The Future of Midwifery and Homebirth in Australia?

Image may be NSFW.
Clik here to view.A lot of changes have occurred in Australian midwifery over the last few years, and I think many midwives and women are unsure or confused by them. I am going to attempt to make a clear and coherent summary of the changes, and discuss the impact of them now, and in the future for midwifery and homebirth. There are going to be a lot of acronyms in this post which may be new to some and familiar to others. So here is a glossary before I begin:

• ACM – Australian College of Midwives
• AHPRA - Australian Health Practitioner Regulation Authority
• AMA – Australian Medical Association
• ANMC - Australian Nursing and Midwifery Council
• ICM – International Confederation of Midwives
• NMBA - Nursing and Midwifery Board of Australia
• PII – Professional Indemnity Insurance
• PPM - Privately Practising Midwife
• RANZCOG – Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Before AHPRA and PII (pre 2010)

The following is an overview of how PPMs worked based on myself and other midwives I know. I realise there will be some variation across individual midwives…

Before AHPRA PPMs were regulated in the same way as any other midwife – at the time this was by ANMC. They collaborated with GPs, hospitals and other health care practitioners, referring and transferring care when needed. The ACM’s ‘consultation and referral guidelines’ were freely available online which meant women could access them, and they formed the basis of discussions around scope of practice and consultation/referral. If a woman transferred to hospital during labour the PPM could no longer act as a ‘midwife’ – instead handing over the professional role and responsibility to the hospital midwife. This allowed the PPM to focus on the woman’s emotional, physical and advocacy needs rather than on the needs of the institution. Hospital midwives are well placed to work within their environment – they know how to deal with the obstetricians, equipment, medications, policies and paperwork. There was no indemnity insurance available for PPMs (since 2001) – so they worked without it. PPMs were employed directly by women and worked directly for women. The above factors were discussed and stated in a signed mother-midwife contract. 

Meanwhile consumer groups such as Maternity Coalition and the ACM were pushing for medicare funding for PPMs. I supported this, and still believe that the health care system should fund homebirth, and that all women should have access to PPMs regardless of their financial situation. There was/is also a government commitment to increasing access to continuity of care for all Australian women.

In 2009 AHPRA was formed in order to have one National registration body rather than individual State registration boards. This was to prevent dangerous healthcare practitioners switching states to continue practising. The ANMC was absorbed into this new registration body. The role of AHPRA is to register and regulate all health care professions including midwifery. Each profession has their own Board within AHPRA – and the Nursing and Midwifery Board of Australia (NMBA) is responsible for midwives and nurses. To understand why midwifery is so entangled with nursing in Australia see Fahy’s (2007) article ‘an Australian history of the subordination of midwifery’ . The perception of midwifery as a branch of nursing underpins the ongoing medical control of the profession described below. Anyway – back to the NMBA. The primary role of the Board is to ‘protect the public’ ie. these are the people who deal with misconduct hearings and ensure midwives are undertaking continued professional development. The formation of AHPRA brought with it two key changes to PPM practice - eligibility and indemnity insurance.

Eligible midwives

In 2010 the ’eligible midwife registration standard’ came into effect. The aim of this was to enable women to access medicare rebates for PPM care. In order to get rebates women need to engage the services of an ‘eligible midwife’. Note that rebates are not available for homebirth – only antenatal care, birth in a hospital/birth centre (where the PPM has visiting rights) and postnatal care. To become eligible, the midwife must apply to AHPRA for notification and demonstrate that she mets the requirements which are:

• current general registration as a midwife in Australia with no restrictions on practice
• midwifery experience that constitutes the equivalent of three years’ full-time post initial registration as a midwife
• current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
• successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
• 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
• formal undertaking to complete within 18 months of recognition as an eligible midwife, or the successful completion of a course to acquire the skills required to order diagnostic tests and prescribe scheduled medicines

You can download the ‘guidelines and assessment framework for the registration standard for eligible midwives‘ for further details about the requirements. It could be argued that these requirement (excluding prescribing – which is whole other rant/issue) merely reflect the normal scope of midwifery according to the ICM. However, in Australia most midwives are unable to practise to their full scope due to constraints imposed by the structure of the medicalised maternity system.

The ‘eligible’ classification is often misunderstood, with many believing that you must be eligible to be a PPM or attend homebirths. This is untrue, and many of us continue to work as described above, choosing not to be ‘eligible’ for a number of reasons. There is also an assumption that an eligible midwife is ‘better’ and ‘more experienced’, and again this is not necessarily true. For example, a midwife can gain eligibility without any experience in attending homebirths. The point of eligibility was/is for women to access medicare rebates – not to create a separate and higher class of midwife.

Medicare eligibility has resulted in a number of changes. Firstly, it has increased women’s access to continuity of care and given them access to rebates for maternity care via a PPM. Many midwives have set up as PPMs and midwifery group practices are popping up everywhere – again this increases women’s choices. Some midwives are continuing their homebirth practice with the additional benefit of women being able to claim rebates if they wish. Other midwives are setting up new practices. There are so many different ways in which eligible midwives are working… I am not going to attempt to list them all. In my local area maternity service options for women have increased from hospital (public or private) or PPM in 2009; to hospital, midwifery led birth centre (medicare rebates), midwifery group practice (medicare rebates), non eligible PPMs and eligible PPMs. And for those who do not want to engage with standard maternity services there are birth workers, doulas and the option of freebirth.

However, medicare rebates come at a price…

Collaborative arrangements

In order for a woman to claim medicare rebates for care by a PPM, the PPM must have a collaborative arrangement. The nature of this arrangement has evolved since 2010…

Initially, during negotiations with AHPRA about eligibility, the requirement was going to be that the midwife must ‘demonstrate’ collaboration with medical practitioners and health services. This would have been easy – PPMs were doing this anyway (see above), and documentation would have provided evidence. However, the AMA and Rural Doctors Group ensured that the requirement became a signed collaborative arrangement with a medical practitioner. Interesting that doctors got the final say in midwifery practice. I doubt there are any midwives involved in negotiations with AHPRA about how obstetricians practice. Disappointingly midwives and consumers (the ones at the table) agreed to this requirement in order to gain eligibility, maintaining that they would work to change the requirement in the future. Personally, I think they should have refused to allow medicine to control midwifery practice in this way, even if it meant losing eligibility. Instead, the types of collaborative arrangements midwives were required to have were determined as (Dept of Health):

1. being employed or engaged by a medical practitioner or an entity that provides medical services; OR
2. receiving patients on written referral from a medical practitioner; OR
3. a signed written agreement with a specified medical practitioner/s; OR
4. an arrangement in the midwife’s or nurse practitioner’s written records

There was/is no obligation for doctors to collaborate. And in case there is any confusion about this, the AMA published a handy  guide for doctors ‘collaborative arrangements – what you need to know’ stating clearly that: “If you do not want to be part of a collaborative arrangement, or you are unable to reach agreement on the appropriate terms of a collaborative arrangement, then there is no obligation to be part of one. You do not have to commit to being part of a collaborative arrangement for any particular period.” And check out the wording in RANZCOG’s template for a ‘collaborative maternity care agreement between eligible midwife and specialist obstetrician or general obstetrician’ - talk about patriarchal and condescending. 

The collaborative arrangement was the equivalent of requiring the manager of Woolworths to agree in writing to allow customers to buy vegetables directly from a local farmer.  Not surprisingly, getting a collaborative arrangement, and therefore claiming medicare rebates was fairly impossible. In 2013 in response to the predictable ‘difficulties with establishing collaborative arrangements’ an amendment was made to the requirement expanding the types of collaborative arrangements. Now, in addition to a collaborative arrangement with a doctor who provides obstetric services (as above), a PPM has two further options for collaboration:

1. That she is credentialed for a hospital, having successfully undergone a formal assessment of his or her qualifications, skills, experience and professional standing. It is expected that appropriately qualified medical practitioner/s would be involved in the assessment; OR
2. That she has a written agreement with an entity other than a hospital that employs or engages at least one obstetric specified medical practitioner.

Effectively medical practitioners, individually or via the institutions they work in still control access to medicare for PPMs.

Midwives are pretty resourceful, and many have found ways to make this work for them and the women they care for. However, it is very dependent upon the people and organisations providing collaborative arrangements. Because it is so complex, there is a lot of confusion and misunderstanding. For example, some believe that a medicare eligible midwife cannot care for a woman having a VBAC. This is not true. She can – just as any PPM can. She may not be able to secure a collaborative arrangement to do so ie. there will be no medicare rebate for that care. However, in some cases medical practitioners or hospitals will agree to antenatal and postnatal care by a PPM for VBAC women. Women need to discuss options and boundaries with their individual PPMs… regardless of eligibility. This is part of negotiating the mother-midwife relationship.

Currently eligibility and collaboration remain an ‘opt in’ choice for both midwives and women. Personally I have chosen not to ‘opt in’ because I feel that the current collaborative arrangement requirements are not aligned with my philosophy of midwifery and ‘with-woman’ care… and I won’t compromise. There are women who also feel this way, and specifically want a non-eligible midwife. Or, who do not want to jump through the hoops required to access a medicare rebate (eg. booking into hospital). While both options are available – eligible and non-eligible PPMs – women can choose the option that works best for them.

However, this choice may disappear in 2015…

Professional Insurance Insurance – the wolf at the door

AHPRA registration standards require that all health care professionals have ’professional indemnity insurance’ (PII) for all aspects of their practice. No big deal for midwives working within the system because they are covered vicariously by the organisations they work for. But this left PPMs with a problem. There was no insurance product available for them, and to practice without insurance breached their registration standards. Long story short, following a lot of protests and negotiations a compromise was found. Two insurance companies stepped in with PII and we now have two products, both excluding homebirth. MIGA only provides insurance to eligible midwives and covers antenatal care, labour in hospital/birth centre and postnatal care. Medisure will insure any PPM for antenatal and postnatal care only. 

Because there is no cover available for homebirth an exemption for PII during a homebirth is in place until June 2015. Not surprisingly, neither insurance company is jumping at the chance to offer PII for homebirth. The NMBA recently published a report on PII for midwives which analyses the issues involved with offering an insurance product that covers homebirth with a PPM. The difficulties centre on the size of the market (ie. number of homebirths/PPMs buying the product); working out the probability of a claim; and working out the size and type of a potential claim. The report includes a lot of discussion about ‘risk’ and ‘risk assessment’. It also suggests that an option could be to make any PII product only available for medicare eligible midwives to ensure ‘confidence and certainty’ within the insurance market about PPM practice. It is likely they will also dictate further requirements for cover such as women must undergo particular screening tests (bloods, u/s, etc.) and be classified as ‘low risk’. These issues are already being faced in the United Kingdom by women and PPMs.

So far there has been no official response to the insurance report from the ACM. The recent Maternity Coalition magazine included this divisive statement in relation to protecting midwives and women’s choices:

“Many midwives feel that they are in a vulnerable legal position. This is often because they are not doing these things [following professional standards re. scope, information giving and documentation]. If we could confidently demonstrate that homebirth midwives as a group were practising in this manner then it would be easier to secure insurance for intrapartum homebirth care and resist the push to regulate homebirth more strictly.” (Ann Catchlove)

It is the NMBA’s role is to regulate midwives… all midwives, including homebirth midwives. All midwives must follow professional standards, provide adequate information, and keep adequate documentation. Yes, individual homebirth midwives may fail to do this… and so might individual hospital midwives. Some would argue that information giving by hospital staff is often below the legal standard for consent (e.g. ARM, induction). Either way, there are already mechanisms in place to hold midwives accountable for their practice via NMBA and civil law. Indeed, considering the number of vexatious reports submitted to the NMBA against PPMs, it could be argued that the mechanisms are working too well (Jo Hunter is presenting about this issue at the Homebirth Conference in March). Unfortunately, we are never going to ‘confidently demonstrate’ that all midwives within any model of care or birth setting are practising in a particular way. Aligning midwifery with medicine and allowing medicine to regulate midwifery practice will not reduce risk. Evidence-based, woman-centred care will reduce risk. How about requiring all midwives to undergo a regular consumer-led ‘midwifery practice review’ assessing their practise against evidence and midwifery philosophy?

The future of midwifery and homebirth?

The following predictions are from my own crystal ball, and some optimists may consider them pessimistic. I think that in 2015 a PII insurance product will be made available that will cover homebirth, but only for eligible midwives accredited by hospitals, and for women booked into the hospital system for shared care and who meet particular ‘low risk’ criteria. PPMs without eligibility will no longer be able attend homebirths – to do so would mean practising without insurance ie. breaching their registration. Women who are not classified as ‘low risk’ will be unable to have a registered midwife at their homebirth (eg. previous c-section, gestating beyond 41 weeks). I think that the professional midwifery organisations will go along with this in order to gain the mandatory insurance and protect private midwifery practice (limited) at homebirth. These changes will have a significant impact on a minority of midwives and women:

Midwives: Non eligible midwives will either become eligible; or stop providing PPM services; or hand in their registrations and become unregulated ‘birth workers’ (however, in South Australian this could lead to criminal charges). Newly qualified midwives will struggle to gain the experience required to become eligible due to limited continuity of care within the maternity system. PPM practice will be dictated by the constraints of an insurance product who’s focus will be on eliminating risk based on medicalised notions of ‘risk’.

Women: Access to midwives and options for care will be limited. Women who do not meet the requirements for insurance cover will be unable to have a registered midwife at their birth. Many women will go along with the requirements (including to switch to hospital birth) but others will not, and their only option will be to freebirth (this is already happening in Ireland). There is a big difference between choosing to freebirth and feeling there is no other choice.

I think we have lost sight of what is important - the essence of midwifery, being ‘with woman’ regardless of where or how the woman chooses to birth, or with whom she chooses to birth. Unfortunately, I think we have come too far down the track and midwifery has become entangled with medicine and the needs of insurance companies. I can’t see a way out of this mess can you? What I find most frustrating is the lack of discussion about these issues within the Australian midwifery profession. In contrast, in the UK where PPMs face the same insurance issues there are protests, marches and campaigns. Either, Australian midwives don’t know what is going on, or they agree with the changes, or they don’t care – I’m not sure which. I’d love to know your thoughts.

Image may be NSFW.
Clik here to view.

Image may be NSFW.
Clik here to view.