What is the position and/or importance of independent midwives as an option for pregnant women?

This is a question put to me by a lawyer representing a midwife who is answering charges of unprofessional conduct with the regulatory board. I will express my opinion on the position and/or importance of independent midwives as an option for pregnant women, and provide statistical information as to the current status of independent midwifery practice in Victoria.

My report is based on my midwifery qualification and more than 30 years’ experience in midwifery, including teaching, writing, professional and regulatory work.

It is my opinion that midwives are capable of practising privately and independently as primary maternity care providers, ensuring safety and wellbeing for the mother and child, and effectiveness of the service provided. Some current statistical information will be provided below.

The Definition of the midwife (ICM 2005) (the Definition), which is accepted in Australian midwifery education and professional codes of practice, states that “The midwife is recognised as a responsible and accountable professional ... to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.”

The Definition does not comment on issues of employment by an agency, or self-employment. Although most Australian midwives work as employees of maternity hospitals, the option of being self employed has existed historically. The midwife who practises privately enters an agreement with the individual woman (client) who pays the midwife’s fee. There is no government funding for privately employed midwives, which compares with free hospital based maternity services.

The Definition states that “A midwife may practise in any setting including the home, community, hospitals, clinics or health units.” The independent midwife is the only provider of home birth services in most communities. The current exceptions in Victoria are publicly funded home birth programs based at Sunshine and Casey hospitals.

The question of the importance of independent midwives as an option for pregnant women is a personal one. Childbirth is not a medical condition, and many women who choose home birth object to what they perceive to be excessive and unnecessary use of medical intervention in hospital births.

A woman planning to give birth at home understands that the midwife does not use drugs to stimulate labour or to take away pain, as is commonly available in hospital.

The Definition addresses situations in which transfer from home to hospital may be advised: “This care includes … the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.”

The ACM (2008) National Midwifery Guidelines for Consultation and Referral (Guidelines) are also used by midwives in the provision of primary maternity care. These guidelines are not designed to be prescriptive, and are to be used within the context of informed decision making by the individual woman.

When a complication such as non-cephalic presentation is detected, the midwife will usually seek to arrange consultation with a specialist medical practitioner (obstetrician). The woman is able to make decisions based on the advice she receives. Transfer of care from planned home birth to a hospital or private obstetrician will only occur if the woman chooses that option.

When transfer of care occurs, the independent midwife usually continues to provide private midwifery care within the context of the new care plan.

There are occasions when, after a midwife has advised and referred a woman for specialist medical consultation, the woman chooses to continue with a plan for spontaneous labour and birth. This may be against medical advice. The woman makes an informed decision as a competent person.

The number of women who give birth at home is small, approximately 0.2% of all births in Australia (Laws and Sullivan 2009, p21).

There is controversy about the safety of planned homebirth in Australia, particularly since the publication in the Medical Journal of Australia of Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Kennare et al 2010), in which all births recorded as planned homebirths over a 16-year period were reviewed retrospectively. Many questions have been asked about statistical method and conclusions drawn. There are probably only two women in the study whose babies died who started labour at home planning a homebirth. The others whose babies died had all transferred before the onset of labour, which means that the management of the labour was in the hands of the hospital, not the independent midwife.

Annual reports on perinatal data are published in Victoria by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, within the Department of Human Services. The most recent published report refers to births in 2007 (CCOPMM 2009). Of the 253 women whose births were coded as planned home births, seven babies were admitted to hospital nurseries. This is a similar rate of admission to the group of babies born at small hospitals with less than 100 births annually. (CCOPMM 2009, page 30). I am not able to draw conclusions about these births.

There is a degree of uncertainty in all births.

[If you would like the references quoted above, please contact me joy@aitex.com.au to request them, or leave a comment with your email address)

RCM Campaign for normal birth

The Royal College of Midwives (RCM), the professional body for midwives in the United Kingdom, has a Campaign for normal birth.

The protection of normal birth will, without doubt, save lives of mothers and babies and reduce morbidity in both developed and developing countries.

The promotion of normal birth is a message that must be a top priority for all midwives and other maternity care providers in an age that embraces gadgets, quick fixes and technology, and ignores the sensitive intuitive processes that are essential to human life.

The support of normal birth is contingent on the undeniable fact that the safest and most wonderous way for a baby to be brought into this world is, in most cases, in harmony with natural physiological processes.

The midwife holds the key to protecting, promoting, and supporting normal birth. The midwife has the skill and duty to be 'with woman' as the first level (primary) care provider, and to engage and work with other specialist providers when and if the individual woman or her baby need specialist intervention.

It seems to me that 'normal birth' is perceived to be the default position in midwifery care: if there are no complications, 'normal birth' will ensue. In fact, nothing could be further from the truth.

Having practised independently for the last 15+ years, I have learnt, mainly through refelctive learning, that the practice of promoting, protecting and supporting normal birth is in fact the most demanding, engaging professional challenge that I have ever known.


Here is an example of the very useful links featured at the Campaign for normal birth site:
Latest news
* Cathy Warwick comments on the Lancet editorial which criticises homebirth and midwife-led care
* Promoting normal birth key to cost savings
* Midwifery Care and Normal Birth - Recent Policy statement by Canadian Association of Midwives
* Specialist preparation pre-pregnancy produces no measurable outcome benefits
* Giving birth at home is as safe as doing so in hospital with a midwife



Readers of this and related blogs will be aware of the enormous threats that are at present being experienced by midwives who practise privately in Australia.  Government 'reform' of maternity services threatens to restrict midwifery with excessive bureaucracy and rules that ignore women's basic human rights and autonomy in choosing their care provider and place of birth.  Rather than focusing on the dog's breakfast of 'guidelines', 'frameworks' and regulations, I call on all midwives to shift our focus to a campaign for normal birth.

Breastfeeding babies exclusively

These two mothers breastfed their babies at a rally outside the Health Minister's office.  Well done!

Exclusive breastfeeding for the first six months of life, followed by continued breastfeeding as well as a diet made up of nutritious family foods to the age of two years and beyond is the gold standard in infant nutrition.

Far too few babies in our world get past the first week exclusively breastfed, which sets them up for subesquent feeding difficulties.

I won't try to explain why exclusive breastfeeding is so important to both mother and baby. Sufficient to say that the principle "In normal birth there should be a valid reason to interfere with the natural process" applies as much to the establishment of breastfeeding as it does to progress in labour. Interferences will likely interrupt natural physiological processes, including mother-baby attachment, bonding, onset of lactogenesis 2, baby's ability to suckle, baby's gut flora, jaundice, and a mother's acceptance of the maternal role, just to mention a few.

A baby who is born at home, whose mother takes the baby to her breasts and who is able to initiate breastfeeding without interruption in the next hour or so is very unlikely to ingest anything other than his own mother's milk in the first week of life. It's a busy week, with baby eagerly taking the breast frequently through the day and night, and often with both parents facing endurance challenges. Some mothers and babies face some of the not uncommon difficulties with flat nipples or very large breasts or whatever. But by about day 4 or 5 there is an abundance of wonderful milk, a baby who sleeps blissfully after spending time at the breast, and there's light at the end of the tunnel.

The over-medicalisation of birth has led to many babies experiencing non-physiological challenges at birth, and this leads on to wasting of the baby's energy resources, painful surgical wounds in the mother, and separation of mother and baby. The end result is that babies are given artificial formula feeds to 'supplement', 'top up', or 'complement' what the baby is able to get from the breast.

Where the natural provision for a baby is ideally suited to the baby's physiological needs, of small volumes of colostrum that coats the digestive tract and supports cell proliferation and colonisation of the gut with the normal bacterial flora, the baby who is given, at 2 hours of age, 30ml of the white chemical concoction that is called infant formula has the whole process interrupted and interfered with. While that baby's energy needs may be met a whole lot of other needs are being denied.

A midwife recently told me that she was concerned about her client giving birth in a particular hospital because any baby born over 4 kilos was immediately treated as if at high risk of hypoglycaemia. The baby would be taken to the nursery, separated from the mother soon after birth, and blood glucose levels tested. With interruption to the first breastfeed, and separation, it's likely that a 'negative' result - blood sugar level lower than the required amount - would be obtained. That baby would then be given a formula feed, and the whole process repeated in a couple of hours. A mother who objects to the infant formula will be given information about the horror of hypoglycaemic brain damage, and only someone who is well informed knows that she has another option - to breastfeed effectively.

With approximately one in three babies in hospitals being born by caesarean surgery. The usual post operative pain management regime in hospitals in Melbourne maternity hospitals is Endone (a narcotic, dangerous drug that comes with the warning, "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child."), Panadol and Voltaren. I have written about Endone at my villagemidwife blog



Anyone who takes exclusive breastfeeding seriously knows it's an uphill battle in most hospitals. Even the Baby Friendly hospitals. It has been 15 years since the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was produced and adopted. The Declaration, adopted by all WHO and UNICEF Member States, has been a key strategy on improving health of infants and young children through optimal nutrition. [for more information go to Innocenti + 15]

Maternity care today is so wedded to infant formula use that it will take a major reformation to change the trend. The community must demand protection of the infant's right of access to the breast. We must also demand that human infants are given only human milk: that milk banks should be available for any additional requirements of breastfed babies.