Australia’s mothers and babies 2008

The Australian Institute of Health and Welfare has released a new report today:

In 2008, 292,156 women gave birth to 296,925 babies in Australia. The increase in births continued, with 2,720 more births (0.9%) than reported in 2007. This is the second year that the rate of caesarean section has not significantly increased with a 0.2% rise from 30.9% in 2007 to 31.1% in 2008.

Click on the link to view the media release and report.

Baby boom slows, but more births to older mothers

A fall in the rate of women giving birth suggests the baby boom may have peaked, according to a report released today by the Australian Institute of Health and Welfare (AIHW).

The report, Australia’s mothers and babies 2008, shows there was a 0.6 percentage point fall in the overall rate of women aged 15 to 44 years giving birth, from 64.9 per 1,000 women in 2007 to 64.4 per 1,000 women in 2008. Of these, an estimated 3.2% of women who gave birth received assisted reproductive technology (ART) treatment.

‘The proportion of older women giving birth has continued to rise over the past 18 years,’ said Associate Professor Elizabeth Sullivan, of the Institute’s National Perinatal Statistics Unit located at the University of New South Wales.

‘The proportion of mothers aged 35 years and over increased from about 11% in 1991 to about 23% in 2008. Mothers aged 40 years and over made up almost 4% of all women giving birth in 2008 compared to 1.4% in 1991.’

The average age of mothers in 2008 was 29.9, up from 27.9 in 1991, and the average age of first-time mothers increased from 25.8 years in 1991 to 28.2 years in 2008.

‘There are a number of factors that contribute to delayed childbearing, including social, educational and economic factors and increased access to assisted reproductive technology,’ Associate Professor Sullivan said.

Indigenous mothers were younger, with an average age of 25.1 years in 2008, compared with 30.1 years for non-Indigenous mothers. The average age of first-time Indigenous mothers was 21.0 years.

For a second year in a row, the rate of caesarean section did not increase, with 31% of women who gave birth doing so by caesarean section. A further 57% had a non-instrumental vaginal birth.

Indigenous mothers had a lower caesarean rate than non-Indigenous mothers (25% compared with 31%). Advancing maternal age was associated with higher rates of caesarean section.

About 11% of mothers had an instrumental (forceps or vacuum extraction) assisted vaginal birth. This rate has remained stable over the last decade.

Instrumental birth was more prevalent in major cities, and a larger proportion of women who had instrumental deliveries were first-time mothers.

The proportion of women who smoked while pregnant was 16%. Over half of Indigenous mothers reported smoking during pregnancy (51%), compared with 14% of non-Indigenous mothers.

Of babies born in 2008, 6.1% of live births were of low birthweight (less than 2,500 grams). This rate of low birthweight was the lowest in the decade 1999–2008.

Letters to public hospitals requesting collaborative arrangements

Midwives practising privately are now able to apply to be noted by the Nursing and Midwifery Board of Australia as eligible for Medicare, and clients of these midwives are now able to claim rebate on the midwife's fees.  Women enquiring about private midwifery services are now asking midwives, "will I be able to claim Medicare rebate on your fees?"

There are just a few midwives in the country who are able to offer Medicare rebate.  Others are working towards it.

One of the hurdles that a midwife needs to successfully negotiate in order to achieve this status is to comply with the National Health (Collaborative arrangements for midwives) Determination 2010.

Midwives who are continuing to provide private midwifery services for women planning homebirth are seeking an arrangement to cover collaboration in situations when women in their care are referred to a public hospital for obstetric review, such as for prenatal assessment or monitoring when indicated, or transfer of care.

With reference to the (Collaborative arrangements for midwives) Determination, the pathway which we have been advised is suitable for public hospitals providing collaborative arrangements for midwives whose clients are planning home birth is as follows:

[Excerpts from National Health (Collaborative arrangements for midwives) Determination 2010]
4 Specified medical practitioners
For the definition of authorised midwife in subsection 84 (1) of the Act, the following kinds of medical practitioner are specified:
...
(c) a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.

5 Collaborative arrangements — general
(1) For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:
...
(b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;
(c) an agreement mentioned in section 6 for the midwife;
...
6 Agreement between eligible midwife and 1 or more specified medical practitioners
(1) An agreement may be made between:
(a) an eligible midwife; and
(b) 1 or more specified medical practitioners.
(2) The agreement must be in writing and signed by the eligible midwife and the other parties mentioned in paragraph (1) (b).
......

In the case of an authorised midwife providing care for a woman ‘W’, having a collaborative arrangement under section 4(c) above with the director of obstetrics or another doctor ‘D’ authorised by the hospital to participate in a collaborative arrangement, the midwife would write a letter to the doctor, and keep a copy of the letter in the woman’s notes, stating that Doctor D is the specified medical practitioner under whom the woman would be admitted if admission to hospital was indicated. The letter would say something like
“Dear Dr D, Ms W is a woman in my care who is planning home birth, who has booked in to your hospital for backup if indicated. At present there is no indication, and I will contact you should any problems or concerns arise. This collaborative agreement is required so that Ms W can claim Medicare rebate on my fees.”

Please note that this collaborative arrangement does not apply to intrapartum care, after transfer of women who had planned home birth from private care in the community to a public hospital. There is no Medicare item number for intrapartum midwifery care for planned homebirth. The intrapartum options for midwives, covered by Medicare are outlined in the Federal Register of Legislative Instruments F2010L02640. These items refer to planned hospital births at which the midwife is in attendance, privately employed by the woman. This option requires visiting access arrangements to be in place, including collaborative arrangements for intrapartum obstetric referral.

Towards Normal Birth in NSW

Towards Normal Birth in NSW, a policy directive, with a requirement for mandatory compliance, was released earlier this year.
"This policy provides direction to NSW maternity services regarding actions to increase the vaginal birth rate in NSW and decrease the caesarean section operation rate; to develop, implement and evaluate strategies to support women and to ensure that midwives and doctors have the knowledge and skills necessary to implement this policy."

Carolyn Hastie has listed her 21 strategies to keep birth normal at her thinkbirth blog.

A NZ midwife, Sarah Stewart, has provided the link to the RCM list of ten top tips.

Midwives around the world have in recent years been promoting normal birth as a definitional duty of care, rather than a default position.

The policy directive Towards Normal Birth in NSW contains many parallels with the global Baby Friendly Hospital Initiative (BFHI), in the protection, promotion and support of breastfeeding. It is a simple step from BFHI to the protection, promotion and support of the normal physiological processes in the whole birthing continuum, rather than waiting until the baby has been born and needs food. The '10 steps to providing woman centred labour and birth care' (p8) parallels the BFHI '10 Steps'.

The NSW Health Department has taken a brave step in the right direction with this document. Time will tell whether 'mandatory' means just that, or something else. The implementation check list (Attachment 1) states that "All Area Health Services must achieve the measures by 2015."

We would love to hear from any readers in NSW. How's it going?

Listening

Midwives Rosie and Joy

After a Skype conference call that linked midwives in locations around the country for the APMA annual general meeting, the group at my house had a very valuable time of *listening* to each other. We sat around the table and we ate sandwiches and boiled fruit cake and drank our tea or coffee.

Our little group included those who have been in private practice from anything from five to 20 years. We also covered a wide spectrum of positions as far as Medicare and particularly the Collaboration arrangements are concerned.

Listening was so useful, and we asked ourselves to not try to debate or challenge the person who was speaking. (that’s quite a challenge in itself). We asked each person to talk about their current status with the Medicare eligibility application, and their plans.

I have recently had an in-depth conversation with a midwife who believes that no midwife should even attempt to take up the Medicare eligibility because “only women who consent to referral will be eligible for Medicare”, and that in supporting the Government’s Medicare reform a midwife is supporting discrimination against women. I have heard calls for midwives to stand together. I have read on a midwife’s blog “APMA representing private medicare midwives, and once again the rest of the midwives and the women who want a no fuss homebirth are left wondering ....”

Another midwife has written publicly “While women in Ireland, Hungary and the USA are being shackled physically we certainly are being shackled metaphorically here in Australia not just by legislators, hospitals and obstetricians but some of our own midwives and women who accept this treatment without even raising a pen to paper to object.”

These statements come after years of distress and fear amongst midwives and women who employ us, about the future.

Now that the legislation has been set down midwives have a clear choice as far as Medicare is concerned – either to do what we can to work within the ‘system’ as it is, or not. While we have the exemption for homebirth, we can continue attending women in their homes.

I believe we need to stay together as much as possible, or face further marginalisation of private midwifery practice as we know it. I hope that those among us with political skill will continue to work to improve equity and access for all women, and protect the scope of practice of the midwife.

A colleague who joined in our discussion yesterday spoke in very clear terms, differentiating between a midwife’s issues and a woman’s issues. I wish I had recorded what she said, but of course we were not recording anything.

I would encourage independent midwives to meet with your colleagues, and take time to *listen* to each other.

Collaborative arrangements for midwives

Earlier posts on this blog and others have sought to tease out some of the issues that have been brought to light with the Australian government's attempts at reform of maternity care.

Since mid-2008, with the announcement of the Maternity Services Review, midwives and birthing activists have written and argued and pleaded for improvements that are based on evidence and women's rights.

That campaign is ongoing. There is plenty of work to be done.

Some midwives are now seeking to take up the offer of Medicare (MBS) and limited prescribing rights (PBS) that have progressed through legislation, and are now being implemented.

Each midwife has some serious hurdles that we will need to overcome in order to be granted these 'privileges', and enabling our clients to claim Medicare rebates on services that are linked to Medicare items. Perhaps the most challenging is the requirement, spelt out in the National Health (Collaborative arrangements for midwives) Determination 2010 for an authorised midwife to have a signed collaborative arrangement with a doctor, or alternatively to follow a lengthy and prescriptive documentation process.

Of the options for signed arrangements, the first option is that the midwife is employed by the doctor or doctors. This is not a likely option for midwives who practise privately in communities. Obstetric group practices already employ midwives in their rooms, and these midwives probably provide valuable assistance in seeing the large numbers of women who pass through the rooms. But it is doubtful whether, even if these midwives are granted eligibility for MBS and PBS, they will be encouraged by their bosses to practise authentic midwifery, including practising on their own authority, promoting normal birth, and working in partnership with women throughout the episode of care. These midwives are likely to continue as obstetric assistants: some may scrub to assist at caesareans; some may even take on a caseload. But unless they are practising in true co-labor, as professionals in their own right, the 'reforms' are unlikely to make any changes to maternity care standards or outcomes.

The second option for signed arrangements is that the woman is "referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner". This option is quite fascinating. The obvious question is, why would a "specified medical practitioner" - a doctor who makes a living that is proportionate to the number of women who receive private maternity services from him or her, refer a woman to a midwife? This option will require strong women who approach these doctors, armed with their own plan, and request a referral that meets the requirements for collaborative arrangements.

The third option for signed arrangements appears to be the one that may be suitable for midwives who are practising privately and attending home births. This option will require the specified medical practitioner to be "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement." In this scenario the doctor who signs the arrangement may not be the doctor who provides collaboration in situations when women in our care, who are planning home birth, are referred to the hospital for obstetric review, such as for prenatal assessment or monitoring, or transfer of care. The doctor who signs the agreement with the midwife may be the medical director or head of obstetrics in a public hospital, who delegates the "authority to participate in collaborative arrangements" to the obsterics registrar. Such collaboration is applicable to the midwife’s provision of private prenatal care, and postnatal care. There is no Medicare item number for intrapartum midwifery care in the community (homebirth), so collaborative arrangements are not required to cover home birth.

Midwives who contact their local public hospitals with the purpose of seeking a signed collaborative arrangement are encouraged to communicate with APMA, or MIPP, in reporting the responses of the hospitals. These responses will be important information that will be used in reviewing and revising the legislation in the coming year(s).

Press release from Minister Roxon

From MinisterRoxonMedia@aph.gov.au

The Health Minister says:

"PATIENTS WIN AS NURSES AND MIDWIVES ACCESS MEDICARE AND THE PBS

[Comments and highlighting added by the blogger]

Nurse Practitioners and Midwives will from today be able to access the Medicare Benefits Schedule and provide Pharmaceutical Benefits Scheme medicines in the community.

For the first time highly skilled Nurse Practitioners and Midwives will be able to provide taxpayer subsidised services to patients outside of the public system in medical practices and the community.

[Blogger: We don't know of any midwives who have been successful in their applications for Medicare and PBS.  Readers are asked to provide links to any press releases that may identify midwives who have been awarded Medicare provider numbers
ps - one midwife has informed APMA that she is now 'eligible'/]

This is a momentous day for the nursing and midwifery professions and a great day for patients who will be able to claim a rebate, and benefit from better access, closer to home in a wider range of settings.

[Blogger: Home birth is not included in the Medicare reforms.  Women planning home birth may be able to get Medicare rebates on midwives' charges for prenatal and postnatal care, but not for birth.  The only Medicare  rebates for birth are for birth in hospital, attended privately by the midwife who has visiting access arrangements with the hospital, and collaboration arrangements with a named medical practitioner.]

...
Midwives will be able to deliver maternity care, including antenatal and postnatal care in the community, and undertake deliveries in a hospital.
 

...
Nurses and Midwives will be required to work in collaboration with medical practitioners when providing MBS services and PBS prescriptions.

[Blogger: Medical practitioners are not required to work in collaboration with midwives.]   



For today's article Medicare extended to nurses, midwives by Mark Metherell in The Age, click here.