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.


Monday, November 12, 2012

rare birthing footage

http://youtu.be/8NLyORwJCOk

This youtube link is really worth watching. 


Sunday, November 04, 2012

BREECH

When I think about breech births the pictures that come to mind are women who I have attended for breech vaginal births, as well as a few other stories that have been preserved in my memory.

There's Sally, who gave birth unassisted to her 'feet first' baby one night in an ambulance.  I had palpated her abdomen that afternoon: head down, very mobile.  When she went to bed she felt a huge movement, and knew that baby had done a forward roll into a breech presentation.  She got up, went to the toilet, and as she sat down her waters broke, a foot and some umbilical cord presented.  Sally kept a cool head, gently put the loop of pulsing cord back into her vagina (to keep it warm), explained what had happened to her husband, who called the ambulance and me.  Sally's first baby had been born by emergency caesarean after finding that he was presenting breech.  Her second baby had been born (cephalic) at home in my care.  This was the third.

The paramedics arrived quickly, and they assisted Sally as she walked to the vehicle, pausing as she laboured strongly.  Sally told me later in detail how she waited for the head to be born, and supported her baby as he took his early breaths.  By the time I connected with them Sally and baby were resting at the nearby hospital emergency room.  After birthing the placenta, we went home again and had a cup of tea, with vegemite toast.

A few others of these mothers have already been written about in this blog.  [Thanks here to the blogger search function!]


In 2007 I wrote generally about vaginal breech birth, and the deskilling of midwives and obstetricians.  I noted that:
 The very real situation that presents itself today is the deskilling of midwives, and of obstetricians, in breech birth. A baby may be harmed or die simply because the midwife or doctor did not know what a more skilled person could have done to achieve the best outcomes.
In 2008 I wrote about The 'B'-Word, and told two breech birth stories, about one whose baby was born at home after ECV, and another mother whose baby developed a serious spastic brain injury from hypoxia, after abruption of the placenta some minutes before the birth.

In 2009 I wrote 'Thinking about vaginal breech births' in the leadup to the screening of a video 'breech in the system'.

In 2011 I wrote about normal birth for a breech baby, reflecting on the work of colleagues in bringing vaginal breech birth to the attention of the maternity professions and public.

In (March) 2012, reflecting on twin and breech births, I wrote about safer and better systems of care:

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001).


Another memorable breech (first twin) birth took place in 2009, and has been noted in the post titled 'Why bother coming here if you won't let us manage you the way we think is best?' 
and the follow-up post 'Drive-through birthing'.


The purpose of today's essay is not just to collect stories, but to assert my belief that we can change, and put effort into making "our systems of care safer and better".  By "our systems of care", I include all aspects of professional maternity care, from the 'village midwife' primary carer, and the bush hospitals, to the big tertiary maternity units.

I believe this is happening.  Women's Healthcare Australasia and the University of New South Wales, Sydney have advertised a program 'Hands off the breech'[click here for speaker' profiles] to be held 30 November and 1 December.  Several of these speakers will be presenting their talks in Melbourne and Warrnambool in Victoria, also in early December - click here for program.  I plan to attend the session hosted by Monash Medical Centre - one of the 'big 3' maternity hospitals in Melbourne, and a strategic place to get the discussion about vaginal breech birth happening.

Social media is active in this regard, and many messages are being posted on a facebook site linked to the Breech Birth ANZ site.

For some, the changes are too little, too late.  Mothers have told me that they agreed to caesarean births for their breech babies because they were afraid.  Fear works against the protective intuitive forces in spontaneous birth.

Mothers have said to me, "Are you willing to attend breech births at home?"  That is a question that I can not give an immediate answer to.  I am committed to doing all in my power to protect the wellbeing and safety of mother and baby.  There are times when a breech birth (or twin) at home could come into that scope.  Other times there will be discussion and the decision may be made to go to hospital.

That's enough from me for today.  Thankyou for your comments.

PS
The following comment was left today (14 Nov 2012) on an earlier post about breech birthing.  I have included it here as it is relevant to the discussion:


motherwho (http://motherwho.wordpress.com/) has left a new comment on your post "THE ‘B’ WORD Breech. A woman today whose baby is...":

Hi Joy, thanks for writing this post! I enjoy reading your blog although this is my first comment.

My second baby was born last month (in Melbourne). My midwife first detected she was presenting breech at 29 weeks which was not a concern at the time, but as the weeks went on she stayed in the same position. At 36 and a bit weeks after much stress, acupuncture, moxibustion, massage, swimming, hypno-tracks, spinning babies.com, etc, etc, the little bub was still breech.

The hospital I had a [back up] booking at were most likely only giving me the option of an 'elective' caesarean (not really elective when it is the only option you are given?), so we went to another hospital and had a successful ECV. I went into labour spontaneously and had my baby girl at home last month.

I feel so lucky to have escaped the knife and terrified that it seemed to be the only option, had my baby remained breech, as we had decided we would prefer not to go ahead with our plan for a homebirth if she stayed in that position.

I still feel confused about the system we had to navigate and realise that if we had have been less educated we would not have questioned it. I can only imagine my recovery and the distress I would have felt now with a 5 week old baby and a toddler running around had things have been different.

My youngest sister is now a graduate midwife and I don't think she has ever seen a vaginal breech birth, nor has she been taught how to support a woman/baby should one arise under her care.

Definitely cause for great concern, in my opinion. 


Thankyou 'motherwho' for sharing your journey.