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.

Looking forward

From time to time I have taken the opportunity on this blog to write about the complex and often challenging position I and other midwives have found ourselves in as we work through and apply government 'reforms' and changes to our practices.

Now, at the end of the first week of January 2012, I want to summarise my position as a midwife, attending individual women for birth and associated prenatal and postnatal care, and what developments I expect and hope for in the coming year.

Firstly, on the positive side of the ledger:

• Babies are being born, and thriving - beautifully.
• Women are being transformed in the process of giving birth.  That's a wonderful thing to witness.
• Collaborative arrangements are being set up with a couple of supportive GP-obstetricians, who are happy to give women referrals for the midwifery services they choose.
• Collaborative arrangements are being set up occasionally with obstetricians, after the woman and baby have been discharged from hospital, enabling one-to-one postnatal care for the woman.
• Medicare rebates are being paid to women who use the services of participating midwives.
• I am happy to bulk bill additional antenatal and postnatal visits, which continue until the baby is 6-7 weeks old.

On the negative side of the ledger:

• Some public hospitals at which women make homebirth back-up bookings are refusing to acknowledge the collaboration in the way that has been spelt out in the legislative determination, in that there is, for example, no provision for a 'specified medical practitioner', who is "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.", or any acknowledgment "when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy" ...   
• Midwives eligible for Medicare are required to sign an undertaking to complete a course in pharmacology within 18 months, yet there is no such course accredited.  
• No midwives have access arrangements to privately attend women admitted in hospitals.  This means that women who choose to give birth in hospital, with their private midwife in attendance, must accept the hospital's employed midwife as the leading midwife at the time of the birth.  This situation can lead to unnecessary conflict.
• There is no insurance product to indemnify midwives attending women privately for home birth.  The government has exempted midwives from the requirement until 2013, and we don't know what (if?) plans are afoot to rectify the situation.

Logically, indemnity insurance does not change outcomes - it simply provides a pot of money that can be fought over in the law courts, should there be an adverse outcome.   I consider the only solution to the insurance problem is to set up a no-fault compensation scheme, to which all health professionals contribute, which provides a suitable level of financial support to those who suffer disability or loss, separate completely from the apportioning of blame.

Midwives who face regulatory or coroner's inquiries into incidents in which they were involved are being advised to obtain legal representation.  While ideally a professional should be investigated by peers, it seems that the process of investigation into conduct is becoming increasingly formalised, with inherent costs and isolation of the practitioners.

I have recently accepted a role as Vice President in Australian Private Midwives Association (APMA), which represents private midwives nationally.  I have been a member of this organisation, and have written and edited the APMA blog for the past couple of years.  It is a privilege for me to work alongside the President Marie Heath and the other committee members.  Keep an eye on that blog if you are interested in the national private midwifery scene.

I continue my involvement in Midwives in Private Practice (MIPP), which represents midwives practising privately mainly in Victoria.  See the MIPP blog.  MIPP is a participating organisation in Maternity Coalition (MC).  The concept of partnership between the woman and the midwife is carried through into the relationship between MC and MIPP. 

There are plenty of challenges to keep me busy in the midwifery profession broadly, as long as I have the (physical, mental, spiritual) strength to continue my practice.  I enjoy consulting with women and attending them professionally in their homes, mentoring  other midwives, giving lectures to midwifery students at Deakin University School of Nursing and Midwifery, and my involvement in the Professional Development Unit at Deakin.

Family and home responsibilities keep me busy, and my beautiful grand-children remind me of the every-changing needs of our most precious resource.

Thankyou for your comments