Saturday, January 21, 2012

too posh to push?

Apparently not, at least in sunny Queensland, where the statewide rate of caesarean births has soared to 34 percent of all births, and where private hospitals have the highest rate of caesarean section deliveries (47.9 percent) in Australia. [for the press release from University of Queensland Centre for Mothers and Babies, click here.]

Who is really responsible for the continuing increase in rates of caesarean births in this country?

  • Are too many obstetricians greedy, seeing a surgical procedure as better $ return for their time? 
  • Are too many obstetricians fearful of litigation, and thereby placing unrealistic risk-management boundaries on women in their care? 
  • Are too many public and private hospital maternity units over-crowded, leading to pressure on staff to get babies delivered without what is seen as delay, but what may simply be giving the time that's needed? 
  • Are too many midwives so de-skilled that they are unable to provide basic midwifery care, working in harmony with natural processes in labour? 
  • Are too many women so trusting of professional care, so ignorant of their own natural ability in birth, that they allow interferences and interruptions in their pregnancies and labours, leading to the cascade of interventions? 

If you said 'yes' to all, go to the top of the class.

There's lots of information on the www about caesareans. For a summary of pros and cons that may assist women in making informed decisions about births after caesarean, you can download a .pdf file Maternity Coalition INFOSHEET.

and, btw
What do you think can be done to reduce the rates of unnecessary caesarean births?

Thursday, January 19, 2012

National Maternity Services Plan Annual Report

This report is only 9 pages long, and is worth reading. National Maternity Services Plan 2011 Annual Report
Barriers to implementation and mitigation

The introduction of MBS and PBS benefits for services provided by eligible midwives to provide greater access to maternity care provided by midwives working in collaboration with doctors has had a gradual take-up, as potentially eligible midwives seek to establish the collaborative arrangements required. The Commonwealth is monitoring collaborative arrangements under a framework agreed by the Minister for Health and Ageing which includes stakeholder consultation, collection of data on the management of enquiries, stakeholder surveys and analysis of MBS data. A survey of stakeholder experiences of collaborative arrangements is expected to be conducted by Healthcare Management Advisors (HMA) on behalf of the Department of Health and Ageing by late 2011 and again 12 months later. HMA will be contacting midwives and obstetricians to participate in the surveys. The evaluation of the Queensland Health pilot site for midwife credentialing will also provide information on the establishment of collaborative arrangements.

Tuesday, January 17, 2012

Medicare and midwives

[The following post is written by Joy Johnston, who is a member of APMA. Any opinions expressed are those of the writer, and are not necessarily shared by the organisation.]

It is useful for midwives to consider an opinion piece in the MJA, What is wrong with Medicare?, by Tony D Webber (MJA 2012; 196 (1): 18-19), and a linked article on The Conversation, 17 January 2012, Look beyond the hype to see what’s really wrong with Medicare.

The writers of these two articles have strong credentials.
Dr Webber states that he was
"Director of Professional Services Review (a role established to protect the integrity of Medicare and the Pharmaceutical Benefits Scheme) for over 6 years, ..."
and that
"From the beginning, there were inadequate safeguards in a scheme based on the honour system. In no other area of public expenditure where recipients have significant control has so little attention been paid to audit."
The author of the second article, Jim Gillespie, is Deputy Director, Menzies Centre for Health Policy & Senior Lecturer in Health Policy at University of Sydney.

Midwives and maternity activists who have been lobbying government for many years, remember the clear statement by then Labor Health Minister Dr Carmen Lawrence that Medicare will NEVER be available to midwives. It's now history that Kevin Rudd, with Health Minister Julia Gillard, have introduced Medicare for eligible midwives, and that every day midwives are giving our clients receipts that entitle them to rebates, or using EFTPOS machines to bulk bill for some services. Surely this is good, for midwives and our clients.

We midwives would do well to hear the concerns of these two well-informed writers.
The serious claims made by Dr Webber are to do with rorts and inefficiencies estimating that "2–3 billion dollars are spent inappropriately each year." An example quoted is that "After the Safety Net was introduced, a small group of obstetricians raised their fees for antenatal care from around $3000 to nearly $10,000."

In his useful analysis of a complex situation, Dr Gillespie states:
"But the Medicare system wasn’t designed to encourage continuity of care. Instead, it uses fee-for-service to fragment care into short episodes. A major criticism of the current system is that it doesn’t provide optimal care because it’s episodic and as a result, it may be creating incentives for abuse of the system as doctors’ incomes are generated by multiplying episodes of care."

Continuity of care, and of carer, are key principles valued within midwifery standards, codes, and models of care.   Evidence and logic support systems that link a pregnant-birthing woman to a known midwife who provides the primary level of maternity care.  Most women like to know and trust their hair-dresser!  How much more significant is it that those who have the intention to approach childbirth as a physiological event (rather than a medical procedure) would like to know and trust our midwife!

Maternity care offered the health system an excellent opportunity to reform funding to protect continuity of care, based on the total basic package of care for each woman in pregnancy and birth. Normal pregnancy is one potential *item* that is very definable - there is no such thing as chronic pregnancy! Complications are also definable - Medicare items already exist for such medical services.  Once labour starts a baby has to be born, and the modes of transfer from the womb to the outside world are limited. Postnatal services are, similarly, containable.

However, by applying the standard Medicare model of fragmented items to Medicare funding for midwifery services, the same weaknesses that are so obvious in medically-managed Medicare have been carried across to midwifery-Medicare.   Medicare does not have any limitation or expectation as to the number of claims made on certain midwifery items, for example, prenatal and postnatal consultations.  A midwife can provide as many postnatal consultations in the first 6 weeks of the baby's life, and Medicare will rebate the amount calculated on the scheduled fee, plus the extended safety net.  If a midwife provided 42 postnatal visits for a woman, and received the Bulk Bill rebate of $65.50 for each consultation, a total of $2,751 would be paid from the public purse to that midwife.  Would that be considered over-servicing?  Perhaps - it's an unlikely scenario.  If that daily consultation with a particularly needy mother and her baby kept them well, and out of hospital, surely the health money would be well spent, and the midwife should be congratulated.  But isn't that taking continuity of care to an extreme?  Would the midwife be rorting the Medicare system?  Do we need more rules, more stringent 'safeguards', to define what would be reasonable, or will (most) midwives do the right thing - whatever that is?

In giving this example I have touched on an area of change for private midwives.  In the past, before private midwives had Medicare provider numbers, the client paid the midwife's fee for each visit, or the midwife did extra visits without charging.  Now, Medicare-participating midwives who are able to comply with the collaboration rules can provide much more affordable care.  Women who are experiencing difficulties in the early postnatal period, even after discharge from hospital, are now able to engage a private midwife the whose fees are mostly rebated by Medicare.  A woman who had a private obstetrician for pregnancy and birth, for whom Medicare rebated several thousand dollars, is now able to be rebated by Medicare for a midwife's care.

In this post I have not attempted to justify or explain the new Medicare-funded private midwifery, which has been in operation since November 2010.  I consider that although the system we have is flawed, midwives are seeking to work within the system, and the benefit is a greater degree of financial equity for women who employ midwives for professional care.

Tuesday, January 10, 2012

Revised Professional Indemnity Insurance Arrangements Registration Standard

The Nursing and Midwifery Board of Australia has distributed the following message:
A revised Professional Indemnity Insurance Arrangements Registration Standard for nurses and midwives will be in place from the 10 January 2012. ... The registration standard was approved by the Australian Health Workforce Ministerial Council on 11 November 2011.

The revised registration standard:

• will ensure all nurses and midwives are able to practice in accordance with legislative and professional practice requirements

• will be included in the NMBA Safety and Quality Framework for the regulation of midwives including privately practicing midwives providing planned homebirths, and

• is supported by updated and comprehensive guidelines for midwives.

The registration standard can be accessed at

The Guidelines for Professional Indemnity Insurance Arrangements for Midwives can be accessed at: 
Q&A DISCUSSION added 11 January 2012 

Some midwives who have read the new PII Registration Standard have questioned the meaning of the statement:
Requirements: ...

3. Nurses and midwives in different types of practice will require different levels of PII cover, according to their particular level of risk.  The following PII cover should be considered:
a). civil liability cover
b). unlimited retroactive cover and
c). run-off cover.

The definition of ‘retroactive cover’ is given: “Retroactive cover means PII arrangements which cover the insured against claims arising out of, or as a consequence of, activities that were undertaken in the course of the practitioner’s professional practice, prior to the date of commencement of the insurance.” (emphasis added)

Q: What does this mean, in reality, for a privately practising midwife?

A: The requirement in the standard says this ‘unlimited retroactive cover’ should be considered. [Note: this statement has not changed since the earlier draft of the document, circulated for comment.]

Q: How would a midwife would come to the conclusion that unlimited retroactive cover is necessary or not in private midwifery practice? How would a midwife weigh up their “particular level of risk” and conclude that retroactive cover is necessary? 

A: These questions are theoretical, because there does not seem to be any indemnity insurance product for midwives that offers anything like retroactive cover. When midwives apply for insurance we are required to disclose any incidents that may lead to legal action. 

I don’t mean to trivialise the matter. It’s difficult to explore these issues, because they are very emotive.

This standard says
“4. It is the responsibility of nurses and midwives to understand the nature of the cover under which they are practising” 
As I see the situation around this revised registration standard, it doesn’t change anything.

Friday, January 6, 2012

Safety and quality goals for health care

A consultation paper on the Australian Safety and Quality Goals for Health Care has been released for comment. The website for the commission is

APMA is preparing a response, in which we will apply the draft goals to our area of interest - private midwifery, particularly at the primary maternity care level. We are seeking to have private midwifery practice seen as a standard option in Australian health care, just as general medical practitioners (GPs) are. Submissions will be published at the commission’s website, and hopefully we will say something that can be carried forward into the final consultation paper, which then should be used to influence government policy.  (It's optimism that keeps some people moving forward!)

The three draft goals are  
1. Safety of care: That people receive their health care without experiencing harm. Initial priorities are to:
• reduce harm from adverse medicines events and improve quality use of medicines
• reduce harm from healthcare associated infections through effective infection control and antimicrobial stewardship.  
2. Appropriateness of care: That people receive appropriate, evidence-based care. Initial priorities are for:
• people living with type 2 diabetes
• people with acute coronary syndrome or stroke.  
3. Partnering with patients and consumers: That there are effective partnerships between patients, consumers and healthcare providers and organisations at all levels of healthcare provision, planning and evaluation.

APMA will seek to inform the commission about the failure of health care reform in maternity care – that the government’s reforms have been obstructed; that no midwives have clinical privileges in hospitals; that there is no indemnity insurance product for midwives attending births privately in the woman’s home; that midwives experience considerable difficulties applying the collaboration rules when hospitals are keen not to collaborate in a way that the determination sets out ...

APMA will seek to make strong presentations on each of these draft goals, as applied to maternity care. Our focus will be on the majority of women; well women with uncomplicated pregnancies, for whom the midwife is the agreed appropriate primary care provider, who collaborates with medical/hospital services as the need arises.

Here are a few initial comments, which readers may wish to think about in preparing your own responses or submissions:
1. Safety of care in maternity includes promoting and protecting natural processes in birth. We need to come out strongly in criticism of mainstream maternity care with unacceptably high rates of induction and the consequences; rates of caesarean; long term morbidity from unnecessary caesarean surgery. We need to give references and show statistics of how private midwifery provides safety and effectiveness in primary maternity care. Medicines and microbes are also matters of great importance in the promotion of unmedicated childbirth, and keeping mother and baby together after birth.
2. Appropriateness of care, with evidence based care, is also a topic about which we can wax lyrical.
3. Partnering with 'patients' (is a woman who is pregnant, who is receiving maternity care, a 'patient'?  Does that word not suggest that some form of illness exists?) and consumers is a key (definitional) aspect of midwifery. I heard a lecture by a well-respected professor of Law and Medicine, who pointed out that there is no legal or ethical expectation of partnership between a doctor and a patient. This, in her opinion, was a major difference between midwifery and medicine.

This blog does not usually attract much comment.  Despite that fact, your comment is most welcome.