Thursday, September 10, 2009

What will Medicare rebates mean?

A guest editorial 'Medicare rebates for midwives: An analysis of the 2009/2010 Federal Budget' appears in the September issue of the Journal of the Australian College of Midwives (ACM) (Women and Birth 2009, Volume 22 Issue 3). The authors are Liz Wilkes, Bruce Teakle, and Jenny Gamble - Queenslanders who are well known in maternity and midwifery activism. Liz is a privately practising midwife; Bruce is a homebirth dad and birth activist; and Jenny is a midwife academic.

This editorial explores some of the initial concerns that many midwives have expressed, both publicly and privately, about the wisdom and application of the government's 'reform' plans. The legislation sets conditions for midwife eligibility, including that the midwife be "appropriately qualified and experienced"; "working in collaboration with doctors"; under an "advanced midwifery credentialing framework".

The authors rightly note that the normal "full scope" of midwifery practice - which, incidentally, everyone who graduates with a midwifery qualification is supposed to be competent in - has been redefined as "advanced practice". They note that no other profession is required to be "working in collaboration" with another professional group as a separate requirement to their professional codes and competencies. And what does 'collaboration' mean? Watch this space - the definition has not been written yet. Likewise the meaning of "appropriately qualified and experienced", or the "advanced midwifery credentialing framework".



While initially midwives expressed delight at the bravery of the Health Minister to open a pathway for publicly funded private midwifery practice, the draft legislation does not look good on closer scrutiny. It lacks attention to detail, and lacks understanding of the foundations of midwifery. In a bumbling effort to prevent "polarising the professions", the legislation has managed to discard all private midwifery practice as it currently exists, considering it 'controversial'.

I consider the best option at present would be to send it all back to the drawing board.

I have been involved in the call for reform of maternity services since the mid-1990s. 'Medicare for Midwives' has been a catchy slogan that many have taken up eagerly.

I have not supported 'Medicare for Midwives'. My argument has been that the Medicare system as we know it is NOT a suitable funding system for primary maternity care. Medicare fragments care into 'items' - fragments a woman into prenatal, intrapartum, and postnatal care, as most Australian women today experience. Medicare causes buck-passing between federal and state health departments. The federal health funding covers prenatal care through Medicare rebates to doctors, and the Medicare Safety Net. State and Territory health funding covers acute care for birth and the early postnatal days. This is the domain of the hospitals. The recipient of materntiy care is pushed from pillar to post - "that's not my problem, it's theirs'"!

Holistic primary maternity care by comparison is woman-centred, meaning that the pregnant woman/mother-baby dyad are central throughout the continuum of care. Midwives providing woman-centred care work with caseloads, or at the very least in small group practices. Notions of partnership between a woman and her known midwife, promotion of normal birth, and preventative measures - all of which are fundamental elements in the international definition of the midwife (ICM 2005), are nigh impossible in fragmented models of MEDI-care.

My objections to Medicare for basic maternity have not been allayed in any way since the draft legislation has been available. It is nonsensical to imagine that midwives will be able to set up private practices that are modeled on medical practice. Noone has even attempted to describe how a midwife will practice within this Medicare-funded fragmented scheme.


Reform, like any structure, cannot work without reliable foundations. The structural framework required for reform of midwifery is to agree firstly on the principles that define midwifery. This is not a matter for a committee of interest groups, dominated by medicine, under the direction of the Health Minister. Midwifery has been defined, and the definition has been refined and updated regularly by the International Confederation of Midwives.

I do not want to see the group of reform bills pass in their current form. They fail at the very foundational level. Australian women deserve a funded maternity system that works for them and their babies.

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