Thursday, February 26, 2009

What does the Report of the Maternity Services Review mean?

Having read the Report and its Recommendations, I understand that Australia could very well be looking at the end of private midwifery practice.

For those who aren't aware of the expected changes in regulation of midwives, and other health professionals, the new system of national registration is to be implemented 1 July 2010. Without insurance, self employed midwives will be unable to register. The hope within professional circles was that the federal government would provide the means by which indemnity insurance could be available, just as they did for the obstetricians when their medical defence organisations were in strife a few years ago.

The mention in the recommendations of 'consideration' of insurance for midwives (and privately practising midwives are the only ones who need it) is so couched in provisions and escape clauses that I for one feel it's a very remote possibility.

The 'consideration' of an indemnity arrangement would [only] be for "appropriately qualified and skilled midwives, within collaborative team-based models". What does the reviewer think a midwife is? Our qualification is obtained and kept within a standard process of education and annual renewal - just as is the case for other professionals. A midwife who provides primary maternity care, the most basic level of care there is, has skill working in harmony with the natural processes in pregnancy, birth, and care and nurture of a newborn baby. The definition of the midwife (ICM 2005)
requires a midwife to promote normal birth, and to work in partnership with women - amongst other things. Curiously missing from the government's Report is any notion of the midwife's duty of care to promote normal birth, and partnership with women ????

The use of the term 'midwife' throughout the document is incongruous with the international definition of a midwife. When you read 'midwife' in the report, it may make more sense if you substitute the term 'maternity nurse' or even 'obstetric assistant'.

By the end of this year, without a professional rescue arrangement, independent midwives throughout Australia will have to stop making bookings for births after 1 July 2010.

The report recommends providing indemnity for midwives in “collaborative team-based models”. What does that mean? Collaborative models usually have doctors and midwives working together – even though midwives do midwifery and doctors do obstetrics which is a different job. Even the privately operated midwifery group practices would not, I fear, be considered collaborative models.

Independent midwives do work in collaborative models. We make bookings at public hospitals for women planning homebirth - in Melbourne the Women's and Monash Medical Centre accept these bookings on the authority of the midwife's referral. If we consider a medical review is advisable we can write a letter of referral, and ask the hospital to advise on further action. That's collaboration, and it's consistent with common sense and the ACM national midwifery guidelines for consultation and referral. But I don't need to convince readers of this blog about that - it's obvious to anyone with their eyes open.

I don't understand the need of the Review to sacrifice the independent midwife - to use us as a scapegoat. We offer a service (one to one primary care midwifery with the option of homebirth) that is not available under other maternity models of care. Our outcomes are excellent.

What should the 250 or so women who plan homebirth each year in Victoria do? What should the 30 or so midwives in Victoria, who currently provide homebirth services, do?

Many of the submissions to the Review asked for consideration of homebirth as a publicly funded option. The Review has come back with a strong NO on that one. Why? Here are a couple of quotes ...

"Many of the consumers who participated in the Review consultation process had strongly held views about government funding for models of care that included birthing in a home setting. A number of submissions to the Review referred to the evidence of positive outcomes for homebirths for low-risk pregnancies. The Review concluded that, while homebirth is the preferred choice for some women, they represent a very small proportion of the total." (p20)

Excuse me! Didn't you notice that it's very difficult and costly to organise homebirth - surely the consistent small number says something about how important homebirth is?
"In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term)." (p21)

Sooo ... the midwives and women don't count - it's all about maternity health care professionals. Peace and harmony in the home is more important than equity and fairness. Homebirth does not require a bunch of experts - it's about well women giving birth with a midwife or 2 in attendance. It's not rocket science! But it gets better ...

"The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing
the expansion of collaborative approaches to improving choice and services for Australian women and their babies."

So the Review, in its wisdom, has decided that, rather than "polarising the professions" it will shut down the choice of homebirth.

Homebirth women, a minority group within the Australian birthing community, can be dismissed. They don't matter. Homebirth midwives, a minority group within Australian midwifery, can be deregistered. Our professional commitment, our livelihoods, don't matter.

And do you know what's a real worry? It's the silence of midwives - my colleagues in both private practice, and in employed midwifery. There has been very little discussion or comment on any of the forums, email lists, or blogs that I have checked out. Keep your heads down ladies. Perhaps it's just a bad dream?

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