AUSTRALIAN COLLEGE O F MIDWIVES INCORPORATED
REPORT AND RECOMMENDATIONS FROM THE JOINT BIRTH CONSULTATIVE COMMITTEE The Report and Recommendations f r o m theJoint Birth Consultative Committee is now before the members of the three Colleges who participated in its formulation. The State delegates of ACMI have been requested to disseminate this report at Branch level and elicit responses f r o m the membership.
equivalent qualifaction and /or training are appropriate providers of maternity care to a level d e p e n d e n t u p o n their training, experience and geographic circumstance.
I would therefore ask all members to read this report and send comments to the National Office before December 31, 1992.
8. The recognition that Specialist Obstetricians may manage any pregnancy, but that they are m o s t efficiently utilised in the care of w o m e n with complications or as a consultant to other care givers.
It is envisaged that further dialogue between the three College Executive will takeplace during December a n d following this meeting thef i n a l report will bepresented to appropriate Government Departments.
9. Further d e v e l o p m e n t o f c o m m u n i c a t i o n , rapport and trust between Midwives and Medical Practitioners at all levels o f maternity care.
Lorraine Wilson Editor
10. Each p r o f e s s i o n a l g r o u p recognises a n d acknowledges the special knowledge and skills of each g r o u p involved in maternity care.
Summary Summarised below are the necessary elements in the models of maternity care r e c o m m e n d e d by the Joint Birth Consultative Committee.
11. An acceptance that g o v e r n m e n t authorities responsible for health care provide the necessary financial resources for the models of maternity care r e c o m m e n d e d by the Joint Birth Consultative Committee of the Australian College of Midwives Inc., The Royal Australian College of General Practitioners and The Royal Australian College of Obstetricians and Gynaecologists.
1. The p r o m o t i o n of childbirth as a healthy life event for the majority of w o m e n , w h e r e the individuality of each w o m a n is recognised. 2. Stress the safety and well-being of mothers and babies as being of p a r a m o u n t concern. 3. The availability of safe options of care for all women. 4. The p r o m o t i o n of the c o n c e p t of shared responsibility, accountability and involvement in decision making b e t w e e n the w o m a n , her partner or support persons and the service providers. 5. The provision of quality care which is sensitive to w o m e n ' s varying needs, i.e. social-cultural, emotional and physical. 6. The recognition that midwives working with recognised medical support are appropriate care givers in normal pregnancy and are appropriate m e m b e r s of a team w h e r e complications develop or exist. 7. The recognition that General Practitioners, holding the Diploma in Obstetrics RACOG or DECEMBER 1992
12. Support for the accreditation of appropriately qualified individuals, w h e t h e r Midwives, General Practitioners or Obstetricians, to hospitals within their service area.
Introduction Over several meetings, and after consultation with professionals and consumers interested in maternity care, the Committee reached consensus on four models of maternity care w h i c h it believes are acceptable to all c o n c e r n e d and has agreed on recommendations which would assist in the further d e v e l o p m e n t and s m o o t h implementation of these models. The models of care are: a. Midwifery Care in which the pregnancy, having b e e n screened to establish low risk, is managed by a Midwife or team of Midwives in a hospital or appropriate setting with established medical support. ACMIJOURNAL
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AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
b. General Practitioner Obstetric Care in w h i c h normal and low risk pregnancies are managed by a General Practitioner Obstetrician. Notwithstanding this, it will be appropriate, particularly in rural areas, for General Practitioner Obstetricians to manage pregnancies of higher risk, according to their degree of training and experience, and in accordance with the guidelines of the Joint Consultative Committee of The Royal Australian College of Obstetricians and Gynaecologists and The Royal Australian College of General Practitioners (JCC). c. Specialist Obstetric Care in w h i c h at risk or normal pregnancies are managed by a Specialist Obstetrician. d. Shared Care in which the maternity care is shared by the General Practitioner Obstetrician and the Specialist Obstetrician and the Midwife in a variety of situations. The overall emphasis for all models is on the safety and quality of care for w o m e n , the woman's right to exercise i n f o r m e d choice regarding that care, and support for the w o m a n in her choice. Two meetings, 'Birth 2000', were held in Melbourne and Sydney in an attempt to consult with the relevant interest groups about these models and provide an o p p o r t u n i t y for dialogue amongst varying types of participants, including professionals ranging f r o m Specialist Obstetricians to rural General Practitioners, to Midwives f r o m all spheres of practice, G o v e r n m e n t representatives and consumers. Through this process the strengths and weaknesses of these different models and strategies for implementation or i m p r o v e m e n t of the various models were discussed. There was seen to be a n e e d for an i m p r o v e m e n t in attitudes and c o m m u n i c a t i o n skills of all practitioners involved in maternity care. There is also a need for improved communication between professionals and the public they serve, together with heightened public awareness and understanding of the safe options o f birth available to them. Concern over medico-legal issues relating to all models of care and responsibility of the professionals involved, particularly w h e r e transfer of care occurs, continued to be expressed. PAGE 4
ACMI JOURNAL
In developing recommendations, b o t h general and specific, it was pertinent to examine the strengths and weaknesses of the models of care and the strategies for improvement within the models. These are reviewed b e l o w and the r e c o m m e n d a t i o n s follow. Models
of Care
a. M i d w i f e r y care: Midwives are ideally placed to function as primary health care professionals. Their sphere of practice has b e e n clearly articulated and agreed at international levels by midwives, their obstetrical colleagues and the World Health Organisation.
That practice may occur in hospital based maternity services, birthing centres, designated hospital beds for midwives, and c o m m u n i t y based or visiting midwife services. Midwives emphasise the physiological 'wellness' m o d e l of care, but are also able to detect the deviations from normal in m o t h e r and child and procure appropriate medical referral. Midwives have a p h i l o s o p h y of e m p o w e r i n g w o m e n to give birth naturally and can provide continuity of care within certain boundaries. An a b u n d a n c e of midwifery expertise is located geographically close to families, thus providing family centred care in m a n y roles associated with birthing. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.1 There is a p o o r understanding by the public of the availability and advantages o f this model.
1.2 Accessibility to this m o d e l is at present time limited. 1.3 There is sometimes a difficulty in clearly defining accountability w h e n transfer occurs from this m o d e l of care to a medical practitioner model. 1.4 Quality of care m a y be a p r o b l e m w h e n it is difficult for Midwives to gain the experience necessary for c o m m u n i t y practice. S t r a t e g i e s to i m p r o v e t h i s m o d e l o f c a r e include: 2.1 The establishment of trust, support and comm u n i c a t i o n b e t w e e n midwives and o t h e r maternity care providers. DECEMBER 1992
AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
2.2 The provision for Midwives to access hospital services. 2.3 Fostering of education in the c o m m u n i t y as to what the midwifery m o d e l can offer. 2.4 E n h a n c e m e n t o f o p p o r t u n i t y for appropriate continuing education, c o m p e t e n c y developm e n t and maintenance of competencies for registered midwives. 2.5 Provision of increased funding from health authorities for implementation of midwifery models of care. 2.6 Examination and negotiation of mechanisms to enable midwives to order agreed routine ancillary tests, prescribe authorised medications and initiate referral processes to a General Practitioner Obstetrician or Obstetrician in the m a n a g e m e n t of pregnancy. 2.7 Rebates from Medicare and private health funds for a range o f midwifery services he negotiated.
1.5 Potential medico-legal p r o b l e m s and the additional cost o f medical i n d e m n i t y insurance associated with this m o d e l m a y discourage general practitioners f r o m providing maternity care. 1,6 There is a constant pressure, such as present health insurance trends, which causes loss of patients to hospital units u n d e r the Medicare structure. Strategies to improve this model of care include: 2.1 Raise the awareness of this m o d e l of care amongst the other health care professionals.
2.2 Raise c o m m u n i t y awareness of the role of the General Practitioner in maternity care by public education. 2.3 Improve the training for General Practitioners in maternity care in b o t h the urban and rural environments. 2.4 Provide appropriate remuneration.
b. G e n e r a l P r a c t i t i o n e r O b s t e t r i c Care: General practitioners are the p r e d o m i n a n t group providing ongoing, comprehensive, whole family primary care to the Australian community, as such they are also ideally placed to practice low risk obstetrics and are committed to the natural birthing process. It can broaden the c o n s u m e r ' s choice, for example with ethnic w o m e n , and provides an effective use of economic and m a n p o w e r resources, together with the appreciation of medical and social p r o b l e m s and a knowledge of the local resources available to the pregnant woman. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.1 There is a lack of hospital access at the present time for c o n f i n e m e n t of w o m e n b y General Practitioners.
1.2 The Gencral Practitioner/Obstetrician may be held in low esteem b y the consumer. 1.3 There is a particular stress on rural General Practitioners practicing obstetrics in geographic and professional isolation. 1.4 2'he Practitioner may have difficulty in providing a l o c u m for his/her maternity practice to allow time for recreation and education. This particularly applies to rural doctors. DECEMBER 1992
2.5 Initiate changes in the health insurance system. 2.6 Reduce the prohibitive cost of legal indemnity premiums. 2.7 I m p r o v e d c o m m u n i c a t i o n needs to o c c u r with colleagues, other health professionals and consumers. c. S p e c i a l i s t O b s t e t r i c Care: The features of specialist care are the high educational standards required to reach specialist status; m a n d a t o r y recertification o f the Specialist Obsmtrician; and expertise in high risk maternity care. There is a popular c o n s u m e r choice for this model. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.1 It is difficult to sustain the availability o f this m o d e l on a large scale due to geographic and e c o n o m i c limitations,
1,2 Lifestyle stress for the obstetrician and his/her family. 1.3 Inadequate health insurance rebate. 1.4 This m o d e l m a y be perceived as polarising towards a state of illness rather than normality. ACMI JOURNAL
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1.5 May be perceived to be wasteful o f skills and training w h e n Specialist Obstetric Care is used p r e d o m i n a n t l y in m a n a g e m e n t o f low risk pregnancies. S t r a t e g i e s to i m p r o v e t h i s m o d e l o f c a r e include: 2 . 1 E n c o u r a g i n g practice at a level of care, appropriate to the specialist's training and skill. 2.2 Education to improve communication skills and appreciation o f social and c o m m u n i t y issues. 2.3 Further consideration o f medico-legal impedim e n t s to practice, 2.4 Seeking out ways to p r o m o t e and ensure mutual recognition amongst professionals.
1.5 Lack o f a recognised formal m e t h o d of equitable division of remuneration amongst participants. 1.6 Difficulties in the interaction between colleagues w h e r e there is not always the same recognition of ability and trust amongst professionals, S t r a t e g i e s to i m p r o v e t h i s m o d e l o f c a r e include: 2.1 Its use should be limited to situations w h e r e the w o m a n would clearly benefit. 2.2Written acceptable guidelines professionals involved.
for
all
2.3 C o m m u n i c a t i o n and co-ordination within the professional team, 2.4 A clear limit to the n u m b e r of caters.
2.5More specialist input into health policy in the community.
2,5 C o m m o n record system held by the consumer.
2.6Multi-disciplinary quality assurance c o n s u m e r involvement should occur.
2.6 Active support and encouragement for improved collegiate relationships within the health teams involved in maternity care.
with
2.7 I m p r o v e d c o m m u n i c a t i o n by the provision of accurate and accessible information and involvem e n t of the c o n s u m e r in decision making.
Recommendations
2.8 Better access for high risk patients to hospital clinics.
Recommendations management:
relating to institutional
It is r e c o m m e n d e d : d. S h a r e d Care This type of care ensures continued convenience for consumers and a choice of the health care providers, particularly for those with specific needs, and can provide a cost effective form of care. There can be an agreed plan o f care b e t w e e n the w o m a n and her medical practitioners, general practitioner and specialist and/or midwife, and support can be available f r o m a multi-disciplinary team if required. Collaborative models of care b e t w e e n midwives, g e n e r a l p r a c t i t i o n e r s a n d o b s t e t r i c i a n s are increasing, These arrangements could be enhanced a n d e x p a n d e d to p r o v i d e s a t i s f a c t i o n for professional care givers and i m p r o v e d maternity services. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.2 Inappropriate use o f the model. 1.3 Discontinuity of care. 1.4 Potential for b r e a k d o w n in communication. PAGE 6
ACM1JOURNAL
1. That M a t e r n i t y M a n a g e m e n t C o m m i t t e e s in health areas and/or institutions be d e v e l o p e d
(a) Institute and/or support models of maternity care as r e c o m m e n d e d by the Joint Birth Consultative Committee.
(b) Upgrade present hospital birthing environments to provide aesthetically appropriate and safe areas for labour and delivery,
(c)
Facilitate attitudinal changes amongst care givers to the models o f maternity care.
(d) Institute Accreditation Committees to develop guidelines for birth practitioners at all levels; incorporating collegiate guidelines for care, (for example the ' R e c o m m e n d e d Guidelines Relating to Hospital Access and Delineation of Clinical Privileges in Obstetrics for General Practitioners' the Joint Consultative Committee of the RACOG and RACGP). DECEMBER 1992
AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
(e) Promote appropriate and accessible childbirth education for all women.
R e c o m m e n d a t i o n s Relating to Quality Assurance:
2. That systems o f quality assurance and p e e r r e v i e w be d e v e l o p e d to:
1. QA as an e s s e n t i a l p r o f e s s i o n a l activity:
(a) Involve all maternity care practitioners. (b) Monitor all aspects of maternity care, including change of professional treatment and evaluation of such care.
3. That c o n t i n u i n g e d u c a t i o n p r o g r a m m e s be p r o v i d e d which: (a) Are multi-disciplinary, e.g. seminars/workshops.
(a) T h a t all those c o n c e r n e d with maternity care should be involved in formal quality assurance programmes, which are designed specifically to suit the particular model of care and the environment in which it operates. (b) That accreditation of all providers o f maternity care involved in an institution be linked to their participation in an appropriate QA programme.
(b) Include involvement with administrative bodies and consumers.
(c) That QA programmes should be multidisciplinary and, where appropriate, should include input from consumer groups.
(c) Provide a forum for education and discussion of legal issues.
2. Education in the area o f QA in m a t e r n i t y care
Recommendations Issues:
(a) T h a t
Relating to Education
1. Undergraduate and Postgraduate Education: (a) TheJBCC recommends that the Colleges jointly conduct a review of the teaching o f maternity care in Undergraduate and Postgraduate Education.
2. Continuing Education (a) T h a t the individual Colleges invite members of other Colleges to participate in as many o f their ongoing education activities as is reasonable/ appropriate. For example: (i) The State Branches of the Australian College o f Midwives conduct annual conferences to which other Colleges be invited. (ii) The Australian College o f Midwives also conducts a Biennial Conference, with involvement from the other Colleges.
educational institutions offering undergraduate education in medicine or nursing, or postgraduate education in obstetrics or midwifery, be surveyed to establish the place of education about QA in their curriculum.
(b) T h a t , tbllowing the collection of data o n existing activity in this area, the Colleges should develop guidelines for undergraduate and postgraduate education in the area o f quality assurance in maternity care.
(c) T h a t the Colleges sponsor continuing education programmes in the area of quality assurance in maternity care for the members o f all three Colleges.
R e c o m m e n d a t i o n s Relating to Legal Issues S u r r o u n d i n g Maternity Care: The following recommendations are made:
(b) That continuing education points, or quality assurance acknowledgment (RACGP), be allocated by the Colleges for attendance at such programmes.
1. T h a t the care o f pregnant w o m e n should be the joint responsibility amongst those involved. This responsibility should be shared between the Obstetrician, General Practitioner Obstetrician, Midwife, the hospital, the system, the pregnant w o m a n herself and her partner. Each individual should be accountable for his/her actions.
(c) That the Colleges continue to sponsor multidisciplinary continuing education activities.
2. T h a t models for such care should exist as outlined in this paper.
DECEMBER 1992
ACMIJOURNAL
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AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
5. The availability of antenatal care by a General Practitioner Obstetrician.
3. T h a t appropriate guidelines and/or protocols for such models of care be determined at the point of service delivery.
6. The availability of antenatal care by a Midwife.
4. T h a t all practitioners must be sure that they practice within accepted guidelines or standards.
7. Intrapartum (including delivery) care by a Specialist.
5. T h a t all parties accept the legal consequences of such arrangements.
8. Intrapartum (including delivery) care by a General Practitioner Obstetrician.
6. T h a t all participants in maternity care must make individual a r r a n g e m e n t s for medico-legal indemnity.
9. Delivery only by a Specialist.
7. T h a t discussions take place with Law Reform Groups and policymakers to ensure a system within which there is likely to be fair and appropriate outcomes of medico-legal litigation. Recommendations Insurance System:
Relating to the Health
T h a t the Medicare System should recognise and r e c o m p e n s e the following: 1. The availability of total medical care by a Specialist for a high risk patient. 2. The availability of total medical care by a Specialist for a low risk patient. 3. The availability of total medical care by a General Practitioner Obstetrician. 4. The availability of total care by a Midwife.
10. Delivery o n l y by a General Practitioner Obstetrician. 11. Intrapartum care (excluding delivery) by a General Practitioner Obstetrician. 12. Intrapartum care (excluding deilvery) by a Midwife. 13. Variations additions (e.g. third degree tear repair) to the above items. 14. Shared antenatal care with fee per visit being paid. Recommendation Collaboration:
Relating to Future
The following r e c o m m e n d a t i o n is made: 1. T h a t collaborative dialogue continue and that the Executive bodies of the three Colleges m e e t to determine the format of future collaboration.
New mum's e x p e r i e n c e m a n y t e n d e r feelings... PERINEAL PAIN should not be one of them.
PERINEAL REPAIR by
LA T R O B E U N I V E R S I T Y
MICHELLE NISBET, R.M.
and LINCOLN MIDWIFERY SCHOLARSHIP Applications are invited for the 1993 Lincoln Midwifery Scholarship, worth $2,500. The scholarship will be awarded to a student enrolled in a higher degree conducted by the Department of Nursing at La Trobe University, whose major focus of study and research is midwifery. For further information contact Ms Glennis Fricker, 418-6905.
PAGE 8
ACMIJOURNAL
BRONWYN ROUSE, R.M. This book, written and illustrated by practising midwives will be an excellent reference for anyone undertaking or learning perineal repair.
'Clear, concise,easy to follow diagrams including knot tying'. Cost of publication: $25.00 (including postage and handling) AVAILABLE ONLY FROM
The Australian College of Midwives Please send requests and cheques to: PERINEALREPAIRBOOK THE AUSTRALIANCOLLEGEOF MIDWIVES 260 ALBERTSTREET EASTMELBOURNE3002
DECEMBER 1992
REPORT AND RECOMMENDATIONS FROM THE JOINT BIRTH CONSULTATIVE COMMITTEE The Report and Recommendations f r o m theJoint Birth Consultative Committee is now before the members of the three Colleges who participated in its formulation. The State delegates of ACMI have been requested to disseminate this report at Branch level and elicit responses f r o m the membership.
equivalent qualifaction and /or training are appropriate providers of maternity care to a level d e p e n d e n t u p o n their training, experience and geographic circumstance.
I would therefore ask all members to read this report and send comments to the National Office before December 31, 1992.
8. The recognition that Specialist Obstetricians may manage any pregnancy, but that they are m o s t efficiently utilised in the care of w o m e n with complications or as a consultant to other care givers.
It is envisaged that further dialogue between the three College Executive will takeplace during December a n d following this meeting thef i n a l report will bepresented to appropriate Government Departments.
9. Further d e v e l o p m e n t o f c o m m u n i c a t i o n , rapport and trust between Midwives and Medical Practitioners at all levels o f maternity care.
Lorraine Wilson Editor
10. Each p r o f e s s i o n a l g r o u p recognises a n d acknowledges the special knowledge and skills of each g r o u p involved in maternity care.
Summary Summarised below are the necessary elements in the models of maternity care r e c o m m e n d e d by the Joint Birth Consultative Committee.
11. An acceptance that g o v e r n m e n t authorities responsible for health care provide the necessary financial resources for the models of maternity care r e c o m m e n d e d by the Joint Birth Consultative Committee of the Australian College of Midwives Inc., The Royal Australian College of General Practitioners and The Royal Australian College of Obstetricians and Gynaecologists.
1. The p r o m o t i o n of childbirth as a healthy life event for the majority of w o m e n , w h e r e the individuality of each w o m a n is recognised. 2. Stress the safety and well-being of mothers and babies as being of p a r a m o u n t concern. 3. The availability of safe options of care for all women. 4. The p r o m o t i o n of the c o n c e p t of shared responsibility, accountability and involvement in decision making b e t w e e n the w o m a n , her partner or support persons and the service providers. 5. The provision of quality care which is sensitive to w o m e n ' s varying needs, i.e. social-cultural, emotional and physical. 6. The recognition that midwives working with recognised medical support are appropriate care givers in normal pregnancy and are appropriate m e m b e r s of a team w h e r e complications develop or exist. 7. The recognition that General Practitioners, holding the Diploma in Obstetrics RACOG or DECEMBER 1992
12. Support for the accreditation of appropriately qualified individuals, w h e t h e r Midwives, General Practitioners or Obstetricians, to hospitals within their service area.
Introduction Over several meetings, and after consultation with professionals and consumers interested in maternity care, the Committee reached consensus on four models of maternity care w h i c h it believes are acceptable to all c o n c e r n e d and has agreed on recommendations which would assist in the further d e v e l o p m e n t and s m o o t h implementation of these models. The models of care are: a. Midwifery Care in which the pregnancy, having b e e n screened to establish low risk, is managed by a Midwife or team of Midwives in a hospital or appropriate setting with established medical support. ACMIJOURNAL
PAGE 3
AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
b. General Practitioner Obstetric Care in w h i c h normal and low risk pregnancies are managed by a General Practitioner Obstetrician. Notwithstanding this, it will be appropriate, particularly in rural areas, for General Practitioner Obstetricians to manage pregnancies of higher risk, according to their degree of training and experience, and in accordance with the guidelines of the Joint Consultative Committee of The Royal Australian College of Obstetricians and Gynaecologists and The Royal Australian College of General Practitioners (JCC). c. Specialist Obstetric Care in w h i c h at risk or normal pregnancies are managed by a Specialist Obstetrician. d. Shared Care in which the maternity care is shared by the General Practitioner Obstetrician and the Specialist Obstetrician and the Midwife in a variety of situations. The overall emphasis for all models is on the safety and quality of care for w o m e n , the woman's right to exercise i n f o r m e d choice regarding that care, and support for the w o m a n in her choice. Two meetings, 'Birth 2000', were held in Melbourne and Sydney in an attempt to consult with the relevant interest groups about these models and provide an o p p o r t u n i t y for dialogue amongst varying types of participants, including professionals ranging f r o m Specialist Obstetricians to rural General Practitioners, to Midwives f r o m all spheres of practice, G o v e r n m e n t representatives and consumers. Through this process the strengths and weaknesses of these different models and strategies for implementation or i m p r o v e m e n t of the various models were discussed. There was seen to be a n e e d for an i m p r o v e m e n t in attitudes and c o m m u n i c a t i o n skills of all practitioners involved in maternity care. There is also a need for improved communication between professionals and the public they serve, together with heightened public awareness and understanding of the safe options o f birth available to them. Concern over medico-legal issues relating to all models of care and responsibility of the professionals involved, particularly w h e r e transfer of care occurs, continued to be expressed. PAGE 4
ACMI JOURNAL
In developing recommendations, b o t h general and specific, it was pertinent to examine the strengths and weaknesses of the models of care and the strategies for improvement within the models. These are reviewed b e l o w and the r e c o m m e n d a t i o n s follow. Models
of Care
a. M i d w i f e r y care: Midwives are ideally placed to function as primary health care professionals. Their sphere of practice has b e e n clearly articulated and agreed at international levels by midwives, their obstetrical colleagues and the World Health Organisation.
That practice may occur in hospital based maternity services, birthing centres, designated hospital beds for midwives, and c o m m u n i t y based or visiting midwife services. Midwives emphasise the physiological 'wellness' m o d e l of care, but are also able to detect the deviations from normal in m o t h e r and child and procure appropriate medical referral. Midwives have a p h i l o s o p h y of e m p o w e r i n g w o m e n to give birth naturally and can provide continuity of care within certain boundaries. An a b u n d a n c e of midwifery expertise is located geographically close to families, thus providing family centred care in m a n y roles associated with birthing. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.1 There is a p o o r understanding by the public of the availability and advantages o f this model.
1.2 Accessibility to this m o d e l is at present time limited. 1.3 There is sometimes a difficulty in clearly defining accountability w h e n transfer occurs from this m o d e l of care to a medical practitioner model. 1.4 Quality of care m a y be a p r o b l e m w h e n it is difficult for Midwives to gain the experience necessary for c o m m u n i t y practice. S t r a t e g i e s to i m p r o v e t h i s m o d e l o f c a r e include: 2.1 The establishment of trust, support and comm u n i c a t i o n b e t w e e n midwives and o t h e r maternity care providers. DECEMBER 1992
AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
2.2 The provision for Midwives to access hospital services. 2.3 Fostering of education in the c o m m u n i t y as to what the midwifery m o d e l can offer. 2.4 E n h a n c e m e n t o f o p p o r t u n i t y for appropriate continuing education, c o m p e t e n c y developm e n t and maintenance of competencies for registered midwives. 2.5 Provision of increased funding from health authorities for implementation of midwifery models of care. 2.6 Examination and negotiation of mechanisms to enable midwives to order agreed routine ancillary tests, prescribe authorised medications and initiate referral processes to a General Practitioner Obstetrician or Obstetrician in the m a n a g e m e n t of pregnancy. 2.7 Rebates from Medicare and private health funds for a range o f midwifery services he negotiated.
1.5 Potential medico-legal p r o b l e m s and the additional cost o f medical i n d e m n i t y insurance associated with this m o d e l m a y discourage general practitioners f r o m providing maternity care. 1,6 There is a constant pressure, such as present health insurance trends, which causes loss of patients to hospital units u n d e r the Medicare structure. Strategies to improve this model of care include: 2.1 Raise the awareness of this m o d e l of care amongst the other health care professionals.
2.2 Raise c o m m u n i t y awareness of the role of the General Practitioner in maternity care by public education. 2.3 Improve the training for General Practitioners in maternity care in b o t h the urban and rural environments. 2.4 Provide appropriate remuneration.
b. G e n e r a l P r a c t i t i o n e r O b s t e t r i c Care: General practitioners are the p r e d o m i n a n t group providing ongoing, comprehensive, whole family primary care to the Australian community, as such they are also ideally placed to practice low risk obstetrics and are committed to the natural birthing process. It can broaden the c o n s u m e r ' s choice, for example with ethnic w o m e n , and provides an effective use of economic and m a n p o w e r resources, together with the appreciation of medical and social p r o b l e m s and a knowledge of the local resources available to the pregnant woman. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.1 There is a lack of hospital access at the present time for c o n f i n e m e n t of w o m e n b y General Practitioners.
1.2 The Gencral Practitioner/Obstetrician may be held in low esteem b y the consumer. 1.3 There is a particular stress on rural General Practitioners practicing obstetrics in geographic and professional isolation. 1.4 2'he Practitioner may have difficulty in providing a l o c u m for his/her maternity practice to allow time for recreation and education. This particularly applies to rural doctors. DECEMBER 1992
2.5 Initiate changes in the health insurance system. 2.6 Reduce the prohibitive cost of legal indemnity premiums. 2.7 I m p r o v e d c o m m u n i c a t i o n needs to o c c u r with colleagues, other health professionals and consumers. c. S p e c i a l i s t O b s t e t r i c Care: The features of specialist care are the high educational standards required to reach specialist status; m a n d a t o r y recertification o f the Specialist Obsmtrician; and expertise in high risk maternity care. There is a popular c o n s u m e r choice for this model. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.1 It is difficult to sustain the availability o f this m o d e l on a large scale due to geographic and e c o n o m i c limitations,
1,2 Lifestyle stress for the obstetrician and his/her family. 1.3 Inadequate health insurance rebate. 1.4 This m o d e l m a y be perceived as polarising towards a state of illness rather than normality. ACMI JOURNAL
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1.5 May be perceived to be wasteful o f skills and training w h e n Specialist Obstetric Care is used p r e d o m i n a n t l y in m a n a g e m e n t o f low risk pregnancies. S t r a t e g i e s to i m p r o v e t h i s m o d e l o f c a r e include: 2 . 1 E n c o u r a g i n g practice at a level of care, appropriate to the specialist's training and skill. 2.2 Education to improve communication skills and appreciation o f social and c o m m u n i t y issues. 2.3 Further consideration o f medico-legal impedim e n t s to practice, 2.4 Seeking out ways to p r o m o t e and ensure mutual recognition amongst professionals.
1.5 Lack o f a recognised formal m e t h o d of equitable division of remuneration amongst participants. 1.6 Difficulties in the interaction between colleagues w h e r e there is not always the same recognition of ability and trust amongst professionals, S t r a t e g i e s to i m p r o v e t h i s m o d e l o f c a r e include: 2.1 Its use should be limited to situations w h e r e the w o m a n would clearly benefit. 2.2Written acceptable guidelines professionals involved.
for
all
2.3 C o m m u n i c a t i o n and co-ordination within the professional team, 2.4 A clear limit to the n u m b e r of caters.
2.5More specialist input into health policy in the community.
2,5 C o m m o n record system held by the consumer.
2.6Multi-disciplinary quality assurance c o n s u m e r involvement should occur.
2.6 Active support and encouragement for improved collegiate relationships within the health teams involved in maternity care.
with
2.7 I m p r o v e d c o m m u n i c a t i o n by the provision of accurate and accessible information and involvem e n t of the c o n s u m e r in decision making.
Recommendations
2.8 Better access for high risk patients to hospital clinics.
Recommendations management:
relating to institutional
It is r e c o m m e n d e d : d. S h a r e d Care This type of care ensures continued convenience for consumers and a choice of the health care providers, particularly for those with specific needs, and can provide a cost effective form of care. There can be an agreed plan o f care b e t w e e n the w o m a n and her medical practitioners, general practitioner and specialist and/or midwife, and support can be available f r o m a multi-disciplinary team if required. Collaborative models of care b e t w e e n midwives, g e n e r a l p r a c t i t i o n e r s a n d o b s t e t r i c i a n s are increasing, These arrangements could be enhanced a n d e x p a n d e d to p r o v i d e s a t i s f a c t i o n for professional care givers and i m p r o v e d maternity services. W e a k n e s s e s a s s o c i a t e d w i t h t h i s m o d e l are: 1.2 Inappropriate use o f the model. 1.3 Discontinuity of care. 1.4 Potential for b r e a k d o w n in communication. PAGE 6
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1. That M a t e r n i t y M a n a g e m e n t C o m m i t t e e s in health areas and/or institutions be d e v e l o p e d
(a) Institute and/or support models of maternity care as r e c o m m e n d e d by the Joint Birth Consultative Committee.
(b) Upgrade present hospital birthing environments to provide aesthetically appropriate and safe areas for labour and delivery,
(c)
Facilitate attitudinal changes amongst care givers to the models o f maternity care.
(d) Institute Accreditation Committees to develop guidelines for birth practitioners at all levels; incorporating collegiate guidelines for care, (for example the ' R e c o m m e n d e d Guidelines Relating to Hospital Access and Delineation of Clinical Privileges in Obstetrics for General Practitioners' the Joint Consultative Committee of the RACOG and RACGP). DECEMBER 1992
AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
(e) Promote appropriate and accessible childbirth education for all women.
R e c o m m e n d a t i o n s Relating to Quality Assurance:
2. That systems o f quality assurance and p e e r r e v i e w be d e v e l o p e d to:
1. QA as an e s s e n t i a l p r o f e s s i o n a l activity:
(a) Involve all maternity care practitioners. (b) Monitor all aspects of maternity care, including change of professional treatment and evaluation of such care.
3. That c o n t i n u i n g e d u c a t i o n p r o g r a m m e s be p r o v i d e d which: (a) Are multi-disciplinary, e.g. seminars/workshops.
(a) T h a t all those c o n c e r n e d with maternity care should be involved in formal quality assurance programmes, which are designed specifically to suit the particular model of care and the environment in which it operates. (b) That accreditation of all providers o f maternity care involved in an institution be linked to their participation in an appropriate QA programme.
(b) Include involvement with administrative bodies and consumers.
(c) That QA programmes should be multidisciplinary and, where appropriate, should include input from consumer groups.
(c) Provide a forum for education and discussion of legal issues.
2. Education in the area o f QA in m a t e r n i t y care
Recommendations Issues:
(a) T h a t
Relating to Education
1. Undergraduate and Postgraduate Education: (a) TheJBCC recommends that the Colleges jointly conduct a review of the teaching o f maternity care in Undergraduate and Postgraduate Education.
2. Continuing Education (a) T h a t the individual Colleges invite members of other Colleges to participate in as many o f their ongoing education activities as is reasonable/ appropriate. For example: (i) The State Branches of the Australian College o f Midwives conduct annual conferences to which other Colleges be invited. (ii) The Australian College o f Midwives also conducts a Biennial Conference, with involvement from the other Colleges.
educational institutions offering undergraduate education in medicine or nursing, or postgraduate education in obstetrics or midwifery, be surveyed to establish the place of education about QA in their curriculum.
(b) T h a t , tbllowing the collection of data o n existing activity in this area, the Colleges should develop guidelines for undergraduate and postgraduate education in the area o f quality assurance in maternity care.
(c) T h a t the Colleges sponsor continuing education programmes in the area of quality assurance in maternity care for the members o f all three Colleges.
R e c o m m e n d a t i o n s Relating to Legal Issues S u r r o u n d i n g Maternity Care: The following recommendations are made:
(b) That continuing education points, or quality assurance acknowledgment (RACGP), be allocated by the Colleges for attendance at such programmes.
1. T h a t the care o f pregnant w o m e n should be the joint responsibility amongst those involved. This responsibility should be shared between the Obstetrician, General Practitioner Obstetrician, Midwife, the hospital, the system, the pregnant w o m a n herself and her partner. Each individual should be accountable for his/her actions.
(c) That the Colleges continue to sponsor multidisciplinary continuing education activities.
2. T h a t models for such care should exist as outlined in this paper.
DECEMBER 1992
ACMIJOURNAL
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AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED
5. The availability of antenatal care by a General Practitioner Obstetrician.
3. T h a t appropriate guidelines and/or protocols for such models of care be determined at the point of service delivery.
6. The availability of antenatal care by a Midwife.
4. T h a t all practitioners must be sure that they practice within accepted guidelines or standards.
7. Intrapartum (including delivery) care by a Specialist.
5. T h a t all parties accept the legal consequences of such arrangements.
8. Intrapartum (including delivery) care by a General Practitioner Obstetrician.
6. T h a t all participants in maternity care must make individual a r r a n g e m e n t s for medico-legal indemnity.
9. Delivery only by a Specialist.
7. T h a t discussions take place with Law Reform Groups and policymakers to ensure a system within which there is likely to be fair and appropriate outcomes of medico-legal litigation. Recommendations Insurance System:
Relating to the Health
T h a t the Medicare System should recognise and r e c o m p e n s e the following: 1. The availability of total medical care by a Specialist for a high risk patient. 2. The availability of total medical care by a Specialist for a low risk patient. 3. The availability of total medical care by a General Practitioner Obstetrician. 4. The availability of total care by a Midwife.
10. Delivery o n l y by a General Practitioner Obstetrician. 11. Intrapartum care (excluding delivery) by a General Practitioner Obstetrician. 12. Intrapartum care (excluding deilvery) by a Midwife. 13. Variations additions (e.g. third degree tear repair) to the above items. 14. Shared antenatal care with fee per visit being paid. Recommendation Collaboration:
Relating to Future
The following r e c o m m e n d a t i o n is made: 1. T h a t collaborative dialogue continue and that the Executive bodies of the three Colleges m e e t to determine the format of future collaboration.
New mum's e x p e r i e n c e m a n y t e n d e r feelings... PERINEAL PAIN should not be one of them.
PERINEAL REPAIR by
LA T R O B E U N I V E R S I T Y
MICHELLE NISBET, R.M.
and LINCOLN MIDWIFERY SCHOLARSHIP Applications are invited for the 1993 Lincoln Midwifery Scholarship, worth $2,500. The scholarship will be awarded to a student enrolled in a higher degree conducted by the Department of Nursing at La Trobe University, whose major focus of study and research is midwifery. For further information contact Ms Glennis Fricker, 418-6905.
PAGE 8
ACMIJOURNAL
BRONWYN ROUSE, R.M. This book, written and illustrated by practising midwives will be an excellent reference for anyone undertaking or learning perineal repair.
'Clear, concise,easy to follow diagrams including knot tying'. Cost of publication: $25.00 (including postage and handling) AVAILABLE ONLY FROM
The Australian College of Midwives Please send requests and cheques to: PERINEALREPAIRBOOK THE AUSTRALIANCOLLEGEOF MIDWIVES 260 ALBERTSTREET EASTMELBOURNE3002
DECEMBER 1992
