The review is a great first stop, but we can’t stop there.
An independent review of primary healthcare providers’ scope of practice is just one of the measures aimed at ensuring Australia’s healthcare system is adaptable to ensure it meets our nation’s future needs.
There is a strong focus on clinician input at all four stages of the review and this week a three-week roadshow got underway – a series of roundtables that will allow all key stakeholders the opportunity to contribute in person and feel heard.
The review, “Unleashing the Potential of our Health Workforce” is aptly named from my perspective because there is so much potential in the midwifery workforce. The review is timed well and of enormous relevance.
We are a workforce with the capacity to significantly impact women and families particularly in rural and regional areas if midwives can work to our full scope.
This review is well underway and already five key themes coming out of an initial consultation process have been identified. These themes are legislation and regulation; employer practices and settings; education and training; funding policy; and technology.
Let’s break down these themes and see what they mean for midwifery.
Legislation and regulation
Differing legislation across states and territories in Australia, and variation within a jurisdiction’s regulations are significant barriers to midwives working to full scope of practice.
The variation between states, health districts and hospitals means that some midwives might have to be “credentialed” additionally for things that are well within their scope – like water birth – while others don’t. Often a midwife can work across multiple states and territories, and in fact midwives hold a national registration, so these variations create confusion and risk.
In July 2023 Endorsed Midwives were given approval to prescribe medical abortion which will improve access to sexual and reproductive health care.
The impact of this is so important, especially for women in rural and remote areas, as it reduces the need to travel large distances to access appropriate healthcare services.
But while the federal approval to prescribe is there, there’s been a pregnant pause in changing the state, territory and federal legislation that will actually allow this to happen. An important change if it eventuates, noted in this issues paper, will be the harmonisation of the Poisons Act so that the same regulations for prescribing exist across Australia.
Employer practices and settings
This is about challenging the current practice (fragmented care) and setting (hospital) and shifting to a new paradigm that we know works for women and for midwives – providing primary maternity care in the community.
Midwives providing care outside the hospital setting is beneficial everywhere, but particularly in rural and remote areas. The number of Endorsed Midwives – those midwives who can prescribe medication and diagnostic tests – is on the rise and this is a great thing.
Midwives can improve universal access to reproductive healthcare in areas such as abortion services, prescribing contraceptives and additionally, maternal, child and family health if they undertake further postgraduate study.
All health professionals working to full scope in Australia benefits the consumer, the health professional, and the employer.
Furthermore, women accessing midwives for their care aren’t competing for limited GP appointments and clogging up hospitals unnecessarily, leaving these vital services free for those who actually need them.
Education and training
Access to ongoing training and education is important to ensure health professionals are able to work to the full scope of practice, as well as to develop new skills.
Midwives don’t currently have the same incentives for professional development as other professions. Midwives welcomed recent inclusion in the government Workforce Incentive Program, however more is needed to attract and retain midwives to the profession such as the funding of clinical placements for students and HELP debt removal for midwives. In addition, there are workforce and roster demands which are exacerbated for midwives working in rural and remote areas.
Leadership and team culture impact on education and training. While midwives can work autonomously and provide comprehensive care to women and families, nurturing multidisciplinary relationships through effective communication and joint education, training and evaluation will be beneficial to everyone.
An example of this is providing designated time to work through case reviews and obstetric emergency training. Understanding the role of the midwife enables all health professionals to work to full scope of practice in the multidisciplinary environment.
Funding policy
Midwives working to their full scope of practice in continuity of care models, where women receive the bulk of care outside of the acute hospital setting is cost effective, costing about 22% less than the standard fragmented care most women are forced to choose through a hospital. Another reason to change our default model of care.
Medicare rebates for midwives are not fit for purpose, especially for those midwives working in private practice. MBS items for midwives are limited to antenatal care up to only six weeks postpartum. Access is also limited to only endorsed midwives. This means midwives are not able to provide care to women and families beyond six weeks postnatal, which impacts on the important period of transitioning to parenting, prescribing contraceptive care and important mental health screening. The structure of hospital-based care and funding is also not fit for purpose.
Changes to funding policy would ideally see block funding for maternity care and separate and additional claimable items for antenatal visits, birth and postnatal visits. This is a necessary change and would be much more functional for women and midwives in the real world.
Technology
Access to technology is vital for all care providers. The Australian Digital Health Agency has introduced My Health Record which is a fantastic initiative, but there’s a catch. So far, no midwifery software is conformant, meaning EMs are still locked out of uploading to this service, preventing them from working to their full scope.
Similarly, My Medicare – how primary care providers interact with Medicare – needs review to make it functional for all.
Midwives are experts in normal birth and should be further enabled to work in the primary care space where they work with women outside of hospitals, in the community, providing continuity of care. This is the proven gold standard of care for women in Australia through their pregnancy, birth and postnatal period.
It’s what women want, the outcomes are better and cheaper, but curiously it’s still not the default maternity care choice.
I have no doubt that the recommendations from this review will further support the argument that we need midwives to work to their full scope of practice in order to increase access to desired models of care for women and to attract and retain midwives into the profession.
This review is a great first step, we just need to be brave enough to take the next one; implementation.
Alison Weatherstone is the Chief Midwife of the Australian College of Midwives.