handing over and signing off

a few days in the tropical sunshine can boost an old girl's energy reserves!

Dear reader,
As I wrote a couple of weeks ago, MiPP is undergoing a restructure.
MiPP members have decided that, as a group they will move out of Maternity Coalition, and sit under the umbrella of Midwives Australia.

At this time I am nearing the end of my midwifery practice: I need to leave homebirths and activism to the younger, stronger midwives.  I have therefore decided to step down from my roles in MiPP.  I want to publicly thank my MiPP colleagues (past and present) for the trust they have placed in me over many years, as representative at professional and governmental meetings, as spokesperson to the media, and as confidante and sometimes mentor/guide to younger midwives.  Before signing off, and handing this site over to someone else, I would like to take a moment to tell you some of my midwifery story.


I found my way into MiPP and independent midwifery practice in 1993, after I had taken a 'package' from a permanent employed night shift position at St George's Hospital, a small maternity unit in Kew.  St George's was closing its maternity wards, and amalgamating with Box Hill to form the Birralee Maternity Service.  At that time I thought I would like to support women for births in hospital - had no idea then that planned homebirth was an option supported by a growing body of evidence.  I knew I was 'good' at sorting out breastfeeding problems, and thought I could set up a little business as a midwife lactation consultant.   When I heard about MiPP meetings, bi-monthly on Saturdays in the Board Room of Vaucluse Hospital in Brunswick, I (innocently) went along.

I was ready, personally, to move into private work at that time.  My youngest child was 12, and I felt he and the other three young teens would not be upset if they needed to look after themselves after school, in the event that I was not home.  They were at the stage of life when they needed parents a driver instructors and taxi services, but not too much personal involvement, thank you! I was in my early 40s.  Coming off 'nights', I felt strong and well rested - going to bed each night!  I got myself elected to the executive of the Victorian Branch of the Australian College of Midwives; got involved in Maternity Coalition, Midwives and Mothers Action (MAMA), Australian Radical Midwives and Mothers (ARM) and any other group that seemed interested in reform of maternity care.  Remember, this was pre-internet, pre-email.  We had big, clunky mobile phones, and some midwives carried pagers.

Back to MiPP.  The midwives who were active in MiPP at that time were a bunch of strong women; each different, and all very different from me.  Soon after joining I had read and heard enough to whet my interest in homebirth.  Being a practical person, I soon worked out that homebirth was the one *item* that midwives in private practice had, that made independent midwifery practice sustainable.  And, reading the professional literature, I experienced a bit of an epiphany: that hospital did not make birth safe.

MiPPs who welcomed me into the group included Jenny Parratt, Annie Sprague, Mary McKenzie McHarg (Reilly) [now deceased], Christine Shanahan, Robyn Thompson, and Patrice Hickey.  Someone, early in my membership, aware of my lack of 'alternative' credentials, asked me how I thought I would get clients.  By this, she was referring to the fact that I had no sign of feminst or hippy roots, and my own four children had been born in hospitals.  I have never used homeopathics, or consulted a naturopath.  I was/am a pretty 'straight' person, with white anglo-saxon protestant middle class Christian conservatism written all over me.

Anyway, despite these 'obvious' drawbacks, Chris, Robyn and Annie all managed to invite me as 'second' midwife (unpaid) to witness homebirth.  I was converted!  After the third 'witness' experience, and after making a note of the paperwork and who I needed to contact to register births, I considered myself ready to fly 'solo'.   That was 1993.   By 1997, I was fully involved and passionate about my brilliant career.  I started writing a journal, much of which was later copied to my business website.   I loved midwifery, became an oxytocin junkie, and loved writing about my experiences.  At the same time I was writing a lot of professional submissions, reviews and papers, including the publication of Planned Homebirths in Victoria 1995-1998 (Parratt and Johnston 2002.  ACM Journal Vol 15 No 2) [available as .pdf on request], and the National Maternity Action Plan (Maternity Coalition 2002).  At some time I received an invitation to present a lecture on the midwife in private practice to the midwifery students at Deakin University; a role that I have loved, and repeated each year.  At some time I received the Irving Buzzard award, managed by the Victorian Branch of Australian Nursing Federation ANF (now ANMF) for midwifery leadership.

...

By 2006 I found out about blogging, and, after a tentative start, with a post on natural birthing in Australia today, I was off!  I found that by writing whatever I was discussing with clients or colleagues, I could record the essence of my midwifery knowledge.  I loved the idea of the unlimited page that blogging offered.  I loved the serial nature of the medium: that I could go back months or even years later and review what I had written.  I loved the possibility of a huge audience, spread over the globe. I discovered how to use search functions and other electronic functions that some glorious geek invented just for me!

By 2008 I began this MiPP blog: midwivesVictoria, and made it into an electronic magazine, recording items and news that might be of interest to other independent midwives, and women who are interested in engaging us for professional services.


I hope someone else will take this blog, and its audience, into their life, and make it relevant to the changing terrain of midwifery in Victoria today.

I plan to continue writing midwifery stories and critical comment on current issues on my personal blog http://villagemidwife.blogspot.com.au/.  I am also available as villagemidwife at facebook.


signing off
Joy Johnston

The costs of institutional births

I would like to share this youtube video https://www.youtube.com/watch?v=7eZJqMhxD00 The Costs of Institutional Births: a wake-up call for obstetricians, presented by Dr Amali Lokugamage at the recent RCOG conference in India.

It's an excellent summary of the (growing) body of knowledge around birth place, the physiology of birth, birth ecology, sociology, economics, continuity of midwifery care, ... and quotes some of the great Australian research on these matters.

Please take a moment to watch the presentation, and share it with others who are committed to improving maternity care for mothers and babies.

MiPP review and restructure

The current membership of Midwives in Private Practice (MiPP) is 31 midwives, whose home addresses are predominantly across the Melbourne metropolitan area, and a few in rural Victoria.  MiPP is recognised within Victoria as a professional stakeholder, representing privately practising midwives.


MiPP has, since its inception in the late 1980s, functioned as a collective of privately practising midwives who provide primary maternity care in our communities.

Midwives who practise within caseload or group practice models of care are not able to predict their availability for meetings or professional development or even family birthdays!  The 'needs' of mothers and babies in our care, particularly around the time of labour and birth, take precedence in our lives.  Despite this obvious restriction, MiPP members have

• attended MiPP meetings, usually bi-monthly, 
• prepared submissions to relevant reviews by government, statutory and professional bodies, and 
• provided occasional comment to the media on issues that concern our members. 

Decision-making is by consensus, and communication between meetings is by email.
Since the mid-1990s, MiPP has been a Participating Organisation in Maternity Coalition (MC). Recently, the MC management committee announced a review of its Constitution, in which MC intends to delete the category of ‘Participating Organsiation’ from its structure, and change its name to 'Maternity Choices Australia'. Under the new Constitution, MiPP would be able to become a Branch of MC.    This constitutional review has prompted MiPP to reconsider its organisational structure.

Another significant proposed change to the Constitution is in the Statement of Purposes:
change from:
“... a national (Australian) umbrella organisation made up of individuals and groups who share a commitment to improving the care of women in pregnancy ...” 
to:
“... a national (Australian) consumer advocacy organisation made up of individuals and groups who share a commitment to improving the care of women in pregnancy, birth and the postnatal period.”

The options that MiPP has at this time are:
1. Continue our organisational relationship with MC. Members are welcome to vote on changes to the Constitution.
2. Leave MC and set up an independent association
3. Leave MC and establish a new organisational relationship under another body
4. Other?




The following is a summary of responses to other questions in the survey:

The midwives 

• Four of the 14 respondents have been members of MiPP for more than 11 years; three for 6-10 years; and seven for less than 5 years. 
• These midwives report having attended 182 planned homebirths, as the primary carer (‘first midwife’) in the year 2013. 
• These midwives report that in the year 2013, they attended 77 births in hospital after transfer of care from planned homebirth, and 73 planned hospital births. 
• Additional midwifery services, apart from the primary caseload (for planned homebirth) include antenatal and postnatal consultations, lactation/breastfeeding consultations, counselling, and maternal and child health visits. 
• Only two of those midwives who completed the survey are not eligible/endorsed, or working towards eligibility or endorsement to prescribe 

Comments 

Members value MiPP for mutual support, sharing, networking and professional contact with other privately practising midwives.

Since the federal government’s maternity reforms implemented in 2010, there have been significant changes in the way midwives are able to work in private practice, enabling Medicare rebates for clients, and as midwife prescribers.  Victorian midwives do not yet have collaborative agreements with public hospitals, one of the key promises in the reform package.

Your comments are welcome.

Definition of obstetric violence/Definición de violencia obstétrica

Lecture by Dr. Amali Lokugamage at the RCOG World Congress 2014 in India.

Obstetric violence  
"Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
"It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
"It is also the act of disregarding the emotional needs of mother and baby throughout the whole [childbearing] process"



This video was prepared by Jesusa Ricoy-Olariaga .

Further comment and discussion at villagemidwife blog

Advertising

The new AHPRA Advertising Guidelines came into effect 17 March, and we await the next move.  See previous posts for the detail of our concerns.

AHPRA has responded to pressure from professional groups.  The NMBA and other Boards are using a system of updated FAQ (frequently asked questions)

Updated on 24 March

...

There is a clear difference between advertising – which requires an advertiser’s intent to promote a health service – and unsolicited online comment, which does not involve an advertiser’s intent to promote a health service.

This seems to clarify the issue of unsolicited positive comments about a midwife that may appear on social media, on a site that is not under the control of the midwife.

It does not clarify the issue of Birth Stories which are posted on, or linked to, the midwife's website or social media site.  Many birth videos and photo montages identify the midwife.  This has been discussed earlier. 

The question in our minds will be, does AHPRA consider that everything posted on a midwife's website is advertising? 


Your comments are welcome.

AHPRA ACTION Campaign: enough is enough!

Readers who have been following the health professional news about the new AHPRA Advertising Guidelines are invited to sign this Change.org petition, which petitions AHPRA to remove Section 6.2.3 from the Advertising Guidelines.  SIGN HERE

By way of reminder ... from the Advertising Guidelines:

6.2.3 Testimonials
Section 133 of the National Law states:
(1) A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that – 
...
 (c) Uses testimonials or purported testimonials about the service or business

For more about this part of the Guideline, go to Birth Stories.

It has occurred to me that even Birth Notices that were very popular in the past, when we all read the daily newspaper, could have breached AHPRA's extremely narrow interpretation of 'testimonial'.  [I think social media has replaced the Birth Notices column in the newspaper!]


In discussing Birth Stories within the (relative) sanctuary of a closed facebook group for eligible midwives, one midwife expressed the opinion that " birth stories belong to women, and [I] do not see why midwives feel they have to publish them, and think they could be construed as advertising if published in midwives' own space."


Time will tell!

Yes, birth stories do belong to women - and if you can show me a birth story that focuses on the midwife and appears to have a purpose or intention to promote (/advertise) that midwife's practice, then perhaps it could be called a testimonial.

The guideline says "Testimonials can distort a person’s judgment in his or her choice of health practitioner."

The overarching purpose of regulation of health professionals is the protection of the public. Protection of the public from rogue or negligent or incompetent professionals and the like. Protection of the public from charlatans and snake oil sellers who would deceive and manipulate unsuspecting potential clients.
 
The scope of the midwife who works in primary maternity care, and the leading theme in birth stories, is natural, unmedicated, unmanaged, (sometimes noisy, sometimes messy, always unpredictable) birth.  Natural childbirth is unique in the spectrum of health care: it requires the woman to do *it* herself! There are no shortcuts, no special breathing techniques, no therapies, no magic words or products to be bought, that make natural childbirth better than it already is.

It seems to me that AHPRA is looking for a broad brush that covers every possibility in regulated health. I don't think AHPRA is necessarily targeting midwives in the 'patient stories' part of the guideline.


In conclusion (for now), I support the AHPRA ACTION campaign, and have signed the petition calling for the removal of Section 6.2.3.

The National Law, which prohibits the use of testimonials in advertising the service or business of a regulated health professional, continues.   The onus in this matter must be for AHPRA to demonstrate that the statement (comment - positive or negative - that identifies a regulated health professional on social media, midwife's website, YouTube video, or newspaper Birth Notice) must be shown to be advertising the practitioner or the service in order for it to be called a testimonial.


An excellent series of blog posts about 'social media' by Geraldton WA GP Dr Edwin Kruys provide more argument and comment, particularly from the medical practitioner's point of view.  You can follow Dr Kruys on Twitter at https://twitter.com/EdwinKruys.


Note: The opinions expressed in this post are those of the writer, Joy Johnston.

Your comments are welcome.

... more on health professionals and advertising

This post is a continuation of the discussion on Birth Stories a couple of weeks ago on this blog, and on the villagemidwife blog.

AHPRA has published several revised guidelines that are to become effective from 17 March.

For registered health practitioners
Guidelines for advertising regulated health services
March 2014

... "A practitioner must take reasonable steps to have any testimonials associated with their health service or business removed when they become aware of them, even if they appear on a website that is not directly associated and/or under the direct control or administration of that health practitioner and/or their business or service. This includes unsolicited testimonials. (emphasis added)"

An article Medical board’s online backflip 
7th Mar 2014
Neil Bramwell
published in Medical Observer adds another perspective to this interesting dilemma faced by AHPRA: that an aspect of the revised guidelines are not acceptable or workable.

... But [Medical Board of Australia] MBA chair, Dr Joanna Flynn, has now said the policy was only ever intended to apply to proactive advertising or promotion of a regulated health service. “There is a clear difference between advertising, which requires an intent to promote the health services, and unsolicited online comment over which practitioners do not usually have control,” she said.

... However, the MBA now recognises that practitioners are unable to control what is written about them in a public forum.

This article relates to a statement 'Online comment not always advertising'  by the Medical Board at the MBA website.

... the Medical Board "now recognises that practitioners are unable to control what is written about them in a public forum." - good!

Can you imagine a health practitioner trying to follow public forums, then trying to get them to take down anything that mentioned them in connection with clinical issues?

The guideline is branded by AHPRA, and adapted for each of the professional Boards.  I expect the NMBA will follow the MBA.

How did the regulatory authority not see this?  The guideline is clear:

"... even if they appear on a website that is not directly associated and/or under the direct control or administration of that health practitioner and/or their business or service. This includes unsolicited testimonials."

The revised Guidelines for advertising regulated health services need to be revised to remove these unworkable, misguided statements. 


The other issue for midwives is the use of birth stories, which the guideline refers to as testimonials ('patient stories'), which are prohibited under the Act.  I (Joy Johnston) have written to the NMBA about this - we must argue strongly that birth stories that are freely written by the woman are not for the purpose of advertising, and should not be classed as testimonials.


Midwives, please don't take birth stories off your websites; don't delete the name of the midwife; don't ask women to be silent about their experience of birth. We need to stand firm on this one. 


Disclaimer:
Opinions expressed in this article are those of the author, Joy Johnston.


Additional information 17/3/14
A legal opinion on the matter
AHPRA UPDATES THE RULES: TESTIMONIALS AND SOCIAL MEDIA ARE IN THE REGULATOR’S SIGHTS is available at
http://www.tresscox.com.au/resources/resource.asp?id=1474#.UyZ69IV7SUP

Another link added 22/3/14 Sarah Stewart's blog post:  AHPRA provides guidance for the guidance on advertising, but still leave health professionals with concerns

Croakey ‘No comment’: now the Medical Board tests social media landscape with advertising guidelines Marie McInerney

 

Your comments are welcome.

New private midwifery practice in Brunswick

The My Midwives premises at 31 Weston St Brunswick has been fitted out especially to create a warm and inviting community hub for pregnant women and families in the early post-natal period.  The services offered will include Medicare rebateable pregnancy and postnatal care, lactation services, antenatal education, pre and postnatal yoga and a range of complementary therapies.

 

Enquiries:  Gabriella Piemonte 0425 774 543    Hannah Quanchi   0400 564 103

Birth stories

Women have written and told their birth stories, and shared their birth pictures for as long as I can remember.  Birth stories have been a significant part of the natural birth movement, as women have claimed ownership and responsibility for their life decisions, including decisions related to maternity care.  Since the advent of the wonderful www, birth stories have been placed on websites, forums, blogs, and other social media sites.  A quick review of the midwives websites linked to this page tells us that many midwives have 'Birth Stories' as one of the features of their sites.

A new revised version of the NMBA guideline for advertising regulated health services, to come into effect next month (March 2014), appears to prohibit the publication of birth stories by midwives, or by others who may (intentionally or not) link a midwife to the story.

The National health practitioner law prohibits testimonials as a form of advertising.  The revised guideline states (p9):
  

6.2.3 Testimonials
Section 133 of the National Law states:
(1) A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that – 
...
 (c) Uses testimonials or purported testimonials about the service or business 

The National Law does not define ‘testimonial’, so the word has its ordinary meaning of a positive statement about a person or thing. In the context of the National Law, a testimonial includes recommendations, or statements about the quality of a regulated health service including clinical care, personal experiences of a regulated health service or about the benefits of a particular practitioner or regulated health service by someone who received the service. Testimonials can distort a person’s judgment in his or her choice of health practitioner. They may misrepresent the skills and or expertise of practitioners and create unrealistic expectations of the benefits such practitioners may offer health consumers. Testimonials in advertising include:
1. using or quoting testimonials on a website, such as patients posting comments about a practitioner on the practitioner’s business website, particularly when the website encourages patients to post comments and/or selectively publishes patient comments, and/or
2. the use of patient stories to promote a practitioner or regulated health service.

There are a number of independent websites that invite public feedback/reviews about a patient’s experience of a regulated health practitioner, business and/or service. These websites are designed to help consumers make more informed decisions and increase transparency of interactions.

A review is not considered to be a testimonial or purported testimonial, in breach of section 133 (1)(c) of the National Law when it only comments on non-clinical issues, regardless of whether it is positive, negative or neutral.

Reviews must not contain statements about the quality of clinical care received from the regulated health practitioner, business and/or service.

A practitioner must take reasonable steps to have any testimonials associated with their health service or business removed when they become aware of them, even if they appear on a website that is not directly associated and/or under the direct control or administration of that health practitioner and/or their business or service. This includes unsolicited testimonials.

‘Reasonable steps’ include taking action in the practitioner’s power, such as directly removing, or requesting removal, of the testimonials. For example, a review on a social media site that states ‘Appointment ran very late and magazines were old’, is not considered a testimonial as it makes no reference to the clinical care provided by a regulated health practitioner, business or service. However, a review on the same social media site that states ‘Practitioner was quick to diagnose my illness and gave excellent treatment’, is a testimonial which references clinical care and is considered in breach of the National Law.

Once the practitioner becomes aware of the testimonial, they must take reasonable steps to have the testimonial removed (also refer to Section 7.1 on social media). 

This new guideline appears to prohibit birth stories either on the midwife's website or somewhere else. "Testimonials in advertising include ... 2. the use of patient stories to promote a practitioner or regulated health service" and "a testimonial which references clinical care and is considered in breach of the National Law." There are some lovely birth montages and videos on youtube that give a visual promotion of the birth - including pictures of the midwives and reference to their names.  Are these also in breach of the law?

Perhaps it could be argued that a birth story or montage (on the midwife's site or someone else's) is not being used to *promote* the practitioner; rather to educate the public. I don't think this argument would hold. Midwives are in business, and businesses promote themselves because the only way they can keep going is if they make enough money. 

It seems to me as though there is a problem with this very inclusive definition of the word 'testimonial'. Surely a person's story of their own birth is theirs to tell or not? The guideline says "Testimonials can distort a person’s judgment in his or her choice of health practitioner." 

The overarching purpose of regulation of health professionals is the protection of the public.  Protection of the public from rogue or negligent or incompetent professionals and the like.  Protection of the public from charlatans and snake oil sellers who would deceive and manipulate unsuspecting potential clients.

Perhaps this sort of restrictive guideline is appropriate in health related services that may be seen to prey on people's vanity: expensive medical or surgical treatments that are carried out, with little chance of lasting effect on health or wellbeing?   Perhaps this is an instance in which the midwife is different from other regulated health practitioners?

It would appear that the strong arm of the law is being used as 'Goliath' against the 'David' of the natural childbirth movement.  Natural childbirth is unique in the spectrum of health care: it requires the woman to do *it* herself!  There are no shortcuts, no special breathing techniques, no therapies, no magic words or products to be bought, that make natural childbirth better than it already is. 

Would the birth story of a woman who wanted to give birth naturally after a previous caesarean be able to 'distort a person's judgment' about the professional capacity of the midwife?  Surely there is benefit to the public in being able to consider the events and decisions that led to the birth of a baby?

If birth stories (aka testimonials, under the revised guidelines) really can distort a woman's judgment in her choice of midwife, would it not be more reasonable to require a disclaimer to be displayed with birth stories, warning the public about this risk?  By removing birth stories from publicly accessible sites, are we returning to old ways, speaking only of such things in hushed tones behind closed doors?  Surely that is not appropriate in today's world.

Disclaimer:
Opinions expressed in this article are those of the author, Joy Johnston.

Thanks to Niki for sharing this special moment

What medicines are midwives prescribing nationally?

Please note:
If you are a midwife prescriber in Australia, you are invited to contribute to this survey.



There is a high degree of enthusiasm amongst midwives who have achieved endorsement as prescribers.

The Midwife prescriber facebook group facilitates discussion about prescribing issues.  The group welcomes members who have the eligible midwife prescriber endorsement, and those who are working toward it, and others who have a strong interest in the subject. At the time of writing there are 130 members.
 

A new vision for maternity care

ARM 2013 - click to enlarge

The mother-midwife relationship:
"central to maternity care: the midwife caring for the mother and providing a safe space in which she can develop confidence in her own ability to give birth and mother her baby."  (ARM 2013, p3)





Last year, 2013, the UK Association for Radical Midwives (ARM) published its New Vision for Maternity Care.

The basic principles are copied in this post.  The Vision document is only 16 pages, and well worth the read.  In the Conclusion, ARM states:

"This is our New Vision for the maternity services of the future.  We wish to change the perceptions of the general public about birth and about midwives so that we can practise the profession for which we have been trained.  Organisational change and financial and educational input is needed to start the process.  Once women know other women who have experienced birth with continuity of care and real autonomy, whether at home or in hospital, this care will be expected.  This new standard of care will bring about improved clinical outcomes for mother and baby, substantial savings for the NHS and positive cultural change within maternity services and the wider public.  Babies whose mothers have a more confident start to motherhood will have a happier and healthier start to life.

Midwives are unique in their combination of skill, sensitivity and training to be 'with woman' through one of life's landmark experiences which has long-term effects on the individual, the family and society as a whole.  We must generate a new respect for both motherhood and midwifery.  We owe it to ourselves and to future generations."

MATERNITY INFOSHEETS

Maternity Coalition has had a group of INFOSHEETS available online since 2006. INFOSHEETS provide consumer information that is current, accurate, evidence based, women centred, and independent of maternity care providers. INFOSHEETS will assist women to make informed decisions about their maternity care, regardless of their chosen place of birth or care provider.

These documents are presented as .pdf files, which can be downloaded, copied and distributed freely without change.  They are used by midwives, as handouts to clients, at public events, and by other maternity education providers.

Over time each of the INFOSHEETs needs to be reviewed, revised and updated.  Any document that is found to have errors or out of date information can be revised immediately.  New INFOSHEETS can be developed at any time.

Anyone who would like to have a part in the current review process, please join the MATERNITY INFOSHEETS facebook group.