midwife prescriber

Midwives across this country are extending our practices as those who are classified as 'eligible' complete the requirements for endorsement to prescribe scheduled medicines.  For the details of notation and endorsement, go to the NMBA website.   The most recent statistics (June 2013) provided by NMBA tell us that 22 midwives had endorsement to prescribe medicines, of the 212 midwives who have the 'eligible' notation on their registration.

To access the NMBA Prescribing Formulary for Eligible Midwives with a Scheduled Medicines Endorsement, as a .pdf document, search formulary+midwives at that site (the hyperlink I tried was incomplete).  This document lists the medicines, route of administration, duration of use, and indications for use, and states that:

A scheduled medicines’ endorsement identifies those midwives who are considered by the Board to be qualified to:
• administer, obtain, possess, prescribe or supply specified schedule 2, 3, 4 and 8 medicines to the
extent authorised under the relevant legislation that applies in the State or Territory in which they practise;
• use those medicines appropriately for the management of women and infants during the
pregnancy, birth and post natal periods; and
• apply to Medicare Australia for a Pharmaceutical Benefits Schedule prescriber number.
The Board has approved the lists of schedule 4, schedule 8 and intravenous medicines (below) for prescribing by eligible midwives with a scheduled medicines endorsement. These lists are to be read in conjunction with the Board’s Guidelines and Assessment Framework for Registration Standard for Eligible Midwives and the Registration Standard for Endorsement for Scheduled Medicines for Eligible Midwives (July 2010).

Another fount of useful information about Medicare and Prescribing is the Medicare site for Nurse Practitioners and Midwives.

Making the transition from being an 'ordinary' midwife (with all the social and professional restrictions that we have become used to) to the new class of eligible midwife who has a Medicare number, a Prescriber Number, and a personalised script pad may at times call for support and discussion between peers.  With this in mind, a new group has been formed using a social media site.   It's a closed group, and those who send a request to join are asked to introduce themselves to the group.

Midwife Prescriber - Australia

This group is for discussion about prescribing issues, for eligible midwives who have the prescriber endorsement, and those who are working toward it.
There may be clinical questions, for which members are able to share insight and experience.
Members may have questions about processes.
Files and links to the medications lists in the various states and territories can be shared and stored at this site.

This new group grew to 50+ members in its first 24 hours of existence.  One member who joined by invitation is a supportive obstetrician.

A midwife who has worked independently for many years may be unsure of which antibiotic would be best for a postnatal uterine or wound infection.  In previous years that midwife would have referred a woman with suspected infection to a hospital or doctor for diagnosis and prescription.  Now that midwife can arrange to have a high vaginal swab taken for culture and sensitivity, and prescribe a suitable antibiotic treatment.

The Schedule 4 medicines listed on the NMBA formulary, and on the Pharmaceutical Benefits Scheme (PBS) Midwife Items, as being suitable for postnatal infection, include Amoxycillin, Amoxicillin with clavunic acid, Cephalosporin, Dicloxacillin, and Lincomycin, with several others that are not PBS items.

The complexities of knowing which drug is best, which dose is appropriate in the situation, how often it should be taken, and for how many days - this is the sort of knowledge that a midwife needs to have in order to act professionally in this situation.  Eligible midwives are required to have collaborative arrangements for each woman, and it is anticipated that a phone call will be made to the collaborating doctor or hospital, or a friendly supportive obstetrician, if the midwife is in any way uncertain of the best course of action.



ps. Note that some States have formularies that have been gazetted by that jurisdiction, while others have adopted the NMBA formulary.

Click here for a FAQ document from the Victorian Health Department.

Your comments are welcome.

MATERNITY SERVICES FOR TEMPORARY WORKERS IN AUSTRALIA

Public hospitals in Melbourne, and in other parts of this country, have closed their doors to women who do not have Medicare.  Women who present needing care at a public hospital are being told they must pay an $11,000 deposit, or leave without being attended to.  They are told to go to a private obstetrician, and make a booking at a private hospital, with an estimated $15,000+ cost to the woman.

The more affordable alternative is private midwifery services for planned homebirth, costing around $5,000.  However, an estimated 20% of women who are planning homebirth need to be transferred to hospital when their care needs exceed the capacity of midwives in the home.  These women arrive, with their midwife, at a public hospital, because they have no other option.  The midwife's duty of care to the woman and her baby is to refer to an appropriate service; regardless of the cost. 

Women who are in Australia on temporary work visas, such as 457, must have private health insurance.  However, it seems that the available insurance policies are woefully inadequate when maternity services are needed.  Women who have spoken to independent midwives, seeking to arrange their intrapartum and immediate postnatal care, have said that they simply can't afford the hospital fees.

This situation is unacceptable!

The time of childbirth, more than any other time of life, requires skill from the care providers, leading to security for the mother.  Although 'birth is not an illness' (WHO Fortelesa Declaration 1985), illness can quickly arise in pregnancy and birth, threatening the lives of the mother and her child.   

The data that midwives send to the Victorian Government Perinatal Data Collection Unit, and similar units in other States and Territories, and sent on to the Australian Institute for Health and Welfare, Mothers and Babies reports, does not give a field to identify the woman who are ineligible to use the national free public hospital services.  The outcomes will never be reported - they are likely to remain under the radar.


Is there a solution?

I would suggest at the very least that public hospitals need a process by which overseas workers, many of whom are from the poorest countries of the world, are able to access affordable maternity and neonatal care.  Yes, midwives can provide basic primary care in the community, at an affordable rate.  But, when a woman needs specialist obstetric referral, surely a 'no frills' option can be provided by the public hospitals, at considerably less cost than what is on offer from Melbourne's plush private hospitals.

Your comments are appreciated.

Medicare review

The federal government health department has engaged consultants to review the incorporation of Medicare into midwifery practices.  Yesterday the MAMA practice was visited, and focus groups and interviews carried out with midwives and mothers.

I don't know if or when the public (you and I) will see any such reports, but this sort of review is expected a couple of years after major policy and funding changes by our government.

A midwife/maternal and child health nurse asked the reviewers to note that the maternity reform initiative, subsequent to the Maternity Services Review, is notable in its lack of public education or advertising.  The government's response to the Review was a  "$120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives. This Budget package provides Australian women with more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services."



More "choice in maternity care" is not accessible if women don't know about it.  Medicare rebate for midwife-attended births means nothing if midwives can't have visiting access to hospitals.  Yet the rationale for the reforms is more safety and better outcomes for mothers and babies: achieved through continuity of midwifery care.


Any other government health initiative, such as immunisation, or safe sleeping, or smoking cessation or ... is presented to the target audience public with the aid of professionally prepared TV and radio advertising, brochures, posters, and the like.

Midwife primary care with Medicare rebates is the best kept secret in the country. 

Why aren't there posters about continuity of care from a known midwife in places where women of childbearing age will see them? Why haven't we seen letters sent to doctors explaining how they can collaborate with midwives? Why are hospitals working harder than ever to actively prevent midwives from achieving visiting access? 

Your comments are, of course, welcome.

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.

MAMA featured in newspaper article

From The Age, 18 January 2013

WOMEN are flocking to private midwives to gain access to cheaper services under Medicare, and the demand has led to Victoria's first midwife clinic.
Two years ago, federal changes allowed eligible private midwives to offer Medicare rebates for some pregnancy services.
To December, national Medicare figures show that 152 eligible private midwives had provided 30,264 services to pregnant, birthing, and postnatal women. ...

Read more: http://www.theage.com.au/victoria/growing-demand-spawns-victorias-first-midwife-clinic-20130117-2cw9p.html#ixzz2IUrv69uP

Source: The Age

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.

letter to doctors

A letter is being distributed to doctors in Victoria who have agreed to participate in collaborative arrangements with midwives.

Re: INFORMATION FOR OBSTETRICIANS AND GPs

Dear Doctor

This letter is being sent to doctors who have worked with midwives in providing access to Medicare rebates for antenatal and postnatal private midwifery services.  We understand that this new option, which has been available since November 2010, has brought about changes in the way midwives and doctors collaborate in maternity care. 

Collaboration

Midwives who have achieved notation on the Nursing and Midwifery Board of Australia (NMBA) Midwives’ Register as ‘eligible’ are able to apply for Medicare provider numbers.  Certain antenatal and postnatal items attract rebate; the proviso being that there is a collaboration arrangement with a doctor for that particular woman.  The requirement for collaborative arrangements between participating midwives and medical practitioners is to provide pathways for consultation, referral or transfer if or when the woman’s care requires it.  Midwives in Victoria are not, at present, able to provide intrapartum care that attracts Medicare rebate for our clients in hospitals.

Midwife prescribers

Midwives are also able to undertake a course in pharmacology which leads to endorsement on the public register. Once endorsed, the midwife may apply for a Pharmaceuticals Benefits Scheme (PBS) number and prescribe certain medications for mothers and babies.  The changes to Victoria’s drugs and poisons legislation which enables endorsed midwives to become prescribers was gazetted 30 November 2012 http://www.gazette.vic.gov.au/gazette/Gazettes2012/GG2012S410.pdf#page=1 .  This document contains the list of medicines from the poisons schedules 2,3, 4 and 8, which midwives are now able to prescribe.

A participating midwife can order some pathology tests and investigations, and can refer women and babies directly to obstetricians and paediatricians.  The midwife is required to send a copy of the results to the collaborating doctor.

Home birth services provided privately by a midwife do not attract Medicare rebates, even if the midwife is participating in the Medicare scheme. Homebirth services may be claimable through certain private health funds.  Hospital backup arrangements for women planning homebirth are made with the nearest suitable public maternity hospital, and may involve a booking in process.  Arrangements for referral and transfer of care to hospital in acute situations are made by the midwife in attendance.

Midwives and insurance

All midwives are required to have professional indemnity insurance. Privately practising midwives purchase insurance that covers them for antenatal and postnatal services. Midwives with Medicare eligibility have access to a Commonwealth-subsidised professional indemnity insurance (http://www.miga.com.au/content.aspx?p=160 ) for the ante and postnatal care they provide, as well as the birth services that they provide in hospitals to their private clients.

If you have any further questions about midwives and Medicare; what services they may provide, or how to work with a midwife who has Medicare, you could contact the Australian College of Midwives.

The midwives whose names and practices are listed below are Victorian midwives who are Medicare-eligible, or who are in the process of obtaining notation for Medicare.  We look forward to continuing professional cooperation between midwives and medical practitioners, in providing effective and safe maternity services for mothers and babies in our communities.

We also take this opportunity to extend to you Season’s Greetings.

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.