Monday, September 23, 2013

"I need to know when that will happen with midwives. So I ask again: when can we expect to see this?"

Three cheers for Colleen Hartland, the member for Western Metropolitan, for the questions she asked of the Minister for Health, Hon David Davis, in the Victorian Parliament last week:

Parliamentary question

Ms HARTLAND (Western Metropolitan)—My question today is for the Minister for Health. In 2011 the Department of Health asked the Royal Women’s Hospital, Monash Medical Centre and Mercy Hospital for Women to develop a framework for collaborative arrangements between Victorian public hospitals and eligible midwives. These arrangements would allow for the provision of private midwifery services in public hospitals so that labouring women can receive care from their chosen midwife private practitioner if or when they are admitted to hospital. The draft framework was provided to the department in 2012, and after review the final draft was provided to the minister in February this year. My question for the minister is: when will the framework be made public, and when will private midwives have appropriate formal arrangements with hospitals to improve the continuity of care that is provided to labouring women?
Hon. D. M. DAVIS (Minister for Health)—I can inform the house that the series of steps outlined by the member is substantially accurate. I can also inform the house that Ms Hartland and I had a conversation around this yesterday to find a way to look forward to greater choice and greater options for women. When I am satisfied with the formal advice I have received on each aspect of this matter, we will make an announcement. I can assure the member that it will not be too far away.
Supplementary question
Ms HARTLAND (Western Metropolitan)—The minister and I did have a conversation yesterday about a separate matter; this is another report. I am very concerned that, considering this issue of maternity services went to him in February this year, there is a dragging of feet. Private obstetricians have these arrangements with public hospitals. I need to know when that will happen with midwives. So I ask again: when can we expect to see this?
Hon. D. M. DAVIS (Minister for Health)—When I am satisfied with the arrangements that would operate in the public interest and for the safety of the women who would seek to give birth under these arrangements and when the advice that I am provided enables me to make those decisions with great confidence, then I will make those decisions. I am prepared to look at innovative arrangements that will provide greater choice and greater safety, arrangements that provide the best outcomes for women and their babies in our community. The preparedness to request and receive the advice is a clear demonstration of the government’s preparedness to take innovative steps in this area. They will be taken in a way——
The PRESIDENT—Thank you, Minister.

Thankyou, Ms Hartland!

"there is a dragging of feet"
Those who have been following this blog over time will be aware that the matter of access arrangements for midwives to attend our clients in public hospitals is an important one.  Midwives have, since the federal government's 2010 maternity reforms were announced, been preparing themselves for the promised changes, one of which is visiting access to hospitals.  As Ms Hartland said in the Victorian Parliament, "there is a dragging of feet".

The MiPP collective in Victoria has welcomed at least 10 new members for whom this applies.  Midwives have resigned or reduced their hospital and birth centre employment, with the understanding that they will be able to attend women privately, and that women will be able to give birth at a public hospital, in their care, with Medicare rebate for the service.  This change in career is not undertaken lightly: midwives have financial and career commitments and goals like everyone else.  Yet they have found themselves ostracised by the very people who were professional colleagues up 'til the time they achieved the Eligible Midwife notation. 

Hospital access for midwives nationally
The State that has led the way with credentialing midwives who are able to attend women admitted to hospital (particularly for intrapartum midwifery services) is Queensland.

The Nursing and Midwifery Board (NMBA) report on registration statistics June 2013 reports that 84 of the total 212 midwives with the 'eligible' notation on their registration are from Queensland (see pic below).  A search of Medicare Item #82120* (see description below) for the 2012-2013 financial year reveals that 134 of the 138 claims paid were from Queensland (and, it is likely that the other 4 were claimed in error, and will be refunded to Medicare).
click to enlarge

Clearly, there is "dragging of feet" in most of the country!

*Medicare Item 82120

Management of confinement for up to 12 hours, including delivery (if undertaken), if:
(a) the patient is an admitted patient of a hospital; and
(b) the attendance is by a participating midwife who: (i) provided the patient’s antenatal care; or (ii) is a member of a practice that provided the patient’s antenatal care
(Includes all attendances related to the confinement by the participating midwife)

"In the public interest"
The Health Minister told the Parliament that: 
"When I am satisfied with the arrangements that would operate in the public interest and for the safety of the women who would seek to give birth under these arrangements and when the advice that I am provided enables me to make those decisions with great confidence, then I will make those decisions. I am prepared to look at innovative arrangements that will provide greater choice and greater safety, arrangements that provide the best outcomes for women and their babies in our community."

"In the public interest", "greater safety", "best outcomes for women and their babies" - these are all expected by our society.  Laws governing access to professional services, and the regulation of professionals, are supposed to be about public interest, safety, best outcomes ...

And, as it happens, best maternity care outcomes for women and babies are achieved, according to truckloads of evidence, when midwives are able to provide primary maternity care for women in a way that is consistent with the international definition of the midwife (ICM 2011).

According to the Honourable Health Minister, someone needs to come up with "innovative arrangements" that "provide the best outcomes for women and their babies in our community".

How innovative can we get?  This is what it looks like:

  • Midwife provides antenatal services through the pregnancy, working within her scope of practise as the primary maternity care provider, and refers for obstetric review or other medical review as indicated 
  • Woman and midwife prepare for the care, whether it is uncomplicated, spontaneous, and unmedicated, or not
  • Woman contacts midwife when in labour, and midwife arranges to be in attendance at the appropriate time
  • Midwife is 'with woman' continuously through established labour and birth, and a few hours after the birth
  • Midwife continues to provide primary maternity care through the postnatal period, both while they are in hospital, and after the woman and baby return home.
Innovative?  Hardly, but it's the model that leads to the best possible outcomes ...

There is no real difference between this model being provided by a midwife in private practice, and 'caseload' provided by a midwife employed by the hospital, except that the woman chooses the midwife.  Is that so bad? 

What would need to be changed?

Please note that opinions expressed in this post are those of the writer, midwife Joy Johnston.  Your comments are welcome.

Saturday, September 21, 2013

human rights and childbirth

A number of Australian midwives and birth activists are watching with interest the campaign demanding human rights in childbirth, particularly in European countries where midwives may face criminal proceedings when they attend women for homebirth.

For information on this movement, and details of the next conference, click the hyperlink:
Birth Rights in the European Union: Mobilizing Change
Monday November 4th 2013
in Blankenberge, Belgium

Rights .... choices

The meaning of phrase 'human rights and childbirth' may be debated at length. Notions of individual freedom, fairness, equality, respect ... - such ideals are often at odds with what happens in the real world.

Human rights in the European Union should not be very different from those in resource-rich Australia, or developing countries such as Papua New Guinea where national maternal morbidity and mortality rates are among the highest in the world.  Yet the choices that are available for women in childbirth vary enormously from place to place, and between socio-economic groups, as variable as differences in outcomes.

What are the intrinsic *rights* of any (human) woman in her childbirth experience?

Let's consider this question: Does a woman have the right to demand the type of birth she considers best?   

Does a woman have a *right* to a birth that requires expert medical, midwifery, and nursing services, and a host of related ancillary services, in order to achieve her chosen birth: induction of labour, regional anaesthesia (spinal/epidural), or even elective caesarean?  I am not asking if a woman can access these elements of her choice - ability and right are two different matters.  And many readers may claim that it's easier in Australia today to access elective caesarean on demand than to access a maternity service that has a good track record with spontaneous, unmedicated, (garden-variety-natural) birth.

I would suggest that there is no human rights imperative in medically managed birth.  In modern maternity services there are professional/legal duties of care, to help and not to harm, but the access to surgical intervention or medical treatment is limited by factors such as availability of the necessary resources, and professional willingness to support the woman's individual choice. 

Which brings me to the other side of the question, Does a woman have the right to demand the type of birth she considers best?

Does a woman have a *right* to a birth that avoids medical intervention and optimises her chance of working in harmony with natural physiological processes?

Not really.  Perhaps there is more of a right in this situation than in the former, because the woman is the only person able to give birth spontaneously, and she does have the right to refuse any 'help'.  But in essence the woman's ability to proceed along the natural pathway, and give birth to a healthy baby without complication, is not about human rights.  It's about a finely tuned process that relies on physical, hormonal and emotional elements that can be either supported and protected by those who are with the labouring woman, or terribly messed up, to the detriment of the mother and her baby.  Even if 95% of women who received optimal support and care (whatever that looks like) through their childbearing experience were able to proceed naturally and spontaneously to great births, the other 5% of women who wanted natural births would miss out.  It's not a right unless it can be applied to all.

Effective maternity services are ones that provide the 'best practice' options for all women, placing the individual woman at the centre of the package of care that is available for her.  In most cases, it is not possible to plan or choose the outcomes.  Careful decision making throughout the journey enables the woman to access the best care, and thereby expect the best outcomes. 


Decision making is a process that constantly evolves as we move through a childbearing episode.  The trump card that a woman has is 'Plan A' - her capacity to do it without assistance or education or coaching or therapies or any outside help*. But it's the fine line between Plan A and Plan B, when intervention is likely to lead to better outcomes - that may call for expert and timely professional action.

There are times when the best option is not clear, when doing one thing may avoid one potential risk, but for some increase another.  This question of risk-utility analysis in decisions around childbirth is huge, and will, I hope, continue to occupy the minds of each generation of mothers and their professional care providers (whoever they are) for as long as childbearing continues.

I fought/aggitated for the rights of women to have their husband/partner present in hospital births in the early 1970s. I gave birth to my fourth child in a birth centre in 1980 - my personal statement of ownership of my birthing potential, and moving out of medicalised childbirth. I mention this because I have seen and experienced the changes in maternity care over 40 years in 2 continents, and am now nearing the end of my period of usefulness as a midwife.

The physiology of the birthing process requires a woman to minimise the activity of her neocortex - her thinking brain - and work with her intuitive brain as she progresses towards the climax of giving birth. This is where the authentic midwife is able to be guardian of the space, so that the woman is free to do the primal, hormonally driven (rather than intellectually driven) work of giving birth. The reality in my mind is that this is not a matter of empowerment or conscious choice - or of any sort of legal *rights*.

A woman's body will do the work of birth if it can, whether she likes it or not, because we are wonderfully made.  On the other hand, decisions about interventions which are designed to protect the wellbeing of mother and/or baby, when obstetric complications arise, are influenced by wealth and availability of /funding for maternity services.

*Note that I am not advocating for 'free' birth: Giving birth under 'Plan A' is an option regardless of place of birth or professional services available.  A woman can give birth without assistance or education or coaching or therapies or any outside help in the care of a midwife, a doctor, a hospital or any other service.

Sunday, September 15, 2013

midwives and medicines

The Nursing and Midwifery Board of Australia (National Board) is consulting publicly on the draft Registration standard for endorsement of registered nurses and/or registered midwives to supply and administer scheduled medicines under protocol and invites comments and feedback from interested parties.  The proposal is that provisions which are already in place for midwives (and nurses) in rural and remote settings be extended across the professions.

For more information, and to access the consultation discussion paper and draft Registration standard, click here.

The National Board is inviting submissions from the public, as well as professional groups and individuals.

Please note that this consultation does not relate to midwife prescribers: eligible midwives who have completed a course of study approved by the National Board, and been endorsed to prescribe scheduled medicines.

Why is this an important issue?

A midwife who is currently recognised as being able to supply and administer scheduled medicines under protocol is usually a midwife employed by a health service or hospital.  The employer has set down protocols under which a midwife is permitted to use a scheduled drug.  This has been in effect, to a greater or lesser degree, for many years.  Oxytocics for prevention or management of postpartum haemorrhage are an obvious category of drugs that every midwife is expected to be able to manage competently.  A midwife may also supply and administer an anti-emetic in labour, antibiotics in labour as prophyllaxis for Group B Streptococcus, or Anti-D to prevent Rhesus immunisation.  These are prescribed by a doctor, dispensed and sold by a pharmacist, and subsequently supplied and administered by a midwife to the woman in her care.

What is the relevance of this consultation for independent midwives?

Midwives who practise privately, being employed directly by the woman rather than by a health service or hospital, may also be affected by any Registration Standard that the National Board develops.  Midwives attending homebirths have historically for many years carried oxytocics, and used them when required.  The midwife may ask women to obtain a prescription for Syntocinon 10units and Syntometrine from their local doctor.  The midwife usually makes decisions about administration on her own authority, with the wellbeing and safety of the mother, in relation to postpartum blood loss, being the primary concern. This process is not covered by any formal protocols or reporting mechanisms.  The midwife does not usually consult about the need for the scheduled medicine with the doctor who signed the prescription - delay could lead to compromise. 

The proposed Registration Standard

"...  will ensure that registered nurses and midwives who work in situations where medical and nursing supervision is low and the clinical risk is relatively high are educationally prepared and competent to supply medicines to their patients/clients."
Women planning homebirth in the care of an independent midwife are usually well, and in spontaneous labour.  Homebirth is a situation where the midwife acts on her own authority.  Whether a midwife is practising solo, or with another midwife, each midwife is responsible to act in a competent and professional manner.  There is no clinical supervision of independent midwifery practice.  Obviously, the 'clinical risk' is relatively high.  This places private midwifery practice within the scope of the National Board's proposed Registration Standard.

The education of all midwives is required to prepare midwives for basic midwifery practice, as stated in the ICM Definition (2011):

... The midwife is recognised as a responsible and accountable professional who works in partnership with women to
give the necessary support, care and advice during pregnancy, labour and the postpartum period, to
conduct births on the midwife’s own responsibility and to
provide care for the newborn and the infant.
This care includes
preventative measures,
the promotion of normal birth,
the detection of complications in mother and child,
the accessing of medical care or other appropriate assistance and
the carrying out of emergency measures.   

MIPP will be preparing a submission to this consultation.

Your comments are, of course, welcome.

Tuesday, September 10, 2013

regulation of midwives

Several MIPP midwives were amongst 60+ national attendees at a meeting this week in Melbourne, hosted by AHPRA.
The meeting was called 'The Light at the End of the Tunnel Midwifery Workshop', and presentations were made by various midwifery leaders and regulatory people.

The aim of the Workshop was:
1. To improve and foster understanding between the NMBA, midwives and stakeholders regarding midwifery issues incorporating:
a. Accreditation & education
b. Midwifery Practice
c. Association
d. Workforce 
2. To move closer to the intent of the National Registration and Accreditation Scheme by ensuring that there is a common understanding about midwifery practice.
Mary Chiarella from the NMBA chaired the workshop.  The round table discussions and feedback were well organised.  Attendees will receive summary notes and powerpoint slides, and the Board is committed to using the information gathered in the workshop as policies are developed.

Separate midwifery regulation
There will be a review of the national law (? next year - not sure) and there is support amongst midwives for a separate Midwifery Board to be established.  Although the current NMBA can be seen as an improvement on its preceding state and territory nurses boards, many midwives believe that the profession of midwifery is not well served by the current arrangements.  In the meantime the need for midwives to be on each of the state and territory Boards (members appointment by jurisdictional health minister), and to be on panels hearing complaints regarding midwives practice, were stressed by several attendees.

Quality and Safety Framework, and practice review
It was noted that a new quality and safety framework is being developed and will be distributed for comment in the near future. It will cover all midwifery practice - not just homebirth/private practice. There seemed strong support for midwifery practice review by all midwives. 

Home birth after caesarean, and mandatory notifications
One issue that was raised, which some readers may be interested in, is that independent midwives in some areas have been 'reported' for planning vaginal birth after caesarean (VBAC) homebirths. They have been told by the hospitals that notifications have been made under mandatory reporting: meaning that the person who made the report believes that a midwife who plans HBAC has departed from accepted professional standards, and is thereby placing the public at risk. The members of the national Board who were at this workshop were emphatic that this sort of action does not have the support of the NMBA . It's a practice issue, and the Board does not have any policy in regard to HBAC.

Making a 'mandatory notification' is a serious step that is aimed at preventing members of the public who receive professional services being placed at risk of harm, and should only be taken with sufficient reason.  Making a notification that is vexatious or not in good faith may expose the reporting practitioner to proceedings for defamation. Women who ask midwives to attend them for planned homebirth after a previous caesarean usually do so believing that this care plan gives them the opportunity to come into spontaneous labour, and establish labour without interruption. 

There was some discussion around the impact on the midwife of notifications and investigations into professional conduct.  Participants requested that the Board provide support for midwives who face proceedings by NMBA and AHPRA, as they defend their professional position.  The public interest is served not only by punitive measures for professionals who have misbehaved, but by ensuring that everyone is treated with respect and natural justice and their cases are dealt with in a timely, transparent and accountable manner.

Tuesday, September 3, 2013

letters from MIPP

About a month ago we reported on amendments to legislation applying to eligible midwives and Medicare.

The ability of a midwife to attend a woman giving birth in a hospital was a major item in the Medicare reforms, introduced more than three years ago.

Yet ...

  • Despite many assurances that the Victorian government supports the federal government's maternity reforms, and has developed a framework for credentialing of midwives, no midwives in Victoria have made collaborative agreements with hospitals.  
  • Midwives are able to buy insurance policies through MIGA, underwritten by Treasury, providing uncapped cover for women receiving midwifery services from eligible midwives for birth in hospital - yet they can't get access to the hospitals.
  • Women would be able to claim up to approximately $1500 rebate for intrapartum midwifery services (2 midwives) - if the midwives could get access to the hospitals.
  • Midwives are continuing to provide professional services for women in their communities, and accompanying them to hospital for birth or other specialist obstetric services if and when the need arises.
  • Midwives report that some doctors who have previously agreed to collaborate with midwives have withdrawn, giving reasons such as "I don't think homebirth is a good idea" - when the collaborative arrangement covers only antenatal and postnatal midwifery services.
This is unacceptable.  What other profession would sit back and accept persistent exclusion from their usual places of practice?  Why are women who would prefer to give birth in hospital in the care of their known and trusted midwife being prevented from doing so? 

A new round of letters has been sent by MIPP to the public hospitals, respectfully requesting an update on progress.

A similar letter has been prepared, and is being sent to obstetricians and GPs who have agreed to collaborate with midwives, usually through a letter of referral, or in some instances, through a signed collaborative agreement.

The content of this letter is copied below:

Re:  Collaboration and hospital visiting access for Midwives

Dear Doctor
This letter is to inform you of recent changes in legislation governing the requirement for collaborative arrangements for eligible midwives, such as referral of women to the midwife for antenatal and postnatal midwifery services.  We thank you for your participation in collaborative arrangements to date, which have enabled women to claim Medicare rebate on the fees of midwives who have Medicare provider numbers. 
Since the introduction in April 2010 of amendments to the Health Insurance Act (1973), some midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements.
In recognition of this, at the 10 August 2012 Standing Council on Health (SCoH) meeting, the Commonwealth agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. On July 25th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 was introduced.
Accordingly, the purpose of the regulation is to enable midwives to demonstrate collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity. The regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed for clinical privileges within a hospital.  It is expected that the hospital will have a formal written agreement with such midwives, addressing consultation, referral and transfer of care, relevant clinical guidelines and locally determined policies.
Letters have been sent to the public maternity hospitals on behalf of MIPPS, requesting an update on the processes that are being implemented, by which the hospitals will provide eligible midwives the opportunity to have collaborative arrangements.  Until these new processes are established, midwives and our clients will continue to rely on the collaborative agreements and arrangements, such as referral, that have been used in the past couple of years.
Yours sincerely,

Your comments are welcome.