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.

Collaborative arrangements for midwives

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).