letters from MIPP

About a month ago we reported on amendments to legislation applying to eligible midwives and Medicare.

The ability of a midwife to attend a woman giving birth in a hospital was a major item in the Medicare reforms, introduced more than three years ago.

Yet ...

• Despite many assurances that the Victorian government supports the federal government's maternity reforms, and has developed a framework for credentialing of midwives, no midwives in Victoria have made collaborative agreements with hospitals.  
• Midwives are able to buy insurance policies through MIGA, underwritten by Treasury, providing uncapped cover for women receiving midwifery services from eligible midwives for birth in hospital - yet they can't get access to the hospitals.
• Women would be able to claim up to approximately $1500 rebate for intrapartum midwifery services (2 midwives) - if the midwives could get access to the hospitals.
• Midwives are continuing to provide professional services for women in their communities, and accompanying them to hospital for birth or other specialist obstetric services if and when the need arises.
• Midwives report that some doctors who have previously agreed to collaborate with midwives have withdrawn, giving reasons such as "I don't think homebirth is a good idea" - when the collaborative arrangement covers only antenatal and postnatal midwifery services.

This is unacceptable.  What other profession would sit back and accept persistent exclusion from their usual places of practice?  Why are women who would prefer to give birth in hospital in the care of their known and trusted midwife being prevented from doing so? 


A new round of letters has been sent by MIPP to the public hospitals, respectfully requesting an update on progress.

A similar letter has been prepared, and is being sent to obstetricians and GPs who have agreed to collaborate with midwives, usually through a letter of referral, or in some instances, through a signed collaborative agreement.

The content of this letter is copied below:

Re:  Collaboration and hospital visiting access for Midwives

Dear Doctor

This letter is to inform you of recent changes in legislation governing the requirement for collaborative arrangements for eligible midwives, such as referral of women to the midwife for antenatal and postnatal midwifery services.  We thank you for your participation in collaborative arrangements to date, which have enabled women to claim Medicare rebate on the fees of midwives who have Medicare provider numbers. 

Since the introduction in April 2010 of amendments to the Health Insurance Act (1973), some midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements.

In recognition of this, at the 10 August 2012 Standing Council on Health (SCoH) meeting, the Commonwealth agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. On July 25^th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 http://www.comlaw.gov.au/Details/F2013L01432 was introduced.

Accordingly, the purpose of the regulation is to enable midwives to demonstrate collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity. The regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed for clinical privileges within a hospital.  It is expected that the hospital will have a formal written agreement with such midwives, addressing consultation, referral and transfer of care, relevant clinical guidelines and locally determined policies.

Letters have been sent to the public maternity hospitals on behalf of MIPPS, requesting an update on the processes that are being implemented, by which the hospitals will provide eligible midwives the opportunity to have collaborative arrangements.  Until these new processes are established, midwives and our clients will continue to rely on the collaborative agreements and arrangements, such as referral, that have been used in the past couple of years.

Yours sincerely,

Your comments are welcome.

Maternity care plan

Midwives who are eligible to participate in Medicare, and offer Medicare rebates for women in their care, have this item in the Medicare schedule:

Item 82115

Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks, if:

(a) the patient is not an admitted patient of a hospital; and

(b) the participating midwife undertakes a comprehensive assessment of the patient; and

(c) the participating midwife develops a written maternity care plan that contains:

(i) outcomes of the assessment; and

(ii) details of agreed expectations for care during pregnancy, labour and delivery; and

(iii) details of any health problems or care needs; and

(iv) details of collaborative arrangements that apply to the patient; and

(v) details of any medication taken by the patient during the pregnancy, and any additional medication that may be required by the patient; and

(vi) details of any referrals or requests for pathology services or diagnostic imaging services for the patient during the pregnancy, and any additional referrals or requests that may be required for the patient; and

(d) the maternity care plan is explained and agreed with the patient; and

(e) the fee does not include any amount for the management of labour and delivery (Includes any antenatal attendance provided on the same occasion) Payable only once for any pregnancy

[Schedule 1 Part 1 of

Health Insurance (Midwife and Nurse Practitioner) Determination 2011]


It's clear from the legislation that a 'maternity care plan' is an important aspect of the antenatal care  provided by a participating midwife.  The professional attendance linked to Item 82115 is to take at least 90 minutes, and the scheduled fee is $319.00.  This compares with other antenatal attendances of at least 40 minutes, with a scheduled fee of $53.40.  Clearly, someone who advised the writer of this piece of legislation considered that the writing of a maternity care plan, and the other tasks (listed above) are very significant.


A midwife who has recently received her endorsement as an eligible midwife wrote to a social media site "I wonder if anyone could share their written maternity care plan format? Just want to know what you include and how to set it out ..."

This is a good question.  What does a maternity care plan look like?


It has occurred to me that the ICM Definition of the Midwife is a clear statement of a midwife's maternity care plan:

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.
...

The insurance company MIGA, in consultation with ACM and APMA, has developed a care plan that some midwives have adopted.  This care plan has a lot of boxes to tick, and much of the information would be collected routinely by midwives in taking a history and discussing care options with each woman.  Those who are using specially designed software would have many of the points of this care plan covered in entering the client information, and would be able to generate a maternity care plan printout when required.


The maternity care plan is to be kept with other professional records for each woman and baby, by the midwife.  The care plan usually does not need to be shared with anyone, unless asked for, for example, in a Medicare audit or an investigation.

There is ongoing discussion and concern about the relationship between midwives and public hospitals, particularly those hospitals that have, to date, refused to discuss any collaborative arrangements with midwives. MIGA states that, in order to meet the legislative requirements, a midwife is required to have:

• A Collaborative Arrangement with a doctor or Hospital, or

• A Care Plan communicated to a public Hospital providing obstetric services

• You should ensure this is acknowledged by the Hospital either in writing or as a record in your notes of an oral acknowledgement

  
  
  We note here that midwives in Melbourne, and many other places, who have attempted to comply with this requirement of acknowledgment (written or oral) by a hospital have had no success.  The hospitals have, to date, not been interested in collaborating with midwives.  Some hospitals have returned care plans to the midwife, and instructed her not to send them.   This problem seems to be ongoing, as was discussed in a previous post on this blog.
  
  XXX
  
  
  The MIGA maternity care plan seems to attempt to cover the 'what if' situations, in which a midwife might be required to defend her or his actions.  That makes sense - that's the job of insurance companies.
  
  But, ...
  
  Midwifery is not, primarily, about defensive practice.  It's about the midwife acting in a way that protects the wellbeing and safety of mother and baby.  It's about being 'with woman', in a special professional relationship.  It's about health promotion: healthy mothers and babies.  Midwives should not be instructed by an insurer, an entity that exists to make a profit for shareholders, as to the care plans they make.
  
  Midwives are encouraged to make a positive statement in each woman's maternity care plan, such as:
  
  "When providing primary maternity care for a well woman, the plan is to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. If illness or complications are suspected, a transfer to the planned hospital would be arranged without delay for urgent obstetric concerns, ..."
  
  
  

amended regulation

Health Insurance Amendment (Midwives) Regulation 2013 - F2013L01432

 

On July 25^th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 was introduced.

The purpose of this regulation is to enable midwives to have collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity.

This new regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed by a hospital, having successfully completed a formal assessment of her or his qualifications, skills, experience and professional standing.  At present processes exist with some public maternity services for midwives to be recognized as shared antenatal care affiliates.  It would seem reasonable to expect that these processes could be extended to meet the requirements for collaborative arrangements during intranatal and postnatal care as well as antenatal. 

Three years ago, in April 2010, the Health Insurance Act (1973) was amended to provide for new arrangements to enhance and expand the role of certain midwives, allowing for a greater role in the provision of quality health services through primary maternity care.  Since the measure was introduced, midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements, and has prevented some women from receiving Medicare rebates.  

Midwives who have achieved endorsement on the AHPRA Register of Midwives as Eligible (for Medicare and Prescribing) have achieved a high standard of clinical practice.  They have gone to considerable financial and personal cost, in complying with the requirements of the Board.  When a midwife is in private practice, with a Medicare provider number and a Prescriber number, that midwife has access to the most advanced model of clinical practise in primary maternity care available to midwives in Australia.

A few midwives participating in Medicare have a collaborative arrangement in the form of a signed agreement with an obstetric medical practitioner: an arrangement that applies to all women in their care.

Most midwives, however, require a separate collaborative arrangement for each woman in their care.  This is the reason many midwives have reported ongoing difficulties in establishing collaborative arrangements. Each collaborative arrangement needs to be requested, and negotiated separately.   

One of the options for collaboration is referral:

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

A general practitioner doctor (GP) who provides obstetric services, such as shared antenatal care, is able to act as a specified medical practitioner who refers a woman to an eligible midwife for midwifery treatment.  

Midwives who have received letters of referral, or other collaborative arrangements, from GPs or obstetricians, recognise that there have been areas of uncertainty and difficulty in establishing meaningful collaboration that meets the legislated requirements and is in the interests of the wellbeing of the mother and her baby.  Some GPs have expressed serious concerns about their liability, should there be an adverse outcome at some time in the future.  No amount of assurance by the midwife that she/he is accountable, and insured (except for homebirth) will satisfy a doctor if their insurer tells them not to take the risk of supporting midwives.

In recognition of the difficulties experienced by midwives in achieving collaborative arrangements, the government agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. This amendment to the regulations potentially takes the pressure off GPs, in that midwives will (theoretically, at least) be more able to establish collaborative agreements with hospitals.  The woman's GP will not be ignored, as there is a continuing requirement for a discharge letter, copies of any test and investigation results, and reports of referrals, to be sent to the GP.

MIPP is engaging in ongoing discussions with public maternity hospitals, in an effort to forge new pathways for credentialing by the hospitals for midwifery care that spans the full episode of care. 

Perhaps this amended regulation will be the impetus for progress in maternity hospitals that have, to date, been resistent to change.  The need for collaborative arrangements to be facilitated through the public maternity hospitals to which we refer women in our care is obvious.  The systems need to be seamless and transparent, protecting the wellbeing and safety of mother and child, as well as offering a reliable and accountable process for members of the midwifery profession, and for the hospital and its employees.




Your comments are appreciated.

Is there any progress toward hospital visiting access for privately practising midwives?

"Yes", and "No."
(don't hold your breath!)

Readers of this blog are probably aware that Australian government reforms that were implemented in November 2010 provided pathways, namely professional indemnity insurance and public funding via Medicare, that support eligible midwives to attend women privately throughout the months of maternity care from early pregnancy to six weeks after the birth.  Medicare funding for labour and birth (Items #82120 and #82125) applies only when the birth takes place in a hospital at which the midwife has been granted visiting access/clinical privileges.

So far, Victorian midwives have been unable to achieve the goal: there is no hospital that grants private access for midwives.   

For some of the background to the hospital credentialing process in Victoria, click here, or use the 'search this blog' function in the right column.

Is there any progress toward hospital visiting access for privately practising midwives?

"Yes."  We have been advised that the Maternity and Newborn Program within the Victorian Health Department is in the process of publishing a guide, which gives a framework for public health services (hospitals) to participate in collaborative arrangements with eligible midwives, including admitting and practice rights.

... and "No."  Before we celebrate, we are reminded that there is a big proviso: the individual health services are self governing, and have 'discretion', meaning that this guidance framework from the Victorian government's health department does not have any authority that would require a health service to open its doors to midwives.


Midwives in Melbourne who have written to, and visited, local public hospitals to express interest in being amongst the front runners in this new venture have received professionally polite but distinctly negative responses.   A considerable number of midwives have resigned from their hospital employment after they received their eligibility for a Medicare Provider Number - which applies to private midwifery practice, not employment.  These midwives have expressed frustration at the lack of support in the profession, and in the community, for what many consider to be the most advanced scope of clinical practice for a midwife.  These midwives are now being 'up-skilled' as homebirth practitioners, because homebirth is the only setting open to midwives to provide continuity of care and to attend births.

Midwives who are interested in applying for visiting access at one or more public hospital(s) that provide maternity services will need to prepare for a new round of letters to hospital management.  As we wait for, and lobby for change, we continue to remember that the midwife is 'with woman'; that the best setting for birth is something that is often explored as a woman progresses in labour, and the midwife's actions are intended to ensure the wellbeing and safety of a mother and her child.

Individual Health Identifier for newborns

The following message has been received by hospitals and midwives who attend homebirths.  For more information about the national e-health system, click here.

Good morning - I am writing to provide you with information about verified Individual Healthcare Identifier (IHI) arrangements for newborns. 

The Department of Human Services (DHS) has made provision for hospitals and midwives to record a newborn’s verified IHI in its Newborn Child Claim for Paid Parental Leave, Family Assistance and Medicare (FA101) form in the July 2013 version of the FA101 form (Reference FA101.1307).  The form is supplied to hospitals and midwives in the DHS Parent Pack. 

Effective from 1 July, the Proof of Birth page of the form (page 16) enables a verified IHI number for a newborn to be recorded.

DHS has advised that until such time hospitals have the software to create a verified IHI for a newborn, the hospital should select “No” to the question on page 16 - Was the newborn child’s Individual Healthcare Identifier (IHI) created by the hospital? 

We would be grateful if you could communicate this information through your channels.  DHS is also communicating this through its channels. 

If you have any questions on this please contact the DHS Healthcare Identifiers Service helpline on 1300 361 457.

Kind regards

Christine Borthwick
Engagement Analyst
nehta National E-Health Transition Authority

t  07 3023 8413

m 0407 872 470

Publicly funded homebirth in Australia

Publicly funded homebirth in Australia: a review of
maternal and neonatal outcomes over 6 years

Authors: Christine Catling-Paull, Rebecca L Coddington, Maralyn J Foureur and Caroline S E Homer, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium

From the Medical Journal of Australia (Med J Aust 2013; 198 (11): 616-620.):

Results: Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%.

Conclusion: This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia.

These results are consistent with the large Dutch study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

The two Victorian publicly funded homebirth programs, at Sunshine and Casey hospitals, were not included in this study, which took data from 2006-2010. 

For more discussion about risk and homebirth, go to villagemidwife blog.

for the record ...

A couple of dodgy situations have arisen in the Melbourne private midwifery world this past week, and I am noting them here, for the record.  People will not be named, but be assured, these stories are not fictional.

Story #1 - Woman W1 and doctor GP:

W1: (39 weeks pregnant, planning homebirth) "My midwife told me to ask you for the paperwork I will need to register the baby's birth, and get the baby bonus."
GP: "I have never been asked for that paperwork.  In fact I don't know where to get it."

For readers who are unfamiliar with the process, this paperwork is issued after birth by the midwife who attends a birth at home, or by the hospital where the baby was born. 

The GP phoned a well known and respected midwife to inquire as to how to obtain the paperwork.  That midwife immediately questioned the request.  If W1 is in the care of a midwife, that midwife should issue the paperwork, and sign the declaration to enable registration with Centrelink, baby bonus or paid parental leave, adding the baby's name to Medicare card, and other standard processes including obtaining a birth certificate.  Simple as that!

In this case W1 is probably planning homebirth without a registered midwife in attendance.  Call it freebirth or pure birth or attended by a birth worker or whatever you like.   A GP would be unwise to issue the birth paperwork, unless she or he was also prepared to attend the birth and sign the professional declaration.

Story #2 - Lay birth attendant LBA phone call to midwife M2:

LBA: "I am looking for a midwife who will visit the woman W2 in her home once labour has started, and do an assessment so that we can be sure she is at least 4 centimeters dilated."
M2: "Why do you want this?"
LBA: "Because W2 had a caesarean birth last time and she does not want to go to hospital until she is in established labour ..."
M2: "Let me get this straight.  You are asking me to visit when you call me, check mother and baby, give you that information, then go away?"
LBA: "Yes."

A midwife is immediately wary of this request for a number of reasons.  Here are a few:

• the professional relationship is between a midwife and a woman; not the woman's friend, or partner, or employee.

• information obtained in an assessment (maternal observations: frequency, strength and duration of contractions; fetal observations including lie, presentation, position, heart rate; and dilatation of the cervix) will not necessarily give the information that W2 or LBA are after.  The skill of midwifery includes interpretation of clinical observations over time.  

• the midwife cannot delegate professional responsibility for midwifery care to an unqualified, unregulated person.

 A midwife would be unwise to attend a woman in labour unless she or he was also prepared to attend the birth and take professional responsibility for decisions made.  An exception would be if another midwife who was unable to attend a client who said she was in early labour, asked the midwife to provide a 'locum' service and report back.

 One of the realities of physiological birth is that the labour must begin spontaneously - in the woman's own time.  Most women make the decision themselves as to when to ask their midwife to attend, or when to go to hospital.  Sometimes they get it wrong - too early, too late!  Sometimes just right. 

This dilemma will not be resolved by having a private midwife provide a one-off consultation.  If people want that sort of information, they could 'do it yourself' DIY.  They could get hold of a fetal monitor and listen to the baby's heartbeat as much as they want to.  They could get hold of a little internal camera that takes pictures of the cervix.  The technology exists.  Also blood pressure monitors, a thermometer, ...  

'DIY' will never replace the midwife, who is 'with woman' in a partnership that requires trust and reciprocity throughout the episode of professional care.