Review of the ACM Guidelines

The College (ACM) has announced a review of the ACM National Midwifery Guidelines for Consultation and Referral (2nd Edition) (2008)
If you do not have a copy, you can download a .pfd version here.

Readers who are members of ACM will have received a message about this review.

The review questions are:

• Do you have any corrections or changes to be considered for the next edition? 
• Do you have any additions that should be considered? 
• Do you use appendix A? 
• Does appendix A work or how does it need changing? 

The guidelines are meant for all midwives, so even if you aren’t a member of ACM, please put your mind to these questions.
The APMA response will address the questions with private midwifery practice in mind.  Private midwifery practice has changed significantly since 2008, when the current version was published, for example:

• All midwives who practise privately are required to have professional indemnity insurance
• An exemption from the indemnity insurance requirement is in place until June 2013, and is expected to be extended to 2015, for midwives attending homebirths privately
• Many midwives are now able to offer Medicare rebates for a range of antenatal and postnatal midwifery services.  
• A few midwives are offering Medicare rebates for intrapartum midwifery services in hospitals where they have clinical privileges/visiting access.
• A few midwives have endorsement on the public register as PBS prescribers

"Endorsed as qualified to prescribe schedule 2, 3, 4 and 8 medicines required for midwifery practice across pregnancy, labour, birth and postnatal care, in accordance with relevant State and Territory legislation"(AHPRA)

• Many midwives are enrolled in university studies that will lead to endorsement as prescribers.

Readers are welcome to make comments in relation to this review, either directly to ACM, or via APMA.

Newsletter June 2012

APMA is working to represent and advocate for private practice midwives at federal and state/territory levels, and provide support and encouragement for our members.

Private midwifery today 
Midwives have experienced enormous changes in the past few years, and no-where more so than for those who practise privately, with national regulation and the government’s reform package.

The National Maternity Services Plan, an outcome of the Maternity Services Review (2008), was endorsed by the Australian Health Ministers’ Conference in November 2010. This Plan provided governments with a strategic national framework to guide policy and program development.

One focus of the reform package is private midwifery practice, extending options of primary maternity care for women who expect to be able to give birth in the care of a midwife – often referred to as 'low risk', or 'normal risk' women.

We are seeing trends in private midwifery, as more midwives access notation for Medicare eligibility. Midwives joining APMA today are less likely than in previous years to be working in the private homebirth scene.

Highlighting a few points of interest

• Prescribing course: The Nursing and Midwifery Board (NMBA) has announced the approval the inaugural program of study which will lead to Endorsement for Scheduled Medicines for Eligible Midwives. This is a program of study will enable eligible midwives, once their study is completed, to obtain an endorsement to prescribe scheduled medicines. The accredited program is within a Graduate Certificate in Midwifery at Flinders University (South Australia).  See previous post.
• Attempts by midwives to achieve admitting rights in hospitals have been met with little encouragement, and a great deal of discouragement. 
• Midwives who have achieved Medicare eligibility and set up private practices, with the intention of attending women for birth in hospital, express great concern over the obstructions and restriction of trade that they face in practising their profession. Perhaps an unintended outcome of the reform process will be increased numbers of private homebirths and increased numbers of midwives upskilling to private homebirth practice! 
• The College of Midwives (ACM) is setting up a private practice committee, to advise its governing Board on private practice matters. APMA expects to receive an invitation to nominate a representative for that committee. 
• Private practice and homebirth have in the past often been referred to interchangeably. This is no longer the case, and APMA is clear that we represent private practice midwives. 
• The need for regulation of midwives by midwives (ie a Midwives Board) is obvious.

Professional Indemnity Insurance 
APMA and other midwifery organisations (including ACM, Midwives Australia) have met with representatives of the Department of Health and Ageing, and insurance group MIGA.

APMA’s position is that we consider the current available options for professional indemnity (PII) to be inadequate for midwives, and therefore not in the public interest, with the potential that midwives will be prevented from lawfully practising midwifery because they are unable to obtain suitable insurance. This is unacceptable.

We have been told that the lack of PII cover for intrapartum care has already led to some midwives not renewing their registration and working as unregulated birth attendants.

Issues include the indemnity cover for

• a midwife who is called at short notice to work as locum for another midwife 
• the midwife who attends a homebirth as second midwife 
• cost and sustainability, especially in setting up 
• a midwife joining a group practice 
• students and mentoring of midwives entering private practice 

APMA strongly recommends the introduction of a no-fault compensation scheme to replace or reduce the impact of mandatory PII requirement for midwives. The statutory regulation of midwives should be the point of entry into the midwifery profession, not the availability or affordability of indemnity insurance.

Invitation to midwives to join APMA 
Membership is open to all current private midwives, midwives with previous experience in private midwifery who wish to remain informed, and midwifery students that wish to enter private practice after completion of their studies.
If you wish to become a member, please email details of your private midwifery experience/aspirations. Membership fees Renewal of membership is now due:
• full membership $80
• student or non-earning members $40.

Midwives and medicines

The Nursing and Midwifery Board (NMBA) has announced the approval the inaugural program of study which will lead to Endorsement for Scheduled Medicines for Eligible Midwives. This is a program of study will enable the existing 114 eligible midwives, once their study is completed, to obtain an endorsement to prescribe scheduled medicines, and, the Board claims, to practice to their full scope of midwifery practice.


The accredited program is within a Graduate Certificate in Midwifery at Flinders University (South Australia), and is comprised of 2 topics:
MIDW9009 Pharmacology for Midwives and
MIDW9010 Investigations and Diagnostics for Midwives.
They are both 9 unit topics and they are offered externally. The topics can be studied together in one semester of full time study or one topic a semester as part time.

Application for the course through SATAC and it will commence in semester 2 this year. The SATAC Code is 2GC087 Graduate Certificate in Midwifery and applications for a second semester commencement close on 25 June.

Midwives who have achieved notation on the Register as eligible for Medicare were required to make an undertaking to the Nursing and Midwifery Board of Australia (“the Board”):-

• 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. I also understand that if I am not able to provide the Board with the necessary evidence of successful completion of the required program within 18 months, the notation as an eligible midwife may be revoked. I understand that a failure to comply with the above undertaking may constitute behaviour for which conduct proceedings may be taken under the Health Practitioner Regulation National Law (South Australia). 

* Note that this deadline has been recently extended by 12 months, as recently reported in this blog.


Midwives who have completed courses that have been recognised as substantially equivalent are not yet able to prescribe scheduled medicines.  The Victorian law (Drugs and Poisons) is yet to be amended to enable midwife prescription.

Midwives who are practising in primary maternity care, with or without participation in Medicare, have only minimal reliance on scheduled drugs.  We do not carry dangerous drugs, such as Pethidine, which is often used in hospital for obstetric analgesia.  Some midwives arrange with the woman's GP a prescription for prophylactic antibiotics for women who test positive to Group B Streptococcus. The scheduled drug that is considered essential for midwives attending births in the community is Syntocinon, a synthetic oxytocic, to be used postnatally to prevent or treat post partum haemorrhage.  Women obtain this drug, and sometimes a stronger oxytocic, Syntometrine, on a doctor's prescription, and their midwife takes responsibility for its administration. 

 

our purpose

This statement of purpose has been drafted by the APMA committee, in discussion with members and supporters.

The (Draft) purpose of Australian Private Midwives' Association (APMA) is  
To represent and support midwives who practise privately in any setting

In functioning as the national body representing midwives who are in private practice, APMA seeks

• 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 support and care for members in a non-judgemental way, with flexibility to respond to different people and situations
• To share information with members and the wider community

Note: Private midwifery practice encompasses the full scope of practice that is open to midwives registered in Australia, and is not limited to the setting of practice, such as homebirth, or funding for practice, such as Medicare-eligibility.

Your comments and discussion are welcome.

A new career pathway for midwives?

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

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

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

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

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

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

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

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

Joy Johnston

Thankyou for your comments.

Where are the midwives who practise privately?

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

Western Australia

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

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

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

South Australia

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

Homebirth SA Blog
Facebook

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

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

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

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

MiPP blog
List of MiPP midwives

New South Wales

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

Marie Heath (Goulburn)

Queensland

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

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

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

My Midwives

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

Arranging collaboration

Each time a Medicare-authorised midwife agrees to work with a woman in providing midwifery services we have to navigate the sometimes-challenging terrain of collaborative arrangements'.

Without a collaborative arrangement that meets the requirements set down in the National Health (Collaborative arrangements for midwives) Determination 2010, the midwife is not permitted to offer a Medicare rebate for services. The degree of ease or difficulty experienced in reaching tick in the collaboration box varies from woman to woman. In last week's blog post I listed some of the situations that midwives have faced in attempting to arrange collaboration, ranging from simple and workable, to outright obstruction by a medical practitioner.

A midwife who has recently obtained her Medicare provider number, and who is setting up private practice for the first time, has decided to focus on postnatal midwifery services, rather than primary midwifery care that spans the prenatal, labour and birth, and postnatal episode of care for individual women. The midwife contacted the Medicare office, and reported:

"they [Medicare] don't need collaboration, all they want just referral from a doctor."

"the doctor can be a GP who does not have the diploma of obstetrics."

"also called the two insurance companies, who confirmed, no need for a collaborative agreement for postnatal, only referral from a doctor which could be a GP who initially made the booking in."

This apparently conflicting advice highlights the need for a serious review of the government's Maternity Reform package and the associated bureaucratic processes. There is no differentiation made in the legislation between prenatal or postnatal midwifery services; they all come under the same set of requirements. It is ludicrous for the Medicare office to tell a midwife that "You don't need collaboration, only a referral from a doctor." The referral letter IS the collaboration arrangement, according to Section 5 (1) (b) of the Determination.

Midwives who seek to meet the Medicare-related requirements take the relevant legislative instruments into consideration in preparing a care plan for each woman. Using a highlighter, here is a summary of two new laws which impact on midwifery services:

For each episode of care, the midwife needs to consider:
1. National Health (Collaborative arrangements for Midwives) Determination 2010 [NH(CM)] 
2. Health Insurance (Midwife and Nurse Practitioner) Determination 2010 [HI(MNP)]

Specified Medical Practitioner for this episode of care: _____________________________________

Collaborative agreement or arrangement under Section 5 NH(CM): ______________________

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:
(a) the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;
(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;

(d) an arrangement mentioned in section 7 for the midwife.

If the collaborative arrangement is (d) above [Section 7 midwife’s written records] 

(1) (a) the (specified) named medical practitioner(nmp): _________________________ 

(b) Midwife has told the patient of collaborative arrangement with nmp: 

(c) acknowledgement by nmp: 

(d) plans for consultation, referral, and transfer of care to nmp: 

(2) (a) record of any consultation or other communication with nmp: 

(b) record of any referral to nmp: 

(c) record of any transfer of care to nmp: 

(d) acknowledgment of receipt by nmp/hospital of booking: 

(e) acknowledgment of receipt by nmp/hospital of maternity care plan: 

(f) record of imaging& pathology results to nmp: 

(g) discharge summary to nmp and usual general practitioner

MIDWIFERY SERVICES [HI(MNP)] 

• Practice arrangement [HI(MNP) 4(2)(a)] for midwife with primary booking in this care plan: partner / employee / [other] ___________
• Other midwife who provides relief services or locum [HI(MNP) 4(2)(b/c)]:
• Requirement [HI(MNP) 6] for collaborative arrangement has been met:
• Requirement [HI(MNP) 7(1)(a)] service has been met:
• Requirement [HI(MNP) 7(1)(b)] (not employed) has been met:
• Labour and delivery [HI(MNP) 8] requirements (1) to (4) have been met if applicable:



In addition, a midwife who intends to attend a woman for birth in the home is required to have the woman sign an agreement, in which the woman acknowledges that she understands that there is no professional indemnity insurance for home birth, and that midwives are exempt until 30 June 2013 from having insurance for homebirth.

These are just a few examples of the new and complicated terrain that privately practising midwives in Australia must navigate.  In time midwives will face audits and investigations, and will be held accountable for the way we practice.  Midwives who wish to discuss practice in more detail with their peers are invited to join Australian Private Midwives Association (APMA), and contribute to APMA yahoo! group email discussions.

insurance and private midwives

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. 

Collaborative arrangements

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

Eligible Midwives

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.