Infomidwife

Collaborative Maternity Care Agreement - give your feedback

2012-02-09T08:33:00.002+08:00

RANZCOG has developed a template for Collaborative Maternity Care Agreement between Eligible Midwife and Specialist Obstetrician or General Practice Obstetrician for use by Specialist Obstetricians or GP Obstetricians and Eligible Midwives.

It is very important to give your Feedback.
It is acknowledged that the template agreement will not be suitable for all settings and that not all Obstetricians will wish to enter into a collaborative arrangement, but all comments will be considered.RANZCOG

Please send feedback to Rupert Sherwood by email to ganderson@ranzcog.edu.au or by fax to +61 3 9419 0672.

Sending your response is important, this is how your voice and numbers count, please be proactive, read the document in its entirety... and give your feedback.

Born Alive Rule - is it time to rethink

2012-02-08T21:47:00.021+08:00

A few seconds after birth:

There is much debate over recent months regarding this issue; traditionally in Australia and some other countries a fetus has no rights until “Born Alive”, otherwise considered the “Born Alive Rule”. This rule has been around since the 17th century, at this time viability was considered when the woman could feel the fetus this was generally known as “the quickening”. It is now the 21st century technology is advancing at great speed, ultrasound is very definitive, there is no question now about the viability of a term fetus, is it time to reconsider the rights of the term fetus. An embryo is usually from fertilization, early stages of growth and then a fetus from 12 weeks of pregnancy; The definition of a term fetus is when it is considered that the fetus can survive outside the uterus without any assistance this happens from 37 weeks - 40 weeks. Once born most people refer to the infant as a baby.

When considering the question of fetal rights it is important to consider what is considered a human being? Is the fetus a human being? What or who is a person? Can the fetus survive outside the woman’s body? These questions raise many ethical questions: My masters 10yrs ago was, is it time to re think fetal rights, and I concluded then that a woman’s autonomy was sacrosanct. 10 yrs on I think it is time to open Pandora’s box and debate the issue again.

The born alive rule can be viewed from several perspectives; women - pregnancy – domestic violence – violence against pregnant women – criminal responsibility. I am going to view several circumstances; This blog is not a judgement of anyone, I am expressing a point of view to illicit debate on the issue of does a ‘term fetus’ need rights:

A recent case in WA, Matthew Silvestro who had a history of domestic violence was found guilty of causing grievous bodily harm when he drove his car into another car, causing his pregnant partner Vanessa De Bari serious harm (she spent 8mths in hospital recovering from injuries) including the death of her 8 month fetus. His sentence was a two year driving suspension and $8000.00 fine to which he pleaded he was unemployed and unable to pay this fine he ordered to pay costs of $119.20

South Australia’s coroner has been conducting an inquest into several homebirth deaths of term fetus’s. The issue of “sign of life” and the “Born Alive Rule” has been bought into question and debated. Another issue that has been debated during the SA coronal inquiry is the decision to have a home birth, particularly because it involved twins a higher risk – and that no backup plan was made. One twin was born alive at home and the second suffered brain damage and died later. This is not a judgement, this is about questioning what is a human life? And does a fetus have a right to life? Do we have the right to dictate by our actions whether a term fetus lives or dies? It is time to debate this question further.
Dr McCaul said at the SA coronial inquiry:
"I had a strong sinking feeling because I felt she strongly still wanted to go ahead with a home birth," she said.
"I don't think it's safe to deliver twins at home. I think the risk of complications is high.
"She listened to what I had to say but I didn't feel that it was influencing her. I don't know that frustrated was the right word. I felt a bit powerless I think."

Another case from SA that has a questionable ruling that of Tate Spencer-Koch case in which the coroner states “Tate had been a perfectly viable fetus until the time of her delivery........the PEA (Pulseless Electrical Activity) that excited in Tate after her birth, acknowledging as I do that it was slow and could not support a mechanical heart beat, and could not be reversed, is to be regarded as the last vestige of her human existence. This last vestige existed at a time after she had been fully delivered. As such it was a sign of life that existed after she had been fully delivered. (1.27)
.......the PEA of 15 beats per minute that was detected in Tate approximately 10 minutes after she was fully delivered was a sign of life for the purposes of the law......all facts of the born alive rule have been satisfied in this case and I find Tate was a person in the eyes of the law and for the purposes of the jurisdictional requirements of the Coroners Act 2003”.(1.28)
This case will change the course of history if this definition of a sign of life remains......it is my opinion that PEA is not a sign of life and that is because at this stage there is no cardiac output, you are essentially dead....there is only an electrical current that runs through your body as the last automatic process of the body....it does not mean you are alive.... It is however interesting to read the process and see how the coroner has come to his conclusions, it is all about words and how they are used and what they mean.

Interestingly in the case of R v Iby a case of an assault that caused the subsequent death of a fetus/child. This case heard that the presence of a heart beat was sufficient to satisfy the born alive rule. It was also found that there was no ‘common law definition of what constitutes ‘life’ for the purposes of the born alive rule (248).

WHO defines live birth as
Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life - e.g. beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles - whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born
.

Fetal rights is a real dichotomy the right of a woman to her own autonomy and her body v the right of a fully formed term fetus who would live if able to be born..... what is the answer...In my mind there is no question that a term fetus is a human being: What is required is that there is community support / structures for midwives who choose to support women who make these choices; one thing is for sure, women have the right to choose where and how to birth – what is required is for hospitals and health professionals to be more flexible.

In 1999 Regina McKnight the first woman in South Carolina was convicted of homicide by child abuse in 2001 after a jury bought scientifically unsupported arguments that her cocaine use caused the stillbirth. Regina suffered the charge for suffering an unintentional stillbirth after having used cocaine during her pregnancy.

McKnight unsuccessfully appealed her conviction in 2002, challenging the constitutionality of using murder statutes to prosecute women who experience stillbirths. But in a split decision, the state Supreme Court upheld her conviction, offering a novel interpretation of the state's homicide laws. The court held that any woman who unintentionally heightens the risk of a stillbirth could be found guilty of homicide with "extreme indifference to human life." Under this doctrine, the court held, any pregnant woman who engages in activity "potentially fatal" to her fetus could be charged with murder.

In 2008, the Supreme Court ruled that McKnight had an unfair trial... McKnight argues that counsel was ineffective in her preparation of her defense through expert testimony and cross-examination...and the court also found that the information given to the jury about the supposed link between McKnight's cocaine use and her stillbirth was not scientifically supported. More importantly this ruling sends a clear message to lawyers as it was found that current research simply does not support the assumption that antenatal exposure to cocaine results in harm to the fetus, and the opinion makes clear that it is certainly ‘no more harmful to a fetus than nicotine use, poor nutrition, lack of antenatal care, or other conditions commonly associated with the lower socio economic group. This ruling will send a clear message to lawyers to get the facts right and not be misguided by medical misinformation.

It is a travesty that Regina McKnight spent 9 years in prison for a crime she did not commit and in South Carolina 90 women have been convicted of drug use during pregnancy, this is not the answer to the problem.

As a midwife sometimes this issue creates a dilemma for me as I firmly believe in the woman’s right to choose what happens to her body. That is under no circumstances should she be forced to accept any treatment she does not want. How do we balance the need to protect the term fetus that is a fully formed human life, but for the fact it has not been born alive it has no rights.... one minute in utero it has no rights, however once born and shows a sign of life you cannot kill it..... this just does not make sense to me........

I do think a term fetus should be afforded some right to life.....but I'm not sure how we can do this without impinging on women's right to autonomy, which must take precedence.

References:
CORONERS ACT, 2003 SOUTH AUSTRALIA RULING OF CORONER
http://www.courts.sa.gov.au/courts/coroner/findings/findings_2010/Spencer-Koch_Tate.pdf
R v Iby (2005) 63 NSWLR 278, 248
http://stopthedrugwar.org/chronicle/2008/may/16/pregnancy_south_carolina_supreme
26484 - McKnight v. State; http://www.sccourts.org/opinions/displayOpinion.cfm?caseNo=26484National Advocates for Pregnant Women: http://www.advocatesforpregnantwomen.org/
Doctor says mother ignored homebirth warning:
http://www.abc.net.au/news/2011-11-17/home-birth-twins-death-coroner/3677156
Pic ref: http://www.solarnavigator.net/animal_kingdom/humans/babies.htm

The art of listening and compromising with women

2012-01-23T21:39:00.009+08:00

As a midwife the art of listening is imperative, not only listening but hearing what the woman is saying and wanting. This in its self comes with its own inherent problems because as a midwife you know what a woman wants, however this can be like walking a tightrope as a midwife is bound by rules and regulations, therefore it is about the language you use and the compromising you can implement to satisfy both the woman and the institution.

Language is commanding, it is all in the way it is presented; an example would be; you are having trouble monitoring(cardiotocograph (CTG) a woman and she is having a syntocinon (a synthetic form of a hormone oxytocin) infusion for an induction of labour (IOL). It is important to monitor the baby’s heart rate through this procedure as sometimes babies have a negative reaction to the drug and it needs to be stopped. The policy states that a woman having a syntocinon infusion needs to be on a CTG –however in this instance you cannot effectively monitor the woman. What is the midwife to do? The midwife reports to the doctor, the instructions are “the woman must be monitored, put a fetal scalp electrode on”. The procedure is explained to the woman, a small, tiny hook is put on the scalp of the baby, so we can monitor the baby – the woman flatly refuses this option, a definite “NO”. Next: the woman is told, “If you don’t have the scalp electrode and we cannot monitor you, our policy states we must do this. Therefore we will stop the drug and you can walk around for an hour, and if you don’t have contractions, we will start the drug again and you HAVE to have the scalp electrode attached”.

There is something profoundly wrong with this statement: the language is authoritarian, demanding, controlling, there is no compromising, no listening, no discussion, and it creates fear and rebellion and backs the woman into a corner. There has to be a better way of walking the tight rope without losing our balance and falling off. It may be sometimes possible to hold the monitor in place enabling a good CTG reading, thereby giving a good outcome, however I acknowledge that this can be difficult.

What do you do if a woman is refusing best practice, policy, or guidelines?

The answer, discuss the issues in a non-threatening way; give the reasons / evidence why it is important to do whatever it is you want; get the doctor to discuss the issues with the woman; clearly document all discussions and the reasons why the woman is refusing the treatment, however ensure that the woman understands the implications for her decision. It is also a good idea to read back your notes to the woman so that she clearly understands the implications of the discussions and it is how she sees the situation.

At the end of the day the decision will lie with the woman, if she is of sound mind, she is able to consent to treatment or equally refuse treatment. Part of our job is to give her balanced information to enable women to make an informed choice.

A policy is usually best practice and is to be followed. A guideline is as it suggests a guideline that usually outlines how the policy works; both are usually well referenced and evidenced based. In a legal proceeding the policy and guidelines of the time are called to guide the current practice at the time and the expected care to be provided.

Midwives are not and should not be expected to be doctor’s messengers; if doctors have these sorts of explicit instructions, they should be discussing this directly with the client/woman and not expecting midwives to pass on these instructions. The ANMC Competency standards, code of ethics and code of conduct all state that collaboration is essential with health professionals, this means discussing and sharing finding the middle ground, not just regurgitate doctors sentiments, doctors need to be building this relationship with the woman to also find a way to compromise. Midwives need to be mindful of the issue of “failing to obey a doctor’s order” this is a whole separate blog which I will be doing very soon. Working within a system you could face disciplinary action or be sacked for “Gross misconduct”…. Watch this space.

It must be remembered that the woman is the consumer, with her own freely chosen subjective preferences and desires. Doctors tend to practice paternalism – thinking that they know best. Paternalism in medicine is defined as acting for the welfare of the woman, often interfering with or disregarding the woman’s autonomy. Doctors need to find the middle ground.

Autonomy means ‘self-rule’, to act autonomously a woman needs liberty and independence from controlling influences, it is the right to hold your own views. As a midwife we walk a tightrope, balancing the woman’s needs, the requirements of the regulatory bodies and doctors recommendations…….the bottom line remains if a woman is of sound mind, well informed of her choices, she can refuse any treatment, however she needs to clearly articulate these choices together with the possible implications of her choice.

ref pic: http://lukespad.wordpress.com/

The challenge of collaboration:

2012-01-18T21:53:00.008+08:00

http://www.nhmrc.gov.au/guidelines/publications/cp124

I have written about collaboration in the past and it still seems elusive, however a few of my esteemed colleagues have managed to gain some sort of formal collaboration. The word ‘collaborate’ means ‘to work with another, cooperate’. However so far, the collaboration has been limited to antenatal and postnatal care, and intrapartum care being only provided by the doctor. When it comes to continuity of midwifery care, through all phases of pregnancy the problem arises when the woman goes into labour - the birth is still in the realm of the doctor. The woman goes to hospital and is cared for by the doctor, they still hold onto this part. However I have noted that times and attitudes are changing and maybe given a little more time the doctors will not be so territorial regarding ‘normal low risk’ births.

I would dearly love to see women with the opportunity to have a midwife in their home for the early part of labour, to support, encourage, nurture and be with woman. Keeping the woman in their own environment with a midwife until they are ready to go to hospital in established labour, this could prevent the cascade of intervention and we would have more normal births.

I do wonder whether the threat of things going wrong and not in the doctors control; in other words the threat of litigation is the motivator, together with no real benefit for the doctor to collaborate with the midwife. What is the incentive for the doctor to collaborate? Maybe if we a sign a Medicare no to "collaboration" doctors might do so... Most doctors I have written too are happy to continue as they have for the past years; however the issue is, that women are requesting midwives and continuity of midwifery care, it is time for change.

NHMRC was commissioned by the Dept of Health to develop national guidance on collaborative maternity care as part of the national maternity reforms they produced a whole document about the process of “Collaborative Maternity Care”. This was to encapsulate maternity care collaboration placing the woman at the centre of her own care, whilst supporting the health professionals who care for her. Thus ensuring her cultural, psychological and clinical needs were met. The NHMRC produced a pamphlet for women to help explain collaboration; I have yet to see this document widely distributed.

The pamphlet explains to women that

“Midwives provide care to women during pregnancy – from conception until early parenting in collaboration with other health care providers. Midwives can provide most aspects of ‘low risk’ pregnancy, labour and birth, and postnatal care to women. They may need to refer you to, or talk with, a doctor or other services if you or your baby have or develop problems”

Obstetricians & GP “Provide specialised care for mothers and babies in collaboration with other health care providers. They can look after women with “routine” and “complicated” pregnancies and births, and provide labour and birth care in hospitals.

Pregnancy is a very special time for women and families, it is very important to ensure you are getting quality safe care including informed choice from your service provider, whether it is an obstetrician, midwife or GP Obstetrician. That your choices are being heard and respected, you also have the right to say ‘no’ to treatments you do not want, don’t ever be afraid to ask for a second opinion.

Collaboration is about working in partnerships with each other in order to facilitate the wishes of the woman and her family. Recently I experienced true collaboration with a hospital in facilitating a woman’s birth, what we need is the Determination of July 2010 overturned or amended for midwives to collaborate with a Health Service, rather than an individual doctor.

Here’s to ‘continuity of midwifery care’, every woman having the opportunity to have a midwife and doctors and midwives working in partnership.

What you need to do if you want to be a Private Practice Midwife in WA

2012-01-18T16:05:00.008+08:00

Western Australia is unique in many ways, but particularly in the area of Midwifery, it is the only State in Australia where you have to declare your intention to practice midwifery as a private practitioner to the Health Dept. In principle I think it is important for the regulatory body to know who is practicing independently, however I think rules pertaining to this should be National, not state by state. However despite my personal views it remains that for WA you need to register your intention to practice privately (independently).Therefore it is important to take several steps:

1. Ensure you are eligible to practice midwifery
2. Be a registered midwife (NMBA - AHPRA)
3. Review recency of practice standards
4. There are no rules as to how long after registration that you can practice privately(exemption until July 2013)
5. Review Health Act Regulations 1914 Midwives Notification
6. Lodge the form to the Health Dept (your intention to practice) Notification
7. Secure Insurance (VERO or MIGA) all private practice midwives (independent) must have insurance
8. Review guidelines for insurance (NMBA - AHPRA)

Medicare for Midwives: for this you need to be an Eligible midwife (private/independent)

An eligible midwife has completed three years midwifery covering antenatal, intrapartum and postnatal care.

1. Complete Midwifery Practice Review (or equivalent) (ACM)

2. Review the application form for addition of notation as an eligible midwife
3. Currently registered as a midwife, with no restrictions

4. Current competence to provide pregnancy, labour, birth and postnatal care to women and their infants.

5. Midwifery experience that is equivalent to three years full time post initial registration as a midwife.

6. Formal undertaking to complete within 18mths - course for prescribing (course has to be approved by the Board)
7. 20 additional hours per year of continuing professional development relating to the continuum of midwifery care.

That's it, not much to do.....but please remember to register with the Health Dept your intention to practice privately. Also remember there is currently no insurance for Homebirth.
We need more eligible midwives, so please consider taking up the challenge, and offering women continuity of midwifery practice.

No Collaborative Agreements: No equality or justice:

2011-11-19T22:11:00.010+08:00

12 months on and I still do not have access or a collaborative agreement:

As a private practice midwife I have not been able to secure a written collaborative agreement or access to hospitals to facilitate the care of my private clients; Unfortunately for the women of WA, there is only one Tertiary hospital and to date this hospital has not supported the role of the 'eligible midwife' or women's choice to be cared for by a private midwife within the tertiary hospital setting. This is totally unacceptable and goes against the governments National Maternity Plan initiative.

There have been many obstacles to try and implement midwifery reform within Australia: To date as far as I am aware there are a handful of collaborative agreements and no credential pathways for access to hospitals for private midwives:

If you remember the National Health Collaborative Determination July 2010 outlines the requirements for private midwives to work within the community; This Determination is clearly not working; for whatever reasons, personal or professional 95% of Obstetricians / GP Obstetricians are not choosing to enter into a formal collaborate agreement with midwives; There has to be a better system in place that does not require midwives to be reliant on Obstetricians who clearly do not want to collaborate -this effectively puts a midwife out of business, and gives women little or no choice. This will not stop women, they will just birth without a midwife.

I have written to over 50 Obstetricians, receiving only 3 responses (negative): the latest response being:

"I do not intend to enter into one of these agreements...... Planned birth at home is clearly associated with higher rates of both perinatal morbidity and mortality and I cannot support it"

.... he went on to wish me well in my venture..... Just how well does he think I am going to do with no hope of getting a collaborative agreement? Maybe that is the plan! This appears to be the general attitude of Obstetricians in WA. The evidence clearly supports homebirth for low risk women, however my request was for continuity of midwifery care not homebirth.

The Determination has to be changed or rescinded to stop the monopoly and control of doctors over midwives, this system is clearly not working;

Just taking a step backwards;

From November 1 2010, women receiving midwifery care could claim a Medicare rebate for services rendered from an eligible midwife:

On 12 November 2010, the National Maternity Services Plan (the Plan) was endorsed by the Australian Health Ministers’ Conference.

The Plan recognises the importance of maternity services within the health system and provides a strategic national framework, as endorsed by state, territory and Commonwealth Governments for the five year period 2010-2015

Within the first 12 months the plan's priority 1 was to:

1.2.1 Australian governments facilitate increased access to midwifery-managed models of care for normal risk women, e.g. midwifery group practice or birthing centres, while maintaining support for choice of, and access to, medically managed
models of care. Australian governments facilitate increased access for public patients to midwifery and medical practitioner continuity of carer programs

1.2.2 Jurisdictions develop consistent approaches to the provision of clinical
privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners

NOT ACHIEVED - the first year has passed and we are no closer to achieving these outcomes;

It is apparent that women are not being offered true choice within maternity services and Health Services are required to be more flexible. The evidence is clear that midwifery continuity of carer affords better outcomes for women; it reduces intervention and provides for improved parenting. This includes homebirth as an option for uncomplicated pregnancies. Therefore it is imperative, to achieve the strict intention of the National Maternity Services Plan, to protect mothers, babies and achieve best outcomes in maternity care, the Australian Health Ministers need to provide PII insurance for Intrapartum care at home for uncomplicated pregnancies, rescind the current Determination requiring written collaborative arrangements with an obstetrician and compel local Health Districts / Services to provide clinical privileges for eligible midwives, as a matter of urgency.

Ref: picture: http://www.ontheissuesmagazine.com/2010summer/2010summer_Ross.phpA Feminist Vision: No Justice-No Equity by Loretta Ross - My mother always asked the question, "Why would I want to be equal to men, when I've been superior to them all my life?"

Head on the chopping block – HOMEBIRTH:

2011-10-25T22:18:00.014+08:00

Homebirth the hot topic: combine that with autonomy, women’s choice of place of birth no matter what the risk factor and you have an explosive cocktail and a subject that will divide a nation. There has been much written on this subject and sadly what is bringing it to the forefront again is term foetuses (babies) dying at home, with or without a health professional.

In 2009 there were 30,760 women giving birth in WA and the average age was 29.5yrs, the majority of women (98.8%) gave birth in hospital. Non Hospital births 1.2% including Born Before Arrival (BBA) (0.4%) and babies born at home (0.8%). The caesarean section rate was 33.3% (10,241) of the women recorded as having had a previous caesarean section 87.1% had a repeat section. What we need to be doing is reducing the caesarean section rate and concentrating on is promoting normal birth.

In 2010 WA had 245 homebirths, 203 occurred with the Community Midwifery Program and 42 homebirths with private practice midwives. We have 19 private practice midwives registered with the Health Dept and 5 eligible midwives.

This debate about homebirth revolves around less than 1% of women, not that I am suggesting that their views are not important; however there are 99% of women that need midwifery input to improve their birth experiences. It seems that a disproportionate amount of time is spent on homebirth in relation to the work that needs to be done to improve maternity services for all women.

I will start with my position as a midwife on the subject in the current Australian context;

Do I believe that women have the right to choose where and how to give birth? YES.

Do all women need a midwife throughout the continuum of pregnancy, birth and postnatal period? YES.

Should homebirth be an option for all women? The evidence shows that homebirth is safe for uncomplicated pregnancies.

Should all women have a midwife? YES

Should high risk women birth at home supported by a midwife? This is the six million dollar question; professionally and personally I would answer NO, based on the lack of protection for the midwife to facilitate this choice. However it is not that simple; usually women who are choosing homebirth for high risk pregnancies have experienced some sort of birth trauma, are extremely fearful of hospital and usually have knowledge of the associated risks, each case needs to be evaluated individually. It is unfair to label all these women as zealots or radical. What needs to happen is to listen to what the issues are and find more flexible ways to support these women providing continuity of midwifery care, collaboration with an obstetrician within a safe health system.

What is a problem is if midwives / or de-registered midwives keep supporting high risk homebirth without collaboration and health service support. Recently there have been several high risk homebirth deaths. If the term fetus (babies) keeps dying in the homebirth setting we will be endangering homebirth for uncomplicated pregnancies. Worse still women will lose their autonomy because the term foetus will be afforded more rights similar to what has happened in the USA. Currently in Australia a foetus has no rights under law until born alive, but this concept is being challenged.

What needs to happen is that health services need to be more flexible, by having visiting rights for private practice midwives allowing them to bring their women into hospital and continue to caring for them. When fearful women present they should be facilitated to birth in a low risk setting such as a secondary hospital or birth centre supported by the tertiary hospital. Specialist obstetricians could travel to see the women and support the secondary hospital – it is about being flexible – considering the psycho-social issues of the women. Having all high risk women being herded into a hospital like cattle is giving them no choice or options therefore creating more fear. Remembering there is established legal principle that a mentally competent woman can refuse treatment. It is no wonder that these women choose to birth at home or freebirth. Freebirth is an unsafe and unacceptable practice and Health Services are failing women if this is the only option they feel they have.

We as midwives need some sort of supervision or mentoring system to support us in difficult clinical situations therefore allowing us to support these women. We need legislative changes to protect the midwife to stay with women no matter what the risk and where she chooses to birth, we need health services to be more flexible and supportive. We need women to be demanding that Health Services and Doctors be flexible, it’s about open communication and negotiation.

Three questions:

What do you think about the homebirth debate?
Would you have a high risk birth at home?
Would you freebirth?

Ref: WA Mothers and Babies 27th Annual Report – Midwives Notification System
photo credit: http://offthebroiler.wordpress.com/2006/11/21/death-of-a-turkey/

Inspired.....

2011-08-28T19:42:00.012+08:00

It's been a difficult week and I am sure next week the news will be all about Homebirth and midwives... so brace yourselves: Today I rekindled my passion, after a hard week.

“Courage is going from failure to failure without losing enthusiasm.” – Winston Churchill

I was delighted when I was asked to talk to a group of midwives who wanted more information about becoming a eligible midwife, we certainly need more: I was greeted by approximately 10 wonderful midwives and a consumer, all keen to learn more about setting up their own business and eligibility: we spent the next two hours discussing the current issues for midwives and some of the difficulties that we are facing as a profession. Whilst I acknowledged that we have some difficulties, I do think that we need to continue to put pressure on the government to follow through on the Maternity reforms; issues such as visiting rights for eligible midwives, so that continuity of midwifery care is an option for all women.
What I found fantastic about today was the interest and that it was younger midwives who traditionally have worked in a hospital who are embracing these new challenges and thinking about working in a different model of care, being more autonomous and wanting to work in the community...which is best for women, and what we all strive for...they were looking for ways of making it work within their current settings....it was really exciting to work with them to suggest the best ways forward for change... it is very important to have change agents spread out to inspire and encourage these changes; change is about knowing people, its about being passionate.... change sticks when people embrace it..and that is what we have to do... I see such potential in midwives being able to set up antenatal clinics....working side by side with Obstetricians, shared care - and six weeks postnatal care that we can provide in the woman's home, how brilliant is that? once a few people start doing it...the knock on effect will be phenomenal.... the issue is that the doctors are fearful of losing control ...and we all know when people are fearful they do things they would not normally do:

Yes we are currently experiencing some issues and that's because this whole concept is new, there is much change and not just small changes they are all huge... National Registration, new Act, insurance, Medicare provider numbers: no wonder we are all reeling with fear.... these are catastrophic changes - independent midwifery has never been so regulated... and this all creates an atmosphere of mistrust: we have to work together...

I found it refreshing today to meet so many midwives that were keen to begin to think about working within a different model of care and this gave me great hope for the future...we need to embrace the changes and work together to implement different models of care...and challenge the medical model, with this comes a word of caution.... the consumer demand has to be present; women need to want 'continuity of midwifery care'.

We still have some major hurdles to overcome with the maternity reforms: collaboration, indemnity insurance, visiting rights and more midwives to take up eligibility.

“The greatest barrier to success is the fear of failure.” – Sven Goran Eriksson

Confusion reigns.......

2011-08-24T18:02:00.010+08:00

A sad state of affairs: it seems that continuity of midwifery care is the last thing on anyone’s political mind:

To say I am confused would be an understatement; two urgent issues: Insurance and the practice role of a midwife: for months I have been asking the question can a Midwife be a support person or advertise as a doula? to me a Midwife is a Midwife is a Midwife, not a doula or support person.....these are all roles within the scope of a midwife...I remember as a registered nurse you could not work as a career I would think the same would apply to midwifery; however due to the recent kerfuffle surrounding private insurance for midwives and the requirements of the regulatory agency... midwives have been looking at different ways of presenting themselves to elevate some of these problems and still support the woman and her choice. I have written twice to NMBA asking for clarification on this issue... Today a colleague highlighted to me that on the AHPRA website under frequently asked questions; ‘Regency of Practice’ gives a definition of what is meant by ‘Practice’ http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ.aspx

Q2. What is meant by ‘Practice’?
A. Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a nurse or midwife. For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care. It also includes working in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery

In effect this means if you are a registered midwife you cannot act as a support person or a doula, because we have the knowledge and skills of a midwife.....this has far reaching repercussions and when you add the recent problem with the MIGA insurance into the picture it gets worse.

The MIGA cover clearly states you are not covered for

“midwifery services which are provided by you to a public patient (even if the public patient is in a private hospital).

This then leads me to the question when you are working in a hospital and you finish your shift and you stay back to support the woman because you choose too...because of the bond you have with your woman...this may be seen as interference as the woman may look to you for a clinical decision... in effect this will not be permitted as you will not be covered by the hospitals vicarious liability insurance because your role is a midwife not a support person.....I may have got the wrong end of the stick, but what’s good for one is good for all....

We as midwives are now backed into a corner... One would think with the Medicare provider number and the maternity reforms midwives would be rejoicing ...however the long arduous road to credentialing / visiting rights to hospitals have created many problems; the process is taking too long; the inability of obstetricians to agree to collaborative arrangements have left the maternity reforms in tatters....and the personal cost to many midwives trying to make this work is enormous; I am paying MIGA for the privilege to be insured only to find that I am not and its good money going out the window, I don’t have money to waist, however it seems that MIGA is profiting very well from this venture. At the end of the day both women and midwives are suffering here and the process are very unclear.... the only time you find out that something is wrong is when you have been reported... this is all unacceptable.

I have had good support from the Minister of Health WA, Office of the Chief Nurse/Midwife and the Chief Medical Officer, however this is not enough, no one can make collaboration happen:
As for collaborative arrangements, I have written over 40 letters to GP Obstetricians and Obstetricians asking for a collaborative agreement and have had one response, politely saying ‘no’. Where does this leave me...absolutely no where?
The other day I went with my client to meet her obstetrician, you know build bridges, be nice etc and he could barley look at me...he never addressed me once, there was no professional courtesy. How are we to move forward when we are met with such resistance.... it is a sad state of affairs. My client employed an independent midwife so that she could have continuity of care with a midwife, she choose a midwife for her knowledge and experience to enable her to facilitate the birth she wants knowing that the midwife would support her through this process.... this now is even a problem.

I also pay premium insurance through MIGA and it seems for nothing: I have no hospital access, no collaborative arrangement; yes I do have women booked, now I am in a quandary what to do; that I cannot be a support person because this may be a reportable offence this leaves us nowhere to move......my only saving grace is that I have access to a hospital as a casual midwife but this is only a temporary solution so one client is safe...as for the others I will have to bare the consequence as I have committed to being a support person... something has to give soon. I may have to look at not booking anyone further until the processes are in place and who knows when that will be...

Please if anyone has any further news on this issue let me know...
Very frustrated and disillusioned eligible midwife:

ACM Interim Homebirth Position Statement and Guidance for Private Practice Midwives

2011-08-08T20:54:00.011+08:00

It is long overdue, a position statement on Homebirth for Australia from the ACM, well done: since 1987 RANZCOG has had an endorsed position statement that opposes homebirth: Since 2007 there has been a joint statement from the RCM & RCOG supporting homebirth for low risk women:

Now the ACM has an interim position statement that supports homebirth for the woman who has a 'low risk'; which is in line with the current Australian Legislation: The ACM cannot contradict the regulatory authority which created the Quality and Safety Framework.

This brings me to the Introduction of the Statement; yes 'women have the right to choose where and how they wish to give birth'..... as I have discussed before in previous blogs...women always have this choice...what they don't have is the right to a midwife to support that choice...because of how the legislation is set-up here.... for women that are in a 'risk category' a midwife needs to consult and collaborate with an obstetrician and this does not happen.... certainly not in WA....this is not from a lack of trying from private practice midwives / independent midwives to collaborate with doctors; As a privately practising midwife I have tried to no avail to get doctors to collaborate; they do not answer emails, letters phone calls. I have had some success with one doctor however the doctor is reluctant to put anything in writing.
A midwife owes the woman a duty of care to provide a safe environment and work within the defined scope of practice...very few obstetricians will support a homebirth for any risk category....and here we have a quandary; unlike the UK that supports midwives to support women in whatever choices they make.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG) does not endorse Home Birth.
In Australia about 0.2% of women deliver their babies at home. However this may be an underestimate, as it is unlikely that all babies born at home are recorded in perinatal data collection statistics.
Whilst mindful of a women’s right to personal autonomy and decision making, RANZCOG
cannot support the practice of Home Birth due to its inherent risks and the ready availability of safer birthing practices. Where a woman chooses to pursue Home Birth, it is important that this is an informed choice, considering all the benefits and possible adverse outcomes.

RCOG and Royal College of Midwives joint statement
The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.

The ACM is the professional body for midwives and I urge midwives to comment on the Position statement: contact the college and express your point of view, do you agree with it? How would you change it? give a balanced view:
Send submissions by email to info@midwives.org.au or by post to PO Box 87, Deakin West ACT 2600. Only submissions with identified senders and a return address will be considered, you have until 23rd September 2011.

As for me I've read lots of comments on the Statement and the guidance document, one comment that keeps appearing is that a scarred uterus is a 'new concept' or 'new rule'.... this is nothing new.... a scarred uterus has always been considered 'high risk' I suppose what is new is the terminology of a scarred uterus...but the concept is old...

My objection with the Guidance Document is the fact that as a private practising midwife we are required to consult with an obstetrician prior to or at booking-in: this is an unrealistic expectation; I am usually booking a woman at anywhere from 8-12 weeks: I would prefer a booking visit with the obstetrician at 20 weeks to discuss the plan of care: The Woman is encouraged to attend this appointment with her midwife and create a plan of care...if the woman chooses a different pathway this also needs to be discussed and a plan made to facilitate this choice: this is clearly documented and all parties sign the document understanding all the risks associated with it: however I am not sure that this will be enough to protect the midwife in a court of law: What we need to be working towards is a continuity of care model...supporting high risk women to birth in hospital with her private midwife having visiting rights to all hospitals.

Remember please to send your comments to: info@midwives.org.au

Report concerns or risks......

2011-07-26T14:07:00.007+08:00

Mandatory reporting is not only in Australia.... the UK is calling for more health professionals to blow the whistle...
NHS staff told to 'report concerns or risk investigation'

Health regulators should warn nurses, doctors and midwives they may be investigated if they fail to report concerns about colleagues, MPs say.

The General Medical Council (GMC), which regulates doctors, said it was committed to doing more in this area.

It is interesting that not many doctors report each other, the old school boy tie mentality is alive and well.... this is evident by the following statement;

The GMC is currently investigating doctors at Stafford Hospital whose own work was blameless, but who allegedly failed to report colleagues.

It seems though no one has a problem about reporting nurses and midwives.....
maybe the culture will change and there will be fairness about reporting all unsafe health practitioners or health practitioners that put the public at risk....

We have to remember it is about professional responsibility, being aware of professional codes and guidelines and aware of what is good and poor clinical practice. It is also about employers being open and transparent about what occurs within its institution and taking appropriate steps to rectify any untoward activities and not turning a blind eye. Clients have to be protected and advocated for by the health professional, not bullied or manipulated into receiving treatments they do not understand or want.

Fantastic new project: One World Birth

2011-07-26T13:41:00.004+08:00

Sign up to One World Birth with Sheila Kitzinger, Michel Odent, Ina May Gaskin, Elizabeth Davis, Cathy Warick and more.......

One World Birth is also building a community of birth professionals to connect, inspire and to help deliver change, to make birth better and safer everywhere.

Click on this link to sign up
One World Birth.com

Homebirth: A reminder July 2012 is looming

2011-07-23T08:12:00.021+08:00

Following on from my previous blog which generated much discussion; lets remember the figures we are talking about: In Australia less than 1% of women homebirth: In the UK 10% of women homebirth and there is a call by doctors to increase that figure and have more 'low risk' birth centres and homebirth: I wish the AMA would say that:

The role of the midwife is clearly defined; anything outside of 'normal' needs collaboration with an obstetrician in partnership with the woman. However we do have some serious issues within maternity services that force women to birth alone (freebirth) which is unacceptable: as I have alluded to before partly due to there being no support or protection for the midwife under the legislation.

The Determination (National Health arrangements for Midwives) of 2010 set out the rules for collaboration which to this date has been difficult to secure. As far as I am aware there are only a few collaborative arrangements in this country, one of them being Melissa Maimann (Eligible Midwife) and Dr Andrew Pecese.

As privately practising midwives in Australia we are in real threat to losing the ability to support women at home for a 'normal' homebirth, so where will that leave HBAC, (homebirth after Cesarean section): HBAC needs to be done in collaboration with an obstetrician; come July 2012 the exemption for private practice midwives / independent midwives (these terms are used interchangeably) will cease to exist. If we or the government cannot secure insurance for Homebirth we will lose this right: and only publicly funded homebirth programs will exist.

As I have said before the consumer must help to take this forward: we saw the result from the Homebirth Rally in Canberra. We all have to work in partnership with , professional bodies and consumers: Women need to be asking their obstetricians for midwifery care: Ask your GP surgery, what is their position regarding Midwives; will they facilitate shared care with a midwife outside a hospital system? we need to focus on the AMA - we need to get them to the table and debate these issues with the consumer groups such as Childbirth Australia.

My real fear is that we will go down the same path as the USA (Pregnant and Miscarry....Do not pass go; Go directly to Jail) and we will lose rights for women and gain more fetal rights; choices for women will be limited due to legislation, we need to act now by working together and find a solution: One solution is for 'continuity of midwifery care'.

There is no quick fix to these issues, this will be a long slow political journey of negotiation to get what we want: which means providing different models of care, such as 'continuity of midwifery care' access to hospitals for privately practising midwives: the right of the midwife to support the informed choice the woman has made: This has to be a united journey not fragmented into separate issues, Homebith v HBAC or 'low risk' v 'high risk'.
We need to move towards 'every woman needs a midwife' and 'continuity of care'.

Challenging times for women and midwives (HBAC)

2011-07-21T23:24:00.012+08:00

Sad and disturbing times for both women and midwives:

As a private practice midwife it is very important to understand the boundaries of my role as a midwife; some are outlined in my previous blog “government paying us lip service”. Many midwives are facing complex ethical dilemmas:
As a UK trained midwife I was used to being able to do a homebirth for a woman who has risk factors and has had collaboration and consultation with an obstetrician through the local Health Authority and has chosen a homebirth despite these risk factors. The difference being that in the UK there is a Supervision system of midwives (supervisor of midwives) that provides midwives with support and backup. Also within the UK system you are protected by legislation that states that only a midwife or a doctor can assist with the birth except for an emergency in which case anyone can help.

S16 (1) A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth: Nurses Midwives and Health Visitors Act 1997(UK)

In the UK a woman’s choice is respected in that she can birth at home and the local Health Authority has to provide a midwife for the homebirth if one is available (National Health Services Act). Also the Royal College of Obstetrics and Gynaecology (RCOG) and Royal College of Midwives have a Joint Statement No.2. -April 2007 supporting homebirth and work together to support this. However here in Australia a major problem is that the AMA categorically opposes Homebirth.

The Nursing and Midwifery Council (NMC) works in the same way as AHPRA in its role to protect the public to ensure that midwives work within their scope of practice which is low risk ‘normal’ and provide a safe environment for birthing women. Independent Midwifery is also under threat in the UK as there is no insurance for private practicing midwives: see Homebirth and the Law reference list: http://www.homebirth.org.uk/law.htm

The Health System is different in Australia; therefore we cannot really compare with the UK except to say that both regulatory authorities work in the same way, in protecting the public and ensuring that midwives provide safe and competent care for the woman.

Legal Advice: I am not a lawyer and not giving legal advice; this is my interpretation of the legal advice given to me)

I have to state that my position as a midwife is that yes I believe in “women having choice in place of birth” and I believe that every woman should have midwifery care. I also have to state that I believe my role as a midwife is dealing with the “normal” and anything that falls outside of the parameters of “normal” I will collaborate with an Obstetrician, working in partnership with the woman to achieve a mutual arrangement and provide midwifery care throughout. I would like to see more liberal / flexibility surrounding place of birth for high risk women instead of always sending women to tertiary centres where they often feel alienated and fearful this would be a step in the right direction.

In light of the recent debate surrounding HBAC, I have sort some legal advice regarding the issue of VBAC (vaginal birth after caesarean) and having a homebirth. I wanted to know where I stood legally when a woman approaches me as a midwife asking for this service, should I decide to book a planned homebirth for H/VBAC – in terms of my responsibilities and my registration/licence: You have to remember that a good lawyer can argue a defence for anything and there is always a defence to be had.

The first question you have to ask is - What does the professional bodies say about HBAC / VBAC?
The professional bodies are the AMA and ACM – (the AMA has 90% membership, do not support homebirth, and is very powerful & political) does this give you an idea of what the answer will be to the first question.

Second question: What does the regulatory body stipulate about HBAC/ VBAC? Here you have to look at the current codes and guidelines that govern midwifery practice; you could compare with the UK, NZ and USA;

Thirdly : Have you provided unbiased informed choice, have you got collaboration (Dr; support) for the H/VBAC is it clearly documented, have you clearly documented the risks associated with HBAC/ VBAC , are you providing a safe environment for the woman; and have you an emergency care plan, are you working within your scope of practice?

There may be a possible defence, how successful this would be is the unknown quantity as it has not been tested yet and I can assure you I am not going to be the first to do this.

Women do have a choice of place of birth; however the choice to have a midwife present in the home environment for a risk associated birth is a limited option due to the legislation and the regulatory authority. However if the midwife chooses to accept the HBAC he/she maybe risking disciplinary action which could mean losing his/her registration and or having restrictions on his/her practice together with a lengthy legal case that will be distressing and costly.

How to move forward:
The answer is to work on changing legislation, to something similar to the UK and gaining support from the AMA to collaborate with midwives in listening to what women want. Helping and facilitating women achieve the kind of birth they want in a safe environment with a health professional to support them, whether that is in hospital or the home. Providing different models of care which include continuity of care no matter what the risk factor is.

It is very clear that the consumer/woman has to lead the impetus for change, the demand must come from them otherwise nothing will change; it is the power of the voter to change legislation.

The government is paying us lip service:

2011-06-29T23:41:00.007+08:00

There are three burning issues for me currently: Mandatory reporting, women’s choice to birth where and how they want and ‘continuity of midwifery care’; each deserves a separate blog.

I have refrained from blogging recently because things have been politically difficult and I have been trying to keep a low profile, but it hasn’t worked, so I might as well just carry on and express my opinions.

I am in a real quandary as with many midwives, there is a fine line we walk and I have erred on the side of caution and to no avail. What keeps me on the straight and narrow is the fact that I value my registration. That is not to say I don’t value the woman’s choice, but if that choice compromises my registration I will think very carefully about the consequences before making a decision.

Up until recent times this has not presented a problem, however since the introduction of the new legislation namely the Health Practitioner Regulation National Law (WA) 2010. With this legislation came mandatory reporting, if I had known the implications of this piece of legislation I would have fought harder to see it changed. I had no idea until it started happening, that is the reporting of midwives. This is not about pitting midwife against midwife; this legislation is about ‘mandatory reporting’ the same as ‘mandatory reporting’ for child abuse...... it is the law and if you don’t there are consequences for not doing so ( it is noted that there are no penalties prescribed under the National Law for practitioners who fail to notify, but you may be subject to conduct or performance action)....Most reports have been made by Health Services or Medical Practitioners, however it is interesting to note that it seems that only midwives are being reported using this clause: s140(d)
s.140 of the National Law defines ‘notable conduct’ as where a practitioner has; (a).., (b).., (c)..., (d) placed the public at risk of harm because the practitioner has practised the profession in a way that constitutes a significant departure from accepted professional standards.’
The explanation given in the AHPRA document Guidelines for mandatory notifications (p4)
The term ‘accepted professional standards’ requires knowledge of the professional standards that are accepted within the health profession and a judgement about whether there has been a significant departure from them.
The notifiable conduct of the practitioner must have placed the public at risk of harm as well as being a significant departure from accepted professional standards before a notification is required. However, the risk of harm just needs to be present - it does not need to be a substantial risk, as long as the practitioner’s practice involved a significant departure from accepted professional standards. For example, a clear breach of the health profession’s code of conduct which placed the public at risk of harm would be enough.

Maybe we should start reporting doctors for placing the public at risk by overzealous reasons for caesarean sections, or rupturing membranes when it’s not required, or induction of labour for social reasons. I am sure there are many reasons doctors give that are unfounded and put the public at risk. Why are health services or midwives not reporting doctors for unsafe practice or out of scope practice as readily as they are reporting midwives, there seems to be a real disparity in the reporting mechanism.
If hospitals are going to use this piece of legislation then use it fairly on all health practitioners not just midwives, this is paramount to a witch-hunt we have moved back 20yrs, why not just burn us at the stake.

Our problem lies with the legislation, it is the law and this is what needs to be addressed to resolve some of these issues. Australia currently has no protection for midwives who choose to support the woman's choice of care which falls outside of the recommended standard of care - a midwives role is "normal" - I can hear all the rhetoric.

Choice:
It seems that women do not have choice; choice seems to be relative to the situation or dependent on certain conditions – if your BMI remains normal, if your glucose level stays low, if you don’t have a scar on your uterus etc etc,. Working within frameworks is not something new for midwives and balancing the woman’s autonomy against these frameworks can be difficult and often puts the midwife in a stressful position which may lead to an inquiry and threats of negligence.

Informed choice is a fundamental issue, autonomy the right to self determination – not when it comes to health and perceived risk. Mavis Kirkham states that ‘in our own culture, obstetric ideology is particularly coercive. The medical definition of safety and risk means that while minor choices exist, conceptual choices cannot.’
“.......You can have your baby any way you like as long as you understand that I must step in when the safety of you and the baby is involved’ (Shelley Romalis 1985 p 190). How many times have you heard this?

The women the consumer must stand up and demand what is rightfully theirs, the right to birth where and how they want and protection for the midwife who cares for that woman’s choice.

The gloves are off, because I think the government is paying us as midwives lip service. Since November 1 2010, we have seen many changes, Medicare rebates, eligibility and insurance for midwives; however the maternity reforms certainly in WA are lacking in substance and commitment from the State government.

ref:Informed Choice in maternity care: Edited by Mavis Kirkham (2004)

It’s been a while since I blogged.... life in the fast lane

2011-06-09T23:25:00.010+08:00

Canberra - Autumn

I have really missed blogging even felt guilty about not writing and sorry to my faithful readers for the lack of updates, but as usual the build up towards the end of semester (marking, studying, and meetings) takes its toll on my time to blog....

Let’s see where I got up to.... sorting out collaborative agreements... progressing with CeMGP “the practice”.... writing copious letters and getting limited responses....working three days a week at Uni.....my commitments to the College continue...picking up three units in my study this semester was not a wise move...note to self “don’t do that again”, no more than 1 or 2 units or drop something else... almost forgot I was sick....feeling better now... the mediation continues.... it really keeps me sane I do notice my anxiety levels rise when I don’t meditate... Thank God on Saturday I get an injection of super duper all day retreat... that should centre me again.

Jasmine - I think mummy ate all that chocolate

On the grandchildren front the birthday season for this year has begun, as they get older they are harder to buy for.... Jasmine is now 7, Dylan (June) 6yrs & Jessica (Aug) 6 yrs, Talia (June) 4, Sam (July), Isabella (July) and Logan (Oct) will be 3yrs old and off course our newest one Tayla is 7weeks old.... by far the greatest pleasure I get is from the grandies...they are truly delightful and the light of my life.....

Talia's party:

As the semester comes to a close and the marking is complete, its time to read a book or novel.... today as I was buying birthday pressies for family and friends I spied a couple of books that leapt off the shelf into my bag via the cashier.... I wanted them all...but alas some are for gifts, however I will keep and read “The Wish” it did appeal to me.... so will give some feedback once I’ve read it.... I think I am back in the swing for my blog... will update on the political agenda for midwifery in my next entry:
Ciao!

Understanding Collaborative arrangements for midwives

2011-05-12T22:42:00.000+08:00

Well as usual life has been extremely busy and I have quite a few blogs to catch up on... like our Good Friday grandchild Tayla.... birth experience coming soon...but first what has been consuming my time is trying to secure collaborative arrangements.

Collaboration was always going to be problematic as it was never a sure thing, it was doomed from the beginning because it was the medical profession trying to control midwives and midwifery.

The question is now how to make it work without having to have a signed agreement. This is how I see it... first it is about closely reading the National Health Collaborative arrangements for midwives Determination 2010 carefully... scrutinising every word.

Part 2 of the Collaborative arrangements; sets out the general requirements of the collaborative arrangements; (what is required or our core choices. It is interesting when you examine our choices as midwives, the only one that I find palatable is 7(1)a,b,c,d).

(1) For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:

(a) the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;

(b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;

(c) an agreement mentioned in section 6 for the midwife;

(d) an arrangement mentioned in section 7 for the midwife

.
This means we can choose one of these options....what will work for me is 1(d)which I will explore fully here...the other options are not going to be discussed at this time. Please check the full document if you want to find out more.

6 Agreement between eligible midwife and 1 or more specified medical practitioners
(1) An agreement may be made between:
(a) an eligible midwife; and
(b) 1 or more specified medical practitioners.
(2) The agreement must be in writing and signed by the eligible midwife and
the other parties mentioned in paragraph (1) (b).

(d) section 7

7 Arrangement — midwife’s written records (this means we do all the writing and do not need a signed arrangement).

(1) An eligible midwife must record the following for a patient in the midwife’s
written records:

(a) the name of at least 1 specified medical practitioner who is, or will be,
collaborating with the midwife in the patient’s care (a named medical practitioner);

(b) that the midwife has told the patient that the midwife will be providing
midwifery services to the patient in collaboration with 1 or more
specified medical practitioners in accordance with this section;

(c) acknowledgement by a named medical practitioner that the practitioner will be collaborating in the patient’s care;

(d) plans for the circumstances in which the midwife will do any of the
following:
(i) consult with an obstetric specified medical practitioner;
(ii) refer the patient to a specified medical practitioner;
(iii) transfer the patient’s care to an obstetric specified medical
practitioner.

For me this is easier than getting a signed agreement...my experience is that obstetricians are reluctant to sign a collaborative agreement.
I email or write to the obstetrican refering my client when I book them into the hospital of the client's choice. The obstetrician replies thanking you for the referral (acknowledgement by named medical practitioner)you also make a plan of action should transfer or obstetric care be necessary and you consult with them when the situation requires, sounds all very reasonable.

I always inform my clients that I will be collaborating with an obstetrician... it is a shame this is not a reciprocal arrangement...in that obstetricians inform their clients of midwives and midwifery care. It all seems to be a one way street......

The determination then outlines the requirements for documentation of the midwife's written records.....
(

2) The midwife must also record the following in the midwife’s written records....
(a) any consultation or other communication between the midwife and an obstetric specified medical practitioner about the patient’s care;
(b) any referral of the patient by the midwife to a specified medical practitioner;
(c) any transfer by the midwife of the patient’s care to an obstetric specified medical practitioner;
(d) when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy;
(e) when the midwife gives a copy of the patient’s maternity care plan
prepared by the midwife to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy;
(f) if the midwife requests diagnostic imaging or pathology services for the patient — when the midwife gives the results of the services to a named medical practitioner;
(g) that the midwife has given a discharge summary (however described) at the end of the midwife’s care for the patient to:
(i) a named medical practitioner; and
(ii) the patient’s usual general practitioner.

Something I have found very interesting on this journey; is with all my corospondence to GP surgeries, doctors, and hospitals no one has written a response to me... not even a common courtesy of saying thank you for your letter we will respond in due course.....

So I find it amusing as I read the determination and it states "when the midwife gives a copy of the patients' maternity care plan etc etc etc or copy of results to the named medical practitioner - acknowledgement that the named medical practitioner has recived a copy... when no one has responded to any of my letters... and I have sent many.. now whose responsibility is it to ensure acknowledgement is given? surely it is the person receiving the information and it is not my responsibility to ensure a response?????

The next step is Credentialing and or visiting rights... this currently seems like Mt Everest.....and I am not a climber of mountains... so heaven help me.....

Waiting patiently for grandchild no 8.....

2011-04-20T21:55:00.007+08:00

The art of patience I think is disappearing, we are always in a rush for things to happen or to be done, we want everything yesterday...sadly this is a reflection of the times.

Pregnancy traditionally is anywhere from 37 - 42 weeks, which is nine months and one week. More than 90% of babies do not arrive by the predicted date. So it is not unusual for a mother not to go into spontaneous labour just because its her due date. Technically you are not overdue until 42 weeks, but alas you see women are being offered inductions of labour (IOL) from 37 weeks.

Some mums battle with health professionals consistently about this issue..why is it that once you get to about 38/39 weeks you are offered and IOL, it seems like we are trying to change the boundaries of normal gestation times: Fair enough if there is a medical reason for an induction: as in the fetus (baby) is at risk or the mother, but not because you look uncomfortable or because we can.... IOL can lead to a cascade of intervention and we all know where that ends up. We need to let nature take its course, it stands to reason if you have reached 40-42 weeks and you have not gone into labour your body is clearly not ready....and you have to wonder have we got the dates right? This can already be disheartening for the mother who is eagerly awaiting her new arrival and can sometimes be annoying after so much of anticipation and excitement and pressure from family and friends.

Sadly it is not just health professionals that put pressure on mums, it is society that is friends, family, acquaintances, all saying when is this baby coming.... why don't you just get induced and have it over and done with....it seems everyone is in a hurry....sometimes too this is born out of fear, fear that something may go wrong and we as midwives need to be constantly reassuring about the normal processes of birth.

Then off course comes the advice about how to be induced naturally...and believe me everyone has a story about this one.... (some women have tried it all and none of it worked, like wise some women have tried one or two and it has worked....you never know your luck until you try)
Some of the traditional ways are:
Walking, housework, spicy food (curry) raspberry leaf tea, nipple stimulation and if you are really game clitoral stimulation; intercourse (love making) which releases the hormone Oxytocin which is called the love hormone... this then gets the contractions started; essential oils such as lavender and clary sage; membrane sweep; acupressure and most importantly be calm and think positively..... but like anything it is practice that makes perfect.... doing it just once or twice is not going to make it happen... it is something that you are going to consistently do over a few days or so...ensuring that everyone is safe and you can feel the fetus moving...

Formal Induction of labour: starts with prostin gel or Foley Catheter; artificial rupture of membranes, Syntocinon drip.....epidural? however this needs to be a blog all on its own....

We are waiting for contractions to begin....passing of a mucous plug, waters breaking.... all signs of the beginning.....the deadline is looming...

Lamenting about the lost art of nursing care:

2011-04-07T23:26:00.007+08:00

This is a plastic slipper-pan....mine was papermache...even more lightweight...

I have recently been in hospital, nothing serious but none the less needing/requiring some nursing care: There is nothing like a bit of firsthand experience to relay to nursing and midwifery students the importance of a caring attitude..... I also say that people generally complain about staff that are rude and give the impression of not caring ...that is a distinct difference to the nurse who just doesn’t give a shit.

I do have to say that I find being a patient extremely difficult because I do not want to relinquish any sort of control of my life.....to someone else particularly someone who really doesn’t care. On the whole my care was good..... However it is always the little things that make life all the more difficult..... like your tray being placed out of reach and you can’t move....emmm a little difficult.... and ringing the call bell to use...yes the dreaded bedpan... and it takes 20mins for the nurse to appear....then a further 15mins before you get the slipper pan.... oh no..... you can just feel your bladder is about to burst...and then you have this ridiculous looking slipper pan and you know it’s just not going to happen....at this point I wished I had a penis...it would be so much easier....but alas no we take a deep breath and ask to be left alone to contemplate emptying your bladder lying flat on your back and trying not to be in any pain.... it seems a fate worse than death...trying to pee in these conditions.... remembering you have done this all about 4hours ago and wet the bed in the process...then you have to go through the embarrassment and the changing of the bottom sheet.......anyway about half an hour later I think yes... I’m done.... ring the bell... by now the slipper pan is well and truly stuck to my buttocks... the nurse comes in “are you finished” yes thank you... Ok let’s get it out then.... lift up.... tummy muscles work frantically and lift.... as the nurse manoeuvres the pan out .... oops yes you guessed it.... a spillage...but of course... how can this flimsy product hold several litres of fluid without having a mishap......oh did I mention it is the middle of the night....the nurse says “oh that’s good....it didn’t spill did it?” emm... I lament and say...” I think that the bed is wet”....no says the nurse it’s your perspiration... it will dry very quickly....and slips out the room very quickly carrying her overladen slipper pan.... and me... well she doesn’t know that I am a nurse / midwife educator and am totally blown away by this blatant lack of insight into poor care....now here I am the patient....at this stage a not well patient who has pain, now lying in a wet bed and wondering is it worth the trouble to ring the bell wait another 20mins and complain about my care , have the sheet changed creating more pain or shall I just lay here and hope that I fall asleep as I am still affected from the anaesthetic... to which I do just that (I have to say this only happened once, not all the staff were like this).

I should think it is equally as difficult for a man to pee lying down.....

In the next bed was an elderly frail lady whom I had not met but could hear through the curtains that she had some sort of facial surgery and could only swallow. I came to this conclusion because I could hear her trying to swallow her drinks and her meals came in a bowl, she had hardly any visitors and was very quiet. It is interesting trying to assess someone you have not seen by the care she received from the nursing staff. Some nurses would come in very chirpy “Good morning, I have some pills for you, oh your poor darling, that looks uncomfortable let me crush your pills”....to, hello here are you pills.... Patient “oh I find it hard to swallow can you crush them” nurse – just try; patient; ok..... Cough; splutter; splutter; tears........oh Ok I will be back...... surprisingly it was the younger nurses that showed less caring....this occurred at least 4 times a day all with differing responses.... On the second day when the nurse came in and said “here are your pills and asked her to swallow them after the patient had asked for them to be crushed...... I could not bear to hear the patient again try to swallow....that I yelled through the curtains..if I could have got up without causing myself pain I would off.... why don’t you just crush or give her dissolvable paracetamol......the nurse scurried out the room and came back with dissolvable pills.... I know there is nothing worse than a busy body not minding their own business..... but it just had to be done...later when I got up ...the elderly lady said thank you to me for asking the nurse to crush her pills...and explained she had two sons lived away and it was difficult for them to visit...but they would say something if they knew.... and said I don’t know why some of the nurses won’t crush my pills.....she became teary and wondered whether it was all worthwhile.... I sat with her talking about life and I was saddened that none of the nurses found time to spend any time with this frail lonely woman who has had some remarkable facial surgery and how any nurse could possibly ask someone to attempt to swallow when visibly it was obvious that this was an onerous task for the elderly woman....

I know we all use the excuse that we as nurses and midwives are overworked, but please, caring and compassion is what we are about... it is a basic human need.....everyone is so busy with the task that there was absolutely no caring or compassion ......

My dilemma as an academic is how we teach our students to be caring and compassionate in a world that demands tasks to be completed in unrealistic timeframes.... and why are we producing young nurses that do not have a caring philosophy.....

Tip to nurses.... you never really know who the person you are looking after.... therefore be kind, caring and professional to all.... treat your patients like you would like to be treated yourself... and if you are having a bad day stay home..... don't inflict it on your patients.....

Privacy Act: patient consent to collect and disclose information:

2011-03-30T22:23:00.003+08:00

This is a gentle reminder for all privately practicing midwives to get patient / client consent to collect and disclose information, especially now that there are eligible midwives: something else we have to set up for the practice........

All organisations that provide a health service are covered by the Privacy Act (whether or not they are small businesses). Organisations providing a health service include:
traditional health service providers such as private hospitals and day surgeries, doctors and specialists
• pharmacists
• allied health professionals such as psychologists
• complementary therapists like naturopaths and chiropractors and
• in some cases other services like gyms, fitness services and weight loss clinics, child care and schools (if they provide a health service and hold health information).

The National Privacy Principles set out how organisations should collect, use, keep, secure and disclose personal information. They cover collection, use and disclosure date quality
Further information on the new privacy legislation can be obtained from the Australian Privacy Commissioner’s web site http://www.privacy.gov.au/

Don’t leave Privacy to chance:

10 steps to protecting other people’s Personal Information:

1. Collect only the information your require
2. Don’t gather personal information just because you can and just in case you require it
3. Tell people what you are doing with the personal information you are collecting
4. Consider whether you should be using personal information for a particular reason
5. Think about whether you need to divulge the information
6. If people ask, give them access to the personal information you hold about them
7. Keep personal information secure
8. Don’t keep information longer than you need to
9. Keep information accurate and up to date
10. Consider making someone in your organisation or agency responsible for privacy

Use and Disclose example: with my consent, the practice staff will use and disclose your information for purposes such as:
- account keeping and billing purposes
- referral to another medical practitioner or health care provider
- sending of specimens for analysis
- referral to a hospital for treatment and or advice
- advice on treatment options
- the management of our practice

Ensure that you gain the clients consent (best to have written consent) for the practice or midwife to collect, use and disclose personal information as outlined and I understand that I may withdraw my consent as to use and disclosure of my personal information......

ref pic:http://health-link.com.au/PrivacyPolicy.aspx

What’s in a name? Independent; Private Practice Midwife; Eligible Midwife

2011-03-23T23:43:00.005+08:00

As I ponder how to advertise myself on the Internet I look at the possible variables and it comes down to “independent midwife” or “private practice midwife”, so let’s have a look at what difference a name makes:

What's in a name? That which we call a rose
By any other name would smell as sweet.

Shakespeare

By definition: dictionary.com “independent” –an independent person or thing.... not influenced or controlled by others in matters of opinion.... thinking or acting for oneself..... not subject to another’s authority or jurisdiction. – A free thinker.... not influenced by the thought or actions of others....

“private” – belonging to some particular person ( personal belonging)...pertaining to or affecting a particular person or a small group of persons; individual; personal; undertaken personally or individually without the presence of others; alone

“private practice” – independent and not as an employee; mainly pertaining to medicine;

Quote by George Bernard Shaw;

“He said that private practice in medicine ought to be put down by law. When I asked him why, he said that private doctors were ignorant licensed murders.”

Thesaurus.com: private practice by definition pertains to general medical care.... family practice and independent pertains to separate, liberated, free – alone, aloof, self governing

When I did a Google /Yahoo search of “independent midwife” the search generated pages of independent midwives Australia wide and internationally. The Google/Yahoo search with “Private Practice Midwives” generates equally a list of midwives however I have to say not as many as “independent” and more groups and associations....

It is interesting to note that the new Health Practitioner Regulation National Law Act 2010 refers to Private Practice Midwives and makes no mention of Independent Midwives: therefore I think there is a change in terminology .... moving towards private practice....

The upshot of this exercise highlighted that it doesn’t matter about the name women will find you whether you are called “independent or private midwife” so to throw the cat amongst the pigeons I am going to call myself “eligible private midwife”. My rationale for this is to focus on the legislative changes for midwives by highlighting the ‘eligible’ aspect therefore informing women of the ability to access Medicare rebates for midwifery care.

Remember; a midwife is a midwife is a midwife.... eligible, independent, private makes no real difference what matters is that you are a midwife.

The lost art of letter writing: Etiquette:

2011-03-23T20:55:00.005+08:00

I come from an era of when someone sends you a letter, remembering that a letter is in place of the spoken word..... It is polite to respond particularly in business; it was accepted etiquette to respond and say thank you for your letter, we will respond shortly or whatever the reasons are.....this is not the case anymore. Not responding is tantamount to rudeness, being uncivil as if to ignore a person who is talking to you.

Question: Do we put emails into the same category as a letter?

The end of February I sent a letter to our Private Health Fund with a query of an overpayment, this was a substantial over payment and we were keen to find out whether our fortnightly payments were going to be reduced and a refund of the overpayment. Up until last week I had not heard anything, so I rang them to ask had they received my letter. The Health Fund, said, yes we are processing your claim. When I asked “why did you not respond in writing”, their response was “oh we don’t do that, it’s not our policy”...... I asked how am I to know you received the query then... “emm” she said... “I guess you have to wait or call to confirm it has been received” as you can imagine I was less than happy with that response... the outcome was that the young lady assured me she would ring back when the claim had been assessed and completed..... I find this disgraceful business etiquette..... the Health Fund rang today to confirm that they were going to credit our membership... they did not ask if we wanted a refund.... and they were not going to send a statement to show how they came to their conclusions, even when it was asked for they said ‘it is not the way we do business” WHAT!... again not how I thought business should be run.... where is the accountability? what I do know is that if we owed them money...we would be receiving an account on a weekly basis....

Over the last 6 months I have written many letters and emails, mainly business orientated; I have come to notice that I have not had any responses to my letters. I wonder why this is. I have written to politicians, hospitals, GP’s with very little response not even the common courtesy to say thank you for your letter and we wish you well.....or we are looking into your enquiry and will inform you of the outcome. But alas no responses..... There could be several reasons for this.... one they don’t want to know about what I am asking.... or is letter writing just an out dated exercise... maybe I should twitter, or Facebook.... only joking:
Writing letters is about keeping in touch, building relationships and politeness ...it’s about presenting your business and responding shows good etiquette even if you do not want the product.....or service:

I do think as a society we are losing the art of letter writing on a personal level because communication via the internet has exponentially grown and therefore letter writing is not really necessary. Although I do think it is an art worth keeping..... but very few people do it anymore, which is a sad reflection of the times.

picture ref:http://www.pubarticles.com/article-letter-writing-write-formal-informal-letters-notes-1244769964.html

The art of being patient: Centred Midwifery Group Practice:

2011-03-19T22:04:00.006+08:00

The Centred Midwifery Group Practice....it's interesting for me,in my mind the vision of the practice is a complete success, it flows smoothly and seems easy.... however the reality is somewhat different there are so many other variables involved to which I have no control. Yes that might be naive of me or it could be that the vision I have is so strong that it propels me to do the things I do... However the truth is that this is going to be a long slow process and I need to rethink the way forward in terms of my sustainability and how we are going to get collaboration working.... as my friends, colleagues and family keep telling me that “Rome was not built in a day” and it has taken us 20 years to get Medicare rebates for midwives.... a valued colleague said yesterday “ you are going to fall on your bottom and few times...the trick is to get back up and keep going,” “why are you surprised?” ......The answer is that I have a vision and the vision doesn’t have the stonewalls..........

The story thus far: The Group Practice has a brilliant dedicated team or midwives/consumers working to build the practice: We owe Berry Digital Design(Cass) an enormous Thank you she has done all our logo designing flyers, business cards / letterheads/invoices/receipts etc, printing and all pro bono...I highly recommend her so check out her website: if you want any designing or printing done. We have our email x6 is setup secretary@centredmgp.com and director@centredmgp.com the website and blog is coming as I type... so watch this space.....Our rooms are at the Conscious Conception and Birth Centre and we are now setting up the office with equipment: if anyone has a phone fax and photocopier/computer they would like to donate please let me know: Medicare provider number obtained, Insurance paid, pathology and diagnostic rights have all been secured and we are working on collaborative arrangements with the local Health Service..... this will take time: Most importantly we are starting to get clients and this is what keeps us going.... our practice is about offering women choice the choice to birth with a known midwife.... continuity of midwifery care....it’s about having time to talk to women, engage and build trusting relationships with women and their family throughout pregnancy birth and the postnatal period...

It is an exciting process setting up a new midwifery group practice in WA....
The next step is to go and visit the local hospitals, MP’s and GP surgeries to introduce the Practice and rally up support.... go to consumer meetings and get the word out there.....and last but not least advertising for clients....... it really is very exhilarating watching it all coming to fruition.
We need more midwives to pick up eligibility..... if you are an experienced midwife and want to work with women in the community, that is at home and hospital births please consider this option....contact me for more information about the process that is required for eligibility it’s not difficult you just need three years post registration working across the continuum of midwifery: or visit the AHPRA website and follow the links to eligibility:

As for me.... it is practising the art of patience’s....slowly, slowly, slowly..... Diplomacy and political lobbying; continue meditation... this has really proven helpful in slowing my mind chatter and keeping a calm demeanour...
Watch this space for our grand opening...... date coming soon......

Rules of engagement and Facebook:

2011-03-18T23:21:00.006+08:00

Firstly I want you to think about why do you engage in Facebook (FB)? What is your primary focus?...this question is very important as you will read further into this blog. For me it is about connecting with people, friends, associates, overseas family, local family, it’s about linking, networking and disseminating information.... FB is one of the fastest growing social mediums in the world...it is changing the way we communicate.... I see it as a fantastic way to get information out to the cyber world..... and remember it stays there forever:

A recent study shows that 54% of Australians use FB.........

Recently a friend described and instance where she was reprimanded in her work place over a Facebook (FB) comment, in fact she did not write the comment she ‘liked’ the comment; I thought that the reprimand was a rather excessive step, so I delved into the possible legal implications of such an activity and have decided that there are some specific rules that you need to consider when engaging on FB.... in fact we all know the rules I think that often people believe the comments they are making are so ambiguous, insipid or insidious that it won’t be connected to them or their work place..... Think again.

The term ‘friend’ on FB is a false term it lures you into a artificial sense of security; come on think about it.... how many of us really have 200-300 friends in real life?.... when I was growing up they use to say “if you are lucky, you will be able to count your true friends on one hand”..... In FB the people I allow in yes are called ‘friends’ and some truly are but the majority are valued colleagues, acquaintances, ex students, friends of friends...etc... not what I consider true ‘friends’, I have to say I like them otherwise I would not invite or accept them..... but in the true sense of the word friends.... most of them are not.... please don’t misunderstand this.... but it is a fact of life: Therefore I go back to the question Why do you engage in FB? You have to really consider who you let into your FB world and what you publish. Keep work and FB separate.

After doing a web search regarding some legal issues on FB... I have come up with a list of rules that might help you keep out of trouble in the work place or anywhere else relating to FB.

Rule 1: really consider carefully who you are letting into your FB as a ‘friend’, if you allow mangers, work colleagues/associates this means you let your work into your private life. Ensure you have a closed privacy setting.

Rule 2: Do not mention anything to do with your work place no matter how insignificant you think it is... if you can be connected to your work by your comment you probably break the golden rules of ‘confidentially’ and ‘Code of Conduct’.

Rule 3: Be mindful of the photos of yourself you allow on FB, these photos become the property of FB and if you are acting in an unbecoming manner this could come back to bite you later. Don’t allow people to take your photo without asking you and letting you know if it is going on FB.

Rule 4: Do not write on FB when you are angry or under the influence of alcohol once the information is in cyber space it stays there: Internet Defamation is the fastest growing litigation ....so don’t write anything derogatory about anyone.

Rule 5: People seem to believe what you do outside of work does not affect your work life....WRONG....this is dependent on what it is and if you have you bought your profession/company/school into disrepute? Just think of our footballers .....there is a prime example of unbecoming behavior.

Rule 6: Social responsibility: this is like a duty of care to society, a reciprocal duty: we owe society and society owes us a mutually beneficial obligation. Be kind to each other.

The bottom line FB is on your employers radar; remember be careful who you invite in your world, don’t talk about work, don’t say anything derogatory and be mindful of the photos you let FB have:

Have a read.. How to use FB without loosing your job over it.....
Happy Facebooking!!!!!!!

Busy, Busy, Busy, but loving it:

2011-03-12T22:01:00.007+08:00

Life is a wonderful journey with lots of lessons to learn... however I can't believe that I can still be so naive in terms of maternity reform. I have so many things to blog about its hard to know where to start:

Friendship: my friend returns to the UK this evening ...yes I am sad because we have so much in common and it is nice to share with someone who accepts you for who you are and knows your failings and understands your vulnerability: we may not see each other often these days but each time we do its like we've never been apart..... there is something so special about the kinship that women have with each other....

This now brings me to my spiritual journey.... Buddhism and mediation: there are many different categories within Buddhism... the one I am exploring is Kadampa Buddhism.. I am half way through the eight steps to happiness ( 8 week course)...which at times really has tested my way of being...the fundamental way of my thinking processes is being challenged: "May I take defeat upon myself and offer them the victory"..... I am having huge problems with this.... yes I can hear you say... that's because you have an ego problem...and maybe I do.... but it is really hard to do this...so I have been taking little steps.... I just don't say anything malevolent ... I just keep quiet... and I don't think it either...I try to work out why I am so angry or upset... and cherish them instead...and I have to say I think it is working slowly...I did say slowly... but it is making me rethink the way I say things....I don't think I have quite reached Abraham Lincoln's philosophy; The best way to destroy an enemy is to make him a friend; the journey continues.

Maternity reforms: this has been very frustrating these last few weeks... and I have had to cherish many times on the phone when I am getting blocked at every corner...requesting pathology and radiology access has been problematic...the reforms have been in place since November 1 2010; yet all pathology and radiology depts have not prepared for this process....I have had almost every excuse under the sun...such as databases need to be changed, it has to go through the billing committee... even staff education has not occurred.....so we cant give you access until all this has been achieved....FRUSTRATING.... I have noted on the Medicare webpage that they have PBS forms already but we can't use them as there are no approved courses yet.... strange this is available.... anyway after a few weeks of inconvenience the pathology process for two companies and one radiology dept has been approved... so this is good news it will be smooth sailing from here on in......

Good news....the process has began, my first pathology and radiology requests went through without a hitch....my woman at 13/40 has had all her first trimester screening completed.... should get the results next week....it is a fantastic feeling for both of us.... to have the complete package of care... just brilliant.....watch this space for more...

Singapore was dazzling, I just love the teaching, the students are keen, enthusiastic and in the workshops they never cease to amaze me with there wild imaginative stories there is never a dull moment....I spent most of my time teaching and in my spare time at Sim Lim Square the techno junkie's toy shop....visited my local Buddhist temple had a philosophical discussion about lying with a monk....ate chili crab and to die for satay sticks.... oh and I forgot I tried an ice cream sandwich... yes with coloured bread....

A Festschrift to celebrate the careers of two remarkable women:

2011-02-19T22:31:00.009+08:00

I was privileged today to find myself sitting amongst many wonderful people and some great academics, I heard many wonderful stories of two amazing women who have had diverse and awe-inspiring careers which has had tremendous impact on the midwifery profession and will do for many years to come, Pat Brodie & Nicky Leap.

Until today I did not know what a “Festchrift” was, I meant to look it up on the internet….but just did not get round to it…. So was relieved today when I heard lots of people had no idea what it was…..and that it actually means “a living book of your life” a celebration of your career by others on the occasion of retirement, what a fantastic idea, just brilliant….. Someone likened it to being at your own funeral, except you are there to enjoy it….. but then Pat said it would be a very long funeral” ….. to me it really is a bit like “this is your life”.

There was opportunity for great networking….. Too many wonderful people to name them all …. Besides you all know who you all are…great to see you and have a chat…. The energy and inspiration goes a long way to maintaining your enthusiasm for when you get home… and need to carry on the task of change and ensuring women have choice and midwifery care…….

For me it was an inspirational day, the room was filled with liveliness….. my soul was rejoicing at the many possibilities for midwifery…..if only we had this sort of leadership everywhere in Australia….some places are truly isolated and continue to have an uphill battle…..we need to spread the talent….

Key take home messages that resonated for me ……

“Square peg in around hole” - midwives
“The less you do the more you give” – care in labour
“Every woman needs a midwife and sometimes a doctor too” - collaboration
“Community based continuity of care for all risk categories of women” – private practice
“The key is good collaboration”
“Morbidity of women during childbirth is only going to increase due to repeat caesarean sections and the obesity crisis…..” – Obstetrician
“Midwives are essential for primary care”
“Address the equalities of women and birth”
"From little things big things grow - Group practice

A truely wonderful time in Sydney..... the only downside was that I didn't stay an extra day or two do some shopping.....not that I have money for shopping...lol

Homebirths in the news again....

2011-02-09T22:49:00.009+08:00

It is interesting that the debate is always around homebirth...is it safe or not.... however should we ban hospital births because babies die there as well. The language used "doctors divided" "the Health Dept" is allowing homebirth to continue... where is the choice factor here for women.. in fact where is the discussion with the women... in what other form of health treatment do you get autonomy so blatantly ignored as in this one...if someone refuses treatment the doctors accept this ...why is it so different in this instance.... Women have the right to choose where and how to birth....a well informed woman will make the right decision for herself and her baby....no where do I see any of these considerations here.

See the full story on 6 minutes Doctors divided over homebirth reports
We all know that statistics can be manipulated.... and the figures don't break down the women who choose to birth at home when they know their baby is going to die through an abnormality.

I would also like to know if BBA (Born before Arrival not planned homebirth) and en route births are registered as a hospital or homebirth.... also we know that statistics can be manipulated to which ever outcome you want....the figures also do not separate the women who choose to have a homebirth whose baby has an abnormality:

The other group of women that are missing from the report are the ones that Freebirth.... this is an unknown entity...we know it happens and these figures would alter the homebirth outcomes.... so really we still don't have a good indication as to the statistical value of the current outcomes.

The more the medical profession demand that women birth where they want them to the more the divide will grow…. It is time to listen to what women want…. The choice to have information and make and informed choice whether it is one the medical profession agrees with or not…... It is called autonomy. Dome doctors are openly hostile about homebirth. It is about communication, trust, building a therapeutic relationship, not based on fear, it is about being flexible and learning new ways of doing and communicating with women about birthing options.

The one thing that’s a reality is that women are being bullied and made to feel guilty, for choosing a homebirth. Their autonomy is being eroded and paternalism reigns supreme. It is time to change this……its about informed choice and autonomy.

Medicare and the Midwife

2011-02-08T20:55:00.005+08:00

The journey to obtaining Medicare Provider number has been an interesting one..... Now to learn all the things I need to know about what and how I can claim......
The Medicare provider number is a unique number issued by Medicare Australia to registered health professionals. They are also used to identify health professionals. As a health professional you need a provider number for each location you work..... Therefore I have two... one for the office and my home is the other one.
Currently a midwife can use the provider number to refer to a specialist or for pathology and diagnostic imaging, once we have done the required course in pharmacology then we will be able to also prescribe......
A provider number does not necessarily mean you can attract Medicare benefits for the services you provide.
Before a health professional can attract a Medicare benefit, they must satisfy legislative requirements set out in the Health Insurance Act 1973 which for midwives is the Determination – see Midwife Reform Legislation Fact Sheet.
Medicare has a great online service which makes it easier for you to do business with Medicare Australia; It will make claiming and downloading forms much easier.....also online e-learning, I just completed a couple of e-learning packages.. can't wait for the prescribing course.... one would think that this would of been in place already.
I think it is great that women will be able to claim for midwifery services.... it is long overdue....

The question is do you use a partograph or not?

2011-01-28T22:36:00.010+08:00

The partograph or partogram graphically represents key events in labor and provides an early warning system for the health professional caring for the woman. Until recently I had not given this much thought, I just accepted as part of my practice. I would use a partograph as part of my normal care in labour. I do notice when I go to different hospitals how they all vary slightly. Some are just cumbersome, some not practical and some just down right difficult to use......... and as for that action line....that is a different question all together... I would happily use a partograph without the action line...because part of my normal practice is to know that if the woman is at 4cm and contracting well (3-4:10) then her cervix is dilating and I would make a mental note that in 6 hours I would expect to being seeing signs of being fully dilated.

I understand possibly the need for a partogram in the hospital setting when you have several people looking at the notes; therefore there needs to be a quick review process. However in a home setting you are the only person as well as your partner midwife looking at the notes...so I question the value of using a partogram:

As I was doing a search on the web looking for a partograph template, I found lots of literature supporting the use of the partograph and the action line in preventing or recognising obstructed labour. In fact The World Health Organization partographs are the best known partographs in low resource settings. Some people argue the partograph is essential for good decision making.....and therefore is considered best practice...

A midwife is legally bound to document to clearly / comprehensively all our care, recognise / interpret /act / inform on abnormalities found in a timely fashion however does this mean she/he has to use a partogram to do this?

I am thinking that it is not necessary to use a partogram in the home setting if your documentation clearly tells the story.

What do you think?

can you write your notes in a fashion that does not need a visual expression of what is occurring? and does it make a difference using a partogram?

please leave me a comment on what you think?

Insurance for Midwives:

2011-01-23T21:01:00.006+08:00

Now that I have a Medicare Provider number & eligibility it's time to consider my insurance; the options that midwives have are:
A government supported insurance through MIGA (The Medical Insurance Group) or Mediprotect insurance;

The question you have to ask is which insurance do you choose? here is all the information: an important factor to consider is which company offers run-off-cover:

Read MIGA information Booklet:
Frequently asked questions:
Payment options:
Risk Managment workshops:
Maternity Care Plans & Collaboration
Product disclosure Statement:Application form:

Mediprotect - Vero - wording of policy document:
Application form:

As you can see from the summary of information available.. there is more information provided by MIGA than Mediprotect:

The most important factor for me is, I need intrapartum cover when birthing in a hospital as a private practice midwife and run off cover; therefore my choice of insurance will be governed by this; I have therefore applied with MIGA and will see how much my costs will be, although I have a good idea of what it will be.......

I have also sort guidance from my accountant and lawyer.....so that I am fully aware of my requirements.....it is exciting times....

Writing My Memoir Journey:

2011-01-21T22:59:00.005+08:00

Ian and I have come down to Margaret River for a well earned break just for a few days; as usual we spent some time in the Margaret River bookshop...and I spotted this book “write your memoir – the soul work for telling your story” by Dr Allan G Hunter....what attracted me to this particular book is that it refers to your writing as your soul work, that resonated with me, because I think that when you write your life story you have to also be thinking at a deeper level and this may also bring about change...so I had to have it...my wonderful husband Ian bought it for me.

Ian is such a patient man, he supports all that I do, he must think there she goes again...another project started. In his wisdom, he said ok, this is a great place for you to start writing, and he is correct it is tranquil, nature surrounds, the birds, butterflies and flies for company and the occasional truck or car that flies along the road, just to remind you that life goes on. I start to type away on my computer under the grand Oak tree that has its own stories to tell, I can at least say the memoir has begun.

I have wanted to write my story for many years it is something I want to do for myself and I did begin several years ago compiling a timeline of events to keep me on track, I will have to put it together with this work and keep writing. This off course is a long term goal, so I will chip away at it slowly. We have decided that it would be good to book a regular yearly holiday to Basildene Manor to keep the project going.... and Ian well he is sitting beside me listening to his ipod story..... enjoying the same wonderful peace and quiet.....

Busselton Jetty:

Medicare Provider Number:

2011-01-21T22:16:00.008+08:00

At last I have my Medicare Provider Number.... yeah...First eligibility,(see blog how to apply for eligibility) then Medicare Number and Insurance... all set to go.... website, business cards, flyers, something is missing.... yes the "women" wanting continuity of midwifery care.... I have booked my first woman.... and so life goes on... poor Ian is wondering how we are going to pay for the insurance......???

Applying for a Medicare Provider Number is relatively easy, however I have to say for WA applications are not processed here they are sent to Canberra so might take a few extra days for this reason..... interestingly you have to provide a signed form for every address that you will be working from and you will receive a provider number for each location.... for example if I was to work out of two officers, I would give each address and for a home visit I will use my home address as the office... therefore potentially you could have several address and provider numbers...

I have sent my application for my MIGA insurance today... and hopefully that will take a week or so to sort out and then I am set to go.....this is an interesting journey.... a brave new world....

My Road to Meditation:

2011-01-17T00:11:00.008+08:00

I dabbled in meditation back in the nineties and met the Dalai Lama when he came to Perth…. I subsequently read his autobiography and thought that if I was to have my time over again I would be a Buddhist. I continued to be a part time practicing Catholic and turned more to being spiritual rather than religious. I read books about quantum time (physics), Road less travelled, You Can Heal Your Life, My Mother Myself, A Course in Miracles and many more…..trying to find a sense of spirituality… life got busier and busier and both religion and spirituality took a back seat…. Never leaving… always at the back of my mind but never that priority.

My recent trip to Tanzania I was touched by the strength of the ordinary Tanzanian, the courage in the face of adversity…. The pain that people suffered and accepted as part of their life….what was unbearable for me was to see children suffering in hospital… from the baby that was crying and needed comforting and no staff to do this, his nappy changing and there was no nappy…. Or the toddler that was screaming because he was being bathed in Potassium permanganate dissolved in warm water to come up with a nice pink colored solution, having his burns debrided with no pain relief, it brought tears to my eyes…… I was both humbled and frustrated…. The disparity between rich and poor was at times palpable. The health issues seemed so insurmountable, that I need a way to stop my mind from churning…… I realized that my spirituality was missing… it was not even dormant it had gone……

Last year was very busy and stressful particularly then end of the year was even more so, after I came back from Canberra, I was at breaking point and realized I needed to stop….. I had decided to either go back to church on Sundays or start meditating….I usually go to midnight mass, have for the last 30 yrs… there was a new Parish priest at the church I usually go to… and it was the worst service I have been to for a very long time….no inspiration…… there was nothing….I was like a stranger, I came away knowing I was not going back….

I did an Internet search for a Buddhist retreat starting in January…and would you believe it one was starting on the 2nd January…. I booked in for the week and I have not looked back since then….. I felt like I had found my way home……very strange…. Time will tell how I go….. I feel calmer…. My mind is less chaotic and I now have strategies to slow it down…..I have set myself some boundaries as far as work is concerned…. And am working on my discipline to continue with my meditation on a daily basis with a quarterly retreat to keep me focused…I found a meditation centre here in Singapore and went this afternoon, which was a great end to my teaching weekend……watch this space...

Happy Chinese New Year "Rabbit" Happiness and Prosperity to all....

Ethical /moral points of view:

2011-01-15T22:12:00.009+08:00

I really enjoy teaching in Singapore the array of different cultures and ethical / moral points of view always make me reflect on life and consider another point of view: Ethics and morality are often interchanged…. Some people confuse ethics and think that it is ethical standards or a code of ethics even religion, which it is not…there is a subtle difference between ethics and morals….. Ethics is how society views social structure where as morals are a personal characteristic which often includes a religious flavor…. However generally people use the terms to mean one and the same…. Let’s face it morals are influenced by our religious, spiritual, cultural, scientific or learned experiences. Ethics goes one step further than morality in the sense that we have ethical theories (Utilitarian & Deontology)and principles, such as autonomy, beneficence, non-malefence, justice and veracity. Peter Singer states “Ethics has no necessary connection with any particular religion, nor with religion in general."

Interestingly I believe as we get older we generally change our point of view…. I think with maturity comes an understanding and wisdom and letting go of idealism. I think back to the days when I was a nursing student at 18… young and idealistic; I wanted to save the world from its self… I was given this knowledge as a student nurse and it was fantastic…. This particular day I was working in a rehabilitation ward looking after an elderly man recovering from major surgery, taking his blood pressure…and suddenly there was no blood pressure… I looked at the man and yes he was grey, pale, he had just passed away as I was talking to him….my first instinct was to resuscitate him…..so I did… when the team arrived someone read his chart and said….”he’s not for resus so maybe we shouldn't be doing this” I looked up and continued for a few more minutes then stopped. The man had died. The matron who was a nun asked me to see her in the office….. I had no idea what I had done wrong…. She asked me why did you resuscitate the patient. I am embarrassed now by my answer…. But I said… “God has given me the knowledge to resuscitate this man if he wants him to die he will die anyway”. The nun just looked and me and said nothing…..As I look back I can see I thought I knew best…. Ask me what I would do today…. I would respect the patients request not to be resuscitated…. I am not saying all young people are like this but I do think as we get older our morals, values and ethical views change due to our life experiences…. That is just part of life and getting older……

As a health practitioner I maintain that you have to have a good sense of “self” in order to care for your clients. That is understanding your own moral and ethical grounding, this sense of self awareness allows you to understand why you react in the way you do and allows you to step back and not be judgmental in the care you are providing to the client. I must say I did not become self aware until I was in my 30’s.

As we know there is no right or wrong when it comes to discussing ethics; however when you focus on the hard issues such as capital punishment, abortion, organ transplant, euthanasia, genetic testing, and allocation of health resources the students came up with some pretty black and white answers, they are rather pragmatic about the whole issue. Singapore’s Medical Council is currently reviewing its code of ethics to keep in line with the advancing technological age (biotechnology) and the demand for organ transplants and genetic issues. This is an attempt to hold the health profession more accountable for decisions made within these areas.

Recently President Obama called on Americans to “expand our moral imaginations, to listen to each other more carefully, to sharpen our instincts for empathy, and remind ourselves of all the ways our hopes and dreams are bound together”. This was an attempt to defuse the abortion debate in America which often reverts to violence due to such opposing views. But the reality is we all worlds apart in finding solutions – everyone has their own idea about polices and justice. Often our moral imaginations are so divergent that never the twain shall meet.

When I asked the students how valuable do they consider human life within today’s society? Everyone said it is valued, and yes it is wrong to kill another human being; except if they have killed another person…..(Singapore has the death penalty) I then asked what about drug traffickers? They haven’t directly killed anyone. Again most agreed that yes they deserved to die because they contribute to someone else’s death or changed circumstances; even though they are really only the carrier or victim because the real culprit is rich and to clever to be caught….this was food for thought. So in essence the wrong person is being killed: In order to question the rules of society I then asked what about the woman who is stoned for committing adultery….(not in Singapore). In this instance the person that is being killed is the woman; the man did not get the same punishment. This did generate some discussion and most agreed that this was wrong……however most agreed with the philosophy that if some takes a life theirs should be taken.

Abortion always creates a debate…. No one can agree on this topic, I wonder if the world will ever reach a consensus on this; Pro Choice v Pro Life; with a multi-cultural, multi-religious class it was an interesting discussion at least there was a discussion and an expression of opinions however the divide still remains; does life begin at conception? Or when the fetus moves @ 16 weeks or when the fetus can live independently from its mother? Is abortion under 12 weeks acceptable? What about late term abortion for abnormality or not? All these questions need to be explored by the people and policy makers in a peaceful and respectful way.

The ethical debate will continue on many subjects, should the alcoholic or drug addict have a liver transplant, the smoker have a triple bypass, what if a prisoner for murder needs a kidney transplant.....Should the pregnant woman who is a drug/alcoholic be in prision?(as they do in America), I hope this never happens in
Australia, the list is endless... what is the individuals responsibility towards health care....rich v poor.... if you can't help yourself in improving your health care.... should the government support your treatment....? we are spending billions of dollars on health care.... what is the solution? the debate about health care resources continues.

My plans for 2011

2011-01-01T20:26:00.006+08:00

It would not be a New Year without setting some goals, writing them on your blog makes it harder to break and you are more accountable.... I find it very useful each year to reflect on the year gone by and plan for the following year... some of my goals are as a result of reflecting the year gone bye..... one decision I have come to as a result of my trip to Tanzania is to spend more time on my spirituality. Equally importantly I need to reduce my stress levels.

Spirituality: - Dharmapala Buddhist Centre – starting January 2nd with a week guided meditations – I am committing to the first week four sessions a day for the first two days.... and then two evening session for the rest of the week... then I will do the evening sessions... My aim is to meditate each day and go at least once or twice a week to a group mediation to keep me focused.

Study – Must complete my assignments on time.... devote more time to my study and learn to say “No” to anything that interferes with it......

CeMGP – Centred Midwifery Group Practice – much is required this year, I am so excited about the success of this practice...continuity of care is the focus... advertising, clientele, staff..... I am really excited about this business and its growth.... the website and blog is coming by the end of January.

Work – I have reduced my teaching hours.... starting a new curriculum therefore much work is required for my units.... Singapore is exciting and challenging...and I am not ready to give this up... I am looking forward to meditating in the temples when I next visit.

Clinical Practice – I will be signing up for casual midwifery work...the decision is which hospital and probably a shift or two a week...

It is an exciting year and I am really focused this year on getting my spirituality & study on track then every else will fall into place.

6 Key points to keep in mind this year;
Spend less, watch my weight, be less wasteful, exercise 5 out of 7 days, meditate everyday, keep a work life balance.

I am determined and dedicated as always to put women and midwifery first for greater choices for childbirth.

Photo reflection 2010

2010-12-30T16:05:00.000+08:00

An extraordinary year:

2010-12-30T12:04:00.011+08:00

As the end of the year sets and the New Year dawns we often think of the year gone by…at least I do…it seems to me that the years are getting busier and time is flying bye…this could be a reflection that I am getting older however I don’t feel older, but sure as hell my body keeps reminding that I am….

As this has been a humongous year in line with my recent trip to Tanzania I am going to list the 10 highs and lows of the year: it is so handy having a blog to look back on to jog the memory when so much happens in a year.

Top 15 highlights for 2010 – the order is not significant

Meeting the Prime Minister (K Rudd) & Health Minister
Listening to proceedings in Parliament and hearing the words 'midwife' 'midwifery' continuity of care' spoken so many times and in a positive light
Teaching in Singapore / Meeting up with friends in Sydney
Putting in Submissions / politically lobbying
24hr Virtual IMD Celebrations (Sarah Stewart)
Linda’s Holiday – Perth to Carnarvon – (being a Skype Midwife)
Sitting on Uluru….breathing in the atmosphere
Making a decision about my study – starting a new degree
News of a new Grandchild (April 2011)
Medicare Provider Number for Midwives
Gaining Eligibility
Starting Centred Midwifery Group Practice Inc (CeMGP)
My Tanzanian experience
Family, friends & some great work colleagues

The Grandchildren

Jasmine started Yr 1, Dylan Pre-Primary, Jessica Kindy
Talia coming into her own, starting to stand up for herself,
Sam, Isabella and Logan all going through the terrible two’s

Top 11 Disappointments:

The division over collaborative arrangements and the Determination 2010
Homebirth debate / Insurance issues
Miscarriage in the family
Election dirty politics
Factions within Midwifery
Lack of team work and loss of integrity from esteemed colleagues
Bullying issues
Muffin passed away
A better disciplinary process (Hospital) for midwives using their piers
son-in-law having a back operation
Seeking & acting on legal advice for defamation

As you can see the highs thankfully outweigh the disappointments….and my lists are not exactly 10…. See you have to be adaptable in life…best laid plans of mice and men...lol.
Wishing everyone that reads my blog a happy, peaceful, safe and successful 2011:

Thank you for a wonderful Christmas

2010-12-26T00:13:00.004+08:00

I have not felt much like Christmas this year, partly I think it is that I have not had much lead up to Christmas: This is the first year I have not taken the grandchild to carols by candlelight.... something I really do enjoy:

Midnight Mass was uneventful, the Church was not over flowing... usually it is standing room only....but this year it was 3/4 full... there was a new priest...and I was not use to him,... I was not inspired by his sermon.. another first we sang Happy Birthday to Jesus... a strange concept for me... in all the years I have gone to Midnight Mass this was a first...I was less than impressed.... again I am not sure why....

Christmas morning for me is relaxing...the family come over late afternoon, however my daughter Kirsten (who stayed over to help) stated..."I've never known Christmas morning to be relaxing... preparing for Christmas dinner for 20 plus".... different concepts on what is relaxing... but you see for me that is relaxing....the thought of preparing a feast....pleasing all the children with a banquet of wonderful food, Turkey that melts in your mouth.... beef fit for a King, ham, asparagus salad, peas with pancetta,cauliflower gratin (made by Margaret K)green bean and broccolini balsamic salad, roast potatoes, pumpkin, stuffing balls, onions and of course Yorkshire puds and gravy: Fruit salad, Christmas cake, panettone, chocolates, ..wine,juice, beer.... etc.

Most of all I love it when Santa comes and gives all the children there presents... I love watching the excitement when they open their presents...it is such a delight. Christmas for me is about family, friends, children, love, giving, good food, laughter and fun....I had the best Christmas ever and I am so grateful for a wonderful family: God Bless You All......love mum xx

First Eligiable Midwife for WA:

2010-12-24T08:21:00.007+08:00

At last on my return from Tanzania I received a letter from AHPRA (16th Dec) that they had met on the 2nd December and have approved my application:

"An eligible midwife competent to provide pregnancy, labour, birth and post natal care and qualified to provide the associated services and order diagnostic investigations required for midwifery practice. In accordance with relevant State and Territory legislation.
Eligible midwife, but NOT qualified to obtain endorsement under section 94 to prescribe Schedule 2, 3, 4 & 5 medicines required for midwifery practice in accordance with State and Territory legislation".

It goes without saying that all midwives once you have successfully completed your course are by definition eligible midwives, we just have another criteria to get now for legislation and that is "eligibility" (three years experience post registration across the full scope of midwifery).... see the AHPRA website for more information.
A notation goes on the public register so that anyone can see if you are eligible or not.....
Next step is applying for a MBS provider number, I will be doing this between Christmas and the New Year;
One of next year's plan is to complete the Prescribing and Diagnostic courses....which are not up yet.....but will start following this up... Roll on the New Year..... NOW come on all you WA midwives start applying for eligibility:

ref pic: henry.k12.ga.us

Midwifery in Tanzania

2010-12-22T22:12:00.013+08:00

This is a snapshot of midwifery in Tanzania from my perspective, it does not refer to anyone specific, the judgements are made from my personal observations:
Tanzania a country in which health resources are minimal and much help is required: the lack of staff, general caring and privacy being high on the agenda.
Clean room

In the public hospital the labor ward has approx 12-14 beds; the beds are hard and there is no visible linen, the windows and doors remain open and there is a problem with flies. I did notice curtains around some of the beds, but they are rarely used. The ward is split into three sections, with a resuscitation area for the babies, however I did not see any resuscitation equipment.

Labor bed

There is a long wooden bench for the women to sit on after birth; and there is a clean and dirty room, however it is a stretch of the imagination. There is a small room attached that has four beds and this is called the eclampsia ward...... the incidence of eclampsia appears to be high, and the antenatal care is insufficient in the prevention of the condition... this could be due to the low resources therefore not enough education. There are some rudimentary posters on the walls for treatment of PPH and Eclampsia, generally the ward is constantly busy, noisy often used as a thoroughfare.

A normal 24hrs could see anywhere from 74 – 120 births; on the days I spent there the average birth rate over 24hrs was 75-85 births a quiet time; the lack of staff is a massive problem and the ward is laden with students; as I commented in my nursing in Tanzania blog.... the structure of nursing is very different to Australia.... nursing and midwifery are together in every course and I suppose this also will assist with the shortage of staff.... just to remind you of the career structure..... enrolled nursing & midwifery is now a 2 yr course ( previously 4yrs) entry level is equivalent to yr 10 (form IV), as student midwives these students conduct 20 normal births and 10 high risk (breach, face, brow presentations etc) supervised by a qualified midwife. Diploma nurses and midwives if they have moved up from enrolled nurses will do a further 10 normal births and 5 high risk, and this takes a further 1 yr, also supervised by a qualified midwife. Diploma nurses/midwives straight from school good scores for form IV, three yr course. These nurse/midwives if they want to convert to a degree course will have to do another 3 yrs (6yrs in total). Lastly there are degree nurses and midwives (3yrs course) entry level form VI (TEE / TER level) these students require 30 normal and 15 high risk births. Confused......it took me a while to work it out.....

Part of the problem is that students outnumber the registered staff... and you don’t know who is an enrolled /diploma or degree nurse/midwife student until you ask and then I was still not clear who is accountable for what. On my shift there were 6 students and 2 registered nurse/midwives and a doctor........ at one stage I had four labouring women at fully with just me myself and I.... oh and my nursing students (as if in a maternity setting) it was frantic.....The African women need to bring with them 4 Kanga’s..... these are traditional cloth /dress, pieces of material (2 meters long) one piece is cut in half... so there are two for the baby.....the women use one as a sheet on the bed, they often have one they are wearing and the others are for after the birth and the baby.....often the women are naked, privacy does not seem to be an issue..... People walking in and out of the labor ward as if it was a thoroughfare.... flies were annoying.... it was hot/humid everyone was sweating, no way of cooling down.....there was no visible water anywhere, at times I felt useless and helpless.....I allocated my nursing students to stay with each woman attempting to provide some comfort.... and encouraging them to drink some water, which the women bring in themselves; I found a pinard on the desk, so was showing the students how to use one....there was no electrical fetal monitoring.... (not such a bad thing).

Delivery pack

Two women had syntocinon running, so I listened to their fetal hearts first.... all seemed well.... then I moved to the second two women..... These two seemed to be going head to head as to who was going to deliver first..... I called out for some help..... and a doctor came forward.... he was less than helpful....however he did yell for someone else to assist.... whilst he was with me I asked if he could translate to my women as I wanted her to stand up or turn over to aid her birth..... his response was “no we like them on their backs so we can see what is happening” he promptly called for a student midwife to assist me and yelled at the women to push harder......I regretted asking him to translate..... as we were preparing for birth.... I found the delivery pack.... but could not find a cord clamp..... by now the woman was pushing well the student midwife had disappeared momentarily ..... so I asked my favourite doctor who had taken his spot at the desk... watching the events...no curtains.... three naked women in the room all pushing....”excuse me, I can’t find a cord clamp I ask”.... “ ah you want a cordie clampie ask the woman or look in her bag, she has them”..... now the student has returned... and I am informed that the women bring in a cord clamp, a roll of cotton wool for the birth and her kanga’s, food and water for herself. If the woman does not have a cord clamp you find some cotton or tear a piece of material to tie the cord.... thankfully the woman has purchased a cordie clampie.....I could not find the scissors to cut the cord.... emm that’s because we use a blade....at one stage I needed to clean around the perineum and asked my student nurse for a paper towel..... forgetting where I was (the poor student went looking for one until I called sorry forgot where we are, we both nervously laughed) it was tough to use cotton wool for everything....it is hard doing a vaginal examination using cotton wool....it was a beautiful birth....a truly special moment...third stage went well, syntocinon given as usual.... the woman was exhausted...now it was time for her to get up and go and sit on the bench... I had taken too long and the student midwife was hurrying me along.... it was only 40mins after the birth..... the student midwife cleaned the bed with the two dirty Kanga’s, “I asked what happens to them now” she continued to clean the bed, rolled them up and put them in a plastic bag and gave them back to the woman...... no laundry required.... the woman sat on the bench drank her water and had a bite to eat (a piece of bread I think)... and started breastfeeding....

We then weighed the baby..... the woman was then transferred to the postnatal ward (we walked her across) within 90mins..... she then stays on the ward for 6hrs and walks home or catches the bus with her baby..... the postnatal ward may have two or three women to a bed.....I counted 12 beds, saw no baby cots...... the women lay exhausted on the bed with their babies...some crying...soulful eyes watching you... they have a resigned look on their faces...as if this is my life.....the nurse is sitting at the desk......the ward is packed a sea of faces.... there were be a couple of nursing assistants walking around assisting with breastfeeding.....it was heartbreaking, poignant and I was sadden by the obvious pain of life.

Resuscitation bed

It wasn’t long before there were two more babies..... All healthy and well.... the last woman was having difficulty and was going for a Cesarean section..... they don’t have forceps or ventouse births in this hospital, however I could see the benefit of using a kiwi cup ...... but that’s a different story.....the Cesarean section rate is about 20% and on the increase......only about 40% of women birth in the hospitals, the rest are out in the rural areas.....

Traditional Birth Attendants

We did visit a dispensary that was well equipped for births and I did meet some traditional birth attendants..... who also state they birth women on their backs on the floor... I did find this interesting.... I tried to share my experience of changing positions and it was met with great laughter.....

Transport poster rural area

In the rural clinic the women come whenever they have time or feel they need to attend.... with their first babies they seem to be more vigilant and clearly the more babies they have the less inclined they are to come to the clinic early they normally show up at about 32 weeks.... the clinic we visited was 2.5 hours away from the hospital.... and transport if things go wrong is difficult..... they often have to cope or find alternative ways of getting to the hospital.....

My students really enjoyed this placement and I am sure that 4/5 students will go on to do their midwifery; for me I was dismayed and the visions stayed with me for days and I am still troubled by the conditions that women are in.... and I would be keen to be able to help in a more substantial way.........The issues that struck me most: Technology v no technology: Caring / compassion v no caring / compassion: women being totally alone with no support: the total lack of staff: Birth flat on their back in bed:

There was a complete contrast in the private hospital.....the birth rate for November was approximately 50 for the month, there were no patients on the day we spent several hours there.... privacy is still an issue with three labour beds in the one room... the labor ward has just been renovated so was very modern ...

.....there were brand new beds.... however I was dishearten when I saw the strips remain in place on the bed.... for me this would mean because they are there they will be used..... There was a CTG machine...... in another room there were two labor beds... and there was one private room....( the executive room of course at a price). What was surprising was they had a spar bath.... it was great to see... however would need education re its use..... (I was asked to give a lecture on waterbirth that’s another blog). There seemed to be more staff here and they did seem more caring...and providing one-to-one care... but this was only a snapshot so I really could not give an accurate account......it was reassuring.... but sad at the same time.... because most women could not afford this care.......

My maternity time was an experience,as was my whole Tanzanian clinical practice....... I met some phenomenal people and some I hope to continue to keep in contact with...... more in my next blog......

Dreams; Dreaming:

2010-12-19T23:08:00.012+08:00

Last night I dreamt that I was swimming in the ocean, it was a beautiful clear ocean, I love the sea.....my husband was standing on the shore as he normally does..... I was a little afraid a healthy respect of the ocean, it was a nice sunny day and I just love to swim in the ocean, so continued to swim. I then noticed some fish middle size fish... this frightened me a bit more but they seemed non threatening..... so I continued to swim...... more and more fish came.... they seemed to have their mouths open and looked half out of the water.... I was starting to panic the more fish that I sore... and then there seemed to be snakes and eels in the water, now I was terrified and swam for the shore completely panicked...... I woke in a sweat.... afraid there were just too many fish and eels in the water.......I was out of breath and afraid..... I looked around and thought “thank God I am in my bed, it was a dream”.......

In trying to make sense of my dream, I thought is must be that I have been a busy the few months, in fact an extremely busy year; certainly ending in a big way, in many ways very difficult I have to say I am tired, and sadden by many great women being wounded and continue to be wounded all in "the best interest" of midwifery, women, life, work.....I have to ask the question is it worth it? But deep down I know it is for the sake of all women and midwives, not just one or two groups... the one’s who shout the loudest.....and care the lest for all women and midwives.

The poverty and lack of resources in most parts of Africa - the uncaring of our fellow man/woman/child......it leaves me feeling completely drained...however hopeful of progress with help and resources.... I enjoyed teaching in Singapore.... it is was worlds apart shopping on Orchard Road v Dar Es Salaam .........it really is food for thought!

A dear friend of ours, not so close these days but from the past, well thought of & loved, lost their son of 34yrs (Peter); our boys all use to play soccer together: Peter was larger than life, enjoyed life to the fullest; listening to his eulogy it was a full life packed into 34yrs, but oh so young to die & so suddenly: the memorial service was packed and there was not a dry eye, men, women and children all crying........as we sat in the Limerick Bar at Rosie O'Grady's celebrating Peter’s life " I pondered as you do on your own life" what would they say about me? I have so much more to do.... so much more to give.... so much to share.... the energy spent on nonsense is a tragedy.... I want to yell from the highest mountain...pull your heads in......get on the same page!!!!!!!

The Kids putting up the Xmas tree....

Family is most important.... letting them know how much I love and am proud of them, watching the grandchildren grow up and being able to influence that growth....sharing the passion of life...teaching them to reach for their dreams and passions......everything is possible.....not to get bogged in the minutia of bullshit......listen to your inner voice and you will know what are the correct things to do in life.... that is really one of the most important lessons..... That is to trust your own judgement...... listen to and trust your inner judgement..... then follow that ...... you can’t go wrong........

It is times like these I like to go back to a favourite poem of mine Desiderata:

Go placidly amid the noise and the haste,
and remember what peace there may be in silence. .......... Avoid loud and aggressive persons;
they are vexatious to the spirit.......... Exercise caution in your business affairs,
for the world is full of trickery....... Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.......... Beyond a wholesome discipline,
be gentle with yourself.
You are a child of the universe
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.
Therefore be at peace with God,
whatever you conceive Him to be.
And whatever your labors and aspirations,
in the noisy confusion of life,
keep peace in your soul.
With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful. Strive to be happy

Singapore 2010

Nursing in Tanzania:

2010-12-12T11:45:00.012+08:00

The airport:

It is hard to know where to start with this blog... as there is so much to tell, therefore I think there will be several blogs relating to Tanzania; The main focus of the trip was to take 20 nursing students from five different universities to experience nursing in Tanzania. My first impressions were biased with a preconception of what things would be like, having already lived in Africa, however some things still were confronting and the total lack of resources, water, infra-structure (in rural areas) and medication still came as a surprise:

The process through customs, immigration is the usual for any African airport, slow, hot and humid, confusion as to which forms to fill out, eventually we all got through.... the main currency for Tanzania is shillings..... 1000.00 approx for each $1.00.... we changed some currency and got some local sim cards for our phones, we were met at the airport which was fantastic.... we were all bundled into cars and buses, with our luggage perched preciously at the back of the bus. Our hotel was about 35 mins from the airport, the first thing that struck me was the amount of cars on the road.... it did not take long to realise that they all drive like lunatics.... it was equal to Egypt which I thought have the worst driving in the world. There were hundreds of people milling around, over crowed buses and many street markets......

Health care in Tanzania is dependent on social status and level of income is the most predominant social determinant of health for people. This means access to clean water, sufficient food and reasonable health care. Health care access is further compromised due to issues of geographical location and distance to services as well as lack of resources and technology. It was interesting to note that everyone has access to mobile phones even when electricity was not available.

Our Hotel:

We arrived at our hotel ...... pleasant, clean, small, friendly staff.... the first thing I noticed was there was no bar fridge.... now I know what you are thinking....no not for alcohol... I wanted a cold drink of water.... alas this was to be one of my biggest complaints.... a must in a hot humid country....the availability of cold water and tea and coffee making facility.... minor things really, just shows how spoilt I am. Every day began at 0530... the bus collected us at 0645 to get us to both hospitals..... we would split into two groups, two supervisors and 10 students in each hospital: one to a private hospital and a government hospital.... then the following week we would swap. Mine was the government hospital first.... this was a baptism by fire.... it was a culture shock for all, I was a acutely aware of how the students would be coping, sights, smells, queue’s of people, sad hollow eyes watching our every move....we stood out like beacons in our stark white uniforms; at times I felt like the fish in the fish bowl..... Intruding into the lives of people I could not really make a huge difference to....We would attend the hospital handover, all given in English we would then go to our allocated wards.

I had to focus on the task at hand..... once orientated to the ward we would begin to assess the situation and decide how to move forward.... each ward had a notice board which listed the 10 most common disease and drugs used, together with the tasks for the day: There was no surprise to find No 1 condition in the medical ward was HIV (there are medications and treatments for HIV which was good to see), I learned about the finger test for HIV.... great idea quick and efficient, next condition was Malaria, hypertension, anaemia and diabetes: each ward (medical & surgical male and female) consisted of approx 30 beds, sparse furniture, a single sheet on the beds and some ceiling fans, however the wards were stifling hot.........patients bought in their own food and water; sometimes it was hard to know where to start.... so often I would get students to take vital signs, as this was something I knew they could do well and would start the two way conversation... however our Swahili consisted of “Jambo” – Hello, or “ Hujambo” – how do you do, “Jina langu ni......Pauline – my name is....

The nurses work very hard and are short staffed, often 1 RN to a ward, a couple of student nurses and nurse assistants; doctors milling around, completing ward rounds, barking orders, nursing assistants scurrying around to get tasks completed. There was often only one oxygen cylinder and the ethical decision would be who needed it the most... and sometimes someone would come urgently from another ward requiring the oxygen cylinder ..... what do you do?

The sister's desk:

The drug cupboard was sparse, patients are ordered medications and it is a pay as you get service.....the students coped remarkably well.... all equipment used for patients are paid for by the patient, such as IV cannula’s, drips, catheters, tests etc, everything we take for granted here.... it really makes you appreciate the excellent health care service we have.

We witnessed some interesting procedures and dressings, at times did some teaching as well as sharing experiences and ideas.... it was an interesting journey: documentation, nursing notes, filing cabinets, policies were all nonexistent in the literal sense.... there were two cardboard boxes... marked “discharge notes” a stark reminder of where we were....... Pain seemed second nature to patients....as well as lack of dignity and privacy due to overcrowding and lack of resources..... the hard working underpaid nursing staff and health workers, were not well respected......they do the best they can in these harsh conditions, always with a resolve that things would get better. Also acutely aware of how the situation must look to us the ‘foreign nurses’ apologising for the bad conditions and stating they just do not have enough staff or resources to treat all these patients.

I was amazed at how long people wait to see a doctor or nurse; they have walked for hours and sit patiently in the sun until they are seen, with not a word of complaint.... just happy to be seeing someone and getting some treatments. Our challenge was often to think of cheaper effective ways of treatments, dressings etc choices of medications were limited to bare essentials.......families assisted with patient care, feeding and bathing.......traditional medicines were popular and the stigma of HIV was an issue: I was surprised to see that bowel obstruction was very common – top 10 surgical conditions were: Intestinal obstruction, peptic ulcer, pyomyocties (infection of the muscle), hernia, haemorrhoid, hydrocele, osteomylitis, burns, diabetic wounds, and motor vehicle accidents (no surprise there with the driving we witnessed).

The nursing system is three tiered; enrolled nurses (2yrs training nurse/midwife), registered nurse/midwife (degree course 3yrs), diploma registered nurse/midwife (3yrs or 1yr after EN course): nursing assistant (2yrs – can go on and do diploma RN 3yrs); a diploma RN/M can go on and complete the degree course 3yrs – equal to 6yrs: Their scope of practice is wide and varied........the medical system is equally complicated: from medical assistants to degree MD’s. The graduation I attended had only 10 degree RN/M’s, 20 diploma RN/M’s and 40 Doctors graduating....... nursing is not considered a prestigious career, parents try to discourage their daughters from doing nursing if they are going to do a degree.......nursing assistants and diploma nurses usually complete form 1V (equivalent to year 10).

discharge notes:

The question I ask is how do we make a difference? Some of the students who travelled will travel again, they have all be touched by the experience, maybe two or three will go back to Africa and help make a difference; I think you need to stay in one area for a two – six month placement and introduce structures for change; working alongside our fellow nurses exchanging ideas and promoting change: providing mentorship, support for the new students, therefore providing for the future..... Fundraising for essential equipment (gloves, alcohol gel, fob watches, thermometers etc); now that this will be an ongoing project I am hopeful that we will be able to make a difference in some small way:

On our last day we met four first year nursing students, all straight from school, they were so young, full of enthusiasm, our students took them under their wing and taught them vital signs, it was delightful to see, gave them some text books, our equipment, stethoscopes, thermometers etc... and we wished them well. I have promised to keep in touch with one student and provide some mentorship from a distance. If I am to return I will ensure to follow her up.........This has been an incredible journey for me and I will be forever touched by the courage of the patients I have met and for some of the brave nurses I worked with....... I am eternally humbled from the experience.......I have met some fantastic students who are know RN’s and also have made special friends with the other supervisors from our trip........partners in crime.......next blog..... Midwifery!

Good luck to all my students (now RN's)as well as the new students starting....life is a continuous journey which we are all learning.....

Back to my roots Africa:

2010-11-28T22:19:00.019+08:00

We have been in Africa Tanzania for a week now…. I will be blogging about the clinical experiences soon but just had to share this wonderful weekend with my friends and the world. Despite all the hardships that can clearly be seen in parts of Africa the country and its wildlife are absolutely magnificent….Africa is rich with warm friendly people, diverse cultures and stunning wildlife. I began to feel as if my soul had returned home once I got off the aeroplane. The steamy airport….. crowds of people a disorganized chaos was all reminiscence of my times spent in Zimbabwe.

Our weekend was spent at Mikumi National Park: the park is in Morogoro Region, in the southern tourist circuit of Tanzania. This is the nearest park to the commercial capital of Tanzania, Dar Es Salam. It is about 288 km west of the city and takes about 5 hrs by car. We travelled in convoy in land cruiser troopies 8 to each vehicle that includes the driver (who is a local). The road is bitumenised all the way to the park. The park gets its name from the spindle – shaped borassus palm trees which are typical of the area. Mikumi National Park with an area of 3230sq.km is the fifth largest park. It lies between the villages of Doma and Mikumi on the Dar Es Salaam-Tunduma road. The Mkata River-flood plain, with its hardpan, ridges, swamps and black-clay grassland, the miombo woodlands on the hill to the east and west, and the rivers with their fringe of tall trees and dense thickets. Often it looked like it was going to rain…. Thankfully it didn’t; the short rains usually fall during November and December. Long rains are from March to May.

Everyone relaxed and really enjoyed the weekend, it was just not long enough…..being with the students all week, it was great to see them relax as well as us (the supervisors). We were warned that the animals wander around the grounds and to walk together and be watchful. As we sat drinking; me with a gin and tonic and as we had lunch we watched the animals arrive at the waterhole; zebra, warthog (pumba) and her babies and a small family of elephants…. It was brilliant to watch the elephants drinking and having a mud bath…..the giraffe were ambling in the background grazing on the leaves ….. what a wonderful world we live in….it was a time to reflect, re-energize and rejuvenate.

We stayed in small lodges made from mud….self contained double rooms. The windows were open spaces covered by a wired mesh similar to fly wire. We were all sharing; I was sharing with two other fantastic women…. We chose our beds unpacked our bags then out for our first adventure in the land cruisers. The usual application of sunscreen and insect repellent…. Excitement in the air…..a beautiful sunny day….the African air. It was not long before we came across our first elephants, then impala, lots of impala they are almost like our kangaroo’s…. we were all glued to the scenery trying to spot the next animal…when I called out “there’s a Kangaroo” ……on our way back to the village we came across a group of Giraffe, they are so spectacular to watch…. elegant and graceful. Alas still no Lions: The African sunset was spectacular as expected….. got back to the village…. Had a double gin and fanta as there was no tonic….tasted great… a fabulous dinner….beef stew and veg whilst watching animals at the waterhole….. later that evening the lions came to visit…some of the students were disturbed and frightened, the park employees escorted everyone back to their rooms….. it was a hot night…the electricity went off at 11pm so no more fans….. we slept under mosquito nets…it was a hot sticky night….as for me I had tooth ache so took a bucket load of pills and could feel my tooth throbbing…..but did manage to get to sleep…..

Up on Sunday morning at 0600hrs out to go for the morning safari drive; wonderful morning… a bit cloudy…weather great…cool; spotting animals… we came across a herd of elephants…. Unbelievable…the female leads the herd and the rest follow there were two calves in the herd… we spent quite a while admiring them it was so quiet you could hear them walking, they came very close to us…. Fantastic pictures…..we drove for an hour watching…. I was standing feeling the wind on my face…….feeling very much at home in one with the land…..the driver got a phone call and then began driving very fast…., we knew there was something to be seen…. We finally caught up with the other group to find a pride of lions who had very recently killed a buffalo, it was disemboweled…. There was a lioness close by well camouflaged, we all were excited and scrambled to get pictures…the safari was complete now that we had seen lions in the day….it was back for breakfast then the homeward journey back to the hotel (5hrs).

It was fantastic to see large herds of buffalo, wandering groups of elephant, wildebeast, zebra, impala, baboon, warthog, jackal and giraffe. Most spectacular was the sight of a fresh kill of a Buffalo by a pride of lions…… wow… just amazing.
Giraffes are the tallest of all living land mammals. The animal’s typical gait is rather slow, deliberate and remarkably graceful, almost as if the actions were filmed in slow motion.

Elephants have a gestation of 24months and live to about 60yrs, they weigh 3-4 tons and they eat 375kg of food….wow

I have to mention that the traffic (in Dar Es Salam) and the cars / buses are just diabolical – they are crazy drivers; how there are not more accidents I do not know…. We cringed more than a few times on our journey….. overtaking… causing the oncoming traffic to take responsibility to move out the way…..our drivers were excellent: There was a small gift shop on sight which I bought some material for the girls (Kanga) a traditional piece of cloth used for clothes: Now it is back to reality we have another week left….

spot the lion: sitting watching her kill...the pride was further back under a tree too far to take pictures:

I have written this blog on the homeward journey on the bus, as we are often stuck in traffic and hopefully I can upload it when I get back to the hotel, if the wireless is working....Watch this space for further tails and I have many…… photos will be coming soon.. it has taken me over an hour to upload these few.....it is back to work tomorrow...

I'm feeling very relieved and excited:

2010-11-19T23:59:00.007+08:00

I am so grateful my life is filled with love, passion, abundance and excitement;
I was so relieved that my exams are over for this semester, I had forgotten how you stress when you feel under pressure to perform in examinations... I do wonder the value of examinations.... for two hours I regurgitated information, not necessarily in a organised fashioned, everything I knew relating to the topic I just vomited it onto the paper, so much so that my hand was sore from all that writing.... you know we are just not use to that type of writing any more...why don't they move with the times....we should have computers....automatic spell check, legible writing.... I did think the faster I was writing to get the information down before my time was up...my writing was getting worse... and was thankful I was not marking these papers...now that would be a nightmare....the topics were broad and I should think hard not to be subjective when marking..... Well enough about that it is finished and forgotten until I get my results;

Marking is all done....and most of the students did well.....just amazing how much you can fit into a day.....

Tomorrow I am off to Tanzania...the spare bed is full of what should be going into my suitcase....with the uniforms....nice starch white tops...and navy blue three quarter pants....emmmmm..... aprons, gowns, gloves, etc etc etc....oh and all the books we are donating to the midwifery library.....I have been reading up on all sorts of exciting treatments.... and life in Tanzania.... bought my US dollars...not that there will be much time for any shopping....and got the first aide kit.

We are going on a Safari ...the middle weekend we are there.... I am waiting in anticipation of all that we will see and experience over the next two weeks... I am sure that I will experience many things... and be ever grateful for the wonderful country we live in.... Australia....watch this space for updates.... or the report when I get back....i guess it depends on several factors...internet....and time. take care until next time;

ref pic; http://trekkertime.com/index.php/Site/Tanzania

Centred Midwifery Group Practice Inc (CeMGP)

2010-11-17T10:23:00.006+08:00

Wow it is official….this has been a dream of mine for some time and became a reality today when the Dept of Commerce called me today to confirm our application for incorporation was successful. We are the first private Midwifery Group Practice for WA this is a huge step. I am so proud this is a fantastic achievement. We are a fantastic team of dedicated Midwives;

This idea has been mulling around in my head since returning to WA 7 years ago… however it is only since the Maternity Reform has the idea become a reality…. Women being able to access Medicare Rebates for midwifery services.

In July 2010 I talked about the idea, shared with a few people and in August asked a group of equally passionate women to come on board with this concept…..We met at my home for a day workshop and nutted out some key ideas…. One of which was the name Centred Midwifery Group Practice (CeMGP). I will not blog today the story from then till now I will save that for future blogs…. This is to share our fantastic news and say we are here….. watch this space…..for our Website, Facebook page and blog...all being designed as I type....

Our Philosophy: “We put you at the centre of your experience”. We are group of committed midwives, dedicated to providing safe, competent, continuity of care, individualised and professional midwifery care and support to the well woman and her baby throughout pregnancy, birth and early parenthood.

I am so excited I can hardly contain myself.... this is so huge it is a dream come true......more to come in the coming days.....this is just the beginning...... of a wonderful fruitful experience with women and birth.

Homebirth in the news again.......negative press: when will it stop?

2010-11-17T06:57:00.011+08:00

Homebirth is never long out of the news: strangely enough it is usually in the negative; When will doctors learn that it is not an issue of HOMEBIRTH it is an issue of CHOICE; Choice for women not doctors;

The Weekend West's headline was "Ban pleas on 'risky homebirths' now it is hard to openly discuss the leaked draft report - yesterdays front page of the West "Two quit as row over homebirths escalates" relating to the same leaked report, now calling for the Government Funded Programme supporting homebirth for low risk women:

I can not tell you how many midwives have quit due to lack of choice for women and lack of autonomy in the work place.....it never makes the front page of the newspaper this is doctor driven against the choice for women to have midwifery led care;

It is time again for women to stand up and be counted even if you would not choose a homebirth....this is far more than having a baby at home it is about how you as a woman make choices about your body..... most women will choose what is best for their babies....and do not have to be dictated to by the medical profession about how to do it...it is our bodies, our choice our life...... this is paternalism at its best... there is no grantee in life... and unfortunately babies do die....Babies also die in hospital.....there are many iatrogenic injuries that are caused in hospitals.... women are and have been traumatised in hospitals by the health professional... so don't try to say that having a baby in hospital is any better, in fact for the low risk women it can be devastating and equally for the high risk situations,.......

I cannot respond to the draft report because it is published yet, this is scaremongering at its best; Now midwives have the right to Medicare and can provide more options for women...the doctors are playing dirty........I wonder who leaked this information?

Things you can do...is write to your local Member of Parliment... with your concerns about lack of choice.....

Remember this is about choice for place of birth....not just homebirth...making the issue about homebirth is scaremongering.....watch this space.... for the release of the report.

Picture from Bring Birth Home: http://bringbirthhome.com/about/ have a look at this website... and read her story:

My feet are not touching the ground:

2010-11-13T20:31:00.010+08:00

This is usually a busy time of year....semester finishing, marking, getting ready for Christmas etc, etc, etc; However for me this is a particularly busy time.... semester is finishing and I have my usual marking....thankfully I love this assessment so it is easier to mark and the students also enjoy it and usually do it well, this makes marking so much easier...and as a teacher it is rewarding to read so many good papers;

I am taking on a new challenge...GLOBAL HEALTH ALLIANCE next Saturday i leave with 20 students from 5 universities (4 students from my university) in an inaugural project to Tanzania...to broaden their healthcare skills, provide care to people in the developing world, and to expand their cultural awareness.
“The placements are unique in that it is the first time the five WA universities have collaborated, as part of the GHAWA program, in sending a combined student and supervisor cohort to a developing country,”

“The trip will expose students to a unique healthcare environment which will improve their ability to work in challenging settings and help them to adapt to new cultural scenarios.”

The student nurses will travel with expert clinicians and will commence placements at Hubert Kairuki Memorial Hospital and Amana Hospital in the Tanzanian former capital of Dar Es Salaam.

We will also travel to two rural community health centres, Masaki and Masangaya Health Centres, where the students will undertake supervised clinical practice.

We are hoping that the international placements will allow the students to develop skills and knowledge in dealing with transcultural healthcare issues.

I am so excited...but as you can imagine this has increased my work load... preparing for this trip has been interesting and I don't know how I am going to fit all the protective equipment in my suitcase, together with the text books I want to donate as well as some other essentials...so watch this space for how the trip goes....but that is next Saturday....before then...I should be studying instead of writing this blog...but its called a break....

I am sitting two exams next week...Tuesday and Thursday.... finish my marking... have a couple of meetings....did I leave anything out.... ah yes there is still the surprise to announce which I anticipate to be middle next week....see the family and get on the plane..I think I also have a performance review......its called effective time keeping: or insanity:

I return after two weeks have two days to get Board of Examiners and supplementary papers out and then go to Singapore for three days of intensive teaching.... for trimester three..and two days shopping of course...can't forget that.... home for several hours then off to Canberra for another meeting... no wonder my husband and family think I have too much on my plate... but you know I have done all the Christmas shopping the grandchildren have their presents... if I get time I will wrap them before I go :)..... I will be home for the 17th December.... YEAH: enough time to sort out the Christmas dinner:

My mantra is " I have enough time in the day to get all I need to do done"
ok back to cramming now......

WE ARE FREE

2010-11-11T14:38:00.005+08:00

Today we are free
but it is a day of mixed emotions
a day of celebration and mourning
a day of smiles and tears
a day of joy and sorrow.
On this day in 1945
We overcame the enemy
our land became ours once more
but the victory was not free
we paid dearly for our freedom
we paid with lives
the lives of our brothers in arms
So today we celebrate our freedom
with joy and smiles
but also with sorrow and tears
for those we loved and lost
Today we are free.
We wear our uniforms with pride
as we parade for our Prince
our wives, children and grandchild
but in our hearts and minds
we are still captive
captives of the memories of that time
so today we celebrate and mourn
and remember.

TODAY WE ARE FREE

Written by Maria Sutherland 1998
http://msbeliever.tripod.com/WWIIremember.html

Update for eligibility: still waiting!

2010-11-10T20:55:00.006+08:00

Update on my application; I thought that I was very meticulous with my application but alas this was not the case; there is particular certified list of people that are required and I used a university academic which is not allowed;
the Certified List for AHPRA

Justice of the Peace, Bail Justice, Registrar or Deputy Registrar
 Commissioner for Declarations, Commissioner for Oaths, Commissioner for Affidavits (dependent on jurisdictions)
 Lawyer
 Accountant (member of the ICA, ASA, NIA or CPA)
 Registered members of the teaching profession
 Member of the police force
 Sheriff or Deputy Sheriff
 Public Notary
 Permanent staff member of AHPRA (I think it would be easier to take your certificates and copies into your local office to be certified)

Second I have written a two page letter to the Chair of the NMBA to ask why they are asking for the last 5yrs of experience (Statement of Service) instead of the 3 yrs required by the Registration Standards; I did send a letter from a manager who did deem me competent, however did not address the ANMC competencies, this was rejected for that reason. Finally why when we have successfully completed the Midwifery Practice Review (MPR) do you require a letter from a manger addressing the ANMC competencies? the goal posts keep moving;

Anyway I have resent my documents certified in the correct manner by a commissioner of declarations (a pharmacist) together with the letter asking for clarification and I have had no response to date. I have also forwarded this information onto the National ACM as evidence of issues relating to applying for eligibility; Really this process is cumbersome and unacceptable. I guess these issues will come up at the next Board meeting which I think is the 18th November; just as well I am not in a hurry, I feel for those midwives who do need this urgently;

A bottle of Red......frustration of midwifery;

2010-11-10T12:22:00.008+08:00

I had a bottle of red...with my husband, I am trusting him to proof read this blog as I feel positively tipsy ; I have had a bad day....a meeting from hell ego’s present in the room; I feel disempowered in my current position... people not being honest with their intentions.... all it takes is open honest discussion; and a colleague received some bad news that is really unfair.... why does life have to be so unfair; I really feel that we as a profession get the rough end of the stick.....I pride myself on integrity and honesty... I get so frustrated with women who do not stand up for women’s rights (but I guess this is dependent on your point of view) and maybe everyone thinks their point of view is correct...it truly is a man’s world and when we get women in power they seem to think the most important thing is to be accepted by men...that means playing by the man’s rule..... I am really feeling for a colleague of mine who I have grown to know on a intimate basis and trust her judgement and skill as a midwife I am really saddened that situation has not worked out for her as I had hoped and with my knowledge and expertise I have not been able to help her and for that I am truly sorry. All I have to say is as long as midwives are not protected by law we are open to the rules of nurses and we are very different.

Midwives need legislation to protect them to truly ‘be with woman’. Managers who are managing midwives need to be a midwife to really understand the issues that midwives face.... ideally they also need to understand what homebirth is about and the reality of choices women make at a homebirth; this problem highlights that nurses do not understand the autonomy and bond midwives have with women....... I guess a bottle of red will allow you to say almost anything I am distressed for my colleague that life has turned out this way... and even after a bottle of red it doesn’t stop the pain of what she is feeling... and there for the Grace of God go I..... here I am about to embark on a huge adventure for women and midwifery and I wonder if it is all worthwhile, because in one instant it can all be gone...we work so hard as a midwife to advocate for women.....to facilitate their choice.... but alas in Australia there is no protection for the midwife if things go wrong...and yes babies do die.. ..often despite our best efforts and for reasons beyond our control...errors are made because we are human but they are made every day in a hospital and babies die in hospital .....that is the process of life... we do our best to reduce the errors or mistakes;

We know that we are medically dominated that it is really unacceptable....however for this to change...it needs women to stand up and be counted... if you want the birth you want then you need to say so.... stand up and tell the medical profession this is what you want.... it is only in women’s voices will you be heard and midwives can then facilitate what you want; women have the power......you only have to say....

As for my colleague I am sorry.... you have to fight to the end degree... ..For what you believe in.... as for me...I will strive to be the best I can... I am thankful for my family that supports me...even though it takes so much time away from them and to my friends...thank you for keeping me on the straight and narrow... I have to learn to stop wearing my heart on my sleeve...feeling the pain of others: Also take more time out from all these pressures;

....I will continue to do the greater good for women and midwifery.... the end result is a Midwives Act to support the choice of women and protect the midwife.....well the bottle of red is finished my husband my lovely husband has stopped me from the second bottle.... wow he is wondering what has hit him........ I have to say drinking does not solve any problems but hell, I sure felt good for a short while;

It is the next day; I have substantially edited this blog... and am very thankful I did not post it last night.....surprisingly I did not sleep well, my liver was objecting to the alcoholic abuse it received; Today I have drunk a litre of water with two paracetamol. I have to say that this is a rare occurrence drinking a bottle of wine, usually it is only a glass or two on the weekend.

I am reflective and still wondering how to take this issue further; and my husband cannot stop laughing at me:

A new day begins and the journey continues;

How to apply for eligibility:

2010-11-01T20:53:00.018+08:00

Today I sent in my application for an eligible midwife; like anything new the process is TIME consuming and there will be teething problems: I am hoping that I have completed everything as required; You do not need insurance to apply for eligibility; I have to say that I have had to send my application to Sydney as WA is not ready for this process: Here is my step by step process:

Step 1; Go to the AHPRA website and download on the first page fourth heading ‘Registration’ on drop down menu second one down click ‘Registration Process’; left hand side blue box; fifth one down; click common registration forms; Standard Format for Curriculum Vitae:print and save this form.

Step 2; While on the AHPRA website go to the Nursing and Midwifery site and download the Registration Standards for the Eligible Midwife third from the bottom; then on the left hand side fifth from the bottom click on forms; a third of the way down the page look for the heading Notations; click on Application for addition of notation as an eligible Midwife; print and save this form.

Step 3: Now you need to read and complete the forms; to make sure you meet these requirements before you apply; I have heard that there has been a problem with Independent Midwives who do not have Midwifery Managers.... so watch this space.... I would think that maybe one way around that might be that they could sign a statutory deceleration..... as this is legally binding.... but that will be for the Board to decide....lets hope they will work it out soon...

a. Current general registration as a midwife in Australia with no restrictions
on practice; You need to add your registration number with AHPRA:

b. Midwifery experience that constitutes the equivalent of 3 years full time
post initial registration as a midwife; Here you need a letter from your current Midwifery Manager outlining that you have worked across the continuum of midwifery care, antenatal, intrapartum and postnatal this letter is dated and signed;
You also need a statement of service; this is obtained from your HR department; I rang Health Corporate Network and gave them the years I work at the government institution and they sent me a very detailed statement of service;

c. Current competence to provide pregnancy, labour, birth and post natal
care to women and their infants; this can be proven by completing the Midwifery Practice Review (ACM) or some other accredited program(I don't know of any other one apart from the ACM one.

d. Successful completion of an approved professional practice review
program for midwives working across the continuum of midwifery care; as above

e. 20 additional hours per year of continuing professional development
relating to the continuum of midwifery care; if you have MidPLUS this will be easy you will just print out your summary; If you do not have MidPLUS you will have to produce evidence of attaining these points; copy your certificates and get them certified copies; I did not send any originals of certificates they were all certified copies.

f. Formal undertaking to complete within 18 months of recognition as a
eligible midwife; or the successful completion of: I wrote a letter using this wording saying that i will formerly undertake the course when it is ready.

i. An accredited and approved program of study determined by the
Board to develop midwives’ knowledge and skills in prescribing, or
ii. A program that is substantially equivalent to such an approved
program of study. As above.

Step 4: Follow the Standard format for CV; as it is slightly different to your current one; I just cut and pasted from my regular CV. One thing that is very different is the request for clinical / procedural skills - with this one I made up a table that gave the dates of my general clinical competences such as Obstetric emergencies; suturing, IV cannulation, neonatal resuscitation etc; and added certified copies of the certificates; You must make a declaration that your CV is true and correct and sign it. The CV has to be an original not a copy;

Step 5; add payment for your application; $90.00

Step 6: you also need someone to witness your signature when you have completed the application form

Step 7; Make sure you go through the checklist it is helpful to ensure you have completed everything; although the checklist does not ask for a letter from the manager and this is a requirement; Not sure why when you provide a statement of service;

Step 8; Take a copy of what you have prepared, I find this always good practice; double check it again and then post it to the AHPRA office in your capital city; if in WA post to Sydney NSW for the interim until the office is more settled in WA, as we only came on board middle of October.

I found this process tedious especially having to photocopy and get 16 copies certified of my qualifications and certificates; the CV was not problematic but had to be changed from my usual format; the letter from the employer was not difficult nor was obtaining the statement of service you just need to allow for the time to prepare for this application; I am hoping now that I have all this information that hospitals who require credentially will not want any more than this and when you have prepared it once it is then done.... life should be easy now....NEXT STEP MEDICARE PROVIDER NUMBER:

Lets hope I have not forgotten anything and have completed the application as required... will let you know how I get on......go on be daring take the step and apply for eligibility;

For more information visit the AHPRA website;

Ref: picture; http://www.clipartof.com/details/clipart/46255.html

Being a student again: a humbling experience:

2010-10-29T22:51:00.004+08:00

As a lecturer myself I consider that I am a considerate fair and equitable person when I am dealing with students, in fact it applies to all aspects of my life ; one thing I really don’t appreciate is being taken for a ride.... in other words when students “take the piss” then I come down like a ton of bricks;
As some of you are aware I have commenced another course reaching for new heights..... My aim is still woman and birthing focused..... equality, autonomy and right to refuse treatment; the right for women to choose where to birth and with a midwife.
Being a student in a completely new discipline has been daunting....going from experienced to something completely different, a whole new style and way of thinking....it really is letting go and learning new ways of being....I still have not mastered this... I guess it will take some time; patience is the lesson I need to master;
As I reach the end of the semester (13 weeks) and start to cram for exams, which incidentally I think is the worst way to learn anything.....I really appreciate the way that I interact with the students whom I have been privileged to teach. Most of the lecturers I have encountered over the past 13 weeks have all been inspiring, articulate and passionate, exactly how it should be; however there is always one.....that is challenging. This one is a male.... he takes a tutorial group... he walked into the class.... or I should say he strutted in and said “hello I am Fred and I Fucking swear.... and if you fucking don’t like, there is the fucking door” well I was flabbergasted my jaw hit the floor.... there were students squirming in their seats...myself included. Here is a man who is presumably highly intelligent.... or so I thought, holds down a very important job and I am sure he would not swear in a court room...so I wonder why he would do so in class.....Our assignment was a case study that we would work on and discuss in a tutorial group, this is nothing new similar way of teaching that I have adopted.... I did notice that I used to say to my students “now this is easy, just follow the model as I go through it” of course it seemed so easy to me, as I teach it week in and week out.... with enthusiasm I might add.....when my tutor went through the case study at 100 miles an hour, telling me how easy it was..... the penny dropped for me.... this is exactly what I said to my students.... “I felt like saying of course its “Fucking” easy you teach it week in and week out and you know it, but alas I did not, I sat quietly and decided I would never tell my students how easy something was.... because it’s not me doing it” lesson learned;
The other valuable lesson I have learned is how vulnerable you can feel as a student: I mean I know that this is possible but as a student you want to pass, so therefore you do not want to be to argumentative as marking is so subjective a terrible way to feel and you don’t want a personality clash; if your tutor does not like you, would it affect your mark, theoretically no.... I felt several times when I questioned the tutor’s methods I was quickly reminded who was the student and who was the teacher....how could I forget this? I decided it would be best to grin and bear it.... until the unit was over... then I could have my say! Now we are at week 14 he has become nicer....more considerate for the first year students.... even thoughtful.... it must be the semester is nearly over..... and all I can say is thank God for both of us; this experience has made me reflect more on my own teaching methods and I am ensuring that I am always fair and equitable.

Community Midwifery Program AGM

2010-10-16T23:47:00.009+08:00

My day started with some housework.....watching my grandson play his first game of tee-ball, they look so cute and little, wow Dylan at 5 hit the ball quite well and I was impressed; It did remind me of when my children started playing tee ball, the weekends of sport; As for Miss Bella she has just learned to play tag.... so spent my time watching and then playing tag... it was fun; I had enough time to stop and look at a school fete and couldn't’t resist buying a snoring teddy bear... I thought the grandkids would enjoy it when they come and visit....

The afternoon was spent at the CMPWA AGM; it was a delightful meeting, relaxing, it is so good to go a meeting and see mums, babies, (mums breastfeeding) midwives and yes a politician; Rachel Siewert Greens Senator for WA; it was refreshing.... you cannot go to many meetings in the current political climate and not talk about “the determination”; Rachel was a dynamic presenter, she outlined the history of the Maternity Services Review and the enormous progress that has been made in terms of maternity reforms; and the greatest voices are that of women with their babies..the march onto Parliament House the success of the mother of all rallies, in which the government realised what an error was made by not including homebirth in the Maternity Reforms which then lead to a retraction and a two year exemption on homebirth; which I might remind everyone that we have 18mths left and we need to be formulating a plan to include homebirth; one thing was evident for me and that is the power play of the AMA, politicians and midwives; I have said this before that we need to be focusing on the choices of women, the right to choose where and how to birth..The right to refuse treatment... the right to self determination of women.....not just about homebirth; we need this legislated as they do in the UK and NZ: then it is not about the AMA or midwifery, it is about women:

Rachel also discussed the views of many stakeholders, the many varied views on the determination; she gave some detailed background about the process of allowing and disallowing the determination and the possible way forward; she also acknowledged that in the mean time it was important to collate all the evidence of collaboration not working and forward this information to her office; the Australian College of Midwives is also collating this information so you could forward instances of collaboration not being effective to members@midwives.org.au

It was time for a bite to eat a cuppa, mingling & networking..... I was fortunate to meet Dr Ralph Hickling who is a retired Obstetrician; he is launching his new book entitled; “Childbirth today: Too many caesars, not enough joy?” a very interesting man... the book launch will be on Thursday 28th October at 6pm in the Fremantle Town Hall; if you are free come down and buy a book.....I can't wait to read it....

The AGM followed the break; Debbie Slater gave the Chair’s report eloquently and speedily, elections were conducted, no new business and the meeting was done.... the quickest AGM I have been to in a while... fantastic..... Then there was cake and more chatting....every midwives dream.....

It was late afternoon by now, I had enough time to call in to see a friend on the way home before dinner with my sister-in-law and an early night.... ah but the blog needs to be written...... so maybe not so early to bed, but its Sunday tomorrow sleep in day;

Do we ever learn from history?

2010-10-14T08:56:00.002+08:00

I found this pearl:

In 1960 they asked 'Why are most mothers in this country delivered while lying flat on their backs? Traditionally it would seem thatwomen were delivered in a sitting position. Recently it has been re-discovered that this position can reduce pain fromsevere back-ache during labour. The sitting position also reduces by 23% the strain on the heart compared with therecument (sic) position. Many women find that lying on their backs during the second stage of labour is uncomfortable(especially so as they are so often required to do this on a high, hard, narrow "bed") - "like a stranded whale". Surely aproperly designed delivery chair would not be beyond the bounds of 20th Century ingenuity?’Sonia Willington, AIMS Newsletter 2

Why are we asking the same question 50yrs later?

Time for Medicare Provider Numbers; it has only taken 24yrs

2010-10-13T23:02:00.007+08:00

On the weekend I was in Melbourne and I was fortunate to hear this piece of information which made me sit up and think.... has much changed over 24yrs?..and if we miss this chance will it take another 24yrs?

The information comes from " COMMONWEALTH OF AUSTRALIA MEDICARE BENEFITS REVIEW COMMITTEE (2ND REPORT) JUNE 1986 p 230;

Submissions concerning midwifery were received from the National Midwives Association the Royal Australian Nursing Federation, the New South Wales Nurses Association, the Launceston North Coast Home Birth Support Group and numerous Private individuals. ......Most of the submissions proposed that midwife be recognised on an equal footing with medical practitioners in respect of the payment of Medicare benefits for certain services associated with uncomplicated birthing........of the many medical and paramedical issues raised with this committee, the question of the payment of registered midwives generated the greatest depth of paramedical submissions addressed 25% were midwifery related......

Has much changed in 24 years..... we are on the brink of change.

Some midwives are confusing the Medicare Provider Number with the requirement of insurance. However the issue of insurance is a requirement of National Registration s129(1)registered health practitioner must not practise the health profession in which the practitioner is registered unless appropriate professional indemnity insurance arrangements are in force in relation to the practitioner's practice of the profession.

In order to have a Medicare Provider Number you need to be an eligible midwife... Have a look on the Australian Nursing and Midwifery Board site to remind you what these requirements are;

The Health Insurance (Midwife and Nurse Practitioner) Determination 2010; for the Medicare Provider Numbers... check out the determination; the Midwifery services and fees range from $31.10 -$724.00 also is included 6 weeks of postnatal care...which is excellent for women and will also help provide greater postnatal care....

This is the beginning of new things, an opportunity of greater access for all women... however we must remember that unfortunately this does not include homebirth...therefore we need to more than ever keep the pressure on the government.. to pass this service fee onto women who choose a homebirth.....

Sad state of affairs for WA homebirth! Give me a break

2010-10-13T12:42:00.010+08:00

Currently in Western Australia there are several options for having a baby.... you can check out this website; Having a Baby in WA - birthing options; the website offers information relating to most birthing options; Recently there has been much debate over Homebirth, with the Maternity Services Review and National Registration which now makes it law for midwives to have insurance cover and this is attached to registration; with an exemption to homebirth insurance for two years;

WA has a government run homebirthing program; Community Midwifery WA which provides a homebirthing option; the website carries valuable information for the women of WA including the pros and cons of Homebirth; The AMA has taken it upon themselves to object to this information saying that Homebirth is not a safe option and wants a warning on the website to alert women to this issue;
Today there has been great debate over this point; on the ABC radio show this morning; The health Dept chief medical officer Simon Towler says... that homebirth was a safe option... However the Health Dept says there has now been a warning included to the homebirth site,
now this is a very clever point; there is more than one way to skin a cat.....

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists do not endorse homebirths.
You can read their College Statement here.
The Royal College of Obstetricians and Gynaecologist in the UK do support homebirths – see here for their joint statement with the Royal College of Midwives.

Read the article; "Website promoting homebirths amended";

The AMA's WA president David Mountain said the website information about home births was misleading and did not warn about the dangers involved....

The article also goes on to mention that women should speak to an expert in this area.... well that has to be a midwife an expert in the 'normal process'.
51 WA doctors 'too dangerous' to treat patients without rules

In one case, an obstetrician found guilty of conducting rogue surgery has been allowed to continue practising - but has been banned from using forceps when he delivers babies

Another story over the weekend..... Parents sue over botched forceps birth....."A BABY boy could be left with brain damage after a WA obstetrician's bungled attempt to use forceps during his delivery".

I challenge the AMA Dr David Mountain to please put a "a warning for low risk women having a hospital birth for all iatrogenic injuries caused by a hospital admission for birth". More than 2,500 people die from hospital related injuries.... the Cesarean section rate is higher than ever..and still there are injuries and deaths associated with that....the risks for women having an unnecessary cesarean far outweigh the risks of a homebirth...see the ican website for the facts. .....

Give us a break AMA; Why don't you listen to what women want!

Time, Love, Passion and Life: Children:

2010-10-05T19:00:00.017+08:00

Time is of the essence; My mother use to say "Pauline there is only time for the quick and the dead" I wish I had Hermione Granger, time watch... that alters time so you can fit it all in...from the Harry Potter movies. There is no doubt that I am a work-a-holic... I have been very well trained for this...again mother use to say "don't sleep your life away, get up and do something".

Over the years I have learned to relax and wind down... I love spending time with Ian on our spontaneous outings...or our occasional golf game.... and the day trips with the Grandchildren are a genuine treat..this is what memories are made of.....even the sitting and watching a Disney cartoon with them is delightful.... Finding the balance with 7 soon to be 8 grandchildren, and a passion for my work can be difficult....but I think the time spent with the children make it more special for both of us....if I was to ask the grandchildren what are their favourite moments with me, it will have something to do with going out on one of Nana's trips...

I have collected a few sayings that really sum up what I think about time.....that relates to family, work and life..... can you guess which one I like most?

Time is making fools of us again. ~J.K. Rowling

Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you. ~Carl Sandburg

If you want work well done, select a busy man - the other kind has no time. ~Elbert Hubbard

"Time is a great healer, but a poor beautician." - Lucille S. Harper

"Dost thou love life? Then do not squander time, for that's the stuff that life is made of." - Benjamin Franklin

"The bad news is time flies. The good news is you're the pilot." - Michael Altshuler

"All the flowers of all of the tomorrows are in the seeds of today."- Chinese Proverb

"I am only one, but still I am one. I cannot do everything, but still I can do something. I will not refuse to do the something I can do." - Helen Keller

Love makes the world go round.....I think of love and remember the first movie I saw about love.....yes the classic "Love Story" with Ryan O'Neil & All McGraw:

"Where do I begin (Andy Williams)
To tell the story of how great a love can be
The sweet love story that is older than the sea
The simple truth about the love she brings to me
Where do I start

The other great movie that I watch when i just want to switch off or feeling low...that gives me a lift is the wonderful "Sound of Music" I love the scene when Christopher Plumber kisses Julie Andrews for the first time... on the garden bench....it is just such a romantic moment...I know it's sad... but I love it...

love is what makes life worthwhile, I could not be me without my family and friends; the profound love that you have for your children is for some reason multiplied with your grandchildren.... and I think this is because you are wiser, less strict, you can see the error of your ways as you get older.... or you become a soft touch for those beguiling eyes...they are just so beautiful....

It's kind of fun to do the impossible. Walt Disney

If you want to make enemies, try to change something. Woodrow Wilson (1856-1924)

Life is short and we have never too much time for gladdening the hearts of those who are traveling the dark journey with us. Oh, be swift to love, make haste to be kind. Henri Frédéric Amiel

When we are motivated by goals that have deep meaning, by dreams that need completion, by pure love that needs expressing, then we truly live life. Greg Anderson

Teach only love for that is what you are.
A Course In Miracles

I love life, my family and I am passionate about women, midwifery, midwives, law, ethics, fairness & equality and having fun with my children..... but most of all I want to achieve my dreams and vision...and teach the grandchildren about being passionate and following dreams.....for this I need the love and support from my family.....because this is who I am and what is most important next to them.....time is of the essence:

ref for picture;http://www.flickr.com/photos/shewatchedthesky/2835193235/
Passion: http://www.art.com/products/p10345310-sa-i1058105/paula-scaletta-passion.htm

Pondering the profession of Midwifery:

2010-10-03T22:17:00.009+08:00

I have spent the weekend away from the email and work to try and recuperate from a really bad dose of the flu..... I must be run down, I have taken the opportunity to ponder my future..........The recent months have created much, discussion, passion, excitement, lobbying, stress, anguish, disillusionment, tension and more recently a more pronounced division within the profession of midwifery; even to the point of a midwife reporting the Australian College of Midwives to the ICM (International Confederation of Midwives) which I find extraordinary, I would of thought this would be saved for something so terrible; not here a modern, young progressive country such as ours with excellent maternal and infant outcomes however not so good midwifery services.... I am lost for words at this dissatisfaction within the ranks.....from what I can determine there is a strain of midwives that believe that no matter what the risk factor a midwife can provide the primary care without the necessary collaboration: I am particularly thinking of the twins, footling breach, high blood pressure, more than 1 caesarean at home type births; the homebirth that is not recommend at home. Any high risk category requires an obstetrician, this does not mean that you cannot have midwifery care but you have to collaborate with an obstetrician and birth in hospital.

Tawny Frog Mouth Owl (Male)

This has caused me to reflect on what my own vision is for midwifery within Australia as we are on the cusp of change or no change as it may be. Before I can discuss this it is important to say that I have only practiced midwifery in Australia for 7 years now after completing my midwifery in the United Kingdom and working there for several years, so my basic ideology of midwifery comes from my experiences in the UK. When I first arrived back to Australia as a Midwife it was extremely different and difficult to work as an autonomous midwife to the same level as in the UK, in fact impossible: I even tried the Birth Centre where I was told “no we do not do water births, you have to pull the plug out”, tried independent practice but the thought of no insurance and no support system was too much of a risk, I nearly gave up the profession several times as I felt it was a losing battle.

Nevertheless what kept me strong was the idea of being a change agent and influencing the public perception (namely women and not just the minority of women) of midwifery in Australia so I continued the journey for change and the freedom of midwifery from the medical model which is so prevalent in Australia. So how does one go about change in such a huge way, it seemed only right that you should join the peak professional body for midwives, which is the Australian College of Midwives; whose philosophy is.... “Our vision is to be the leading organisation shaping Australian maternity care for the benefit of women and their families”. The college’s work is to provide a unified voice for the midwifery profession, supporting midwives to reach their full potential and ensuring all childberaring women have access to continuity of care by a known midwife”....The College has grown significantly recently as the profession has gained recognition and respect. The numbers of midwives within Australia has been difficult to quantify.... and so too are the numbers of independent midwives; with nursing and midwifery being lumped together; However due to the new National Registration and separate registers for nurses and midwives, we will finally be able to separate nurses and midwives and determine the numbers of midwives etc;

Tawny Frog Mouth Owl (Female with baby)

Traditionally in Australia midwifery has been seen as a tack on postgraduate course to nursing....in recent years we have seen the introduction of the Bachelor of Midwifery course which will also improve the profile of midwifery as being separate from nursing; ....... ever since I can remember (20yrs ago) the reputation of midwives is that “they are outspoken/bossy women” “consider themselves better than the rest” “ a bunch of dykes or lesbians” “difficult women” ‘feminists” and I am sure you know more than me, you have to wonder who put these labels upon us? And as I ponder my future.... all these anecdotal comments about midwives are no different now to 20yrs ago..... I have to say I aspire to being a “feminists in the truest sense of the word” I have always valued and wanted equality for women and I firmly believe to be a high-quality midwife one of the qualities is to be a feminist or have feminist ideology.
There are three main facts that I think are imperative to where we currently stand politically: What is a midwife: Medical dominance in obstetrics; Private Health Insurance:

The leaning tree

The role of the Midwife: I was amazed on my return to Australia how very little was known about who a midwife is? What is the role of the midwife? Coming from a system where every woman sees the midwife at 6/8 weeks at the GP surgery to women not seeing a midwife until 19/20wks...... unforgiveable for a woman & midwife. Therefore the first trimester is left to the GP/Obstetrician......no wonder they don’t want to give this up now as it is money lost to them......I realise that funding is different here in Australia as compared to the UK, but this just illustrates that there are huge changes required for women and the medical profession in Australia; interestingly if you examine midwifery history you will see that the UK and NZ have gone through several battles similar to the ones we are going through on two fronts, that from outside midwifery (political/medical) and internally from the difference of opinion from the independent sector of midwifery.

The second main point is the medicalisation of childbirth; it seems to me that in Australia generally women take on face value what a doctor says and takes very little responsibility for their own health care or pregnancy.... they seem to have the notion that “Doctor knows best” “just do what you think is right” you are the doctor, however I think this is slowly changing, I am hoping women are changing and taking more control of their bodies and their pregnancy;

Thirdly is private health insurance; here in Australia the uptake of private health is far greater than in the UK, and women seem to think that private health equals better, higher quality health care, which is not the case. Most importantly women think that obstetrician means best possible care whilst pregnant, and this is definitely not the case; private obstetric care means higher caesarean section rates and longer stays in hospital. Yes you need an obstetrician when things go wrong or you have a high risk factor.... but there is no reason why a woman should not be seeing a midwife alongside the obstetrician....but this rarely happens.....

As far as childbirth goes, Australia has a history of being medically led, midwives and midwifery is starting to gain some recognition, up until this point there has been no funding to support the profession of midwifery; the AMA is very strong and with its blanket rule of no support for homebirth this clearly indicates there is no support from that front. The independent midwives feel that the ACM is not supportive enough because they choose to take the safe route which will benefit many women & midwives rather than a few...and this is not to say that the few are unimportant, absolutely not, but small steps of change need to occur in order for greater change to follow; therefore working towards changing a medically dominated system that cannot be changed overnight and made to accept midwifery led care when this is a whole new way of thinking, in this country....... I have always thought it is best to take small careful considered steps to success rather than giant steps trampling on people to get the same result.

My vision is similar to that of the College in that I think that every childbearing woman should have access to continuity of care by a known midwife and that

I would like to see the ACM have its own industrial arm and legal support for its membership

(separated from the ANF)...... however in saying that.....I do despair for the future of midwifery in this country with such fragmentation within the profession........ As for me I am still pondering..... Shall I stay or shall I go? Is there a point to all this?

Isabella 2yrs old, her expression says it all!

It is time to be thankful......

2010-09-29T21:56:00.006+08:00

In this political climate when everyone has a different opinion I thought I would remind everyone to be kind and gentle with each other..... there are feelings around:

It is central to remember the most important things are kindness, empathy and we do respect each others point of view even though it is different. It does not mean that we are not nice people....so remember when making comments and sending emails, not to be unkind rude and personal..... I came across these pictures and thought I would share it..... as a reminder to us all... that life is short, and there is time to be thankful for the wonderful things we have in life and how lucky we truly are:

The AMA has put out its Collaborative Arrangements:

2010-09-28T22:29:00.015+08:00

There is much speculation surrounding this document; yes there are parts of it that make me cringe.... however it must be equally difficult for the AMA, not that any midwife wants to hear that;
Collaborative Arrangements what you need to know? the irony of this document has to make you laugh or cry:

"Working with other health professionals is an everyday feature of clinical practice for a modern medical practitioner. Effective teamwork can improve patient outcomes, create new opportunities for learning,and build a shared understanding of the skills that each person brings to the care of a patient."

Oh yes everyone is a patient even the well woman = this equals paternalism at its best; yes our medical colleagues are great at being paternalistic they feel they have the right to make that decision for the woman because they believe they know what is best; consequently, if the vulnerable woman is not able to make decisions or is not in a position to do so they are often coerced or made to feel fearful therefore making the decision the doctor wants.

“In a sense, this statutory requirement reflects the planned team care arrangements that have set parameters for collaboration in areas where doctors, midwives and nurses have always worked together - our hospitals.”

If we examine this statement they do say that it is “planned team care” and the word ‘collaboration’ means working together – not the GP/Obstetrician is in charge – it means a two way street. It will be interesting to see this work! because the doctors have the power and the money.... and automatically think they are in charge.

For me there are four main points that are important:

If we do not embrace these changes, then pressure will mount on the Government to relax the requirement for collaborative arrangements to be in place. This would risk fragmentation of care to the detriment of patients.

This is the most telling statement of all.... this means the AMA is seriously concerned that if they the doctors do not collaborate then changes will be made......this is in our favour.

Yes they are correct in saying that

“Some doctors will be challenged by the Government’s reforms, which will fund new models of patient care.”

This is clearly an understatement, we as midwives are certainly challenging them and if this collaborative framework does not work it will be changed; The doctors are back pedaling, they are fearful of losing money... so they are picking up stumps and are not going to play.

What should you do when a patient does not want to follow agreed clinical guidelines?

This may place you in a difficult situation.
The AMA believes that the best way of handling this is to ensure that your written collaborative arrangement clearly states that you will only provide care in accordance with accepted medical practice and within accepted clinical guidelines.
It should also clarify what will occur in circumstances where a patient declines to
follow these guidelines. If this occurs and you decide you cannot provide ongoing care for that patient, you will need to ensure that you advise the patient and the midwife/ nurse practitioner so that an alternative arrangement can be put in place by the nurse practitioner/midwife.
How you will address this issue if it occurs needs to be agreed prospectively in order to avoid a situation where you are forced to continue care because of a lack of
alternative arrangements.

This is nothing new, this is how the AMA works in every day practice, so this is no surprise....the only thing that is different is that they are blatant about and it is in writing.... there is no such thing as the clients right to choose the type of care they want or the right to refuse treatment.

Lastly I would like to be able to check the credentials of the doctors...what are their statistics, are they registered? how many women are not happy with their care etc? we should be able to check their register; that would be fair and just, equality.

Despite these issues I do think that we need to push forward, these are challenges put in our way and in time it will seem like a storm in a tea cup.

My vision is that all women will have the choice of continuity of midwifery care with a midwife and the right to claim a Medicare Rebate for fee for services;
Whilst I do not like the wording in this Determination I can see that this is still a historic time for midwifery....Opportunity is knocking..... walk through and make it work...if it doesn't you can always reject it.... but if we don't try we will never know it will always be a speculation

Taking a day to smell the roses....or look at the spring flowers

2010-09-27T22:17:00.009+08:00

life has been so hectic lately i have not had time to scratch myself and sometimes have been quiet disillusioned by it all...which way do you go....so it came as no surprise when I became unwell....late nights...etc.. and to make matters worse I have had the worst flu ever...which left me with bilateral Otitis Media (middle ear infections. My head felt like it was going to explode with the pressure.... I really empathise with those poor little babies and toddlers that get recurrent ear infections no wonder they are so miserable.....poor babies.

Finally the antibiotics have kicked in and relief is finally here... my husband baned me from the computer and mobile phone and took me out for the day to smell the roses....a delightful spring day... it was so refreshing...just what the doctor ordered.... we took a lovely country drive from Perth, Northam to York.... and there were some lovely flowers along the way....

We came upon an unusual couch...made from bricks.... very clever... as my husband was a brickie in his past life I received a lecture about how difficult it would be to make....he was intrigued by this icon...as he referred to it... I tried as I might to be rivetingly excited by it all but alas.... unless it has something to do with birthing and women my passion was just not evident....poor darling...we then went for a walk in the bush and admired the wonderful display of spring flowers..something we both really enjoyed......life is truly wonderful.

We also came across this great little bookshop called "the book lady" in one of the country towns...always a great little find.... we sat for ages looking at books...just delightful.. I picked up one called "letters from a Fainthearted Feminist" by Jill Tweede. I opened the book at page 71

"I've been brooding about those fairy tales where Snow White, Sleeping Beauty the Ice Queen, the Little Mermaid and other happily resting ladies get woken from their snoozes by a peck from Prince Right on the old liperoos..Male fantasies about arousing female virgins, What?....But did anyone inform the ladies in question that once they're awakened passions - ie a permanently insomniac infant - all they will desire in life is to return from whence they came"

how true is that..... you see I could not leave the little book behind... I will be sure to read it to my grand-daughters....

Together we stand, divided we Fall

2010-09-26T20:30:00.011+08:00

The universe is change; our life is what our thoughts make it.

A strange phenomenon occurring in the universe around Australia, their is great indecision around, everything seems to be 50/50; first we have an election that had all the bookies saying it will be very close; this therefore means a society that is split; split in every sense of the word; values; principles; taxes and the people who will lead us: there was no clear leader presented....or party..... what is that telling us about our present status? indecision; This means we will have an election sooner than later.... because a divided house will fall.

The AFL final that is a draw...not that I care really accept that I do like to know who wins and loses these main events.... fancy not having a sudden death outcome, like a 5th quarter, extra time.... goal kicks something rather than repeat the game...that seems like a huge money spinner for the AFL........it is time to rethink the rule about a drawn game......

Then we have the Midwifery legislation - Determination for collaborative care; which has the midwifery profession up in arms talking, lobbying at great lengths; however I do not believe for one moment that this is 50/50 it is more like 70/30; 70 for 30 against; The profession is unanimously agreed that the wording is not correct. However what splits them is whether to accept something that is not quite right or throw the whole thing out and not have it at all for possibly years to come.

An interesting point is that it is now in the hands of the parliamentarians... who are equally as indecisive.... in the mean time; women, midwives, homebirth midwives, independent midwives, consumer groups are all pitting themselves against each other, saying some horrible things...making accusations to each other who's right/wrong ... it is all very sad.... in many instances bullying each other to get the perceived upper hand just as bad as the politicians... and at the end of the day we will all lose...... WOMEN & MIDWIVES and the AMA is clapping knowing they are the true winners here!
Something is in the air!

How is it that there can be such diverse beliefs and each thinking there's is the only right way.......the Homebirth/independent contingent is the loudest complainant shouting the loudest saying we are destroying midwifery...but have never given it a go..... in the survey that I have conducted the numbers are 20:4 in favour of accepting rather than losing everything and the counting continues; If we use the election as a marker to what people believe we can see that life does go on... it is how you go forward to make it work is the real task....... what ever happens it is evident that there is a clear divide between midwives; and I firmly believe this is because not all midwives work within their scope of practice;

As for the future of midwifery "together we stand, divided we fall" that is up to us!

Interesting that the Gospel states; (eg. Mark 3:25: If a country divides itself into groups which fight each other, that country will fall apart". Never a truer word spoken.

PLEASE EVEN IF YOU HAVE A DIFFERENT POINT OF VIEW BE KIND TO EACH OTHER;

Ref; picture & first quote comes from Why affirmations work

The greatest good.....for the greatest many;

2010-09-23T22:26:00.011+08:00

What do we do when we have a moral dilemma? we examine our values and beliefs....where do these values and beliefs come from???? Values determine what we appreciate in life, what we reject and what we feel dispassionate about.

Take our current dilemma within Midwifery - do we? don't we accept the current determination? that is the question; now as I don't have a crystal ball, I have to judge by the facts; before I do I will explore two ethical theories that applies to our dilemma:

Deontology: which is duty bound based on a moral action regardless of their consequences; I like to think of the classic example is that we should not lie, however many people lie to save the feelings of the other person. However you are duty bound to tell the truth regardless of the consequences; for the good of a single person;

Telelogy - Utilitariansism - also known as consequentialism; actions can only be judged right and or good on the basis of the consequences they produce - therefore 'the greatest good for the greatess many' - therefore opposite to Deontology;

I always considered myself more deontology than utilitariansim.... however on this occasion I am the opposite;
A friend of mine gave me a classic analogy about the determination: it goes, " Dear Santa, thank you for the new red bike, but I really don't like red, and the wheels are two small, so no thanks I would rather go without my brand new bike" or the alternative response could be "thanks Santa for the new bike, yes I don't like red and the wheels are two small, but in the mean time I will ride the bike until l save some money paint it and put new wheels on"

I have always considered that the midwife provides continuity of midwifery care to "normal" "low risk" women.... once a complication arises then it is time to collaborate with our colleagues the obstetricians; this is done as professional to professional...... this is not recognised here in Australia.

I have circulated information far and wide about the issues at hand; the majority of feedback from midwives and some women has been to accept the the determination and the main reason being it is the first step to bigger better things; we can change something we have, not something we don't have;

There is much rhetoric about this subject; I fail to see how we are harming by accepting this, if the choice is this or nothing; yes I understand it is not perfect and I for one do not want to be beholding to an obstetrician. However I come back to the same point that this is very new to Australia, midwives are not as autonomous as our counterparts in the UK and NZ... so there has to be a period of trial or adjustment change is always difficult and does not come without a price......this is the first step to massive change... we have to keep working at it to get what we want....at the end of the day you can choose to accept this process or not.... you don't have to have a medicare provider number.... women still can choose an independent midwife.....and not claim a medicare rebate......

The facts remain the same:

The Determination:
Will not prevent private midwives being able to practice (they can still access insurance)

Will not prevent women being able to make choices –If you are having a homebirth and choose not to access Medicare you do not need a signed agreement with a doctor.

Only affects midwives seeking to access Medicare and midwives can choose not to do this.

Is not included in the NMBA Quality and Safety Exemption Framework supporting private midwives providing homebirth services

Does not re-define the ICM definition of a midwife – it does not define the role or scope of practice of midwives in Australia. It only defines how midwives can access Medicare if they choose to do so. Midwives can still work in public and/or private practice and access insurance and register as a midwife (under our current regulatory requirements that have an accepted definition and scope of practice of the midwife in Australia).

Does not mean that midwives must have a signed agreement with a doctor – this is only IF YOU CHOOSE TO ACCESS MEDICARE - Midwives can have
a. an individual signed agreement with a doctor
b. a referral of a woman to you
c. clinical privileging
d. an agreement signed by the medical director of a hospital.

Does not mean you need acknowledgment in writing - we have been told by the Minister’s advisors that a midwife writing in her own clinical notes that results etc have been sent to the hospital/doctor where they have a collaborative arrangement meets this requirement.

Would you throw out the baby with the bath water?

2010-09-20T15:04:00.009+08:00

Currently midwives particularly homebirth private practice midwives are up in arms (and rightly so) about the recent Determination where Midwives are to be virtually signed of by doctors. That is as a privately practicing midwife (independent) you need to collaborate with an Obstetrician or GP obstetrician before being able to claim a Medicare rebate for the midwifery services provided. I might add that there is nothing in the Determination to make doctors collaborate with midwives or any benefit for doctors to collaborate.... so I am not sure why they would even consider it as we (midwives) would be competition for them in terms of financial remuneration therefore less money in their pockets..... emm not sure this will work?

If you are a midwife this seems a sort of sellout, Medicare for collaboration; However the woman is able to recoup some funds with this system therefore allowing more women this option of care....that is continuity of midwifery care and also midwifery led care;

Now as I see it there are two schools of thought......

1: If the government does not change the wording of the current determination; you go all out and say no to collaboration as it stands therefore we lose the right to a Medicare rebate and the legislation falls over; and we maintain the status quo as in the past which is no funding or rebates for women choosing private practice midwifery led care.... and it does not go before Parliament again for three years.... and if the government changes we may never have this opportunity for a long long time.... we will still have insurance requirements and regulations, that will not change.

or

2: we say yes to the collaboration as it stands, work to make it a viable option and see how and if it would work and if it does not work we then collate the evidence and go back to the politicians to lobby for changes to the determination knowing it does not work, rather than speculating that it does not work....therefore whilst we are battling for change women are able to claim a Medicare rebate for midwifery services? and Midwives are recognised for the profession that it is... which should have a medicare provider number.....and be recognised as autonomous clinicians.

Once the system (Medicare) whether it is effective now or not would be beneficial as we can work on changes....but if we never get it in place it will be years before we get back to this position and all our work up to this point would be for nothing as would of achieved nothing and the status quo remains.

What would you do in this situation?

The Homebirth debate: I want to pull my hair out!

2010-09-01T21:43:00.013+08:00

Some arguments presented; I am working through some thoughts and decided to blog it!

I will start with the role and scope of a midwife; the midwife is the specialist in dealing with the 'normal' pregnancy & birth and recognising when things become abnormal and then refer to an obstetrician. All medium and high risk pregnancy should be seen by an obstetrician, you could have shared care or good collaborative care so that the woman can have continuity of care with her midwife whilst seeing the obstetrician.

I can see some independent/private midwives totally disagreeing with my definition of what a midwife's role or scope of practice is. However this is determined by the ANMC competency standards / Ethics / Conduct and the ANMC decision making framework. The scope of practice for a midwife is clear; that is dealing with what is 'normal'. The ACM referral guidelines are also used to guide midwives in private practice - there are recommended conditions of which women should be referred (evidenced based) and when to refer women. this document protects the midwife if followed.

The government funds a small percentage of homebirths through the CMPWA programme, therefore women can claim through medicare - this is for approx 450 women per year. The program accepts healthy low risk women and the demand is greater than what is available.

As far as I am aware there are no Midwifery Group practices in WA, which really is a tragedy, as most other states have several MGP both private a publicly funded.
I do wonder if the women who choose independent midwives know the scope of practice of a midwife and to what extent she/he can practice? and do independent midwives ever say to the women this is out of my scope of practice I am not qualified to do this? however I will support you in the hospital setting?

There are a number of independent/private midwives who practice in WA, these are separate from the government funded midwives. Independent/private midwives will have a fee for service for which women cannot currently claim through medicare. This can be limiting for women and expensive.

Interestingly like private obstetricians private midwives are not required to follow public/government policy because they are privately employed. However they are responsible to the regulatory body which for midwives is the Nursing and Midwifery Board of Australia (from October for WA).

I do understand and empathise with the woman that has been so traumatised that she just cannot face going to hospital or even seeing a doctor due to her mis-treatment, this is very real and happens all too often. Recently this was evident in the 750 submissions made by women/men when asked about maternity services in Australia. Who cares for these women? The women are so fearful they would rather freebirth.... this is a terrible reflection of the state of maternity care in Australia. We are letting these women down.

I am frustrated with the homebirth debate; on one hand you have the independent midwife who at all costs will defend the right to support a woman of her "choice" to birth at home whether she is medium or high risk (and rightly so otherwise who looks after them). They believe that the woman has the right to choose homebirth because she is well informed and knows all the associated risks with birthing at home with a risk factor, therefore has the right to self determination and the right to refuse treatment. There are health professionals who do believe the midwife should walk away from this woman in other words abandon her in labour because your registration is at risk. There are obstetricians who believe that women do not have the right to choice when they are high risk......that it is the obstetricians professional right to make the correct decision in the 'best interest of the woman and baby'.

The law in Australia does not protect this midwife when she/he works outside of the scope of practice. Unlike the UK where the midwife is protected by legislation and is not allowed to abandoned the woman..... We need this type of protection in Australia for the midwife. Currently the independent midwife works out on a limb and is not supported and alienated by the hospital system.

The problem I have with the above scenario is that the midwife is not qualified to care for the high risk woman she/he would be working out of the scope of practice, because this is not within the role of the midwife and this worries me. I am not saying our role as a midwife is not to support this high risk woman, it is to support and provide collaborative care for the risk factor associated with the pregnancy, however often doctors will not collaborate unless the woman does as the doctor suggests.......this is a lose - lose situation.

The trouble as I see it is that fundamentally women are not being heard by health professionals, they feel pressured, bullied and are often scared into submission by the health professional, therefore choose an alternative model of care this may include freebirthing (birthing without a trained health professional present). Hospitals are not flexible, they are rigid and not prepared to meet the woman half way.... it appears that's its the hospital way or the highway...and women will choose the highway.

So what is the answer?
If I sound frustrated I am?
Please tell me how we move forward?
How do we stop women from feeling alienated and force independent midwives to work outside their scope of practice?

Court ordered medical treatment for pregnant woman in the US

2010-08-27T22:43:00.006+08:00

Informed consent and right of refusal are accepted legal concepts. The woman has the right to make informed decisions, including consent or refusal of any aspect of her care. The courts have consistently affirmed that the autonomy of the individual prevails, even when a patient refuses to consent to life-saving treatment.

Autonomy; Even when his or her own life depends on receiving medical treatment an adult of sound mind is entitled to refuse it. This reflects the autonomy of individuals and the right to self determination........as you will read from Judge Butler-Sloss in the St George’s Healthcare NHS Trust case where a woman was forced by a court order to have a caesarean section against her will...... You could liken this to the current issues surrounding women making a choice to have a ‘Homebirth’..... and doctors applying pressure and creating a ‘fear’ culture to ensure that women choose hospital as opposed to homebirth.....

Judge Butler-Sloss in St George’s Healthcare NHS Trust v S (1999) “...while pregnancy increases the personal responsibilities of a woman it does not diminish her entitlement to decide whether or not to undergo medical treatment. Although human and protected by the law in a number of different ways..., an unborn child is not a separate person from its mother. Its need for medial assistance does not prevail over her rights. She is entitled not to be forced to submit to an invasion of her body against her will, whether her own life or that of her unborn child depends on it. Her right is not reduced or diminished merely because her decision to exercise it may appear morally repugnant.,....”.

Now in the US where the fetus has arguably had more rights than its mother in some states, which in my opinion is outrageous the State of Florida has recently ruled that a woman who refused medical treatment was ordered to comply with her doctor’s orders. The woman a mother of two who was experiencing complications during her pregnancy was ordered to hospital, made to receive medical treatment and have a caesarean delivery.

“The trial court ruled that the woman's refusal of medical treatment placed her pregnancy at high-risk and created a "substantial and unacceptable" risk to her fetus. The trial court said the state's interests in protecting the fetus superseded the woman's privacy interests, and she was ordered to comply with her doctor's orders. The woman submitted to hospitalization, medical treatment and a caesarean delivery, although the fetus was delivered stillborn.”

The case went to appeal and the decision was overturned......

“In its ruling, the appeals court said the state's interest in the life of the fetus becomes compelling only when the fetus reaches viability, as outlined in the 1973 U.S. Supreme Court ruling on Roe v. Wade. The court added that there was no indication of viability when the trial court ordered medical treatment and that even if viability were shown, the trial court applied the wrong legal test. The "test to overcome a woman's right to refuse medical intervention in her pregnancy is whether the state's compelling interest is sufficient to override the pregnant woman's constitutional right to the control of her person, including her right to refuse medical treatment," the court said in its ruling. It added that the state also must show that its method of pursuing the compelling state interest is narrowly tailored to protect the woman's rights”.

However for this woman her rights have been totally obliterated..... mind you this case now becomes another precedent and hopefully some other woman does not have to go through the same ordeal. We have to remember that women have the right to self determination; because they are pregnant they do not lose that right.

We in Australia have to be mindful that this does not happen here, that women’s right to self determination is not eroded such as this.

“The American Civil Liberties Union, which filed a friend-of-the-court brief in support of the woman, said in a statement that the ruling is "an important decision for the right of women to make their own medical choices." Diana Kasdan, a staff attorney with the ACLU Reproductive Freedom Project, said that women "do not relinquish their right to determine their own medical care when they become pregnant."

Ref:.http://www.medicalnewstoday.com/articles/197902.php

St George’s Healthcare NHS Trust v S [1999] Fam, 26’ [1998] 3 All ER 673

Deciding who to vote for?

2010-08-18T22:08:00.007+08:00

Deciding who to vote for?
The Australian election is on Saturday and it is down to the wire...it will be a close call. What is it that makes you decide who to vote for? This election I have been more political than ever before...why is this? Because women and midwifery matter and now more than ever I feel that my vote counts more than ever. The recent battle for the profession of midwifery is almost equal to what women went through to get the vote (the SUFFRAGETTES)... equal rights the right to choose how to birth, the right to refuse treatment also more importantly the right to informed choice & continuity of care of a known midwife.

Your vote matters.......

We know who the major parties are; Labor; Liberal and Greens; over the years I have fluctuated between all the parties and in the days of Democrats, I was a staunch supporter. I will decide on Saturday.......and I will VOTE!

I do believe that the Labor Party Nicola Roxon as Health Minister has truly broken boundaries and put midwives, midwifery & nurse practitioners on the map..... however her latest Determination of 2010 has seriously let us down...and yes I can see that the AMA played a large part in this equation immediately prior to an election.... you are going to do what you think will get you re-elected.... however the Determination is seriously flawed and will not work for women, midwives or obstetricians and they the doctors currently hold the balance of that power, this is un-Australian..... midwives are currently regulated and do not need to have Dr’s veto their practice in order to claim a Medicare rebate.....I do feel that the Labor party are aware of this problem now and will change it if re-elected......

I am willing to give the devil I know another chance as opposed to the devil that is worse......a chance to prove it is worse... but will decide on the day....

On the other hand Liberals Tony Abbott has notoriously ignored the plight of midwives and our colleague nurses, a female dominated profession. He is a staunch Catholic therefore Pro life and not Pro Choice.....Tony Abbott’s history as Health Minister speaks for itself...non productive... and I am not so sure he is compassionate in terms of refugees......I wonder if he is promising to reduce the surplus where are we going to pay for it?.....

The problem with elections is that we get so many promises we end up not knowing who to believe......I would not want to be a politician...

The Greens Rachel Siewert....The "Australian Greens said today that midwives are furious with the Federal Government over recently released regulations governing the way they practice".
......The Greens are great supporters of midwives they are the only party that has a Homebirth policy and that have put women, midwifery and midwives openly on the agenda..... and it is very important that they control the senate to keep the bastards honest.....and maybe control the balance of power.......

Issues are numerous..... Refugees; Work Choices; Health; Education, Surplus, and the list goes on.... my message is don’t waste your vote...... if neither of the major parties don’t do it for you then vote for Greens or an Independent.... but vote because it matters.

Legal issues? Homebirth again!

2010-08-10T15:37:00.006+08:00

The Medical Observer writes Homebirths GP's new legal dilemma.... "If your patient decides on a midwife-led home birth and asks for prescriptions, could you be legally liable if something goes wrong?"
sometimes I am still amazed at what the AMA will come up with next..... really it should be no surprise that this tactic would be used.....
"Midwives are able to legally administer Syntocinon but cannot prescribe it, until 1 November when changes to federal laws mean nurse practitioners will have limited access to the MBS and PBS."
Giving syntocinon has always been part of a Midwives role, this drug is not new to the profession....it is part of our job, however the drug is only used if there is postpartum hemorrhage.
Part of a midwives course is a detail pharmacological unit, which entails knowing about the drugs used within midwifery there use and contraindications of drugs..... the way this article reads is as if this is a new drug that midwives have no idea about.....midwives are trained professionals.

According to Homebirth Australia spokesperson Justine Caines, the group has had reports of women in the ACT, NSW, Queensland, Victoria and SA who have been refused scripts for Syntocinon, vitamin K and ultrasound referral by their GP.

She says there is a steady growth in home birth as more women become what she calls “refugees” from the hospital system, reluctant to return for another birthing experience of “substandard or unsafe care”.

Ms Caines condemns the decision to refuse women these scripts and believes GPs are being unnecessarily cautious.

“I think [GPs] have less to fear than when they normally prescribe, as in this case the woman is in the care of a registered midwife,” she says.
Indemnity insurers are not so confident. There are legal risks for GPs if they do choose to prescribe painkillers, vitamin K or Syntocinon to patients wanting a home birth, they say.
Cheryl McDonald, medico-legal manager at MIGA (which will handle the new Midwives Insurance Scheme) says GPs are quite within their rights to refuse to write scripts in the case of home births, where they have no control over the medical outcome.

This really makes a mockery of the Collaborative arrangements Determination 2010....and really begs the question, how well thought out was the collaborative arrangements....? and did the AMA plan this all along knowing that these arrangements would not be workable. I am all for good collaborative arrangements that are workable, fair and equitable, not power orientated.

As midwives we have to be as proactive as the AMA..... we need to be allowed to practice our profession just as they are......this is about monopoly, money and power.
We need to be considering "women's choice" fairness and equity and right to refuse....

ref pic: littlekanga-roo.blogspot.com

"Greens Will Act to Help Midwives Media Release"

2010-08-07T18:18:00.003+08:00

Read what the Greens have to say about “the collaboration determination”

Greens Will Act to Help Midwives Media Release | Spokesperson Rachel Siewert Saturday 24th July 2010, 10:01am

The Australian Greens said today that midwives are furious with the Federal Government over recently released regulations governing the way they practice. Greens spokesperson for Health, Senator Rachel Siewert has committed to immediate action on the regulations upon the resumption of Parliament.

“As soon as the Senate next sits, the Greens will move a motion to disallow the collaborative arrangements regulation,” Senator Rachel Siewert said today.

“This regulation puts doctors in total control of midwives and makes a mockery of the Government's $120 million “Medicare for Midwives” reforms,” said Senator Siewert.

“The government released its definition of collaborative arrangements for midwives out of parliamentary session, and it’s easy to see why- their approach is unacceptable and demeaning to midwives and they didn't want to draw attention to them during the last week of sitting.

“Midwives are concerned that this determination effectively means that if a doctor does not agree with a woman’s choice of midwife, they do not have to participate and will withdraw their collaboration.“Midwives will have to work under the control of a doctor in order to access Medicare payments.

They must have a signed agreement with a doctor who agrees to the way they are providing care or have all elements of care planning acknowledged at every step.“We’re speaking about trained and regulated professionals who have been insulted by the reforms put forward.

“If the government does not trust regulation of health professionals to ensure that practitioners are working safely, it is a very sad indictment of their own health care system.

“The government has failed to deliver anything like the promises they made for midwifery reform and at the same time have given power of veto of one medical profession over another.

"Women are outraged that they have been told that Medicare rebates will be available for private midwifery care and now the reality is that this will be limited to those employed in an obstetric model which many women have said over and over again that they don't want," concluded Senator Siewert

Working as an Private Practice Midwife with the new legislation:

2010-08-05T16:44:00.007+08:00

As from the 1st July 2010 all of Australia except for WA has joined National Registration (AHPRA) and therefore requiring indemnity insurance when registering as a Midwife, or Nurse Practitioner. WA is expecting to join National Registration in mid October 2010, until then the Nurses and Midwives Act 2006 applies.

There are a few ways in which this can be achieved in Australia with the new Collaborative Arrangements: If you are already in private practice/independent you can use the exemption clause from the Health Practitioner Regulation National Law Act 2009 s284 (Exemption from requirement for professional indemnity insurance arrangements for midwives practising private midwifery)

During this time the midwife does not contravene section 129(1) which states you need private indemnity insurance to be registered. However the midwife must ensure that he/she has a signed consent form from the woman in relation to having no insurance. However you need to be mindful of 284(1)(c)i “the midwife complies with any requirements set out in a code or guideline about reports to be provided by midwives practising private midwifery; and(ii) any requirements in a code or guideline relating to the safety and quality of the practise of private midwifery.
Codes to note: New Code of Ethics for Midwives August 2008: New Code of Professional Conduct for Midwives August 2008: Midwifery Competency Standards August 2008:

In simple terms you can continue to practice as an independent/private practice midwife and the women you are looking after will pay for your services as per normal and will not be able to claim a Medicare rebate. As per normal you are advised to keep exemplary notes about the care you have provided and audit your practice and outcomes, so when it is time in two years to apply for Homebirth insurance midwives will have the data to prove that homebirth has good outcomes and is cost effective.
Registration standard for Eligibility: to claim MBS and PBS you will need to be an ‘eligible’ midwife, this means three years experience in the continuum of midwifery care. Completion of further studies relating to pharmaceutical and diagnostic investigations and 20 hours of continuing professional development per year.

National health (Collaborative arrangements for midwives) Determination 2010 – National Health Act 1953 – this document outlines the collaborative arrangements for midwives – basically this document states that midwives have to collaborate (although we already do this and is part of our competency standards) – consultation between the midwife and an obstetric specified medical practitioner, referral of women to a specified midwife, or the midwife is employed or engaged by 1 or more obstetric practitioners or an ‘entity’ that employs obstetricians. The Arrangement – midwife’s written record..... this actually means that you have to enter into a written arrangement that both parties agree to about the care of the woman.....strangely enough there is no provision in this document for what the woman may want here...because if the woman chooses something outside the sphere of the realms of normal the midwife will not be able to continue the care because she will probably not have the support of the obstetrician therefore will not be collaborating and the woman is left stranded...... now what do we do...and herein lies the problem........ with having the medical model trying to control midwives.

At this point in time there is nothing that we can do about this Determination..... the horse has bolted......(a determination is allowed or disallowed) nothing will go forward until after the election.....My fear is that with a Liberal government we will go backwards, there is a slim chance with the labour government that we may be able to amend this document however the Greens are showing more positive support for our plight with this unworkable document.... As a midwife I want to be able to offer women the choice of birthing at home without having to have an obstetrician sign off my care..... I am a professional and know my boundaries, I work within my codes.

I see the way forward as lobbying the government to change this determination by having a strategy of safe clinical care, auditing homebirth and outcomes, peer review and supervision process and risk management strategies...without having to have my care signed off by a Dr...... not to mention the cost effectiveness of midwifery led care as opposed to hospital base care. We need to lobby the government find out who you local MP is and send them an email or letter:

“Hi, I am ………………….., my address is ………………and I live in (your electorate’s name). I would like to let you know that I am concerned with the recent determination passed by the ALP government - the National Health (Collaborative arrangements for midwives) Determination 2010. Midwives already collaborate with medical colleagues but I don’t want them to have to enter a “collaborative arrangement” or any kind of signed agreement with a doctor for the purpose of getting Medicare. I also want all maternity care policies to have the right to informed choice (right of refusal) written in to them. I want a long term solution so that women always have an ability to access homebirth care and I want national visiting access to public hospitals for all eligible midwives.”

It is time to be politically active.......contact your local MP and find out what their position is!

Do you have to believe in God to lead the country?

2010-08-03T15:14:00.004+08:00

I was outraged the other morning to hear that Archbishop Barry Hickey is questioning whether Julia Gillard should lead the country because she is an atheist……. Well two things came to mind for me…would he have the same question if the opposition leader was not a so called devout Catholic and second many people turned to atheism when they discovered there so called spiritual leader “priest’ was a child paedophile or an abuser of some sort…….I think that the Archbishop should stick to religion and cleaning up his own back yard before criticising Julia Gillard’s belief’s and the church should keep out of politics…… The Catholic Church is renowned for keeping women as second class citizens…….... and also look at what the 'so called good priests and nuns' have done in the past in relation to child and sexual abuse...not sure that their belief in God made them good people......

‘God’ it’s hard to be a successful woman in a man’s world, Julia Gillard has good leadership qualities. Who is anyone else to judge what sort of person she is because she announces she is an atheist….....how shallow are people..... the qualities I see in Julia Gillard is that she is law abiding, conscientious, kind and considerate... intelligent articulate etc etc etc....

We need to be looking at policy not gender or belief in God......

Collaborative arrangements for Midwives:

2010-07-22T20:51:00.021+08:00

Well; after a long awaited time we finally know what the collaborative arrangements are.....I must say I am disappointed...after lots of negotiation I feel let down and that the machinery of money, politics and power have yet again trampled on the profession of midwifery.

The other issue is the upcoming election; we are in a crucial stage....Labour stays so does the current status quo...Liberal in and we lose it all....I do think that NICOLA ROXON Minister for Health and Ageing has tried to do the best for Midwives and also trying to accommodate the AMA.....without losing any ground and yes she too has to protect her position so that Labour remains in power.

This document is hard to read, you need to read it several times to work out exactly what it is saying.
For example if you read this section:

Specified medical practitioners
For the definition of authorised midwife in subsection 84 (1) of the Act, the
following kinds of medical practitioner are specified:
(a) an obstetrician;
(b) a medical practitioner who provides obstetric services;
(c) a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative
arrangement.

First impression is that an independent midwife or private practice midwife cannot practice without having an obstetrician sign them off..... however (c) indicates that any hospital doctor can act as an collaborative partner...therefore the hospital will act as an collaborative partner....

Now if we look at section 7: this part is more hopeful in that if we get a hospital to support private practice this will work as collaborative arrangement: we could extend it to domino births.....the problem with all this collaborative how much is truly required.... if everything is normal then there needs to be no collaboration....and yes...there has to be a hospital booking which will mean collaboration with a doctor...at least once..but thereafter you would not see the doctor again if everything is normal....and this is as it should be.....

Arrangement — midwife’s written records
(1) An eligible midwife must record the following for a patient in the midwife’s
written records:
(a) the name of at least 1 specified medical practitioner who is, or will be,
collaborating with the midwife in the patient’s care (a named medical
practitioner);(b) that the midwife has told the patient that the midwife will be providing midwifery services to the patient in collaboration with 1 or more
specified medical practitioners in accordance with this section;
(c) acknowledgement by a named medical practitioner that the practitioner
will be collaborating in the patient’s care;

If doctors truly were collaborative they would be referring more women to our current Birth Centers, but they do not because they want the control and money.... It is hard to even imagine that doctors will refer to the midwife....for normal care...because they do not even believe in Birth Centres.... how will they make this massive change when they do not even support homebirth.....?
I would like to see that they are made to refer women to midwives... instead of the old school boy tie club and kick backs to specialists.....

The bottom line is, it's the women's choice....it is about continuity of care and that every woman needs a midwife.

Keep focused on the dream, the passion and the right of women to choose where they want to birth their babies, the right to informed choice and the right to have a midwife.

Click on this link:
National Health (Collaborative arrangements for midwives) Determination 2010