supervision?

This is an amazing old piece of stitching. 
But, I don't think it is meant to represent a ruptured uterus!

Recently, the Nurses and Midwives Board of Australia (NMBA, or Board) has invited midwives to participate in a series of focus groups and consultations that will lead to a process of supervision for privately practising midwives.  I and a number of other midwives and stakeholders have been invited to participate in three expert consultations with the law firm, Pricewaterhouse Coopers (PwC) that has been engaged to oversee the project, and advise on potential models.

This midwife supervision project is all about the statutory duty (of the NMBA) to provide a level of protection for the public through regulation and support of the midwifery profession.  Whether or not they introduce supervision for PPMs, or for all midwives, and what it will look like (how supervision will work) is unknown.  Note that the Board has recently replaced its ‘Safety and quality framework for midwives attending homebirths’ with a SQF for all midwives http://www.nursingmidwiferyboard.gov.au/News/2014-04-30-safety-and-quality-framework.aspx

 


If you are a midwife who has worked in the United Kingdom, you will know that all midwives there have a supervisor, who answers to the local regulatory authorities, who in turn answer to the national regulator.  The process is at present being reviewed.  [See Parliamentary and Health Services Ombudsman's Conclusions and Recommendations -added to this post 19/6/14]

The current model of supervision, in the UK context, is a "means of promoting excellence in midwifery care, by supporting midwives to practise with confidence ...", and  a means of protection of "women and babies by actively promoting a safe standard of practice." (NMC 2009.  Modern Supervision in Action: a practical guide for Midwives, p3)

That two-sided goal, to protect mothers and babies, at the same time as supporting midwives, is what statutory regulation seeks to provide.  A process that is focused solely on weeding out those midwives who may have performed poorly in a particular situation is unbalanced and probably unnecessarily punitive.  A process that is focused solely on supporting midwives, and ignores the need for careful correction and improvement, is also unbalanced and may lead to tragic, preventable outcomes for the consumer, and loss of that midwife to the workforce. 

At present in this country any midwife is able to elect to work in a self-employed capacity, or employed privately by a midwifery group practice.  A small number of midwives have chosen one of these pathways, with very little, or no postgraduate experience working in the more structured, and more supervised, environment: mainstream hospital maternity wards.  Within hospital employment models a midwife who has recently graduated will be given support and a process of structured performance reviews over time.  A midwife whose practice does not meet the standard expected within the unit may be asked to agree to a performance contract that includes measurable outcomes.

Midwives who are practising privately form a very small proportion of the profession.  Yet, we are an easy target for bureaucratic control.  In the past few years we have jumped through amazing hoops in order to achieve eligibility for Medicare, and notation on the register as midwife prescribers.  We are instructed and guided by the Board, the insurers, Medicare, and professional bodies, and the list of codes, guidelines and instructions grows constantly.  In my opinion, there is no need for a professional supervision program for all privately practising midwives.  It would be an enormous waste of resources, for very little gain.

I would like to urge the NMBA to establish a targeted professional supervision program, with a strong focus on adult learning through peer discussion and reflection, directed at those midwives who have recently commenced private practice, as well as those who have had complaints or notifications made about their private practice.  The midwife may be required to comply with a program of professional supervision for a period of time, such as 5 years, or a number of episodes of care (eg 50) in which the woman is receiving primary maternity care from that midwife.  The midwife supervisor would need to be a respected and experienced member of the profession, who has demonstrated her/his ability to practise midwifery in the private practice context.  At the end of the supervision period, the supervisor would advise the NMBA of the midwife's successful completion, or recommend an extension.  If at some time the supervisor forms the opinion that the midwife's practice does not meet the Board's standard, there may be restrictions to practice imposed, and the process of notification, investigation, and a hearing would need to be initiated.   The Board has supportive processes like this available for nurses and midwives who seek help in dealing with mental health issues, or alcohol or other substance addiction. 


The opinions shared and explored here are my own.  I would be very happy to discuss this matter further with midwives or others, either through the comment function on this blog, or at my villagemidwife facebook site.

 

Why do private midwives need hospital visiting access?

Yes, I gave birth to my four children in hospital. This is #1

In a perfect world, would every woman want to give birth in the privacy of her own home?

Perhaps.

In a perfect world, there would be no sickness, no pain, no decay, corruption ... no need for hospitals either.

But we don't live in a perfect world.  No matter what steps we take to optimise health of mother and baby; to optimise the positioning of the baby in the womb for a normal birth; to prevent infection; to prevent social disorders that result from smoking, substance abuse, and obesity ... no matter ... the midwife is always watching and observing in case complication or illness arises.

Home is a wonderful place for birth when the woman and baby are well, and progressing normally.  At any time the decision to stay at home may need to be reviewed.

Some people may tell me I am being driven by fear in saying this.  We in the 'natural birth' realm see slogans such as 'Trust Birth'.  I hear midwives speaking of the physiological processes in birth as though they come with an iron-clad guarantee.

No! and No!

Don't get me wrong.  Birth is an amazing, awesome process - most of the time.  Natural physiological processes in birth and breastfeeding, together with the cocktail of hormones, and the physical and psychological factors that can influence these processes are truly wonderful - most of the time.

There is no better way for most than the natural process.  God the creator made the woman's body as well as the man's, mysteriously in the image of God, and said it is good.  That is a profound truth.  The balancing truth is that today we are able to protect and save life, through medical intervention, to a greater degree than ever before.

That's where hospitals come in to my thinking today.

I'm not talking now about a perfect world.  However, a better world is a reasonable goal.

There will always be women who need or choose to give birth in hospital.   These women ought (in a better world) to be able to use the services of a known and trusted midwife in hospital.  That option is not commonly available in the world we live in today.  Some women are fortunate that they have a wonderful midwife allocated to care for them in their labour, or even in a caseload/know your midwife program.  But the usual feature of birth in Australia today is that a woman is attended in labour by a stranger - someone she has not met prior to coming into labour.  Women with financial resources and private health insurance might have an obstetrician who has provided their antenatal care, with whom they feel a bond of trust, but that doctor is not in continuous attendance - the midwife/stranger is. 

In a better world, women would be able to engage their own midwife, or small group of midwives, who are committed to providing continuity of care that spans the community and the hospital.

In a better world, midwives would be able to choose to work either privately or as employees of a hospital or health service; either as shift workers, or with a personal caseload, or in one of the multitude of hybrid models of care that are designed to meet the individual needs of the women as well as the midwives.  These options should provide reasonable rates of pay and conditions.  Midwives can only do our job well when we are in good shape ourselves.  We teach women to be intuitive about the needs of their children and themselves - we ought, in a better world, to apply the same thinking to ourselves.

The journey to maternity reform has been an uphill one.  I am hoping that it won't be long before we see a pathway to a better world of maternity care.

Thankyou for your comments.

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.

 

IDEALS AND REALITIES

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.


LOOKING AHEAD:
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.

More evidence ...

... demanding action.

For many years the buzz word in maternity care has been 'evidence'.  'Evidence-based' maternity care guidelines can be found everywhere. 

Application of the evidence into mainstream maternity care is quite another matter.

From my perspective, it's great to see another piece of reliable evidence supporting midwifery continuity of care /caseload midwifery/ one-to-one midwifery.  This evidence is published in a respected professional journal, BJOG, and International Journal of Obstetrics and Gynaecology, reporting on research carried out under the strict rules of randomised controlled trials, by the La Trobe University team of midwifery academics, led by Associate Professor Helen McLachlan.

The title of the paper is:
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Authors: McLachlan et al, BJOG (2012).


The team of authors of this paper includes midwife academics who were prominent in the 'Team Midwifery' research from LaTrobe Uni more than a decade ago.  'Team midwifery' was adopted into many mainstream maternity units, in an attempt to reduce the huge number of midwives who provided care for individual women during their prenatal, intranatal, and postnatal experience.  Women were allocated to the 'Green team' or the 'Pink team'.  Midwives work ordinary hospital nursing shifts.  Women under 'team midwifery' are usually attended in labour by midwives who are strangers. 

Two papers addressing Team Midwifery, authored by Professor Ulla Waldenstrom and others, and Mary-Anne Biro and others in 2000 in the journal BIRTH presented the research findings, and a commentary was written by Karyn Kaufman.  Kaufman, a midwife academic and a member of a community-based midwifery practice in Canada highlighted in her review the lack of difference between the control or ‘standard care’ and the intervention, team midwifery.  Kaufman commented that “midwifery care that follows strict medical protocols is not the same as midwifery care that is enacted from a philosophy of normal birth and is individually negotiated with labouring women.”  This statement sounds logical, yet many Australian midwives at the time may not have realised that midwifery care for well women can be enacted from a philosophy of normal birth.

The primary outcome of the continuity of care by a primary midwife (caseload midwifery) trial is that

"In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk shows promise for reducing caesarean births."  

Besides having fewer caesareans, women allocated to 'caseload' were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care.  

Good for mother, good for baby.

Good for the midwife, too.

In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

When a reduced likelihood of caesarean can be demonstrated for women at low risk of complications, it's time for the midwifery profession to celebrate.  

Evidence demands action.

This is reliable evidence.

This research was carried out under strict controls.

Midwives and maternity services must be challenged to apply the evidence to practice.  The usual practise of midwifery should be in a caseload model, working autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A').  Not as shiftworker nurses in hospitals who work as assistants to obstetricians.  

Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.

a career in private midwifery?

... continuing thoughts on this topic from the MIPP blog.

with Sue and baby Benjamin - photo taken by Amy, used with permission

Today I want to focus on questions that arise for midwives and midwifery students who are considering a career in private midwifery practice. If you want to practise privately, independent of the mainstream maternity hospitals (public or private) which provide employment for the great majority of midwives in this country, you need to find a sustainable way to work.

Most midwives who practise privately in this country rely for 'business' almost exclusively on individual women who seek the one-to-one midwife who will work with them when they labour and give birth.  Midwives in private practice have caseload bookings, with individual women, usually across the spectrum of pre-, intra-, and postnatal services.

Most births at which the woman's chosen midwife is the primary/leading professional in attendance - the one who takes responsibility for the conduct of the birth and ensuring the wellbeing of mother and child in that acute episode of care - are in the woman's own home. There are midwives with clinical privileges in hospitals in the South-Eastern corner of Queensland (Toowoomba, Ipswich, Brisbane, Gold Coast), and Sydney. I don't have the details, but can follow up if anyone wants to know more.

What does a private midwifery practice look like, from a business perspective?

We need to consider the practice (the acts and being of midwifery) separately from the business (structure and financial aspects).

The midwife's practice can be 'solo' (working as the only professional midwife booked by a woman for the episode of care) or in arrangements where two or more midwives work together to provide the primary care for each woman who is booked with them. This is often described as a 'group practice'.

The private midwife's business arrangements for earning a living can be a simple 'fee for service' in which the woman/client pays that midwife directly, or the fee may be paid to an employer/company which in turn remunerates the midwife for the work she undertakes. The employer in the latter instance could be a midwifery group practice, or another business such as a group of obstetricians. The midwife may or may not be a partner in the practice.  Whatever the arrangement, laws applying to tax, employment and superannuation must be complied with.

My system for management of payments is that any money that is transacted, whether by cash, credit card, cheque, or electronic transfer, and whether by the woman or by Medicare (bulk billing) is immediately recorded by hand in a small 'Cash Receipt' book with carbon copies.  This automatically generates a number for the receipt, as all the pages are numbered, and I add a prefix which refers to the number on the outside of the booklet - at present the prefix is 17.  The top page is placed in the client's file, and the carbon page stays in the receipt book.  The receipt number and information will be entered into my Quickbooks accounting system when I get to it.  This is the basis for my income tax, and quarterly BAS returns.  Midwifery services do not generate the goods and services tax (GST), but the GST charged on purchases by the midwife in carrying out her business can be claimed from the ATO.

Most of my midwifery practice is 'solo', with some bookings made in which I practise with another midwife.  Recently I have enjoyed working with my colleague and friend, Jan Ireland from MAMA, in providing midwifery services for a woman who was booked with Jan.  I will describe this case from the perspective of the new Medicare arrangements, as it demonstrates how midwives are able to work together within the collaborative arrangement and maternity care plan set up by the midwife who has made the primary booking.

In this case, from the Medicare perspective, the second midwife is able to act as a reliving midwife or locum for the primary midwife.  The locum is described in legislation
Health Insurance (Midwife and Nurse Practitioner) Determination 2011, Health Insurance Act 1973,

Part 4 Interpretation

(1) In this Part: collaborative arrangement, for a participating midwife’s patient, means a collaborative arrangement mentioned in regulation 2C of the Health Insurance Regulations 1975. delivery includes episiotomy and repair of tears.

(2) For this Part, a participating midwife is a member of a practice that provides a patient’s antenatal care if the midwife:

(a) participates (whether as a partner, employee or otherwise) in the provision of professional services as part of the practice; or

(b) provides relief services to the practice; or

(c) provides professional services as part of the practice as a locum.

The arrangement by which I have provided (b)'relief services to the practice' or (c) 'professional services as part of the practice as a locum' is under (a) 'otherwise', since I am neither partner nor employee of MAMA.



Midwives who are beginning private practice, and who have Medicare eligibility, may consider the 'relief/locum' model, either as partner, employee, or otherwise, as a means of getting started.  



I commenced this post with a question, 'a career in private midwifery?'.  I believe there is a great potential for midwives to aspire to extending their midwifery practice when they step out of hospital employment into private practice.  However there are also significant risks, which all would do well to consider. 

Midwives who practise privately in a community are able to support each other, with relief/locum services, on one hand, while on the other they may be competitors for business.  Being able to accept and work constructively with this dynamic is a key to sustainability in private midwifery practice, not just for the individual midwife, but also for the community served by midwives over generations.

midwives in the making

(c) Picture used with permission

Yesterday I had the privilege of presenting a 1.5 hour talk on private midwifery practice to the midwifery students at Deakin University in Burwood. I love having the opportunity to inspire the next generation of midwives.

I know some visitors to this blog are studying midwifery, in many countries. In today's post I want to give you an outline of my presentation, and links to some of the key documents.

The parts of the presentation were:

• Overview and introduction: developing a strong 'midwife identity'
• Private midwifery practice, changes in legislation with Medicare rebates and other changes for eligible midwives. Go to Midwives Australia for more information and links
• Planning for birth: philosophy of birth based on the statement that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996); decision-making concepts of 'Plan A' and 'Plan B', birth preparation meeting handout
• DVD of a beautiful home/water birth [One picture used here with permission - the visual image is sooo powerful!]
• Highlighting aspects of midwifery practice that can apply only when the whole labour progresses under natural hormonal, unmedicated processes: physiological third stage, and baby's transition from the womb
• Questions

Please follow these links if you are interested in the topics mentioned. I intend to prepare a post on 'Planning for birth' at my private midwifery blog - will do that as soon as I can.

For the record, my relationship with the Deakin University School of Nursing and Midwifery is that I am employed as a casual lecturer, and as a tutor and marker for some of the midwifery Professional Development Unit Learning Packages. Several years ago I prepared one of the Learning Packages on the midwife in the community (PDU 323) and more recently I have written a Learning Package on Caseload and Homebirth midwifery, which is being processed in preparation for release.

Plans for the new year

As the sun goes down on 1 January 2011 in our part of the world, others have just seen the New Year in.

I have noticed from the statistics function on this blog that a large number of the visitors to this blog are in the United States. G'day, folks! I am delighted to have you visit. I have wonderful memories of five winters in Michigan, and have attached a family pic, with me holding our first baby, that takes us back 37 years.

New Year 1974, at our home in Biscayne Way, Haslett Michigan

Twelve months ago, I and other Australian midwives were wondering if we would be able to practise legally, after 1 November. We are practising, and intend to continue. I won't say without change - anyone who is so set in their ways that they are not willing to change should not be practising. We must continue to change and grow in our understanding of birthing processes, while we adapt and work within the limitations of our own lives (such as ageing), and the law.