Friday, March 05, 2010

Maternity reform hijacked 2

Consumer choice
The women who employ midwives privately do so for many reasons. In most instances a midwife is employed with the intention of promoting and supporting physiologically normal processes in birth. Since midwives do not have visiting access/ practising rights at hospitals, planned homebirth is the main setting in which Victorian midwives practise. Some women employ midwives privately to accompany them to hospital for the birth. The main reason is that with a private midwife a degree of partnership and trust are able to be formed, and the woman's preference for continuity of carer. While no-one can predict the course of events, the process of making informed decisions in labour and birth can be enhanced.

Evidence from Victorian and other Australian data collections, and international peer reviewed publications supports the effectiveness and safety of planned home birth in the care of a midwife, with access to specialist medical services when the need arises.

Normal midwifery practice includes the ability to refer and make timely decisions about the need to transfer care from home to hospital, or from a primary care facility such as a birth centre or hospital that does not provide emergency obstetric surgery to a higher level hospital. Victorian independent midwives, who have demonstrated accountability and transparency in their private midwifery practice over many years, have exemplary statistics, as recorded by the Health Department's Perinatal Data Collection Unit (PDCU). Planned homebirth, with a midwife as the responsible professional in attendance, is at least as safe a choice in Victoria as planned hospital birth, and the rate of interventions such as caesarean or other operative birth is very low. For example, the PDCU Performance Indicator analysis for standard first-time mothers who planned homebirth showed that 6.5% have caesarean births (DoH Letter dated 15 October 2009) which compares favourably with the statewide public hospital rate of approximately 15%, and the statewide private hospital rate of approximately 27% for standard primiparae in 2007-08 [Source: Victorian Maternity Service Performance Indicators, 2009].

The end result of this reform is likely to be that private midwifery practice will be further marginalised, forced into a grey zone, on the edge of legal practice, or even underground. The outcome of unrealistic restriction to private midwifery practice is that women who plan homebirth may look to unregulated maternity care providers, who are prepared to work outside the law. This cannot be considered safe or acceptable.

Who will be held accountable for adverse outcomes that could have been prevented, with a little bit of a sense of fairness in protecting the choice of consumers who wish to plan to give birth at home?

Competition considerations
Under the Trade Practices Act, government is required to promote competition in health policy, to ensure reasonable choice for consumers and defensible cost for government; that regulations stand or fall on whether benefits can be shown to be greater than costs.

The privileged monopoly that has been granted by successive Australian governments to the medical profession is indefensible in maternity services. While midwives are quite capable of providing primary maternity services for the majority of pregnant women, continuing as the responsible professional carer throughout the labour, birth, and postnatal period, this model of care is largely unavailable in our communities.
There is no public funding for private midwifery care.
Funding arrangements between federal and state health departments fragment maternity care, which is not good practice.
Medicare rebates apply to services provided by GPs or specialist obstetricians, while there is no broad access to midwife led models of care.
The Medicare safety net uses public funds to further privilege the private obstetric market.
Tax rebates on private health insurance also privilege the private obstetric market.

Despite repeated calls by midwives' associations, there has been no serious attempt to apply a public benefit test to maternity-related policies which provide a monopoly for the medical profession, and stifle competition by midwives.

Competition considerations include the need for public funding for consumers who choose maternity services provided by a private midwife, equity and parity with doctors in access for midwives to public funding support for private indemnity insurance, which would likely lead to visiting access for midwives to practise in public hospitals.

Policies for which a public benefit cannot be demonstrated must be repealed or modified so that they do not reduce competition.

For more comment on this topic, go to
Part 1 Background
Part 3, Professional Indemnity Insurance, and Collaborative Arrangements

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