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 joy@aitex.com.au ]

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.

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