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.

NETWORKS

click to enlarge

Since taking on the job of acting president of APMA, I have spoken with various organisations, including the Australian College of Midwives (ACM), Australian Nursing Federation (ANF), Midwives Australia (MA), Maternity Coalition (MC), Midwives in Private Practice (MiPP) and Homebirth Australia (HA) on behalf of APMA. 

Midwives have asked me why there are so many organisations?  And why would a midwife join multiple organisations?

That has led me to setting down the diagram above, illustrating the 'NETWORKS' that currently exist for Australian midwives.  At a first glance, you will see circles and lines that overlap, interconnect, and are often tangled.  A 2-dimensional drawing can only touch on the complexity of the interconnections and tangles that happen between and among groups that rely on membership from members of the profession for their funding, and on unpaid involvement of committed members in achieving their goals.

Each organisation is independent of the others, yet there are times when APMA, representing the interests of private midwives, will sit at the table with these and other groups representing the interests of midwives from an overall professional perspective, midwives and nurses who are employees within a unionised workforce, midwives and lay people who seek to improve maternity services, and highly committed activists promoting homebirth.

Within and between each part of the network are social networking options, including sites on facebook, blogs, Skype calls and email groups.  Today we have unprecedented access to each other.

Having worked in various roles in midwifery and maternity advocacy organisations for the past twenty years, I am convinced that we - those who have volunteered our time and skill, and paid our dues - have achieved a great deal.  We have, in many ways, helped to define our professional boundaries.  See ROADBLOCKS for examples.

The job is not completed.  In fact, I doubt that it will ever be completed; new issues will continually appear on the horizon, and will need people with vision and strength to work through whatever professional or legislative processes there are that present obstacles to what we believe is a reasonable standard of midwifery care, and in the interest of the health and wellbeing of mothers and babies in our care.

The current big issue is professional indemnity insurance (PII), which is mandatory for all health professionals, yet is not available for midwives attending women for homebirth.

Homebirth has for many years been the main practice setting for midwives practising privately.  Making something that is not available mandatory has the potential to wipe out private midwifery practice for homebirth; using the (profitable) insurance market as the de facto regulator of private homebirth midwifery. 

An exemption has been granted for midwives until June 2013.  We do not know what will happen when that exemption runs out.  Will the exemption be extended further? 

The situation is unacceptable.  If mandatory indemnity insurance is truly in the public interest, how can that tiny minority of women (<0.5%) who engage midwives privately for homebirth be excluded from what the rest of society is entitled to? 

The obvious question to ask is how does the public benefit from mandatory PII?


Without going into detail, many who have grappled with this question believe the mandatory PII requirement is not in the public interest, and should be replaced by a different scheme.  The model for such a scheme is already being worked on by our government, in a compensation scheme for people with disability.  We consider a no-fault insurance scheme, into which all regulated health professionals pay a proportion of their earnings, similar to that which exists in New Zealand, would provide better support for those who need it than does mandatory PII.  That means such a scheme would be in the public interest, and would provide more equity for midwives and the women who engage us privately for planned homebirth.

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.

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. 

Collaboration for homebirth with a General Practitioner

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.