Thursday, March 22, 2012

A new career pathway for midwives?

As more midwives take up the option of obtaining notation as Medicare-eligible, we are witnessing a series of changes in the career aspirations and practice choices that midwives make.
The ranks of the private branch of the midwifery profession have in the past year been swelled by a new group of midwives who have great hopes for a new career pathway. Many of these newly private midwives have come out of relatively senior positions in hospital employment, chosen a name for their new business, hung up a shingle (published a web page), and distributed pamphlets and business cards promoting their private midwifery care. There is new energy and enthusiasm as they spread the word that it’s a good idea for every woman to consider who will be attending her at the time when she labours and gives birth.

Judging by advertised courses and workshops, the new midwifery career pathway is a growth area for education providers and related services, including insurers.

 The newly self-employed midwife has plans to apply for clinical privileges in local hospitals when that option becomes a reality. In the mean-time, some have negotiated casual employment in hospital maternity units, so that they can provide personal labour and birth care for the women who have employed them privately in the antenatal period, and for whom they will provide private services postnatally.

The new private midwife may not use the title ‘independent’ - a problematic adjective in the world of politically correctness. The newcomer to the ranks of private practice is, in the world of new midwifery, a ‘team player’, who, in theory at least, acts in every situation within collaborative arrangements with the ‘team-leader’, the obstetrician, of course—not the woman!

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.

APMA has received information from midwives who are at different places on the private practice spectrum: from those who have ceased midwifery practice since the maternity reforms were introduced; those who are under investigation by the regulatory authority; those who have invested their life savings into establishing and maintaining practices, rooms, and services; and those who work as solo midwife for births in homes that are scattered over vast distances. There is a big question mark over the future for private midwifery homebirth attendance, with the exemption from professional indemnity insurance for homebirth being limited to June 2013.

Although ‘new’ private midwives have invested time and money and a great deal of effort in achieving notation as Medicare-eligible, purchasing expensive indemnity insurance, and setting up their practices, with the hope of being able to provide expert continuity of care for women who give birth in hospitals where they (the midwives) have been awarded clinical privileges, there is little evidence in most of the country of progress on the part of hospitals—public or private— being eager to open up such options.

Maternity service provision must be based on the fact that professional care from a midwife is essential, not optional, for all pregnant women and their babies. When the current plan for maternity reform was being developed, midwives were told “Unless and until the Government is shocked and shamed into realising that Australian women are now scrambling to find the birthing centre of their choice, and in some cases scrambling to find any professional who will deliver their child, the situation will not improve." (J Gillard 2005)

Joy Johnston

Thankyou for your comments.

Wednesday, March 21, 2012

Where are the midwives who practise privately?

[The following brief overview of private midwifery options is anecdotal, incomplete, and reported in good faith, knowing that situations change constantly.]

Western Australia
There are currently 11 Medicare-eligible midwives in WA, but how many are actually practising at the moment I’m not sure.  Some will do homebirths but others are only doing intrapartum care in hospital. 

There are currently no admittance/access rights for eligible midwives, so care in hospital is usually achieved through an arrangement by which the midwife is casually employed by WA health when she does the intrapartum care in hospital. WA Health are currently developing an access agreement.

There are 3 or 4 other privately practicing midwives in Metro Perth and two in the South West. I don’t think any are currently doing VBACs at home.  Some are only taking repeat clients. 

South Australia
The options in SA are limited because almost all of the midwives live in a similar geographical area. Most of us travel but it still is limited. Of the 9 working and taking on clients, 6 live in the Adelaide Hills and the next one coming into it also live up here.  There are 3 who are Medicare eligible, 1 eligible midwife about to start, 3 who are not eligible but are registered. 

Homebirth SA Blog

Midwives in Private Practice (MiPP) is a collective of midwives, and a participating organisation in Maternity Coalition. MiPP members work in Group Practices, partnerships, and solo practices, providing private midwifery services for women planning homebirth, as well as hospital births. MiPP members also mentor other midwives who are commencing private practice. Although Victoria is a relatively small State, there are areas where no private midwifery services can be accessed.

Recent government-funded homebirth programs have been offered for selected women through Sunshine and Casey Hospitals.

One Victorian Medicare-eligible midwife has completed a medications course which has been accepted by AHPRA. However, Victorian legislation needs to be changed before midwives are able to take up the PBS reforms.

In Melbourne more and more doctors are saying "no" to women who request referral or another pathway so that the woman can receive the Medicare rebate.  The government’s reform is pretty empty if women can’t even access Medicare rebates.   An obstetrician at the local hospital told me “I don’t support that model”

MiPP blog
List of MiPP midwives

New South Wales
Northern NSW - there were about 8 midwives attending homebirths a few years ago, with maybe 3 being private practice (PPM) only, and the other midwives also working in public hospitals. Now there are no PPMs-only in this region, but there is one midwife who attends some homebirths and is also employed in a hospital, and one other midwife who is Medicare eligible and attends some homebirths and is also a caseload midwife. There is another PPM who lives on the Gold Coast Qld and travels to the region. We have also had a govt funded homebirth program approved here which should be up and running shortly. That may impact further on numbers of births available for PPMs. 
Marie Heath (Goulburn)

Toowoomba-Ipswich My Midwives offer women the choice of 4 midwives in Toowoomba and 2 in Ipswich.  We also have a lactation consultant who just does lactation privately but is an eligible midwife (provides antenatal and labour as an employee in hospital).  Women can choice place of birth (home, birth centre, public hospital).  They only receive a Medicare rebate for birth for birth centre or public hospital.  They receive Medicare rebates for antenatal and postnatal care no matter where they have their baby.  Many of the private funds provide a rebate for some element of the woman’s care as well if the woman has private health insurance. 

We bulk bill completely women attending Young Women’s Place for antenatal and postnatal care and we can attend women admitted as public patients under a fractional employment model with the hospital.  The tendency though is not to admit women as public patients unless we have to because we do find that having them admitted as the primary client of the midwife rather than as a public patient makes a difference in terms of autonomy in the woman’s care.

We have a signed collaborative agreement with Toowoomba public hospital obstetricians.  In practice one of us [midwives] meets with them fortnightly to discuss any issues we have or we book women in at a specific time for a referral or consultation.  At the time of admission the women are admitted in the care of (or “under”) the primary midwife and we consult if/as required with one of the obstetricians.  For women birthing at home, we just attend as normal and let the hospital know if we have any dramas.
My Midwives

For more links to websites of privately practising midwives, go to Midwives Australia

Monday, March 19, 2012

Where are the midwives?

[For a rough estimate of distance, think of a red dot as 100Kilometers]

Several years ago the Federal Opposition Health spokesperson made a speech to midwives. She said that midwives have:

“limited opportunities to practise as primary carers and provide continuity of care to women” and

“Unless and until the Government is shocked and shamed into realising that Australian women … ” and

“I believe that midwives … are key heath care professionals whose role in the care of women and their babies has yet to be fully realised in the Australian health care system” 

The speech was to the Annual conference Midwifery By The Sea - Riding The Waves Of Change of the New South Wales Midwives Association, 20th October 2005.  The speaker was the woman who went on to become Prime Minister, the Hon Julia Gillard. Here's a little more from that speech:
"Clearly this is no time for turf warfare between doctors and midwives, but it is time for all health care professionals involved in delivering obstetrics care to mount a combined attack on the Howard Government to force them into action to address this situation. Unless and until the Government is shocked and shamed into realising that Australian women are now scrambling to find the birthing centre of their choice, and in some cases scrambling to find any professional who will deliver their child, the situation will not improve."
The [Rudd-] Gillard government have brought in maternity reform, as readers of this and other maternity-related sites will know all too well. Ms Gillard declared in 2005 that "this is no time for turf warfare between doctors and midwives ..." YET this government delivered the virtual control of private midwifery practice to doctors, in the form of a piece of legislation called the Collaboration Determination.

The words (mainly) of the PM herself ring true:
"it is time for all health care professionals involved in delivering [maternity] care to mount a combined attack on the [Gillard] Government to force them into action to address this situation." 

This month, APMA has conducted a brief review of private midwifery services, asking midwives and maternity consumers to tell us what's on offer where they live.

Here are the current trends:
  • Areas with access to private midwifery services are mainly the [more densely populated] capital cities and a few regional centres, as demonstrated on the map. 
  • Established midwifery practices that have taken up Medicare rebate options since November 2010 continue to provide homebirth services. 
  • Homebirth, which has been predominantly the domain of private midwifery practice in Australia for many years, is increasingly being made available through publicly funded hospital-based programs. 
  • Established midwifery practices that have continued without Medicare rebates are providing homebirth and other private services in their communities. 
  • The emergence of new private midwifery practices with Medicare includes some providing midwifery care across the prenatal and postnatal periods, with hospital births, while others a focus on postnatal services. 
  • Progress towards hospital visiting access for private midwives has been noted in Toowoomba (Qld) and Sydney (NSW). 
  • Unregulated birth attendants are reported to be available to provide homebirth services in some areas. 

In many areas, women are still "scrambling to find the birthing centre of their choice, and in some cases scrambling to find any professional who will deliver their child." 

The new rules present midwives and the women who employ us with unnecessary obstacles when attempting to comply with legislated requirements for collaboration.  There is no public interest in these new rules.  The health and wellbeing of women and their babies is not improved by the hurdles they are now required to jump.  Some women are choosing to forgo the Medicare rebate than have to go to an unsympathetic doctor, cap in hand, requesting a referral to their chosen midwife.

It's time for women and midwives to take Julia's own advice, and  "mount a combined attack on the Gillard Government to force them to address this situation."