MiPP review and restructure

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


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

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

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

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

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

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




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

The midwives 

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

Comments 

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

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

Your comments are welcome.

What medicines are midwives prescribing nationally?

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



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

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

relationships between independent midwives and public hospitals

Midwives who work independently, who are employed directly by the woman and her family to provide midwifery services in pregnancy, birth, and postnatally, are at the front of efforts to reduce unnecessary medicalisation of birth, and to protect, promote and support the natural processes in birth when ever this is reasonable.

It would be simplistic and untrue to paint a black/white, bad/good picture of the medicalised birthing world (hospitals) compared with the holistic, woman-centred world of private midwifery and homebirth.  Unfortunately, many of the stories of disempowered mothers who found themselves experiencing a cascade of medical interventions carried out by strangers, without their informed consent, are stories from hospitals.

Equally lamentable are the stories that become public knowledge after coronial investigations into deaths, when midwives were providing care for planned homebirth.  Any evidence of delay in advice by the midwife that the care should be transferred to hospital places a cloud over independent midwifery and homebirth.

midwife prescriber

Midwives across this country are extending our practices as those who are classified as 'eligible' complete the requirements for endorsement to prescribe scheduled medicines.  For the details of notation and endorsement, go to the NMBA website.   The most recent statistics (June 2013) provided by NMBA tell us that 22 midwives had endorsement to prescribe medicines, of the 212 midwives who have the 'eligible' notation on their registration.

To access the NMBA Prescribing Formulary for Eligible Midwives with a Scheduled Medicines Endorsement, as a .pdf document, search formulary+midwives at that site (the hyperlink I tried was incomplete).  This document lists the medicines, route of administration, duration of use, and indications for use, and states that:

A scheduled medicines’ endorsement identifies those midwives who are considered by the Board to be qualified to:
• administer, obtain, possess, prescribe or supply specified schedule 2, 3, 4 and 8 medicines to the
extent authorised under the relevant legislation that applies in the State or Territory in which they practise;
• use those medicines appropriately for the management of women and infants during the
pregnancy, birth and post natal periods; and
• apply to Medicare Australia for a Pharmaceutical Benefits Schedule prescriber number.
The Board has approved the lists of schedule 4, schedule 8 and intravenous medicines (below) for prescribing by eligible midwives with a scheduled medicines endorsement. These lists are to be read in conjunction with the Board’s Guidelines and Assessment Framework for Registration Standard for Eligible Midwives and the Registration Standard for Endorsement for Scheduled Medicines for Eligible Midwives (July 2010).

Another fount of useful information about Medicare and Prescribing is the Medicare site for Nurse Practitioners and Midwives.

Making the transition from being an 'ordinary' midwife (with all the social and professional restrictions that we have become used to) to the new class of eligible midwife who has a Medicare number, a Prescriber Number, and a personalised script pad may at times call for support and discussion between peers.  With this in mind, a new group has been formed using a social media site.   It's a closed group, and those who send a request to join are asked to introduce themselves to the group.

Midwife Prescriber - Australia

This group is for discussion about prescribing issues, for eligible midwives who have the prescriber endorsement, and those who are working toward it.
There may be clinical questions, for which members are able to share insight and experience.
Members may have questions about processes.
Files and links to the medications lists in the various states and territories can be shared and stored at this site.

This new group grew to 50+ members in its first 24 hours of existence.  One member who joined by invitation is a supportive obstetrician.

A midwife who has worked independently for many years may be unsure of which antibiotic would be best for a postnatal uterine or wound infection.  In previous years that midwife would have referred a woman with suspected infection to a hospital or doctor for diagnosis and prescription.  Now that midwife can arrange to have a high vaginal swab taken for culture and sensitivity, and prescribe a suitable antibiotic treatment.

The Schedule 4 medicines listed on the NMBA formulary, and on the Pharmaceutical Benefits Scheme (PBS) Midwife Items, as being suitable for postnatal infection, include Amoxycillin, Amoxicillin with clavunic acid, Cephalosporin, Dicloxacillin, and Lincomycin, with several others that are not PBS items.

The complexities of knowing which drug is best, which dose is appropriate in the situation, how often it should be taken, and for how many days - this is the sort of knowledge that a midwife needs to have in order to act professionally in this situation.  Eligible midwives are required to have collaborative arrangements for each woman, and it is anticipated that a phone call will be made to the collaborating doctor or hospital, or a friendly supportive obstetrician, if the midwife is in any way uncertain of the best course of action.



ps. Note that some States have formularies that have been gazetted by that jurisdiction, while others have adopted the NMBA formulary.

Click here for a FAQ document from the Victorian Health Department.

Your comments are welcome.

Maternity care plan

Midwives who are eligible to participate in Medicare, and offer Medicare rebates for women in their care, have this item in the Medicare schedule:

Item 82115

Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks, if:

(a) the patient is not an admitted patient of a hospital; and

(b) the participating midwife undertakes a comprehensive assessment of the patient; and

(c) the participating midwife develops a written maternity care plan that contains:

(i) outcomes of the assessment; and

(ii) details of agreed expectations for care during pregnancy, labour and delivery; and

(iii) details of any health problems or care needs; and

(iv) details of collaborative arrangements that apply to the patient; and

(v) details of any medication taken by the patient during the pregnancy, and any additional medication that may be required by the patient; and

(vi) details of any referrals or requests for pathology services or diagnostic imaging services for the patient during the pregnancy, and any additional referrals or requests that may be required for the patient; and

(d) the maternity care plan is explained and agreed with the patient; and

(e) the fee does not include any amount for the management of labour and delivery (Includes any antenatal attendance provided on the same occasion) Payable only once for any pregnancy

[Schedule 1 Part 1 of

Health Insurance (Midwife and Nurse Practitioner) Determination 2011]


It's clear from the legislation that a 'maternity care plan' is an important aspect of the antenatal care  provided by a participating midwife.  The professional attendance linked to Item 82115 is to take at least 90 minutes, and the scheduled fee is $319.00.  This compares with other antenatal attendances of at least 40 minutes, with a scheduled fee of $53.40.  Clearly, someone who advised the writer of this piece of legislation considered that the writing of a maternity care plan, and the other tasks (listed above) are very significant.


A midwife who has recently received her endorsement as an eligible midwife wrote to a social media site "I wonder if anyone could share their written maternity care plan format? Just want to know what you include and how to set it out ..."

This is a good question.  What does a maternity care plan look like?


It has occurred to me that the ICM Definition of the Midwife is a clear statement of a midwife's maternity care plan:

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 insurance company MIGA, in consultation with ACM and APMA, has developed a care plan that some midwives have adopted.  This care plan has a lot of boxes to tick, and much of the information would be collected routinely by midwives in taking a history and discussing care options with each woman.  Those who are using specially designed software would have many of the points of this care plan covered in entering the client information, and would be able to generate a maternity care plan printout when required.


The maternity care plan is to be kept with other professional records for each woman and baby, by the midwife.  The care plan usually does not need to be shared with anyone, unless asked for, for example, in a Medicare audit or an investigation.

There is ongoing discussion and concern about the relationship between midwives and public hospitals, particularly those hospitals that have, to date, refused to discuss any collaborative arrangements with midwives. MIGA states that, in order to meet the legislative requirements, a midwife is required to have:

• A Collaborative Arrangement with a doctor or Hospital, or

• A Care Plan communicated to a public Hospital providing obstetric services

• You should ensure this is acknowledged by the Hospital either in writing or as a record in your notes of an oral acknowledgement

  
  
  We note here that midwives in Melbourne, and many other places, who have attempted to comply with this requirement of acknowledgment (written or oral) by a hospital have had no success.  The hospitals have, to date, not been interested in collaborating with midwives.  Some hospitals have returned care plans to the midwife, and instructed her not to send them.   This problem seems to be ongoing, as was discussed in a previous post on this blog.
  
  XXX
  
  
  The MIGA maternity care plan seems to attempt to cover the 'what if' situations, in which a midwife might be required to defend her or his actions.  That makes sense - that's the job of insurance companies.
  
  But, ...
  
  Midwifery is not, primarily, about defensive practice.  It's about the midwife acting in a way that protects the wellbeing and safety of mother and baby.  It's about being 'with woman', in a special professional relationship.  It's about health promotion: healthy mothers and babies.  Midwives should not be instructed by an insurer, an entity that exists to make a profit for shareholders, as to the care plans they make.
  
  Midwives are encouraged to make a positive statement in each woman's maternity care plan, such as:
  
  "When providing primary maternity care for a well woman, the plan is to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. If illness or complications are suspected, a transfer to the planned hospital would be arranged without delay for urgent obstetric concerns, ..."
  
  
  

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.

MAMA featured in newspaper article

From The Age, 18 January 2013

WOMEN are flocking to private midwives to gain access to cheaper services under Medicare, and the demand has led to Victoria's first midwife clinic.
Two years ago, federal changes allowed eligible private midwives to offer Medicare rebates for some pregnancy services.
To December, national Medicare figures show that 152 eligible private midwives had provided 30,264 services to pregnant, birthing, and postnatal women. ...

Read more: http://www.theage.com.au/victoria/growing-demand-spawns-victorias-first-midwife-clinic-20130117-2cw9p.html#ixzz2IUrv69uP

Source: The Age

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.

An update on midwife prescribing

Midwives who have achieved eligibility for Medicare (MBS) under the Commonwealth Government's National Maternity Service Plan (2010) are also preparing to extend our practices to include prescribing, and participation in the Pharmaceutical Benefits Scheme (PBS).  Midwives with PBS authorisation will be able to prescribe, supply, and administer scheduled medicines. 

Historically, midwives attending homebirth have obtained the few medicines we need in private midwifery practice through a doctor's prescription.  The midwife has administered these drugs without a legislated process.  Oxytocics for the management of post partum haemorrhage by intramuscular injection have been prescribed by doctors for women in our care, and purchased (in boxes of 5 ampoules) from local pharmacies.  The midwife assesses the woman's condition, and administers the drug on her/his own authority.  The management of the third stage pf labour is basic to midwifery, and it is in the public interest that all midwives maintain their competency in the use of oxytocics: that this is not restricted to those who have PBS authorisation. 

A number of Victorian midwives are enrolled in the 6-month Pharmacology course at Flinders University in Adelaide, which is the only such accredited course for midwives seeking PBS authorisation.  We know of a couple of midwives who have completed courses in pharmacology which have been accepted by the regulatory authority (AHPRA) as equivalent. 

Each state and territory have already either undertaken, or are in the process of making, the necessary legislative changes to authorise registered midwives to prescribe under the PBS.  

The Victorian Health Department has appointed the 3CentresCollaboration to consult with stakeholder groups, and to prepare a draft list of Schedule 2, 3, 4 and 8 medicines for prescribing by midwives in Victoria.  The work has advanced to the final checking of the list before it is approved in the law.  The stakeholder groups and experts who have been invited to review the list include relevant midwifery and obstetric colleges, unions and professional organisations, employers of midwives, consumer groups with a remit or interest in midwifery, maternity services or associated services as well education providers (ie midwifery pharmacology course providers). 

The scope of prescribing is limited to medicines appropriate for midwifery practice across pregnancy, labour, birth and post natal care (including neonates up to six weeks).  Midwives who will use their PBS endorsement include those providing private antenatal and postnatal care in a variety of settings and intrapartum care as a private midwifery provider to a private client either at home, or (when midwives are able to have clinical privileges/visiting access) within a health service. 

[MiPP has submitted a response to the draft documents.]
 
Your comments are welcome.

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.

ROADBLOCKS

please click on picture to enlarge

Last week I reported on the Senate motion calling for immediate action on the obstacles facing privately practicing midwives in Australia.

"Roadblocks frustrating women's right to choose a range of birthing arrangements needs clearing." ... "It is time governments across Australia joined together to enable midwives to properly do their work." 

The Senate motion focused on the ROADBLOCK of obstruction midwives face in seeking access to hospitals, enabling us to properly do our work, attending women through the labour and birth of their babies, in addition to pre- and postnatal services.

Another ROADBLOCK that midwives face is the veto given to doctors through the requirement that a signed collaborative arrangement be made to enable women to claim Medicare rebate on the fees of midwives who are participating in Medicare.

Here's an actual scenario:
Ms A is pregnant with her first baby, and has been seen by local GP/Obs/Womens Health Dr B.  Ms A then decides she would like to be in the care of a midwife who will attend her privately in labour.  Ms A is undecided as to whether she wants to give birth at hospital or at home.  It's all very new to her!

Ms A visits Midwife C, who agrees to the booking, and advises her about a collaborative arrangement.  Ms A visits Dr B, with a letter from Midwife C explaining the collaborative arrangement requirements of Medicare, and requesting a referral for antenatal and postnatal midwifery services. (and that's where it gets interesting)

Dr B's response, in writing, is:

"Unfortunately we [Dr B and Midwife C] have neither met nor previously worked together professionally and I have no knowledge of your practice, your approach to patient care, and your professional experience. Clearly you will understand that I am unable to participate in a collaborative arrangement unless I am completely confident that Ms A will be provided with the best standard of practice.
"A clear written agreement between patient, nurse practitioner [this is the first mention of a nurse practitioner] and the nominated medical practitioner is essential to ensure that there is clear delineation of roles and responsibility, to avoid misunderstanding and to ensure the best patient outcome.
"In summary in order to collaborate with a midwife on the antenatal/postnatal care of a patient I need a copy of current registration and indemnity insurance, schedule of visits planned and routine investigations to be ordered and protocol for sharing records/results/referrals/transfer, prescribing arrangements, protocols for following up abnormalities and plans for communication/consultation with named medical practitioner including where and how these would occur and remuneration arrangements. ..."

A first reading of this letter might lead one to believe that the doctor is acting with integrity. However, if this doctor’s requests were followed by Midwife C it would set up another tier of regulation, and another tier of responsibility on the part of the doctor.  A midwife who has achieved eligibility for Medicare has undergone a rigorous application process which includes extensive professional monitoring.  The midwife's registration can be checked on the public register, and there would be no point in complying with the collaborative arrangement rules if the midwife did not actually have current participation in Medicare. 

When GPs write referrals to psychologists, or dentists, or other ‘allied health’ funded under Medicare’s extended care arrangements, do they ask for a similar level of disclosure? I doubt it.

The closing phrase in the quote from Dr B "and remuneration arrangements" suggests there might be something else on her mind -- $$.  After all, why would a doctor whose livelihood is partially reliant on women, such as Ms A, want to refer Ms A to a midwife? Conflict of interest? Undoubtedly.

This letter demonstrates the unworkability of the collaborative arrangement ROADBLOCK as it stands.  The legislation attached to the government's maternity reforms is in and of itself preventing midwives from  properly doing their work.

This is the opinion of the writer.  Your comments are welcome.
Joy Johnston

a career in private midwifery

I was recently contacted by a journalist who was keen to write a story about private midwifery as a career. He told me his audience is people who are contemplating a career in health, and he hoped to shed light on the ins and outs of the particular career that was in the spotlight. He told me he wanted to present information in an informal, conversational manner, and even hoped for a bit of humor; that by the time a reader had read the piece they would have not only an idea of the particular career profile, but also know something about the person who had been interviewed for the article.

It all sounded good. Sure, I said, I'm happy for you to interview me.

With the wonderful technology of bluetooth in the car I was able to commit a 40 minute time slot as I drove from Vermont to Preston, between the homes of two new mothers. I talked passionately about the fact that birth is not an illness; that midwives form a trusting partnership with the individual women in our care; that our focus is the woman and her baby. But this did not seem to be useful information, as far as my interviewer was concerned. He told me the story shouldn't be about women who birth or midwives in general; it needed to be about what I was actually physically and mentally doing and feeling in my job. And it should be about the vivid little details involved in the processes you perform.  I came away from these interviews with a sense that I had not satisfied the journalist's investigative drive.  I felt that I was in one world, and he was in another, and that what I said was simply not making any sense.  I felt disappointed, because the more he plied his questions, the more my attempts at answers seemed to be unacceptable.

I write a lot about my experiences and feelings and the vivid little details of my job.  I hope any readers of this and other midwifery blogs are able to grasp the passion and values that midwives share with the women in our care.

Since the introduction of the Australian government's maternity reform package, new career opportunities are being opened up for midwives who want to practise privately. Midwives have obtained their Medicare eligibility notation, and hung up their shingles (set up web pages and social media sites). Here's a quick overview of what is required to get to this point in a midwifery career:

• Graduate from a university course that leads to registration as a midwife
• consolidate midwifery experience for at least 3 years full time employment across the full scope of midwifery practice
• undertake the Midwifery Practice Review through the Australian College of Midwives
• obtain a detailed reference that meets the AHPRA requirements, gather all the required documentation, have copies made and witnessed, and apply to AHPRA for notation as a Medicare-eligible midwife.  Expect this application process to take several months.
• purchase professional indemnity insurance
• join a private practice, or set up your own private midwifery business.  

Women can employ a midwife for any part or the prenatal, labour and birth, and postnatal care, or for the lot.  The midwife can charge as much or as little as she/he chooses.  If the midwife is participating in MBS, specific collaborative arrangements are required.  The Medicare rebate that the woman is able to claim varies according to factors such as the Medicare safety net.
 
Is private midwifery practice a realistic career option?

The Midwives in Private Practice (MiPP) collective has had between 20 and 30 active members since it was formed in 1989.  Most of these midwives have had other employment, such as casual work in a maternity hospital, in addition to their private work.  There have been a small number (estimated 5) for whom the private midwifery practice is their family's main source of income.  Most MiPP members over the years have had their own caseloads, with homebirth being an option for all midwives.

With the government's maternity reforms, time will tell if more midwives are able to sustain private practice.  Some who have Medicare are not experienced in homebirth, and it would not be wise for such midwives to offer homebirth care without first undertaking a program of learning and mentorship to extend their practice to homebirthing. 
    
Other midwives might want to offer an opinion on this.  

Joy Johnston