Collaboration or control? Midwifery and Obstetrics

SOME very positive recommendations for women and midwives have come from the National Maternity Services Report.

One essential outcome was the extension of the Medicare Benefits Schedule and the Pharmaceutical Benefits Schedule to eligible midwives in November 2010. This supports the full contribution that midwives can make to maternity care in urban, rural and remote areas and provide women with real choices.

Despite the positive recommendations, the last-minute insertion of the “Determination” — known as the National Health (Collaborative arrangements for midwives) Determination — could hinder Health Minister Nicola Roxon’s good intentions for maternity reform.

US President Barack Obama said: “A good compromise, a good piece of legislation, is like a good sentence; or a good piece of music. Everybody can recognise it. They say, ‘Huh! It works.’ It makes sense.”

The collaborative arrangements for midwives certainly get no “Huh!”. Six months into the new era of maternity care. The era where midwives can provide Medicare rebatable services to women. It is very apparent that few private obstetricians are willing to collaborate with midwives.

Apparently, there are currently three in Australia.

Midwives always feared that they would use these arrangements to try to control midwifery practice. It would give an impact on women’s childbirth choices. For instance, to refuse to collaborate if a woman chooses to give birth at home.

Of most concern is the effect of these collaborative arrangements on women living in rural and remote communities. Communities where there may be no doctors at all or doctors on short-term contracts with whom midwives must constantly try to negotiate.

There is now a real risk that midwives will not be able to take up the government’s reforms, so they are doomed to fail.

Women are not at the heart of these considerations. Rather, medical practitioners, political bastions and hip pockets hold ultimate sway.

I have just returned from the US, where similar requirements for collaborative arrangements that have been in place for the past 15 years are now being successfully overturned. I wonder why we seem unwilling to learn from the mistakes of others.

There were three ramifications of the US collaborative arrangements that led to an untenable situation. First, it was obstetrician specific, so when a supportive obstetrician retired or moved elsewhere, this left midwives high and dry.

Second, insurance companies put pressure on obstetricians. They threatened to increase premiums if the doctors took on what the insurers considered an increased liability risk.

Third, when midwifery practices became successful and threatened obstetric incomes, obstetricians withdrew from the collaborative arrangements. In New York last July, just as Australian midwives were forced to accept this untenable piece of legislation, the Midwifery Modernization Act was signed into law. This overturned the collaborative arrangement requirement for New York midwives.

Fifteen other US states have overturned similar legislation and other states are now following suit.

Why were these laws put in place in the US in the first place? The answer is political expediency — it got midwifery reforms in and placated the medical profession in order to enable progress. Except it ultimately impeded progress and stifled midwifery as a profession.

US midwives and women were able to demonstrate successfully that this arrangement led to less safe care. Also it was anticompetitive in nature, enabling one competing profession to restrict and dictate the trade of another.

Collaboration is, of course, a very fine and commendable part of safe maternity care, which midwives support wholeheartedly. None of us is an island in health care, and safe care is dependent upon our mutuality.

I was part of the NHMRC Collaborative Guidance Committee that produced a very fine document in 2010.

The document outlining the principles of effective collaboration — without signed agreements. We defined collaboration as “a dynamic process of facilitating communication, trust and pathways that enable health professionals to provide safe, woman-centred care”.

Trust is at the heart of collaboration, along with respect. A signed agreement with a doctor cannot force this into place. Practice and professional regulatory obligations are already in place. Examples of such is the Australian College of Midwives consultation and referral guidelines. These guide midwives as to when to consult and refer.

Internationally, the definition of a midwife says “The midwife is recognised as a responsible and accountable professional …”

So are the collaborative arrangements about collaboration or control?

The success or failure of these reforms inevitably will provide the answer. Sadly, while the professions are at war it is women who will miss out.

Originally posted 18th June 2011