Answer to homebirth question

Bruce Teakle, Maternity Coalition National Committee Member, recently answered a question in response to the update on the MC webpage, around what it all means for women due next year who want to birth at home with a midwife....

In answer to a question about what this means for women due next year:

Midwives need to buy PI insurance.

Women planning a homebirth after 1 July 2010 will need to find a private midwife who has purchased insurance. As many people will be aware already, the new national health practitioner regulations require all health practitioners from 1 July 2010 to have professional indemnity insurance.

Midwives currently have 2 choices in insurance:

1. The insurance policy sold by Mediprotect is only for antenatal and postnatal care. It is relatively low cost (starting at under $2000/year) and does not have specific requirements regarding eligibility or collaboration. The Mediprotect website (www.mediprotect.com.au ) gives some information about the policy.

2. The insurance policy sold by MIGA is subsidised by the Commonwealth Government, and is available only to "eligible midwives" according to the standard set by the Nursing and Midwifery Board of Australia. It is much more expensive than the Mediprotect policy, starting at $5000/year for up to 29 births/year ($2250/year if not providing any intrapartum care in private paractice) and covers births in hospital. Comprehensive information about the policy is available from the MIGA website (www.miga.com.au ), including the policy document which lists requirements for "collaborative arrangements". These requirements include the midwife's responsibility to share certain information with a doctor or hospital.

There may be major differences in what each of these policies cover, so it is important for midwives to carefully consider their choice.

MIGA insurance requires "collaborative arrangements" or "communication of a care plan"

The requirements for "collaborative arrangements" in the first released version of the MIGA policy were problematic, requiring acknowledgements from hospitals of intent to collaborate in women's care, and receipt of the woman's care plan and test results. The policy was amended in response to midwifery and consumer feedback, and now makes allowance for insurance when hospitals are not collaborative (or haven't yet developed processes for collaboration).

Now the minimum requirement is for midwives to send a copy of each woman's care plan to the hospital, and confirm that the hospital has received it, and send other items of information about the woman's care to the hospital. This is of course subject to the woman's consent.

An update about this is provided at the MIGA website (www.miga.com.au ).

Services from "eligible midwives" will receive Medicare rebates

The good news is that from 1 November 2010, there will be Medicare rebates payable for the services of eligible midwives in private practice, subject to certain conditions. Rebates for midwifery services will be paid for specific "items" or types of visits with a midwife, in the same way as visits to doctors. Currently intrapartum (labour and birth) care at home is not rebatable, but antenatal and postnatal care for a woman planning a homebirth can be. The $ value of rebates is expected to be published soon, but midwives can be expected to usually charge more than the rebate for each service. These rebates, plus any Medicare Safetynet payments, will make care from eligible midwives significantly cheaper for women.

Midwives will need "collaborative arrangements" with doctors or hospitals

The conditions for Medicare rebates include the requirement for each rebatable item of care to be provided under a "collaborative arrangement" with a doctor. These requirements are listed in detail in the MIGA insurance policy, and are expected to become regulations to the Medicare for midwives law any day now. "Collaborative arrangements" require midwives to gain agreement from a doctor to collaborate with them in the woman's care. They also require women to book into a hospital, even if only as a backup plan.

For women planning a homebirth, the collaborating doctor can be expected to be a doctor authorised by a public hospital to enter such an arrangement. We now have 4 months for health departments and hospitals to work out what this means, and how they will do it. We don't expect it to be easy, especially to begin with, for midwives to gain agreement from hospitals on collaborative arrangements. We hope that state health Ministers and Departments work hard until November setting up policies, processes and expectations of public hospitals about collaboration with eligible midwives.

Women may need to be a bit pushy

While Australia's hospital systems are learning to collaborate with midwives in private practice, there is likely to be some extra work to do. Women planning a homebirth with an eligible midwife, and wanting to receive Medicare rebates for their care, may have to approach their hospital themselves to ask them to agree to collaborate in their care. If they don't get the right answer, they may need to escalate their efforts by asking the hospital administration to assist, and if that is unsuccessful escalating the matter further. Maternity Coalition, the Australian College of Midwives, state Members of Parliament and state health complaints agencies need to know about hospitals which refuse to collaborate with private midwives.

In the longer run

The establishment of private midwives as part of the health care system is a major reform. While it is currently very stressful for midwives and for many women, it will also have a big and (hopefully) positive effect on hospital culture and systems over time.

In time, we expect that processes will be established in some places to allow women to have continuity of care from their chosen midwife for hospital birth. This will be a significant challenge for hospital systems, and there are various options for how this might happen.

Good luck!

Bruce Teakle

Maternity Coalition National Committee Member