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)