January 13, 2003

Independent midwifery

Had dinner last night with two good friends who are independent midwives. The conversation roamed around births (as you would expect!) and eventually we came to the hassles that they encountered when transferring women to hospital. So often independent midwives are met with hostility and suspicion when they need to transfer a woman during a birth, sometimes in ways that could jeopardise the labouring woman (for example, when the receiving midwife or doctor disputes the diagnosis made by the independent midwife, resulting in unnecessary delay).

I guess many of us feel a bit intimidated when we are confronted by a professional who is obviously competent, in charge of the situation and willing to take responsibility, especially if we are feeling a bit unsure of our own skills in some way. Many of the attempts to restrict the scope of practice of these midwives probably stems from feelings of inadequacy by those who feel they should be in control, or who feel that their territory is being threatened by an “interloper”.

If the NSW Government grasps the nettle and decides to introduce models of midwifery care that will enable and support home birth options (amongst other innovative schemes), they will need willing midwives to take up the challenges of providing the necessary services. If these new schemes come at a price of curtailing the autonomous practice that has been the hallmark of the independent midwives, then I think few will want to be a part of the new ways of working, and may leave the field rather than subject themselves to restrictions on their work. My friends were certainly of this view. If anyone tried to impose guidelines or limits on the services they could offer women, they would rather leave midwifery than submit. This is even if the Government offers to cover their professional indemnity insurance as part of the bargain.

I hope that some equitable system can be hammered out that leaves everyone a winner. Many women want to do their own thing with birth and engaging an independent midwife is the only possible way of achieving this without hassles. Hospital based midwives need the strong example of home births to remind them of the beauty of birth as well as its normality. Fear and vested interests are again likely to prevail when it comes to Government decision making - unless we can be sensible about this there is a risk that we will lose some of our best examples of midwifery practice in this country. This must not happen!

Posted by andrea at January 13, 2003 03:48 PM

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OK I am going to be daring, and it is a little scary but oh well. I want to know what is wrong with guidelines and how they would restrict autonomous, independent practice? It is my understanding that most if not all professions have guidelines, procedures, and protocols that members of the profession have argued about, discussed and come to consensus on. As part of my education at Seattle Midwifery School (described by some here as a "feral school") during our Professional Issues Courses we looked at guidelines to independent practice in the USA, Canada, New Zealand, The Netherlands and Great Britain. The guidelines vary but there is a lot of commonality. Also not every individual midwife follows the guidelines. It was difficult to find such guidelines for Australia, is this because they don't exist? Before we graduated we were required to produce our own guidelines, procedures and protocols manuals for our independent practice. It was understood that if we went to work for somebody else then these would critical to our decision making process regarding accepting a position.

In the current litigious environment, the state government has had to underwrite professional indemnity insurance for independent licensed midwives in the state of Washington. In the process midwives there have PI if or when they practice within certain guidelines, midwives who accept clients outside of those guidelines are not covered for those clients. The state of Washington is rather unique in the USA in that it funds public health care for pregnant women and their families with the provider of their choice regardless of income. And so the state funds homebirths.

It seems to me that it is undeniable that homebirth is the safest birthing option for low risk women and their babies. The issue comes down to who decides who is a low risk client and thus a candidate for homebirth? Obviously it should be the primary stakeholders: the woman, her family and her midwife, however I do believe there are other stakeholders and they may include other midwives (ACMI?), perhaps other health care professionals, health insurance companies, indemnity insurance companies, employers or contractors of the midwives, and midwifery clients. I have probably left some group out or included a group others feel strongly about not including, I personally have no vested interest in who to include, I am just trying to think of all who could be affected (stakeholoders).

It bothers me that homebirth is only available to a select few in Australia and yet could quite possibly be available to the vast majority of women if we could agree on guidelines for risk assessment. And yes, I know this is a can of worms, but maybe we need to look at the worms.

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