Saturday, June 2, 2012

Medical dominance in maternity care

A culture of medical dominance in maternity care today is so deeply ingrained that few people are aware of it.

For decades, until ‘sunsetted’ as recently as 1995, Victorian Midwives Regulations required supervision of midwives by doctors. A midwife was required, for example, to have a doctor’s permission to carry out a vaginal examination of a woman. There was no mention of informed consent from the woman.

This culture came into direct conflict with professional developments in midwifery, organised and promoted globally through the International Confederation of Midwives (ICM), and clearly articulated in the ICM Definition of the Midwife, which is a foundational document in all Australian midwifery education and codes of practice.

At the same time, in response to the tragic outcomes linked to loss of breastfeeding in developing countries, UNICEF and World Health Organisation (WHO) introduced the global Baby Friendly Hospital Initiative. Protecting women’s and babies’ physiological processes in breastfeeding is an extension of such protection in birth, and is an ongoing challenge to the midwifery profession.

The federal government’s Maternity Services Review (2008), its Report and the 2009/10 Budget Package: “Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives”, ignored or conveniently side-stepped homebirth, the main practice area of privately practising midwives. While promoting choice for women through access to privately practising midwives, preference was given to ‘collaborative’ models, under obstetric control, which often exclude midwife led primary maternity care options. The carrot of more choice (for women) came with the stick of what was called collaboration (for midwives) as defined in the law, which could be more realistically interpreted as supervision.

In providing ‘more choice in maternity care’, the reform package actually gave veto power to a doctor, over the midwife’s ability to provide Medicare rebate to a woman in her care. The National Health (Collaborative arrangements for midwives) Determination 2010 requires very specific signed collaborative arrangements to cover all aspects of a midwife’s practice. There is no requirement or onus on doctors to sign a collaborative arrangement, and in many instances women have experienced frustrating refusals by doctors, who refuse to ‘collaborate’ with a midwife in the legislated way. More choice? No!

Midwives in most States have experienced outright refusal when we have requested processes to achieve clinical privileges in public hospitals, despite government-guaranteed and heavily subsidised indemnity insurance for midwives. Midwives are welcome, as long as, and only if, they are employees. There is no process for private midwifery practice.

I have pondered the changes I would experience in my professional life, if I were able to have clinical privileges in a hospital. Here are some initial thoughts.
My current caseload is around 20 births per year; most being planned homebirths. Some months I have 4 or 5 bookings; some months none. If the work was more reliable, I would like to have a more consistent caseload for myself, and even work in a group practice with two or more other midwives. With hospital visiting access I would soon be able to increase to a full time caseload - in round figures, to book two planned hospital births each month in the local maternity hospital (Box Hill, which is about 15 minutes' drive from my home), and continue to book two women each month for homebirth.

I would be able to plan to have no bookings for at least one month each year, and would have another midwife cover my practice as a locum for that month.  It all sounds good.

At this point in time I do not know if I will apply for clinical privileging at a public hospital, even if that were available. I will need to weigh up the 'cost' against 'benefit'. It would be difficult to make such a major transition without the expectation of a reasonable caseload, and a supportive environment in which to work. Learning the systems and processes within a hospital will require a lot of commitment and support. I might need to leave that ground-breaking work to midwives who have recent experience in hospitals.

I am putting my thoughts on the record here, because I would really love to see the change in mainstream public maternity care that will not only accept midwives working privately with women, but embrace and support the change.  Only when this is happening will we start to see an easing of crippling medical dominance in maternity care, and at the same time see unbiased collaboration between midwives and doctors within hospitals.

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