Australian Private Midwives Association

membership in APMA

2012-02-03T17:39:00.000+11:00

The APMA committee are checking our membership database, and sending a reminder message to those whose membership has lapsed due to unpaid subscription fees.

This is a good opportunity to invite other midwives who are practising privately in Australia to consider taking out membership, and joining other colleagues in our effort to improve maternity care through access to private midwifery.

For more information about APMA, please click here, and fill out the membership inquiry message.

Of course – should you feel able or willing to make a donation to APMA to assist us further to meet the goals of APMA it would be greatly appreciated.

The fee for renewal of membership is $50.00 annually.Please make payment by direct deposit/electronic transfer into the APMA account, and include your name in the message.

The APMA bank account is:BSB: 067-105Account #: 10344192

If you are no longer practising as an independent midwife, and would like to continue as a ‘supporter’ of APMA, please let me know [joy@aitex.com.au], and that will be recorded on our database.

The APMA committee are also in the process of preparing a Statement of Purpose. Some of the points noted at a recent brainstorming session are:

To represent midwives who practise privately – across the full scope of practice, not just Medicare-eligible midwives, not just homebirth midwives
To support and care for members in a non-judgmental way, with flexibility to respond to different people and situations
To respond to issues related to private practice midwives
To present the needs of private practice midwives to the regulatory authority – eg to ensure that midwives’ peers are used as experts in investigations and hearings
To lobby in the political sphere, in response to current issues
To share information with members and the wider community

Members and other readers are welcome to contribute your ideas and suggestions to the development of a Statement of Purpose.

Thankyou.
Joy Johnston
(Vice President, and blogger)

too posh to push?

2012-01-21T14:50:00.000+11:00

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?

National Maternity Services Plan Annual Report

2012-01-19T19:44:00.000+11:00

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.

Medicare and midwives

2012-01-17T10:47:00.002+11:00

[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.

Revised Professional Indemnity Insurance Arrangements Registration Standard

2012-01-10T16:05:00.001+11:00

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 http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

The Guidelines for Professional Indemnity Insurance Arrangements for Midwives can be accessed at: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx

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.

Every midwife who is offering private midwifery services is required to have PI insurance that covers all antenatal and postnatal aspects of care
Midwives attending homebirths privately are able to obtain exemption for the attendance at homebirth, if they comply with the requirements set down in the current Board-approved Safety and Quality Framework for Privately Practising Midwives attending homebirths.

Safety and quality goals for health care

2012-01-06T17:25:00.000+11:00

A consultation paper on the Australian Safety and Quality Goals for Health Care has been released for comment.The website for the commission is http://www.safetyandquality.gov.au/

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.

AIHW report 2009

2011-12-22T15:47:00.004+11:00

The Australian Institute of Health and Welfare (AIHW) has published its statistical report Australia's mothers and babies 2009, released: 21 Dec 2011 author: AIHW (Li Z, McNally L, Hilder L & Sullivan EA)

In 2009, 294,540 women gave birth to 299,220 babies in Australia. The increase in births continued, with 2,295 more births (0.8%) than reported in 2008. The average age of women who gave birth in Australia has increased gradually in recent years, from 29.0 years in 2000 to 30.0 years in 2009.

The full report is available at the AIHW website.

The following excerpts are likely to be of particular interest to readers of the APMA blog.

Homebirths

In 2009, there were 863 planned homebirths, representing 0.3% of all women who gave birth. The highest proportions were in Tasmania (1.4%) (Table 3.14). It is probable that not all homebirths are reported to the perinatal data collections.

The mean age of mothers who gave birth at home was 31.7 years (Table 3.45). The proportion of mothers younger than 20 was 1.6%, and the proportion aged 35 and over was 30.2%.

The proportion of mothers who gave birth at home who identified as being of Aboriginal or Torres Strait Islander origin was 1.7%.

Most women who gave birth at home were living in Major cities (58.6%) (Table 3.45).Of mothers who gave birth at home, one-quarter had their first baby (25.0%), and 75.0% were multiparous. The predominant method of birth for 99.5% of women who gave birth at home was non-instrumental vaginal (Table 3.45).The presentation was vertex for 98.1% of women who gave birth at home.Of babies born at home in 2009, 99.8% were liveborn. The mean birthweight of these liveborn babies was 3,646 grams (Table 3.45). The proportion of liveborn babies of low birthweight born at home was 0.9%, and the proportion of preterm babies born at home was 1.0%.

Private midwives are, and have been for many years, the main providers of homebirth care for Australian women. This report does not seem to distinguish between babies born at home in 'private' or 'public' care.

Method of birth and hospital sector

Method of birth for women who gave birth in hospitals was compared by hospital sector and state and territory (Table 3.40).

Women who gave birth in public hospitals reported higher levels of non-instrumental vaginal birth than those in private hospitals (61.5% compared with 43.4%).

Private hospital patients had higher proportions than public hospital patients of vaginal births requiring forceps (3.6% compared with 3.0%) or vacuum extraction (10.5% compared with 7.1%) (Table 3.40).Of women who gave birth in public hospitals, the highest rate of forceps deliveries was in the Australian Capital Territory (6.1%), and of those in private hospitals, the highest rate of forceps deliveries was in the Northern Territory (6.7%). Vacuum extraction was most common for both public and private hospitals in Western Australia.

Of women who gave birth in hospitals in Australia in 2009, 32.6% had a caesarean section delivery. The caesarean section rate of 42.5% for women in private hospitals was higher than the rate of 28.4% for those in public hospitals. The highest rate of caesarean section deliveries in private hospitals was in Queensland (47.9%), followed by Western Australia (41.8%) and Northern Territory (41.0%) (Table 3.40).

NOTE:Data from Victoria are not finalProvisional data were supplied by Victoria for this report and limited to Perinatal NMDS data items. The numbers of mothers and babies in Victoria in Australia may change when the final data are used. Tables will be updated when NPDC data from Victoria are received. Tables in this version of the report are footnoted accordingly.

Sarah Buckley: Is homebirth safe?

2011-12-05T10:09:00.001+11:00

Sarah Buckley comments on the question:
Is homebirth safe?

Homebirth has been in the news recently, with reports that homebirth may be unsafe.

If you read an article that reports this, it is important to note the background of the researcher or commentator, and where the research has been published. As you may be aware, there are many vested interests in the maternity care system, including individuals and institutions who could lose much of their livelihood if homebirth became more popular.

As well as this, many of us enter the caring professions with a strong "need to be needed".

It can be confronting, especially for those with long years of training, to realise that women's bodies are superbly designed for labor and birth (as I describe in my ecstatic birth ebook), and that the vast majority of mothers and babies will birth safely anywhere, without outside assistance. (As my friend, and neonatal resuscitation teacher extraordinaire Karen Strange says, "Birth is designed to work, even if there is no-one else around")

The debate about homebirth safety is not just about home birth. It is the tip of a centuries-old argument that began when medical doctors first entered the birth room: is birth intrinsically safe, or an accident waiting to happen? Can we trust women's bodies or do we need to constantly improve them with monitoring, medicating and otherwise intervening?

This argument continues to rage in other aspects of birth: for example a recent paper argues that routine induction for all women at 39 weeks (as compared to 'expectant management') would be cost-effective and beneficial for all mothers and babies.

However, as my writing and research shows, there are many known safety factors in normal birth, and likely many more that we have not yet discovered. Without a full understanding of these factors, any attempt to 'improve' birth for healthy mothers and babies is unlikely to succeed.For example, we still do not understand the processes that initiate labor, but have identified mechanisms that switch on brain protecting factors. and that do not operate before term in other animals.

You can read more on my website about homebirth safety and benefits (and see an interview with my daughter Emma** ) and my blog post Ten things to love about homebirth.

Midwives and prescribing

2011-11-30T13:49:00.001+11:00

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”

A template has been provided for this mapping exercise.

Mapping of XXXX University’s Therapeutic Medication Management Course against Accreditation Standards Essential Course Requirements for programs of study leading to endorsement for scheduled medicines for Eligible Midwives

ESSENTIAL COURSE REQUIREMENTSPrescribing medicines requires a robust knowledge base. The content of the program must reflect the fact that prescribing is a competence-based professional act, and will aim to enable midwives to develop their knowledge and skills in prescribing, and will include the critical elements relating to clinical assessment, judgement and evaluation. The educational organisation designing a program or units of study designed to develop the competence of midwives in this area must demonstrate the four components of prescribing as outlined below to obtain the approval of the NMBA.

INFORMATION GATHERING
• Medication history, adverse drug reactions, medicine taking behaviour, adherence
• Presenting health, relevant health and maternity history
• Current problems
• Relevant signs symptoms
• Pathology results
• Guidelines, protocols, pathways

CLINICAL DECISION MAKING
• Clinical assessment
• Consider ideal therapy
• Balance risks/benefits of drug-drug, drug recipient, drug-disease/condition problems
• Consider beliefs and needs re medication of woman and her infant
• Consider economical/availability of therapeutic options
• Select drug, form, route, dose, frequency, duration

MONITOR and REVIEW
• Review control of signs and symptoms
• Review adherence
• Review woman or her infant’s outcomes
• Consider need for therapy to be tailored to person, continued or ceased
• Reflection by prescriber, peer feedback and review

COMMUNICATE DECISION AS AN INSTRUCTION TO (GENERATE ORDER)
• Other health professionals/prescribers to continue and monitor (including discharge)
• Midwife to administer or supply
• Pharmacy staff to review and dispense or arrange supply
• Woman, her nominated partner, family or friend to administer

Each of the essential components of prescribing required in approved courses demonstrating midwife competence is listed and the applicant notes components of study within the course demonstrating the required essential requirements.

The second part of this exercise is to map
Pharmacology Knowledge and Skills required for prescribing and appropriate qualifications for programs of study leading to endorsement for scheduled medicines for Eligible Midwives

In addition, any course accredited for the purpose of ensuring midwives have the pharmacology knowledge and skills required for prescribing and appropriate qualification, the following elements will be incorporated:

Legislation, regulations and policies relevant to the prescribing of medicines
Prescription writing and documentation
Professional accountability and responsibility
Professional relationships and referral
Anatomy, physiology and pathophysiology
Pharmacology and pharmacokinetics
Assessment, history, diagnostics investigations and data for prescribing
Common medicine prescribed across the continuum of midwifery care
Safety of medicines (quality use of medicine principles)
Safety and quality – risk management and error prevention in medication management, contraindications and the use and safety of medicines during pregnancy, including teratogenesis
Psychology of prescribing
Critical appraisal, integration of research relevant to prescribing of medicines
Information sources regarding medicines
Over-the-counter medicines and polypharmacy
Combinations with complimentary therapies, and the contraindications during pregnancy and breastfeeding
Considerations when working with women with drug addiction and substance use problems (and the need for consultation and referral in these situations)
Behavioural aspects in relation to medication ‘compliance’
The role and function of therapeutics agencies and the regulation of medicine (including the role of the Therapeutic Goods Administration).

Further information or comment is welcome. Midwives who have undertaken the units of study necessary for notation as PBS eligible may have some advice that you would like to share with others.

Broadening the discussion about home births

2011-11-15T09:00:00.001+11:00

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.

ACM Position Statement on Homebirth Services 2011

2011-11-13T17:40:00.001+11:00

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?

Births in South Australia: Summary and recommendations

2011-11-10T18:00:00.001+11:00

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

Summary
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:

General
>> 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.

Antenatal
>> 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).

Professional
>> 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 (www.health.sa.gov.au/ppg).

Infant
>> 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.

midwifery in Australia

2011-11-04T11:10:00.000+11:00

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

Medicare and eligible midwives

2011-11-03T09:31:00.000+11:00

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 www.health.gov.au/mbsonline

Obstetric items and referrals

Requesting diagnostic services

social networking

2011-09-17T12:34:00.000+10:00

In this post we draw attention to social networking sites, such as Facebook.This topic is addressed at the UK Nursing and Midwifery Council (NMC) 'Advice by topic' site.Reference was made to this advice in the September 2011 issue of the Victorian health department's Maternity and Newborn Clinical Network Newsletter.From the UK NMC:

This advice addresses specific issues around social networking sites such as Facebook, but its principles can be applied to all kinds of online communication, including personal websites and blogs, discussion boards, email groups and instant messaging. It also covers all kinds of content shared online, including text, photographs, images, video and audio files.

PS: See also, Caroline Hastie's thinkbirth blog on social media and professional black humor, which draws our attention to the writings of Anne Marie Cunningham , a GP and Clinical Lecturer in Cardiff University, Wales, UK, who is interested in the use of new technologies to further medical education.

MUMS MATTER!

2011-09-05T07:55:00.001+10:00

AnnouncingAPMA's on-line campaign: Mums Matter!

This campaign is aimed at bringing the issue of women's rights back on the agenda (as it has slipped off many politicians' radars!)

We have 1 week before pollies are back in Canberra. By then we want 20,000 supporters sending emails sent to pollies across the country.

It is super easy only takes 2 mins. Please pass on far and wide. We know different women make different decisions but the vast majority support each others ability to make them.

APMA is also asking for pledges of $20 to fund our campaign continuing. We don't need to all travel to Canberra this time we want to make it cheap, easy but still effective.

PLEASE follow this link, enter your details, and sendhttp://mumsmatter.good.do/mums-matter/

Maternity reform

2011-08-26T14:45:00.000+10:00

ReformBasket case: Roxon forces midwives to collaborate, now they face regulatoryaction if they do
NEW: Press release

Position Statement on Home Birth

2011-08-25T19:40:00.002+10:00

Midwives and other interested parties are preparing critiques and responses to the ACM ‘Interim’ homebirth documents . The College is inviting comments on the documents, which are an interim position statement, guidance for privately practising midwives providing midwifery care for planned homebirth, and a literature review. None of these documents have undergone academic peer review. The closing date for submissions is 23rd September 2011.

The Nursing and Midwifery Board of Australia has "endorsed the Australian College of Midwives position statement on Homebirth." The full significance of this rapid endorsement by the regulatory body, of an 'interim' document, prior to consultation with the profession, is not clear.

We refer readers to the International Confederation of Midwives' (ICM) Position statement on homebirth

It states, after a brief introduction:

POSITION:
The ICM supports the right of women to make an informed decision to give birth at home. The midwife who elects to provide professional services for women in their homes should be able to do so within a nation’s health service. The ICM recognises that not all nations have the legislation or health service structure which supports home birth, and urges national governments to review the scientific literature on the subject and progress to a maternity service which includes it as an option for women giving birth.
GUIDING STATEMENT TO MEMBER ASSOCIATIONS:
Member Associations based in countries where women do not have access to a full range of options as to where they can safely give birth, are encouraged to negotiate with their governments for this to occur.

The Australian College of Midwives (ACM) is a member association of ICM. Any position statement of the ACM should usually be consistent with, and reflect, the Position Statement of the ICM. The professional College for midwives in Australia is expected to negotiate with our government to provide a full range of options, including homebirth, where women in this country can safely give birth. Please remind the College of this ICM position and guiding statement in your submissions.

insurance and private midwives

2011-08-24T14:08:00.001+10:00

All regulated health professionals have been required, since 1 November 2010 when the new National Health Practitioner Regulation law came into effect, to have professional indemnity insurance.

There is no insurance product that covers homebirth, which is the mainstay of private midwifery practice. An exemption from indemnity insurance for homebirth has amended the requirement for insurance, and this is in effect until 30 June 2013.

Midwives who practise privately have the choice of two insurance products. One of these, from MIGA, is the only one that will provide intra-partum cover for Medicare-eligible midwives to attend certain hospital births, as it has government backing. The other product, from Vero Mediprotect insures midwives for provision of private prenatal and postnatal services and education, but excludes birth. [These links are included for information only, and this statement should not be construed in any way to direct midwives to one particular product.]

Recent developments with regard to insurance have been outlined at the MiPP blog, since we learned that a 'mandatory reporting' notification was made of a midwife who was considered to be practising without insurance. We understand that this midwife was in a public hospital with a woman who had planned homebirth. After transfer of care to the hospital, the midwife continued in a supportive role with the woman: the usual practice in Australia when women transfer from planned home birth to hospital care.

There seems a small window for those with MIGA insurance if the woman is admitted ‘private’. The MIGA-insured midwife then may be covered.Most hospital backup booking arrangements that are made by or for women who are planning homebirth are with public hospitals. The possible pathway that is being looked at is that the woman is admitted as a 'private' patient in the public hospital. Some larger hospitals have 'in house' obstetricians. In this case the obstetrician on call at the time of admission will assume responsibility for the care of the woman and baby. Other hospitals have local obstetricians, paediatricians, and obstetrically qualified GP's on roster, to be called in for public as well as private patients.

ACM Position Statement on Homebirth, "endorsed"

2011-08-19T13:50:00.001+10:00

From the AHPRA website

“The Nursing and Midwifery Board of Australia has endorsed the Australian College of Midwives position statement on Homebirth. The College is inviting comments on the position statement; the closing date for submissions is 23rd September 2011. The position statement is available from the Australian College of Midwives website.”

totally flawed research

2011-08-13T15:01:00.002+10:00

Listed as a top article in today's Age, readers are confronted with the question: 'Caesarean births a better option for mothers? 'The article tells us that "Dr Stephen Robson, an associate professor of obstetrics at Australian National University, is recruiting 1000 pregnant women to test the long-held view that vaginal deliveries are better than caesareans for healthy women with uncomplicated pregnancies."

This 'study' requires well women who are expecting their first child, of whom 500 choose a caesarean (for no medical reason) and 500 plan a vaginal birth, and will look at "psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates."

"Good luck!" I say. Good luck to the mothers and babies - they will need it.

This research is not good science - whatever results are achieved will not come anywhere near testing the safety of vaginal vs surgical births for healthy women with uncomplicated pregnancies.

What sort of ethics committee would give approval to this research?Anyone who has studied basic health science will know that the numbers in this study are so small that confounding variables will make the data useless.

Of the 500 women planning vaginal birth, assuming that they are standard pregnant women who receive standard maternity care, at least 30%, and possibly up to 50% will experience a Caesarean birth. That leaves the vaginal birth cohort of 250-350. Many of these women will receive powerful narcotic drugs either by injection or epidural; drugs that are kept locked up in the 'dangerous drugs' cupboard. A considerable number of the 'vaginal birth' cohort will have their labours stimulated artificially with synthetic prostaglandins and oxytocin; and many will be 'assisted' to give birth by obstetricians wielding forceps or ventouse caps. All of these interventions carry potentials for harm to the mothers and babies, with a potential to influence depression and breastfeeding rates.

Of the 500 women planning elective pre-labour Caesarean, there will be other variables. A few may even labour spontaneously and quickly, and give birth vaginally! A considerable number of the surgically delivered babies will experience difficulties with breathing, and require special care for the first day or so. A few of these babies may be very ill.

A few mothers in the elective Caesarean cohort will develop wound infection, and many will develop internal adhesions that may complicate future births. A few may experience serious iatrogenic complications of the surgery, including accidental surgical damage to uterus, bladder, ureters, or bowel; drug administration errors; harm resulting from spinal anaesthesia; and haemorrhage. Subesquent pregnancies for these women also bring the potential for abnormal placenta formation, with placenta accreta and percreta placing a woman at great risk of serious haemorrhage requiring urgent hysterectomy as a life-saving measure.

In 1996, World Health Organisation made the profound statement that "In normal birth there should be a valid reason to interfere with the natural process." (in Care in Normal Birth: a practical guide, p4) It's a no-brainer.

Today, Australian women are being enlisted into research that pretends to address the question of which is better, vaginal birth or abdominal surgery. It's a stupid question.If the safety of vaginal birth for the primigravid well woman is considered anywhere near the risk of a Caesarean, it's an indigtment on what happens to women planning vaginal birth. The researchers need to find ways to protect and promote the natural processes in birth, while reserving surgical intervention for those who have a 'valid reason'.

I hope there are midwives and doctors whose critical thinking alarm bells start sounding when they are asked to enlist women in this study, and I hope the women who are approached tell the researchers what they can do with their trial.

This is a personal opinion, and is not a policy statement for Australian Private Midwives Association.

Your comments are welcome.

News for privately practising midwives and women planning homebirth

2011-08-06T10:37:00.002+10:00

from
Australian Health Ministers’ Conference
COMMUNIQUÉ
5 August 2011

Professional Indemnity Insurance Exemption for Independent Privately Practising Midwives
"Ministers agreed to a further 12 month extension of the exemption to 1 July 2013 while further options are explored with a report back to the next Health Ministers meeting."

Your comments are, of course, welcome.

MotherBaby Childbirth Initiative

2011-07-29T17:37:00.004+10:00

[click image to enlarge]

In 1996 the Coalition for Improving Maternity Services (CIMS) created the Mother-Friendly Childbirth Initiative (MFCI): 10 Steps to Mother-Friendly Hospitals. Although designed specifically for the U.S, the MFCI had global impact. In response to strong international pressure, the CIMS International Committee was formed with the goal of creating an international initiative that would be applicable in all countries and settings. It became the International MotherBaby Childbirth Organization (IMBCO) in 2007. In collaboration with grass-roots representatives from every world region and an international Technical Advisory Group (consisting of representatives from WHO, UNICEF, ICM, FIGO, Lamaze International, and many others), IMBCO created the International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal MotherBaby Maternity Services and launched it in 2008.

The purpose of the IMBCI is to call global attention to the importance of the quality of the mother’s birth experience and its impact on the outcome, the risks to mother and baby from inappropriate medical interventions and lack of access to appropriate emergency care, and the scientific evidence showing the benefits of optimal MotherBaby care based on the normal physiology of pregnancy, birth, and breastfeeding. The IMBCI 10 Steps set the gold standard for excellence and superior outcomes in maternity care. The IMBCI has been translated into over 20 languages and is being put to many uses in the developed and developing worlds. Its 10 Steps are currently being implemented in 3 pilot/demonstration sites--hospitals in Quebec, Brazil, and Austria. This presentation will describe the IMBCI and the multiple ways in which it is being put to work around the world. A critical component of the IMBCI is that it highlights the fact that “women’s and children’s rights are human rights” and that “access to humane and effective health care is a basic human right.”

The Asia-Pacific Regional Representative of the International MotherBaby Childbirth Organization is midwife Rachael Austin, dnraustin[at]bigpond.com from Theodore, Queensland.

Collaborative arrangements

2011-06-29T19:18:00.002+10:00

Midwives providing services eligible for Medicare rebates are required to have evidence of a collaborative arrangement with a specified medical practitioner for each woman in their care. In essence, the midwife is required to have written records of:
(a) the name of at least one collaborating medical practitioner;
(b) that the midwife has told the woman ["patient"] about the arrangement;
(c) acknowledgement by a named medical practitioner that the practitioner will be collaborating in the woman’s care;
(d) plans for the circumstances in which the midwife will consult, refer, or transfer care to that medical practitioner.

Midwives who have contacted the Department of Health and Ageing (DoHA) have given examples of situations in which collaborative arrangements have been difficult to obtain. The hurdle that is proving particularly difficult is (c) acknowledgement by the doctor that he/she will be collaborating. Doctors who have for many years worked collaboratively alongside midwives have baulked at the idea of putting their signature on a collaboration document.

Many midwives attending homebirths privately have for many years had good collaborative arrangements with public maternity hospitals. If a woman or baby in the midwife’s care requires transfer to hospital, or referral for specialist assessment in pregnancy, the process of consultation, referral and transfer is straight-forward, which is in the interest of the wellbeing of mother and baby.

For example, when the woman and midwife have completed the hospital booking-in process, the hospital gives the woman paperwork with the woman’s name on it, clearly marked ‘HOMEBIRTH BACK-UP’. This is evidence of the collaborative arrangement, but at present this sort of arrangement cannot be used as evidence of collaboration for the purposes of Medicare rebates.

In response to midwives' letters to the DoHA, Rosemary Bryant (Chief Nurse and Midwife) wrote:

The Australian Government, through this Department is continuing to monitor these difficulties through a range of activities including monitoring correspondence received- including your email, calls to our hotline and data from Medicare. We will also be undertaking surveys of midwives, obstetricians and GP obstetricians in the coming months to ascertain what is working, what is not working and then we’ll develop responsive action accordingly. Through our evaluation activity we’ll also be talking to pregnant women, women planning pregnancy and their families, about their experiences and awareness of the reforms to maternity services more generally.

I can assure you that the Government is committed to increasing choice of and access to maternity services in Australia, and maintaining our high standards of safety and quality through supports for workforce and infrastructure.

With reference to reports that doctors are reluctant to enter collaborative arrangements with midwives because of indemnity insurance concerns, Ms Bryant stated:

The Government has put in place arrangements that allow eligible midwives to obtain solid and affordable professional indemnity insurance cover that provides peace of mind for midwives and their clients. The Commonwealth-supported cover, which is provided through insurer MIGA (www.miga.com.au) is, in effect, unlimited. It covers eligible midwives for their full scope of practice, except intrapartum services in relation to planned home births. Obstetricians, GPs who provide obstetric services and hospitals can be confident that the Commonwealth-supported MIGA product provides strong, reliable professional indemnity cover for privately practising midwives. Therefore, from an insurance perspective, collaborating with a midwife who has the benefit of Commonwealth-supported cover is no different from collaborating with another medical practitioner who holds their own medical indemnity insurance cover.

Comments are welcome

Do women have a right to choose natural birth?

2011-06-17T10:40:00.003+10:00

It's a simple question. Do we?

We know that most women are able to give birth under natural, physiological conditions, and we know that for most women and babies there is no safer way than via that natural physiological process.

But, being able is different from having the right to choose.

Here are a few ridiculous questions:
"Do people have the right to choose to breathe?"
"Do babies have the right to choose to learn to walk?"
"Do we have the right to choose to eat?"

The answer, of course, is that it's not about a 'right' - breathing, walking, eating, ... are basic physiological processes for the normal function of our bodies, as is the process of giving birth.

Not every person is 'able' to function at the normal level in breathing, walking, eating, or in birth, all the time. But, in the cases of breathing, walking, and eating, and a host of other physiological activities, there is an unspoken expectation that 'it' will happen, under the direction of natural processes. The drugs and machines and complex medical interventions that have been developed in the medical world are used only when the natural function is deficient in some way.

It's at this point that giving birth 'naturally' is different from, for example, breathing 'naturally'. The knowledge of birth as a natural process that is not only safe but brings clear advantages over any other possible processes has been virtually lost from the world of maternity care and from the public. This 'medicalisation' of birth is escalating over time, with continuing increases in reliance on technology rather than skill at working in harmony with the natural physiological processes, to protect, promote and support health in the mother and child.

"In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

This statement should be the guiding principle for all materntiy services. Clearly, it's not. Most fail miserably, but are not even aware of their deficit.

The ever-rising Caesarean birth rate is evidence of the maternity system's failure to understand and to work in harmony with normal birth. It's around 30% of all births in Australia, and the USA, and other developed countries. It's much higher in some hospitals and locations.

AB wrote:

I live in a developing country, Guatemala, where women are not educated about birth choices and many times they only have one option. Due to lack of money they go to the public hospitals where there is more than 70% C-section rate. Then, confronted with birth trauma, they search for any other option possible. Many of them find my midwife with Manos Abiertas, a clinic dedicated to helping these women have a natural birth.

In a developed country, people have the luxury of forming a self-educated opinion on their preferred manner of giving birth, thankfully, and we are working towards making that an option in Guatemala.

The clinic that helps mostly indigenous and low income Guatemalan women works on a sliding pay scale. This often means patients visit free of charge or pay much less than their visit costs, because most can't afford the $5 for a checkup. However, as anyone involved in midwifery knows, there are always numerous costs involved.

I am asking you to help by spreading the word via an interview with one of the only licensed midwives in Guatemala who has her own birth clinic: Hannah Freiwald. The situation is also explained in this blog story

If you can link to us on your blog or forum, more people will see and hopefully help. I am not a midwife. I am only a citizen who supports my midwife and who sees a very great need with the women of Guatemala. If nothing else, they need the power to choose their birth. They need the right and education to know and choose what happens with their own bodies. Together, we can make this an option.

Thank you,

Manos Abiertas
"All women have the right to dignified health care."

Thankyou AS for bringing this matter to our attention.

Returing to the question posed: "Do women have a right to choose natural birth?", I hope the reader agrees with me that this is a ridiculous question.

It's not a matter of right to choose. Women will usually give birth naturally and safely if given the opportunity.

It's more a matter of the skill and intention of the care-provider. Many women in Australia face the same lack of skill, and lack of understanding in their maternity care that is faced by indigenous and low income women in Guatemala. These women face systematic interference/intervention into the finely tuned natural physiological processes of birth, as well as crippling anxiety that impedes progress. Although attended by people with the title of 'midwife', these women feel isolated and fearful. Even those who, prior to labour, thought they would like 'natural birth' are quickly convinced that they need all the 'help' that the hospital has to offer.

The cascade of interventions is then unstoppable. Medical management of birth, whether vaginal or caesarean, is the only option.

Midwives in Australia, and in much of the developed world, must accept responsibility for the unacceptably high (and rising) rate of Caesarean births in our countries. Midwifery is the only profession that has access to the knowledge and skill of working in harmony with the natural processes in birth.

PS: A recent Cochrane review "Non-clinical interventions for reducing unnecessary caesarean section" has been highlighted in US-based Medscape article "Cesarean Delivery Prevention Efforts Should Target Clinicians" (Author: Norra MacReady)

To reduce the number of unnecessary Cesarean deliveries, the focus should be on clinicians, a new meta-analysis suggests. Mandatory second opinions, peer review feedback, postcesarean surveillance to prevent repeat cesarean deliveries, and guidelines endorsed and supported by local opinion leaders ...

While noting that the midwife is absent in these reports, the recommendation that 'clinicians' (ie the obstetric doctors who perform caesarean surgery) be required to justify the decision to operate is worth consideration. Applying this research to the Australian maternity context, it would appear worth requiring midwives who are in attendance when the decision is made to engage in collaborative critical peer review and professional reporting, alongside the obstetrician.

Thankyou, reader, for visiting this blog. Your comments are always welcome.

How is the private midwifery profession faring?

2011-06-02T20:46:00.005+10:00

Midwives have had six months since the federal government's Medicare reforms became effective (1 November 2010). Midwives, and the women who employ us, have a mere thirteen months before the exemption from professional indemnity for attending births in homes expires (1 July 2012). It's a good time to take stock of our situation.

There is a handful of midwives around the country who are 'eligible' to provide pre-and post-natal services for which Medicare refunds apply. Another handful of midwives are at various places in the application process. Other midwives continue to provide private midwifery services without seeking Medicare provider numbers.

Approval for notation as 'eligible' is granted by a State Board of the Nursing and Midwifery Board of Australia.

Midwives are able to purchase indemnity insurance that covers antenatal and postnatal care. No indemnity insurance is available for attending home birth. There is an insurance product that has Treasury support to provide cover for intrapartum private midwifery care in hospital. However we are not aware of any hospital yet that will award visiting access/clinical privileges to a midwife. The response that many midwives have received when making inquiries about being granted clinical privileges has been far from positive.

A person considering employing a midwife privately may wonder how to find an 'eligible' midwife, and thereby take advantage of the Medicare rebate. While there is no publicly available listing of these midwives, here are a couple of links and suggestions:

A: If you know the name of a midwife, a search of the public register at the AHPRA site will give information including 'notation' - curiously listed with 'conditions', 'undertakings' and 'reprimands'
Endorsements: No
Conditions: No
Undertakings: No

Notations: Yes

Reprimands: No

Then click 'view details' for that midwife, and you will be informed that:

Ms XX is an eligible midwife competent to provide pregnancy, labour, birth and post natal care and qualified to provide the associated services and order diagnostic investigations required for midwifery practice, in accordance with relevant State and Territory legislation. Eligible midwife, but NOT qualified to obtain endorsement under section 94 to prescribe Schedule 2, 3, 4 & 5 medicines required for midwifery practice in accordance with State and Territory legislation.

B: If you are searching for a midwife, and don't have a specific name to search, you may find a site that lists 'find a midwife'. After finding a midwife in your area, follow the instructions A above to check if that midwife has the Medicare notation on the register.
For example:
Midwives Australia
Midwives in Private Practice (Victoria)
Pregnancy, Birth and Beyond
Independent midwives and birth workers in South Australia
Homebirth Access Sydney
Home Midwifery Association (HMA) (Qld)

Confusion abounds about homebirth as a choice. New laws and regulations for midwives are poorly understood in our communities, and even amongst health professionals.

Readers are welcome to leave inquiries in the comments section of this blog, or to send an email message to Midwives Australia via the online contact form.

Senate Inquiry into AHPRA, the day before International Midwives' Day

2011-05-02T16:37:00.017+10:00

Press Release:
Australian Private Midwives Association and Midwives in Private Practice

Midwives will present at a Senate Hearing into the national regulator – AHPRA - on Wednesday 4th May, the day before Midwives Day is celebrated around the world.

Marie Heath, National President of the Australian Private Midwives Association, today indicated that many unfounded complaints/notifications against midwives would be raised in a move that many see as part of an international war against homebirth.

“Midwives working in private practice are almost universally facing disciplinary action,” Mrs Heath stated “We have been swamped with midwives facing action from AHPRA. Most of these midwives then have restriction on their practice put in place before they have an opportunity to defend themselves. Many midwives face a sudden inability to practice, therefore cannot make a living. Women are then faced with the potential of not having their care provider in birth. It is unacceptable.”

The move to national registration had been welcomed by midwives hoping that this would provide consistency across states and an emphasis on timely responses to registration and complaints. “Unfortunately the opposite has occurred. Midwives in private practice seeking Medicare provider numbers which have been available since November have ended up bogged down in red tape, unsure of requirements and unable to get their provider numbers. Most are waiting months before they even know whether their application is being considered.” Joy Johnson from Midwives in Private Practice added.

Mrs Heath indicated that these two matters of complaints handling and processing of registration requirements would form part of the evidence to be given today. “For midwives in private practice Government reforms in maternity services aimed to provide access to Medicare for women for hospital births. However we are yet to see one midwife nationally able to provide continuity - pregnancy, birth and postnatal care. It is unacceptable and we expect the Minister to step in.”

“For the self-employed midwife there is not a lot to celebrate tomorrow on International Midwives Day. The international slogan is “The world needs midwives now more than ever”. It is disappointing that this theme does not seem to be accepted in Australia.”

Contacts: Liz Wilkes 0423 580585
Marie Heath 0400 774 725
Joy Johnson 04111 90448

Join the global webinar to celebrate International Midwives' Day 5 May

2011-04-26T17:04:00.003+10:00

Plans are set for the Virtual International Day of the Midwife on May 5th. The program, which spans the 24-hour period, with speakers from the various continents, has now been finalised, and it looks to be a very interesting and diverse program: http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011

It's a good idea if you haven't participated in web based seminars like this, to get your computer sorted ahead of time in terms of technology. Please go to this page: http://internationaldayofthemidwife.wikispaces.com/How+to+use+Elluminate

Here is more detailed information for speakers:

http://internationaldayofthemidwife.wikispaces.com/Speakers

The organiser is well known midwife-blogger Sarah Stewart.

Look forward to seeing you on May 5th.

APMA submission to Senate Inquiry

2011-04-16T09:11:00.001+10:00

APMA has made a joint submission with Midwives in Private Practice (MIPP) to the Senate Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA). To access the submissions, click here.

The three matters that our submission has focused on are
1. AHPRA’s administration of the registration process for Medicare benefits
2. Concerns around the administration by AHPRA of complaints against privately practising midwives
3. Professional Indemnity Insurance for midwives practising privately.

INFOSHEET: The Third Stage of Labour

2011-04-01T11:57:00.002+11:00

This is the second in the current review of the INFOSHEET series. To download this, and other INFOSHEETs, click here.

The revised INFOSHEET - click to enlarge

This INFOSHEET deals primarily with natural physiological Third Stage, the time from the spontaneous, unmedicated birth of the baby to the spontaneous birth of the placenta. It may seem like stating the obvious, but remember that physiological Third Stage can only be considered when the rest of labour, the first and second stages have been physiological and uncomplicated, and mother and baby are well.

In today's maternity care world, relying heavily and often unnecessarily on medical interventions including pain medications, anaesthesia, continuous fetal monitoring, and surgical measures, the proportion of women who proceed through their births in harmony with normal physiological processes is small. Likewise, midwives and doctors in mainstream maternity care have become progressively deskilled in their care of women for whom physiological birth is a realistic option.

A midwifery student who will graduate as a midwife in a few months wrote:

"I have been at X[health network] as a mid student since Feb 2010, I have seen one attempted physiological third stage where the mum had enough after a while and we discontinued and went for active managment. I have not had any other women request physiological management. For those who are not aware it is also worth noting that women who chose to birth in X's homebirth program must sign a contract stating they agree to active 3rd stage managment at home, as physiological third stage is not offered in the [hospital's] homebirth program."

This is a common scenario in midwifery education, and in maninstream maternity care today. In reviewing the Third Stage INFOSHEET, the working group will need to address the issue of evidence relied upon in support of active management, and what the current guidelines around active management advise.

I believe it is important that we take an assertive position, now that the Cochrane review (2010) has concluded that, for women at low risk of bleeding,
“there was no significant difference identified for severe haemorrhage.”

The revised INFOSHEET will address debate internationally around the risk vs benefit of active management in resource-rich settings.

Also, as has been noted in the reviewed INFOSHEET on Baby's Transition, there is more debate now than a few years ago around time of clamping of the cord. The Women’s Clinical Practice Guidelines requires ‘early’ clamping of the cord 2-3 minutes after birth, rather than depriving the baby of the placental blood. Guidelines from another major Level 5 hospital requires injection of oxytocic as the anterior shoulder is delivered, or within one minute of the birth of the baby, followed by:

"Clamp and cut the umbilical cord.
In the preterm, If maternal /neonatal condition allows, in collaboration with the neonatal resuscitation team, consider delaying clamping the cord for up to 2 minutes. Delayed cord clamping has been shown to diminish the risks for the pre term baby of needing a transfusion, being hypotensive or having an interventricular haemorrhage." (Southern Health cp-ma42)

Readers will understand that there is an imperative that those midwives who seek to work in harmony with the natural physiological processes, and promote normal birth when ever possible, establish clear statements about physiological Third Stage.

For further reading, go to
The ICM page on post partum haemorrhage
.
The FIGO-ICM Joint statement (2006)

Thankyou for comments and discussion on this important topic.

Senate Inquiry into AHPRA

2011-03-27T16:06:00.002+11:00

Link here to the Senate Inquiry into AHPRA.

Submissions should be received by 14 April 2011.

All midwives in this country are registered and regulated through Australian Health Practitioners Regulation Agency (AHPRA).

The federal Opposition Health spokesman Peter Dutton MP has called for a Senate enquiry into the workings of AHPRA.

Many midwives, and women who employ us privately, are concerned about the process that has been implemented by AHPRA for midwives applying for notation on the Register as eligibile for Medicare provider numbers - a reform that was implemented by the government in November 2010. Submissions by midwives' organisations, individual midwives, and women who want midwives to attend them privately, will address the excessive and repeated delays in processing applications.

Women whose midwives are waiting for their notations of eligibility are, understandably, distressed. Clients of midwives who have Medicare Provider numbers are able to claim substantial rebate - estimated up to $1000 in total, on prenatal and postnatal care provided by the midwife. The failure of a midwife to achieve eligibility means that this amount of money, to which the women/clients are entitled, cannot be accessed.

Please note that there are Procedures to be observed by Senate Committees for the protection of witnesses.

Your comments here are welcome, as are your submissions to the Senate inquiry.

Revision of INFOSHEET

2011-03-12T11:11:00.001+11:00

Revised INFOSHEET, A baby's transition from the womb to the outside world.
If you would like a .pdf copy of this INFOSHEET, please send an email request to Joy Johnston joy[at]aitex.com.au
Thankyou for your comments.

INFOSHEET: A BABY’S TRANSITION FROM THE WOMB TO THE OUTSIDE WORLD

2011-03-01T16:44:00.004+11:00

Please read through this INFOSHEET, and post any comments about the statements made, the evidence to support those statements, and the usefulness of the information.

A BABY’S TRANSITION FROM THE WOMB TO THE OUTSIDE WORLD

Consider the impact on the baby’s transition ...

Drugs to relieve pain in labour

Consider the impact of opioids such as Pethidine by injection, and epidural and spinal-epidural anaesthetics.

Clamping of the Umbilical Cord

Consider the increased volume of blood, and reduced risk of anaemia, to the baby when we delay the clamping of the cord.
The cord may be around the baby’s neck at birth, and some attendants will clamp and cut the cord before the baby’s shoulders are born. Consider alternatives.
Consider the impact on the baby when cord blood is collected for stem cell harvesting.

Skin to skin placement at birth

Consider the newborn baby’s ability to stay warm when kept naked against mother’s skin immediately after birth. This practice is important in temperature regulation of the newborn, as well as bonding and initiation of breastfeeding soon after birth.

Suction of the newborn at birth

Consider the impact on the baby of suction in the mouth, nose, trachea and stomach. Note that there is no evidence that a vigorous, mature infant is helped by suction, even if there is meconium in the amniotic fluid.

Resuscitation of the baby using Oxygen

Current research questions the value of using Oxygen, rather than room air, during resuscitation of the baby who is not able to breathe independently immediately after birth.

Breastfeeding

Consider the importance to the baby of unlimited access to the mother’s breast as she or he learns to breastfeed, and consider the amazing protective and nutritional properties of breast milk.
There is a strong body of evidence in favour of protecting, promoting and supporting the natural processes in birth, and the baby’s transition to life outside the womb.

Discussion
Birth is a time of enormous change for a baby. The transition from life inside the mother’s womb, to life in this world, requires many important natural or physiological changes to take place. The baby’s lungs need to expand and take in the air, providing oxygen and taking away carbon dioxide. The baby’s heart needs to redirect the blood so that the circulation to the placenta is shut down, and the blood is directed to the lungs. The baby needs to maintain normal body temperature. The baby needs to obtain food. These functions, and many more had, in the womb, been managed naturally via the placenta and the mother’s body.

The vital changes take place naturally at birth when mother and baby are well. Over time many interventions into the birthing process have been adopted by midwives and other birth attendants. Some interventions in certain situations are life-saving, while others are not based on evidence for improved outcomes for mother or baby. Practices that are common in maternity settings today, that may have an impact on the baby’s transition to life outside the womb, include:

the use of medicines (drugs and natural substances) in labour
mechanical suction of the baby’s airways
early clamping of the umbilical cord
separation of mother and baby
strategies to keep baby warm, and
methods of resuscitation of a baby who is not breathing at birth.

In this INFOSHEET we draw attention to various practices. We encourage parents who are seeking maternity care that supports and promotes the natural processes and wellness to discuss these and any other issues that are important to you with your primary caregiver. You can seek to ensure that the midwife or other professional who is attending you in labour understands your wishes for the care of your baby during the transition from the womb to the outside world.

This INFOSHEET is based largely on a published paper, ‘Evidence-Based Practices for the Fetal to Newborn Transition’ (Mercer et al 2007), which provides a review of the relevant literature.

Natural birth is a mother’s own resource
Pregnancy, birth and breastfeeding are natural biological processes. Most women and babies are well during this time, and will be able to proceed through spontaneous unmedicated labour, and give birth to a healthy baby who breastfeeds and thrives naturally. In fact, unless there is a valid reason to interfere, the natural biological processes are the safest for both mother and baby.
There are many aspects of birthing which are un-knowable, and your birth plan should allow for and support your informed decision making at all times. Women who know and trust their midwife or doctor may be more confident in making decisions than those who do not know their primary carer.

Reference: Judith S Mercer and others, 2007. Evidence-Based Practices for the Fetal to Newborn Transition. J Midwifery Womens Health 2007:52(3)262-272

ps. A question has been asked about delayed cord clamping and the possibility of jaundice in the baby.

Evidence from research has been summarised in the Cochrane Reviews http://www2.cochrane.org/reviews/en/ab004074.html

Effect of timing of umbilical cord clamping at birth of term infants on mother and baby outcomes (McDonald and Middleton 2008)

At the time of birth, the infant is still attached to the mother via the umbilical cord, which is part of the placenta. The infant is usually separated from the placenta by clamping the cord. The timing of this clamping is one part of the third stage of labour (the time from birth until delivery of the placenta) which can vary according to clinical policy and practice. Early cord clamping is believed to lead to a reduced risk of bleeding after birth (postpartum haemorrhage). This review of 11 trials showed no significant difference in postpartum haemorrhage rates when early and late cord clamping were compared. For neonatal outcomes it is important to weigh the growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.

Review of INFOSHEETS

2011-02-14T09:49:00.003+11:00

Blog readers are invited to download INFOSHEETS, in preparation for their review.

The current set of INFOSHEETS were a project of Maternity Coaliton, to present reliable consumer information on key maternity topics. The INFOSHEETS project was led by midwife Joy Johnston (the editor of this blog and several others).

The INFOSHEETS series are designed to assist women to question and communicate with their care-givers, and make informed decisions about their maternity care, promoting care that is appropriate for the individual woman.

The current INFOSHEET topics are:

Preparing Your Birth Plan

Your birth plan … is a personal statement of issues that are important to you. This INFOSHEET is intended to assist you in preparing a birth plan, and is particularly focused on protecting natural, physiological processes in labour, birth, and the early postnatal period.

“Who Cares?” Choosing a Model of Care

The model of care that you choose in pregnancy may have an impact on the options and choices that are subsequently available to you during childbirth.

Baby's Transition

“Birth is a time of enormous change for a baby. The transition from life inside the mother’s womb, to life in this world, requires many important natural or physiological changes to take place.”

Baby's First Feed

“A healthy newborn baby who is kept in skin to skin contact with the mother from birth will begin to seek her breast, usually within minutes of birth.”

The Third Stage of Labour

The third stage is a pivotal time for the health and wellbeing of mother and baby, and the beginning of their life-long relationship.

Labour in Water

How you will manage pain is a decision that you need to consider in planning for spontaneous, unmedicated birth. Deep water immersion is a valuable, non-medical, drug free ‘comfort measure’ for women in labour.

Bearing Down or Directed Pushing?

Whether to follow the instinctive urge of bearing down, or to have another person direct the pushing efforts, is a decision that each mother needs to consider in planning for spontaneous birth.

A Healthy Pelvic Floor After Childbirth

“… many women experience injury at the time of birth which may lead to leaking of urine or faeces (incontinence), sagging organs (prolapse), and related problems with sexual intercourse, and with their feelings of self worth.”

Pre-Labour Rupture of Membranes

For a small number of women, the membranes rupture (water breaks) prior to the onset of labour. The medical term for this is Pre-labour Rupture of Membranes (PROM).

Induction of labour

Understanding what induction is, and why it may be an important and even life-saving intervention for some women, will help you to make informed decisions.

Births After Caesarean

If you have already had a caesarean birth, and plan to have more pregnancies, an important decision for you to make will be whether you should plan vaginal or surgical birth. Here are some facts for you to consider in making an informed decision.

Breech Birth

At term, 3-4% of babies will be presenting in the breech position. … Whether to plan for natural vaginal breech birth, or a medically managed (either vaginal or caesarean) birth, is an important decision.

Please leave COMMENT if you wish to have any of these topics discussed at this blog.

Congratulations Justine Caines!

2011-01-26T17:06:00.004+11:00

Today's Australia Day honors list included the Medal of the Order of Australia (OAM) being awarded to Justine Maree CAINES, who is well known to APMA as a maternity consumer activist.

Justine Caines, OAM

Citation: For service to the community, particularly in the area of women's health, maternity care and education.

September 2009, Canberra - more than 2000 people protest the government's maternity reforms, which threatened to deny Australian women the right to homebirth with a private midwife.

Eligible Midwives

2011-01-21T18:08:00.003+11:00

Notation on the Register of Midwives as an 'eligible midwife' enables that midwife to apply to Medicare for a provider number, thereby providing rebate from the Australian government's Medicare program on certain midwifery services. Eligible midwives will also be able to prescribe certain scheduled medicines, after completion of an approved course of study, and after State and Territory laws have been amended to allow midwives to prescribe.

The national Nursing and Midwifery Board of Australia's (NMBA) Guidelines and Assessment Framework for Registration Satandard for Eligible Midwives and Registration Standard for Endorsement for Scheduled Medicines for Eligible Midwives (pictured above) is available for downloading as a .pdf document at the Codes and Guidelines section of the NMBA website.

The Requirements are as follows (copied without editing from the Guidelines document)

To be entitled to be identified as an eligible midwife, a midwife must be able to demonstrate, at a minimum, all the following:
(a) current general registration as a midwife in Australia with no restrictions on practice
(b) midwifery experience that constitutes the equivalent of three years’ full-time post initial registration as a midwife
(c) current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
(d) successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
(e) 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
(f) formal undertaking to complete within 18 months of recognition as an eligible midwife, or the successful completion of
(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.

In order to demonstrate part (c) current competence ..., the Board has noted that more than one reference may be required to ensure that all aspects of the midwife's performance and scope of practice are addressed. In an undated statement from the Board, titled 'Professional Practice Reference/s to support an application for notation as an Eligible Midwife to the Nursing and Midwifery Board of Australia', two options for references are given. The referees suggested are a 'Midwife Manager', an obstetrician, or (unspecified) member of the multidisciplinary team.

The referee is required to provide their own professional registration and employment details, and:

"In addition the referee must note their professional relationship with the applicant midwife, including the time period of that professional relationship.

"The following aspects of the midwife’s performance and detail of the scope of midwifery practice are required to support the application.

"The referee should address the applicant midwife’s performance in relation to the four competency domains as described in the ANMC National Competency Standards for the Midwife 2006.

"The referee needs to address how the applicant midwife is qualified to provide pregnancy, labour, birth and post natal care to women and their infants; including the capacity to provide associated services, and order diagnostic investigations; appropriate to the eligible midwife’s scope of practice. This includes whether the applicant midwife has the skills, knowledge and attitudes expected of a midwife to work within the midwifery scope of practice which includes giving:

"the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

"The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care. A midwife may practise in any setting including the home, community, hospitals, clinics or health units
"(excerpt from International Definition of the Midwife, adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia)."

The midwife applying for notation, in the mind of the author of this requirement, would appear to be a person who is currently in the employ of a hospital, and who wants to launch out into private practice. That midwife, who has possibly been employed in a caseload program within the hospital, would ask the midwife manager to write a reference, being careful to state all the important points noted above. The midwife would perhaps also ask an obstetrician who works at the hospital to attest to her/his competence to recognise abnormalities and complications, and to refer and collaborate appropriately. Perhaps also a paediatrician would be kind enough to give a reference, covering the midwife's practice as regards newborn care. A lactation consultant could write a reference with regards to breastfeeding.

A midwife in private practice who has not worked in a hospital unit for some time would not be known by either the midwife manager, the obstetrician, the paediatrician, or the lactation consultant. If that midwife asked one of these members of the hospital's multi-disciplinary team to write a reference confirming the midwife's competence across the full scope of midwifery practice, as defined by ICM (2005), it is likely that any such person would, at the best, be able to confirm that only a small fragment of the midwife's practice appears to be good. It is possible that some members of the multidisciplinary team would be reluctant to put their professional reputations on the line in the way required, for a variety of reasons. Competition for business may be considered.

A privately practising midwife's professional practice review, however, gives clear evidence of the midwife's caseload, a summary of outcomes, examples of referral and transfer of care, and reflective accounts outlining the way in which the midwife acted to fulfil her/his duty of care as described in the Definition (ICM 2005) and in Australian codes and competency standards - all without any potential conflict of interest such as is obvious in the previous example.

The Board's processes should be workable, and should not disadvantage any group within those who are expected to apply for notation as eligible midwives.

Resuscitation Guidelines

2011-01-13T20:00:00.003+11:00

The Australian Resuscitation Council (ARC) has now published its revised resuscitation guidelines for Basic, Advanced, Paediatric and Neonatal Life Support. These changes reflect the most recent scientific evidence which was evaluated and recently published by the International Liaison Committee on Resuscitation (ILCOR) and its member organisations, including the Australian Resuscitation Council.

The guidelines continue to emphasise the importance of commencing resuscitation and providing good quality CPR. Resuscitation should be commenced where the person is unresponsive and not breathing normally as feeling for a pulse is unreliable in determining if a person needs resuscitation. It is now recommended that at the commencement of resuscitation 30 chest compressions are provided before giving the initial rescue breaths. The compression / ventilation remains at 30 compressions to 2 ventilations. The ARC also recommends that if a person is unwilling or unable to provided full CPR (ie chest compressions plus rescue breathing) then they should provide continuous chest compressions at a rate of just over 1 compression per second.

The revised guidelines for Basic, Advanced, Paediatric and Neonatal Life Support are available at www.resus.org.au and for the first time have been jointly developed and published with the New Zealand Resuscitation Council (NZRC).

[Thanks to Rachael Austin for this update]

listing of sites for Australia's maternal and perinatal statistics

2010-12-31T09:43:00.002+11:00

National
AIHW National Perinatal Statistics Unit
The most recent general report is Australia's Mothers and Babies 2008

ACT
Maternal and Perinatal Health Series 45

New South Wales
2007 Mothers and Babies

For 2007, there were 144 planned homebirths across NSW with 31 planned homebirth/hospital admissions, so a transfer rate across the state of 21.5%. The highest homebirth rate was North Coast NSW (Port Macquarie to Tweed Heads) with 44 planned homebirths but it also had the highest reported transfer rate of 25.5%. This rate included the Natural Birth Education and Resource Centre (now closed) which registered its births as homebirths and transfer as homebirth transfers, not birth centre births.

There were also 490 babies Born Before Arrival (BBA) which may include some babies who were born unassisted but went to hospital for their paperwork.

Queensland
Perinatal Statistics Queensland

Northern Territory
Mothers and Babies 2006

Western Australia
Perinatal Statistics in WA 2007

South Australia
Pregnancy Outcome in South Australia 2008

Tasmania
[report not found at http://www.dhhs.tas.gov.au/ ]

Victoria
Publications of the CCOPMM
also, see Maternity and Neonatal Performance Indicators.
Further summaries of home birth, and discussion at this blog.

Outcomes for planned home births 2008 (Victoria)

2010-12-29T16:41:00.007+11:00

Click on picture to enlarge

The two pages copied above are from the Victorian government's perinatal data statistics unit, which is part of the Consultative COuncil on Obstetric and Paediatric Mortality and Morbidity (CCOPMM). The publication is:
Hospital profile of maternal and perinatal data
Homebirths for the year 2008

Each hospital receives a copy, and homebirth data are aggregated into a virtual 'hospital' for statistical purposes.

These data are not published on the internet, but are sent to each Victorian maternity hospital, and to independent midwives who provide the data.

This report, for the first time, "reports on all births that were planned to occur at home, regardless of whether they actually occurred at home or in hospital. Previous Profiles reported only on outcomes for achieved home births. This new format will provide more useful information, for example for informing women who are considering homebirth." (page 2)

These data refer to women attended privately by independent midwives in Victoria, as the publicly funded home birth pilot program commenced in 2010. The following information has been selected from the Homebirth 2008 Profile, for interest of readers of this blog:

There were 299 actual births at home, of 344 planned home births; the total number of births in Victoria in the year 2008 was 72,206
The number of actual home births (and planned home births) has been rising steadily:
2003: 151 (183)
2004: 180 (227)
2005: 182 (218)
2006: 198 (231)
2007: 249 (298)
35.4% of women planning homebirth were mothers aged 35 years and older, compared with 20.8% in public hospitals, and 39.3% in private hospitals.
1% of all women giving birth were recorded as Aboriginal. There were no Aboriginal women who gave birth at home.
32% of women planning to give birth at home were primiparous (first birth), compared with 43% of all births.
93% of women planning to give birth at home came into spontaneous labour, compared with 37.7% statewide.
6.4% of primipara planning to give birth at home had epidural/spinal anaesthesia, compared with 34.2% in public hospitals, and 50.2% in private hospitals.
93% of women planning to give birth at home did so without any medical analgesia, compared with 26.4% of all births.
91.5% of women planning to give birth at home gave birth unassisted, with baby presenting cephalic.
86.4% of primiparous women planning to give birth at home progressed to an unassisted cephalic birth, compared with 49.7% in public hospitals, and 30.8% in private hospitals.
Four women (1.2%) who planned to give birth at home proceeded to a vaginal breech birth, compared with 0.4% statewide.
97% of the babies of women who planned to give birth at home had an Apgar score 7-10 at 5 minutes.
Fifteen babies (4.4%) of women who planned to give birth at home were admitted to Special Care Nursery. No babies were recorded as being admitted to Neonatal Intensive Care Nursery.

Of all the maternity care statistics, life, and death, are absolutes. Our society has an expectation of good outcomes for all births, particularly those which take place in homes. Midwives rightly face scrutiny if anything goes wrong.

The article copied above refers to an important question: When is a life a life?, published in the Australian Nursing Journal, Vol18 No1, July 2010, page 22. This article refers to the Coroner's involvement in investigating the birth and death of baby born at home in South Australia. The case has been reported in the public press, and the midwife has written publicly about aspects of the case.

The loss of life of a previously healthy baby in any circumstances, born or unborn, is a tragedy. The midwife's duty of care is the promotion of the wellness and safety of both mother and baby. However, there are some emergencies that can arise, regardless of the place of birth, which unfortunately lead to death or serious damage.

The homebirth statistics reported on here demonstrate good outcomes.

Survey on prescribing courses for midwives

2010-12-18T17:04:00.002+11:00

The following message has been forwarded by Liz Wilkes, a leader in APMA and Midwives Australia

Re: Prescribing courses for midwives

From 1 Nov 2010, Eligible Midwives are able to prescribe certain medicines under the PBS. One of the requirements to become an Eligible Midwife is the completion of a “program of study or equivalent — prescribing” meeting the requirements of the Nursing and Midwifery Board of Australia (NMBA).

The Department of Health and Ageing (DoHA) has asked NPS: Better choices, Better health to undertake a project to look at the feasibility of prescribing courses for midwives to prepare them for this additional role. As part of this project, we have designed the following survey to help us better understand the perspective and expectations of potential students of prescribing courses. Below is some information about the survey.

What is the purpose of the survey?
The purpose of this anonymous survey is to consult prospective students who may be thinking of undertaking a prescribing course to fulfil one of the requirements in becoming an Eligible Midwife. We encourage you to complete the survey if you are currently practising as a midwife, or you have a midwifery degree and you are planning to practice as a midwife. This information will be invaluable to the Department of Health and Ageing and NPS in considering how best to support and assist midwives and/or potential course providers in the future. The idea of a survey came from the project reference group comprising representatives from the NMBA, the Australian Council of Nursing and Midwifery, and the Australian College of Midwives, as well as representatives from groups with expertise in prescribing education and drug therapy education.

Why has the survey come to me?
We are seeking to understand the perspective and expectations of potential future students of prescribing courses. This is an emerging area of practice and it is important to gain as much information as possible to assist midwives and/or potential course providers.
The Australian Private Midwives Association has kindly agreed to assist us by sending the survey to its members.

Who should complete the survey?
We invite all currently practising midwives, or those with a midwifery degree who are planning to practice as a midwife to complete the survey. Feel free to pass on the survey to relevant colleagues. We ask that each person only completes the survey once.

How do I access the survey?
Please click on this link
(http://www.surveymonkey.com/s/nps_midwives_survey_students) and you will be taken to the survey directly.

What is the timeframe for completion?
The survey will take approximately 15 minutes to complete. The survey is open from now until 10 January 2011. We would appreciate it if the survey could be completed as soon as possible.

What will happen to the findings from the survey?
The data will be collated and analysed by NPS, and the findings will be reported to DoHA.

Who do I contact for further information?
If you would like further information, please contact Dr Michelle Koo, Manager, Educational Design and Support, NPS on 02 8217 8742 or via email at mkoo@nps.org.au.

Who is NPS: Better choices, Better health?
NPS is a not-for-profit organisation funded by the Australian Government of Department of Health and Ageing to enable better decisions about medicines and medical tests. For more information, visit www.nps.org.au

Thank you and kind regards,
Dr Michelle Koo
Manager
Educational Design and Support team
Innovation and Learning

A GP practice withdraws collaboration

2010-12-16T17:06:00.002+11:00

click to enlarge

The letter copied above, with the name of the doctor who wrote it blocked out, was sent to this blog by its recipient. This letter was written by one of the GPs in Bendigo who, in the past, had been willing to support women choosing homebirths. The main 'support' received in such cases is that the doctor orders routine blood tests and investigations, and facilitates access to the blood bank for women with Rhesus Negative blood to receive prophylactic Anti-D. One would wonder what 'Duty of care' this doctor perceives is appropriate for these women once this facility is no longer available?

The writer makes reference to a paper comparing planned home births with planned hospital births, published in the American Journal of Obstetrics and Gynecology 2010, by Joseph R. Wax and colleagues.
[Maternal and Newborn Outcomes in Planned Home Birth Vs. Planned Hospital Births: A Meta-Analysis, Wax JR, Lucas FL, Lamont M, et al., Am J Obstet Gynecol 2010]

Using various statistical analyses, this author claimed that there is a three times higher neonatal mortality rate of babies in the planned home birth group than in the hospital birth group. This paper has a familiar ring to it: readers will recall the AMA publication of Kennare et al's retrospective analysis of data from South Australia, and the outrageous conclusions made by the authors. For links and comment, go to the MIPP blog.

A voice of reason has been published by Medscape Ob/Gyn & Women's Health, a respected online medical review site.

Medscape convened a 'Roundtable' in Ob/Gyn & Women's Health,
Experts Argue the Continuing Home Birth Issue
Perspectives on the Joseph R. Wax and Colleagues Home Birth Study in AJOG

The following excerpt is copied from Section 6: Eugene Declercq, PhD

After a long decline,[10] the number of home births has started increasing in the United States. ... Four years do not make a trend, but the rate of home birth is the highest it has been since 1994 and the total number of home births (26,667) is the highest since 1991.

It is in this context that we confront numerous problems faced by researchers trying to resolve the question of safety of home birth. Limited space prevents a full discussion of the barriers to such research, but 3 important ones are:
Design. The gold standard -- a randomized trial -- is not feasible because women will not let themselves be randomly assigned to a given birth site. To argue that the safety of home birth can only be established by a randomized trial presumes that home births are unsafe. Because a randomized trial is impossible, then logically home birth can never be shown to be safe.
Measurement. Because our focus is on planned home births, how do we define such births to make sure we exclude accidental home births (eg, precipitous labor) and include home births that result in transfers to the hospital? Current US data systems do not facilitate such tracking, although some US studies have tried to address this problem as have several recent studies from other countries.
Statistical power. Because planned home births typically involve healthy women, poor outcomes are rare, and hence very large samples are needed to identify differences.

These limitations are among the constraints that Wax and colleagues[1] tried to overcome with their meta-analysis of studies that met certain criteria. The dearth of appropriate studies resulted in inclusion of some studies that are old (data from the 1970s),[25] studies that inferred rather than documented planning status, and studies that were primarily from other countries (only 2 of the 12 were US-based). The decisions that have drawn the most criticism have involved the largely unexplained inclusion and exclusion of certain studies. The inclusion of data from Pang and colleagues' study,[26] done in Washington state, drew fire because it was the source of most of the reported neonatal deaths and it could only infer planning status, which was defined as "home births of singleton newborns of at least 34 weeks' gestation [with] a midwife, nurse or physician listed as either the birth attendant or certifier..." The difficulty with that definition is seen in a recent 19-state study of births occurring at home in which planning status was indicated.[27] In that study, I and my colleagues found that 87% of the unplanned home births occurred after 34 weeks and 69% of the home births attended by physicians were unplanned. In addition, 22% of the planned home births were attended by "other" attendants; these would have been excluded by Pang and colleagues.[26] This means that Pang and colleagues probably both erroneously included physician-attended full gestation home births in the planned home birth category and excluded "other" attended planned home births. In fairness, our study was published in the same month as Wax and colleagues' study and years after Pang and colleagues' study, but one cannot now claim that the potential problems with selection bias simply cancel each other out.

Of greater consequence was Wax and colleagues' exclusion of the largest study of planned home births ever done: that by de Jonge and colleagues[7] in the Netherlands, with more than 300,000 planned home births. Wax and colleagues' decision to use neonatal mortality at 28 days as their primary outcome unfortunately led them to exclude that study, which reported on perinatal and neonatal mortality up to 7 days. After controlling for confounders, de Jonge and colleagues reported no added mortality risk in planned home births. The size of their study overwhelms that of Wax and colleagues' meta-analysis and was the basis on which the meta-analysis found no difference in perinatal mortality. Perinatal mortality, which includes fetal deaths, would seem a more appropriate outcome measure. Neonatal mortality is also widely used, but how important is the distinction between 7 and 28 days? Over the past decade in the United States, about 80% of all neonatal deaths up to 28 days have occurred in the first 7 days. Apparently, de Jonge and colleagues are now examining their data out to 28 days. Would anyone seriously suggest that such a great concentration of home birth-related deaths occurring between 7 and 28 days would alter their core finding of no added risk? If de Jonge and colleagues find no difference at 28 days, Wax and colleagues' meta-analysis would also most likely find no overall difference in neonatal mortality. What happens then -- are their findings withdrawn? Does the journal publish a retraction, even after it made Wax and colleagues' article an "editor’s choice"?

Currently under way is the Birthplace in England study, another large, well designed study of home, birth center, and hospital births. The fact remains, however, that the debate over home birth will not be resolved by this or any study, no matter how well designed. At its core, the home birth debate is ideological, centering on 2 diametrically opposed perspectives on birth held by groups that generally do not communicate with each other and unfortunately often hold each other in disdain. Perhaps the question we should be asking is not what is right or wrong about any study on this topic. Rather, why are increasing numbers of US women who are experienced in birth (80% with parity 2 or higher) choosing to reject hospital-centered systems of maternity care that so many well-meaning clinicians want to make better?

First MEDICARE MIDWIFE Birth

2010-12-04T10:23:00.000+11:00

Congratulations to Liz and the family of baby Eli.

The Chronicle [Toowoomba, Qld] article announces:

Baby Eli is an Australian first

Baby Eli may wonder what all the fuss is about but he really is a very special little boy.

The third son of Stacey and David Silver is the first to be born under the care of Australia’s first Medicare eligible midwife, Toowoomba resident, Liz Wilkes.

Medicare payments for midwives were introduced on November 1 as part of National Health reforms.

Ms Wilkes along with others, has established the new clinic My Midwives in Toowoomba.

The clinic will employ 5 midwives, mentor midwifery students and provide outreach services. ...

Australia’s mothers and babies 2008

2010-11-24T12:02:00.000+11:00

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

2010-11-22T19:01:00.000+11:00

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

2010-11-17T13:40:00.000+11:00

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

2010-11-13T13:49:00.000+11:00

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

2010-11-02T14:38:00.000+11:00

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

2010-11-01T14:53:00.000+11:00

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.

Minister Roxon's advice: "suck it and see"

2010-10-27T15:13:00.001+11:00

Women’s Right to bodily autonomy and a midwife’s right to practice: We’ll just have to “suck it and see”

Writer: Anonymous

Historic times yet I get the distinct feeling they won’t want to be remembered. Julia Gillard, a declared feminist and yet we are on the cusp of the most draconian midwifery regulation dressed up as reform. From November 1 midwives will be able to claim Medicare funding but only when controlled by a doctor. Midwives are educated and registered to provide complete care for healthy women. Despite common misconception midwives are not handmaidens to doctors, but professionals in their own right.

Naturally it is appropriate for midwives to have established links to a range of other health professionals, this enables a woman to receive timely advice and care. When a midwife and obstetrician are respected for their role and a woman is recognised as the primary decision maker, best practice care is possible. This does not happen in Australia. Many women have been led to believe that their bodies are revolting, faulty with birth a barbaric process that should be managed. Couple this with a system that has financially rewarded huge increases in surgery with little scrutiny, indeed one that saw the likes of Graeme Reeves [NSW the 'Butcher of Bega'] continue to practice. It’s easy to see why obstetrics controls childbirth’s billion-dollar industry.

Maternity reform was the first cab off the health reform rank. Considering it’s the highest volume area, accounting for the greatest number of bed stays, that seemed appropriate to reform advocates. Perhaps this was Minister Roxon’s first mistake, she was overheard saying ‘I want to get maternity over with first and then move onto chronic disease’. I am sure she understood the turf war and passionate consumer advocates it seems she had little understanding of how political (read profitable) pregnant woman are.

Allegedly the AMA threatened a $7 million anti-government campaign pre election if midwives were able to claim Medicare in their own right. Their deal that individual doctors controlled midwives access to funding and the decisions of the birthing woman. If a woman makes a decision not supported by an individual doctor access to funding and midwifery care is likely to be withdrawn.

It is possible that the Gillard Government is contravening its responsibilities under the Convention of the Elimination of all forms of Discrimination Against Women (CEDAW). If international convention is too abstract then perhaps the plight of rural and remote women is more convincing. In rural areas, GP’s control maternity care, even when a GP has ceased obstetric practice the establishment of midwifery models has been vigorously opposed.

Women are forced to relocate or risk travel in labour rather than access local midwifery models. The cultural damage for Aboriginal women is considerable. If Medicare funding was not shackled to the permission of an individual medical practitioner midwives could establish rural clinics. This could have enhanced safety and removed the financial and emotional burden of many rural families.

These and many other issues were formally raised. The Maternity Services Review received 950 submissions, nearly double that of the National Health and Hospitals Reform Commission. The consumer led juggernaut then continued to achieve the nigh impossible, 2 Senate enquires into the same bill (something only seen a handful of times) coupled with a Senate record number of submissions, 2507. Over three thousand gathered outside Parliament House to protest the way the reform in September 2009.

The political cost has been high with Minister Roxon embarrassed by poor advice. It is unclear why but a senior bureaucrat and ministerial adviser both with carriage of maternity reform have both ‘moved on’.

Last week ‘reform representatives’ met with the Minister, the meeting was only achieved after the same women ran in ultra marginal seats in the recent federal election. While seemingly having an open door policy to the AMA, maternity consumers have been repeatedly refused access.

Many criticised the Rudd/Roxon health reform citing it was rather hospital reform, with little focus on health, wellness or consumer engagement. Perhaps that can be explained with yet another medical practitioner appointed by the Minister. Dr Judy Searle, an Obstetrician, seemed unmoved by the participants pleas regarding rural maternity services citing it as ‘a hard area’ but the quote of the meeting must go to the Minister herself who is reported to have responded to the participants comments regarding women’s rights to self determination rather than proposed medical control by saying we will just have to “suck it and see”. So that’s how Labor feminists do women’s rights.

Note: This essay was sent anonymously to APMA.

Disrespect and abuse of women in childbirth

2010-10-21T19:03:00.000+11:00

Rally outside AMA House in Melbourne

We would like to hear stories from women and midwives who have encountered disrespect and/or abuse in maternity care.

Many anecdotal accounts are available. Many women and midwives wrote their stories in submissions to the Australian government's Maternity Services Review.

Two well known academics in the field of women's studies have asked that midwives and mothers who are willing to share their stories contact them. This is not, at this stage, funded research. The aim is to make up a collection of accounts that demonstrate issues of women's autonomy and rights in birthing - as both birthgivers and the women workers who care for them. These accounts will be useful in presentations to human rights advocates, and women's health networks.

If you would like your story considered for this project, please send a message to Joy [joy@aitex.com.au].

Click here to read of the US

WA Health Department statement on Home Birth

2010-10-14T16:34:00.000+11:00

Home Births

In Australia there are a small number of women who elect to have home births. In WA, approximately 200 women have a homebirth each year representing between 0.65-0.8% of all births.

Some countries have higher rates of planned homebirth. For example around 2% of all births in the UK are homebirths and in the Netherlands this is much higher at around 30%. In these countries the infrastructure for safe home birthing is well established and outcomes are usually positive.

There has been controversy about the safety of births at home with differences in opinions between health professionals and sometimes it may be difficult to obtain a balanced view.

In 2007 WA Health commissioned a review of evidence into Models of Maternity Care. This review discusses the safety of planned home births by women of low obstetric risk.

The review concluded that
"Planned home birth with a qualified home birth practitioner is a safe alternative for women determined to be at low risk of pregnancy complications." view full review-see page 11 (external site) (PDF 1.22MB)

You should be aware that your midwife will advise transfer to hospital if complications arise and that there should be a clear plan in place with your local hospital to allow a smooth transition to hospital care, should it become necessary, at any point during your pregnancy, labour or birth.

Some women opt for homebirth after a prior birth experience within a hospital environment that may have not met their expectations. For a few of these women homebirth is not a safe choice due to pre-existing medical problems or previous pregnancy or birth complications. If this applies to you we encourage you to make an appointment with senior members of midwifery and medical staff at the hospital to discuss your concerns. They will then be able to support you to ensure your next birth experience will be more rewarding.

If you are considering a homebirth make sure you are fully aware of the potential and often unpredictable complications that may arise during labour and birth before you make your choice.

Community Midwifery Program WA (external site) provides continuity of midwifery care for low-risk women who are planning to birth at home.
Royal Australian and New Zealand College of Obstetricians and Gynaecologists Homebirth statement (external site) (PDF 520KB)
Royal College of Obstetricians and Gynaecologists Homebirth statement (external site) (PDF 84KB)
Report: Review of home births in Western Australia (August 2008) (external site) (PDF 445KB)

News from the West

2010-10-14T15:38:00.000+11:00

From Western Australia

RESPONSE [to the article below] by Community Midwifery WA

“In response to their objections we have updated the website to include a Research page – we are all for transparency and our aim is to provide women with evidence-based information to enable women to make an informed choice. See our new update page

The report was picked up by the ABC and the AMA and Simon Towler (Chief Medical Officer of WA Health) were interviewed. Dr Towler stood by their support of CMWA, the CMP and their own website “Having a Baby”.

Later on, Consumer spokesperson spoke on 6PR along with the AMA and – again – Dr Towler provide some comment. Again, the support of CMWA and CMP was very welcome.”

The following Article was published in The West Australian newspaper, Oct 13th page 17. Medical reporter Cathy O’Leary

Leading WA doctors have attacked the Health Department's promotion of home births on its website, saying it has biased information and fails to acknowledge the risks to women and their babies.

Dr Louise Farrell, the former WA head of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Australian Medical Association wants the information changed or a link to the Community Midwifery Program removed .

The department's webpage on home births refers to an external website detailing advantages and disadvantages.

Last year, the department released findings of an independent review of home birth safety that found they were generally no riskier when well supported, but doctors maintain they are riskier.

Dr Farrell said the department should promote the safest and best options for women yet was publicising a practice that had poorer outcomes.

It already had to remove information promoting home birth for women who previously had a caesarean after doctors complained. "But it still seems to promote home birth as an equally safe option compared to other models and I think there's a problem with that," Dr Farrell said.

AMA WA president Dave Mountain said the department should remove the website's content until it had more balanced information.

"Choice is a good thing, but I'm against ill-informed choice and the problem with the site is that it's extremely unbalanced and portrays home birth in a way which is highly supportive and uses biased language," he said. "Although there's some research suggesting that in very well-selected people home birth can be reasonably safe, there have been significant concerns about the rates of neonatal deaths and poor outcomes."

Chief medical officer Simon Towler said the department recognised some women wanted a home birth and referred them to the CMP, a publicly-funded service for low-risk women.

He said the recent review found a planned home birth with a qualified practitioner was a safe alternative for women at low risk of complications.

But the site was being changed to include references to the review and the RANZCOG policy on home birth.

GetUp! campaign: reduce caesarean rates

2010-10-12T21:52:00.000+11:00

You can leave your comments here

APMA Position Statement on Collaborative Arrangements

2010-10-11T08:22:00.000+11:00

Australian Private Midwives Association (APMA) represents midwives in private practice.

The National Health (Collaborative arrangements for midwives) Determination 2010

requires written agreement or acknowledgment by a medical practitioner for Medicare funding to be available for services provided privately by a midwife
defies the International Confederation of Midwives (ICM) Definition of the midwife - it prevents autonomous practice for Medicare funded midwives.
defies the ICM Declaration (Glasgow 2008) which states that legislation developed in member countries must enable midwives to practice in their own right.
prevents most current private practice midwives from accessing Medicare funding.

The impact of the National Health (Collaborative arrangements for midwives) Determination 2010 on ALL of midwifery is likely to include:

Low uptake of these reforms by midwives
Minimal benefit to women whose seek a midwife as their primary maternity carer
Uptake only by midwives working for obstetricians as they will be able to access the required arrangement

Midwives working for obstetricians are likely to practice within the medical model, rather than a midwifery model. This will lead to progressive erosion of midwifery as a profession, and progressive loss to women of access to midwives who are skilled in the art of midwifery

As midwives become more entrenched in the medical model, midwifery skills will be lost and women's access to normal birth will be diminished even further than it is now

Private practice midwifery will become known as the model whereby midwives are working in private medical practices, with little regard for those self employed midwives who currently provide true midwifery care at this current time

Acceptance within the maternity workforce that midwives require medical sign off for Medicare and therefore further erosion of opportunity for midwives to work autonomously

APMA is opposed to Parliamentary progress of the National Health (Collaborative arrangements for midwives) Determination 2010 in its current form.

APMA will continue to lobby for the National Health (Collaborative arrangements for midwives) Determination 2010 to be disallowed, withdrawn and rewritten in an acceptable form.

The NHMRC Draft National Guidance on Collaborative Maternity Care document is at http://www.nhmrc.gov.au/guidelines/consult/consultations/ngcmc.htm

'midwifery models of care' in rural Queensland

2010-10-10T16:33:00.000+11:00

[This account has de-identified the midwife and location. It is a clear example of the ridiculously restrictive environment in which midwives are required to practise.]

Letter

I have had various discussions with managers/project officers who are attempting to roll out hybrid 'midwifery models of care' for the rural sector. From my own personal observations -

It is clear that GP's are the primary carer with the midwife as the after thought so as not to upset them.
GP's are scared they will lose an income stream to their rural practice often with the right to private practice to the local hospital.
Managers do not want to lose the doctor as the rural community backlash will be fast and vicious (rightly so).
Higher places of office are providing non-reassuring advice to the facility managers, happy to provide details specific to my application verbally.
It is clear managers are thinking they can switch a midwife's hat on for a few hours of the day to provide antenatal care or birth care. Essentially they are employed as a nurse first.
It is clear until nursing workforce shortages are addressed there will be no change in practice in rural areas that ensure continuity of care with a known midwife as midwives 'offering' themselves to be in these new models are still being put on rosters and not annualised salaries plugging up nurse shortages. Burn out for midwives will occur rapidly.

Geographical boundaries in keeping care within local communities to ensure the care is local, owned by the consumer and feels safe (Rebirthing Report) are being ignored in the drive for efficiencies in combining some projects when viewed in a remote office in some districts.

Collaboration for homebirth with a General Practitioner

2010-10-10T15:59:00.000+11:00

A well known Melbourne GP, Peter Lucas, has attended homebirths with midwives for many years.

An excerpt from his website:

“For some 35 years Dr Peter Lucas and Wattle Park House has offered collaborative care with home birth families and the midwives they have chosen to assist them with their experiences.
"This will continue but assumes that the Wattle Park House medical practitioner attends the birth.
"Until midwives obtain full indemnity cover which includes the labour and delivery, collaboration at a distance is fraught with uncertainty in a medico-legal sense, and cannot be seriously entertained.”

Midwives are concerned that although this doctor is willing to enter what has been called a "collaborative" arrangement with a midwife, he (or his insurance company) are setting conditions on his collaboration and transferring the primary carer role from the midwife to himself. If midwives were to enter into agreements with Peter, they would no longer be the primary carer for their own clients. The arrangement negates the notion of continuity of care from the midwife who practises on her own authority, and renders useless the process of applying for Medicare/PBS eligibility for these women for their antenatal care, as the doctor will be providing that.

Examples of lack of collegiality by some doctors

2010-10-09T22:36:00.000+11:00

In preparation for the implementation of Medicare reforms, commencing 1 November, midwives and maternity consumers have been asked to record evidence of any obstruction to collaboration.

The following message has been received from a midwife in Melbourne:

"A number of my clients have been advised by the GP, when going to their office requesting blood tests, ultrasounds etc, that if they are having a midwife attended home-birth then the GP does not want to be involved in their care beacuse of the lack of insurance for midwives in private practice. This is a major barrier to collaboration in my opinion. I have been searching RACGP websites for some confirmation of this issue and have found some. The attached document (the RACGP submission to government) states:
"What are the workforce barriers to integrated models of care?
• Insurance
As stated previously the RACGP finds the present unavailable of insurance for
privately employed midwives a deterrent. Some GPs want to access midwives on a
sessional basis as they do for other doctors, but find this not possible in the current
climate."
Link:

"Do any of the Midwives/clients have it in writing that GP's are refusing to collaborate already? I have personally found this to be a frustrating and potentially negilgent treatment of women. They [the women] ask for a simple test and the GP refuses - what if there IS an undetected problem because of the GP's refusal to provide care?"

NOTE:
The Australian Medical Association has published a document Collaborative Arrangements: What you need to know in preparation for the inclusion of eligible midwives and nurse practitioners in Medicare funding from 1 November 2010.
This guide is intended to provide you with guidance on important information to consider when entering into a collaborative arrangement with a midwife or nurse practitioner.
Contents:

The legislation
Effective collaboration is good for patients
What is a collaborative arrangement?
Does the midwife/nurse practitioner meet the relevant MBS/PBS requirements?
Indemnity insurance
Is there any obligation to participate in a collaborative arrangement?
Are there any restrictions on which medical practitioners can participate in a collaborative arrangement?
Can more than one medical practitioner be a party to a collaborative arrangement?
Is a collaborative arrangement required for every patient?
Do you have confidence in the midwife or nurse practitioner?
Remuneration
Should you insist on a written agreement?
Clinical settings where services will be provided
What matters should be included in a collaborative arrangement?
Best practice guidelines
What should you do when a patient does not want to follow agreed clinical guidelines?
What happens if things do not work out?
Where can you obtain more information about relevant MBS and PBS arrangements?

Link to Medicare information: Midwives and Nurse Practitioners

New blogger

2010-10-09T22:23:00.000+11:00

That's me at a rally outside the Health Minister's office

Hello, this is Joy Johnston.

I would like to introduce myself, as I have put my hand up to work with this blog. My blogs are perhaps the best way of telling you how I use this valuable medium.

Through the villagemidwife blog I share my own midwifery stories and make critical comment on current issues.

midwivesVictoria is a site I manage for the Midwives in Private Practice (MiPP) group, a collective of independent midwives in Victoria.

Private Midwifery Services is a more recent blog, in which I have addressed the very complex and often vexed issue of reform of maternity services, particularly as it has impacted on independent practice including homebirth.

My blogging experience goes back several years. On my blogger dashboard I have about a dozen sites, and there's a Word Prss quilt blog out there too! I use blogs as records that are maintained in a systematic fashion over time, and easily retrieved. A blog is like a magazine that, instead of having pages that you turn, has pages that continue on down the screen and into the past. The links on the side bar of the blog invite the reader to explore further. Documents and posters can be posted on the blog as images, and enlarged by a right click from the mouse.

Anyone who is older than about 40 will remember the pre-digital, pre-internet era. As a budding activist for maternity reform as recently as the early 1990s, I did cutting and pasting of articles that were put together into a photocopied magazine, or a single page. We had a computer and a printer, but there was no ability to do special page layouts. Instead of mail merge for addresses, we addressed envelopes by hand. The marvel of fax could be used then to get messages out quickly to hospital maternity units.

Then came email, firstly through the Uni, and then at home. What emancipation!

The world of midwifery, and maternity activism, has groups that connect with each other through direct email, Yahoo! groups, and in recent years other social networks such as Facebook and Twitter. In those groups it's very easy to become inwardly focused, with pretty well everyone speaking the same language, or at least those who engage in discussion are. And there is usually, in my experience, a silent majority.

A blog enables information to be shared with anyone who is interested. The networks formed by blogs, with links to other similar blogs and websites, can lead readers down interesting and complex pathways. This crossing of professional and cultural boundaries is useful as an adjunct to the more restricted group discussions.

Blogs enable tracking of numbers of visitors to the site: a sort of statistical self-worth meter. Comments are useful, sometimes agreeing, and sometimes putting an opposing view. The hardest thing for a blogger to face is the doldrums, when noone out there seems interested in all the fascinating material that one has collected and shared. Photos can be used too, and will often draw attention to an otherwise bland page of text.

Australian Private Midwives Association welcomes our readers. Comments that address issues of interest to our group are welcome.

Doctors to gain veto powers over midwives and birth choices

2009-11-16T22:46:00.000+11:00

Doctors to gain veto powers over midwives and birth choices
Maternity Coalition brief

On 5 November the Government announced that the “Medicare for midwives” Bills would be amended to require midwives to have “collaborative arrangements”with “medical practitioners” before being eligible for professional indemnity insurance or Medicare rebates:
Doctors must approve each midwifeʼs entry to private practice:

Midwives will be required by Commonwealth law to have “collaborative arrangements” with“one or more medical practitioners” before being eligible for Commonwealth-subsidised professional indemnity insurance (PII).

PII will be a prerequisite for a midwife to enter private practice, under new national registration laws, being enacted state by state. Doctors will be able to unilaterally withdrawal from collaborative agreements with a midwife, rendering her uninsured, and legally unable to practice in a private professional capacity. This legally mandates medical control over midwives’ ability to register and work in private practice.

This will be set in Commonwealth law, which can only be changed by Commonwealth Parliament. These provisions are contained in the Health Legislation Amendment (Midwives and Nurse practitioners) Bill 2009. Doctors must approve womenʼs access to Medicare rebates for midwifery care:

Midwives will also be be required by Commonwealth law to have “collaborative arrangements”with “one or more medical practitioners” before their services are eligible for Medicare rebates. This allows medical control of individual women’s access to midwifery care.

This is potentially defacto “parallel regulation” of the midwifery profession: Medical practitioners will control the registration status of midwives, despite their being a discrete, separately regulated profession.

Medical professional organisations could set guidelines for collaborative arrangements, potentially forming defacto regulatory standards for midwifery endorsement and practice. This gives doctors right of veto over womenʼs choices in birth care: Any model of care – women’s choices in birth care – using private practice midwives, or developed under the Commonwealth’s new arrangements, will be subject to medical control or veto. This gives medical practitioners inprecedented control over women’s choices and access to care.

The proposed legislation is anti-competitive:

One group of providers will be able to control consumer access to another group of providers of the same business service, e.g. antenatal care. “Collaborative arrangements” may be legally restricted to privately practicing doctors:

The amendments do not specifically include hospitals as able to form collaborative arrangements with midwives. They require medical practitioners to be “of a kind or kinds specified in the regulations”.

It is unclear whether a hospital, health service district or authority may be included within the definition of “one or more medical practitioners”, but it appears unlikely.

Doctors who are employees of public hospitals can’t make “collaborative arrangements” as employees of the hospital they work for. They work for the hospital, attend their workplace when rostered on and collaborate in line with hospital policies.

A range of very serious consequences would flow if these arrangements were restricted to privately practicing doctors. Consequences could include:

No new midwifery models in public hospitals.
No private midwifery practice.
No homebirth care from midwives in private practice.
Practice midwives in private obstetricians rooms could be the only viable model of private practice or Medicare-funded midwifery.
The amendments do not improve “safety” or “continuity” for Australian mothers:

Midwifery is a profession with standards, guidelines and codes of practice developed to ensure the safety of midwifery care in any setting. Doctors, who are trained in a different skill-set, do not midwifery practice.

Continuity of care has been a fundamental goal of the midwifery reforms. These amendments make this continuity much more difficult to deliver.

No provision is made in the amendment specifying that collaborative arrangements will be based on patient safety or continuity of care. Medical practitioners will have veto on their own terms. This brief represents the best information available to Maternity Coalition on 9 November 2009. We are actively seeking ongoing clarification and dialogue with Government in order to ensure women and families have access to accurate information.

For more information contact: Bruce Teakle 07 3289 0231, teakle@maternitycoalition.org.au

MEDIA RELEASE

2009-11-08T20:29:00.000+11:00

MEDIA RELEASE
Australian Private Midwives Association
Contact: National President Liz Wilkes 0423 580585
Medical veto impacts women’s access to care: Women Rally.
The Federal government may stall on the blocks of its first major initiative in health as the reform of maternity services hits stumbling blocks and criticism. Women will rally around Australia tomorrow to ensure choices are not lost in the wash up. Liz Wilkes, National President of the Australian Private Midwives Association, will join women and midwives outside Kevin Rudd’s electorate office in Brisbane. Women are seeking assurances that new legislation around private midwives registration and practice will not reduce options for care. “Midwives are educated and regulated to provide care for pregnancy, labour and birth on their own responsibility under the International Confederation of Midwives definition of a
midwife,” Ms Wilkes stated “Suddenly we are told that doctors control the ship and that doctors will be able to decide who can do what.”

Legislation due before the Senate was amended on Thursday by the Government to require midwives to work at all times in formal collaborative arrangements with doctors as a condition of insurance. Doctors will be able to veto these arrangements effectively giving the medical profession the ability to control which midwives can be insured and register. “The reform of maternity services is the first test of the Governments health reform agenda. It looks like the medical lobby may stall these reforms before they even get started.” Ms Wilkes said today “Placing one profession at the complete mercy of another for registration makes a mockery of professional regulation in this country.” Women at the centre of the scuffle are concerned that the amendment may erode rather than expand choices as doctors make decisions about what types of care to support. Many choices such as homebirth, vaginal birth after caesarean and care in rural areas may be lost if doctors do not form the formal agreements with midwives. “For the midwives who are currently self-employed it is no longer a matter of referring a woman who needs care to the appropriate person. Formal agreements with doctors will determine which of these educated, experienced and skilled midwives can actually register.” Ms Wilkes added “Regulators should control midwifery professional standards, not how a doctor feels about a particular midwife. This takes midwifery back 50 years.”

Women are worried about the choices in birth and are calling on the Prime Minister to make sure that in implementing this first serious reform in health, options for choice are not lost. Women rally at 10.30am November 9 at electorate offices of Kevin Rudd Brisbane, Julia Gillard Melbourne, Tanya Plibersek Sydney and Stephen Smith Perth.

Contacts: Liz Wilkes 0423 580585 (Brisbane and national)
Marie Health 0407266004 (Sydney)
Sally Westbury 0422 894 496 (Perth)
Clare Lane 0416 130291 (Melbourne)

Position Statement

2009-11-01T21:50:00.000+11:00

Position Statement on

Planned Home Births with a

Midwife

Adopted by APMA: 29 October 2009

Introduction

Australian Private Midwives Association (APMA) represents the majority of privately practising midwives in Australia, who are also the responsible professional attendants at the majority of homebirths in this country. APMA aims, through representing private midwives at national professional discussions, to support women through promoting and protecting continuity of midwifery primary care. APMA is a key stakeholder in any professional discussion about homebirth.

Many APMA members are active professionally in the Australian College of Midwives (ACM), as well as in groups that establish partnership between midwives and consumers, such as Australian Society of Independent Midwives, Midwives in Private Practice, Maternity Coalition, Homebirth Australia, Home Midwifery Association (Qld), Homebirth Access Sydney (NSW), Birth Matters (SA), and Birthing and Babies Support (BaBS).

The following statement represents the view of APMA on planned home births with a midwife. APMA reserves the right to revise and update this Position Statement as time passes. APMA encourages ACM and other stakeholder organisations to endorse this statement and adopt it without change as their Position Statement on Home Births with a Midwife.

Position Statement on

Planned Home Births with a

Midwife

1. We support home birth with a midwife in attendance for women who have uncomplicated labours.

Midwives practising in any setting are responsible and accountable for their decision making about their own scope of practice and referral and transfer of care.
We support the use of the National Midwifery Guidelines for Consultation and Referral (ACM 2008) as a guide in midwifery referral decisions.

2. We support and adopt the International Confederation of Midwives’ (ICM) Definition of the Midwife (2005) (attached below), which is foundational to all midwifery practice, including homebirth. The ICM Definition of the Midwife establishes the following principles which apply in this statement:

The principle of ‘partnership’: “The midwife … works in partnership with women …”
The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
The principle of continuity of carer (‘caseload’) – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”

3. We support the right of every woman to access a midwife as the primary maternity caregiver who works in partnership with the woman throughout the episode of care, who is able to be the responsible professional in attendance at the birth either at home or hospital, and who is able to make appropriate referral and transfer of care when required.

We support a woman’s right to self-determination and control over her body and her pregnancy, including the right to give birth in the place of her choice.
We support and value the woman’s ability to make informed decisions about place of birth, and other choices as her pregnancy and labour progress, in partnership with a known and trusted midwife of her choice.

4. We support the right of a midwife to practise privately¹ in a fee-for-service or funded relationship with the client, or to take up employment.

5. We support only those regulatory restrictions that are able to pass the ‘public interest’ test: “How does this promote health and wellbeing in the mother and baby?”²

6. We support an expectation of equity, including equal pay for equal work throughout a midwife’s scope of practice. Midwives who provide primary maternity care are entitled to the same public funding, the same opportunity to charge a fee-for-service, the same access to hospital referral, and publicly supported indemnity insurance, as medical practitioners providing the same maternity services.³

7. We support processes by which midwives are able to gain experience and mentoring in order to commence and demonstrate continuing competence in homebirth practice.

8. We support seamless and reliable processes by which midwives are able to make hospital bookings for women planning homebirth, and arrange transfer to the hospital in a timely way when needed.

Definition of the Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia

Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990

International Definition of a Midwife

2009-10-08T19:39:00.000+11:00

A midwife is a person who, having been regularly admitted to a midwifery education programme, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.

The midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife's own responsibility and to provide care for the newborn and infant. This care includes preventive measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counseling and education, not only for the woman, but also within the family and community. This work should involve antenatal education and preparation for parenthood and may extend to women's health, sexual or reproductive health and childcare.

A midwife may practice in any setting including the home, community, hospitals, clinics or health units.