Thursday, October 30, 2008


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

For distribution; many thanks.


Gavan Woinarski
Executive Director
McAuley Foundation

678 Victoria Street
Richmond VIC 3121
Phone : 03 8416 7896
Mobile: 0447 389 517
Fax : 03 8416 7955

Monday, October 27, 2008

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.

Friday, October 24, 2008

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.

Sunday, October 19, 2008

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.

Saturday, October 18, 2008

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.

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.

Monday, October 13, 2008

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]

Saturday, October 11, 2008

Midwives Rock!

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

Friday, October 10, 2008

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.

Thursday, October 2, 2008

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.