Friday, March 5, 2010

Maternity reform hijacked 3

Professional indemnity insurance
One of the key features of the new national health practitioner legislation is the mandating of the requirement for professional indemnity insurance for all registered health professionals. Midwives stand alone in the field, as the only group unable to purchase private indemnity insurance.

Midwives in Canada and New Zealand practise with government provisions for professional indemnity insurance, being treated equitably with other maternity service providers, ie doctors. Midwives in Australia, by comparison, have been repeatedly sidelined in all government provisions for indemnity, giving doctors privilege across the scope of maternity services. Midwives who are employed by hospitals or health services are covered by vicarious liability provisions, as well as by insurance which is part of membership in the union, the Australian Nursing Federation, Victorian Branch. Midwives who practise independently, who are self employed, have done so without indemnity insurance since about 2001. Under the legislative reforms that are today being debated, the best that the federal government has offered this group of self employed midwives is a two-year exemption from being required to have private indemnity insurance for home birth. This is an irrational approach to dealing with a real problem. It simply puts the problem under the mat with the rest of the dust.

That small group of self-employed midwives, probably less than 50, who provide private midwifery services for less than one% of Victoria's birthing population, have been sidelined in the federal government's Report of the Maternity Services Review, and in subsequent legislative reforms. These midwives and the women who employ them have become an unwanted and aggravating minority group, writing multiple submissions to inquiries, and letters to politicians. Thousands of mothers, fathers, and little children, with midwives and other concerned people, have rallied in sites around the country, and have experienced the dictator Rudd's response that he is unmoved. These people are intelligent, and they vote. They know their human rights to self-determination in all matters of their own bodies. They know that pregnancy and birth is not an illness, and they know that the midwife is in many cases the most appropriate professional able to provide primary maternity care, with a commitment to protecting and working in harmony with natural physiological processes. They also know that the botched reform of this federal government is likely to restrict their choices in maternity care, rather than improve access and choice.

Doctors who provide maternity services, that is, specialist obstetricians and general practitioner obstetricians (GP-Obs) receive huge public funding to ensure indemnity insurance for their private practices. There is no rational reason why midwives should not receive similar government support. Victorian Health Minister Andrews, and other state and territory health ministers, together with their federal counterpart, have blocked any such suggestions.

The focus so far in health practitioner regulation has been the federal political scene, because the primary legislation is national. The Victorian Health Department now has responsibility nationally to develop a Safety and Quality Framework that will be required for midwives to continue their private practices and be entitled to the two-year exemption from indemnity for attending home births. This process is already wobbly. Many stakeholders in all states and territories have appeared before the Department's consultants, and the only thing that is clear is that nothing is clear.

Collaborative arrangements
Health Minister Roxon has repeatedly asserted that "The Government's intention has always been to ensure that the midwife and nurse practitioner reforms are underpinned by collaborative arrangements between health professionals."
Collaboration in its true sense, 'co-labor(ing)', is fundamental to a midwife's practice. The midwife's definition and scope of practice require referral to a doctor or suitable medical service when complications requiring medical intervention arise. But midwifery does not stop when a complication is detected and care becomes more complex. The midwife continues with the woman, and collaborates with doctors, nurses, pathologists, physiotherapists, dentists, or whoever else is able to provide care that will be in the interests of the wellbeing of mother and child.

The requirement for collaborative arrangements has been brought through into legislative amendments as an agreement signed by a doctor or doctors. It seems that Minister Roxon's tunnel vision expects that midwives will be able to find doctors who will sign off as agreeing to collaborate with them. Many midwives anticipate that any such request would be met with refusal by the doctors in their communities. The medical union, the Australian Medical Association (AMA), as well as the obstetricians professional body, Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), have been outspoken in their opposition to private midwifery and homebirth. The requirement for up-front signed agreements around collaboration is handing the power of veto of midwifery private practice to the medical profession.

There is no requirement for doctors to access signed collaborative agreements signed by midwives. Yet all doctors providing maternity services NEED midwives to work with them - that's understood.

It seems that Minister Roxon's tunnel vision has missed the obvious fact that if an uninsured midwife is attending home birth, it is highly unlikely - even impossible - that a doctor's insurance provider would agree to indemnify the doctor who enters a collaborative arrangement with that midwife.

For further comment on this topic, go to
Part 1 Background
Part 2 Consumer choice, and Competition Considerations

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