midwivesVictoria

the death of a mother who gave birth at home

2012-01-31T21:17:00.002+11:00

There is no easy way to present this issue. The word 'death' confronts us with an absolute reality. A maternal death is shocking. A baby and her sister have lost their mother, a man has lost his beloved wife and the family have lost a daughter, sister, friend ...

Here's the story so far, as it has been presented in the online and print media and television today.

Herald Sun, Lucie van den Berg - Mum dies in home birth tragedy
The Age, Megan Levy - Home birth mum's tragic end
Herald Sun blogger Susie O'Brien - Homebirthing is just too risky
The Punch blogger Tory Shepherd Home births are prone to many complications
[and hundreds of comments to these two blogs]

The submission made by Caroline Flammea, Nick Lovell and daughter Lulu Lovell to the federal government's Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills

The opportunity for sensational headlines was not lost. 'Home birth death' filled half the front page of the Herald Sun today.

Victoria's Health Services Commissioner Beth Wilson is reported as having said she had "long held concerns about home births when medical back up may not be immediately available." Perhaps Ms Wilson is unaware of the usual practice of homebirth midwives to arrange transport to hospital, and collaboration with specialist medical services when complications are detected.

One would wonder if there are also "long held concerns" about the many smaller public hospitals and private hospitals that do not have medical personnel on site 24/7. Surely no-one imagines that all pregnant women should be herded into large baby-factory hospitals that process births like cars off a production line?

One would wonder if the thankfully infrequent examples of sudden and unexpected death of a previously well mother who gives birth spontaneously in large tertiary level hospitals also lead to knee-jerk reactions and pronouncements before all the facts of the case have been considered.

This is not the time to argue the safety of home birth. The sympathy of every midwife and every person who cares about working for better births is with this family, the midwives who attended the birth, and all the health service personnel and paramedics who provided care to a woman and her family in her last hours.

Birth has never been safer, for mother or baby, than it is in this country today. As rates of caseareans increase, and rates of complications related to placental implantation increase, new life-threatening risks will arise for those women. The midwife's challenge, to work in harmony with natural physiological processes, is as real and as important today as it has ever been.

[Any opinions given in this article are those of the writer, Joy Johnston, and are not necessarily those of other members of the collective, Midwives in Private Practice.]

hospital access for Medicare-eligible midwives

2012-01-19T16:16:00.000+11:00

A few months ago I reported on the work of a reference group set up by the Victorian Health Department to develop consistent approaches to the provision of clinical privileges for midwives within public maternity services, to enable admitting and practice rights for eligible midwives, and a new option for women who seek maternity care that protects continuity between the woman and her midwife.

Midwives in Private Practice (MIPP) was represented at the three meetings of the expert reference group.The 'deliverable' of this initial consultation process, which has been managed by the 3Centres Collaboration, is a draft document which provides a framework, and templates for paperwork and various records. This document will progress through careful checking by the Health Department, before it is able to be released. It is hoped that this document will provide a reliable process whereby public maternity hospitals in Victoria will be able to proceed with making arrangements whereby midwives are able to attend women privately for birth and other maternity care in the hospitals.

Readers may wonder how many women would want to be attended privately for birth in public hospitals? How many midwives would apply for visiting privileges, and what number of private clients/births would they be able to expect in a year? It is not known how many women in Victoria employ a midwife privately to attend them in labour in a public hospital. An estimate would be 100-200. Many more employ unregulated birth support people. Some midwives would attend 10-20 planned hospital births each year; others only occasionally.

For many years the predominant focus of private midwifery practice throughout Australia has been homebirth. However, since the introduction of notation as a Medicare-eligible midwife, the options for private midwifery practice have been extended. Some midwives who have achieved their Medicare notation/provider numbers have no experience in, and no intention of attending home births. Their plan is to provide continuity of care (and carer) for women giving birth in hospital. This suggests that as the number of Medicare-eligible midwives increases, the demand for hospital admitting and practice rights will also increase. If 10 newly eligible midwives were each taking 40 caseload bookings for planned hospital births, the estimated 100-200 per year could be 500-600. It's still a tiny proportion of the State's annual number of births, but it's a potential growth area.

In order for a midwife, or doctor, or anyone, to be allowed to practise in a hospital facility, there are basic instructional and policy matters that need to be communicated. Routine fire evacuation plans and other emergency procedures are essential for safety of patients and staff and all concerned. Everyone needs to be skilled in use of the hospital's computer systems, entry of data, admission and discharge, reporting of incidents, ... just to name a few examples.

A midwife who is employed in a hospital, who also has a private practice, or who has recently moved from hospital employment to private practice, would be able to quickly meet the requirements for emergency procedures, IT processes, &c. This midwife would be ideally situated to take up admitting and practice rights. The hospital knows the midwife, and the midwife knows the hospital. The process might be more challenging for a midwife who has not practised recently in the hospital.

It is important to remember that there is a woman and a child behind every episode of maternity care. Private midwifery care for birth is a model that focuses on the woman and her baby, not on the care provider or the facility. MIPP members look forward to the day when the options and arrangements for maternity care will truly value the woman, and thereby promote healthy outcomes.

Questions and answers 2: VBAC

2012-01-18T11:22:00.003+11:00

The questions for today are focused on vaginal birth after caesarean surgery, VBAC.

This is the second post in the current series

about midwives who have (or plan to obtain) Medicare provider numbers
about planned homebirth
about planned hospital birth
about vaginal birth after caesarean surgery (VBAC)
about women who have certain 'risk' factors
about ...

I have shaded the 'planned homebirth' and 'planned hospital birth' lines as well as the VBAC line, because the place of birth, home or hospital, is a *setting* - not an outcome.

Women often ask independent midwives:
"Will you be my midwife for a HBAC?", or HBA2C (where H=home, and 2=2, and where, because it's at H, it's obviously V)
(and yes, we use abbreviations freely!)

The only truthful answer is "I have no idea, because it's impossible for me to know where your baby will be born!"

But, what is implied in the question "Will you be my midwife for a HBAC"? is,

"If you are my midwife,

are you willing and able to provide the professional services I am likely to need in order to give birth safely at home, and
do you have the skill to recognise situations in which you would advise me to transfer to hospital, and
do you have the wisdom to guide me?"

Planning VBAC at home is perhaps the simpler option from the woman's and midwife's point of view, because it's clear that in order to give birth the woman and her baby need to be well, at Term, and come into strong labour *naturally* - without induction or augmentation of labour, and without relying on medical strategies for pain management. It's clear that if a decision point is reached when medical expertise, or technology, are recommended, these are accessed by transferring care to the medical/obstetric/midwifery/nursing team in hospital. Transferring to hospital does not mean that the plan for VBAC is given up.

Yet planning VBAC at home may be considered by some to be unreasonable risk-taking. Midwives attending homebirths are required to comply with various guidelines that have been approved by the regulatory authority, such as the Safety and Quality Framework.[Open this link and scroll down to 'Eligible Midwives']. The Safety and Quality Framework seeks to ensure that women understand that the midwife has no professional indemnity insurance for homebirth, and requires a midwife providing homebirth services to

adhere to recognised consultation and referral guidelines developed by the Australian College of Midwives (ACM) and to have processes and relationships in place to demonstrate compliance with the guidelines.

The ACM Guidelines list Casearean Section as

6.3 Previous Obstetric history
6.3.11 Caesarean Section
CODE B = CONSULT [Evaluation involving both primary and secondary care needs. The individual situation of the woman will be evaluated and agreements will be made about the responsibility (medical or midwifery) responsibility for maternity care]

The journey to homebirth for a midwife and woman, using the ACM Guidelines, may then proceed to Appendix A: WHEN A WOMAN CHOOSES CARE OUTSIDE THE RECOMMENDED ...
This process seeks to ensure that the midwife and other maternity professionals are advising the woman clearly, and the woman is making an informed decision.

If the midwife is Medicare-eligible, there are other requirements for collaborative arrangements before the midwife's fees can be rebated through Medicare. This is the case whether the plan is to give birth at home or hospital.

When planning VBAC in hospital, many of the same issues arise for women who intend to proceed without medical intervention, unless there is a valid reason. Most hospital guidelines require midwifery staff to obtain continuous electronic monitoring. The woman in this situation is able to decline, if she makes that decision.

A VBAC in hospital can proceed with continuous electronic fetal monitoring, epidural anaesthesia, IV fluids, a urinary catheter, forceps or other assistance that is available within the scope of a medically managed vaginal birth. Or a VBAC in hospital can proceed without any of these interventions.

Women planning VBAC in hospital would do well, if they can, to find a hospital that has a track record that demonstrates an understanding of VBAC. When you inquire about making a booking at the hospital, ask if the hospital has a clinical practice guideline or other written document that you can take away to read. Some hospitals have this material on the internet - click here for the Women's VBAC guideline. This will give you an idea of what you are likely to experience. Your midwife can help you understand the detail.

Specific questions can be asked of the hospital such as what is their current rate of planned vbac (out of all women who have had previous C/s surgery), and actual vbac. The denominator in the actual vbac rate is usually the number who planned vbac, or who commenced spontaneous labour. So if a hospital says "We have a 65% VBAC rate" it probably means that of all women with a previous C/S who intend to undergo a 'trial of scar' and commenced labour, 65% had vaginal births."

The decisions that need to be made in any pregnancy and labour (bac or not) are the same. Plan A. If mother and baby are well, and there is no valid reason to interfere with the natural process, the authentic midwife will act in a way that supports and protects natural physiological processes that lead to safe birth. This includes minimising any interruption or interference with the labouring woman.

Questions and Answers - Medicare-eligible midwife starting up private practice

2012-01-12T15:53:00.000+11:00

Hello dear reader,
I am preparing a series of posts on general questions asked by women and midwives about private midwifery practice. If you have questions, please add them in the comments section, or send me an email joy@aitex.com.au

In preparing questions and (attempting) answers, please note that questions on clinical conditions can only be addressed in a general way, and cannot replace the face-to-face discussion and decision-making between a woman and her midwife or other care provider. Also readers are welcome to provide additional information or discussion via the 'comments' section, or to write guest posts.

Frequently asked questions can be grouped, and colour-coded to help organise:

about midwives who have (or plan to obtain) Medicare provider numbers
about planned homebirth
about planned hospital birth
about vaginal birth after caesarean surgery (VBAC)
about women who have certain 'risk' factors
about ...

Today's question, to get the ball rolling, is:

Q. I wish to practise as an eligible midwife providing antenatal education and postnatal care. How do I go about getting started?

A. The short answer is that there is a great deal of scope for Medicare participating midwives to offer private midwifery services, including antenatal care and postnatal care.

When commencing private practice, a midwife is advised to find an experienced mentor, who is willing to support the midwife's entry into private practice. You may avoid a few headaches!

The longer answer ...

Women who receive midwifery care from a chosen midwife in private practice who is Medicare-eligible, and who has fulfilled the requirements such as collaborative arrangements and indemnity insurance (these have been written about previously on this blog. Use the search function if you want to check out previous posts) will receive rebate on the midwife's fees for services that have a Medicare item number. The amounts of rebate are set out in legislative tables that are available for anyone interested.

The following brief summary is quoted from the government's ComLaw website.

Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162
Schedule 1 Midwifery services and fees
Part 1 Midwifery services and fees

Part 1 of Schedule 1 of the Determination sets out the relevant general midwifery services, assigns applicable item numbers, item descriptors and fees for the services. These items enable the payment of Medicare benefits to patients of participating midwives for antenatal, birthing and postnatal care:·

an initial antenatal attendance of at least 40 minutes duration (item 82100);·
a short antenatal attendance of up to 40 minutes duration (item 82105);·
a long antenatal attendance of more than 40 minutes duration (item 82110);·
development of a maternity care plan for a pregnant woman, where the pregnancy has progressed beyond 20 weeks (item 82115);·
management of a confinement for up to 12 hours (item 82120);·
management of a confinement in excess of 12 hours, where care of the patient is transferred from one midwife to a second midwife (item 82125);·
short postnatal attendance of up to 40 minutes duration (item 82130);·
long postnatal attendance of at least 40 minutes duration (item 82135); and·
six week postnatal attendance (item 82140), after which the woman would see her general practitioner.
Antenatal and postnatal services may be provided in a range of settings including in consulting rooms, community clinics and the woman’s home. Medicare benefits for the management of labour and delivery are only payable where the service is provided to an admitted patient of a hospital, including a hospital birthing centre.

Please note that there is no Medicare item number for antenatal education. However, midwives provide education for each woman in their care, relating the science and art of midwifery to that woman's personal situation, and guiding the woman in her preparation for birth and mothering.

A midwife who intends to provide Medicare-rebated prenatal (items 82100, 82105, 82110, 82115) and postnatal services (items 82130, 82135, 82140) is able to charge a fee, or bulk bill. The amount of rebate the woman receives will depend on her status with the Extended Medicare Safety Net (EMSN) capping system.

For example, if the midwife's charge for a 1-hour postnatal visit (Item 82135) in the woman's home is $120, the scheduled fee for that item is $75.05, and the EMSN (if applicable) is $20.65

The rebate a woman who has passed the Safety Net threshold is $75.05+$20.65=$95.70.
Out-of-pocket expenses for that consultation are $24.30.

On the other hand, if the midwife chooses to do so, she may 'Bulk Bill' for that item. The midwife receives the 'Benefit 85%' (of the scheduled fee) payment of $65.60 into her nominated bank account, from the public purse. The midwife may consider the ease of bulk billing, and the opportunity to provide a greater number of postnatal visits without increased cost to the woman, to outweigh the lesser unit payment.

Midwives participating in Medicare are able to obtain portable EFTPOS machines from their bank, which enable easy and quick credit card payments (swipe the credit card), Medicare rebates into the client's debit card account, and bulk bill payments (swipe the Medicare card).

Where to go for more information:
Midwives Australia
has a wealth of information and links at its website. Midwives Australia is a not-for-profit organisation supporting midwives through these changes with practical hands on initiatives, programs and resources.

Your comments are very welcome.
Please note that any opinions expressed in this blog are the opinions of the writer, Joy Johnston, and may not necessarily be shared by other members of MiPP.

"homebirthing is a sensitive and controversial issue"

2011-12-23T15:38:00.000+11:00

The report said “homebirthing is a sensitive and controversial issue”.
The irony of this statement was clear when it appeared in Improving Maternity Services in Australia – The Report of the Maternity Services Review (2009). Homebirth continues to be both sensitive and controversial today.

Maternity Coalition's Summer 2011 issue of Birth Matters devoted significant space to the extremely sensitive and controversial end of homebirth; "high-risk homebirth". MC President, Ann Catchlove, wrote a deeply personal and moving column referring to the death of a baby in a highly publicised homebirth, that "I hope that we will have realised that the way to respond to "high-risk homebirth" is not by prohibition and persecution but by seeking to understand why women make decisions and giving them real options within the system. Meanwhile, in the here and now, a mother is being treated in a most unfair and unjust manner. We need to stand up and say that is wrong."

In an article published in the (UK-based) AIMS Journal Vol 23 No3 2011, Joy Johnston (who is also the author of this blog) wrote:

The constant recurring theme in Australian and international midwifery regulation is the public interest. The Australian medical profession considers obstetric supervision of all maternity care to be in the public interest, and assesses midwifery as incapable of delivering optimal and safe maternity care in settings outside obstetric surveillance. The issue of home birth is the pimple on the end of the maternity system’s nose. It won’t go away, it hurts when touched, and it’s a real nuisance.

The large 'Birthplace' study [click here for link and comment] looking at place of birth in the UK is to:

effectively be replicated in Australia from 2012 with a NHMRC funded birthplace study led by Professor Caroline Homer from the University of Technology, Sydney.Feeding in to the Maternity Services Review recommendations for more research and national data collection, the study will investigate outcomes from about 45,000 births across public and private hospitals including birth centres, freestanding midwifery units and homebirths, both publicly and privately funded.“We need to continue to grow the evidence and what has to be unpacked are the important pieces of information for women – their chances of a normal birth versus a caesarean section or their chances of good outcomes versus bad,” Homer said.“We haven’t had a big national study which clearly defined intended place of birth at onset of labour, not at 12 weeks. Smaller studies have also been a bit vulnerable because of their low numbers.” (quoted from Nursing Review, 21 Dec 2011)

MIPP is currently undertaking a REVIEW OF PLANNED HOMEBIRTH FOR ‘AT RISK’ WOMEN IN VICTORIA, 1999-2009. The data for this audit is being prepared by the Victorian Perinatal Data Collection team. Women included in this audit are those identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories: Multiple pregnancy; abnormal presentation (especially breech); preterm labour prior to 37 completed weeks of pregnancy; post term pregnancy 42+ weeks; and previous caesarean birth. It is anticipated that at least one paper for publication in a professional peer-reviewed journal will come out of this review, and it is hoped that valuable information will be highlighted.

Hospital back-up bookings for planned homebirth

2011-12-12T16:19:00.001+11:00

Midwives practising privately in and around Melbourne have, for many years, used the booking and emergency referral arrangements provided by the Women's hospital. The process has been simple: the midwife can fax the woman's details to the hospital, and the woman is given a hospital record number confirming the booking. The midwife provides copies of any blood test and other investigations relevant to the pregnancy, and contacts the hospital if and when obstetric referral is required.

In the past two years, after the Women's hospital relocated from the old Carlton site to its present site in Parkville, and, coincidentally as the numbers of births increased with the recent 'baby boom', restrictions have been placed by the hospital on which women are able to make bookings. For women who are experiencing uncomplicated pregnancies (which is usually the case for women planning homebirth), only those who live in the Women's local area are able to make a booking. The hospital was apparently bursting at the seams. Midwives who had previously brought women transferring from planned homebirth to the hospital from distant locations are now referring women who need medical attention to the nearest public maternity hospital.

Some midwives objected to the change. Transferring to the Women's had been a well-managed matter, that the midwife could confidently navigate. Professional respect between the independent midwife and the hospital staff, and vice versa, was generally upheld. This of course tends to reassure the (labouring-birthing) woman, who is at the *centre* of the care. [The good relationship between Midwives in Private Practice (MIPP)s and the Women's has been written about previously in this blog - eg see July 2008]

The Women’s hospital is now undertaking a review of ‘Services provided by the Women’s hospital in relation to women who choose to give birth at home’. A letter to participating midwives states that The Women’s “has identified a number of issues associated with its existing homebirth backup arrangements and, in recent months, significant concern regarding the clinical risks has heightened.” The Women’s Executive “has decided to review the current arrangements in order to clarify the Women’s role and responsibilities in this area and to determine the most appropriate processes for supporting women who choose to give birth at home.”

The fact that "significant concern regarding the clinical risks has heightened" in recent months, in relation to homebirth, is a matter that midwives who attend homebirths care a great deal about. Has there been some change in the way midwives practise, or in the way midwives and women planning homebirth proceed through their decision-making processes? Is there a problem specific to the Women's, or ...?

MIPP leaders have also been aware of some issues that would come under the heading of 'clinical risk'. During the past couple of years, with the federal government's Maternity Services Review; the passing of new legislation requiring professional indemnity insurance which was not accessible; the 'exemption' for homebirth; and the Medicare provisions for participating eligible midwives - this has been a time of unprecedented stress and concern for midwives practising privately, attending women for planned homebirth.

An application was made some months ago to the Victorian Perinatal Data Collection Unit (VPDC) by MIPP for retrospective information on the birth outcomes of women identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories:

Multiple pregnancy;

abnormal presentation (especially breech);

preterm labour prior to 37 completed weeks of pregnancy;

post term pregnancy 42+ weeks; and

previous caesarean birth.

There has been an unexpected delay in obtaining the data requested, as 2009 data cannot yet be publicly released. We understand that the delay has been related to the change from manual data entry to electronic data entry at some sites. We will inform our members and readers as soon as something becomes available. The VPDC publishes data on actual homebirths (and outcome data for each hospital providing data to the system) each year. The MIPP audit is seeking information on outcomes specific to 'at risk' pregnancies and planned homebirth.

Thankyou to anyone who has read this far. We will keep you updated on matters of interest to the private midwifery community, as information becomes available.

Your comments are welcome.

Safety of home birth - the UK Birthplace study

2011-12-01T09:02:00.001+11:00

Birthplace study

Reference:

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study.

BMJ 2011;343:d7400 doi: 10.1136/bmj.d7400

This new cohort study from the UK reports on birth outcomes for healthy women with low risk pregnancies.

As with all research, statistics can be interpreted differently by different people. In this post I want to give a general overview of the research, and provide links for those who are interested in reading more.

The first point to note is that the title 'Birthplace' may be misleading. The outcome data was sorted according to PLANNED [not actual] place of birth.

Readers may remember a study from South Australia (Kennare et al 2010) which received considerable press coverage as it claimed huge increases in adverse outcomes for planned homebirths. For more comment and links relating to that study, click here.

Although there are major differences between planned homebirth in the UK and planned homebirth in Australia, valuable lessons can be learned when we review and critically consider the meaning of results of research.

Births at home or in hospital: risks explained is an article at the NHS Choices: your health your choices website. The explanations given are well considered: compare with the titles and subsequent content of newspaper articles listed and linked at the end of the piece.

Links to the headlines
First-time mothers warned over home birth risks. The Daily Telegraph, November 25 2011
Home births three times more risky than hospital, says study. Metro, November 25 2011
Women with low-risk pregnancies 'should have birth choices'. The Guardian, November 25 2011
First-time mothers who opt for home birth face triple the risk of death or brain damage in child. Daily Mail, November 25 2011
Home as safe as hospital for second births. The Independent, November 25 2011
Home birth risks up for new mums. The Sun, November 25 2011

Another commentary worth reading is at the Having a baby blog. The writer Marina Colville concludes:

This study supports government policy to offer choice in place of birth to all women. However, there remains a severe lack of viable community midwifery services with associated expertise which means most women do not have a realistic choice of where they give birth despite a potential claim to the contrary by a range of Trusts. This issue should be addressed by NHS managers who have so far largely not implemented this long standing government policy particularly in the face of extensive evidence from this study showing the cost-effectiveness of it.
Make no mistake, any attempt to change the maternity service following this study will be as tortuous as the previous years of inaction but this study is vital fuel for the fire making the case for better birth experiences for women and babies.

Your comments are welcome.
ps: for Sarah Buckley's comments on the question 'Is homebirth safe?' and links to her work, go to http://australianprivatemidwivesassociation.blogspot.com/

Invitation from MAMA

2011-11-25T21:51:00.001+11:00

Celebrate with MAMA

As a way to say thanks for all of the help & support you have so kindly given to us, you and your family are warmly invited to celebrate the successful opening of our centre…

Sunday 4th December 2011

1pm – 4pm

at38 Gatehouse Drive, Kensington

Champagne and Finger Food will be served throughout the afternoon

Please RSVP by 25th November 2011

to KylieTel: 03 9376 7474

Email: admin@midwivesandmothers.com.au

Membership in MiPP

2011-11-17T15:57:00.001+11:00

A MiPP meeting in 2009

MiPP is a collective of privately practising midwives in Victoria.
MiPP meetings are usually by-monthly, in locations to suit members. Communication is mainly by email, either directly or via the maternitycoalitionmidwives Yahoo! Group.

MiPP welcomes applications for membership from registered midwives, who seek employment/income from private midwifery practice, and who are willing to provide primary maternity care for women and their babies across the continuum of pregnancy, birth, and the postnatal period.

Full members' entitlements include listing on the MiPP brochure, and on the MiPP page at the Maternity Coalition website.

Associate membership is available for midwives and midwifery students who are interested in private midwifery practice.

It is a couple of years since MiPP published a brochure. We are now preparing a new brochure, and asking members to indicate their desire to renew their membership. Midwives who wish to join MiPP as new members are welcome to apply. Applications are reviewed by MiPP on an individual basis. A current full member of MiPP may be named as a sponsor to new members.

Please note that a midwife who wishes to commence private practice, outside the hospital/acute healthcare sector, is encouraged to seek mentoring with an experienced independent midwife.

Although the MiPP collective is based in Victoria, registered midwives from other parts of Australia are welcome to join our group.

For more information, or to request a membership form to be sent by email, please contact joy[at]aitex.com.au, or phone 0411190448.

MIPP is affiliated with Maternity Coalition Inc, as a 'Participating Organisation'.

Maternity Coalition is a consumer and midwife advocacy organisation, committed to protecting pregnancy and childbirth as natural processes, and to supporting the role of the midwife as a primary maternity care provider. All MiPP members are also members of Maternity Coalition, and receive a copy of the journal Birth Matters quarterly.

Collaborative arrangements with Medicare-eligible midwives for Victorian public hospitals framework

2011-11-04T11:29:00.000+11:00

The following communication to stakeholders has been distributed:

November 2011

Work has now commenced in Victoria on a framework for public health services that provides guidance on the appropriate mechanisms to consider, implement or review collaborative arrangements with [Medicare] Eligible Midwives (EM) providing midwifery care to women who are admitted privately and seeking to birth in hospital under the care of the EM.

The framework will give effect to action item 1.2.2 of the National Maternity Services Plan (2010) and will identify the key issues and areas that need to be considered by public health services including operational, legislative, regulatory and professional issues and requirements at the Commonwealth, state and health service level.

The 3Centres Collaboration is undertaking the work on behalf of the Department of Health (DH), including consultation and drafting of a framework.

The scope of the framework is to provide guidance on the specific issues related to collaborative arrangements between EMs who are providing care for women admitted as private patients, and Victorian public hospitals.

The framework will be accompanied with tools and resources to assist with implementation. The framework will need to be adaptable to the specific demands of smaller/rural services as well as large metropolitan services and while it will be guided by what is being put in place in other states/territories it will need to reflect the specific governance arrangements for Victorian health services.

An expert reference group (ERG) of key stakeholders and sector interests has been convened to provide additional advice to the DH and the 3 Centres Collaboration.

Broad community and sector consultation will take place in November 2011 and provide an opportunity for managers and clinicians involved in maternity care, GPs and GP Obstetricians, midwives, and consumers to learn and contribute to the development of the framework. Locations for the forums are Warrnambool, Bendigo, Ballarat, Wangaratta, Traralgon and Melbourne.

For information about the ERG and the dates, times and venues for the consultation forums visit www.health.vic.gov.au/nursing. It is expected that the framework will be completed for ratification and dissemination in February 2012.

An open letter to Bridget Lynch, past President of ICM

2011-10-24T12:16:00.000+11:00

This letter, written by midwife Robyn Thompson, is addressed to Bridget Lynch, immediate past President of the International Confederation of Midwives (ICM). The Australian College of Midwives (ACM) is a member organisation of ICM.

I was privileged to be introduced to, and speak with you Bridget at the Australian College of Midwives Conference on Thursday October 20th 2011 in Sydney.I was in the right place at the right time in midwifery history.

A passionate midwife of 38 years, 25 of those having been invited to midwife with women in their homes, it was an unbelievablerelief to hear your wise midwifing, your words of wisdom and direction.

Bridget, your presence and words were even more important after years of repeated professional horizontal violence in this country. Very similar at times to that of, the professional violation that we witnessed during the Annual General Meeting at this conference.

That aside now, it is hard to fathom as an elder of rich midwifery experience and many more years with life experience, how midwives, the very people who nurture the mother and her baby can contemplate disrupting the human rights of any woman. The right to be in her quiet, protected space, the place where she finds it safe to journey with her womanly‐mammalian strengths through growing, giving birth and mothering her new baby.

I remind myself how lucky we all were at this time in history to hear your guiding direction, the leader of ICM displaying her true connection ‘with woman – with midwife’. A voice of experience, advising Australian Midwives to avoid the pitfalls of political power and dominance, to stand strong and united, with one voice as a profession in our own right.

Bridget through your encouragement, you have provided the unique opportunity for Australian midwives to rethink their professional redirection.Your advice for strategic planning with the members, a ‘bottom up’ rather than the ‘top down’ approach will certainly be a new challenge. Your advice to seek out expert advisors in specific areas and to feel good about paying for that expert service, will be another new challenge.

If we are smart we will draw on your advice to strategise the way we will steer and strengthen the future of midwifery.

My hope, like yours has been to move healthy women out of hospitals for the sick and injured, back into Community Birthing Homes, where midwives attend women.

With many new challenges for future direction we should be ready to reclaim the "silos" of Midwifery Education, Midwifery Regulation and Association to ensure that our right as a Midwifery profession is distinct from nursing and medicine.

You made me feel like there is new hope and because of that I can now look forward to some happy twilight years because of your sensible, expert advice and internationalleadership.

In appreciation,yours in midwifery

Robyn Thompson
Midwife
Maternal & Child Health Nurse
(Formerly Registered Nurse)
Bachelor of Applied Science
PhD Candidate
midwifeconsultant[at]gmail.com
http://www.breastfeedingconsultant.com

the reshaping of private midwifery practice

2011-10-18T18:49:00.002+11:00

Private midwifery practice is undergoing real changes, as midwives who have Medicare provider numbers are able to offer certain midwifery services for which women will receive substantial Medicare rebates.

There is scheduled fee for each item, from which rebates are calculated [variation in amount payable depends on a person's safety net]. For example:

Initial antenatal professional attendance (history) [Item # 82100] $51.35
Short antenatal consultation (less than 40 minutes) [Item # 82105] $31.10
Long antenatal consultation (more than 40 minutes) [Item # 82110] $51.35
Maternity Care Plan meeting after 20 weeks (at least 90 minutes) [Item # 82115] $306.90
Attendance for labour and birth planned hospital birth (when midwife has visiting access) [Item # 82120] $724.75
Short postnatal consultations in your home (less than 40 minutes) [Item # 82130] $51.35
Long postnatal consultations in your home (more than 40 minutes) [Item # 82135] $75.55
6-7 week postnatal review of mother and baby [Item # 82140] $51.35

Midwives in private practice have, to a great extent, built our practices on attending women for homebirth. The 'niche' in the market has grown slowly over the years. The midwife primary carer is responsible to provide antenatal, birth, and postnatal midwifery care, and to refer appropriately if medical care is indicated.

Homebirth programs with public funding are a fairly recent innovation in Victoria. Pilot programs offering homebirth out of Casey and Sunshine hospitals, both situated in Melbourne's population growth corridors, are being evaluated before any roll-out of this option within public hospital systems.

Midwives in private practice (MIPPs) who are eligible for Medicare provider numbers, as well as those who have not sought the eligibility notation, are continuing to provide homebirth services.

In considering the reshaping of private midwifery practice, I would encourage the reader to reflect on the complex nature of consumer 'demand', social expectations around birth, and financial considerations in decisions around maternity care.

The government's reforms, enabling Medicare rebate for certain midwifery items, will not, of themselves, result in women flocking to private midwifery care. The number of eligible midwives is small, and the capacity of each midwife to take client bookings for care across the pre-intra-postnatal continuum is limited. There are at present no hospitals in Victoria, public or private, where a midwife has authority to attend a labouring/birthing woman, even though many of the Medicare-authorised midwives have purchased the government-supported indemnity insurance that covers intrapartum care.

One potential growth area for MIPPs is with a new group of women: those who have given birth in hospital, and who wish to access private midwifery care postnatally, in addition to what has been provided by the hospital (private or public) where they gave birth. The Medicare item numbers and rebates for postnatal care in the 6-7 weeks after birth will make this option more attractive than it has been in the past.

Midwives practising privately could meet a real need, particularly with women who are experiencing difficulties with breast feeding, or other complex needs within the scope of the midwife's practice. Midwives may choose to bulk bill or charge rebate only in certain situations, but it is likely that in most instances there will be a co-payment. Electronic payment and rebate options are available for midwives to set up with their bank and Medicare.

There does not seem to be any cap on the number of rebate claims a woman can make in that period of time. Although it doesn’t come anywhere near the ideal of continuity of carer through the whole episode of care, it would give that woman a known midwife to consult with through weeks 1-6.

Key issues for midwives

2011-10-07T18:55:00.001+11:00

Referring to the development of visiting access arrangements for midwives in public hospitals (see previous post), the following comment has been offered by a highly respected 'elder' of the midwifery profession, Helen Sandner, from Bendigo.

I would just like to put forward a few key issues that I think are paramount for future discussions and consideration in the planning and implementation of a written document.

Midwives autonomy. In saying this I do not mean in a dictatorial way, but I believe that it is important to acknowledge that we are registered to practice as autonomous practitioners. It is only the Government that is putting us back under the auspices of the medical profession with the Collaborative Determination.
Collaborative respect. We deserve equal respect and I would like to see this in writing. We are not underdogs or lesser professionals and this needs to be acknowledged and therefore we should be referred to in any document with the same level of professionalism as any other healthcare professional.
Consent, informed decisions and right of refusal. All without saying the women should be the focus and these points should be acknowledged in any written document.

Helen Sandner
Midwifery Practice Coordinator
Central Victorian Midwifery Group Practice

mipps and public hospitals in Victoria

2011-10-06T22:38:00.001+11:00

Independent midwives in Victoria have for many years encouraged and guided women planning homebirth to make backup bookings with public hospitals. Those women who experience complications are referred to the back-up hospital. The midwife usually continues with the woman in labour, visits her in hospital postnatally, and picks up postnatal care after the woman and baby have been discharged. This process does not usually receive any special attention; it's just the way midwives work. Recent posts have discussed the midwife's role in hospital based intrapartum care.

A multi-disciplinary reference group has been brought together by the Health Department, to inform and support a process under which eligible midwives (ie midwives who have a notation on their registration that they are eligible for Medicare*) will be able to attend women privately in public hospitals.

This action by the State Health Department is an outcome of the [Federal government's] National Maternity Services Plan, which requires “... jurisdictions (to) develop consistent approaches to the provision of clinical privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners ...”

There are many details to be worked through, and of course the issues for rural/regional hospitals are often different from the big metro hospitals. Of particular interest to all concerned is the development of a process whereby a midwife has is able to book and admit a woman privately to hospital, attend her for antenatal care, and for birth in the hospital, and postnatal care in the hospital and the woman's home. The process would require the midwife to have a clear arrangement for referral to an obstetrician if indicated. Since most public maternity services have obstetricians and GP-obs covering the service on a roster system, the midwife and her client need to tap into that process of cover.

Hospitals have processes in place for 'credentialling' visiting medical officers. Processes that are set up for midwives will be consistent with those for other health professionals. When a woman is admitted as a patient of a private obstetrician, the hospital provides midwives and other staff and services that are considered necessary to enable appropriate care. This is also the expectation of midwives. We anticipate having access to the full range of services and personnel within the hospital's operating systems.

Midwives have been asked if they are also pursuing visiting access in private maternity hospitals. This option would fit quite well with the legislation, National Health (Collaborative arrangements for midwives) Determination 2010. However, anecdotal reports from midwives who have considered this option lead us to doubt that private hospitals or the obstetricians who work in them will welcome collaborative arrangements with midwives for midwife-attended births. One concern is that Dr A might be very happy to work with Midwife B, but Dr A works only 1 weekend in 3, and Dr A's colleagues, Drs C and D, do not agree to a collaborative arrangement with Midwife B.

Midwives, hospitals, and government face a complex and multi-faceted area of endeavour as we proceed along the road to visiting access to public hospitals. We know that it can be done. Midwives in New Zealand, Canada, the UK, and many European countries have access to hospitals as well as homes. The goal is that the woman and her baby have the opportunity to receive consistent expert care from a known and trusted midwife, who is able to provide primary maternity care in any setting.

* eligibility includes access to PBS, the Pharmaceutical Benefits Scheme, by which midwives will be able to prescribe certain medicines. Before this reform can be realised in Victoria, legislative reform is required to the Drugs, Poisons and Controlled Substances Act. Eligible midwives are required to sign an undertaking that they will complete a course of study in prescribing/medication management for midwives within 18 months of having the notation on the register. To date there is no course approved by the regulatory body for this purpose.

Don't give up!

2011-10-02T15:49:00.003+11:00

An opinion
Joy Johnston

I wrote in a recent email to fellow independent midwives, "Don’t give up! Midwifery has survived darker days than this one."
One younger midwife who received that post asked me what I meant. Was I referring to midwives being burnt at the stake, or similar historical atrocities?

Those dark days certainly rate high in the shame file. But, realistically, it's a long way removed from any midwife today.

Midwifery is the one health profession that challenges the medical/legal establishment at its core. Midwifery enables women to get on with the job of being mothers without interruption, and will only seek treatments or interferences from outside sources (natural or pharmacological; alternative or mainstream) when complications present.

Dark days through which midwifery has survived include days that I and other midwives practising in Australia today have come through. As recently as 1996, the Midwives' Regulations in Victoria required a midwife to practise at all times under the supervision of a doctor. A midwife was not permitted to perform a vaginal examination without a doctor's permission. A midwife was also required to wear clean clothes of a washable material.

Although these arcane rules were put aside ('sunsetted') in 1996 with new policy directions of the State Health Department, the effect of the Midwives' Regulations, medical supervision of midwifery, has been preserved. Ongoing attempts to reign in and control the midwifery profession, particularly the independent part of it, are offered with the laudable intention of protecting the wellbeing and safety of mothers and babies who may come under the midwife's powerful coercive pressure. Plenty of evidence of this position can be found in submissions to the Maternity Services Review, as previously discussed at this and other sites.

Dark days for the midwife today might include the suspension of her right to practise, or she even be imprisoned for doing no more than is widely considered basic midwifery. Even more likely, a midwife today may spend many months or years facing investigations and hearings by the regulatory authority, following trivial and vexatious complaints by colleagues; often other midwives. That midwife may experience mental and physical symptoms stemming from anxiety and depression. One such midwife wrote after being released from a series of vexatious allegations of professional misconduct: "That is 18 months of my life wasted in worry, stress and on anti depressant medication. Crazy stuff." She has withdrawn from private practice.

A midwife from South Australia wrote:

When I first was involved in a home birth support group in 1977 the women were helping each other, and sometimes one of two lay midwives may have been available to attend. It was totally underground. I offered midwifery care and listened to the women and developed an approach to care that created education, safety, support for many women. ...

Now with all these changes supposedly to give midwives and women more choice and increase safety, we are back at 1977. Only now the women are even more educated, more autonomous in their decisions and many of them more damaged by the system and the medicalization of birth.

There is little midwifery because most women enter an obstetric model with midwives having to practice obstetric care. Women are traumatized in a way that can not be allowed to keep happening! Coercion scare tactics of "you or your baby could die" or after a women births some one says "if you'd been at home you would have died". This is the lack of truth that pervades maternity care. Women care about their babies more than anyone else. I'm ashamed of the decisions that have been impacted on women in the name of midwifery reform & safety.

(From Rosemary Vaher née Smart, used with permission)

It's not simply 'them' and 'us'. 'Hospital' vs 'home'; 'employed' vs 'private'; 'obstetrics' vs 'midwifery'.

Midwives who have achieved the new standard of being eligible for a Medicare provider number, and whose clients are now able to claim some rebate on their midwife's fees for antenatal and postnatal care have been referred to in a derogatory sense as 'collaborators'. Midwives who attempt to explain the new regulatory framework that is now in effect, and how this may impact a plan for birth, have been black listed in web-based social networks. Some who read this blog may be aware of other examples.

When a group attacks its own members there is little hope for its continued existence. We don't need to fear outside forces - self destruction will happen if we don't actively prevent it. My plea to all who care about authentic midwifery, and who seek to protect natural physiological processes in birth, is that we maintain our support for one another, continue to talk to each other, hear and respect different points of view, and continue 'with woman' through this present dark time.

Don't give up!

Australian midwifery's Position Statement on Homebirth

2011-09-14T11:01:00.000+10:00

MIPP and other midwifery and maternity consumer groups are preparing our responses to the ACM Interim Positon Statement on Homebirth. See previous posts at villagemidwife and an earlier post on this blog.

It's a complex and important matter.

The ACM Interim position statement was endorsed by the regulatory authority prior to its release to the midwifery profession for comment. Having been endorsed, the Position Statement on Homebirth comes under the midwifery Safety and Quality Framework which details the requirements with which a privately practising midwife must comply in order to be exempt from requiring insurance for providing intrapartum care for homebirths.Under the national law,

284 1 (c) the midwife complies with any requirements set out in a code or guideline approved by the National Board under section 39 about the practise of private midwifery, including—(i) any requirement in a code or guideline about reports to be provided by midwives practising private midwifery; and(ii) any requirement in a code or guideline relating to the safety and quality of the practise of private midwifery.

In the interests of public protection, it is essential that midwives reject the ACM Interim Position Statement on Homebirth (IPSH), and work with the College to develop a statement that is consistent with current midwifery practice and philosophy.

The woman's decision-making role in spontaneous unmedicated childbirth - the only option in home birth - has been ignored and avoided in an apparent attempt to enforce boundaries around aspects of clinical safety.

Consider, for example, some of the evidence referred to and relied on by the College in support of its IPSH. Reference is made to both the Kennare et al (2010) paper on planned homebirth in South Australia, and the widely discredited Bastian et al (1998) [note this paper is outdated by academic standards], which included data collection by unreliable and unacceptable methods.

Midwives' comments on Kennare et al (2010) can be accessed online. I draw readers' attention particularly to a critique attributed to leading midwife academics, who are also prominent members of the College of midwives, Hannah Dahlen and Caroline Homer.

Another valuable commentary was published by midwife Caroline Hastie at her Thinkbirth blog.

Birth is as safe as life gets Dr Pesce. The therapeutic use of self as a health care practitioner is what makes both life and birth safer. As Barbara Katz Rothman says "birth is about making strong and capable mothers". Time to stop pulling the rug from under women's sense of self with all this 'turf war' rhetoric!

Since pregnancy and birth are truly natural states, and are not, per se, reliant on outside management, the woman has a basic natural right to maintain personal control over primary level decisions, including if and when she goes to hospital. The midwife is the professional care provider with the skill and the ability to attend births at home. If a position statement which is endorsed by the regulatory authority effectively restricts the midwifery profession to attending only home births that meet criteria for being at ‘low risk’ from a clinical/obstetric perspective, a significant number of women will be either excluded from making an informed decision about home birth, or they may engage the services of unregulated attendants and continue to plan home birth. Neither of these options is in the interests of the mother’s and her baby’s wellbeing.

In drawing attention to the need of all pregnant-birthing women for midwifery services, we are not promoting management of complicated births in the home. We are, rather, highlighting the importance of access for all birthing women to continuity of skilled care from a known midwife, and the importance of midwives being able to provide professional services in all settings. The partnership that is formed between a midwife and the woman enables the ongoing process of informed decision making by the woman throughout the episode of care.

Your comments on this important matter are welcome.

Is caesarean now the normal way to give birth and should we be worried?

2011-09-09T15:31:00.001+10:00

From theconversation: A hot topic: Is caesarean now the ‘normal’ way to give birth, and should we be worried? written by midwife academic, Professor Caroline Homer.

We must remember that 'usual' is not necessarily 'normal'. The physiological norm for pregnancy, childbirth, and nurture of the infant will always engage the woman's and baby's sensitive hormonal systems and deep intuitive knowledge.

The WHO statement "In normal birth there should be a valid reason to interfere with the natural process" (Care in Normal Birth, 1996) is a guiding principle.

Many midwives have lost a great deal of the knowledge and skill we need to work in harmony with natural processes in the childbearing continuum. Fortunately, the knowledge of normal birth is stored in a woman's brain, in the deep intuitive area. Even if/when the rates of Caesarean and other medically managed births exceed the rates of spontaneous, unmedicated births, that knowledge will survive for those who want to access it.

2011-09-05T10:35:00.001+10:00

The Australian Private Midwives Association (APMA) has just launched an on-line campaign, called Mums Matter!

This is aimed at bringing the issue of women's rights back on the agenda (as it has slipped off many politicians radars!) We have 1 week before pollies are back in Canberra. By then we want 20,000 supporters sending emails sent to pollies across the country. It is super easy only takes 2 mins. Please pass on far and wide.

We know different women make different decisions but the vast majority support each others' ability to make them.APMA is also asking for pledges of $20 to fund our campaign continuing. We don't need to all travel to Canberra this time we want to make it cheap, easy but still effective. Here's the link http://mumsmatter.good.do/mums-matter/

Thankyou for passing this message on.

Role of the registered midwife in private practice when the woman is admitted to a health service as a public patient

2011-09-04T18:40:00.000+10:00

A new position statement has been circulated by the Nursing and Midwifery Board of Australia, concerning the role of the midwife who supports a woman admitted to a public hospital. Extracted from that position statement:

... The midwife may choose to withdraw when the care of the woman is assigned to the health facility’s health care professionals. However, should the woman request it, the midwife may choose to remain as a support person to the woman either as paid or unpaid as agreed between them.

The Board recognises that the midwife has no obligation to stay with the woman and that it is an individual decision for the midwife. If the midwife chooses to stay with the woman - and therefore take on a support person role - the midwife must articulate the change in role to the woman, who should then consent to the midwife’s involvement as a support person only. The midwife should also clarify her change in role from midwife to support person with the health service.

The decision by the midwife to remain as a support person is linked to the woman’s right to choose the person(s) whom she wishes to be with her during birth. ...

Readers of this blog will know that midwives and women in our care have had reason to be very concerned about the apparent new 'rules' that had arisen, applied to private midwives attending our clients in hospitals which, for the record, do not yet have any process by which the midwife can be credentialed for clinical privileges/visiting access. With that in mind, some midwives are expressing a sense of relief that the unthinkable - abandoning a labouring woman when she is admitted to hospital - might happen. This position statement offers a pathway by which the midwife can continue 'with woman' after she has been admitted to hospital.

Mandatory reporting

2011-08-24T12:35:00.000+10:00

There is a great deal of discussion and some dismay in the world of private midwifery, since we learned that a 'mandatory reporting' notification was made of a midwife who was deemed to be practising without insurance.

We understand that this midwife was in a public hospital with a woman who had planned homebirth. After transfer of care to the hospital, the midwife continued in a supportive role with the woman: the usual practice in Australia when women transfer from planned home birth to hospital care.

A midwife is, by the root meaning of the word, and by definition, with woman - not with a particular setting (home/hospital), or with a desired outcome (natural birth), or with a model of care.A midwife's commitment is to the woman.

The Health Practitioner Registration National Law 2009, and linked State and Territory legislation, require registered health practitioners and employers to notify the regulatory agency AHPRA, which in turn notifies the Nursing and Midwifery Board of Australia (NMBA). Notifiable conduct includes matters that are clearly in the public interest, including allegations of working while intoxicated by alcohol or drugs, allegations of sexual misconduct, allegations that the [midwife] is putting the public at risk of substantial harm due to an impairment or departure from accepted professional standards. ... [see full text here]

The issue of notifiable conduct in the example outlined above requires a huge stretch of credibility, which I do not think will be upheld in any legal challenge.The notification is based on an extremely narrow definition of 'Practice', taken from the NMBA website, Frequently Asked Questions (FAQ):

4 May, 2010 Recency of Practice FAQs Q1. What is ‘Recency of Practice’? A. This means that a practitioner has maintained an adequate connection with, and recent practice in, the profession since qualifying or obtaining registration. Q2. What is meant by ‘Practice’? A. Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a nurse or midwife. For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care. It also includes working in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession and/or use of their professional skills.

This definition of 'Practice' is contained in the NMBA Recency of Practice Registration Standard and clearly does not apply to insurance requirements. If it did you would expect it to be in the professional indemnity insurance registration standard but it is not. [added later] Note: This definition of Practice also appears under 'Definitions' at the AHPRA website.

Dear fellow-midwives, we need to carefully consider the 'Mandatory Reporting' rules.

that the person who reports you needs to have formed the belief that you, the midwife, have placed the public (your client) at risk of substantial harm due to practising midwifery in a way that constitutes a significant departure from accepted professional standards.
that a midwife has a duty to the woman, and must weigh up the impact any potential harm to the woman that she may not get an insurance payout if she sues you, because you have no insurance, against the other potential harm that she may face if you abandon her.

I say we have strong grounds to defend ourselves. We will surely be able to argue that such a notification is vexatious. We have advice from the nursing union ANF Vic that making a notification that is vexatious or not in good faith may expose the notifier (registered health professional or employer) to proceedings for defamation. A notification not made in good faith is "not protected from civil, criminal and administrative liability" (Mandatory Reporting: A guide for ANF members).Please see my blog and the APMA blog for further information and discussion on this important matter.

Your comments are welcome.

A scarred uterus

2011-08-06T12:07:00.003+10:00

The Australian College of Midwives (ACM) has released an Interim Homebirth Position Statement for comment.

The ACM Interim Guidance for privately practising midwives providing midwifery care for a planned homebirth state:

"There are some contraindications to a planned homebirth which women should be informed of at booking. These are:
• Multiple pregnancy
• Abnormal presentation (including breech presentation)
• Preterm labour prior to 37 completed weeks of pregnancy
• Post term pregnancy of more than 42 completed weeks
• Scarred uterus"

While the first four: multiple pregnancy, abnormal presentation, preterm labour, and post 42 weeks' would usually, in most midwives' practices, be triggers for a midwife to advise at least obstetric review with consideration of transfer of care from planned home birth to planned hospital birth, many women in our care have planned and achieved home birth after caesarean (HBAC) - after a scarred uterus - without complication. Many others have made informed decisions to move from planned home birth to hospital care, with the continuous support of their independent midwife, and have achieved what can only be described as optimal outcomes for mother and baby.

As in all maternity care, there are no guarantees about outcomes. You probably know of situations in which better outcomes might have been achieved with a different set of decisions.

The only way in anyone’s book to approach vaginal birth after caesarean (regardless of the planned place of birth) is spontaneous onset of labour, which usually means at home, quietly and privately. The optimal situation as far as I can see is that the woman is able to call her midwife who will work with her in either setting – home and hospital. By 'black banning' the scarred uterus from HBAC, it is likely that some women will feel they have no option but to go it alone, or to engage unskilled help, with sometimes tragic and avoidable consequences. One part of my motivation in writing this blog today is my deep sadness for those women, babies, and families, and the midwives and other health professionals and community members who have had parts to play in these cases.

Dear reader, please take a deep breath, and read on.

There is a further layer in this discussion to which I need to draw your attention.
The Interim Guidance document states that, in relation to women who fall outside the boundaries of this position statement:

"Following documented discussions and appropriate consultation and referral as may be indicated, a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies."

What does this mean?

How would this new 'rule' apply to a privately practising midwife who is asked to attend a woman with a scarred uterus, for planned home birth?

Midwives need to consider the ethical consequences of this proposed new rule. Of course, from time to time, a midwife and a woman may reach an agreement that they are not able to continue care - this is very different from the new rule which gives the midwife the right to abandon a woman in her care.

At present the only place a midwife has the authority to attend women for birth is at home. We must remember, however, that there is no insurance exemption for midwives who attend women privately in the capacity of a 'support midwife' for planned hospital birth. Midwives in private practice are exempt from the requirement for professional indemnity insurance when attending home birth.

ACM has requested comment on both the interim position statement and the interim guidance for privately practising midwives by close of business 23rd September 2011.
Send submissions by email to info@midwives.org.au or by post to PO Box 87, Deakin West ACT 2600. Only submissions with identified senders and a return address will be considered.

Background:

ACM was contracted by the Commonwealth to develop the Homebirth Position Statement for the NMBA.

ACM state that they have conducted a targeted consultation with key stakeholders, including Maternity Coalition, APMA, and Midwives Australia. The ACM branches were also invited to provide feedback on the draft document. MIPP also provided feedback, outlined at this blog post.

A treasure-trove of literature

2011-07-28T20:49:00.002+10:00

Readers who are serious about understanding and discussing aspects of maternity care will find an excellent resource at:
click here

This is a listserve site for a discussion group of Canadian Family Physicians (the equivalent of the Australian General Practitioner), hosted by Dr Michael Klein.

The site contains links to a huge amount of useful literature and debate.
One example, which many readers of this blog will want to print out and review in some detail is Home Birth: An annotated guide to the literature (Vedam et al, May 2011).

Births after Caesarean

2011-06-29T10:54:00.007+10:00

Is spontaneous natural labour and birth a realistic option?

The answer, in each case, depends on decisions made during the pregnancy and as the labour progresses.

Most midwives, and many doctors, would encourage women to give birth vaginally. Unless there is a specific and valid reason to avoid vaginal birth, there is no safer way for mother and baby than spontaneous, natural, unmedicated vaginal birth.

A pregnant woman who intends to give birth spontaneously, naturally, whether or not she has had previous Caesarean births, has significant decisions to make as her pregnancy progresses. Each decision is in effect a fork in the road, guiding and determining the subsequent course of the journey.

Here are a few key decision points:
Decision Point #1: Model of care and primary care provider
Decision Point #2: Onset of labor
Decision Point #3: Progress in labour
Decision Point #4: Giving birth
Decision Point #5: Third stage/ baby's transition

The woman who is able to make the decision consistently to continue in a normal physiological pattern of activity, and avoid medical 'help' in its many forms, is the person most likely to achieve vbac.

The woman who simply assumes that the hospital/service/doctor/midwife has the skill and capacity to support her desire for vbac may be disappointed. There is huge variation in the rates of attempting and achieving vbac in maternity services. (The images below are not very clear - you can download them in .pdf files from the Vic Health Department publications site.)

In Victoria the Health Department have a very useful system of reporting Performance Indicators for public maternity hospitals. The hospitals are named, and rates given for the various indicators. For links to these publications click here, and go to Victorian Maternity Services Performance Indicators complete set for 2008-09 August 2010.
[Quoting from p17]

MAT 4. Vaginal births after primary caesarean section
...
Clinical significance
Nearly one third of all babies in Victoria are born by caesarean section. While many of these procedures are necessary and improve outcomes for women and babies, they also can prolong recovery from the birth, increase the small risk of serious morbidity after the birth, increase the risk of major complications in subsequent pregnancies, particularly problems with placentation, and require additional resources. Reducing the number of avoidable caesarean sections minimises these
problems. There are two main strategies for achieving this: preventing a woman’s first caesarean section; and encouraging women who have had a prior caesarean section to attempt a subsequent vaginal birth (VBAC) and supporting them to achieve it.
...
Observations on the data

(see images Mat4a and Mat4b)

Thirty-seven hospitals each had at least five women give birth whose only prior birth was by caesarean section. The rate of attempted VBAC for these women ranged from zero to 68 per cent.
Twenty-two hospitals had a least five of these women plan a VBAC for their second birth.
The range of achieved VBAC at these hospitals was 40 per cent to 86 per cent.
At least 50 per cent of women who planned a VBAC achieved a VBAC at 18 of the 22 hospitals; at least 60 per cent achieved VBAC at 13 hospitals.
Over time, the rate of women who plan a VBAC has remained steady at 30 per cent. However, there is wide variation in the rate of women planning a VBAC across hospitals. This may be a reflection of clinician practice variation and warrants further investigation.
There is an encouraging upward trend in the proportion of women planning VBAC who achieve VBAC.

Midwives who practise privately, or independently, are ideally situated to work with women who plan vbac. The midwife and the woman are able to achieve a model of care that is personal and centred on the woman. The midwife as primary carer is able to move with the woman as she makes each decision. The woman who is able to make the decision consistently to continue in a normal physiological pattern of activity, and avoid medical 'help' in its many forms, is the person most likely to achieve vbac. The midwife who has a professional partnership with the woman planning vbac will provide information and advice with the aim of protecting the wellbeing and safety of mother and child.

To download an INFOSHEET on Births after Caesarean, click here.
For the Homebirth Australia Facebook page Save HBAC in Australia, go to http://www.facebook.com/homebirthaustraliaconference

Transfer to hospital from planned homebirth in the Melbourne area

2011-06-15T14:49:00.003+10:00

Midwives in and around Melbourne have received a letter from the Women's Hospital in Parkville, telling us that backup bookings for women planning homebirth will now restricted to the local area. Women outside the catchment area for the Women's, who require transfer of care, are to "present to the local maternity hospital closest to your client's home."

Midwives attending homebirths privately in and around Melbourne have for many years had good collaborative arrangements with the Women’s Hospital and Monash Medical Centre in Clayton. If a woman or baby in the midwife’s care requires transfer to hospital, or referral for specialist assessment in pregnancy, the process is straight-forward, which is in the interest of the wellbeing of mother and baby. When the woman and midwife have completed the hospital booking-in process, the hospital gives the woman paperwork with the woman’s name on it, clearly marked ‘HOMEBIRTH BACK-UP’.

Other public hospitals that have, under this arrangement, been by-passed, will now be approached for back-up bookings. These include the Northern, Mercy, Box Hill, Angliss, Dandenong, Casey, Sandringham, Werribee Mercy, and Sunshine. Perhaps there are more.

The alternative is to present un-booked at a hospital. This practice is best avoided, for obvious reasons.

A midwife's commitment to the woman in her care is to always act to promote the wellbeing and safety of mother and child. There is no way to predict the possible need for transfer of care. Women who choose the care of a private midwife for planned homebirth are not a uniform group. Each pregnant woman has a unique personal story which sometimes includes aspects of risk. The group of women who plan homebirth are usually assessed as low risk, but there is no risk-free situation whether birth is planned at home or hospital. Risk may be associated with previous pregnancies, or weight, or something else.

The main hurdle faced in planning homebirth is to be able to labour spontaneously, without medical stimulants or pain relief. This fact is not trivial. Professional advice by the midwife, and the sort of decision-making that has to take place when a change of plan is being considered, are often strongly influenced by the woman's progress and ability to accept the work of labour.

A midwife who is confident in approaching a hospital when transfer of care is indicated is able to guide the woman without anxiety. Even though there is likely to be disappointment when the plan for home birth is no longer reasonable, the midwife continues 'with woman', and provides information and support as the woman negotiates a different journey.

Update on private midwifery in Victoria

2011-06-08T09:08:00.001+10:00

If you are interested in the national private midwifery scene, or trying to locate a midwife outside Victoria, please go to the APMA blog.

For links to websites of private midwives, scroll down this page to web links.

To locate a midwife in Victoria, go to the MIPP list at Maternity Coalition. Alternatively, you can leave a comment at this blog.

Midwives who have received notation as being eligible for Medicare provider numbers have reported to the group on their experiences.

Hospital visiting access for midwives:
There is no Victorian hospital at which a private midwife can attend her clients as a visiting midwife, despite the government-supported indemnity insurance plan that midwives have purchased at great expense. We understand that the Victorian Health Department has given funding to the 3 Centres group to sort out hospital visiting rights/clinical privileges for eligible midwives - a project that may report at the end of this year. Midwives who go to hospital with their clients are doing so without any professional recognition.

Medication course:
Although midwives sign an undertaking to complete a medication course within 18 months of being eligible, there is no university with an approved course for midwives. One member is doing the Nurse Practitioner course in Pharmacology from Flinders, SA, with the hope that that will be acceptable as an equivalent. However Victorian legislation needs to be amended before midwives are able to prescribe.

Collaborative arrangements and referrals:
Midwives in some rural areas are having more success than those in Melbourne. Doctors who are willing to sign such forms have been advised by their insurers that they should not do so. Some obstetricians are happy to sign for planned hospital birth with midwife support, but not for homebirth.

Jan Ireland and Kelly Langford are opening rooms in Kensington in August. Jan is keen to support other midwives who want to become eligible.

Difficulties are being experienced around explaining Medicare to clients, issues with indemnity insurance, and the low number of Medicare claims from Victoria.

Professional Development options

2011-05-26T19:07:00.000+10:00

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The packages provide health professionals with the opportunity to update their professional skills, support their current practice, take another career direction or seek an alternative entry pathway into Higher Education.

Packages are delivered via distance education over a 12-week period. Students are able to work at their own pace within this timeframe and are offered in Trimester 1, Trimester 2 and Summer Trimester (numbers permitting).

Learning Packages are available in either full (with assessment) or audit (without assessment) format.Studies in contemporary midwifery practice, lactation and care of the neonates may be of particular interest to midwives in practice.

Applications for study in Trimester 2 commencing on 11 July close in mid June.
Applications for study in Trimester 3 commencing on 14 November close in mid October. For further information about areas of study available, please follow the link below or contact P.D.U.staff directly on (03) 9251 7776.

http://www.deakin.edu.au/hmnbs/pdu/

homebirth position statement

2011-05-23T19:19:00.000+10:00

Members of MIPP who are also members of the Australian College of Midwives (ACM) will be aware that "ACM is working with both the NMBA and the Commonwealth to develop a contemporary homebirth position statement within the next three months."
(Australian Midwifery News, Autumn 2011 issue, page 3.)

MIPP is a collective of self-employed midwives in Victoria. We all attend women as primary maternity care providers for planned home births. Our members include active members and fellows of the Australian College of Midwives, and members of other professional organisations.

In developing a Position Statement on Homebirth, we draw the attention of ACM to the summary of the APMA POSITION STATEMENT on PLANNED HOME BIRTHS WITH A MIDWIFE
[http://australianprivatemidwivesassociation.blogspot.com/]
1. We support home birth with a midwife in attendance for women who have uncomplicated labours.
2. We support and adopt the International Confederation of Midwives’ (ICM) Definition of the Midwife (2005), which is foundational to all midwifery practice, including homebirth.
3. We support the right of every woman to access a midwife as the primary maternity caregiver who works in partnership with the woman throughout the episode of care, who is able to be the responsible professional in attendance at the birth either at home or hospital, and who is able to make appropriate referral and transfer of care when required.
4. We support the right of a midwife to practise privately in a fee-for-service or funded relationship with the client, or to take up employment.
5. We support only those regulatory restrictions that are able to pass the ‘public interest’ test: “How does this promote health and wellbeing in the mother and baby?”
6. We support an expectation of equity, including equal pay for equal work throughout a midwife’s scope of practice. Midwives who provide primary maternity care are entitled to the same public funding, the same opportunity to charge a fee-for-service, the same access to hospital referral, and publicly supported indemnity insurance, as medical practitioners providing the same maternity services.
7. We support processes by which midwives are able to gain experience and mentoring in order to commence and demonstrate competence in homebirth practice.
8. We support seamless and reliable processes by which midwives are able to make hospital bookings for women planning homebirth, and arrange transfer to the hospital in a timely way when needed.

>>>>>>>>>><<<<<<<<<<
Your comments are welcome.

Join the global webinar to celebrate International Midwives' Day 5 May

2011-04-26T17:11:00.000+10:00

Plans are set for the Virtual International Day of the Midwife on May 5th. The program, which spans the 24-hour period, with speakers from the various continents, has now been finalised, and it looks to be a very interesting and diverse program: http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011

It's a good idea if you haven't participated in web based seminars like this, to get your computer sorted ahead of time in terms of technology. Please go to this page: http://internationaldayofthemidwife.wikispaces.com/How+to+use+Elluminate

Here is more detailed information for speakers:

http://internationaldayofthemidwife.wikispaces.com/Speakers

The organiser is well known midwife-blogger Sarah Stewart.

Look forward to seeing you on May 5th.

MIPP submission to Senate Inquiry

2011-04-15T18:30:00.000+10:00

Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA)

MIPP has made a joint submission with Australian Private Midwives Association (APMA). To access all the submissions received by the committee,
click here

The matters addressed in this submission are in response to our experiences during the recent transition from individual State and Territory-based regulation of the midwifery profession to the national regulation of the midwifery profession under AHPRA.

We draw to the attention of the Inquiry the following matters, which will be discussed in more detail in the body of this submission:
1. AHPRA’s administration of the registration process for Medicare benefits
.1 Midwives are required by AHPRA to provide a reference from hospital midwife manager or obstetrician when applying for notation as eligible for Medicare benefits. This is an unreasonable request for many privately practising midwives.
.2 ‘Prescribing’ course. Midwives who apply to AHPRA for notation as eligible for Medicare benefits are required to sign an undertaking to complete within 18 months of recognition as an eligible midwife, an accredited and approved program of study determined by the Board to develop midwives’ knowledge and skills in prescribing ...” There is at present no such course available for midwives.
.3 Some midwives have experienced unacceptable delays and a lack of fairness in processing applications for notation as eligible midwife.
.4 We draw to the attention of the Inquiry the implications for consumers/ private clients of midwives whose applications have been delayed without good reason.
.5 We assert that there is a strong potential for misunderstanding in the obstetric and hospital midwifery communities as to the meaning of collaboration. Legislation that privileges obstetricians, placing them in a supervisory role for midwives, must be repealed.

2. The administration by AHPRA of complaints against privately practising midwives
.1 A privately practising midwife’s registration had been suspended prior to the changeover to the new legislation. This midwife has been unable to work and earn a living, yet she has not yet been given an opportunity to present her case in person, or to have her suspension lifted.
.2 At least two midwives have recently had conditions (supervised hospital practice) placed on their registrations without any investigation into the complaint. This is as effective as a suspension, with the midwife losing her ability to earn a living while the conditions apply.

3. Professional Indemnity Insurance. AHPRA, through the Nursing and Midwifery Board (NMBA), is currently in the process of drafting requirements for insurance for midwives. We wish to draw this to the attention of the Inquiry, as midwives in private practice are the only professional group unable to purchase indemnity insurance to meet the requirements of the national legislation.

A flawed analysis

2011-04-08T10:34:00.000+10:00

This week's leading story on Medscape OB/GYN and Women's Health [Medscape_OBGYN@mp.medscape.com]
Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong

A Flawed Analysis

The highly charged debate over the safety of home birth was inflamed by the publication of a meta-analysis by Joseph R. Wax and coworkers,[1] which concluded that "less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate." The statistical analysis upon which this conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings,[2-6] this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion,[7] meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research.

In this article we describe in detail numerous mistakes in design, methodology, and reporting in the Wax meta-analysis that place clinicians and patients at risk for being misinformed.

Soon after the Wax et al article was published, the Midwives Alliance of North America published a similar critique.

Click here for the MANA press release, published by midwivesVictoria blog at the time.

Wax and colleagues were mirrored at about the same time by a similarly outrageous 2010 publication by Kennare et al in the Medical Journal of Australia.
Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (MJA 2010;192:76-80)

The authors of the Australian study, which looked retrospectively at data, claimed that "planned homebirths had a perinatal mortality rate similar to that for planned hospital births, but a sevenfold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia." Huge confidence intervals and small numbers were clear limitations, as well as decisions about inclusions and exclusions, yet the flawed conclusions have been circulated widely in a shrowd-waving "doctor knows best" campaign.

Homebirth via public hospitals

2011-03-24T12:55:00.002+11:00

A midwife from Casey Homebirth service, at a maternity conference, with the 'gear' that she takes to a home

In December 2009 we noted at this blog the announcement that some Victorian women would be able to access homebirth via a publicly funded pilot scheme.

Two metropolital hospitals, Casey in the South-East and Sunshine in the West, have their homebirth programs up and running. We have also been told by a reliable person that Monash Medical Centre, a level 5 hospital in Clayton, is planning to offer homebirth as part of comprehensive maternity services this year. [Click on the highlighted words to go to the websites of the hospitals mentioned]

I have recently met up with a group of the midwives employed at Casey. I was impressed at their enthusiasm for their work. They told me they are loving the work.

Homebirth is a basic aspect of midwifery practice. It allows the practitioner an opportunity to develop a strong midwife identity, accepting the authority in decision-making at any time in the episode of care, and particularly at the time of birth. Homebirth is 'PLAN A' - the woman giving birth spontaneously, without medical intervention, and the midwife acting in harmony with normal physiological processes.

Working in a public hospital homebirth program enables midwives to practise one-to-one (caseload) primary maternity care without taking on the professional marginalisation that is experienced when midwives go into private practice.

Midwives who have moved into private practise may not value this aspect of the hospital program to the same degree as those who take the hospital caseload-homebirth positions.

Hospital midwives are able to provide care for the group of women booked in their caseload, with structured 'backup' processes from other midwives in the program, and arrangements for handing over care if a labour is very long. These midwives value their employment contracts, through which they have a reliable income, employment benefits such as sick leave and long service leave, and their relationship with their clients is separate from their ability to earn a living.

By way of comparison, independent (private practice) midwives value the strong commitment they make to individual women, and very rarely ask another midwife to take over. The 'employment' arrangement is a private one, between the individual woman and her private midwife or midwives.

Both options - private and public - have potential advantages and disadvantages.

‘Hospital at home’ is a reality. Hospitals are over-crowded, and it makes sense to provide services in the home when possible. The hospital risk management includes the latest gadgets that may be useful, such as the 'Neopuff TM' machine shown in the picture above. With the strict policies on inclusion in the program, it’s very unlikely that the midwives will need to use the neopuff. That will come out in audits down the track.

The inclusion by hospitals of this item should not be seen as suggesting that all midwives attending homebirths need to carry such equipment. There would need to be some compelling evidence that babies born at home would be better off. Hospital babies, many of whose labours are induced when they not quite ready to be born, depressed by narcotics, and premature, ... are the ones that would clearly benefit from the Neopuff TM.

Homebirth via public hospitals is a valuable addition to publicly funded maternity services. Women and their babies benefit, as homebirth requires the promotion of normal physiological birthing, feeding, and nurture processes. Midwives benefit in being separated from reliance on unnecessary medical interventions.

I anticipate that there will, in time, be an exchange of midwives between the public and private homebirth options. This will be good for midwifery, and good for birthing women.

Comments by readers are most welcome.

NMBA and Professional Indemnity Insurance

2011-03-11T19:54:00.001+11:00

The Nursing and Midwifery Board of Australia is seeking feedback from all stakeholders on the revised Professional Indemnity Insurance Arrangements Registration Standard, and Guidelines. Click here for the link.

Submissions are due by 6 May.

The Board is seeking feedback on the following two approaches:
Approach 1:
The Board specifies a minimum amount of cover for professional indemnity based on advice from the insurance industry.
Approach 2:
The Board does not specify a minimum amount of cover for professional indemnity.

Two approaches are outlined because the Board has received some feedback that the draft Guideline should include advice about the minimum dollar value of quantum of cover for midwives wishing to practise independently. The Board realises however that there are potential drawbacks to both approaches, and is therefore keen to provide the most useful advice to practitioners seeking PII cover.

Blog readers are invited to share your views on professional indemnity insurance generally, and any points that you think ought to be included in submissions to this inquiry.

New arrangements for midwives

2011-02-23T11:39:00.001+11:00

A number of privately practising midwives are progressing towards being endorsed as eligible for Medicare. At least one MIPP who practises in and around Melbourne expects to receive notification of that endorsement tomorrow (24 Feb) after her application is approved by the Nursing and Midwifery Board (NMBA).

A .pdf fact sheet summary (pictured) of the New arrangements for midwives is available here.

A similar fact sheet for the medical profession, addressing the new arrangements for midwives, and especially collaborative arrangements between doctors and midwives, and hospitals and midwives, is available here.

The MIPP Professional Practice Review (PPR) has been submitted to the Nursing and Midwifery Accreditation Council (ANMAC) for approval. The MIPP PPR is a review process for midwives who practise the full scope of midwifery for individual women in primary maternity care settings. The PPR enables a midwife to demonstrate personal competence to peer reviewers of the full scope of midwifery practice over time and across the continuum of care, as defined by the International Confederation of Midwives (ICM, 2005), and further developed in current Australian midwifery codes and standards.

Successful completion of a professional practice review is a requirement for midwives applying for notation as eligible. The one process that has been approved is the ACM Midwifery Practice Review (MPR).

Private midwifery in Victoria at the end of January 2011

2011-01-31T16:24:00.006+11:00

This post is a brief round-up, especially aimed at midwives considering private practice as a career option, and women considering employing midwives to attend and work professionally with them throughout the birthing continuum, including when they give birth.

Eligible midwives
Midwives are now able to apply for eligibility for Medicare provider numbers, thereby enabling clients to claim certain rebate on the midwife's fees. For more information on eligible midwives, go to the APMA blog. If you would like further detail on the $ amount that is rebatable, and the items under Medicare, please send an email request to the blogger, joy[at]aitex.com.au [email address not hyperlinked, as this can encourage spam] The amount of rebate that a woman with an uncomplicated pregnancy and birth could expect to obtain via Medicare, for private midwifery services, is about $700 for the antenatal and postnatal care segment, and $724 for attending birth in hospital, working as the private midwife with clinical privileges/visiting access in that hospital [an option that does not yet exist in this State]. Note that there is no indemnity insurance for home birth, and no Medicare item number for home birth.

Collaborative arrangements
Midwives who have Medicare provider numbers are required to comply with laws that describe suitable collaborative arrangements, in order to avail their clients of rebates. This requirement is discussed in greater detail at the APMA blog.

Hospital visiting access
Midwives who have Medicare provider numbers and are insured with the inndemnity insurance product that has Government underwriting are theoretically able to apply for visiting access/clinical privileges at a public maternity hospital. Meetings and correspondence between Victorian hospitals and midwives have, to date, failed to provide any pathway by which this option is actually possible.

Homebirth
Homebirth can now be accessed either privately, with independent midwives, or in a couple of public hospital pilot projects. These are through Sunshine hospital (in the Western suburbs) and Casey hospital (in the outer South-Eastern suburbs). The announcement of these homebirth programs is available in an earlier post on this blog.

A message left by 'Shane' stated

I have recently met two of the midwives and one obstetrician working in this program and it seems wonderful. I am keen to read the evaluation and to hear of the outcomes, in terms of women's satisfaction, neonatal and post-natal morbidity and mortality,caesarean rates and maternal morbidity and mortality.

We do not have outcome statistics from these programs yet. There is usually a lag of a couple of years before statistics are published. Many interested parties will be keen to see those statistics, and any other research that is done. I expect there will be a few academics lining up to write Masters and Doctorate theses.

MidwivesVictoria keep our ears to the ground for news, and share it with our readers when ever possible. We have heard that Southern Health is planning a new homebirth program from its Clayton campus, providing homebirth services for 50-60 women per year.

We have also been informed by women who have made inquiry about homebirth through these publicly funded services that:

Women must agree to all the tests and investigations that are offered
Women who intend to avoid the injection of oxytocic drugs for Third Stage are excluded from planning homebirth
Women who are having their first baby (primipara) may be discouraged from planning homebirth.

nhmrc and Vitamin K

2011-01-13T14:22:00.001+11:00

Forwarding message:
I would like to inform you that the NHMRC Joint statement and recommendations for vitamin K administration to newborn infants to prevent vitamin K deficiency bleeding in infancy (the Joint Statement) was re-issued in by NHMRC CEO in November 2010.

The Joint Statement was published in 2000 and reissued unchanged by NHMRC in 2006 following a recommendation from NHMRC Council. In 2010, a literature review on vitamin K prophylaxis to newborns was undertaken by NHMRC followed by two rounds of expert consultations. Following the literature review and expert consultations, the recommendations contained within the Joint Statement remain unchanged.

The revised Joint Statement has an accompanying brochure Vitamin K for newborn babies. Information for parents. This brochure was updated to be consistent with the revised Joint Statement. Both of these publications are available at https://www.nhmrc.gov.au/publications/synopses/ch39syn.htm.

Also attached is a flier promoting the re-issuing of the Joint Statement and the vitamin K brochure for your distribution.

If you have any questions, please call me on 02 6217 9013.

Kind regards,
____________________________________________________
Marion Carey
Project Officer | Health Evidence & Advice
National Health & Medical Research Council

Homebirths 2008 in Victoria

2010-12-29T18:21:00.002+11:00

For summary and comment go to the APMA blog.

A NEW ERA IN THE USE OF DRUGS IN OBSTETRICS - Primal Health Research Newsletter Vol 18. No 2

2010-12-26T18:41:00.002+11:00

PRIMAL HEALTH RESEARCH

A NEW ERA IN HEALTH RESEARCH

Published quarterly by Primal Health Research Centre

Charity No.328090

72, Savernake Road, London NW3 2JR

michelodent@googlemail.com

Winter 2010 Vol 18. No2

**************************

www.primalhealthresearch.com

(Free access to the Primal Health Research Data Bank)

Click on

www.wombecology.com

(The route to early birds REGISTRATION for the Midpacific Conference on Birth and Primal Health Research. Honolulu October 2012))

Michel Odent will be on tour in Australia in May, speaking at the CAPERS Passage to Motherhood Conference in Brisbane, and at Workshops in Melbourne, Sydney, Perth, as well as Christchurch and Auckland (NZ) on other dates. Click on the website for details, and to register.

A NEW ERA IN THE USE OF DRUGS IN OBSTETRICS

In a typical modern birth, the release of natural oxytocin is replaced by an intravenous drip of synthetic oxytocin, while an epidural analgesia is a substitute for the physiological systems of protection against labour pain, particularly the release of endorphins. Until now pharmacological assistance in childbirth has been based on a simplistic principle, which is hormonal replacement. Even if, in the near future, the basic needs of labouring women are universally accepted, and even if non-pharmacological methods for facilitating the physiological processes develop, one cannot imagine the end of pharmacological assistance in childbirth.

Learning from clinical observation

One can anticipate, however, the development of a new basis for this kind of assistance. This new step will imply that the specifically human handicap in childbirth is understood. In other words, it implies that the concept of neocortical inhibition is not ignored any more.

This leads me to recall how, in 1964, I suddenly and unexpectedly understood the most important aspect of birth physiology. A friend of mine, a medical doctor working for a French pharmaceutical firm, gave me some samples of the recently synthesized Gamma-Hydroxybutyric acid (GHB). In the context of the 1960s he was already in a position to explain that it was an analogue of GABA (Gamma-Aminobutyric acid) and that it could not be dangerous since it was an integral part of the mammalian central nervous system.1 This newly commercialized substance was presented as a sedative medication and as a promising agent in anaesthesiology. My friend added that, according several preliminary reports, it was also sharing the properties of oxytocin.

This is how I had the experience of births with drips of what is called in France Gamma-OH. With such a drip labouring women were getting completely crazy, shouting in the corridors, pulling out their intravenous needle, scaring the midwife...but the baby was born right away. Of course such scenes we unacceptable in a hospital setting and we had to be cautious with possible unreported negative side effects. The main result of this audacious experiment – that we had to stop immediately – was a sort of revelation: when the activity of the neocortex is eliminated, human beings have more similarities with the other mammals: this is what makes birth easy. I had understood the concept of neocortical inhibition and the solution nature had found to overcome the human handicap. I had understood that the neocortex of a labouring woman must not be stimulated.

Since that time we have learned a lot about the inhibitory effects of GHB and GABA.2 In fact GHB has found limited clinical use as an anaesthetic agent. On the other hand, a widespread interest for this drug developed recently, because it has emerged as a major recreational drug and public health problem. Illicit forms are available under a number of names, such a G, or liquid ecstasy. Its property to neutralise neocortical inhibitions explains the notoriety of this “date-rape drug” – in other words a compound used to facilitate sexual assault.

My understanding of the effects of neocortical inhibition in childbirth has been reactivated about ten years later through another significant anecdote. A young mother was celebrating the birth of her one day old baby in a double bedroom. Her neighbour was in prelabour. This is how glasses of champagne were exchanged. The effect of champagne was so spectacular that a baby was born through a ‘fetus ejection reflex’ on the way to the birthing room.3 It is well known that champagne is a special wine. Thanks to the bubbles, alcohol is brought immediately to the brain. The ability of alcohol to change human consciousness has been known for ages. Today we understand how alcohol works: one of its effects is to bind to the GABA receptors.4

I also learned a lot from the easy way schizophrenic women were giving birth before the widespread use of powerful antipsychotic treatments. It has been demonstrated that unmedicated schizophrenic people have neocortical inhibition deficits. Interestingly powerful antipsychotic drugs such as clozapine tend to potentiate the effects of GABA.5

Learning from word of mouth

It is significant that the psychedelic drugs used for their spiritual virtues have also been used to facilitate labour. This is the case of cannabis, which has been, and still is, a Holy plant in many cultures all over the world. Although some European countries, Canada, and some US states have legalised medical cannabis, it is only through anecdotes and word of mouth that we are learning about its actual effects in the particular case of the birth process. The biochemical effects of the cannabinoids – the most prevalent psychoactive substances in cannabis – have been widely studied. In 1990, the discovery of cannabinoid receptors located throughout the brain and body, along with endogenous cannabinoid neurotransmitters, suggested that cannabis affects the brain in the same manner as a naturally occurring brain chemical. Cannabinoids play an easy to observe role in neocortical activity, with a distortion of the perception of time and space; furthermore, they affect pain transmission by interacting with the system of endorphins.6 Their effects on the birth process can therefore be easily interpreted.

The Daime, a drink known generically as Ayahuasca, is another typical example of a drug used for both its spiritual virtues and its reputation to facilitate the birth process. It is the basis of a spiritual practice, the Santo Daime, which was founded in the Brazilian Amazonian state of Acre in the 1930s and became a worldwide movement in the 1990s. Because the Daime is legal for religious use in Brazil, some midwives know about the effects of this drug during labour and do not hesitate to report their observations. This decoction is made from two or more plants, such as the leaves of ‘Psychotria viridis’, which have high concentrations of the psychoactive compound dimethyltryptamine. Not only is this substance found in many plants, but it is also created in small amount by the human body during normal metabolism. Its natural function remains undetermined. The stomach normally digests it, so that it does not reach the brain if consumed orally, except if it is mixed with a ‘monoamine oxidase inhibitor’ (MAOI). Interestingly the Daime also contains a vine, such as Banisteriopsis caapi, which is a source of MAOI. One can wonder how the natives found this combination without knowing anything about the interaction in the stomach of dimethyltryptamine and MAOI !

All drugs have side effects.

The point is not to promote the use in childbirth of GHB, marijuana, daime, or even champagne. It is much more to learn from the effects of drugs that do not belong to the official pharmacopoeia, and to realise that as long as birth physiology is not understood as a chapter of brain physiology, pharmacological assistance in childbirth is reduced to hormonal replacement. The current dominant approach is based on the use of substitutes for oxytocin, endorphins, and prostaglandins. It is possible that in the near future a greater importance given to the concept of neocortical inhibition, new questions about plastic related substances such as phtalates, and new questions about the transfer of synthetic oxytocin across the placenta and the fetal blood brain barrier will justify a more cautious use of what is today the main component of pharmacological assistance in childbirth.

However all drugs have side effects and it takes time to evaluate risks and benefits of new pharmacological agents. In the case of drugs that interfere with brain functions, it will be essential to think long-term, in other words to take into account the primal health research perspective. This is suggested by animal experiments, such as those by Carol Kellogg, who studied the long-term consequences on the offspring of diazepam – a widely used sedative drug acting on the GABA receptors. One of the significant conclusions of her experiments is that exposure to this drug at the end of fetal life induces behavioural effects that do not become apparent in exposed animals until young adult ages.7 There are other significant conclusions of these series of studies suggesting the need to think long-term when manipulating brain receptor during the early phases of development. For example if male rats have been exposed to diazepam before being born, the expected adolescent surge of testosterone does not occur.8

The importance of keeping in mind the possible long-term effects of drugs used during the perinatal period is also a lesson to learn from studies by Bertil Jacobson and Karin Nyberg about the risk factors for drug addiction: opiates and nitrous oxide used during labour appear as risk factors in all their studies.9,10,11,12

Finally, even if a more cautious approach regarding pharmacological assistance in obstetrics is probable during the twenty first century, and even if the concept of in-labour non-emergency caesarean is better understood, the priority will always be to rediscover the basic needs of labouring women, as long as the main objective is to facilitate in our societies the release of an abundant flow of love hormones in critical periods of human life.

Michel Odent

References:

1 – Laborit H. 4-hydroxybutyrate. Int J Neuropharmacol 1964;32: 433-451

2 – Snead OC, Gibson M. Gamma-hydroxybutyric acid. NEJM 2005; 352:2721-2732.

3 – Odent M. Champagne and the fetus ejection reflex. Midwiferytoday

4 - Santhakumar V, Wallner M, Otis TS. Ethanol acts directly on extrasynaptic subtypes of GABAA receptors to increase tonic inhibition. Alcohol 2007; 41 (3): 211–21.

5 - Liu SK, Fitzgerald PB, Daigle M, et al. The relationship between cortical inhibition, antipsychotic treatment, and the symptoms of schizophrenia. Biol Psychiatry. 2009 Mar 15;65(6):503-9. Epub 2008 Oct 31.

6 - Fattore L, Cossu G, Spano MS, et al. Cannabinoids and reward: interactions with the opioid system. Crit Rev Neurobiol. 2004;16(1-2):147-58.

7 - Kellogg CK, Yao J, Pleger GL. Sex-specific effects of in utero manipulation of GABA(A) receptors on pre- and postnatal expression of BDNF in rats. Brain Res Dev Brain Res 2000 Jun 30;121(2):157-67.

8 - Kellogg CK, Kenjarski TP, Pleger GL, Frye CA. Region-, age-, and sex-specific effects of fetal diazepam exposure on the postnatal development of neurosteroids. Brain Research 2006 Jan 5;1067(1):115-25. Epub 2005 Dec 22.

9 - Jacobson B, Nyberg K. Obstetric pain medication and eventual adult amphetamine addiction in offspring. ACTA Obstet. Gynecol. Scand. 1988; 67:677-682

10 - Jacobson B, Nyberg K. Opiate addiction in adult offspring through possible imprinting after obstetric treatment. BMJ 1990;301:1067-70.

11 - Nyberg K, Allebeck P, Eklund G, Jacobson, B. Socio-economic versus obstetric risk factors for drug addiction in offspring. Brit. J. of Addiction 1992; 87:1669-1676

12 - Nyberg K, Allebeck P, Eklund G, Jacobson, B. Obstetric medication versus residential area as perinatal risk factors for subsequent adult drug addiction in offspring. Paed. and Perinatal Epid. 1993;7: 23-32.

[This article has been posted with permission of the author, Michel Odent. ]

The “right to respect for private life” in Europe

2010-12-21T20:40:00.002+11:00

The following article is copied from the Hungarian Civil Libities Union site.

Victory in Strasbourg for the cause of home birth!
December 14, 2010 17:03

Today, the European Court of Human Rights in Strasbourg handed down a judgment in which it holds that the Hungarian state has violated the “right to respect for private life” guaranteed by the European Convention on Human Rights.

Exactly one year ago today, a pregnant Hungarian woman applied to the European Court of Human Rights. In her claim, the complainant alleged that the Hungarian state had violated her right to the respect of her private life by threatening midwives with sanctions and thus effectively preventing her from choosing to give birth at home. The complainant was represented by the HCLU’s attorney, Dr. Tamás Fazekas.

In its decision announced on 14 December 2010, the Court, in a decision of 6 against 1, held that the failure of the Hungarian state to regulate the issue results in a violation of the right to privacy guaranteed by Article 8 of the European Convention on Human Rights. A joint concurring judgment was submitted by Judges Sajó and Tulkens, while Judge Popovic wrote a dissenting opinion.

(1) The Court held that the right to respect for private life includes the right to choose the circumstances of birth.

(2) The Judges argued that the section of the Government Decree that imposes fines on midwives assisting at home births constitutes an interference in the exercise of the rights of the complainant and of similarly situated pregnant mothers.

(3) According to the Court’s opinion, the threat of sanctions – along with the absence of a specialised, comprehensive regulation in this area – are detrimental to the complainant’s ability to choose home birth. This in turn constitutes a violation of the legal security for the exercise of privacy rights, and in particular, violates the principle of legal certainty.

“We find this judgment to be very important”, stated Dr. Tamás Fazekas, attorney for HCLU, “because this means that, so long as Hungary fails to enact legislation regulating home birth, and so long as professionals assisting at out-of-institution births are unable to obtain a license for their work, Hungary is in violation of the European Convention on Human Rights”.

Survey on prescribing courses for midwives

2010-12-18T17:07:00.000+11:00

If you are a midwife practising privately in Australia, or if you intend to practise midwifery privately, please go to the APMA blog, read the message, and follow the links to the survey.

How can I plan vbac?

2010-12-04T11:58:00.002+11:00

The following letter (copied with permission) has been received from a woman who would dearly love to give birth spontaneously to her child next July.

I am 'just' pregnant, about 8 weeks. I had an 'emergency' caesarean with my first child after going with midwife led care through at XX Hospital.

I had a really hard time coming to terms with having has a caesarean and now seem to have anxiety when going in to the hospital.

We are a 1 income family and on a health care card, so although I would love to have a homebirth it is not going to be possible. I have contacted [a MIPP] and was hoping I could get medicare covered antenatal care and possible birth support in hospital, but after reading from your blog and midwives Victoria website this looks like it also won't be possible.

I am typing to you with tears in my eyes because I am unable to have the birth I want because I don't have enough money. Is there anything I can do?

I wrote many letters to the government during the health services review and am just so angry that we are not treated normally, respectfully and responsibly. Someone else's decision for me to have a caesarean means my choices are so limited now and that frightens me.

Every reader will probably see something different in this brief note.
The risk of attempting vbac is often mis-understood and overstated, leading to risk management protocols in hospital that are likely to lead to repeat caesarean surgery. Click here for more detail on risk.

The obstetricians' College Statement sets out advice on TOL (trial of labour), including:

admission to hospital relatively early in labour
intensive maternal and fetal surveillance intrapartum, including continuous electronic fetal monitoring.

Midwives advising women who are intending to give birth physiologically will encourage minimal interference as labour establishes and progresses. If their plan is to go to hospital for the birth, the transfer will usually occur after the labour has established. Key features of midwife care for planned vbac include:

trust: the woman and midwife establish a partnership based on reciprocity and trust
the woman calls the midwife to be with her at her home when her labour has established
the midwife carries out basic assessments of fetal and maternal wellbeing, and progress, in an unobtrusive way
the woman is able to proceed to home birth vbac, or to make an informed decision to go to hospital when and if needed

Clearly there is a huge difference in the way independent midwives and obstetricians approach vbac. There is no evidence of poor or worse outcomes when women plan vbac at home. Some go to hospital; some proceed to vaginal births in hospital and some proceed to another caesarean birth.
The woman who, like the writer of the note inserted in this post, is unable to afford the 'luxury' of a private midwife, may feel abandoned by a maternity care system that does not provide optimal care for her.

HOWEVER ...

The only way ANY woman can have a vbac is if she gives birth under her own power, in harmony with her body’s natural processes in birth. It’s not about place, or even care providers.

It’s about being well at Term, coming into spontaneous labour, and progressing well. That all happens at home. If you can do that you can give birth in the hospital without too much trouble, and no one can stop you.

visiting access to public hospitals?

2010-11-25T17:28:00.001+11:00

Midwives who are members of MiPP have been writing letters to the directors of their local public hospitals, enquiring about implementation of the government's reforms that will enable midwives to attend women privately in hospitals.

A draft of the letters is posted at this blog.

[click picture to enlarge]

The attached letter has been received in response to the MIPP letters to Box Hill and Angliss hospitals, which provide maternity services for women the Eastern and outer-Eastern suburbs of Melbourne. This area, coincidentally, is also home to a considerable proportion of the midwives who are in private practice in Victoria.

Note that the hospitals are seeking legal clarification around the collaborative arrangements determination – “to make collaborative arrangements workable for everyone involved.”

Breaking down the medical monopoly as far as midwives' access to hospitals is concerned will be one of the most significant changes of the government's maternity reform. The marginalisation of independent midwives, and consequently of homebirth, has come about because there is no other place where midwives can enter private agreements to provide professional services for women.

Of course women planning homebirth and independent midwives can continue to use public hospitals as public patients for homebirth backup, but the option of a privately employed midwife who has clinical privileges in a hospital is a model of care that doesn’t exist in this country at present. It will take some courageous midwives, and the women who employ them, to be front runners.

Midwives with Medicare provider numbers

2010-11-23T10:29:00.005+11:00

If you have been following this and linked blogs you will know that the government's provisions for eligible/authorised midwives to have Medicare provider numbers, enabling their clients to claim some rebate on fees for private midwifery services, are now operational.

At the time of writing, we know of two midwives - one in Qld and one in NSW - who have successfully negotiated the legislated requirements for notation as eligible midwives, and are offering Medicare rebates in this way for prenatal and postnatal items. [For details of the rebates payable on midwifery services, go to Federal Register of Legislative Instruments F2010L02640]

We are not aware of any midwife practising privately with Medicare rebates for intrapartum (labour and birth) care in a hospital. The state and territory government health departments are "working on" arrangements for midwives to be awarded visiting access to admit private clients to public hospitals. The other possibility, that a private obstetrician employs an eligible midwife, thereby enabling the midwife to access Medicare, providing services for private midwifery care, presumably in a private hospital, is another pathway that seems theoretically possible. MidwivesVictoria will keep readers informed as information is received.

If you are a 'consumer' of midwifery services - a woman who is pregnant or who is planning to have a baby in the near future - you may be wondering if there is a midwife near you, who is able to offer Medicare rebates on her fees. The names and locations of eligible/authorised midwives will not be posted on this blog, but inquiries will be forwarded to email lists so that any midwives practising privately in the area are able to respond. If you do not want to use the comments function on this blog, please send an email to mipps@maternitycoalition.org.au

4 December 2010

ps: Liz Wilkes from Toowoomba (Qld) has attended the country's first Medicare-Midwife birth. For details follow the link at the APMA blog.

What the women said ... 3

2010-11-14T19:28:00.001+11:00

... in their submissions to the Maternity Services Review.

Today's theme is homebirth. Access to homebirth midwifery services, funding for homebirth, acceptance of homebirth, evidence supporting homebirth ... themes that were a repeated refrain in many submissions.

"Women have been the big losers in maternity care for many years. The promise of a maternity review at the 2007 election to put women first has been a farce. The 900 submissions were more than the whole of the Health and Hospital Reform consultation process. Over 400 of these called for access to homebirth, yet the report of the maternity service review and subsequent budget excluded homebirth."

[Justine Caines, Daily Telegraph]

Theme 3: Homebirth

3.1 "resentful and disempowered" in private hospital [028]

I gave birth to my daughter in a private hospital, and despite having a completely natural and postive birth, I felt resentful and disempowered with the pregnancy and postnatal "care" I received from the obstetrician and hospital system, including the labour and birth and hospital stay.
I have since given birth to my son at home, and had the most wonderful care throughout the whole pregnancy, birth and postnatal period from my midwife, whom I will be engaging next time round when we have our next baby.

3.2 Trust [032]

We homebirthed our three children with the assistance of beautiful, confident midwifes. They guided and assisted us through the physical and emotional relationships with our new baby and ourselves. The core of this is TRUST in myself to birth in a strong, empowering way, in my partner to support me in this process and in our midwife.

3.3 Cost of homebirth [048]

We have a 15 month old boy who was born at home by our choice (based on a lot of research which proved that home-births had better outcomes for mother and baby). It was a truly amazing experience for us and we feel by doing this we also helped reduce the strain on local hospitals, who at the time had a women give birth in the waiting room due to the lack of availability of delivery rooms (due to a baby
boom).
...
We would love to have another child, maybe even another couple of children, however due to the cost, we don't know if this will be an option for us (we are young parents struggling to meet loan repayments for our house). ... A homebirth costs around $3500-4500 in rural regions, more in cities. ... Seems a little unfair given that those that birth at home are actually doing the government a favour by reducing the burden on hospitals. It seems very likely that we won't be having a baby for the country!!

It would be ideal if medicare could cover some of the costs of homebirths to make this option more affordable (especially for those that can't afford private health insurance). I believe if more people knew about the advantages of birthing at home and it was a lower cost option than hospital, a much larger percentage of the population would be birthing at home (we are your typical young married couple,
homebirth is not just for "hippies"). And thereby reducing the burden on hospitals. For the poorer amongst us that have babies, they birth in public hospitals, this is the only option, they cannot birth at home because HOMEBIRTH IS UNAFFORDABLE!!.

3.4 Confident with home birth [106]

I am sharing with you my personal views and experiences in hope of contributing to the much needed changes surrounging maternity issues.
I started my family quite young. I have a 20 month old and twins due in 4 weeks and I have just had my 23rd birthday. For all my children I have planned homebirths, my first being so successful I feel confident to birth my twins at home.

3.5 HBA2C Birth at home after two Caesareans [814]

On consultation with the local and only practising obstetrician (for what is considered within the current health system a high risk pregnancy, by virtue of previous caesarean) we were unhelpfully informed that the mother in question had "..a morbid desire to achieve a natural birth at any cost" and that "..two caesarean sections in the uterus constitute a potentially lethal medical condition for herself and her unborn baby. She has placed herself and her unborn baby in danger once before and she is attempting to do this again. In the circumstances she should at least have psychological counselling and assessment." We were threatened with a notification to Department of Community Services as it was insinuated that our desire to birth without unnecessary intervention was a form of reckless endangerment of the unborn child.

Our baby's birth was conducted without tying up limited resources in our hospital system, the same system that did not allow a trial of the birth by natural methods, utilising the safeguard of emergency services should they be required without transfer. The birth proceeded without the use of drugs, and did not involve significant abdominal surgery as was proposed as our only option in the health care system. Further, the mother was in her own environment during recovery, leading to the minimum of disruption for the family unit. Our independent midwife has continued postnatal care over the past week, visiting 3 times within the week to check mother & baby's health and progress post birth.

3.6 8 children born at home [810]

We are in our 40s and we have birthed all of our 8 children at home in the care of an independent midwife.

What the women said ... (2)

2010-11-10T12:53:00.000+11:00

... in their submissions to the Maternity Services Review.

Today's theme is, for want of a better word, 'rural'. This means distance, relative isolation, lack of access to services, and much more. Here are some direct quotes. Women's descriptions of their own feelings have been highlighted. The number noted in square brackets [n] denotes the reference number for the submission.

Theme 2: Giving birth in Rural Australia
2.1 Excluded from local hospital 'low risk' maternity service [030]
I write this to you as a mother of four children who had to travel 80 kilometres just to give birth to them.

When my husband and I found out that we were expecting our first child, due to be born in early 2001, we were hoping that we would be able to birth him in our brand new local hospital, which was completed in the previous year. It was a state-of-the-art facility, complete with Maternity ward and we were excited to think that our child could be born there. Although we knew that in the “old” hospital that the Maternity unit had been downgraded to only accept those women considered “low risk” – women who had no previous complications during birth and those who were multiparas (women on subsequent pregnancies), we hoped that with this new hospital it would bring a new opportunity for those women previously excluded to be able to birth there.

But we were to find out that the status quo would continue at the new hospital. This meant that I was excluded from our local hospital and that I would now have to travel a 160 kilometre round trip to the next town to see a Doctor I had never met before, in a town I didn’t frequent and give birth in a hospital far away from family. There was the vague hope that after I gave birth I would be able to travel back to my local hospital for my post-partum hospital stay, but within 6 months of my falling pregnant, even this option was taken away from me.

And even then there was no guarantee that I would give birth in this hospital. It was only a small District Hospital and could only take women after 38 weeks of gestation, women with singleton pregnancies, women with no health complications for themselves or their babies. If you were in any way considered to be “high risk” then you were forced to travel to the NEXT hospital, which was a further 80 kilometres away.

The situation has only become more dire as the years have gone on. Not one single pregnant woman I talk to doesn’t have concerns that she will not make it to the hospital in time and fears either giving birth at home unattended or by the roadside. This raises another, separate issue, in that the husbands and partners of these labouring women are under even more pressure to get them to the hospital “on time”.

It makes me wonder if women and their babies will have to start dying before anything is ever done about this situation.

2.2 What models are needed for maternity services for rural and remote communities? [279]
All women wherever they live throughout Australia, want the option of giving birth to their babies in their own communities in a shared experience with their families, even if this does not eventuate, but most importantly they want to be sure that the experience will be safe, both for themselves and for their baby.

Women in rural and remote areas are no different from their city sisters in having the same wishes, but rarely are these wishes realised. If their preferred option is not available locally they have to travel away from home, sometimes long distances to metropolitan centres, where they are dislocated from their support structures. They often have significant financial outlays for travel and accommodation. However, like most people who live in rural, regional and remote areas, they are pragmatic, and accept that they need to make some compromises for living in small communities. Nevertheless they have a right to access more options than currently exist for them.

The most pressing needs faced by families in rural and remote areas are to have
• A range of service options that are Geographically accessible
• Assistance with travel to access services only available at a distance.
• Special consideration for women with complex needs.

2.3 Midwife in local community, and suitable accommodation for families [272]
I live in a very small rural community on Eyre Peninsula, South Australia. Our home is a two and a half hour drive from the Port Lincoln Hospital, where my two children were born.
In particular we feel that the services provided by the Community Midwife were exceptional. It was a joy to have this naturally caring and very experienced lady visit our home during pregnancy and in the early weeks of our babies’ lives. She was always ready to listen and offer practical advice to help us through various issues, either in person or over the phone. By completing a range of tests at home, we were spared long and expensive trips to see the doctor. The Community Midwife is an essential service for small, remote areas such as ours.

The biggest concern I have had is lack of suitable accommodation for pregnant women from surrounding regions in Port Lincoln. Two weeks before my second baby was due I had to stay at my sister’s in-laws nearer to Port Lincoln. Other local women’s experiences have included staying for several weeks at a caravan park, and having to clean a rental house immediately after leaving hospital. We need a better solution.
I feel very strongly that women from the areas surrounding Port Lincoln need access to a special house in Port Lincoln where they can stay with their partner and family in the final week or two of pregnancy. Partners and older children also need somewhere to stay while mum stays in hospital. Mothers may even be able to leave hospital earlier and stay in the house with a midwife’s support. A special ‘Rural Maternity House’ would take away many concerns that long distance mothers have. It would make pregnancy and labour safer and more positive for all.

What the women said ...

2010-11-07T17:43:00.003+11:00

... in their submissions to the Maternity Services Review

The website at which the submissions are posted has a statement:

We have received many personal accounts from individuals. These provide a valuable insight into people's experience of maternity care in Australia and were considered by the Review Team in preparing the Review Report for the Minister.

Today I have taken the opportunity to look at just a few of those personal accounts from individuals, and separated out into themes (not in any particular order). Today's theme is Caesarean births and VBAC. Here are some direct quotes. Women's descriptions of their own feelings have been highlighted. The number noted in square brackets [n] denotes the reference number for the submission.

Theme 1: Caesarean births and VBAC

1.1 Cascade of interventions in primiparous woman at a birth centre [515]

For my first child, I was 25 and healthy, considered “low-risk”. I booked into the local Birth Centre at the public hospital (it sounds easy but in reality I was put on a ballot, missed out, then made it in when some poor unfortunate woman was shunted out for whatever reason). I attended antenatal appointments with the same midwife, who I thought was on the same page as me regarding birth. I wanted a drug free, intervention free birth. I was well-informed and well-educated.

However during labour my midwife told me she had to perform several interventions which I had been led to believe weren’t routine in the Birth Centre. These included vaginal exams (VEs), the premature rupturing of my waters, and coached pushing (when I was actually not fully dilated and not wanting to push yet as it didn’t feel right).

It is hard to stand up for yourself during labour, so I did not protest any of these interventions, yet they caused, in a cascade of interventions, my cervix to swell and my progress went backwards. My midwife said I needed an epidural and syntocinon to speed things up, even though that was the last thing I wanted, but quite disheartened I agreed. After getting me set up she then left to go home, which I saw as abandonment. My continuity of care ended there. After a few hours I was at the same point, having apparently progressed no further, and the obstetrician suggested a caesarean. Quite defeated and wanting the whole sorry ordeal over I consented to a caesarean that would have been completely unnecessary had my midwife kept her hands to herself.

1.2 Caesarean followed by a feeling of disconnectedness and a profound sense of grief [538]

I had my first baby by emergency caesarean section in a public hospital after a planned home birth. My main care provider for this pregnancy was a community midwife with the Community Midwifery Program here in Perth. During the pregnancy I felt supported by my midwife in any decisions I made about my pregnancy and birth options (Routine ultrasound, strep B testing, water birth etc), and despite the resulting caesarean section, I felt the continuity of care was extremely valuable in making my pregnancy an exciting event for my family, as were able to create a caring and professional relationship with my midwife, leading to feeling secure as my birth approached.

During the birth I experienced great care at home from my primary and back up midwife, however once we transferred to hospital, their role as my primary care providers was not recognized by the hospital, and subsequently I lost faith in my body’s ability to birth as I received fragmented care from a number of different midwives and at least 3 different obstetricians, all of whom I had never met, and who did not take the time to discuss the progress of my labour with me. My resultant Caesarean section was a traumatic experience, and I was not able to hold my son immediately, leading to a feeling of ‘disconnectedness’ from him which sadly lasted well into his first year.

After the birth I experienced symptoms similar to those which I now believe similar to Post Traumatic Stress Disorder, with an inability to sleep, flashbacks of the anesthesia and caesarean procedure itself, and a profound sense of grief that my experience of meeting my first born child had not been the joyous occasion I had hoped it would be.

1.3 VBA2C [404]

Our first baby was born in private hospital by emergency caesarean after a failed induction. My husband and I were left to ourselves in the delivery room for long periods. When we did see someone they were total strangers, people we had never before met, who came and went as shifts changed. Minimal help with breastfeeding was provided until 4 days later I had a wonderful agency nurse who spent an hour in the middle of the night giving me the support I so desperately needed. The whole experience was very frightening and traumatic. I was subsequently diagnosed with postnatal depression.

During my second and third pregnancies we paid for our own private midwife who was with me during the pregnancy, labour and post birth. Although our second child was also born by emergency caesarean, I had the continuity of care that made all the difference to the experience. She was with me throughout labour, then in theatre, and afterwards she helped me in recovery where she enabled my baby to stay with me and ensured I received all the help I needed with establishing breastfeeding.

Finally, with the support of my own midwife I was able to birth our third child vaginally, without intervention and will never forget the hormonal high and feelings of self respect, dignity and peace that contrasted so starkly with the terror, grief and despair I felt when my first child was born.

1.4 Emergency Caesarean followed by VBAC [516]

I had my first baby in a public hospital. He was born by emergency caesarean because he was brow presentation. ... I had assumed that my care at the hospital would be in keeping with basic tenets of human rights- that I would be treated with dignity and respect during birth. This was not my experience.

During the 13 hours of labour prior to the emergency caesarean I experienced a shift change of midwives and felt that the second midwife wasn’t confident to guide me. I felt that she gave up on me. I remember her telling me that she had recently had a caesarean and that it wasn’t that bad. I had painful internal examinations during contractions. The bright lights and the public nature of the environment made me feel violated. This fragmented care with people moving in and out of the birthing room upset the flow of events.

Once the wave of interventions had begun I felt there was no any other option in that environment than to do what I was told and to be a ‘good girl’. Several professionals told me that I would be risking my baby to try anything different. I was frightened, I felt coerced and patronised by the midwives and the obstetrician. I demanded that I try every other monitoring option prior to the surgery which was my most feared scenario. As a way of trying to reclaim some sense my own power in the birthing process I wanted to have my baby remain with me and I wanted somebody to stay with me in recovery. I was denied both of these. Post surgery I lay on a bed for an hour shivering alone, without my baby. I felt exposed and ashamed. This deeply impacted my confidence and the crucial bonding with my baby and set the conditions for what I now recognise as Post Traumatic Stress after the birth. I believe this was caused by a combination of factors namely a restrictive birth environment. I suffered a deep sense of failure and grief which has only been resolved with my second birth.

I approached the second birth very differently and chose a homebirth. My partner was also very enthusiastic that we try this after the previous hospital experience. In spite of the fear mongering about VBAC and the dangers of uterine rupture my second baby boy was born peacefully at home in the water. My main care provider was a midwife in private practice. During the pregnancy I experienced great support to make my own choices. During the birth I had no internal examinations. There was no sense of time constraints during the nine hour labour. It was on my own terms and I felt comfortable and safe in my home environment. I felt that my midwife trusted in my innate ability to birth and believe this had a very powerful effect on the birthing outcome.

After the birth I felt great satisfaction and reclamation of my own dignity. I believe this was due to the wonderful support provided by my carer and the continuity of care I experienced.

These four accounts speak eloquently for themselves.
Recommendations of the Report of the Maternity Services Review (The Report) include:
"2. That the Australian Government, in consultation with states and territories and
key stakeholders, initiate targeted research aimed at improving the quality and
safety of maternity services in select key priority areas, such as evidence around
interventions, particularly caesarean sections, and maternal experience and
outcomes, including from postnatal care."
The Report trivialised homebirth and stated that "Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28" The Report ignored the many submissions by women who called for greater access to home birth and private midwifery services.

Comments from readers are welcome.

Singing group in Northcote for pregnant women

2010-10-30T16:29:00.000+11:00

Ten Moons is a singing group for pregnant women. It provides a creative and safe space for women to come together and sing music that is all about feeling good. Experience some of the incredible health benefits that singing can offer during pregnancy and meet with other women in the community over song and a cup of tea.

For more information contact Gabby 0425 774 543 or email tenmoonsong@gmail.com

Medicare funding from 1 November 2010 ?

2010-10-22T16:00:00.002+11:00

Some midwives and maternity consumers are waiting eagerly for the ability to claim Medicare payments for private midwifery services. A previous post gave the link to the Medicare fee schedule, and discussion on the required signed collaborative arrangement with one or more doctors that must be in place for a midwife to apply for a Medicare provider number.

To search for the legislative instruments go to the Commonwealth Government site.

This is a brief status update. With only a week until 1 November, we are wondering how it's progressing.

It appears that Medicare is ready to give midwives provider numbers and to rebate midwives' fees, AHPRA is not. It appears that AHPRA does not yet have a process up and running to proceed with applications for notation as an eligible midwife.

The optimists among us suppose that women will be able to back-claim from November 1 for Medicare. We will be interested to see what happens there.

We have been advised not to use the application form for notation as an eligible midwife on the AHPRA website as it needs to be amended – does not fit the criteria for eligibility. Will be re-loaded in a few weeks …

Remember the signed collaborative arrangement between an eligible midwife and one or more doctors, which is a mandated part of the provision of Medicare for midwifery services. Many midwives believe this law (Determination) denies the midwife's right to practise on her own authority, and potentially allows a doctor to veto the professional agreement between a midwife and a woman in her care. See the Australian Private Midwives Association (APMA) statement on the Collaborative Agreement.

Much more could be written, but it's Friday afternoon and my mind is tired. I hope this update is of use to some of our readers.

Midwives wishing to apply for a Medicare Provider Number can access information and forms at the Medicare website.

Letters to public hospitals

2010-10-19T16:53:00.000+11:00

Members of Midwives in Private Practice (MiPP) are sending letters on behalf of MiPP to public hospitals with maternity services, requesting a process that will enable midwives to achieve visiting access to provide private midwifery services for our clients in the hospital.

This is the pro-forma of the letter:

Director of Maternity Services
XXX Hospital

Dear XX
I am writing with reference to the recent health practitioner registration reforms, particularly in relation to eligible midwives being insured for the full scope of midwifery services including attending birth in hospital. The changes include the availability of government supported professional indemnity insurance for midwives, and being able to access Medicare provider numbers and limited prescribing and ordering of tests.

We understand that the reforms that impact on primary maternity services are intended to be consistent with the key principles developed by Australian Health Ministers Advisory Council (AHMAC 2008) “Primary Maternity Services in Australia – A Framework for Implementation. (Attachment 1). Midwives in private practice support each of these key principles, and look forward to being able to provide quality primary care for women who plan to give birth in hospital.

Members of Midwives in Private Practice (MiPP) and Australian Private Midwives Association are contacting all public hospitals to request details of how eligible midwives may proceed to apply for visiting access/clinical privileges. Would you please inform me of how your hospital is proceeding with implementation of the relevant changes, and the process for application and implementation of visiting access for midwives who are not employed by the hospital.

Yours sincerely

XXXX
On behalf of MiPP

ATTACHMENT 1

KEY PRINCIPLES
“Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” articulated the following principles which underpin the range of models of maternity care available to women in Australia. These principles involve:
• ensuring services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience

• ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman

• maximising the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals such as paediatricians and Aboriginal health workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery

• offering continuity of care, and wherever possible continuity of carer, as a key element of quality care

• ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence ¬based best practice care

• ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework

• providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required

• working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.

AIMS for a better birth

2010-10-14T08:39:00.000+11:00

AIMS is the Association for Improvements in the Maternity Services.
AIMS has been at the forefront of the childbirth movement for more than forty years.

* Working towards normal birth
* Providing independent support and information about maternity choices
* Raising awareness of current research on childbirth and related issues

Although AIMS is based in the UK, many of the challenges in maternity services are the same in Australia, and globally.

excerpts from AIMS Informed Consent
An analysis of enquiries to the AIMS Helpline reveals that almost without exception women who intend to birth at home are given a long list of the ‘risks’ the staff perceive them to be taking. We have yet to hear from any woman who was also given a list of the risks of a hospital birth, so we have produced our own and suggest that this should be handed out to all women who intend delivering in hospital.

INFORMED CONSENT FOR GIVING BIRTH IN HOSPITAL

This Trust supports the view that women have choice and in order properly to exercise that choice they need to be fully informed of the risks in association with childbirth.
The following are the risks of a hospital delivery:

This hospital operates a shift system which means it is unlikely that you will be attended by the same midwife throughout your labour.

Because [the hospital is] short of staff you are unlikely to have the continuous support of a midwife as she will probably be trying to attend to at least two other women.

As this hospital has a 25% [to 30%] caesarean operation rate this means that you have at least a 1 in 4 chance of having a caesarean. Please be aware that this is major abdominal surgery that:

doubles the risks of maternal mortality,
increases the risk of damage to other internal organs and blood vessels,
carries a risk of infection, which may prolong a hospital stay,
interferes with the establishment of breastfeeding and
delays post operative recovery.

Research has also shown that this type of surgery:

produces harmful side effects according to which anaesthetic is used,
lowers fertility rates in women,
may increase the incidents of post natal depression,
adversely affects the baby because of the anaesthetic used,
can accidentally cut the baby as the incision is made,
produces babies who are less likely to breastfeed,
results in babies with breathing difficulties because they haven't received the benefits of being squeezed through the vaginal canal,
increases the risk of miscarriage in future pregnancies,
produces a greater risk of childhood asthma and
results in a greater risk of Sudden Infant Death Syndrome.

As the World Health Organisation has stated that there is no improvement to maternal or infant health when the caesarean operation rates exceeds 10% you should
understand that we are tr ying to reduce our caesarean rate.

...

You should understand that in this hospital, which is a high technology obstetric unit, only 1 in 6 women expecting their first baby and only 1 in 3 women expecting their subsequent babies will have a normal, straightforward, birth.

This hospital applies a time limit on the second stage of labour, this is not applied for your benefit it is imposed in order to ensure that you deliver as quickly as possible so that we can use your bed for another woman.

At this hospital the midwives will cut the cord as soon as the baby is delivered, this has adverse effects on the baby, but you need not worry we have resuscitation equipment at hand to help the baby breathe.

At this hospital the majority of women will give birth on their backs, despite the research indicating how this position increases the difficulty in pushing the baby out and causes trauma to both mother and baby.

This hospital prefers women to be quiet when they are in labour ... Therefore, in order to maintain a more subdued atmosphere, you will regularly be offered a range of opiate-based drugs ... Please be aware that this can lead to an increased chance of your child becoming a drug addict in later life and if administered at the wrong time during labour, will result in your baby being born in a dangerously stupefied state.

Do not worry, as the medical staff will inject the baby with an antidote as soon as it is born.

...

Source: AIMS JOURNAL VOL:19 NO:4 2007

Medicare funding from 1 November 2010

2010-10-09T17:54:00.003+11:00

The Health Insurance (Midwife and Nurse Practitioner) Determination 2010 has been released. To search for the legislative instruments click here.

We will keep our readers informed as soon as we hear of any progress by midwives in incorporating Medicare into their private practices.

There are widely different opinions held as to what the Medicare-Midwife will look like, what she will be required to do. Here is a section from the piece of regulation, the National Health (Collaborative arrangements for midwives) Determination 2010
...

5 Collaborative arrangements — general
(1) For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:
(a) the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;
(b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;
(c) an agreement mentioned in section 6 for the midwife;
(d) an arrangement mentioned in section 7 for the midwife.

(2) For subsection (1), the arrangement must provide for:
(a) consultation between the midwife and an obstetric specified medical practitioner; and
(b) referral of a patient to a specified medical practitioner; and
(c) transfer of a patient’s care to an obstetric specified medical practitioner.

...

This is legislative language that confuses many.

The Medicare-Midwife (medi-wife) will:

* have a close working relationship with a group of obstetricians (no doctors work 24/7 these days)
* provide prenatal checks in the community, possibly in 'rooms' shared with obstetricians or other doctors (it has been suggested that a new GP Superclinic could include medi-wives)
* attend births in private hospitals where she has visiting access, and where the 'senior' member of the professional team is always the obstetrician
* be able to order basic tests and prescribe basic drugs, such as oxytocics
* provide postnatal services for mothers and babies in hospital, and possibly at home.

It is not yet clear whether public hospitals, which currently provide obstetric backup for the clients of privately practising midwives who plan homebirth, will accept the new medi-wife as a practitioner with visiting access.

Midwives are at present contacting public hospitals and requesting details of the hospitals' processes and time lines in preparation for enabling midwives to practise in the hospitals with visiting access.

PRINCIPLES underpinning maternity reform

2010-10-05T10:10:00.004+11:00

Key Principles

“Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” articulated the following principles which underpin the range of models of maternity care available to women in Australia. These principles involve:

ensuring services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience
ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman
maximising the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals such as paediatricians and Aboriginal health workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery
offering continuity of care, and wherever possible continuity of carer, as a key element of quality care
ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence based best practice care
ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework
providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required
working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.

[This document is Attachment 1 to the draft Safety and Qualitiy Framework for private midwifery, a document which is currently being adopted by the Nursing and Midwifery Board of Australia]

Dissenting voices from ACMQ

2010-09-30T21:47:00.000+10:00

This message has been distributed widely, and is posted here with permission of Dr Jenny Gamble, representing the Queensland Branch of the Australian College of Midwives.

E Bulletin from ACMQ Executive Regarding the Medicare Determination:

The distribution last Wednesday of an e bulletin from the ACM national office concerning the Medicare determination has caused considerable confusion amongst members in Queensland and we believe does not present all of the options available to us.

ACMQ Executive acknowledges that the ACM National President and Board members are working hard on this issue and making some difficult decisions representing the colleges view at a national level. This E bulletin to members is in no way meant to be divisive or to detract from the work undertaken at national level. However, ACM national has concentrated on one option in the e-bulletin and we seek to provide an alternative for consideration by members.

In agreement with ACM national ACMQ Executive unreservedly supports Medicare for midwives, but the determination needs to be changed.

ACM Queensland Executive continues to have a bottom line position that we will not accept a “collaborative arrangement” with a medical practitioner that requires a signed agreement or provides an opportunity for a doctor to veto a midwives ability to access Medicare funding.

ACMQ Executive does not endorse the ‘keep silent, don’t rock the boat it’s too high risk’ position proposed by ACM national. .
ACMQ does not promote putting Medicare at risk.

...
ACMQ Executive believes that by using fear-based tactics the minister’s advisors have created panic that Medicare will not start and thereby hope to prevent midwives lobbying to change the determination. It is the opinion of the ACMQ Executive that pressure from the government on ACM National to cease lobbying to alter the medical veto over midwifery practice is a deliberate strategy to stop pressure to change the wording of the determination.

The Minister has the ability to change the determination any time. She clearly does not want to do so (and is possibly under pressure not to do so by the medical lobby) and will not do so unless midwives lobby.
...
ACMQ Executive offers the alternative position that we do not change our lobbying strategy. Members continue to ask for the wording in the determination to be altered. We recognise that in the immediate term it is unlikely that this will cause the Minister to change the wording. However early next year, with more evidence, it may become more obvious that there is a real difficulty in the currently worded determination.

ACMQ Executive is of the opinion that the strongest strategy is to indicate that we do not accept the current wording allowing a medical veto and that we stick together on this.

...
ACMQ Executive believes continuing to lobby to change the determination before a motion to disallow can even be introduced, let alone voted on, does not carry the level of risk outlined by the ACM national e-bulletin.

Timeline for the Determination:
• Determination was signed off by Governor General on 16 July which means that the Medicare for Midwives legislation is ready to commence on 1 November.
• Parliamentary process requires that because the determination is only signed off by Governor General, it is tabled in parliament in first six sitting days of the new parliament (28, 29, 30 Sept 2010, 26, 27, 28 October 2010).
• On the day it is tabled a new timeline commences in which a motion to disallow can be introduced within 15 sitting days. Therefore, if the determination is tabled on 28 Sept (the first day of the new parliament) the last possible day on which a motion to disallow can be introduced is the first sitting day of 2011 which is late Feb or early March. There is nothing ACM can do to alter these timeline as it is a fixed parliamentary process.
• On 1 November Medicare for midwives will commence.
...

ACMQ Executive maintains the line that the determination is unacceptable, that we continue to lobby that it is unacceptable and that we demand a meeting with the Minister (not only her advisors).
...
All midwives who experience difficulty accessing Medicare due to an inability to obtain a signed medical agreement have the opportunity to keep the pressure on by notifying ACM national, ACMQ and the Minister’s office of the practical difficulties created by the determination.

If it turns out that the determination is working well and women have no difficulty accessing Medicare funded midwifery care this will soon become apparent. If this is the situation then any motion to disallow can be withdrawn as stated earlier.

ACMQ’s position involves lobbying to change the determination and buying time to see if the determination will or won’t work.

ACMQ Executive holds the view that a frank and fulsome communication between all members is required to ensure that a representative view can be tabled if the situation occurs that the determination will be voted on in the Senate/House of Representatives.

Before sending this communication we have considered all aspects of this complicated situation in detail. Thank you for considering this alternative option, it is now completely up to you as a member to decide if you would like to write to/contact your MP, the Minister, Jenny Gamble as our National Delegate and ACM National to lobby for the wording of the determination to be changed.

ACMQ Executive will continue to apply pressure and lobby to get the determination changed.

This e-bulletin is supported unanimously by the ACMQ Executive:
Hazel Brittain - President
Jodi Bunn – Executive Member
Jenny Gamble – National Delegate
Richard Hayes - Treasurer
Bec Jenkinson - Consumer
Marie McAuliffe – Executive Member
Mandy Ostrenski – Executive Member
Sue Rath – Executive Member
Mary Sidebotham – Vice President
Barb Soong – Executive Member
Teresa Walsh - Secretary
Kellie Wilton - Student

ACM President on the Determination

2010-09-30T17:30:00.003+10:00

The following response has been received today, 30 September 2010, from Hannah Dahlen, President of the Australian College of Midwives. It is in response to an email from me, expressing my disagreement with the position taken by the ACM in accepting the Determination (see previous posts).
I consider it essential that our College should ensure that midwives are able to continue to practise midwifery on our own authority.
Hannah has asked me to post her comments at this blog. The message I received from Hannah is posted here without any change.
Joy Johnston

I agree this Determination is far from perfect and we have fought it in every way possible to have it changed. In New Zealand it took them 17 years to get a National Access Agreement and they had many little steps along the way to achieve the final outcome. We have received some concessions now from the Minister that take us away from sign off by an individual doctor and these include being able to have clinical privileging with a hospital (the old visiting rights) and this will be considered a collaborative agreement.
The National Maternity Plan, which is the most midwife friendly plan I have ever seen, contains an evaluative framework for the uptake of the Eligible midwife along with commitment to State and Territory clinical privileging, which as I said could in itself form a collaborative arrangement. This means we can keep a very close eye on where it is working and where it is not. The Minister has promised to us (ACM) and the ANF that she would change the Determination if is not working but this would not happen in the first months of roll out which is why the idea of disallowing and dragging out the debate until next year won¹t work. If it does drag on until next year Midwives could have started accessing Medicare and have women booked and it could all fall over and where would these women and midwives be left stranded. The Minister has made it clear that she will not change or put up a new Determination if it is disallowed. There are many midwives in the College that have fought for access to Medicare for twenty years now and the College cannot let this be lost at the last moment.

This not a good piece of legislation by any stretch of the imagination but you rarely get everything you want the first time in reform. I believe there are enough ways we can make this work and then hold the government to account for changes when it does not. The AMA have also been told the same thing by the Minister very clearly and I quote ³If we do not embrace these changes then pressure will mount on the Government to relax the requirement for collaborative arrangements to be in place² (Andrew Pesce).

We have sought legal advice over the best way to approach this as we desperately want the best for women and midwives and have clear advice that ³disallowance is not the appropriate means by which to seek amendments of the Determination² and it is highly risky with current volatile coalition who are willing to say NO to everything not because they care about midwifery but just want to say NO.

It is important to note that the Determination does not affect all midwives only those who choose to become eligible midwives and want to access Medicare. It is also important to note that the Determination has been removed from the Quality and Safety Framework after much protesting on ACM¹s part. It is also important to note that even the MIGA policy has a care plan option that gets around the collaborative arrangement with a doctor. There is nothing in VERO if that is the choice midwives make.

Just to remind people that we have made many changes and gains along the way in this reform process. We began with the Eligible midwife needing five years experience, a Masters degree and to be a Midwife Practitioner.
Homebirth was nearly going to be made illegal last year. We have got removed from the Insurance Bill the requirement for a collaborative arrangement with a named practitioner. We have had the Determination removed from the Safety and Quality Framework. These are big gains and yes we haven¹t got what we wanted from the Determination.

I think often with reform we need to take a foot in the door approach and then wedge that door open and get through with all the changes that need to be made. ACM has not given up on this and have sent a letter to the Minister for Health yesterday once again asking for named practitioner to be removed and acknowledgment to be removed. We will I promise not give up. There seem to be all sorts of rumours flying including a crazy one about the ACM doing a deal with the AMA. Can I assure you all this has not occurred and will not occur and we remain as committed to women and midwives as ever.

With respect and good wishes
Hannah Dahlen
President ACM

Australian Medical Association on Collaborative Arrangements

2010-09-28T14:44:00.002+10:00

AMA has published a document 'Collaborative Arrangements: What you need to know' in preparation for the inclusion of eligible midwives and nurse practitioners in Medicare funding from 1 November 2010.

MIDWIVES PLEASE NOTE

All midwives who experience difficulty obtaining a signed collaborative agreement with a medical practitioner, in an effort to comply with the Determination, are asked to notify private midwives' groups (APMA, MiPP), the midwives' professional body (ACM) and consumer and midwife lobby groups such as Maternity Coalition. Copies of your letters, and the responses you receive (or lack of response) will be used as evidence in reviewing the implementation of maternity reform.

Why midwives can not accept the Determination

2010-09-23T11:32:00.007+10:00

Readers of this blog will know that a piece of legislation, The National Health (Collaborative Arrangements for Midwives) Determination 2010 (the Determination), which has been discussed previously, was introduced by the Health Minister just prior to announcing the election.

Midwives who are members of the national professional body, the Australian College of Midwives (ACM) should have received an URGENT e-bulletin from ACM, which states:

"On the balance of information that we have to date, we feel that lobbying to disallow the Determination is placing the whole maternity reform package at risk. Although a compromise position is what some might call ‘incremental reform’ it is still an extraordinary time for midwifery in Australia and one we have been fighting to attain for many years."

Why can midwives not accept the Determination?

We believe that ACM should be calling for the Determination to be disallowed. It appears that ACM is putting financial considerations ahead of professional matters. I (Joy J) was an ACM Victorian Branch executive member in the 1990s when we fought to be freed from regulations which required that a midwife be supervised by a doctor. ACM is, by supporting the Determination, turning midwifery and maternity reform back a couple of decades.

In an attempt to defend the position I am taking, I draw attention to a list of so-called 'facts', in the ACM URGENT e-bulletin:

ACM claims that

"The Determination
1) Will not prevent private midwives being able to practise (they can still access insurance)

Midwives in private practice will, under the Determination, be required to choose EITHER medically supervised practice (with Medicare), with all births taking place in hospital (NO homebirth) OR continue private practice in our communities without the hope of government funding for any of our services, and without the hope of hospital visiting access.

ACM also claims that the Determination

2) Will not prevent women being able to make choices - if you are having a homebirth and choose not to access Medicare you do not need a signed agreement with a doctor.

This claim is nonsense. By supporting a two-tiered midwifery system (the homebirth midwives and the Medicare midwives), ACM is ignoring the basic scope of midwifery practice, in any setting.

ACM also claims that the Determination

3) Only affects midwives seeking to access Medicare and midwives can choose not to do this

Does ACM think it's reasonable that midwives should give up the defining features of midwifery practice, and accept supervision by the medical profession?

ACM also claims that the Determination

4) Is not included in the NMBA Quality and Safety Exemption framework supporting private midwives providing homebirth services

Of course not! The Determination is a piece of legislation.

ACM also claims that the Determination

5) Does not re-define the ICM definition of a midwife - it does not define the role or scope of practice of midwives in Australia. It only defines how midwives can access Medicare if they choose to do so. ...

Of course not! By agreeing to medical supervision of the midwife's practice, the ICM definition is OFF THE TABLE. The 'midwife' working under the Determination will become a new breed of obstetric handmaiden.

There are a couple more examples of SPIN under the heading of THE FACTS.

Midwives will be giving up midwifery if they accept the poisoned chalice of Medicare funding with this Determination. Change of funding mechanisms, as will occur when midwives are able to practise with Medicare rebates, does not equate to reform of maternity services. The Australian government's commitment to a $120 Million reform package is floundering because this government (in its previous state, and continuing through to the present leadership) has refused to listen to the very people who are intimately involved in maternity care (midwives and mothers), and has submitted to a 'doctor knows best' subservient mentality. The midwifery profession has an opportunity to stand up and take responsibility for ourselves, or cave in to the bullying that is seeking to force us into someone who is unrecognisable in current international midwifery literature.

Related posts:
NEW Maternity Coalition national blog
Homebirth Australia
Maternity Coalition
villagemidwife
Lisa Barrett's blog

link to Lisa Barrett's Homebirth Video - born in the Caul

2010-09-20T08:56:00.000+10:00

Readers of this blog will enjoy the wonder and beauty of this birth.

ICM: Legislation to govern midwifery practice

2010-09-16T18:13:00.002+10:00

The International Confederation of Midwives' GLASGOW Declaration 2008

Legislation which is enacted to govern the practice of midwives should:

• enable midwives to practise freely in any setting

• ensure the profession is governed by midwives

...

• allow for the midwife to practise in her own right

...

LEGISLATION TO GOVERN MIDWIFERY PRACTICE

BACKGROUND
In order to protect both the public and midwives themselves, it is important to regulate and license midwives, and the programmes and establishments used in their training. It is also essential not to give the license or accreditation ‘for life’. Hence, a set of accreditation requirements must be instituted for the accreditation (and re-accreditation) for fixed periods of time. For the individual midwife this should be based on her/his ability to demonstrate that she/he has the required skills and abilities to practise the profession safely according to the national requirements.

Midwifery legislation is the part of a nation's laws that relate to the profession and practice of midwifery. Midwifery regulation is the set of criteria and processes arising from the legislation that identifies who is a midwife and who is not, and describes the scope of midwifery practice.

Registration, sometimes called licensure, is the legal right to practise and to use the title of midwife. Regardless of the type of mechanism used, it is important to ensure that the process is and continues to be transparent, fair and robust; it should therefore be evaluated periodically. There is also a need for mechanisms that enable previously practising midwives to return to service after a prolonged absence.

STATEMENT OF BELIEF
The ICM believes that there should be appropriate legislation relating to the practice of midwives in all countries. ICM also believes that professional associations should work with governments to find ways to maximise service delivery capacities in countries. This will imply the establishment of good human resource management policies and regulations, as well as the involvement of professionals in determining service standards for the provision of high-quality care at all levels in both the private and public sectors.

POSITION
Legislation which is enacted to govern the practice of midwives should:
• enable midwives to practise freely in any setting
• ensure the profession is governed by midwives
• support the midwife in the use of life-saving knowledge and skills in a variety of settings in countries where there is no ready access to medical support
• enable midwives to have access to ongoing education
• require regular renewal of right to practise
• adopt a ‘Definition of the Midwife’ congruent with the ICM definition, appropriate to the country within the legislation
• provide for consumer representation on the regulatory body
• recognise that all women have a right to be attended by a competent midwife
• allow for the midwife to practise in her own right
• recognise the importance of separate midwifery regulation and legislation which supports and enhances the work of midwives in improving maternal, child and public health
• provide for entry to the profession that is based on competencies and standards and which makes no distinction between routes of entry
• provide the mechanism for a regulatory body that is governed by midwives with the aim of protecting the public
• provide for regular review of the legislation to ensure it remains appropriate and not outdated, as midwifery education and practice and the health services advance
• encourage the use of peer review and analysis of perinatal, maternal and newborn outcomes in the legislative review process
• provide for transition education programmes in the adoption of new legislation requiring increased levels of competency of the midwife.

GUIDING STATEMENT TO MEMBER ASSOCIATIONS:
Member Associations are urged to use this statement to achieve legislation
which will be appropriate for the practice of midwifery in their country.

RELATED ICM DOCUMENTS
• ICM position statement. Framework for midwifery legislation and
regulation. ICM, 2002.

OTHER RELEVANT DOCUMENTS
• Mother Baby Package: Implementing Safe Motherhood in Countries. Geneva,
Switzerland: WHO, 1994.
• ICM. Definition of the Midwife. ICM, 2005.
• Bryce GK. Overview paper presented to Workshop on Legislation, May 1983
Vancouver ICM Congress (Unpublished).
• The Safe Motherhood Action Agenda. Priorities for the next decade. Report
on the Safe Motherhood Technical Consultation October 1997 Sri Lanka, Family
Care International.

Adopted at Glasgow Council meeting, 2008
Due for next review 2014

[The International Confederation of Midwives (ICM) supports and advises associations of midwives. The ICM is an accredited non-governmental organisation and works closely with the WHO, UNFPA, UNICEF and other organisations worldwide to achieve common goals in the care of mothers and children.]

Roxon reappointed as Health Minister

2010-09-14T15:38:00.002+10:00

There has been a collective sigh of dismay as midwives and advocates for basic human rights in maternity care note the renewal of Nicola Roxon's portfolio as the Minister for Health (and Ageing).

Minister Roxon swallowed the guidance of the AMA (Australian Medical Association) and refused to listen to women and midwives. Remember girls, doctor knows best.

Prime Minister Gillard promised a new era in health before the Rudd government was elected, and she became his deputy.

These very women have sold out women's basic human rights, in a mad rush to reform health, by further restricting access of women to private midwifery, and barring midwives who attend women in their homes from any semblance of acceptance in the health system or professional recognition. We (midwives) are experiencing unprecedented threat to our very right to exist.

During the years of the previous (Rudd) Labor government we were informed that Labor had a mandate to reform maternity care.

This (Gillard) government has now been put on notice. They got in by a whisker, and while under Rudd they trumpeted their mandate to reform health, there is no mandate for anything now.

Everyone with an interest in birth needs to increase the pressure on Roxon and Gillard, and keep private midwifery and the related theme of women’s rights in the public eye. If as has been forecast this government does not run its full term, voters will be given another opportunity to voice their disgust at the bureaucratic heavy-handedness that has been dished out since the government commenced its efforts to reform maternity services.

The statement by the four independent women who stood for seats in marginal electorates, ‘Gillard Government signs away women’s rights’ still applies.

Minister Roxon, her advisors and bureaucrats, and the AMA, reckon it’s in the public interest to wipe out private midwifery as we know it today. Women cannot be allowed to decide where or how or with whom they should give birth. The midwife's private practice that focuses on promoting physiological birth, and working in harmony with natural processes, is under increasing threat.

A new professional pathway is being opened by our government for the private midwife: who works with [and supervised by] an obstetrician, within the private health sector, with the client being able to access partial recovery of costs via Medicare. This 'midwife' will be no more than the obstetrician's handmaiden. The legislative changes introduced quietly as 'National Helath (Collaborative arrangements for midwives) Determination 2010' have quashed any hope that independent midwives may have had of accessing Medicare rebates for some of their services.

From the Independent candidates' statement:

“The day before the Federal election was announced there were changes made to existing midwifery legislation. Defined as "collaborative arrangements", the changes, in essence, give doctors a veto over women's choices.

“Basically, the changes detail that any midwife whose patient wants to claim through Medicare must get permission from a Doctor for the decisions made during the pregnancy and birth.

“These new laws give Doctors veto rights over women’s birth choices.

“It is unlikely that Doctors will agree to collaborate with private midwives, with some receiving advice from their insurer that collaborating would void their insurance."

complaints and notifications against midwives

2010-09-02T15:12:00.005+10:00

Midwives practising privately in Victoria face a high risk of experiencing complaints to the registration authority about their actions.

Protesters rally outside AMA house in Melbourne, in support of private midwifery

The number of Victorian independent midwives with current investigations into compaints is seven or eight, out of a group of less than thirty. This rate of complaint is disproportionately high when compared with midwives in other practice models. Midwives are asking "why?"

There are, of course, complex issues in any complaint about a professional person's actions or competence or ability to practise at an acceptable standard. The statutory body with responsibility for investigating and making decisions about a midwife's professional actions is the Nursing and Midwifery Board (NMBA), which acts under the Australian Health Practitioner Regulation Agency. The principle of acting in the public interest - protection of the public from unprofessional or incompetent or unscrupulous operators - is the reason for existence of statutory regulation of health professionals.

In recent months and years the defining of a midwife's scope of practice and even who is suitable for a midwife to accept when providing care have been further complicated by government bureaucracy, under what has been presented as 'reform'. While the 'reform' is offering the carrot of Medicare (public) funding for prenatal care and visiting access to hospitals for intrapartum care, the stick at the other end of the donkey is adherence to a high level of risk management that is dictated and overseen by competing medical interests.

Without going into detail, independent midwives face the possibility of restrictions that go beyond anything we have previously faced. For example, is a woman who has had a previous caesarean birth a suitable candidate to be in the primary care of a midwife? What about a woman who has had two caesareans?
or a woman with a high BMI (too fat)?
or a woman who has twins?
or a woman whose baby is presenting breech?
or a woman who had a post partum haemorrhage with her previous birth?
or a woman who comes into spontaneous labour at 36 weeks?
or a woman whose baby has not yet been born at 42 weeks?
or ...

Now is a good time to go back to the question what is a midwife?

ICM Definition of the Midwife (2005) is a core document of the International Confederation of Midwives [http://www.internationalmidwives.org/ ]

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

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.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

[Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.]

Principles that provide a framework for midwifery practice

The ICM Definition of the Midwife (2005) establishes the following principles:

The principle of ‘partnership’: “The midwife … works in partnership with women …”
The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
The principle of caseload – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”

I would encourage midwives who face complaints and notifications to come back to the principles outlined above, and to review our practices in the light of these principles. A midwife who can demonstrate that her practice was consistent with the ICM Definition has strong footing for defending her actions.

Independent's Preferences may determine Corangamite

2010-08-20T11:13:00.001+10:00

Protesters outside Nicola Roxon's office

Media Release

Friday August 20 2010

Contact: Sally-Anne Brown 0438 708 693

Independent's Preferences may determine Corangamite

Independent candidate for Corangamite Sally-Anne Brown has today announced she has not directed preferences to one major party over the other following the collapse of negotiations with both parties.

Neither party would commit to ensure the currently tabled 'collaboration determination' for women to be eligible for medicare funding with a private midwife be disallowed, to ensure a woman's right to informed consent be drafted into a new document. “ It is incredible that both major parties are prepared to risk loosing their bid for Corangamite, rather than revamp a document which costs them nothing”, said Ms Brown, adding “the major parties have once again bowed to the nation's most powerful union lobby, The Australian Medical Association” at the expense of birthing women across the nation”, she added.

As late as Tuesday night both parties were making calls to the Independent candidate requesting her preferences. “This is a clear indication both Liberal and Labor know the seat of Corangamite currently held by 0.9 % will come down to the wire”, said Ms Brown, adding “I was crystal clear that if I had a commitment in writing to uphold a woman's right to informed consent then I would deliver my preferences. Instead the major parties have sold women's rights down the river”, she said. Ms Brown is unimpressed that Australia's first female PM Julia Gillard and Health Minister Nicola Roxon, both members of Emily's list which advocate strongly to uphold women's rights are supporting the position.

Ms Brown a nurse and midwife of 28 years declared her candidacy for the seat of Corangamite following a twenty year policy platform by both parties to force women to travel to cities to birth. “Since the early 90’s over 70% of maternity units have closed in remote and rural Australia including the Apollo Bay and Lorne maternity units, forcing women to travel hundreds of kilometres to birth”, said Ms Brown, adding “our maternity system currently the highest volume of health beds at over 300,000 per annum is a lucrative business and a broken mess”, she added.

Due to mandated insurance requirements effective July 1 – eleven of the thirteen private midwives that serviced the 8,000 sq kms of Corangamite have had to cease their practice due to exorbitant insurance premiums and the move by medicos to veto a woman's right to make informed decisions about her maternity care. “To bypass a woman's right to consent in any aspect of her care constitutes a breach of ethical, legal and professional requirements of practice that must be adhered to by all health professionals, regardless of public or private practice”, she added.

Ms Brown is campaigning primarily on maternity services reform and on a strong social, environmental and health policy platform.

Ø Bring Births Back to Local Communities

Ø Zero Emissions by 2020 & a price on Carbon

Ø Housing affordability

Ø Improved roads & public transport

www.sallyannebrown.com
Authorised by Sally-Anne Brown, 3 Scott Place Apollo Bay, Victoria 3233

Who's the REAL health minister?

2010-08-11T09:22:00.004+10:00

NEWS RELEASE

Wednesday 11 August 2010

Independents in Key Marginal Seats Join Forces and Ask:

Will the Real Health Minister Stand Up at Today’s National Press Club Address

Across health there are hundreds of community groups advocating for improvements in health. For four women across 3 states the lack of any real action in maternity reform has led them to stand as independent candidates.

Michelle Meares, Amy Bell, Sally-Anne Brown and Rebecca Jenkinson are standing in the seats of Robertson, Macquarie, Corangamite and Dickson respectively. These seats are ultra marginal and these women are united by a common passion to improve maternity care for Australian women rather than seeing health services dominated by the self interest of the Australian Medical Association (AMA).

Maternity reform was the first cab of the rank in Rudd’s health reform plan. Nicola Roxon announced funding midwives through Medicare for the first time. “This legislation had the capacity to greatly improve care for women across the country and was initially well received.” says Rebecca Jenkinson, teacher, mother of 2 children and independent candidate for Dickson.

Whilst consultation with a range of stakeholders has occurred it has been clear to those participating that the medical lobby has controlled the decisions within the reforms. “Nicola Roxon has put the self interest of the doctors union above the needs of Australian families as they continue to suffer, especially in rural and remote areas.” said Sally-Anne Brown a nurse and midwife from rural Victoria, running in the electorate of Corangamite.

“In the last month we have come to the conclusion that Nicola Roxon is not really Australia’s Health Minister and Peter Dutton is not the shadow minister. The real minister is Dr Andrew Pesce, President of the Australian Medical Association.” said Michelle Meares, IT consultant and mother on NSW’s Central Coast. “Despite unprecedented support from the women of Australia for maternity reform, Minister Roxon turned her back on them caving to pressure from the AMA that has resulted in legislation being snuck through, signed off by the Governor General the day before the election was called.”

The Determination ( National Health Collaborative arrangements for midwives Determination 2010) passed on the election eve requires medical sign off or agreement before women can receive a Medicare payment for private midwifery care. This legislation gives doctors the power of veto not only over the practice of midwives but also the choices pregnant women make.

“This move looks likely to contravene Australia’s commitment to the Convention on the Elimination of all Discrimination Against Women (CEDAW). How can the women of the ALP introduce legislation that prevents a woman from making decisions about her own body, giving veto to medical practitioners” said Sally-Anne Brown. Amy Bell, mother and nurse from the Blue Mountains region adds “Women have asked us to step up and represent the voices of women on this issue and they are standing behind us all the way.”

Rebecca Jenkinson is also dismayed that Shadow Health Minister, Peter Dutton has also refused to take a stand on this issue. “As a member of his electorate I am aware of the women that have met with and written to Peter Dutton. We are yet to see any positive protection from the coalition for the rights of women to make decisions. We can only assume that Minister’s Roxon and Dutton believe the AMA has more currency than Australian families”

All candidates report great support on the ground. For too long maternity care has been thought of as a ‘soft issue’. One only needs to see the catastrophic effects of postnatal depression, family breakdown and child abuse to know that how we support new families, especially mothers matters greatly. Amy Bell adds “Maternal suicide is the leading cause of death in the first year after birth – we have to look at more positive ways to support women.”

These candidates join together to ask when will Nicola Roxon and Peter Dutton (who are speaking together today at the National Press Club) be honest enough to announce that the AMA is the real driver of health policy in Australia.

Contact: Rebecca Jenkinson 0439 765 633
Michelle Meares 0439 645 372
Sally-Anne Brown 0438 708 693
Amy Bell 0432 928 014

Authorised by Sally-Anne Brown, 3 Scott Place Apollo Bay Victoria 3233

Gillard Government signs away Women’s Rights

2010-08-07T15:20:00.002+10:00

Sally-Anne Brown leads a rally outside Health Minister Roxon's office

A political statement on behalf of four women standing for election as Independents

August 3, 2010

FOLLOWING the Government’s backwards changes to national midwifery regulations, thousands of Australian women are voicing their concern.

Their urgent voices have just over a month to address draconian amendments to proposed new laws.

Collectively, thousands of voices have culminated in four women running as independent members in critical marginal seats in an attempt to talk to Australia’s law makers.

These four independents will stand in the marginal federal seats of Robertson on the NSW Central Coast, Corangamite in southern Victoria, Macquarie in the Blue Mountains, NSW, and Dickson in northern Brisbane, Queensland.

“We had no choice but to stand for Parliament. We are standing as Independents to represent the voices of thousands of women around Australia. These women are angry about the effect the Gillard Government’s new maternity laws will have on their birth choices,” Robertson candidate Michelle Meares said.

“The day before the Federal election was announced there were changes made to existing midwifery legislation. Defined as "collaborative arrangements", the changes, in essence, give doctors a veto over women's choices.

“Basically, the changes detail that any midwife whose patient wants to claim through Medicare must get permission from a Doctor for the decisions made during the pregnancy and birth.”

“These new laws give Doctor’s veto rights over women’s birth choices.”

“It is unlikely that Doctors will agree to collaborate with private midwives, with some receiving advice from their insurer that collaborating would void their insurance.”

“This is unworkable. It will not allow women to be able to afford midwives for
home births.”

After the election, once the caretaker Government steps aside and the Senate resumes sitting, there will a two-week window in which the changes can be disallowed.

“When the senate resumes we have two weeks in which to change the “collaborative arrangement” the Government wants to impose.

A similar situation developed in the US state of New York. But the law was found to be unworkable. It was repealed when the Midwifery Modernization Act was passed in July.

Each of the four candidates disagrees with the recently passed legislation forcing midwives into "collaborative arrangements" with doctors. Specifically they are pushing for:
• A guarantee that the medical veto over women's choices will be removed
• A commitment that women's rights to informed consent (including the right of refusal) will be expressly recognised in all codes, guidelines and frameworks relating to midwifery practice
• Ensure that privately practising midwives have visiting rights in hospitals across the country
• A commitment to funding and insurance for homebirth to ensure equity for all Australian women

Men do not give birth and should not be allowed to push women into this position.

MEDIA INQUIRIES
The four candidates:
Robertson – web producer/consumer advocate Michelle Meares
Phone: 0439 645 372
http://www.michellemeares.com

Corangamite –midwife Sally Anne Brown
Phone: 0438 708 693
http://sallyannebrown.com

Macquarie – nurse Amy Bell
Phone: 0432 928 014
http://www.wix.com/amyrbell/independentformacquarie

Dickson – teacher Rebecca Jenkinson.
Phone: 0439 765 633
http://bit.ly/a4KXOz
www.homebirthaustralia.org

New information on professional indemnity insurance for midwives

2010-08-04T14:55:00.001+10:00

The scanned page here is from a Draft Summary of Professional Indemnity Insurance for Midwives, developed by the NMBA. This flow chart outlines the process for midwives to comply with the professional indemnity insurance (PII) requirements of the National Registration and Accreditation Scheme which has been in effect since 1 July this year.

When I have found a link to the document at the NMBA website I will add that to this post.

As has been clearly stated for all to read, in this and other blogs and professional websites, midwives have sought to protect our right to practise midwifery as it has been defined internationally by the ICM - see Definition of a midwife. This ICM Definition is foundational to all Australian midwifery codes and courses of study. It is not something that can be ignored by legislators or regulators.

According to this flow chart, there are three options for private midwifery practice.

1. ONLY PROVIDING HOMEBIRTH intrapartum midwifery services with no antenatal or postnatal care. --- Midwife does not require PII.

2. and 3. Midwife intends to provide private antenatal, intrapatum care in hospital setting &/or postnatal care. --- Midwife must purchase PII.

#2 Midwife provides private midwifery services for pre and postnatal care without any access to Medicare, and purchases appropriate PII.

#3 Midwife provides private midwifery services for pre, intra, and postnatal care, and has the notation by the NMBA as a midwife who is eligible for Medicare. The midwife purchases PII from the Australian Government-supported authorised insurance provider.

Option #1 is unreasonable - UNPROFESSIONAL!
There is no point in calling ourselves midwives if we cannot practise midwifery. It's outrageous to be forced into being in the position, as this flow chart indicates, of "Only providing homebirth intrapartum midwifery services with no antenatal or postnatal care." What sort of midwife would take professional responsibility for homebirth without also providing prenatal and postnatal services? How is it that a body charged with regulation of midwifery in this country should consider a statement like that reasonable, that it should appear in a draft flow chart under the NMBA letterhead?

This is madness, as the regulators try to squeeze a square peg (NRAS) into a round hole (midwifery). The requirement for PII, with the 2-year exemption for homebirth, was never a workable arrangement.

The midwife is 'with woman' - not 'with homebirth'! In normal, physiological labour the woman and her midwife agree on the best place for birth as progress and other events at the time are taken into account.

Collaborative arrangements for midwives eligible for Medicare funding

2010-07-25T14:18:00.000+10:00

The National Health (Collaborative Arrangements for Midwives) Determination 2010 has now become law.

Midwives who anticipate taking up the provisions of this reform, and applying to be eligible for Medicare funding and other extensions to practice from 1 November 2010 now have a clear process to follow.

Concerns about a potential medical veto have been raised repeatedly in discussions, email groups, and submissions to the law makers. The Queensland Branch of Maternity Coalition has published a blog post outlining these matters.

"The Determination provides 4 options for collaborative arrangements. Each option requires the midwife to have some form of permission from a doctor, before a woman can receive Medicare rebates.

"The minimum form of permission is an "Arrangement - midwife's written records" (section 7 in the Determination). This option requires a named doctor of a specific type to acknowledge "that the practitioner will be collaborating in the patient’s care", and that the named doctor has received copies of a hospital booking letter and a maternity care plan.

"These requirements will make it very difficult for women to access Medicare-funded care from midwives in private midwifery practice. We don't expect midwives in private midwifery practice (working for themselves, not a doctor) to be able to find private doctors who are willing to enter collaborative arrangements with them. In some cases this may be possible under very specific conditions. However it is unrealistic to expect that private doctors will collaborate in the care of women planning homebirths.

"Even for women planning births in public hospitals, these requirements for collaborative arrangements will make it extremely unlikely for them to be able to access Medicare-funded midwifery care. There is no reason to expect public hospital doctors to enter the required collaborative arrangements with private midwives. They have no incentive, and there is no sign that state governments are planning to push them.

"In March 2010 when the Senate was debating this legislation, the Government stated that "There is no intention to provide a right of veto over another health professional’s practice". However, under intense pressure from the medical lobby, this is exactly what has occurred. Most importantly, it is women's choices and access to care which are being vetoed, to protect medical control of the maternity marketplace.

"If these reforms are to deliver the "choice and access" promised to Australian women by Government, the medical veto must be removed. Midwives must be accountable to the women they care for, and to their regulating body, not to another profession."

QUESTION: WHAT SHOULD A MIDWIFE WHO WISHES TO BE ELIGIBLE FOR MEDICARE DO?

Midwives who wish to be authorised will need to approach doctors and hospitals in their area, obtain agreement, and prepare care plans that meet the legal requiremens established in this Determination.

A new website, Midwives Australia, has up to date information on Medicare eligibility.

The Queensland branch of the Australian College of Midwives has announced a pre-conference workshop on Medicare for midwives. Click here for details.

Safety and Quality Framework for Privately Practising Midwives attending homebirths

2010-07-24T16:43:00.000+10:00

This document has now been circulated, pending final endorsement/modification and adoption by the Nursing and Midwifery Board of Australia.

Readers who would like to have a copy of the document emailed to them may request it by email: mipps@maternitycoalition.org.au

Key Principles [Attachment]

“Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” articulated the following principles which underpin the range of models of maternity care available to women in Australia. These principles involve:

· ensuring services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience

· ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman

· maximising the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals such as paediatricians and Aboriginal health workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery

· offering continuity of care, and wherever possible continuity of carer, as a key element of quality care

· ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence based best practice care

· ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework

· providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required

· working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.

EXCERPT
The Safety and Quality Framework

The framework is consistent with the principles underpinning provision of primary maternity care (Attachment 1) and recognises the full scope of midwifery practice.

The framework also recognises that women will make the final choice about their care and birthing choices in most circumstances. It is incumbent upon privately practising midwives (PPMs) to provide balanced and contemporary clinical advice to ensure that informed decisions are able to be made.

PPMs are expected to adhere to recognised consultation and referral guidelines developed by the Australian College of Midwives (ACM) and to have processes and relationships in place to demonstrate compliance with the guidelines.

The ACM guidelines were developed to guide midwifery practice more broadly and do not specifically to cover homebirths. Distance and time to travel to an appropriately staffed maternity service should be considered when assessing suitability for this option of care. These factors are in addition to undertaking an assessment of risk for this birthing option.

Women with a singleton pregnancy, cephalic presentation, at term and free from any significant pre existing medical or pregnancy complications are those identified in the ACM guidelines as clearly meeting criteria for midwifery led care.

When PPMs are the primary carers for women who fall outside of these criteria, the consultation and referral pathways must be documented and followed. Clearly articulated and documented plans of escalation and collaboration are integral to provision of safe high quality care leading to positive outcomes for mothers and babies.

PPMs are required to document advice provided to women in their care about midwifery scope of practice, risks and escalation processes.

In addition they will enlist the services of another registered maternity care professional to provide a second opinion in situations where the woman chooses not to follow clinical advice about the need for interventions or transfer. A written record of these processes is essential to verify adherence to the framework in the event of any adverse outcome and /or subsequent legal action or professional investigation.

Birthing from within WORKSHOPS

2010-07-20T15:37:00.005+10:00

BIRTHING FROM WITHIN facilitators Pam England and Virginia Bobro are finally coming to Australia! They will be leading two three-day workshops, one near Sydney at a retreat centre (18-20 Sept.) and the other in Melbourne (23-25 Sept.).

For info and to register, click here.
Discount for early registrations ends soon. Register today!

The intensive workshops, open to all birth-related professionals, will cover the following material, and much more:
• Birth as a rite of passage, and the childbearing year as a hero’s journey—what this means and why it is important;
• How to prepare women for birth following the hero’s journey model;
• How to build a solution-focused mindset that helps women (and their partners) cope with pain, fatigue, and the unknown in labor and postpartum;
• Teaching and mentoring to prevent emotional birth trauma;
• Utilizing Masculine/Feminine polarity to facilitate labor and postpartum;
• How to lead a Special Class Just for Fathers.
This is a warm, fast-moving workshop. It inspires beginners, validates and deepens what the experienced know, and uplifts the jaded and weary ones.

Pam England, former nurse-midwife, author of Birthing From Within and Labyrinth of Birth, now works as a Childbirth Mentor, Storyteller, Birth Story Listener, and Creative Director of BIRTHING FROM WITHIN. Pam is mother to two sons; she lives and teaches in Albuquerque, New Mexico, and leads workshops around the world.

Virginia Bobro, began her work in birth as a La Leche League Leader and doula. She is currently the Managing Director of BIRTHING FROM WITHIN She is the mother of three and lives in Santa Barbara, California. and facilitates BFW workshops around the world.

A midwife in Oregon says of our workshop: “I loved the book Birthing From Within, and began using some ideas and exercises in my appointments with parents. I thought the workshop might be nice. The workshop was amazing—more mind-blowing than the book! We went much deeper and further than I thought possible. My work is forever changed.”

birthsmart

2010-07-18T13:29:00.002+10:00

MANA critique of Wax et al, Am J Obstet Gynecol 2010

2010-07-12T10:51:00.002+10:00

July 6, 2010
From Midwives Alliance of North America
FOR IMMEDIATE RELEASE
Contact:
Geradine Simkins, CNM, MSN, president@mana.org
Susan Moray, CPM, pressofficer@mana.org

RE: Maternal and Newborn Outcomes in Planned Home Birth Vs. Planned Hospital Births: A Meta-Analysis, Wax JR, Lucas FL, Lamont M, et al., Am J Obstet Gynecol 2010

A new meta-analysis rushed to on-line publication well before its availability in print, concluded that less medical intervention, which is a characteristic feature of planned home birth, is associated with a tripling of the neonatal mortality rate compared with planned hospital births. In a study published online on July 1, 2010 in the American Journal of Obstetrics and Gynecology (AJOG), researchers at Maine Medical Center in Portland, Maine analyzed the results of multiple studies from around the world. The lead investigator, Joseph R. Wax, MD, Department of Obstetrics and Gynecology, Maine Medical Center, stated, “Our findings raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group.”

However, Canadian researchers whose data showing the safety of home birth in a well-organized and regulated system, were used in the meta-analysis, are sharply critical of the study. Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia said the U.S. conclusions did not consider the facts. “A meta-analysis is only as good as the articles entered into the meta-analysis—garbage in, garbage out. Moreover, within the article, Wax et al did their own sub-analysis of the studies in the meta-analysis, after removing out-of-date and low quality studies, and found no difference between home and hospital births for perinatal or neonatal mortality. Yet in the conclusion, they choose to report the results of the flawed total meta-analysis, which showed the increased neonatal mortality rate. Klein said that this is apparently a “politically motivated study in line with the policy of the American College of Obstetricians and Gynecolgists (ACOG) who is unalterably opposed to homebirth.”

Saraswathi Vedam, a nurse midwife and researcher at the University of British Columbia who is considered to be an expert on assessing the quality of literature related to homebirth, states that the study is deeply flawed for several reasons, particularly, “the authors’ conclusions are not supported by their own statistical analysis.” Vedam states that Dr. Wax et al acknowledges the consistent findings of low perinatal and neonatal mortality in planned home births across the best quality studies they reviewed “but amazingly Wax does not emphasize or even mention this in his sole conclusion.” This begs the question of whether the author’s analysis and reporting of reviewed articles on homebirth do not support his foregone conclusion about the safety of homebirth.

Childbearing women and those involved in maternal and child health policy should be made aware of the flaws and erroneous claims in the Wax et al study. There is a substantial body of evidence-based literature from well-designed studies that establishes the safety of planned homebirth with a skilled birth attendant. The fact that the American College of Obstetricians and Gynecologists maintains its position in opposition to homebirth, despite the evidence of its safety and efficacy, makes one question ACOG’s motive in publishing Wax’s substandard study.

Midwives are the primary care providers in out of hospital settings. Whether their work is studied and scrutinized here in the US or abroad the findings are consistent. Trained midwives are qualified health professionals who have the requisite expertise to provide mothers and newborns with outstanding care, using less intervention, resulting in outcomes that are as good as their cohorts who birth in hospital settings under the care of obstetricians.

The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman’s choice regarding care providers, including skilled midwives, and place of birth.

Geradine Simkins, CNM, MSN
President & Interim Executive Director

homebirth in the news again

2010-07-08T20:29:00.002+10:00

TV loves celebrity, and lovely Dannii Minogue has brought homebirthing into the news.

Today I have been interviewed by Channel 10 news. The questions they asked me were about primipara over 35 years of age, and transfer from planned homebirth to hospital.

Channel 7 Today Tonight program also aired comments I made about the safety of homebirth when interviewed some months ago. The questions in this interview were in response to outrageous claims about homebirth made in the Australian Medical Journal. For more on that, click here.

[The 7PM show includes a blog.]

The current focus on homebirth has come with the news that Dannii Minogue went to the Royal Women's Hospital, having booked under an alias, and subsequently gave birth to a baby boy. The parents and the baby's celeb aunty Kylie have tweeted their delight to the whole world.

So why is that story newsworthy?

Dannii had employed midwives - members of this blog's own Midwives in Private Practice - to attend her privately, with the intention of giving birth at home.

The reason for Dannii's change from home to hospital has not been made public. It appears that mother and baby are well, which is the goal of all midwifery care.

The fact that planned homebirth includes a 'Plan B', including a back-up booking at a hospital that can provide specialist obstetric care if and when required, seems to be conveniently ignored by some of those who make their thoughts public. It appears that sensationalism sells papers:

"Another woman is suspicious of modern medicine - until she really, really needs it:
POP star Dannii Minogue and her new baby son are bonding in hospital as they recover from a dramatic home birth halted at the last minute. Complications midway though a planned home birth forced the star to hospital to deliver her baby in safety." (Andrew Bolt)

The comments to that blog make interesting reading if you have nothing better to do, and if you are aware that uninformed opinion is just that.

There is absolutely no shame or 'failure' in moving from a planned home birth to a hospital birth.

The safest and most appropriate way for most women to give birth is in harmony with their own body's natural physical-hormonal processes. That's 'Plan A'. The professional practitioner who is best equipped to enable and protect 'Plan A' is the known and trusted midwife who has the responsibility of primary maternity care provider. That's what midwives in private practice do. That's why women employ us.

The midwife is committed to the woman - not to the place of birth.

Approximately 20% of women planning homebirth at the onset of labour will go to hospital for the birth. Some of these will have caesarean births; some will receive medical forms of pain management or augmentation of labour and proceed to vaginal births.

Primipara are more likely to change from home to hospital births than multiparous women. This is also the case in transfers from birth centres to standard delivery wards. The birth of our first baby is a huge physical and emotional challenge for most mothers. There is no shame or failure in reaching a decision to seek appropriate medical intervention.

in sympathy

2010-06-30T11:32:00.001+10:00

The midwifery and homebirthing communities in Victoria are in mourning at the tragic death of our colleague Mary Reilly.

Our heartfelt sympathy goes to Mary's children, her extended family, and her community.

Insurance for homebirth midwives

2010-06-20T15:07:00.005+10:00

With only 10 days left before legislation requiring midwives to have indemnity insurance for all our private practice excluding homebirth, we midwives want to know what insurance product is available, what it will cost, and how it will impact on the service we provide for women and babies in our care.

I am taking care to update readers in a factual way, although when you have read to the end of this post you may be less than confident in knowing the way forward. What you read here is the opinion of the writer, with links to the information provided by the insurance companies. This information may change from time to time as the sites are updated.

A previous post on this blog has information about the two products on offer, and links to their sites.

Updating the situation:
The VERO Mediprotect insurance provides indemnity only for prenatal and postnatal midwifery services. It has an excess of $2,500 with each and every claim.

The MIGA insurance, which covers prenatal, birth in hospital, and postnatal care claims to be "the sole provider under a new Government supported Scheme to provide Professional Indemnity Insurance to privately practising midwives" (from the MIGA website), now linked to the front page of the College of Midwives.

A News Flash from MIGA (18 June) states that "Over the next few days we will be updating the policy and other information on our website to reflect the changes which essentially relate to the collaborative requirements and employment."

A third avenue by which midwives have investigated obtaining insurance that meets the new legislative requirements is through membership in the nurses and midwives union, ANF. In several States (Vic, Qld and WA), all ANF members, EXCEPT independent midwives, have a professional indemnity insurance cover of $10 Million, with legal representation and support thrown in. The curious fact is that this policy is sourced from VERO. Members have pointed this fact to the ANF professional, legal, and industrial departments and written emails and letters reminding ANF that now homebirth is exempt, surely the risk to the organisation is minimal, and no greater than the 'risk' any other member's private practice engenders. ANF must have private practice nurses working in high risk nursing such as diabetes, wound care, and probably many other fields, and these members are indemnified. To date, ANF Victorian Branch has consistently rejected members' attempts to engage on this matter, responding with rather dismissive letters that contain obvious inaccurate information, while ANF Qld and ANF WA branches have given some members a positive response - that their membership insurance will meet the requirements of the new legislation, EXCLUDING homebirth.

I have written about this publicly because midwives who are members of ANF expect their union to apply its principles of fairness and support for workers to them as well as our colleagues who are employed. ANF has in the past decade hidden behind the belief that midwives in private practice, and homebirth, are high risk and cannot be insured. With the exclusion of homebirth, ANF now has the opportunity to stand up for members who are midwives. This matter is now being referred to the federal ANF level.

Back to the two insurance options, VERO-Mediprotect and MIGA.

Advice from Paul Currall, Director, Medical Indemnity Section at the federal Department of Health (dated 15 June 2010) is that:
"Professional indemnity insurance is a registration requirement, .... The obligation is on the midwife to have appropriate insurance arrangements in force, and midwives will need to consider whether the Mediprotect policy is appropriate for them. As it is a registration requirement, if it becomes an issue then it will be the Nursing and Midwifery Board which is the relevant body."

[Note that the complete contents of the email that this advice appeared in are copied below for those who are interested.]

In conclusion, here are some of the apparent differences between the two insurance products currently on offer (as I understand the situation. If I have missed anything please let me know).

VERO-Mediprotect:

the less expensive option
excess of $2,500 with each and every claim

My opinion: this insurance product appears to meet the requirements at present for midwives in private practice, covering prenatal and postnatal care, and excluding homebirth. A woman in the care of a midwife who is skilled in basic midwifery as primary carer is extremely unlikely to experience incidents which would lead to claims on such an insurance policy. When a woman in our care is transferred to hospital, the midwife who accompanies her has no practising rights in the hospital.

MIGA

the more expensive option
offers medico-legal support
requires risk management at the instigation of the insurer
no excess
Option A provides cover for midwives eligible for MBS/PBS and hospital birth
Option B is similar in cost to VERO-Mediprotect, BUT is available only "if providing no Intrapartum Care at all in your private practice"*

My opinion: this product will be useful when midwives practising privately are able to attend their clients to give birth in hospital, limit their practice to hospital birth, and when the clients are able to claim Medicare rebates (due to commence November 2010). * Since the raison d'etre for the midwife as primary carer is continuity of care, enabling the development of trust and reciprocity between the woman and her known midwife, what's the point of providing NO intrapartum care? [sigh! They just don't get it, do they?]

The MIGA insurance appears to usher midwives into a new era of defacto regulation by in insurance company that exists to make money for its shareholders. In essence, as far as MBS/PBS eligible midwives are concerned, the NMBA becomes a rubber stamp committee.

NOTE: The views expressed in this post are that of the author only and are not intended to be advice. Individual midwives should of course make their own investigations before determining which insurance product is most suitable for their practice.

Question from the College of Midwives to the Medical Indemnity section of the Health Department:
"Is it the case that a midwife wishing to apply for an MBS provider number will need to purchase the MIGA policy? That’s what I’ve been presuming, because I know that the provider number will not discriminate between a midwife doing pregnancy care only and one doing everything, so presumably they have to be insured to do everything?

"The answer to this question will as you would no doubt anticipate be of particular interest to the HB midwives, who are weighing up now whether to take up the MBS option or to simply practice under the exemption with the Vero policy."

Response to the above question, from Paul Currall (dated 15 June 2010):
"Professional indemnity insurance is a registration requirement, not a separate requirement for MBS/PBS access. The obligation is on the midwife to have appropriate insurance arrangements in force, and midwives will need to consider whether the Mediprotect policy is appropriate for them. As it is a registration requirement, if it becomes an issue then it will be the Nursing and Midwifery Board which is the relevant body.

"A midwife wishing to apply for an MBS provider number must meet the NMBA's requirements for registration as an eligible midwife. These are the same requirements that a midwife needs to meet in order to be eligible for the MIGA insurance policy.

"If the midwife meets the NMBA requirements for registration as an eligible midwife, then she/he can apply to Medicare Australia for a provider number to gain access to MBS rebateable services. In the case of a midwife who has insurance cover for ante and post natal services only (and provides intrapartum services for homebirth), access to MBS funds will only be available with respect to clinically relevant ante and post natal midwifery services.

"If a midwife is an eligible midwife for the purposes of the National Health Act 1953 and is approved to prescribe medicines in the state and territory in which she/ he will be practising, the midwife can apply for approval as an authorised midwife, a PBS prescriber, and be allocated a prescriber number."

in the newspapers

2010-06-13T14:47:00.001+10:00

The words 'home birth' and 'midwives' have appeared in headlines of articles in the Sunday Age today. Here are the links to the articles:

With a little Sunshine, home birth rate is due to expand
JOHN ELDER
June 13, 2010

"THE number of home births in Victoria is on the rise, with a publicly funded program using midwives from Sunshine Hospital gaining popularity.

"Since the pilot scheme was launched in January, hospital midwives have overseen seven home births. [continued]

Many midwives unaware new laws affect them
JOHN ELDER
June 13, 2010

"LEGISLATION giving midwives greater authority over the maternity care of Australian women will be launched at the end of the month, but it could take years before real changes are delivered. [continued]

Readers may be wondering, is this good news?
Has all the political activism around birth, and particularly home birth, paid off?
Are Midwives in Private Practice (MiPP) in Victoria, the group managing this blog, happy with progress?
Are mothers who want to give birth at home confident that they will be able to access the professional midwifery services that they desire?

Please send a comment if you have an opinion on this. Unfortunately many will answer 'No' to each of these questions.

Midwives' opinions range from grudging acceptance that a midwife's scope of practice has been restricted, through the government's reform, to a very narrow interpretation of 'normal'; to outrage that we are being forced to give up our right to autonomous practice.

A recent blog by South Australia midwife Lisa Barrett on collaboration has drawn valuable comment.

The Save Birth Choices blog discusses the fact that Homebirths are legal but Midwives not indemnified
"Women choosing a homebirth and their midwives will take little comfort from the implementation of the Rudd Government’s professional indemnity insurance cover for practising midwives this week. [continued]

The newspaper article featuring the birth of baby Banjo through the Victorian government's pilot homebirth project at Sunshine Hospital (situated in Melbourne's Western suburbs) is good news. Women who are able to access the pilot, who might not have even considered privately attended homebirth, are given an opportunity to proceed through their birthing journey with known and trusted midwives, who are able to provide homebirthing care.

Midwifery is not for the faint-hearted. Being professionally responsible and accountable for the birth of a baby, whether in a hospital building, or in a home under hospital protocols, or in a home as an independent practitioner requires a midwife who prioritises consideration of the wellbeing of the woman and her child at all times. Midwifery cannot be fear-driven. Birth is not an illness. The midwife who understands working in harmony with natural physiological processes, who commits to protecting and promoting wellness in birthing and nurturing the newborn child, adheres to the principle that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996).

When birth is not normal, or when a valid reason arises to interfere with the natural process, the woman who is partnered by a trusted midwife is able to make informed decisions as she progresses through what can be a frightening and unpredictable journey.

Writing a letter

2010-06-03T19:28:00.000+10:00

This is a compelling account of a birth and the trauma suffered by the woman.

Quote from Pulse: Voices from the heart of medicine

"I wrote the letter because I wanted the doctors and hospital staff to understand my perspective and to appreciate the devastating impact that this event had had on my life and family.

"I also wanted them to consider the inept and unfeeling care we'd received from first to last--including the failure to get me into a delivery room quickly enough, the brutal response to the hemorrhage (which better care might have prevented in the first place) and the inappropriate discharge of my ill newborn.

"I wanted them to change the way they conducted business so that no one else would have to endure what I did."

NEW Insurance options for midwives

2010-05-15T10:51:00.005+10:00

The Australian College of Midwives has circulated to members information on new insurance options for midwives who provide private maternity care (excluding homebirth) and education.

"1. The Commonwealth supported insurance policy

Last week, Health Minister Nicola Roxon announced that MIGA (Medical Insurance Group of Australia) has won the contract to offer midwives professional indemnity insurance, with support by the Commonwealth under the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Act 2010 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Act 2010. Click here to see the Minister's press release.

The policy will provide insurance cover for eligible midwives for pregnancy and postnatal care in any setting, and for labour and birth care in a clinical [ie hospital] setting.

This policy will cost $7,500 per year for full time practice. Reduced rates will be available for caseloads that are less than full time.
...
The policy is not yet available to purchase, but is expected to be available very soon, and will definitely be available before 1 July 2010. You can read more about the policy by visiting MIGA's website, or ask questions by phoning them on Freecall 1800 777 156

"2 Vero insurance policy for pregnancy and postnatal care only
A second option for meeting the insurance requirements is to purchase a policy through an insurance agent called Mediprotect. ... The policy will cover pregnancy and postnatal care in any setting. It does not provide cover for labour and birth care in any setting.

...

Vero is an Australian insurer, regulated under the Australian Prudential Regulatory Authority. You can elect to have cover of $1million, $2million or $5million. Prices vary depending on the level of cover you choose and which state you live in (because of stamp duties), but because labour and birth care is excluded, this policy is less expensive than the Commonwealth-supported one with MIGA. Information about the Vero policy can be obtained from the Mediprotect website or by phoning Mediprotect on 07 3426 0440."

********* (end of copied material)

The Vero insurance will cost a midwife between $1,830 p/a for a $1,000,000 cover, to $3,010 p/a for $5,000,000 cover. The excess on the policy is $2,500 (each and every claim).

Other possible insurance options, yet to be confirmed, will be available for members of some of the State branches of the union, Australian Nursing Federation (ANF). At present, all members of ANF in Victoria except independent midwives have professional indemnity insurance. Queensland Nurses Union has a similar member policy. It is anticipated that this member benefit will be extended to midwives' private practices, with the exclusion of home birth. If you are interested in this option, you should contact ANF.

Is birth at home a human right?

2010-05-12T19:43:00.000+10:00

Is there a human rights argument in the choice of place of birth?

Is our government failing in its human rights commitments, as a signatory to conventions such as United Nations Convention on the Elimination of all forms of Discrimination Against Women CEDAW, by maintaining the state-sanctioned discrimination against women who plan to give birth in their home?

Can you think of any other natural, physiological function of the human body for which we experience discrimination that seeks to force all to follow government-mandated management in hospital? What would our society do if similar discrimination was enacted for a uniquely MALE function?

These are some of the questions that are being asked. Your comments are welcome.

More discussion here.

Jenny Parratt - a midwife

2010-05-10T17:15:00.001+10:00

Congratulations to Jenny Parratt, a midwife who lives in Mandurang Victoria, who is a founding member of Midwives in Private Practice (MiPP)

Professor Kathleen Fahy of the University of Newcastle (NSW), writes "I am thrilled to announce that Jenny Parratt has been awarded her PhD after examination with no correction and high praise. Her oversees examiners were in the UK, Professor Mavis Kirkham and A/Prof Dennis Walsh (very eminent in midwifery)."

FEELING LIKE A GENIUS: ENHANCING WOMEN'S CHANGING EMBODIED SELF DURING FIRST CHILDBEARING
Jenny writes:
My dissertation is focused on women's holistic wellbeing in terms of their changing embodied sense of self. It considers the way a woman's embodied sense of self changes during the childbearing period and the factors in childbirth that seem to be positively related to her improved sense of self.

Fourteen women answered questionnaires and told their stories of childbearing change; these stories have now been published (details below).

In the dissertation I establish how a person's embodied self is complex and continually changing relative to the various contexts of existence. I show how a woman's improved sense of self is related to the degree to which she is able to feel herself as an embodied whole and intrinsically powerful person. I use the concept 'genius change' to represent a woman's active and effortful use of intrinsic power, in addition to her developing trust in that power. The dissertation explains how midwifery factors that are unsupportive of a woman's improved sense of self, called 'habitual practices', undermine a woman's sense of her own power and encourage reliance on her usual responses to change. 'Empowering practices' are shown to be positively related to a woman's improved sense of self. These practices guide a woman to connect with and actualise her intrinsic power in new and previously unanticipated ways. The dissertation is significant for midwifery practice and education because it makes explicit how a midwife can optimise a woman's psychophysiological wellbeing in ways that uniquely suit the diverse requirements of each woman.

The women's stories are published as 'Parratt, J. (2009). Feelings of
change: Stories of having a baby. Raleigh: Lulu.com'. This book is available
from:
http://www.lulu.com/content/paperback-book/feelings-of-change-stories-of-hav
ing-a-baby/7846284

24 Hour Virtual International Day of the Midwife 2010

2010-05-04T16:36:00.002+10:00

Starting in New Zealand at midday Wed 5th May, the virtual celebration will proceed around the globe for the following 24 hours.

24 Hour Virtual International Day of the Midwife May 5th 2010 [click for link]

Dr Deborah Davis (University of Technology, Sydney, Australia) and Sarah Stewart (Otago Polytechnic Education Development Centre, Dunedin, New Zealand) would like to invite you to celebrate International Day of the Midwife on May 5th 2010 by joining us at some stage during the 24 hour Virtual International Day of the Midwife event.

The problem with face-to-face events is that geography and time zones prevent many midwives meeting on an international level. However, online resources and tools such as Second Life, Elluminate and Skype allow midwives to meet, communicate, share information and resources in a far more flexible way than face-to-face meetings. Thus, this 24 hour virtual celebration of midwifery allows us all an opportunity to meet at some stage during the day, be it at 'live' or real time meetings or asynchronous sessions.

Eligible midwives

2010-04-27T10:50:00.002+10:00

Here's a link to the Nursing and Midwifery Board of Australia's Guidelines and Assessment Framework for the Recognition and Endorsement of Eligible Midwives

Comments by readers are welcome.
Comments can also be read at other midwives' blogs - see Lisa Barrett's blog.

woman centred care, midwife led care, or what?

2010-04-25T17:10:00.001+10:00

I like to think that woman centred care and midwife led care are two sides of the same coin: that ideal of best practice - the midwife using her skill and knowledge in a way that results in optimal care and best outcomes for the mother and her child, and through them, to the community.

What do we really mean by woman centred care?

Or by midwife led care?

Are midwives just power hungry, demanding their slice of the pie claiming a 'right' to being at least one of the professional care providers that women are able to choose from?

Stepping back momentarily from midwifery, and speaking as a woman who wants only the best for women and babies, I can confidently argue that services offering primary maternity care that

places the individual woman at the centre of each decision and plan

promotes health and normal physiological wellbeing in maternity care

enables and supports women in normal childbirth without relying on potentially dangerous drugs and surgery

enables establishment of exclusive breastfeeding

supports timely access and transitions to specialist medical services for mother or baby

...
are indeed as close to optimal maternity care as is humanly possible to imagine.

And the good news is that the person who is able to provide this whole package is the midwife. Not any midwife, but the midwife who commits to being with that individual woman, establishing a partnership based on trust, and (literally) LEADING and guiding the woman as she negotiates her personal maternity care. That midwife makes decisions, with the woman, about critical directions in the journey.

A recent Science and Sensibility blog post by Amy Romano, titled
What’s Behind the Cochrane? (or…, “The Good News About Midwives Gets Better!”) explores 'gold standard' research in maternity care. When we look at the best research evidence into models of maternity care, we can conclude that optimal care is midwife led care. That means a woman has a known midwife who not only provides the primary service throughout the pregnancy, birthing, and postnatal phases; who is the responsible professional in attendance at birth; and who accesses/ refers to specialist services when and if required.

Amy Romano warns:
"Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies."

This warning should not be dismissed lightly. Although this is written to a predominantly North American audience, it's as relevant in Australia. We hear and read of women who book with a particular obstetrician who has a name for vaginal births, and that he encourages to have a personal attendant in the form of a doula. Yet the evidence supporting that model is no where near as strong as the evidence supporting midwife led care.

The Cochrane reviews offer the highest level of reliable research that is available to the medical community today. Yet the availablity of midwife led care is shockingly poor in this country. Our health bureaucrats and advisors to policy makers take the liberty of cherry picking certain evidence, while conveniently ignoring the evidence supporting midwife led maternity care.

Australian maternity care and health are undergoing unprecedented reform at present. What comes out the other end of the reform process is anyone's guess. What is clear is that it will be top-heavy with bureaucracy. On this particular issue of midwife led care, the NHMRC Collaborative Guidance has discretely avoided mention of midwife led care with the statement:

"9. Collaboration aims to maximise a woman’s continuity of carer by providing a clear description of roles and responsibilities to support the person that a woman nominates to coordinate her care (her ‘maternity care coordinator’)."

Readers might reflect on the difference between a midwife who has a role as professional leader of the care, and that of care coordinator.

A colleague has recently written "The most important idea I had [in responding to the NHMRC document above] is to change the language from Women Centred Care to Women LED care. If this is successful then all the blah about respecting autonomy and legal rights is an academic exercise - think about it. I keep thinking that the woman is surrounded in the centre!."

I have to disagree. Woman LED care negates that time-honoured and valued role of the midwife.

As I worked with a young woman in labour the other night, progressing very slowly through first stage, I needed, on occasion, to take the lead. I knew what needed to happen, but I could not do it for her. Her partner and I would dearly have loved to be able to do something that relieved her exhaustion, stopped her vomiting, allayed her fears, made her bearing down more effective ... . As the responsible professional I asked myself several times if we had crossed a line; if would need to go to the hospital. I wrote the letter of referral - a letter that did not get used. It was all there in black and white: labour commenced many hours previously, after more than 24 hours' rupture of membranes; we had experienced difficulty maintaining adequeate hydration; the contractions became less frequent than is usual. Yet this strong woman continued to progress, and her baby showed no sign of distress. Baby was born beautifully, at home.

This birth tested the partnership of a woman and midwife. The midwife leading the care enabled the woman to experience a natural event that was outside anything she had ever previously imagined. The midwife trusting the woman, and the woman trusting her midwife allowed a decision making process that put the woman/child at the centre of the care, and enabled success in a marathon that takes more physical and emotional strength than either woman or midwife know they have.

Yet in completing that endurance course, the mother and baby are strong in mind and body. That is the outcome we are wanting. It is not easily achieved, but it is precious and worth working for.

Faceofbirth teaser

2010-04-16T13:42:00.000+10:00

Faceofbirth — 06 April 2010 — Teaser for the upcoming documentary the Face of Birth. A documentary about pregnancy, childbirth and the power of choice.
Category: Film & Animation
Tags:
Face of birth Face of birth childbirth homebirth documentary interviews Gavin Banks Kate Gorman Greg Hall face giving water women

Croakey on the AMA

2010-04-13T10:49:00.000+10:00

Readers of this blog may remember previous links to CROAKEY, the health blog of the independent news reporting organisation CRIKEY.

Here's a new post, focusing on the Australian Medical Association (AMA), and its claim that its president Dr Andrew Pesce, should be seen as the “Chief Health Policy advisor to all political parties”.

This is not the first time Dr Pesche has assumed the role. His influence on Health Minister Roxon in the report of the Maternity Services Review and subsequent legislation, particularly in requiring midwives to have 'collaborative arrangements' with doctors, is already on the record.

World Health Day, April 7, 2010: 1000 Cities, 1000 Lives

2010-04-07T19:17:00.002+10:00

Join La Leche League International (LLLI) and the World Alliance for Breastfeeding Action (WABA) In Celebration of – World Health Day, April 7, 2010:
1000 Cities, 1000 Lives

This year’s World Health Day theme addresses the challenges surrounding the growing urban population. The World Health Organization is calling upon cities across the globe to be counted among the “1000 cities” dedicated to improving the health in urban areas.
The Challenges
• Virtually all population growth over the next 30 years will be in urban areas.
• The urban poor suffer disproportionately from a wide range of diseases and other health problems.
• The major drivers of health in urban settings are beyond the health sector.
• Actions and solutions exist to tackle the root causes of urban health challenges.
• Build partnerships with multiple sectors of society to make cities healthier.

Breastfeeding: A Paradigm for Change
What role might breastfeeding play in addressing the challenges and offering at least a partial solution?
... [read more]

from Homebirth Australia

2010-04-05T07:53:00.002+10:00

An Extraordinary General Meeting will be convened 21 April via Teleconference.

For more information, or to join Homebirth Australia, go to the website.

'The world needs midwives now more than ever'

2010-03-24T14:14:00.005+11:00

International Midwives Day - 5th May 2010

Midwives around the world celebrate the 'International Day of the Midwife' on May 5th every year. The aim of the day is to celebrate midwifery and to bring awareness of the importance of midwives' work to as many people around the world as possible.

The recurrent ICM theme for 2010 is 'the world needs midwives now more than ever.' This theme was created in 2009 in response to a need to increase Midwife numbers around the world to achieve WHO Millennium Development Goals (MDGs) by 2015. In total 350,000 more midwives are needed by 2015 in order to:
- Improve Maternal Health;
- Reduce Child Mortality; and
- Combat HIV/AIDS, Malaria and Other Diseases.

Achieving the Millennium Development Goals requires a global, national and local commitment to grow a strong, well-educated midwifery workforce within functioning health service delivery systems.

Although the Millennium Development Goals seek to enable improvements in health for the most disadvantaged people in the world - people who do not usually come into the care of independent midwives in Australia - these goals are as important in middle class Melbourne as they are in the slums of the world's poorest countries.
Australian independent midwives promote health for mothers, babies and families. Our statistical data demonstrate excellent outcomes for mothers and babies in our care.

More information, and items to help with local celebrations can be got from the College of Midwives.

GO GIRL Australia!

2010-03-17T15:39:00.000+11:00

Midwife Marg Phelan is ready to cycle around this great land, for midwives, women, normal birth and breastfeeding.

Check out her website at

www.gogirlaustralia.net.au

Reclaiming Birth RALLY in the UK

2010-03-12T10:27:00.002+11:00

Around 1,000 men, women and children turned out, the procession filled Westminster Bridge, as far as the eye could see there were flags and banners. The fight goes on.

Maternity reform hijacked 3

2010-03-05T16:25:00.003+11:00

Professional indemnity insurance
One of the key features of the new national health practitioner legislation is the mandating of the requirement for professional indemnity insurance for all registered health professionals. Midwives stand alone in the field, as the only group unable to purchase private indemnity insurance.

Midwives in Canada and New Zealand practise with government provisions for professional indemnity insurance, being treated equitably with other maternity service providers, ie doctors. Midwives in Australia, by comparison, have been repeatedly sidelined in all government provisions for indemnity, giving doctors privilege across the scope of maternity services. Midwives who are employed by hospitals or health services are covered by vicarious liability provisions, as well as by insurance which is part of membership in the union, the Australian Nursing Federation, Victorian Branch. Midwives who practise independently, who are self employed, have done so without indemnity insurance since about 2001. Under the legislative reforms that are today being debated, the best that the federal government has offered this group of self employed midwives is a two-year exemption from being required to have private indemnity insurance for home birth. This is an irrational approach to dealing with a real problem. It simply puts the problem under the mat with the rest of the dust.

That small group of self-employed midwives, probably less than 50, who provide private midwifery services for less than one% of Victoria's birthing population, have been sidelined in the federal government's Report of the Maternity Services Review, and in subsequent legislative reforms. These midwives and the women who employ them have become an unwanted and aggravating minority group, writing multiple submissions to inquiries, and letters to politicians. Thousands of mothers, fathers, and little children, with midwives and other concerned people, have rallied in sites around the country, and have experienced the dictator Rudd's response that he is unmoved. These people are intelligent, and they vote. They know their human rights to self-determination in all matters of their own bodies. They know that pregnancy and birth is not an illness, and they know that the midwife is in many cases the most appropriate professional able to provide primary maternity care, with a commitment to protecting and working in harmony with natural physiological processes. They also know that the botched reform of this federal government is likely to restrict their choices in maternity care, rather than improve access and choice.

Doctors who provide maternity services, that is, specialist obstetricians and general practitioner obstetricians (GP-Obs) receive huge public funding to ensure indemnity insurance for their private practices. There is no rational reason why midwives should not receive similar government support. Victorian Health Minister Andrews, and other state and territory health ministers, together with their federal counterpart, have blocked any such suggestions.

The focus so far in health practitioner regulation has been the federal political scene, because the primary legislation is national. The Victorian Health Department now has responsibility nationally to develop a Safety and Quality Framework that will be required for midwives to continue their private practices and be entitled to the two-year exemption from indemnity for attending home births. This process is already wobbly. Many stakeholders in all states and territories have appeared before the Department's consultants, and the only thing that is clear is that nothing is clear.

Collaborative arrangements
Health Minister Roxon has repeatedly asserted that "The Government's intention has always been to ensure that the midwife and nurse practitioner reforms are underpinned by collaborative arrangements between health professionals."
Collaboration in its true sense, 'co-labor(ing)', is fundamental to a midwife's practice. The midwife's definition and scope of practice require referral to a doctor or suitable medical service when complications requiring medical intervention arise. But midwifery does not stop when a complication is detected and care becomes more complex. The midwife continues with the woman, and collaborates with doctors, nurses, pathologists, physiotherapists, dentists, or whoever else is able to provide care that will be in the interests of the wellbeing of mother and child.

The requirement for collaborative arrangements has been brought through into legislative amendments as an agreement signed by a doctor or doctors. It seems that Minister Roxon's tunnel vision expects that midwives will be able to find doctors who will sign off as agreeing to collaborate with them. Many midwives anticipate that any such request would be met with refusal by the doctors in their communities. The medical union, the Australian Medical Association (AMA), as well as the obstetricians professional body, Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), have been outspoken in their opposition to private midwifery and homebirth. The requirement for up-front signed agreements around collaboration is handing the power of veto of midwifery private practice to the medical profession.

There is no requirement for doctors to access signed collaborative agreements signed by midwives. Yet all doctors providing maternity services NEED midwives to work with them - that's understood.

It seems that Minister Roxon's tunnel vision has missed the obvious fact that if an uninsured midwife is attending home birth, it is highly unlikely - even impossible - that a doctor's insurance provider would agree to indemnify the doctor who enters a collaborative arrangement with that midwife.

For further comment on this topic, go to
Part 1 Background
Part 2 Consumer choice, and Competition Considerations

A challenge to the AMA

2010-02-25T15:48:00.002+11:00

To review our previous post on the sensationalist misrepresentation of home birth statistics by the Medical Journal of Australia, click here.

The following article has been published in the British Medical Journal, 24 February 2010, doi:10.1136/bmj.c826
Cite this as: BMJ 2010;340:c826

Observations
Medicine and the Media
Science, politics, and headlines in the home birth war
Melissa Sweet, journalist, Sydney

Why did the media report new research as showing that outcomes of home births are much worse than those for hospital delivery? Melissa Sweet reports

Last month the Medical Journal of Australia published a study on outcomes of home birth that generated many media stories sounding the alarm about the safety of such births.1
Many stories focused on the study’s findings that babies were seven times more likely to die during labour in a planned home birth and in particular were 27 times more likely to die from asphyxiation. Some also did mention the finding that there was no significant difference in the overall perinatal mortality rate between planned home births and those planned for hospital delivery.

These were also all findings highlighted in the media release accompanying the journal, which made no mention of uncertainty surrounding the relative risk estimates. The confidence interval for both was wide: 1.53 to 35.87 for intrapartum deaths and 8.02 to 88.83 for deaths from intrapartum asphyxia.

Nor did the press release mention the numbers of deaths involved or the absolute risks. ...
[Unfortunately the remainder of this article is available only to subscribers]

________________________________________
MS holds an honorary position at the University of Sydney’s School of Public Health and moderates a health blog, Croakey, which has covered the home birth story.

References
1. Kennare RM, Keirse MJNC, Tucker GR, Chan AC. Planned home and hospital births in South Australia, 1991-2006: differences in outcomes. Med J Aust 2010;192:76-80.
2. Australian Medical Association. Planned home births linked to a higher risk of perinatal deaths in childbirth. www.ama.com.au/node/5275.
3. Pesce AF. Planned home birth in Australia: politics or science? Med J Aust 2010;192:60-1.
4. Woloshin S, Schwartz LM, Kramer BS. Promoting healthy skepticism in the news: helping journalists get it right. J Natl Cancer Inst 2009;101:1596-9.

Community Cabinet in Ballarat

2010-02-21T14:01:00.002+11:00

Consumer members of Maternity Coalition in Ballarat were successful in putting key questions to the Prime Minister, Kevin Rudd, who passed the questions to Health Minister Nicola Roxon.

Anyone who has not followed the process of maternity reform, who listens to this film clip, may ask what's the problem. The Health Minister has absolutely guaranteed that:

homebirth will not be forced underground
women's rights in birth will not be vetoed by the Australian Medical Association

The spin doctors have carefully woven this web, and the Minister is well scripted. There are clues in subsequent statements, even in this video clip. For example,

homebirth will not be forced underground. Of course not! The Victorian government has announced three publicly funded pilot homebirth schemes that are connected to public hospitals. As long as there are women who can jump through the hoops set by these pilots, and as long as there are midwives who are prepared to work in managed programs, homebirth can continue. Anyone who lives outside the radius covered by these pilots, or whose 'risk' profile excludes them from participating in the pilots, or ... - well you're on your own. BUT this government is NOT forcing homebirth underground.
women's rights in birth will not be vetoed by the Australian Medical Association. The doctors don't want homebirth at all. The AMA, RANZCOG, NASOG, and others consider that birth can only be safe if it happens in hospital. So as long as women are in hospital, or in the virtual hospital in the home (under the supervision of the hospital), women's rights haven't changed.
people (midwives and doctors) will be requred to work together! The Minister put on her most paternalistic/dictatorial (Queenly, as in Alice in Wonderland) voice to make this proclamation. She illustrated it with telling us that we will need to have backup arrangements (for homebirth). Excuse me! If she, or her advisors/spin folk had read even a few of the thousands of submissions made to the multiple government reviews, she would know that midwives and women planning homebirth do make backup arrangements. She would know that the obstacles are erected by hospitals, not as a result of any unwillingness by midwives to 'work together' as she puts it. She would know that midwives do consult with obstatricians or other doctors, and refer when appropropriate - AND that by all outcome measures we provide effective and safe primary maternity care. What Roxon obviously does not understand is that, for many women, giving birth is a spontaneous, non-medicalised event. It can happen in the privacy of their own home. It is not an illness. Only those who experience illness or complication need medical attention.

In summary, it seems that midwives who agree to provide private midwifery services for planned homebirth will, after 1 July this year, be under a great deal of pressure to accept only those whose risk profile is totally uncomplicated. The women who have had previous caeasarean, or grand multiparity, or multiple pregnancy, or too fat, too thin, ... - they will be expected to go straight to [hospital], do no pass go, do not [see a midwife].

[ADDED 24 Feb]
From the Hansard:

Senator McGAURAN
Rest assured that I know all about the incompetence of Minister Roxon, who has flown under the radar. It is not just this issue; a whole array of issues in her portfolio ought to be brought out.......

I was in Ballarat recently for the community cabinet—‘community cabinet’?; it was Mr Rudd’s sideshow. That was all it was. You should have seen the glum faces on all of the ministers who turned up. What a joke. In this portfolio is the midwives issue, denying women the choice to have home births. That was what dominated the community cabinet. I got a guernsey; I was there in the front row. I could not believe it. It was a sight to see the one ego on display. He really does have a big ego. You have to see it to believe it, and you are all compliant to it. It is a joke. When are you going to stand up and speak on an issue?

This Prime Minister is so frightened of the midwives issue he is not willing to meet the public outside of a controlled situation. When he had to unveil the Kevin Rudd bust in Ballarat—as many of you know, in the gardens there there are busts of every Prime Minister— he did not turn up. He left the council, the Mayor and everyone else standing
there waiting for him to appear at 11 am. He just did not turn up. He did not even ring ahead to say he was not going to turn up. Can you imagine the embarrassment and the frustration? Do you know why?
Because there were midwives protesting there waiting for him and wanting to speak to him. Of course, they have dubbed it as ‘cowardly’.
That is the portfolio I want to speak on.

National consultations on Quality and Safety Framework for Midwifery Care

2010-02-18T15:12:00.002+11:00

Many of Victoria's privately practising midwives, as well as maternity consumer activists, have attended meetings today with representatives of the Department of Health's Maternity Services Program (Ms Julie Jenkin) and the Maternity and Newborn Clinical Network (Dr Jeremy Oats and Ms Debby Rodgers). Similar meetings are also being held in other capital cities.

The purpose of the consultations is to develop a 'Quality and Safety Framework' which midwives in private practice will be required to agree to IF we wish to be exempt from the requirement for private indemnity insurance for attending home births. For more on the exemption, click here.

We were reassured, once again, that the government has no intention of preventing midwives from continuing their private practices. BUT the caveat is that we must comply with a framework that is yet to be declared.

Having carefully considered the draft framework, we have no confidence that we will be able to comply.

Submissions will be made to the consultation by the end of February, and we will keep our readers informed.

Please note that these comments focus on the midwife and our right to practise midwifery in the setting of the woman's choice. While it is likely that midwives will continue to practise after 1 July, we have deep concern for women whose 'risk profile' includes factors such as previous caesarean births, previous post partum haemorrhage, multiparity, breech, post 42-weeks gestation, as well as age and BMI considerations. These women are often the ones who seek out a private midwife, and who may choose to plan home birth at present. The 'quality and safety framework' appears to be a bureaucratic effort to prevent such women from accessing any care outside the hospital system.

OUR BODIES, OUR BABIES, OUR RIGHTS

2010-02-12T14:54:00.003+11:00

Another
NATIONAL DAY OF ACTION - AUSTRALIA WIDE

THURSDAY FEBRUARY 18

Main Event is in Ballarat where Kevin Rudd will be - Please wherever you are in Victoria please come and join us to send a clear message to Rudd that we are now UNMOVED and will continue to fight this.

BALLARAT
When: Thursday, February 18 from 10:00 am to 12:00 am
contact: karlskeys@hotmail.com
Place: to be confirmed

Other events will be in
Perth
Brisbane
Hobart
Gosford
Adelaide
Hunter/Newcastle
Blue Mountains
Cairns
Darwin

(still some places being finalised, watch the websites below and register at mybirth for updates on the campaign)

Do you think Australian women, not Kevin Rudd should make decisions about their own healthcare? If so come and support us.

Visit the MyBirth website for Campaign tools & Event details
- posters to download and distribute, banners for your website/blog and register to be notified of upcoming events in your area

When having a baby do you want to make choices about your health care?

New reforms introduced by the Rudd Government were meant to increase support to women, giving them the option of choosing a midwife to care for them.

Many women have said they would love this care, especially because the care would come from 1 midwife from early pregnancy, through labour and birth and up to 6 weeks after the birth. The best part being, many midwives provide home visits! Pure Luxury.

Many Mums think this care is long overdue!

Enter the problem! The Australian Medical Association has decided that women will only be able to choose midwifery care if a Doctor agrees. This means if a doctor is not prepared to support the local midwives, then women will not have access to care.

We believe while women may seek advice and support from their doctor that ultimately they have the right to make decisions about their bodies.

There are events running in every State so spread the word!

This is for EVERY WOMEN (and their families and friends) and EVERY CHOICE, please forward this on to every person you know who supports the right to choose!

For media reports go to
ABC

Channel 7 Sunrise

Channel 7 News

The exemption

2010-02-05T16:29:00.000+11:00

The next big hurdle for privately practising midwives (PPMs) is to ensure that we are able to access 'Exemption' from indemnity insurance for homebirth from 1 July 2010, until 2012. Without that exemption it will be unlawful to provide any midwifery services for homebirth. Midwives will be required to purchase indemnity insurance for the other parts of our practice - prenatal and postnatal. Exact definitions of what is prenatal and what is postnatal and what is 'birth' for the purposes of the exemption are yet to be found.

Does 'birth' start at the beginning of labour, and how is the beginning of labour to be defined for the purposes of the exemption? And does 'birth' end after the placenta has been birthed, or does it end at some other time?

The Federal and State/Territory Health Ministers decided at their meeting last September that midwives providing homebirth care would be given access to an exemption from the requirement to hold professional indemnity insurance for a period of 2 years subject to three conditions. The conditions are:
1. That PPMs report all homebirths according to the requirements of their jurisdiction
2. That women booking with a PPM receive written disclosure that the PPM is practising without insurance
3. That PPMs agree to a Quality and Safety Framework for midwifery care

Point .3 is the one receiving most attention, and is the focus of the face to face consultations that are being held, at which organisations are being invited to comment on the draft document.

MiPP has prepared a response which is to be presented to the consultation by several members. This response will also provide the basis for written submissions. MiPP has gathered evidence to support our submission.

In summary, we urge the Consultation to recommend to the government

that the only mandatory requirement for a midwife to engage in private practice be that the midwife is registered
that all midwives who are currently in private practice should be eligible for the exemption
that midwives who choose to commence private practice during the two-year exemption period be able to proceed with fair and reasonable processes
that the two years of the exemption be used to review and record private midwifery practice so that any regulatory changes can be introduced in a systematic and evidence-based way
that midwives in private practice be treated equitably with other midwives, and with other regulated health professionals in their ability to practise their profession privately.

Other groups whose draft submissions are being circulated amongst members for commment are those of the Australian College of Midwives, and the Australian Private Midwives Association.

Senate Committee's findings

2010-02-01T20:35:00.001+11:00

The Senate committee "recommends that the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 with amendments, the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-Off Cover Support Payment) Bill 2009 be
passed."
Click here for the full report

Senator Rachel Siewert (Australian Greens) in her minority report recommended that
"the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill is amended by replacing reference to ‘collaborative arrangements’ with a requirement that eligible midwives demonstrate collaborative practice and that in the definition of a participating midwife, midwives would be required to demonstrate ‘collaborative practice’ by using standardised clinical documentation for planning and provision of care. This would record specific indications of collaborative practice, in particular consultation and referral as required, with the consent of the women for whom care is provided."

ADDITIONAL COMMENTS by the The Coalition Senators
"... acknowledge the concerns of stakeholders regarding the Government’s proposed amendment to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009. Significant concerns were originally raised about the affect of the amendment on the ability of Midwives to gain indemnity insurance and therefore be registered. The Minister has since given notice that the Government will withdraw the amendment relating to the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009. The Coalition Senators acknowledge the importance of an appropriate collaborative arrangement that provides for patient safety and confidence. Mothers-to-be and midwives have not been assisted by the Health Minister’s numerous changes in policy direction and the Coalition will reserve the right to consider the regulations that define the nature of collaborative arrangements between nurse practitioners, midwives and medical practitioners."

Australian College of Midwives' website

2010-02-01T11:33:00.000+11:00

Keep up with maternity news, using a new listing that appears at the website of the Australian College of Midwives, which has recently been updated.

Link to the BJM

2010-02-01T11:25:00.000+11:00

Midwives may enjoy receiving a monthly email update from the British Journal of Midwifery

To view articles click here

News articles also appear at the site
Midwives have been advising pregnant women not to have the swine flu vaccination
It has been reported that midwives have been strongly advising pregnant women not to have the swine... read more

Bev's review of politics and homebirth

2010-01-25T10:08:00.000+11:00

Over half of the submissions to the Federal Government Inquiry into Maternity Services in March 2009 were from consumers and nearly 60% asked for greater support for, and access to, homebirth. The extreme naivety of leaving home birth off the agenda because "it would polarise the professions" has caused chaos. If you believe in the chaos theory, midwives and mothers have emerged victorious. Midwives and homebirth are now on the agenda.

Home birth families around the country have been fascinated to read the new South Australian study published in the MJA (Medical Journal of Australia) on Monday 18th January. For babies born at home there were only 2.5 deaths per 1000 actual homebirths making homebirth 328% safer for babies than birth in hospital. When the detail of the study was exposed and the data analysed correctly by experienced exponents of research analysis, the perinatal mortality for homebirth is 2.5 babies per 1000 births compared to 20.1 babies per 1000 births in hospital.So women can safely choose homebirth in South Australia.

Sophisticated high level research in the United Kingdom, Netherlands, New Zealand and Canada has already confirmed that women are more satisfied with midwife led birth. In spite of false claims by the erstwhile leaders the of the AMA (Australian Medical Association) this South Australian research study, reinforces the view of advocates for women, that home birth is now only way for women to claim back normal birth. In fact one leading obstetrician Marsden Wagner in the USA puts it more bluntly "get the Hell out of Hospital".

The other good news from the study, was that homebirth provides: a lower incidence of episiotomy (an unkind cut), higher incidence of intact perineum, less 1st. 2nd and 3rd degree tears than in hospital women, less incidence of post-partum haemorrhage, no statistical difference in babies' apgar (colour breathing) score.

The new study assessed the outcomes of almost 300,000 births in South Australia from 1991 to 2006 which resulted in approximately (8.2/1000) or 2550 baby deaths in hospital. Of the 1141 planned home births the rate was declared to be 7.9/1000 EXCEPT that 7 of these 9 births died in hospital.
The claim that the research demonstrated that baby’s had a 7 times more likelihood of dying in homebirth is false.
The attribution to planned homebirth for at least 4 of those deaths which were congenital abnormalities, is specious.
There is no explanation given for the approximately 2500 deaths in hospital.
The other false claim of "27 times more likely to die of birth asphyxia " ( lack of oxygen either before during labour or at birth) is exposed when it is clear that only one baby died for that reason at home during the selected 16 years. The mother refused to go to hospital due to previous bad hospital experience.

Caesarean surgery, removing the baby through the mother's abdomen, is taking place for one in three women and higher in Australian private hospitals. These doctor led positively reinforced decisions are nothing short of assault and battery of women. Obstetrician David Elwood from Canberra stated to Norman Swan on Health Matters on 2.11.09 "now that we manage surgically so well then there is no turning back to normal vaginal birth" he further stated that "we" set the surgery for 39 weeks. "I was up during the night recently performing a caesarian (surgery) because a woman came into labour before 39 weeks.". Even more scary another doctor Caroline de Costa from Qld stated to Norman Swan that women "now have right to choose between vaginal and abdominal birth".

Duty of care, that is, "first do no harm" seems to be missing. In Brazil the abdominal surgery rate for birth is 80%. According to recent research from South America, repeat surgery for future births, is putting women at risk of loss of fertility, haemorrhage and/or death. Recent strong causal links have been made with the high incidence of asthma. Lack of exposure to normal flora of the mother's skin and the absence of squeezing out fluid from the lung as in normal vaginal birth are stated to be the reason. High rates of psychosocial and physical illness are also linked to this surgery.

It is interesting that M. Keirse who was co-author of the South Australian study was also co-author of 3rd Edition of a Effective care in Pregnancy in which it was stated that it is inherently unwise and perhaps unsafe for women with normal pregnancies to be cared for by an obstetric specialist. The Health Minister Nicola Roxon, stated in a letter to me, that the Australian Government has recommended a review of the high rates of abdominal surgery for birth and intervention . Federal MP Darren Chester from East Gippsland spoke to me of the high regard in which he held the midwives of East Gippsland who were lead carers in their children's births. Matt Viney State MP from Warragul told me that two of his children were born at home with a midwife.

Most of the placards and speakers at the rally I attended outside the Melbourne office of the AMA on Wednesday 20th January last, called for Dr. Pesce’s resignation. The AMA were called on to ask for his resignation. The AMA as a group of medical professionals must be prepared to take responsibility for the gross distortion of facts by its leading representative

• This attempt to frighten women is an indictment on the current maternity system in Australia - it that which needs fixing - removing homebirth won’t do this.

Beverley Walker Mother of 4 Grandmother of 7.
Midwife Ethicist & Health Scientist
Lobbyist and Activist.