Homebirth Policy WA

Pauline Costins (Eligible Endorsed Midwife) RN: RM: Juris Doctor

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Discussion points

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!  Maternity services plan !  History of homebirth in WA !  Publicly funded Homebirth in WA !  Inclusion criteria & Exclusion criteria !  Decisions inconstant with the policy !  Referral pathways / Transfer to hospital !  Women’s right to choose and refuse !  Convention Elimination Discrimination Against Women

(CEDAW) – Human Rights !  Legal issues !  Case Study

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Objective of the homebirth policy

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!  “working together across Western Australia. A Policy Framework is to improve care provision of pregnancy and in childbirth”

Background

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!  2008 – Review of homebirths in WA !  Highlighted that women have a right to choose a

maternity care option that suits them !  Develop systems that support safe and satisfying systems

of care !  Provide a diversity of options for women

Definition

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!  This policy defines homebirth as “ a planned event where the woman chooses to give birth at home, with care provided by a midwife”

WA Homebirths

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!  Approximately 200 women have a homebirth !  0.06 – 0.8% of all births !  Transfers

!  Pain relief !  Obstructed labour

8 http://www.health.wa.gov.au/publications/documents/perinatal/WA_Mothers_Babies_2010.pdf

Who provides homebirth

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!  Publicly funded by !  Community midwifery program (CMP) North Metropolitan

Area Health Service !  Midwifery Group Practice, Bunbury Hospital WA Country

Health Service (WACHS)

!  Private fee paying home birth service !  Private / independent Practicing Midwives or !  Eligible / Endorsed midwives (Medicare Provider number)

Who should have a homebirth?

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!  Inclusion Criteria !  Is over 18 !  Has the capacity to give informed consent !  Lives within a geographical boundary no further than 30 mins

from a maternity service !  Regular antenatal care from first trimester !  Booked into a homebirth program by 35 weeks of pregnancy !  A singleton pregnancy

Inclusion criteria

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!  Cephalic presentation – 37 – 42 weeks !  Has current Ambulance Cover !  Suitable home environment

!  Clean running water & electricity !  Vehicular access !  Hygienic sanitation !  Working phone

Exclusion criteria

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!  Previous obstetric history !  Caesarean section !  Postpartum hemorrhage !  Shoulder dystocia !  Retained placenta requiring manual removal !  Perinatal death at term or a normally formed infant

Exclusion criteria

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!  Medical history !  Pre-pregnancy BMI < 18 and > 35 !  Any significant medical condition !  Uncorrected female genital mutilation

!  Social determinates of health !  Domestic violence !  Alcohol and or drug dependency

!  Other considerations !  Will not accept blood and blood products !  Previous baby with GBS neonatal sepsis !  Newborn or child at risk of harm

Care pathways for pregnancy and homebirth

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!  Antenatal Care !  Terms of Care agreements

!  Three times during pregnancy !  At enrolment !  28 weeks !  36 weeks

Terms of care - agreement

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Care pathway

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!  Intrapartum !  Two health professionals must be present for the birth !  Providing immediate support and clinical assistance in

emergency situations !  Collegial team spirit among midwives !  Improved documentation at births !  Safe working hours !  Consultation !  Attention and surveillance

Care pathway

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!  Postnatal !  Care of the mother after birth !  Care of the baby after the birth

A decision that is inconsistent – with this policy

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!  The woman has the right to rescind consent at any time and the decision made needs to be acknowledged and supported.

!  Go through appendix 6 “In the course of labour or urgent situations when the steps for discontinuing care have not been undertaken or completed, as stated in this policy and the letter of withdrawal, the midwife may not refuse to attend the woman. Equally where a woman refuses emergency transfer of care in the course of active labour, the midwife must remain in attendance. Documentation of the ongoing consultation with the obstetrician/specialist throughout the labour and birth is essential.”

Appendix 6

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Planned Hospital Care

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!  If the birth is planned to take place in the hospital maternity support. !  the obstetrician remains the primary care giver. !  The woman is to make her own way to hospital and meet their

midwife at the hospital. !  It is understood that the Homebirth Program midwife

will not attend the woman at home if the woman believes that she is in labour but will direct her, or her support person that the midwife will meet here at the hospital.

!  Establish if an Ambulance is required and advise the woman or support person that one will be called for her if necessary.

Consultation referral and transfer

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!  Risk factors !  Antenatal factors !  Intrapartum factors !  Postpartum factors

Transfer to hospital

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!  Consent process !  How to transfer !  Urgent ambulance assistance !  Non-urgent ambulance assistance !  Private vehicle transfer

Refusal to transfer

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!  Clinical situation has varied from normal !  The client must be referred to the Terms of Care

Document !  Consult with another midwife & share the information

with the client and support people !  Document !  Still declines

!  Request second midwife !  Notify on-call hospital !  If an emergency situation is anticipated call an ambulance

Roles

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!  Primary midwife !  Support midwife !  Doula !  Receiving hospital

Professional and legal requirements - midwife

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!  Experience !  Competencies !  Continuing professional development !  Indemnity insurance !  Documentation and record keeping !  Reporting, evaluation and audit !  Clinical incident reporting

Essential equipment for a homebirth

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Food for thought

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!  Autonomy v Paternalism !  Human Rights !  Convention of Elimination Discrimination Against Women

(CEDAW) !  Fetal rights v Maternal rights !  Consent v Cohesion !  Language of Fear

Legal issues

woman midwife

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!  Consent v Cohesion !  Language used – fear

based !  Right to refuse treatment !  ‘born alive rule’ !  Contributory negligence

!  Scope of practice !  Competence !  Ethics !  Collaborative care !  Criminal code – s290 !  Negligence

Human Rights and CEDAW

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!  Right to privacy !  Freedom from discrimination !  Article 2: Country duties (CEDAW) !  Article 3: Equity (CEDAW)

Case study 1

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!  Normal pregnancy !  Booked for a homebirth with private midwife !  No Medicare !  Collaboration with tertiary hospital !  Booked back up hospital at 20 weeks !  ? Small for dates at 30 weeks refer to hospital post ultra-sound

scan for review and plan !  Individualised Growth chart – within normal limits !  Progress as normal !  Labour commenced !  Problem second stage !  Progressed to birth

Case study 2

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!  Booked with private midwife for hospital birth continuity of midwifery care.

!  Previous large baby 4.2kg, shoulder dystocia and 2litre hemorrhage.

!  Booked at local hospital !  Required tertiary hospital care !  Client refused care of tertiary hospital !  Negotiations !  Terminated contract with private midwife !  Free-birthed

References

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!  Women's and Newborns Health Network – Policy for Publicly funded homebirths including Guidance for Consumers, Health Professionals and Health Services (Revised October 2013). Government of WA Dept of Health 2013.

!  Preparing for the First Birth: Mothers’ Experiences at Home and in Hospital in Australia. Hannah G. Dahlen, PhD, RN, RM, BN (Hons), M(CommN). Lesley M. Barclay, RN, RM, BA, MEd, PhD. Caroline Homer, RM, PhD. J Perinat Educ. 2008 Fall; 17(4): 21–32.

!  Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years. Christine Catling-Paull, Rebecca L Coddington, Maralyn J Foureur and Caroline S E Homer, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium. Med J Aust 2013; 198 (11): 616-620.

!  http://www.health.wa.gov.au/publications/documents/perinatal/WA_Mothers_Babies_2010.pdf