A new vision for maternity care

ARM 2013 - click to enlarge

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





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

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

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

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

'private in public' midwifery

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

Dear colleagues

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

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

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

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

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

 

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

How many midwives are we talking about?

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

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

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

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

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

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

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

Where do homebirths fit in?

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

Private midwifery is no longer synonymous with homebirth.   

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

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

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

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


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

Your comments are welcome.

letters from MIPP

About a month ago we reported on amendments to legislation applying to eligible midwives and Medicare.

The ability of a midwife to attend a woman giving birth in a hospital was a major item in the Medicare reforms, introduced more than three years ago.

Yet ...

• Despite many assurances that the Victorian government supports the federal government's maternity reforms, and has developed a framework for credentialing of midwives, no midwives in Victoria have made collaborative agreements with hospitals.  
• Midwives are able to buy insurance policies through MIGA, underwritten by Treasury, providing uncapped cover for women receiving midwifery services from eligible midwives for birth in hospital - yet they can't get access to the hospitals.
• Women would be able to claim up to approximately $1500 rebate for intrapartum midwifery services (2 midwives) - if the midwives could get access to the hospitals.
• Midwives are continuing to provide professional services for women in their communities, and accompanying them to hospital for birth or other specialist obstetric services if and when the need arises.
• Midwives report that some doctors who have previously agreed to collaborate with midwives have withdrawn, giving reasons such as "I don't think homebirth is a good idea" - when the collaborative arrangement covers only antenatal and postnatal midwifery services.

This is unacceptable.  What other profession would sit back and accept persistent exclusion from their usual places of practice?  Why are women who would prefer to give birth in hospital in the care of their known and trusted midwife being prevented from doing so? 


A new round of letters has been sent by MIPP to the public hospitals, respectfully requesting an update on progress.

A similar letter has been prepared, and is being sent to obstetricians and GPs who have agreed to collaborate with midwives, usually through a letter of referral, or in some instances, through a signed collaborative agreement.

The content of this letter is copied below:

Re:  Collaboration and hospital visiting access for Midwives

Dear Doctor

This letter is to inform you of recent changes in legislation governing the requirement for collaborative arrangements for eligible midwives, such as referral of women to the midwife for antenatal and postnatal midwifery services.  We thank you for your participation in collaborative arrangements to date, which have enabled women to claim Medicare rebate on the fees of midwives who have Medicare provider numbers. 

Since the introduction in April 2010 of amendments to the Health Insurance Act (1973), some midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements.

In recognition of this, at the 10 August 2012 Standing Council on Health (SCoH) meeting, the Commonwealth agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. On July 25^th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 http://www.comlaw.gov.au/Details/F2013L01432 was introduced.

Accordingly, the purpose of the regulation is to enable midwives to demonstrate collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity. The regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed for clinical privileges within a hospital.  It is expected that the hospital will have a formal written agreement with such midwives, addressing consultation, referral and transfer of care, relevant clinical guidelines and locally determined policies.

Letters have been sent to the public maternity hospitals on behalf of MIPPS, requesting an update on the processes that are being implemented, by which the hospitals will provide eligible midwives the opportunity to have collaborative arrangements.  Until these new processes are established, midwives and our clients will continue to rely on the collaborative agreements and arrangements, such as referral, that have been used in the past couple of years.

Yours sincerely,

Your comments are welcome.

amended regulation

Health Insurance Amendment (Midwives) Regulation 2013 - F2013L01432

 

On July 25^th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 was introduced.

The purpose of this regulation is to enable midwives to have collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity.

This new regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed by a hospital, having successfully completed a formal assessment of her or his qualifications, skills, experience and professional standing.  At present processes exist with some public maternity services for midwives to be recognized as shared antenatal care affiliates.  It would seem reasonable to expect that these processes could be extended to meet the requirements for collaborative arrangements during intranatal and postnatal care as well as antenatal. 

Three years ago, in April 2010, the Health Insurance Act (1973) was amended to provide for new arrangements to enhance and expand the role of certain midwives, allowing for a greater role in the provision of quality health services through primary maternity care.  Since the measure was introduced, midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements, and has prevented some women from receiving Medicare rebates.  

Midwives who have achieved endorsement on the AHPRA Register of Midwives as Eligible (for Medicare and Prescribing) have achieved a high standard of clinical practice.  They have gone to considerable financial and personal cost, in complying with the requirements of the Board.  When a midwife is in private practice, with a Medicare provider number and a Prescriber number, that midwife has access to the most advanced model of clinical practise in primary maternity care available to midwives in Australia.

A few midwives participating in Medicare have a collaborative arrangement in the form of a signed agreement with an obstetric medical practitioner: an arrangement that applies to all women in their care.

Most midwives, however, require a separate collaborative arrangement for each woman in their care.  This is the reason many midwives have reported ongoing difficulties in establishing collaborative arrangements. Each collaborative arrangement needs to be requested, and negotiated separately.   

One of the options for collaboration is referral:

5 (1) (b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;

A general practitioner doctor (GP) who provides obstetric services, such as shared antenatal care, is able to act as a specified medical practitioner who refers a woman to an eligible midwife for midwifery treatment.  

Midwives who have received letters of referral, or other collaborative arrangements, from GPs or obstetricians, recognise that there have been areas of uncertainty and difficulty in establishing meaningful collaboration that meets the legislated requirements and is in the interests of the wellbeing of the mother and her baby.  Some GPs have expressed serious concerns about their liability, should there be an adverse outcome at some time in the future.  No amount of assurance by the midwife that she/he is accountable, and insured (except for homebirth) will satisfy a doctor if their insurer tells them not to take the risk of supporting midwives.

In recognition of the difficulties experienced by midwives in achieving collaborative arrangements, the government agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. This amendment to the regulations potentially takes the pressure off GPs, in that midwives will (theoretically, at least) be more able to establish collaborative agreements with hospitals.  The woman's GP will not be ignored, as there is a continuing requirement for a discharge letter, copies of any test and investigation results, and reports of referrals, to be sent to the GP.

MIPP is engaging in ongoing discussions with public maternity hospitals, in an effort to forge new pathways for credentialing by the hospitals for midwifery care that spans the full episode of care. 

Perhaps this amended regulation will be the impetus for progress in maternity hospitals that have, to date, been resistent to change.  The need for collaborative arrangements to be facilitated through the public maternity hospitals to which we refer women in our care is obvious.  The systems need to be seamless and transparent, protecting the wellbeing and safety of mother and child, as well as offering a reliable and accountable process for members of the midwifery profession, and for the hospital and its employees.




Your comments are appreciated.

Priorities

click to enlarge

When MiPP (Midwives in Private Practice) members met for our first meeting of 2013, we took some time to discuss the current state of our segment of the midwifery profession in Victoria: private midwifery practice.

We asked ourselves, "What are the main challenges faced by private midwifery practice in Victoria?"
We agreed that:

1. Midwives need to be able to practise midwifery, whether we are self-employed, or not.  Current State and Federal processes have continued to marginalise the private practice midwife, unfairly restricting our scope, and preventing us from attending women who give birth in hospital.  Women in our care who give birth at home are discriminated against in that they are not eligible for the Medicare rebate for 'management of confinement' [Medicare Item Number 82120 (and 82125)].  These item numbers apply only when women are attended in hospital by a midwife who has been awarded visiting access to practise midwifery privately in that hospital.  No Victorian hospital has yet awarded visiting access to a midwife. 
2. The National Health (Collaborative arrangements for midwives) Determination 2010 (Collaboration Determination) is unworkable, and needs to be deleted from the law.  This piece of legislation requires midwives to obtain an arrangement signed by a suitably qualified doctor, for each woman receiving midwifery services, in order for the woman to receive Medicare rebate.   This requirement does not protect the public interest: rather, it sets up systems that are often difficult for the pregnant woman who is seeking private midwifery services.

This sort of problem is not unique to Australia.  People who are aware in international midwifery issues will know that midwives in the UK, Ireland, and Hungary, are also fighting to retain their right to practise midwifery privately.  Women in New Zealand, Canada, and the Netherlands, by contrast, have access to midwives who practise autonomously in their communities, both home and hospital, under public funding that covers the cost of the midwifery services.

Discussion on a woman's rights, under human rights laws and charters, has increased with reference to our European colleagues, such as Agnes Gereb.

In this regard, is it better to argue for the midwife's right to work as a midwife, or for the woman's right to access the services of a midwife?  This is the question I put to a lawyer who practises in human rights, and the response was:

Human rights law is focused on the woman.  BUT, the rights of the woman encompass the availability of good quality services and choices, and restrictions on midwives such as the inability to get insurance and the inability to work in the system directly affect the rights of the woman so although you have to make an extra step in the argument, you can still make improvements for midwives via the rights of women.

This is nothing new.  The relationship of midwife: 'with woman' is foundational to both ancient and modern concepts of midwifery.

What, then, is so special about the midwife who practises privately?  Don't women in Victoria have enough access to midwifery through the public and private hospital system?  Why should a small group of midwives who work outside the mainstream system be listened to?

This discussion could go on and on ...!

In essence, the small professional group which MiPP represents is a front-runner in promoting excellence in midwifery practice in this State, and nationally.  Although small, we are not a trivial fringe group that could be ignored.  We insist that in using our qualification, 'midwife', to the best standards of professional practice, we are promotion health and well being in the mothers and children in our care. We are using contemporary evidence to lead the midwifery profession.

We are not content to work exclusively in the homebirth sector.  A midwife is 'with-woman'; not 'with-setting-for-birth'.  Homebirth is not an outcome; it's a setting that is decided on as a woman proceeds in spontaneous unmedicated labour.

By insisting on a fair deal for midwives, we are opening the way for better maternity care options, and better outcomes, for mothers and their babies.  That's win-win, and surely it's the woman's and baby's right.