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:

...

Part 2                 Collaborative arrangements

5              Collaborative arrangements — general

         (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.

6              Agreement between eligible midwife and 1 or more specified medical practitioners

         (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.