The hospital problem

It's two years since our federal government's maternity reforms have provided significant new support for private midwifery practice.

Since November 2010, midwives have been able to provide taxpayer subsidised services to patients outside of the public system.  A search of Medicare statistics for the financial year July 2011 to June 2012 reveals that there were 16,474 'Midwife services' rebated, accounting for more that one million dollars of taxpayer's funds. 

A key component of the reform agenda was hospital access for births: that midwives would be able to deliver maternity care, including antenatal and postnatal care in the community, and, as the then Health Minister Nicola Roxon announced, "undertake deliveries in a hospital."  

Access for midwives to maternity hospitals has turned out to be problematic.  Except for Queensland Health, which has established processes for midwives to have access to public hospitals in Toowoomba, Ipswich, and Gold Coast, midwife-attended births in hospitals have not become a reality.

In fact, I have observed a gradual increase in resistance to midwives attending our clients privately in hospitals in Melbourne over the past two years.  I am trying to understand why this is happening.  Here are a few pieces of the puzzle:

• Private in public:  Melbourne's large tertiary maternity hospitals (Women's, Monash, and Mercy) employ specialist obstetricians rather than the visiting consultant who, in return, is able to use the service for his or her private patients.  The director of obstetrics at one of these hospitals has told me that 'private in public' is the major obstacle to midwives being granted clinical privileges.  
• Credentialling for clinical privileges: Smaller metropolitan and regional hospitals rely on doctors to provide consultancy services for obstetrics, anaesthetics, paediatrics, and other specialties, as well as GPs who provide primary care that includes basic maternity services.  The processes for credentialling of these doctors for clinical privileges in public hospitals are managed by each hospital, guided by the Health Department and the VMIA (public hospital insurer).  This process was expected to be extended to provide for credentialling of midwives, and meetings of key stakeholders were convened in 2011.  I attended these meetings, as representative of Midwives in Private Practice (MiPP)   A report was given at a conference in May, but since then there appears to have been no progress and the report has not yet been made public.
• 'Support person':  At present when a midwife in private practice attends a private client in a hospital (private or public), either with a woman who intended to give birth at the hospital, or when transferring from planned homebirth, we may be called a 'support person'.  This is a head in the sand mentality on the part of hospital employees: we are midwives, are accountable for all our actions, and have a real duty of care to those who employ us as midwives.  

Here are a couple of examples of the increasing resistance to midwives by Melbourne's public hospitals:

Recently I visited a mother and baby the day after the birth: the mother had experienced a complex and life threatening labour, and had been delivered by caesarean.  I introduced myself at the desk and asked if I could visit my client.  The nurse in charge told me somewhat grudgingly that she would let me in, but that I was not to discuss clinical matters with the patient.  I must have looked shocked (which I was).  "Why?  Is something wrong?" I asked.  "No, but you must not interfere with the hospital's care of patients", was the reply.  I informed the nurse that I had no intention to interfere; that I was there for the woman and I would discuss anything the woman wanted to discuss!  I reminded the nurse that 'patients' are not prisoners: that they are free to discuss anything with anyone. [see comment after this post]

Another private midwife was invited to meet with a senior member of the midwifery staff to discuss complaints about her behaviour in the hospital. A midwife in the birth suite had complained that she could not work with women who had this private midwife with them, because the women looked to their midwife for guidance and support!  (And this is a hospital where research has demonstrated a range of improved outcomes for mothers and babies when the woman is attended by a known midwife who has a personal caseload!  It's no secret that women value a trusting relationship with their own midwife.)


What should we be doing about hospitals?

Some Medicare-participating midwives have negotiated casual employment arrangements with a hospital, so that when their clients are admitted in labour, the private midwife becomes an employee of the hospital, and provides midwifery care for that woman.  The midwife is paid by the hospital for the hours of employment.   I do not see this as a solution - it's a temporary filler at best.  The Medicare provisions for midwife attendance in labour and birth cannot be applied: Item #82120, Scheduled Fee $739.25

Management of confinement for up to 12 hours, including delivery (if undertaken), if:

(a) the patient is an admitted patient of a hospital; and

(b) the attendance is by a participating midwife who: (i) provided the patient’s antenatal care; or (ii) is a member of a practice that provided the patient’s antenatal care

(Includes all attendances related to the confinement by the participating midwife)

[Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011]



Earlier this week I wrote about women's rights in childbearing, and quoted from the recently updated Cochrane review of planned hospital birth compared with planned home birth for low-risk pregnant women, in which the authors commented:

"It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications."

If maternity services are serious about basing practice on evidence; if the government is serious about providing maternity services that are appropriate and in the interests of safety and wellbeing of mother and baby, then the option of homebirth MUST be seriously addressed across the board.  As long as there are disincentives and professional biases that prevent the majority of women from accessing homebirth, and that prevent midwives from offering affordable private midwifery services in all communities, we will continue to see the cascade of interventions fast-tracking women and babies into medical emergencies.


Thankyou for your comments