Wednesday, September 26, 2012

The hospital problem

It's two years since our federal government's maternity reforms have provided significant new support for private midwifery practice.

Since November 2010, midwives have been able to provide taxpayer subsidised services to patients outside of the public system.  A search of Medicare statistics for the financial year July 2011 to June 2012 reveals that there were 16,474 'Midwife services' rebated, accounting for more that one million dollars of taxpayer's funds. 

A key component of the reform agenda was hospital access for births: that midwives would be able to deliver maternity care, including antenatal and postnatal care in the community, and, as the then Health Minister Nicola Roxon announced, "undertake deliveries in a hospital."  

Access for midwives to maternity hospitals has turned out to be problematic.  Except for Queensland Health, which has established processes for midwives to have access to public hospitals in Toowoomba, Ipswich, and Gold Coast, midwife-attended births in hospitals have not become a reality.

In fact, I have observed a gradual increase in resistance to midwives attending our clients privately in hospitals in Melbourne over the past two years.  I am trying to understand why this is happening.  Here are a few pieces of the puzzle:
  • Private in public:  Melbourne's large tertiary maternity hospitals (Women's, Monash, and Mercy) employ specialist obstetricians rather than the visiting consultant who, in return, is able to use the service for his or her private patients.  The director of obstetrics at one of these hospitals has told me that 'private in public' is the major obstacle to midwives being granted clinical privileges.  
  • Credentialling for clinical privileges: Smaller metropolitan and regional hospitals rely on doctors to provide consultancy services for obstetrics, anaesthetics, paediatrics, and other specialties, as well as GPs who provide primary care that includes basic maternity services.  The processes for credentialling of these doctors for clinical privileges in public hospitals are managed by each hospital, guided by the Health Department and the VMIA (public hospital insurer).  This process was expected to be extended to provide for credentialling of midwives, and meetings of key stakeholders were convened in 2011.  I attended these meetings, as representative of Midwives in Private Practice (MiPP)   A report was given at a conference in May, but since then there appears to have been no progress and the report has not yet been made public.
  • 'Support person':  At present when a midwife in private practice attends a private client in a hospital (private or public), either with a woman who intended to give birth at the hospital, or when transferring from planned homebirth, we may be called a 'support person'.  This is a head in the sand mentality on the part of hospital employees: we are midwives, are accountable for all our actions, and have a real duty of care to those who employ us as midwives.  
Here are a couple of examples of the increasing resistance to midwives by Melbourne's public hospitals:

Recently I visited a mother and baby the day after the birth: the mother had experienced a complex and life threatening labour, and had been delivered by caesarean.  I introduced myself at the desk and asked if I could visit my client.  The nurse in charge told me somewhat grudgingly that she would let me in, but that I was not to discuss clinical matters with the patient.  I must have looked shocked (which I was).  "Why?  Is something wrong?" I asked.  "No, but you must not interfere with the hospital's care of patients", was the reply.  I informed the nurse that I had no intention to interfere; that I was there for the woman and I would discuss anything the woman wanted to discuss!  I reminded the nurse that 'patients' are not prisoners: that they are free to discuss anything with anyone. [see comment after this post]

Another private midwife was invited to meet with a senior member of the midwifery staff to discuss complaints about her behaviour in the hospital. A midwife in the birth suite had complained that she could not work with women who had this private midwife with them, because the women looked to their midwife for guidance and support!  (And this is a hospital where research has demonstrated a range of improved outcomes for mothers and babies when the woman is attended by a known midwife who has a personal caseload!  It's no secret that women value a trusting relationship with their own midwife.)


What should we be doing about hospitals?

Some Medicare-participating midwives have negotiated casual employment arrangements with a hospital, so that when their clients are admitted in labour, the private midwife becomes an employee of the hospital, and provides midwifery care for that woman.  The midwife is paid by the hospital for the hours of employment.   I do not see this as a solution - it's a temporary filler at best.  The Medicare provisions for midwife attendance in labour and birth cannot be applied: Item #82120, Scheduled Fee $739.25


Management of confinement for up to 12 hours, including delivery (if undertaken), if:
(a) the patient is an admitted patient of a hospital; and
(b) the attendance is by a participating midwife who: (i) provided the patient’s antenatal care; or (ii) is a member of a practice that provided the patient’s antenatal care
(Includes all attendances related to the confinement by the participating midwife)
[Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011]



Earlier this week I wrote about women's rights in childbearing, and quoted from the recently updated Cochrane review of planned hospital birth compared with planned home birth for low-risk pregnant women, in which the authors commented:
"It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications."
If maternity services are serious about basing practice on evidence; if the government is serious about providing maternity services that are appropriate and in the interests of safety and wellbeing of mother and baby, then the option of homebirth MUST be seriously addressed across the board.  As long as there are disincentives and professional biases that prevent the majority of women from accessing homebirth, and that prevent midwives from offering affordable private midwifery services in all communities, we will continue to see the cascade of interventions fast-tracking women and babies into medical emergencies.


Thankyou for your comments

Friday, September 7, 2012

Journal: Spring time

The first case study for the course (worth 20% of the final mark) has been submitted, and although I have done some reading and a little work on the portfolio, I have also taken some time off.

Just as a midwife works in harmony with the seasons of life, the care of plants demands a similar submission to natural forces.  So thisafternoon I found myself drawn to my little collection of Bonsai trees.  Some of them needed work - trimming the roots and refreshing the potting mix.  The job needed to be done before the warm weather comes.  Some of the trees - the Japanese Maple and the nectarines - have put out beautiful tender new leaves.  Others, such as the Japanese Elm, have no shoots yet.

Japanese Maple, about 4 years old
I am a beginner with the art of Bonsai.  A few years ago I started with a couple of little trees from the garden shop on Springvale Road, where there is an amazing collection of Bonsai trees, and some seedlings from stone fruit that had grown up in our garden.

I have become very attached to my collection: the little trees that grow and look happy as long as I keep their tiny patch of soil damp.  In summer, they require watering twice a day.  This winter I have watered them a couple of times a week, and there has been plenty of rain as well.

I am able to practice patience as I quietly observe the changes over time.  It's a valuable midwifery skill.






The same little Japanese Maple, a year ago


Thankyou for your comments

Saturday, September 1, 2012

Journal: writing prescriptions

Thismorning I have gone through the process of online submission of the first Case Study, which I wrote about in my most recent posting.  I found that I needed to restrict myself, as the word count was 2000-3000 words.  The additional material that I decided needed to be cut from the case study has mostly been pasted into my portfolio.

Today's task is to learn how to write prescriptions.  The list of medicines that are given for students to practice includes some drugs that I carry at present (such as lignocaine for perineal repair, and syntocinon to treat postpartum haemorrhage, and paediatric vitamin K), as well as narcotics oxycodone and panadeine forte, that I would seek to avoid. Antibiotics such as Amoxil and flucloxacillin may occasionally be useful.

My response to this assignment is complex, on several different levels.  While I am happy to upskill and have authorisation to prescribe medicines that are within my scope of practice, I feel conflicted as I am concerned that many midwives will prescribe just because they can.

One restriction that independent midwives have lived and worked under for as long as I can remember is that we have very little reliance on drugs.  Antibiotics, such as penicillin, are prescribed in many hospitals for any labouring woman who has tested positive to group B streptococcus (GBS).  In my practice, I do not swab for GBS, and I do not use antibiotics as a prophylaxis.  This is a safe practice, as long as there is no artificial rupture of the membranes, and as long as there are no internal examinations in early labour with ruptured membranes.  This practice is also safe because there is the stated intention to treat with antibiotics if symptoms of infection arise, particularly an unstable maternal temperature, with fetal tachycardia.

While every care plan focuses on avoidance of harm from the potentially catastrophic GBS infection, the plan to treat prophylactically is not without risk.  The use of antibiotics can lead to adverse effects in mother and baby, and long term morbidity. 

As an elder of the midwifery profession, I do not expect that my practice will change much, even when I have the right to prescribe from whatever formulary is available to midwives.  The PBS list is different from the NMBA list, which is different from the Victorian government's list (which has not yet been approved). 

I do hope younger midwives who move up in the ranks will hold to the basic knowledge of working in harmony with healthy natural processes in normal birth.  The principles of promoting, protecting, and supporting normal physiological processes are in the interests of mothers and babies, and are at the core of normal midwifery practice.

Thankyou for your comments