Saturday, October 2, 2010

The current state of private midwifery practice

This is a brief summary - more detailed information can be sourced, of course.

Private midwifery practice for planned homebirth
Midwives continue to practise as we have for many years, providing the full scope of pre-, intra- and postnatal services for women who want to give birth at home, working without medical interference, without drugs to stimulate labour or relieve pain, and in harmony with natural physiological processes.

Midwives continue to provide statistical data to the government data collection agencies, as we have done for many years.

Midwives inform our clients that we are not able to purchase professional indemnity insurance for homebirth, and that the government has provided a 2-year exemption from this requirement, until June 2012. We don't know what will happen after that date.

The Nursing and Midwifery Board (NMBA) is preparing a Safety and Quality Framework document which (according to the most recent draft) is:
  • "consistent with the principles underpinning provision of primary maternity care (Attachment 1) and
  • "recognises the full scope of midwifery practice.
  • "recognises that women will make the final choice about their care and birthing choices in most circumstances [MOST circumstances ???]
"It is incumbent upon privately practising midwives (PPMs) to provide balanced and contemporary clinical advice to ensure that informed decisions are able to be made."

The Framework also relies heavily on the ACM National Midwifery Guidelines for Consultation and Referral (2008). A further 'guidance' document on collaboration is being prepared under the auspices of the National Health and Medical Research Council (NHMRC) - we have not seen drafts of that yet.

Private Midwifery practice for planned hospital birth
Many women who intend to give birth in hospital employ a midwife to attend them for birth, and provide continuity of care through the pregnancy to the postnatal period. Although private midwives do not have visiting access arrangements with hospitals, the partnership between the labouring woman and her known and trusted midwife is able to transcend most situations in which a hospital protocol might derail normal birth. The woman and her private midwife make decisions about when to travel to hospital, as the midwife uses her knowledge and skill to protect the natural processes in birth and early parenting.

This aspect of private midwifery practice goes unrecognised in Australian birth reports. The woman who plans homebirth, then transfers her care to hospital can be tracked statistically, but not the woman whose plans include a private midwife for planned hospital birth. The position of the private midwife in hospital has not been mentioned in all the so-called 'reform' that we are engaged in at present.

Private midwifery practice and Medicare-eligible midwives
This is the aspect of private midwifery practice that is set to emerge from 1 November, less than one month away. There are more questions at present than answers.

The Medicare-eligible midwife who I will refer to as the 'MEDI-WIFE' will be a very different person from the ordinary privately practising midwife. The MEDI-WIFE will:
  • have a close working relationship with a group of obstetricians (no doctors work 24/7 these days
  • provide prenatal checks in the community, possibly in 'rooms' shared with obstetricians or other doctors
  • attend births in private hospitals where she has visiting access, and where the 'senior' member of the professional team is always the obstetrician
  • be able to order basic tests and prescribe basic drugs, such as oxytocics
  • provide postnatal services for mothers and babies in hospital, and possibly at home.

The Australian Medical Association has published Collaborative arrangements: what you need to know, in preparation for the birth of the MEDI-WIFE.

A great deal of discussion is taking place in the world of midwifery about the signed collaborative agreements that have been required, under law, for a midwife to be eligible for Medicare &c. Go to the MiPP blog for more information.

Midwives are now being asked to record examples of our efforts to comply with the requirements of the Determination, so that the implementation of the government's maternity 'reform' can be reviewed over time.


  1. I am not sure, but I don't know of midwives in QLD who care for women privately in a private hospital. From my limited knowledge (I am a CNM from the US and have lived here 2 years) all of the private practice in QLD is home birth.

    I'm also not sure what you're getting at with your description of the "medi-wife." The tone is somewhat negative, yet for women in QLD who can only choose midwifery care in a public hospital or at home, it seems to me that what you call a medi-wife would be a much better option for private pregnancy and birth care than an obstetrician or a GP. In my practice in the US, I had all of what you detail (and more, actually, because my scope of practice there included well woman gynae care and was even broader in maternity care than the scope here) and an excellent working relationship with obs who trusted my skills and judgment and left me alone unless I requested a consultation.

    I don't see a problem in acknowledging the role of an obs as consultant for women who require consultant care for whatever reason. Until midwives are able to care for the full range of complex obs problems, we will always need a doctor around. I don't support the determination with its requirement of a signed agreement, and the Government is mistaken not to offer any incentives to doctors to collaborate. However, it seems possible that any obs who actually do step up to collaborate may be more of a mind to trust and respect the midwives they work with and less concerned with being the senior team member.

    Interesting times.

  2. Hello quiltmidwife, and thankyou for this comment in what is a very complex arena.

    I don't know of any midwives in Australia who work privately in a private hospital, but that is the model that has been offered under the government's reform package.

    There is not meant to be any tone applied to the word I have made up, 'medi-wife'. It shortens 'Medicare Midwife'.

    I think the point about collaboration is that a midwife acts within the scope of midwifery practice, which by definition includes referral and cooperation with other care providers when complications are detected. A midwife who would like to "care for the full range of complex obs problems" would no longer be a midwife - she would need to go off and become registered as an obstetrician.

    I wonder if you are practising in Qld?

    PS I also have a passion for making quilts - see blog

  3. Nice "meeting" you, Joy. No, I am not practising in QLD, which accounts (partially anyway) for my imperfect understanding of how it goes here. I decided when we moved here that I was too old & grumpy to cope with the (from my point of view) excessively restrictive scope of practice in QLD, and am instead doing postgraduate studies.

    You got my point exactly though - that as midwives we won't ever care on our own for the full range of complex problems. (Nor, frankly, did I ever want to.) What's sad is that the consultation and referral document was insufficient assurance to the medical lobby that midwives would do the right thing.

    As wonderful and appropriate as home birth can be, there will always be women who want continuity of midwifery care in hospital. What's exciting to me about the Medicare legislation is that - if there are indeed doctors willing to collaborate, and if midwives actually get visiting rights - these women will have the option to access midwifery care and still have the private hospital births that they want. And get some money back from Medicare as well. It seems like a win-win, provided good relationships can develop between midwives and doctors. I recognise there are a lot of "ifs" here. One of the frustrating things is it seems like the Government have made a start but then just left us hanging, as it were, with no support for making collaboration or visiting rights happen.

    I think that midwives may be over-represented among quilters - it seems we like to do things with our hands (although I am a machine stitcher all the way) - I occasionally post a photo of a quilt I'm working on at my blog (


  4. I keep forgetting to post my name: Maryann Long.


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