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Concern grows over collaborative arrangements

Midwives fear doctors will have final say on women’s choice, writes Annie May.

Midwives are fuming over new laws that will give doctors a veto over women’s choice, calling for them to be scrapped once parliament returns.

From 1 November, midwives will be able to provide Medicare funded care to women in the community and in hospitals as part of a number of maternity reforms announced last year by Health Minister Nicola Roxon.

But in a change to the legislation, doctors will now have the final say on whether midwives can access the rebates.

In July, Roxon signed off on a determination defining collaborative arrangements, confirming the fears of midwifery and nursing groups that Roxon would cave to pressure from doctors.

The options for collaborative arrangements include acknowledgement by a named doctor that the “practitioner will be collaborating in the patient’s care, and that the named doctor receives copies of a hospital booking letter, maternity care plan and a discharge summary at the end of care.

Each option effectively makes women’s access to MBS rebates for midwifery care subject to approval from a specified medical practitioner, said Lisa Metcalfe, Maternity Coalition national president.

“The definition of collaborative arrangements leads to a range of problems, and don’t improve safety, access or continuity for Australian mothers,” she said.

“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 cost shifting maternity care to MBS through the gradual development of midwifery models.”

Associate Professor Hannah Dahlen, president of the Australian College of Midwives, said the requirements were of real concern.

“We are yet to see whether doctors will be willing to collaborate with midwives and whether they will use this arrangement to try and control midwifery practice and impact on women’s childbirth choices,” she said.

“We know that women and their babies experience measurable benefits from one-to one care from a midwife but midwives now can’t take up this historic opportunity to provide Medicare services without a collaborative arrangement with a doctor or doctors.”

The potential ramifications, said Dahlen, include reduced choice for women if doctors veto options such as vaginal birth after caesarean or homebirth, and added risk as women may refuse to engage with maternity services when needed. Midwives could also feel pressured into practices women don’t want, she said.

“We are most concerned about the effect of these collaborative arrangements on women living in rural and remote communities where there may be no doctors at all or doctors on short term contracts that the midwife will constantly be trying to negotiate with. There is a real risk now that midwives will not take up the government’s reforms and they will fail,” she said.

The ACM will be watching the impact of this legislation closely and are asking members to report any cases where the medical profession uses the arrangements to “control midwifery practice or deprive women of choice”.

The Greens spokesperson for Health, Senator Rachel Siewert has pledged to move a motion to disallow the collaborative arrangements regulation as soon as Senate resumes.

“Not only do the Greens think a more collaborative and integrated model of practice is possible – it is absolutely necessary,” Siewert said.

The new government needs to listen to women, said Metcalfe.

“Women have clearly communicated their concerns about this issue. They have attended numerous meetings and briefings, sent hundreds of letters and submitted a record number of submissions to Senate inquiries. Despite this, women’s interests appear to have been ignored in favour of doctors. The government must recognise that women are the key decision makers in their maternity care - not clinicians,” she said.

“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.”

The Maternity Coalition has called for the following points to be addressed.
• that the requirements for permission from a doctor be removed from the Medicare for midwives legislation (collaborative arrangements for midwives), thus ensuring that women’s choices are protected;
• that women's rights to informed consent (including right of refusal) are expressly recognised in all codes, guidelines and frameworks relating to midwifery practice;
• that a long-term solution be sought for women to continue to have access to midwife-attended homebirth;
• that the federal government provide strong leadership to ensure jurisdictions provide mechanisms for visiting rights for midwives in public hospitals.

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