CALL FOR ABSTRACTS - ACM 2009

The Australian College of Midwives 16th Biennial Conference: "Midwives & Women: A Brilliant Blend" is being held at the Adelaide Convention Centre, from the 22 - 25 September 2009.

The Conference Committee has prepared a draft program and is now calling for abstracts consistent with the theme established for the Conference, "Midwives & Women: A Brilliant Blend". All abstracts must meet the theme and the following day by day structure:

Day one: Midwives Working with Women
This will explore the diverse ways that midwives and women work together to achieve safe satisfying maternity care.

Day two: Midwives Working for Women
This examines the innovative often-invisible ways that midwives work to enable healthy safe and satisfying birth maternity care in various environments and context.

Day three: Midwives and Women: Looking back and moving forward
This will be a fascinating day exploring what has been, what is and what our hopes and directions are for the future of midwifery and maternity care.

PLEASE SEE CALL FOR ABSTRACTS FOR FURTHER INFORMATION AND ABSTRACT GUIDELINES AND DUE DATES.

To register your early interest in presenting an abstract or poster, or attending the conference, or if you are seeking further information in relation to the requirements for abstract submissions, please contact the Conference Managers:

Shanna Sheldrick or Jessica Bosnakis
All Occasions Management
Telephone: +61 8 8125 2200
Email: shanna@aomevents.com or jessica@aomevents.com

Australian Mothers Speak – UNPRECENDENTED INQUIRY RESPONSE

On Tuesday this week the Federal Maternity Review published submissions on their website.
Go here for Nicola Roxon’s media release.


MATERNITY COALITION'S MEDIA STATEMENT
Contact: Justine Caines 0408210273
Melissa Fox 0404 88 2716

Yesterday, Federal Health Minister, Nicola Roxon released the first 400 of over 900 submissions received as part of the Maternity Services Review.
“This is an unprecedented response. The whole of health inquiry, The National Health and Hospitals Reform Commission only received 500 and yet one area of health, maternity care, elicits more than 900 and largely from consumers” said Justine Caines, National President of Maternity Coalition and mother of seven.
“It is heartening that the Minister is a Mother of a young child herself. Women across Australia are relying on Ms Roxon to hear their pleas and make major reform that sees maternity care focus on the needs of women rather than clinicians.” said Melissa Fox, Vice President and mother of two.
Also released yesterday was the 2006, Mother’s and Babies Report. While this reveals the statistics around pregnancy and birth, submissions to the enquiry provide a human face. Many submissions reveal a system that does not allow women to make choices about their bodies or their babies that is damaging and sometimes inhumane.
“Women are waiting longer before they start a family because they’re having careers and independent lives first. When the time comes to have babies, we expect to be treated with dignity and respect, and to make our own choices.” said Ms Fox

“The medical model is still (for the most part) stuck in the 1950's when women were expected to submit all decision-making to others, and to take the consequences in silent stoicism. This is why the review received over 900 submissions. Women are no longer happy to lie back and push out babies for their country.” said Ms Caines

“Welcome to the new wave of feminism: both career women and mothers want their intelligence and rights to be respected.” said Ms Caines

Maternity Services Review - Update

Approximately one half of the 900 submissions received by the Review are now available for public perusal at the Review website. There is plenty of interesting reading, both in the accounts of personal experiences in maternity care, in responses by special interest groups and organisations, and in large submissions by maternity-related professional bodies.

Here are a few snippets, to whet the appetite of blog watchers:
The Australian Society of Anaesthetists (ASA):
"...
• believes that the existing model of obstetric care, where doctors and midwives collaborate together in a doctor led team, delivers the best maternity outcomes,
• ... and
• warns that proposals for change to the existing model of maternal care are driven mainly by social forces rather than concerns about the safety of mothers and their babies."

Women's Hospitals Australasia (WHA) ...
"recommends a national review of the medical indemnity insurance. ... WHA favours a universal no fault approach to medical insurance."

Midwives Naturally ..."We propose a changing of the entire system where funding is linked to the women (as in New Zealand). The client should be able to make an informed decision about where they give birth and with whom. Midwives are the only care providers who can provide a total service throughout the normal childbirth continuum. In order to achieve this, midwives must be able to order tests and ultrasounds, prescribe medications, within their scope of practice. At present midwives have to send their clients to other health care providers and this results in over servicing and increased cost to the woman. Midwives need visiting access to all hospitals. Currently some hospitals in Melbourne are refusing to allow women to make a backup booking for homebirth services, thus denying such women equal access to public health services that their hospital birth counterparts have full access to. This discriminates against women who are choosing home birth and therefore midwife led care, both of which are supported by research as being models of care that provide women with great satisfaction with their birth experience, less interventions and improved breastfeeding outcomes."

Australian Society of Independent Midwives (ASIM)
"Suggested changes to afford women a homebirth choice would include;

• Private Health Funds legislation making it compulsory for Funds to include
‘out of hospital birth’ packages alongside hospital birth benefits.

• Federal legislation to protect the public and the practitioners involved in
homebirths e.g. a National Midwife Practitioner Act

• Medicare provider numbers for Midwife Practitioners so that women do
not have to pay for the privilege of having their babies at home.

• Authority for Midwife Practitioners to request routine pregnancy
diagnostic and pathology tests

• Authority to prescribe emergency medications associated with the act of
giving birth e.g. life-saving oxytocics

• Professional indemnity insurance cover for Midwife Practitioners available
through Government-funded insurance schemes"

National Society of Specialist Obstetricians and Gynaecologists (NASOG):
"NASOG does not support the concept of independent midwifery led care for women in labour. As acknowledged at the review’s Models of Care round table consultation forum, all effective maternity care is collaborative. NASOG believes that it is preferable that a single individual carer take overall responsibility for care of a woman in labour and the obstetrician is the most appropriate choice for such a role. If a woman chooses to have care from a midwife, then NASOG believes that midwife should have a formal relationship with a nominated obstetrician/GP obstetrician."

Australian College of Midwives (ACM):
"While mortality outcomes for women and babies are good and comparable with other developed countries, there are nonetheless significant areas for improvement. Challenges include:
 the comparatively poorer mortality outcomes for Aboriginal and Torres Strait Islander mothers and babies;
 rising rates of caesarean birth with associated increased morbidity for mothers and babies;
 problems with equity of access to services especially for rural and remote women;
 the fragmented and stressful nature of care for most women, and in particular the lack of continuous support during labour;
 lack of choice for women wanting continuity of care (the only choice currently being a specialised obstetrician) For most women, there are no local services offering continuity of care by either doctors or midwives;
 an over-reliance on providing primary maternity care to mostly well women in acute hospital settings, which are increasingly overcrowded and understaffed; costly, and pose iatrogenic risks in terms of intervention, infection, medication errors, and other complications;
 lack of professional support postnatally, following discharge from hospital, to help in the critical early days and weeks with the transition to parenting a newborn baby
 shortages of midwives and GP obstetricians and a lack of co-ordinated strategies for addressing these shortages, and
 the current lack of accountability and transparency of services to consumers."

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCCOG)
"6. Home Birth
29. Home birth is NOT supported as it is associated with an unacceptably high rate of adverse outcomes.
30. RANZCOG recognises home birth will occur and therefore recommends minimum standards.
31. Women choosing home birth should be cared for by both an experienced medical practitioner and a registered midwife, each of whom has agreed to participate.
32. Women considering home birth should seek information from their home birth provider about the provider’s experience in home birth, and their contingency plan in the event of an emergency, including options for hospital transfer."

... ENJOY!
Your comments and discussion about these and other issues raised in the Review are welcome on this blog.

NSW - Acute services in public hospitals

The final report of the Garling Inquiry into acute services in NSW public hospitals was released on Nov 27th.

Quoting from the overview, p24
"Mothers
1.151 I received a large number of submissions about maternity services and the need to give midwives more freedom and responsibility for being involved with helping mothers have babies.
1.152 This is a complex question because some of the matters I was asked to make
recommendations about really belong in the Commonwealth sphere and don’t fall within
my Terms of Reference. As well, there quite complex issues about safety and quality
which require careful thought. Nevertheless, I felt able, on the basis of the evidence which I received to make recommendations about enhancing the midwifery workforce, and seeing whether midwifery case-load models of care where the same midwife looks after the mother from their first appointment until about 4 weeks after the birth of the baby can be introduced to more hospitals than at present. I make a specific recommendation, in the interest of the safety of the mother and child which is that NSW Health only offer birthing facilities for low risk mothers in hospitals which satisfy the following criteria:
(i) the hospital has an adequate number of health professionals qualified and trained to assist with the birth, such as midwives or VMOs with the necessary credentials; and
(ii) the hospital has, on-site, or else has the ability to transfer the mother within 30 minutes travel time to a hospital which has on-site, the workforce and facilities to perform an emergency caesarean section." [Report, p24]

Perinatal Data

The Victorian perinatal data collection unit (PDCU) has revised its data form, to be used from 1 January 2009. Midwives who are currently listed by the PDCU as those who attend homebirths will receive the new forms this month.

Five independent midwives attended a training day today, presented by the PDCU, to explain the changes to the form, and to discuss the planned electronic transmission of data from hospital data collection systems to the PDCU. Midwives reporting on homebirths, and small maternity hospitals which do not have the data collection systems running, will continue to fill out the forms manually, and post them to the PDCU. The information sent in hard copy will be entered into the system as it is at present.

New information fields that appear in the revised form include the aboriginality status of the baby as well as the mother; smoking; times of onset of labour, onset of second stage, and rupture of membranes; indication for induction; fetal monitoring in labour; waterbirth; amount of blood loss; hepatitis B Vaccination; and breastfeeding status. The leading intrapartum care provider (midwife, obstetrician, or GP) will also be recorded.

More information is available at the PDCU website http://www.health.vic.gov.au/perinatal/ , including the Guide for the completion of the Perinatal Morbidity Statistics form.

AUSTRALIAN DOCUMENTARY LOOKING FOR MIDWIVES

The changing structure of our 21st century family and work arrangements is deeply impacting on life experiences - particularly profound life moments such as birth, love and death.

We are hoping to get in touch with midwives to ask them their opinions about this - we are particularly interested in speaking with midwives who do not have their own children yet, but plan to have children in the future.

At this stage, this would not be a commitment to be in the documentary - we would just like to talk to women midwives about their thoughts and experiences as part of our preliminary research.

The documentary is planned to go into production at the end of February/beginning of March 2009 and will be shooting around the Sydney area.

The documentary has just been funded by Screen Australia - Australia's national film funding organisation. It is being directed by co-directors Tom Murray and Madeleine Hetherton. We are both experienced documentary makers who have directed a number of documentaries for broadcasters such as the ABC, SBS and commercial channels.

We would love to talk to you! Please call or email us if you would like more information.
Madeleine Hetherton 0408 6222 203 madspace@bigpond.com

Tom Murray M:0402 439 912 tarpaulin@ozemail.com.au

Victoria lags behind in maternity reform

Maternity Coalition MEDIA RELEASE
Sunday November 16 2008

Catch up Daniel Andrews - Nicola Roxon is way ahead

In September Health Minister, Nicola Roxon announced a review of maternity services, making it the 38th since 1985.
“We believe the only issue to have more inquiries commissioned is petrol prices. Women and their babies have been political hot potatoes, and we hope this is about to change”, said Deborah Loupelis, Victorian Secretary of Maternity Coalition and mother of 2.
Victoria is no different. In 2004 an excellent policy document was released, Future Directions. This document supports the establishment of primary midwifery care for women across the state.
“Instead of enhancement, since the review the state government has ripped midwifery apart, closing birth centres and the successful Rosebud maternity unit on the Mornington Peninsula.
“Maternity Coalition has been working for maternity reform for a long time. We have heard countless stories of women desperate for a better system. It is encouraging that finally a Federal Health Minister is listening. Minister Roxon has outlined the need for reform, flagging the enhancement of 1-2-1 care and indemnity protection for midwives across Australia.”
“We need Victorian Minister, Daniel Andrews to catch up. With an increase in births across the state many maternity units are bursting at the seams, they are simply not safe. Local primary midwifery services will give women safe, supportive and sustainable care.”
“Since September, women from all over Australia have been sending Maternity Coalition copies of their submissions to the Review. Initial feedback from the Department of Health has been that the total number of submissions they’ve received is overwhelming.”
“Although we have not been surprised by the volume of responses, we are buoyed by the depth of emotion from Australian women who support our vision of broadened maternity choices”.
“Today women from across Victoria will share the stories they have submitted, demonstrating how much 1-2-1 midwifery care has meant to them. They are gathering at TREASURY GARDENS from 1pm in a display of UNITY, ACTION & REFORM”
We applaud Minister Roxon’s positive stance, we understand, however, with 37 inquiries before that now is time for action. Women across the nation are saying there have been enough investigations. 1-2-1 midwifery care is the gold standard and women deserve that option now.”

Contact:
Janie Nottingham 0420620808

PICNIC at Treasury Gardens, Sunday 16 November, from 1pm

We are all invited to join Maternity Coalition for this picnic.

The theme is ‘Great Expectations’: The Future of Maternity Care in Australia

Federal Minister for Health, Nicola Roxon has recently set up a review into Australian maternity services.

The benefits of the care of a known midwife throughout, pregnancy labour and birth are well documented: they include reductions in surgery, increased rates and duration of breastfeeding, reduction in post natal depression, and greater maternal satisfaction.

Midwifery care that integrates clinical assessment and monitoring within a social framework, has considerable capacity to improve health and related outcomes for Indigenous women and others who are known to be at increased risk of poor outcomes.

The cost of maternity care has risen significantly. Obstetricians have increased their fees by 269% since the Medicare Safety-net was introduced in 2004. While midwives are educated and registered to provide the entire episode of care for healthy women (approx 75%) a lack of funding and indemnity insurance still prevents this. It is estimated that around 1% of midwives work to their registered capacity.

Maternity Coalition is uniting the women and midwives of Australia to support Minister Roxon’s work and seeks support from politicians across the country. Maternity Coalition is hosting community events across the country. There is considerable media interest.

On Sunday 16 November families from across Victoria will meet in Treasury Gardens from 1pm.

Please come and hear from women across the state regarding the current broken maternity system and how 1-2-1 community midwifery will transform services in both regional and metropolitan areas.

Should you be unable to attend would you please consider sending a message of support, because in someway birth affects us all.

Victorian Co-ordinator, Janie Nottingham (03) 59748364 or 0420620808
janie.nottingham@gmail.com

DELAYING CORD CLAMPING

Early cord clamping, immediately after birth and prior to cessation of pulsation of the cord, is performed routinely in many hospitals as part of managed third stage. Women planning to give birth in Birth Centres or at home will often be aware of the advantages to the baby of delayed cord clamping, or not clamping or cutting the cord, and request physiological 'unmanaged' third stage. This is the usual practice for many independent homebirth midwives.

An article in yesteday's Sunday Age, 'Trial to test benefit of delayed cord cutting' brought the welcome news that research is being undertaken - "leaving the cord unclamped for 60 seconds, holding the baby below the placenta and allowing gravity to let blood from the placenta enter the baby." The trial focuses on babies born more than 10 weeks early - the vulnerable, premature babies, who would not be likely to survive without expert neonatal specialist care.

In a normal birth setting - that is, a baby at term, spontaneous onset and progress of labour without stimulation, and spontaneous cephalic birth of a healthy baby - the mother herself is able to take her baby into her arms when she is ready. This may be immediately after the birth, or may be minutes later. There should be no need to put times and restrictions on the position of the baby.

The ICM/FIGO joint statement on active management of third stage is the 'evidence based' protocol followed in many major maternity hospitals.
"Active management of the third stage of labour consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include:
· Administration of uterotonic agents
· Controlled cord traction
· Uterine massage after delivery of the placenta, as appropriate."

This protocol requires "Clamp the cord close to the perineum (once pulsation stops in a healthy newborn) and hold in one hand."

Waiting for pulsation to cease can be a precious time for the mother, in touching and observing her newly born child. A pulsating cord usually means the baby is OK. Even in the highly complex birthing situations a baby born with a pulse is likely to be fine.

I have observed many instances of actively 'managed' third stage in which the clamping of the cord is immediate, allowing a baby to be whisked away from the mother so that medical personnel can perform their ritual 'lifesaving' acts. This must have a profound impact on both mother and baby, interfering with bonding and increasing fear in both. Many mothers accept the interventions uncritically, believing that they were performed in the best interests of the child.

Professionals and parents need to critically examine the evidence around these serious interventions. Many lay people who read a blog such as this one may feel overwhelmed by the huge differences between holistic midwifery practice, and the highly interventionist obsteric services that are provided for the majority of women. As an immediate action that anyone who is concerned that their baby's umbilical cord may be clamped prior to cessation of pulsation, should discuss with their care providers and ask what is their usual practice.

Any midwife or doctor who is willing to clamp a pulsing cord should, in my opinion, be challenged.
Joy Johnston

MILK BANK at MERCY

Here's a press release:

Mercy Hospital for Women is planning the establishment of Victoria's first Breastmilk Bank. This unique facility will provide the best possible alternative nutrition when a mother's own milk is not available.

To advance this pioneering project there is an information and celebration occasion planned for Thursday 20 November at Docklands. This informal social event is being hosted to bring together, advocates, supporters and donors to learn more about Victoria's first Breastmilk Bank.

If you would like to receive an invitation to this event or to receive an information brochure please contact the Mercy Health Foundation by phoning 8416 7815 foundation@mercy.com.au

For distribution; many thanks.

Gavan

Gavan Woinarski
Executive Director
McAuley Foundation


678 Victoria Street
Richmond VIC 3121
e-mail:gwoinarski@mercy.com.au
Phone : 03 8416 7896
Mobile: 0447 389 517
Fax : 03 8416 7955
www.mercy.com.au

MIPP Recommendations to the Review

Summary of Recommendations to the Review
• that all basic maternity service issues be applied to the woman, rather than to the service provider.
• that midwives be authorised to order appropriate tests for women in their care (ie within the scope of the midwife’s practice)
• that midwives be authorised to prescribe appropriate medications, such as oxytocic drugs and Anti-D immunoglobulin
• that professional indemnity insurance be available for midwives who are self employed, with an equal arrangement to that which is provided by the government to support medical practitioners
• that women who plan homebirth with an independent midwife be able to claim the same public funding that would be applied to their care as those who plan to give birth in a public hospital (ie, the funding is linked to the woman, not to the service provider)
• that the option of homebirth be made available to women who plan to give birth without medical intervention.
• that incentive schemes be set up to reward maternity services and midwives who demonstrate effective care which minimises unwarranted interventions.
• that steps be taken to enable women and midwives to work together to improve maternity services, particularly those provided for well women who do not require medical intervention.
• that programs of community education and professional education be facilitated to bring about greater awareness and valuing of physiologically normal birth as the safest way of birth for most mothers and babies.
• that the BaBs model of community based peer support be made available to all women, as part of a package of reforms that have been foreshadowed in the Maternity Services Review.
• that peer support services be managed locally, with support within the infrastructure of local maternity service provision.
• urgent reform to remove the funding monopoly that restricts access to midwife-led basic maternity care, and gives unfair advantage to medical practitioners providing the same services.
• that the Government remove restrictions on midwifery practice, including lack of government funding for midwives’ services, and lack of hospital visiting access for midwives, which is linked to a lack of professional indemnity insurance
• that the Government provide the means for all women to choose midwife-led maternity care
• that independent midwifery practice be accepted by the Review as an effective model for midwife-led maternity services.
• that all infrastructure for publicly funded maternity services be developed within the principle of woman-centred care.

Woman-centred care: MIPP response to the Maternity Services Review

We consider the most appropriate way to consider basic maternity service provision is from the woman, up – rather than from the service, down. This leads to woman-centred care, which is theoretically a goal of maternity service provision.

Maternity care models that centre on the mother-baby dyad acknowledge the fundamental facts of modern maternity care, including:
• Birth is not an illness
• The midwife is the only primary carer who is equipped to attend women throughout their maternity care
• Each woman/baby requires a specific, time limited episode of care
• Mothers or babies who experience complications or illness require specific services that are appropriate for the condition

Current Australian maternity services are frequently unable to apply evidence based best practice options broadly, because funding for maternity care, whether in the public or private sector, dictates models that are service-centric and provider-centred rather than woman-centred.

We believe it is unhelpful to consider basic maternity service from a ‘rural and remote’ versus ‘urban’ framework. The woman (mother-baby dyad) is the unit, and basic maternity care needs for well women are the same regardless of location or other epidemiological factors.

We therefore recommend to the Review that all basic maternity service issues be applied to the woman, rather than to the service provider.

Maternity Services Review Question 7. How is current Commonwealth funding targeted? - continued

Continuing from the previous post, in which I outlined how the government’s funding monopoly supports the one competing professional care provider, the doctor, and all but excludes the midwife.

How has this happened?

The simplest way of exploring maternity care issues is to look at it from an individual woman's perspective.

Although a midwife is able to provide all the maternity care for a woman who is well and does not require medical attention and gives birth in her own home, the midwife's services are paid for entirely by the woman. On the other hand, there is a complex set of rebates through Medicare if the woman receives maternity services from a doctor, for birth in a hospital. The 'simplest' option, from the woman's point of view, is to make a booking at a local public hospital, and have prenatal care through a hospital clinic. The only money she may be asked for will be 'add-on' services, such as childbirth education.

Some public hospitals have midwives providing continuity of care in group practices or KYM (know your midwife) programs; a few have birth centres; and others have teams of midwives. Many women don't meet any midwives, or have a booking visit with a midwife, but receive their prenatal care from one or several doctors, who may or may not be on the scene when they are in labour.

The reason for this great divide for a woman, between prenatal care and the care she receives in labour and birthing, is that prenatal care is funded through Medicare, which is Commonwealth government funding. Doctors are the only maternity care professionals with Medicare provider numbers.

The funding which covers the birth and early postnatal care comes from State health funding agreements that are sorted out by Health Ministers. This money filters down to the hospitals, which pay their employed midwives and doctors and other staff, and private doctors when there are visiting arrangements in effect.

From the individual woman's point of view, there is no government funding available to her if she engages a midwife privately.

Does this mean that the service provided by a midwife is in some way of lesser quality than that which attracts government funding? No. A midwife is a responsible professional, and is accountable not only to the woman who employs her, but also to the community through the regulatory body. The midwife has a duty of care to act in the interests of mother and baby at all times.

Statutory regulation of professionals such as doctors, midwives, nurses, dentists, physiotherapists, psychologists, and other groups is done in the public interest. This means that the law requires that people who practise these professions are educated to the required standard, and are currently registered. The regulation of these professions is a serious and complex process which seeks to protect the public from unprofessional or negligent care by people who are not qualified to provide that care. A person who is not a midwife cannot 'hold out' to be a midwife; that is, cannot call themself a midwife, or offer midwifery services.

So, returing to the question, "How has this happened?". How can a woman who obtains maternity care from a midwife, who is fully qualified and regulated by law to provide such care, be unable to get any government funding to cover the cost of that care. How has a monopoly been so firmly entrenched, effectively forcing women into medical/obstetric care options, and virtually extinguishing the midwife's ability to compete for work?

There is only one reason monopolies are able to exist in health-related laws. If the alternative presents an unacceptable risk to the public. Antibiotics and other restricted drugs can only be obtained from a pharmacy, with a prescription from a medical practitioner. That's a monopoly that's clearly appropriate. If you need surgery to remove your Appendix, that can only be provided by a regulated medical professional - the local Vet can't to do it for you. Another appropriate monopoly.

The monopoly that restricts the practice of midwives, so that the only place where government funding for midwifery is available is in hospitals, is an inappropriate monopoly.

Turn the coin over now. What skill does an obstetrician or a local GP have with promoting and protecting normal birth? Perhaps they do respect normal birth. How did they learn that? Most likely, from midwives. The obstetrician is a specialist, a highly educated surgeon. The knowledge and skill of working in harmony with nature's wonderful processes in pregnancy and birth is what midwifery is all about.

So the Australian Commonwealth government's funding monopoly, targeted to doctors and restricting women's access to midwives, not only ensures financial security for doctors, but also supports the medical domination of birth. This leads to progressive increases in rates of operative birth and subsequent increases in morbidity for women and their babies. There is no argument in the public interest to support the medical monopoly of maternity funding; there is, in fact a strong argument against it.

The most appropriate targeting of the government's funds would be to ensure that midwives act as primary carers for all women, and collaborate with doctors to provide the service needed for those who experience illness or obstetric complications.

Maternity Services Review Question 7. How is current Commonwealth funding targeted?

Current Commonwealth funding for maternity services supports a deeply embedded funding monopoly which directs healthy pregnant women into private medical care, and obstructs women who seek primary maternity care from a midwife. This targeting of government funds is, we believe, contrary to the Trade Practices Act, and should be reformed as soon as possible.

The fact that the government’s funding monopoly supporting the one competing professional care provider, the doctor, and all but excluding the midwife is in breach of the Trade Practices Act was clearly pointed out by Professor Allan Fels in 1998, when he was Chairman of the Australian Competition and Consumer Commission (ACCC),
"competition policy is based on the premise that consumer choice, rather than the collective judgment of the sellers, should determine the range and prices of goods and services that are available. Or in other words that competitive suppliers should not pre-empt the working of the market by deciding themselves what their customers need, rather than allowing the market to respond to what consumers demand."

The role of the ACCC includes
"looking at health professionals' conduct to determine whether it promotes or hinders patients' interests in being able to choose among a variety of service and price options according to their needs."
(from The Trade Practices Act and the Health Sector, Australian College of Health Service Executives, 1998.)

The following list uses the government’s funding items listed in the Review’s Discussion Paper, and briefly outlines the way in which these items support a funding monopoly that is not in the interest of the consumer of maternity services.

FUNDING DISCUSSION
1. Medicare Benefits Schedule Applies only to doctors, and excludes midwives. The woman who seeks maternity care from a midwife is required to pay the fee independently
2. Extended Medicare Safety Net Applies only to the fees charged by doctors, and is particularly useful in rebating part of the large booking fees charged by obstetricians for private maternity patients, many of whom are low risk and their care needs are within the scope of midwifery.
3. Private Health Insurance Rebate This rebate supports the monopoly of obstetrics over healthy pregnant women, as in #2 above.
Few private health insurance companies offer rebates for midwives services. Most women who seek the care of a midwife privately pay for that without any rebate.
4. Australian Health Care Agreements Most public hospitals accept doctors providing private services, but exclude midwives. The only midwives who can attend women in hospitals are those employed directly by the hospital.
5. Support for professional indemnity insurance The Federal government’s ‘rescue packages’ in the early 2000s, after the collapse of United Medical Protection, included large annual sums under the Policy Support Scheme to support obstetricians and rural procedural GPs who are the mainstay of rural maternity services. No such rescue packages have been available to midwives, who practise without indemnity insurance. In Northern Territory, where professional indemnity insurance is mandated, independent midwifery is illegal.

A midwifery student's perspective - for the Maternity Services Review

Katrina Flora

I write as a student midwife who is a few weeks away from graduation and becoming a registered midwife. I am completing the Bachelor of Midwifery in Melbourne and as such have completed most of my clinical training in large urban tertiary hospitals.

The Bachelor of Midwifery is designed to prepare me and my peers for a midwifery career incorporating woman-centred care, continuity of care and evidence based autonomous practice. However our clinical experiences and the nature of the models of care available do not match that for which we have been trained.

The main maternity hospitals in Melbourne provide care which is fragmented and which serves the needs of the institution before that of the midwives who work and the women who birth in them. My experiences on clinical placement in these hospitals have, in many ways, been profoundly disappointing and I believe I have seen why there is such a high rate of burnout among midwives and why the profession struggles to keep midwives in the job.

Currently midwives have very little access to models of employment which would allow them to provide continuity of carer. Seeing a woman through her pregnancy, labour and birth, and into the postnatal period means the midwife can develop a trusting relationship, tailor the care to the individual needs of that woman, and truly be with woman - the real meaning of midwife. As a student I have experienced this continuity by following thirty women through their pregnancies, births and postnatal periods. The relationships I developed and learning I gained through each of those journeys has been incredibly enriching and satisfying for me.

Yet the employment models available to me on graduation and into the future are totally fragmented. Mostly midwives care for laboring women they have never met and know very little about. While many midwives do their best to develop rapport with the women they care for, it is very difficult to establish a relationship which might be helpful for the woman and satisfying for the midwife. Consequently I believe it is easy for midwives to become cynical and jaded in their care.

In addition I have been witness to an almost total domination of obstetric care in the maternity services I have seen in the past three years. When midwives are denied autonomy, and work under the narrow restrictions imposed by obstetric care which is often not evidence based, job satisfaction can plummet. In this type of model, midwives can feel like little more than a task-oriented robot that has very little capacity to engage in partnership with birthing women.

As a soon to be registered midwife I cannot foresee a long career in a fragmented model which offers no continuity and very little autonomy. In the absence of publicly funded caseload models I see myself in private practice. This in itself is not an unattractive option but poses other issues such as the lack of professional indemnity insurance and questions of income security. I am thrilled to see the discussion opening up around midwifery care and the possibility of widespread caseload models, autonomy and the provision of Medicare provider numbers and PI insurance. It is a long overdue and positive step for Australian women and midwives.

[Thankyou Katrina for this reflection on your career options. jj]

Midwives Rock!

Here's a cute promotional video posted by Carolyn, who is a midwife and teacher in Dunedin, New Zealand.

Midwife-led versus other models of care for childbearing women

A new Cochrane Review has analysed studies which compare midwife-led models of care with other models of care for childbearing women and their infants.
The following statement is copied from the reference given above

Plain language summary

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks. The review concluded that all women should be offered midwife-led models of care.

Midwifery Practice Review workshop

A College of Midwives workshop on MidPLUS and Midwifery Practice Review was held in Carlton today. Those who attended were, notably, midwives in independent practice, in group practices, and a few who are usually seen at College events. Patrice Hickey who has appeared previously on this blog, welcomed the presenters and attendants as Victorian president of the College. Patrice is the boss midwife (not sure of her title!) at Sunshine hospital, and a contingent of midwives who are part of the new Midwifery Group Practices at Sunshine were also present.
The sessions were interesting and well presented, guiding participants through the processes that have been set up for midwives to record ongoing professional development and prepare for the formal practice review.

I was very disappointed that more midwives were not there.

Having been there, and profited from the presentations (while knitting a pretty summer hat for my grand daughter Poppy) I have to ask myself why were there only 30 or so midwives in the room? Why not 300? Here are a few of my thoughts:
* Was there adequate promotion? I received at least one email and a letter in the post, and it was noted in the recent issue of Australian Midwifery News. I expect there was a mailout to hospital maternity units. Members of the College who didn't know about it are probably not reading the College materials.
* Are there too many professional events? This is possibly the reason for some not attending. Next week there is a 2-day seminar on emerging issues in pregnancy, birth, and postnatal care at the Women's. A couple of weeks after that there is a symposium on Having a Baby in Victoria, hosted by Maternity Coalition. There are online meetings and tutorials about many relevant topics that can be downloaded from the web. Midwives have plenty of opportunity to access formal and informal learning.
* Are midwives complacent about continuing professional development? I think so. We have not had any fixed requirement in the past - when we renew our registration each year, we pay a fee and make a declaration that we are competent to practice. This is one of the areas that we are going to be forced to change, in that national regulation of health professionals, to be introduced in 2010, will mandate ongoing professional learning and peer review. Audits will be carried out as a routine. In less than two years' time midwives will be expected to adopt new attitudes towards our professional status, so it's not a bad idea to start making the change now.

Maternity Services Turf Wars

Justine Caines has written a Croakey blog 'Maternity Services Turf Wars have not helped women'.
While agreeing with the main points in the essay, I have posted a comment in which I argue that there is no turf war.

Joy Johnston
Monday, 29 September 2008 3:12:44 PM
We all refer to it as a *turf war*, but really, there is no war. Many years of health policy from both parties, and a submissive attitude from generations of Aussie mothers have put maternity services into the capable and trustworthy hands of the medical profession. Almost totally.

If it really was a turf war, there would have to be 2 sides battling it out. Obstetricians and midwives, you say. We do see the odd little skirmish between a midwife and an organisation representing obstetricians, or the medical association, but it's like the ant standing on the elephant's toe.

If there really was a turf war, there would have to be something that you could call 'turf' - a playing field of sorts. The pregnant woman? That's a finite number of people, for a particular period of time - should be the sort of sums that the public health bean counters are very happy with. But maternity care in this country is not provided as a package based on the individual woman/pregnancy. It's provided on Medicare schedules, each for fragments of the whole care, and state government funding arrangements with hospitals. The individual woman is not really part of the equation. Medicare excludes midwives because they aren't doctors. Hospitals employ midwives, but once again, to provide fragments of care.

Midwives who work privately with individual women are not able to provide that service in hospitals, as we don't have visiting access, or insurance. We can provide it in the home, and the woman can pay. We have become experts in home birth. Our care includes health promotion in pregnancy, protection of normal birth, protection and support of breastfeeding and bonding and early nurture. If a complication requiring medical attention arises we arrange a referral and collaborate with those who are expert in complicated birth. It's win-win.

But it has nothing to do with a turf war. The care is provided outside the 'system' - on the woman's and the midwife's own turf.

Gloria Lemay

Here's the blog for childbirth activist Gloria Lemay http://www.glorialemay.com/blog/
Gloria has been a prominent activist for normal birth in Canada for many years. Glria is a contributing editor of Midwifery Today Magazine, an Advisory Board member of the International Cesarean Awareness Network (ICAN).

High caesarean rates in this country

I heard the Life Matters Maternity Teamwork interview of Dr Jolyon Ford, one of the keynote speakers at the ACM 'Breathing new life' conference (see next page in this blog). He had a lot to say about emergency obstetrics. I was disappointed with the interview, as the focus ignored the real issue in maternity care, and in reducing rates of caesarean, which is promoting normal birth.

The focus was on older, fatter mothers failing to progress, and distressed babies, and taking scalp blood samples from the babies. The age or size of a mother is not a clear predictor of her outcomes in childbirth. We have evidence that inductions of labour increase the likelihood of caesareans; we know that augmenting labour with oxytocics can cause distress in the baby; we know that continuity of midwife carer reduces a woman's likelihood of requesting dangerous drugs to deal with the pain of labour.

It may interest readers to know that in Victoria 37% of the mothers who gave birth at home in 2006 (the most recent published record) were aged 35 or over - a percentage slightly higher than the private hospital rate (36.3%) and considerably higher than the public hospital rate (19.2%). Giving birth at home means no inductions or augmentations, and no dangerous drugs or epidurals - they do it themselves. Bravo to the older women giving birth!
Joy Johnston

(a version of this comment appears on the guestbook of the Life Matters program)

Time to normalise birth in the 21st century

Press release from Australian College of Midwives

Breathing New Life into Maternity Care Conference
(Gold Coast, Holiday Inn, September 18th-20th 2008)

A multidisciplinary conference – Breathing New Life into Maternity Care – will bring together maternity care providers and consumers to discuss ways in which to reduce the skyrocketing caesarean section rate and improve care for women, their babies and families.

“This comes hot on the heels of the Commonwealth discussion paper on Improving Maternity Services in Australia and the Primary Maternity Services in Australia Framework”, said Professor Brodie, President of the Australian College of Midwives. “It gives us a wonderful opportunity in this country to put women at the centre of our maternity service planning and to collaborate with each other to achieve this end.”

Dr Andrew Kotaska, a Clinical Director of Obstetrics and Gynaecology in Canada and a keynote speaker at the conference, has called for “normalising birth in the 21st Century”. He said, “with skyrocketing rates of intervention during birth in modern industrialized countries we need a clear definition of normal birth. To empower women and caregivers to embrace normal birth will require a critical examination of our overestimation of common obstetrical risks and our risk-based culture in general. Current caesarean section rates of 30% are not justified to ensure safety and can be reduced.”

Henci Gore another keynote speaker at the conference and author of the widely acclaimed books The Thinking Woman’s Guide to a Better Birth and Obstetric Myths Versus Research Realities said, "It isn't a matter of figuring out what approach and practices produce safe, effective, satisfying, and cost-effective maternity care. We already know. Every group everywhere that has ever come together to make this determination has come up with essentially the same recommendations. The time has come for the government and health care providers to live up to their obligation to the childbearing women.”

Melissa Fox, Vice-President of Maternity Coalition, Australia’s umbrella maternity consumer organisation said, “mums and babies deserve the best start to life. This is the foundation for future health. Strong babies and Mums mean stronger families and healthier communities. Governments and carers need to re-orient maternity services, keeping mothers and families at the centre. We believe the best way to ensure this is to have consumers making decisions alongside care providers to make strong and effective policy and new models of care where there is collaboration and respect between all.”

Professor Brodie said, “With over 250 midwives, doctors, consumers and policy makers in one room, this conference is set to be one of the most exciting and powerful events we have seen in over a decade of maternity care. The key to the future is effective relationships between the health professionals and systems that support the skills of the health professionals in a networked seamless environment that is so important for the provision of safe, satisfying care.”

Contact:
Media Spokesperson, Australian College of Midwives, Assoc Professor Hannah Dahlen 0407 643 943.
President, Australian College of Midwives, Professor Pat Brodie 0417 544 824.
Executive Officer, Australian College of Midwives, Dr Barbara Vernon 0438 855 529.

Questions for Maternity Services Review

The following questions have been posed by the Maternity Services Review, in the Discussion Paper from the Australian Government, Improving Maternity Services in Australia. Responses need to be submitted by 31st October 2008.
MiPP members are preparing a written response, and we would appreciate any comments from our blog readers. Please use the 'comments' function of the blog, or contact us by email. You are also encouraged to send your own responses, so that your voice counts in this review.

QUESTIONS:
(see Discussion Paper for more information)

• What models for maternity services for rural and remote communities are working well?
• What are the key elements to applying such models more broadly?
• What aspects of the Australian context are driving high intervention rates?
• What actions are required to address this?
• What, if any, are key support services, including peer support which warrant national coverage?
• What is required to ensure the quality and consistency of key support services?
• How is current Commonwealth funding targeted?
• What are the key professional development needs for the maternity workforce?
• How will models of workforce support vary in rural and urban settings?
• What are the potential areas for change to expand midwife-led care across antenatal, birthing and postnatal services?
• What are the existing effective models for midwife-led maternity services?
• What are the key workforce barriers to integrated models of care?
• What key infrastructure is needed?
• Are there any other issues the Review should consider?
  

From Carolyn Hastie

I've created a mind movie visualisation tool for pregnant women. I would love to have your feedback about it.

http://au.youtube.com/watch?v=uHdP_sATb-s

It is a great way to get important information out there to women. One woman has commented

"that was very nice. I made my decision not to have kids when I was a young teenager when I found out about the pain of birthing. If I had something like this back then my decision may have been different."

If you can comment and rate the video on YouTube, that would be fantastic.

For those of you who don't know me, I'm a midwife manager of a stand alone birth centre/service at Belmont, NSW Australia. We just won the 'best health care unit' at the Quality Awards last Thursday. We have been in operation for 3 years and our statistics are fantastic!

best wishes, Carolyn Hastie

"Gratitude is not only the greatest of virtues, it is the parent of all the others"
Cicero

A midwife's struggle

A midwife who has ceased her private practice wrote this letter, which is shared on this blog with the writer's permission:
"I have been wanting to become more involved but have absolutely no energy, can't even think very straight at present and consider that I am in some part burnt out, whether by life in general, or the experience of my foray into homebirth or both - I really don't know. I believe very strongly though that I will recover and have the energy and passion once again to be a force for women, babies and families. At present, I ache with the pain of the daily abuses I see being condoned in the name of safety. I am getting along in the postnatal wards, and take some small measure of satisfaction from the response I have to being kind, compassionate and patient with the women that I see there.
"I feel I want to weep most of the time, but the reality is that I need to continue to provide for MY family and this is my profession. Sounds like martyrdom when I think about it, but I really do get a lot out of being able to let families know that it doesn't have to be this way and that they have rights."

This story is not unusual. Many midwives are longing to be part of a more humane, woman-centred midwifery care structure, but the realities of their lives and current maternity services are like a restrictive fence that they can see through but not pass through. I want to thank the midwives and others who are working to reform maternity care for all women. I would also like to honor and encourage the midwives who have given it a go, but not been able to find a place for their dream yet. Keep your dream. Keep your midwife identity. Be ready to be 'with woman' when the opportunity presents, even when that opportunity is a shift in the postnatal ward of a hospital in which 50% of the women are post caesarean.

Remember the Bible story of Noah and the great flood. We are told that after the rain had stopped and the waters began to recede, Noah sent first a raven, then a dove out of the ark, and they came back, not being able to find a place to nest. After seven days Noah sent the dove again, and it came back with a freshly plucked olive leaf. After another seven days Noah sent the dove a third time, and this time it did not return.
The midwife who tries to offer a better maternity service for women, and is unable to sustain it, is like the dove who returned with the sprig of the living olive tree. She can see the possibilities, but is not quite ready. The time will come when that dove leaves and is able to set up her own nest.
Joy Johnston

Meeting with Patrice

A recent meeting of MIPPs with Patrice Hickey, who is the Victorian President of the Australian College of Midwives

The following brief notes reflect some of the discussion at the meeting

• Midwives’ right to make a living. Note that national regulation of health professionals will be in place July 2010. This will bring a lot of change nationally, as well as to the regulatory bodies for each profession.
• Community midwifery. The 3 Tertiary units (Womens, Mercy, and Monash) are being progressively restricted in whose bookings they can take. Womens and Monash provide booking services for transfers from planned homebirth.
• PERS Perinatal Emergency Retrieval Service. Headed by Dr Jackie Smith. Discuss hospital options particularly when there is a possibility that newborn intensive care services will be required.
• ACM Midwifery Practice Review. Patrice encouraged all MIPPs to undergo the MPR on 3-yearly cycles, and for some to become reviewers. Meeting planned by ACM Thursday 2 October.
• Consultation. Independent midwives need to consult with hospital registrars and senior medical and midwifery staff. The ACM National Midwifery Guidelines are a guide, but are not able to be used in a prescriptive or punitive way.
• Federal government. Health Minister Nicola Roxon has established a maternity advisory committee.
• Nurses Board. ACM will seek assurance that the Board will engage with ACM when midwives are under investigation, and that a midwife with relevant experience will be part of any investigation or hearing into a midwife’s practice.
• Prescribing and Ordering for midwives. Qld health department is making progress in this area.
• Access to public maternity hospitals. All public hospitals are required to accept all patients for whom they are equipped to provide services. Women who are planning homebirth and need emergency admission to a local hospital should be admitted unbooked. Sunshine Hospital is happy to make homebirth backup bookings.
• Some midwives report that GPs refuse to order blood tests and investigations for women who plan homebirth. This is not acceptable.

Any unacceptable behaviour towards independent midwives or our clients by public hospitals, or by other health professionals, should be addressed in a professional manner. There is a lot of positive change in the system, and we need to move with it.

Maternity Services Review

From the Federal Government's announcement of the Maternity Services Review
The Review is the first step in developing a comprehensive plan for maternity services into the future.

The Review will:

o canvass a wide range of issues relevant to maternity services, including antenatal services, birthing options, postnatal services up to six weeks after birth, and peer and social support for women in the perinatal period;
o ensure that all interested parties have an opportunity to participate; and
o inform the development of a National Maternity Services Plan.

go to http://www.health.gov.au/maternityservicesreview

midwifery debate

The following responses were sent to the Editor of newspapers which published a small article 'Doctors Attack Midwives Proposal'

The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.

Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.

I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.

Joy Johnston
(most of this was published in Letters to the Editor 12 September)

Sirs

Dr Capolingua knows full well that the Maternity Services Review is not about homebirths but about increasing choices for women in maternity services.

In terms of her comments about the safety of homebirth, readers should be aware that last year the WA Health Dept commissioned a review of evidence relating to issues of maternity care. This review was carried out by the Women and Infant Research Foundation at King Edward Memorial Hospital in Perth. This review entitled: “Models of Maternity Care: A Review of the Evidence” 3 includes an Evidence Summary Point on page 16. The summary states:

“Planned homebirth with a qualified home birth practitioner is a safe alternative for women determined to be at low obstetric risk by established screening criteria.”

The WA Maternity Services Framework launched last year supports the provision of midwifery-led care for women in WA not only for homebirths but for women who choose to birth in hospital: which is what women in WA want. Support for this at a Federal level is to be welcomed.

Reform in maternity services in Australia is urgently required and, at last, both State and Federal governments have woken up to the fact.

For the sake of women and their families could the AMA not work collaboratively with the government, midwives and consumers to provide maternity services that work rather than seeking to protect their patch?

Debbie Slater

Perth, WA

It is to be expected that the AMA as a medical trade union would attack any discussion on midwives’ roles in the health system (Doctors Attack Midwives Proposal September 11th). We must, however, challenge the inaccuracies used in their response.

Firstly, the Maternity Services Review is not about homebirth but about facilitating women's choice in a safe, informed environment. The majority of women will have their babies in hospital and the majority of midwives will work in hospitals.

Secondly, the rhetoric about doctors needing to 'supervise' midwives is unhelpful. We need to all work together as respectful professionals, knowing when and where to access the expertise of the other.

Thirdly, the current model does not work well, as is asserted by the AMA, when we have: unacceptable outcomes for Indigenous mothers and babies; high rates of unnecessary medical intervention; lack of access to continuity of care by midwives despite evidence supporting its benefits, safety and cost effectiveness; lack of postnatal care; closure of around 120 rural maternity services in the past 10 years; a midwifery workforce shortage (1,800) due to workplace stress and lack of opportunities; rising birth costs affecting government, insurance funds and women; low rates of breastfeeding at six months (34%); increasing rates of perinatal depression and maternal suicide; lack of insurance for midwives.

Finally, it is time to stop the war and start working together to address these issues. It can no longer be about ‘us’ it must be about women.

Dr Hannah Dahlen

Spokesperson for the Australian College of Midwives

Midwifery debate

The following responses were sent to the Editor of newspapers which published a small article 'Doctors Attack Midwives Proposal'


The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.

Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.

I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.

Joy Johnston

It is to be expected that the AMA as a medical trade union would attack any discussion on midwives’ roles in the health system (Doctors Attack Midwives Proposal September 11th). We must, however, challenge the inaccuracies used in their response.

Firstly, the Maternity Services Review is not about homebirth but about facilitating women's choice in a safe, informed environment. The majority of women will have their babies in hospital and the majority of midwives will work in hospitals.

Secondly, the rhetoric about doctors needing to 'supervise' midwives is unhelpful. We need to all work together as respectful professionals, knowing when and where to access the expertise of the other.

Thirdly, the current model does not work well, as is asserted by the AMA, when we have: unacceptable outcomes for Indigenous mothers and babies; high rates of unnecessary medical intervention; lack of access to continuity of care by midwives despite evidence supporting its benefits, safety and cost effectiveness; lack of postnatal care; closure of around 120 rural maternity services in the past 10 years; a midwifery workforce shortage (1,800) due to workplace stress and lack of opportunities; rising birth costs affecting government, insurance funds and women; low rates of breastfeeding at six months (34%); increasing rates of perinatal depression and maternal suicide; lack of insurance for midwives.

Finally, it is time to stop the war and start working together to address these issues. It can no longer be about ‘us’ it must be about women.

Dr Hannah Dahlen

Spokesperson for the Australian College of Midwives


Sirs

Dr Capolingua knows full well that the Maternity Services Review is not about homebirths but about increasing choices for women in maternity services.

In terms of her comments about the safety of homebirth, readers should be aware that last year the WA Health Dept commissioned a review of evidence relating to issues of maternity care. This review was carried out by the Women and Infant Research Foundation at King Edward Memorial Hospital in Perth. This review entitled: “Models of Maternity Care: A Review of the Evidence” 3 includes an Evidence Summary Point on page 16. The summary states:

“Planned homebirth with a qualified home birth practitioner is a safe alternative for women determined to be at low obstetric risk by established screening criteria.”

The WA Maternity Services Framework launched last year supports the provision of midwifery-led care for women in WA not only for homebirths but for women who choose to birth in hospital: which is what women in WA want. Support for this at a Federal level is to be welcomed.

Reform in maternity services in Australia is urgently required and, at last, both State and Federal governments have woken up to the fact.

For the sake of women and their families could the AMA not work collaboratively with the government, midwives and consumers to provide maternity services that work rather than seeking to protect their patch?

Debbie Slater

Perth, WA

VBAC

Due the absolute epidemic of C/S performed in the last decade I feel there are more & more women seeking VBAC and wanting to do it at home (for obvious reasons).

According to The Australian College of Midwives www.midwives.org.au/
Women with a scar on their uterus are not considered low risk & are therefore not within the scope of practice for a caseload/homebirth midwife. They are flagged 'C' for consultation or transfer of care!
However so are women who are grande multis, women with psych disorders & 'failure of head to engage at full term' yet I attend them at home.
Still.....................ACMI are our guiding body.

I'm really struggling with this right now. I am getting increasing requests for H/B VBACs.
I'm perfectly comfortable with the process of labour with a scar.
Good surgery should be sound when healed shouldn't it ?
I don't hear anyone telling athletes not to compete with their reconstructed knees/ankles/shoulders etc do you ?

What do you all think ?
Am I the only one struggling with this ?
I'd appreciate your viewpoints.

Brenda Manning

conferences coming up in October

Here's some free publicity for a couple of reasonably-priced conferences in Melbourne, that midwives should enjoy. I haven't worked out how to attach a .pdf file to the blog, but you can follow the link or contact by email.

From Having a baby in Victoria to Future Directions and beyond
Friday 31 October, organised by Maternity Coalition (follow this link for brochure and bookings) Presenters include midwives Liz Chatham, Pat Brodie and Nicky Leap; sociologist Kerreen Reiger; researcherRhonda Small, and obstetrician Euan Wallace.
Note: Consumers who would like to attend this symposium can apply for a specially reduced fee, made possible with a grant from the Department of Human Services.

Emerging issues in pregnancy, birth and postnatal care
Thursday 9 and Friday 10 October, organised by The Women's. To request a flyer, contact tracey.savage@thewomens.org.au Tel: 03 8345 2147
This two-day seminar has many of Melbourne's leading maternity academics and midwives presenting the current evidence and debate on topics including caseload midwifery, diabetes, breastfeeding, caesareans, postnatal care, length of stay, and much more.
Note: Homebirth is notably absent from the list of topics. Victoria is a little behind other States.

"But whose art frames the questions?"

In light of the recent discussions around guidelines, I was reminded of Maggie Bank's article "But whose art frames the questions?".
Maggie writes:
Midwives need to be vigilant to ensure the defining of appropriate midwifery practice has not been colonized by obstetric thought. Any guiding must reflect the essential Midwifery Model of Care in the evidence amassed and the way in which it is applied. ...

http://www.birthspirit.co.nz/Articles/Articles/But%20whose%20art%20frames%20the%20questions.pdf

Whilst the discussion is centred around the NZ scene, it is applicable to our conditions also. Maggie's thoughts are well worth considering.

Regards,
Gaye

Gaye Demanuele

Looking for a homebirth midwife

[Photo: MIPPs meeting with Shared Care coordinators at the Women's]


We received an email from a mother who I will call Tammy (not her real name), who was trying to find a midwife who would attend a homebirth from 35 weeks gestation. Tammy explained that her first child was born at about 35 weeks, weighing 2.3 kilos, after spontaneous onset of labour. The baby had no difficulty breathing, and fed well at the breast, and maintained body temperature well (three of the possible challenges that premature babies face). The only treatment the baby required while in hospital was phototherapy for jaundice, with "lots of love and care from mummy in nursing __'s poor bruised heels from all the blood tests".
I expect that anyone who reads this blog will recognise that the accepted range for 'Term' or maturity is 37 to 42 weeks. A baby born at 35 weeks is 'premature'.

Midwives who ignore well established standards do so at their own (professional) risk, and are possibly also putting the mother and baby at extra risk. The safety of homebirth internationally has been established in the normal birthing population. If homebirth midwives are holding themselves out as being practitioners in prematurity, twins, breech, and other clearly complicated births we are on very thin ice. A baby born spontaneously at 35 weeks may actually be mature, and this will be recognised soon after the birth. But even an apparently minor intervention such as blood tests and phototherapy for bilirubin are in many of these little babies considered essential for the baby's wellbeing.

By definition the midwife's duty of care includes "preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical or other approtpriate assistance and the carrying out of emergency measures." (ICM 2005 www.internationalmidwives.org/)

The Australian College of Midwives www.midwives.org.au/ has recently undertaken a review of its National Midwifery Guidelines for Consultation and Referral (see blog posting 20 July 08). We (MIPP) have engaged in that review, in seeking to achieve a document that will enable "the midwife to integrate evidence with experience (clinical judgment) in providing midwifery care; and to assist midwives in their discussions with women." (from the draft)

Following Tammy's email several MIPPs replied, seeking the opinion of their peers on this matter. The clear consensus from those who replied to the group was that we state that from 37 weeks is the usual time after which we are happy to attend birth in the home, and would consider the individual situation in the 36-37 weeks period. Of course in this instance the midwife could say yes now, knowing that it's likely that this baby will not be born pre-term. They may even have to have the discussion about postmaturity!

There is no fixed protocol for independent midwives in attending homebirth. We are independent in professional decision-making, and we are accountable for all decisions we make.

The ACM Guidelines are a guide, but should not be seen as prescriptive. Some independent midwives will agree to plan homebirth that carries a degree of potential complication with the belief that the woman will be better attended than unattended, or forced into a potentially harmful situation. That level of decision making requires an understanding of the responsiblities and rights of both the mother and the midwife. It is not a simple matter of booking a midwife who will agree to a particular issue, such as homebirth for a premature baby.

The midwife's selection criteria and guidelines for referral do not prevent the woman from making an informed decision, for her own reasons, which contradicts the midwife's advice. That's a very different situation from the one in this instance, when the mother is seeking a midwife who will agree from the start to working outside standard guidelines.

A wise midwife will encourage Tammy to talk about what she wants, and will use the discussion as an opportunity to explore informed decision making, personal autonomy, and the responsibilities of the midwife. Independent midwives may have greater scope than those employed by hospitals to work in a partnership with each woman, but a midwife cannot simply ignore basic guidelines or professional standards.

Joy Johnston

MIPP Peer Review

Midwives working independently within the MiPP collective meet a couple of times each year for what we call Peer Review. This is, for us, an informal process based loosely on the New Zealand model of professional standards review.

"The concept that the individual midwife continues to develop and grow throughout her professional life forms the basis of [Peer Review]. By participating in a review, a midwife is demonstrating her commitment to her own ongoing professional development. Reflection on practice … provides the opportunity for midwives to learn from their own actions, and from the feedback they receive from clients. … Reflection with the members of the [Review] panel enables the midwife to explore her own practice issues in a supportive and confidential atmosphere. The fact that the midwife participates in a forum with peers (the profession) and consumer representatives (the public) demonstrates accountability for practice." (NZCOM 2001. Midwifery Standards Review)

Due to our small numbers, and our inability to commit to a particular time because we may be called to attend a birth, our Peer Review meetings follow a less structured path than is currently followed in New Zealand, or in the Australian College of Midwives' Midwifery Practice Review (MPR). The MPR encourages midwives to undergo a detailed self-assessment and self-reflection exercise; a face to face review discussion with a specially prepared midwife and consumer; and receive guidance and support in developing a personal Professional Development Plan.

In summary, Peer Review:

• Is voluntary
• Is confidential. The summary data provided contains no features identifying clients or other professionals or institutions. Members participating in a peer review agree to maintain confidence about the midwife, and the information discussed.
• Supports the individual midwife's professional development.

World Breastfeeding Week 1-7 August 2008

Mother support: going for the gold
http://www.worldbreastfeedingweek.org/

Health professionals today like to use the term 'evidence based'.
Mother support is truly an evidence based intervention in health promotion through breastfeeding. WABA 2008 states:
Mother Support: Evidence that it Works
"The recent Cochrane Review evaluated 34 trials from 14 countries for effects on the duration of any breastfeeding (both partial and exclusive) and exclusive breastfeeding alone. The review found that all forms of support, professional and lay, analysed together, significantly extended the duration of any breastfeeding, and had an even greater effect on the duration of exclusive breastfeeding." Read more at http://www.waba.org.my/

Review of ACM Guidelines

The Australian College of Midwives (ACM) has published a draft of the revised National Midwifery Guidelines for Consultation and Referral (Guidelines) http://www.midwives.org.au/ForMidwives/PracticeGuidelines/tabid/308/Default.aspx

Individuals and groups have been responding to ACM, and there has been discussion amongst midwives on email lists. In accepting the need for a systematic set of Guidelines, there is a hope that the professional identity of midwives will be enhanced, and that collegial relationships with other providers of maternity and newborn care (including doctors, nurses, midwives, and allied health), will be effective in providing the best options for each mother and baby. The need for Guidelines that deal with consultation and referral, and possibly transfer of care from a midwife led model to a collaborative, multidisciplinary team that is obstetrician led is clear in ensuring a seamless process for the woman and her baby when the need arises.

Anyone reading this blog will probably already realise that independent midwives are an endangered species. Midwifery in Australia is restricted to the point of near suffocation, and midwives who come to this country after working in other developed countries (incl UK, Canada, Netherlands, Denmark, NZ) are shocked at the lack of professional recognition in such basic matters as arranging routine blood tests, and access to oxytocic drugs. We face social and financial and professional exclusion. We can't get professional indemnity insurance. Although we are fully recognised as providers of maternity care, women who use our services have no public funding when a midwife provides the same service as doctors and hospitals provide. No equal pay for equal work!

Many midwives are paralysed by fear. It's not fear of adverse events in birth - it's a fear of what our colleagues may do if we dare to step outside the usual authoritarian system. It's a fear of being regulated and reviewed by people whose expertise is in nursing, not in midwifery. It's a fear of being misunderstood, and possibly losing our right to practice; our livelihood, over trivial disagreements with those who have power.

Our profession will never thrive until midwives are proud of our identity and our authority. The title 'midwife' is protected by law in all States and Territories in this country, meaning that a person who has not achieved and maintained a recognised midwifery qualification cannot call themself a midwife. Yet midwives themselves easily give away their unique identity, as the primary care provider who works in partnership with each woman, promoting normal birth, health and wellness for the woman and her family.

The following points have been made by a group of independent midwives, including several Victorian MiPPs, in our submission to the ACM.

• We accept the Guidelines, with further ongoing refinement, as being a statement that guides midwives in decision making, particularly in the interface between primary maternity care, and collaborative care within a multidisciplinary team.
• We accept the Guidelines as being a useful risk management tool for maternity service providers.
• We express our concern at the potential for misuse of the Guidelines, affecting some models of midwife-led care. Midwives who are regulated and employed within authoritarian, medically dominated systems have experienced punitive action, apparently with the support of ACM Guidelines. We recommend that a statement be included in the revised Guidelines to protect the scope of practice of the midwife in all settings.
• Although the revised Guidelines quote the ICM Definition of the Midwife (2005), we recommend that the Guidelines draw attention to the fact that the midwife’s duty of care now includes, since 2005, “the promotion of normal birth”. This change in the Definition is potentially useful to midwives who may consider that, in a particular professional situation, their advice and actions are consistent with the promotion of normal birth rather than strict adherence to a professional guideline.
• We recommend that the phrase ‘evidence based’ be deleted, except where specific reliable evidence is quoted.
• We recommend that the reference list be limited to papers or documents referred to directly in the document, and to current literature reviews that inform the midwife’s decision to consult or refer. If a paper is considered important enough to be included in the references, a referencing system such as footnote could be used to identify the reference, as in the Preamble.
• We recommended that the word ‘support’ or ‘support person’ be removed from any ACM documentation referring to midwives as it devalues the midwife’s title which is protected by law throughout Australia.

[We welcome your comments on these points and recommendations. We will be meeting with ACM later this month to discuss our recommendations. Joy Johnston)