Monday, November 11, 2013

'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:

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

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  Those numbers are out of date, and we know that they are increasing each week.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.

1 comment:

Joy Johnston said...

Many midwives doubt the commitment of hospitals to make the necessary changes that will enable midwives to work 'private in public'. Even with this framework document, the hospital boards have independence in their decisions. However in my reading today of the framework document I noticed a statement that is relevant here: "In Victoria, public health services are independent statutory entities governed by a Board of Management that is ACCOUNTABLE TO THE MINISTER FOR HEALTH (p6. excuse the shouting please). So the people of Victoria need to write to the Minister for Health, and to their local MPs, and insist that these changes be implemented. So, ladies (and any gents who care) - we have more work to do!