The Quality and Safety Framework for Homebirth

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448. The long-awaited final draft of the QSF is now out for public consultation. I have copied excertps from it below. PPM refers to privately practising midwife.

National Registration demands that all health professionals have professional indemnity insurance that covers all aspects of the care that they provide, however there is no insurance for births that take place at home in a private capacity. The QSF is in place to provide a framework so that private midwives can continue to provide homebirth services and secure an exemption to the requirement of insurance for home birth. Private midwives will still need insurance to cover pregnancy and postnatal care.

... the Health Ministers have agreed to provide an exemption for PPMs attending a homebirth until June 2012 subject to certain conditions. No other privately practising clinicians are able to practise without insurance. This exemption only applies to intrapartum services provided in the home. The conditions that AHMC required are that: • PPMs report all homebirths according to the requirements of their jurisdiction • Women booking with a PPM receive written disclosure that the PPM is practising without insurance coverage for intrapartum care services in the home • PPMs participate in a Safety and Quality Framework for midwifery care

... For the framework to be legally required, the NMBA (Nurses and Midwives Board of Australia) will need to, using section 39 of the National Law, develop and approve a code or guideline that contains or reflects the contents of the framework. As such the final say on the contents and mandatory use of this framework will rest with the NMBA as the professional regulating body.

Context The choices made by women about their maternity care and birthing are commonly determined by: • previous pregnancy and birthing experiences, including ... levels of intervention • a strong desire for continuity of carer • confidence that respect for their choice of care and carer will improve outcomes for themselves and their babies • a personal philosophy that is congruent with a preference for care to be provided outside of a clinical setting.

The choices made by midwives in this context about the antenatal, intrapartum and postnatal care which they offer are commonly determined by: • a preference to work as a private practitioner • a perception that working within a clinical setting limits their ability to work across the full scope of midwifery practice • a strong desire to provide continuity of care through pregnancy, labour and birth and the postnatal period • a belief that the woman’s wishes can be more effectively addressed by engaging with a privately practising midwife • a personal philosophy that is congruent with a preference for care to be provided outside of a clinical setting.

Midwives are qualified health professionals whose practice is governed by ... the Nursing and Midwifery Board of Australia (NMBA) and ... the requirements of ... the Australian College of Midwives and their guidelines. Those in public systems also work within the parameters, and protection, of the clinical governance of the employing organisation ... The NMBA Continuing professional development standard requires a minimum of 20 hours of professional development to be undertaken by all registered nurses and midwives each year.

... the National Health & Medical Research Council draft “National Guidance on Collaborative Maternity Care” was disseminated. It is acknowledged that this document, together with “Primary Maternity Services in Australia – A Framework for Implementation (AHMAC 2008)” and “National Midwifery Guidelines for Consultation and Referral” Australian College of Midwives 2nd Edition 2008, are consistent with the spirit and intent of the development of the Framework.

... This framework will be provided to the NMBA with the intent that it is placed in a code or guideline. Once in a code or guideline of the NMBA, PPMs will need to adhere to it in order to meet the requirements of the exemption. The way in which the NMBA monitors the adherence to any code or guideline is a matter for them to decide ...

Safety and Quality Framework for Privately Practising Midwives attending homebirths

To be exempt from requiring insurance for providing intrapartum care for homebirths, the privately practising midwife is expected to comply with a number of requirements. The exemption and its requirements are reflected within the National Law as reproduced below.

... to be exempt from requiring insurance for providing intrapartum care for homebirths, the privately practising midwife will be required to abide by any safety and quality framework that the NMBA has approved and required through a code or guideline. It is intended that this framework will be provided to the NMBA to consider for such a purpose. Until it is approved by the NMBA it is not a legal requirement for PPM to use this framework in order to be exempt.

The framework is written to ensure safe, quality care of the woman and her baby choosing to birth at home with a privately practising midwife. Women considered appropriate for inclusion in this option of care are women with a singleton pregnancy, cephalic presentation, at term and free from any significant pre existing medical or pregnancy complications. Further to this, distance and time to travel to an appropriately staffed maternity service should be considered when assessing appropriateness for this option of care.

The framework ... is not intended as a document which is exclusionary. It does, however, articulate parameters of midwifery led care as a mechanism to balance the priorities of women’s choice and quality and safety of maternity care to deliver positive outcomes for mothers and babies.

... both the midwife and the woman need to be informed early in the pregnancy of the likelihood of needing to interact with other health professionals and the potential for transfer to other care settings. Given that access to continuity of care is a primary driver of women to choose private midwifery models, choice of appropriate models of care including clearly articulated plans of escalation and collaboration, are integral to satisfaction levels.

... the ACM Consultation and Referral Guidelines and the principles and practices outlined in the draft NHMRC National Guidance on Collaborative Maternity Care are a key element of this Safety and Quality Framework.

The midwife's requirements to fulfil the QSF will increase the standard of care and provide the public with an expectation of safety, collaborative care and higher standards:

Minimum Quality and Safety Requirements for Interim Exemption from Insurance

In addition to holding current registration in their State or Territory, or with the Nursing and Midwifery Board of Australia after 1 July 2010, to comply with the exemption from the insurance requirement of the National Registration and Accreditation Scheme midwives need to be able to provide evidence outlined in the table below:

- written information detailing evidence informed materials (consumer information package) - Process for complaint management (Documented process, including complaint escalation information) - Consumer participation (Women involved in case and peer review) - Consumer satisfaction templates - Documented evidence informed clinical practice guidelines on which practice is based e.g NHMRC, NICE, or state & territory guidelines - Referral pathways: clearly articulated referral pathways for referral and /or consultation in accordance with ACM Consultation and Referral Guidelines - Comprehensive clinical notes to share with other health professionals engaged in the woman’s care - Reporting of all births as per each state & territory requirement - Clinical audit: Comprehensive clinical notes to guide reflective practice and enable review and evaluation of care provided - Clinical Risk: incident & adverse event reporting - documented process in accordance with state and territory requirements - Sentinel event reporting: documented process in accordance with state and territory requirements - Documented involvement in case investigation. - Risk profile analysis: documented process for identification and evaluation of clinical risk and evidence of correcting, eliminating or reducing these risks - Professional Development: maintenance of professional standards - complies with NMBA minimum standards - Awareness and monitoring of new procedures and practices - Involvement in professional organisation/s and documented schedule for formal practice review and mentoring processes - Competency standards - ensures appropriate skills and experience - Demonstrates practice in accordance with ANMC national competency standards for the Midwife - Continuing professional development: documented evidence of attendance at ongoing and regular education and research activities determined by the NMBA standard relating to CPD - Maintenance of professional portfolio

The Nursing and Midwifery Board of Australia (NMBA), the principal regulatory body for the midwifery profession, is the appropriate authority to hold the governance of this framework. While significant consultation has occurred, the decision to accept or use this framework in whole or in part is a matter for the NMBA to decide.

This framework is not a legal requirement for a PPM who is exempt, until it is approved in a code or guideline by the NMBA under s39 of the National Law.

Positives: - Insistence on high standards of private midwifery practice - Commitment to quality and safety - The potential for medicare-eligible midwives to offer women the option of home, birth centre or hospital birth, with all antenatal and postnatal care funded. Hospital and birth centre births will also be funded, but not homebirths. This opening up of options will improve safety by increasing options to women. - Midwives will be able to remain the primary carers in the ecent of hospital transfer. - This document reflects great respect for women's choices to engage a private midwife for a homebirth and provides support to the midwife (in terms of a framework) and to women (in terms of safety). - The enormous amounts of media generated by the maternity services reforms have had a positive impact on homebirth, just by increasing awareness of homebirth as a respected and mainstream option.

Negatives: - Some are disappointed that twins, breech and other risk-associated pregnancies cannot be supported in a homebirth. - The requirements on the midwife who wishes to attend private homebirths are fairly onerous if the midwife had previously not attended to any quality, safety, professional development and documentation issues. - The cost of the government insurance is prohibitive for many midwives, although it may be possible that other insurance products may be available that will only cover antenatal and postnatal care.

Melissa Maimann, Essential Birth Consulting 0400 418 448