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

Senate passed motion to support private midwives

From Greens Senator Lee Rhiannon

Senate support private midwives

10 May 2012 | Health, including preventive / Women

The Senate today passed a motion calling for immediate action on the obstacles facing privately practicing midwives in Australia.

"The government set aside $120 million in 2010 for midwives in private practice to access Medicare and the PBS, but hardly any have been able to do so," said Dr Richard Di Natale, the Greens Spokesperson on Health. "Because they can't get visiting access rights, they can't be by their patients if they get admitted to public hospitals."

The Senate motion called upon the government to work with states to resolve visiting access issues and to clear any other roadblocks preventing privately practicing midwives accessing Medicare and the PBS.

"This situation has to change. Mothers want and expect continuity of care, not to have to say goodbye to their chosen midwife at the hospital doors. The Senate has now recognised the issue and it is now up to the states to deliver."

Australian Greens Senator and spokesperson for women Lee Rhiannon said:
"Australia is still well behind when it comes to midwifery compared with other nations such as Norway. "Roadblocks frustrating women's right to choose a range of birthing arrangements needs clearing. "Midwives are known to provide extremely safe and high quality care, facilitating continuity over the pregnancy, birthing and post natal periods.

"It is time governments across Australia joined together to enable midwives to properly do their work."

Motion Notes 

on 1 November 2010 $120.5 million was made available to improve choice and access to maternity services, and for eligible midwives to work in private practice Australia; to provide greater access to maternity care provided by midwives, Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) benefits were made available for services provided by eligible midwives; eligible privately practicing midwives are not currently able to work to their full scope of practice and claim MBS and PBS because access and admitting rights to public hospitals have not been established by state and territory governments.
Calls on the Minister for Health and Ageing to work with COAG and Australian health ministers to urge state and territory action on access and admitting rights to public hospitals for eligible privately practicing midwives; investigate any further support necessary for privately practicing midwives to transition into private practice, to work to their full scope of practice and access MBS and PBS benefits; and consult with stakeholders.

NMBA celebrates International Midwives' Day

Media release
4 May 2012
Nursing and Midwifery Board recognises special day for midwives 

The Nursing and Midwifery Board of Australia (the National Board) recognises the important role of midwives in communities across the nation. May is an important month for the midwifery profession with the International Day of the Midwife being commemorated worldwide tomorrow – 5 May 2012.

More than 39,000 midwives are currently registered with the National Board. The International Day of the Midwife has been celebrated since 1991 and in 2012 the commemorative day’s theme is ‘Midwives Save Lives’.

National Board Chair Anne Copeland said the day was a perfect opportunity to reflect on the invaluable contribution of midwives not only in Australia but globally in tackling maternal, newborn and infant mortality. “Midwives working in Australia take pride in their work of caring for women and their babies. Midwives also contribute to the midwifery profession by providing important feedback to the National Board on registration standards, professional codes, standards and guidelines, and consultations relating to midwifery practice”, Ms Copeland said. “Their willingness to engage with the National Board is vital when determining evidence-based standards to guide the profession”.

The National Board plays a key role in keeping the public safe by ensuring that women have access to qualified and competent midwives to provide quality care. “The fact that midwives can now prescribe scheduled medicines as an eligible midwife is an example of progress within the midwifery profession in Australia and is a further service to the community in expanding the right to choose a specific health care provider”, Ms Copeland said.

The National Board welcomed the opportunity to approve the inaugural program of study from the Flinders University, a Graduate Certificate Midwifery (Leading to Endorsement for Scheduled Medicines for Eligible Midwives) on Monday 30 April 2012. The implementation of this approved program of study will enable the existing 114 eligible midwives, once their study is completed, to obtain an endorsement to prescribe scheduled medicines and practice to their full scope of midwifery practice.

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

choice of home birth: a human right?

This heading 'choice of home birth: a human right?' refers to the woman, not the midwife. Is it a woman's right to choose home birth?

Many would argue that the choice of home birth is a human right. As recently as 2010, the European court ruled that the choice of home birth is a European human right (please read on to the end of this post for the source of that piece of information).

Whatever the woman's right in choosing to give birth in her own home, that 'right' is at best meaningless if the woman is not able to access professional midwifery services.  In the absence of a suitably skilled midwife, the woman who hopes to exercise her 'right' to home birth must either give up the notion of home birth, or proceed without professional midwifery care.


In this brief essay I am seeking to apply the notion of a woman's right to choose to give birth in her home, to current Australian situations in which midwives may feel that they are not able allowed to attend certain women: those who have risk factors, such as post maturity, a previous caesarean or other obstetric complicated birth, a multiple pregnancy, or a baby in breech presentation.

Midwives who attend home births independently are facing increasing pressure to conform to external professional protocols which seek to define who is, and who is not 'suitable' to be in the care of a midwife. Such documents become instruments of a society's expectation on women giving birth, effectively forcing conformity on the midwife, and indirectly on the woman.

The current protocols (also referred to as guidelines and position statements) in relation to a midwife attending a woman for planned home birth, include:
AHPRA Safety and Quality Framework for Privately Practising Midwives attending homebirths
ACM Position Statement on Homebirth Services 2011
ACM Guidance for Midwives regarding Homebirth Services 2011

Other codes and professional documents, such as the ACM National Midwifery Guidelines for Consultation and Referral (Second Edition 2008) that apply to all midwives can also be used to restrict the scope of the midwife's practice.

The broad principles underpinning contemporary midwifery are defined by the International Confederation of Midwives in the Definition of the Midwife (2005 – it was revised 2011), which stated

“The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. 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 and the carrying out of emergency measures. ... A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”  [Note that this paragraph is unchanged in the revised (2011) ICM Definition of the Midwife.]

This definition is a core statement in Australian midwifery codes, eg the Codes of Ethics and Professional Conduct for Midwives in Australia.

Midwives around the world, in all levels of socio-economic and health status, grapple with the home birth issue.  In recent generations in developed countries, the professionalisation of midwifery has progressed hand in hand with the medicalisation of birth.  Australian midwifery education and regulation is a good example of this phenomenon.  Under current laws, midwives are the like poor cousins of nurses in the professional regulatory scene.  It may be difficult for midwives to have complaints against them investigated and heard by professional peers who have any recent midwifery practice experience.  Determinations by investigators in cases of professional conduct may have little relevance to the real world in which the midwife works.  The focus of the medicalised midwifery on risk factors and mainstream 'broad brush' risk management in hospitals can easily overshadow any acknowledgement of the woman's informed decisions.  The well known Monte Python skit, 'The Meaning of Life' applies: the woman on the bed calls out "Can I do anything?" and is told without delay "No, you're not qualified!" 

It is worth noting that the ICM Position Statement on Home Birth emphasises the social/family aspect of birth, as distinct from a medical condition.

“Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs. There is a consequent need and demand for care that is close to where and how people live, close to their birthing culture, and at the same time safe. The World Health Report 2005 states that ‘There is a value in the rituals surrounding birth, and in keeping these as a central feature of family life. The setting for birth may therefore be the woman’s home, a local health facility or, if medical or surgical care is likely to be needed, a hospital. Furthermore a recent (2010) the European court judgement declared that the choice of home birth is a European human right.” 

[For more detail on the European Court decision, click here]

The woman who, notwithstanding her knowledge of her own particular 'risk' status, asks a midwife to work with her to protect and promote normal physiological birthing in her home, is as entitled to professional midwifery care as the woman who chooses care in a birth centre or hospital.  The conversation between the midwife and the woman will address the woman's plans as to how she hopes to give birth to her baby, and what will happen if her midwife advises transfer of care to an obstetric unit.  This is not new or unusual in midwifery.  Every woman who comes into spontaneous labour has to make decisions about when to go to hospital, or when to ask the midwife to attend, if home birth is planned. 

In conclusion, I do not want to seem to encourage midwives to encourage 'at risk' women to see home birth as their only option.  In my experience, a woman with twins, or breech presentation, or BAC, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing.  This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

The midwife is also enabled to fulfill her duty of care to the woman, without exposing herself unnecessarily to potential investigations for professional misconduct.

Maternity Coalition's NEW Newsletter

Readers are invited to join the email list for a FREE newsletter, planned monthly, from Maternity Coalition.

To access the February 2012 issue, click HERE

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Midwives in Private Practice (MiPP) is a participating organisation, under the Maternity Coalition 'umbrella', and all members of MiPP are also members of Maternity Coalition.
Maternity Coalition members receive the excellent quarterly journal, Birth Matters, pictured here. 

To become a member of Maternity Coalition, click HERE

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.