Friday, October 29, 2010

Midwives with Medicare 2

During this past week there has been an increse in activity in preparation for the advent of the medicare-midwife next Monday 1 November.

Midwives seem to be positioning themselves in two main camps: pragmatism, making the best of the situation, on one hand, and resistance to what is seen as removing the midwife's right to autonomy in practice as well as threatening the woman's right to informed consent. Much of the disagreement centres around legislation requiring a collaborative agreement between a midwife and a named doctor in order for the midwife to be able to access Medicare funding, and visiting access in hospitals for intrapartum care.

The Australian Private Midwives Association (APMA) position statement on Collaborative arrangements [click here] opposes the Determination, contending that:
"Private practice midwifery will become known as the model whereby midwives are working in private medical practices, with little regard for those self employed midwives who currently provide true midwifery care at this current time."

A recent meeting between the Health Minister Nicola Roxon and four independent candidates who stood in extremely marginal seats in this year's federal election, and maternity activist Justine Caines, has given rise to an interesting report published anonymously at the APMA blog. The writer indicates that
"It is possible that the Gillard Government is contravening its responsibilities under the Convention of the Elimination of all forms of Discrimination Against Women (CEDAW)."... and
"The political cost has been high with Minister Roxon embarrassed by poor advice."
 The Australian College of Midwives (ACM) has promoted the pragmatist position, with statements such as:
"The College maintains the view that while this Determination is a poor piece of legislation we need to continue working with the Minister’s Office and the Department of Health and Ageing to provide evidence that will support the Minister in making any necessary changes. The College is dedicated to ensuring that midwives and women are not disadvantaged by this legislation." (e-Bulletin 29/10/2010)
 Leaders in ACM have encouraged members to accept the Determination, indicating a fear that the whole maternity reform process could be derailed if there were to be a motion to disallow the Determination, and that motion were passed.  The reforms that enable midwives to claim Medicare funding, and have limited prescribing rights, and the right to order basic tests and investigations are seen as being of great value to the profession as a whole, while the potential disadvantage that comes with a return to medical supervision of a midwife's practice, sold under the guise of team work/collaboration, is seen as an acceptable trade off.

Midwives continue to work through these issues.

I hope to be able to keep readers informed of progress.

Monday, October 25, 2010

Midwives with Medicare

sisters Anna and Jenni, and their beautiful babies

Today I have checked through the application form that midwives are required to complete in order to obtain a Medicare provider number.

I would love to be able to say to my clients that from 1 November they will be able to claim Medicare rebates on my fees. However, as I do not yet have a doctor who will meet the legal requirements of the Midwives Collaborative Arrangements Determination I cannot proceed with any such application.

If you want to check the full detail of the Medicare fee schedule, go to the Federal Register of Legislative Instruments F2010L02640. [I can't find the link, but I have the document saved as a .pdf]

Here are a few examples of the Medicare fee schedule for a participating midwife's services:
Item 82100
Initial antenatal professional attendance by a participating midwife,
lasting at least 40 minutes, including all of the following:
(a) taking a detailed patient history;
(b) performing a comprehensive examination;
(c) performing a risk assessment;
(d) based on the risk assessment — arranging referral or transfer of the patient’s care to an obstetrician;
(e) requesting pathology and diagnostic imaging services, when necessary;
(f) discussing with the patient the collaborative arrangements for her maternity care and recording the arrangements in the midwife’s written records in accordance with section 2E of the Health Insurance Regulations 1975
Payable only once for any pregnancy

Item 82120
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)
Payable once only for any pregnancy (H)

Item 82130
Short postnatal professional attendance by a participating midwife, lasting up to 40 minutes, within 6 weeks after delivery

Clearly it would be in the intersts of both the woman and the midwife for this funding to be accessible. Midwives practising in homebirth would at least be able to give their clients the benefit of rebates for prenatal and post natal visits. Once midwives have visiting access at public hospitals (this is still theoretical), women who choose to have their own midwife attend them at a hospital would be able to claim a substantial rebate for the fee.

As I have considered how I could possibly comply with these requirements, without giving up my integrity as a midwife, the only pathway I can see is if I can obtain a collaborative arrangement with a public hospital. In effect, that's the way I have collaborated with the medical profession for many years. My clients have homebirth backup bookings at (usually) the Women's, Monash Clayton, or Box Hill. If medical referral is needed at any time through the episode of care, the medical team on duty at the time accepts the referral.

I will keep readers informed as we progress down this pathway.
A quick calculation of the fees payable by Medicare for:
  • an uncomplicated hospital birth (1 midwife) $1504.65
  • antenatal and postnatal care for planned home birth $779.90
[These amounts are calculated assuming that the mother has 3 long and 2 short prenatal checks; and two long and 3 short postnatal checks.  Other once only consultations as described in the legislation.] 

Saturday, October 16, 2010

Reflecting on progress in midwifery

Hello Grandpa!

When I studied midwifery (in the early 1970s) we learnt about the hormones in the menstrual cycle and the physiology of conception. We learnt about FSH and LH and oestrogen and progesterone and testosterone. We knew that oxytocin existed, but it was just the hormone the caused contractions of the uterus. The synthetic copy of oxytocin, Syntocinon, was used liberally as it could be measured and given in a 'scientific' way. I don't know if oxytocin crucial role in milk let down and love making was mentioned. The action of endorphins as natural opiates, and adrenaline and nor-adrenaline were part of that complex mystery waiting to be better understood. I don't remember any mention of bonding or maternal behavioural adjustments.

When Noel (my husband for the past 37 years) studied veterinary medicine in the late 1960s he learnt the same physiology. Vets became fascinated with the world of artificially managed conception, ovum transfer, and surrogacy in the world of producing the fittest and most highly desired offspring.

Noel's Masters and PhD research explored the protective effect of colostrum in the newborn calf. He showed that colostrum protects the calf against diarrhoea (scours) and septicaemia (blood poisoning) in the early days after birth. This result sounded obvious to me, but was important scientific knowledge at the time. My journying with him through academic processes, including the literature review and carrying out the research, informed me a great deal and opened my mind to critical thinking.

... move through time to today.

Noel and I are now doting grandparents. We have seen huge changes in our own understanding of the physiology of all things to do with childbearing, reproduction, and a human mother's ability to love and care for her child.

Acquiring knowledge of natural physiological processes in childbearing and nurture of the infant has been a fascinating journey that has, for me, absorbed my mind over most of the past three or four decades. It's an incomplete process.

As long as I am able to call myself a midwife I will have a duty of care to promote normal birth. I hope that midwives around the world will also claim that purpose.

Wednesday, October 06, 2010

Looking at the big picture

A lovely young woman in my care came for a prenatal checkup, beaming. After the usual hello she told me of her sister's birth a few days ago. Her sister gave birth to her first baby at a big public hospital, without any assistance, without any drugs! The wonder of physiological birth - the miracle of birth - has left its mark on this woman's mind. I was pleased to hear the story. Normal birth is worth protecting.

We know that birth is not an illness, yet a normal birth is often something that is a surprise rather than the expected pathway.

Medical dominance in birth has, for many people, extinguished this amazing knowledge. Midwives and doctors often see birth as a minefield, expecting disaster at any moment. Then they proceed to interfere, interrupt, intervene ... and hey presto ... they were right!

Years ago we midwives who were budding activists for promoting normal birth used the Fortelesa Declaration (WHO 1985) to get the message out that ‘Birth is not an illness’.

In the early 1990s we used the Innocenti Declaration (UNICEF and WHO) on the rights of the newborn to put pressure on maternity services in relation to breastfeeding and bonding.

In the mid-90s we promoted the ICM Definition of the Midwife, which is now incorporated into national codes of midwifery practice and educational standards.

We still have a long way to go. We need to constantly go back to this ‘big picture’ stuff, and hold it up as our standard.

The current state of play in the government's efforts at legislative reform (see another blog) is simply unacceptable to midwives under international and national midwifery standards.

Midwives have to just say NO! It’s not good enough to say we will take baby steps to Medicare funding. Compromise that is wrong is simply wrong, and will be regretted in the long run.

Friday, October 01, 2010

the safety of sharing a bed with a baby

Newspaper and other public media outlets are declaring that "Sharing bed raises infant death risks"

I have, for many years, encouraged mothers to consider co-sleeping. I was part of a group who prepared a co-sleeping brochure "Is your baby sleeping safely?" [2004 BFHI Australia]

Sue Cox explores the complex issue of safe co-sleeping and breastfeeding [see full article], with reference to James McKenna who has written and spoken extensively on the matter:
Professor McKenna defined co-sleeping as not about sharing a physical area, ie a bed, but having the baby within arm's length. He continued on by saying that breastfeeding and co-sleeping are the same adaptive complex designed by natural selection to maximise infant survival and parental reproductive success; there is no documented scientific study to show deleterious consequences of co-sleeping in safe environments; we have come to think of the abnormal as normal; and we are mistaking parental best interests for the infant's best interest. He suggested that current Western beliefs are based on Western European cultural history in which infanticide by 'overlying' existed and was so commonplace that same-bed co-sleeping was outlawed. This cultural history also favoured the notion of romantic love, patriarchal household authority and sanctity of parental privacy.

The claim that bedsharing raises infant death risks originates from the South Australian Coroner's review of the deaths of five babies, aged 3 weeks to 10 months. [full report]

The forensic pathologist has been reported to say that "Western culture had turned co-sleeping into something dangerous. ... in some cultures babies traditionally slept with their parents, but usually on firm bedding or on the floor without the weight of heavy covering."

Rather than a *blanket* outlawing of all co-sleeping, parents need to know where the danger lies. The same principles apply whether the mother is co-sleeping with her baby or placing her baby in another location such as a cot.

Avoid unsafe physical situations:
One of the five babies who died was suffocated when she became entrapped in the cushions at the back of a couch after falling asleep with her father.
Any parent knows about the exhaustion that we all face with the changes in the early days of parenting. It is not safe for anyone to lie on a couch with a baby. It is not safe for a baby to be sleeping in any environment where she can become trapped under or between cushions, pillows or other bedding. It is not safe for a baby to go to sleep lying on a parent who is also falling asleep, or even to let a baby sleep with other children.

Avoid unsafe temperature rise
A baby who is over-dressed, or over heated is placed at danger. Never use an electric blanket or other bed heaters with a baby. When sleeping with a baby, use cotton sheets and wool blankets, which allow air flow and moisture balance, rather than synthetic blankets and quilts/doonas. It is not safe to have pets in a room with a baby.

Avoid unsafe parental situations
Parents who have taken substances that may suppress their ability to respond (eg alcohol, cold medication, sleeping pills), or parents who smoke, should not co-sleep with their babies.

A breastfeeding mother who sleeps with her baby is intentionally responsive to the baby, and will usually form a C-shape with her own body around her child. In this way she will be responsive and alerted by any unusual movement by the child.

Sleep studies have shown mothers and babies interacting significantly while both appear to be sleeping. Mothers who follow intuitive patterns of mothering are able to learn safe sleeping with their infant, as well as being able to put their baby down in a safe place such as a cot for sleep.

Reference [quoted in Sue Cox's article linked above]:
McKenna JJ 1998 Breastfeeding and Mother-Infant Co-sleeping as an Adaptive System: Historical and Biocultural Perspectives. "Breastfeeding The Best Investment," CAPERS August Seminar, Melbourne, Australia.