Monday, February 03, 2014

some of the carrots and sticks of maternity reform

A few weeks ago I wrote:
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. ...
Today I would like to look closer at an example of what I mean by the 'stick'.

  • One-to-one midwifery is accessible only to the relatively wealthy, who can afford to pay, and the lucky, who are accepted into public hospital caseload programs,

One-to-one midwifery refers to the best practice continuity models of maternity care in which a woman has a known midwife who provides the first level of professional services (primary maternity care) from booking, through labour and birth, and through the postnatal period.  This episode of care extends from early pregnancy through to about six weeks after the birth.

Private midwifery care is perhaps the most reliable model that provides one-to-one midwifery, in that each privately practising midwife usually makes a strong commitment to being with the women booked with her.  One-to-one care options in public hospitals include 'Know your midwife' and other caseload or group practice options in which midwives have modified caseloads.  These models often provide a reduced commitment by the individual midwife, as midwives may share time 'on call' and 'off call', in an effort to improve productivity and cost effectiveness.

Having said that one-to-one midwifery is a best practice model, I would like to state that it is not an elite or exclusive model; it is not wasteful of resources or midwifery skill.  The status quo in mainstream maternity care, having hospital midwives rostered on shifts to cover the anticipated work load, is more wasteful of staff time and expertise.  There are times when rostered midwives are under-used, because it is impossible to predict when women who come into spontaneous labour will actually labour, and how they will progress.  It would be better in terms of staff planning if only a core midwifery staff were employed as shift workers, and the majority of midwives were linked to the women and attended the women from their own caseload, with support from hospital core staff.

Yet, when discussing caseload, we have found in the past decade or so that midwives who challenged the status quo were informed that a woman who used public maternity services should not expect the 'Rolls Royce' model! (Meaning that if choice and continuity of care was the best, it was not going to be offered to women who paid nothing for their care!!!).  Another big obstacle is that many midwives are unwilling to change from the known routines of rostered shifts, to the comparably less predictable caseload work. 
One-to-one midwifery seeks to foster a partnership based on reciprocity and trust between the woman and her known midwife.  The essence of midwifery is a relationship, being with woman at the time of giving birth.   It is not always easy for the midwife.  The midwife needs to accept the unpredictability of the birthing process, and engage with the woman in providing care that meets the woman's needs.  Yet as midwives we are very happy to parrot phrases like 'woman-centred care'.  If the care is truly centred on the woman, surely the benefits to the mother and baby can in many instances outweigh the costs to the midwife?  And, I can say with confidence, the midwife can benefit greatly as she learns to work in harmony with wonderful natural processes.

The National Maternity Action Plan (NMAP), published by Maternity Coalition in 2002, promoted the concept that every pregnant woman needs access to a known midwife who provides primary maternity care, and who refers the woman to specialist medical and hospital services, while continuing as primary maternity care provider, when indicated.  If you would like to consider NMAP  in more depth, please go to A New Vision for Maternity Care.

I began this post by saying a 'stick' of the maternity reform is the cost to the woman.

While NMAP promoted the concept that all women should be able to choose the primary care of a known midwife, there is insufficient funding in the current maternity reform package to enable midwives to care for women without a significant co-payment.

While NMAP promoted the concept that government maternity funding should be linked to each pregnant woman, enabling the woman to have choice of model of care and care provider, and equal payments for equal work, the current maternity reform package has led to over-servicing and double dipping from the public purse.  In fact, those who choose to pay can have a private obstetrician as well as a private midwife, call it collaboration, and receive maximum rebate from Medicare.  They may also get conflicting advice, as the obstetrician will usually see him/herself as the principal decision maker - the concept of informed decision making by the woman is ignored or unknown.  The wealthy get more services, but with the overservicing comes an exceptionally high rate of caesarean birth and other questionable outcomes.  

As noted in another post, ARM's New Vision (2013) calls for radical change:

"... that services would be funded and organised from the bottom up around individual women and their families and within the communities in which they live.  Birth at home or in a local birth centre should be the preferred option for all low-risk women.  Community maternity care needs separate funding to promote, enable and support normal birth where possible.  This is a more efficient, less costly, friendlier and safer way to provide maternity care.
Instead of being the default place of birth, the consultant-led obstetric unit would become the place to care for women at higher risk of complications and a place for transfer in labour for emergency care ... [with] continuity of care from a known midwife." (p3)

I would encourage everyone who has an interest in maternity care to maintain the hope that the vision, of the woman at the centre having choice and continuity from a known midwife primary carer, will one day be achieved for all women.

Your comments are welcome.

In a future post I hope to address another 'stick'
  • 'Collaboration' that is actually bullying

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