Thursday, November 25, 2010

visiting access to public hospitals?

Midwives who are members of MiPP have been writing letters to the directors of their local public hospitals, enquiring about implementation of the government's reforms that will enable midwives to attend women privately in hospitals.

Tuesday, November 23, 2010

Midwives with Medicare provider numbers

If you have been following this and linked blogs you will know that the government's provisions for eligible/authorised midwives to have Medicare provider numbers, enabling their clients to claim some rebate on fees for private midwifery services, are now operational.

At the time of writing, we know of two midwives - one in Qld and one in NSW - who have successfully negotiated the legislated requirements for notation as eligible midwives, and are offering Medicare rebates in this way for prenatal and postnatal items. [For details of the rebates payable on midwifery services, go to Federal Register of Legislative Instruments F2010L02640]

We are not aware of any midwife practising privately with Medicare rebates for intrapartum (labour and birth) care in a hospital. The state and territory government health departments are "working on" arrangements for midwives to be awarded visiting access to admit private clients to public hospitals. The other possibility, that a private obstetrician employs an eligible midwife, thereby enabling the midwife to access Medicare, providing services for private midwifery care, presumably in a private hospital, is another pathway that seems theoretically possible. MidwivesVictoria will keep readers informed as information is received.

If you are a 'consumer' of midwifery services - a woman who is pregnant or who is planning to have a baby in the near future - you may be wondering if there is a midwife near you, who is able to offer Medicare rebates on her fees. The names and locations of eligible/authorised midwives will not be posted on this blog, but inquiries will be forwarded to email lists so that any midwives practising privately in the area are able to respond. If you do not want to use the comments function on this blog, please send an email to

4 December 2010
ps: Liz Wilkes from Toowoomba (Qld) has attended the country's first Medicare-Midwife birth. For details follow the link at the APMA blog.

Sunday, November 14, 2010

What the women said ... 3

... in their submissions to the Maternity Services Review.

Today's theme is homebirth. Access to homebirth midwifery services, funding for homebirth, acceptance of homebirth, evidence supporting homebirth ... themes that were a repeated refrain in many submissions.

"Women have been the big losers in maternity care for many years. The promise of a maternity review at the 2007 election to put women first has been a farce. The 900 submissions were more than the whole of the Health and Hospital Reform consultation process. Over 400 of these called for access to homebirth, yet the report of the maternity service review and subsequent budget excluded homebirth."
[Justine Caines, Daily Telegraph]

Theme 3: Homebirth

3.1 "resentful and disempowered" in private hospital [028]
I gave birth to my daughter in a private hospital, and despite having a completely natural and postive birth, I felt resentful and disempowered with the pregnancy and postnatal "care" I received from the obstetrician and hospital system, including the labour and birth and hospital stay.
I have since given birth to my son at home, and had the most wonderful care throughout the whole pregnancy, birth and postnatal period from my midwife, whom I will be engaging next time round when we have our next baby.

3.2 Trust [032]
We homebirthed our three children with the assistance of beautiful, confident midwifes. They guided and assisted us through the physical and emotional relationships with our new baby and ourselves. The core of this is TRUST in myself to birth in a strong, empowering way, in my partner to support me in this process and in our midwife.

3.3 Cost of homebirth [048]
We have a 15 month old boy who was born at home by our choice (based on a lot of research which proved that home-births had better outcomes for mother and baby). It was a truly amazing experience for us and we feel by doing this we also helped reduce the strain on local hospitals, who at the time had a women give birth in the waiting room due to the lack of availability of delivery rooms (due to a baby
We would love to have another child, maybe even another couple of children, however due to the cost, we don't know if this will be an option for us (we are young parents struggling to meet loan repayments for our house). ... A homebirth costs around $3500-4500 in rural regions, more in cities. ... Seems a little unfair given that those that birth at home are actually doing the government a favour by reducing the burden on hospitals. It seems very likely that we won't be having a baby for the country!!

It would be ideal if medicare could cover some of the costs of homebirths to make this option more affordable (especially for those that can't afford private health insurance). I believe if more people knew about the advantages of birthing at home and it was a lower cost option than hospital, a much larger percentage of the population would be birthing at home (we are your typical young married couple,
homebirth is not just for "hippies"). And thereby reducing the burden on hospitals. For the poorer amongst us that have babies, they birth in public hospitals, this is the only option, they cannot birth at home because HOMEBIRTH IS UNAFFORDABLE!!.

3.4 Confident with home birth [106]
I am sharing with you my personal views and experiences in hope of contributing to the much needed changes surrounging maternity issues.
I started my family quite young. I have a 20 month old and twins due in 4 weeks and I have just had my 23rd birthday. For all my children I have planned homebirths, my first being so successful I feel confident to birth my twins at home.

3.5 HBA2C Birth at home after two Caesareans [814]
On consultation with the local and only practising obstetrician (for what is considered within the current health system a high risk pregnancy, by virtue of previous caesarean) we were unhelpfully informed that the mother in question had "..a morbid desire to achieve a natural birth at any cost" and that "..two caesarean sections in the uterus constitute a potentially lethal medical condition for herself and her unborn baby. She has placed herself and her unborn baby in danger once before and she is attempting to do this again. In the circumstances she should at least have psychological counselling and assessment." We were threatened with a notification to Department of Community Services as it was insinuated that our desire to birth without unnecessary intervention was a form of reckless endangerment of the unborn child.

Our baby's birth was conducted without tying up limited resources in our hospital system, the same system that did not allow a trial of the birth by natural methods, utilising the safeguard of emergency services should they be required without transfer. The birth proceeded without the use of drugs, and did not involve significant abdominal surgery as was proposed as our only option in the health care system. Further, the mother was in her own environment during recovery, leading to the minimum of disruption for the family unit. Our independent midwife has continued postnatal care over the past week, visiting 3 times within the week to check mother & baby's health and progress post birth.

3.6 8 children born at home [810]
We are in our 40s and we have birthed all of our 8 children at home in the care of an independent midwife.

Wednesday, November 10, 2010

What the women said ... (2)

... in their submissions to the Maternity Services Review.

Today's theme is, for want of a better word, 'rural'. This means distance, relative isolation, lack of access to services, and much more. Here are some direct quotes. Women's descriptions of their own feelings have been highlighted. The number noted in square brackets [n] denotes the reference number for the submission.

Theme 2: Giving birth in Rural Australia
2.1 Excluded from local hospital 'low risk' maternity service [030]
I write this to you as a mother of four children who had to travel 80 kilometres just to give birth to them.

When my husband and I found out that we were expecting our first child, due to be born in early 2001, we were hoping that we would be able to birth him in our brand new local hospital, which was completed in the previous year. It was a state-of-the-art facility, complete with Maternity ward and we were excited to think that our child could be born there. Although we knew that in the “old” hospital that the Maternity unit had been downgraded to only accept those women considered “low risk” – women who had no previous complications during birth and those who were multiparas (women on subsequent pregnancies), we hoped that with this new hospital it would bring a new opportunity for those women previously excluded to be able to birth there.

But we were to find out that the status quo would continue at the new hospital. This meant that I was excluded from our local hospital and that I would now have to travel a 160 kilometre round trip to the next town to see a Doctor I had never met before, in a town I didn’t frequent and give birth in a hospital far away from family. There was the vague hope that after I gave birth I would be able to travel back to my local hospital for my post-partum hospital stay, but within 6 months of my falling pregnant, even this option was taken away from me.

And even then there was no guarantee that I would give birth in this hospital. It was only a small District Hospital and could only take women after 38 weeks of gestation, women with singleton pregnancies, women with no health complications for themselves or their babies. If you were in any way considered to be “high risk” then you were forced to travel to the NEXT hospital, which was a further 80 kilometres away.

The situation has only become more dire as the years have gone on. Not one single pregnant woman I talk to doesn’t have concerns that she will not make it to the hospital in time and fears either giving birth at home unattended or by the roadside. This raises another, separate issue, in that the husbands and partners of these labouring women are under even more pressure to get them to the hospital “on time”.

It makes me wonder if women and their babies will have to start dying before anything is ever done about this situation.

2.2 What models are needed for maternity services for rural and remote communities? [279]
All women wherever they live throughout Australia, want the option of giving birth to their babies in their own communities in a shared experience with their families, even if this does not eventuate, but most importantly they want to be sure that the experience will be safe, both for themselves and for their baby.

Women in rural and remote areas are no different from their city sisters in having the same wishes, but rarely are these wishes realised. If their preferred option is not available locally they have to travel away from home, sometimes long distances to metropolitan centres, where they are dislocated from their support structures. They often have significant financial outlays for travel and accommodation. However, like most people who live in rural, regional and remote areas, they are pragmatic, and accept that they need to make some compromises for living in small communities. Nevertheless they have a right to access more options than currently exist for them.

The most pressing needs faced by families in rural and remote areas are to have
• A range of service options that are Geographically accessible
• Assistance with travel to access services only available at a distance.
• Special consideration for women with complex needs.

2.3 Midwife in local community, and suitable accommodation for families [272]
I live in a very small rural community on Eyre Peninsula, South Australia. Our home is a two and a half hour drive from the Port Lincoln Hospital, where my two children were born.
In particular we feel that the services provided by the Community Midwife were exceptional. It was a joy to have this naturally caring and very experienced lady visit our home during pregnancy and in the early weeks of our babies’ lives. She was always ready to listen and offer practical advice to help us through various issues, either in person or over the phone. By completing a range of tests at home, we were spared long and expensive trips to see the doctor. The Community Midwife is an essential service for small, remote areas such as ours.

The biggest concern I have had is lack of suitable accommodation for pregnant women from surrounding regions in Port Lincoln. Two weeks before my second baby was due I had to stay at my sister’s in-laws nearer to Port Lincoln. Other local women’s experiences have included staying for several weeks at a caravan park, and having to clean a rental house immediately after leaving hospital. We need a better solution.
I feel very strongly that women from the areas surrounding Port Lincoln need access to a special house in Port Lincoln where they can stay with their partner and family in the final week or two of pregnancy. Partners and older children also need somewhere to stay while mum stays in hospital. Mothers may even be able to leave hospital earlier and stay in the house with a midwife’s support. A special ‘Rural Maternity House’ would take away many concerns that long distance mothers have. It would make pregnancy and labour safer and more positive for all.

Sunday, November 7, 2010

What the women said ...

... in their submissions to the Maternity Services Review

The website at which the submissions are posted has a statement:
We have received many personal accounts from individuals. These provide a valuable insight into people's experience of maternity care in Australia and were considered by the Review Team in preparing the Review Report for the Minister.

Today I have taken the opportunity to look at just a few of those personal accounts from individuals, and separated out into themes (not in any particular order). Today's theme is Caesarean births and VBAC. Here are some direct quotes.  Women's descriptions of their own feelings have been highlighted.  The number noted in square brackets [n] denotes the reference number for the submission.

Theme 1: Caesarean births and VBAC

1.1 Cascade of interventions in primiparous woman at a birth centre [515]

For my first child, I was 25 and healthy, considered “low-risk”. I booked into the local Birth Centre at the public hospital (it sounds easy but in reality I was put on a ballot, missed out, then made it in when some poor unfortunate woman was shunted out for whatever reason). I attended antenatal appointments with the same midwife, who I thought was on the same page as me regarding birth. I wanted a drug free, intervention free birth. I was well-informed and well-educated.

However during labour my midwife told me she had to perform several interventions which I had been led to believe weren’t routine in the Birth Centre. These included vaginal exams (VEs), the premature rupturing of my waters, and coached pushing (when I was actually not fully dilated and not wanting to push yet as it didn’t feel right).

It is hard to stand up for yourself during labour, so I did not protest any of these interventions, yet they caused, in a cascade of interventions, my cervix to swell and my progress went backwards. My midwife said I needed an epidural and syntocinon to speed things up, even though that was the last thing I wanted, but quite disheartened I agreed. After getting me set up she then left to go home, which I saw as abandonment. My continuity of care ended there. After a few hours I was at the same point, having apparently progressed no further, and the obstetrician suggested a caesarean. Quite defeated and wanting the whole sorry ordeal over I consented to a caesarean that would have been completely unnecessary had my midwife kept her hands to herself.

1.2 Caesarean followed by a feeling of disconnectedness and a profound sense of grief [538]
I had my first baby by emergency caesarean section in a public hospital after a planned home birth. My main care provider for this pregnancy was a community midwife with the Community Midwifery Program here in Perth. During the pregnancy I felt supported by my midwife in any decisions I made about my pregnancy and birth options (Routine ultrasound, strep B testing, water birth etc), and despite the resulting caesarean section, I felt the continuity of care was extremely valuable in making my pregnancy an exciting event for my family, as were able to create a caring and professional relationship with my midwife, leading to feeling secure as my birth approached.

During the birth I experienced great care at home from my primary and back up midwife, however once we transferred to hospital, their role as my primary care providers was not recognized by the hospital, and subsequently I lost faith in my body’s ability to birth as I received fragmented care from a number of different midwives and at least 3 different obstetricians, all of whom I had never met, and who did not take the time to discuss the progress of my labour with me. My resultant Caesarean section was a traumatic experience, and I was not able to hold my son immediately, leading to a feeling of ‘disconnectedness’ from him which sadly lasted well into his first year.

After the birth I experienced symptoms similar to those which I now believe similar to Post Traumatic Stress Disorder, with an inability to sleep, flashbacks of the anesthesia and caesarean procedure itself, and a profound sense of grief that my experience of meeting my first born child had not been the joyous occasion I had hoped it would be.

1.3 VBA2C [404]
Our first baby was born in private hospital by emergency caesarean after a failed induction. My husband and I were left to ourselves in the delivery room for long periods. When we did see someone they were total strangers, people we had never before met, who came and went as shifts changed. Minimal help with breastfeeding was provided until 4 days later I had a wonderful agency nurse who spent an hour in the middle of the night giving me the support I so desperately needed. The whole experience was very frightening and traumatic. I was subsequently diagnosed with postnatal depression.

During my second and third pregnancies we paid for our own private midwife who was with me during the pregnancy, labour and post birth. Although our second child was also born by emergency caesarean, I had the continuity of care that made all the difference to the experience. She was with me throughout labour, then in theatre, and afterwards she helped me in recovery where she enabled my baby to stay with me and ensured I received all the help I needed with establishing breastfeeding.

Finally, with the support of my own midwife I was able to birth our third child vaginally, without intervention and will never forget the hormonal high and feelings of self respect, dignity and peace that contrasted so starkly with the terror, grief and despair I felt when my first child was born.

1.4 Emergency Caesarean followed by VBAC [516]
I had my first baby in a public hospital. He was born by emergency caesarean because he was brow presentation. ... I had assumed that my care at the hospital would be in keeping with basic tenets of human rights- that I would be treated with dignity and respect during birth. This was not my experience.

During the 13 hours of labour prior to the emergency caesarean I experienced a shift change of midwives and felt that the second midwife wasn’t confident to guide me. I felt that she gave up on me. I remember her telling me that she had recently had a caesarean and that it wasn’t that bad. I had painful internal examinations during contractions. The bright lights and the public nature of the environment made me feel violated. This fragmented care with people moving in and out of the birthing room upset the flow of events.

Once the wave of interventions had begun I felt there was no any other option in that environment than to do what I was told and to be a ‘good girl’. Several professionals told me that I would be risking my baby to try anything different. I was frightened, I felt coerced and patronised by the midwives and the obstetrician. I demanded that I try every other monitoring option prior to the surgery which was my most feared scenario. As a way of trying to reclaim some sense my own power in the birthing process I wanted to have my baby remain with me and I wanted somebody to stay with me in recovery. I was denied both of these. Post surgery I lay on a bed for an hour shivering alone, without my baby. I felt exposed and ashamed. This deeply impacted my confidence and the crucial bonding with my baby and set the conditions for what I now recognise as Post Traumatic Stress after the birth. I believe this was caused by a combination of factors namely a restrictive birth environment. I suffered a deep sense of failure and grief which has only been resolved with my second birth.

I approached the second birth very differently and chose a homebirth. My partner was also very enthusiastic that we try this after the previous hospital experience. In spite of the fear mongering about VBAC and the dangers of uterine rupture my second baby boy was born peacefully at home in the water. My main care provider was a midwife in private practice. During the pregnancy I experienced great support to make my own choices. During the birth I had no internal examinations. There was no sense of time constraints during the nine hour labour. It was on my own terms and I felt comfortable and safe in my home environment. I felt that my midwife trusted in my innate ability to birth and believe this had a very powerful effect on the birthing outcome.

After the birth I felt great satisfaction and reclamation of my own dignity. I believe this was due to the wonderful support provided by my carer and the continuity of care I experienced.

These four accounts speak eloquently for themselves.
Recommendations of the Report of the Maternity Services Review (The Report) include:
"2. That the Australian Government, in consultation with states and territories and
key stakeholders, initiate targeted research aimed at improving the quality and
safety of maternity services in select key priority areas, such as evidence around
interventions, particularly caesarean sections, and maternal experience and
outcomes, including from postnatal care."
The Report trivialised homebirth and stated that "Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28" The Report ignored the many submissions by women who called for greater access to home birth and private midwifery services.

Comments from readers are welcome.