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  1. 1

    oovergro

    These arguments assume that obstetricians are male- the womans body etc.
    Hence discussion with underlying assumption of sexism
    A quick look would show that the medical workforce is not male dominated.
    There are a lot of female obstetricians.
    They are as reluctant as their male colleagues to be involved in a situation that might leave a dead or maimed baby

    Reply
  2. 2

    john2066

    Lets face it, the AMA are Australia’s most powerful trade union, and they will do anything in their power to maintain their monopoly over medical services. If that means stopping home births, they will stop home births. Ironically of course, they make sure there aren’t enough doctors regardless by restricting drastically specialist numbers.

    Stop this outrageous closed shop now!

    Reply
  3. 3

    Kim Bulwinkel

    john2066
    I am saddened by your comment. It shows great lack of knowledge and gives insight ++ into your preconceived ideas that unfortunately seem to also come all-too-frequently from the mouths of our federal & state politicians.
    1] The AMA is not a Trade Union and has never been able to be. It is expressly disallowed from any trade union type role because of its structure as a diverse professional representative organisation.
    2] The AMA has no control or even influence, unfortunately, over doctor numbers trained or registered in this country. Our calls for government to increase doctor training numbers in an orderly and sustainable way back in the mid 1990s were scornfully rejected with much personally directed invective [ I was on the receiving end ].
    3] Specialist training requires practical training environments & posts, trainers, time to train, a realistic monetary value to be assigned to training and certain standards to be maintained. All of these issues are, again unfortunately, beyond any sort of control of the AMA. The facts are that most training of specialists is done on an honorary basis by College members/trainers [not AMA], training posts are linked to public hospital beds – all under great pressure of numbers, resources etc. [not under any control of the AMA]. Training of specialists takes TIME to do and time is under impossible efficiency pressures in public & private health delivery environments [ the AMA has no influence over the length of a minute, an hour or the number of hours in a day! ].
    More modern generations of health care providers and students want a better work-life balance – much of the best training happens outside of those parameters [ again not controllable by the AMA ]. No one, including the AMA, has yet figured how to assign & allocate a financially viable value to the training process – everyone wants the outcome but no-one wants to pay!!
    john2066, please think and learn before emotionally ‘lashing out’. You can ban the AMA if you like …. make them disappear and the only result will be that you will have no-one to blame. All else will remain the same.

    Reply
  4. 4

    liliwyt

    Thanks Hannah. A thought-provoking piece. I agree that the definition of “safety” in regards to childbirth is limited, but understandable given the current business model of health care. Obstetricians are only interested in the successful delivery of a viable infant – that is what they are trained to do and the professional consequences for them are dire if the worst happens and the child or the mother dies as a result of the childbirth process. With the pressure of several mothers in labour and having to attend each one in a birthing unit, the obstetrician has at his/her disposal the tools to bring forward or delay a birth so that each mother receives “timely” care. All very ethical and above-board. That is not to say, however, that the definition can not be changed – a wider lens of maternal and infant health and wellbeing should be considered and this, I feel, is where the midwife model is applicable and is not inimical to the medical model.

    In an ideal world midwives and obstetricians should be working together. This continuous sniping only does harm to all concerned.

    Reply
  5. 5

    Jenny Advocat

    liliwyt, I agree with you except for the bit about “all very ethical and above board”. It depends from whose perspective you are look. It is certainly not ethical to induce my labor (or delay it!) or inject me with hormones to hasten delivery of the placenta (or any other of the tools at the disposal of the obstetrician) because of the pressure the obstetrician is under! Ethical childbirth can only be achieved when intervention is undertaken soley for the health of the mother and baby–not to conform to the time constraints of the system. If we broaden the definition, we will have to confront some of these practices which are about the system, not the individuals who enter it. I agree, working together is always preferrable, regardless of how realistic that is, the sniping won’t solve anything.

    Reply
  6. 6

    midwife

    Everything old is new again. There is nothing new in this article. For 38 years practising responsible midwifery has always been about the woman and what she needs, never any argument about this. Midwives have and still work in mutually respectful relationships with general practitioners and obstetricians. Nothing has changed, and nothing is new in these recommendations, except for the interference of politicians who rub shoulders with the likes of Dr Pesce for their own political and financial gain. The new breed of AMA and Politics has some belief that they can control every other profession and women too. Not so, midwives will continue to fight for their professional rights, and women will fight for their bodily and womanly rights. Midwifery is a respected profession in it’s own right, mutual recognition of the very different skills does not mean control of one profession over another.
    Midwives provide midwifery services not obstetrics, and vice versa. Midwives provide their services for women, in keeping with the International Confederation of Midwives and statuatory regulations. Midwives who are self-employed are not beholden to doctors or institutions, they are employed by, and contracted to the women and are accountable for their actions.
    Most importantly midwives are not ‘support persons’ when they enter the institutuion with a woman they responsibly transfer for the opinion of another professional. Midwives, when they cross the threshold of the hospital entrance will not accept this insult of pseudo deregistration, change of status, or change of title just because they consult with a team of institutionally employed professionals. When midwives who work ‘with women’ in any setting consult and/or refer they do not change the status of MIDWIFE to ‘support person’, they do not relinquish their registration, qualification or experience. There is no ownership of the woman or the midwife. Harmony within the team depends on the respect individuals have for the woman, and they together are the link in consultation with her for the best possible outcome, each respected for their level of knowledge, their experience, and most importantly for their ability to sit and communicate with, and talk eye to eye, face to face, with the woman at her level, not over her in a stance of dominance.
    There are many responsible doctors in the Australian community who happily respectfully work with women and midwives. So the debate that continues is more about removing the politicians, the modern poorly informed restrictions, and multitude of position statements and guidelines that attempt to impede the practice of the qualified midwife, and let the professionals who are skilled and mutually respect the woman and her rights get on with what they are educated and qualified to do. Hospitals are for the sick and injured, not for the healthy. Keeping women out of hospitals for the sick and injured, returning to Community Birthing Homes and facilitating homebirth for the majority of women is the safest, and most responsible way for pregnancy, labour, birth and postnatal 6 weeks in this country. Mature Midwife.

    Reply
  7. 7

    liliwyt

    Hi Jenny – I agree, the “ethics” are questionable and perhaps I should have parenthesised that phrase as you did. My point was that, certainly from the obstetricians’ and hospital administrators’ pov, it is preferable to deliver a baby “safely” and in some respect to control the timing of that using the medical technology available to them. It is certainly not against the law to do so. And my understanding is that you would have a hard time finding an Ethics Committee that would disagree with that, although proving “informed consent” may be problematic.

    Does that make it right? No. As a woman, I agree it is not ethical (using the purest definition of the term) to use those means as part of a system that is more interested in KPIs than my and my baby’s wellbeing.

    Reply
  8. 8

    Jenny Advocat

    Hi liliwyt. Yes, when looked at from the pov of hospital docs and admins, true, that would look “safer” to them. But, (and I sense we are agreeing), if a broader view is taken, it would include better attention to the more subtle ways in which otherwise unnecessary (to health) interventions in a low risk, healthy pregnancy and birth, can impact upon the overall health and well being of both mothers. No one would argue against safety. However, our very understanding of the term “safe” requires some unpacking. I believe we haven’t even begun to understand (scientifically) the impact this kind of institutional treatment can have on mothers and babies.

    Like the midwife above states, hospitals are for sick people (and I’m glad they are there when we need them, I take access to them as a right, an entity to be questioned and improved in an ongonig basis and called upon when necessary) but pregnant and laboring women should generally not be included in that category. To do so can only be politically driven and fear based.

    Reply
  9. 9

    BeverleyW

    When I ask women why they choose home birth their reply is “I want to feel safe”. Home is where they feel safest. For some women this is their first birth – most are well read, but there are those that are not. For a few the choice is a “can do” idea. If there are problems of access to a midwife some search far and wide. The commitment to have a home birth is matched by the statements about giving birth as one of pure joy compared with previous experience/s in various hospital settings. Statements such as “why did I ever go to hospital?” I wish I had known that this is what it is like. Most women I speak with about choice of home birth, have experienced a traumatic time in hospital. They speak of feeling out of control, noisy place, the staff are rushed and if they had a surgical birth their baby was taken away to a special care nursery and they found this alarming. They felt that if they had agreed to have to have an induction and if it led to a Caesarian Birth they felt cheated especially when they found the reasons were specious if not wrong. Many had heard of home birth choice and that is what they want the right to do. There are those I also hear from who want a hospital birth because they need a break for a stressful situation at home and those reasons are sometimes because of abuse at home (usually alcohol related) and this is across the spectrum of poor or well off homes. Work related fatigue and large families is another reason for choosing hospital given by some women. Respite these days is really only for those that can afford private care – otherwise early discharge is the custom in public hospitals. I am interested that Dr. Pesce is still talking up mortality and not acknowledging morbidity – Post Natal Depression and post surgical fatigue and poor breastfeeding statistics due to lack of support and access to the baby as a result of major abdominal surgery and chemical inductions, haemorrhage, infection, episiotomy and sometimes even hysterectomy.

    I am supportive of a better dialogue between professionals to achieve safe hospital birth and safe home birth. From my times when hospital birth prior to chemical and surgical terminations of pregnancy (inductions) was rare and when doctors were real and men were men and women had been running their own hospital in Melbourne (Queen Victoria). while the playing field was not fair or equal then there was respect for each other in that field – dialogue worked. For me dollar driven obstetrics means that dialogue is impossible when midwives are not acknowledged with remuneration nor are their private practices are not equally supported by government funds through Medicare. That “dog don’t hunt”.

    I wonder whether those above are aware of threats to the current government about millions of AMA dollars would be spent to prevent midwives accessing Medicare. Doctor owned and subsidised Insurance is not an even playing field. When mortality rates in hospital are still around 9.00 per thousand with limited transparency of the why and Caesarian Rates are way above WHO recommended rates in private hospitals something in the state of this Nation is on the nose.

    Yes there are female obstetricians but unfortunately their mentorship is not focused on care of the woman in labour of afterwards with breastfeeding it is focused on how fast can we get this woman in and out of hospital. One private obstetrician in a major teaching hospital refuses to come to births after 5.00 pm and encourages 38 week inductions on weekdays. When pushed by a woman who was able to disprove the supposed reason for the induction in her haste to expedite the normal vaginal delivery pulled on the cord and broke it. Leading to a great deal of distress for the grandmother the mother and the husband. The is woman was not allowed to move around in labour. Enuf said –

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  10. 10

    Kim Bulwinkel

    Great debate! So much would be made much easier if the medico-legal implications, risks & costs of the types of decisions being discussed here were removed from the field of play in obstetrics & paediatrics completely.

    Lets be novel and enshrine in water-tight legislation that women take full personal responsibility for their birthing choices and decisions. They can seek the education and opinion that they wish or are able to access. They make their decisions and then wear the full consequences of their decisions. Society doesn’t wear the cost consequences. Insurers don’t have to factor in the payout and legal process costs. Midwives and obstetricians are freed up from onerous protocols, legal standards and crippling costs. Decisions have consequences!

    For the record, I am not an obstetrician or a medical practitioner that has ever had responsibility for a delivery in 34 years of practice.

    Reply
  11. 11

    Jenny Advocat

    Kim, I’m all for personal responsibility, and certainly that plays a role. But let’s not pretend that anyone’s decisions are made in a vacuum. What information will be made available to women prior to making that decision? Which women will be empowered and which will be disadvantaged by such legistlation? There are a lot of things to consider before wiping our hands of social responsibility. As a society we are not very good at encouraging people or helping them to understand their bodies, I think a lot needs to change before personal responsibility can be at the centre of this debate.

    Reply
  12. 12

    Sue Ieraci

    This essay presents an unusual view of the safety of birth – one which, I suspect, would not be supported by the majority of our community. Dahlen acknowledges that there are several well-defined risk-factors that threaten the lives of newborns in the homebirth situation. These include the readily-identifiable conditions of breech presentation and twins. If any other health care profession identified these causes of neonatal mortality and injury, but failed to adapt their guidelines to minimise the risk, there would be public outrage. How many parents truly value the home environment over the safety of their baby?

    Dahlen presents the argument that perinatal mortality isn;t everything in birth safety – that maternal pshchological morbidity is important too. Of course it is. However, this essay reflects the other side of the argument – the severe and long-lasting psychological effects on BOTH parents of losing a child in childbirth. Is Dahlen really asserting that the psychological morbidity to a mother from having an unexpected cesarean delivery is greater than the extreme and ever-lasting grief for both parents of losing a newborn?

    Finally, if it is true that the greatest cause of maternal death in the child-bearing years is psychological distress, we must remember that, in the past, it was childbirth. It’s important not to forget that the advances in clinical care for both pregnancy and delivery are the reason that maternal mortality within labour and delivery are so low in our societies. In the developing nations, where women cry out for access to the clinical care that we can be so critical of, the balance of safety is very stark.

    Reply
  13. 13

    liliwyt

    Kim, I agree that the current medico-legal climate is not conducive to the kind of reforms we are discussing here. It could be argued that situation has come about because of specious compensation claims being made against doctors in general. It certainly has prevented many GPs from practicing obstetrics, which was much more commonplace 30 years ago.

    Your point also seems to come from the perspective of the woman taking “full responsibility” for any harm that comes to her during childbirth. What about the consequences of poor decisions made by the medical staff attending her?

    Yes, making women aware of their own personal responsibility is important – any patient, for that matter, should be playing a much more active role in the decision-making process around their health care. But it needs to be done by providing informed consent. That can’t be done until all the implications are discussed and it certainly can’t be done (as Jenny pointed out) when the patient has limited health literacy. When you consider that around 40% of all Australians have low levels of health literacy, taking such action as legislating for personal responsibility in childbirth becomes problematic.

    Jenny @9 – yes, I agree the definition of “safety” needs to be looked at more broadly.

    Reply
  14. 14

    Kim Bulwinkel

    Jenny,

    I think that you miss my point. Specialist medical practitioners are energetically & aggressively pursued to be made responsible for outcomes that they often have not been able to influence despite their best of intentions and the best possible applications of their knowledge, time, experience and skills. This comes at great personal, emotional & financial cost. The AMA tries hard to find the right solutions from a professional point of view but always seems to attract the invective of the type that is being used in the above commentary – very unfair & ill-informed.

    Midwives and their clientele have to realise that if they want the inevitable problems with a percentage of deliveries to be miraculously and effectively dealt with, they will need the input of skilled obstetricians and paediatricians. There will be a significant percentage of significant problems. The specialists will then be aggressively and energetically made responsible as soon as they answer the telephone, receive a fax to their rooms or even walk past the end of room or corridor.

    Surely everyone involved in this debate must understand that this paradigm is not sustainable or even tolerable. Don’t take the wheels off the car before it has stopped travelling at 100 kph!!

    Reply
  15. 15

    Kim Bulwinkel

    And how does one get informed consent 20 minutes into a catastrophic pph or an obstructed labour in a patient that you have never seen before?

    Reply
  16. 16

    Kim Bulwinkel

    The natural conclusion of this argument line is that there wont be any poor decisions being made by attending medical staff because there actually wont be any medical staff in attendance. Touche!

    Reply
  17. 17

    liliwyt

    Kim – I take your points, coming from the current paradigm, and I agree that what is being argued here may not fit easily into that paradigm.

    For myself, I don’t think that childbirth should be the sole domain of the midwives OR the medical specialists, but that their roles are complementary.

    Let’s take a hypothetical for a walk …

    A woman discusses her birthing plan with a midwife early in the pregnancy. That plan includes all possible scenarios. The woman is screened for potential complications at specific points during the pregnancy. If there is a possibility that a complication could arise, the woman meets with an obstetrician (not necessarily the one that is on duty when she is in childbirth – given the variability in delivery dates & times and rosters, etc) to discuss possible medical interventions. Counselling on what the woman could expect in childbirth continues throughout the pregnancy, led by the midwife, supplemented by information from the obstetrician. At some point, well before she goes into labour, the woman signs a written agreement which outlines the birthing plan, all things considered.

    Reply
  18. 18

    Hugh (Charlie) McColl

    Keep walking, liliwyt. I want to see what that “written agreement” means, all things considered, when you get to the hospital at midnight.

    Reply
  19. 19

    Jenny Advocat

    Kim, yes, I may be missing your points. I am interested in the majority of ‘normal’ births, low risk, without problems, and you seem to be talking about some (“significant”?) percentage requiring necessary emergency intervention. I question the need for calling for so much intervention and suspect the true emergencies would be fewer and farther between if we had a health system that worked better with women and educated practitioners to respect and cultivate knowledge about the body which is being lost. You seem to be coming from a position of defending medical practitioners (which is fine) but, as neither a medical practitioner nor someone working for them, I am more interested in mothers and babies. I take your point that there is a lot of pressure on practitioners to get it right, but I wonder, why don’t midwives working outside the hospital system have such a big problem with medico-legal issues?

    Reply
  20. 20

    Sue Ieraci

    Jenny – you ask “why don’t midwives working outside the hospital system have such a big problem with medico-legal issues?”

    Firstly, in Australia, there are very few of these. Secondly, if they work within the guidelines, they have to follow risk-out guidlines and having a workign relationship with an obstetrician (to get indemnity cover). If they are registered midwives, working under these circumstances, then they are accountable for their decisions. The number of independent midwives working under these conditions, with indemnity cover, is very small. The number of high-risk homoe births they manage must therefore be close to zero.
    On the other hand, the home birth deaths that are currently being investigated by the SA coroner have occurred in the hands of some pracititoners who have stepped outside the regulatory framework by rejecting registration – and therefore accountability. They cannot (in practical terms) be sued if they don’t carry insurance. And lastly, the women who want to birth with them believe in them so strongly that they are highly unlikely to hold them accountable.

    Reply
  21. 21

    Kim Bulwinkel

    The doctors are the easy target who have the insurance & therefore the source of financing to feed the needs, real perceived or otherwise. This is the biggest issue, not the righteous reasons usually put up by the idealists. Maybe the answer is to encourage that the obstetrician should go the way of the procedural GP. I believe that this scenario actually played out in Nevada USA not so long ago & continues to be a major issue. …. http://www.soroptimist.org/articles/article_obstetricians.html.

    Watch what happens to the medicolegal issues that midwives will face when the source of sueable funding disappears.

    It is sad but true that this debate probably doesn’t have a satisfactory outcome without the removal of the medicolegal, training and acceptable standards issues.

    Reply
  22. 22

    midwife

    It’s obvious this debate is not changing anything, medical practice is fear based, fear of he medico-legal implications, fear of midwives making midwifery decisions with women, fear of midwifery being a rightful profession. Pegnancies continue, modern medicine is never in a position to make the right decisions all the time, neither is any other profession. However, most of the time they do make the right decisions. The fear of midwives is about control of the profession. So doing what has been done for centuries and is still alive amongst sensible professionals. Consult and refer both ways, talk to each other on equal terms and leave the politicians out of professional decision making.

    Reply
  23. 23

    liliwyt

    Kim – I for one don’t believe that obstetrics will become obsolete because midwifery is asking for equal recognition and I don’t think that is what the midwives are advocating for. From my own experience, if it wasn’t for my obstetrician, I wouldn’t be alive and, probably, neither would my son. And I’m sure there are many women who would tell similar stories. Of course obstetricians have a role to play. As midwife @20 says “consult and refer both ways (between midwives and obstetricians), talk to each other on equal terms”. How is that threatening to obstetricians?

    Are you saying that medical doctors are continually living under fear of being sued by their patients? Is this perception based in reality?

    Reply
  24. 24

    Kim Bulwinkel

    Liliwyt – The short answer is yes. Any co-operative model between nurse practitioners, midwives, physician assistants will expose the medical practitioner / specialist to the not insignificant risk of being held responsible for the outcome of any management event. The insurers factor in that risk then charge an appropriate premium.
    Even answering the telephone or having a “corridor hypothetical” can be now used to pull in the medical practitioner into the legal mire. There is currently no such thing as “equal terms”. I hope you read my link posted above.

    The only way out of this difficult situation if you want to advance your ideals without changing the current rules at present is for the medical practitioners / specialists to bow out and leave it to “other health professionals”. The maternal and perinatal morbidity and mortality statistics of 100+ years ago make interesting reading. I am personally glad that I am very close to quitting in my own field.

    Reply
  25. 25

    liliwyt

    Hi Kim – I’ve read that piece and I agree that the soaring costs of medicolegal insurance are pricing a lot of Australian doctors out of some types of medical practice, including obstetrics. This has been an issue since the 1980’s and, for me, is more a whole-of-system problem than due to a tension between medical practitioners and allied health practitioners. In some cases, it could be argued that allied health practitioners (like midwives) have been given more access to patients to cover the gaps left by doctors who have left the field. But is that the fault of the allied health practitioners?

    Personally, yes, I think if midwives (and other AHPs) want equal professional recognition then they should also be held equally liable if something does go wrong. Again, I don’t think anyone in this debate is suggesting that obstetricians should be left to carry the can legally, but I do see that putting obstetricians in the position of only dealing with childbirth in an emergency situation where there is a higher risk of complication, leading to a potential litigation, is not ideal.

    Again, it comes down to the current system. It’s clearly not working for many doctors, not just obstetricians. But attacking midwives for wanting collaboration is not a very effective way of dealing with the issue. All health workers should be working together to deal with the medicolegal monster.

    Reply

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