Transfer from Planned Birth at Home Guidelines - A Safety and Quality Process

Professor Caroline HomerPresident: Australian College of MidwivesProfessor of Midwifery (UTS)

Obstetric Malpractice ConferenceAugust 2016

Australian College of Midwives

A national, not-for-profit organisation which is the peak professional body for midwives in

Australia

Australian context

• About 300,000 births each year in Australia• Almost all births occur in hospitals, in

conventional labour-ward settings. • In 2013▫ 97% of women gave birth in hospitals▫ 2.0% in birth centres▫ 0.3% at home (n=958) ▫ 0.3% unplanned born before arrival (BBA)

Source: AIHW (2015). Australia’s Mothers and Babies 2013 .

• Hospital status▫ Public hospitals – 72%▫ Private hospitals – 28%

• Two-thirds (67%) of women gave birth within 1 day of admission to hospital and 97% within 2 days of admission

• Median length of stay after birth was 3.0 days.

Source: AIHW (2015). Australia’s Mothers and Babies 2013 .

Current midwifery guidelines• National Midwifery

Guidelines for Consultation & Referral 3rd Edition Issue 2

• Provide information regarding the suitability of different maternity care options

• Endorsed by RANZCOG in 2015

Women giving birth• Average age of women▫ Hospitals - 30.1 (44% under 30 years)▫ Birth centre - 29.9 years (45% under 30 years)▫ Home - 32.0 (31% under 30 years)

• First time mothers – Primiparity▫ Hospitals – 44%▫ Birth centres – 35%▫ Home – 25%

• Lowest socioeconomic status areas▫ Hospitals – 21%▫ Birth centre – 16%▫ Home – 12%

Source: AIHW (2015). Australia’s Mothers and Babies 2013 .

Models of care for homebirth

• Publicly-funded homebirth▫ Currently 14 programs around Australia

• Private practice homebirth

Homebirth• Homebirth is contentious in Australia• More than 60% of submissions to the 2009

National Maternity Services Review were about homebirth▫ Most wanting access to homebirth

• Commonwealth funding for access to homebirth was not supported

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Dahlen et al (2010) Women & Birth doi:10.1016/j.wombi.2010.11.001

Homebirth rates

• Australia - 0.3% • USA - 0.59% • UK – 2.6% ▫ 8% at King’s College London▫ 40% in South East London model

• Netherlands - 30%

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Homebirth creates emotions

• Homebirth is polarised in many countries• Professional groups have opposing views• Researchers have opposing views• The statistics are pored over in fine details ▫ Sometimes brutally on both sides

• In the Maternity Services Review (2009) homebirth was excluded from reforms because it was deemed ‘‘a sensitive and controversial issue’’

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Why do women choose homebirth

• Want home-like setting• Feel strong, confident and capable• Want support for normal birth including access

to water, VBAC• Want siblings and other support people at the

birth• Don’t want to travel in labour• Poor experience in hospitals before• Want to be protected from hospital procedures

Current challenges in Australia• All practising health professionals must have

professional indemnity insurance (PII)

• PII for privately-practising midwives providing homebirth services has not been available since 2001

• In recognition of the unavailability of a PII product for privately practising midwives providing birth at home services, Health Ministers agreed to an exemption from this insurance requirement until December 2019

An effort to obtain PII …

• Queensland Health asked the Australian College of Midwives to develop a Midwifery Practice Scheme

• MPS—the basis for professional indemnity insurance for Queensland privately-practising midwives

▫ If agreed, could be implemented as a national scheme

• Transfer guidelines are an essential element of this work

Transfer

• Transfer in labour is common and usually a sign of good practice

• Can be positive and negative for women, transferring midwife and receiving clinicians▫ Historically – not always positive

Transfer ratesAuthor and year Country Transfer (in

labour) %Amelink-Verburg et al, 2008 Holland 29

Anderson & Murphy, 1995, United States 10Blix et a., 2012, Norway Norway 12Brocklehurst et a., 2012 England 21Cheyney, 2011 United States 12Davies, 1997, England 14Durand, 1992, United States 12Janssen et al, 2002 Canada 17Janssen et al, 2003 Canada 23

Source: Fox, Sheehan, Homer, International Journal of Childbirth Volume 4, Issue 2, 2014

Most common reasons for transfer

• Most occur for non-urgent reasons:▫ delayed progress in labour▫ the woman’s request▫ pharmacological pain management

• Less common▫ postpartum haemorrhage▫ neonatal resuscitation or respiratory distress

Source: Fox, Sheehan, Homer, International Journal of Childbirth Volume 4, Issue 2, 2014

Challenges• For women and their midwife – they are

‘Transferring out of the comfort zone’

• Having someone there who you know is on your side, who shares your values, who you’ve chosen to be on your team, that you’ve spent time with leading up to the birth and then who would continue to be with you afterwards … people you trust, whose opinion you trust, that is the key to having a positive birth experience at a hospital (woman).

Source: Deborah Fox. Presentation from Australian College of Midwives Conference, 2015 – PhD study.

Women have to make a journey

▫ It’s being removed from your little comfortable place into a place that’s not your place…you’d had your little nest where you were going to give birth and then suddenly it changed (woman).

▫ We know that for how people cope with things afterwards, half the time it’s not what actually happens to them, it’s how it was communicated to them…if they had time to think about their choices…Sometimes in obstetrics there is no time, but usually there is….even five minutes can make a big difference [to women] (obstetrician).

Source: Deborah Fox. Presentation from Australian College of Midwives Conference, 2015 – PhD study.

Good transfers should be celebrated

You do hear ‘This is a homebirth failure’. I always pull people up and go, ‘Well actually, let’s look at what’s happened, somebody has had a care plan, things have gone different to expectations, well that’s been recognized and appropriate transfer has been arranged, that’s the system working. That’s a success, that’s not a failure’. The only time I would think of it as a failure would be if the problem isn’t recognized or the decision to transfer when the problem is recognised isn’t made, those sorts of things, that’s a failure in the system (obstetrician)

Source: Deborah Fox. Presentation from Australian College of Midwives Conference, 2015 – PhD study.

Why are guidelines needed

• Uncertainty about the process ▫ Women▫ Midwives providing homebirth▫ Clinicians receiving women

• Lack of clarity about what to do when a woman declines transfer

• Documentation inconsistencies

Process of development

• Part of the Midwifery Practice Scheme project▫ Funded by Qld Health

• MPS provides a framework of processes, policies and guidelines to support the continual development of midwives ▫ potentially assist insurers’ to be confident about

the quality and safety in order to provide professional indemnity insurance for privately-practising midwives

Consultation

• Working group development• Steering Committee included:▫ ACM▫ PPMs▫ RANZCOG▫ Maternity Choices Australia▫ ANMF▫ Chief Nursing and Midwifery Officers▫ Maternity Services Inter-Jurisdictional Committee▫ Lawyer▫ Australian Commission on Safety and Quality in

Health Care• Broad consultation through workshops and online

Purpose• provide guidance to midwives in situations where

transfer from a planned birth at home into hospital is required during the intrapartum and immediate postpartum period and up to 6 weeks postpartum, for the woman and/or her newborn

• provide guidance to midwives if the woman declines transfer for herself and/or her newborn

• provide the template Transfer of Care Summary for use by the midwife transferring the woman and/or her newborn from home to hospital.

Antenatal preparation• During pregnancy, the midwife: ▫ informs the woman of: ▫ circumstances which may result in the need to

transfer, and possible timing of that recommendation; ▫ the Transfer from Planned Birth at Home Guidelines▫ arrangements for accessing real-time consultation and

hands-on clinical support throughout the continuum of care1; and ▫ their role and scope of practice at the hospital if

transfer is required▫ documents this discussion and the fact that the

Transfer from Planned Birth at Home Guidelines have been provided.

Antenatal preparation• The midwife:▫ recommends hospital booking in▫ recommends ambulance insurance▫ recommends the woman engages with the booking hospital

and other maternity care providers for consultation, referral and/or transfer of care, if indicated▫ establishes a professional relationship with the booking

hospital▫ recommends that Recommends the woman take preparatory

steps for a potential transfer. � organising support to assist with transport, child seat in the

car, a birth/postnatal bag packed and child care arranged▫ adjusts plan for transfer should new circumstances arise; and ▫ documents all discussions and decisions

Principles

• Decision making about transferring from a planned birth at home to hospital should occur in consultation with the woman.

• The midwife should discuss the rationale, urgency and safest approach to transfer with the woman.

• The woman must provide informed consent before she is transferred except in the case of an emergency where the woman lacks the capacity to consent.

The guidelines

• The midwife▫ recommends transfer to the woman when

indicated▫ communicates the rationale and level of urgency

of transfer to the woman▫ obtains informed consent from the woman to

transfer to hospital

Travel recommendations …

• The midwife makes recommendations to the woman about the safest mode of transport

▫ In the event of an emergency or birth is imminent:� transfer in an ambulance

▫ If transfer is not urgent� woman and her support team travel in private car

• The midwife:▫ makes arrangements for transfer and explains

these to the woman ▫ phones ahead to the receiving hospital to alert

them to the woman’s arrival and circumstances▫ elicits assistance from the woman’s support

team if needed▫ provides clinical care while awaiting transfer▫ travels to the receiving hospital

• The midwife:▫ documents the decision-making process and

clinical care provided, and brings the woman’s clinical records to the hospital▫ presents to the hospital with the woman to

provide a handover to the receiving staff. This is done verbally and followed by a written handover for inclusion in the woman’s hospital records▫ remains with the woman in hospital during the

intrapartum and immediate postpartum period, where possible

• If the woman declines to transfer to hospital, the midwife follows the process described in Appendix 1.

In an emergency …

• The midwife:▫ requests to travel in the ambulance to provide

clinical care if required. � recommended that the midwife also bring basic

equipment not already available in the ambulance (i.e. obstetric Doppler, infant bag and mask, oxytocic medication)

� requests that the woman and baby, if born, travel in the ambulance together, skin-to-skin unless the woman or baby need individualised clinical care.

Non-emergency

• If transfer is not urgent, the midwife follows the woman’s private car.

Transfer for the newborn

• Similar process for the transfer of the newborn including emergency life-saving care and non-emergency care

If a woman declines transfer to hospital

• Detailed process outlined including▫ Calling additional hands-on clinical support▫ Calling an ambulance▫ Notifying the hospital (with the woman consent)▫ Documentation

Summary• Homebirth will continue to occur▫ Safe and effective transfer is an important element

of safe care▫ Guidelines may assist

• Australian College of Midwives keen to work with all stakeholders to resolve the PII challenge and ensure women have access to safe models of care – including homebirth

Policies & Guidelines for Midwives

Available from:

https://www.midwives.org.au/policies-guidelines-midwives