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.

 

indemnity insurance: who benefits?

It's a simple question.  Who benefits from indemnity insurance?

We're all familiar with insurance: home and contents insurance, vehicle and third party property insurance, health insurance, travel insurance ...  Some are mandatory; some are not.  

Narrowing the field a little ...
... to mandatory indemnity insurance for midwives as regulated health professionals.  Who benefits from that?

The obvious answer is that the consumer - the mother+baby who receive professional care from the midwife - are potential beneficiaries.  When/if a mother or her baby experience adverse outcomes that may have been avoided under professional care that may have been done differently, that mother or baby are able to sue the midwife for the loss they claim to have suffered.

An eye for an eye!

The matter is placed in the hands of lawyers.

If the midwife has indemnity insurance, the insurer advises and supports the midwife.  The insurance policy may have exemptions and limits that are taken into consideration.

Sometimes a settlement is reached without going to court.  Money is paid to the person who suffered loss, and that's the end of it.

Or the case is scheduled to be heard in the appropriate law court.

If the court agrees that the midwife was culpable, an order is made that a sum of money be paid to the person who suffered loss in the care of the midwife.

Who benefits?
[simple!]
The person who was harmed.


The complication is the availability/affordability of indemnity insurance.  This is a global problem.  No-where in the world is there an indemnity insurance product for individual midwives that provides assurance of sufficient funds to pay out for the life-long health needs of a baby who is severely disabled by hypoxia at the time of birth. 

It's not a new problem.  I have been attending births without indemnity insurance since it became unavailable in 2001.   I (and others in this country) have been permitted to continue practising without insurance for births, while our government agencies attempt to solve the problem.  Midwives in oz are at present exempt from having indemnity insurance for privately attended homebirth, because it's not available. This exemption will be reviewed by June 2015.

Australia's national regulatory board published a research report on professional indemnity insurance for midwives in December 2013.

The UK Department of Health has rejected a proposal by Independent Midwives UK, concluding that government funding of midwives' insurance will not give patients protection (DoH News story 6 March 2014).

German midwives and mothers have been holding huge public rallies - see hebammenblog and scroll down to 13 March (and use translation if, like me, you don't understand German)

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defence schemes which cost more than some midwives earn.


I am considering this threat to private midwifery practice from as many perspectives as I can.  Readers may consider my concerns to be tainted by self-interest, because I practise midwifery privately.  But, as I am close to retirement from attending births, I see myself as a commentator who knows the terrain well.

From a professional perspective, the cost of indemnity insurance demands consideration.  Midwives who are taking a full caseload (40+ births per year as primary carer, as well as other midwifery services) are paying between approximately $2,000 to $7,500 annually.  Neither of the policies on offer covers homebirth; the more expensive policy covers birth attendance in a public hospital at which the midwife has been credentialed and awarded clinical privileges.  The number of women planning homebirth with a privately practising midwife is small - less than 0.5% of the birthing population.  Midwives who take too many bookings burn out quickly, and women lose faith with their private one-to-one midwife if she is not available to attend their births. 

That's the top end of the scale. 

Midwives who have a very small caseload; perhaps only a few bookings for primary care per year, are also required to have indemnity insurance, and the minimal cost is approximately $2,000.  Those midwives, possibly living in rural towns or properties, may work part time as employees in the local hospital, and see their small 'private practice' as an expensive hobby.   

From a professional business perspective, there is clearly a point at which the cost of private practice outweighs any perceived benefit.   

As fees for indemnity insurance increase, and the cost is passed on to the client, some midwives will not be able to earn enough to afford meaningful PII, unless they charge high fees that make their services unaffordable to the majority of women.

It's a self-defeating cycle.

costs progressively rise - 

midwives burn out or fail to attract enough business to continue offering their professional services - 

reduced access to private midwifery services for women

However, the bigger issue (imho) is the myth that mandatory indemnity insurance is somehow in the public interest, when the vast majority of cases of cerebral palsy, for example, cannot be linked to an action or omission by any professional care provider (hospital or home), and there's no claim on anyone's insurance.
 
From a social perspective, does our society think that midwives should be free to provide services privately (independently) to women, in a way that is affordable and accessible? 

Or the other side of the same coin, that women should be free to engage a midwife privately? 

Most women in our society like to be able to control who provides other personal, intimate services such as hair cutting, or beauty services for removal of unwanted hair, so why would they not want to have a say in who attends them for the most intimate of professional services?

But most women in our society have no idea of the scope of a midwife's practice, or indeed of their own birth-right: to give birth safely and triumphantly under amazing natural forces.
 
The midwife's ability to protect, promote and support normal birth is limited by the professional/regulatory control: a state's duty to protect the public through the regulation of the profession.

The UK government article that I referenced above suggests that midwives should be able to form 'social enterprise' businesses that purchase insurance for members. To me (I do enjoy the one-to-one relationship between me and the woman for whom I provide primary maternity care) this sounds like layers of unhelpful nanny state control that provides only a mirage of safety.

The indemnity insurance situation for midwives in Germany is different from that in Australia or UK.  A German midwife informed me that "Our "independent" midwives do not practice "privately" or "outside" the system.  Here their service are still covered by national healthcare and their "extinction date" has just been pushed back another year as the insurers will offer indemnity insurance for another year to come (with another raise of 20% and limited for another 12 months and the sum covered cut down to half of what it covered before…)" 

Back to the initial question:
Who benefits? 

• when a midwife's indemnity insurance does not cover what midwives do?
• when the increasing costs of providing midwifery services prevents some midwives from offering their professional services, thereby reducing access of women in the community to midwives?
• when the increasing pressures associated with providing midwifery services lead to burn-out and break-down and unsustainable commitments being made
• when the increasing costs of providing midwifery services leads to business models that focus on risk management and the bottom line $$ rather than the woman-midwife partnership?

Who benefits?

• Not the consumer/client/woman+baby
• Not the midwife
• Not the community

someone else!



Dear reader, today I have only touched on these matters.  What solutions can we propose?
 
In the present climate I see reports of cases before the coroner that are likely to have had good outcomes if they had been managed differently.  I read reports of midwives taking extreme positions on management of women with known risk. 

I have phone calls from women who think they would like homebirth because they don't like hospital.   

The solution is not to be found in ever-tightening rules being imposed on midwives.

The solution is not to be found in governments throwing money at the insurance industry.

One aspect of the solution, as I understand birth, must be that a midwife can arrange to provide care for women in hospital as well as home.  

I would like to see the 'villagemidwife' concept available in any town or community where a midwife chooses to work in a professional capacity, providing primary maternity care for individual women.  The setting for births in this midwife's practice must be determined by the woman's and baby's needs at the time of birth.

A society that provides regulation of midwifery must also ensure the ability of the midwife to practise midwifery.  That is the only way to protect the public.  A society that makes midwifery unaffordable, inaccessible, or restricted to homebirth, is depriving its mothers and babies of one of the most basic health promotion services that human existence has ever known.

more about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.


Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:

• spontaneous onset of labour, and
• spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.

Baby Bonus gone

The federal treasurer's announcement in the Budget 2013 that there is to be no Baby Bonus from early 2014 is, in my opinion, a sad legacy of the present government, and an equally lamentable commentary on the opposition's lack of support for those who need it most. 

It sometimes takes a cartoon to speak truthfully about political situations.  Thanks, Australian.

Mothers who stay at home with their young children, particularly in the pre-school years; mothers who do not benefit from paid parental leave because they do not have employment out of the home; families who live on one income - these are the ones who will miss the baby bonus most.  And, as it happens, many in this sub-group of modern Australian communities are the ones who also value wellness and protection of health in pregnancy, birth, and nurture of their babies - and who employ a midwife privately.  Many mothers have 'afforded' homebirth, knowing that they will be entitled to the baby bonus.  So, in that sense, I must declare that my interest in the baby bonus is, in part, linked to my need to earn a living as a midwife.

I don't have time thismorning to write any more, but will get to it as soon as I can, and add to this post.  Any comments from readers will be appreciated, either in the comments section here, or by email.

later...
Responses received in 4 our so hours since I wrote include:

Cancelling the baby bonus demonstrates ...

"undervaluing of the role of a parent"

Yes, the current social pressure to have children of all ages cared for by specially designated child care businesses does ignore the very real intuitive and personal roles of parents in caring for, guiding, and teaching their own children.

"full time parenting is not recognised as gainful or important.  ... the role of a stay at home mum has been labelled 'for the chronically unambitious'."

Outrageous!

"I think this really will have an impact of breastfeeding and extended breastfeeding rates."

No doubt!

...

Then, there are those who have seen what they consider to be abuse of the government's over-generous middle class welfare, new parents who have boasted of purchasing the flat screen TV, state of the art coffee machine, new sofa or a trip to Bali.

or, as a midwife notes, 

"the women in [low socio-economic area/suburb] who come back and have a new baby each year, and can't wait to get the Centrelink forms filled out so that they can get their payments."

Yes, any social welfare scheme can be abused.  We Australians have many supports provided by government at the time when our babies are being born and nurtured, including family tax benefit, parenting payment, as well as the child care benefit and child care rebate for children in approved care facilities.  For more detail, click here.

A quick review of media around the scrapping of the baby bonus informs me that there will be an end to the current baby boom, that teenage pregnancies will be discouraged, and that families will no longer have 'one for the country', as proposed by Peter Costello in 2004.  The consensus amongst thinking people seems to be that the baby bonus is better relegated to the wastebin of bad economic management.

Here's a story.  Once upon a time ...

There were two men in a certain city.  One was very rich, and he had properties and flocks and herds and many possessions.  The other was very poor, and lived near the rich man.  He owned just one ewe lamb, which the poor man had bought.  The poor man and his family loved that lamb, and it ate their food, and drank from the same cup, and slept in the poor man's arms.  Now one day a traveler arrived at the rich man's house, and he invited the traveler to stay for dinner.  The rich man did not take a lamb from his own flock, but in stead took the lamb from the poor man, killed it and had it prepared for his meal.

[This story is based on the one in 2 Samuel 12.]

I see the cancellation of the Baby Bonus as the rich man taking from those who are weakest and least able to defend their own interests in the political arena.

When (then Treasurer) Peter Costello introduced the Baby Bonus reform legislation in 2002, he stated that:

"The Baby Bonus recognises that one of the hardest times for families, financially, follows the birth of a first child. A family could lose one of its two incomes for a period of time as the mother, or father, gives up or reduces paid employment to care for the child." [click here for more]

The need for support when one parent gives up or reduces paid employment to care for a child is an ongoing need.  By all means, the provision of the baby bonus should be refined and managed in a way that minimises abuse.  In the current financial situation, I believe it would have been prudent for the opposition to hold to the long-term support of this program, rather than supporting the government's plan to use the ewe lamb owned by the poor man to feed the rich man's guest.

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.

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.