Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Midwife, Ms B
Midwife, Ms C
A Report by the Health and Disability Commissioner
(Case 04HDC05503)
Parties involved
Mrs A Consumer
Mr A Consumer's husband
Baby A Consumer's daughter (deceased)
Ms B Provider/Midwife
Ms C Provider/Midwife
Dr D Obstetrician and gynaecologist
Dr E Obstetric registrar
Dr F Obstetric registrar
Ms G Delivery Suite Coordinator
Dr H Paediatric registrar
Dr I Paediatric consultant
Ms J Midwifery Director
Ms K Group Manager, Women's, Child and Public
Health
Dr L Clinical Director, Women's Health
Overview
On 5 April 2004, the Health and Disability Commissioner (HDC) received a complaint, forwarded by the Nursing Council of New Zealand, about the services provided to Mrs A by independent midwives Ms B and Ms C. The complaint was made by the Otago District Health Board (ODHB), which also subsequently complained directly to the HDC. The ODHB was concerned that the two midwives had acted inappropriately during the vaginal breech delivery of Mrs A's baby, Baby A. The ODHB said that the midwives' inappropriate actions had contributed to the death of Baby A.
On 28 September and 28 October 2004, Ms B, Mrs A and the ODHB were notified that the following issues were to be investigated:
- The appropriateness and adequacy of Ms B's assessment and management of Mrs A's pregnancy during the antenatal period.
- The appropriateness and adequacy of Ms B's assessment and management of Mrs A's labour.
- The appropriateness and adequacy of Ms B's communication with secondary services during Mrs A's pregnancy, labour and delivery.
On 23 February 2005, the investigation was extended to include Ms C. She was notified that the following issues were to be investigated:
- The appropriateness and adequacy of the care Ms C provided to Mrs A during her labour and delivery in March 2004.
- The appropriateness and adequacy of Ms C's communication with secondary services during Mrs A's pregnancy, labour and delivery.
In May 2005, the Police advised that they were charging Ms B with manslaughter in relation to the death of Baby A. On 21 July 2005, my investigation was suspended and the parties were notified that I would consider whether to recommence the investigation at the conclusion of the Police proceedings.
High Court proceedings
The prosecution was the result of a request by a Coroner to the Police to investigate the circumstances of Baby A's death. Ms B was charged with manslaughter. The charge alleged that Ms B had "undertaken medical treatment, the doing of which was or might have been dangerous to life, namely the provision of midwifery services, omitted without lawful excuse to use reasonable knowledge, skill and care in administering such treatment". Ms B pleaded not guilty to the charge, and a jury trial commenced in the High Court in early March 2006. The trial concluded on 21 March 2006, when the jury returned a verdict of not guilty.
'No further action' decision
In April and May 2006, Mr and Mrs A and Ms B were interviewed by HDC to ascertain their views on the issues and lessons to be learnt from this case. This was to help me decide whether to proceed with the investigation. I also spoke to representatives and staff at the Otago District Health Board, and convened a meeting of expert maternity advisors - both midwives and doctors.
Section 38(1) of the Health and Disability Commissioner Act 1994 gives the Commissioner the discretion to take no further action on a complaint if the Commissioner considers that, having regard to all the circumstances of the case, any further action is unnecessary or inappropriate. In deciding whether to exercise this discretion, I may take into account actions already taken to ensure clinical safety or review the conduct of a health professional.
In this case, the following actions have been or are to be taken:
a) The Otago District Health Board (ODHB) has investigated the service Ms B and Ms C provided to Mrs A. As a result, supervision conditions were imposed on Ms B and Ms C in order for them to continue to have an access agreement with the Board.
b) The Midwifery Council of New Zealand has reviewed Ms C's competence to practise. The Council has imposed a supervision order on Ms C requiring that she meet monthly with a peer/supervisor to discuss monthly practice issues and complete some courses on evidence-based practice. However, Ms C has appealed the order and successfully applied to the District Court for the order to be stayed from 22 November 2006 until the appeal has been heard. A date is yet to be set for the appeal to be heard.
Ms B's competence has been reviewed and the review panel's draft report is scheduled to be considered by the Midwifery Council at its meeting on 5 and 6 December 2006. The report is expected to be finalised early in 2007 after Ms B has been given the opportunity to respond to the draft.
c) Ms B has undertaken a three-day intensive course, "Midwifery Skills for Emergencies". She has also enrolled in an "Advanced Life Support in Obstetrics" (ALSO) course and has begun further study through a School of Midwifery on a postgraduate paper.
d) The ODHB has developed "Referral to Queen Mary Specialists" guidelines with extensive input from Lead Maternity Carers (LMCs),[1] and obstetric and midwifery staff, to provide clarity with regard to the referral process.
e) The ODHB has enquired into steps taken by Waitakere Hospital, in West Auckland, to successfully improve relationships between midwives and specialists. It has enlisted the help of one of the senior clinicians involved in that initiative, Dr Robin Youngson, to lead a similar initiative at ODHB.
f) On 21 November 2006, with the University of Otago Bioethics Centre, I convened a public forum attended by midwives and obstetricians from Dunedin, representatives from their Colleges, students and members of the public, to discuss ethical, legal, and professional issues relating to informed consent in maternity care.
g) Finally, I note that the Ministry of Health is in the process of reviewing the national maternity services access agreement that covers the work of LMCs in maternity facilities. This review is not as a result of this case, but it is very timely.
In light of these various initiatives, I consider that it would be inappropriate to recommence my investigation into this matter. It would also be impractical. Since the conclusion of the trial, it has become clear that the recollection of key individuals is now coloured by some of the testimony and the media debate that followed the verdict. My ability to obtain independent expert advice and to facilitate a fair, simple, speedy and efficient resolution of this complaint (as required by law) has been compromised.
Furthermore, I am also required to consider the views of the consumer. Both Mr and Mrs A have indicated that they do not support the complaint, and they do not want further investigation.
Nevertheless, having reviewed all the information, I believe that there are significant lessons to be learnt. The death of Baby A was a tragic outcome. It is important to consider what could be done differently to avoid similar events in future.
…
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:
RIGHT 4
Right to Services of an Appropriate Standard
(1) Every consumer has the right to have services provided with reasonable care and skill.
…
(5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
RIGHT 6
Right to be Fully Informed
(1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
…
(b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option; …
Relevant standards
Section 88 of the New Zealand Public Health and Disability Act 2000 (effective from 1 July 2002):
"APPENDIX 1
GUIDELINES FOR CONSULTATION WITH OBSTETRIC AND RELATED SPECIALIST MEDICAL SERVICES
1.0 PURPOSE OF GUIDELINES
This document provides guidelines for best practice based on expert opinion and available evidence. It is the intention that the guidelines be used to facilitate consultation and integration of care, giving confidence to providers, women and their families.
For the purposes of these guidelines, referral to specialist services includes both referral to Secondary Maternity or to a specialist, as defined in this Notice. …
2.0 CIRCUMSTANCES WHERE GUIDELINES MAY BE VARIED
The guidelines acknowledge that General Practitioners, General Practitioner Obstetricians and Midwives have a different range of skills. The guidelines are not intended to restrict good clinical practice. There may be some flexibility in the use of these guidelines:
(a) The practitioner needs to make clinical judgements depending on each situation and some situations may require a course of action which differs from these guidelines. The practitioner will need to be able to justify her/his actions should s/he be required to do so by their professional body.
It is expected that the principles of informed consent will be followed with regard to these guidelines. If a woman elects not to follow the recommended course of action, it is expected that the practitioner will take the appropriate actions such as seeking advice, documenting discussions and exercising wise judgement as to the ongoing provision of care.
(b) It is also recognised that there may be some circumstances where the requirement to recommend consultation places an unnecessary restriction on experienced practitioners, particularly where there is no immediate access to specialist services. The individual practitioner can come to an appropriate arrangement with the specialist.
It is agreed that, in accordance with good professional practice, a practitioner must record in the notes the reasons for the variation from the guidelines.
…
5.0 LEVELS OF REFERRAL
These Guidelines define three levels of referral and consequent action
Level 1
The Lead Maternity Carer may recommend to the woman (or parents in the case of the baby) that a consultation with a specialist is warranted given that her pregnancy, labour, birth or puerperium (or the baby) is or may be affected by the condition. Where a consultation occurs, the decision regarding ongoing clinical roles/responsibilities must involve a three way discussion between the specialist, the Lead Maternity Carer and the woman concerned. This should include discussion on any need for and timing of specialist review. The specialist will not automatically assume responsibility for ongoing care. This will depend on the clinical situation and the wishes of the individual woman.
Level 2
The Lead Maternity Carer must recommend to the woman (or parents in the case of the baby) that a consultation with a specialist is warranted given that her pregnancy, labour, birth or puerperium (or the baby) is or may be affected by the condition. Where a consultation occurs, the decision regarding ongoing clinical roles/responsibilities must involve a three way discussion between the specialist, the Lead Maternity Carer and the woman concerned. This should include discussion on any need for and timing of specialist review. The specialist will not automatically assume responsibility for ongoing care. This will depend on the clinical situation and the wishes of the individual woman.
Level 3
The Lead Maternity Carer must recommend to the woman (or parents in the case of the baby) that the responsibility for her care be transferred to a specialist given that her pregnancy and labour, birth or puerperium (or the baby) is or may be affected by the condition. The decision regarding ongoing clinical roles/responsibilities must involve a three way way discussion between the specialist, the Lead Maternity Carer and the woman concerned. In most circumstances the specialist will assume ongoing responsibility and the role of the primary practitioner will be agreed between those involved. This should include discussion about timing of transfer back to the primary practitioner.
New Zealand College of Midwives Midwives Handbook for Practice (2002):
"Standard two
The midwife upholds each woman's right to free and informed choice and consent throughout the childbirth experience.
Criteria
The midwife:
- Shares relevant information, including birth options, and is satisfied that the woman understands the implications of her choices
…
- understands the implications of her choices
- Clearly states when her professional judgment is in conflict with the decision or plans of the woman
- Discusses with the woman, and colleagues as necessary, in an effort to find mutually satisfying solutions …
Standard six
Midwifery actions are prioritised and implemented appropriately with no midwifery action or omission placing the woman at risk.
Criteria
The midwife
…
- identifies deviations from the normal, and after discussion with the woman, consults and refers as appropriate
- works collaboratively with other health professionals and community groups as necessary
-
has the responsibility to refer to the appropriate health professional when she has reached the limit of her expertise.
Decision
This case raises important issues about informed consent and the responsibilities of midwives when mothers want to deliver their babies in a way that may be contrary to medical advice. It raises key questions about the duty of midwives to the unborn child, particularly when the child's well-being may be compromised by the mother's choices. It highlights tensions between the midwifery and medical approach to maternity care, and the critical importance of effective communication and good cooperation to ensure safe, good quality care.
Informed consent
Although Mrs A chose to go to the hospital, she wanted to have her baby as naturally as possible, with few people present in the birthing room. Mrs A had specified that she would prefer no medical intervention, but she had "left the door open" to accept secondary medical care if necessary. Her birth plan, which she wrote in the 38th week of her pregnancy, specified that she would consent to interventions if she, Mr A and the midwives were in agreement that intervention was "medically necessary".
A number of factors placed Mrs A and her baby at high risk with a vaginal birth. This was her first baby, and the baby was in a breech position. Additionally, Mrs A was being treated for thyrotoxicosis and, in the last weeks of her pregnancy, she had a positive vaginal swab for Group B Streptococcus. This meant that under certain circumstances, both she and the baby were at risk of serious infection, and antibiotics could be needed during labour.
In light of these factors, Ms B as the LMC, and Ms C as the back-up midwife, needed to keep Mrs A well informed about the risks and the actions necessary to ensure that she and her baby would be safe, and updated about risks and options as her labour progressed.
Mrs A believed that she had made informed choices about the management of her labour and delivery, having consulted obstetricians, books, and the midwives. In her detailed birth plan, Mrs A specified that the decision regarding medical intervention would be made after discussions between herself, her husband and the midwives. Mrs A had not previously experienced childbirth or the difficulty of trying to make decisions in the midst of active labour, when concerns are being raised. As discussed below, she was seemingly unaware of the practical difficulty of calling in medical staff at the last minute, if they had been excluded until that stage.
In her response to my provisional opinion, Ms B advised that Mrs A was "cognisant of what was happening" during her labour and well able to make decisions, an example being her refusal during the labour to have antibiotics. Ms B submitted that there is no evidence that any "impracticality" of the birth plan led to the tragic outcome.
I acknowledge that Mr and Mrs A had given a great deal of thought to their choices and sought information from a variety of sources. All the evidence indicates that Ms B had discussed the birth plan in detail with Mrs A.
Consumers are free to make choices that others in a similar situation would not make, and that they may later regret (with the benefit of hindsight). The important proviso is that the consumer needs to be well informed about the risks of a proposed approach - as required by Right 6(1)(b) of the Code. It appears that Mrs A was generally well informed. However, I am not convinced that she realised that her plan to leave "the door open", if necessary, was flawed given the tense relationship between primary and secondary maternity care providers at QMMC, and the practical difficulty of calling in doctors who had been excluded until the eleventh hour.
Safety net
When, despite advice to the contrary, Mrs A chose to try to deliver her baby vaginally, Ms B had a duty to communicate clearly that her baby was at risk, and that a safety net needed to be in place, in case things went wrong.
At the heart of the Code of Health and Disability Services Consumers' Rights is the right to co-operation among providers to ensure quality and continuity of services. Furthermore, Standard 6 of the Midwives Handbook for Practice requires consultation and referral. Ms B appropriately complied with this requirement by referring Mrs A to specialists earlier in the pregnancy, but when Mrs A arrived at hospital, the obstetric team was not notified and a paediatrician was not put on standby.
Although there was no formal protocol on breech births, Ms B knew that it was the usual practice at QMMC for a breech delivery to be transferred to the obstetric team, that a Caesarean section was the preferred delivery option, and this had been recommended to Mrs A by Dr F and Dr D. Ms B subsequently acknowledged that it is not common in New Zealand hospitals for a woman to have a vaginal breech delivery. She explained that in this case, she was operating outside her "usual system" and supporting a woman who was seemingly well informed, but firmly wanted no medical involvement unless necessary. As a result, she may have "us[ed] the wrong rule to solve a problem". In an effort to comply with Mrs A's wishes she continued to view the labour as progressing normally, and the baby as active with a normal heartbeat. Ms B accepts that "the rule" she could have applied was that the baby was breech, with inherent risks, and that obstetric and paediatric back-up was required.
In response to my provisional opinion, Ms B submitted that given the "history of stand-up arguments between midwives and obstetricians in the corridors of Queen Mary" and "the climate that was prevalent", it was simply not realistic to have obstetricians/paediatricians on standby - "they would have either insisted on full involvement (something Mrs A did not want) or would have refused because they were not allowed full involvement".
I note, however, that Mrs A now says that her "understanding was that the hospital and the specialists were the back-up plan and safety net, and that they were on site and available to me at any time, if we wanted it". This suggests that Mrs A did not appreciate the practical difficulty of calling in medical staff at the last minute, if they had been excluded until that stage.
There was a subsequent opportunity for the midwives to revisit the labour management decisions. At 6.20pm Ms B became concerned by the fetal heart rate and suggested calling an obstetrician. It seems that Mrs A did not consent to any doctors coming in. Mrs A was fully absorbed in birthing her baby, and Mr A was "struggling to take in more information". In these difficult circumstances, with the fetal heart rate appearing to settle, Ms B did not call for obstetric support because she considered the birth was imminent.
In the debate that followed the High Court proceedings, a group of 60 midwives at Auckland District Health Board were polled on how they would respond to a mother with a baby in breech position who decided not to take medical advice to have a Caesarean section. Seventy-nine percent said they would discuss the risks and options with the mother and proceed with a vaginal delivery. Sixty-one percent said they would not notify the hospital obstetrician of the mother's arrival if the mother did not wish this to happen. The results of this informal survey indicate that not all women are being adequately informed, and that the majority of midwives will keep obstetric staff in the dark if that is the mother's wish.
The Midwives Handbook states that the midwife is to uphold each woman's right to free and informed choice and consent, but a midwife must clearly inform the woman when her professional judgement is in conflict with the woman's decisions. It is not just a matter of supporting a mother in her choices. In my view (with which I note Ms B "actively concurs"), the midwife has a duty to use her knowledge and experience to minimise the risk to the mother and baby. It would be an unusual woman who would risk the life and well-being of her baby in order to adhere to her choices for her labour and delivery, if the midwife is clear about the risks her choices pose.
It must, however, be repeated that Mrs A was generally well informed about the risks to her baby and herself. I accept the submission that "[Ms B] did not blindly support [Mrs A's] choices". Further, I acknowledge that the fractious environment at QMMC made it difficult to ensure that a safety net was in place.
Fetal distress
Ms B said that it was not until two minutes before the birth that any real problem emerged, and Mrs A supports this view.
However, at the trial there was conflicting evidence about whether there was an earlier point at which Ms B and Ms C should have recognised that Baby A could be in distress, reassessed the situation and sought obstetric and paediatric backup. There were differing expert views about whether Ms B and Ms C failed to identify a concerning fetal heart pattern that started with tachycardia at 6.20pm. It was suggested that they were falsely reassured when the heart rate appeared to settle at 7.30pm. One expert stated that when there was a further episode of tachycardia at 7.50pm, although the birth was imminent at that time, they should have been aware that all was not well with this baby, and advised Mrs A of the risk to her baby and called for backup. Another expert could not see the deceleration in the baby's heart rate, said the tachycardia was mild and variable, and stated that the midwives were right to be reassured. Without further investigation, I am unable to make a final determination on this matter.
Relationships and communication
Above all else, this case highlights the need for effective communication between professional groups, particularly those who are responsible for the care of "at-risk" women.
Ms B has sought to explain why she did not alert the obstetricians and paediatricians and, at the very least, have them on standby after Mrs A arrived at QMMC, and during the labour. Ms B has noted that relationship issues at the maternity unit provide relevant and important context to these events. She gave the example of women who had made choices with the advice of one obstetrician, and had then been overruled by another obstetrician at the unit. She said that pressure was brought to bear upon the midwife to get the woman to "change her mind". Mrs A also spoke of relationship problems at the unit, and expressed concern that medical staff would not respect the choices of women in labour. I accept that the tensions that existed at QMMC were a significant contributory factor in Mrs A's case.
Ms B's clients commonly include women at the outer limits of risk who, for a variety of reasons, prefer not to have medical intervention in their labour and delivery. Her concern is that, if these women are not confident that their midwife will support their wishes, they will refuse to book into the hospital and expose themselves and their babies to greater risk by not having any maternity supervision and/or having a home birth. To this end she acts as her clients' advocate, working with the obstetric teams to ensure the best results for the mothers and babies.
I have discussed the issues arising from this case with a number of maternity advisors. The consensus of opinion is that there was evidence of poor relationships between practitioners and that these relationships influenced how events were managed.
The ODHB recognises that there are ongoing tensions between primary and secondary maternity care providers, and this case has exacerbated these tensions. Co-operation and collaboration between midwifery and medical colleagues is vitally important if women are to receive good quality maternity care. For whatever reasons, it appears that this did not happen.
As noted above, the ODHB's review provided an opportunity to examine the lessons to be learnt. The ODHB is in the process of pursuing initiatives to improve relationships and communication between practitioners.
Criminal proceedings
Another lesson from this case relates to the criminal proceedings. As I have noted publicly, in my view the criminal prosecution of a health practitioner should occur only in exceptional circumstances. The risk of such prosecutions is that they discourage health practitioners from acknowledging and reporting errors, and drive mistakes underground.
There is growing recognition in New Zealand and overseas that patient safety is best promoted by focusing on the systems that contribute to adverse events, and learning from mistakes. Rather than seeking to "name, blame, and shame" individual practitioners (such as in criminal proceedings), the modern approach is to prevent recurrences by recommendations to improve individual and system performance.
There is a place for the criminal law in the clinical setting where a health practitioner kills a patient by reckless acts or omissions. But in cases of unexpected patient death, even where gross negligence may be proved, a manslaughter prosecution is likely to do more harm than good. It delays and frustrates the regular mechanisms for health practitioner accountability. Most importantly, no health practitioner is likely to share their mistakes in a peer review setting if Police search and seizure is a possibility. The real causes of patient deaths will remain hidden, and the potential to learn from mistakes will be lost.
The prosecution in this case has taken a toll first and foremost on Ms B and Mr and Mrs A, but also on the ODHB staff and the wider midwifery profession, and has cast a long shadow on my investigation. It highlights the need for careful reflection by the Police and the Crown prosecutor whenever such a prosecution is contemplated.
Access agreements
Ms B and Ms C are independent LMC midwives who at the time of these events had an access agreement with the ODHB. The access agreement is a contractual arrangement between a self-employed LMC and a maternity facility. It authorises the LMC to access the facility to provide "labour and birth and inpatient postnatal care to the practitioner's maternity clients". As noted above, there has been tension between some independent midwives and some members of the ODHB maternity service. In part this tension has arisen because the philosophy of care of some LMCs is at variance with the Board's policies and procedures, and there is no obligation on the part of an access agreement holder to comply with Board policy.
I accept Ms B's submission that the events of Baby A's birth cannot be linked to the access agreement. However, I am concerned that if LMCs have an agreement to access a birthing facility, they should be bound by the safety and quality policies and procedures of the facility. Obviously it is important that local LMCs have input into the development of such policies, and that they are evidence-based . These are issues I have highlighted in previous HDC opinions, notably 04HDC04652, 17 January 2006.
I acknowledge that LMCs who are members of the New Zealand College of Midwives (as are approximately 80%) agree to follow the practice guidelines promulgated by the College. All LMC practitioners are bound by the requirements of the standard section 88 guidelines. Nonetheless, investigations of maternity care lead me to believe that, on occasion, there is a wide variation in professional standards. A small number of LMCs take safe practice to the outermost limits.
The national maternity service agreement is currently under review by the Ministry of Health. It is to be hoped that the new agreement will provide a framework to support the provision of safe, high quality care in maternity facilities.
In this case, there were no formal protocols relating to breech births, but there was an understanding at the ODHB that there was a preference for breech babies to be delivered by Caesarean section at 39 weeks. The reasons why that did not occur in this case have been thoroughly examined and relate to tensions between the obstetric and midwifery staff, and the mother's wishes, rather than to the ODHB protocols and access agreement conditions. Ms B complied with the access agreement conditions, the College Midwives Handbook for Practice and the section 88 guidelines.
Women in New Zealand, like Mrs A, believe that a "safety net" is in place if they choose to delivery their baby in a public hospital. That belief is illusory if there are barriers (including fraught relationships) to LMCs communicating important information to fellow health professionals who may be called to assist. In my view, where a consumer and her LMC use a birthing facility, the practitioner should alert staff at the facility to the labour in progress and give a broad overview of the situation. The facility staff (including obstetric staff) need to be able to discuss the situation with the LMC. Good communication between practitioners (particularly primary and secondary care services) is essential so that risks can be discussed and contingency plans put in place in the interests of the woman and her baby.
Conclusion
In conclusion, in light of the actions taken by the ODHB, the Midwifery Council, Ms B and Ms C in response to these events, and taking into account the strongly held views of Mr and Mrs A , I have decided to take no further action on this complaint and to discontinue my investigation.
Follow-up actions
- A copy of this report will be sent to the Midwifery Council of New Zealand, and a partially anonymised copy will be sent to the New Zealand College of Midwives, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Ministry of Health.
- A partially anonymised copy of pages 1-3, 4 (first paragraph only) and 24-38 of my final decision (deleting the names of all parties except Otago District Health Board, Queen Mary Maternity Centre, Waitakere Hospital, and Dr Robin Youngson) will be placed on the HDC website, www.hdc.org.nz, to draw media and public attention to the important issues raised by this case. I acknowledge Mr and Mrs A's wish to maintain the privacy of their health information and, for that reason, have deleted the remainder of the report from the copy to be placed on the HDC website. However, given the public interest in this case, and the fact that (as a result of the High Court proceedings) a lot of information is already in the public domain, I have decided that the key parts of my decision (notably the 'Overview' and the 'Decision') should be made publicly available in an anonymised form.
- I have asked the Otago District Health Board to advise me by 28 February 2007 of the outcomes of the initiatives currently under way to improve relations between maternity practitioners in Otago.
[1] Lead Maternity Carer refers to the general practitioner, midwife or obstetric specialist who has been selected by the woman to provide her with comprehensive maternity care, including the management of her labour and delivery.