently required and, at last, both State and Federal governments have woken up to the fact.

For the sake of women and their families could the AMA not work collaboratively with the government, midwives and consumers to provide maternity services that work rather than seeking to protect their patch?

Debbie Slater

Perth, WA

VBAC

Due the absolute epidemic of C/S performed in the last decade I feel there are more & more women seeking VBAC and wanting to do it at home (for obvious reasons).

According to The Australian College of Midwives www.midwives.org.au/
Women with a scar on their uterus are not considered low risk & are therefore not within the scope of practice for a caseload/homebirth midwife. They are flagged 'C' for consultation or transfer of care!
However so are women who are grande multis, women with psych disorders & 'failure of head to engage at full term' yet I attend them at home.
Still.....................ACMI are our guiding body.

I'm really struggling with this right now. I am getting increasing requests for H/B VBACs.
I'm perfectly comfortable with the process of labour with a scar.
Good surgery should be sound when healed shouldn't it ?
I don't hear anyone telling athletes not to compete with their reconstructed knees/ankles/shoulders etc do you ?

What do you all think ?
Am I the only one struggling with this ?
I'd appreciate your viewpoints.

Brenda Manning