Saturday, January 04, 2014

midwifery directions for 2014

Greetings to my little band of readers and thinkers and birth nerds.

In my first blog entry for 2014, not knowing what lies ahead, I hope this new year brings you valuable learning and the satisfaction of knowing that you have contributed well to whatever your work is.

There is an old saying that the pen is mightier than the sword.  I am using the internet to wield a (virtual) pen/sword (whatever that might mean in today's world) in my campaign to protect, promote and support health through childbirth.  The midwifery-childbirth scene is in need of protection. The context is discussion around the future of midwives and homebirth in Australia, stimulated by midwife-blogger Rachel Reed.  I would encourage you to read the post, and the comments.

Protecting the healthy, natural processes in pregnancy, birth, and nurture of the baby
The struggle we face, for which the virtual pen may be employed, is our duty to protect the ability of women to move naturally and safely through their childbearing, and of babies to achieve health through working in harmony with natural processes, unless there is a valid reason for intervention.  There is no safer and better way to proceed. This is not the midwife who uncritically sits on her hands in some sort of utopic idealistic world.  It is the midwife who correctly recognises threats, both external and internal, and takes appropriate action.  

The big threats that are being discussed within the midwifery profession today relate to insurance and regulatory pressures on the midwife's scope of practice.  These threats are not new.

The mandating of professional indemnity insurance (PII) for all regulated health professionals has led to attempts by insurers to provide an affordable and acceptable product for midwives.   That product doesn't exist, either in Australia or overseas.   The current exemption that has been provided (at present until June 2015), for midwives attending homebirth privately, is inequitable for the midwives and the women in our care.  Yet a system by which the client and the midwife can 'opt out' of the law that requires insurance is probably the only way that will keep the professional doors open to privately attended homebirth. 

Regulatory pressures that have increased since the previous government's maternity reform package was implemented in 2010 are like the carrot and the stick.  The 'eligible midwife' carrot is that certain midwives earn special privileges:  Medicare rebates, clinical access to hospitals, and prescriber authority.  The 'eligible midwife' stick is the linked requirements and cost of professional indemnity insurance, collaborative arrangements with obstetricians, and getting over increased bureaucratic hurdles such as the midwifery practice review.  There is no reliable evidence that this approach will make birth safer for mothers and babies, or eliminate the fear of a rogue element in midwifery.

At present any midwife, except those who have specific restrictions imposed on their registration, is able to practise midwifery without supervision, in the way that they choose.   Any midwife is able to set up private practice, and offer fee-for-service arrangements within the scope of midwifery.

The concern that has been expressed amongst midwives, and in the blog post referred to here, is that we are moving in the direction of restriction as to which midwives - only those who are 'eligible' - are permitted to attend women for homebirth.   This, to my knowledge, is only "hear-say" at present.  I have seen no document from the regulator or from a professional body, committing us to this direction. 

I cannot accept such a change.  Midwifery, as defined by ICM, and as established in education and professional standards, is not dependent upon the business model under which it is provided, or the intended place of birth.  A midwife is able to practise midwifery in any setting.  Homebirth midwifery is the most basic level - every midwife should be competent.   

The protection of the natural processes in childbirth should not, in itself, be linked to PII and regulatory pressures.  But it is.  Midwives who work independently are free to establish an individual care plan with a woman.  The woman who employs a midwife privately is able to develop trust with that midwife, and vice versa, and with trust comes the ability to challenge. 

Private midwifery encourages strengths in the relationship between midwife and woman, at the same time as it allows weaknesses.  While the increasing medicalisation of birth can bring harm to many, through unnecessary use of dangerous drugs and potentially risky surgery, medical processes used appropriately can save lives of mothers and babies.

I hope that during the coming year we will see wisdom prevail in decisions made about the midwifery profession.


Anonymous said...

Hi Jan
Thanks for opening debate about these issues.
You state re. homebirth being limited to eligible midwivesL
"This, to my knowledge, is only "hear-say" at present. I have seen no document from the regulator or from a professional body, committing us to this direction."
The insurance report clearly recommends this and the ACM is yet to comment on this report or declare their stance in relation to limiting homebirth to eligible midwives. I think we'd all feel better with a clear statement of support for PPMs regardless of model of service.

Joy Johnston said...

Rachel, I would think ACM is bound to support midwives who are covered by the ICM Definition - which defines the midwife's scope, 'in any setting', but has no comment on the business model under which the midwife is paid.
I don't think I have seen the insurance report - they may not know about the Definition.
Interesting times ahead!
Joy (not Jan - she's a friend of mine :-)

Denise Hynd said...

NZ LMC (self-employed) midwives have PII cover through a combination of levies (based on their Caseloads) to the national Accident Compensation Commission and increased membership fees to the NZ College of Midwives. Bill Shorten tried to get a National Injury Insurance Scheme as well as the National Disability Insurance Scheme up but had to be satisfied only with the later with-in the term of Gillard government! If both of these had, or do eventuate (with a Shorten government) then Australia will have the equivalent of NZ’s ACC ( WA Greens Senator Rachel Sewiert’s cheif policy advisor said to me last June in Perth ‘this could be a means of part cover for Homebirth in Australia as it is in NZ! Please follow this up with Bill Shroten’s or Rachel’s offfice. Most recently I have asked Sarah Stewart at ACM who should understand the NZ set-up as she lived and worked here - to check this out, lobby and spread the word!
You could go and see Bill Shorten also!!

Joy Johnston said...

Hello Denise, and thankyou for your suggestions. The new national disability compensation scheme which the previous government brought in is being implemented, but (unfortunately!) does not provide the same compensation as the NZ system. The PII requirements are mandated in the legislation. Midwives who want the NZ system will need to follow your example and move there!