Reviewing the past couple of years

To Daddy

A couple of years ago the federal Health Minister announced a Maternity Services Review, declaring that the government intended to provide “More Choice in Maternity Care – Access to Medicare [funding] and PBS [prescribing] for Midwives”. The monopoly of government funding for maternity care being available only for services provided by doctors and hospitals was to be broken.


The Review’s Discussion Paper acknowledged the call by consumers and midwives for radical reform and more appropriate use of the midwifery workforce, quoting Maternity Coalition (2002) National Maternity Action Plan, which called for all women to be able to access a known midwife who would provide one-to-one primary maternity care from early pregnancy through postnatal care, providing for births in the setting of the woman’s choice, with seamless transfer arrangements when required.

Midwives and birth activists encouraged everyone who cared about birth to write to the Review. An unprecedented number of submissions were received by this and subsequent reviews. In September 2009, approximately 2000 people flocked to the national capital and rallied outside Parliament House, in the rain, with babies in slings and little children waving banners. [See MIPP blog] It was very clear by then that the offer of “More choice in maternity care” was actually “... as long as it’s not homebirth with a private midwife” – the very choice that many of those who wrote their stories and attended rallies were determined would not be taken from them.

The Report of the Maternity Services Review was published in due course, and the birthing activist community was shocked. Private midwifery was apparently to become illegal, due to the impossible hurdle of mandatory indemnity insurance. Women and midwives were understandably angry. The vision of going underground arose: midwives attending women discretely and unlawfully for birth at home, and parents finding an alternate pathway for registration of their child’s birth. The tone of the Report was paternalistic to the extreme; a socialist government dictating maternity care, strongly influenced by shroud-waving risk-averse medical groups, and ignoring women’s basic rights to undergo a normal physiological event, childbirth, in their own homes and on their own terms.

The government’s maternity reform package has now become law. Since 1 November 2010, midwives have been able to apply for notation on the Register as eligible for Medicare and PBS. A small number of independent midwives have achieved this new standard, and others are awaiting the outcome of their applications.

Even when a midwife is prepared to practise according to the new private midwifery model dreamt up in the rarefied atmosphere of bureaucracy, the reform ‘carrot’ that offered access to Medicare funding and other extensions to practice for midwives in private practice had a very big ‘stick’ attached – that a midwife would also be required to have a collaborative arrangement with a named doctor in order to access the funding. The clock appears to have been wound back many years to the days when all midwives were supervised by doctors.

Inter-professional collaboration, consultation and referral is no impost on midwives: it’s a basic principle in midwifery practice that when there is a valid reason to interfere with the natural process, a medical practitioner who specialises in obstetrics is one who brings essential skills and expertise to the care team, greatly improving the outlook at that point in time for mother and baby. However the model that has been written into Australian laws demands that the midwife obtains a signed collaborative agreement or arrangement with a doctor, without requiring that doctors reciprocate. Spokesmen for the medical profession have questioned the liability of a doctor who enters a collaborative arrangement with a midwife, fearing that their own insurance policies would not be effective if a woman sued the midwife for damages.

Without getting bogged down in speculation about how midwives will be able to navigate this untested and awkward new terrain, careful reading and interpretation of the legislative instrument seems to allow room for midwives to continue private practice without being overwhelmed by the watchful eye or hot breath of medical supervision. Pathways that are being forged include arrangements with the medical staff of public maternity hospitals, rather than with individual private obstetricians.

The constant recurring theme in Australian and international midwifery regulation is the public interest. The medical profession considers midwifery incapable of delivering optimal and safe maternity care in settings outside obstetric supervision and surveillance. The issue of home birth is the pimple on the end of the maternity system’s nose. It won’t go away, it hurts when touched, and it’s a real nuisance.

Public interest means looking at safety: maternal and perinatal morbidity and mortality. Various retrospective studies comparing outcomes from homebirth with hospital birth have been published recently, with strongly debated and contested conclusions. Disagreement centres around inclusion and exclusion criteria, and what is actually being measured, such as perinatal mortality or neonatal mortality. Results can vary widely, from the de Jong et al (2009) study in the Netherlands reporting that there is no difference in preinatal outcomes for low risk women at home or in hospital, to the Wax et al (2010) report of a meta analysis of several studies, concluding that planned home birth is associated with a tripling of the neonatal mortality rate compared with planned hospital births.

Australian government regulatory efforts are likely to continue with the agenda of removing the option of homebirth in the care of privately practising midwives. Women and midwives, and all who care about the way future generations of our children are born, need to stand strong. As long as the regulators take this parernalistic approach, forcing all women into hospitals for childbirth by shutting down any reasonable alternatives, we have no option but to fight for our God-given right to give birth under normal physiological conditions, unless there is a valid reason for another pathway to be taken.