IMAGE CREDIT: ANNA TODD
GP referral refusal position statement
Importance/problem
Privately Practising Midwives (PPMs) are currently required to obtain a referral from a GP, health service or Obstetrician in order to provide Medicare rebatable antenatal and postnatal care to women. Unfortunately, this collaboration is often one-way, whereby the GP/OB is required to provide referral but doesn’t necessarily follow up or form a relationship with the midwife they have referred to. Around Australia, women are continuously being refused referrals to a Privately Practising Midwife (PPM) by their General Practitioner (GP), sometimes with the reason given being that their practice policy dictates they are unable to refer. This is despite their right to informed, woman-centred antenatal, intrapartum and postnatal care. Given the knowledge that midwifery-led continuity of care improves outcomes for both mothers and babies (Sandall et al., 2016), and that birth at home leads to no differences in maternal or neonatal mortality yet significantly better maternal morbidity (Homer et al., 2019; Hutton et al., 2019; Scarf et al., 2018; Davies-Tuck, 2018), care with a PPM should not only be a valid option in Australia but should also be supported by our other healthcare providers.
Australia’s PPMs are some of the most qualified pregnancy, birth and postpartum specialists available, having undertaken a Bachelor’s degree, having had to practice a minimum of 3 years within the hospital system and undertaking continual professional development activities in order to register and go into private practice, as well as being regularly audited while practicing. To suggest that a GP who has minimal antenatal, birth and postnatal experience should have to refer to a specialist is insulting to the midwifery profession as a whole. Furthermore, we have observed that when GPs do refuse referral to the women they are caring for these women either go elsewhere for referral, reducing the continuity of care they would usually have with their chosen GP, are out of pocket for expenses incurred without Medicare rebate, or choose to go through their pregnancy alone, without any medical care; all of these options reduce the safety for women and babies.
Our aims
We aim to push against the requirement for PPMs to collaborate with other healthcare providers in order to provide Medicare rebatable care. We aim to ensure that PPMs can provide Medicare rebatable antenatal, birth and postnatal care to women without first seeking referral from a GP, OB or healthcare service, maintaining safety for women and babies and providing midwives with the respect their profession deserves.
How will we do this?We will continue to lobby against mandatory collaborative agreements, raise these issues with the Australian Health Practitioners Regulation Agency (AHPRA) and keep these collaborative agreements in mind when sitting in on policy and legislative changes, such as those currently being considered within changing the Medicare funding for intrapartum care to include homebirths. We will continue to call out GP practices who do have policies against referring to PPMs, and will continue to follow the insurance trail to determine whether insurers have suggested they are unable to provide insurance to GPs who refer to PPMs.
Where are we now? We have undertaken a research project to determine the various effects of GP referral refusal on women and have presented this at the Homebirth Australia Conference in 2019, and continue to share this information with organisations including Maternity Choices Australia and Homebirth Australia. We also made this information readily available and shareable via our website, and will continue to share the information widely. We are still working on removing the mandated collaborative agreements from legislation for PPMs and from Medicare related documents. We have been in touch with RACGP about the GP referral refusal issue and had the below response.
Download position statement
Privately Practising Midwives (PPMs) are currently required to obtain a referral from a GP, health service or Obstetrician in order to provide Medicare rebatable antenatal and postnatal care to women. Unfortunately, this collaboration is often one-way, whereby the GP/OB is required to provide referral but doesn’t necessarily follow up or form a relationship with the midwife they have referred to. Around Australia, women are continuously being refused referrals to a Privately Practising Midwife (PPM) by their General Practitioner (GP), sometimes with the reason given being that their practice policy dictates they are unable to refer. This is despite their right to informed, woman-centred antenatal, intrapartum and postnatal care. Given the knowledge that midwifery-led continuity of care improves outcomes for both mothers and babies (Sandall et al., 2016), and that birth at home leads to no differences in maternal or neonatal mortality yet significantly better maternal morbidity (Homer et al., 2019; Hutton et al., 2019; Scarf et al., 2018; Davies-Tuck, 2018), care with a PPM should not only be a valid option in Australia but should also be supported by our other healthcare providers.
Australia’s PPMs are some of the most qualified pregnancy, birth and postpartum specialists available, having undertaken a Bachelor’s degree, having had to practice a minimum of 3 years within the hospital system and undertaking continual professional development activities in order to register and go into private practice, as well as being regularly audited while practicing. To suggest that a GP who has minimal antenatal, birth and postnatal experience should have to refer to a specialist is insulting to the midwifery profession as a whole. Furthermore, we have observed that when GPs do refuse referral to the women they are caring for these women either go elsewhere for referral, reducing the continuity of care they would usually have with their chosen GP, are out of pocket for expenses incurred without Medicare rebate, or choose to go through their pregnancy alone, without any medical care; all of these options reduce the safety for women and babies.
Our aims
We aim to push against the requirement for PPMs to collaborate with other healthcare providers in order to provide Medicare rebatable care. We aim to ensure that PPMs can provide Medicare rebatable antenatal, birth and postnatal care to women without first seeking referral from a GP, OB or healthcare service, maintaining safety for women and babies and providing midwives with the respect their profession deserves.
How will we do this?We will continue to lobby against mandatory collaborative agreements, raise these issues with the Australian Health Practitioners Regulation Agency (AHPRA) and keep these collaborative agreements in mind when sitting in on policy and legislative changes, such as those currently being considered within changing the Medicare funding for intrapartum care to include homebirths. We will continue to call out GP practices who do have policies against referring to PPMs, and will continue to follow the insurance trail to determine whether insurers have suggested they are unable to provide insurance to GPs who refer to PPMs.
Where are we now? We have undertaken a research project to determine the various effects of GP referral refusal on women and have presented this at the Homebirth Australia Conference in 2019, and continue to share this information with organisations including Maternity Choices Australia and Homebirth Australia. We also made this information readily available and shareable via our website, and will continue to share the information widely. We are still working on removing the mandated collaborative agreements from legislation for PPMs and from Medicare related documents. We have been in touch with RACGP about the GP referral refusal issue and had the below response.
Download position statement