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.

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]

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!)

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.