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.

Australia's mothers and babies 2011

The AIHW report, Australia's Mothers and Babies 2011, has been released today.  This and similar reports provide useful information about trends in maternity care across the nation.  The AIHW site has a large number of related publications.


From the report:

• In 2011, there were 1,267 women who gave birth at home, representing 0.4 % of all women who gave birth. The highest proportions were in Victoria and Western Australia (0.8%) (Table 3.18). It is probable that not all homebirths are reported to the perinatal data collections.

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.

letters from MIPP

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

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

Yet ...

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• Midwives report that some doctors who have previously agreed to collaborate with midwives have withdrawn, giving reasons such as "I don't think homebirth is a good idea" - when the collaborative arrangement covers only antenatal and postnatal midwifery services.

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


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

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

The content of this letter is copied below:

Re:  Collaboration and hospital visiting access for Midwives

Dear Doctor

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

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

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

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

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

Yours sincerely,

Your comments are welcome.

Publicly funded homebirth in Australia

Publicly funded homebirth in Australia: a review of
maternal and neonatal outcomes over 6 years

Authors: Christine Catling-Paull, Rebecca L Coddington, Maralyn J Foureur and Caroline S E Homer, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium

From the Medical Journal of Australia (Med J Aust 2013; 198 (11): 616-620.):

Results: Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%.

Conclusion: This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia.

These results are consistent with the large Dutch study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

The two Victorian publicly funded homebirth programs, at Sunshine and Casey hospitals, were not included in this study, which took data from 2006-2010. 

For more discussion about risk and homebirth, go to villagemidwife blog.

Ireland: No Country for Pregnant Women

Press Release - AIMS Ireland

No Country for Pregnant Women

This past weekend, as the nation celebrated International Women’s Day and Mother’s Day, an Irish Maternity Hospital initiated an invasive procedure on a pregnant woman against her will. ‘Mother A’ was denied patient autonomy and the right to informed refusal when the drastic and unprecedented measure of an emergency High Court sitting was called in order to compel her to undergo a Caesarian section. The risk of uterine rupture was cited as one of the main reasons for the urgency in this case but this risk is widely reported as being 0.1% or 1/1000. This is what Dr. Michael Turner, Obstetrician at the Coombe Hospital has called: “exaggerated, professional scaremongering...and it must stop”. (VBAC Conference, 2012)

State-sanctioned coercion of medical procedures on pregnant women or any other competent adult is not only unacceptable but it is also unlawful in other jurisdictions, such as the USA and the UK (Re AC [1990] & Re S [1998]). ‘Informed consent’ and ‘informed refusal’ abuses are common issues reported to AIMS Ireland by women.

Jene Kelly of AIMS Ireland states: “there is an overwhelming acceptance by the public and some maternity service providers in Ireland that a pregnant woman’s right to informed consent, or informed refusal, is not reliable and that women who exert their rights are selfish. It is this mentality that has allowed atrocities such as symphysiotomies, miscarriage misdiagnoses, unnecessary hysterectomies by Dr Neary and all the other reported assaults against women by our maternity system to continue to go unanswered in Ireland for so long. This is no country for pregnant women. ”

AIMS Ireland reports that women who are bullied into consenting do not fulfill the principles of informed consent and therefore are entitled to sue the doctors for assault. For example, a woman who was forced to have a caesarean section against her wishes in the UK sued the doctors (Ms S v St George's NHS Hospital Trust, 1998) and was awarded £36,000 damages. It is time that Irish women did the same. Threatening women, bringing women to the high court, removing women’s rights and choices - these bullyboy tactics do not promote trust between women and their care providers. How can you trust a system that doesn’t acknowledge your rights? Women are choosing to leave the system as a result.

Annette is one of these women. She is lobbying the HSE for a homebirth following a previous Caesarean section. The HSE currently does not recognize informed choice for homebirth for women who fall outside strict exclusion criteria in site of a European Court of Human Rights ruling recognizing a woman’s right to decide how and where she births. Annette does not meet criteria following her previous Caesarean, despite having subsequent successful vaginal births. Annette asks: “Is it HSE policy to use the High Court as a method of intimidation and coercion, when a patient tries to exercise her right to informed decision making, as laid out by the European Court of Human Rights (Ternovsky v Hungary, Under Article 8)? We are humans, with great intellect. We are capable of informed discussion and decisions regarding our pregnancies and births in the best interests of ourselves, our babies and our families. I feel anger, disappointment and bewilderment. Today as a woman and mother, I grieve.”

###

AIMS Ireland Press Contacts:

Jene Kelly 087 681 9095

Krysia Lynch 087 754 3751

Barbara Western 086 385 3344

AIMS Ireland is a consumer-led voluntary organisation that was formed in early 2007 by women following their own experiences in the Irish maternity system. Our mission is to highlight normal birth practices, which are supported by evidence-based research and international best practices, and campaign for recognition of maternal autonomy and issues surrounding informed choice and informed refusal for women in all aspects of the maternity services; from Caesarean section to homebirth. AIMSI campaigns on the grounds that birth choice is a basic human right as declared at the International Conference of Human Rights and Childbirth, “It is a fundamental human right for women to choose the circumstances in which they give birth, with whom and where, including a choice between hospital and home birth” and Article 8, European Court of Human Rights

'free birth'

Birth is, and probably always will be, a contested territory.

An unknown number of women have made the choice to 'free birth': to give birth without professional attendance.  This phenomenon is happening in Australian communities, at the same time as the independent/homebirth midwifery profession is undergoing increasingly demanding levels of regulation from statutory bodies and by way of professional expectations set by our peers. 

While any competent individual has autonomy for their own actions and their own bodies, the issue becomes more complex when that body is a woman's body, which is carrying an unborn child.  And although courts in various countries have upheld the right of a woman to refuse, for example, caesarean surgery that is intended to protect the life of the child, there are many subtle forces that direct a woman in to compliance with social norms.  

Why 'free birth'?
... access? 
Women who proceed with a plan for 'free birth' are not necessarily unable to access a midwife privately to attend homebirth, although this is sometimes the case. 
... cost?
the cost of private midwifery services for homebirth may be prohibitive.
... belief?
the woman who has formed a strong belief that the presence of any qualified person (ie midwife) will inhibit her ability to proceed naturally with birth, considers that she is better off without any professional attendant.
... objection?
A woman may object to some practice, such as listening to the fetal heart sounds, that a midwife may consider to be a basic requirement for safe practice.
... substitution?
an unregulated birth attendant may be willing to act in supporting the woman, and guiding her through her birth, effectively substituting for the midwife.

Whatever the reason, each woman / each situation, is unique.

Here is a hypothetical example.

Ms A and her partner have had two children previously.  Baby #1 was born in hospital, after a long and painful labour, in which Ms A had augmentation of labour, an epidural, and a forceps birth. 

Ms A felt traumatised after that birth, and in her second pregnancy decided that she wanted homebirth.  The midwives who attended her in labour were unhappy with her progress, and recommended that she transfer in labour to hospital.  Baby #2 was born in hospital: a big baby; and another difficult birth. 

Ms A reflected on her experience, and believed that the midwives were fearful, and that she would have been better off without them.  She therefore chose 'free birth' for her third child, and invited two friends who worked as doulas to be with her to support her for the birth.

Ms A's complex process in choosing 'free birth' included her belief that the presence of midwives for baby #2 had inhibited her progress, and the availability of a substitute for professional attendants.

In recording this hypothetical example, I would like to be very clear that I understand that Ms A made choices and decisions that she believed would be in the best interests of herself and her baby. 


The issue of 'free birth' was addressed in a Victorian ABC TV story 7.30 report last Friday.

Several of the people interviewed for this story were asked if they supported the recent recommendation by the South Australian Coroner that it should be an offense for a person to attend birth without having the qualification of midwife or doctor.  The response from Hannah Dahlen, on behalf of the Australian College of Midwives, included a statement that the answer to 'free birth' is not to be found in cracking down, to 'exterminate' its practitioners, as it will only be driven underground.

I concur with this.  Although the events that led to the recommendation by the SA Deputy State Coroner are tragic, I do not consider that legislation to protect midwifery practice in South Australia would or could achieve the desired aim of improved public safety.

The choice that some women make, to give birth to their babies at home, takes into account individual social preferences and reasons. Since birth at home is the outcome of a spontaneous physiological natural process, there is no legislation that can control who a woman consults in pregnancy, or who is with, or not with, a woman who is labouring or giving birth spontaneously.

A woman’s right to self-determination in making decisions such as where she gives birth, and with whom, will not be controlled or altered by legislation designed to protect midwifery practice.

It is my belief that the government’s support for the regulated midwifery profession, with funding for homebirth programs, protection of the full scope of private midwifery practice including hospital visiting access, and education for the public in maternity choices, will result in greater protection of public interest than the proposal to protect midwifery practice.

Joy Johnston

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.