Friday, January 04, 2013

Looking ahead: midwife-led primary maternity care

Today is a hot day in Melbourne, and I am taking this moment to set down my thoughts on how I and other midwives can continue to practise our profession.

Prior to the holiday break I wrote a progress report, two years after the introduction of reforms to government funding of maternity care.

There was clearly an expectation within the government, and the midwifery profession and the maternity advocacy community that the injection of $$ to fund midwifery would also open up greater acceptance of the work of the midwife.   It was assumed that private midwifery would ease the work of the over-burdened hospital system, public and private.  I cannot see evidence of this.  In fact, the money from the public purse has probably increased over-servicing by multiple service providers, rather than any cost shifting from the state (hospital) to the federal (Medicare) health budgets.


The unique product that midwife-led primary maternity care offers a woman is a midwife who is the primary or first contact throughout the episode of care.  This is, in my opinion, the ideal option for any woman, and the ideal model in which a midwife can practise.  This ideal requires the midwife to be flexible in the time she will attend the mother, particularly during the labour, birth, and the early postnatal days.  The midwife's caseload is usually described by the number of bookings she has each month.  This ideal is supported by expert opinion and research, in the interests of the wellbeing and safety of mother and baby. 

Caseloads for midwives mean that the mother is in the care of a known midwife who intends to be the leading care professional through pregnancy, birth, and the postnatal period, unless care is referred to a specialist obstetrician (or hospital obstetric service).  In this case, the midwife may continue to provide midwifery care, in consultation/cooperation with others (doctors, midwives, nurses, and other health services as required).

In reality, this ideal is rarely achieved.  This ideal should not be linked to planned place of birth, but in reality it is.  The only way most women can plan to have a known midwife as their primary carer throughout the episode of care is to plan homebirth. 

In reality, Australian hospitals and midwives are resistent to the changes that would be needed to make caseload midwifery options work for midwives in mainstream maternity services.  Women receive fragmented care that comes with all sorts of names attached: shared antenatal care, team care, obstetric clinic, midwives clinic, and many more.  Maternity wards and staff are used to midwives as shift workers, who are allocated to provide care for the women in the ward at the beginning of a shift.  The mother receives antenatal, perinatal and postnatal care from a group of midwives, doctors, and others, without knowing who will attend her at any time.

The maternity 'reforms' seem to be fragmenting the maternity care a midwife can provide, under a skewed concept called collaboration.

Midwives don't always agree on the way forward.
One midwife might be a pragmatist, and make an arrangement with the hospital maternity ward that she will be employed as a casual staff member when her clients are ready to be admitted. 

Another midwife is holding out, and hoping, for visiting access to the hospital.

One midwife might be an idealist, who will only make bookings to provide care for women who are committed to home birth. 

Another midwife is not interested in where the woman is intending to give birth ...

I have come to this latter position.  I recognise and respect the choice that a woman has to make, in the world in which we live, as to the intended place of birth.  I also know that this decision can change in a flash, for all sorts of reasons.  There are times when a woman who plans hospital birth reconsiders her options, perhaps in the weeks leading up to birth.  I am happy to work through this process.

One change that I and some of my colleagues have made, in response to the current climate of disrespect for the work of the private midwife, is to encourage women who intend to give birth in hospital to make a deliberate choice about the package of care they receive.  A woman can choose to receive primary care from a midwife, without having to plan home birth.  In some situations the hospital accepts a booking, but in others the woman will be unbooked.  This should not be a problem.   The administrative burden on the hospital of admitting an unbooked woman, especially in well staffed city and suburban hospitals, is not great.  The private midwife provides copies of any relevant tests and investigations, and a handover to the staff member who admits the woman.

Some midwives who have had Medicare provider numbers since 2010 have not yet established viable private midwifery practices.  They continue to juggle shift work in part-time or casual work at hospitals, while they seek private work.  Women are being discharged from public and private hospitals before they are confident in caring for themselves or their babies.  Many of these women would, I believe, appreciate home visits from a private midwife who has Medicare.  This is not happening.  The hospitals do not refer women to midwives.  They are happy to say "See your GP if you have a problem", but not "See your local private midwife before problems arise."

In conclusion, we still have a lot of work to do.

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