Homebirth Australia Submission to the South Australia Department of Health and Ageing Proposal to Protect Midwifery Practice
Download Homebirth Australia Submission to the South Australia Department of Health and Ageing Consultation on the Proposal to Protect Midwifery Practice [PDF] March 2013
Homebirth Australia Submission to the Department of Health and Ageing Homebirth Roundtable
Download Homebirth Australia Submission to the Department of Health and Ageing Homebirth Roundtable [PDF] June 2012
Homebirth Australia Submission to Nursing and Midwifery Board Inquiry
Download Homebirth Australia’s Submission to the indemnity insurance Nursing and Midwifery Board Inquiry [PDF] May 2011
Homebirth Australia Submission to Senate Inquiry
Download Homebirth Australia’s submission to the Senate Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA) [PDF] April 2011
Submission from Homebirth Australia to ACM
Download Homebirth Australia’s submission to the Australian College of Midwives re the Interim Homebirth Position Statement and Guidelines for Privately Practising Midwives September 2011 [PDF]
Key points are:
Contraindications for homebirth
The list of contraindications for homebirth ignores what we know, that many women will continue to choose to birth at home who fit into these risk profile categories. And with good reason, Vaginal Birth After Caesarean (VBAC) success rates for women choosing home as their place of birth in Australia are around 95% as compared to in hospital where success rates are as low as 6.7% The Position Statement must recognise this and explicitly respect a woman’s right to choose, and her midwife’s right to continue to provide care for her. A midwife cannot be placed in a position where she is forced by her own professional body to abandon the care of a woman if she and her family make their own well-informed decision to birth at home. These women will be left without a care-provider and that is completely unacceptable.
Mandatory Consultation with an Obstetrician
Mandatory obstetric consultations must be removed from the Interim Homebirth Position Statement and associated Guidelines.
To force a women into obstetric hospital based care against her will is a breach of the common law rights of a woman and established case law including St George’s Healthcare NHS Trust v S (1998) 44 BMLR 160 (CA) UK and Re MB (1997) 38 BMLR 175 (Court of Appeal) UK.
We refer you to the National Guidance on Collaborative Maternity Care commissioned by the Department of Health and Ageing and released in 2010 from the National Health and Medical Research Council (NHMRC). In it’s discussion of collaboration this document states:
A woman decides who she involves in this decision-making process, be it a health professional, partner, doula, her extended family, friends or community, and should be free to consider their advice without being pressured, coerced, induced or forced into care that is not what she desires (McLean and Petersen 1996). Women have the right to decline care or advice if they choose, or to withdraw consent at any time. Therefore, if a woman declines care or advice based on the information provided, her choice must be respected (UNESCO 2005). Importantly, women should not be ‘abandoned’ because of their choice (FPA Health and Read 2006, Faunce 2008; NHMRC consultations 2009).
The Interim Homebirth Position Statement and associated Guidelines are in direct conflict with the recommendations in the National Guidance on Collaborative Maternity Care as they encourage midwives to abandon the care of a woman who makes their own choices and declines care/advice, and they enforce mandatory consultations with Obstetricians.
Over the coming years, the impacts of the ACM Homebirth policy will become apparent if it is not modified to ensure private midwives can continue to provide care for all Australian women who make an informed choice to birth at home. The ACM Interim Homebirth policy is forcing midwives to do what is essentially illegal by insisting on treating women against their will. If the point of the ACM Guidelines is to improve safety, then in it’s current format it is going to be counter-productive. There will always be a core group of women who will continue to birth at home regardless of their designated ‘risk profile.’ The College is asking their members who are privately practising midwives to make impossible choices about whether to abandon a woman’s care or force medical treatment upon their clients. Compliance with the ACM Interim Homebirth Position Statement and associated Guidelines in their current format will result in midwives acting illegally as a direct result of ACM policy.
Some home truths on a woman’s right to choose
Michelle Meares – The Daily Telegraph – April 06, 2012
HOME birth is not about being selfish.
It is about safety and choice. In the UK, women have this choice and it is supported by the government and medical system. In New Zealand and the Netherlands, women have this choice. More than 29,000 babies are born at home with midwives every year in the US.
This debate is not about home-birth women versus hospital-birth women.
Home-birth supporters want women to have a choice of where they give birth and for all birth choices to be equally respected and supported. For the safety of their babies and themselves, women must have access to the highest standard of medical care wherever they choose to birth – home, hospital or birth centre. Women have a legal right to to give birth at home but are rapidly losing the support of health care supporters. Some women are choosing to give birth without a care provider as they cannot access one, or feel so traumatised by their previous birth experience.
In Australia, latest national data shows there were 863 home births. There were two foetal deaths at home births, meaning they have a 99.8 per cent live birth rate.
Induction rates are appallingly high in Australia, caesarean rates also – both of these carry high risks to mothers and babies. More than one in three women who give birth in some hospitals are given an episiotomy (surgical cut). There is no medical reason for this extremely high rate when other hospitals have an episiotomy rate as low as one in 25 women.
The term “birth rape” was discussed in The Daily Telegraph yesterday. It is a very confronting term, yet for some women that is genuinely their experience.
Some women report being held down, procedures performed on their most intimate area without consent while screaming out “No”.
In the UK, the Royal College of Obstetricians supports home birth, the International Confederation of Midwives and the International Federation of Gynecology and Obstetrics say women should not be denied the choice to home birth, yet in Australia, the Australian Medical Association and Royal Australian & New Zealand College of Obstetricians and Gynaecologists do not support home birth and in many cases, actively work against providing safe home-birth services.
In the UK, New Zealand and the Netherlands home birth is funded and supported by government and integrated into the health care system so women have access to emergency assistance. The European Court of Human Rights agrees. It was recently ruled that a woman has the right to choose the circumstance of how she becomes a parent and this includes the right to choose to give birth at home.
Instead of judging each other, women should work together to create the best maternity care system Australia can deliver across all locations – hospital, birth centre and home?
Our babies deserve that.
Australian Homebirth Consortium – Consensus Statement
In response to the ongoing threat to homebirth in Australia and the Australian College of Midwives (ACM) releasing the Interim Homebirth Position Statement and Guidelines for feedback, Homebirth Australia has consulted with stakeholder groups across the country. As a result, the Australian Homebirth Consortium (AHC) has been formed from interested stakeholder groups including consumers and midwives. The aim of the Australian Homebirth Consortium is to bring the groups working for homebirth together to share information and work together for the future of homebirth in Australia.
There is significant concern amongst many midwives and consumers as the ‘interim’ statement is already being used to regulate the care that women can receive and being cited in disciplinary proceedings for midwives. The ACM Interim Homebirth Position Statement has been endorsed by the Australian Health Practitioner Regulation Agency (AHPRA) and the Nursing Midwifery Board of Australia (NMBA), before feedback has been received from consumers and private midwives.
We the undersigned request:
• That the Australia College of Midwives immediately withdraw the current position statement on homebirth as it is currently negatively impacting on women and midwives, and formally consult widely with midwives, consumers, their representative groups and others affected by this regulation before reformulating this statement.
• That the Australia College of Midwives formulate a guideline whether part of the ACM Interim Homebirth Position Statement and associated Guidelines or separate, that clearly and unequivocally endorses and documents the process for a woman’s right to informed refusal and the midwife’s right to provide care for her in pregnancy, labour, birth and postpartum irrespective of the woman’s risk status and without regulatory or legal consequence for the midwife or the woman.
Download the consensus statement here. [PDF]
Individual Feedback to ACM on Homebirth Position Statement
We encourage all our members to send individual submissions to the Australian College of Midwives on the Interim Homebirth Position Statement. It is due by 23 September 2011. Email your feedback to firstname.lastname@example.org. Read the statement and guidelines on the ACM website here.
Save HBAC in Australia
Urgent Call to Action
Women’s rights to choose where and how they give birth are once again under threat
In Western Australia in late June, a private midwife attended a HBAC (Homebirth after Caesarean). Her case is currently under investigation. The information we have is that she operated within her scope of practice and followed the ACM guidelines completely and the woman birthed beautifully at home. However the hospital where she was booked into in case of the need to transfer, reported the midwife. She has since had restrictions placed on her registration. She was given only 36 hours to respond to Australian Health Practitioner Regulation Agency (AHPRA). Women in her care, who are due to birth in the coming weeks are left without a midwife, and her livelihood has been taken away.
This sets an extremely serious, and worrying, precendent.
This is not an isolated incident. Read more here about how you can take action today to protect HBAC in Australia.
Feedback to Australian College of Midwives
27 May 011
Homebirth Australia was asked to provide feedback to the Australian College of Midwives draft Homebirth Position Statement.
We have engaged with homebirth and maternity interest groups from across the country and our united position was that our organisations are unable to endorse the ACM draft document. Key stakeholders developed a homebirth position statement in October 2009, namely, Homebirth Australia, Maternity Coalition, Australian Private Midwives Association and the Australian College of Midwives. As this document was developed together and drafted in a spirit of consensus we believe this document adequately reflects appropriate midwifery practice, based on the ICM definition and the rights and responsibilities of women who chose to give birth at home.
Our combined position is that the October 2009 document (along with contemporaneous flow-chart) remains the agreed position until all parties, through consensus, draft another
• Homebirth Australia
• Maternity Coalition
• Australian Private Midwives Association
• The Australian Society of Independent Midwives
• Midwives Australia
• Homebirth Access Sydney
• Dunedin Homebirth Association
• Blue Mountains Homebirth Group
• Hunter Home and Natural Birth Support
• Caesarean Awareness Recovery Education Support SA
• Homebirth Network of SA
• Midwives in Private Practice
• Nimbin Birth and Beyond
• Birth Choices South West WA Inc
Download the letter from the organisations above. Download the flow chart agreed to in October 2009.
Thursday September 23 2010
Homebirth Australia’s Committee Position to the National Health (Collaborative arrangements for midwives) Determination 2010
The National Health (Collaborative arrangements for midwives) Determination 2010 (the Determination) is totally unacceptable for the following reasons:
It gives veto power over women’s rights to bodily autonomy and the scope of midwifery practice to medical practitioners.
It will create a 2 tiered system, enabling funding only if one agrees with the particular views and practices of an individual medical practitioner (with no guarantees around evidence based practice and certainly no recognition of the common law rights of women as health consumers.
We believe Australia is contravening its agreement to CEDAW (Convention on the Elimination of all forms of Discrimination Against Women), particularly the Beijing protocol that states
17. The explicit recognition and reaffirmation of the right of all women to control all aspects of their health, in particular their own fertility, is basic to their empowerment;
Curbing the practice of midwives who wish to become eligible for Medicare practice contravenes the International Confederation of Midwives definition of a Midwife and Australia’s commitment to the 2008 Glasgow Declaration that states
“Legislation which is enacted to govern the practice of midwives should:
• enable midwives to practise freely in any setting
• adopt a “Definition of the Midwife’ congruent with the ICM definition, appropriate to the country within the legislation
• recognise that all women have a right to be attended by a competent midwife
• allow for the midwife to practise in her own right
• recognise the importance of separate midwifery regulation and legislation which supports and enhances the work of midwives in improving maternal, child and public health”
Homebirth Australia supports a universal funding arrangement for all pregnant women in Australia. We believe that individual women should be able to direct that funding. Homebirth Australia supports funding private midwifery care for birth at home and in hospital.
Current Medicare related legislation requires a determination around collaboration in order to operate. We do not support the proposed determination and call for a complete re-write.
Homebirth Australia understands many consumers do not have the means to pay for a private midwife. Medicare funding could greatly assist. Whilst we see the current determination as totally unworkable we support seeing this process through to the end conclusion in the hope that Minister Roxon will put the common law rights and international obligations protecting women ahead of the desires of the medical lobby.
Response to the Position of the Australian College of Midwives (ACM) to the determination
The Australian College of Midwives say not allowing the National Health (Collaborative arrangements for midwives) Determination 2010 is ‘too risky’ as then access to Medicare funding and PBS will be lost. Homebirth Australia strongly disagrees.
Instead, we ask women if they can agree to a legislative instrument that hands control of a woman’s right to determine her healthcare and a midwife’s actual practice to a medical practitioner. The current instrument requires midwives to seek permission to practice, whilst requiring nothing of medical practitioners and providing no safeguards for women.
Sunday August 28 2010
Justine Caines and Dr Andrew Pesce, Head of the Australian Medical Association Debate 2GB Radio
Saturday July 30 2010
Homebirth Australia Newsletter – July 2010
SECONDARY REGULATIONS JUST RELEASED & THE ELECTION – WHAT YOU CAN DO
The Secondary Regulations which define “collaborative arrangements” have just been released and as feared they give doctors a veto over women’s choices.
You can view the document here
With the election looming on 21st August we have 3 weeks when the politicians are listening a little more than usual to voters. It is time to pick up the pen, the phone or turn on your computer and once again, contact your Federal members.
1. Check which electorate
you are in and who the candidates are in your electorate. The AB C
election website has links to this information – click on the “Green Guide” link.
(Be sure to check back on the website as new candidates are announced)
2 .Contact each of the candidates and ask them what their position is on the recently passed legislation forcing midwives into “collaborative arrangements” with doctors. Specifically we are pushing for:
• A guarantee that the medical veto over women’s choices will be removed
• A commitment that women’s rights to informed consent (including the right of refusal) will be expressly recognised in all codes, guidelines and frameworks relating to midwifery practice
• Ensure that privately practising midwives have visiting rights in hospitals across the country
• A commitment to funding and insurance for homebirth to ensure equity for all Australian women
3. There are a number of women standing as Independent candidates in marginal seats who are homebirth advocates. Lets give them all the support we can – including spreading the word to people you know in their electorates, or helping them out with leg-work for the campaign.
MICHELLE MEARES – Robertson (Central Coast NSW) – visit website
SALLY ANNE BROWN – Corangamite (Southern Vic/Geelong VIC) – visit website
AMY BELL – Macquarie (Blue Mountains NSW) – visit website
REBECCA JENKINSON – Dickson (Brisbane outer Northern QLD) – visit website
4. Email your contact details to email@example.com and you will be notified by text message when Julia Gillard or Tony Abbott are close by so you can pull out your ready made protest sign and confront them about the issues. The more
Thursday June 10 2010
Homebirth Rights and Responsibility – A response to Susie O’Brien from Justine Caines
Let’s lock up the homebirthers. I must admit it has got a ring to it. Lets make the law retrospective and capture Bill Grainger and his wife Natalie, Noni Hazlehurst, Tracy Bartram, not to mention Cameron Daddo, Tropfest’s John Polson, John Butler, and even former Prime Minister Bob Hawke’s daughter, Sue. They could join the thousands more, amongst them doctors and lawyers who have chosen homebirth after considered research.
Susie O’Brien’s piece was irresponsible and insulting. Her own story does not have any relationship to the safety of homebirth. She states that she had complexities in pregnancy which resulted in induction with resultant complications. Inductions do not take place at home. Homebirth safety comes from maximising wellness with a healthy unmedicated woman cared for by a midwife who has got to know the woman and her family over many months. The vast majority of these births do not go horribly wrong without warning and for the women choosing homebirth, the benefits far outweigh the minute chance of a problem.
The other assumption in most of these arguments is that emergency care in our hospital system is immediate. This flow on from this fallacy is that hospital birth is always safe and is superior in all cases. In private hospitals obstetricians and anaesthetists are off site most of the time, often called in, sometimes from their homes or beds. Large public teaching hospitals have staff 24/7 but with competing interests and pressure in these busy units ‘instant’ detection and response of a problem is rare.
As a columnist Susie feels qualified to dictate the limit of women’s rights. Homebirth is too risky for a baby therefore women must not have that choice; it is a selfish woman who puts her needs above her child. Perhaps Susie’s next column can reveal if she supports the rights of women to have a caesarean when there is no medical need? Is that OK for babies? We know that at least 30% of these babies need care from a Neonatal Intensive Care Unit simply as a result of their mode of birth. What is the limit then of the “selfish” woman – is she selfish exposing her baby to a 30% chance of a NICU visit.
Families will continue to choose homebirth. We have a responsibility to provide them with a registered midwife. Nicola Roxon’s legal background has served her well. She understands Australia’s responsibilities to international conventions such as the Convention of the Elimination Against all forms of Discrimination and case law that has established the rights of adults to determine how or not their body is treated.
Whilst many women may not choose homebirth the majority respect the rights of women to make decisions. Most do not demonise women’s choice. They also understand that parents will make thousands of decisions affecting their children. Yes, they should be responsible for those decisions and demonstrate they have made an informed decision. This applies for those choosing medical intervention as well as homebirth.
What every Australian family deserves is access to a registered health professional, Minister Roxon knows that it is possible to provide this. Homebirth care must be funded and indemnified like all medical births are. In this I am thankful that Nicola Roxon is our Health Minister rather than Susie O’Brien.
Response to Herald Sun Article – Home Births a Major Risk by Susie O’Brien. 8/06/2010
Wednesday June 9 2010
Media Release: Will Women’s issues be the election slow burner? First of many electorate protests in Macquarie – the most marginal
Today women will gather in protest outside the Springwood Sports Club challenging Minister for women, Tanya Plibersek to do her job and protect the rights of women and candidate Susan Templeman to work to ensure safe maternity care that meets the needs of local women.
“This is the first of many protests demonstrating to both major parties that there is a Mums Army out their angrily demanding their basic rights.” said Justine Caines Homebirth Australia spokesperson. Read Full Article»
Tuesday May 25 2010
Response from Homebirth Australia: Safety and Quality Framework guiding Midwifery Care provided by Privately Practising Midwives attending homebirths from Homebirth Australia
How can a woman’s human and common law rights be eroded by the Quality and Safety Framework?
Despite making written and verbal representations regarding established legal rights of women, the QSF fails to reflect the significance of these rights. The QSF states
“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 builds on existing effective practices and relationships. It 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”.
These statements contradict one another and will very much act as an exclusionary document. Homebirth Australia estimates that as many as 50% of homebirths would not meet the above criteria.
Homebirth Australia suggests the following statement:
Quality and safety is a central feature of this framework. The right of women to informed consent is acknowledged as is a health professionals right to provide clinical information and advice. Health professionals have a responsibility to provide balanced information and to be confident that information is understood. Women have a responsibility to demonstrate they understand this information and to articulate ongoing decisions.
Homebirth Australia understands that this document and the approach from Government will be risk adverse. This approach does not however need to come at a cost of removing established rights of women. It would be prudent to address the fact that a growing number of women with what most obstetricians would consider a ‘risk factor’ are choosing homebirth and will continue to do so. If this is understood and articulated there is a much better chance to develop understanding and appropriate clinical pathways for consultation and referral. By ignoring or shunning the women that make these choices we risk underground practice and birth without a skilled attendant. Homebirth Australia does not support women being put in this position and hopes that government will accept this approach as part of a risk adverse strategy.
In the case of rural and remote Australia it seems perverse logic to accept that current options are ‘safe’ for women (removal from their families and the risk of road side birth whilst travelling in labour) while the care of a registered midwife at home is seemingly less safe.
Duty of Care Protection for Midwives
Whilst the right of informed consent for health consumers has legal precedent, ‘Duty of Care’ protection for midwives is not established in Australia. This has led to many unnecessary incidents and deepened the chasm between midwives providing homebirth care and other health professionals, namely obstetricians. By ignoring this government further exposes itself to possible allegations of preventing access to registered health professionals for homebirth care and thus safety.
As part of the face-to-face consultations Homebirth Australia raised this with Dr Oats. His understanding and empathy was refreshing. Dr Oats stated clearly that as a practicing obstetrician if he advised a woman to have a caesarean section and she refused and there was a poor outcome as a result his registration would not be ‘on the line’. For a homebirth midwife the same is not true, currently if they continue to provide care (even after they have advised and documented clinical advice against homebirth) they face the real prospect of disciplinary action and de-registration. This document has not addressed this very real concern. Homebirth Australia hopes the Nurses and Midwives Board of Australia (NMBA) does not take the same approach.
It is positive to see the Australian College of Midwives guidelines for consultation and referral cited as a critical document. Homebirth Australia understands that the guidelines recommend certain conditions for midwifery care. The revised edition however has a clear pathway for women who make choices that fall outside of the guidelines. As a participant of the revision process, Homebirth Australia notes the main reason for this pathway was as a result of midwives being targeted for providing care to women with obstetric risk factors, primarily vaginal birth after caesarean.
The multi- disciplinary committee was unanimous in its desire to protect midwives and women by providing a clear pathway (including documentation requirements).
Homebirth Australia does not support a melding of the ACM and RANZCOG guidelines. RANZCOG has a policy of not supporting homebirth. The vast majority of its fellows would never have attended a homebirth, nor is there a depth of experience of supporting women across the many hours of labour (and with it a strong understanding a labour physiology). Homebirth Australia understands the importance of co-operation with obstetricians, anaesthetists and paediatricians, but co-operation and collegial relationships does not equate to dictating who can do what and where. This approach has to date prevented positive working relationships and on too many occasions impacted on safe practice.
Homebirth Australia’s submission in March outlined the relevant common law and human rights conventions surrounding women’s health. Please find them attached again this time as an appendix. Homebirth Australia asks that they are acknowledged and utilised in the final version of the QSF provided to the NMBA.
The Convention of the elimination of all forms of discrimination against women (CEDAW) declares 
States Parties condemn discrimination against women in all its forms, agree to pursue by all appropriate means and without delay a policy of eliminating discrimination against women and, to this end, undertake:
(d) To refrain from engaging in any act or practice of discrimination against women and to ensure that public authorities and institutions shall act in conformity with this obligation;
(e) To take all appropriate measures to eliminate discrimination against women by any person, organization or enterprise;
(f) To take all appropriate measures, including legislation, to modify or abolish existing laws, regulations, customs and practices which constitute discrimination against women;
1. States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning.
2. Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.
Common Law Rights in Australia
The often-quoted passage from the decision of Cardozo J, in the case of Schloendorff v Society of New York Hospital1, clearly articulates the principle that-
“Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient’s consent, commits an assault.”
Forrester provides the following analysis
“As an example, if a competent adult patient refuses treatment it will not be a defence for the health professional to argue the treatment was given with the intention of improving the patient’s condition. In addition, a competent adult patient is not obliged to explain or justify the basis for their refusal nor provide any reasons as to why they have made their decision.”
United Nations (1979) The Convention of the elimination of all forms of discrimination against women. http://www.un.org/womenwatch/daw/cedaw/cedaw.htm
 1 (1914) 211 NY 125 at 126
 Kim Forrester “Refusal of treatment and absolute right of the patient or client” The Queensland Nurse, April 2007 pp10-11
Keep Private Midwifery Alive!
Homebirth a Choice not a Crime
It is important to write to, or make an appointment to meet your local Federal politician. You can find your local federal politician through the AEC Website
If you can’t do this, PLEASE send your local federal member a letter with your homebirth story and a photo that shows them how safe and supportive homebirth is. Send a copy of the letter and photo to Health Minister, Nicola Roxon Politician’s Fact Sheet/Info for your letter.
Minister For Health and Aging
Parliment House Canberra ACT 2601
• The Maternity Services Review Report is the 38th review or inquiry into maternity services since 1985 – An unprecedented number of submissions was received (950) Only 500 were received for the National Health and Hospital’s Reform Commission
• Over half (53% of the consumer submissions to the MSR discussed homebirth and yet the MSR did not recommend publicly funding for homebirth.
• There are plans for a national registration body (July 2010), a necessary registration requirement is indemnity insurance. If private practicing midwives are not assisted with indemnity insurance the option of homebirth will be illegal. This is not acceptable. Women will continue to choose homebirth, many after hospital trauma.
• It is not appropriate to force women to give birth at home without a midwife
• Midwives are currently prevented from working to their level of registration and education
• Child-birth is the largest volume area of health, with now over 280,000 births/yr
• Midwives are the only health professionals without indemnity insurance, despite a $500 M support package for medical practitioners since 2001
• Maternity funding placates the entrenched medical dominance, promoting the professional ‘turf-war’
• Maternity care is unique in the fact that it is a finite episode. There are considerable benefits to establish a package payment, a ‘baby-bonus’ type payment for healthcare
• Since the Medicare Safety-net was introduced in 2004 payments to Obstetricians have increased by around 300%
• Private health insurance is essentially a ‘closed-shop’ for maternity care. Women are forced to utilise private obstetricians.
• Private maternity care could be more supportive and much cheaper if private midwifery was enabled. Current homebirth midwives are the most experienced in providing 1-2-1 midwifery care. They need to be able to continue to practice to guide the essential reform process.
• Many accepted reforms have come from homebirth midwives and women (partners present at birth, use of warm water for pain relief, removing unnecessary and inappropriate routine interventions enemas, shaving, episiotomy)
The Maternity Services Review Report: No more Homebirth?
Bruce Teakle 8 March 2008
The recently released report of the Federal Maternity Services Review proposes some promising reforms. It could, if implemented in the most positive spirit, bring huge breakthroughs in many areas of maternity care.
The Report recommends improving women’s access to midwifery care and information about pregnancy and birth. It proposes culturally appropriate care for indigenous women, better support for women in pregnancy and postnatally, and more collaborative relationships between caregivers. Its ultimate goal for Australian mothers is “safe, high-quality and accessible care based on informed choice” (page iii).
Australia has waited a long time for the reforms proposed in the Review. However, there is a dark side to the Report. The Report proposes an end to women’s access to midwifery care for homebirth, except possibly within state-run services. If the Report’s recommendations are followed, homebirth midwifery could become illegal in 2010 with the introduction of National Registration of health caregivers. The full Report can be downloaded from this website: http://www.health.gov.au/internet/main/publishing.nsf/Content/maternitys…
Below are some key points, with quotes from the Report, to help women who want to lobby for their right to access safe, legal homebirth in Australia:
1. Women choosing homebirth are a trivial minority: A strong point is made of the small number of homebirths which occur in Australia: P16: shows a graph of declining numbers of homebirths in Australia from 1991 to 2006.
P16: “Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28 compared with 2.7 per cent in England and Wales,29 2.5 per cent in New Zealand,30 and 0.6 per cent in the United States.” 31 P20: “New Zealand maternity data for 2004 found that, while 4.5 per cent of mothers had planned a homebirth, only 2.5 per cent actually experienced a homebirth.”
The reasons for the small Australian numbers are not explored, in particular the great difficulty most Australian women have accessing information or care for homebirth. No comparison is made with other minority choices, such as caesarean section on request, and there is certainly no consideration of banning these choices. The Reviewers acknowledge the high number of individual submissions from women who desired greater access and funding for homebirth. Despite this, it appears the Reviewers have been more responsive to the input of those who want to control women’s choices.
2. Homebirth will not be retained as a choice for women: The Report is very clear that it does not support reforms which increase or fund women’s access to homebirth: Pp20-21: “In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.” P21: “While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time. It is also likely that professional indemnity cover support for a Commonwealth- funded model that includes a homebirth setting would be limited, at least in the short term. It is likely that insurers will be less inclined to provide indemnity cover for private homebirths and, if they did provide cover, the premium costs would be very high. Indemnity issues for midwife care more broadly are considered in Chapter 6.2.”
The Report proposes Commonwealth support for Medicare and indemnity insurance for midwives, but only working in non-homebirth practice. Midwives working outside these restrictions would not be able to legally practice, due to impending reforms: P53: “For privately practising midwives, it is not currently a requirement in most jurisdictions to have professional indemnity cover in place before registration is granted. However, this situation is expected to change under the proposed new National Registration and Accreditation Scheme.”
The consequence of all this is that homebirth practice by private midwives (most homebirth care) would not be insured, and would be illegal under national registration laws, scheduled to take effect in July 2010. State-run homebirth services (currently operating in NT, NSW, SA, and WA) might also be forced to close, if non-homebirth maternity services attract Commonwealth funding (through Medicare for midwives) but homebirth services do not.
3. Scientific evidence does not inform the recommendations regarding homebirth: Although some reference is made to scientific evidence on some issues in the report, no reference is made to evidence regarding the outcomes of homebirth. It appears that medical opposition alone informs the Review’s position: P21: “The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.”
4. The safety of women birthing without a caregiver can be overlooked P21: “Of concern to the Review Team is the number of submissions and other evidence that suggests a small number of Australian women are choosing homebirths without the support of an appropriately trained health professional. Accordingly, as with any other maternity care model, the Review Team considers that appropriate standards, monitoring and evaluation should be integral components of any service involving homebirth.” Women choosing to birth at home without a trained caregiver will not be helped by “standards, monitoring and evaluation”, because they are outside the system. The Review Team appear not to understand that these women are within neither a “maternity care model”, nor a “service involving homebirth”.
Maternity Coalition’s experience is that most women birthing at home without a trained caregiver do so because they are unable to access midwifery care at home, and unwilling to use hospital-based services. It is frequently a choice made in desperation. The way to help these women is to provide them access to a high standard of midwifery care in their preferred venue. The Reviewers overlook the likelihood that the loss of homebirth midwifery care will push more women into unattended homebirth. This would ensure an absence of standards, monitoring or evaluation of any homebirth outcomes.
5. Medical extremists will become more cooperative if they are given a veto on women’s choices The proposed reason for preventing homebirth midwifery is that it “risks polarising the professions”.
The implied strategy seems to be for Government to restrict midwifery practice, against scientific evidence, against the principle of women’s informed choice and against the safety of determined homebirthing women. The presumed intention – for less collaborative doctors to become more respectful of the evidence, principles of informed choice, and women’s perspectives on safety; seems a highly unlikely outcome. The Reviewers reinforce a subordinate position for midwives relative to doctors by proposing to restrict midwifery practice in line with the prejudices of less collaborative doctors. This undermines the relationships they hope to enhance.
The Government must make it clear that the needs, interests and autonomy of women come first. Healthcare policy and services should not be corrupted by the prejudices of health care professions, which prosper on taxpayer funds.
Fear or leadership? The Minister, Nicola Roxon, is aware that significant modernisations of the healthcare system have historically been met with protest, threats, and predictions of disaster by extreme medical voices. Reforms of Australia’s maternity care system will always provoke this sort of reaction. Those reforms include normalising midwives’ access to public funding and insurance, and women’s access to options including homebirth. It appears that the Reviewers have conceded to fear of extreme medical voices, over the interests of women. Hopefully the Minister, who is directly accountable to women, will be braver.
Speak out now! The Review Report has been prepared by Department of Health staff, to advise the Minister for Health, Nicola Roxon. The Minister will decide which of the Department’s advice she will take. If there is enough community outcry about the proposed loss of homebirth, the Minister may decide to act in the interests of choice.
Every Australian has a Federal Member of Parliament (MP), whose job is to represent their interests.
Every person who cares about maintaining homebirth choice should contact their Federal MP, preferrably by both letter and with a personal visit.
To find contact info for your MP: ♣ Go to http://apps.aec.gov.au/esearch/ and enter your locality in the “Search Federal Electorates” window. ♣ In the next window, click on the name of your electorate for more information. ♣ On the electorate page, click on “profile and map”. ♣ For contact info for your MP (“Current Member Details”), click on the “Parliament of Australia Website” link.
Write to your MP and tell them how important it is to you that women can choose homebirth.
Ask them to contact the Minister for Health on your behalf.
Recognise the good sides of the Review, and expect them to help you.
Meet with your MP. Phone their electorate office and ask for an appointment, to talk about the Federal Maternity Review.
Take some friends from the same electorate.
Tell them why women should have choice.
Your MP is expecting a letter or visit from a mother, not a professor. Tell them why birth and choice are so important to you.
Talk about scientific evidence or policy processes if you want, but you are the expert about your own story.