It is time to be thankful......

In this political climate when everyone has a different opinion I thought I would remind everyone to be kind and gentle with each other..... there are feelings around:

It is central to remember the most important things are kindness, empathy and we do respect each others point of view even though it is different. It does not mean that we are not nice people....so remember when making comments and sending emails, not to be unkind rude and personal..... I came across these pictures and thought I would share it..... as a reminder to us all... that life is short, and there is time to be thankful for the wonderful things we have in life and how lucky we truly are:

The AMA has put out its Collaborative Arrangements:

There is much speculation surrounding this document; yes there are parts of it that make me cringe.... however it must be equally difficult for the AMA, not that any midwife wants to hear that;
Collaborative Arrangements what you need to know? the irony of this document has to make you laugh or cry:

"Working with other health professionals is an everyday feature of clinical practice for a modern medical practitioner. Effective teamwork can improve patient outcomes, create new opportunities for learning,and build a shared understanding of the skills that each person brings to the care of a patient."

Oh yes everyone is a patient even the well woman = this equals paternalism at its best; yes our medical colleagues are great at being paternalistic they feel they have the right to make that decision for the woman because they believe they know what is best; consequently, if the vulnerable woman is not able to make decisions or is not in a position to do so they are often coerced or made to feel fearful therefore making the decision the doctor wants.

“In a sense, this statutory requirement reflects the planned team care arrangements that have set parameters for collaboration in areas where doctors, midwives and nurses have always worked together - our hospitals.”

If we examine this statement they do say that it is “planned team care” and the word ‘collaboration’ means working together – not the GP/Obstetrician is in charge – it means a two way street. It will be interesting to see this work! because the doctors have the power and the money.... and automatically think they are in charge.

For me there are four main points that are important:

If we do not embrace these changes, then pressure will mount on the Government to relax the requirement for collaborative arrangements to be in place. This would risk fragmentation of care to the detriment of patients.

This is the most telling statement of all.... this means the AMA is seriously concerned that if they the doctors do not collaborate then changes will be made......this is in our favour.

Yes they are correct in saying that

“Some doctors will be challenged by the Government’s reforms, which will fund new models of patient care.”

This is clearly an understatement, we as midwives are certainly challenging them and if this collaborative framework does not work it will be changed; The doctors are back pedaling, they are fearful of losing money... so they are picking up stumps and are not going to play.

What should you do when a patient does not want to follow agreed clinical guidelines?

This may place you in a difficult situation.
The AMA believes that the best way of handling this is to ensure that your written collaborative arrangement clearly states that you will only provide care in accordance with accepted medical practice and within accepted clinical guidelines.
It should also clarify what will occur in circumstances where a patient declines to
follow these guidelines. If this occurs and you decide you cannot provide ongoing care for that patient, you will need to ensure that you advise the patient and the midwife/ nurse practitioner so that an alternative arrangement can be put in place by the nurse practitioner/midwife.
How you will address this issue if it occurs needs to be agreed prospectively in order to avoid a situation where you are forced to continue care because of a lack of
alternative arrangements.

This is nothing new, this is how the AMA works in every day practice, so this is no surprise....the only thing that is different is that they are blatant about and it is in writing.... there is no such thing as the clients right to choose the type of care they want or the right to refuse treatment.

Lastly I would like to be able to check the credentials of the doctors...what are their statistics, are they registered? how many women are not happy with their care etc? we should be able to check their register; that would be fair and just, equality.

Despite these issues I do think that we need to push forward, these are challenges put in our way and in time it will seem like a storm in a tea cup.

My vision is that all women will have the choice of continuity of midwifery care with a midwife and the right to claim a Medicare Rebate for fee for services;
Whilst I do not like the wording in this Determination I can see that this is still a historic time for midwifery....Opportunity is knocking..... walk through and make it work...if it doesn't you can always reject it.... but if we don't try we will never know it will always be a speculation

Taking a day to smell the roses....or look at the spring flowers

life has been so hectic lately i have not had time to scratch myself and sometimes have been quiet disillusioned by it all...which way do you go....so it came as no surprise when I became unwell....late nights...etc.. and to make matters worse I have had the worst flu ever...which left me with bilateral Otitis Media (middle ear infections. My head felt like it was going to explode with the pressure.... I really empathise with those poor little babies and toddlers that get recurrent ear infections no wonder they are so miserable.....poor babies.



Finally the antibiotics have kicked in and relief is finally here... my husband baned me from the computer and mobile phone and took me out for the day to smell the roses....a delightful spring day... it was so refreshing...just what the doctor ordered.... we took a lovely country drive from Perth, Northam to York.... and there were some lovely flowers along the way....



We came upon an unusual couch...made from bricks.... very clever... as my husband was a brickie in his past life I received a lecture about how difficult it would be to make....he was intrigued by this icon...as he referred to it... I tried as I might to be rivetingly excited by it all but alas.... unless it has something to do with birthing and women my passion was just not evident....poor darling...we then went for a walk in the bush and admired the wonderful display of spring flowers..something we both really enjoyed......life is truly wonderful.



We also came across this great little bookshop called "the book lady" in one of the country towns...always a great little find.... we sat for ages looking at books...just delightful.. I picked up one called "letters from a Fainthearted Feminist" by Jill Tweede. I opened the book at page 71

"I've been brooding about those fairy tales where Snow White, Sleeping Beauty the Ice Queen, the Little Mermaid and other happily resting ladies get woken from their snoozes by a peck from Prince Right on the old liperoos..Male fantasies about arousing female virgins, What?....But did anyone inform the ladies in question that once they're awakened passions - ie a permanently insomniac infant - all they will desire in life is to return from whence they came"

how true is that..... you see I could not leave the little book behind... I will be sure to read it to my grand-daughters....

Together we stand, divided we Fall

The universe is change; our life is what our thoughts make it.

A strange phenomenon occurring in the universe around Australia, their is great indecision around, everything seems to be 50/50; first we have an election that had all the bookies saying it will be very close; this therefore means a society that is split; split in every sense of the word; values; principles; taxes and the people who will lead us: there was no clear leader presented....or party..... what is that telling us about our present status? indecision; This means we will have an election sooner than later.... because a divided house will fall.

The AFL final that is a draw...not that I care really accept that I do like to know who wins and loses these main events.... fancy not having a sudden death outcome, like a 5th quarter, extra time.... goal kicks something rather than repeat the game...that seems like a huge money spinner for the AFL........it is time to rethink the rule about a drawn game......

Then we have the Midwifery legislation - Determination for collaborative care; which has the midwifery profession up in arms talking, lobbying at great lengths; however I do not believe for one moment that this is 50/50 it is more like 70/30; 70 for 30 against; The profession is unanimously agreed that the wording is not correct. However what splits them is whether to accept something that is not quite right or throw the whole thing out and not have it at all for possibly years to come.

An interesting point is that it is now in the hands of the parliamentarians... who are equally as indecisive.... in the mean time; women, midwives, homebirth midwives, independent midwives, consumer groups are all pitting themselves against each other, saying some horrible things...making accusations to each other who's right/wrong ... it is all very sad.... in many instances bullying each other to get the perceived upper hand just as bad as the politicians... and at the end of the day we will all lose...... WOMEN & MIDWIVES and the AMA is clapping knowing they are the true winners here!
Something is in the air!

How is it that there can be such diverse beliefs and each thinking there's is the only right way.......the Homebirth/independent contingent is the loudest complainant shouting the loudest saying we are destroying midwifery...but have never given it a go..... in the survey that I have conducted the numbers are 20:4 in favour of accepting rather than losing everything and the counting continues; If we use the election as a marker to what people believe we can see that life does go on... it is how you go forward to make it work is the real task....... what ever happens it is evident that there is a clear divide between midwives; and I firmly believe this is because not all midwives work within their scope of practice;

As for the future of midwifery "together we stand, divided we fall" that is up to us!

Interesting that the Gospel states; (eg. Mark 3:25: If a country divides itself into groups which fight each other, that country will fall apart". Never a truer word spoken.

PLEASE EVEN IF YOU HAVE A DIFFERENT POINT OF VIEW BE KIND TO EACH OTHER;

Ref; picture & first quote comes from Why affirmations work

The greatest good.....for the greatest many;

What do we do when we have a moral dilemma? we examine our values and beliefs....where do these values and beliefs come from???? Values determine what we appreciate in life, what we reject and what we feel dispassionate about.

Take our current dilemma within Midwifery - do we? don't we accept the current determination? that is the question; now as I don't have a crystal ball, I have to judge by the facts; before I do I will explore two ethical theories that applies to our dilemma:

Deontology: which is duty bound based on a moral action regardless of their consequences; I like to think of the classic example is that we should not lie, however many people lie to save the feelings of the other person. However you are duty bound to tell the truth regardless of the consequences; for the good of a single person;

Telelogy - Utilitariansism - also known as consequentialism; actions can only be judged right and or good on the basis of the consequences they produce - therefore 'the greatest good for the greatess many' - therefore opposite to Deontology;

I always considered myself more deontology than utilitariansim.... however on this occasion I am the opposite;
A friend of mine gave me a classic analogy about the determination: it goes, " Dear Santa, thank you for the new red bike, but I really don't like red, and the wheels are two small, so no thanks I would rather go without my brand new bike" or the alternative response could be "thanks Santa for the new bike, yes I don't like red and the wheels are two small, but in the mean time I will ride the bike until l save some money paint it and put new wheels on"

I have always considered that the midwife provides continuity of midwifery care to "normal" "low risk" women.... once a complication arises then it is time to collaborate with our colleagues the obstetricians; this is done as professional to professional...... this is not recognised here in Australia.

I have circulated information far and wide about the issues at hand; the majority of feedback from midwives and some women has been to accept the the determination and the main reason being it is the first step to bigger better things; we can change something we have, not something we don't have;

There is much rhetoric about this subject; I fail to see how we are harming by accepting this, if the choice is this or nothing; yes I understand it is not perfect and I for one do not want to be beholding to an obstetrician. However I come back to the same point that this is very new to Australia, midwives are not as autonomous as our counterparts in the UK and NZ... so there has to be a period of trial or adjustment change is always difficult and does not come without a price......this is the first step to massive change... we have to keep working at it to get what we want....at the end of the day you can choose to accept this process or not.... you don't have to have a medicare provider number.... women still can choose an independent midwife.....and not claim a medicare rebate......

The facts remain the same:

The Determination:
Will not prevent private midwives being able to practice (they can still access insurance)

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.

Only affects midwives seeking to access Medicare and midwives can choose not to do this.

Is not included in the NMBA Quality and Safety Exemption Framework supporting private midwives providing homebirth services

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. Midwives can still work in public and/or private practice and access insurance and register as a midwife (under our current regulatory requirements that have an accepted definition and scope of practice of the midwife in Australia).

Does not mean that midwives must have a signed agreement with a doctor – this is only IF YOU CHOOSE TO ACCESS MEDICARE - Midwives can have
a. an individual signed agreement with a doctor
b. a referral of a woman to you
c. clinical privileging
d. an agreement signed by the medical director of a hospital.

Does not mean you need acknowledgment in writing - we have been told by the Minister’s advisors that a midwife writing in her own clinical notes that results etc have been sent to the hospital/doctor where they have a collaborative arrangement meets this requirement.

Would you throw out the baby with the bath water?

Currently midwives particularly homebirth private practice midwives are up in arms (and rightly so) about the recent Determination where Midwives are to be virtually signed of by doctors. That is as a privately practicing midwife (independent) you need to collaborate with an Obstetrician or GP obstetrician before being able to claim a Medicare rebate for the midwifery services provided. I might add that there is nothing in the Determination to make doctors collaborate with midwives or any benefit for doctors to collaborate.... so I am not sure why they would even consider it as we (midwives) would be competition for them in terms of financial remuneration therefore less money in their pockets..... emm not sure this will work?

If you are a midwife this seems a sort of sellout, Medicare for collaboration; However the woman is able to recoup some funds with this system therefore allowing more women this option of care....that is continuity of midwifery care and also midwifery led care;

Now as I see it there are two schools of thought......

1: If the government does not change the wording of the current determination; you go all out and say no to collaboration as it stands therefore we lose the right to a Medicare rebate and the legislation falls over; and we maintain the status quo as in the past which is no funding or rebates for women choosing private practice midwifery led care.... and it does not go before Parliament again for three years.... and if the government changes we may never have this opportunity for a long long time.... we will still have insurance requirements and regulations, that will not change.

or

2: we say yes to the collaboration as it stands, work to make it a viable option and see how and if it would work and if it does not work we then collate the evidence and go back to the politicians to lobby for changes to the determination knowing it does not work, rather than speculating that it does not work....therefore whilst we are battling for change women are able to claim a Medicare rebate for midwifery services? and Midwives are recognised for the profession that it is... which should have a medicare provider number.....and be recognised as autonomous clinicians.

Once the system (Medicare) whether it is effective now or not would be beneficial as we can work on changes....but if we never get it in place it will be years before we get back to this position and all our work up to this point would be for nothing as would of achieved nothing and the status quo remains.

What would you do in this situation?

The Homebirth debate: I want to pull my hair out!

Some arguments presented; I am working through some thoughts and decided to blog it!

I will start with the role and scope of a midwife; the midwife is the specialist in dealing with the 'normal' pregnancy & birth and recognising when things become abnormal and then refer to an obstetrician. All medium and high risk pregnancy should be seen by an obstetrician, you could have shared care or good collaborative care so that the woman can have continuity of care with her midwife whilst seeing the obstetrician.

I can see some independent/private midwives totally disagreeing with my definition of what a midwife's role or scope of practice is. However this is determined by the ANMC competency standards / Ethics / Conduct and the ANMC decision making framework. The scope of practice for a midwife is clear; that is dealing with what is 'normal'. The ACM referral guidelines are also used to guide midwives in private practice - there are recommended conditions of which women should be referred (evidenced based) and when to refer women. this document protects the midwife if followed.

The government funds a small percentage of homebirths through the CMPWA programme, therefore women can claim through medicare - this is for approx 450 women per year. The program accepts healthy low risk women and the demand is greater than what is available.

As far as I am aware there are no Midwifery Group practices in WA, which really is a tragedy, as most other states have several MGP both private a publicly funded.
I do wonder if the women who choose independent midwives know the scope of practice of a midwife and to what extent she/he can practice? and do independent midwives ever say to the women this is out of my scope of practice I am not qualified to do this? however I will support you in the hospital setting?

There are a number of independent/private midwives who practice in WA, these are separate from the government funded midwives. Independent/private midwives will have a fee for service for which women cannot currently claim through medicare. This can be limiting for women and expensive.

Interestingly like private obstetricians private midwives are not required to follow public/government policy because they are privately employed. However they are responsible to the regulatory body which for midwives is the Nursing and Midwifery Board of Australia (from October for WA).

I do understand and empathise with the woman that has been so traumatised that she just cannot face going to hospital or even seeing a doctor due to her mis-treatment, this is very real and happens all too often. Recently this was evident in the 750 submissions made by women/men when asked about maternity services in Australia. Who cares for these women? The women are so fearful they would rather freebirth.... this is a terrible reflection of the state of maternity care in Australia. We are letting these women down.

I am frustrated with the homebirth debate; on one hand you have the independent midwife who at all costs will defend the right to support a woman of her "choice" to birth at home whether she is medium or high risk (and rightly so otherwise who looks after them). They believe that the woman has the right to choose homebirth because she is well informed and knows all the associated risks with birthing at home with a risk factor, therefore has the right to self determination and the right to refuse treatment. There are health professionals who do believe the midwife should walk away from this woman in other words abandon her in labour because your registration is at risk. There are obstetricians who believe that women do not have the right to choice when they are high risk......that it is the obstetricians professional right to make the correct decision in the 'best interest of the woman and baby'.

The law in Australia does not protect this midwife when she/he works outside of the scope of practice. Unlike the UK where the midwife is protected by legislation and is not allowed to abandoned the woman..... We need this type of protection in Australia for the midwife. Currently the independent midwife works out on a limb and is not supported and alienated by the hospital system.

The problem I have with the above scenario is that the midwife is not qualified to care for the high risk woman she/he would be working out of the scope of practice, because this is not within the role of the midwife and this worries me. I am not saying our role as a midwife is not to support this high risk woman, it is to support and provide collaborative care for the risk factor associated with the pregnancy, however often doctors will not collaborate unless the woman does as the doctor suggests.......this is a lose - lose situation.

The trouble as I see it is that fundamentally women are not being heard by health professionals, they feel pressured, bullied and are often scared into submission by the health professional, therefore choose an alternative model of care this may include freebirthing (birthing without a trained health professional present). Hospitals are not flexible, they are rigid and not prepared to meet the woman half way.... it appears that's its the hospital way or the highway...and women will choose the highway.

So what is the answer?
If I sound frustrated I am?
Please tell me how we move forward?
How do we stop women from feeling alienated and force independent midwives to work outside their scope of practice?