Is this discrimination against midwives? midwife prescriber Juliana Brennan

Is this discrimination against midwives?  Juliana Brennan:

About 3 weeks ago I found out that I was the first midwife in Australia to receive a PBS prescriber number.  I received this notification over the phone and in writing!

As part of becoming a Medicare eligible midwife I had to sign an undertaking to AHPRA that within 18 months of becoming Medicare eligible I would conduct a course of study in Pharmacology to become an endorsed midwife, with a medicare provider number and a PBS prescriber number. 

In 2005 I completed a pharmacology component of the Master’s Degree in Clinical Nursing (Nurse Practitioner) at Monash University, as back then, I thought the only way forward for me was to aim to become a Midwife practitioner (equivalent to Nurse Practitioner).

After I became an eligible midwife, I was invited to apply for equivalence for my pharmacology course to be recognised as a suitable course of study for my Midwifery endorsement.  This process of applying through AHPRA was very tedious (to say the least) but eventually it was decided in my favour by AHPRA that I should become the first midwife in Australia to be able to prescribe medicines based on the Prescribing Formulary put out by the Nursing and Midwifery Board of Australia.

I wrote my first prescription: for Lignocaine 1% in 20mls (a Schedule 4 medicine, listed on the AHPRA midwives formulary and the Victorian midwives formulary), and was told that it is only available at certain pharmacies, especially those attached to a Public Hospital offering Maternity Care.  However, the RWH and Eastern Health pharmacies told me they are not allowed to accept my prescription as I am not employed by the hospital!  So after all my work as outlined above, doing a course that I was required to do by AHPRA, I am not able to submit a prescription for the medicines I am legally allowed to prescribe in a public pharmacy attached to the hospitals!

Thankfully the pharmacist at Knox Private Hospital agreed to accept my prescription and had the medication needed in stock!

Even so, this does not make sense to me that a public pharmacy attached to a hospital would not accept my script, despite me having a PBS prescriber number.  Does this mean that a pharmacy like the RWH can’t accept a prescription from an outside Dr?  No it doesn’t as I have already had a script dispensed for one of my clients that was written by a Dr before I became an endorsed midwife.  The Dr is NOT an employee of the hospital.

So is this discrimination against midwives?

Many midwives have fought tirelessly to gain clinical access to several public maternity hospitals around Melbourne.  I stopped writing letters 6 months ago, as now I don’t even get a response. 

If I had clinical access to a public hospital, then my prescriptions could be accepted the pharmacist at RWH told me.

So my question is “Why does AHPRA insist on Eligible Midwives completing a suitable course of study in pharmacology in order to become endorsed midwives if we have no way of gaining access to hospitals as privately practicing Midwives, and no way of having our prescriptions for medicines dispensed from a pharmacy attached to a public maternity hospital”?

Juliana Brennan

RN, RM, M.Mid

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.

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.

MIPP submission to Senate Inquiry

Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA)

MIPP has made a joint submission with Australian Private Midwives Association (APMA). To access all the submissions received by the committee,
click here

The matters addressed in this submission are in response to our experiences during the recent transition from individual State and Territory-based regulation of the midwifery profession to the national regulation of the midwifery profession under AHPRA.

We draw to the attention of the Inquiry the following matters, which will be discussed in more detail in the body of this submission:
1. AHPRA’s administration of the registration process for Medicare benefits
.1 Midwives are required by AHPRA to provide a reference from hospital midwife manager or obstetrician when applying for notation as eligible for Medicare benefits. This is an unreasonable request for many privately practising midwives.
.2 ‘Prescribing’ course. Midwives who apply to AHPRA for notation as eligible for Medicare benefits are required to sign an undertaking to complete within 18 months of recognition as an eligible midwife, an accredited and approved program of study determined by the Board to develop midwives’ knowledge and skills in prescribing ...” There is at present no such course available for midwives.
.3 Some midwives have experienced unacceptable delays and a lack of fairness in processing applications for notation as eligible midwife.
.4 We draw to the attention of the Inquiry the implications for consumers/ private clients of midwives whose applications have been delayed without good reason.
.5 We assert that there is a strong potential for misunderstanding in the obstetric and hospital midwifery communities as to the meaning of collaboration. Legislation that privileges obstetricians, placing them in a supervisory role for midwives, must be repealed.

2. The administration by AHPRA of complaints against privately practising midwives
.1 A privately practising midwife’s registration had been suspended prior to the changeover to the new legislation. This midwife has been unable to work and earn a living, yet she has not yet been given an opportunity to present her case in person, or to have her suspension lifted.
.2 At least two midwives have recently had conditions (supervised hospital practice) placed on their registrations without any investigation into the complaint. This is as effective as a suspension, with the midwife losing her ability to earn a living while the conditions apply.

3. Professional Indemnity Insurance. AHPRA, through the Nursing and Midwifery Board (NMBA), is currently in the process of drafting requirements for insurance for midwives. We wish to draw this to the attention of the Inquiry, as midwives in private practice are the only professional group unable to purchase indemnity insurance to meet the requirements of the national legislation.

Survey on prescribing courses for midwives

If you are a midwife practising privately in Australia, or if you intend to practise midwifery privately, please go to the APMA blog, read the message, and follow the links to the survey.