Saturday, 19 December 2009

Collaboration: Doctors don't want to be like ambulances at the bottom of the cliff: waiting for disasters

                                                    COMMONWEALTH OF AUSTRALIA
Proof Committee Hansard
Reference: Health Legislation Amendment (Midwives and Nurse Practitioners) Bill
2009; Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill
2009; Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009

This is an uncorrected proof of evidence taken before the committee.
It is made available under the condition that it is recognised
as such.

Dr Weaver—The other message we got in forming our submission for the Maternity Services Review was that doctors did not want to have a woman brought into hospital with all sorts of problems when they had had no opportunity to be involved in her care and then have to make quick decisions. The woman would have the perception that everything was going all right until they saw the doctor. There was no opportunity to be involved in care early. In other words, they do not want to be seen, as somebody said, as the ambulance at the bottom of the cliff. They wanted and needed to have that involvement, to be able to have a discussion with the woman, in the event that problems arose during her labour, as they do. The clear message we got from the fellowship of the college was that they did not want to have to pick up the pieces at the end of something.

CHAIR—That being their only role?

Dr Weaver—That being their only role. Again, most of them acknowledged that they worked in good
systems of care and they valued and respected their midwifery colleagues and were happy to work with them,but as I said, the clear message was that they did not want to have to pick up the pieces from so-called independent midwives.

CHAIR—The term ‘collaboration’ seems to be agreed by everyone. In the absence of the detail of what that means, people are able to put their worst-case fears of what that could mean as opposed to what it will mean and that gets into that circular process. I think that the fact that the amendments were put out before people had a sense of what that could mean has in some ways created an even greater difference. Certainly the evidence today from the various midwives groups and consumer groups was as I said: they put forward cases where they had to date had no effective collaboration and had in effect been stopped from doing what they wanted to do by various parts of the system—and it varied. They felt that collaboration that was dependent upon having that approval, which up until now has not been there, could mean that they would not be able to continue to operate.

The consumers were saying that it should be ‘consumer informed consent’—that was the term that was consistently used. The idea is that the consumer, having clear information from all of the people involved in providing the service, can then have their role clarified and codified in that process. Have I missed anything in that process?

The comments by Dr Ted Weaver are illuminating in that they strike at one of the basic problems threaded throughout this long 'turf war' history of midwives, women and medical men/women.

The idea of doctors waiting for disasters to happen in maternity care indicates their problem based medical training. Their training is problem based because doctors are about curing and alleviating sickness and injury.  Emergency doctors work in emergency departments to take care of people who come in following accidents or illnesses which occur during/as a result of engaging in their activities of daily living.  Emergency doctors don't want to get to know bike riders, tennis players, skiers, swimmers or drivers before they have an accident or before they do what it is they are doing in their lives as they are living them.

The problem with problem based training is that doctors are trained for problems.  That is how it should be when there are problems to deal with. However, when the subject under scrutiny is a normal healthy process that is different as fingerprints for every woman who undergoes it and even for the same woman in different pregnancies, that uniqueness and variability creates a problem for the problem minded.

Healing is a natural healthy process. Healing occurs because something has been damaged as a result of some insult or other.

However childbirth is a natural healthy process and is generally the result of loving, fun activity, not some insult or other (although occasionally and tragically, pregnancy can result from rape).

Healing can be aided and propelled by drugs or surgery.

Childbearing however, is helped most by loving, encouraging companionship.

Drugs and surgery are doctors realm. Loving, encouraging companionship is a midwife's realm.

Childbearing would be better conceptualised as a form of extreme 'sport' than an illness model of human activity. Women's bodies are perfectly suited to give birth, just like people's bodies are perfectly suited to become runners, skiers or long jumpers etc. Preparation, understanding, practice and supportive encouragement are needed to ensure their bodies' function optimally.

Therefore obstetric doctors 'waiting' for disasters is appropriate. Emergency doctors wait for broken ankles etc. Obstetricians are more sensibly employed 'waiting' for women who need intervention, rather than imposing intervention on normal healthy processes that are expressed individually. Ted Weaver's throw away phrase 'as they do' at the end of his statement of waiting for problems to occur in labour, is a powerful indicator of the way that a practitioner's failure to appreciate diversity in the way that human birth is expressed, coupled with an expectation of problems leads to actions, like interventions, to speed things up etc creating the very problems they are worried about. 

Interestingly, when women are given the kind of care that informs, supports and encourages them through their experience of childbearing, as the statistics demonstrate, heroic 'rescues' are very few and far between.   As Jenny Gamble's practice statistics, our Newcastle private practice statistics and the Belmont Birthing Service Statistics show (plus many overseas examples), women and babies are safe and mothers are more satisfied with their experiences when they are provided with one to one midwifery care.

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