Monday, November 26, 2012

TWO YEARS LATER

It's two years since November 2010, when the Australian government announced sweeping maternity reforms that promised to give women a better deal in their maternity care.  The Report of the Maternity Services Review acknowledged that:
"... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care."

There are several posts on this site addressing the 2008 Review, and the subsequent recommendations and legislative reform.  For example, go to March 2010 Maternity Reform Hijacked, parts 1, 2, and 3; and the September 2010 one on Medicare funding: carrot or poisoned chalice.

Many midwives around this country have accepted the challenge, jumped through all the hoops, and achieved notation as Medicare eligible.  Our invoices for antenatal and postnatal midwifery services include the Medicare item numbers, and women are able to obtain Medicare rebate.  Some midwives are offering certain services at the Medicare bulk bill rate, which involves the swipe of a Medicare card in a little EFTPOS machine; the entry of a few details using the numbers on the machine, and the bulk bill payment shows up in the midwife's nominated bank account the next day.

The other major change that was brought about by the reform package was the ability of midwives to prescribe certain scheduled drugs: drugs that at present only a doctor can prescribe.  The first group of students in the Graduate Diploma of Midwifery from Flinders University are soon to receive their final scores for the Pharmacology exam paper, which we sat last Thursday, and which accounts for 50% of the mark.  For my journal as a student, go to this and subsequent entries.

On the positive side of the 2-year report of the 'reform' process we can record Medicare.  For example, Item number 82115, with a scheduled fee of $313.05 is
Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks,...
]
The Medicare statistics website reveals that, in the 12 months October 2011 to October 2012, a total of $325,005 was paid out by Medicare for Item #82115.
The breakdown of amounts is (in order of magnitude):
Queensland $114,010
Victoria $63,944
South Australia $55,081
NSW $44,308
WA $40,720
ACT $3,241
Tas $2,912
NT $788
This is only one item number.  Other reports can be generated at the Medicare Item Reports site.


On the negative side of the leger, there are several points to note.  This list is my personal one, made from my experience.


  1. Medicare Collaboration:
    It is becoming increasingly difficult in some areas to obtain collaborative arrangements that meet the requirements for midwives to provide Medicare rebates for women.
  2. Access to practising in public hospitals: Despite expert multi-disciplinary committees and meetings and reports, it's clear that public hospitals do not welcome the idea of midwives practising privately within their confines.
  3.  Access to practising in private hospitals: Are you kidding?
  4. The homebirth problem: Midwives attending homebirth are doing so without indemnity insurance.  Surely the time of birth, regardless of place, is the very time when insurance may be useful. 
  5. The future of private midwifery practice: I believe it is becoming more difficult over time to sustain private midwifery practice.  I believe some (probably well meaning) captains of the industry have an agenda to rid our society of homebirth.
Two years on, and the private midwifery profession is more restricted than it was previously.  There has been no expansion of the "range of models of maternity care" - the stated purpose of the maternity reforms.

*****

In conclusion, today I sat in a court room in Melbourne, as the case of complaints into the professional practice of a colleague was commenced by AHPRA.  The law under which the complaints are being heard prevents publication of the name of the complainant, and in this case the names of the women who employed the midwife have also been suppressed.

The legal inquiries and arguments will proceed over the coming days, and the midwife will eventually be told what findings have been made against her, and what conditions may be placed on her ability to practise her profession. [see MidwivesVictoria]

The issue that will, I believe, be at the centre of the case is whether a midwife is *allowed* to attend birth at home for a woman who has recognised risk factors.  The other side of that same coin is whether a woman who has risk factors, such as post maturity, previous caesarean, or twins, is *allowed* to give birth at home.  I have written *allowed* this way to highlight the statutory process that is being employed here, using the regulation of the profession to either permit or prevent certain activities, that are seen - rightly or wrongly - as 'operating on the fringe'.

I am not able in a blog to explore these issues fully.  I would like to make a clear statement that I consider the duty of care of the midwife who agrees to provide primary care for any woman, regardless of the risk status of that woman, to include the promotion of the wellbeing of mother and child, and where reasonable, the protection of spontaneous natural life processes.  The woman is the one who has the final choice on accepting or refusing any intervention.

The midwife practising privately brings skill and knowledge that may not be accessible or reliable in the hospital, where ad-hoc staffing issues often take precedence over the interests of the individual woman.

What progress have we made in the two years since the Maternity reform package was enacted?  Very little.  The only place most midwives are able to practise is the home.  The only way a woman can rely on a midwife is if she plans home birth.


1 comment:

babs40000 said...

I sense a frustration and the snuffing out of private midwifery. It is just getting too hard. A recent DOHA survey sent out for us midwives to comment on has been extended because of concern in how few have responded.
Mmm I think this reflects a sense of hopelessness and powerlessness we are feeling. I know of several midwives who have let their midwife registration lapse as they cannot work under the 'rules' whilst seemingly the collaborative doctors have simply continued their veto over midwives work, value and effort without fear of losing income, status or punishment by the various Health departments.
The toughest group to convince of our value and worth are our midwife friends who work in a hospital. They follow rules, protocols and are much thought after by the system. I am an intruder to their comfortable way of working. I love being with woman, supporting her on her journey to becoming a mother but I cannot do that in a hospital that ignores women's wishes, that seems to be harming so many women by their practices measured by throughput as pressure for maternity beds mount. I will give this 'collaboration' and Medicare another year before I decide to leave Australia or pursue another career path.