the importance of trust

I (Joy Johnston, aka villagemidwife - see note at the end of this post) often say to women in my care, "I need to trust you, and you need to trust me."

This sounds reasonable to me, particularly within the context of primary maternity care that spans the pre-, intra- and postnatal periods.  While midwifery is not rocket science, the commitment a woman and her family make to a new baby is perhaps the most far-reaching investment they will ever make.  Trust is something to value: it's not lightly given; it's not easily won; and once won it can be lost.  I can not assume that a woman in my care is trusting me, and she may not know if I am trusting her.  This is the case especially when difficult decisions need to be made: when I am asking the woman to trust my professional judgment and advice in order to protect the wellbeing of the mother or child.

According to contemporary thinking, midwives and women engage in a partnership that is based on reciprocity and trust (a phrase coined, as far as I know, by sociologist-academic Karen Lane.)  It's a two-way relationship.  It's a relationship that builds over time, and is tried and potentially strengthened as each woman and her midwife navigate the unique terrain that each pregnancy-birthing episode offers.

Partnership should not be seen as an idealistic notion: the current internationally accepted definition of the midwife includes:

... The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.... (International Confederation of Midwives)

The stark reality of life is that some people find it difficult to trust anyone, while others give away their trust lightly to anyone who sounds as though they know what they are talking about.  Most people fit somewhere between the two extremes.  The definition of the midwife is looking at the big picture, while the experience many women have with a midwife or midwives may be far removed from any sense of working in partnership.  Similarly, midwives who provide continuity for their own caseload of women may find themselves in situations in which the sense of partnership is sub-optimal.

A young midwife told me she felt that a woman in her care does not trust her because she has had only a few years' midwifery experience.  A couple of comments that the woman made left the midwife wondering if she was able to continue as midwife. 

That discussion prompted me to think a lot about what it means to trust, and the importance of trust in midwifery - in the processes of decision-making that a midwife uses.

I do not, ultimately, trust birth.  Birth, like any other part of life, is able to be complicated by disease and corruption.  The midwife's role in maternity care is to firstly work in harmony with awesome natural processes, and secondly to recognise complication and intervene to prevent loss of life or damage. If I trusted birth there would be no need to work as a midwife.  I would simply accept 'Que sera sera' (what will be will be).

I have reflected on the many women for whom I have provided midwifery services over the years, and wondered if my statement, "I need to trust you, and you need to trust me" is true.

Many women have gone through the birthing process with minimal intrusion or action by me: my job is to be 'with woman': to watch and occasionally give support, then fill out the paperwork.  In almost all of these cases there has been, I believe, a working partnership based on reciprocity and trust.  The woman who is trusting her midwife is able to surrender to the work of her body when the time comes.

Some women have needed more than I have been able to give them in community based midwifery care, and we have transferred care to a hospital maternity service.  I expect that in some of these situations the woman's ability to trust me as her midwife, or to trust herself as the birth-giver, has been less than optimal.  In some, my ability to trust myself as midwife, or the woman as the birth-giver has been compromised.  At times I may have been too weary, or emotionally drained, or fearful, or ...




Spring 2013

Tomorrow is the official start of Spring in the southern hemisphere.  It's exciting to see the tender young leaves on deciduous trees, and flowers on the fruit trees.

Spring 2013: Bonsai Japanese Maple and azalea

The signs of new life are within the natural processes that offer endless wonder and thrill to those who are ready to see.

Midwifery has taught me to respect and work in harmony with the natural processes as much as is possible.

These little bonsai trees have been in my care for several years. 






postscript...
Don't believe everything you see on the internet!
I began today with "I (Joy Johnston, aka villagemidwife...)" because, for some reason Blogger (the program I use to write this and other blogs) thinks I have changed my name. Probably my own fault - I told my sister I would help her get started writing a blog, and somehow Blogger now thinks that I am my sister - Barbara Clark. Everything I have written is now attributed to her, so I need to either find out how to get into my blogger profile and change my 'name', or get used to writing under a pseudonym. I have followed the instructions to go to Blogger profile, but keep getting a message "oops that didn't go well"!

I'm just venting, but if you have a suggestion for fixing it, I'm keen to get it sorted out! XXjoy

pps
Thanks Paul for fixing it.

physical midwifery

Today I am pondering the physical demands of my sort of midwifery, at the primary maternity care end of the professional spectrum.  This means that I, the midwife am committed to being with woman, regardless of time or place. 

It means that I accept phone calls at any hour, and that I am prepared to get in my car and go to a woman who calls me. 
It means that I lug my equipment - the case with supplies; the oxygen cylinder; the bag and mask; the baby scales ... up flights or stairs, or wherever they need to be. 
It means that I have no idea when I will be home again; that I have to organise my private life so that my absences are manageable within my family. 
It means that I need strategies for driving home safely after a long night on the job, so that I don't fall asleep at the wheel.
It means that when my ageing body complains, with aches and pains in shoulder, or foot, or wherever, I am prepared to carefully consider my capacity to continue in my profession.

But, you might say, it's the birthing woman who is physical.  She's the only one who can give birth.  She's the only one who can breastfeed and nurture and love that baby as mother.

Yes.  Birthing is the essence of phyiscality.

When I studied midwifery we were taught about the 3 'p's:

• the passage (birth canal)
• the power (contractions of uterus and mother's expulsive efforts)
• the passenger (the baby)

Then someone added another 'p': the psyche - the mother's emotional and psychological acceptance of birthing, including the impact of fear and anxiety (adrenaline and other fight-or-flight hormones) on the process.


You might think that being a midwife is a matter of sitting on your hands, or better still, knitting. 

When I was working as a midwife in a hospital the physical demands of my job included traversing long corridors to check on the women in my care, or to answer the 'buzzer'.  It included manual lifting of women from theatre trolleys to beds, or positioning women who couldn't move themselves.  It included leaning across the bed to assist babies with breastfeeding, or to extract minute amounts of liquid gold colostrum from breasts of new mothers.

Today my office is in my home, and I spend much of my time here.  I am glad I don't have the physical demands of mainstream hospital midwifery to deal with.  I'm glad I don't need to work night shifts, although some of the best times for being with woman in hospital are in the wee hours. 

I'm glad I have strength sufficient for the task.

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.

availability of midwives for homebirths

Today I would like to explore a few issues around the availability of midwives to provide professional services for homebirth, and suggest what I see as a way forward.

These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.

'Risk' - however defined - is a major obstacle.  The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital.  This narrow mindedness is not informed by evidence or by logic.

The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.

With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded.  A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program.  Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.

Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.

These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes.  Yet midwives say very little. 

These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder.  An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care.  Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth.  Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access.  When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.

$$ Cost is significant in private homebirth.  While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives.  Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging.  For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate.  The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.

The other factor in cost of private homebirth is the number of midwives.  Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more.  A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth.  I disagree.  Strongly!

I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives.  I cannot support this option - it scares me.  I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula?  A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".

Practical matters: the main one that comes to mind is the distance across this wide brown land.  Gone are the days of the village midwife on her bike.  Each time I visit a client, I am using precious fuel.  Likewise, each time a woman comes to me.  If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife.  (An exception is a few special women who I have attended on several occasions over the years.  I have become a part of those families, and it's lovely to return for the birth of the next baby.)

Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home.  Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.

Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.   

What am I saying?

I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth. 

• midwives need to think critically about risk
• midwives need to work to make primary maternity care by a known midwife affordable
• midwives need to wake up to their capacity to provide midwifery services in homes and hospitals, for all women.

CULTURAL HYSTERIA?

Readers of this blog are probably familiar with the historical roots of 'hysteria'; the Greek word ὑστέρα (hystera) meaning womb, the condition of the wandering womb, and recommended treatments.

"Galen, a prominent physician from the 2nd century, wrote that hysteria was a disease caused by sexual deprivation in particularly passionate women: hysteria was noted quite often in virgins, nuns, widows and, occasionally, married women. The prescription in medieval and renaissance medicine was intercourse if married, marriage if single, or vaginal massage (pelvic massage) by a midwife as a last recourse.[1]" [Wikipedia]

The Medical Dictionary that my computer's online dictionary led me to offers this information:

hysteria hys·ter·i·a (hĭ-stěr'ē-ə, -stēr'-) n.

A neurosis characterized by the presentation of a physical ailment without an organic cause, such as amnesia.

Excessive or uncontrollable emotion, such as fear.[Link]

I wish to contend here that there is a cultural hysteria in response to midwifery.  A cultural neurosis that leads to excessive and uncontrollable fear about that highly contested terrain, childbirth.

While midwives are recognised internationally as essential providers of primary maternity care, Australian midwives (and our sisters in many other developed countries) face exclusion and restriction when simply practising our profession.

Cultural hysteria with regard to midwifery depicts the midwife as someone who lacks skill in management of obstetric emergencies, events that are bound to happen, leading to a mass fear reaction.  Cultural hysteria sets up a fearful scenario, and uses that scenario to prove its point.

I don't have answers to every possible scenario, but I do know that in the State of Victoria, where I live and work, data from privately attended planned homebirth have been collected and reported on for many years, demonstrating the clinical effectiveness of planned homebirth in the care of a midwife.

The mothers who planned to give birth at home have not been uniformly 'low risk': they include births after Caesarean, mothers who are older, or who have had more births, or whose babies are bigger than average.  They are ordinary women, who just want to give birth to their babies.

The midwives have not undertaken any special courses of study: they are simply competent midwives, who seek to work in harmony with physiological processes, and who, generally, refer women appropriately when complications are suspected. 

The Victorian government’s Perinatal Data Collection (PDC) unit within the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) publishes an annual profile that captures all planned homebirths in the state, and puts the data alongside cumulative data from hospitals and statewide totals. These reports, although retrospective, carry a high degree of reliability.

The reports over the past 20+ years have shown planned homebirth in the care of a midwife as a safe option in terms of maternal and perinatal morbidity, with many features that are considered protective of the mother’s and baby’s wellbeing and safety. 

For example, in 2008, the most recent set of published data in this series:
• 91.5% of women planning homebirth had unassisted cephalic births, compared with 55.4% state-wide.
• Approximately 5% of women planning homebirth at the beginning of labour had caesareans, compared with 19% in small ‘low risk’ (<100 births) hospitals, and 31% statewide.

When looking at the baby outcomes for the same group (2008),
• 95.6% of babies born to mothers who planned homebirth at the beginning of labour did not require admission to a hospital nursery, which is approximately the same as the rate for small hospitals with less than 400 births per year.

These data support our contention that there is safety and protection of wellbeing for mother and baby when midwives attend women for planned homebirth.


I recognise that individual cases may be held up as examples of things going very wrong in birth, whether that birth takes place in a tertiary hospital, a private hospital, the woman's home, a birth centre, or in the back seat of the car. 

There are risks associated with birth, as there are particular risks linked to any life event.

I believe that the safety and wellbeing of mothers and babies in our community is enhanced by a strong midwifery profession that is recognised as essential in effective primary maternity care.

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.

old-style midwifery

I have tried to capture the essence of the 'extraordinary'

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

[From APMA Blog]



Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

Notation on the Register

I have now completed my application for 'notation' on the midwives register, as a midwife eligible for Medicare. My CV has been adapted to comply with the AHPRA standard, and copies of documents need to be certified as correct, also in compliance with the required standard.
This process has been a challenging one for me. A few of my trusted colleagues and friends wonder why I would even try to become 'eligible'. By accepting a terribly flawed process, am I not supporting our society's attempts to medicalise women's lives, and to give a veto power to the medical profession over midwifery and women's choice of physiological birth?
Readers who have followed this process will understand that the decisions midwives must make are complex.

I have come to a pragmatic point of acceptance:
... that the government has enacted a process for certain midwives to be eligible for Medicare.

The person who will benefit from my being eligible for Medicare is the woman, not me. The woman will be able to claim back some of the fee I charge - possibly one third for planned home births, and more if and when I am able to attend a woman privately for hospital birth.
I will seek to do all in my power to prevent this process from taking away a woman's freedom, or working under medical supervision in primary maternity care.

There are several hoops to jump through yet, and it may be a couple of months before I hear back from the Nursing and Midwifery Board of Australia if my application is successful.