Sunday, July 25, 2010

Collaborative arrangements for midwives eligible for Medicare funding

The National Health (Collaborative Arrangements for Midwives) Determination 2010 has now become law.

Midwives who anticipate taking up the provisions of this reform, and applying to be eligible for Medicare funding and other extensions to practice from 1 November 2010 now have a clear process to follow.

Concerns about a potential medical veto have been raised repeatedly in discussions, email groups, and submissions to the law makers. The Queensland Branch of Maternity Coalition has published a blog post outlining these matters.

"The Determination provides 4 options for collaborative arrangements. Each option requires the midwife to have some form of permission from a doctor, before a woman can receive Medicare rebates.

"The minimum form of permission is an "Arrangement - midwife's written records" (section 7 in the Determination). This option requires a named doctor of a specific type to acknowledge "that the practitioner will be collaborating in the patient’s care", and that the named doctor has received copies of a hospital booking letter and a maternity care plan.

"These requirements will make it very difficult for women to access Medicare-funded care from midwives in private midwifery practice. We don't expect midwives in private midwifery practice (working for themselves, not a doctor) to be able to find private doctors who are willing to enter collaborative arrangements with them. In some cases this may be possible under very specific conditions. However it is unrealistic to expect that private doctors will collaborate in the care of women planning homebirths.

"Even for women planning births in public hospitals, these requirements for collaborative arrangements will make it extremely unlikely for them to be able to access Medicare-funded midwifery care. There is no reason to expect public hospital doctors to enter the required collaborative arrangements with private midwives. They have no incentive, and there is no sign that state governments are planning to push them.

"In March 2010 when the Senate was debating this legislation, the Government stated that "There is no intention to provide a right of veto over another health professional’s practice". However, under intense pressure from the medical lobby, this is exactly what has occurred. Most importantly, it is women's choices and access to care which are being vetoed, to protect medical control of the maternity marketplace.

"If these reforms are to deliver the "choice and access" promised to Australian women by Government, the medical veto must be removed. Midwives must be accountable to the women they care for, and to their regulating body, not to another profession."


Midwives who wish to be authorised will need to approach doctors and hospitals in their area, obtain agreement, and prepare care plans that meet the legal requiremens established in this Determination.

A new website, Midwives Australia, has up to date information on Medicare eligibility.

The Queensland branch of the Australian College of Midwives has announced a pre-conference workshop on Medicare for midwives. Click here for details.

Saturday, July 24, 2010

Safety and Quality Framework for Privately Practising Midwives attending homebirths

This document has now been circulated, pending final endorsement/modification and adoption by the Nursing and Midwifery Board of Australia.

Readers who would like to have a copy of the document emailed to them may request it by email:

Key Principles [Attachment]

“Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” articulated the following principles which underpin the range of models of maternity care available to women in Australia. These principles involve:

· ensuring services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience

· ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman

· maximising the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals such as paediatricians and Aboriginal health workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery

· offering continuity of care, and wherever possible continuity of carer, as a key element of quality care

· ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence ­based best practice care

· ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework

· providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required

· working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.

The Safety and Quality Framework

The framework is consistent with the principles underpinning provision of primary maternity care (Attachment 1) and recognises the full scope of midwifery practice.

The framework also recognises that women will make the final choice about their care and birthing choices in most circumstances. It is incumbent upon privately practising midwives (PPMs) to provide balanced and contemporary clinical advice to ensure that informed decisions are able to be made.

PPMs are expected to adhere to recognised consultation and referral guidelines developed by the Australian College of Midwives (ACM) and to have processes and relationships in place to demonstrate compliance with the guidelines.

The ACM guidelines were developed to guide midwifery practice more broadly and do not specifically to cover homebirths. Distance and time to travel to an appropriately staffed maternity service should be considered when assessing suitability for this option of care. These factors are in addition to undertaking an assessment of risk for this birthing option.

Women with a singleton pregnancy, cephalic presentation, at term and free from any significant pre existing medical or pregnancy complications are those identified in the ACM guidelines as clearly meeting criteria for midwifery led care.

When PPMs are the primary carers for women who fall outside of these criteria, the consultation and referral pathways must be documented and followed. Clearly articulated and documented plans of escalation and collaboration are integral to provision of safe high quality care leading to positive outcomes for mothers and babies.

PPMs are required to document advice provided to women in their care about midwifery scope of practice, risks and escalation processes.

In addition they will enlist the services of another registered maternity care professional to provide a second opinion in situations where the woman chooses not to follow clinical advice about the need for interventions or transfer. A written record of these processes is essential to verify adherence to the framework in the event of any adverse outcome and /or subsequent legal action or professional investigation.

Tuesday, July 20, 2010

Birthing from within WORKSHOPS

BIRTHING FROM WITHIN facilitators Pam England and Virginia Bobro are finally coming to Australia! They will be leading two three-day workshops, one near Sydney at a retreat centre (18-20 Sept.) and the other in Melbourne (23-25 Sept.).

For info and to register, click here.
Discount for early registrations ends soon. Register today!

The intensive workshops, open to all birth-related professionals, will cover the following material, and much more:
• Birth as a rite of passage, and the childbearing year as a hero’s journey—what this means and why it is important;
• How to prepare women for birth following the hero’s journey model;
• How to build a solution-focused mindset that helps women (and their partners) cope with pain, fatigue, and the unknown in labor and postpartum;
• Teaching and mentoring to prevent emotional birth trauma;
• Utilizing Masculine/Feminine polarity to facilitate labor and postpartum;
• How to lead a Special Class Just for Fathers.
This is a warm, fast-moving workshop. It inspires beginners, validates and deepens what the experienced know, and uplifts the jaded and weary ones.

Pam England, former nurse-midwife, author of Birthing From Within and Labyrinth of Birth, now works as a Childbirth Mentor, Storyteller, Birth Story Listener, and Creative Director of BIRTHING FROM WITHIN. Pam is mother to two sons; she lives and teaches in Albuquerque, New Mexico, and leads workshops around the world.

Virginia Bobro, began her work in birth as a La Leche League Leader and doula. She is currently the Managing Director of BIRTHING FROM WITHIN She is the mother of three and lives in Santa Barbara, California. and facilitates BFW workshops around the world.

A midwife in Oregon says of our workshop: “I loved the book Birthing From Within, and began using some ideas and exercises in my appointments with parents. I thought the workshop might be nice. The workshop was amazing—more mind-blowing than the book! We went much deeper and further than I thought possible. My work is forever changed.”

Monday, July 12, 2010

MANA critique of Wax et al, Am J Obstet Gynecol 2010

July 6, 2010
From Midwives Alliance of North America
Geradine Simkins, CNM, MSN,
Susan Moray, CPM,

RE: Maternal and Newborn Outcomes in Planned Home Birth Vs. Planned Hospital Births: A Meta-Analysis, Wax JR, Lucas FL, Lamont M, et al., Am J Obstet Gynecol 2010

A new meta-analysis rushed to on-line publication well before its availability in print, concluded that less medical intervention, which is a characteristic feature of planned home birth, is associated with a tripling of the neonatal mortality rate compared with planned hospital births. In a study published online on July 1, 2010 in the American Journal of Obstetrics and Gynecology (AJOG), researchers at Maine Medical Center in Portland, Maine analyzed the results of multiple studies from around the world. The lead investigator, Joseph R. Wax, MD, Department of Obstetrics and Gynecology, Maine Medical Center, stated, “Our findings raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group.”

However, Canadian researchers whose data showing the safety of home birth in a well-organized and regulated system, were used in the meta-analysis, are sharply critical of the study. Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia said the U.S. conclusions did not consider the facts. “A meta-analysis is only as good as the articles entered into the meta-analysis—garbage in, garbage out. Moreover, within the article, Wax et al did their own sub-analysis of the studies in the meta-analysis, after removing out-of-date and low quality studies, and found no difference between home and hospital births for perinatal or neonatal mortality. Yet in the conclusion, they choose to report the results of the flawed total meta-analysis, which showed the increased neonatal mortality rate. Klein said that this is apparently a “politically motivated study in line with the policy of the American College of Obstetricians and Gynecolgists (ACOG) who is unalterably opposed to homebirth.”

Saraswathi Vedam, a nurse midwife and researcher at the University of British Columbia who is considered to be an expert on assessing the quality of literature related to homebirth, states that the study is deeply flawed for several reasons, particularly, “the authors’ conclusions are not supported by their own statistical analysis.” Vedam states that Dr. Wax et al acknowledges the consistent findings of low perinatal and neonatal mortality in planned home births across the best quality studies they reviewed “but amazingly Wax does not emphasize or even mention this in his sole conclusion.” This begs the question of whether the author’s analysis and reporting of reviewed articles on homebirth do not support his foregone conclusion about the safety of homebirth.

Childbearing women and those involved in maternal and child health policy should be made aware of the flaws and erroneous claims in the Wax et al study. There is a substantial body of evidence-based literature from well-designed studies that establishes the safety of planned homebirth with a skilled birth attendant. The fact that the American College of Obstetricians and Gynecologists maintains its position in opposition to homebirth, despite the evidence of its safety and efficacy, makes one question ACOG’s motive in publishing Wax’s substandard study.

Midwives are the primary care providers in out of hospital settings. Whether their work is studied and scrutinized here in the US or abroad the findings are consistent. Trained midwives are qualified health professionals who have the requisite expertise to provide mothers and newborns with outstanding care, using less intervention, resulting in outcomes that are as good as their cohorts who birth in hospital settings under the care of obstetricians.

The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman’s choice regarding care providers, including skilled midwives, and place of birth.

Geradine Simkins, CNM, MSN
President & Interim Executive Director

Thursday, July 8, 2010

homebirth in the news again

TV loves celebrity, and lovely Dannii Minogue has brought homebirthing into the news.

Today I have been interviewed by Channel 10 news. The questions they asked me were about primipara over 35 years of age, and transfer from planned homebirth to hospital.

Channel 7 Today Tonight program also aired comments I made about the safety of homebirth when interviewed some months ago. The questions in this interview were in response to outrageous claims about homebirth made in the Australian Medical Journal. For more on that, click here.

[The 7PM show includes a blog.]

The current focus on homebirth has come with the news that Dannii Minogue went to the Royal Women's Hospital, having booked under an alias, and subsequently gave birth to a baby boy. The parents and the baby's celeb aunty Kylie have tweeted their delight to the whole world.

So why is that story newsworthy?

Dannii had employed midwives - members of this blog's own Midwives in Private Practice - to attend her privately, with the intention of giving birth at home.

The reason for Dannii's change from home to hospital has not been made public. It appears that mother and baby are well, which is the goal of all midwifery care.

The fact that planned homebirth includes a 'Plan B', including a back-up booking at a hospital that can provide specialist obstetric care if and when required, seems to be conveniently ignored by some of those who make their thoughts public. It appears that sensationalism sells papers:

"Another woman is suspicious of modern medicine - until she really, really needs it:
POP star Dannii Minogue and her new baby son are bonding in hospital as they recover from a dramatic home birth halted at the last minute. Complications midway though a planned home birth forced the star to hospital to deliver her baby in safety." (Andrew Bolt)

The comments to that blog make interesting reading if you have nothing better to do, and if you are aware that uninformed opinion is just that.

There is absolutely no shame or 'failure' in moving from a planned home birth to a hospital birth.

The safest and most appropriate way for most women to give birth is in harmony with their own body's natural physical-hormonal processes. That's 'Plan A'. The professional practitioner who is best equipped to enable and protect 'Plan A' is the known and trusted midwife who has the responsibility of primary maternity care provider. That's what midwives in private practice do. That's why women employ us.

The midwife is committed to the woman - not to the place of birth.

Approximately 20% of women planning homebirth at the onset of labour will go to hospital for the birth. Some of these will have caesarean births; some will receive medical forms of pain management or augmentation of labour and proceed to vaginal births.

Primipara are more likely to change from home to hospital births than multiparous women. This is also the case in transfers from birth centres to standard delivery wards. The birth of our first baby is a huge physical and emotional challenge for most mothers. There is no shame or failure in reaching a decision to seek appropriate medical intervention.