Monday, December 31, 2012

Letter to the Sunday Age

[In response to the front page article, 'Patient power troubles GPs', Sunday Age, 30/12/12]

I find it troubling that some doctors are not happy with the concept of independent experts who support a patient’s decision making in medical care. 

The statements by Dr Hambleton of the AMA suggest that he is attempting to protect the old ‘doctor knows best’ position of privilege in our society – perhaps that’s part of his job description?

I also take exception to Dr Hambleton’s questioning of “the need for private midwives to be escorting women during hospital births.”

I am one of those private midwives, and I would like to explain briefly why I provide primary maternity care, and attend birth, whether it occurs in hospital or the woman’s home.   

A midwife’s unique skill is the ability to work in harmony with the natural processes through pregnancy, birth, and the postnatal period.  Birth is not an illness.  The midwife’s duty includes promoting health, supporting wellness, and protecting the woman’s ability to do the work of bearing and nurturing her children.  Only when and if complications or illness are present does the midwife need to collaborate with medical and/or hospital systems, and only then with the woman’s informed consent.  Most women trust the midwife’s guidance, but there are grey areas in maternity care, just as there are in the world of GP doctors. 

The planned setting for birth is not set in concrete.  Many women who plan hospital births experience the ‘coming ready or not’ baby who arrives in all sorts of places, including the bathroom at home, the back seat of the family car, or the hospital carpark or lift.  Some women who plan homebirth need to change their plan and move to hospital, for all sorts of reasons.   

Midwives who practise privately, independent of the hospital system, are able to offer personal continuity throughout the episode of care and be with the woman in labour wherever she is.  Privately employed midwives seek to establish a partnership with each woman in our care, at a level that simply cannot be achieved without significant investment of time prior to the birth.  Privately employed midwives offer a distinct professional care package to each woman.  The women who employ us usually intend to give birth spontaneously,  without relying on medical pain management strategies, or artificial augmentation of the birth process, unless there is a valid reason at the time for such a decision to be made.

When private midwives ‘escort’ women to hospital, we have usually provided significant professional services for that woman through the prenatal period.  Several Medicare items give rebate for services such as the initial consultation, long or short antenatal checks, and the development of an individual maternity care plan.  The woman may have laboured at home, in the care of her private midwife, prior to traveling to hospital.  The woman knows her private midwife’s voice, and touch, and is able to be confident within the care plan.  The care plan includes the ongoing process of  informed decision making, with the wellbeing and safety of mother and child being the guiding principle. 

Postnatally the private midwife continues to provide expert professional services, within the primary maternity care relationship.  Postnatal Medicare items are available until the seventh week after the birth.

Dr Hambleton’s attempt to trivialise the private midwife’s role as “so someone can hold their hand” is offensive to me.  If I hold the hand of a labouring woman, it is a significant act of professional support for which that woman has employed me.

Joy Johnston
25 Eley Rd, Blackburn South Vic 3130
03 9808 9614

Tuesday, December 18, 2012

Progress report: 2 years

It has been two years since the federal government's maternity reforms became effective, with the political spin of  “Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives”, stating that "... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care." (for more detail click here)

consumer preference was very clear: thousands of submissions to inquiries, many from ordinary mums and dads and grandparents, many of whom had never previously made any attempt at political action.
consumer preference in this instance was overwhelmingly in favour of the option of homebirth attended privately by a midwife.
since current evidence supports planned homebirth, with access to suitable obstetric hospital services when required, as being at least as safe as hospital birth for most women, I fail to understand the action of the government in summarily excluding homebirth from any Medicare benefit.
(Many have made plausible suggestions about a paternalistic, nanny-state, socialist policy that seeks to provide a one-size-fits-all plan for maternity care.  'Informed decision making' has become a one of those hollow phrases that are used because they sound so fine.)

The package of maternity reform focused on professional indemnity insurance, Medicare, and PBS (pharmaceutical benefits scheme) for midwives, with provisions for midwives to attend our clients privately for birth in hospitals.  Looking at each of these elements:

  • Midwives are now covered by professional indemnity insurance (PII) for all antenatal or postnatal services, and for intrapartum services provided in (just a few) hospitals.  Midwives attending homebirth have been granted an exemption from PII until June 2015.  The obvious problem with this arrangement is that if PII is a rational and reasonable product, cover for intrapartum care would be essential.  But, since noone in the insurance industry has been able to come up with an affordable insurance product for midwives, the exemption has been put forward as a stop-gap measure. (more here)  Perhaps the implementation of the government's National Disability Insurance Scheme will ease pressure on the insurance market, and bring some relief to this stalemate.  Independent midwives in the UK at present face loss of their ability to practise because PII has become mandatory.  This is definitely not in the public interest, and is an example of regulation of a profession being delegated to the insurance industry.
  • Medicare provider numbers are being used by an estimated 150-200 midwives nationally.  The provision of Medicare rebates for women who receive part of or all their maternity care from privately practising midwives should lead to a reduced reliance on maternity hospitals, which are in may places overstretched, overbooked, and under-staffed.  Yet, midwives who have asked hospitals to refer women to them for shared antenatal care, or for primary care with a plan for hospital birth, have (almost uniformly) received negative responses.   Victorian midwives in private practice continue to experience roadblocks to implementing the promised reforms. 
  • The PBS provisions of the reform package are yet to be fully implemented.  We know of one midwife in Victoria who has been endorsed by the Board for prescribing.  Other midwives will be applying now, having completed the Flinders University's Graduate Certificate in Midwifery (pharmacology and diagnostics).  The Victorian legislative changes have recently been gazetted (click here), enabling authorised midwives to become prescribers. 
The hospitals where intrapartum care is (or soon will be) provided by private midwives are Toowoomba, Gold Coast, and Ipswich, in Queensland.  The model has been established with My Midwives

Collaboration, the core requirement for Medicare funding to be accessed by the woman, continues to present huge challenges to midwives.  Most midwives who practise privately have women coming to them from many different communities.  These women see different doctors, and it is not possible for the midwife to have met or worked with most of these people.  Some doctors are ready and happy to refer women to midwives for private care; some refuse outright; and some go to extraordinary lengths to cover themselves, in case something goes wrong.  One doctor sent a letter by registered mail to the private midwife and the pregnant woman, informing them that she (the doctor) opposed home birth under any circumstances.  No evidence was given for this position.  In the discharge letter to the GP, the midwife wrote:

... I acknowledge receipt of your letter in which you stated that you do not endorse homebirths.  I would like to direct you to the Cochrane (2012) review of planned hospital versus planned home birth, in which the authors state “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.” 

Hospital visiting access has been the dream of some privately practising midwives.  There are many practical reasons why they would like to offer hospital birthing to their clients, the obvious one being that this is where most Australian women intend to give birth.  Homebirth can be seen as unusual, and not well understood.  

At present an investigation is being undertaken by the ACCC into specific cases of anti-competitive behaviour by obstetricians or hospitals, blocking access to midwives.  Any midwives who have documentary evidence that they believe would contribute to this inquiry may contact me by email, and I will give you the names and contact details for the case officers who are heading up this investigation. [Joy Johnston ]

Is there a way ahead?  Is there a light at the end of this next tunnel?

Midwifery is a legitimate option for women seeking maternity care.
Midwives are able to offer basic maternity services, regardless of where that birth is planned.

Fellow midwives, I encourage you to reconsider the way we provide midwifery care for mainstream women who intend to give birth in a hospital.  In the past we, the 'good girls', have entered shared care arrangements where possible, and provided private midwifery services in addition to the services provided by public hospitals, accompanied these women to hospital in labour, and done all in our power to protect, promote and support wellness, within the constraints of the system that would prefer us not to be involved.  

The new midwifery led primary maternity care model will be woman-centred, and community based.  The hospital will be excluded from the model until the time comes to use the hospital, whether that is during labour, or before or after birth.  Since independent midwives have been excluded from hospital collaboration, we have no choice but to act autonomously within the community, at the same time as collaborating with the specified medical practitioner for that woman, and providing a written handover to the hospital when hospital care is required.  

Women who choose this model of care may be classified as 'planned homebirth', when in fact they did not plan homebirth.  That doesn't matter - it's not about the setting, or the statistics.  The main goal of this proposal is that women are able to access midwifery primary care from a known and trusted midwife: 'more choice' from 'expanded models' of maternity care.

This post contains the opinions of the writer, which are not necessarily shared by all members of MIPP.

Your comments are welcome.

Friday, December 14, 2012

letter to doctors

A letter is being distributed to doctors in Victoria who have agreed to participate in collaborative arrangements with midwives.


Dear Doctor

This letter is being sent to doctors who have worked with midwives in providing access to Medicare rebates for antenatal and postnatal private midwifery services.  We understand that this new option, which has been available since November 2010, has brought about changes in the way midwives and doctors collaborate in maternity care. 

Midwives who have achieved notation on the Nursing and Midwifery Board of Australia (NMBA) Midwives’ Register as ‘eligible’ are able to apply for Medicare provider numbers.  Certain antenatal and postnatal items attract rebate; the proviso being that there is a collaboration arrangement with a doctor for that particular woman.  The requirement for collaborative arrangements between participating midwives and medical practitioners is to provide pathways for consultation, referral or transfer if or when the woman’s care requires it.  Midwives in Victoria are not, at present, able to provide intrapartum care that attracts Medicare rebate for our clients in hospitals.

Midwife prescribers
Midwives are also able to undertake a course in pharmacology which leads to endorsement on the public register. Once endorsed, the midwife may apply for a Pharmaceuticals Benefits Scheme (PBS) number and prescribe certain medications for mothers and babies.  The changes to Victoria’s drugs and poisons legislation which enables endorsed midwives to become prescribers was gazetted 30 November 2012 .  This document contains the list of medicines from the poisons schedules 2,3, 4 and 8, which midwives are now able to prescribe.

A participating midwife can order some pathology tests and investigations, and can refer women and babies directly to obstetricians and paediatricians.  The midwife is required to send a copy of the results to the collaborating doctor.
Home birth services provided privately by a midwife do not attract Medicare rebates, even if the midwife is participating in the Medicare scheme. Homebirth services may be claimable through certain private health funds.  Hospital backup arrangements for women planning homebirth are made with the nearest suitable public maternity hospital, and may involve a booking in process.  Arrangements for referral and transfer of care to hospital in acute situations are made by the midwife in attendance.
Midwives and insurance
All midwives are required to have professional indemnity insurance. Privately practising midwives purchase insurance that covers them for antenatal and postnatal services. Midwives with Medicare eligibility have access to a Commonwealth-subsidised professional indemnity insurance ( ) for the ante and postnatal care they provide, as well as the birth services that they provide in hospitals to their private clients.
If you have any further questions about midwives and Medicare; what services they may provide, or how to work with a midwife who has Medicare, you could contact the Australian College of Midwives.
The midwives whose names and practices are listed below are Victorian midwives who are Medicare-eligible, or who are in the process of obtaining notation for Medicare.  We look forward to continuing professional cooperation between midwives and medical practitioners, in providing effective and safe maternity services for mothers and babies in our communities.
We also take this opportunity to extend to you Season’s Greetings.

Friday, December 7, 2012

Victorian Drugs, Poisons and Controlled Substances Act amended

Friday 30 November 2012

Drugs, Poisons and Controlled Substances Act 1981

Pursuant to section 14A(1) of the Drugs, Poisons and Controlled Substances Act 1981 (‘the
Act’), I, David Davis, Minister for Health, hereby approve the Schedule 2, 3, 4 and 8 poisons or
classes of Schedule 2, 3, 4 and 8 poisons that are listed in the tables below for the purposes of
the authorisation under section 13(1)(bc) of the Act, of a registered midwife whose registration is
endorsed under section 94 of the Health Practitioner Regulation National Law.

In relation to the substances listed in Table 5 below, this approval is limited to use for the
purposes of an emergency or for intrapartum purposes only.

This approval takes effect from the date of publication in the Victoria Government Gazette.

Table 1: Schedule 2 Poisons by SUSMP LISTING/NAME

Table 2: Schedule 3 Poisons by SUSMP LISTING/NAME

Table 3: Schedule 4 Poisons by SUSMP LISTING/NAME

Hepatitis B Vaccine
Influenza Vaccine
Nitrous Oxide

Table 4: Schedule 8 Poisons by SUSMP LISTING/NAME

Emergency and Intrapartum USE Only
Table 5: Schedule 4 Poisons by SUSMP LISTING/NAME


[Your comments are welcome]

Thursday, November 29, 2012

questions ...


"Do you [the midwife] consider that after you have informed the woman of risk, such as twins, that it is appropriate for you to agree to homebirth?"

"In your opinion, what is more important: the right of the woman to have informed choice, or the safety of the mother and baby or babies?"

"If a woman who was having quadruplets told you she wanted to give birth at home, and you informed her of the risk, would you agree to attend her for homebirth?" 

"Isn't the reality that if the midwife says 'Yes, I'll come to your homebirth of quads, isn't the midwife giving the green light to the woman's wishes?"

Continuing from the previous post, I want to further record and begin to explore lines of questioning that have been pursued by the barrister acting for AHPRA, in a formal hearing into the professional conduct of a midwife who attended births for two women classified as risk categories C and/or B in the ACM National Midwifery Guidelines for Consultation and Referral - in this case the 2004 version of that document.  In both cases there was a transfer of care to hospital; mothers and babies are well.  

The legal expert's job in the hearing is to prove allegations that the midwife acted in an unprofessional manner when she attended these births privately at the homes of the women.  The case relies heavily on the categorisation of risk in the ACM Guidelines.

The midwife has retained the services of a barrister to defend her.  The costs have accumulated to in excess of $20,000.

The panel of three, appointed by AHPRA to hear the case, includes one person who is a nurse academic, who lists RM (registered midwife) in her cv that is available online.  This person has published in her field, but there is no mention of midwifery or maternity in the titles listed.  This person has listed memberships in professional organisations, and there is no mention of any midwifery or maternity related organisation.   The other two members of the panel are a lawyer, and a nurse whose specialty area is psychiatry.

I am recording this point because there is an expectation in hearings into professional conduct that the evidence will be heard by peers.  The panel in this case was totally lacking in peers, and the one member who listed RM should perhaps reconsider her use of the title RM.  Midwives continue to be judged by nurses, as nurses, despite the reforms that have restored the register of midwives.

The pursuit of information by the Board's barrister, who acted like a blood hound, included many questions about choice and risk and safety.  The complexities of informed decision-making over time, and within that woman's real world, were barely acknowledged.  The relationship between 'risk' and 'safety' was not explored.  If the 'guidelines' identify 'risk' ... it's *obviously* unsafe, and not suitable for a midwife to be providing primary care in the home.

The midwife expert witness called by the defense barrister brought some clarity and sense to the hearing, with her consistent and persistent assertion that safety can only be achieved when a mother's right to informed decision making is protected and upheld.

Midwives and others who promote humane maternity care around the world have been alerted to the criminal case against Hungarian midwife-obstetrician Ágnes Geréb.  For an update on this case, click here.

Tuesday, November 27, 2012

Questioning a midwife about women and risk

I am reluctant to make any broad statements about privately practising midwives and the way each one approaches a professional situation in which the woman has risk factors.  Each midwife, and each woman, is unique.  In fact, that's what the often repeated phrase 'woman centred care' points to: that the care for each woman is approached by her midwife from an individual perspective.

A midwife whose practice is under the regulatory spotlight for events that led to allegations that she has engaged in unprofessional conduct when she agreed to provide homebirth care for women in a risk category* is on the stand, under oath, and quizzed by the Barrister acting on behalf of the statutory body.  Here are a selection of the questions that this midwife may be required to answer.  Perhaps other midwives will take a moment to reflect on how we would answer these questions.

* The 'risk' profile could include, for example, postmaturity, prematurity, birth after caesarean, multiple pregnancy, breech presentation.  

With reference to a woman who wishes to give birth at home, the midwife is asked:
"Do you accept that you have a professional responsibility to inform the woman of risks?"
"Do you consider that after you have informed the woman of risk, such as post maturity, or previous caesarean, that it is appropriate for you to agree to homebirth?"
"Do you accept that homebirth after caesarean (hbac) entails higher risk than homebirth without previous surgery?"
"Do you agree that risks in a vaginal birth after caesarean (vbac) birth are better managed in hospital if they occur?"
"If as you say there are some risks for the vbac at home, why did you not record this in your notes?"
"What evidence do you rely upon for permitting vbac at home?"
"What special preparations did you make for a high risk birth at home?"
"Did the mother lead the decisions about homebirth, or did you give her the green light?"
"Did you consider saying no to homebirth, and sending the woman to a doctor?"
"In your midwifery practice, do you follow the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (ACM Guidelines)?"
"Do you accept that the ACM Guidelines state that the pathway for birth after caesarean is to at least consider referral and transfer to obstetric care?"
"Do you accept the first guiding principle of the ACM Guidelines, that 'As a primary caregiver, the midwife, together with the woman, is responsible for decision making.'?"
"Do you as midwife accept that you and the woman are jointly responsible for the decision to give birth at home?"
"On reflection, with the wisdom of hindsight, do you agree that you made a poor decision in providing home birth care in this situation?"
"Are you able to give the panel the assurance that if you were faced with a similar situation again, you would act differently?"
"Don't you think that a woman who is more than 10 days postmature, and unable to give birth in a small hospital, is too high risk for homebirth, where there are even fewer resources on hand than at a small hospital?"

The main 'requirement' for homebirth is that the woman is able to labour spontaneously without medical stimulation of labour or pain relief.  Midwives attending homebirth use no drugs to stimulate labour or to ease pain.  The only stimulation of labour available for homebirth is natural processes, such as walking, nipple stimulation, sexual intercourse, and perhaps a special meal.  If a woman who has had a previous caesarean, or whose baby is in a breech presentation, intends to give birth spontaneously, she usually accepts the requirement for spontaneous onset and good unmedicated progress in labour. 

The polarisation of midwifery care into 'planned homebirth with a private midwife' and 'standard hospital care for birth' is in itself unreasonable.

Physiological birth is a basic function of the female of the species.  In our world today we have the opportunity to interrupt physiological processes if we think they are progressing in a way that would lead to poor outcomes.

Consider any other physiological process: breathing, for example.
I breathe because that's what my body does.
I continue to breathe whether I am conscious of the fact or not.
If breathing becomes difficult, this can be a warning sign that prompts me to seek medical attention.

In the same way, a physiological labour will proceed because that's what the woman's body does.
She will continue to labour whether she is paying attention to it or not.
If labour becomes difficult, this can be a warning sign that can prompt transfer to another level of care.

Planned homebirth is 'Plan A'.  The midwife checks the fetal heart, or records signs of progress, or monitors the woman's vital signs in preparation for intervention if that becomes necessary.  The midwife has (or should have) no intention to interrupt the natural processes without a valid reason.  A transfer to hospital, 'Plan B,' is a change in the plan.   There are different rules in operation under 'Plan B' than 'Plan A'.

Effective decision making in labour requires a shared responsibility for the decisions that are made.  The midwife has a certain body of knowledge, and familiarity with the processes, and the woman has other knowledge about herself, her values, and her life direction.  Together they are able to navigate the often unpredictable journey of bringing a baby into the world.  A midwife is not a hired help, employed to facilitate a certain preferred option.  Active participation in decision making protects the wellbeing and safety of mother, baby(ies), and the future of the midwife.

Birth is a highly contested zone.  Our society takes a paternalistic attitude towards birth, through the regulation of the midwifery and medical professions, and the oversight of institutions such as hospitals.  This is good - to a degree.

However, the one who is literally 'holding the baby' at the end of the day is the mother, and she is usually within an immediate family and broader community.  Unless the mother-family-community relationships are broken down beyond repair, the best place for a child to be cared for and to grow is within that network.  A midwife works in partnership with the woman, for the childbearing period, promoting health, protecting wellness, and supporting the development of healthy families.

There will always be aspects of risk that either exist prior to the onset of labour, or that develop during labour.  The midwife who recognises and acts appropriately in the care relationship, and the woman who engages in an intelligent way in decision-making, will have a high level of safety built into their care plan.  There is no safer way than Plan A for a well woman to approach birth.  When complications are present the care decisions become more complex, and the need for medical attention becomes more urgent.  A midwife and woman working together in a trusting relationship bring strength and confidence to the decision making process.

Your comments are welcome.

Wednesday, November 21, 2012

Homebirth backup arrangements

Melbourne's MIPPs were invited to meet with midwifery management at the Women's Hospital today, to hear about changes that will be implemented to the hospital's homebirth backup arrangements from 1 January 2013.

The Women's has, for many years, provided a 'booking' process by which midwives have made a backup arrangement with the hospital for women planning homebirth.  This arrangement will be ceased from 1 January.  Women for whom midwives are providing private care will be seen in the Emergency department, and admitted without having previously made a booking.

The hospital has reached this position after reviewing its processes.  The 'booking' was of a clerical nature only - the hospital has had no professional clinical review of the paperwork, including results of blood test and other investigations, until or if the woman has actually been admitted. 

The Women's is a busy, complex place: there were more than 7,300 births in the past 12 months.  The number of women who present without having had prior care from the hospital antenatal services is small.

How does this change impact on private midwifery care in the community?  

  • A woman whose midwife refers her to the Women's is able to expect appropriate maternity care.  
  • The midwife who is caring for the woman privately in the community is able to phone the hospital Emergency department, and provide verbal and written handover at the initial triage, and after admission.  Sometimes midwives who phone the hospital have reported difficulty, when the phone is not picked up within what seems a reasonable period of time.  The advice is always to put the woman's and baby's needs first, and to present at the hospital without calling if needed.

How does this change impact on collaboration between private midwives and public hospitals?
  • It doesn't.
  • The hospital is not under any obligation to accept collaborative arrangements with midwives, even though, under the federal government's Medicare reforms, there is a legislative/ bureaucratic expectation that midwives who provide Medicare rebates for women will establish collaborative arrangements with hospitals [Click here].
What does the National Health law require in terms of collaboration between a midwife and a hospital?
  • The National Health law appears to envisage hospital births: a setting for which no midwife in Victoria, or in most of the nation, is able to have clinical privileges.  The issue of hospital backup for homebirth is not specifically addressed.  Rather the law requires arrangements that cover consultation, referral and transfer of care: the very process that backup arrangements cover.
  • The National Health (Collaborative arrangements for Midwives) Determination 2010 states:

         (1)   For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:
                (a)    the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;
               (b)    a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;
                (c)    an agreement mentioned in section 6 for the midwife;
               (d)    an arrangement mentioned in section 7 for the midwife.
         (2)   For subsection (1), the arrangement must provide for:
                (a)    consultation between the midwife and an obstetric specified medical practitioner; and
               (b)    referral of a patient to a specified medical practitioner; and
                (c)    transfer of a patient’s care to an obstetric specified medical practitioner.
         (3)   A collaborative arrangement, other than an arrangement mentioned in section 7, may apply to more than 1 patient.
         (4)   However, an acknowledgement mentioned in paragraph 7 (1) (c) may apply for more than 1 patient.

         (1)   An agreement may be made between:
                (a)    an eligible midwife; and
               (b)    1 or more specified medical practitioners.
         (2)   The agreement must be in writing and signed by the eligible midwife and the other parties mentioned in paragraph (1) (b).

In practice, a woman who books for homebirth with a Medicare-authorised midwife, is advised by her midwife on steps they need to take in order to fulfill the requirements collaborative arrangements.  For example, a referral to the midwife, signed by an specified medical practitioner (defined in section 4) for provision of antenatal and postnatal midwifery services, covers the part of the care that attracts Medicare rebate.  The arrangement includes hospital backup, should consultation, referral or transfer of care be indicated. 

There is a big black hole in the National Health law as far as birth at home is concerned, and the hospitals are understandably going about the job of tightening up their processes. 

Enough from me for today.   Your comments are very welcome.