Midwife led maternity care

It's easy to rattle off phrases such as 'woman centred care' or 'continuity of care' or 'continuity of carer' or 'evidence based care' because that's the politically correct language (from a maternity care point of view) of our day. These words are popping up repeatedly in the documents that are being prepared by government agencies in preparation for the implementation of the government's maternity reform packages. We should all feel very confident, shouldn't we?

There is one evidence based care option that has largely been avoided in the process; 'midwife led maternity care'. It's not PC in Australian maternity circles to talk about anyone leading care. We are being told that we need to talk about 'collaborative' care.

Quoting from the NHMRC Draft National Guidance on Collaborative Maternity Care,
"Principles of maternity care collaboration:
1. Maternity care collaboration places the woman at the centre of her own care, while supporting the professionals who are caring for her (her carers). Such care is coordinated according to the woman’s needs, including her cultural, emotional, psychosocial and clinical needs.
2. Collaboration empowers women to choose care that is based on the best evidence and is appropriate for themselves and for their local environment.
3. Collaboration enables women to make informed decisions by ensuring that they are given information about all of their options. This information should be based on the best evidence, and agreed to and endorsed by professional and consumer groups.
...
9. Collaboration aims to maximise a woman’s continuity of carer by providing a clear description of roles and responsibilities to support the person that a woman nominates to coordinate her care (her ‘maternity care coordinator’)."
[you can read it all here]

It sounds excellent: the woman nominates her 'maternity care coordinator'. Those who want a midwife can arrange midwife led care. Right?

Not really. I will try to explain.

Some who want a midwife as maternity care coordinator will, hopefully, be able to have a midwife who is employed within public hospital birthing programs similar to those that already exist. The midwife will be able to coordinate the care, but only within the hospital's protocols, as is the case in many midwife care models today. That's where there may be a problem. These protocols are strictly controlled by the hospital's medical authorities.

This is not midwife led care.

It's a hybrid that restricts midwives, and is unlikely to make much difference to outcomes when compared with the standard care in those hospitals.

Examples of restrictions experienced by midwives working under hospital protocols are already emerging. A mother who has had previous home births, and who is booked in a hospital homebirth program (one of the Victorian government's 'pilot' homebirth sites) has been told she will NOT be permitted to have a physiological third stage. The midwife is REQUIRED to inject an oxytocic, actively managing third stage. Another mother who has had previous home births has been told she is not permitted to give birth at home under the 'pilot' because one of her previous births was a caesarean. She has been told that a pilot program is very closely watched, and her presence in the pilot would skew the figures.


A recent Lamaze blog post by Amy Romano, titled
What’s Behind the Cochrane? (or…, “The Good News About Midwives Gets Better!”) explores 'gold standard' research in maternity care. When we look at the best research evidence into models of maternity care, we can conclude that optimal care is midwife led care. That means a woman has a known midwife who not only provides the primary service throughout the pregnancy, birthing, and postnatal phases; who is the responsible professional in attendance at birth; and who accesses/ refers to specialist services when and if required.

Amy Romano warns:
"Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies."


At present there are very few options of midwife led maternity care in mainstream Australian public hospitals. (There are none in private hospitals).

What we don't know yet

The big changes facing midwives who provide private midwifery services and attend homebirths will be implemented from 1 July - only two and a half months away!
Most professional planning, particularly in the field of primary maternity care, is done many months before the date.  We know that we will be required to have professional indemnity insurance that covers everything we do professionally, excluding homebirth.
What we don't know yet includes:

Who will provide the indemnity insurance?

What that insurance will cost?

What 'excluding homebirth' means, precisely.  When does homebirth begin and end, for the purposes of this insurance?

What will we be required to do to access the exclusion for homebirth? 

We have been informed that the Quality and Safety Framework [see the MiPP blog], for which national consultations with stakeholders have been held, will be released next Monday 19 April.

As I have written previously on this blog, I am confident that private midwifery practice will continue past 1 July. We expect to be able to buy private indemnity insurance products that 'cover' all aspects of our practices, except homebirth, and to meet the other requirements that are yet to be finalised.

As far as I know, insurance brokers who are looking into providing this special insurance product for midwives' private practices have not yet put any offers on the table publicly. The Australian College of Midwives has informed members that it has a product which will be available for a fee in addition to membership fees. The Australian Nursing Federation (Victorian Branch) has informed members that it is also negotiating a product suitable for members who are independent midwives.

Midwifery group practices or business (such as the business linked to this blog, Aitex Private Midwifery Services) which employ midwives for private services will also need to access professional indemnity insurance to cover the services provided by their employees.

Questions about professional indemnity insurance for midwives

Questions asked in the Senate Community Affairs Committee in February by Senator Rachel Siewert have shone some light on the changes midwives are facing as a result of the federal government's maternity reform. The complete Hansard is available. I have selected excerpts below (in italics) for comment.

Under the maternity reform package that has now passed both houses of Parliament, midwives will be required to have collaborative arrangements with doctors in order to be eligible for the government's insurance product which will be linked to Medicare, prescribing and ordering tests.

The doctors are not *required* to reciprocate. The logical question that arises is, will the requirement of collaborative arrangements with doctors allow the doctors to control or veto midwifery practice?

This is not a far-fetched notion. Even today, before any of these reforms come into effect, some doctors refuse to provide services, such as ordering blood tests, if they know a woman is planning homebirth attended by a private midwife. Women have been told by their GPs that the GP is not willing to accept the 'risk', from an indemnity point of view, of collaboration with a midwife. Midwives who try to make collaborative arrangements with local hospitals, establishing transparent and seamless processes for referral and transfer to hospital care when appropriate often face barriers and difficulties.


The questions asked by Senator Siewert, and the responses by the Department of Health and Ageing (DOHA) are very useful for those midwives who are trying to understand how these reforms will impact on our ability to practise midwifery, and what changes we may be incorporating into our professional lives in the coming year.

It is clear from the Hansard excerpts below that some insurance providers would refuse to cover obstetricians or GPs whose collaborative arrangements with uninsured or 'underinsured' (ie no cover for homebirth) midwives. This is fairly logical, and will potentially put a stop to the midwife's efforts to comply with the law.  
Reforms that give with one hand and take away with the other are of no use to anyone.


The actuarial advice to the Department is interesting, being based on "the historical data relating to claims experience of obstetricians in Australia." Perhaps they could think of no better comparison. But it would be similar to comparing the risk associated with employing a swimming instructor to guide your child in developing skill in the water, with the risk of major surgery on the child. 


Hansard Page: CA 118

Senator Siewert asked:

When the Department asked medical indemnity insurers whether an insured doctor would remain insured if they have a collaborative arrangement with a midwife, even if the midwife is not insured for home births, can you give us the process that you have used, the questions that you asked and their response.

Answer:

Prior to Ms Huxtable’s letter to the Committee Secretary on 21 January 2010, the Department had spoken to four of the five medical indemnity insurers in Australia who insure doctors. The Department has since received written advice from all five insurers that a doctor collaborating with a midwife will not result in a doctor's medical indemnity policy becoming 'void'.

The five medical indemnity insurers were asked to respond to three questions.

1. Would a medical indemnity policy issued by your insurer to a member/insured respond on behalf of the insured in the event of a claim against the insured in relation to an incident that involved collaboration with a midwife?
All insurers responded "Yes"; with most noting that this would be to the extent that their insured was liable and was acting within the scope of practice covered by the policy.

2. Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an uninsured midwife? If so, what is the reason for the policy not responding?
Four of the five insurers responded "No". The fifth has responded to two member queries. The insurer’s answer is at Attachment A.

3. Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an underinsured health professional (including an underinsured medical practitioner)? [Note: 'underinsured' refers to a situation where an insured is not insured for the full scope of his/her practice, and where the insured actually provides services in relation to his/her full scope of practice during the period of cover.]
Four of the five insurers responded "No."

The fifth responded as follows:
“Members are certainly advised that they must select the appropriate practice category, retroactive date, make accurate declarations of risk history etc. Members who are acting as supervisors/trainers are advised that they must have the appropriate qualifications/training and experience for the nature of their practice and select the appropriate practice category for the training/supervision they are providing. Trainees providing health services under the supervision of a trainer rely on the indemnity of the trainer and are advised of the expectation that their trainer/supervisor must have the appropriate qualifications, training and experience and indemnity for that role. That advice is provided because if not then they are in effect “underinsured”. The situation of anticipating underinsurance however does not normally arise (and hasn’t previously to my knowledge) because underinsurance is not usually known until after the event and usually at the time the claim is made.

That is not the situation here as it is now understood that midwives currently do not have any medical indemnity insurance for home births.”
Attachment A
Response from an insurer to questions about doctors collaborating with midwives

Question 2

Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an uninsured midwife? If so, what is the reason for the policy not responding?
I understand that the insurer has been contacted by 2 members in relation to midwife queries.

The first contact (some months ago) concerned a hypothetical situation requesting the insurer’s views on the scenario and the level of cover afforded by the Insurance Medical Indemnity Insurance Policy in such a situation.

The Underwriting Committee reviewed the scenario and in response to the questions asked advised that;

 There is a general requirement that members have the appropriate recognised qualifications, training and experience for the health services they provide.

 The insurer’s Constitution at 1.2 details Objects of the Company and states at 1.2(c) “to promote honourable and to discourage irregular practice”.

 The medical indemnity insurance policy does not cover independent contractors and in the event of a claim in relation to the actions of an uninsured health service provider, any associated/related health practitioner could also be named in proceedings even if due only to the fact that they held indemnity insurance.
Consequently, it was the view of the Committee that the scenario put forward (where an injured mother or baby may not have access to compensation) did not meet the insurer’s requirements under its Constitution. The Committee observed that on this basis it would not seem appropriate for a member to be involved. The Committee also observed that there was no appropriate practice category for the nature of practice proposed (which was not shared care as defined and not obstetric practice).

The Committee stated that based on the scenario presented that if a member notified the insurer that they were to become involved in such practice (such notice being a requirement under 5.1.5 of the Insurance Policy), that it is likely that the insurer would give notice in accordance with 12.2.2 of the Insurance Policy (where the insurer asks the policyholder to cease a practice and if they do not do so, cover will cease for that practice after 14 days).

The Committee observed that the above would not apply to actual good Samaritan or emergency matters where there is no expectation/anticipation of a member’s involvement in the care of the patient.

Member contact 2 (this week). In summary the member held a “General Practice - consultations and office procedures (non-procedural) practice category. GP’s in that practice category who meet the general requirements of appropriate recognised qualifications, training and experience are permitted to provide shared ante-natal care. As required under shared care the member had referred the pregnant patient early to hospital to book in and had continued to provide care appropriate for shared ante-natal care on that understanding.

The member wrote to us because it had subsequently come to their attention that the patient had not presented the referral/booked-in to hospital and apparently intended to have a midwife assisted homebirth.

The member was advised that;
 their current practice category was no longer appropriate (as they were no longer providing shared-care as defined)
 if there was an intention to continue to provide ante-natal care outside of the shared-care requirements permitted under their current practice category
 that they needed to provide the insurer with documentation showing that they had the appropriate recognised qualifications, training and experience for any expanded ante-natal role and

 members who met the qualification, training and experience requirements for management of pregnancy outside of shared-care arrangements normally selected an Obstetrics category.”


Hansard Page: CA 119

Senator Siewert asked:

Could you provide us with the data on which the actuarial assessment was based that assisted the Department to work out the cost of the Commonwealth supporting indemnity insurance for midwives, particularly midwives who are practising in hospitals and the numbers of births and dangers thereof. Also tell us if state by state is relevant information.


Answer:

The assessment by the Australian Government Actuary was based on the historical data relating to claims experience of obstetricians in Australia. Other matters were factored in, including the key assumptions listed below.

The Actuary’s analysis assesses actuarial and financial risk, rather than the clinical risk of dangers of birth. The actuarial analysis was prepared at a national level and the Actuary was not asked to undertake state by state analysis, as the small number of midwives would not have led to meaningful analysis.

Key assumptions were:

Number of eligible midwives 196 midwives in 2010-11, rising to 712 midwives in 2013-14
Average claim size $227,000
Percentage of claims over $1 million 7%
Number of claims per 1,000 births 1.1 claims
Full time caseload of each midwife 40 births per annum
Claim inflation rate 6%
Claim discount rate 6%

Countdown - 3 months

A midwife's life follows the progression of time as babies in their mothers' wombs develop. I have a calendar on the wall of my office with the names of women in my care written at the time their babies are due. These names are ticked after the baby has been born.

The other gestation that we are watching carefully is the progression towards broad reforms of midwifery regulation in this country, that will remake the face of maternity care.

The big milestones will be:


#1 1 July 2010, when legislation mandates indemnity insurance for all registered health practitioners, with a 2-year exemption for certain midwives attending home birth.
#2 1 November 2010, when eligible midwives will be able to provide services that attract public funding via Medicare rebates. Prescribing medications and ordering pathology tests will also be part of this reform.
#3 1 July 2012, when the 2-year indemnity exemption for homebirth expires.


I am confident that private midwifery practice will continue past #1, 1 July.  We expect to be able to buy private indemnity insurance products that 'cover' all aspects of our practices, except homebirth, and to meet the other requirements that are yet to be finalised.
I am also becoming more confident that a means will be found whereby some established independent midwives will be able to incorporate #2, the Medicare and related reforms into their practices.

Some midwives will seek to continue private practice without public funding.  The reasons they will give for taking this approach include

• too many bureaucratic hoops to jump through
• professional decision making being constrained by impersonal guidelines
• excessive paperwork anticipated
• fear of ... 

The requirement for 'collaboration' by midwives has been written into various levels of the new regulation.  The picture that has been erroneously painted is that independent midwives set ourselves up as a 'one-stop shop', avoiding collaboration with the medical profession.  This is untrue.  This is fear-mongering by those who do not want midwives recognised in Australia as professionals with a discreet body of knowledge and scope of practice.


Under the legislative reforms, midwives will be REQUIRED to have collaborative arrangements with doctors. 
Doctors will not be required to return the favour.

I have concluded that the most obvious meaning of the verb 'collaborate' - to co-labour or to work together - is not understood.

Last week I attended a meeting hosted by the National Health and Medical Research Council (NHMRC), in which stakeholders were given an opportunity to comment on a draft document 'National Guidance on Collaborative Maternity Care'.  This is an extensive document that has a lot of good midwifery stuff in it.   A great deal of government funded work has gone into fixing a problem that doesn't exist.


When we move the focus of maternity care from the providers (midwives/doctors/hospitals/health services) to the individual pregnant/birthing woman (+child), the needs of the recipient(s) of care direct the service, rather than the service directing the recipients.

This is woman-centred care.

A woman who is well, and progressing without complication through pregnancy and birth, in the care of a midwife does not need to be seen by an obstetrician, a GP, a neurosurgeon or any other doctor.  Collaborative arrangements are in place, without being enacted for that episode of care.  But a woman who develops severe headaches in pregnancy may access specialist care (not necessarily healing or wellness, unfortunately) when the midwife coordinating her care advises her to consult with an obstetrician, who may refer her on to a brain specialist. 


Enough from me for now!
Joy

controversy about breech births

Breech Birth Woman-Wise, published in 1998 by NZ midwife Maggie Banks, is an excellent and very useful resource for midwives and for women considering the need to give birth to a breech baby.


*****
 Tomorrow the first year medical students at Monash University will be exposed to some of the contorversy that exists around breech births. The class is Sociology. Most of these students are bright young school leavers whose almost perfect scores in their VCE exams have allowed them to take their first step into the privileged world of medicine.

The course seeks to expose the students to the views of a range of participants, including women who have had a breech baby, midwives in private practice, private obstetricians, and lay birth support people. I have participated in this class for several years now. It would be easy in this debate to present a black and white, 'medical/surgical' versus 'midwifery/holistic' scenario, but that would not be truthful. I hope to demonstrate informed decision making that occurs within a professional relationship between mother and her known midwife.

The aim of the class, and subsequent tutorial discussion, is to ensure that the students understand that people have divergent views on professional bodies of knowledge that inform decision making in maternity care, and develop some understanding of the roles of individuals within maternity care.


Four instances of breech birth come to mind. By telling the stories of these mothers and their babies, I hope to share my knowledge in a way that will be useful to others.

We will call the four women A, B, C, and D.

They were all well women at Term, and the reason they are appearing in this account is that their babies were all presenting bottom-first, breech. This presentation occurs naturally in approximately 3-5% of babies at Term.

Mother A was pregnant with her first baby. At 37 weeks' gestation, after abdominal palpation and auscultation (listening to baby's heart sounds) the midwife was confident that A's baby was breech. After discussion A decided to request external cephalic version (ECV). However the obstetrician who performs ECVs disagreed with this plan, as ultrasound showed that the level of amniotic fluid aroung A's baby was less than normal. The obstetrician recommended elective caesarean surgery. A's choice was breech vaginal birth, against medical advice, or elective caesarean. She chose caesarean.

Mother B, pregnant with her second baby, was planning homebirth with an independent midwife. At 38 weeks' gestation, B told her midwife that she thought her baby was presenting as breech, as she was aware of a hard round lump (her baby's head) just under her ribs. B went to the hospital and requested ECV. Her request was denied, and she was told she would be scheduled for caesarean surgery. B went home and arranged acupuncture and moxibustion from her traditional Chinese medicine practitioner, without the desired effect. After several subsequent conversations with hospital staff, B was able to arrange a consultation with the obstetrician. B convinced the obstetrician to attempt ECV, having informed the doctor that she intended to proceed with vaginal birth whether the baby had turned or not. The ECV was successful, and B gave birth at home the next day.

Mother C, pregnant with her second baby, was booked to give birth at a suburban private hospital. C's doctor was happy with her condition when he checked her at 38 weeks. At 39 weeks' gestation C's labourb began spontaneously. C arrived at hospital in strong labour, and shortly thereafter her membranes ruptured. The presence of unmixed meconium in the amniotic fluid suggested undiagnosed breech, and with the next contraction the baby's feet were visible. The hospital midwives called the doctor urgently, and he said he was on his way. The midwives prepared C for 'delivery' - lying on her back on the bed, with her legs in stirrups. About 10 minutes after the waters had broken, the baby's body was visible up to the shoulders. There was a small bright bleed, and the baby became pale. The umbilical cord stopped pulsing. The doctor arrived only a few minutes later and delivered the baby's head, and proceeded with resuscitation of the baby - artificially stimulating heart beats and breating. The baby was taken to special care nursery, and although he survived, he was later diagnosed with cerebral palsy which was thought to have resulted from the hypoxia at the time of his birth.

Mother D, pregnant with her fourth baby, was planning homebirth with an independent midwife. At 35 weeks, the midwife and D both suspected twins, and D had an ultrasound which confirmed the suspicion. The leading twin was breech. The midwife advised obstetric review, and agreed to support D in her plan for vaginal birth unless there was a clear reason why this would not be safe, and D wanted to change her plan. The obstetricians who D consulted were strongly opposed to any plan for vaginal birth. The midwife then contacted another hospital, where a couple of obstetricians were known to support vaginal breech births, and vaginal twin births (not necessarily at the same time). These doctors also strongly advised D to accept caesarean surgery, and once again, D refused. D was confident that she would be able to give birth spontaneously. She agreed to plan hospital birth in case emergency surgery was needed. D came into spontaneous labour one morning, and proceeded to give birth to her first twin (breech) at 10.30am, her second twin (cephalic) at 11.30 am, and they all went home that afternoon.


Mothers today have many choices, especially in childbirth.  A mother who is informed about the options is able to weigh up the potential positive and negative aspects of any choice that she considers, and reach her own conclusion.

There was no 'informed choice' for mother C.  Undiagnosed breech is a phenomenon that is likely to continue occurring as long as babies are being born.  The point is that midwives and many doctors have been de-skilled in breech vaginal births.  As in this case, the baby needed to be born immediately, and the few minutes delay in waiting for the doctor to arrive may have cost dearly.  In this instance the position of the mother, supine rather than upright, may even have delayed the baby from being born spontaneously.  It's a true story - we will never know what would have happened if.

Maternity reform hijacked

With the passing of the federal government's national health practitioner regulation legislation, and subsequent legislative amendments in states and territories, changes which are claimed will improve maternity care options for women have been made to the regulation of midwives.

Midwives in Australia, and particularly in Victoria, can not at the present time work to their full professional capacity. This package of reform had the opportunity to
• disable anti-competitive restrictions to midwifery,
• leading to improved maternity outcomes for mothers and babies,
• increased choice for consumers and access to midwife led models of care both in the community and in hospitals, and
• better career options for midwives
• with the potential for less attrition from an already stressed workforce.

However, this legislation [Statute Law Amendment (National Health Practitioner Regulation) Bill 2010] and linked bills nationally do nothing to address the current state of affairs for midwives. While other comparable OECD countries (eg UK, Netherlands, Canada, NZ) recognise the midwife's scope of practice as a primary health care professional, with responsibility to work on her/his own authority, midwives in Victoria will continue under this legislation to be unreasonably restricted, effectively fulfilling a role of obstetrician's assistant, doing what the doctor orders.

Whether you look at this so called reform from a consumer choice angle, or from a competition policy - Trade Practices Act (ref Hilmer report) perspective, or from a professional's right to practise in that profession without interference from another profession, this package is a prime example of socialist health policy being selectively applied to a section of the community, at the direction of the medical profession which has a clear interest in keeping midwifery in the status quo and preventing increased competition. This, and other health related reforms are examples of the federal Labor government's extreme style of bungling bureaucratic micromanagement, as is now progressing with reforms to the management of public hospitals. The roof insulation debacle, led to tragedy and loss, and yes, we believe this reform could also result in avoidable deaths and loss

Background
Until as recently as 1995, midwives in Victoria practised under an archaic set of rules, the Midwives Regulations 1985. These regulations included the requirement that midwives
• must wear clean clothes of a washable material
• must act under the supervision of a doctor
• must not perform a vaginal examination without a doctor's permission.
[Whose vagina? one might ask.]

The midwife of that set of regulations more resembled the gin-sodden crone who Charles Dickens called Sairey Gamp, than the well educated professional midwife who was practising in Victoria in the 1990s, and who may still be attending births today.

The Midwives Regulations 1985 sunsetted in 1995, and were not renewed. Under the new Nurses Act 1993 there was no Register of midwives: midwife became an 'additional qualification' noted on the nurses register. The apparent 'trade off' for midwives was the expectation of professional self-regulation.

With the expectation that the Midwives Regulations would sunset, the new Nurses Board of Victoria called together stakeholders with an interest in midwifery, and in 1996, published a Code of Practice for Midwives in Victoria. This Code of Practice was based on the International Confederation of Midwives' Definition of the Midwife, which had been endorsed by the international Obstetrics and Gynaecologists' professional organisation (FIGO), and World Health Organisation.

The Code of Practice promoted the principles of woman-centred care, partnership between the midwife and the woman, competence of the midwife, and collaboration between the midwife and other providers of maternity services. These principles were, and are still today, in harmony with best practice standards in midwifery. The Code of Practice was acclaimed as world class, and ushered in significant changes in mainstream midwifery practice in this State.

At the same time, other countries such as New Zealand and Canada had introduced legislation which significantly reformed midwifery and the maternity care terrain. Midwives in New Zealand were able to be the LMC, the leading maternity carer, or primary maternity care provider, for women throughout the pregnancy-birth episode of care. Women were able to choose their own LMC.

Midwives gained the entitlement to equal pay with doctors when providing equal services in maternity care, visiting rights to practise in hospitals, and other reforms such as prescribing and ordering tests. Midwives in Australia do not have these rights, and the federal government's reforms around Medicare and prescribing for midwives are a dog's breakfast of uninformed bureaucracy, which is likely to make eligibility beyond the reach or interest of most skilled midwives.

For more comment on this topic, go to
Part 2 Consumer choice, and Competition Considerations
Part 3 Professional Indemnity Insurance, and Collaborative Arrangements

Continuing the countdown ... February

As we progress toward 1 July, just over 4 months away, independent midwives continue to have many questions, and no answers, as to what the regulation of our professional activity will look like after that date.  Many of these questions are linked to the 'exemption' from indemnity insurance for midwives attending homebirth.  I have written about that at the MiPP blog.  Only those midwives who have been granted the exemption will be able to attend homebirths lawfully.

Questions midwives are asking include:

Will all midwives who are currently attending homebirths be granted the exemption, and thereby be permitted to continue providing this service for the coming two years?

Will I be able to continue to earn my living lawfully as a midwife?  If not, what will I do?  [join the dole queue?]

What will the women who are planning homebirth do?

We have no answers yet to these questions.

Some midwives have already declared that they are not accepting bookings post 1 July.  Others (including me) are informing women who inquire that there is a degree of uncertainty, yet we are optimistic that a way will be found through the uncharted terrain.  Many midwives are distressed and angry.

The Victorian consultations around the national Quality and Safety Framework for the exemption from profession indemnity insurance for homebirth are booked for next Thursday 18 February.  The consultation team, appointed by the Victorian health minister, will listen to presentations in capital cities, and will come up with a set of rules that all midwives who are given the exemption will be expected to follow.  The process for governance, or policing of compliance will also be decided.

There is a pessimist in me that says it's likely those rules have already been written - that we are giving the health department the opportunity to tick the box that they have 'consulted' with stakeholders.

Yet I am holding on to enough optimism and belief in the value of authentic midwifery, that if enough people speak the truth, it might get through.


Private or independent midwifery should not, in my opinion, focus exclusively or even primarily on home birth.   The midwife's commitment is to the woman and her child, not to the setting in which the care is provided.  Home is a very wonderful and reasonable choice for most women, but is not the ultimate. 



Midwives provide primary maternity care that is tailored to each woman's personal needs and choices, as well as being based on best standards of contemporary midwifery practice. Studies have shown that women who receive care from the same midwife or small group of midwives throughout pregnancy and birth have improved outcomes and greater satisfaction than those who do not receive continuity of carer.

Midwives providing private midwifery services:

· seek to establish a one-to-one partnership with each woman

· limit the number of clients booked so that we can provide a personal, reliable service

· commit to being with each woman as her personal professional carer throughout the episode of care. This sort of midwifery practice is often referred to as ‘caseload’ midwifery

· commit to being with each woman in the setting she chooses for her birth, either home or hospital, and with the personal support team that she chooses

· If you give birth at home your midwife will give you the paperwork required for registering the birth, claiming the ‘Baby Bonus’, adding your baby’s name to your Medicare card, …

· If some unforseen circumstance prevents your midwife from attending you, a colleague will usually be able to stand in for her.


A midwife’s unique skill in providing primary maternity services is her ability to work in harmony with natural processes, to promote health, and to enhance wellness in both mother and baby. In situations where a mother or baby experience illness or complications the midwife continues to provide the personal midwifery care, while collaborating with medical services and specialists as we seek to provide appropriate care.


The main choice a woman has to make in primary maternity care is a very basic choice: to proceed without intervention/interference/interruption, or not. Provided there is no valid reason to interfere with the natural processes in birthing, midwives recommend, and support women to work in harmony with their own wonderful bodies, rather than relying on drugs and other medical or surgical processes, which all have side effects and a potential to cause harm.


Sometimes it’s not clear, and there are choices that a mother needs to make about a course of action. A midwife will seek to provide information, and answer questions, so that the client can make an informed decision.

We look forward to accompanying each woman on her wonderful, personal journey, as she brings a new life into her family and community.

Joy Johnston

Do midwives ignore science?

This week I was interviewed by the producer of Channel 7's Today Tonight program. The questions were about the safety of homebirth, in response to the paper published recently in the Medical Journal of Austraila, 'Planned home and hospital births in SA, 1991-2006: differences in outcomes'.

For more detail about this publication, and links, go to the MiPP blog.

This is important topic, and I am pleased to be asked to comment.

The producer quizzed me several times about safety.
How can I, a (mere) midwife, disagree with the conclusions published in a scientific journal?
Didn't I know that doctors go to university for 8 or more years?
Didn't I know that animals die out there in the wild?


I pointed out that no matter how educated they are, doctors don't practise midwifery.   Midwives do.  

I hope I answered in a useful way, and I hope the little part of the recording that ever reaches the television screen will be true and helpful. When I reflected on the questions later in the day, I wondered if the producer knows about statistics: that they can be manipulated and used to deceive. 

The paper, written by leading epidemiologists in South Australia, makes claims that perinatal death and particularly death from asphyxia are more likely to happen in the group of planned home births - those babies whose mothers planned to give birth at home - compared with those babies whose mothers planned to give birth in the hospital. I do not question their findings. 

It's the conclusions that are drawn that I question. 

Note the emphasis on 'planned' home births. These are not actual home births. Many of these deaths happened in hospital despite the interventions and monitoring carried out in the hospital.

Does anyone turn the spotlight in the same way on the outcomes for women who planned to give birth in the big private hospital in Melbourne, known in the trade as 'Caesar's Palace'?  Of course not.  That would be bad for business. 

The authors themselves have given enough information that a fair minded person using the intra-occular statistical test (it hits you between the eyes) would conclude that there is a great deal of safety in the planned homebirth model of care.  In the body of the paper, the authors state that "in the 16-year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth, or timing of transfer to hospital might have made a difference to the outcome." (p79)  An amazingly significant statement.  Just think about it!


The focus that this paper, and indeed the focus our society places on 'planned' place of birth places an unrealistic, and in my opinion, undue emphasis on the planned setting for birth. Noone can predict outcomes, regardless of the model of care.

The best standard of care available for any well woman with an uncomplicated pregnancy is primary care from a known and trusted midwife, who has the skill to work in harmony with natural processes in birth, and who is able to move seamlessly from home to hospital if required. The woman is able to come into labour spontaneously, to progress without undue interruption or interference, and to make decisions about obtaining medical/hospital referral if the need arises.

The paper appears to trivialise the outcomes for women who want to give birth vaginally after a previous caesarean, stating in the Discussion that "several women accepted for home birth also had previous caesarean sections." (p79) Elsewhere in the same paper it is stated that "From 1998-2006, 56 of 635 women (8.8%) with a previous caesarean section planned a home birth, of whom 32 (57%) gave birth at home." (p77) That's a few more than "several"!
There is no evidence given of poor outcomes for these women, yet women who have had a previous caesarean birth are amongst those considered to have risk factors which some would consider require the greater fetal surveillance that is practised for births after caesarean in hospital. The State government's Policy for Planned Home Birth in South Australia, which is used in government funded homebirth programs, does not permit women who have had a previous caesarean to plan home birth:

"Contraindications:

...

6.4 The following conditions preclude a woman giving birth at home.

Obstetric history—previous:

�� caesarean section;" (p7)

I, and my midwifery colleagues, do not lightly discount a paper such as this one.  Our first concern is the wellbeing and safety of mother and baby.  I find that midwives and homebirth mothers/parents are very cognisant of the scientific literature. A retrospective study such as the SA one must be understood in context of its own limitations, and put next to other reliable sources of information.

In fact the SA study gives considerable evidence of the safety of home birth for those who actually give birth at home, in the care of a midwife.

MOTHERBABY SUPPORT GROUP

Mothers with babies in their first year,
and pregnant women
are invited to join our 

Motherbaby Support Group

The group meets fortnightly through the school term, providing

· Mother to mother peer support

· interactive adult learning for mothers,
with midwives, in a setting that
promotes and protects wellness in birth and mothering

· responsiveness to issues raised
and experiences encountered, and much more

For more information, call Joy Johnston
04111 90448 - 03 9808 9614
or email joy@aitex.com.au

http://privatemidwiferyservices.blogspot.com/

http://villagemidwife.blogspot.com/

Birth and Breastfeeding

My holiday reading this year has been Michel Odent's Birth and Breastfeeding (First published in French 1990, in English 2003, Reprinted 2007).
Not that I have had many days to devote to reading!

Dr Odent's writings have been familiar terrain for me for many years, and I am indebted to this man for his persistent efforts to describe and explain the natural physiological processes in everything to do with childbearing.  The subject keeps me attentive for new information, as well as on the lookout for anything I find implausable, and need to think more critically about. I do not want to be a gullible 'true believer' in my understanding of these topics.  Birth and Breastfeeding did not disappoint.

There are several questions posed in a postscript, and I copy three of them here for further refection:

• What if maternal qualities become the main criterion for the selection of aspiring midwives?  The need to feel safe without feeling observed or judged is satisfied by the proximity of a mother-figure.
• What if obstetrics becomes a medical discipline at the service of women and midwives?
• What if the Caesarean section recovers its status of a wonderful rescue operation, while obstetric forceps find their place only in the museums?
  

continuing the countdown

The context of writing this post is that it's hot outside. Melbourne has sweltered yesterday and last night, and I am thankful for air conditioners in houses and cars. My thoughts go out to all mothers with new babies.

I have no new news since my last entry on this blog.

A couple of draft documents that will have an impact on the way midwives practise privately after 1 July this year have been circulated, and I am doing what I can to prepare responses. Other midwives and birth activists are also committing precious time to writing responses.


The most significant matter at the moment (from where I sit) is the exemption of birth from indemnity insurance. See the MiPP blog for the current news.

The big question is, Which midwives will be allowed to access the exemption from indemnity insurance?



The draft framework document once again raises the idea of mandatory
". evidence of formal arrangements for professional and medical backup as demonstrated by signed letter from collaboration partners"

This requirement itself would exclude most midwives from access to the exemption, unless the government also provided, at considerable cost, a bureaucratic system that established a process to tick the box - a silly notion. Even though I respect and from time to time work with various obstetricians, I don't have obstetricians who I could ask to give me a signed letter of collaboration. I and others will be arguing this in our submissions to the inquiry, and we believe we can use a letter from Health Minister Roxon in preventing this particular requirement from being adopted into regulatory processes.

I believe every midwife should be free to choose to work in a private, self employed capacity, practising midwifery. Therefore every midwife should be able to claim the exemption from indemnity insurance for attending birth, either in the woman's home or in hospital. Midwifery is a discreet scope of practice that limits what a midwife can, and cannot do.

Secondary regulation, which this draft framework is, can not be used to replace or preempt the basic regulation of the midwifery profession. There can be only one gatekeeper into the midwifery profession in a jurisdiction, and the body with that responsibility is the regulatory Board, which has the authority to investigate, take disciplinary action, and in extreme cases, remove or restrict the practice of a midwife. This grave responsibility cannot be delegated to insurance providers or other regulatory panels.

I think we, independent midwives, have to approach this framework as positively as we can. We are the privately practising midwives of Australia; we are legally registered to practise midwifery. We have already argued to the Health Minister and the Senate hearing why it is unreasonable to mandate the signed collaborative agreement, and those arguments, which appear to have achieved some significant changes, can be aired again. Midwives are able to produce evidence of collaborative practice (however it is defined). We draw the line on having double jeopardy at the hands of a competing profession, obstricians.


There continues to be a degree of uncertainty about how private midwifery will look after 1 July, when the government's reforms will come into effect. I am hopeful that there will continue to be a place for every midwife to attend women who choose their care, whether it's through publicly funded programs or privately.

Countdown to July 2010

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.

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.

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.

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.

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.

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.