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1 The Australian College of Midwives (ACM) thanks the Participating Midwives reference Group for the opportunity to make a submission regarding the MS Review of midwifery items. 1. Principles 1.1 Access The current requirements for midwives to meet in order to secure a Provider Number are out of step with practise and impose inequitable, unfair barriers to midwives compared to other health professionals who also enjoy access. 1.2 Endorsement to prescribe scheduled medicines The requirement to have an endorsement with the Nursing and Midwifery Board of Australia is reasonable. However, the requirement to have 5000 hours of practise in the registration standard has no relevance to the midwife s scope of practise and does not require those hours of experience to be in prescribing. At the prescribing summit held in Canberra, the pharmacist advising the CNMOs and the NMBA on nurse and midwife prescribing emphasised that authority to prescribe should relate to scope of practise only and not to experience. The scope of practise of a midwife with an endorsement to prescribe scheduled medicines is exactly the same as a midwife upon initial registration. Prescribing by a midwife for the midwife s scope of practise is not advanced practise. The only pre-requisite should currently be a requirement to complete an accredited program of study in prescribing. The profession looks to seek this additional learning to be incorporated into undergraduate programs. That the review of the registration standard for the Endorsement for scheduled medicines for midwives 1 be bought forward as matter of urgency to ensure alignment with the appropriate pre-requisites to attain a provider number. 1.3 Collaborative agreement The requirement of the midwife to enter into a written collaborative agreement. This mechanism discriminates against midwives and introduces gatekeeping by medical practitioners which is not in the best interest of the woman. It is a one-sided impost on a midwife and does not recognise the professional accountability of a midwife to collaborate when appropriate. 1 P a g e 1

2 ACM is aware that the reason given at the inception of the scheme was to enable ease of audit by Medicare around collaboration. It is a crude, meaningless measure of collaboration and should be removed. The ACM National Midwifery Consultation and Referral Guidelines and the NMBA Safety and Quality Guidelines are far superior. This unreasonable and onerous requirement has led to poor access to birth care by a participating midwife. Whilst it is recognised that States and territories are responsible for admitting rights to hospitals, this one-sided impost has created significant barriers in State and territory policy. This has minimised access for participating midwives. Its removal would reflect the primary intent of this scheme offer women more choice. It is understood that work is underway to remove this requirement for Nurse Practitioners and it should be similarly removed for midwives. That the legislation requiring written collaborative agreements be revised to remove this requirement. 1.4 Women Many women live in regional, rural and remote Australia where there are no specialist or even GPs. Women need access to maternity care close to where they live. Midwives are well placed to provide appropriate maternity care given the right access to Medicare. Consideration should also be given for vulnerable women such as those from linguistically diverse and Aboriginal and/or Torres Strait Islander populations. This is a matter of safety for the women. 1.5 Rebates for women It should be a first principle that rebates for women should be the same where the services provided are the same. Whilst antenatal and postnatal rebates are comparable, the labour and birth items do not reflect the time and are considerably out of step with GP obstetricians and specialist obstetricians attending normal birth. 2. Current items 2.1 Initial antenatal attendance (item 82100) The initial antenatal attendance is a significant event requiring extensive history taking, education and counselling. This attendance is around 90 minutes and is considerably longer than a long antenatal attendance. That initial antenatal attendance rebate be reviewed to reflect this time required by the woman. 2.2 Short and Long Antenatal and postnatal attendance Standard antenatal care requires the woman to receive at least 40 minutes of care but up to 60 minutes of care from a midwife. Further, women requiring extended support for the maintenance of breastfeeding often require support for up to 12 weeks after the baby is born. Recommendations: That item Short antenatal attendance be defined as up to 60 minutes. That item Long antenatal attendance be redefined as over 60 minutes. P a g e 2

3 That item Short postnatal attendance by redefined as up to 60 minutes. That item Long postnatal attendance be redefined as over 60 minutes. That the postnatal items cut off limit be extended to 12 weeks after the baby is born. That the rebates for women are increased to reflect this time spent is consistently proportional to time spent by GPs on antenatal and postnatal care for women. 2.3 Labour and Birth The nomenclature used to define these items is very old fashioned and implies that the women are detained. Delivery indicates that something is done to women whereas the women give birth. The two labour and birth in hospital items have a 12 hour time limit on the first item (82120) before the 2 nd midwife item (82125) can be claimed. In reality midwives have often provided several hours of labour and birth support at home prior to hospital admission but a second midwife cannot be claimed until 12 hours after admission. The rebate for this item does not reflect the continuous attendance by a midwife for the woman. It is not comparable to attendance by an obstetrician whose attendance is intermittent. Early labour support is a difficult area generally but support that is needed by many women. Spurious labour could be happening for days requiring midwifery support at home intermittently. This a question of safety for the woman who is potentially being cared for by a midwife who has been working for more than 18 hours. Consideration should be given to a one off labour support item in this instance. It could be time limited and as a once off payment for early labour support. Recommendations: That the word confinement is replaced with labour and birth and delivery is replaced by birth. That the rebate available for the women is reviewed to reflect continuous attendance by the midwife for up to 12 hours. That an additional item for early labour support be developed week Postnatal discharge item (82140) This item has a smaller rebate to the woman than long postnatal (82135) however this is usually an extensive appointment including assessment of contraception needs, referral to family GP, birth debriefing and assessment of perinatal mental health. That the rebate for this item (82140) be reviewed to ensure consistency with item Screening and Diagnostics 3.1 Pregnancy Care Guidelines Consideration should be given to expanding access to diagnostic and screening items to reflect the recommendations in the Pregnancy Care Guidelines 2. The range of careening and diagnostic tests approved and available for women in pregnancy needs to be reflected in the scope of practise of the midwife. The scope of practise of the midwife is clearly articulated in 2 P a g e 3

4 4. Referral the ICM definition of a midwife 3 i.e. The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The woman needs the midwife to have the authority to undertake the right screening and diagnostic investigations in order to make appropriate consultation and referral. This ensures that specialists have the appropriate results available when the woman presents for consultation. It also prevents unnecessary additional consultations with a specialist thus not inconveniencing the woman and saving costs to Medicare. That the screening and diagnostic items available to participating midwives reflect the requirements of the Pregnancy Care Guidelines. 3.2 Public hospitals South Australia has progressed implementation of a program to enable endorsed midwives to prescribe in public hospitals4. Participating midwives should be able to prescribe and order screening and diagnostic tests as employees of public hospitals. This would save considerable time for junior doctors and circumvent the custom and practice of doctors leaving signed forms available for midwives or signing forms without knowing anything about the woman. That participating midwives be enabled to order screening and diagnostic tests as employees in public hospitals. Under the Regulation 2 of the Health Insurance Regulations 1975, a midwife can make a referral to a paediatrician or to an obstetrician if the referral arises out of a midwifery service provided by the midwife. The midwife also assesses perinatal mental health and physical wellbeing in terms of the impacts of hormones on joints and tendons and nutrition. In labour, a woman will request an epidural for pain relief. The midwife should be able to refer the woman to an anaesthetist for both an antenatal planning session and for an epidural in labour. That the regulations be revised to allow midwives to refer to an anaesthetist, psychologist and allied health professionals such as physiotherapists, acupuncturists, chiropractors and dietitians artment+of+health/system+performance+division/nursing+and+midwifery+office/nursing+and+mid wifery+professional+practice/nursing+and+midwifery+advanced+and+extended+scope+of+practice P a g e 4

5 5. Additional considerations 5.1 Homebirth There are clear safety and quality guidelines for midwives attending birth at home, and midwives have undergone extensive audit procedures by the NMBA to ensure compliance. As the recommendation is for 2 midwives in attendance, the rebate for the woman should be sufficient to reflect this expectation. That the labour and birth items be extended to cover birth at home. 5.2 Parent education Midwives spend much time providing parent education for groups of women with their partners over 2 to 3 hours each week. This education not only provides the woman with essential information but also builds her confidence in birthing and in parenting. It is a service needed by the women. It could be limited to a number of events such as four or the antenatal items could be enhanced to reflect this. That consideration be given to an item that includes parent education. 5.3 Perinatal Mental Health Midwives currently include screening for domestic violence and perinatal mental health within their practise. Consideration should be given to the additional input required of midwives when women disclose domestic violence or have perinatal mental health issues. That the new perinatal mental health items for GPs be extended to participating midwives. 5.4 Independent Hospital Pricing Authority (IHPA) In 2017, the IHPA undertook an extensive project to progress the development of a bundled efficient price for maternity care provided by a public hospital which incorporated four antenatal visits, in hospital labour and birth and two postnatal home visits. The components were based on current practice and not on the evidence base for continuity of carer or postnatal support in the community. The advantages of a bundled price as a funding mechanism for public hospitals includes the creation of equitable care being provided. The development of any bundle of maternity care for women as a Medicare item requires consultation with the industry and expansion of the antenatal and postnatal elements. That work be undertaken to explore the benefits of an additional bundled Medicare item for continuity of carer through the continuum of care. 5.5 Complex care There are no antenatal or postnatal items appropriate for extensive consultations if there are significant investigations or treatment required for example investigation of reduced fetal movements antenatally or providing extensive breastfeeding support postnatally. Sometimes several hours are needed for thorough investigation and possible consultation and referral perhaps leading up to admission to hospital. P a g e 5

6 That consideration be given to one off extended antenatal consultation item and extended postnatal consultation item with specific requirements reflecting the management of complexities. P a g e 6