regulation of midwives

Several MIPP midwives were amongst 60+ national attendees at a meeting this week in Melbourne, hosted by AHPRA.
The meeting was called 'The Light at the End of the Tunnel Midwifery Workshop', and presentations were made by various midwifery leaders and regulatory people.

The aim of the Workshop was:

1. To improve and foster understanding between the NMBA, midwives and stakeholders regarding midwifery issues incorporating:

a. Accreditation & education
b. Midwifery Practice
c. Association
d. Workforce 

2. To move closer to the intent of the National Registration and Accreditation Scheme by ensuring that there is a common understanding about midwifery practice.

Mary Chiarella from the NMBA chaired the workshop.  The round table discussions and feedback were well organised.  Attendees will receive summary notes and powerpoint slides, and the Board is committed to using the information gathered in the workshop as policies are developed.

Separate midwifery regulation
There will be a review of the national law (? next year - not sure) and there is support amongst midwives for a separate Midwifery Board to be established.  Although the current NMBA can be seen as an improvement on its preceding state and territory nurses boards, many midwives believe that the profession of midwifery is not well served by the current arrangements.  In the meantime the need for midwives to be on each of the state and territory Boards (members appointment by jurisdictional health minister), and to be on panels hearing complaints regarding midwives practice, were stressed by several attendees.


Quality and Safety Framework, and practice review
It was noted that a new quality and safety framework is being developed and will be distributed for comment in the near future. It will cover all midwifery practice - not just homebirth/private practice. There seemed strong support for midwifery practice review by all midwives. 

Home birth after caesarean, and mandatory notifications
One issue that was raised, which some readers may be interested in, is that independent midwives in some areas have been 'reported' for planning vaginal birth after caesarean (VBAC) homebirths. They have been told by the hospitals that notifications have been made under mandatory reporting: meaning that the person who made the report believes that a midwife who plans HBAC has departed from accepted professional standards, and is thereby placing the public at risk. The members of the national Board who were at this workshop were emphatic that this sort of action does not have the support of the NMBA . It's a practice issue, and the Board does not have any policy in regard to HBAC.

Making a 'mandatory notification' is a serious step that is aimed at preventing members of the public who receive professional services being placed at risk of harm, and should only be taken with sufficient reason.  Making a notification that is vexatious or not in good faith may expose the reporting practitioner to proceedings for defamation. Women who ask midwives to attend them for planned homebirth after a previous caesarean usually do so believing that this care plan gives them the opportunity to come into spontaneous labour, and establish labour without interruption. 

There was some discussion around the impact on the midwife of notifications and investigations into professional conduct.  Participants requested that the Board provide support for midwives who face proceedings by NMBA and AHPRA, as they defend their professional position.  The public interest is served not only by punitive measures for professionals who have misbehaved, but by ensuring that everyone is treated with respect and natural justice and their cases are dealt with in a timely, transparent and accountable manner.

for the record ...

A couple of dodgy situations have arisen in the Melbourne private midwifery world this past week, and I am noting them here, for the record.  People will not be named, but be assured, these stories are not fictional.

Story #1 - Woman W1 and doctor GP:

W1: (39 weeks pregnant, planning homebirth) "My midwife told me to ask you for the paperwork I will need to register the baby's birth, and get the baby bonus."
GP: "I have never been asked for that paperwork.  In fact I don't know where to get it."

For readers who are unfamiliar with the process, this paperwork is issued after birth by the midwife who attends a birth at home, or by the hospital where the baby was born. 

The GP phoned a well known and respected midwife to inquire as to how to obtain the paperwork.  That midwife immediately questioned the request.  If W1 is in the care of a midwife, that midwife should issue the paperwork, and sign the declaration to enable registration with Centrelink, baby bonus or paid parental leave, adding the baby's name to Medicare card, and other standard processes including obtaining a birth certificate.  Simple as that!

In this case W1 is probably planning homebirth without a registered midwife in attendance.  Call it freebirth or pure birth or attended by a birth worker or whatever you like.   A GP would be unwise to issue the birth paperwork, unless she or he was also prepared to attend the birth and sign the professional declaration.

Story #2 - Lay birth attendant LBA phone call to midwife M2:

LBA: "I am looking for a midwife who will visit the woman W2 in her home once labour has started, and do an assessment so that we can be sure she is at least 4 centimeters dilated."
M2: "Why do you want this?"
LBA: "Because W2 had a caesarean birth last time and she does not want to go to hospital until she is in established labour ..."
M2: "Let me get this straight.  You are asking me to visit when you call me, check mother and baby, give you that information, then go away?"
LBA: "Yes."

A midwife is immediately wary of this request for a number of reasons.  Here are a few:

• the professional relationship is between a midwife and a woman; not the woman's friend, or partner, or employee.

• information obtained in an assessment (maternal observations: frequency, strength and duration of contractions; fetal observations including lie, presentation, position, heart rate; and dilatation of the cervix) will not necessarily give the information that W2 or LBA are after.  The skill of midwifery includes interpretation of clinical observations over time.  

• the midwife cannot delegate professional responsibility for midwifery care to an unqualified, unregulated person.

 A midwife would be unwise to attend a woman in labour unless she or he was also prepared to attend the birth and take professional responsibility for decisions made.  An exception would be if another midwife who was unable to attend a client who said she was in early labour, asked the midwife to provide a 'locum' service and report back.

 One of the realities of physiological birth is that the labour must begin spontaneously - in the woman's own time.  Most women make the decision themselves as to when to ask their midwife to attend, or when to go to hospital.  Sometimes they get it wrong - too early, too late!  Sometimes just right. 

This dilemma will not be resolved by having a private midwife provide a one-off consultation.  If people want that sort of information, they could 'do it yourself' DIY.  They could get hold of a fetal monitor and listen to the baby's heartbeat as much as they want to.  They could get hold of a little internal camera that takes pictures of the cervix.  The technology exists.  Also blood pressure monitors, a thermometer, ...  

'DIY' will never replace the midwife, who is 'with woman' in a partnership that requires trust and reciprocity throughout the episode of professional care.  

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.

Progress report: 2 years

It has been two years since the federal government's maternity reforms became effective, with the political spin of  “Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives”, stating that "... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care." (for more detail click here)

Yes, 
consumer preference was very clear: thousands of submissions to inquiries, many from ordinary mums and dads and grandparents, many of whom had never previously made any attempt at political action.
But,
consumer preference in this instance was overwhelmingly in favour of the option of homebirth attended privately by a midwife.
And,
since current evidence supports planned homebirth, with access to suitable obstetric hospital services when required, as being at least as safe as hospital birth for most women, I fail to understand the action of the government in summarily excluding homebirth from any Medicare benefit.
(Many have made plausible suggestions about a paternalistic, nanny-state, socialist policy that seeks to provide a one-size-fits-all plan for maternity care.  'Informed decision making' has become a one of those hollow phrases that are used because they sound so fine.)


The package of maternity reform focused on professional indemnity insurance, Medicare, and PBS (pharmaceutical benefits scheme) for midwives, with provisions for midwives to attend our clients privately for birth in hospitals.  Looking at each of these elements:

• Midwives are now covered by professional indemnity insurance (PII) for all antenatal or postnatal services, and for intrapartum services provided in (just a few) hospitals.  Midwives attending homebirth have been granted an exemption from PII until June 2015.  The obvious problem with this arrangement is that if PII is a rational and reasonable product, cover for intrapartum care would be essential.  But, since noone in the insurance industry has been able to come up with an affordable insurance product for midwives, the exemption has been put forward as a stop-gap measure. (more here)  Perhaps the implementation of the government's National Disability Insurance Scheme will ease pressure on the insurance market, and bring some relief to this stalemate.  Independent midwives in the UK at present face loss of their ability to practise because PII has become mandatory.  This is definitely not in the public interest, and is an example of regulation of a profession being delegated to the insurance industry.
• Medicare provider numbers are being used by an estimated 150-200 midwives nationally.  The provision of Medicare rebates for women who receive part of or all their maternity care from privately practising midwives should lead to a reduced reliance on maternity hospitals, which are in may places overstretched, overbooked, and under-staffed.  Yet, midwives who have asked hospitals to refer women to them for shared antenatal care, or for primary care with a plan for hospital birth, have (almost uniformly) received negative responses.   Victorian midwives in private practice continue to experience roadblocks to implementing the promised reforms. 
• The PBS provisions of the reform package are yet to be fully implemented.  We know of one midwife in Victoria who has been endorsed by the Board for prescribing.  Other midwives will be applying now, having completed the Flinders University's Graduate Certificate in Midwifery (pharmacology and diagnostics).  The Victorian legislative changes have recently been gazetted (click here), enabling authorised midwives to become prescribers. 

The hospitals where intrapartum care is (or soon will be) provided by private midwives are Toowoomba, Gold Coast, and Ipswich, in Queensland.  The model has been established with My Midwives. 

Collaboration, the core requirement for Medicare funding to be accessed by the woman, continues to present huge challenges to midwives.  Most midwives who practise privately have women coming to them from many different communities.  These women see different doctors, and it is not possible for the midwife to have met or worked with most of these people.  Some doctors are ready and happy to refer women to midwives for private care; some refuse outright; and some go to extraordinary lengths to cover themselves, in case something goes wrong.  One doctor sent a letter by registered mail to the private midwife and the pregnant woman, informing them that she (the doctor) opposed home birth under any circumstances.  No evidence was given for this position.  In the discharge letter to the GP, the midwife wrote:

... I acknowledge receipt of your letter in which you stated that you do not endorse homebirths.  I would like to direct you to the Cochrane (2012) review of planned hospital versus planned home birth, in which the authors state “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.” 

Hospital visiting access has been the dream of some privately practising midwives.  There are many practical reasons why they would like to offer hospital birthing to their clients, the obvious one being that this is where most Australian women intend to give birth.  Homebirth can be seen as unusual, and not well understood.  

At present an investigation is being undertaken by the ACCC into specific cases of anti-competitive behaviour by obstetricians or hospitals, blocking access to midwives.  Any midwives who have documentary evidence that they believe would contribute to this inquiry may contact me by email, and I will give you the names and contact details for the case officers who are heading up this investigation. [Joy Johnston joy@aitex.com.au ]

Is there a way ahead?  Is there a light at the end of this next tunnel?

Midwifery is a legitimate option for women seeking maternity care.

Midwives are able to offer basic maternity services, regardless of where that birth is planned.

Fellow midwives, I encourage you to reconsider the way we provide midwifery care for mainstream women who intend to give birth in a hospital.  In the past we, the 'good girls', have entered shared care arrangements where possible, and provided private midwifery services in addition to the services provided by public hospitals, accompanied these women to hospital in labour, and done all in our power to protect, promote and support wellness, within the constraints of the system that would prefer us not to be involved.  

The new midwifery led primary maternity care model will be woman-centred, and community based.  The hospital will be excluded from the model until the time comes to use the hospital, whether that is during labour, or before or after birth.  Since independent midwives have been excluded from hospital collaboration, we have no choice but to act autonomously within the community, at the same time as collaborating with the specified medical practitioner for that woman, and providing a written handover to the hospital when hospital care is required.  

Women who choose this model of care may be classified as 'planned homebirth', when in fact they did not plan homebirth.  That doesn't matter - it's not about the setting, or the statistics.  The main goal of this proposal is that women are able to access midwifery primary care from a known and trusted midwife: 'more choice' from 'expanded models' of maternity care.

This post contains the opinions of the writer, which are not necessarily shared by all members of MIPP.

Your comments are welcome.

Questioning a midwife about women and risk

I am reluctant to make any broad statements about privately practising midwives and the way each one approaches a professional situation in which the woman has risk factors.  Each midwife, and each woman, is unique.  In fact, that's what the often repeated phrase 'woman centred care' points to: that the care for each woman is approached by her midwife from an individual perspective.

A midwife whose practice is under the regulatory spotlight for events that led to allegations that she has engaged in unprofessional conduct when she agreed to provide homebirth care for women in a risk category* is on the stand, under oath, and quizzed by the Barrister acting on behalf of the statutory body.  Here are a selection of the questions that this midwife may be required to answer.  Perhaps other midwives will take a moment to reflect on how we would answer these questions.

* The 'risk' profile could include, for example, postmaturity, prematurity, birth after caesarean, multiple pregnancy, breech presentation.  

With reference to a woman who wishes to give birth at home, the midwife is asked:

"Do you accept that you have a professional responsibility to inform the woman of risks?"
"Do you consider that after you have informed the woman of risk, such as post maturity, or previous caesarean, that it is appropriate for you to agree to homebirth?"
"Do you accept that homebirth after caesarean (hbac) entails higher risk than homebirth without previous surgery?"
"Do you agree that risks in a vaginal birth after caesarean (vbac) birth are better managed in hospital if they occur?"
"If as you say there are some risks for the vbac at home, why did you not record this in your notes?"

"What evidence do you rely upon for permitting vbac at home?"
"What special preparations did you make for a high risk birth at home?"

"Did the mother lead the decisions about homebirth, or did you give her the green light?"
"Did you consider saying no to homebirth, and sending the woman to a doctor?"
"In your midwifery practice, do you follow the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (ACM Guidelines)?"
"Do you accept that the ACM Guidelines state that the pathway for birth after caesarean is to at least consider referral and transfer to obstetric care?"
"Do you accept the first guiding principle of the ACM Guidelines, that 'As a primary caregiver, the midwife, together with the woman, is responsible for decision making.'?"
"Do you as midwife accept that you and the woman are jointly responsible for the decision to give birth at home?"
"On reflection, with the wisdom of hindsight, do you agree that you made a poor decision in providing home birth care in this situation?"
"Are you able to give the panel the assurance that if you were faced with a similar situation again, you would act differently?"
"Don't you think that a woman who is more than 10 days postmature, and unable to give birth in a small hospital, is too high risk for homebirth, where there are even fewer resources on hand than at a small hospital?"

The main 'requirement' for homebirth is that the woman is able to labour spontaneously without medical stimulation of labour or pain relief.  Midwives attending homebirth use no drugs to stimulate labour or to ease pain.  The only stimulation of labour available for homebirth is natural processes, such as walking, nipple stimulation, sexual intercourse, and perhaps a special meal.  If a woman who has had a previous caesarean, or whose baby is in a breech presentation, intends to give birth spontaneously, she usually accepts the requirement for spontaneous onset and good unmedicated progress in labour. 

The polarisation of midwifery care into 'planned homebirth with a private midwife' and 'standard hospital care for birth' is in itself unreasonable.

Physiological birth is a basic function of the female of the species.  In our world today we have the opportunity to interrupt physiological processes if we think they are progressing in a way that would lead to poor outcomes.

Consider any other physiological process: breathing, for example.
I breathe because that's what my body does.
I continue to breathe whether I am conscious of the fact or not.
If breathing becomes difficult, this can be a warning sign that prompts me to seek medical attention.

In the same way, a physiological labour will proceed because that's what the woman's body does.
She will continue to labour whether she is paying attention to it or not.
If labour becomes difficult, this can be a warning sign that can prompt transfer to another level of care.

Planned homebirth is 'Plan A'.  The midwife checks the fetal heart, or records signs of progress, or monitors the woman's vital signs in preparation for intervention if that becomes necessary.  The midwife has (or should have) no intention to interrupt the natural processes without a valid reason.  A transfer to hospital, 'Plan B,' is a change in the plan.   There are different rules in operation under 'Plan B' than 'Plan A'.

Effective decision making in labour requires a shared responsibility for the decisions that are made.  The midwife has a certain body of knowledge, and familiarity with the processes, and the woman has other knowledge about herself, her values, and her life direction.  Together they are able to navigate the often unpredictable journey of bringing a baby into the world.  A midwife is not a hired help, employed to facilitate a certain preferred option.  Active participation in decision making protects the wellbeing and safety of mother, baby(ies), and the future of the midwife.

Birth is a highly contested zone.  Our society takes a paternalistic attitude towards birth, through the regulation of the midwifery and medical professions, and the oversight of institutions such as hospitals.  This is good - to a degree.

However, the one who is literally 'holding the baby' at the end of the day is the mother, and she is usually within an immediate family and broader community.  Unless the mother-family-community relationships are broken down beyond repair, the best place for a child to be cared for and to grow is within that network.  A midwife works in partnership with the woman, for the childbearing period, promoting health, protecting wellness, and supporting the development of healthy families.

There will always be aspects of risk that either exist prior to the onset of labour, or that develop during labour.  The midwife who recognises and acts appropriately in the care relationship, and the woman who engages in an intelligent way in decision-making, will have a high level of safety built into their care plan.  There is no safer way than Plan A for a well woman to approach birth.  When complications are present the care decisions become more complex, and the need for medical attention becomes more urgent.  A midwife and woman working together in a trusting relationship bring strength and confidence to the decision making process.



Your comments are welcome.

Homebirth backup arrangements

Melbourne's MIPPs were invited to meet with midwifery management at the Women's Hospital today, to hear about changes that will be implemented to the hospital's homebirth backup arrangements from 1 January 2013.

The Women's has, for many years, provided a 'booking' process by which midwives have made a backup arrangement with the hospital for women planning homebirth.  This arrangement will be ceased from 1 January.  Women for whom midwives are providing private care will be seen in the Emergency department, and admitted without having previously made a booking.

The hospital has reached this position after reviewing its processes.  The 'booking' was of a clerical nature only - the hospital has had no professional clinical review of the paperwork, including results of blood test and other investigations, until or if the woman has actually been admitted. 

The Women's is a busy, complex place: there were more than 7,300 births in the past 12 months.  The number of women who present without having had prior care from the hospital antenatal services is small.


How does this change impact on private midwifery care in the community?  

• A woman whose midwife refers her to the Women's is able to expect appropriate maternity care.  
• The midwife who is caring for the woman privately in the community is able to phone the hospital Emergency department, and provide verbal and written handover at the initial triage, and after admission.  Sometimes midwives who phone the hospital have reported difficulty, when the phone is not picked up within what seems a reasonable period of time.  The advice is always to put the woman's and baby's needs first, and to present at the hospital without calling if needed.

How does this change impact on collaboration between private midwives and public hospitals?

• It doesn't.
• The hospital is not under any obligation to accept collaborative arrangements with midwives, even though, under the federal government's Medicare reforms, there is a legislative/ bureaucratic expectation that midwives who provide Medicare rebates for women will establish collaborative arrangements with hospitals [Click here].

What does the National Health law require in terms of collaboration between a midwife and a hospital?

• The National Health law appears to envisage hospital births: a setting for which no midwife in Victoria, or in most of the nation, is able to have clinical privileges.  The issue of hospital backup for homebirth is not specifically addressed.  Rather the law requires arrangements that cover consultation, referral and transfer of care: the very process that backup arrangements cover.
• The National Health (Collaborative arrangements for Midwives) Determination 2010 states:

...

Part 2                 Collaborative arrangements

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.

         (3)   A collaborative arrangement, other than an arrangement mentioned in section 7, may apply to more than 1 patient.

         (4)   However, an acknowledgement mentioned in paragraph 7 (1) (c) may apply for more than 1 patient.

6              Agreement between eligible midwife and 1 or more specified medical practitioners

         (1)   An agreement may be made between:

                (a)    an eligible midwife; and

               (b)    1 or more specified medical practitioners.

         (2)   The agreement must be in writing and signed by the eligible midwife and the other parties mentioned in paragraph (1) (b).

...

In practice, a woman who books for homebirth with a Medicare-authorised midwife, is advised by her midwife on steps they need to take in order to fulfill the requirements collaborative arrangements.  For example, a referral to the midwife, signed by an specified medical practitioner (defined in section 4) for provision of antenatal and postnatal midwifery services, covers the part of the care that attracts Medicare rebate.  The arrangement includes hospital backup, should consultation, referral or transfer of care be indicated. 

There is a big black hole in the National Health law as far as birth at home is concerned, and the hospitals are understandably going about the job of tightening up their processes. 

Enough from me for today.   Your comments are very welcome.

Birth Registration and Birth Certificates

The Victorian Law Reform Commission is conducting a consultation into birth registration and birth certificates, under the Births, Deaths and Marriages Registration Act 1996 (Vic).  The consultation paper is available at the Commission's website.  Submissions to this review are requested by 1 November 2012.

Midwives in Private Practice (MiPP) is preparing a response.

The following questions have been put, to guide responses:

Birth notification 

1. What particulars should the Registrar require at birth notification stage from the responsible person? 
2. Are you aware of any problems with, or do you have any suggestions for improvement of, the notification process? 

Birth registration 

1. Are you aware of any requirement of the registration process that may create barriers to people registering births, in particular people from culturally and linguistically diverse (CALD) or Indigenous communities, or vulnerable or disadvantaged people?
2. Can you suggest ways to make the process for birth registration more accessible, efficient and effective? 

Birth certificates 

1. Are you aware of any requirement of the process for obtaining a birth certificate that may create barriers to people registering births, in particular people from CALD or Indigenous communities, or vulnerable or disadvantaged people? 
2. Can you suggest ways to make the process for obtaining a birth certificate more accessible, efficient and effective? 
3. Should legislation provide for the automatic issue of a birth certificate once a birth has been registered? 

Fees for birth certificates

1. Do you think it is appropriate to charge a fee for a birth certificate? If so, does the current fee create a barrier to obtaining a birth certificate for some people?  
2. The Act allows for a fee waiver but this is rarely granted. What criteria should be applied to the grant of a waiver of fees for a birth certificate? 
3. Should a waiver be possible only on a case-by-case basis or should classes of people qualify (for example those in possession of a Health Care Card)? 
4. Should the criteria for the waiver of fees be explicitly stated in legislation or regulations? 
5. Alternatively, should a policy document outlining these criteria be required to be made public by the Victorian Registry of Births, Deaths and Marriages? 

Vulnerable groups 

1. Are vulnerable or disadvantaged people or those from CALD backgrounds or Indigenous communities more likely to encounter problems with registering a birth or applying for a birth certificate? If so why, and how?

Awareness and access 

1. Is it easy to find out what you need to know about registering a birth and obtaining a birth certificate? 
2. Are members of the community in general sufficiently aware of their obligations and rights to register a birth and to be issued with a certificate?
3. If not, what can be done to improve community awareness and what role should the Victorian Registry of Births, Deaths and Marriages have in improving awareness? 
4. Should legislation be amended to include promoting birth registration and the benefits of obtaining a birth certificate, as a specific function of the Registrar? 

Other 

1. Are you aware of legislative or policy developments in other jurisdictions that may be helpful to consider for Victoria? 
2. Is there anything else you would like to share with us on any aspect of birth registration and obtaining a birth certificate?

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.

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