Where are the midwives?

[For a rough estimate of distance, think of a red dot as 100Kilometers]

Several years ago the Federal Opposition Health spokesperson made a speech to midwives. She said that midwives have:

“limited opportunities to practise as primary carers and provide continuity of care to women” and

“Unless and until the Government is shocked and shamed into realising that Australian women … ” and

“I believe that midwives … are key heath care professionals whose role in the care of women and their babies has yet to be fully realised in the Australian health care system” 

The speech was to the Annual conference Midwifery By The Sea - Riding The Waves Of Change of the New South Wales Midwives Association, 20th October 2005.  The speaker was the woman who went on to become Prime Minister, the Hon Julia Gillard. Here's a little more from that speech:

"Clearly this is no time for turf warfare between doctors and midwives, but it is time for all health care professionals involved in delivering obstetrics care to mount a combined attack on the Howard Government to force them into action to address this situation. 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."

The [Rudd-] Gillard government have brought in maternity reform, as readers of this and other maternity-related sites will know all too well. Ms Gillard declared in 2005 that "this is no time for turf warfare between doctors and midwives ..." YET this government delivered the virtual control of private midwifery practice to doctors, in the form of a piece of legislation called the Collaboration Determination.

The words (mainly) of the PM herself ring true:

"it is time for all health care professionals involved in delivering [maternity] care to mount a combined attack on the [Gillard] Government to force them into action to address this situation." 

This month, APMA has conducted a brief review of private midwifery services, asking midwives and maternity consumers to tell us what's on offer where they live.

Here are the current trends:

• Areas with access to private midwifery services are mainly the [more densely populated] capital cities and a few regional centres, as demonstrated on the map. 
• Established midwifery practices that have taken up Medicare rebate options since November 2010 continue to provide homebirth services. 
• Homebirth, which has been predominantly the domain of private midwifery practice in Australia for many years, is increasingly being made available through publicly funded hospital-based programs. 
• Established midwifery practices that have continued without Medicare rebates are providing homebirth and other private services in their communities. 
• The emergence of new private midwifery practices with Medicare includes some providing midwifery care across the prenatal and postnatal periods, with hospital births, while others a focus on postnatal services. 
• Progress towards hospital visiting access for private midwives has been noted in Toowoomba (Qld) and Sydney (NSW). 
• Unregulated birth attendants are reported to be available to provide homebirth services in some areas. 

In many areas, women are still "scrambling to find the birthing centre of their choice, and in some cases scrambling to find any professional who will deliver their child." 

The new rules present midwives and the women who employ us with unnecessary obstacles when attempting to comply with legislated requirements for collaboration.  There is no public interest in these new rules.  The health and wellbeing of women and their babies is not improved by the hurdles they are now required to jump.  Some women are choosing to forgo the Medicare rebate than have to go to an unsympathetic doctor, cap in hand, requesting a referral to their chosen midwife.

It's time for women and midwives to take Julia's own advice, and  "mount a combined attack on the Gillard Government to force them to address this situation."

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.