relationships between independent midwives and public hospitals

Midwives who work independently, who are employed directly by the woman and her family to provide midwifery services in pregnancy, birth, and postnatally, are at the front of efforts to reduce unnecessary medicalisation of birth, and to protect, promote and support the natural processes in birth when ever this is reasonable.

It would be simplistic and untrue to paint a black/white, bad/good picture of the medicalised birthing world (hospitals) compared with the holistic, woman-centred world of private midwifery and homebirth.  Unfortunately, many of the stories of disempowered mothers who found themselves experiencing a cascade of medical interventions carried out by strangers, without their informed consent, are stories from hospitals.

Equally lamentable are the stories that become public knowledge after coronial investigations into deaths, when midwives were providing care for planned homebirth.  Any evidence of delay in advice by the midwife that the care should be transferred to hospital places a cloud over independent midwifery and homebirth.

'private in public' midwifery

A message today from Katy Fielding, Manager Acute Programs, Victorian Department of Health

Dear colleagues

I would like to inform you that the Minister for Health has recently approved the release of Eligible midwives and collaborative arrangements:

An implementation framework for Victorian public healthservices (the framework).

You will recall that the framework aims to assist public health services to assess how private midwifery services can operate at their service. As the “private in public midwifery” service model is relatively new in Victoria, the framework provides direction for public health services wishing to establish collaborative arrangements with eligible midwives.  The Department plans to evaluate the framework once this new model of care has been in operation for a sufficient period of time.

A hard copy of the framework has been distributed to CEOs of public health services and is available on-line at www.health.vic.gov.au/maternitycare

I am grateful to all of you for your valuable contribution to the development of this framework and welcome any feedback you may have. ...

 

Midwives who have Medicare numbers, and Prescriber numbers (ie achieved notation on their registrations as 'eligible', and endorsement as authorised to prescribe scheduled medicines) are well positioned to move into the new models, in cooperation and collaboration with mainstream public maternity hospitals.

How many midwives are we talking about?

Registration data published by the NMBA for June 2013 noted that 48 (of 212 nationally) midwives in Victoria had notation as eligible midwives, and 8 (of 22 nationally) had endorsement to prescribe scheduled medicines.  Those numbers are out of date, and we know that they are increasing each week.   For example, a social media group set up for eligible midwives (nationally) has more than 200 members, and another group recently set up for midwife prescribers has 100 members.

The conclusion I must draw is that there are many midwives who are ready to move out of employed models into private midwifery practice, as private practice has been redefined by the last federal government.  I believe as midwives leave the mainstream system, it will become increasingly difficult for hospitals to staff their maternity units within the old fashioned shift work models.  They will need to employ core staff only, and have midwives provide the basic care for their own clients, especially in labour, with early discharge wherever possible.  Hospitals will become more and more restricted to providing acute care only.

What will 'private in public' midwifery look like?
From the woman's point of view, it will be similar to the option that some women have, by which they have a private doctor within a public hospital.  Only this way they will have a private midwife who oversees and coordinates their care while they're admitted to a public hospital.

From the midwife's point of view, the care provided will be similar to the option that some midwives have, by which they work in a caseload/continuity of care/'know your midwife' model.  Midwifery practices will make their own decisions as to how they provide 24/7 midwifery cover - whether in a simple 'one to one' model, or having a named midwife on call covering a particular period, then off call at other times.  All midwives providing this 'private in public' midwifery option will be notated as eligible, will have government supported professional indemnity insurance covering intrapartum midwifery services in hospital, and will be credentialed by the hospital for clinical access.

From the hospital's point of view, the specified medical practitioner who will act as the collaborating consultant obstetrician at any time when a visiting midwife seeks discussion, consultation, or referral of women under the 'private in public' agreement will be the doctor authorised by the hospital to do so. 

When will the new 'private in public' midwifery options be available?

Good question.  The short answer is that we don't know.  However, the release of this framework document is an important step in the right direction.  Midwives who seek visiting access are making appointments to meet with hospital administrators.  Mothers who would like to use the 'public in private' midwifery options would do well to write to their local hospitals and request information.

Where do homebirths fit in?

Prior to the introduction of the federal government's maternity reforms, the only setting for private practice was the community, and the only place a privately practising midwife had professional autonomy was the home.  This has changed.

Private midwifery is no longer synonymous with homebirth.   

However, unless the 'private in public' midwifery options are facilitated quickly, many midwives will have no choice but to get into homebirth if they want to practise privately.

The 'private in public' midwifery framework seems obsessed with distancing itself from homebirth. I hope midwives can negotiate agreements with the public hospitals to cover the care we provide for homebirths, but I have no idea how amenable the hospitals will be.

When midwives attend women for planned homebirth one of the most significant decisions that can be made is to transfer from home to hospital.  The way this needs to happen, when it does happen, is without delay, in a seamless and professionally accountable way.  The writers of the reform legislation and the linked documents seem to believe - against all the evidence - that homebirth is dirty.  A lawyer commented on social media: "The more they try to integrate private midwives into the hospital system, the more homebirth becomes isolated and tied up in endless red tape which it becomes more and more impossible for midwives to satisfy."

Homebirth is not going to go away.  In a maternity world of machines that go 'ping', many women and midwives know that there is no better way to give birth than within the woman's own normal physiology, and that this can be achieved within the privacy and safety of the woman's own home, unless a valid reason exists to interrupt the natural process.


Opinions expressed are those of the author, Joy Johnston, and are not necessarily shared by all members of Midwives in Private Practice.

Your comments are welcome.

MiPP today

Midwives in Private Practice (MiPP) is a collective that has operated continuously since the late 1980s, providing peer support, continuing professional education, and a voice for its members.  MiPP has approximately 30 members, some of whom have ‘eligible midwife’ notation on their registration; a few have prescriber endorsement; some are in the process of achieving these; and all are offering their services as midwives with caseloads, providing primary maternity care in a way that is consistent with the ICM Definition of the Midwife (2011).  

A dozen or so midwives have joined the MiPP ranks in recent times.  Most have achieved eligibility for participating in Medicare, and have either resigned their hospital positions, or cut back their employed hours, to enable focus on, and build, their private practices.  Others who have graduated recently do not yet have the three years’ full time equivalent midwifery experience, required for application for notation.

MiPP is a participating organisation in Maternity Coalition.  This governance model has allowed MiPP to focus on professional matters, while supporting, with our membership fees and more, the bigger maternity reform agenda, working with other “individuals and groups who share a commitment to improving the care of women in pregnancy, birth and the postnatal period.” (Maternity Coalition Constitution 2008)

Homebirth is the main practice setting for MiPPs.  No midwife in Victoria has achieved a collaborative agreement with a hospital to cover intrapartum care in the hospital - the only birth option for which midwives are able to purchase indemnity insurance.  This is a matter of ongoing concern to the MiPP and homebirthing community.  Under federal health practitioner legislation, midwives (and all regulated health professionals) are required to have professional indemnity insurance.  However, as there is no indemnity insurance product available to cover private midwives attending homebirth, an exemption has been granted for homebirth, until 2015.

There is no record of the number of women who employ a midwife privately to provide antenatal care, attend them in labour at home, and support them for birth in hospital, with the intention of providing continuity of care, promoting normal birth, and continuing professional services postnatally.  In this model the private midwife is sometimes referred to as “just a support person”, because she has no authorisation by the hospital to practise.  However restricted the role, we note that ’support’ is a legitimate part of midwifery.  Furthermore, we know that the midwife will be judged as a midwife – not as “just a support person”, if actions by the midwife are thought to amount to conduct that is a significant departure from accepted professional standards.  

 
Having noted that midwives attending homebirth are, at present, exempt from the requirement for professional indemnity insurance, it is clear that there is no such 'exemption' for the practice of providing private support for a woman who is planning to give birth in hospital.  The NMBA Guidelines for Professional Indemnity Insurance for Midwives state that:

"Under section 129 of the National Law, midwives must not practise their profession unless they are covered in the conduct of their practice by appropriate professional indemnity insurance arrangements."

It would appear that the midwife who accompanies a woman to hospital, either when transferring care from planned homebirth, or when providing continuous midwifery support in planned hospital birth, is practising without professional indemnity insurance.  It could be argued that the midwife who has no clinical privileges in a hospital is thereby prevented from practising, but, as noted above, the midwife is still a midwife, and may be judged as a midwife if there is a professional investigation into conduct.

As has been documented in this and other social media and professional sites, maternity reform has been, at times, a bumpy ride.  Legislative change takes many years to accomplish.  There is no easy solution to our professional indemnity problems, on the horizon.

Your comments are welcome.