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.
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