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.
Friday, October 30, 2009
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.
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