Over past months I have been recording events and my comments as we progress through uncharted waters of what is supposed to be maternity reform. There have been confusing and sometimes distressing messages, from a privately practising midwife's point of view. I can only imagine how women who value private midwifery service are feeling about it all. A blog is a good repository of information, and from time to time I scroll down through this and other blogs to be reminded and to get my facts straight.
Yesterday I attended a Stakeholders Forum in Canberra, auspiced by (and funded by) the National Health & Medical Research Council on Developing National Guidance on Collaborative Maternity Care. I attended as a representative of Midwives in Private Practice, and plan to write a report on the MiPP blog. It was a big day; I was up before 5 to get to the airport at 6.30.
In summary, the big issues at the moment are a midwife's insurance and our right to practice.
Insurance
We know that every midwife in Australia will be required by law to be insured in order to practise after 1 July next year.
We know that an exemption on this requirement will apply for 2 years to homebirth. The exemption is limited to the birth only.
We have been told, but are yet to see documentation, that an affordable insurance product will be available for midwives to purchase before 1 July, to cover their private midwifery practices (excluding birth).
Right to practice
This indicates that all midwives will be able to continue their private practices lawfully, as long as they have an indemnity insurance.
Rosemary Bryant, who is the health minister's Chief Nurse, confirmed this verbally to me yesterday. This reassurance is somewhat 'reassuring', but I will wait until I have seen the fine print. On face value it appears that midwives will be able to continue practising privately next year, IF ...!
My confidence has been jaded this year by the repeated episodes of this government adding new rules, new hoops to jump through - the most recent being the 'collaboration' amendment to the midwifery legislation. The amendment adds the condition that a midwife must have a "collaborative arrangement". The Health Minister told the parliament "These bills will mean that eligible midwives working in collaborative arrangements with obstetricians or GP obstetricians will be able to access the new government supported professional indemnity scheme."
What we don’t know yet is what this collaborative arrangement will look like. Doctors are not required to have collaborative arrangements with midwives. That sets up the likelihood that some midwives may not be able to practise because they are unable to get a doctor to give them the gold star of approval.
Noone has defined collaboration as it appears in this law.
Noone knows if the doctor’s insurer will support that doctor’s arrangement with midwives; if any legal action against the midwife will imply liability on the doctor’s part.
The point that the Minister, and her advisers, have not acknowledged is that midwives constantly collaborate with doctors, nurses, and other health professionals. It's written into our definition.
Witch hunts and midwives are sadly intertwined in our history. A writer to a midwives email list has proposed that the current attempt at micromanagement of all midwives who attend homebirths is another attempt to control and suppress women. By attempting to remove all midwives who are prepared to focus their attention on women, the system is tidying up that small but embarrassingly indominatable group (reminiscent of a certain fictional Gaulish village).
Midwives who are willing to be independent in their thought and reflective in their learning are also willing to stand their ground because they know that what they have to offer their community must not be relinquished.
Friday, December 11, 2009
Thursday, November 26, 2009
COLLABORATION IN MATERNITY CARE
Collaboration, according to Wikipedia, is
"a recursive process where two or more people or organizations work together in an intersection of common goals — for example, an intellectual endeavor[1] [2] that is creative in nature[3]—by sharing knowledge, learning and building consensus. Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group.[4]..."
Anyone applying this description to the fact of collaboration between a midwife and other professionals in maternity care would be likely to have no difficulty. There is self-evident logic in collaboration.
From the woman's perspective, there is an expectation that any professional care will be effective, safe, and centred on the needs of the woman and her baby. Obviously a woman expects the various professionals to work together. BUT the unique and often forgotten reality in maternity care is that BIRTH IS NOT AN ILLNESS. Only the women who experience illness or medical/obstetric complications come within the scope of requiring medical attention. The women who are well throughout pregnancy and birth, and who intend to give birth spontaneouly without medical stimulants or pain relieving agents will only need to be referred for medical attention if something happens to change this plan.
A midwife who provides primary maternity care for a woman in the childbearing continuum, pregnancy-labour-birth-post birth, is able to consult with and refer to specialist care providers and services if and when needed. This is no different from a dentist who refers you to an oral surgeon if you need surgery in your mouth that is outside the scope of the dentist's scope of practice.
"Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group."
This statement is worth considering when applied to Collaboration in maternity care. The professional leadership in any maternity care collaboration is the primary carer; ideally the known midwife who attends the woman throughout the episode of care. The midwife who has a limited number of women to whom she is committed (referred to as a 'caseload'), and who intentionally establishes a partnership with each woman in her care. New Zealand has defined the 'Lead maternity carer' (LMC), who is identified for each woman receiving maternity care, and can be either a midwife or a doctor.
That's woman-centred care. The woman/baby dyad is positioned at the centre of all decision making. All care is tailored to meet the specific needs of the individual woman and her child.
Unfortunately the woman is not the centre of care in the statements of RANZCOG, the powerful professional body which represents obstetricians in Australia and New Zealand. RANZCOG agrees with Wikipedia that "collaboration requires leadership" but it denies the midwife any role as primary, or 'lead' carer. The RANZCOG form of leadership is heirachical, and not "social within a decentralized and egalitarian group."
The RANZCOG statements make it clear that the obstetrician is the ‘designated clinical leader’ in all collaborations. This is from RANZCOG Guideline:
Suitability Criteria for Models of Care and Indications for Referral within & between Models of Care (2009) …
<2.1. All Models of Care are Collaborative
Clear decision making processes are required within the collaborating team, recognising both the knowledge, skills and experience brought by each team member and the imperative of a designated clinical leader.>
The new legislation that is currently passing through Federal and State parliaments will require midwives to have a written collaborative arrangement in place for all midwifery practice, signed off by a Medical Practitioner and a midwife. It is unclear whether the collaboration would be able to occur with a public hospital, as is currently the case for many women and their midwives. It is likely that the hospital's insurers would deny this option.
Doctors are not required to have collaborative arrangements with midwives. Can you imagine a doctor providing intrapartum and postnatal care for his or her 'women' if there were not a band of helpful midwives in attendance? That would be quite unAustralian.
I will leave it at this point. I am preparing for a Stakeholder forum in Canberra, organised by NHMRC, on Developing National Guidance on Collaborative Maternity Care.
"a recursive process where two or more people or organizations work together in an intersection of common goals — for example, an intellectual endeavor[1] [2] that is creative in nature[3]—by sharing knowledge, learning and building consensus. Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group.[4]..."
Anyone applying this description to the fact of collaboration between a midwife and other professionals in maternity care would be likely to have no difficulty. There is self-evident logic in collaboration.
From the woman's perspective, there is an expectation that any professional care will be effective, safe, and centred on the needs of the woman and her baby. Obviously a woman expects the various professionals to work together. BUT the unique and often forgotten reality in maternity care is that BIRTH IS NOT AN ILLNESS. Only the women who experience illness or medical/obstetric complications come within the scope of requiring medical attention. The women who are well throughout pregnancy and birth, and who intend to give birth spontaneouly without medical stimulants or pain relieving agents will only need to be referred for medical attention if something happens to change this plan.
A midwife who provides primary maternity care for a woman in the childbearing continuum, pregnancy-labour-birth-post birth, is able to consult with and refer to specialist care providers and services if and when needed. This is no different from a dentist who refers you to an oral surgeon if you need surgery in your mouth that is outside the scope of the dentist's scope of practice.
"Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group."
This statement is worth considering when applied to Collaboration in maternity care. The professional leadership in any maternity care collaboration is the primary carer; ideally the known midwife who attends the woman throughout the episode of care. The midwife who has a limited number of women to whom she is committed (referred to as a 'caseload'), and who intentionally establishes a partnership with each woman in her care. New Zealand has defined the 'Lead maternity carer' (LMC), who is identified for each woman receiving maternity care, and can be either a midwife or a doctor.
That's woman-centred care. The woman/baby dyad is positioned at the centre of all decision making. All care is tailored to meet the specific needs of the individual woman and her child.
Unfortunately the woman is not the centre of care in the statements of RANZCOG, the powerful professional body which represents obstetricians in Australia and New Zealand. RANZCOG agrees with Wikipedia that "collaboration requires leadership" but it denies the midwife any role as primary, or 'lead' carer. The RANZCOG form of leadership is heirachical, and not "social within a decentralized and egalitarian group."
The RANZCOG statements make it clear that the obstetrician is the ‘designated clinical leader’ in all collaborations. This is from RANZCOG Guideline:
Suitability Criteria for Models of Care and Indications for Referral within & between Models of Care (2009) …
<2.1. All Models of Care are Collaborative
Clear decision making processes are required within the collaborating team, recognising both the knowledge, skills and experience brought by each team member and the imperative of a designated clinical leader.>
The new legislation that is currently passing through Federal and State parliaments will require midwives to have a written collaborative arrangement in place for all midwifery practice, signed off by a Medical Practitioner and a midwife. It is unclear whether the collaboration would be able to occur with a public hospital, as is currently the case for many women and their midwives. It is likely that the hospital's insurers would deny this option.
Doctors are not required to have collaborative arrangements with midwives. Can you imagine a doctor providing intrapartum and postnatal care for his or her 'women' if there were not a band of helpful midwives in attendance? That would be quite unAustralian.
I will leave it at this point. I am preparing for a Stakeholder forum in Canberra, organised by NHMRC, on Developing National Guidance on Collaborative Maternity Care.
Wednesday, November 25, 2009
Medical dominance in birth
Society and cultural beliefs may not always agree with or understand the ‘promotion of normal birth’ which is, by definition, the duty of every midwife (ICM 2005). Many midwives who may have only practised under medical supervision, may not understand or have any skill in the promotion of normal birth. Regardless of the fashion of the day, and a midwife who does not possess skill in promoting normal birth should be challenged and supported in achieving competence, in the same way as a midwife is required to have competence in newborn resuscitation or any other basic midwifery skill.
In a discussion on ‘Birth Territory: a theory for midwifery practice’ (Fahy and Parratt 2006) the authors postulate that “when midwives create and maintain ideal environmental conditions maximum support is provided to the woman and fetus in labour and birth which results in an increased likelihood that the woman will give birth under her own power, be more satisfied with the experience and adapt with ease in the post-birth period.” (p49)
Are midwives really able to create and maintain ideal environmental conditions for good births? If so, should midwives accept responsiblity, at least in part, for the inability of women in our society to give birth in a spontaneous, physiological way, and to make the adjustments to mothering successfully?
It is not fashionable for midwives to take responsibility for the high caesarean rate in Australia. After all, that's the doctors' domain. Yet surely the national caesarean rate of approximately 30% (and growing) points as much to poor midwifery as it does to interventionist, knife-happy obstetrics.
Midwives who practise as independent primary carers demonstrate excellent outcomes, both locally and internationally. The woman's own home is uniquely suitable for her to engage in a sensitive and demanding physiological process, and the midwife is uniquely skilled at enabling that process.
In commenting on conflicts and tensions between midwifery and obstetric professional groups, Karen Lane (2005) presents the argument that midwives need to “resist the terms of their own professional subordination. In other words, the complexity of midwifery identities will variously position each midwife to accept, resist or just remain ambivalent about the causes and forms of their own oppression.” (p2)
In its submission to the Maternity Services Review (2008), the National Association of Specialist Obstetricians and Gynaecologists (NASOG) state that it “believes that it is preferable that a single individual carer take overall responsibility for care of a woman in labour and the obstetrician is the most appropriate choice for such a role.” (p5) It is clear from this and several other obstetric submissions that the concept of the midwife as the primary or leading professional carer is not understood by the writers of the submissions. NASOG asserts “That current excellent obstetric outcomes are due to a high quality overall maternity service which has historically been medically led.” (p6), and strongly discourages the government from making the reforms foreshadowed in the review’s Discussion Paper.
It can be argued that medical dominance in birth, and devaluing of normal birth in western societies falls within ‘Modernity’ – “a narrow canal through which the vast majority of contemporary cultures have passed or are passing. … Thus in modernising societies, traditional systems of healing, including midwifery, have become increasingly regarded by members of the growing middle and upper classes as ‘pre-modern vestiges’ of a more backward time that must necessarily vanish as modernisation/biomedicalisation progresses.” (Davis-Floyd, 2005 p32)
While it makes sense to class the midwife as a traditional system of healing in a society that understands birth within a medical mindset, it may not be helpful. The modern authentic midwife is not a therapist, not one of the myriad of ‘healing’ modalities that have little evidence and require amazing faith: simply because birth is not an illness, so there is essentially nothing to be healed or ‘therapied’. The midwife’s role is to work in harmony with, and to support and protect the individual woman’s own ability to give birth.
While pre-modern midwives were confronted with the full spectrum of the woman’s challenges in reproduction, the modern midwife is not a one-stop-shop when complications arise. The midwife of today is able to detect “complications in mother and child” and access “medical care or other appropriate assistance” (ICM 2005). The midwife primary carer is able to fulfil this role, with the woman-baby dyad at the centre of care, and effective collaboration that seeks to protect the wellness of mother and child.
Melbourne academic Kerreen Reiger (2006) considers that “In Australia, although governments traditionally promoted medical dominance of birth, recent policy initiatives in several states are encouraging significant change in the mainstream public hospital system.” (p331) The current Victorian policy states that “Ensuring continuity of carer and providing choice thus underpin the new framework for maternity services.” (DHS 2004, p1) These two elements, ‘continuity of carer’ and ‘choice’ would appear to ensure a strong future for caseload midwifery in Victoria. As time passes we will be more able to judge whether ‘ensuring continuity of carer and providing choice’ are indeed established in maternity services.
As the maternity reform process that was ushered in by the Maternity Services Review (2008) has progressed, the reality of medical dominance in birth has become progressively more foreboding. The hope for changes based on evidence coming into mainstream maternity care has been replaced by an unprecedented level of medical control that is being systematically written into the laws of this country. Even the level of access to private midwifery care that women 'enjoy' at present will expire 30 June next year.
It appears to me that Australia's socialist government's efforts to reform public hospital maternity care have entrenched a two-tier health system, reducing the public system to a processing line, while protecting the pockets and privilege of the obstetric/medical class. The small degree of choice that has been provided by private midwives who have carefully worked to "create and maintain ideal environmental conditions" for physiological birth and adaptation to mothering, is being extinguished.
[Note: References have not been given in full. That would encourage students to copy! jj]
In a discussion on ‘Birth Territory: a theory for midwifery practice’ (Fahy and Parratt 2006) the authors postulate that “when midwives create and maintain ideal environmental conditions maximum support is provided to the woman and fetus in labour and birth which results in an increased likelihood that the woman will give birth under her own power, be more satisfied with the experience and adapt with ease in the post-birth period.” (p49)
Are midwives really able to create and maintain ideal environmental conditions for good births? If so, should midwives accept responsiblity, at least in part, for the inability of women in our society to give birth in a spontaneous, physiological way, and to make the adjustments to mothering successfully?
It is not fashionable for midwives to take responsibility for the high caesarean rate in Australia. After all, that's the doctors' domain. Yet surely the national caesarean rate of approximately 30% (and growing) points as much to poor midwifery as it does to interventionist, knife-happy obstetrics.
Midwives who practise as independent primary carers demonstrate excellent outcomes, both locally and internationally. The woman's own home is uniquely suitable for her to engage in a sensitive and demanding physiological process, and the midwife is uniquely skilled at enabling that process.
In commenting on conflicts and tensions between midwifery and obstetric professional groups, Karen Lane (2005) presents the argument that midwives need to “resist the terms of their own professional subordination. In other words, the complexity of midwifery identities will variously position each midwife to accept, resist or just remain ambivalent about the causes and forms of their own oppression.” (p2)
In its submission to the Maternity Services Review (2008), the National Association of Specialist Obstetricians and Gynaecologists (NASOG) state that it “believes that it is preferable that a single individual carer take overall responsibility for care of a woman in labour and the obstetrician is the most appropriate choice for such a role.” (p5) It is clear from this and several other obstetric submissions that the concept of the midwife as the primary or leading professional carer is not understood by the writers of the submissions. NASOG asserts “That current excellent obstetric outcomes are due to a high quality overall maternity service which has historically been medically led.” (p6), and strongly discourages the government from making the reforms foreshadowed in the review’s Discussion Paper.
It can be argued that medical dominance in birth, and devaluing of normal birth in western societies falls within ‘Modernity’ – “a narrow canal through which the vast majority of contemporary cultures have passed or are passing. … Thus in modernising societies, traditional systems of healing, including midwifery, have become increasingly regarded by members of the growing middle and upper classes as ‘pre-modern vestiges’ of a more backward time that must necessarily vanish as modernisation/biomedicalisation progresses.” (Davis-Floyd, 2005 p32)
While it makes sense to class the midwife as a traditional system of healing in a society that understands birth within a medical mindset, it may not be helpful. The modern authentic midwife is not a therapist, not one of the myriad of ‘healing’ modalities that have little evidence and require amazing faith: simply because birth is not an illness, so there is essentially nothing to be healed or ‘therapied’. The midwife’s role is to work in harmony with, and to support and protect the individual woman’s own ability to give birth.
While pre-modern midwives were confronted with the full spectrum of the woman’s challenges in reproduction, the modern midwife is not a one-stop-shop when complications arise. The midwife of today is able to detect “complications in mother and child” and access “medical care or other appropriate assistance” (ICM 2005). The midwife primary carer is able to fulfil this role, with the woman-baby dyad at the centre of care, and effective collaboration that seeks to protect the wellness of mother and child.
Melbourne academic Kerreen Reiger (2006) considers that “In Australia, although governments traditionally promoted medical dominance of birth, recent policy initiatives in several states are encouraging significant change in the mainstream public hospital system.” (p331) The current Victorian policy states that “Ensuring continuity of carer and providing choice thus underpin the new framework for maternity services.” (DHS 2004, p1) These two elements, ‘continuity of carer’ and ‘choice’ would appear to ensure a strong future for caseload midwifery in Victoria. As time passes we will be more able to judge whether ‘ensuring continuity of carer and providing choice’ are indeed established in maternity services.
As the maternity reform process that was ushered in by the Maternity Services Review (2008) has progressed, the reality of medical dominance in birth has become progressively more foreboding. The hope for changes based on evidence coming into mainstream maternity care has been replaced by an unprecedented level of medical control that is being systematically written into the laws of this country. Even the level of access to private midwifery care that women 'enjoy' at present will expire 30 June next year.
It appears to me that Australia's socialist government's efforts to reform public hospital maternity care have entrenched a two-tier health system, reducing the public system to a processing line, while protecting the pockets and privilege of the obstetric/medical class. The small degree of choice that has been provided by private midwives who have carefully worked to "create and maintain ideal environmental conditions" for physiological birth and adaptation to mothering, is being extinguished.
[Note: References have not been given in full. That would encourage students to copy! jj]
Thursday, November 12, 2009
Update - less than eight months to 1 July
[Pic: a card by curly girl design]
As the countdown progresses relentlessly in the same way that the sands pass through the constriction in an hour-glass, midwives continue to ask what will our lives, our practices look like, in less than eight months' time.
Remember that the rationale for the current package of reform was to *improve* health care, *in the public interest*, across the range of regulated health professions. A decision was made in the rarified air of health bureaucracy that the system needed to mandate professional indemnity insurance for all registered health professionals. Even the vocal maternity consumer groups, Maternity Coalition and Homebirth Australia, and professional groups chimed in with calls for mandatory indemnity insurance as a condition of registration.
The rationale was that they were demanding equity. If the government provides subsidised indemnity insurance for doctors, let's demand it for midwives as well. That sounded reasonable enough to ordinary folk.
Few seemed to stop and ask in whose interest indemnity insurance was, and noone was listening to them anyway. The groupthink was that everyone needs it, so that's that.
I recently received a letter from the Victorian Health Minister, Daniel Andrews, in response to some of my correspondence to him. I was amazed to read in that letter, a statement that professional indemnity insurance “goes to the very cornerstone of the scheme which is public safety.”
This is an example of spin that is simply indefensible. Statutory regulation must be in the public interest, to enhance public safety, but there is no evidence of a connection between public safety and the mandating of professional indemnity insurance, nor is there any logic in that statement.
From the start in this ‘reform’ it was delegation of the regulation of midwives to the insurance companies, now with the amendment it will be double regulation again, this time by a doctor. The logical question is “which doctor?” [My lateral thinking says the Minister would then be obliged to provide a doctor for private midwives, in that if a regulation is written into the Act, surely the government must provide the means for it to be carried out. I WISH!] Can anyone imagine the legal ramifications for the doctor who does enter a collaborative arrangement with a privately practising midwife???
The Department of Health and Ageing is very concerned about cost blowouts as a result of their reforms. Good grief, if they would only do their sums they would see that the government could save buckets of money if maternity care was managed consistently with the evidence, following basic principles, in stead of the current ‘anything-goes-as-long-as-the-doctor-says-so’
As it looks today I doubt that any midwives will be able to do any private practice lawfully, although we will be on the register of midwives after 1 July. But I encourage everyone to discuss the situation as openly as you can with women who contact you for bookings. If they are scared off, that’s a shame, but if they want to book us knowing the facts, then we are bound by our duty of care as midwives to give them the best we can.
Perhaps there will be mass complaints to the health ombudsmen, perhaps even some brave law firm will work probono for a group claim. ??? (just musing!)
Friday, November 6, 2009
things are looking grim for midwives
As I write, things are looking grim for midwives. We have talked a lot about the outrageous restriction on a midwife's ability to practise privately and autonomously, but it's worse than that. Our federal government is making laws that will completely redefine midwifery.
A new amendment in the Health Legislation Amendment (Midwife and Nurse Practitioner) bill will require eligible midwives to have a “collaborative arrangement” with a doctor in place at all times.
Midwives have always had collaborative arrangements, in that we consult with medical professionals and refer when we suspect illness or complication. We encourage women to make a booking at a hospital as back up, to access services if and when required.
However, the 'collaborative arrangement' foreshadowed in this legislation appears to be the mandating of a formally agreed relationship that covers every single episode of care provided by the midwife. This is the opposite of autonomous professional practice; it is external supervision of the midwife's practice - a medical veto over care.
No doctor in their right mind will agree to any arrangement that gives the midwife any responsibility in decision making. I don't know any doctor who I could ask to enter such a relationship with me.
In recent months several women coming to me for care have said their local GP was reluctant to be involved (by ordering blood tests) when they said they wanted to plan homebirth. They said the doctors thought they were not allowed to. This is likely to become more acute in coming months.
ALL MIDWIVES in Australia stand to lose if this legislation is passed. The person the Health Minister is concocting is a handmaiden, and obstetric assistant. Not a midwife, but this person will have the title midwife, and we midwives who have served our communities safey and effectively for generations will be made illegal.
A new amendment in the Health Legislation Amendment (Midwife and Nurse Practitioner) bill will require eligible midwives to have a “collaborative arrangement” with a doctor in place at all times.
Midwives have always had collaborative arrangements, in that we consult with medical professionals and refer when we suspect illness or complication. We encourage women to make a booking at a hospital as back up, to access services if and when required.
However, the 'collaborative arrangement' foreshadowed in this legislation appears to be the mandating of a formally agreed relationship that covers every single episode of care provided by the midwife. This is the opposite of autonomous professional practice; it is external supervision of the midwife's practice - a medical veto over care.
No doctor in their right mind will agree to any arrangement that gives the midwife any responsibility in decision making. I don't know any doctor who I could ask to enter such a relationship with me.
In recent months several women coming to me for care have said their local GP was reluctant to be involved (by ordering blood tests) when they said they wanted to plan homebirth. They said the doctors thought they were not allowed to. This is likely to become more acute in coming months.
ALL MIDWIVES in Australia stand to lose if this legislation is passed. The person the Health Minister is concocting is a handmaiden, and obstetric assistant. Not a midwife, but this person will have the title midwife, and we midwives who have served our communities safey and effectively for generations will be made illegal.
Friday, October 30, 2009
Due Date: July 2010
A woman who has missed her period this past week will probably be due to give birth in the first week of July 2010, when the new national registration of midwives and other health professionals comes into effect.
What sort of maternity care will be available for this woman, and any others who become pregnant in the coming weeks and months?
There won't be much change to the medical-hospital maternity models that cater for the majority of women. The government's 'reforms' that will provide Medicare rebate on prenatal and postnatal care provided by as yet undefined 'eligible' midwives will not be in effect until at the earliest November 2010.
Only those women who are interested in private midwifery care will have concerns about their choices of carer and place of birth.
We really don't know what sort of maternity care will be possible after 1 July for women who want homebirth with a privately employed midwife. All midwives who are currently on the state and territory registers will automatically be included in the new national register. But the mandating of professional indemnity insurance will make any private midwifery services unlawful, except for the birth, during the exemption period of 2 years. The boundaries and rules around the exemption have yet to be announced.
The overarching principle that must be kept in mind is that birth is not an intervention or a drug, to be manipulated and managed like stock in a grocery store. The significance of birth in each little person's life; to the mother who gives birth; and to the family into which the baby is brought is a profound element in an extremely complex social order. People who are willing to defy ridiculous restrictions in order to promote normal birth, and to protect wellness and wholeness in birthing, will encounter such action because the alternative is simply unacceptable.
What sort of maternity care will be available for this woman, and any others who become pregnant in the coming weeks and months?
There won't be much change to the medical-hospital maternity models that cater for the majority of women. The government's 'reforms' that will provide Medicare rebate on prenatal and postnatal care provided by as yet undefined 'eligible' midwives will not be in effect until at the earliest November 2010.
Only those women who are interested in private midwifery care will have concerns about their choices of carer and place of birth.
We really don't know what sort of maternity care will be possible after 1 July for women who want homebirth with a privately employed midwife. All midwives who are currently on the state and territory registers will automatically be included in the new national register. But the mandating of professional indemnity insurance will make any private midwifery services unlawful, except for the birth, during the exemption period of 2 years. The boundaries and rules around the exemption have yet to be announced.
The overarching principle that must be kept in mind is that birth is not an intervention or a drug, to be manipulated and managed like stock in a grocery store. The significance of birth in each little person's life; to the mother who gives birth; and to the family into which the baby is brought is a profound element in an extremely complex social order. People who are willing to defy ridiculous restrictions in order to promote normal birth, and to protect wellness and wholeness in birthing, will encounter such action because the alternative is simply unacceptable.
Thursday, October 22, 2009
More on the exemption
We have recently had clarification (from a reliable source) about the 2-year exemption for midwives from the requirement for indemnity insurance. According to a senior official in the National Registration and Accreditation Scheme, the legal interpretation of the exemption has now been completely imbedded into legislation. What this means is that all registered midwives will have to have indemnity insurance to cover antenatal and postnatal care of all women, including those wanting to birth at home. The exemption from the requirement for indemnity insurance covers birth in the home only. Midwives will only be exempt for the actual birth for women birthing at home.
Midwives and mothers who want homebirth need to consider what that actually means. If the government is redefining childbirth and midwifery, two can play at that game. Pregnancy and birth are not an illness. Under this new system I can envisage a midwife in private practice charging a fee for attending the actual birth at home, and having social contact (the ‘cup of tea’) with women instead of what’s now called prenatal and postnatal ‘care’, but achieving the same end. I say this sadly – it’s madness isn’t it!
The Medicare model simply does not fit what we as midwives know as ordinary midwifery care. As Andrew Laming said “Bad policy in two years is still bad policy.” The slogan ‘medicare for midwives’ sounded catchy, but as they say, the devil is in the detail, and we have been had.
It looks to me as though there will be plenty of essential political activity for generations of midwives and women into the future in this country.
In summary, from 1 July 2010:
All midwives will be required to have indemnity insurance for professional practice, except (for 2 years) when they are attending a woman for homebirth.
We don’t know yet what midwives will have to do to get the indemnity product that we expect will be available under government tender. We don't know the costs or conditions that will be attached to that product.
Midwives and mothers who want homebirth need to consider what that actually means. If the government is redefining childbirth and midwifery, two can play at that game. Pregnancy and birth are not an illness. Under this new system I can envisage a midwife in private practice charging a fee for attending the actual birth at home, and having social contact (the ‘cup of tea’) with women instead of what’s now called prenatal and postnatal ‘care’, but achieving the same end. I say this sadly – it’s madness isn’t it!
The Medicare model simply does not fit what we as midwives know as ordinary midwifery care. As Andrew Laming said “Bad policy in two years is still bad policy.” The slogan ‘medicare for midwives’ sounded catchy, but as they say, the devil is in the detail, and we have been had.
It looks to me as though there will be plenty of essential political activity for generations of midwives and women into the future in this country.
In summary, from 1 July 2010:
All midwives will be required to have indemnity insurance for professional practice, except (for 2 years) when they are attending a woman for homebirth.
We don’t know yet what midwives will have to do to get the indemnity product that we expect will be available under government tender. We don't know the costs or conditions that will be attached to that product.
Tuesday, October 13, 2009
Monthly update
My purpose in writing a monthly update is to draw my own thoughts together, as much as to inform others. The terrain of private midwifery practice in Australia is going through great changes at the hands of our government, with varying degrees of input from professional and consumer bodies who have a seat at the discussion tables.
Here are links to the August and September updates.
Meetings have been convened this week in Canberra by the Health Department, with working groups on 'eligibility' and Medicare arrangements for midwives. Considerable discussion has circulated amongst independent midwives about the issue of a suitable 'framework' under which the eligible midwife will practise in the new maternity era that will be ushered in 1 July next year. From what I have read I am not sure that anyone knows what is meant by 'framework'. My concern is that any structure for midwifery must be consistent with the ICM Definition of the midwife (2005) - see earlier blog.
An attempt at micromanagement of midwifery that is mis-named 'framework', dictating detail in an effort to appease competing interest groups, rather than declaring the agreed principles under which midwives practise, will simply not work.
The Australian College of Midwives (ACM) hosted a meeting today in their offices in Canberra. Other organisations invited to the meeting are Australian Private Midwives Assn (APMA), Homebirth Australia, and Maternity Coalition.
Today I am no more confident that authentic midwifery will survive this period of legislative reform than I was a few months ago. Midwives who have practised safely in their communities for many years, and who are highly respected by their clients as well as other professionals, are still wondering what hurdles will be in place in the near future, and whether they will be able to continue providing the basic primary maternity care midwifery services that they are expert in.
Monday, October 12, 2009
When a decision about who to trust must be made
The young mother who I will call Jenny had booked a private midwife as well as being booked at a public hospital birth centre in Melbourne. As the pregnancy progressed, Jenny's plan for homebirth became clearer in her mind, and she retained her booking at the hospital as a backup arrangement.
A couple of days after reaching 37 weeks' gestation Jenny found that her waters had broken. It was a small trickle of clear fluid initially, and it continued to flow. Jenny called her private midwife. Labour had not commenced; Jenny was well; and her baby gave plenty of reassuring kicks, so there was no cause for concern. She had an appointment scheduled at the birth centre that day, and presented at the desk. The midwife who she spoke to was busy and distracted, and asked Jenny if she would perhaps like to come back later.
"Well actually my waters have broken", Jenny said.
"Oh, well you'll need to go and have monitoring" was the reply. Jenny was given instructions on where she needed to go.
A midwife applied the straps of the CTG monitor around Jenny's belly, and was walking away when Jenny asked, "Could you please tell me what this is about?"
"Oh sure!" (as though it was unusual that a woman would want to understand what was being done to her)
...
Jenny then went back to the birth centre with a report that her baby was happy, and a strip of monitor paper to prove it.
"This is your first baby, and you're not in labour. You've got 24 hours (to use the birth centre). After that you will be moved around to the delivery room for an induction of labour. If you're not in labour by 7 tomorrow morning you will be induced. And here's an antibiotic tablet to take at midnight. It might stop you from getting infected."
The midwife's tone was dismissive, fatalistic. Jenny felt gutted, and alone. Her partner had not been able to go with her to the birth centre, and she really missed him at that point. The implied message, as far as she was concerned, was that she had already been written off. There was no discussion of options, of evidence supporting this course of action, or even of anything Jenny could do to encourage the onset of labour.
...
It was after 4pm when Jenny returned to her home and phoned her private midwife.
"You need to decide now who to trust, Jenny. Me, or the hospital. I am going to offer you an alternative plan, which is quite different from the plan that has been offered by the hospital."
Jenny's midwife reassured her that spontaneous onset of labour was very possible; that homebirth was a very real option.
"I want you to go for a walk with your partner when he comes home. I want you to try to let go of all the anxiety and fear. Have a good dinner, and get yourselves off to bed. You will need plenty of energy for the work ahead of you. Call me in the morning and we'll talk about the next step. Call me at any time if you are worried, or if your labour is strong," her midwife explained. "And I don't want you to take that antibiotic. I don't want to mask any signs of infection, if that were happening, which is very unlikely," she added.
Jenny was awake and working hard by three, in good labour, and her midwife was asked to come at about 6am. At 7am her partner called the birth centre to let them know that Jenny would not be wanting an induction of labour. Their beautiful baby was in her arms later that morning.
To download a review of current evidence and guidance on Pre-labour Rupture of Membranes, go to Maternity Coalition's INFOSHEETS.
A couple of days after reaching 37 weeks' gestation Jenny found that her waters had broken. It was a small trickle of clear fluid initially, and it continued to flow. Jenny called her private midwife. Labour had not commenced; Jenny was well; and her baby gave plenty of reassuring kicks, so there was no cause for concern. She had an appointment scheduled at the birth centre that day, and presented at the desk. The midwife who she spoke to was busy and distracted, and asked Jenny if she would perhaps like to come back later.
"Well actually my waters have broken", Jenny said.
"Oh, well you'll need to go and have monitoring" was the reply. Jenny was given instructions on where she needed to go.
A midwife applied the straps of the CTG monitor around Jenny's belly, and was walking away when Jenny asked, "Could you please tell me what this is about?"
"Oh sure!" (as though it was unusual that a woman would want to understand what was being done to her)
...
Jenny then went back to the birth centre with a report that her baby was happy, and a strip of monitor paper to prove it.
"This is your first baby, and you're not in labour. You've got 24 hours (to use the birth centre). After that you will be moved around to the delivery room for an induction of labour. If you're not in labour by 7 tomorrow morning you will be induced. And here's an antibiotic tablet to take at midnight. It might stop you from getting infected."
The midwife's tone was dismissive, fatalistic. Jenny felt gutted, and alone. Her partner had not been able to go with her to the birth centre, and she really missed him at that point. The implied message, as far as she was concerned, was that she had already been written off. There was no discussion of options, of evidence supporting this course of action, or even of anything Jenny could do to encourage the onset of labour.
...
It was after 4pm when Jenny returned to her home and phoned her private midwife.
"You need to decide now who to trust, Jenny. Me, or the hospital. I am going to offer you an alternative plan, which is quite different from the plan that has been offered by the hospital."
Jenny's midwife reassured her that spontaneous onset of labour was very possible; that homebirth was a very real option.
"I want you to go for a walk with your partner when he comes home. I want you to try to let go of all the anxiety and fear. Have a good dinner, and get yourselves off to bed. You will need plenty of energy for the work ahead of you. Call me in the morning and we'll talk about the next step. Call me at any time if you are worried, or if your labour is strong," her midwife explained. "And I don't want you to take that antibiotic. I don't want to mask any signs of infection, if that were happening, which is very unlikely," she added.
Jenny was awake and working hard by three, in good labour, and her midwife was asked to come at about 6am. At 7am her partner called the birth centre to let them know that Jenny would not be wanting an induction of labour. Their beautiful baby was in her arms later that morning.
To download a review of current evidence and guidance on Pre-labour Rupture of Membranes, go to Maternity Coalition's INFOSHEETS.
Sunday, October 4, 2009
A framework for private midwifery practice
There has been a lot of talk in midwifery circles lately about a *framework* that will enable eligible midwives to practise privately within the new environment promised under the government's package of midwifery reform. We have been informed that an "advanced midwifery credentialing framework" will be required for eligible midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors".
Midwives who continue practising privately without insurance in the 2-year period (2010-2012) have been told we will be required to participate "in a quality and safety framework which will be developed ..."
I am very concerned about the misuse of the concept of a regulatory framework, which seems to be interpreted by the government as redefining what midwifery is (to suit vested interests), rather than embracing a wonderful profession. Our professional College, ACM needs to be strong in demanding that the principles of midwifery be used at the foundation of any statements about midwifery in this country.
What is meant by a *framework*?
Google took me straight to Wikipedia,
A framework is a basic conceptual structure used to solve or address complex issues. This very broad definition has allowed the term to be used as a buzzword, especially in a software context.
Framework can also refer to mechanical structures, such as scaffolding.
[and if you are unsure of what a *buzzword* is, Wikipedia can help out there too!]
As time passes I am becoming increasingly more confused as to what is actually meant by our Federal Health Minister, and all who are collaborating with her in bringing about maternity reforms, when they refer to a *framework*.
The challenge in my mind has been to prepare a statement which is a "basic conceptual structure used to solve or address complex issues", that is, midwifery practice.
I found the answer to my quest - the conceptual structure ... in the Definition of the Midwife (2005), a Core Document [ie no buzzwords here] of the International Confederation of Midwives (ICM).
The ICM Definition is foundational to all midwifery practice, including homebirth. Education and Codes of Practice and other guiding documentation of all member organisations, including the Australian College of Midwives, are expected to be consistent with this definition.
The ICM Definition of the Midwife establishes the following principles:
.1 The principle of ‘partnership’: “The midwife … works in partnership with women …”
.2 The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
.3 The principle of continuity of carer (‘caseload’) – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
.4 The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
.5 The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
.6 The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
.7 The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
.8 The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”
Simple logic tells me from the principles of midwifery, that basic midwifery includes, by definition, consultation with and referral to a doctor when appropriate. And, for that matter, referral to a dentist when appropriate. Doctors and dentists don't do midwifery, and vice versa.
So when midwives are told that we are going to be required to undertake "advanced midwifery credentialing framework" in order to be 'eligible' midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors", we are confused.
The only way this makes any sense is to accept the Wikipedia broad definition of *framework*, as a no more than buzzword. Until any framework applied to midwifery practice or credentialling or teaching actually confirms the principles that undergird midwifery, any attempt to describe midwifery's position will flounder.
Midwives who continue practising privately without insurance in the 2-year period (2010-2012) have been told we will be required to participate "in a quality and safety framework which will be developed ..."
I am very concerned about the misuse of the concept of a regulatory framework, which seems to be interpreted by the government as redefining what midwifery is (to suit vested interests), rather than embracing a wonderful profession. Our professional College, ACM needs to be strong in demanding that the principles of midwifery be used at the foundation of any statements about midwifery in this country.
What is meant by a *framework*?
Google took me straight to Wikipedia,
A framework is a basic conceptual structure used to solve or address complex issues. This very broad definition has allowed the term to be used as a buzzword, especially in a software context.
Framework can also refer to mechanical structures, such as scaffolding.
[and if you are unsure of what a *buzzword* is, Wikipedia can help out there too!]
As time passes I am becoming increasingly more confused as to what is actually meant by our Federal Health Minister, and all who are collaborating with her in bringing about maternity reforms, when they refer to a *framework*.
The challenge in my mind has been to prepare a statement which is a "basic conceptual structure used to solve or address complex issues", that is, midwifery practice.
I found the answer to my quest - the conceptual structure ... in the Definition of the Midwife (2005), a Core Document [ie no buzzwords here] of the International Confederation of Midwives (ICM).
The ICM Definition is foundational to all midwifery practice, including homebirth. Education and Codes of Practice and other guiding documentation of all member organisations, including the Australian College of Midwives, are expected to be consistent with this definition.
The ICM Definition of the Midwife establishes the following principles:
.1 The principle of ‘partnership’: “The midwife … works in partnership with women …”
.2 The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
.3 The principle of continuity of carer (‘caseload’) – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
.4 The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
.5 The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
.6 The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
.7 The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
.8 The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”
Simple logic tells me from the principles of midwifery, that basic midwifery includes, by definition, consultation with and referral to a doctor when appropriate. And, for that matter, referral to a dentist when appropriate. Doctors and dentists don't do midwifery, and vice versa.
So when midwives are told that we are going to be required to undertake "advanced midwifery credentialing framework" in order to be 'eligible' midwives, who will also be "appropriately qualified and experienced"; "working in collaboration with doctors", we are confused.
The only way this makes any sense is to accept the Wikipedia broad definition of *framework*, as a no more than buzzword. Until any framework applied to midwifery practice or credentialling or teaching actually confirms the principles that undergird midwifery, any attempt to describe midwifery's position will flounder.
Saturday, September 26, 2009
Who is responsible? - Debunking the myth of doctor liability.
Midwives in Australia as well as other countries face varying degrees of regulation and restriction. Some of this control is enshrined in law, some by monopoly of funding and access to services, while much is the accepted status quo. People don't challenge what they don't recognise as having potential to change.
Historically doctors have taken the leading and thereby controlling hand in health care. This is especially so in maternity care, and midwives around the world have in recent decades strongly resisted medical supervision of midwifery. Most Australian midwives don't recognise this fact, as they work in hospitals and their scope of practice is defined by hospital protocols. Midwives who practise privately, and autonomously, develop a midwife identity that is informed by the partnerships we develop with individual women, and that is consistent with the contemporary international definition of the midwife. Midwives who practise privately know that we are responsible for all decisions, advice, actions, and lack of action in our interactions with women who employ us as their midwives. We consult, refer, and occasionally transfer care to medical colleagues when the situation a woman in our care faces is outside our scope of practice.
The question of 'who is responsible?' with reference to the relationship between doctors and nurses is explored in a paper from the Royal College of Nursing, Australia. The arguments posed in this paper can be applied to midwifery.
Ultimate doctor liability: A myth of ignorance or myth of control?
Author: Andrew Cashin and others
Reference: Collegian Volume 16 • Number 3 • July/September 2009, Royal College of Nursing, Australia
Summary
Ultimate medical doctor responsibility for the care delivered to patients by all professionals is a myth. Legally Lord Denning dismissed the myth in the mid-20th century in England. The assumption that a medical doctor is responsible for the care delivered by nurses has not existed in English and Australian law since that time, and it has been actively refuted. Yet it is a myth that continues to circulate influencing health service, state and federal health policy. For some it is a myth of ignorance and for others it is a means of control. This paper outlines the relevant case law to debunk the myth of ultimate medical doctor control.
________________________________________
The current government's effort to reform maternity service provision in Australia has brought to light the reality that the myth of ultimate doctor responsibility in maternity care is alive and well in this country.
Historically doctors have taken the leading and thereby controlling hand in health care. This is especially so in maternity care, and midwives around the world have in recent decades strongly resisted medical supervision of midwifery. Most Australian midwives don't recognise this fact, as they work in hospitals and their scope of practice is defined by hospital protocols. Midwives who practise privately, and autonomously, develop a midwife identity that is informed by the partnerships we develop with individual women, and that is consistent with the contemporary international definition of the midwife. Midwives who practise privately know that we are responsible for all decisions, advice, actions, and lack of action in our interactions with women who employ us as their midwives. We consult, refer, and occasionally transfer care to medical colleagues when the situation a woman in our care faces is outside our scope of practice.
The question of 'who is responsible?' with reference to the relationship between doctors and nurses is explored in a paper from the Royal College of Nursing, Australia. The arguments posed in this paper can be applied to midwifery.
Ultimate doctor liability: A myth of ignorance or myth of control?
Author: Andrew Cashin and others
Reference: Collegian Volume 16 • Number 3 • July/September 2009, Royal College of Nursing, Australia
Summary
Ultimate medical doctor responsibility for the care delivered to patients by all professionals is a myth. Legally Lord Denning dismissed the myth in the mid-20th century in England. The assumption that a medical doctor is responsible for the care delivered by nurses has not existed in English and Australian law since that time, and it has been actively refuted. Yet it is a myth that continues to circulate influencing health service, state and federal health policy. For some it is a myth of ignorance and for others it is a means of control. This paper outlines the relevant case law to debunk the myth of ultimate medical doctor control.
________________________________________
The current government's effort to reform maternity service provision in Australia has brought to light the reality that the myth of ultimate doctor responsibility in maternity care is alive and well in this country.
Friday, September 18, 2009
Birth Plan for twins
Readers may have seen recent posts on my villagemidwife blog about complex negotiations that have gone into planning for birth of twins, and a summary from the birth.
My purpose in telling this story publicly, with the support of the mother, is to highlight basic midwifery knowledge, that even in complex situations, the physiologically normal processes in birth can be, and often is, the best. The only way to reach physiological birthing in today's world is for the mother to have the confidence to refuse all offers to actively manage the birth. When a midwife and a woman have established a partnership based on trust, respect, and reciprocity, the midwife is able to support the woman as she negotiates complex and unpredictable decision-making.
In this particular case the mother had initially planned homebirth, but on my recommendation, after the twin pregnancy was diagnosed, agreed to change that plan to hospital birth. The mother was pressured and coerced in an attempt by the hospital to achieve compliance and agree to elective caesarean. She listened and discussed what was on offer, yet she believed that the safest way for her to proceed was to wait for spontaneous onset of labour, and to proceed without surgery or anaesthesia. This is what she did.
In this blog we are sharing the framework of a birth plan. This birth plan was prepared at about 36 weeks' gestation. Ultrasound scanning gave no indication of any specific reason which may have swayed the balance towards surgically managed birth, other than the fact that the first twin (A) was presenting as Breech. Size of babies and amniotic fluid around the babies were unremarkable.
BIRTH PLAN
Include statements such as:
• “I plan to give birth to my babies spontaneously unless there is a reason for me to change this plan.”
• “I understand that I have the right to refuse any intervention.”
• “I believe that my birth plan is the best way for me to ensure the safety of my babies and to protect my own health”.
• "I ask that all care providers respect my need for privacy in labour and birth. Please do not interrupt me without good reason. Please minimise the number of people who come into my room, and keep equipment brought into my room to a minimum."
• "If an intervention is recommended, please explain to me the reason and I will consider it, and discuss it with my husband and my midwife so that I can make an informed decision."
DECISION POINTS IN SPONTANEOUS BIRTH FOR BREECH AND TWIN BABIES
Include:
• Onset of labour – may be regular contractions, or breaking of water or both. [Contact midwife]
• Going to hospital – as labour becomes established. Usually labour for the first twin proceeds in a similar way to previous labours. [Discuss with midwife]
• Established labour – check babies are coping well with labour. [midwives will be watching for normal progress over time.]
• Birth of Twin A:
• Urge to push – find upright position
• If membranes have not ruptured when visible at the vaginal opening, midwife will break the sac
• As baby’s body emerges, allow it to hang, assisted by gravity
• No forceful manipulation of the body
• No touching unless absolutely necessary until neck is visible
• Gentle support as face is born
• Clamp and cut cord soon after birth to prevent the possibility of twin-twin transfusion
• Baby to mother, skin to skin, as soon as baby’s condition is good
• Mother rest and enjoy Baby A, while midwife checks condition of Twin B.
• Baby A to breast if mother wishes
• Mother may need to stand and walk, to bring Twin B into to the birth canal
• When contractions return, and mother needs to focus on the birth of Twin B, pass Baby A to father, who stays close by. As long as Twin B's condition is good, there is no reason to speed up the birth by breaking the baby's waters.
• Birth of Twin B:
• Second labour will usually progress quickly once baby is presenting well, as the cervix has been dilated.
• Third Stage: After pulsation of the cord for Baby B has ceased, proceed with administration of oxytocic and controlled cord traction.
[Thanks to English midwife Mary Cronk, for sharing her guidelines for the care of a woman expecting twins. These guidelines have informed me in advising several twin mothers over the past few years.]
My purpose in telling this story publicly, with the support of the mother, is to highlight basic midwifery knowledge, that even in complex situations, the physiologically normal processes in birth can be, and often is, the best. The only way to reach physiological birthing in today's world is for the mother to have the confidence to refuse all offers to actively manage the birth. When a midwife and a woman have established a partnership based on trust, respect, and reciprocity, the midwife is able to support the woman as she negotiates complex and unpredictable decision-making.
In this particular case the mother had initially planned homebirth, but on my recommendation, after the twin pregnancy was diagnosed, agreed to change that plan to hospital birth. The mother was pressured and coerced in an attempt by the hospital to achieve compliance and agree to elective caesarean. She listened and discussed what was on offer, yet she believed that the safest way for her to proceed was to wait for spontaneous onset of labour, and to proceed without surgery or anaesthesia. This is what she did.
In this blog we are sharing the framework of a birth plan. This birth plan was prepared at about 36 weeks' gestation. Ultrasound scanning gave no indication of any specific reason which may have swayed the balance towards surgically managed birth, other than the fact that the first twin (A) was presenting as Breech. Size of babies and amniotic fluid around the babies were unremarkable.
BIRTH PLAN
Include statements such as:
• “I plan to give birth to my babies spontaneously unless there is a reason for me to change this plan.”
• “I understand that I have the right to refuse any intervention.”
• “I believe that my birth plan is the best way for me to ensure the safety of my babies and to protect my own health”.
• "I ask that all care providers respect my need for privacy in labour and birth. Please do not interrupt me without good reason. Please minimise the number of people who come into my room, and keep equipment brought into my room to a minimum."
• "If an intervention is recommended, please explain to me the reason and I will consider it, and discuss it with my husband and my midwife so that I can make an informed decision."
DECISION POINTS IN SPONTANEOUS BIRTH FOR BREECH AND TWIN BABIES
Include:
• Onset of labour – may be regular contractions, or breaking of water or both. [Contact midwife]
• Going to hospital – as labour becomes established. Usually labour for the first twin proceeds in a similar way to previous labours. [Discuss with midwife]
• Established labour – check babies are coping well with labour. [midwives will be watching for normal progress over time.]
• Birth of Twin A:
• Urge to push – find upright position
• If membranes have not ruptured when visible at the vaginal opening, midwife will break the sac
• As baby’s body emerges, allow it to hang, assisted by gravity
• No forceful manipulation of the body
• No touching unless absolutely necessary until neck is visible
• Gentle support as face is born
• Clamp and cut cord soon after birth to prevent the possibility of twin-twin transfusion
• Baby to mother, skin to skin, as soon as baby’s condition is good
• Mother rest and enjoy Baby A, while midwife checks condition of Twin B.
• Baby A to breast if mother wishes
• Mother may need to stand and walk, to bring Twin B into to the birth canal
• When contractions return, and mother needs to focus on the birth of Twin B, pass Baby A to father, who stays close by. As long as Twin B's condition is good, there is no reason to speed up the birth by breaking the baby's waters.
• Birth of Twin B:
• Second labour will usually progress quickly once baby is presenting well, as the cervix has been dilated.
• Third Stage: After pulsation of the cord for Baby B has ceased, proceed with administration of oxytocic and controlled cord traction.
[Thanks to English midwife Mary Cronk, for sharing her guidelines for the care of a woman expecting twins. These guidelines have informed me in advising several twin mothers over the past few years.]
Monday, September 14, 2009
Monthly review
Last month I began a countdown to 1 July 2010. I hope to summarise and review progress over the past month, for my own sake as well as for others who are following events as they unfold. If you don't understand something I have written, or think I have got it wrong, please let me know.
We can be confident that a baby who is conceived this week will be born before 1 July.
A woman whose menstrual period starts this week and conceives when she becomes fertile a couple of weeks from now will attain 42 weeks' gestation in the first week of July.
If you are that woman, and are planning homebirth with a privately practising midwife, you will need to work closely with your midwife, keep a clear mind, and remember your personal rights and responsibilities in giving birth to your child.
In summary
# Health Ministers have agreed to a transitional clause in the current draft National Registration and Accreditation Scheme legislation which provides a two year exemption until June 2012 from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth. (AHMC Communique 4 September 2009)
Although this sounds like a useful reprieve at face value, I see it as a meaningless political gesture to get the pressure off the Health Minister and the government that is presiding over reform that is a dog's breakfast before it's even enacted. Curiously the two-year exemption was announced at 4pm on the last business day before the big rally!
# The Department of Health and Ageing is seeking tenders from insurance companies to provide indemnity for eligible privately practising midwives.
This could potentially make private midwifery technically lawful, while making it so expensive that it becomes more marginal and unaffordable than it is now.
# The Maternity Service Advisory Group, with hugely disproportionate obstetric and medical representation, has been set up by the (federal) Health Minister.
# Key players have been invited to send a representative to three technical working groups to be convened 24 September and 12 October, as a component of the national maternity reform process. The working groups will consider PBS (pharmaceuticals), MBS (Medicare), and eligibility (credentialing).
Australian Private Midwives Assn (APMA) and ACM have been invited to send one representative each. Maternity Coalition have been invited to send two representatives. I don't know who else is to be represented.
My comment:
I will be satisfied that we are moving in the right direction if there can be agreement on broad principles underpinning midwifery practice and primary maternity care.
These principles are well articulated in the ICM Definition of the midwife.
As long as the advisors to the Health Minister are ignorant of the principles underpinning midwifery, and are able to be swayed by interest groups who advocate for midwifery to be a support service to obstetrics, these principles including partnership between a woman and her midwife, promotion of normal birth, and professional competence will not be respected in any of the outputs from working groups and advisory committees.
We can be confident that a baby who is conceived this week will be born before 1 July.
A woman whose menstrual period starts this week and conceives when she becomes fertile a couple of weeks from now will attain 42 weeks' gestation in the first week of July.
If you are that woman, and are planning homebirth with a privately practising midwife, you will need to work closely with your midwife, keep a clear mind, and remember your personal rights and responsibilities in giving birth to your child.
In summary
# Health Ministers have agreed to a transitional clause in the current draft National Registration and Accreditation Scheme legislation which provides a two year exemption until June 2012 from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth. (AHMC Communique 4 September 2009)
Although this sounds like a useful reprieve at face value, I see it as a meaningless political gesture to get the pressure off the Health Minister and the government that is presiding over reform that is a dog's breakfast before it's even enacted. Curiously the two-year exemption was announced at 4pm on the last business day before the big rally!
# The Department of Health and Ageing is seeking tenders from insurance companies to provide indemnity for eligible privately practising midwives.
This could potentially make private midwifery technically lawful, while making it so expensive that it becomes more marginal and unaffordable than it is now.
# The Maternity Service Advisory Group, with hugely disproportionate obstetric and medical representation, has been set up by the (federal) Health Minister.
# Key players have been invited to send a representative to three technical working groups to be convened 24 September and 12 October, as a component of the national maternity reform process. The working groups will consider PBS (pharmaceuticals), MBS (Medicare), and eligibility (credentialing).
Australian Private Midwives Assn (APMA) and ACM have been invited to send one representative each. Maternity Coalition have been invited to send two representatives. I don't know who else is to be represented.
My comment:
I will be satisfied that we are moving in the right direction if there can be agreement on broad principles underpinning midwifery practice and primary maternity care.
These principles are well articulated in the ICM Definition of the midwife.
As long as the advisors to the Health Minister are ignorant of the principles underpinning midwifery, and are able to be swayed by interest groups who advocate for midwifery to be a support service to obstetrics, these principles including partnership between a woman and her midwife, promotion of normal birth, and professional competence will not be respected in any of the outputs from working groups and advisory committees.
Sunday, September 13, 2009
Call for tenders to provide professional indemnity for midwives
From the Business section of The Australian newspaper yesterday:
"The Department of Health and Ageing is seeking tenders from capable and experienced individuals or organisations to provide insurance (in compliance with Australian insurnce legislation) to eligible privately practising midwives.
"The successful tenderer must offer professional indemnity insurance, in the form of a contract with each individual eligible privately practicing midwife who seeks such cover to provide cover for their midwifery services in a manner that is efficient, equitable and timely with effect from July 1 2010 for a total of three years. The successful tenderer must manage all claims during the contract period and certain run off claims after the expiry of the contract and must collect and provide data on incident notifications and claims to Medicare Australia. "
RFT 014/0910
REQUEST FOR TENDER
Professional Indemnity Insurance for eligible privately practising midwives
Tenders close October 8th 2009
If you have been talking to an insurer, please make sure they know about this call.
"The Department of Health and Ageing is seeking tenders from capable and experienced individuals or organisations to provide insurance (in compliance with Australian insurnce legislation) to eligible privately practising midwives.
"The successful tenderer must offer professional indemnity insurance, in the form of a contract with each individual eligible privately practicing midwife who seeks such cover to provide cover for their midwifery services in a manner that is efficient, equitable and timely with effect from July 1 2010 for a total of three years. The successful tenderer must manage all claims during the contract period and certain run off claims after the expiry of the contract and must collect and provide data on incident notifications and claims to Medicare Australia. "
RFT 014/0910
REQUEST FOR TENDER
Professional Indemnity Insurance for eligible privately practising midwives
Tenders close October 8th 2009
If you have been talking to an insurer, please make sure they know about this call.
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.
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.
Tuesday, September 8, 2009
What does the 2-year exemption mean?
What does it mean for privately practising midwives?
What does it mean for women who want to plan homebirth with a private midwife, as distinct from those who plan homebirth under a publicly funded scheme?
The general response by midwives to the announcement of the temporary reprieve is guarded. As I wrote last Friday, we have no reason to trust those who are advising the government, or the government itself. The woeful lack of consultation with midwives in this whole sorry saga, making us pawns that can easily be sacrificed by health ministers in their point-scoring and dodging of responsibility, has forced us to defend ourselves in a way that most midwives have never imagined we would need to do. We are not just talking about our livelihoods; which are in and of themselves legitimate and worth protecting. We are also talking about the safety and wellbeing of a group of mothers and babies whom midwives have served consistently since the beginning of human existence.
Midwives are waiting to see what hoops we will be required to jump through in order to "access the exemption".
One argument private midwives in Victoria have used in our submissions to government authorities and inquiries is the homebirth data that the Victorian government's Perinatal Data Collection Unit collects and analyses each year. It seems that no amount of evidence to the contrary can convince those at the helm of the ship of state that private midwifery practice, even with all the unreasonable restrictions that we face, is safe.
I have made an application to the Perinatal Data Collection Unit to make a Performance Indicator analysis of de-identified data for the past five years, from both homebirths and those who planned homebirth and transferred to hospital. [Here's a link to the 07-08 Performance Indicators You won't find 'Homebirth' in the publications, as our data is included in the Private Hospital aggregate data, because we provide private maternity services. There's a conundrum to consider!]
What does it mean for women who want to plan homebirth with a private midwife, as distinct from those who plan homebirth under a publicly funded scheme?
The general response by midwives to the announcement of the temporary reprieve is guarded. As I wrote last Friday, we have no reason to trust those who are advising the government, or the government itself. The woeful lack of consultation with midwives in this whole sorry saga, making us pawns that can easily be sacrificed by health ministers in their point-scoring and dodging of responsibility, has forced us to defend ourselves in a way that most midwives have never imagined we would need to do. We are not just talking about our livelihoods; which are in and of themselves legitimate and worth protecting. We are also talking about the safety and wellbeing of a group of mothers and babies whom midwives have served consistently since the beginning of human existence.
Midwives are waiting to see what hoops we will be required to jump through in order to "access the exemption".
One argument private midwives in Victoria have used in our submissions to government authorities and inquiries is the homebirth data that the Victorian government's Perinatal Data Collection Unit collects and analyses each year. It seems that no amount of evidence to the contrary can convince those at the helm of the ship of state that private midwifery practice, even with all the unreasonable restrictions that we face, is safe.
I have made an application to the Perinatal Data Collection Unit to make a Performance Indicator analysis of de-identified data for the past five years, from both homebirths and those who planned homebirth and transferred to hospital. [Here's a link to the 07-08 Performance Indicators You won't find 'Homebirth' in the publications, as our data is included in the Private Hospital aggregate data, because we provide private maternity services. There's a conundrum to consider!]
Friday, September 4, 2009
Two-year exemption from indemnity insurance announced today
A reprieve has been announced, giving more time to resolve the impasse caused by the intersection of Bill B (which makes indemnity insurance mandatory) and other bills which are designed to reform maternity services in this country.
Australian Health Ministers’ Conference
JOINT COMMUNIQUE
4 September 2009
Australian Health Ministers met in Canberra today to discuss a range of issues affecting the national health system. The meeting was chaired by ACT Minister for Health, Katy Gallagher.
...
Homebirth
Health Ministers agreed to a transitional clause in the current draft National Registration and Accreditation Scheme legislation which provides a two year exemption until June 2012 from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth.
Additional requirements to access the exemption will include;
- A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.
- Reporting each homebirth
- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.
These provisions will only apply to midwives working in jurisdictions which do not prohibit such practice as at the date of the implementation of the scheme.
...
Other matters referred to in the communique include Health and Hospitals Reform, H1N1 Influenza, Fourth National Mental Health Plan, BreastScreen Australia Evaluation, and Health Workforce Australia.
Comments are welcome on this and other midwifery blogs.
My initial comment centres on the requirements:
A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.
This is not a problem. It's not as though we have been pretending that we have had indemnity insurance all these years! I wonder what 'they' think we tell our clients now?
- Reporting each homebirth
Also, not an issue in Victoria, as it seems that the only homebirths that don't get 'reported' to the government's perinatal data collection unit are the intentionally unattended births.
- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.
This is a totally unknown entity. We will have to look at it when it happens. Past experience has included a woeful absence of consultation by government entities with privately practising midwives, so the stated commitment to consultation is something we will be looking out for!
Joy Johnston
Australian Health Ministers’ Conference
JOINT COMMUNIQUE
4 September 2009
Australian Health Ministers met in Canberra today to discuss a range of issues affecting the national health system. The meeting was chaired by ACT Minister for Health, Katy Gallagher.
...
Homebirth
Health Ministers agreed to a transitional clause in the current draft National Registration and Accreditation Scheme legislation which provides a two year exemption until June 2012 from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth.
Additional requirements to access the exemption will include;
- A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.
- Reporting each homebirth
- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.
These provisions will only apply to midwives working in jurisdictions which do not prohibit such practice as at the date of the implementation of the scheme.
...
Other matters referred to in the communique include Health and Hospitals Reform, H1N1 Influenza, Fourth National Mental Health Plan, BreastScreen Australia Evaluation, and Health Workforce Australia.
Comments are welcome on this and other midwifery blogs.
My initial comment centres on the requirements:
A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.
This is not a problem. It's not as though we have been pretending that we have had indemnity insurance all these years! I wonder what 'they' think we tell our clients now?
- Reporting each homebirth
Also, not an issue in Victoria, as it seems that the only homebirths that don't get 'reported' to the government's perinatal data collection unit are the intentionally unattended births.
- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.
This is a totally unknown entity. We will have to look at it when it happens. Past experience has included a woeful absence of consultation by government entities with privately practising midwives, so the stated commitment to consultation is something we will be looking out for!
Joy Johnston
Wednesday, September 2, 2009
a message from the Victorian Health Minister
The Minister for Health, Hon Daniel Andrews, informed a large group of midwives at the ANF (Vic Branch) conference today that midwives in private practice "need to have dialogue with us [the Department] about what would need to be included in pilot schemes [for hospital auspiced homebirth] for MIPPs to be part of them." There were three or four MIPPs in the gathering of over 150.
Minister Andrews was giving the opening address at the midwifery conference. Much of what he had to say was the same spin we had heard previously. He stressed the importance of his government's plan to introduce hospital-auspiced homebirth, and strongly reiterated his previous statements that he would not be providing any support for independent midwives to obtain indemnity insurance.
He stated that exemptions [from indemnity] would compromise the integrity of the scheme. He avoided the fact that the pilot homebirth programs are no more than a vague plan - not a reality. He said they will be up and running in 2010. [we will see!]
It was clear to me that the health minister is more interested in neat systems and schemes, putting people into boxes, than in respecting the individual woman's autonomy in primary care options, or the individual midwife's right to hang up a shingle and provide this very basic level of care in communities. This is socialist health policy on steroids - restrictions and bureaucratic systems taking precedence over the individual's right to choose who provides the most intimate care in bringing children into the world.
Andrews was dismissive of women who seek private midwifery care. He declared that homebirth is not an important option to most Victorian women. The numbers of women and midwives are too small to matter. His 'hospital in the home' style of homebirth will provide choice for "a lot of women" - tick the choice box! Too bad that most of the women in the State who will be seeking private midwifery services for births after i July next year will not be in the vacinity of the two hospital-auspiced homebirth programs. They will have to make the best choice from what's available to them. They can choose primary care from a private (specialist) obstetrician who may or may not be around if they labour spontaneously, and for that matter who has no skill in the midwife's terrain of physiological birth; or they can choose whatever fragmented model of maternity care is available via the local hospital and general practitioners, with a 'lucky dip' option of midwife allocation in the hospital when midwifery services are most needed. Or, of course, they can choose to DIY - stay at home without a midwife.
Women must stand strongly against the arrogance and rudeness of politicians who refuse to listen. Women who want a midwife to provide primary care - whether the birth is at home or hospital - actually want to avoid costly medicalisation of their births. They want the skill a known midwife brings to their birthing, enabling and protecting normal birth in most cases. Surely this is not too much to ask?
Minister Andrews was giving the opening address at the midwifery conference. Much of what he had to say was the same spin we had heard previously. He stressed the importance of his government's plan to introduce hospital-auspiced homebirth, and strongly reiterated his previous statements that he would not be providing any support for independent midwives to obtain indemnity insurance.
He stated that exemptions [from indemnity] would compromise the integrity of the scheme. He avoided the fact that the pilot homebirth programs are no more than a vague plan - not a reality. He said they will be up and running in 2010. [we will see!]
It was clear to me that the health minister is more interested in neat systems and schemes, putting people into boxes, than in respecting the individual woman's autonomy in primary care options, or the individual midwife's right to hang up a shingle and provide this very basic level of care in communities. This is socialist health policy on steroids - restrictions and bureaucratic systems taking precedence over the individual's right to choose who provides the most intimate care in bringing children into the world.
Andrews was dismissive of women who seek private midwifery care. He declared that homebirth is not an important option to most Victorian women. The numbers of women and midwives are too small to matter. His 'hospital in the home' style of homebirth will provide choice for "a lot of women" - tick the choice box! Too bad that most of the women in the State who will be seeking private midwifery services for births after i July next year will not be in the vacinity of the two hospital-auspiced homebirth programs. They will have to make the best choice from what's available to them. They can choose primary care from a private (specialist) obstetrician who may or may not be around if they labour spontaneously, and for that matter who has no skill in the midwife's terrain of physiological birth; or they can choose whatever fragmented model of maternity care is available via the local hospital and general practitioners, with a 'lucky dip' option of midwife allocation in the hospital when midwifery services are most needed. Or, of course, they can choose to DIY - stay at home without a midwife.
Women must stand strongly against the arrogance and rudeness of politicians who refuse to listen. Women who want a midwife to provide primary care - whether the birth is at home or hospital - actually want to avoid costly medicalisation of their births. They want the skill a known midwife brings to their birthing, enabling and protecting normal birth in most cases. Surely this is not too much to ask?
Monday, August 31, 2009
responsibilities of the homebirth midwife
This week I have been invited to speak briefly at an Australian Nursing Federation (ANF) Victorian Branch midwifery conference. My topic is THE LEGAL AND PROFESSIONAL RESPONSIBILITIES OF A HOME BIRTH MIDWIFE – the buck stops with you!
I plan to make my presentation a tribute to homebirth and private midwifery practice as we know it. I will be using a brief slide presentation about the home-water-birth of a baby girl named Lila, about a year ago. The BMid student who was undertaking one of her follow-through journeys took the photos. Lila’s mother has kindly given me permission to share these intimate images with fellow midwives.
A focus on homebirth, rather than focusing on the woman, sets an unhelpful basis for this discussion. The place of birth, either home or hospital, is a choice that a well woman has if her midwife is competent in attending a physiologically normal birth in any setting. The picture of partnership between a woman and her midwife, who is primary care provider throughout the episode of care, is the key. The midwife is committed to the woman, not to the place of birth.
I plan to make my presentation a tribute to homebirth and private midwifery practice as we know it. I will be using a brief slide presentation about the home-water-birth of a baby girl named Lila, about a year ago. The BMid student who was undertaking one of her follow-through journeys took the photos. Lila’s mother has kindly given me permission to share these intimate images with fellow midwives.
A focus on homebirth, rather than focusing on the woman, sets an unhelpful basis for this discussion. The place of birth, either home or hospital, is a choice that a well woman has if her midwife is competent in attending a physiologically normal birth in any setting. The picture of partnership between a woman and her midwife, who is primary care provider throughout the episode of care, is the key. The midwife is committed to the woman, not to the place of birth.
Saturday, August 22, 2009
indemnity insurance, smoke and mirrors
Australia's private midwives provide a professional service that has stood the test of time, and survived in spite of professional, social, and financial restrictions and disincentives.
The service we have provided to the women and families who employ us is demonstrably effective and highly valued in our communities.
The current media focus on private midwifery and homebirth - the main practice area of private midwives - is disproportionate to the number of midwives or the number of births we attend. Our future is now threatened in an unprecedented way.
Every day or so independent midwives are receiving messages from those who are representing us at federal and state political levels. Messages are also circulating in consumer advocacy circles. The situation is volatile. Our inboxes are clogged, and our minds are too. It is difficult in the multiple conversations that are happening to see the picture clearly. It is difficult when under serious threat to know who to trust, who to avoid, and who to fight.
Differences of opinion are bound to exist, and to become more polarised as time passes. One key issue is professional indemnity insurance.
Organisations that seek to represent the interests of the maternity consumer have come out clearly supporting the mandating of professional indemnity insurance for all registered health professionals. This requirement has been written into the new health practitioner legislation, to come into effect 1 July next year, and appears to have strong political support. Midwives' organisations have also joined the band wagon with idealistic statements about every consumer needing to be able to sue if they suffer harm at the hand of their health care provider.
I don't know how smoke and mirrors work in magic shows, but they do the trick. Every time I see someone put on a self righteous face and talk about the importance of professional indemnity insurance in health care, I wonder if they really believe what they are saying. Are they in effect the children in the front row, believing everything they see and hear as the magician wows the crowd?
The only consistent winners in the professional indemnity insurance scene are the insurance companies - businesses which collect huge premiums, with government support for bigger claims, and the lawyers. The people who suffer as a result of professional misconduct, negligence, incompetence, or a potentially avoidable mistake face a huge complex legal process in making claims. They might do better buying a lottery ticket.
There is much in maternity care that is unknowable and unpredictable. The midwife who works in harmony with natural physiological processes in birth embraces the unpredictability of birth, and is ready to act to protect wellness at any time. This midwife promotes health in the leadup to the climax of birth. It is no secret that the safest way to proceed through the complex terrain of birth is to do so without drugs or surgery. And the person with the professional expertise to facilitate physiological birthing is the known midwife, working in partnership with each woman.
These words have been repeated over and over again in midwifery literature. I doubt there will be anyone reading this blog who does not know this fact.
Indemnity insurance for private midwifery practice has not been available since 2002. Will Nicola Roxon find an indemnity product that can be afforded by midwives, passing on the costs to our clients, and working within the constraints that inevitably come with the product?
The service we have provided to the women and families who employ us is demonstrably effective and highly valued in our communities.
The current media focus on private midwifery and homebirth - the main practice area of private midwives - is disproportionate to the number of midwives or the number of births we attend. Our future is now threatened in an unprecedented way.
Every day or so independent midwives are receiving messages from those who are representing us at federal and state political levels. Messages are also circulating in consumer advocacy circles. The situation is volatile. Our inboxes are clogged, and our minds are too. It is difficult in the multiple conversations that are happening to see the picture clearly. It is difficult when under serious threat to know who to trust, who to avoid, and who to fight.
Differences of opinion are bound to exist, and to become more polarised as time passes. One key issue is professional indemnity insurance.
Organisations that seek to represent the interests of the maternity consumer have come out clearly supporting the mandating of professional indemnity insurance for all registered health professionals. This requirement has been written into the new health practitioner legislation, to come into effect 1 July next year, and appears to have strong political support. Midwives' organisations have also joined the band wagon with idealistic statements about every consumer needing to be able to sue if they suffer harm at the hand of their health care provider.
I don't know how smoke and mirrors work in magic shows, but they do the trick. Every time I see someone put on a self righteous face and talk about the importance of professional indemnity insurance in health care, I wonder if they really believe what they are saying. Are they in effect the children in the front row, believing everything they see and hear as the magician wows the crowd?
The only consistent winners in the professional indemnity insurance scene are the insurance companies - businesses which collect huge premiums, with government support for bigger claims, and the lawyers. The people who suffer as a result of professional misconduct, negligence, incompetence, or a potentially avoidable mistake face a huge complex legal process in making claims. They might do better buying a lottery ticket.
There is much in maternity care that is unknowable and unpredictable. The midwife who works in harmony with natural physiological processes in birth embraces the unpredictability of birth, and is ready to act to protect wellness at any time. This midwife promotes health in the leadup to the climax of birth. It is no secret that the safest way to proceed through the complex terrain of birth is to do so without drugs or surgery. And the person with the professional expertise to facilitate physiological birthing is the known midwife, working in partnership with each woman.
These words have been repeated over and over again in midwifery literature. I doubt there will be anyone reading this blog who does not know this fact.
Indemnity insurance for private midwifery practice has not been available since 2002. Will Nicola Roxon find an indemnity product that can be afforded by midwives, passing on the costs to our clients, and working within the constraints that inevitably come with the product?
Monday, August 17, 2009
APMA Media Release: Senate due to report - homebirth in or out?
Monday August 17, 2009.
Today’s Senate report into proposed legislation which effectively makes attending a homebirth outside of conditions of midwifery registration is being watched closely by the Australian Private Midwives Association. The Senate Community Affairs committee was asked to examine legislation which excludes homebirth from a government subsidised indemnity package – forcing midwives to cease homebirth practice and women to birth at home alone or with unregistered care providers. The legislation, the Health Legislation Amendment (Midwife and Nurse Practitioner) Bill 2009 and two other related bills is in response to the government's Budget measures enabling midwives to access the MBS and PBS and to receive high claims subsidies for professional indemnity insurance.
“We know that this Senate inquiry received over 2000 submissions indicating the depth of support for this issue as a fundamental women’s rights issue” said president of the Australian Private Midwives Association Liz Wilkes “We cannot believe that women will be denied the right to choose where they have their baby in a democratic society.”
The Senate committee heard from many major organisations in a hearing on August 6 and is due to report today.
“We have not seen any evidence that this legislation will make homebirth care safer, in fact it is just the opposite” Ms Wilkes added “The Federal Department of Health have indicated that women will be able to have a health care provider to attend a homebirth, they just won’t be able to be registered or to call themselves a midwife. This seems to be particularly ludicrous given that this is Australia and we are in 2009, not 1909.”
Whilst no clear reason for the exclusion of homebirth has been indicated there has been reference to the cost of indemnity by several sources.
“The Federal Health Minister has indicated that she may examine costing a package of indemnity including homebirth. We would welcome figures on this being bought into the public domain and for the process which determined costing to be examined” said Ms Wilkes. “We expect a supportive outcome of this Senate inquiry. There is a lack of anything to substantiate the governments exclusion of homebirth.”
Media – Liz Wilkes President APMA 0423 580585
in the press
From ethicist Leslie Cannold
Today’s Senate report into proposed legislation which effectively makes attending a homebirth outside of conditions of midwifery registration is being watched closely by the Australian Private Midwives Association. The Senate Community Affairs committee was asked to examine legislation which excludes homebirth from a government subsidised indemnity package – forcing midwives to cease homebirth practice and women to birth at home alone or with unregistered care providers. The legislation, the Health Legislation Amendment (Midwife and Nurse Practitioner) Bill 2009 and two other related bills is in response to the government's Budget measures enabling midwives to access the MBS and PBS and to receive high claims subsidies for professional indemnity insurance.
“We know that this Senate inquiry received over 2000 submissions indicating the depth of support for this issue as a fundamental women’s rights issue” said president of the Australian Private Midwives Association Liz Wilkes “We cannot believe that women will be denied the right to choose where they have their baby in a democratic society.”
The Senate committee heard from many major organisations in a hearing on August 6 and is due to report today.
“We have not seen any evidence that this legislation will make homebirth care safer, in fact it is just the opposite” Ms Wilkes added “The Federal Department of Health have indicated that women will be able to have a health care provider to attend a homebirth, they just won’t be able to be registered or to call themselves a midwife. This seems to be particularly ludicrous given that this is Australia and we are in 2009, not 1909.”
Whilst no clear reason for the exclusion of homebirth has been indicated there has been reference to the cost of indemnity by several sources.
“The Federal Health Minister has indicated that she may examine costing a package of indemnity including homebirth. We would welcome figures on this being bought into the public domain and for the process which determined costing to be examined” said Ms Wilkes. “We expect a supportive outcome of this Senate inquiry. There is a lack of anything to substantiate the governments exclusion of homebirth.”
Media – Liz Wilkes President APMA 0423 580585
in the press
From ethicist Leslie Cannold
Sunday, August 16, 2009
Countdown to 1 July 2010
Any woman who is hoping to conceive in the near future, and give birth in Australia, who is interested in private midwifery services, please stay in touch with private midwives in your area. We care very much about supporting you through the transition that we face.
Click on the photo to enlarge it, and you will see that if the first day of your menstral period is today, and you conceive with your next ovulation, your baby is likely to be born between mid-May and early June.
If the first day of your last menstral period is 10 September, and you carry the baby to 42 weeks' gestation, your baby could be born 1 July.
Please do not assume that midwives will abandon women who intend to give birth at home, or who would prefer to have a privately contracted midwife to attend them for hospital birth after 30 June next year. Please speak to private midwives in your community.
Australian Private Midwives Association
In the past month independent midwives across Australia have banded together under a new organisation, Australian Private Midwives Association, APMA. A management committee and office bearers have been elected, and email lists set up.
APMA "represents midwives in private practice. The association is focused on the safety of women, the ability of women to access quality midwifery care across Australia and the partnerships between women and midwives. APMA supports women’s choice in maternity options within a framework of quality and safety and believes in women being able to access midwives in all settings. APMA unites all midwives seeking to provide continuity of care for women. APMA strives to provide midwives in private practice with information relevant to their practice and advocacy in the political process."
APMA president and spokeswoman, Liz Wilkes from Toowoomba, made a compelling presentation to the Senate Inquiry on behalf of the organisation.
APMA "represents midwives in private practice. The association is focused on the safety of women, the ability of women to access quality midwifery care across Australia and the partnerships between women and midwives. APMA supports women’s choice in maternity options within a framework of quality and safety and believes in women being able to access midwives in all settings. APMA unites all midwives seeking to provide continuity of care for women. APMA strives to provide midwives in private practice with information relevant to their practice and advocacy in the political process."
APMA president and spokeswoman, Liz Wilkes from Toowoomba, made a compelling presentation to the Senate Inquiry on behalf of the organisation.
midwives' blogs tell the story
Several blogs have been presenting the story. Here are a few examples:
The question that was not answered
Insurance measures could force homebirth underground, Opposition says
Homebirth Whisperer
Homebirth, the masters plan
What assumptions underlie the costing of the government's midwife indemnity scheme?
Streaming from the Senate Committee Hearing
The Rally outside Nicola Roxon's office
and
and video footage
I would like to make a list of midwives' blogs at this site, and invite midwives who are blog keepers to trade links. In this way anyone who is interested in following the unfolding events leading up to 1 July 2010 is able to find and follow the links. Please contact me by responding in the comments section, or by email.
Saturday, August 15, 2009
A new midwifery primary care option
Hello!
I am Joy Johnston, and I am an independent midwife in Melbourne, Victoria [Australia]. This new blog is an addition to my villagemidwife blog, and my website.
I am one of the estimated 200 experienced homebirth midwives in this country who will lose our right to practise midwifery privately from 1 July next year, as a result of new legislation that mandates professional indemnity insurance.
I have set up Aitex Private Midwifery Services (APMS), as a transition from the model I have managed since 1993, working as a solo midwife, to whatever private midwifery services I am able to provide and coordinate after July 2010.
APMS has a dual focus: the birthing woman, and the midwife. APMS is a professional service which exists to provide one-to-one private midwifery care for women in pregnancy and birth, and to mentor and guide midwives in caseload midwifery for births in the home or hospital.
If you wonder why the title uses the word 'Aitex', this is the name of the family company that my husband Noel and I have managed since 1989. Aitex allows us to coordinate and share the resources, such as printers, computers, phones, website, and email addresses. Noel is a Veterinary scientist. He understands and fully supports my efforts to promote and protect health through working in harmony with natural, physiological processes in birthing and care of the newborn.
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