Sunday, December 26, 2010

A NEW ERA IN THE USE OF DRUGS IN OBSTETRICS - Primal Health Research Newsletter Vol 18. No 2

PRIMAL HEALTH RESEARCH


A NEW ERA IN HEALTH RESEARCH

Published quarterly by Primal Health Research Centre

Charity No.328090

72, Savernake Road, London NW3 2JR

michelodent@googlemail.com

Winter 2010 Vol 18. No2

**************************

www.primalhealthresearch.com

(Free access to the Primal Health Research Data Bank)

Click on

www.wombecology.com

(The route to early birds REGISTRATION for the Midpacific Conference on Birth and Primal Health Research. Honolulu October 2012))

Michel Odent will be on tour in Australia in May, speaking at the CAPERS Passage to Motherhood Conference in Brisbane, and at Workshops in Melbourne, Sydney, Perth, as well as Christchurch and Auckland (NZ) on other dates.  Click on the website for details, and to register.


A NEW ERA IN THE USE OF DRUGS IN OBSTETRICS

Tuesday, December 21, 2010

The “right to respect for private life” in Europe

The following article is copied from the Hungarian Civil Libities Union site.

Victory in Strasbourg for the cause of home birth!
December 14, 2010 17:03

Today, the European Court of Human Rights in Strasbourg handed down a judgment in which it holds that the Hungarian state has violated the “right to respect for private life” guaranteed by the European Convention on Human Rights.

Saturday, December 18, 2010

Survey on prescribing courses for midwives

If you are a midwife practising privately in Australia, or if you intend to practise midwifery privately, please go to the APMA blog, read the message, and follow the links to the survey.

Saturday, December 4, 2010

How can I plan vbac?

The following letter (copied with permission) has been received from a woman who would dearly love to give birth spontaneously to her child next July.

I am 'just' pregnant, about 8 weeks. I had an 'emergency' caesarean with my first child after going with midwife led care through at XX Hospital.


I had a really hard time coming to terms with having has a caesarean and now seem to have anxiety when going in to the hospital.


We are a 1 income family and on a health care card, so although I would love to have a homebirth it is not going to be possible. I have contacted [a MIPP] and was hoping I could get medicare covered antenatal care and possible birth support in hospital, but after reading from your blog and midwives Victoria website this looks like it also won't be possible.


I am typing to you with tears in my eyes because I am unable to have the birth I want because I don't have enough money. Is there anything I can do?


I wrote many letters to the government during the health services review and am just so angry that we are not treated normally, respectfully and responsibly. Someone else's decision for me to have a caesarean means my choices are so limited now and that frightens me.

Thursday, November 25, 2010

visiting access to public hospitals?

Midwives who are members of MiPP have been writing letters to the directors of their local public hospitals, enquiring about implementation of the government's reforms that will enable midwives to attend women privately in hospitals.

Tuesday, November 23, 2010

Midwives with Medicare provider numbers

If you have been following this and linked blogs you will know that the government's provisions for eligible/authorised midwives to have Medicare provider numbers, enabling their clients to claim some rebate on fees for private midwifery services, are now operational.

At the time of writing, we know of two midwives - one in Qld and one in NSW - who have successfully negotiated the legislated requirements for notation as eligible midwives, and are offering Medicare rebates in this way for prenatal and postnatal items. [For details of the rebates payable on midwifery services, go to Federal Register of Legislative Instruments F2010L02640]

We are not aware of any midwife practising privately with Medicare rebates for intrapartum (labour and birth) care in a hospital. The state and territory government health departments are "working on" arrangements for midwives to be awarded visiting access to admit private clients to public hospitals. The other possibility, that a private obstetrician employs an eligible midwife, thereby enabling the midwife to access Medicare, providing services for private midwifery care, presumably in a private hospital, is another pathway that seems theoretically possible. MidwivesVictoria will keep readers informed as information is received.

If you are a 'consumer' of midwifery services - a woman who is pregnant or who is planning to have a baby in the near future - you may be wondering if there is a midwife near you, who is able to offer Medicare rebates on her fees. The names and locations of eligible/authorised midwives will not be posted on this blog, but inquiries will be forwarded to email lists so that any midwives practising privately in the area are able to respond. If you do not want to use the comments function on this blog, please send an email to mipps@maternitycoalition.org.au

4 December 2010
ps: Liz Wilkes from Toowoomba (Qld) has attended the country's first Medicare-Midwife birth. For details follow the link at the APMA blog.

Sunday, November 14, 2010

What the women said ... 3

... in their submissions to the Maternity Services Review.

Today's theme is homebirth. Access to homebirth midwifery services, funding for homebirth, acceptance of homebirth, evidence supporting homebirth ... themes that were a repeated refrain in many submissions.

"Women have been the big losers in maternity care for many years. The promise of a maternity review at the 2007 election to put women first has been a farce. The 900 submissions were more than the whole of the Health and Hospital Reform consultation process. Over 400 of these called for access to homebirth, yet the report of the maternity service review and subsequent budget excluded homebirth."
[Justine Caines, Daily Telegraph]

Theme 3: Homebirth

3.1 "resentful and disempowered" in private hospital [028]
I gave birth to my daughter in a private hospital, and despite having a completely natural and postive birth, I felt resentful and disempowered with the pregnancy and postnatal "care" I received from the obstetrician and hospital system, including the labour and birth and hospital stay.
I have since given birth to my son at home, and had the most wonderful care throughout the whole pregnancy, birth and postnatal period from my midwife, whom I will be engaging next time round when we have our next baby.

3.2 Trust [032]
We homebirthed our three children with the assistance of beautiful, confident midwifes. They guided and assisted us through the physical and emotional relationships with our new baby and ourselves. The core of this is TRUST in myself to birth in a strong, empowering way, in my partner to support me in this process and in our midwife.


3.3 Cost of homebirth [048]
We have a 15 month old boy who was born at home by our choice (based on a lot of research which proved that home-births had better outcomes for mother and baby). It was a truly amazing experience for us and we feel by doing this we also helped reduce the strain on local hospitals, who at the time had a women give birth in the waiting room due to the lack of availability of delivery rooms (due to a baby
boom).
...
We would love to have another child, maybe even another couple of children, however due to the cost, we don't know if this will be an option for us (we are young parents struggling to meet loan repayments for our house). ... A homebirth costs around $3500-4500 in rural regions, more in cities. ... Seems a little unfair given that those that birth at home are actually doing the government a favour by reducing the burden on hospitals. It seems very likely that we won't be having a baby for the country!!

It would be ideal if medicare could cover some of the costs of homebirths to make this option more affordable (especially for those that can't afford private health insurance). I believe if more people knew about the advantages of birthing at home and it was a lower cost option than hospital, a much larger percentage of the population would be birthing at home (we are your typical young married couple,
homebirth is not just for "hippies"). And thereby reducing the burden on hospitals. For the poorer amongst us that have babies, they birth in public hospitals, this is the only option, they cannot birth at home because HOMEBIRTH IS UNAFFORDABLE!!.

3.4 Confident with home birth [106]
I am sharing with you my personal views and experiences in hope of contributing to the much needed changes surrounging maternity issues.
I started my family quite young. I have a 20 month old and twins due in 4 weeks and I have just had my 23rd birthday. For all my children I have planned homebirths, my first being so successful I feel confident to birth my twins at home.

3.5 HBA2C Birth at home after two Caesareans [814]
On consultation with the local and only practising obstetrician (for what is considered within the current health system a high risk pregnancy, by virtue of previous caesarean) we were unhelpfully informed that the mother in question had "..a morbid desire to achieve a natural birth at any cost" and that "..two caesarean sections in the uterus constitute a potentially lethal medical condition for herself and her unborn baby. She has placed herself and her unborn baby in danger once before and she is attempting to do this again. In the circumstances she should at least have psychological counselling and assessment." We were threatened with a notification to Department of Community Services as it was insinuated that our desire to birth without unnecessary intervention was a form of reckless endangerment of the unborn child.

Our baby's birth was conducted without tying up limited resources in our hospital system, the same system that did not allow a trial of the birth by natural methods, utilising the safeguard of emergency services should they be required without transfer. The birth proceeded without the use of drugs, and did not involve significant abdominal surgery as was proposed as our only option in the health care system. Further, the mother was in her own environment during recovery, leading to the minimum of disruption for the family unit. Our independent midwife has continued postnatal care over the past week, visiting 3 times within the week to check mother & baby's health and progress post birth.

3.6 8 children born at home [810]
We are in our 40s and we have birthed all of our 8 children at home in the care of an independent midwife.

Wednesday, November 10, 2010

What the women said ... (2)

... in their submissions to the Maternity Services Review.


Today's theme is, for want of a better word, 'rural'. This means distance, relative isolation, lack of access to services, and much more. Here are some direct quotes. Women's descriptions of their own feelings have been highlighted. The number noted in square brackets [n] denotes the reference number for the submission.

Theme 2: Giving birth in Rural Australia
2.1 Excluded from local hospital 'low risk' maternity service [030]
I write this to you as a mother of four children who had to travel 80 kilometres just to give birth to them.

When my husband and I found out that we were expecting our first child, due to be born in early 2001, we were hoping that we would be able to birth him in our brand new local hospital, which was completed in the previous year. It was a state-of-the-art facility, complete with Maternity ward and we were excited to think that our child could be born there. Although we knew that in the “old” hospital that the Maternity unit had been downgraded to only accept those women considered “low risk” – women who had no previous complications during birth and those who were multiparas (women on subsequent pregnancies), we hoped that with this new hospital it would bring a new opportunity for those women previously excluded to be able to birth there.

But we were to find out that the status quo would continue at the new hospital. This meant that I was excluded from our local hospital and that I would now have to travel a 160 kilometre round trip to the next town to see a Doctor I had never met before, in a town I didn’t frequent and give birth in a hospital far away from family. There was the vague hope that after I gave birth I would be able to travel back to my local hospital for my post-partum hospital stay, but within 6 months of my falling pregnant, even this option was taken away from me.

And even then there was no guarantee that I would give birth in this hospital. It was only a small District Hospital and could only take women after 38 weeks of gestation, women with singleton pregnancies, women with no health complications for themselves or their babies. If you were in any way considered to be “high risk” then you were forced to travel to the NEXT hospital, which was a further 80 kilometres away.

The situation has only become more dire as the years have gone on. Not one single pregnant woman I talk to doesn’t have concerns that she will not make it to the hospital in time and fears either giving birth at home unattended or by the roadside. This raises another, separate issue, in that the husbands and partners of these labouring women are under even more pressure to get them to the hospital “on time”.

It makes me wonder if women and their babies will have to start dying before anything is ever done about this situation.

2.2 What models are needed for maternity services for rural and remote communities? [279]
All women wherever they live throughout Australia, want the option of giving birth to their babies in their own communities in a shared experience with their families, even if this does not eventuate, but most importantly they want to be sure that the experience will be safe, both for themselves and for their baby.

Women in rural and remote areas are no different from their city sisters in having the same wishes, but rarely are these wishes realised. If their preferred option is not available locally they have to travel away from home, sometimes long distances to metropolitan centres, where they are dislocated from their support structures. They often have significant financial outlays for travel and accommodation. However, like most people who live in rural, regional and remote areas, they are pragmatic, and accept that they need to make some compromises for living in small communities. Nevertheless they have a right to access more options than currently exist for them.

The most pressing needs faced by families in rural and remote areas are to have
• A range of service options that are Geographically accessible
• Assistance with travel to access services only available at a distance.
• Special consideration for women with complex needs.

2.3 Midwife in local community, and suitable accommodation for families [272]
I live in a very small rural community on Eyre Peninsula, South Australia. Our home is a two and a half hour drive from the Port Lincoln Hospital, where my two children were born.
In particular we feel that the services provided by the Community Midwife were exceptional. It was a joy to have this naturally caring and very experienced lady visit our home during pregnancy and in the early weeks of our babies’ lives. She was always ready to listen and offer practical advice to help us through various issues, either in person or over the phone. By completing a range of tests at home, we were spared long and expensive trips to see the doctor. The Community Midwife is an essential service for small, remote areas such as ours.

The biggest concern I have had is lack of suitable accommodation for pregnant women from surrounding regions in Port Lincoln. Two weeks before my second baby was due I had to stay at my sister’s in-laws nearer to Port Lincoln. Other local women’s experiences have included staying for several weeks at a caravan park, and having to clean a rental house immediately after leaving hospital. We need a better solution.
I feel very strongly that women from the areas surrounding Port Lincoln need access to a special house in Port Lincoln where they can stay with their partner and family in the final week or two of pregnancy. Partners and older children also need somewhere to stay while mum stays in hospital. Mothers may even be able to leave hospital earlier and stay in the house with a midwife’s support. A special ‘Rural Maternity House’ would take away many concerns that long distance mothers have. It would make pregnancy and labour safer and more positive for all.

Sunday, November 7, 2010

What the women said ...

... in their submissions to the Maternity Services Review

The website at which the submissions are posted has a statement:
We have received many personal accounts from individuals. These provide a valuable insight into people's experience of maternity care in Australia and were considered by the Review Team in preparing the Review Report for the Minister.

Today I have taken the opportunity to look at just a few of those personal accounts from individuals, and separated out into themes (not in any particular order). Today's theme is Caesarean births and VBAC. Here are some direct quotes.  Women's descriptions of their own feelings have been highlighted.  The number noted in square brackets [n] denotes the reference number for the submission.

Theme 1: Caesarean births and VBAC

1.1 Cascade of interventions in primiparous woman at a birth centre [515]

For my first child, I was 25 and healthy, considered “low-risk”. I booked into the local Birth Centre at the public hospital (it sounds easy but in reality I was put on a ballot, missed out, then made it in when some poor unfortunate woman was shunted out for whatever reason). I attended antenatal appointments with the same midwife, who I thought was on the same page as me regarding birth. I wanted a drug free, intervention free birth. I was well-informed and well-educated.

However during labour my midwife told me she had to perform several interventions which I had been led to believe weren’t routine in the Birth Centre. These included vaginal exams (VEs), the premature rupturing of my waters, and coached pushing (when I was actually not fully dilated and not wanting to push yet as it didn’t feel right).

It is hard to stand up for yourself during labour, so I did not protest any of these interventions, yet they caused, in a cascade of interventions, my cervix to swell and my progress went backwards. My midwife said I needed an epidural and syntocinon to speed things up, even though that was the last thing I wanted, but quite disheartened I agreed. After getting me set up she then left to go home, which I saw as abandonment. My continuity of care ended there. After a few hours I was at the same point, having apparently progressed no further, and the obstetrician suggested a caesarean. Quite defeated and wanting the whole sorry ordeal over I consented to a caesarean that would have been completely unnecessary had my midwife kept her hands to herself.

1.2 Caesarean followed by a feeling of disconnectedness and a profound sense of grief [538]
I had my first baby by emergency caesarean section in a public hospital after a planned home birth. My main care provider for this pregnancy was a community midwife with the Community Midwifery Program here in Perth. During the pregnancy I felt supported by my midwife in any decisions I made about my pregnancy and birth options (Routine ultrasound, strep B testing, water birth etc), and despite the resulting caesarean section, I felt the continuity of care was extremely valuable in making my pregnancy an exciting event for my family, as were able to create a caring and professional relationship with my midwife, leading to feeling secure as my birth approached.

During the birth I experienced great care at home from my primary and back up midwife, however once we transferred to hospital, their role as my primary care providers was not recognized by the hospital, and subsequently I lost faith in my body’s ability to birth as I received fragmented care from a number of different midwives and at least 3 different obstetricians, all of whom I had never met, and who did not take the time to discuss the progress of my labour with me. My resultant Caesarean section was a traumatic experience, and I was not able to hold my son immediately, leading to a feeling of ‘disconnectedness’ from him which sadly lasted well into his first year.

After the birth I experienced symptoms similar to those which I now believe similar to Post Traumatic Stress Disorder, with an inability to sleep, flashbacks of the anesthesia and caesarean procedure itself, and a profound sense of grief that my experience of meeting my first born child had not been the joyous occasion I had hoped it would be.


1.3 VBA2C [404]
Our first baby was born in private hospital by emergency caesarean after a failed induction. My husband and I were left to ourselves in the delivery room for long periods. When we did see someone they were total strangers, people we had never before met, who came and went as shifts changed. Minimal help with breastfeeding was provided until 4 days later I had a wonderful agency nurse who spent an hour in the middle of the night giving me the support I so desperately needed. The whole experience was very frightening and traumatic. I was subsequently diagnosed with postnatal depression.

During my second and third pregnancies we paid for our own private midwife who was with me during the pregnancy, labour and post birth. Although our second child was also born by emergency caesarean, I had the continuity of care that made all the difference to the experience. She was with me throughout labour, then in theatre, and afterwards she helped me in recovery where she enabled my baby to stay with me and ensured I received all the help I needed with establishing breastfeeding.

Finally, with the support of my own midwife I was able to birth our third child vaginally, without intervention and will never forget the hormonal high and feelings of self respect, dignity and peace that contrasted so starkly with the terror, grief and despair I felt when my first child was born.

1.4 Emergency Caesarean followed by VBAC [516]
I had my first baby in a public hospital. He was born by emergency caesarean because he was brow presentation. ... I had assumed that my care at the hospital would be in keeping with basic tenets of human rights- that I would be treated with dignity and respect during birth. This was not my experience.

During the 13 hours of labour prior to the emergency caesarean I experienced a shift change of midwives and felt that the second midwife wasn’t confident to guide me. I felt that she gave up on me. I remember her telling me that she had recently had a caesarean and that it wasn’t that bad. I had painful internal examinations during contractions. The bright lights and the public nature of the environment made me feel violated. This fragmented care with people moving in and out of the birthing room upset the flow of events.

Once the wave of interventions had begun I felt there was no any other option in that environment than to do what I was told and to be a ‘good girl’. Several professionals told me that I would be risking my baby to try anything different. I was frightened, I felt coerced and patronised by the midwives and the obstetrician. I demanded that I try every other monitoring option prior to the surgery which was my most feared scenario. As a way of trying to reclaim some sense my own power in the birthing process I wanted to have my baby remain with me and I wanted somebody to stay with me in recovery. I was denied both of these. Post surgery I lay on a bed for an hour shivering alone, without my baby. I felt exposed and ashamed. This deeply impacted my confidence and the crucial bonding with my baby and set the conditions for what I now recognise as Post Traumatic Stress after the birth. I believe this was caused by a combination of factors namely a restrictive birth environment. I suffered a deep sense of failure and grief which has only been resolved with my second birth.

I approached the second birth very differently and chose a homebirth. My partner was also very enthusiastic that we try this after the previous hospital experience. In spite of the fear mongering about VBAC and the dangers of uterine rupture my second baby boy was born peacefully at home in the water. My main care provider was a midwife in private practice. During the pregnancy I experienced great support to make my own choices. During the birth I had no internal examinations. There was no sense of time constraints during the nine hour labour. It was on my own terms and I felt comfortable and safe in my home environment. I felt that my midwife trusted in my innate ability to birth and believe this had a very powerful effect on the birthing outcome.

After the birth I felt great satisfaction and reclamation of my own dignity. I believe this was due to the wonderful support provided by my carer and the continuity of care I experienced.

These four accounts speak eloquently for themselves.
Recommendations of the Report of the Maternity Services Review (The Report) include:
"2. That the Australian Government, in consultation with states and territories and
key stakeholders, initiate targeted research aimed at improving the quality and
safety of maternity services in select key priority areas, such as evidence around
interventions, particularly caesarean sections, and maternal experience and
outcomes, including from postnatal care."
The Report trivialised homebirth and stated that "Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28" The Report ignored the many submissions by women who called for greater access to home birth and private midwifery services.

Comments from readers are welcome.

Saturday, October 30, 2010

Singing group in Northcote for pregnant women



Ten Moons is a singing group for pregnant women. It provides a creative and safe space for women to come together and sing music that is all about feeling good. Experience some of the incredible health benefits that singing can offer during pregnancy and meet with other women in the community over song and a cup of tea.

For more information contact Gabby 0425 774 543 or email tenmoonsong@gmail.com

Friday, October 22, 2010

Medicare funding from 1 November 2010 ?

Some midwives and maternity consumers are waiting eagerly for the ability to claim Medicare payments for private midwifery services. A previous post gave the link to the Medicare fee schedule, and discussion on the required signed collaborative arrangement with one or more doctors that must be in place for a midwife to apply for a Medicare provider number.

To search for the legislative instruments go to the Commonwealth Government site.

This is a brief status update. With only a week until 1 November, we are wondering how it's progressing.

It appears that Medicare is ready to give midwives provider numbers and to rebate midwives' fees, AHPRA is not. It appears that AHPRA does not yet have a process up and running to proceed with applications for notation as an eligible midwife.

The optimists among us suppose that women will be able to back-claim from November 1 for Medicare. We will be interested to see what happens there.

We have been advised not to use the application form for notation as an eligible midwife on the AHPRA website as it needs to be amended – does not fit the criteria for eligibility. Will be re-loaded in a few weeks …


Remember the signed collaborative arrangement between an eligible midwife and one or more doctors, which is a mandated part of the provision of Medicare for midwifery services. Many midwives believe this law (Determination) denies the midwife's right to practise on her own authority, and potentially allows a doctor to veto the professional agreement between a midwife and a woman in her care. See the Australian Private Midwives Association (APMA) statement on the Collaborative Agreement.

Much more could be written, but it's Friday afternoon and my mind is tired. I hope this update is of use to some of our readers.


Midwives wishing to apply for a Medicare Provider Number can access information and forms at the Medicare website.

Tuesday, October 19, 2010

Letters to public hospitals

Members of Midwives in Private Practice (MiPP) are sending letters on behalf of MiPP to public hospitals with maternity services, requesting a process that will enable midwives to achieve visiting access to provide private midwifery services for our clients in the hospital.

This is the pro-forma of the letter:

Director of Maternity Services
XXX Hospital

Dear XX
I am writing with reference to the recent health practitioner registration reforms, particularly in relation to eligible midwives being insured for the full scope of midwifery services including attending birth in hospital. The changes include the availability of government supported professional indemnity insurance for midwives, and being able to access Medicare provider numbers and limited prescribing and ordering of tests.

We understand that the reforms that impact on primary maternity services are intended to be consistent with the key principles developed by Australian Health Ministers Advisory Council (AHMAC 2008) “Primary Maternity Services in Australia – A Framework for Implementation. (Attachment 1). Midwives in private practice support each of these key principles, and look forward to being able to provide quality primary care for women who plan to give birth in hospital.

Members of Midwives in Private Practice (MiPP) and Australian Private Midwives Association are contacting all public hospitals to request details of how eligible midwives may proceed to apply for visiting access/clinical privileges. Would you please inform me of how your hospital is proceeding with implementation of the relevant changes, and the process for application and implementation of visiting access for midwives who are not employed by the hospital.

Yours sincerely


XXXX
On behalf of MiPP

ATTACHMENT 1

KEY PRINCIPLES
“Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” articulated the following principles which underpin the range of models of maternity care available to women in Australia. These principles involve:
• ensuring services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience

• ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman

• maximising the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals such as paediatricians and Aboriginal health workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery

• offering continuity of care, and wherever possible continuity of carer, as a key element of quality care

• ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence ¬based best practice care

• ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework

• providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required

• working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.

Thursday, October 14, 2010

AIMS for a better birth

AIMS is the Association for Improvements in the Maternity Services.
AIMS has been at the forefront of the childbirth movement for more than forty years.

* Working towards normal birth
* Providing independent support and information about maternity choices
* Raising awareness of current research on childbirth and related issues

Although AIMS is based in the UK, many of the challenges in maternity services are the same in Australia, and globally.


excerpts from AIMS Informed Consent
An analysis of enquiries to the AIMS Helpline reveals that almost without exception women who intend to birth at home are given a long list of the ‘risks’ the staff perceive them to be taking. We have yet to hear from any woman who was also given a list of the risks of a hospital birth, so we have produced our own and suggest that this should be handed out to all women who intend delivering in hospital.

INFORMED CONSENT FOR GIVING BIRTH IN HOSPITAL

This Trust supports the view that women have choice and in order properly to exercise that choice they need to be fully informed of the risks in association with childbirth.
The following are the risks of a hospital delivery:

This hospital operates a shift system which means it is unlikely that you will be attended by the same midwife throughout your labour.

Because [the hospital is] short of staff you are unlikely to have the continuous support of a midwife as she will probably be trying to attend to at least two other women.

As this hospital has a 25% [to 30%] caesarean operation rate this means that you have at least a 1 in 4 chance of having a caesarean. Please be aware that this is major abdominal surgery that:
  • doubles the risks of maternal mortality,
  • increases the risk of damage to other internal organs and blood vessels,
  • carries a risk of infection, which may prolong a hospital stay,
  • interferes with the establishment of breastfeeding and
  • delays post operative recovery.

Research has also shown that this type of surgery:
  • produces harmful side effects according to which anaesthetic is used,
  • lowers fertility rates in women,
  • may increase the incidents of post natal depression,
  • adversely affects the baby because of the anaesthetic used,
  • can accidentally cut the baby as the incision is made,
  • produces babies who are less likely to breastfeed,
  • results in babies with breathing difficulties because they haven't received the benefits of being squeezed through the vaginal canal,
  • increases the risk of miscarriage in future pregnancies,
  • produces a greater risk of childhood asthma and
  • results in a greater risk of Sudden Infant Death Syndrome.

As the World Health Organisation has stated that there is no improvement to maternal or infant health when the caesarean operation rates exceeds 10% you should
understand that we are tr ying to reduce our caesarean rate.

...

You should understand that in this hospital, which is a high technology obstetric unit, only 1 in 6 women expecting their first baby and only 1 in 3 women expecting their subsequent babies will have a normal, straightforward, birth.

This hospital applies a time limit on the second stage of labour, this is not applied for your benefit it is imposed in order to ensure that you deliver as quickly as possible so that we can use your bed for another woman.

At this hospital the midwives will cut the cord as soon as the baby is delivered, this has adverse effects on the baby, but you need not worry we have resuscitation equipment at hand to help the baby breathe.

At this hospital the majority of women will give birth on their backs, despite the research indicating how this position increases the difficulty in pushing the baby out and causes trauma to both mother and baby.

This hospital prefers women to be quiet when they are in labour ... Therefore, in order to maintain a more subdued atmosphere, you will regularly be offered a range of opiate-based drugs ... Please be aware that this can lead to an increased chance of your child becoming a drug addict in later life and if administered at the wrong time during labour, will result in your baby being born in a dangerously stupefied state.

Do not worry, as the medical staff will inject the baby with an antidote as soon as it is born.

...

Source: AIMS JOURNAL VOL:19 NO:4 2007

Saturday, October 9, 2010

Medicare funding from 1 November 2010

The Health Insurance (Midwife and Nurse Practitioner) Determination 2010 has been released. To search for the legislative instruments click here.

We will keep our readers informed as soon as we hear of any progress by midwives in incorporating Medicare into their private practices.

There are widely different opinions held as to what the Medicare-Midwife will look like, what she will be required to do. Here is a section from the piece of regulation, the National Health (Collaborative arrangements for midwives) Determination 2010
...
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.

(2) For subsection (1), the arrangement must provide for:
(a) consultation between the midwife and an obstetric specified medical practitioner; and
(b) referral of a patient to a specified medical practitioner; and
(c) transfer of a patient’s care to an obstetric specified medical practitioner.

...

This is legislative language that confuses many.

The Medicare-Midwife (medi-wife) will:

* have a close working relationship with a group of obstetricians (no doctors work 24/7 these days)
* provide prenatal checks in the community, possibly in 'rooms' shared with obstetricians or other doctors (it has been suggested that a new GP Superclinic could include medi-wives)
* attend births in private hospitals where she has visiting access, and where the 'senior' member of the professional team is always the obstetrician
* be able to order basic tests and prescribe basic drugs, such as oxytocics
* provide postnatal services for mothers and babies in hospital, and possibly at home.

It is not yet clear whether public hospitals, which currently provide obstetric backup for the clients of privately practising midwives who plan homebirth, will accept the new medi-wife as a practitioner with visiting access.

Midwives are at present contacting public hospitals and requesting details of the hospitals' processes and time lines in preparation for enabling midwives to practise in the hospitals with visiting access.

Tuesday, October 5, 2010

PRINCIPLES underpinning maternity reform

Key Principles

“Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” articulated the following principles which underpin the range of models of maternity care available to women in Australia.  These principles involve:
  • ensuring services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience
  • ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman
  • maximising the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals such as paediatricians and Aboriginal health workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery
  • offering continuity of care, and wherever possible continuity of carer, as a key element of quality care
  • ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence ­based best practice care
  • ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework
  • providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required
  • working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.
[This document is Attachment 1 to the draft Safety and Qualitiy Framework for private midwifery, a document which is currently being adopted by the Nursing and Midwifery Board of Australia]

Thursday, September 30, 2010

Dissenting voices from ACMQ

This message has been distributed widely, and is posted here with permission of Dr Jenny Gamble, representing the Queensland Branch of the Australian College of Midwives.

E Bulletin from ACMQ Executive Regarding the Medicare Determination:

The distribution last Wednesday of an e bulletin from the ACM national office concerning the Medicare determination has caused considerable confusion amongst members in Queensland and we believe does not present all of the options available to us.

ACMQ Executive acknowledges that the ACM National President and Board members are working hard on this issue and making some difficult decisions representing the colleges view at a national level. This E bulletin to members is in no way meant to be divisive or to detract from the work undertaken at national level. However, ACM national has concentrated on one option in the e-bulletin and we seek to provide an alternative for consideration by members.

In agreement with ACM national ACMQ Executive unreservedly supports Medicare for midwives, but the determination needs to be changed.

ACM Queensland Executive continues to have a bottom line position that we will not accept a “collaborative arrangement” with a medical practitioner that requires a signed agreement or provides an opportunity for a doctor to veto a midwives ability to access Medicare funding.

ACMQ Executive does not endorse the ‘keep silent, don’t rock the boat it’s too high risk’ position proposed by ACM national. .
ACMQ does not promote putting Medicare at risk.

...
ACMQ Executive believes that by using fear-based tactics the minister’s advisors have created panic that Medicare will not start and thereby hope to prevent midwives lobbying to change the determination. It is the opinion of the ACMQ Executive that pressure from the government on ACM National to cease lobbying to alter the medical veto over midwifery practice is a deliberate strategy to stop pressure to change the wording of the determination.

The Minister has the ability to change the determination any time. She clearly does not want to do so (and is possibly under pressure not to do so by the medical lobby) and will not do so unless midwives lobby.
...
ACMQ Executive offers the alternative position that we do not change our lobbying strategy. Members continue to ask for the wording in the determination to be altered. We recognise that in the immediate term it is unlikely that this will cause the Minister to change the wording. However early next year, with more evidence, it may become more obvious that there is a real difficulty in the currently worded determination.

ACMQ Executive is of the opinion that the strongest strategy is to indicate that we do not accept the current wording allowing a medical veto and that we stick together on this.

...
ACMQ Executive believes continuing to lobby to change the determination before a motion to disallow can even be introduced, let alone voted on, does not carry the level of risk outlined by the ACM national e-bulletin.

Timeline for the Determination:
• Determination was signed off by Governor General on 16 July which means that the Medicare for Midwives legislation is ready to commence on 1 November.
• Parliamentary process requires that because the determination is only signed off by Governor General, it is tabled in parliament in first six sitting days of the new parliament (28, 29, 30 Sept 2010, 26, 27, 28 October 2010).
• On the day it is tabled a new timeline commences in which a motion to disallow can be introduced within 15 sitting days. Therefore, if the determination is tabled on 28 Sept (the first day of the new parliament) the last possible day on which a motion to disallow can be introduced is the first sitting day of 2011 which is late Feb or early March. There is nothing ACM can do to alter these timeline as it is a fixed parliamentary process.
• On 1 November Medicare for midwives will commence.
...

ACMQ Executive maintains the line that the determination is unacceptable, that we continue to lobby that it is unacceptable and that we demand a meeting with the Minister (not only her advisors).
...
All midwives who experience difficulty accessing Medicare due to an inability to obtain a signed medical agreement have the opportunity to keep the pressure on by notifying ACM national, ACMQ and the Minister’s office of the practical difficulties created by the determination.

If it turns out that the determination is working well and women have no difficulty accessing Medicare funded midwifery care this will soon become apparent. If this is the situation then any motion to disallow can be withdrawn as stated earlier.

ACMQ’s position involves lobbying to change the determination and buying time to see if the determination will or won’t work.

ACMQ Executive holds the view that a frank and fulsome communication between all members is required to ensure that a representative view can be tabled if the situation occurs that the determination will be voted on in the Senate/House of Representatives.

Before sending this communication we have considered all aspects of this complicated situation in detail. Thank you for considering this alternative option, it is now completely up to you as a member to decide if you would like to write to/contact your MP, the Minister, Jenny Gamble as our National Delegate and ACM National to lobby for the wording of the determination to be changed.

ACMQ Executive will continue to apply pressure and lobby to get the determination changed.


This e-bulletin is supported unanimously by the ACMQ Executive:
Hazel Brittain - President
Jodi Bunn – Executive Member
Jenny Gamble – National Delegate
Richard Hayes - Treasurer
Bec Jenkinson - Consumer
Marie McAuliffe – Executive Member
Mandy Ostrenski – Executive Member
Sue Rath – Executive Member
Mary Sidebotham – Vice President
Barb Soong – Executive Member
Teresa Walsh - Secretary
Kellie Wilton - Student

ACM President on the Determination

The following response has been received today, 30 September 2010, from Hannah Dahlen, President of the Australian College of Midwives. It is in response to an email from me, expressing my disagreement with the position taken by the ACM in accepting the Determination (see previous posts).
I consider it essential that our College should ensure that midwives are able to continue to practise midwifery on our own authority.
Hannah has asked me to post her comments at this blog. The message I received from Hannah is posted here without any change.
Joy Johnston


I agree this Determination is far from perfect and we have fought it in every way possible to have it changed. In New Zealand it took them 17 years to get a National Access Agreement and they had many little steps along the way to achieve the final outcome. We have received some concessions now from the Minister that take us away from sign off by an individual doctor and these include being able to have clinical privileging with a hospital (the old visiting rights) and this will be considered a collaborative agreement.
The National Maternity Plan, which is the most midwife friendly plan I have ever seen, contains an evaluative framework for the uptake of the Eligible midwife along with commitment to State and Territory clinical privileging, which as I said could in itself form a collaborative arrangement. This means we can keep a very close eye on where it is working and where it is not. The Minister has promised to us (ACM) and the ANF that she would change the Determination if is not working but this would not happen in the first months of roll out which is why the idea of disallowing and dragging out the debate until next year won¹t work. If it does drag on until next year Midwives could have started accessing Medicare and have women booked and it could all fall over and where would these women and midwives be left stranded. The Minister has made it clear that she will not change or put up a new Determination if it is disallowed. There are many midwives in the College that have fought for access to Medicare for twenty years now and the College cannot let this be lost at the last moment.


This not a good piece of legislation by any stretch of the imagination but you rarely get everything you want the first time in reform. I believe there are enough ways we can make this work and then hold the government to account for changes when it does not. The AMA have also been told the same thing by the Minister very clearly and I quote ³If we do not embrace these changes then pressure will mount on the Government to relax the requirement for collaborative arrangements to be in place² (Andrew Pesce).


We have sought legal advice over the best way to approach this as we desperately want the best for women and midwives and have clear advice that ³disallowance is not the appropriate means by which to seek amendments of the Determination² and it is highly risky with current volatile coalition who are willing to say NO to everything not because they care about midwifery but just want to say NO.


It is important to note that the Determination does not affect all midwives only those who choose to become eligible midwives and want to access Medicare. It is also important to note that the Determination has been removed from the Quality and Safety Framework after much protesting on ACM¹s part. It is also important to note that even the MIGA policy has a care plan option that gets around the collaborative arrangement with a doctor. There is nothing in VERO if that is the choice midwives make.


Just to remind people that we have made many changes and gains along the way in this reform process. We began with the Eligible midwife needing five years experience, a Masters degree and to be a Midwife Practitioner.
Homebirth was nearly going to be made illegal last year. We have got removed from the Insurance Bill the requirement for a collaborative arrangement with a named practitioner. We have had the Determination removed from the Safety and Quality Framework. These are big gains and yes we haven¹t got what we wanted from the Determination.


I think often with reform we need to take a foot in the door approach and then wedge that door open and get through with all the changes that need to be made. ACM has not given up on this and have sent a letter to the Minister for Health yesterday once again asking for named practitioner to be removed and acknowledgment to be removed. We will I promise not give up. There seem to be all sorts of rumours flying including a crazy one about the ACM doing a deal with the AMA. Can I assure you all this has not occurred and will not occur and we remain as committed to women and midwives as ever.


With respect and good wishes
Hannah Dahlen
President ACM

Tuesday, September 28, 2010

Australian Medical Association on Collaborative Arrangements

AMA has published a document 'Collaborative Arrangements: What you need to know' in preparation for the inclusion of eligible midwives and nurse practitioners in Medicare funding from 1 November 2010.


MIDWIVES PLEASE NOTE
All midwives who experience difficulty obtaining a signed collaborative agreement with a medical practitioner, in an effort to comply with the Determination, are asked to notify private midwives' groups (APMA, MiPP), the midwives' professional body (ACM) and consumer and midwife lobby groups such as Maternity Coalition. Copies of your letters, and the responses you receive (or lack of response) will be used as evidence in reviewing the implementation of maternity reform.

Thursday, September 23, 2010

Why midwives can not accept the Determination

Readers of this blog will know that a piece of legislation, The National Health (Collaborative Arrangements for Midwives) Determination 2010 (the Determination), which has been discussed previously, was introduced by the Health Minister just prior to announcing the election.

Midwives who are members of the national professional body, the Australian College of Midwives (ACM) should have received an URGENT e-bulletin from ACM, which states:
"On the balance of information that we have to date, we feel that lobbying to disallow the Determination is placing the whole maternity reform package at risk. Although a compromise position is what some might call ‘incremental reform’ it is still an extraordinary time for midwifery in Australia and one we have been fighting to attain for many years."

Why can midwives not accept the Determination?

We believe that ACM should be calling for the Determination to be disallowed. It appears that ACM is putting financial considerations ahead of professional matters. I (Joy J) was an ACM Victorian Branch executive member in the 1990s when we fought to be freed from regulations which required that a midwife be supervised by a doctor. ACM is, by supporting the Determination, turning midwifery and maternity reform back a couple of decades.

In an attempt to defend the position I am taking, I draw attention to a list of so-called 'facts', in the ACM URGENT e-bulletin:

ACM claims that
"The Determination
1) Will not prevent private midwives being able to practise (they can still access insurance)

Midwives in private practice will, under the Determination, be required to choose EITHER medically supervised practice (with Medicare), with all births taking place in hospital (NO homebirth) OR continue private practice in our communities without the hope of government funding for any of our services, and without the hope of hospital visiting access.

ACM also claims that the Determination
2) Will not prevent women being able to make choices - if you are having a homebirth and choose not to access Medicare you do not need a signed agreement with a doctor.

This claim is nonsense. By supporting a two-tiered midwifery system (the homebirth midwives and the Medicare midwives), ACM is ignoring the basic scope of midwifery practice, in any setting.

ACM also claims that the Determination
3) Only affects midwives seeking to access Medicare and midwives can choose not to do this

Does ACM think it's reasonable that midwives should give up the defining features of midwifery practice, and accept supervision by the medical profession?

ACM also claims that the Determination
4) Is not included in the NMBA Quality and Safety Exemption framework supporting private midwives providing homebirth services

Of course not! The Determination is a piece of legislation.

ACM also claims that the Determination
5) Does not re-define the ICM definition of a midwife - it does not define the role or scope of practice of midwives in Australia. It only defines how midwives can access Medicare if they choose to do so. ...

Of course not! By agreeing to medical supervision of the midwife's practice, the ICM definition is OFF THE TABLE. The 'midwife' working under the Determination will become a new breed of obstetric handmaiden.

There are a couple more examples of SPIN under the heading of THE FACTS.

Midwives will be giving up midwifery if they accept the poisoned chalice of Medicare funding with this Determination. Change of funding mechanisms, as will occur when midwives are able to practise with Medicare rebates, does not equate to reform of maternity services. The Australian government's commitment to a $120 Million reform package is floundering because this government (in its previous state, and continuing through to the present leadership) has refused to listen to the very people who are intimately involved in maternity care (midwives and mothers), and has submitted to a 'doctor knows best' subservient mentality. The midwifery profession has an opportunity to stand up and take responsibility for ourselves, or cave in to the bullying that is seeking to force us into someone who is unrecognisable in current international midwifery literature.


Related posts:
NEW Maternity Coalition national blog
Homebirth Australia
Maternity Coalition
villagemidwife
Lisa Barrett's blog

Thursday, September 16, 2010

ICM: Legislation to govern midwifery practice

The International Confederation of Midwives' GLASGOW Declaration 2008

Legislation which is enacted to govern the practice of midwives should:
• enable midwives to practise freely in any setting
• ensure the profession is governed by midwives
...
allow for the midwife to practise in her own right
... 
 

LEGISLATION TO GOVERN MIDWIFERY PRACTICE


BACKGROUND
In order to protect both the public and midwives themselves, it is important to regulate and license midwives, and the programmes and establishments used in their training. It is also essential not to give the license or accreditation ‘for life’. Hence, a set of accreditation requirements must be instituted for the accreditation (and re-accreditation) for fixed periods of time. For the individual midwife this should be based on her/his ability to demonstrate that she/he has the required skills and abilities to practise the profession safely according to the national requirements.

Midwifery legislation is the part of a nation's laws that relate to the profession and practice of midwifery. Midwifery regulation is the set of criteria and processes arising from the legislation that identifies who is a midwife and who is not, and describes the scope of midwifery practice.

Registration, sometimes called licensure, is the legal right to practise and to use the title of midwife. Regardless of the type of mechanism used, it is important to ensure that the process is and continues to be transparent, fair and robust; it should therefore be evaluated periodically. There is also a need for mechanisms that enable previously practising midwives to return to service after a prolonged absence.

STATEMENT OF BELIEF
The ICM believes that there should be appropriate legislation relating to the practice of midwives in all countries. ICM also believes that professional associations should work with governments to find ways to maximise service delivery capacities in countries. This will imply the establishment of good human resource management policies and regulations, as well as the involvement of professionals in determining service standards for the provision of high-quality care at all levels in both the private and public sectors.

POSITION
Legislation which is enacted to govern the practice of midwives should:
• enable midwives to practise freely in any setting
• ensure the profession is governed by midwives
• support the midwife in the use of life-saving knowledge and skills in a variety of settings in countries where there is no ready access to medical support
• enable midwives to have access to ongoing education
• require regular renewal of right to practise
• adopt a ‘Definition of the Midwife’ congruent with the ICM definition, appropriate to the country within the legislation
• provide for consumer representation on the regulatory body
• recognise that all women have a right to be attended by a competent midwife
• allow for the midwife to practise in her own right
• recognise the importance of separate midwifery regulation and legislation which supports and enhances the work of midwives in improving maternal, child and public health
• provide for entry to the profession that is based on competencies and standards and which makes no distinction between routes of entry
• provide the mechanism for a regulatory body that is governed by midwives with the aim of protecting the public
• provide for regular review of the legislation to ensure it remains appropriate and not outdated, as midwifery education and practice and the health services advance
• encourage the use of peer review and analysis of perinatal, maternal and newborn outcomes in the legislative review process
• provide for transition education programmes in the adoption of new legislation requiring increased levels of competency of the midwife.

GUIDING STATEMENT TO MEMBER ASSOCIATIONS:
Member Associations are urged to use this statement to achieve legislation
which will be appropriate for the practice of midwifery in their country.

RELATED ICM DOCUMENTS
• ICM position statement. Framework for midwifery legislation and
regulation. ICM, 2002.

OTHER RELEVANT DOCUMENTS
• Mother Baby Package: Implementing Safe Motherhood in Countries. Geneva,
Switzerland: WHO, 1994.
• ICM. Definition of the Midwife. ICM, 2005.
• Bryce GK. Overview paper presented to Workshop on Legislation, May 1983
Vancouver ICM Congress (Unpublished).
• The Safe Motherhood Action Agenda. Priorities for the next decade. Report
on the Safe Motherhood Technical Consultation October 1997 Sri Lanka, Family
Care International.


Adopted at Glasgow Council meeting, 2008
Due for next review 2014

[The International Confederation of Midwives (ICM) supports and advises associations of midwives. The ICM is an accredited non-governmental organisation and works closely with the WHO, UNFPA, UNICEF and other organisations worldwide to achieve common goals in the care of mothers and children.]

Tuesday, September 14, 2010

Roxon reappointed as Health Minister

There has been a collective sigh of dismay as midwives and advocates for basic human rights in maternity care note the renewal of Nicola Roxon's portfolio as the Minister for Health (and Ageing).

Minister Roxon swallowed the guidance of the AMA (Australian Medical Association) and refused to listen to women and midwives. Remember girls, doctor knows best.

Prime Minister Gillard promised a new era in health before the Rudd government was elected, and she became his deputy.

These very women have sold out women's basic human rights, in a mad rush to reform health, by further restricting access of women to private midwifery, and barring midwives who attend women in their homes from any semblance of acceptance in the health system or professional recognition.  We (midwives) are experiencing unprecedented threat to our very right to exist.

During the years of the previous (Rudd) Labor government we were informed that Labor had a mandate to reform maternity care.

This (Gillard) government has now been put on notice. They got in by a whisker, and while under Rudd they trumpeted their mandate to reform health, there is no mandate for anything now.

Everyone with an interest in birth needs to increase the pressure on Roxon and Gillard, and keep private midwifery and the related theme of women’s rights in the public eye. If as has been forecast this government does not run its full term, voters will be given another opportunity to voice their disgust at the bureaucratic heavy-handedness that has been dished out since the government commenced its efforts to reform maternity services.

The statement by the four independent women who stood for seats in marginal electorates, ‘Gillard Government signs away women’s rights’ still applies.

Minister Roxon, her advisors and bureaucrats, and the AMA, reckon it’s in the public interest to wipe out private midwifery as we know it today. Women cannot be allowed to decide where or how or with whom they should give birth.  The midwife's private practice that focuses on promoting physiological birth, and working in harmony with natural processes, is under increasing threat. 

A new professional pathway is being opened by our government for the private midwife: who works with [and supervised by] an obstetrician, within the private health sector, with the client being able to access partial recovery of costs via Medicare.  This 'midwife' will be no more than the obstetrician's handmaiden.  The legislative changes introduced quietly as 'National Helath (Collaborative arrangements for midwives) Determination 2010' have quashed any hope that independent midwives may have had of accessing Medicare rebates for some of their services.

From the Independent candidates' statement:
“The day before the Federal election was announced there were changes made to existing midwifery legislation. Defined as "collaborative arrangements", the changes, in essence, give doctors a veto over women's choices.

“Basically, the changes detail that any midwife whose patient wants to claim through Medicare must get permission from a Doctor for the decisions made during the pregnancy and birth.

“These new laws give Doctors veto rights over women’s birth choices.

“It is unlikely that Doctors will agree to collaborate with private midwives, with some receiving advice from their insurer that collaborating would void their insurance."

Thursday, September 2, 2010

complaints and notifications against midwives

Midwives practising privately in Victoria face a high risk of experiencing complaints to the registration authority about their actions. 
Protesters rally outside AMA house in Melbourne, in support of private midwifery

The number of Victorian independent midwives with current investigations into compaints is seven or eight, out of a group of less than thirty. This rate of complaint is disproportionately high when compared with midwives in other practice models.  Midwives are asking "why?"

There are, of course, complex issues in any complaint about a professional person's actions or competence or ability to practise at an acceptable standard.  The statutory body with responsibility for investigating and making decisions about a midwife's professional actions is the Nursing and Midwifery Board (NMBA), which acts under the Australian Health Practitioner Regulation Agency.  The principle of acting in the public interest - protection of the public from unprofessional or incompetent or unscrupulous operators - is the reason for existence of statutory regulation of health professionals.

In recent months and years the defining of a midwife's scope of practice and even who is suitable for a midwife to accept when providing care have been further complicated by government bureaucracy, under what has been presented as 'reform'. While the 'reform' is offering the carrot of Medicare (public) funding for prenatal care and visiting access to hospitals for intrapartum care, the stick at the other end of the donkey is adherence to a high level of risk management that is dictated and overseen by competing medical interests. 

Without going into detail, independent midwives face the possibility of restrictions that go beyond anything we have previously faced. For example, is a woman who has had a previous caesarean birth a suitable candidate to be in the primary care of a midwife? What about a woman who has had two caesareans?
or a woman with a high BMI (too fat)?
or a woman who has twins?
or a woman whose baby is presenting breech?
or a woman who had a post partum haemorrhage with her previous birth?
or a woman who comes into spontaneous labour at 36 weeks?
or a woman whose baby has not yet been born at 42 weeks?
or ...


Now is a good time to go back to the question what is a midwife?

ICM Definition of the Midwife (2005) is a core document of the International Confederation of Midwives [http://www.internationalmidwives.org/ ]

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

[Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.]



Principles that provide a framework for midwifery practice

The ICM Definition of the Midwife (2005) establishes the following principles:

The principle of ‘partnership’: “The midwife … works in partnership with women …”
The principle of professional responsibility: “The midwife is recognised as a responsible and accountable professional …”
The principle of caseload – primary care: “The midwife … works … to give the necessary support, care and advice during pregnancy, labour and the postpartum period, …”
The principle of primary care – on the midwife’s own responsibility: “… to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”
The principle of health promotion: “This care includes preventative measures, the promotion of normal birth,…”
The principle of detection of complications, consultation, referral, and carrying out emergency measures: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”
The principle that midwifery care has broad community health implications: “The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.”
The principle of ‘any setting’: “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”

I would encourage midwives who face complaints and notifications to come back to the principles outlined above, and to review our practices in the light of these principles. A midwife who can demonstrate that her practice was consistent with the ICM Definition has strong footing for defending her actions.

Friday, August 20, 2010

Independent's Preferences may determine Corangamite

Protesters outside Nicola Roxon's office
Media Release

Friday August 20 2010

Contact: Sally-Anne Brown 0438 708 693





Independent's Preferences may determine Corangamite



Independent candidate for Corangamite Sally-Anne Brown has today announced she has not directed preferences to one major party over the other following the collapse of negotiations with both parties.



Neither party would commit to ensure the currently tabled 'collaboration determination' for women to be eligible for medicare funding with a private midwife be disallowed, to ensure a woman's right to informed consent be drafted into a new document. “ It is incredible that both major parties are prepared to risk loosing their bid for Corangamite, rather than revamp a document which costs them nothing”, said Ms Brown, adding “the major parties have once again bowed to the nation's most powerful union lobby, The Australian Medical Association” at the expense of birthing women across the nation”, she added.



As late as Tuesday night both parties were making calls to the Independent candidate requesting her preferences. “This is a clear indication both Liberal and Labor know the seat of Corangamite currently held by 0.9 % will come down to the wire”, said Ms Brown, adding “I was crystal clear that if I had a commitment in writing to uphold a woman's right to informed consent then I would deliver my preferences. Instead the major parties have sold women's rights down the river”, she said. Ms Brown is unimpressed that Australia's first female PM Julia Gillard and Health Minister Nicola Roxon, both members of Emily's list which advocate strongly to uphold women's rights are supporting the position.



Ms Brown a nurse and midwife of 28 years declared her candidacy for the seat of Corangamite following a twenty year policy platform by both parties to force women to travel to cities to birth. “Since the early 90’s over 70% of maternity units have closed in remote and rural Australia including the Apollo Bay and Lorne maternity units, forcing women to travel hundreds of kilometres to birth”, said Ms Brown, adding “our maternity system currently the highest volume of health beds at over 300,000 per annum is a lucrative business and a broken mess”, she added.



Due to mandated insurance requirements effective July 1 – eleven of the thirteen private midwives that serviced the 8,000 sq kms of Corangamite have had to cease their practice due to exorbitant insurance premiums and the move by medicos to veto a woman's right to make informed decisions about her maternity care. “To bypass a woman's right to consent in any aspect of her care constitutes a breach of ethical, legal and professional requirements of practice that must be adhered to by all health professionals, regardless of public or private practice”, she added.



Ms Brown is campaigning primarily on maternity services reform and on a strong social, environmental and health policy platform.



Ø Bring Births Back to Local Communities

Ø Zero Emissions by 2020 & a price on Carbon

Ø Housing affordability

Ø Improved roads & public transport





www.sallyannebrown.com

Authorised by Sally-Anne Brown, 3 Scott Place Apollo Bay, Victoria 3233

Wednesday, August 11, 2010

Who's the REAL health minister?

NEWS RELEASE

Wednesday 11 August 2010

Independents in Key Marginal Seats Join Forces and Ask:

Will the Real Health Minister Stand Up at Today’s National Press Club Address
Across health there are hundreds of community groups advocating for improvements in health. For four women across 3 states the lack of any real action in maternity reform has led them to stand as independent candidates.

Michelle Meares, Amy Bell, Sally-Anne Brown and Rebecca Jenkinson are standing in the seats of Robertson, Macquarie, Corangamite and Dickson respectively. These seats are ultra marginal and these women are united by a common passion to improve maternity care for Australian women rather than seeing health services dominated by the self interest of the Australian Medical Association (AMA).

Maternity reform was the first cab of the rank in Rudd’s health reform plan. Nicola Roxon announced funding midwives through Medicare for the first time. “This legislation had the capacity to greatly improve care for women across the country and was initially well received.” says Rebecca Jenkinson, teacher, mother of 2 children and independent candidate for Dickson.

Whilst consultation with a range of stakeholders has occurred it has been clear to those participating that the medical lobby has controlled the decisions within the reforms. “Nicola Roxon has put the self interest of the doctors union above the needs of Australian families as they continue to suffer, especially in rural and remote areas.” said Sally-Anne Brown a nurse and midwife from rural Victoria, running in the electorate of Corangamite.

“In the last month we have come to the conclusion that Nicola Roxon is not really Australia’s Health Minister and Peter Dutton is not the shadow minister. The real minister is Dr Andrew Pesce, President of the Australian Medical Association.” said Michelle Meares, IT consultant and mother on NSW’s Central Coast. “Despite unprecedented support from the women of Australia for maternity reform, Minister Roxon turned her back on them caving to pressure from the AMA that has resulted in legislation being snuck through, signed off by the Governor General the day before the election was called.”

The Determination ( National Health Collaborative arrangements for midwives Determination 2010) passed on the election eve requires medical sign off or agreement before women can receive a Medicare payment for private midwifery care. This legislation gives doctors the power of veto not only over the practice of midwives but also the choices pregnant women make.

“This move looks likely to contravene Australia’s commitment to the Convention on the Elimination of all Discrimination Against Women (CEDAW). How can the women of the ALP introduce legislation that prevents a woman from making decisions about her own body, giving veto to medical practitioners” said Sally-Anne Brown. Amy Bell, mother and nurse from the Blue Mountains region adds “Women have asked us to step up and represent the voices of women on this issue and they are standing behind us all the way.”

Rebecca Jenkinson is also dismayed that Shadow Health Minister, Peter Dutton has also refused to take a stand on this issue. “As a member of his electorate I am aware of the women that have met with and written to Peter Dutton. We are yet to see any positive protection from the coalition for the rights of women to make decisions. We can only assume that Minister’s Roxon and Dutton believe the AMA has more currency than Australian families”

All candidates report great support on the ground. For too long maternity care has been thought of as a ‘soft issue’. One only needs to see the catastrophic effects of postnatal depression, family breakdown and child abuse to know that how we support new families, especially mothers matters greatly. Amy Bell adds “Maternal suicide is the leading cause of death in the first year after birth – we have to look at more positive ways to support women.”

These candidates join together to ask when will Nicola Roxon and Peter Dutton (who are speaking together today at the National Press Club) be honest enough to announce that the AMA is the real driver of health policy in Australia.

Contact: Rebecca Jenkinson 0439 765 633
Michelle Meares 0439 645 372
Sally-Anne Brown 0438 708 693
Amy Bell 0432 928 014




Authorised by Sally-Anne Brown, 3 Scott Place Apollo Bay Victoria 3233

Saturday, August 7, 2010

Gillard Government signs away Women’s Rights

Sally-Anne Brown leads a rally outside Health Minister Roxon's office
A political statement on behalf of four women standing for election as Independents

August 3, 2010

FOLLOWING the Government’s backwards changes to national midwifery regulations, thousands of Australian women are voicing their concern.

Their urgent voices have just over a month to address draconian amendments to proposed new laws.

Collectively, thousands of voices have culminated in four women running as independent members in critical marginal seats in an attempt to talk to Australia’s law makers.

These four independents will stand in the marginal federal seats of Robertson on the NSW Central Coast, Corangamite in southern Victoria, Macquarie in the Blue Mountains, NSW, and Dickson in northern Brisbane, Queensland.

“We had no choice but to stand for Parliament. We are standing as Independents to represent the voices of thousands of women around Australia. These women are angry about the effect the Gillard Government’s new maternity laws will have on their birth choices,” Robertson candidate Michelle Meares said.

“The day before the Federal election was announced there were changes made to existing midwifery legislation. Defined as "collaborative arrangements", the changes, in essence, give doctors a veto over women's choices.

“Basically, the changes detail that any midwife whose patient wants to claim through Medicare must get permission from a Doctor for the decisions made during the pregnancy and birth.”

“These new laws give Doctor’s veto rights over women’s birth choices.”

“It is unlikely that Doctors will agree to collaborate with private midwives, with some receiving advice from their insurer that collaborating would void their insurance.”

“This is unworkable. It will not allow women to be able to afford midwives for
home births.”

After the election, once the caretaker Government steps aside and the Senate resumes sitting, there will a two-week window in which the changes can be disallowed.

“When the senate resumes we have two weeks in which to change the “collaborative arrangement” the Government wants to impose.

A similar situation developed in the US state of New York. But the law was found to be unworkable. It was repealed when the Midwifery Modernization Act was passed in July.

Each of the four candidates disagrees with the recently passed legislation forcing midwives into "collaborative arrangements" with doctors. Specifically they are pushing for:
• A guarantee that the medical veto over women's choices will be removed
• A commitment that women's rights to informed consent (including the right of refusal) will be expressly recognised in all codes, guidelines and frameworks relating to midwifery practice
• Ensure that privately practising midwives have visiting rights in hospitals across the country
• A commitment to funding and insurance for homebirth to ensure equity for all Australian women

Men do not give birth and should not be allowed to push women into this position.

MEDIA INQUIRIES
The four candidates:
Robertson – web producer/consumer advocate Michelle Meares
Phone: 0439 645 372
http://www.michellemeares.com

Corangamite –midwife Sally Anne Brown
Phone: 0438 708 693
http://sallyannebrown.com

Macquarie – nurse Amy Bell
Phone: 0432 928 014
http://www.wix.com/amyrbell/independentformacquarie

Dickson – teacher Rebecca Jenkinson.
Phone: 0439 765 633
http://bit.ly/a4KXOz
www.homebirthaustralia.org

Wednesday, August 4, 2010

New information on professional indemnity insurance for midwives

The scanned page here is from a Draft Summary of Professional Indemnity Insurance for Midwives, developed by the  NMBA.  This flow chart outlines the process for midwives to comply with the professional indemnity insurance (PII) requirements of the National Registration and Accreditation Scheme which has been in effect since 1 July this year.

When I have found a link to the document at the NMBA website I will add that to this post.

As has been clearly stated for all to read, in this and other blogs and professional websites, midwives have sought to protect our right to practise midwifery as it has been defined internationally by the ICM - see Definition of a midwife. This ICM Definition is foundational to all Australian midwifery codes and courses of study. It is not something that can be ignored by legislators or regulators.

According to this flow chart, there are three options for private midwifery practice.

1. ONLY PROVIDING HOMEBIRTH intrapartum midwifery services with no antenatal or postnatal care. --- Midwife does not require PII.

2. and 3. Midwife intends to provide private antenatal, intrapatum care in hospital setting &/or postnatal care. --- Midwife must purchase PII.

#2 Midwife provides private midwifery services for pre and postnatal care without any access to Medicare, and purchases appropriate PII.

#3 Midwife provides private midwifery services for pre, intra, and postnatal care, and has the notation by the NMBA as a midwife who is eligible for Medicare. The midwife purchases PII from the Australian Government-supported authorised insurance provider.


Option #1 is unreasonable - UNPROFESSIONAL!
There is no point in calling ourselves midwives if we cannot practise midwifery. It's outrageous to be forced into being in the position, as this flow chart indicates, of "Only providing homebirth intrapartum midwifery services with no antenatal or postnatal care." What sort of midwife would take professional responsibility for homebirth without also providing prenatal and postnatal services? How is it that a body charged with regulation of midwifery in this country should consider a statement like that reasonable, that it should appear in a draft flow chart under the NMBA letterhead?

This is madness, as the regulators try to squeeze a square peg (NRAS) into a round hole (midwifery). The requirement for PII, with the 2-year exemption for homebirth, was never a workable arrangement.

The midwife is 'with woman' - not 'with homebirth'! In normal, physiological labour the woman and her midwife agree on the best place for birth as progress and other events at the time are taken into account.