Maternity Reforms Dismay
| Hon Nicola Roxon MP, Minister for Health and Ageing House of Representatives Tuesday 27 July 2010,
Dear Minister RoxonRE: National Health (Collaborative arrangements for midwives) Determination 2010 - National Health Act 1953. Maternity Coalition is dismayed at the introduction of the regulations defining collaborative arrangements for midwives that were signed into law by the Governor General on 16 July. Under these regulations there are extremely limited prospects for Australian women to gain the improved choice and access which have been the focus of your maternity reform package. Each of the four options for “collaborative arrangements” make women’s access to MBS rebates for midwifery care subject to approval from a specified medical practitioner. The much feared medical veto on women’s access to MBS-funded midwifery care has been delivered. The definition of “collaborative arrangements” leads to a range of problems, including:
These risks were comprehensively outlined in the Senate Review in December 2009, and have been reinforced by events since then. We note that State Governments have made no apparent progress toward enabling collaborative arrangements between eligible midwives and public hospitals. Women have clearly communicated their concerns about this issue. They have attended numerous meetings and briefings, sent hundreds of letters, many attended the 3000-strong rally outside Parliament House and submitted a record number of submissions to Senate inquiries. Despite this, women’s interests appear to have been ignored in favour of doctor’s. The Government must recognise that women are the key decision makers in their maternity care - not clinicians. Maternity Coalition is extremely disappointed that the reforms which promised so much for women appear likely to deliver so little. It appears that the only workable models under these reforms will be for women with private health insurance to be able to access some midwifery care from a midwife employed by an obstetrician, and the public hospitals costshifting maternity care to MBS through the gradual development of midwifery models. Maternity Coalition requests the Government demonstrates commitment to real maternity reform by guaranteeing they will address the following issues:
Maternity Coalition appeals for urgent action to be taken so that there is some chance of the reforms meeting the stated aim “to increase access and affordability of midwifery services” for Australian women. It is simply not possible for the reforms to deliver for women while a medical veto over access to midwifery care remains in place. The definition of collaborative arrangements must recognise women’s right to reproductive self-determination. We seek a response to this letter by 2 August 2010. Yours faithfully Lisa Metcalfe National President Maternity Coalition cc Julia Gillard Prime Minister Tanya Pilbersek Minister for Housing & the Minister for the Status of Women. |
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Maternity Reforms Update June 18, 2010
Background Maternity Coalition are concerned about the requirements for collaboration in the insurance policy underwritten by the Federal Government. MC is aware of midwives who are unable to find collaborative solutions at their local hospitals and who cannot, therefore, meet requirements for insurance to continue to practise as a midwife. Maternity Coalition wants to gain assurance from NMBA, State Ministers and the Federal Minister for Health that women’s birthing rights will be protected from 1 July. This update will cover:
An Overview Women across the country have expressed much anxiety following the release of the insurance policy underwritten by the Federal Government, particularly in regard to some of the requirements outlined in the policy. Through engaging in discussions with others interested in maternity care, we are already hearing of midwives who are unable to find collaborative solutions at their local hospitals and who cannot, therefore, meet requirements for this insurance policy. Maternity Coalition has heard from many women who feel they have been left in the dark as to where they stand from 1 July. Maternity Coalition is still working hard to ensure women’s birthing rights are protected through our representation on all the working groups of the Department of Health and Ageing (DOHA) involved in implementing the reforms; direct engagement with DOHA; attendance at various consultations; and written submissions. 1 July 2010 - the start of the National Registration and Accreditation Scheme (NRAS)
Requirement to have insurance The NRAS requires all health professionals (initially physiotherapy, optometry, nursing and midwifery, chiropractic care, pharmacy, dental care, medicine, psychology and osteopathy with more to be added post 1 July) to have professional indemnity insurance in order to practise. As many of you are already aware, for a number of years there has been no insurance available for private practice midwives. For a private practice midwife to be registered and thus able to use the title "midwife" they must purchase insurance. Midwives employed in hospitals are covered by professional indemnity as part of their employment. NRAS further information Insurance options
There are currently two insurance products available for private midwives to purchase. Neither of these covers a midwife for the homebirth part of her practice. Although homebirth is subject to a two-year exemption from the NRAS insurance requirements, midwives will still need appropriate insurance to provide antenatal and postnatal services, regardless of the planned location of the birth. The Commonwealth backed insurance policy provided by the Medical Insurance Group (MIGA) has now been released. This policy provides insurance for antenatal and postnatal care as well as intrapartum (birth) care in hospital settings. MIGA insurance policy for eligible midwives [PDF] Maternity Coalition has identified a number of concerns with the policy as currently drafted. We are particularly concerned about how women’s rights to informed choice (and refusal) are limited by this policy. We have raised our concerns directly with the insurance company, DOHA and the Minister for Health. We expect that these issues will be resolved to ensure that the policy is a workable one which actually provides a benefit to consumers. In its original release, it was stated that the insurance policy only provides cover when a midwife is working in collaborative arrangements as defined in Division 6 of the policy. This is the first time that we have seen the definition of “collaborative arrangements” which will be used to define access to Medicare (see below). Maternity Coalition has consistently raised concerns about this requirement and has continued to do so both in the context of this insurance policy and access to Medicare. You can read our submissions to the senate in relation to collaborative arrangements at the bottom of this page. Following representations from APMA, ACM and MC, DOHA advised on Friday 18 June that it would be acceptable, for the purposes of the professional indemnity product offered by MIGA, for midwives who “did not have a collaborative arrangement in place for a particular woman to instead communicate a care plan to the hospital providing obstetric services”. A care plan is a documented plan for consultation, referral and transfer of a woman’s care to a public hospital providing obstetric services. The midwife would be required to keep accurate records of the information provided to the hospital and ensure that the hospital acknowledged receipt of the care plan (verbal acknowledgement is sufficient provided the midwife documents this advice). Mediprotect also offers insurance cover for antenatal and postnatal care only. The only requirement for a midwife to be eligible for this insurance cover is that they must be registered as a practising midwife with the Nursing and Midwifery Board of Australia (NMBA). One of the limitations of this policy is that it is not suitable for midwives providing Medicare rebateable services. Mediprotect PI Insurance for Australian Midwives It is important for midwives to consider what the various policies cover and whether they include representation for disciplinary action from regulators. Homebirth exemption
A second draft of the Safety and Quality Framework guiding Midwifery Care provided by Privately Practising Midwives attending homebirths [Safety & Quality Framework PDF] has been released. It is unclear if this is the final version of the framework. The NMBA will have the final say on the implementation of the framework and it appears it will not be legally required until the NMBA adopts it as a guideline. The draft framework states that it is not intended to be an exclusionary document but it also states that women considered appropriate for inclusion in this option of care are “women with a singleton pregnancy, cephalic presentation, at term and free from any significant pre-existing medical or pregnancy complications”. How this operates in practice and particularly whether a midwife is protected if a woman outside of this description makes an informed decision to birth at home is still unclear. Maternity Coalition has repeatedly argued that the framework must allow for women to make informed decisions about their birth choices. You can read our submissions in relation to the framework on the MC website. What happens now?
With only a couple of weeks until the NRAS takes effect in NSW, Queensland, ACT and Victoria, significant uncertainty remains. Women are, understandably, extremely anxious about whether they will be able to birth at home with the midwife of their choosing after 1 July. The other states have yet to pass the relevant legislation and so the existing requirements in those states will remain until they do so. Maternity Coalition has called on the NMBA to allow for a transitional period to give midwives sufficient time to meet the various requirements that have only recently been set out or are still to be clarified. Maternity Coalition has asked the NMBA to confirm that it will not take action against a midwife who has failed to meet the requirements during the transitional period, if granted. What happens in the future?
1 November 2010 - Medicare for midwives begins As of November it will be possible for midwives to access the medical benefits scheme (MBS) and the pharmaceutical benefits scheme (PBS) provided they meet eligibility requirements [Eligible Midwife PDF] and enter into yet to be fully defined collaborative arrangements. Intrapartum care for homebirth will not be funded by Medicare or PBS. An eligible midwife is a registered midwife who has:
The MIGA insurance policy contains the only published definition of collaborative arrangements, which will be a requirement of access to MBS and PBS. Maternity Coalition has consistently opposed the inclusion of formal collaborative arrangements in the legislation. In the policy, there are three options for a collaborative arrangement. Options 1 and 2 require a medical practitioner or a specialist obstetrician to either refer a woman to a midwife or sign a collaborative agreement. A midwife providing homebirth services is unlikely to find a practitioner who is willing to do either. The third option requires a midwife to document various arrangements with a specified medical practitioner (who can be a representative of a public hospital) in each patient's records and obtain an acknowledgment from that medical practitioner that they will be collaborating in the patient's care. Although this is the option that is potentially most workable for homebirth midwives, Maternity Coalition is aware of the difficulties midwives face even achieving this arrangement. Where does all of this leave homebirth?
Intrapartum care at home is not covered by any of the insurance products currently available but a midwife is required to have insurance that covers antenatal and postnatal care. A midwife attending homebirths might choose to become an eligible midwife (giving her clients the ability to get Medicare benefits for antenatal and postnatal care) but does not have to do so. A homebirth midwife does not have to enter into collaborative arrangements unless she wishes to access the Commonwealth's insurance product and the MBS and PBS. The alternative insurance product for antenatal and postnatal care does not require a midwife to be an eligible midwife or to enter into collaborative arrangements. The future of homebirth as we know it will really come down to the details of the safety and quality framework for the exemption from the requirement to have insurance for birth. Unfortunately we still do not know what the final version of this framework will contain. There is obviously still a great deal of work to be done before consumers can be satisfied that this aspect of the reforms will actually lead to a greater range of choices for birthing women. In particular we don't yet know how intrapartum care in hospital (in terms of midwives having visiting/admitting rights) will work. Maternity Coalition is also concerned that medical practitioners will refuse to enter into collaborative arrangements in cases where a woman is planning to birth at home. Maternity Coalition will distribute a further update as soon as we have more details. Submissions by Maternity Coalition:
Maternity Services Review Submission by Maternity Coalition to the Maternity Services Review Improving Maternity Services 2008 First Senate inquiry Maternity Coalition submission to Senate Community Affairs Committee Inquiry July 2009 Second Senate Inquiry National Maternity Coalition Submission Dec 2009 Maternity Coalition Victoria Submission Dec 2009 NHMRC Draft Guidance on Collaboration Maternity Coalition NHMRC feedback April 2010 Safety and Quality Framework for Privately Practising Midwives - Draft 1: National Maternity Coalition response to draft 1 - March 2010 Maternity Coalition Victoria response to draft 1 - March 2010 Safety and Quality Framework for Midwifery Care - Draft 2: National Maternity Coalition response to draft 2 - May 2010 Maternity Coalition Victoria response to draft 2 - May 2010 You might like to join us on Facebook: The Maternity Coalition Inc on Facebook  |
