possibly postmature

Possibly postmature
and
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 

• the date of the first day of the last period
• the normality of the last period
• the date of quickening

And, if ultrasound is used, there are additional pieces to add to the puzzle.


Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.


A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.


A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?

Why?

          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?


With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 



There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.

No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable. 

collaboration, coercion, and concocted evidence

Today I would like to write about an experience that I have found very difficult, and I know the parents of the baby shared my concerns.

It is not easy for me to write about this.  I'm usually a peace maker.  I'm usually more pragmatic; I don't like being idealistic about birth issues, simply because life is not perfect.

This post follows the previous one, in which I have written about some of the 'carrot and stick' aspects of maternity reform.   One 'stick' is the cost of midwifery services.  While one-to-one primary maternity care by a midwife, and use of hospital facilities only when indicated - the basic best practice model - describes pretty much the scope of private midwifery services, and thousands of dollars are 'saved' by the state for each woman who does not require hospitalisation for birth, the women who choose care from a midwife pay for the privilege.   

The second 'stick' that I want to consider is collaboration. 

Collaboration, which in theory means that professionals work together so that the consumer/patient receives optimal care, is a requirement for eligible midwives who wish to enable women in our care to claim Medicare rebates (See Collaboration Determination 2010).   I have no problem with collaboration.  BUT, I have a big problem when, instead of collaboration a woman in my care is subjected to coercion, bullying, and fear-mongering with concocted data being presented as evidence.  I have a big problem when a bureautically-defined process that's called collaboration is a requirement for midwives, but no doctor, and no hospital is required to reciprocate.

From time to time as I write at this blog I include stories from my experience.  Today's story of (non-) collaboration, coercion, and concocted evidence goes like this:

Background:

Jill and her husband Jack (for want of better names) were expecting their third baby.  Jill is a healthy young woman, and she gave birth without incident to her other two children at home in my care. 
When Jill spoke to me about maternity care for the birth of this baby, I explained that we needed to find a suitable doctor to provide a referral to me for antenatal and postnatal midwifery services, in order to comply with the medicare collaboration rules. 
The local GP who Jill had seen previously agreed to collaborate, and it all looked good.  Jill was happy to see the GP and had routine tests and investigations arranged.  The doctor asked Jill to come back for some checkups during her pregnancy.

>>> fast forward to 36 weeks
I visited Jill and Jack and the children in their home.  I noted that Jill had found the summer heat rather taxing!  We had had a run of four or five very hot days, which is taxing for everyone.  I palpated her abdomen, and thought the baby was not very big.  I remembered that neither of the other two children had been large.  OK, I thought, let's see how this baby looks in a couple of weeks' time.  Jill had been having some troublesome pre-labour contractions, especially in the evening.  I encouraged her to rest, to eat nourishing food, and to keep her baby growing in her womb for a couple more weeks.
A couple of days later Jill's GP saw her, and told her there was a problem: the baby was too small.  An ultrasound to estimate the size of the baby was arranged.  Jill was told her baby was small, and she had too little amniotic fluid.  Jill's GP told her she was to go to the tertiary referral hospital for review.  Jill is a logical thinker, and she tried to discuss her options.  No discussion!  And you had better rethink the plan for homebirth too!
Jill phoned me and told me she was feeling bullied.  She respected the doctor's opinion, and was prepared to accept investigations, but she felt she was being pushed up against a wall.
The next couple of weeks were busy, with visits to the GP, visits to the fetal monitoring unit at the big hospital, arranging family members to care for the children, and arranging time off work for Jack.

>> 38 weeks
Time for another ultrasound growth scan. 
Would you believe it, the baby's not growing as well as we would like!  Estimated weight 2.4 Kilos.
Baby's placenta is fine, but it might not continue to function well.
Advised to have an induction of labour tomorrow.
Jill talked it over with me. 

[I could not help but ask myself, would I have raised the alert about this baby; about this pregnancy?  No, I don't think so.  Had I missed something important?]

Jill was finding the pressure overwhelming.  I reassured her, that she could choose the pathway.  I encouraged her to make the best decision that she could in the situation; that I would work with her at the hospital or at home.
Jill decided to accept the hospital's offer of induction of labour by artificial rupture of membranes.

 ...

The labour and birth progressed normally, and five hours after arriving at hospital, Jill gave birth without incident to her healthy baby boy.   I looked down at him and thought, "he's not too little!"  He later weighed in at a healthy 2.8 kilos.

Later that evening, Jack and Jill wanted to take their new baby home.  The doctor from the paediatric department arrived in their room, and told them the hospital required Jill to remain in hospital for 24-48 hours, so that the baby could be observed for the symptoms of early onset group B streptococcus (EOGBS). 
Jill had received an antibiotic in labour to prevent EOGBS, and argued that she was an experienced mother, and would recognise if her baby became ill.  The doctor then presented some concoction of evidence - who knows what she actually said!  What Jack and Jill heard, and told me, was that they were told that 50% of the babies of mothers with positive GBS swabs will die from the disease.  That's scarry!  Jack phoned me and asked me to talk through EOGBS with them, which I did.  They went home.  Baby continued to feed from Jill's breast and thrived.

[For those who are interested, I would like to note here that GBS is a serious infection.  There is a high mortality statistic related to GBS, but it did not apply in any way to Jill's baby.  A baby who develops GBS and is not treated, either in labour or after birth, would have approximately a 50-50 risk of dying from the infection.  That's why we treat infection in labour or after birth so seriously.]

The coercion and concoction of evidence that Jill has experienced in this episode of care is a very distressing phenomenon.  I wish it was an isolated event.  Sadly it's not.  And I regret that Jill and Jack experienced the coercion and bullying as a result of my collaboration.

Midwives and Medicare

For the past 2+ years I have been able to give clients Medicare rebates for antenatal and postnatal midwifery services.  I am looking forward to having a prescriber number in the near future.  This is part of the government's reform measure, More Choice for Women - Expanding Medicare Support for Midwives, introduced in November 2010.

The basic requirement that I must fulfill before a client can claim a Medicare rebate is that there is a collaborative arrangement in place: a letter or statement, signed by a suitable doctor.  As I have no 'agreement' to meet this need, I must seek out an arrangement for each woman.

There are a couple of doctors who have 'collaborated' with me on more than one occasion.  Most of the time it's a one-off.  Most of my clients live within a 1-hour drive radius of my home.  That's a huge metropolitan area, and some out in nearby towns.  In that area there are thousands of doctors.  Very few have met me.  Some have refused to collaborate, saying that they would thereby be liable for anything I did.

Several months ago a woman who has had three previous uncomplicated births in hospital contacted me.  She wants to have her next baby at home.  I explained Medicare and collaboration, and emailed a letter describing the need for a collaborative arrangement with a doctor, to her.  She took the letter to her local doctor.  In her own words, 

I am just writing to advise you of the trouble that I am having getting a GP to write a referral to your services.

After contracting you to get a letter for the referring doctor, I went to my local GP for confirmation of my pregnancy. They were happy to send me for tests and ultrasounds but when I explained that I didn't want to birth my fourth child in a hospital, but rather have midwifery care and plan a homebirth I was met with an almost hostile response. This GP who had seen me throughout 2 of my previous pregnancys pointed out that he would not write me a referral due to the use of the word "collaborative" . He failed to understand where his duty of care ended and the midwife's began. I tried to explain that I didn't need to see him throughout the pregnancy and that I only needed initial blood tests and this letter but he would not listen. He continued to explain that he would not put his reputation on the line for the sake of my Medicare rebate!

Feeling disheartened I searched for a doctor who had a similar outlook on the way birth should be. I felt positive that this woman would give me the referral I needed.

This time the doctor endorsed homebirth, was happy for me to see a private midwife and ordered the appropriate tests to be sent to my chosen care provider but once more would not write the letter. When I asked for an explanation once again there was talk of scaremongering from insurance companies who had advised her that if she wrote this letter and something went wrong at the birth, even if she was 200ks away she would be liable.

I find it extremely frustrating and disheartening that in order to get the birth that is right for me and my family, I am being financially penalised because my doctors of choice don't fully understand what is required of them.

With this woman's permission, I forwarded her letter to the Health Minister, Hon Tan Plibersek, MP.  The letter I have received from the Minister's office, in reply, gives me hope that the wrinkles may be ironed out.

Excerpts from the Minister's letter, dated 27 May 2013:

The More Choice for Women - Expanding Medicare Support for Midwives, introduced on 1 November 2010, expanded the Medicare arrangements to include midwifery care.  This was in recognition that women should have a range of birthing options available to them and be supported in their choice of practitioner.

Recognising midwives as primary maternity care providers under Medicare was also intended to assist in improving service delivery by enabling better use of the existing workforce ...

 ...

Since the measure was introduced, midwives have reported ongoing difficulties with establishing collaborative arrangements with individual medical practitioners.  This has hindered their ability to provide services under Medicare.

In recognition of this, at the Standing Committee on Health (SCoH) meeting of 10 August 2012, the Minister for Health ... agreed to vary the legislation on collaborative arrangements, to enable agreements between midwives and hospitals and health services.

The Department is currently in discussion with the medical, midwifery  and consumer groups to discuss the detail of the proposed changes.

The Minister recognises that the lack of hospital clinical privileging and admitting and practice rights is a fundamental issue for midwives.  This prevents privately practising eligible midwives from working to their full scope of practice, undermines continuity of care and reduces choice for women.  

As such, the Minister has asked Health Ministers to finalise consistent approaches to credentialing for midwives in public hospitals in line with States' and Territories' commitments under the Maternity Services Plan.

The Minister is committed to supporting increased participation by eligible midwives in the Medicare arrangements and to the proposed changes to the collaborative arrangement requirements that would facilitate this.

Thankyou for raising this important issue.  I trust this information is of assistance to you.
Yours sincerely
[&c]

My comment:
A letter like this to an ordinary inquirer like me does not give any new information.  However, I feel encouraged by the tone of the latter part of the letter.

Specifically:

• that midwives need practising rights in public hospitals 
• that the Minister has put pressure on the State and Territory Health Ministers, to get a move on 
• that public hospitals will be expected to support collaborative arrangements with midwives
• that the Minister is committed to this reform measure.

Readers may also share critical thought about the More Choice for Women ... reform measure, such as:

•  the inequity of signed collaborative arrangements, in that the midwife is required to obtain the arrangement, but no doctor is obliged to agree or to sign anything.  The loser, of course, is the woman.  AND the midwife looks pretty useless.
• the lengthy delays (such as since SCoH in August 2012) in making even the promised changes to the Collaboration Determination
• the obstruction by public hospitals throughout the country, with the exception of a few in S-E Qld, to any progress on practising rights for midwives
• with the above point in mind, surely it's unlikely that these hospitals will agree to collaborate with midwives, even after the legislation has been varied as promised 
• and finally, with an election, and probably a change of government in September, will we see ongoing support for More Choice for Women - Expanding Medicare Support for Midwives?

Your comments are welcome

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,...

[Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162

]
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.

The midwife

I have been enjoying the BBC series 'Call the Midwife', which has been shown on Australian ABC TV.  This week we will see the fifth and final episode in the series.

(If you go to You Tube you can apparently download and watch the full first series.)

Since I began writing my stories in the mid 1990s, in The Midwife's Journal,  I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested.  The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.

Last week I wrote about women's rights in childbearing.  This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife.  The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.

Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.

Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young.  Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.

A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few.  They may follow pregnancy-birth related social media groups and forums.  She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.

I said it's a potentially overwhelming burden of knowledge about aspects of birth.  I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try.  I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax.  I wonder where he obtained this knowledge.  I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.

One mother who gave birth about a week ago had confidence.  I have been with her for several of her babies.  She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze.  Her preparation for birth included good food, adequate rest, and work about her home.

As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet.  I rested on the couch.  Then she invited me into her bedroom: "it won't be long now," she told me.

Quietly and steadily she guided her baby down and out.  There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it.  Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation.  The third stage proceeded without the need for any medical intervention, and there was minimal blood loss.  When I visited this mother she was sitting outside in the gentle spring sunshine.  I saw a well mother, with a well baby at her breast. 


In telling this story I have not mentioned the buzz word of the day: collaboration.  Those in authority today will insist that collaboration is the key to safe maternity care.

Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees.  The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications.  This is basic midwifery.  The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.


Thankyou for your comments.

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.

safer and better systems of care

with my first baby 1973

Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

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). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.

Preparing for Medicare

Wonderful artwork by Poppy to brighten the page.

In early December I wrote about the fact that I had submitted my application to be noted as eligible for Medicare (see blog). I have been told that this application is being processed.
In preparation for submitting an application, all midwives are required to participate in a Professional Practice Review approved by the Board (NMBA). The review that I undertook is the Midwives in Private Practice Professional Practice Review ('MIPP PPR' for short) which had previously been submitted to the Board for approval. Having worked on the MIPP PPR since its introduction in 2002, I enjoyed updating it to meet the written requirements of the new Board, and then undertaking a practice review, and presenting my findings to an experienced and respected midwife colleague.