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.

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.

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

Midwives in Private Practice

Each member of Midwives in Private Practice (MiPP) is

• a registered Midwife in Victoria 
• who derives some income from private midwifery practice 
• and provides primary care for pregnancy, birth & postnatal period  

 
PRACTICE STATEMENT
Midwives In Private Practice (MIPP) is a collective of qualified midwives, providing support, education, and promotion of best practice midwifery in any setting. Each member is responsible for her/his own practice of midwifery, maintenance of professional standards, and appropriate record keeping.
MIPP is a member group of Maternity Coalition Incorporated.

Principles:
The midwife joining or renewing membership agrees to:

• Practice in a way that is consistent with the International Confederation of Midwives' Definition of the midwife 
• Attend MIPP meetings. If this is not possible at any time, the midwife sends an apology, and contributes to current discussion by other means. 
• Contribute to the activities and work of MIPP. 
• Participate in professional standards peer review within the collective.
• Contribute to periodic reviews, providing quantitative and/or qualitative data as appropriate. 

Note: A midwife who wishes to commence private practice, ie ‘fee for service’ outside the acute health sector/hospital, is encouraged to seek mentoring with experienced independent midwives.

The MIPP list at the Maternity Coalition website has been updated recently.  The following midwives are listed, with phone and email addresses:

Alice Barden, Eltham
Amy Gillies, Wantirna South
Andrea Quanchi*, Echuca
Fiona Hallinan, Clifton Hill
Belinda Henkel*, Rosanna
Clare Lane* Mitcham
Helen Barrington, Ferntree Gully
Helen Brown, Heathmont
Helen Sandner, Strathdale
Jan Ireland*, Bentleigh East
Jennie Teskey*, Clifton Hill
Joy Johnston*, Blackburn South
Juliana Brennan* Gruyere
Kelly Langford*, Kensington
Leanne Chapman* Mildura
Louise Norbergen* Montrose
Malinda Morieson, Croydon
Melody Bourne, Brunswick
Nicola Dutton, Bayswater
Sally McCrae, Castlemaine
Sally-Anne Brown, Apollo Bay
Seneka Cohen, Croydon North

Note: Midwives with * after their names are able to provide Medicare rebates.

hospital access for Medicare-eligible midwives

A few months ago I reported on the work of a reference group set up by the Victorian Health Department to develop consistent approaches to the provision of clinical privileges for midwives within public maternity services, to enable admitting and practice rights for eligible midwives, and a new option for women who seek maternity care that protects continuity between the woman and her midwife.

Midwives in Private Practice (MIPP) was represented at the three meetings of the expert reference group. The 'deliverable' of this initial consultation process, which has been managed by the 3Centres Collaboration, is a draft document which provides a framework, and templates for paperwork and various records. This document will progress through careful checking by the Health Department, before it is able to be released. It is hoped that this document will provide a reliable process whereby public maternity hospitals in Victoria will be able to proceed with making arrangements whereby midwives are able to attend women privately for birth and other maternity care in the hospitals.

Readers may wonder how many women would want to be attended privately for birth in public hospitals? How many midwives would apply for visiting privileges, and what number of private clients/births would they be able to expect in a year? It is not known how many women in Victoria employ a midwife privately to attend them in labour in a public hospital. An estimate would be 100-200. Many more employ unregulated birth support people. Some midwives would attend 10-20 planned hospital births each year; others only occasionally.

For many years the predominant focus of private midwifery practice throughout Australia has been homebirth. However, since the introduction of notation as a Medicare-eligible midwife, the options for private midwifery practice have been extended. Some midwives who have achieved their Medicare notation/provider numbers have no experience in, and no intention of attending home births. Their plan is to provide continuity of care (and carer) for women giving birth in hospital. This suggests that as the number of Medicare-eligible midwives increases, the demand for hospital admitting and practice rights will also increase. If 10 newly eligible midwives were each taking 40 caseload bookings for planned hospital births, the estimated 100-200 per year could be 500-600.  It's still a tiny proportion of the State's annual number of births, but it's a potential growth area.

In order for a midwife, or doctor, or anyone, to be allowed to practise in a hospital facility, there are basic instructional and policy matters that need to be communicated. Routine fire evacuation plans and other emergency procedures are essential for safety of patients and staff and all concerned. Everyone needs to be skilled in use of the hospital's computer systems, entry of data, admission and discharge, reporting of incidents, ... just to name a few examples.

A midwife who is employed in a hospital, who also has a private practice, or who has recently moved from hospital employment to private practice, would be able to quickly meet the requirements for emergency procedures, IT processes, &c. This midwife would be ideally situated to take up admitting and practice rights. The hospital knows the midwife, and the midwife knows the hospital.  The process might be more challenging for a midwife who has not practised recently in the hospital.

It is important to remember that there is a woman and a child behind every episode of maternity care.  Private midwifery care for birth is a model that focuses on the woman and her baby, not on the care provider or the facility.  MIPP members look forward to the day when the options and arrangements for maternity care will truly value the woman, and thereby promote healthy outcomes.

Join the global webinar to celebrate International Midwives' Day 5 May

Plans are set for the Virtual International Day of the Midwife on May 5th. The program, which spans the 24-hour period, with speakers from the various continents, has now been finalised, and it looks to be a very interesting and diverse program: http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011

Survey on prescribing courses for midwives

If you are a midwife practising privately in Australia, or if you intend to practise midwifery privately, please go to the APMA blog, read the message, and follow the links to the survey.