Sunday, June 10, 2012

Understanding what's behind an adverse outcome

Today I am recording a few of my personal thoughts in relation to the (lengthy) Coroner's report that was released this past week, in Adelaide.  I have written about it from the perspective of Australian Private Midwives Association (APMA) at the privatemidwives blog.

Principles of accountability and transparency must be applied to professional practice.  When something goes wrong in birth, our society wants to know, and has a right to know what happened.  It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear?  How must I act when a woman in my care understands her personal risk differently from the mainstream?

A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain.  The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity.  So, when I read in the SA Coroner's report that 

"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."
I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?

The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.

This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:
  • if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);  
  • if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean; 
  • if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean) 
That is a superficial, linear argument that fails to recognise the complexities of maternity care.  This suggested course of action ignores the increased risk that each caesarean places on the woman's reproductive future: a risk that does not really show up in the statistical reports.  It passes over the fact that many women who seek private midwifery care are consciously avoiding mainstream services.  It fails to notice that highly skilled, experienced midwives have been excluded from practising in any setting except the home.  And then there are all the issues of trust and continuity in providing optimal maternity care.

I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result.  The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation.  She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]

Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive.  The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives.  The emergency code had been rehearsed, prepared for, and was called into action.  Perhaps that group of midwives will be more ready and competent when it really is called for???

In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety.  I cannot control another person's actions.  I also cannot use these experiences as a reason to stay out of hospital in future situations.  The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.

I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.

The Coroner's recommendations are listed at the end of the 106-page report.  In this blog I am attempting to summarise the recommendations, for future reference:

1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."


Amy Tuteur, MD said...

It hard to imagine anything more morally bankrupt thaan equating a "traumatic" IV for postpartum hemorrhage to the entirely prevetnable deaths of 4 human beings.

Australian homebirth midwives should be ashamed that they are more concerned about their personal income and status than the lives of the babies in their hands.

kateg said...

your patient actually complained about being treated for postpartum hemorrhage? seriously? how do you know the blood loss was not (would not have been significant)?

Joy Johnston said...

Thankyou Dr Amy and 'kateg' for responding to this post.

You have both questioned a case I referred to. The woman did NOT have a post partum haemorrhage - she merely had risk factors that may have increased her chance of PPH, and she had an IV cannula in situ.

I do know the blood loss was minimal at the time, when aggressive treatment for PPH was initiated. I was there, and having been a midwife for almost 40 years I am confident in my clinical judgment. Of course I can't know it would not have been significant if some other course of action had been followed ...

As we tidied up I spoke about the blood loss with the hospital midwife who had been responsible at the birth. She agreed that the blood loss was not excessive - I think the total loss recorded was 400ml.

As for the other comment, that Australian homebirth midwives should be ashamed that we are more concerned about our "personal income and status than the lives of the babies in their hands" - of course, if that were true, I would support it. But I don't know any of those. There is no secure income, and even less status in independent midwifery practice in this country.

ps the tone of Dr Amy's post made me consider deleting it. I would appreciate respectful communication, even when you feel the need to challenge what I or someone else have written.

Anonymous said...

Hi joy,
I think you completely miss the point. Having midwives practice without restriction in any setting??? Seriously? I am an Ob, and I certainly wouldn't want to practice without restriction. That's a preposterous statement and illustrates your lack of understanding about this complex issue, despite your description of your extensive experience.

Hospitals are not without their share of problems, but untrained midwives without the skills to diagnose and manage the complications are not going to solve those problems. How about real midwives, with real training and REGULATED hospital privileges, who can work with physicians as a TEAM to improve care. Or would that threaten you in some way? Avoiding hospitals and receiving substandard care at home isn't the answer for any woman who values the child she is carrying...

Amy Tuteur, MD said...

Ms. Johnston,

You seemed to have missed the point of my comment. It makes absolutely no difference whether the IV was needed or not. No IV, no matter how unpleasant, can EVER be considered equivalent to the loss of a human life.

Australian homebirth midwives ARE more concerned about their personal income and status than the lives of the babies in their hands, and your extremely callous "comparison" of IVs and neonatal deaths is a perfect example of that.

Exactly how many babies have to die before Australian homebirth midwives acknowledge that they are incapable of regulating themselves?

Joy Johnston said...

It's a frosty Monday morning here in Melbourne.
Over the weekend I have reflected on whether there was really something exceptional about what I wrote; whether I should re-consider my attitude, having received such strong responses.
I have re-read the original post, and stand by it. The point of that example (IV cannula insitu) is to identify over-agressive, unnecessary treatment as a potential harm to be avoided. Iatrogenic illness cannot be ignored; in this case the postnatal recovery journey included a urinary tract infection and breast thrush, which may have been avoided.

The comment I made about practising without restriction may have been misunderstood. I have no problem with boundaries, and midwifery is clearly defined. The particular restriction midwives face in Australia is that we are unable to have visiting access in hospitals. I will amend the post by adding (midwifery).

Anonymous said...

Interesting comments. No-one likes to see women upset eg. separation from her baby (although there might have been a very good reason).

I would blame you mainly for the PPH upset.

a) You didn't prepare your patient properly for standard PPH prophylaxis / management.
b) By saying "oh all that was really unnecessary" to your patient, you've reinforced her inappropriate feelings.

Your inactions/actions have caused harm, not the hospital midwives. Reflect.

Homebirth midwives are a dangerous breed generally. I do hope you tell your patients that homebirth is now proven to be more dangerous than hospital birth in low risk primips (Birthplace study) never mind breeches, VBACs etc. before taking their money. Do you?

Joy Johnston said...

Anonymous, you have asked a direct question to me, whether I inform inquirers that homebirth is "now proven to be more dangerous than hospital birth in low risk primips"
My commitment is to the woman, not to the setting.
I would encourage you to reflect on your use of the word 'proven'.

Joy Johnston said...

For those who are interested, here's a comment by Rachel Zimmerman in CommonHealth that I recommend