Friday, March 5, 2010

Maternity reform hijacked

With the passing of the federal government's national health practitioner regulation legislation, and subsequent legislative amendments in states and territories, changes which are claimed will improve maternity care options for women have been made to the regulation of midwives.

Midwives in Australia, and particularly in Victoria, can not at the present time work to their full professional capacity. This package of reform had the opportunity to
• disable anti-competitive restrictions to midwifery,
• leading to improved maternity outcomes for mothers and babies,
• increased choice for consumers and access to midwife led models of care both in the community and in hospitals, and
• better career options for midwives
• with the potential for less attrition from an already stressed workforce.

However, this legislation [Statute Law Amendment (National Health Practitioner Regulation) Bill 2010] and linked bills nationally do nothing to address the current state of affairs for midwives. While other comparable OECD countries (eg UK, Netherlands, Canada, NZ) recognise the midwife's scope of practice as a primary health care professional, with responsibility to work on her/his own authority, midwives in Victoria will continue under this legislation to be unreasonably restricted, effectively fulfilling a role of obstetrician's assistant, doing what the doctor orders.

Whether you look at this so called reform from a consumer choice angle, or from a competition policy - Trade Practices Act (ref Hilmer report) perspective, or from a professional's right to practise in that profession without interference from another profession, this package is a prime example of socialist health policy being selectively applied to a section of the community, at the direction of the medical profession which has a clear interest in keeping midwifery in the status quo and preventing increased competition. This, and other health related reforms are examples of the federal Labor government's extreme style of bungling bureaucratic micromanagement, as is now progressing with reforms to the management of public hospitals. The roof insulation debacle, led to tragedy and loss, and yes, we believe this reform could also result in avoidable deaths and loss

Until as recently as 1995, midwives in Victoria practised under an archaic set of rules, the Midwives Regulations 1985. These regulations included the requirement that midwives
• must wear clean clothes of a washable material
• must act under the supervision of a doctor
• must not perform a vaginal examination without a doctor's permission.
[Whose vagina? one might ask.]

The midwife of that set of regulations more resembled the gin-sodden crone who Charles Dickens called Sairey Gamp, than the well educated professional midwife who was practising in Victoria in the 1990s, and who may still be attending births today.

The Midwives Regulations 1985 sunsetted in 1995, and were not renewed. Under the new Nurses Act 1993 there was no Register of midwives: midwife became an 'additional qualification' noted on the nurses register. The apparent 'trade off' for midwives was the expectation of professional self-regulation.

With the expectation that the Midwives Regulations would sunset, the new Nurses Board of Victoria called together stakeholders with an interest in midwifery, and in 1996, published a Code of Practice for Midwives in Victoria. This Code of Practice was based on the International Confederation of Midwives' Definition of the Midwife, which had been endorsed by the international Obstetrics and Gynaecologists' professional organisation (FIGO), and World Health Organisation.

The Code of Practice promoted the principles of woman-centred care, partnership between the midwife and the woman, competence of the midwife, and collaboration between the midwife and other providers of maternity services. These principles were, and are still today, in harmony with best practice standards in midwifery. The Code of Practice was acclaimed as world class, and ushered in significant changes in mainstream midwifery practice in this State.

At the same time, other countries such as New Zealand and Canada had introduced legislation which significantly reformed midwifery and the maternity care terrain. Midwives in New Zealand were able to be the LMC, the leading maternity carer, or primary maternity care provider, for women throughout the pregnancy-birth episode of care. Women were able to choose their own LMC.

Midwives gained the entitlement to equal pay with doctors when providing equal services in maternity care, visiting rights to practise in hospitals, and other reforms such as prescribing and ordering tests. Midwives in Australia do not have these rights, and the federal government's reforms around Medicare and prescribing for midwives are a dog's breakfast of uninformed bureaucracy, which is likely to make eligibility beyond the reach or interest of most skilled midwives.

For more comment on this topic, go to
Part 2 Consumer choice, and Competition Considerations
Part 3 Professional Indemnity Insurance, and Collaborative Arrangements

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