Monday, October 4, 2010

The Determination and what it means for women in Australia

What is the determination?
For a woman to access Medicare rebates for midwifery care, her midwife must have a collaborative arrangement in place. This is required under the Medicare for Midwives legislation which was passed by Parliament earlier this year. The National Health (Collaborative arrangements for midwives) Determination 2010 is the regulation defining what the phrase “collaborative arrangements” actually means.

The determination was made on 14 July 2010 and says that a collaborative arrangement must be one of the following:
    •    A midwife is employed by an obstetrician; or
    •    An obstetrician or GP obstetrician has referred a patient to a midwife; or
    •    A midwife has a written collaborative agreement with an obstetrician or GP obstetrician that covers one or more patients; or
    •    A midwife has recorded in a woman’s clinical notes the name of the obstetrician or GP obstetrician who will be collaborating in the woman’s care and evidence that the practitioner has acknowledged that they will be doing so.

What are the problems with the determination?

Throughout the reform process Maternity Coalition has expressed our strong concerns about the requirement for collaborative arrangements. MC is disappointed that the details around collaborative arrangements now provide that women’s access to medicare funded care is effectively subject to medical veto.

Essentially each of the options for a collaborative arrangement requires a doctor to approve a woman’s care in order for her to have access to medicare rebateable care. It also means that a doctor can revoke that permission at any time during the woman’s maternity care. This means that doctors can control whether midwives can compete with them in the maternity care marketplace.

Maternity Coalition believes that midwives must be directly accountable to their clients and not to another health professional. Women must be able to make free, informed decisions about their maternity care in consultation with their primary care provider. They should not have to fear that an obstetrician or GP/obstetrician (who may well not be someone they have chosen to engage) will withdraw their consent to their care and therefore their access to Medicare funding.

Maternity Coalition’s position on what should be done about the determination.
Maternity Coalition encourages consumer and midwifery advocates to lobby for changes to the determination and pursue the introduction of a motion to disallow the determination early next year. This would give us the opportunity to debate and document the failings of the determination in Parliament. This may help to put pressure on the Government to make public commitments around its intentions with the legislation.   

The determination does not need to be passed by Parliament in order to take effect - it is is already law. The determination is required to be tabled in Parliament and this was done on 28 September 2010.

Now that the determination has been tabled in Parliament there is a period of 15 sitting days in which a member of either house (usually the Senate) can give notice of a motion to disallow it. Those 15 sitting days don't run out until next year. The motion must then be resolved (voted on or withdrawn) within a further 15 sitting days. Unless a motion to disallow is made Parliament will have no role in reviewing, debating or voting on the regulation.

The determination is in effect during this time and we will have some time to see how it will actually work in practice. This option requires us to work very hard over the upcoming months to document the failings of the determination and the problems that it creates for women.

What can you do?
1.    Keep MC informed about your experiences of “collaborative arrangements”.

A key part of our work over the coming months will be to document women’s experiences of how this is working. We know that a number of women will choose not to access Medicare funded care under such restrictions. We do however want to document what is happening when women try to access Medicare funded midwifery care. We encourage you to communicate directly with hospitals about collaborative arrangements and visiting rights for midwives. MC is working on developing processes for collecting this information but in the meantime you can email
2.    Email the PM and ask her to act to remove the medical veto over women’s choices.

A number of women managed to speak directly to Julia Gillard about this issue during the election campaign. Ms Gillard indicated on a number of occasions that she would look into the issue further. Now is the time to let Julia Gillard know that the women she met during the campaign represent hundreds more who are unhappy about this issue.  You can email the PM here.

You can find some information to help you on the Maternity Coalition website under the heading “Remove the Medical Veto”.

    3.    Please let us know if you live in the Federal electorate of Lyne (Rob Oakeshott), New England (Tony Windsor), Kennedy (Bob Katter)  or Denison (Andrew Wilkie)

These key independents will play a crucial role in the life of the current Parliament and it is important that they understand how important these issues are for rural (and other) women. If you live in one of these electorates please email to let us know.
4.    Email your local state MP

For the reforms to offer any additional options to women state governments will have to show strong leadership. Hospitals need policies and processes to enable them to enter collaborative arrangements with eligible private midwives, and hopefully to enable women to have continuity of care from their chosen midwife for hospital birth.

Please write to your local MP at a state level and ask what your state government is doing to facilitate independent midwives entering into collaborative arrangements with public hospitals and to ask what they are doing to make continuity of care an option for more women.
You can find more information about these issues here.

I want to birth in hospital - how will the determination affect me?    

If you want to birth in a hospital with a midwife in private practice and you want to access Medicare rebates, your midwife will have to have visiting rights at the hospital where you wish to birth and your midwife will also need to have a collaborative arrangement in place.

We encourage women to communicate directly with hospitals about collaborative arrangements and visiting rights for midwives. Please let Maternity Coalition know how things go, and be prepared to ask your Members of Parliament for help if you are unsuccessful getting the care you want.

I want to birth at home - how will the determination affect me?
If you want to access Medicare rebates for antenatal and postnatal care (there is no Medicare available for intrapartum care at home) then your midwife would need to be eligible for Medicare, and have a collaborative arrangement in place. If you do not wish to access Medicare then this does not apply – you do not need to have permission from a doctor to have a homebirth.

You may need to ask your local public hospital to collaborate with your midwife so that you can receive Medicare rebates.  Again, please let Maternity Coalition know how things go, and be prepared to ask your Members of Parliament for help if you are unsuccessful getting the cooperation of your hospital.


    I am pleased to read the MC document after reading various comments summaries and discussions about the Determination. This summary consolidates for me the problems and provides a solution. The content cements my view that women who are the choosers ought to
    (a) collect the information and (b)document evidence of or lack of co-operation by the medical profession with regard to:
    (i) back up with a hospital
    (ii) back up with a doctor
    (iii) provision of access rights for the known midwife when transferred

    I trust that when the survey facility is available on line it will have ease of access to be able to document this evidence.

    I am of the opinion that when we understand the convoluted process of this legislation we will be able to use it to suit the needs of midwives and to enable choice for women.

    We have until the end of January to gather evidence to support our view that the prescriptive rules imposed in this legislation need to be altered or deleted in order to be workable.

    All of us need to come together to agree on that and what those changes should be. I already sense that that has happened - a positive move has occurred in thinking. There is nothing any of us can do to alter anything until near the end of January next 2011. We can agree to that.

    We ought to agree that one or two people are not able to speak for us until we as members of combined individual organisations have been provided with an opportunity to say what we want as midwives and as women.

    Close to 1500 respondents in one survey have stated they will not comply with the prescriptions in this legislation.

    A survey of members with questions specific to the legislation ought to be carried out by ACM APMA CHILDBIRTH EDUCATION CRANA HBA MC as an allied group survey. That is asking a lot but unlike the writing of the AMA there is a pool of excellent and experienced people who should be able to contribute 'core and non core' questions.

    1. Transparency and public sharing of results would be required in order to demonstrate collegiality and unity of purpose to the government.

    2. The government needs to be firmly convinced that we all agree that women are entitled to claim Medicare for the whole of birth with a known midwife.

    3.We also need to agree that the government must allow the woman to choose place of birth and her carer/s.
    4. We must all agree that the practice of the midwife is guided by the International Confederation of Midwives.
    5. The government must be educated to recognise the similarities and differences between the midwife and the medical profession and how giving birth is valued
    6 The government needs to be aware that the medical profession's role is supplementary and only necessary to assist in a medical capacity when the midwife and woman decide the process has moved from normal to abnormal and transfer is in the best interests of mother and baby.

  2. Note that the consumer/client is almost invisible in the Determination, and is referred to as the 'patient'. Ladies, you have been put in your place!

    Maternity Coalition is well positioned to stand up for both consumers and midwives - not separately, but as a unit. We need that partnership.

    Midwives are now approaching public hospitals requesting a process for visiting access/clinical privileges, and setting up a database of responses. We will, of course, share this information as it becomes available.

    A link from this blog to the Midwives in Private Practice blog would be appreciated. MiPP members are all members of MC.