CHOICES

Information Sessions in Melbourne

Winter 2012

@ MAMA

 

For times and program, go to Website: http://choicesforchildbirth.org.au/find-sessions-vic

 

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.

Robyn Thompson reflects on midwifery today

Response to the FOI Release by Robyn Thompson

From the heart and soul of a retiring midwife I thank Homebirth Australia for sending this information.
However, for me this is revisiting old ground. For those of us who spent hours with Nicola Roxon, hours and hours campaigning, me as one of Nicola's constituents, and with Julia Gillard living in my suburb, we were there over the years since the MSR and now we are worse off than ever before.

I no longer trust anyone in politics, the AMA, and some within our own profession, with the exception of Sen Rachael Siewert, WA and Justine Caines with her years of political drive and wisdom.

Sadly for me there is no time to revisit old ground. It's time to 'push' forward as it were. It's time to reclaim our rights, reverse restrictive legislation and offensive language imposed on midwives and women by political/medical game playing.

It's time to educate the new political crew, those who don't understand, while and staying strongly resolved to not accepting control of others over our professional practice. It's time to change our tac, and with good leadership to be strongly on the offensive rather than the defensive. Medicalised control of women, babies and midwives is an international issue, not just national. Midwives can rise again, by recognising their professional skills and being proud that our practice is as distinctly different from obstetrics.

Midwifery is a specialty in it's own right, of being 'with women' through the entire maternity cycle, yet linked at times to include the specialty of obstetrics. Medicalised midwives would be wise to revisit midwifery practice being with women (rather than doctors) through the entire maternity cycle. To re-focus their skills on assisting more women to unhindered natural birth. Turn off the machines that go 'ping', that the administrators are 'leased back'. Stop accelerating labour - reduce unnecessary synthetic pain. Stop administering opioids and other drugs that harm babies, offer emersion in warm water for labour instead. Stop rupturing membranes - leave protective forewaters and hydraulic pressure for the baby, intact. Stop attaching women to restrictive continuous monitoring machines, revisit well educated hearing skills, use a Pinnards stethescope, or hand held dopplers or just your ear. Stop the myriad of unnecessary professional rituals that restrict women. Assist women out of the vulnerable horizontal position. Encourage their inner strengths and let them decide how they will birth their babies.

STOP requesting doctors to sign off our practice, say thank you but NO this is inappropriate, we are professionals in our own right, please recognise that. Women and midwives are stronger than ever before about our their human and professional rights. We are strong enough to shift 'big brother' from our lives and do what evolution, education and practice has taught us, and to connect with the specialty of obstetrics when appropriate.

We all have a responsibility to educate women the midwifery way, to go about our business campaigning constructively, refusing to harm women and babies by re-confirming the wonder of the female body and mind. To carry out our business competently and wisely will strengthen our resolve to inform the medical profession, the politicians and others that women and midwives will no longer agree to participate in bodily abuse at any time in the maternity cycle. That we will by consult and refer if the need arises.

Healthier women and babiesbabies’ means confidently shifting control, including control of the dollar, from others', and return it to women.
Robyn


Thankyou, Robyn for sharing your wisdom.  Joy Johnston

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.

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.