Homebirth backup arrangements

Melbourne's MIPPs were invited to meet with midwifery management at the Women's Hospital today, to hear about changes that will be implemented to the hospital's homebirth backup arrangements from 1 January 2013.

The Women's has, for many years, provided a 'booking' process by which midwives have made a backup arrangement with the hospital for women planning homebirth.  This arrangement will be ceased from 1 January.  Women for whom midwives are providing private care will be seen in the Emergency department, and admitted without having previously made a booking.

The hospital has reached this position after reviewing its processes.  The 'booking' was of a clerical nature only - the hospital has had no professional clinical review of the paperwork, including results of blood test and other investigations, until or if the woman has actually been admitted. 

The Women's is a busy, complex place: there were more than 7,300 births in the past 12 months.  The number of women who present without having had prior care from the hospital antenatal services is small.


How does this change impact on private midwifery care in the community?  

• A woman whose midwife refers her to the Women's is able to expect appropriate maternity care.  
• The midwife who is caring for the woman privately in the community is able to phone the hospital Emergency department, and provide verbal and written handover at the initial triage, and after admission.  Sometimes midwives who phone the hospital have reported difficulty, when the phone is not picked up within what seems a reasonable period of time.  The advice is always to put the woman's and baby's needs first, and to present at the hospital without calling if needed.

How does this change impact on collaboration between private midwives and public hospitals?

• It doesn't.
• The hospital is not under any obligation to accept collaborative arrangements with midwives, even though, under the federal government's Medicare reforms, there is a legislative/ bureaucratic expectation that midwives who provide Medicare rebates for women will establish collaborative arrangements with hospitals [Click here].

What does the National Health law require in terms of collaboration between a midwife and a hospital?

• The National Health law appears to envisage hospital births: a setting for which no midwife in Victoria, or in most of the nation, is able to have clinical privileges.  The issue of hospital backup for homebirth is not specifically addressed.  Rather the law requires arrangements that cover consultation, referral and transfer of care: the very process that backup arrangements cover.
• The National Health (Collaborative arrangements for Midwives) Determination 2010 states:

...

Part 2                 Collaborative arrangements

5              Collaborative arrangements — general

         (1)   For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:

                (a)    the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;

               (b)    a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;

                (c)    an agreement mentioned in section 6 for the midwife;

               (d)    an arrangement mentioned in section 7 for the midwife.

         (2)   For subsection (1), the arrangement must provide for:

                (a)    consultation between the midwife and an obstetric specified medical practitioner; and

               (b)    referral of a patient to a specified medical practitioner; and

                (c)    transfer of a patient’s care to an obstetric specified medical practitioner.

         (3)   A collaborative arrangement, other than an arrangement mentioned in section 7, may apply to more than 1 patient.

         (4)   However, an acknowledgement mentioned in paragraph 7 (1) (c) may apply for more than 1 patient.

6              Agreement between eligible midwife and 1 or more specified medical practitioners

         (1)   An agreement may be made between:

                (a)    an eligible midwife; and

               (b)    1 or more specified medical practitioners.

         (2)   The agreement must be in writing and signed by the eligible midwife and the other parties mentioned in paragraph (1) (b).

...

In practice, a woman who books for homebirth with a Medicare-authorised midwife, is advised by her midwife on steps they need to take in order to fulfill the requirements collaborative arrangements.  For example, a referral to the midwife, signed by an specified medical practitioner (defined in section 4) for provision of antenatal and postnatal midwifery services, covers the part of the care that attracts Medicare rebate.  The arrangement includes hospital backup, should consultation, referral or transfer of care be indicated. 

There is a big black hole in the National Health law as far as birth at home is concerned, and the hospitals are understandably going about the job of tightening up their processes. 

Enough from me for today.   Your comments are very welcome.

NEWBORN SCREENING

INFORMATION FOR PARENTS

This video has been released by the Victorian Newborn Screening Lab, and is available to download here.

Birth Registration and Birth Certificates

The Victorian Law Reform Commission is conducting a consultation into birth registration and birth certificates, under the Births, Deaths and Marriages Registration Act 1996 (Vic).  The consultation paper is available at the Commission's website.  Submissions to this review are requested by 1 November 2012.

Midwives in Private Practice (MiPP) is preparing a response.

The following questions have been put, to guide responses:

Birth notification 

1. What particulars should the Registrar require at birth notification stage from the responsible person? 
2. Are you aware of any problems with, or do you have any suggestions for improvement of, the notification process? 

Birth registration 

1. Are you aware of any requirement of the registration process that may create barriers to people registering births, in particular people from culturally and linguistically diverse (CALD) or Indigenous communities, or vulnerable or disadvantaged people?
2. Can you suggest ways to make the process for birth registration more accessible, efficient and effective? 

Birth certificates 

1. Are you aware of any requirement of the process for obtaining a birth certificate that may create barriers to people registering births, in particular people from CALD or Indigenous communities, or vulnerable or disadvantaged people? 
2. Can you suggest ways to make the process for obtaining a birth certificate more accessible, efficient and effective? 
3. Should legislation provide for the automatic issue of a birth certificate once a birth has been registered? 

Fees for birth certificates

1. Do you think it is appropriate to charge a fee for a birth certificate? If so, does the current fee create a barrier to obtaining a birth certificate for some people?  
2. The Act allows for a fee waiver but this is rarely granted. What criteria should be applied to the grant of a waiver of fees for a birth certificate? 
3. Should a waiver be possible only on a case-by-case basis or should classes of people qualify (for example those in possession of a Health Care Card)? 
4. Should the criteria for the waiver of fees be explicitly stated in legislation or regulations? 
5. Alternatively, should a policy document outlining these criteria be required to be made public by the Victorian Registry of Births, Deaths and Marriages? 

Vulnerable groups 

1. Are vulnerable or disadvantaged people or those from CALD backgrounds or Indigenous communities more likely to encounter problems with registering a birth or applying for a birth certificate? If so why, and how?

Awareness and access 

1. Is it easy to find out what you need to know about registering a birth and obtaining a birth certificate? 
2. Are members of the community in general sufficiently aware of their obligations and rights to register a birth and to be issued with a certificate?
3. If not, what can be done to improve community awareness and what role should the Victorian Registry of Births, Deaths and Marriages have in improving awareness? 
4. Should legislation be amended to include promoting birth registration and the benefits of obtaining a birth certificate, as a specific function of the Registrar? 

Other 

1. Are you aware of legislative or policy developments in other jurisdictions that may be helpful to consider for Victoria? 
2. Is there anything else you would like to share with us on any aspect of birth registration and obtaining a birth certificate?

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.

collaboration

Yesterday the Health Ministers announced the extension of the 'exemption', enabling midwives  (1) to continue our work of attending births without indemnity insurance, until 2015, and (2) to make collaborative arrangements with hospitals and health services.

Go to the APMA blog for the wording of the announcement.

Immediate response from the Australian Medical Association (AMA) called on the Health Ministers to reverse their decision about collaboration, stating that “This decision is transferring sensitive patient care and management from a doctor to a bureaucrat. It must not proceed.”


In response, I have left the following message at the AMA media site:

Dr Hambleton, and AMA
I think it would be good to talk to real midwives who have incorporated Medicare into what we offer women.  We are not dangerous.  We are very conscious of the limitations of natural physiological processes in pregnancy, childbirth, and thereafter - and our own limitations when illness or complications present.
I have been practising independently as a midwife for many years, and I attend women who plan homebirth, as well as women who intend to give birth in hospital. 
The collaborative arrangements that have supported the care I provide for my clients, enabling Medicare rebates on antenatal and postnatal consultations, have been mainly with GPs who have never met me.  This is the sort of letter the doctor receives:
Dear Dr D
W has asked me to provide midwifery services for her, with a plan to give birth at home, and a back-up booking at H Hospital.  W’s calculated due date is XX/XX/XX.  With your referral and collaboration I am able to provide Medicare rebates for W for antenatal and postnatal midwifery services.  I am required to demonstrate a collaborative arrangement with a named medical practitioner, to whom she will be referred if the need arises. 
Under this collaborative arrangement, I am required to send you a Maternity Care Plan (draft attached), results of any tests and investigations, and referrals (obstetric or paediatric).  Also I am required to send a discharge summary to you as the patient’s GP.
In preparing a maternity care plan, I have discussed this with W.  The plan is basically to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise.  We plan to go to the H hospital without delay for urgent obstetric concerns, or W would be referred to you for non-urgent medical indications.
Thankyou for your assistance in this matter.

I ask that you use the resources of the AMA to enhance collaboration between two distinct professions - not to remove the competition.

Joy Johnston

Your comments are welcome.

NEW MIPP BROCHURE

Thanks to Malinda Morieson for preparing and distributing a new version of the MIPP brochure.
For more details click here.

CHOICES

Information Sessions in Melbourne

Winter 2012

@ MAMA

 

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