Saturday, December 19, 2009

Obstetricians' peer pressure: the problems with one sided mandated collaboration

Dr Jenny Gamble, President of the Australian College of Midwives, in her appearance before the Senate Committee on Thursday, 18th December 2009, explained how her private midwifery practice changed overnight because doctors changed their mind about 'collaboration'.

"About 15 months into the arrangement the three obstetricians, whom we had written agreements with, pulled out within the space of 10 days. We lost our livelihood. All of the women on our books—and there were a significant number; they were providing the livelihood of four midwives—who were still in pregnancy and still had their pregnancy, labour, birth and postpartum care to go with us, were now left without the option of continuing care with us and having a hospital birth. Effectively, we were forced into a home birth practice

In fact, the state government had to step in at that stage to make interim arrangements for the
remaining women on our books so that they could continue under our care and have a hospital birth, after much ado—minister visitors, lobbying, submissions. So we were on thin ice—‘Yes, I’ll have a collaborative arrangement with you; oops! No. I’ve changed my mind.’

We did not have any mishaps. We did not have a postpartum haemorrhage. We did not have a baby admitted to a special care nursery. Nobody died. In fact, we have had outcomes from our practice which are world’s best—a seven per cent caesarean section rate, with no postpartum complications and no re-admissions to hospital. We had excellent outcomes and they all pulled out within the space of 10 days—and I always thought it was because they had no-one to sit next to at the Christmas dinner! They had a lot of pressure from their peers not to do it."

Jenny continued, explaining how the proposed bills before the Senate would impact midwifery practice. 


"Under this arrangement, you will not be forced into a home birth practice; you will be forced out of
practice". 

Obviously women's choice of caregiver and place of birth will also be severely curtailed by this legislation.

People point to the fact that Belmont Birthing Service has excellent collaborative agreements, based on the Australian College of Midwives Guidelines for Consultation and Referral.

Thanks to Dr Andrew Bisits, the champion of choice, that's true.  But what would happen if Andrew were to retire, or move elsewhere? Who would take up the challenge to support the practice?

Would the situation have the same outcome for Belmont as it did for Jenny's service when the obstetricians changed their mind? If there was no obstetrician prepared to state categorically that he/she would take over from Andrew Bisits, would the health service continue to provide that option for women?  Worth noting that up the valley, within the same health service, opposition from local GP's means there is no comparable midwifery based service for the women in the area, despite there being local midwives who would like to practice in a continuity of care service and women who lobby to have that care.

Dr Jenny Gamble explains the issues with the proposed amendments to the bills and the idea of mandating a 'collaborative' relationship for midwives only:

"Collaboration is a very important thing in health care and we know that you know that. We also buy in completely to the idea of collaboration and I know my colleagues will talk about how that is already embedded in regulatory frameworks, registration and clinical governance of midwives. At every level we accept collaboration as a concept. When you collaborate with people when one party must and the other party may and there might be reasons that the person who may collaborate does not want to, you do not have collaboration and that is the fundamental problem with all of this. Just because some medical practitioners may, do and will collaborate does not actually make for collaboration and to legislate that you have a signed written agreement with a medical practitioner becomes meaningless and unworkable.

Perhaps we have heard examples today of where the medical practitioner may choose not to collaborate with the midwife in relation to homebirth but in fact from the college’s point of view, we can think of thousands of clinical examples where the woman may make choices that the doctor does not think are in her best interests.


The midwife wants to respect the woman’s right to self-determination, give her information and ensure she is fully informed but also respect her right to make the decision, even if it is a decision the midwife disagrees with—and then she will not be able to find a collaborating doctor to help care for that woman, because the doctor will choose not to participate in care that the doctor does not think is in the woman’s best interests. So right away we have this funny relationship: ‘I’ll decide what’s in your best interests and that’s the sort of care I’ll support.’  


 We are not talking about surgery here; we are talking about having a baby, a normal physiological process for many women with vulnerabilities and risks that might need referral to medical care.

To legislate that one party has to have a collaborative arrangement with another party to practise is
problematic. What we are unclear about, and what has not been able to be cleared up for us, is how far this goes in restricting midwives. If you cannot get a collaborative arrangement with a medical practitioner, does that mean you cannot practise? Does it mean you cannot get access to MBS? Or do they put it in the professional indemnity insurance product that you have to be eligible or have to have a collaborative arrangement to access professional indemnity insurance? And you cannot even get professional indemnity insurance, and you cannot even register. All of that is completely unclear. With all these things being unclear and those questions being unable to be answered by any of the bureaucrats that we have spoken to, it seems to me that to put it in the legislation is a highly flawed position. There are a number of other mechanisms to ensure collaboration. The college, our members, midwives generally and doctors generally all agree collaboration is a good idea. 


It is a benevolent patriarchy when the doctor can decide with whom and when they will collaborate. 

It is not freedom if your freedom is granted by others. (emphasis my addition)

The problems associated with having a group of professionals 'in charge', especially when those professionals can have widely differing viewpoints and practices, means that those who have to work with (read 'under') those professionals are vulnerable to the whims of those they work with.

In the case of midwives and obstetricians, collaboration works well when you have strong, open minded, women friendly, birth comfortable obstetricians together with health services which put women at the centre of concern. When health services put women at the centre of concern, the work of both midwives and obstetricians is equally valued and neither group is preferenced above another.  Of course, when health services are more driven by the culture associated with 'professional silos', then the individual woman and birth friendly obstetrician is under incredible pressure to conform to the 'norm'. As in Jenny Gamble's example, such pressure is difficult to endure without succumbing.

However, those women centred health services and woman and birth friendly obstetricians are few and far between. If obstetricians perception of their 'right to rule' is strengthened by legislation, then support for optimising women's natural processes and midwives ways of working are doomed.

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