Issue 26 / 18 July 2011

ALTHOUGH only a handful of collaborative arrangements have been signed between obstetricians and midwives since national maternity reforms were introduced in November, calls for a policy rethink are premature and counterproductive.

In fact, the reforms provide an exciting opportunity for collaborative maternity care that is safe, locally responsive and woman-centred.

A variety of private maternity care models are possible and we are confident these will build on Australia’s strong record of safety and quality in maternity care. They will also meet the needs of women who want the familiarity and the comfort of knowing the obstetrician and midwife who will be with them through their pregnancy, birth and new parenting experience.

A good starting point for a collaborative arrangement is to acknowledge the over-arching goals of safety, judicious use of evidence-based intervention and the importance of a woman’s satisfaction with her pregnancy and birth experience. Clarity and a good understanding of how individual roles will work need formal discussions to create a documented arrangement.

Obstetricians may be concerned that the new arrangements mean they will not be directly involved in patient care until something goes wrong, while some midwives fear that the arrangements will be used to control midwifery practice, adversely impact on childbirth choices and promote anticompetitive restriction of trade.

We believe we are the first private obstetrician-midwife team in Australia to have successfully negotiated a formal collaborative arrangement and we are very happy with how it has progressed since our first discussions.

The first woman under our joint care gave birth in March this year and we have several others booked through to January 2012.

We share a similar philosophical approach to maternity care and have agreed practice guidelines that we believe to be safe, evidence-based and woman-centred. Some aspects of our initial positions were reconsidered and changed after discussion.

Our approach shows that, when a truly mutual collaborative arrangement is entered into, obstetricians need not be concerned about being left unaware of potential problems, and midwives will not be placed in the untenable position of being involved in care that they might not condone.

Women appreciate the continuity of care, and the assurance that an obstetrician they have met will be involved if medical assistance is required. Feedback from women so far has been outstanding. The main criticism has been that this model of care is not available in other hospitals.

One of the reasons why there are currently so few collaborative arrangements has been the time taken by the Australian Health Practitioner Regulation Agency to endorse eligible midwives and by public maternity units to credential midwives in private practice.

Fees are agreed and written into our agreement so that the woman is fully informed of the out-of-pocket costs. The obstetrician involved is satisfied that remuneration for his input is fair and does not mean his private patients are subsidising those in the collaborative care arrangement.

Our agreed guidelines are explained to patients before they engage our services and childbirth choices are not restricted. In fact, choices are enhanced as the midwife is able to attend births in the full capacity of a midwife in hospital.

Importantly, our model of care does not dictate “transfer” of care, merely a shift in the balance of obstetric and midwifery care because we recognise that every pregnant woman needs her own obstetrician and midwife. We support midwife care during waterbirth, vaginal birth after caesarean section, physiological birth positioning and physiological third stage.

Change is often difficult as we all tend to be creatures of habit. This change brings with it many opportunities for obstetricians and midwives in private practice to work together in ways that are beneficial to both and, importantly, to the women in their care.

The important point is that whatever path is chosen, it will be mutually agreed, clearly understood and acceptable to the woman, midwife and obstetrician.

The maternity reforms will succeed if we remember that midwives and obstetricians are in it for the same reason — to provide safe care that meets the needs of our patients, within a respectful, professional environment.

Dr Andrew Pesce is an obstetrician practising in Sydney and immediate past president of the AMA. Ms Melissa Maimann is a midwife in private practice based in Sydney.

Go to MJA Careers for details of how collaborative agreements can work in practice.

Posted 18 July 2011

3 thoughts on “Melissa Maimann

  1. Debbie Slater says:

    Congratulations Melissa and Andrew. I hope that there will be more obstretricians who will enter into collaborative arrangements with their midwife colleagues. There are women out there wanting to access these models of care, but the models are not widely available.

  2. Shelley Gower says:

    This is a wonderful arrangement for women wanting planned hospital births. Hopefully it will encourage other midwives and obstetricians to consider collaboration. Women will benefit enormously.

  3. Geoffrey Miller says:

    < We support midwife care during ….vaginal birth after caesarean section…. >
    As a medical student, alas many years ago, I witnessed the effect of attempted vaginal delivery after an upper segment Caesarean section. I saw it in the mortuary where mother and child were having a post mortem!
    I am not an obstetrician, but when I was in general practice, I advised referral to an obstetrician to consider a Caesarean section whenever a woman became pregnant after a Caesar. How can the midwife, under the arrangement above, have the primary care of post Caesarean vaginal care?
    On a seperate issue, how much of our money have the government thrown at “national maternity reforms” ALTHOUGH only a handful of collaborative arrangements have been signed between obstetricians and midwives since national maternity reforms were introduced in November?

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