MATERNITY SERVICES FOR TEMPORARY WORKERS IN AUSTRALIA

Public hospitals in Melbourne, and in other parts of this country, have closed their doors to women who do not have Medicare.  Women who present needing care at a public hospital are being told they must pay an $11,000 deposit, or leave without being attended to.  They are told to go to a private obstetrician, and make a booking at a private hospital, with an estimated $15,000+ cost to the woman.

The more affordable alternative is private midwifery services for planned homebirth, costing around $5,000.  However, an estimated 20% of women who are planning homebirth need to be transferred to hospital when their care needs exceed the capacity of midwives in the home.  These women arrive, with their midwife, at a public hospital, because they have no other option.  The midwife's duty of care to the woman and her baby is to refer to an appropriate service; regardless of the cost. 

Women who are in Australia on temporary work visas, such as 457, must have private health insurance.  However, it seems that the available insurance policies are woefully inadequate when maternity services are needed.  Women who have spoken to independent midwives, seeking to arrange their intrapartum and immediate postnatal care, have said that they simply can't afford the hospital fees.

This situation is unacceptable!

The time of childbirth, more than any other time of life, requires skill from the care providers, leading to security for the mother.  Although 'birth is not an illness' (WHO Fortelesa Declaration 1985), illness can quickly arise in pregnancy and birth, threatening the lives of the mother and her child.   

The data that midwives send to the Victorian Government Perinatal Data Collection Unit, and similar units in other States and Territories, and sent on to the Australian Institute for Health and Welfare, Mothers and Babies reports, does not give a field to identify the woman who are ineligible to use the national free public hospital services.  The outcomes will never be reported - they are likely to remain under the radar.


Is there a solution?

I would suggest at the very least that public hospitals need a process by which overseas workers, many of whom are from the poorest countries of the world, are able to access affordable maternity and neonatal care.  Yes, midwives can provide basic primary care in the community, at an affordable rate.  But, when a woman needs specialist obstetric referral, surely a 'no frills' option can be provided by the public hospitals, at considerably less cost than what is on offer from Melbourne's plush private hospitals.

Your comments are appreciated.

Priorities

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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.

Hospital back-up bookings for planned homebirth

Midwives practising privately in and around Melbourne have, for many years, used the booking and emergency referral arrangements provided by the Women's hospital. The process has been simple: the midwife can fax the woman's details to the hospital, and the woman is given a hospital record number confirming the booking. The midwife provides copies of any blood test and other investigations relevant to the pregnancy, and contacts the hospital if and when obstetric referral is required.

In the past two years, after the Women's hospital relocated from the old Carlton site to its present site in Parkville, and, coincidentally as the numbers of births increased with the recent 'baby boom', restrictions have been placed by the hospital on which women are able to make bookings. For women who are experiencing uncomplicated pregnancies (which is usually the case for women planning homebirth), only those who live in the Women's local area are able to make a booking.  The hospital was apparently bursting at the seams.   Midwives who had previously brought women transferring from planned homebirth to the hospital from distant locations are now referring women who need medical attention to the nearest public maternity hospital.

Some midwives objected to the change.  Transferring to the Women's had been a well-managed matter, that the midwife could confidently navigate.  Professional respect between the independent midwife and the hospital staff, and vice versa, was generally upheld.  This of course tends to reassure the (labouring-birthing) woman, who is at the *centre* of the care.  [The good relationship between Midwives in Private Practice (MIPP)s and the Women's has been written about previously in this blog - eg see July 2008]

The Women’s hospital is now undertaking a review of ‘Services provided by the Women’s hospital in relation to women who choose to give birth at home’. A letter to participating midwives states that The Women’s “has identified a number of issues associated with its existing homebirth backup arrangements and, in recent months, significant concern regarding the clinical risks has heightened.” The Women’s Executive “has decided to review the current arrangements in order to clarify the Women’s role and responsibilities in this area and to determine the most appropriate processes for supporting women who choose to give birth at home.”

The fact that "significant concern regarding the clinical risks has heightened" in recent months, in relation to homebirth, is a matter that midwives who attend homebirths care a great deal about. Has there been some change in the way midwives practise, or in the way midwives and women planning homebirth proceed through their decision-making processes?  Is there a problem specific to the Women's, or ...?

MIPP leaders have also been aware of some issues that would come under the heading of 'clinical risk'.  During the past couple of years, with the federal government's Maternity Services Review; the passing of new legislation requiring professional indemnity insurance which was not accessible; the 'exemption' for homebirth; and the Medicare provisions for participating eligible midwives - this has been a time of unprecedented stress and concern for midwives practising privately, attending women for planned homebirth. 

An application was made some months ago to the Victorian Perinatal Data Collection Unit (VPDC) by MIPP for retrospective information on the birth outcomes of women identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories: 

Multiple pregnancy; 

abnormal presentation (especially breech); 

preterm labour prior to 37 completed weeks of pregnancy; 

post term pregnancy 42+ weeks; and 

previous caesarean birth. 

There has been an unexpected delay in obtaining the data requested, as 2009 data cannot yet be publicly released. We understand that the delay has been related to the change from manual data entry to electronic data entry at some sites.  We will inform our members and readers as soon as something becomes available.  The VPDC publishes data on actual homebirths (and outcome data for each hospital providing data to the system) each year.  The MIPP audit is seeking information on outcomes specific to 'at risk' pregnancies and planned homebirth.

Thankyou to anyone who has read this far.  We will keep you updated on matters of interest to the private midwifery community, as information becomes available.

Your comments are welcome.

the reshaping of private midwifery practice

Private midwifery practice is undergoing real changes, as midwives who have Medicare provider numbers are able to offer certain midwifery services for which women will receive substantial Medicare rebates. 

There is scheduled fee for each item, from which rebates are calculated [variation in amount payable depends on a person's safety net]. For example: