letter to doctors

A letter is being distributed to doctors in Victoria who have agreed to participate in collaborative arrangements with midwives.

Re: INFORMATION FOR OBSTETRICIANS AND GPs

Dear Doctor

This letter is being sent to doctors who have worked with midwives in providing access to Medicare rebates for antenatal and postnatal private midwifery services.  We understand that this new option, which has been available since November 2010, has brought about changes in the way midwives and doctors collaborate in maternity care. 

Collaboration

Midwives who have achieved notation on the Nursing and Midwifery Board of Australia (NMBA) Midwives’ Register as ‘eligible’ are able to apply for Medicare provider numbers.  Certain antenatal and postnatal items attract rebate; the proviso being that there is a collaboration arrangement with a doctor for that particular woman.  The requirement for collaborative arrangements between participating midwives and medical practitioners is to provide pathways for consultation, referral or transfer if or when the woman’s care requires it.  Midwives in Victoria are not, at present, able to provide intrapartum care that attracts Medicare rebate for our clients in hospitals.

Midwife prescribers

Midwives are also able to undertake a course in pharmacology which leads to endorsement on the public register. Once endorsed, the midwife may apply for a Pharmaceuticals Benefits Scheme (PBS) number and prescribe certain medications for mothers and babies.  The changes to Victoria’s drugs and poisons legislation which enables endorsed midwives to become prescribers was gazetted 30 November 2012 http://www.gazette.vic.gov.au/gazette/Gazettes2012/GG2012S410.pdf#page=1 .  This document contains the list of medicines from the poisons schedules 2,3, 4 and 8, which midwives are now able to prescribe.

A participating midwife can order some pathology tests and investigations, and can refer women and babies directly to obstetricians and paediatricians.  The midwife is required to send a copy of the results to the collaborating doctor.

Home birth services provided privately by a midwife do not attract Medicare rebates, even if the midwife is participating in the Medicare scheme. Homebirth services may be claimable through certain private health funds.  Hospital backup arrangements for women planning homebirth are made with the nearest suitable public maternity hospital, and may involve a booking in process.  Arrangements for referral and transfer of care to hospital in acute situations are made by the midwife in attendance.

Midwives and insurance

All midwives are required to have professional indemnity insurance. Privately practising midwives purchase insurance that covers them for antenatal and postnatal services. Midwives with Medicare eligibility have access to a Commonwealth-subsidised professional indemnity insurance (http://www.miga.com.au/content.aspx?p=160 ) for the ante and postnatal care they provide, as well as the birth services that they provide in hospitals to their private clients.

If you have any further questions about midwives and Medicare; what services they may provide, or how to work with a midwife who has Medicare, you could contact the Australian College of Midwives.

The midwives whose names and practices are listed below are Victorian midwives who are Medicare-eligible, or who are in the process of obtaining notation for Medicare.  We look forward to continuing professional cooperation between midwives and medical practitioners, in providing effective and safe maternity services for mothers and babies in our communities.

We also take this opportunity to extend to you Season’s Greetings.

Colalboration gone wrong!

The Australian Government’s $120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives, promised that Australian women would have

“more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services.” 

The National Maternity Services Plan (the Plan), endorsed by the Australian Health Ministers’ Conference in November 2010, provided governments with a strategic national framework to guide policy and program development.  The plan declares that primary maternity services will be  

“woman centred, reflecting the needs of each woman within a safe and sustainable quality system."

Year one of the Plan committed jurisdictions to developing 

“consistent approaches to the provision of clinical privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners.”

How is implementation of the Plan progressing?

Midwives report little action or hope of conclusion, on matters to do with provision of clinical privileges for Medicare-eligible midwives within public maternity services, except in Queensland.  Anecdotally we are aware of instances of increasing resistance within some public hospitals to the implementation of programs of clinical privileging for private midwives.


Earlier this week I received an early morning call from a distressed colleague.  Having worked with a woman who was planning homebirth for some hours, this midwife arranged to transfer the woman's care to a major public maternity hospital in Melbourne, where the woman had made a back-up booking.

The midwife, who believes she has had a good relationship with the hospital for many years, was distressed that the doctor who admitted her client refused to accept any verbal hand-over, and rudely walked away when the midwife attempted to carry out a professional conversation with him.

It would appear that efforts are being made within public maternity hospitals to derail any plans to enable admitting and practice rights for eligible midwives.

Within the obstetric community there is a strongly held position that a doctor or midwife who is willing to assist women in 'bad choices' is seen as encouraging 'bad choices'.  Women who have attempted to make arrangements with hospitals to facilitate normal birth in situations of acknowledged complexity, such as twins, breech babies, or even birth after a previous caesarean, have been given no choice.  "If you come here, this is what will happen!"  This is an often repeated scenario in both public and private hospitals.  These women have often sought private midwives to attend them in the relative 'safety' of their own homes.


This post is just skimming the surface of a complex issue.

Collaboration with medical and nursing colleagues, within hospital systems, is a basic expectation in all midwifery. 

Midwives are required, by regulation and by definition, to collaborate. 

“... 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 (emphasis added) and the carrying out of emergency measures.   ” 

(From ICM Definition of the Midwife, 2011)



Midwives also have an expectation of ethical professional behaviour towards those in our care.  The current Code of Ethics for Midwives lists 'values' - which in themselves describe the standard to which we aspire.  There is no place for bullying and domineering behaviours in midwifery.

1. Midwives value quality midwifery care for each woman and her infant(s).
2. Midwives value respect and kindness for self and others.
3. Midwives value the diversity of people.
4. Midwives value access to quality midwifery care for each woman and her infant(s).
5. Midwives value informed decision making.
6. Midwives value a culture of safety in midwifery care.
7. Midwives value ethical management of information.
8. Midwives value a socially, economically and ecologically sustainable environment promoting health and wellbeing.

 (From Nursing and Midwifery Board of Australia)

Midwives need a system that recognises us and treats us fairly.

We call on midwives to continue to stand in partnership with women, demanding equity and fairness in all maternity services provided by our governments - federal and state. Collaboration requires both parties to participate, the hospital and/or doctor, as well as the midwife.  There is no such thing as one-way collaboration.  Midwives are committed to the wellbeing and safety of mothers and babies in our care, and it is our duty to demand that the health care systems support us in achieving this goal.

For those who like to read the advice given to Health Ministers

A Freedom of Information request was recently made by Homebirth Australia to the (federal) Department of Health and Ageing, for documents related to midwives and professional indemnity insurance under the government's reforms.

The documents are now available at this Disclosure log.

What can we learn from these letters and briefing papers?




A convenient 'reason' for delay: "to allow time for data to be collected ..."
With reference to the exemption granted to private midwives from having professional indemnity insurance when we attend homebirth, Health Minister Roxon wrote (May 2011) to her counterparts in State and Territory governments that:

"essentially this was to allow time for data to be collected on the safety of homebirths and to enable a private insurer to develop an appropriate insurance product."

Today I am exploring threads of information, about homebirth and the collection of data on the safety of homebirths, in some of these documents.

I would like to remind readers that homebirth had been the hot potato in the Maternity Services Review (2008), inspiring hundreds of impassioned submissions to the Review from women and midwives who attempted to convince the Health Minister that homebirth was an essential component of maternity services. 
Yet the Report (2009) side-stepped homebirth, giving preference to what it called ‘collaborative’ models, under obstetric control.

Homebirth, according to the Report (2009), was too much a hot potato, and was dropped! 

“In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.” (Report Pp20-21)

[For more discussion on the Report and subsequent events, you can check through the archives of this and other blogs written by midwives and maternity activists.]

That was 2009.  And, it could be said that homebirth did polarise the professions!

2010 brought a reprieve for private midwives and homebirth, in terms of the 2-year exemption referred to in the opening paragraph of this post.


2010 also brought the National Maternity Services Plan, which was endorsed in November by the Australian Health Ministers' Conference (AHMC), committing all jurisdictions to, amongst other primary maternity care programs, publicly funded homebirth.

2011 saw homebirth on the agenda of the February AHMC meeting, with a briefing that drew attention to South Australian 'some' privately practising midwives (PPM) who were

"not practising safely.  This is in the context of at least one high profile case of a death in SA which is currently progressing through the courts.  As a result SA is seeking to strengthen the current monitoring arrangements for PPMs".

 2011: (June) The College (ACM) produced the first Homebirth Position Statement, which was rushed through the system, hastily adopted by the NMBA, endorsed by AHMC, posted on the NMBA website and became part of the regulation standards for midwives, drawing howls of dismay and rejection from midwives.  (See for example, APMA Blogs in mid-2011)

2011: (August) The Health Ministers meeting at ANMC agreed to a twelve month extension to the exemption from PII for private practice midwives attending home births.

2011: (November) The second (revised) ACM Position Statement on Homebirth Services was released, having undergone more constructive consultation with the profession than the previous one.  However, the first Homebirth Position Statement has been retained by the NMBA. 


Throughout this set of documents a recurring theme is data collection:
"allow time for data to be collected on the safety of homebirths ..."
 "the collection of sufficient data on the clinical safety of homebirths"

Data on actual homebirths and planned homebirths has been collected and reported on in Victoria for at least the past 20 years.  How much more is needed?

Each year a PROFILE: HOMEBIRTH document is published by the Perinatal Data Collection (PDC) unit of the Victorian government's Consultative Council on Obstetric and Perinatal Morbidity and Mortality (CCOPMM).  The statewide collection of perinatal data has, over the years, also developed and published Maternity Service Performance Indicators.  (Click here for the 2009 statewide set)

For example, in 2003-2007, there were 170 standard primiparae who planned homebirth, regardless of where the birth took place.  Of these,

MAT-1     none had labour induced (0%) [Statewide rate 2007 was 4.8%]
MAT-1b  11 had Caesarean births (6.5%) [Statewide rate 2007 was 14.8%]

Apart from individual cases that have been highlighted and possibly sensationalised in media reports, there is no reliable statistical evidence of poorer outcomes for either mothers or babies who give birth at home in the care of midwives.  Data supports the safety of homebirth: it is easy to argue the protective effect of many aspects of planned homebirth, for example, primary care by a known midwife, many aspects of social support, spontaneous onset of labour, and appropriate use of medical analgesics, anaesthetics, and uterine stimulants.

Plenty of time has transpired for data to be collected. 

There is no reason for homebirth attended by private midwives to be excluded from indemnity insurance products, and no reason for women to be discouraged from planning homebirth with an independent midwife.

NMBA and Professional Indemnity Insurance

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.