Wednesday, November 30, 2011

Midwives and prescribing

Midwives who have achieved eligibility for Medicare (MBS) are required to sign an undertaking:
• That I will undertake, and successfully complete, within 18 months of recognition as an eligible midwife:-

(i) an accredited and approved program of study determined by the Board to develop midwives’ knowledge and skills in prescribing; or

(ii) a program that is substantially equivalent to such an approved program of study, as determined by the Board.

I understand that until I meet the above requirement I will not be able to seek endorsement for scheduled medicines and will therefore not be prescribing medicines.

As there is at present no option (i) 'accredited and approved program of study', option (ii) is being used, and midwives who have completed a course of study in pharmacological management for Nurse Practitioners are required to undertake an exercise in *mapping* their course against the AHPRA guideline and accreditation standard. For more information regarding each section and for greater context please refer to the “Guidelines for Education Requirements for Recognition as Eligible Midwives and Accreditation Standards for programs of study leading to endorsement for scheduled medicines for Eligible Midwives”

Tuesday, November 15, 2011

Broadening the discussion about home births

An insightful commentary on homebirth by Hannah Dahlen has been published in 'Croakey' blog. Here's a brief excerpt:
The home birth is about more than safety
... The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.  
Home birth also represents starkly the different philosophical frameworks held by midwifery and medicine, and hence the debate over this issue is ideological, contested, longstanding and circumscribed by relationships of power.

Sunday, November 13, 2011

ACM Position Statement on Homebirth Services 2011

The Australian College of Midwives (ACM) has released a revised Position Statement on Homebirth Services 2011, together with a 'guidance' document and literature review. To access the .pdf files, click here.
"The following Position Statement on Homebirth Services 2011 has been developed utilising extensive consultation with all submissions being considered by a Review Panel. The Review Panel consisted of nominees from all Branches (eligible midwives, private practising midwives, midwives providing public homebirth services and midwifery academics) and two representatives from the ACM Consumer Advisory Committee. It should be read in conjuntion with the Guidance for midwives regarding homebirth services 2011."
Readers of this and other midwifery blogs will know that an Interim Position Statement on Homebirth, with a guidance document and lit review were released a couple of months ago by ACM. The position statement was endorsed by the Nursing and Midwifery Board of Australia, prior to the documents being circulated in the midwifery profession for comment. The full significance of this rapid endorsement by the regulatory body, of an 'interim' document, prior to consultation with the profession, is not clear.

The new Position Statement presents a clearer position than the previous one.  One of the key stumbling blocks is what to do with women who choose home birth against the midwife's or other health service's advice.  The new statement addresses informed decision-making, informed consent, and the woman's right of refusal, and acknowledges that "some women may choose a planned homebirth when this is not recommended by a health care provider.  Women should continue to have access to midwifery care whatever they choose."

In a Croakey blog (the Crikey health blog), outspoken obstetric spokesman Dr Andrew Pesce states that:
"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."
Dr Pesce's concluding, and tantalising statement is:
"If they [those individuals and groups which advocate for publicly funded home birth] can cross that Rubicon, they might find that they have broader support than they realise."

I say this statement is tantalising, because it appears to be suggesting that obstetricians and mainstream maternity services would, with agreed boundaries, support publicly funded homebirth.  That is happening in a variety of homebirth models, providing homebirth services for a small number of women around Sydney, Melbourne, Adelaide, Perth, Fremantle, Darwin, Alice Springs. 

I wonder if that support would extend to home birth in the care of a privately employed midwife?

Thursday, November 10, 2011

Births in South Australia: Summary and recommendations

Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 including the South Australian Protocol for Investigation of Stillbirths

This is the Twenty-fourth Annual Report of the Maternal, Perinatal and Infant Mortality Committee, for the year 2009:

1. There was one direct, one indirect, and one incidental maternal death in 2009. The maternal mortality ratio for the last four-year period 2006-2009 was 6.5 deaths per 100,000 women who gave birth, which is low by international standards. It is also lower than in the preceding five-year period where there were 9.1 deaths per 100,000 women. The overall number of deaths was small (five in four years
compared with eight in five years).

2. The Committee reviewed the 189 perinatal deaths of babies born in South Australia in 2009. The perinatal mortality rate for all births (stillbirths of at least 400g or 20 weeks gestation and all live births) was 9.5 per 1,000 births. The stillbirth rate was 7.0 per 1,000 births and the neonatal mortality rate 2.5 per 1,000 live births. Over the past years, declines have occurred particularly in the perinatal mortality rate used for international comparison, i.e. stillbirth and death within the first 7 days of life for babies weighing at least 1,000g. The early neonatal death rate for international comparison remained low in 2009 at 0.9 per 1,000 live births.

3 Eighty-three percent of the perinatal deaths occurred in preterm babies (less than 37 weeks gestation). The leading cause of perinatal death in 2009 was again congenital abnormalities, which accounted for 34% of the deaths. Other leading causes were spontaneous preterm birth (11%), specific perinatal conditions (11%) and stillbirth of unknown cause (11%). There were 21 stillbirths of unknown cause, a rate of 1.1 per 1,000 births in 2009. This rate has fallen in recent years, compared with 2.0 per 1,000 births in 1995-1998. The Committee has distributed its protocol for the investigation of stillbirths to all obstetric units (Appendix 8). Twenty-one deaths were attributed to preterm birth. Preterm birth and poor fetal growth (which contributed 9% of deaths) have been associated with smoking during pregnancy. The proportion of women smoking during pregnancy has been declining in the state. However, in 2009 it remained at 16%.

4. Nine babies of Aboriginal mothers died during the perinatal period. The perinatal mortality rate of 14.6 per 1,000 births with Aboriginal mothers in 2009 was the second lowest recorded, but remained higher than that of 9.3 per 1,000 with non-Aboriginal mothers. The rates of preterm, small-for-gestational-age and low birthweight births with Aboriginal mothers also remained higher. The  proportion of Aboriginal women who smoked during pregnancy was 52% compared with 16% for non-Aboriginal women.

5. The Committee also reviewed the 23 post-neonatal deaths in 2009 of babies born in South Australia, two of which were the babies of Aboriginal mothers. The postneonatal mortality rate remained very low at 1.2 per 1,000 live births. Congenital abnormalities accounted for 11 (48%) post-neonatal deaths. There were 10 ‘Sudden Unexpected Deaths in Infancy’ (SUDIs). Three subcategories of the SUDI deaths can be difficult to distinguish: ‘SIDS’, ‘accidental asphyxiation’ and ‘undetermined cause’. In total, six deaths, including one SIDS death, were attributed to these three subcategories.

6. The infant mortality rate in 2009 was 3.6 per 1,000 live births. The infant mortality rate for babies of Aboriginal mothers of 4.9 per 1,000 live births was the lowest recorded but remained higher than that of 3.6 for babies of non-Aboriginal mothers.

7. From the review of maternal, perinatal and post-neonatal deaths, the Committee makes the following recommendations:

>> NEW - There should be further development and evaluation of culturally appropriate programs to enhance access to, and uptake of antenatal, birthing and postnatal care in Aboriginal communities.

>> Caring for pregnant women should be undertaken in a setting which is appropriate for the level of risk the pregnancy presents for the mother and/or the baby.
>>Women with current or previous serious medical conditions should be reviewed by a physician early in pregnancy.
>> Pregnant women travelling in motor vehicles need to wear seat belts at all times for safety.
>> Pregnant women with a Body Mass Index (BMI) greater than 35 kg/m2 are at higher risk from anaesthesia. A timely referral for an anaesthetic consultation should be considered for women with a high BMI. South Australia is developing a policy for care of bariatric patients.
>> Effective strategies should be pursued to reduce smoking in pregnancy, including culturally appropriate smoking cessation interventions for Aboriginal women.
>> Testing the antibody status of Rhesus D negative women before the first administration of Anti-D is important. A measurable titre of Anti-D antibodies is an indicator of potential alloimmunisation and always requires investigation and a specialist opinion.
>> Early ultrasound determination of chorionicity is advised for twin pregnancies, followed by further surveillance for twin-twin transfusion in monochorionic pregnancies.
>> It is satisfying that the decline in deaths attributed to fetal growth restriction has continued from 7.9% of deaths in 2008 to 7.4% in 2009, compared with 11.2% in 2007. Vigilance to ensure that fetal growth restriction is not missed remains warranted.
>> The institution of streamlined arrangements between rural/level 4 hospitals and their regional level 5/6 maternity service in situations where there is a lack of on-site CTG expertise; this includes easier access of rural practitioners to the consultant on call.

Labour and birth>> NEW - All home births should be conducted in accordance with the ‘Policy for Planned Birth at Home in South Australia’; specifically that the mother should be transferred for hospital care when a planned home birth is complicated by the presence of meconium stained liquor.
>> A previous caesarean section and breech presentation are contraindications for home birth.
>>When induction of labour is deemed necessary in the presence of a uterine scar and an unripe cervix, careful consideration should be given to alternative options such as postponing the induction or caesarean section.
>> Once a decision to perform an emergency caesarean section has been made, it is recommended that fetal monitoring should continue until the commencement of surgery.
>>When feto-maternal haemorrhage is suspected, flow cytometry should be considered to estimate the volume as it is more precise than the Kleihauer test.
>> Carriers of Group B Streptococcus and women with risk factors such as prolonged rupture of membranes require appropriate screening and antibiotic treatment.

Postnatal>> NEW - Where a woman presents with serious medical complications early in the post partum period she should be reviewed by a physician with an interest in obstetrics, if available, as well as by an obstetrician, together with other medical specialists as appropriate.
>> If a diagnosis of pre-eclampsia has been made, the blood pressure should be monitored until it has settled and any abnormalities of renal or liver function or blood counts have been appropriately managed.
>> Non-steroidal anti-inflammatory drugs should be avoided post-partum and post-operatively in women with pre-eclampsia. Low dose aspirin, especially when commenced early in pregnancy, remains an effective drug for prevention of pre-eclampsia.
>> Use of the recently-revised protocol for investigating stillbirths, which has been sent to all maternity units in South Australia (Appendix 8).
>> Seeking parental permission for autopsy, which may provide information most valuable in the counselling of parents and in the management of future pregnancies. The State Perinatal Autopsy Service (telephone 08-8161-7333) is available at no cost to the parents, including those in country areas. Certain categories of death have to be reported to the State Coroner (see page 40).
>> Sending placentas for histological examination with all relevant clinical information in all cases of perinatal death (see Appendix 9).

>> Appropriate training and maintenance of competence in cardiotocograph (CTG) interpretation for all levels of medical and midwifery staff.
>> Ongoing development and implementation of statewide perinatal protocols is recommended (

>> An effective system of appropriate and ongoing support, supervision and referral should be offered to families with known risk factors for adverse child outcome, such as substance abuse, psychiatric illness, extreme youth of the mother or violence in the household. This should be continued at least throughout the first year of life, if not for a longer period of time.
>> Monitoring growth in children, which can be undertaken using the weight percentiles in the child’s Personal Health Record (Blue Book), and investigating why a child is not thriving.
>> Immunisation of children to prevent infectious disease.
>> Vigilance to ensure that potential hazards in the home are removed from the infant’s environment.
>> Vigilance to ensure safe feeding in children under four years of age. Foods that can break off into pieces should not be given, as accidental asphyxiation may occur.
>> Consideration should be given to better ways of identifying serious underlying illness in children presenting to clinicians, for example, Medic Alert bracelets.
>> Systems to facilitate referral by community nurses of high-risk children to paediatricians or tertiary hospitals for urgent appointments need to be considered.
>> Hospitals with high paediatric throughput need provision of 24 hour paediatric expertise.

Friday, November 4, 2011

midwifery in Australia

The Annual Report 2010-2011 of the regulation agency AHPRA and the National Boards reporting on the National Registration and Accreditation Scheme has been released.  The annual report marks the first ever release of comprehensive national data on health practitioner regulation, including state and territory information, and profession-specific data.

At the time of the Report there were 97 [Medicare-] eligible midwives, listed as coming from:
  • 13 NSW 
  • 53 QLD 
  • 5 SA 
  • 4 Tas 
  • 16 Vic 
  • 6 WA 
Here are a few selected quotes from the report and linked documents:
Midwifery was the most female-dominated of the regulated professions, with the largest group of midwives aged 40 to 44 years and practising in Victoria.

Important information for the nursing and midwifery professions in the report includes: –
  •  On 30 June 2011, there were 332,185 nurses and midwives registered to practise in Australia, with nursing and midwifery representing 63% of the total group of registered health practitioners
  • Of these, 1,789 practitioners held midwifery registration only, 290,072 nursing registration only, and 40,324 held dual nursing and midwifery registration
  • New South Wales was nominated as the principal place of practice by the largest cohort of nursing and midwifery registrants
  • Of all nurses and midwives, the largest group was aged 50 to 54 years (51,998 or almost 18% of the profession)
  • 83% (274,228) of the total number of registered and enrolled nurses and dual nursing midwifery registrants are female; and 99.67% (1,783) of midwives are female
  • There were 1,466 nursing and midwifery practitioners in Australia with an endorsement on registration: 624 nurse practitioners; 744 endorsed for scheduled medicines; one midwife practitioner and 97 eligible midwives
  • There were ... 2,483 students of midwifery registered from April 2011, ... 2.5% of registered students across all regulated professions
  • There were 8,139 notifications received about health practitioners in 2010-11, including 1,300 about nurses and midwives. This means between 0.1% and 0.3% of Australia’s 332,185 nursing and midwifery practitioners were subject to a notification relating to either health, performance and/or conduct of the nurse or midwife
  • The Board took immediate action in relation to 115 nursing and midwifery practitioners after receiving a notification about the practitioner’s health, performance and/or conduct. As a result, the Board took no further action in 24 cases, imposed conditions on the registration of 26 practitioners suspended the registration of 36 practitioners; noted four practitioners surrendered their registration and accepted undertakings from 26 practitioners
  • There were 254 mandatory notifications about nurses and midwives in 2010-11, representing just over 58% of all mandatory notifications received across the 10 professions

Thursday, November 3, 2011

Medicare and eligible midwives

click to enlarge
This is the new schedule of fees and rebates that have been increased by 2% as part of annual indexation of Medicare items, effective from 1 November.  The item descriptions can be viewed in full at
Obstetric items and referrals
Requesting diagnostic services