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.

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.

Letter to the Sunday Age

[In response to the front page article, 'Patient power troubles GPs', Sunday Age, 30/12/12]

I find it troubling that some doctors are not happy with the concept of independent experts who support a patient’s decision making in medical care. 

The statements by Dr Hambleton of the AMA suggest that he is attempting to protect the old ‘doctor knows best’ position of privilege in our society – perhaps that’s part of his job description?

I also take exception to Dr Hambleton’s questioning of “the need for private midwives to be escorting women during hospital births.”

I am one of those private midwives, and I would like to explain briefly why I provide primary maternity care, and attend birth, whether it occurs in hospital or the woman’s home.   

A midwife’s unique skill is the ability to work in harmony with the natural processes through pregnancy, birth, and the postnatal period.  Birth is not an illness.  The midwife’s duty includes promoting health, supporting wellness, and protecting the woman’s ability to do the work of bearing and nurturing her children.  Only when and if complications or illness are present does the midwife need to collaborate with medical and/or hospital systems, and only then with the woman’s informed consent.  Most women trust the midwife’s guidance, but there are grey areas in maternity care, just as there are in the world of GP doctors. 

The planned setting for birth is not set in concrete.  Many women who plan hospital births experience the ‘coming ready or not’ baby who arrives in all sorts of places, including the bathroom at home, the back seat of the family car, or the hospital carpark or lift.  Some women who plan homebirth need to change their plan and move to hospital, for all sorts of reasons.   

Midwives who practise privately, independent of the hospital system, are able to offer personal continuity throughout the episode of care and be with the woman in labour wherever she is.  Privately employed midwives seek to establish a partnership with each woman in our care, at a level that simply cannot be achieved without significant investment of time prior to the birth.  Privately employed midwives offer a distinct professional care package to each woman.  The women who employ us usually intend to give birth spontaneously,  without relying on medical pain management strategies, or artificial augmentation of the birth process, unless there is a valid reason at the time for such a decision to be made.

When private midwives ‘escort’ women to hospital, we have usually provided significant professional services for that woman through the prenatal period.  Several Medicare items give rebate for services such as the initial consultation, long or short antenatal checks, and the development of an individual maternity care plan.  The woman may have laboured at home, in the care of her private midwife, prior to traveling to hospital.  The woman knows her private midwife’s voice, and touch, and is able to be confident within the care plan.  The care plan includes the ongoing process of  informed decision making, with the wellbeing and safety of mother and child being the guiding principle. 

Postnatally the private midwife continues to provide expert professional services, within the primary maternity care relationship.  Postnatal Medicare items are available until the seventh week after the birth.

Dr Hambleton’s attempt to trivialise the private midwife’s role as “so someone can hold their hand” is offensive to me.  If I hold the hand of a labouring woman, it is a significant act of professional support for which that woman has employed me.

Joy Johnston

25 Eley Rd, Blackburn South Vic 3130

03 9808 9614

http://villagemidwife.blogspot.com.au/

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.

An update on midwife prescribing

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

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

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

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

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

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

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

Colalboration gone wrong!

The Australian Government’s $120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives, promised that Australian women would have

“more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services.” 

The National Maternity Services Plan (the Plan), endorsed by the Australian Health Ministers’ Conference in November 2010, provided governments with a strategic national framework to guide policy and program development.  The plan declares that primary maternity services will be  

“woman centred, reflecting the needs of each woman within a safe and sustainable quality system."

Year one of the Plan committed jurisdictions to developing 

“consistent approaches to the provision of clinical privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners.”

How is implementation of the Plan progressing?

Midwives report little action or hope of conclusion, on matters to do with provision of clinical privileges for Medicare-eligible midwives within public maternity services, except in Queensland.  Anecdotally we are aware of instances of increasing resistance within some public hospitals to the implementation of programs of clinical privileging for private midwives.


Earlier this week I received an early morning call from a distressed colleague.  Having worked with a woman who was planning homebirth for some hours, this midwife arranged to transfer the woman's care to a major public maternity hospital in Melbourne, where the woman had made a back-up booking.

The midwife, who believes she has had a good relationship with the hospital for many years, was distressed that the doctor who admitted her client refused to accept any verbal hand-over, and rudely walked away when the midwife attempted to carry out a professional conversation with him.

It would appear that efforts are being made within public maternity hospitals to derail any plans to enable admitting and practice rights for eligible midwives.

Within the obstetric community there is a strongly held position that a doctor or midwife who is willing to assist women in 'bad choices' is seen as encouraging 'bad choices'.  Women who have attempted to make arrangements with hospitals to facilitate normal birth in situations of acknowledged complexity, such as twins, breech babies, or even birth after a previous caesarean, have been given no choice.  "If you come here, this is what will happen!"  This is an often repeated scenario in both public and private hospitals.  These women have often sought private midwives to attend them in the relative 'safety' of their own homes.


This post is just skimming the surface of a complex issue.

Collaboration with medical and nursing colleagues, within hospital systems, is a basic expectation in all midwifery. 

Midwives are required, by regulation and by definition, to collaborate. 

“... This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance (emphasis added) and the carrying out of emergency measures.   ” 

(From ICM Definition of the Midwife, 2011)



Midwives also have an expectation of ethical professional behaviour towards those in our care.  The current Code of Ethics for Midwives lists 'values' - which in themselves describe the standard to which we aspire.  There is no place for bullying and domineering behaviours in midwifery.

1. Midwives value quality midwifery care for each woman and her infant(s).
2. Midwives value respect and kindness for self and others.
3. Midwives value the diversity of people.
4. Midwives value access to quality midwifery care for each woman and her infant(s).
5. Midwives value informed decision making.
6. Midwives value a culture of safety in midwifery care.
7. Midwives value ethical management of information.
8. Midwives value a socially, economically and ecologically sustainable environment promoting health and wellbeing.

 (From Nursing and Midwifery Board of Australia)

Midwives need a system that recognises us and treats us fairly.

We call on midwives to continue to stand in partnership with women, demanding equity and fairness in all maternity services provided by our governments - federal and state. Collaboration requires both parties to participate, the hospital and/or doctor, as well as the midwife.  There is no such thing as one-way collaboration.  Midwives are committed to the wellbeing and safety of mothers and babies in our care, and it is our duty to demand that the health care systems support us in achieving this goal.

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