Thursday, September 30, 2010

Dissenting voices from ACMQ

This message has been distributed widely, and is posted here with permission of Dr Jenny Gamble, representing the Queensland Branch of the Australian College of Midwives.

E Bulletin from ACMQ Executive Regarding the Medicare Determination:

The distribution last Wednesday of an e bulletin from the ACM national office concerning the Medicare determination has caused considerable confusion amongst members in Queensland and we believe does not present all of the options available to us.

ACMQ Executive acknowledges that the ACM National President and Board members are working hard on this issue and making some difficult decisions representing the colleges view at a national level. This E bulletin to members is in no way meant to be divisive or to detract from the work undertaken at national level. However, ACM national has concentrated on one option in the e-bulletin and we seek to provide an alternative for consideration by members.

In agreement with ACM national ACMQ Executive unreservedly supports Medicare for midwives, but the determination needs to be changed.

ACM Queensland Executive continues to have a bottom line position that we will not accept a “collaborative arrangement” with a medical practitioner that requires a signed agreement or provides an opportunity for a doctor to veto a midwives ability to access Medicare funding.

ACMQ Executive does not endorse the ‘keep silent, don’t rock the boat it’s too high risk’ position proposed by ACM national. .
ACMQ does not promote putting Medicare at risk.

ACMQ Executive believes that by using fear-based tactics the minister’s advisors have created panic that Medicare will not start and thereby hope to prevent midwives lobbying to change the determination. It is the opinion of the ACMQ Executive that pressure from the government on ACM National to cease lobbying to alter the medical veto over midwifery practice is a deliberate strategy to stop pressure to change the wording of the determination.

The Minister has the ability to change the determination any time. She clearly does not want to do so (and is possibly under pressure not to do so by the medical lobby) and will not do so unless midwives lobby.
ACMQ Executive offers the alternative position that we do not change our lobbying strategy. Members continue to ask for the wording in the determination to be altered. We recognise that in the immediate term it is unlikely that this will cause the Minister to change the wording. However early next year, with more evidence, it may become more obvious that there is a real difficulty in the currently worded determination.

ACMQ Executive is of the opinion that the strongest strategy is to indicate that we do not accept the current wording allowing a medical veto and that we stick together on this.

ACMQ Executive believes continuing to lobby to change the determination before a motion to disallow can even be introduced, let alone voted on, does not carry the level of risk outlined by the ACM national e-bulletin.

Timeline for the Determination:
• Determination was signed off by Governor General on 16 July which means that the Medicare for Midwives legislation is ready to commence on 1 November.
• Parliamentary process requires that because the determination is only signed off by Governor General, it is tabled in parliament in first six sitting days of the new parliament (28, 29, 30 Sept 2010, 26, 27, 28 October 2010).
• On the day it is tabled a new timeline commences in which a motion to disallow can be introduced within 15 sitting days. Therefore, if the determination is tabled on 28 Sept (the first day of the new parliament) the last possible day on which a motion to disallow can be introduced is the first sitting day of 2011 which is late Feb or early March. There is nothing ACM can do to alter these timeline as it is a fixed parliamentary process.
• On 1 November Medicare for midwives will commence.

ACMQ Executive maintains the line that the determination is unacceptable, that we continue to lobby that it is unacceptable and that we demand a meeting with the Minister (not only her advisors).
All midwives who experience difficulty accessing Medicare due to an inability to obtain a signed medical agreement have the opportunity to keep the pressure on by notifying ACM national, ACMQ and the Minister’s office of the practical difficulties created by the determination.

If it turns out that the determination is working well and women have no difficulty accessing Medicare funded midwifery care this will soon become apparent. If this is the situation then any motion to disallow can be withdrawn as stated earlier.

ACMQ’s position involves lobbying to change the determination and buying time to see if the determination will or won’t work.

ACMQ Executive holds the view that a frank and fulsome communication between all members is required to ensure that a representative view can be tabled if the situation occurs that the determination will be voted on in the Senate/House of Representatives.

Before sending this communication we have considered all aspects of this complicated situation in detail. Thank you for considering this alternative option, it is now completely up to you as a member to decide if you would like to write to/contact your MP, the Minister, Jenny Gamble as our National Delegate and ACM National to lobby for the wording of the determination to be changed.

ACMQ Executive will continue to apply pressure and lobby to get the determination changed.

This e-bulletin is supported unanimously by the ACMQ Executive:
Hazel Brittain - President
Jodi Bunn – Executive Member
Jenny Gamble – National Delegate
Richard Hayes - Treasurer
Bec Jenkinson - Consumer
Marie McAuliffe – Executive Member
Mandy Ostrenski – Executive Member
Sue Rath – Executive Member
Mary Sidebotham – Vice President
Barb Soong – Executive Member
Teresa Walsh - Secretary
Kellie Wilton - Student

ACM President on the Determination

The following response has been received today, 30 September 2010, from Hannah Dahlen, President of the Australian College of Midwives. It is in response to an email from me, expressing my disagreement with the position taken by the ACM in accepting the Determination (see previous posts).
I consider it essential that our College should ensure that midwives are able to continue to practise midwifery on our own authority.
Hannah has asked me to post her comments at this blog. The message I received from Hannah is posted here without any change.
Joy Johnston

I agree this Determination is far from perfect and we have fought it in every way possible to have it changed. In New Zealand it took them 17 years to get a National Access Agreement and they had many little steps along the way to achieve the final outcome. We have received some concessions now from the Minister that take us away from sign off by an individual doctor and these include being able to have clinical privileging with a hospital (the old visiting rights) and this will be considered a collaborative agreement.
The National Maternity Plan, which is the most midwife friendly plan I have ever seen, contains an evaluative framework for the uptake of the Eligible midwife along with commitment to State and Territory clinical privileging, which as I said could in itself form a collaborative arrangement. This means we can keep a very close eye on where it is working and where it is not. The Minister has promised to us (ACM) and the ANF that she would change the Determination if is not working but this would not happen in the first months of roll out which is why the idea of disallowing and dragging out the debate until next year won¹t work. If it does drag on until next year Midwives could have started accessing Medicare and have women booked and it could all fall over and where would these women and midwives be left stranded. The Minister has made it clear that she will not change or put up a new Determination if it is disallowed. There are many midwives in the College that have fought for access to Medicare for twenty years now and the College cannot let this be lost at the last moment.

This not a good piece of legislation by any stretch of the imagination but you rarely get everything you want the first time in reform. I believe there are enough ways we can make this work and then hold the government to account for changes when it does not. The AMA have also been told the same thing by the Minister very clearly and I quote ³If we do not embrace these changes then pressure will mount on the Government to relax the requirement for collaborative arrangements to be in place² (Andrew Pesce).

We have sought legal advice over the best way to approach this as we desperately want the best for women and midwives and have clear advice that ³disallowance is not the appropriate means by which to seek amendments of the Determination² and it is highly risky with current volatile coalition who are willing to say NO to everything not because they care about midwifery but just want to say NO.

It is important to note that the Determination does not affect all midwives only those who choose to become eligible midwives and want to access Medicare. It is also important to note that the Determination has been removed from the Quality and Safety Framework after much protesting on ACM¹s part. It is also important to note that even the MIGA policy has a care plan option that gets around the collaborative arrangement with a doctor. There is nothing in VERO if that is the choice midwives make.

Just to remind people that we have made many changes and gains along the way in this reform process. We began with the Eligible midwife needing five years experience, a Masters degree and to be a Midwife Practitioner.
Homebirth was nearly going to be made illegal last year. We have got removed from the Insurance Bill the requirement for a collaborative arrangement with a named practitioner. We have had the Determination removed from the Safety and Quality Framework. These are big gains and yes we haven¹t got what we wanted from the Determination.

I think often with reform we need to take a foot in the door approach and then wedge that door open and get through with all the changes that need to be made. ACM has not given up on this and have sent a letter to the Minister for Health yesterday once again asking for named practitioner to be removed and acknowledgment to be removed. We will I promise not give up. There seem to be all sorts of rumours flying including a crazy one about the ACM doing a deal with the AMA. Can I assure you all this has not occurred and will not occur and we remain as committed to women and midwives as ever.

With respect and good wishes
Hannah Dahlen
President ACM

Tuesday, September 28, 2010

Australian Medical Association on Collaborative Arrangements

AMA has published a document 'Collaborative Arrangements: What you need to know' in preparation for the inclusion of eligible midwives and nurse practitioners in Medicare funding from 1 November 2010.

All midwives who experience difficulty obtaining a signed collaborative agreement with a medical practitioner, in an effort to comply with the Determination, are asked to notify private midwives' groups (APMA, MiPP), the midwives' professional body (ACM) and consumer and midwife lobby groups such as Maternity Coalition. Copies of your letters, and the responses you receive (or lack of response) will be used as evidence in reviewing the implementation of maternity reform.

Thursday, September 23, 2010

Why midwives can not accept the Determination

Readers of this blog will know that a piece of legislation, The National Health (Collaborative Arrangements for Midwives) Determination 2010 (the Determination), which has been discussed previously, was introduced by the Health Minister just prior to announcing the election.

Midwives who are members of the national professional body, the Australian College of Midwives (ACM) should have received an URGENT e-bulletin from ACM, which states:
"On the balance of information that we have to date, we feel that lobbying to disallow the Determination is placing the whole maternity reform package at risk. Although a compromise position is what some might call ‘incremental reform’ it is still an extraordinary time for midwifery in Australia and one we have been fighting to attain for many years."

Why can midwives not accept the Determination?

We believe that ACM should be calling for the Determination to be disallowed. It appears that ACM is putting financial considerations ahead of professional matters. I (Joy J) was an ACM Victorian Branch executive member in the 1990s when we fought to be freed from regulations which required that a midwife be supervised by a doctor. ACM is, by supporting the Determination, turning midwifery and maternity reform back a couple of decades.

In an attempt to defend the position I am taking, I draw attention to a list of so-called 'facts', in the ACM URGENT e-bulletin:

ACM claims that
"The Determination
1) Will not prevent private midwives being able to practise (they can still access insurance)

Midwives in private practice will, under the Determination, be required to choose EITHER medically supervised practice (with Medicare), with all births taking place in hospital (NO homebirth) OR continue private practice in our communities without the hope of government funding for any of our services, and without the hope of hospital visiting access.

ACM also claims that the Determination
2) Will not prevent women being able to make choices - if you are having a homebirth and choose not to access Medicare you do not need a signed agreement with a doctor.

This claim is nonsense. By supporting a two-tiered midwifery system (the homebirth midwives and the Medicare midwives), ACM is ignoring the basic scope of midwifery practice, in any setting.

ACM also claims that the Determination
3) Only affects midwives seeking to access Medicare and midwives can choose not to do this

Does ACM think it's reasonable that midwives should give up the defining features of midwifery practice, and accept supervision by the medical profession?

ACM also claims that the Determination
4) Is not included in the NMBA Quality and Safety Exemption framework supporting private midwives providing homebirth services

Of course not! The Determination is a piece of legislation.

ACM also claims that the Determination
5) Does not re-define the ICM definition of a midwife - it does not define the role or scope of practice of midwives in Australia. It only defines how midwives can access Medicare if they choose to do so. ...

Of course not! By agreeing to medical supervision of the midwife's practice, the ICM definition is OFF THE TABLE. The 'midwife' working under the Determination will become a new breed of obstetric handmaiden.

There are a couple more examples of SPIN under the heading of THE FACTS.

Midwives will be giving up midwifery if they accept the poisoned chalice of Medicare funding with this Determination. Change of funding mechanisms, as will occur when midwives are able to practise with Medicare rebates, does not equate to reform of maternity services. The Australian government's commitment to a $120 Million reform package is floundering because this government (in its previous state, and continuing through to the present leadership) has refused to listen to the very people who are intimately involved in maternity care (midwives and mothers), and has submitted to a 'doctor knows best' subservient mentality. The midwifery profession has an opportunity to stand up and take responsibility for ourselves, or cave in to the bullying that is seeking to force us into someone who is unrecognisable in current international midwifery literature.

Related posts:
NEW Maternity Coalition national blog
Homebirth Australia
Maternity Coalition
Lisa Barrett's blog

Thursday, September 16, 2010

ICM: Legislation to govern midwifery practice

The International Confederation of Midwives' GLASGOW Declaration 2008

Legislation which is enacted to govern the practice of midwives should:
• enable midwives to practise freely in any setting
• ensure the profession is governed by midwives
allow for the midwife to practise in her own right


In order to protect both the public and midwives themselves, it is important to regulate and license midwives, and the programmes and establishments used in their training. It is also essential not to give the license or accreditation ‘for life’. Hence, a set of accreditation requirements must be instituted for the accreditation (and re-accreditation) for fixed periods of time. For the individual midwife this should be based on her/his ability to demonstrate that she/he has the required skills and abilities to practise the profession safely according to the national requirements.

Midwifery legislation is the part of a nation's laws that relate to the profession and practice of midwifery. Midwifery regulation is the set of criteria and processes arising from the legislation that identifies who is a midwife and who is not, and describes the scope of midwifery practice.

Registration, sometimes called licensure, is the legal right to practise and to use the title of midwife. Regardless of the type of mechanism used, it is important to ensure that the process is and continues to be transparent, fair and robust; it should therefore be evaluated periodically. There is also a need for mechanisms that enable previously practising midwives to return to service after a prolonged absence.

The ICM believes that there should be appropriate legislation relating to the practice of midwives in all countries. ICM also believes that professional associations should work with governments to find ways to maximise service delivery capacities in countries. This will imply the establishment of good human resource management policies and regulations, as well as the involvement of professionals in determining service standards for the provision of high-quality care at all levels in both the private and public sectors.

Legislation which is enacted to govern the practice of midwives should:
• enable midwives to practise freely in any setting
• ensure the profession is governed by midwives
• support the midwife in the use of life-saving knowledge and skills in a variety of settings in countries where there is no ready access to medical support
• enable midwives to have access to ongoing education
• require regular renewal of right to practise
• adopt a ‘Definition of the Midwife’ congruent with the ICM definition, appropriate to the country within the legislation
• provide for consumer representation on the regulatory body
• recognise that all women have a right to be attended by a competent midwife
• allow for the midwife to practise in her own right
• recognise the importance of separate midwifery regulation and legislation which supports and enhances the work of midwives in improving maternal, child and public health
• provide for entry to the profession that is based on competencies and standards and which makes no distinction between routes of entry
• provide the mechanism for a regulatory body that is governed by midwives with the aim of protecting the public
• provide for regular review of the legislation to ensure it remains appropriate and not outdated, as midwifery education and practice and the health services advance
• encourage the use of peer review and analysis of perinatal, maternal and newborn outcomes in the legislative review process
• provide for transition education programmes in the adoption of new legislation requiring increased levels of competency of the midwife.

Member Associations are urged to use this statement to achieve legislation
which will be appropriate for the practice of midwifery in their country.

• ICM position statement. Framework for midwifery legislation and
regulation. ICM, 2002.

• Mother Baby Package: Implementing Safe Motherhood in Countries. Geneva,
Switzerland: WHO, 1994.
• ICM. Definition of the Midwife. ICM, 2005.
• Bryce GK. Overview paper presented to Workshop on Legislation, May 1983
Vancouver ICM Congress (Unpublished).
• The Safe Motherhood Action Agenda. Priorities for the next decade. Report
on the Safe Motherhood Technical Consultation October 1997 Sri Lanka, Family
Care International.

Adopted at Glasgow Council meeting, 2008
Due for next review 2014

[The International Confederation of Midwives (ICM) supports and advises associations of midwives. The ICM is an accredited non-governmental organisation and works closely with the WHO, UNFPA, UNICEF and other organisations worldwide to achieve common goals in the care of mothers and children.]

Tuesday, September 14, 2010

Roxon reappointed as Health Minister

There has been a collective sigh of dismay as midwives and advocates for basic human rights in maternity care note the renewal of Nicola Roxon's portfolio as the Minister for Health (and Ageing).

Minister Roxon swallowed the guidance of the AMA (Australian Medical Association) and refused to listen to women and midwives. Remember girls, doctor knows best.

Prime Minister Gillard promised a new era in health before the Rudd government was elected, and she became his deputy.

These very women have sold out women's basic human rights, in a mad rush to reform health, by further restricting access of women to private midwifery, and barring midwives who attend women in their homes from any semblance of acceptance in the health system or professional recognition.  We (midwives) are experiencing unprecedented threat to our very right to exist.

During the years of the previous (Rudd) Labor government we were informed that Labor had a mandate to reform maternity care.

This (Gillard) government has now been put on notice. They got in by a whisker, and while under Rudd they trumpeted their mandate to reform health, there is no mandate for anything now.

Everyone with an interest in birth needs to increase the pressure on Roxon and Gillard, and keep private midwifery and the related theme of women’s rights in the public eye. If as has been forecast this government does not run its full term, voters will be given another opportunity to voice their disgust at the bureaucratic heavy-handedness that has been dished out since the government commenced its efforts to reform maternity services.

The statement by the four independent women who stood for seats in marginal electorates, ‘Gillard Government signs away women’s rights’ still applies.

Minister Roxon, her advisors and bureaucrats, and the AMA, reckon it’s in the public interest to wipe out private midwifery as we know it today. Women cannot be allowed to decide where or how or with whom they should give birth.  The midwife's private practice that focuses on promoting physiological birth, and working in harmony with natural processes, is under increasing threat. 

A new professional pathway is being opened by our government for the private midwife: who works with [and supervised by] an obstetrician, within the private health sector, with the client being able to access partial recovery of costs via Medicare.  This 'midwife' will be no more than the obstetrician's handmaiden.  The legislative changes introduced quietly as 'National Helath (Collaborative arrangements for midwives) Determination 2010' have quashed any hope that independent midwives may have had of accessing Medicare rebates for some of their services.

From the Independent candidates' statement:
“The day before the Federal election was announced there were changes made to existing midwifery legislation. Defined as "collaborative arrangements", the changes, in essence, give doctors a veto over women's choices.

“Basically, the changes detail that any midwife whose patient wants to claim through Medicare must get permission from a Doctor for the decisions made during the pregnancy and birth.

“These new laws give Doctors veto rights over women’s birth choices.

“It is unlikely that Doctors will agree to collaborate with private midwives, with some receiving advice from their insurer that collaborating would void their insurance."

Thursday, September 2, 2010

complaints and notifications against midwives

Midwives practising privately in Victoria face a high risk of experiencing complaints to the registration authority about their actions. 
Protesters rally outside AMA house in Melbourne, in support of private midwifery

The number of Victorian independent midwives with current investigations into compaints is seven or eight, out of a group of less than thirty. This rate of complaint is disproportionately high when compared with midwives in other practice models.  Midwives are asking "why?"

There are, of course, complex issues in any complaint about a professional person's actions or competence or ability to practise at an acceptable standard.  The statutory body with responsibility for investigating and making decisions about a midwife's professional actions is the Nursing and Midwifery Board (NMBA), which acts under the Australian Health Practitioner Regulation Agency.  The principle of acting in the public interest - protection of the public from unprofessional or incompetent or unscrupulous operators - is the reason for existence of statutory regulation of health professionals.

In recent months and years the defining of a midwife's scope of practice and even who is suitable for a midwife to accept when providing care have been further complicated by government bureaucracy, under what has been presented as 'reform'. While the 'reform' is offering the carrot of Medicare (public) funding for prenatal care and visiting access to hospitals for intrapartum care, the stick at the other end of the donkey is adherence to a high level of risk management that is dictated and overseen by competing medical interests. 

Without going into detail, independent midwives face the possibility of restrictions that go beyond anything we have previously faced. For example, is a woman who has had a previous caesarean birth a suitable candidate to be in the primary care of a midwife? What about a woman who has had two caesareans?
or a woman with a high BMI (too fat)?
or a woman who has twins?
or a woman whose baby is presenting breech?
or a woman who had a post partum haemorrhage with her previous birth?
or a woman who comes into spontaneous labour at 36 weeks?
or a woman whose baby has not yet been born at 42 weeks?
or ...

Now is a good time to go back to the question what is a midwife?

ICM Definition of the Midwife (2005) is a core document of the International Confederation of Midwives [ ]

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

[Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.]

Principles that provide a framework for midwifery practice

The ICM Definition of the Midwife (2005) establishes the following principles:

The principle of ‘partnership’: “The midwife … works in partnership with women …”
The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
The principle of caseload – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”

I would encourage midwives who face complaints and notifications to come back to the principles outlined above, and to review our practices in the light of these principles. A midwife who can demonstrate that her practice was consistent with the ICM Definition has strong footing for defending her actions.