"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

18.9.13

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.