Monday, February 25, 2013


click to enlarge
When MiPP (Midwives in Private Practice) members met for our first meeting of 2013, we took some time to discuss the current state of our segment of the midwifery profession in Victoria: private midwifery practice.

We asked ourselves, "What are the main challenges faced by private midwifery practice in Victoria?"
We agreed that:
  1. Midwives need to be able to practise midwifery, whether we are self-employed, or not.  Current State and Federal processes have continued to marginalise the private practice midwife, unfairly restricting our scope, and preventing us from attending women who give birth in hospital.  Women in our care who give birth at home are discriminated against in that they are not eligible for the Medicare rebate for 'management of confinement' [Medicare Item Number 82120 (and 82125)].  These item numbers apply only when women are attended in hospital by a midwife who has been awarded visiting access to practise midwifery privately in that hospital.  No Victorian hospital has yet awarded visiting access to a midwife. 
  2. The National Health (Collaborative arrangements for midwives) Determination 2010 (Collaboration Determination) is unworkable, and needs to be deleted from the law.  This piece of legislation requires midwives to obtain an arrangement signed by a suitably qualified doctor, for each woman receiving midwifery services, in order for the woman to receive Medicare rebate.   This requirement does not protect the public interest: rather, it sets up systems that are often difficult for the pregnant woman who is seeking private midwifery services.

This sort of problem is not unique to Australia.  People who are aware in international midwifery issues will know that midwives in the UK, Ireland, and Hungary, are also fighting to retain their right to practise midwifery privately.  Women in New Zealand, Canada, and the Netherlands, by contrast, have access to midwives who practise autonomously in their communities, both home and hospital, under public funding that covers the cost of the midwifery services.

Discussion on a woman's rights, under human rights laws and charters, has increased with reference to our European colleagues, such as Agnes Gereb.

In this regard, is it better to argue for the midwife's right to work as a midwife, or for the woman's right to access the services of a midwife?  This is the question I put to a lawyer who practises in human rights, and the response was:

Human rights law is focused on the woman.  BUT, the rights of the woman encompass the availability of good quality services and choices, and restrictions on midwives such as the inability to get insurance and the inability to work in the system directly affect the rights of the woman so although you have to make an extra step in the argument, you can still make improvements for midwives via the rights of women.
    This is nothing new.  The relationship of midwife: 'with woman' is foundational to both ancient and modern concepts of midwifery.

    What, then, is so special about the midwife who practises privately?  Don't women in Victoria have enough access to midwifery through the public and private hospital system?  Why should a small group of midwives who work outside the mainstream system be listened to?

    This discussion could go on and on ...!

    In essence, the small professional group which MiPP represents is a front-runner in promoting excellence in midwifery practice in this State, and nationally.  Although small, we are not a trivial fringe group that could be ignored.  We insist that in using our qualification, 'midwife', to the best standards of professional practice, we are promotion health and well being in the mothers and children in our care. We are using contemporary evidence to lead the midwifery profession.

    We are not content to work exclusively in the homebirth sector.  A midwife is 'with-woman'; not 'with-setting-for-birth'.  Homebirth is not an outcome; it's a setting that is decided on as a woman proceeds in spontaneous unmedicated labour.

    By insisting on a fair deal for midwives, we are opening the way for better maternity care options, and better outcomes, for mothers and their babies.  That's win-win, and surely it's the woman's and baby's right.

    Thursday, February 21, 2013

    Petition: Human rights in Irish childbirth

    Wednesday, February 20, 2013

    Is this discrimination against midwives? midwife prescriber Juliana Brennan

    Is this discrimination against midwives?  Juliana Brennan:

    About 3 weeks ago I found out that I was the first midwife in Australia to receive a PBS prescriber number.  I received this notification over the phone and in writing!

    As part of becoming a Medicare eligible midwife I had to sign an undertaking to AHPRA that within 18 months of becoming Medicare eligible I would conduct a course of study in Pharmacology to become an endorsed midwife, with a medicare provider number and a PBS prescriber number. 

    In 2005 I completed a pharmacology component of the Master’s Degree in Clinical Nursing (Nurse Practitioner) at Monash University, as back then, I thought the only way forward for me was to aim to become a Midwife practitioner (equivalent to Nurse Practitioner).

    After I became an eligible midwife, I was invited to apply for equivalence for my pharmacology course to be recognised as a suitable course of study for my Midwifery endorsement.  This process of applying through AHPRA was very tedious (to say the least) but eventually it was decided in my favour by AHPRA that I should become the first midwife in Australia to be able to prescribe medicines based on the Prescribing Formulary put out by the Nursing and Midwifery Board of Australia.

    I wrote my first prescription: for Lignocaine 1% in 20mls (a Schedule 4 medicine, listed on the AHPRA midwives formulary and the Victorian midwives formulary), and was told that it is only available at certain pharmacies, especially those attached to a Public Hospital offering Maternity Care.  However, the RWH and Eastern Health pharmacies told me they are not allowed to accept my prescription as I am not employed by the hospital!  So after all my work as outlined above, doing a course that I was required to do by AHPRA, I am not able to submit a prescription for the medicines I am legally allowed to prescribe in a public pharmacy attached to the hospitals!

    Thankfully the pharmacist at Knox Private Hospital agreed to accept my prescription and had the medication needed in stock!

    Even so, this does not make sense to me that a public pharmacy attached to a hospital would not accept my script, despite me having a PBS prescriber number.  Does this mean that a pharmacy like the RWH can’t accept a prescription from an outside Dr?  No it doesn’t as I have already had a script dispensed for one of my clients that was written by a Dr before I became an endorsed midwife.  The Dr is NOT an employee of the hospital.

    So is this discrimination against midwives?

    Many midwives have fought tirelessly to gain clinical access to several public maternity hospitals around Melbourne.  I stopped writing letters 6 months ago, as now I don’t even get a response. 

    If I had clinical access to a public hospital, then my prescriptions could be accepted the pharmacist at RWH told me.

    So my question is “Why does AHPRA insist on Eligible Midwives completing a suitable course of study in pharmacology in order to become endorsed midwives if we have no way of gaining access to hospitals as privately practicing Midwives, and no way of having our prescriptions for medicines dispensed from a pharmacy attached to a public maternity hospital”?

    Juliana Brennan
    RN, RM, M.Mid

    Monday, February 11, 2013

    'free birth'

    Birth is, and probably always will be, a contested territory.

    An unknown number of women have made the choice to 'free birth': to give birth without professional attendance.  This phenomenon is happening in Australian communities, at the same time as the independent/homebirth midwifery profession is undergoing increasingly demanding levels of regulation from statutory bodies and by way of professional expectations set by our peers. 

    While any competent individual has autonomy for their own actions and their own bodies, the issue becomes more complex when that body is a woman's body, which is carrying an unborn child.  And although courts in various countries have upheld the right of a woman to refuse, for example, caesarean surgery that is intended to protect the life of the child, there are many subtle forces that direct a woman in to compliance with social norms.  

    Why 'free birth'?
    ... access? 
    Women who proceed with a plan for 'free birth' are not necessarily unable to access a midwife privately to attend homebirth, although this is sometimes the case. 
    ... cost?
    the cost of private midwifery services for homebirth may be prohibitive.
    ... belief?
    the woman who has formed a strong belief that the presence of any qualified person (ie midwife) will inhibit her ability to proceed naturally with birth, considers that she is better off without any professional attendant.
    ... objection?
    A woman may object to some practice, such as listening to the fetal heart sounds, that a midwife may consider to be a basic requirement for safe practice.
    ... substitution?
    an unregulated birth attendant may be willing to act in supporting the woman, and guiding her through her birth, effectively substituting for the midwife.

    Whatever the reason, each woman / each situation, is unique.

    Here is a hypothetical example.
    Ms A and her partner have had two children previously.  Baby #1 was born in hospital, after a long and painful labour, in which Ms A had augmentation of labour, an epidural, and a forceps birth. 

    Ms A felt traumatised after that birth, and in her second pregnancy decided that she wanted homebirth.  The midwives who attended her in labour were unhappy with her progress, and recommended that she transfer in labour to hospital.  Baby #2 was born in hospital: a big baby; and another difficult birth. 

    Ms A reflected on her experience, and believed that the midwives were fearful, and that she would have been better off without them.  She therefore chose 'free birth' for her third child, and invited two friends who worked as doulas to be with her to support her for the birth.
    Ms A's complex process in choosing 'free birth' included her belief that the presence of midwives for baby #2 had inhibited her progress, and the availability of a substitute for professional attendants.

    In recording this hypothetical example, I would like to be very clear that I understand that Ms A made choices and decisions that she believed would be in the best interests of herself and her baby. 

    The issue of 'free birth' was addressed in a Victorian ABC TV story 7.30 report last Friday.

    Several of the people interviewed for this story were asked if they supported the recent recommendation by the South Australian Coroner that it should be an offense for a person to attend birth without having the qualification of midwife or doctor.  The response from Hannah Dahlen, on behalf of the Australian College of Midwives, included a statement that the answer to 'free birth' is not to be found in cracking down, to 'exterminate' its practitioners, as it will only be driven underground.

    I concur with this.  Although the events that led to the recommendation by the SA Deputy State Coroner are tragic, I do not consider that legislation to protect midwifery practice in South Australia would or could achieve the desired aim of improved public safety.

    The choice that some women make, to give birth to their babies at home, takes into account individual social preferences and reasons. Since birth at home is the outcome of a spontaneous physiological natural process, there is no legislation that can control who a woman consults in pregnancy, or who is with, or not with, a woman who is labouring or giving birth spontaneously.

    A woman’s right to self-determination in making decisions such as where she gives birth, and with whom, will not be controlled or altered by legislation designed to protect midwifery practice.

    It is my belief that the government’s support for the regulated midwifery profession, with funding for homebirth programs, protection of the full scope of private midwifery practice including hospital visiting access, and education for the public in maternity choices, will result in greater protection of public interest than the proposal to protect midwifery practice.

    Joy Johnston

    Friday, February 1, 2013

    Human Rights in Childbirth: Dignity, Respect & Responsibility

    Human Rights in Childbirth:
    Dignity, Respect & Responsibility

    Friday, 22nd March 2013
    Jasper Hotel Conference Centre, Elizabeth St Melbourne

    This forum will explore the strengths and limitations of human rights and respectful care frameworks in advancing maternity reform in Australia.  It aims to bring together the policy, legal and women’s health communities along with professional providers and birth consumer groups to discuss strategies for improving the quality of care for birthing women and those supporting them.

    This dialogue will build on several recent initiatives:
    •        the European Human Rights conference held in the Hague in June 2012
    •        the Childbirth and the Law conference in Sydney in October 2012
    •        the international initiative, Respectful Maternity Care.
     9.30-9.45 registration and coffee
    welcome and introduction- Dr Cath Crock, Executive Director, Australian Institute for Patient and Family Centred care
    Session 1- Chair:  Professor Rhonda Small
    How valuable are human rights frameworks for evaluating and improving the care of childbearing women?
    10-15am-11.15am: The documentary film: ‘Freedom for Birth’
    11.15-11.30 Morning tea
    11.30-1pm discussion led by panel of speakers:  Dr Liz Curran, Dominique Saunders, Dr Regina Quiazon, Prof Euan Wallace, Bashi Hazard.