NEWSLETTER August 2012

Midwife or support person? 
Joy Johnston

An opinion, for discussion.

When a midwife walks into a hospital with a woman for whom she is providing private midwifery services, that midwife may face a complex and often challenging work environment.

Recently I went to hospital with a woman who I will call Melissa, who was planning vaginal birth after a previous caesarean (VBAC). Melissa's first child had been delivered by emergency caesarean. This time Melissa was well informed, and intentional about all her decisions. Melissa called me when her labour became established, and I went with her as she was admitted to the hospital birth suite. Melissa laboured strongly, and together we considered any decisions that needed to be made.

There is nothing remarkable about this little account. However, the matter that has prompted me to write about hospitals and independent midwives is the question of what to call a midwife who goes to hospital with a woman in her care.

I call that midwife a midwife.

Others call that midwife a 'support person', or a 'birth support person', or even 'only support'!

Why?

Because the independent midwife does not have visiting access/ clinical privileges/ credentialling in that hospital.

This is true - maternity hospitals around the country have dragged their feet on this matter. Despite government-supported indemnity insurance for private midwives providing intrapartum care in hospital, there is no likelihood for most midwives of hospital visiting access in the near future.

So the question is, does a midwife cease to be a midwife, just because the hospital refuses to recognise her professionally? Of course not! A midwife is 'with woman': not with a setting for birth. The midwife's registration is with the regulatory body, which is not under the management of the hospital. And, let's remember that if a midwife acted in a way that was considered unprofessional, she or he would expect to be reported to the regulatory authority as a midwife, not as a 'support person'.

The ICM definition of the Midwife declares that the midwife's Scope of Practice is:

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. 

'Support' is listed in the definition as one of the elements of midwifery. I do not want to seem to devalue support. But the point I want to make is that support is a part of the midwife's scope of practice: not an alternative to midwifery practice, and definitely not an alternative to the title 'midwife'.

 Research: Caseload midwifery 
Midwifery academics from LaTrobe University in Melbourne have published results of the COSMOS trial, which has been undertaken at the Women’s Hospital with funding from National Health and Medical Research Council (NHMRC). The paper, Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial has been published in BJOG, a prestigious international journal of obstetrics and gynaecology, by Helen McLachlan, Della Forster, Mary-Ann Davey, and others.

The research demonstrated that, besides having fewer caesareans, women allocated to 'caseload' arm of the trial were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care. In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

Midwives and maternity services must be challenged to apply the evidence to practice. The usual practise of midwifery should be in a caseload model, enabling midwives to work autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A'). Not as shiftworker nurses who work as assistants to obstetricians in hospitals. Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.


Invitation to midwives to join APMA 
Membership is open to all current private midwives, midwives with previous experience in private midwifery who wish to remain informed, and midwifery students who wish to enter private practice after completion of their studies. www.privatemidwives.com.au/#!membership
Membership fees 
full membership $80
student or non-earning members $40.

Yahoo! Groups – members who would like to join one o0r both of our ‘groups’: ‘privatemidwives’, and ‘apma_medicare’, please contact joy@aitex.com.au

totally flawed research

Listed as a top article in today's Age, readers are confronted with the question: 'Caesarean births a better option for mothers? ' The article tells us that "Dr Stephen Robson, an associate professor of obstetrics at Australian National University, is recruiting 1000 pregnant women to test the long-held view that vaginal deliveries are better than caesareans for healthy women with uncomplicated pregnancies."

This 'study' requires well women who are expecting their first child, of whom 500 choose a caesarean (for no medical reason) and 500 plan a vaginal birth, and will look at "psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates."

"Good luck!" I say. Good luck to the mothers and babies - they will need it.

This research is not good science - whatever results are achieved will not come anywhere near testing the safety of vaginal vs surgical births for healthy women with uncomplicated pregnancies.

What sort of ethics committee would give approval to this research? Anyone who has studied basic health science will know that the numbers in this study are so small that confounding variables will make the data useless.

Of the 500 women planning vaginal birth, assuming that they are standard pregnant women who receive standard maternity care, at least 30%, and possibly up to 50% will experience a Caesarean birth. That leaves the vaginal birth cohort of 250-350. Many of these women will receive powerful narcotic drugs either by injection or epidural; drugs that are kept locked up in the 'dangerous drugs' cupboard. A considerable number of the 'vaginal birth' cohort will have their labours stimulated artificially with synthetic prostaglandins and oxytocin; and many will be 'assisted' to give birth by obstetricians wielding forceps or ventouse caps. All of these interventions carry potentials for harm to the mothers and babies, with a potential to influence depression and breastfeeding rates.

Of the 500 women planning elective pre-labour Caesarean, there will be other variables. A few may even labour spontaneously and quickly, and give birth vaginally! A considerable number of the surgically delivered babies will experience difficulties with breathing, and require special care for the first day or so. A few of these babies may be very ill.

A few mothers in the elective Caesarean cohort will develop wound infection, and many will develop internal adhesions that may complicate future births. A few may experience serious iatrogenic complications of the surgery, including accidental surgical damage to uterus, bladder, ureters, or bowel; drug administration errors; harm resulting from spinal anaesthesia; and haemorrhage. Subesquent pregnancies for these women also bring the potential for abnormal placenta formation, with placenta accreta and percreta placing a woman at great risk of serious haemorrhage requiring urgent hysterectomy as a life-saving measure.

In 1996, World Health Organisation made the profound statement that "In normal birth there should be a valid reason to interfere with the natural process." (in Care in Normal Birth: a practical guide, p4)  It's a no-brainer.

Today, Australian women are being enlisted into research that pretends to address the question of which is better, vaginal birth or abdominal surgery. It's a stupid question. If the safety of vaginal birth for the primigravid well woman is considered anywhere near the risk of a Caesarean, it's an indigtment on what happens to women planning vaginal birth.   The researchers need to find ways to protect and promote the natural processes in birth, while reserving surgical intervention for those who have a 'valid reason'.

I hope there are midwives and doctors whose critical thinking alarm bells start sounding when they are asked to enlist women in this study, and I hope the women who are approached tell the researchers what they can do with their trial.

This is a personal opinion, and is not a policy statement for Australian Private Midwives Association.

Your comments are welcome.