ONLY a handful of collaborative agreements have been signed between obstetricians and midwives since reforms were introduced in November, sparking calls for a policy rethink.

Reforms to the Health Insurance Act mean that midwives and nurse practitioners have had access to the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) since November last year, provided they have collaborative arrangements with a medical practitioner. (1)

The reforms stipulate that private midwives must have an arrangement with an obstetrician to access rebates;however, obstetricians appear reluctant to sign these agreements, which were described as “controversial” when they were approved by the federal parliament in March 2010. (2)

Obstetricians and midwives who spoke to MJA InSight were united in their commitment to collaboration between the professions; but also in their disappointment with the new model of collaborative care.

In a comment piece for MJA InSight, midwifery researcher and associate professor Hannah Dahlen, of the University of Western Sydney, writes that only three agreements had been signed. (3)

Liz Wilkes, a midwife and board member of Midwives Australia, agreed that only about 3‒5 written agreements had been signed nationwide since November. No official records of the numbers of written agreements are available.

Midwives are still able to offer their patients MBS rebates without a written agreement by demonstrating their collaboration with obstetricians through other methods, such as being employed by an obstetrician, or by having a patient referred to them by a doctor.

Even so, only 37 of Australia’s 1760 registered midwives have registered with Medicare for access to the MBS and PBS. An analysis by MJA InSight found that patients have received 1210 MBS rebates for care provided by midwives since the item numbers were introduced in November 2010 (item numbers 82100-82140).

Ms Wilkes, who established a Toowoomba-based midwifery clinic in response to the regulatory reforms, said some obstetricians were extremely reluctant to sign written agreements.

Six midwives in her practice have a Medicare provider number; however, none of them have been able to secure a written agreement with an obstetrician, despite at least 100 written requests to local private obstetricians since November.

“The obstetricians have been quite strident in their rejection [of an agreement]”, Ms Wilkes said.

“It’s a shame because I think there would be a number of different models that would come from this way of working together. It also opens up a range of professional opportunities in terms of learning and working in a collegiate way”, she said.

Dr Rupert Sherwood, a Hobart-based obstetrician-gynaecologist and president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said obstetricians and midwives had a long history of collaboration and questioned the need for the new collaborative care requirements.

“I think you have to ask the question, how unhappy was everybody with the previous arrangement? What was the real need for maternity reform? If there was a real need for reform … wouldn’t you have expected a bigger uptake of the reforms?”

He said his college had several concerns about the new arrangements, such as the understanding that midwives could sign collaborative agreements with public hospital doctors who were not directly involved in obstetric care, leaving obstetricians out of the equation unless something went wrong.

Ms Wilkes said it would be great if there was a policy rethink, ideally removing the legislative determination that requires midwives to demonstrate collaboration to access the MBS and PBS. (4)

“Or at least having something that’s less complex and doesn’t require the midwife to jump through these hoops to demonstrate that she is collaborating with an obstetrician. For example, having a woman booked in to a hospital that provides obstetric services and having ongoing engagement with obstetricians should be enough evidence of collaboration.”

– Sophie McNamara

1. Midwife Reform Legislation fact sheet

2. Sydney Morning Herald 16 March 2010

3. MJA InSight: Hannah Dahlen: Collaboration or control 14 June 2011 

4. Australian Government: National Health (Collaborative arrangements for midwives) Determination 2010

Posted 14 June 2011

11 thoughts on “Midwife collaboration “disappointing”

  1. Murasaki says:

    Surprise surprise! OBs dont want to collaborate with midwives. Blow me down with a feather!
    As a consumer though I don’t want OB collaboration. OBs are there for when something is wrong. They have no place in normal, natural birth. I don’t want to book in to hospital. I don’t book into hospital before I go to the loo or drive to the shops. If there’s an emergency I will call an ambulance. If there’s a non emergency but still serious condition – I will consult a specialist. If everything is going to plan I’ll birth in my own space, my own time, with my chosen support team – which includes a woman MW. It’d be nice to get Medicare but I’d rather pay my own way if it (Medicare rebate) means submitting to obstetric care.

  2. Breoke says:

    Thanks for this article. I think a midwife should be able to practice without the oversight of another medical professional. If the government has confidence in the professional education and registration protocols for midwives and nurses, then they should be confident to have them practice in their own right. Midwives do and will continue to practice collaboratively according to the needs of the woman client.

  3. chiori higashi says:

    Yes, midwives should have access to Medicare rebate for their client without obstetric involvement.

  4. Anne E. says:

    As midwives endeavouring to have a Medicare provider number already have to provide a sufficient understanding of the current legislation in regards to referral guidelines and scope of practice, I do think that they are more than aware of the consequences of their practice and hence should not be forced to double proof that they do collaborate when necessary. So I believe women should be able to access Medicare rebates for midwifery service whether there is a formal collaboration in place or not! We all are here for improving women’s care – how much more complicated can one make this?

  5. BDTeakle says:

    Thanks MJA InSight for bringing attention to this significant obstacle to Australian women’s access to primary, preventative, community-based maternity care. The “medical veto” over women’s access to Medicare for midwifery services is a purely political outcome, achieved by AMA’s direct access to the Minister, and cutting across the consultation process.
    Australian nursing and midwifery regulators have a track record of requiring midwives to consult and refer appropriately, and work within their scope. The “collaborative arrangements” requirement is about controlling access to health care money, not about standards of care. It is so complex and obstructive that even state health departments, who want to make it work for financial reasons, have been unable so far to achieve a single signed agreement with a public hospital in any state.
    Let’s see an Australian government find the guts to cross the AMA and make policy which works for Australian families and taxpayers.

  6. Anonymous says:

    As I have submitted to the NHMRC and the Australian Government this collaboration has required unfair trade practice. The domination of one professional business over another.
    The woman is missing in writing in the documentations about collaboration. Unless the woman is at the forefront with her right to autonomous decision-making in the NHMRC document and her right to choose her carer without fear or favour then collaboration is not in the best interests of the woman or her child.
    The outcomes of the practice of each participant, ie, rates of intervention haemorrhage infection episiotomy and reasons for maternal and fetal death are missing from the hospital and obstetric records for public scrutiny.
    Therefore consent is not informed therefore non-autonomous. The woman is not at the front of the decision-aking let alone central.

  7. Kelly Winder says:

    This collaboration was always going to be a farce; the fact that the inquiry attracted an incredible amount of submissions and excellent presentations in support of midwifery care… yet we’ve come to this. The AMA have always said that they will never support homebirth, so why did this happen? Because the AMA knew if this collaboration was formalised, they would have control – which is clearly being shown here. I know many women who speak to their GPs about homebirth only to be lectured about how its so dangerous and midwives are dangerous. There is not fair, unbiased information being given to women from their GPs so they can make their own choices. They are being railroaded.

    This arrangement as it is, will only succeed in crushing the midwifery profession into the ‘labour & delivery nurse’ model that the USA have. So many skills have been (and will continue to be) lost and the USA now sport some of the highest newborn and maternal death rates in the developed world. If you just take a look at countries who have a high rate of homebirth, you’ll see far less deaths and higher maternal satisfaction rates, better outcomes and much more.

    The AMA have taken away women’s choices, dictated that this is how birth is going to be (their way or the highway) and shown so much arrogance putting their pockets before basic human rights of women – and REAL evidence. If you look for the research and living proof in other countries, it’s there. It’s well overdue – time to establish a workable, supportive program for homebirth so we can have the same great outcomes of other countries.

  8. Rob the Physician says:

    As pointed out elsewhere, there has been collaboration between
    our two professions for centuries…. since when is it necessary
    to have it “enshrined” in writing, which it is the making of
    POLITICIANS anyway……………humbug,humbug !!!

  9. Carolyn Hastie says:

    I find it surprising that doctors are so reluctant to work with midwives in this collaborative way. I have had the very good fortune of working with excellent obstetricians during my 30 plus years of private practice. I value their expertise and they value mine.
    While obstetricians and midwives serve the same population, that is childbearing women, we do so in very different ways. Every childbearing woman in Australia has a midwife for some part of her journey, for most when they are in labour and for the postnatal part of their experience. For increasing numbers of Australian women, midwives are their primary care giver, providing information, education, discussion and midwifery expertise throughout the journey, from first contact in early pregnancy, through labour and birth until the end of the six weeks postpartum period.
    Some women have conditions which require medical expertise during their pregnancy/birth experience and then, midwives and doctors work together, with the woman, for the best outcome.
    Some women choose a private obstetrician to be their lead carer during the childbearing process and enjoy the continuity of care they get through the antenatal period; the midwives in the hospital providing the labour, birth and postnatal care for these women with the obstetricians ‘popping in’ for the birth. The obstetricians I work with recognise that women need the emotional and educational care that I provide and refer women with medical conditions to me so I could provide that dimension of maternity care, while they provide medical care.
    The solution to the current crisis is for us to engage more deeply in conversation with each other. After all, the wellbeing of mothers and babies is what we all want and the research is clear that when there is good collaboration and therefore communication, mothers and their babies are safer.

  10. RN/Student Midwife says:

    It is interesting that obstetrics and midwifery are different professions servicing the same target marget, yet seem to want to do each others job. Psychologists and psychiatrists, also differing jobs, service the same target market, without this turf war… psychologists work privately with their own Medicare provider numbers to provide mental health care, autonomously or within teams, without legislated requirements for collaborative agreements with doctors, and refer to psychiatrists only if their client needs something a doctor can offer that they can’t, like formal diagnosis and medications; and psychiatrists respectfully refer clients to psychologists for care that, whilst I am sure they could provide, is the job of the psychologist, not the doctor. How is it that doctors and midwives can not have the same autonomous but mutually respectful relationship.

  11. Richard Kahler says:

    I am interested in this role outside of midwifery as well. Is there a “take-up” of these roles? We have a nurse practitioner employed to assist in the management of neuro-oncology patients and this has been working well. However, we are concerned regarding the long-term viability of this role as we cannot obtain MBS rebate for inpatient care – only outpatient consultations. Up to now we have been heavily subsidising this role. Most of the care is inpatient care.
    I am interested in any feedback on this issue as well.

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