Update on Agnes Gereb

This report is from Donal Kerry
International Spokesperson
Campaign for Justice for Ágnes Gereb


The story of Dr. Geréb is one that has been played out in the Hungarian criminal courts for the last two years. On December 6th a further phase commences, when she will face a new set of five charges before one of the criminal courts in Budapest.

As you are probably aware Ágnes has been detained without trial since a birth incident of Oct 5th, 2010 (prison, 77days; house arrest, 710 days and counting!). In February this year she was sentenced to two years imprisonment connected to birth incidents occurring in 2006 and 2007. However, the enforcement of this sentence is still pending as the President of Hungary ruled on October, 10th (see his translated statement at http://www.szuleteshaz.hu/en/press-releases-of-the-clemency/) that Ágnes's request for clemency in this matter will not be decided upon by him until the December, 6th trial charges have reached a conclusion in the courts. This upcoming trial will deal with the birth incident of Oct, 5th, 2010, two further birth incidents and also two "administrative" matters.

The Campaign for Justice for Dr. Geréb would very much welcome your involvement and coverage of this new trial as it continues to raise issues around the situation of Ágnes which we consider important for her but also for the rights she is fighting for:

• her own human rights, 
• the rights of Hungarian birthing mothers, and 
• the rights of midwives in Hungary to be dealt in an equitable way with Hungarian hospital doctors with regard to their treatment when involved in adverse birth incidents. 

On December 6th it's her own rights which will first and foremost come under further intense pressure as she continues to deal with:

• concerns that conditions are not in place to offer her a real chance of a fair trial
• the fact that she should not be before the criminal courts, and like in other EU countries should have her actions assessed by a Midwifery Investigation Committee
• that despite or because of being Hungary's foremost defender of women's rights she has received uniquely aggressive treatment from the State Prosecution Service as exampled by the further fact that she has the full public support of the 3 mothers in the birth cases coming before the court and the 200 parents cited by the prosecutor in the 4th case. 

President Áder in his statement of October 10th acknowledged Ágnes's role in helping birthing mothers and home birth itself. This was an important positive comment for Ágnes coming from the highest office holder in the land but it needs to be built upon by receiving the backing of the Hungarian government as well. The President also highlighted the important place of justice and lawfulness in Hungary and to echo this vital point Dr. Geréb supporters both at home and abroad will be calling on the Hungarian government, through the Minister for Justice to review her case and also to closely monitoring her upcoming trial.

We know from our feedback that Ági's story has captured the attention of women everywhere and also of the many interested in human rights. If readers are in a position to move further on this story please let me know and I can provide u with more information on the 5 cases involved and I know Ágnes would be available to reply to written questions that u might wish to put to her.
Yours sincerely,
Donal Kerry
International Spokesperson
Campaign for Justice for Ágnes Gereb
mobile 0036309242190
email: donalkerry@hotmail.com

This message was received through Beverley Beech of AIMS UK.

Radical Midwifery in Holland

Rebekka Visser is a Dutch midwife who gave a presentation on 'Birth: a Human Rights issue?' at the Human Rights in Childbirth conference, convened a few weeks ago in The Hague.

Rebekka has posted the content of her presentation on Responsible Care (in English) at her blog.

It's worth a read! Rebekka explores why midwives seek to control birth.

Now should this mean that to my opinion all midwives must be willing to assist breech births at home? Or that all women must be willing to have their breech baby at home? 
Definitely not!
We need to open the dialogue about our own fears, work with it, finding solutions.

This conference brought together midwives, ethicists, lawyers, obstetricians, mothers, and others for two days, to consider and debate human rights in childbirth.  The event which drove the conference was the imprisonment of midwife Agnes Gereb, from Hungary, a signatory to the European Convention on Human Rights.  Agnes was not present at the conference: she is under house arrest.

Australian midwifery is going through huge changes, and many midwives fear the escalation of authoritarian control over midwifery, and consequently, over women's rights in childbearing.

Regulation of midwifery can only be in the public interest when the system also promotes and protects the midwife's scope of practice professionally.  It's a balance that our society must continue to work towards.

Newsletter May 2012

Keeping members and supporters informed and encouraged! 

Midwifery today, more than ever before, relies on midwives who have the ability to think independently, with the courage to act in the interests of mothers and babies in our care. In this brief newsletter I would like to encourage each midwife to remember why we are midwives, and why we have chosen to work with woman in a private midwifery practice arrangement that is planned around the expectations and needs of each woman through her childbearing journey.

Dear midwife, do you remember ‘once a Caesar, always a Caesar’? Do you remember being taught that cutting an episiotomy would protect the integrity of the woman’s pelvic floor? ... when most babies were ‘sucked out on the perineum’ as soon as their little mouths could be poked and prodded with the suction catheter? ... when babies were wisked away from their mothers and later presented as a little face in a bundle of white toweling?

And, do you remember the first time you witnessed a woman give birth unassisted, unmedicated, and with an ecstatic and triumphant cry? Treasure that memory!

APMA continues to represent and support midwives who practise privately. The boundaries of midwifery practice will continue to be challenged, and midwives will need to be strong and encourage one another in our knowledge of midwifery and of our significant role in our communities.  Midwives who practise privately in Australia are invited to submit a membership application at our website http://www.privatemidwives.com.au/#!membership

On Leave 
APMA President, Marie Heath, is taking leave from the committee from May to July. The committee has asked Joy Johnston from Melbourne to take the Acting President role. Other members of the committee are: Treasurer, Pete Malavisi (WA), Minutes Secretary, Milly Grigg Smith (SA), Public Officer, Sonja McGregor (NSW), and members Abbey Rodda and Clare Lane. Meetings are usually by Skype, and other APMA members are welcome to join in.

Homebirth and AHPRA 
Representatives of APMA and Midwives Australia have met with AHPRA to discuss various issues, including the fact that the Homebirth Position Statement (July 2011), listed at the AHPRA website, is not acceptable to the midwifery profession. This document was prepared without consultation with private practice midwives or consumers, for whom it has serious implications. It has been reported that the July 2011 position statement document meets the stated need of the Health Ministers! (One might ask which Health Minister is planning homebirth!)   AHPRA confirmed that the NMBA is using the July 2011 home birth position statement, and not the revised ACM Position Statement on Homebirth Services (November 2011) which currently appears at the ACM website.

Statement of Purpose
The committee has adopted this Statement of Purpose:

The Purpose of 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 

In brief
• Medicare-eligible midwives with a notation effective from 1 November 2010 to 30 December 2011, will soon receive a letter from the National Board with a new formal undertaking that provides an extension of a further 12 months to complete a Board-approved program of study preparing a midwife to prescribe scheduled medicines in midwifery practice.
• Midwives will be informed by APMA/Midwives Australia when the NMBA-approved course is available.

 

Joy Johnston, Acting President
Mobile – 04111 90448
Email – joy@aitex.com.au

Face of Birth petition

From the Face of Birth website

Online petition supports women's choice in childbirth!

09-Apr-2012

Every woman has the right to decide where, how and with whom she gives birth, but not all women have the same access to funding. If you would like to help change that in Australia, then please sign the petition and spread the word. It only takes a minute!

Readers of this blog will probably know about Face of Birth, and are likely to have signed the petition. IF you haven't, please take a moment CLICK HERE and sign this petition. The number of signatures today is approaching the 500 mark. The Petition site gives people the opportunity to write a comment as to why they signed, which provides an interesting and thought-provoking sub-text to the petition. Here are a few:

 Dr Kirsten Small from Nambour Qld:

Women should not be put in a position where they have to chose between birth at home without a skilled care provider, or the limited menu of options on offer in our hospital.

Denise Hynd, and Australian midwife who has moved to New Zealand:

I will come and practice midwifery when this petition is successful!!

Sally-Anne Brown from Vic

Bring Birth Back Home on Country

Jodi Johnson from Wights Mountain

Because this country is sooo backward in supporting normal birth - through supporting midwifery models.

Michelle Fulcher of Balgownie

Australia's Maternity System is BROKEN and heading towards a more American model will only make it worse and increase the maternity mortality rates!! Look at New Zealand and be BRAVE enough to give Australian women & babies the same protected rights!!! We'll no longer have doctor shortages and midwives will come flocking back!

Bev Walker of Venus Bay Vic

I gave up on the women in the ALP on this issue. Senator Siewert became our hero and one of the few who got it. My first solution would be to get rid of the advisers to the Health Minister and put anyone of several home birth women and midwives in to their place.

Susan Cudlpp from High Wycombe

I am signing because this is a basic truth. Birthing choices are a human right which is being eroded steadily from the lives of Australian women. Women in this country have less and less choice, the medical monopoly exerts more and more power and midwives are unsupported and unprotected.

Marg Phelan from Casuarina NT

Women have the right to birth where they choose and with whom they want. They need to be supported in their choice with Midwives who are fully supported by the Dept of health with Medicare and Insurance. 

Lisa O'Connell from Wentworthville

Because I wanted a homebirth more than anything, but just couldn't afford it on our own! 

The following Comment is from the writer of this post, Joy Johnston

‘Choice’ is a slippery entity that easily moves out of reach when in reality the woman’s access to a particular model of care, or a place in a birth centre or even birth at home is easily overruled by other factors – availability, wealth, service provision and the mother’s or baby’s health status.  In fact, the only real choice a woman has in birth is if she accepts and works in harmony with her body’s natural processes, and finds professional support that will not interfere without a valid reason.

‘Choice’ that is limited by wealth and private health insurance is not choice at all.  A woman who chooses maternity care in a private hospital because she has so called ‘health’ insurance that covers this option may be surprised when she discovers that this choice increases her chances of medical and surgical interventions, and decreases her chances of normal birth.  Those who want normal birth can be appropriately supported by a known midwife who is skilled in protecting wellness in birthing. 

Many of us have been part of the birth reform movement for a long time, in which midwives and consumers have joined together in the ‘choice’ refrain. Now I feel we have been wrong. I think that rather than women's choice we should be demanding the right of the midwife to practise midwifery. If a community has midwives, women can give birth in that community. If a community doesn’t have midwives, or the midwives in the community are shackled to a system that doesn’t even respect the midwife, women can talk about rights and it means nothing. 

A woman really only has one choice: Plan A - DIY (do it yourself), or ask someone else to take over.

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.

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

Assessing progress with Medicare

Let's review and assess private practice midwives and Medicare!

In the past year midwives who have the 'eligible' notation against their name on the Midwives Register have been able, in theory at least, to facilitate Medicare rebates to women in their care. The common process is that the receipt issued by the midwife contains the midwife's Medicare Provider Number, the name and address of the practice as it is registered with Medicare, and the Medicare Item number(s) for services provided.  The woman/client receives rebate of the scheduled fee plus any addition rebate under the Extended Medicare Safety Net scheme.

The Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162 is the legislation that gives detailed description of the Items and the current level of the scheduled fee for midwifery services, from which rebate is calculated.

Australian Private Midwives' Association (APMA) has asked members to provide information about how they are traveling in the new 'Medicare eligibility' terrain. Understandably, much of the response has focused on the requirements of the new legislation for a collaborative agreement or arrangement with a named, specified obstetric medical practitioner - all of which is defined and directed in the law. The midwife is required to demonstrate and record suitable collaboration in order for Medicare rebates to be available to the woman, but there is no linked requirement, or even encouragement, for any doctor to reciprocate when collaboration is requested.

Some midwives are situated in communities where doctors and even public hospitals are willing to enter collaborative arrangements with private midwives. The midwives are getting on with the job of being with woman; the women are receiving expert midwifery care from their own midwives through the continuum, as promised by the Health Minister when the maternity reform package was announced, and receiving significant Medicare rebates for the midwifery services.

However, midwives practising privately in other communities, such as densely populated big cities, or covering rural towns and villages, face multiple challenges each time they attempt to comply with the collaboration law. Here are a few quotes from midwives' responses.

[The collaboration requirements are]

"absolutely unreasonable. We are qualified competent midwives who should not be held to ransom by our medical colleagues. It is mainly unworkable and my clients are having to travel all over the place to get an agreement and they pay a new patient fee and then are told ‘oh no I’m not doing that now’ even though the doctor signed an agreement with another client the week before. It’s not fair on the doctor either as they often don’t understand they are not required to do anything and if there are any deviations from normal then we consult directly with the [backup] hospital. Doctors often say there’s no point to this because we’re doing the same thing and doubling up and it’s not required for a healthy uncomplicated pregnant women. I say "I KNOW, but can you just sign anyway" because it’s just a formality and a requirement until we get the legislation changed!!"

[The collaboration requirements]

"should not have such and emphasis on the midwife being subservient to the doctor. It should also provide an incentive for a doctor to want to collaborate with us!"

[The collaboration requirements]

"are not necessary - we had the same system of referral and transfer here before Medicare and it worked fine but it was not formalised. Now it takes extra time and the doctor has the power to veto - this is not acceptable."

Collaboration can be a relatively simple matter.  A letter of referral (one of the processes by which collaboration is demonstrated) from a doctor Melbourne, who had not previously met this woman, wrote to the midwife:

"Thanks for caring for <M>  for the antenatal and postnatal period of her pregnancy.  She is well.  I am happy to provide collaborative care."   

On the other hand, an obstetrician, who is a senior consultant at a public maternity hospital has said:

"I am not comfortable with this model of care (ie private midwife).  If <M> wants a private midwife she will need to make a booking at [public] hospital, and have all her care under that system.  Any additional care she wants from a private midwife will be at her own cost.  I will not sign a collaborative arrangement."

The midwife, and the woman, must return to the drawing board, seeking a way to meet the collaboration requirements.


Readers are welcome to make their own assessment of progress in the midwife-Medicare labour.
Midwives assess progress (of this labour) externally, and the external features that can be noted include the fact that some women are claiming rebate on midwives' fees.  The amount of this rebate could be up to $1000 per woman/episode of care.

Midwives also assess progress internally, and the internal signs of the Medicare labour are not good.  The efforts made by some obstetricians to isolate and exclude private midwifery, blocking what little financial assistance the woman is entitled to, will lead to distress and obstruction.  The people who will suffer most are the mother and her baby.


Thankyou for your comments.

Safety and quality goals for health care

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