choice of home birth: a human right?

This heading 'choice of home birth: a human right?' refers to the woman, not the midwife. Is it a woman's right to choose home birth?

Many would argue that the choice of home birth is a human right. As recently as 2010, the European court ruled that the choice of home birth is a European human right (please read on to the end of this post for the source of that piece of information).

Whatever the woman's right in choosing to give birth in her own home, that 'right' is at best meaningless if the woman is not able to access professional midwifery services.  In the absence of a suitably skilled midwife, the woman who hopes to exercise her 'right' to home birth must either give up the notion of home birth, or proceed without professional midwifery care.


In this brief essay I am seeking to apply the notion of a woman's right to choose to give birth in her home, to current Australian situations in which midwives may feel that they are not able allowed to attend certain women: those who have risk factors, such as post maturity, a previous caesarean or other obstetric complicated birth, a multiple pregnancy, or a baby in breech presentation.

Midwives who attend home births independently are facing increasing pressure to conform to external professional protocols which seek to define who is, and who is not 'suitable' to be in the care of a midwife. Such documents become instruments of a society's expectation on women giving birth, effectively forcing conformity on the midwife, and indirectly on the woman.

The current protocols (also referred to as guidelines and position statements) in relation to a midwife attending a woman for planned home birth, include:
AHPRA Safety and Quality Framework for Privately Practising Midwives attending homebirths
ACM Position Statement on Homebirth Services 2011
ACM Guidance for Midwives regarding Homebirth Services 2011

Other codes and professional documents, such as the ACM National Midwifery Guidelines for Consultation and Referral (Second Edition 2008) that apply to all midwives can also be used to restrict the scope of the midwife's practice.

The broad principles underpinning contemporary midwifery are defined by the International Confederation of Midwives in the Definition of the Midwife (2005 – it was revised 2011), which stated

“The midwife is recognised as a responsible and accountable professional who works in partnership with women 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. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. ... A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”  [Note that this paragraph is unchanged in the revised (2011) ICM Definition of the Midwife.]

This definition is a core statement in Australian midwifery codes, eg the Codes of Ethics and Professional Conduct for Midwives in Australia.

Midwives around the world, in all levels of socio-economic and health status, grapple with the home birth issue.  In recent generations in developed countries, the professionalisation of midwifery has progressed hand in hand with the medicalisation of birth.  Australian midwifery education and regulation is a good example of this phenomenon.  Under current laws, midwives are the like poor cousins of nurses in the professional regulatory scene.  It may be difficult for midwives to have complaints against them investigated and heard by professional peers who have any recent midwifery practice experience.  Determinations by investigators in cases of professional conduct may have little relevance to the real world in which the midwife works.  The focus of the medicalised midwifery on risk factors and mainstream 'broad brush' risk management in hospitals can easily overshadow any acknowledgement of the woman's informed decisions.  The well known Monte Python skit, 'The Meaning of Life' applies: the woman on the bed calls out "Can I do anything?" and is told without delay "No, you're not qualified!" 

It is worth noting that the ICM Position Statement on Home Birth emphasises the social/family aspect of birth, as distinct from a medical condition.

“Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs. There is a consequent need and demand for care that is close to where and how people live, close to their birthing culture, and at the same time safe. The World Health Report 2005 states that ‘There is a value in the rituals surrounding birth, and in keeping these as a central feature of family life. The setting for birth may therefore be the woman’s home, a local health facility or, if medical or surgical care is likely to be needed, a hospital. Furthermore a recent (2010) the European court judgement declared that the choice of home birth is a European human right.” 

[For more detail on the European Court decision, click here]

The woman who, notwithstanding her knowledge of her own particular 'risk' status, asks a midwife to work with her to protect and promote normal physiological birthing in her home, is as entitled to professional midwifery care as the woman who chooses care in a birth centre or hospital.  The conversation between the midwife and the woman will address the woman's plans as to how she hopes to give birth to her baby, and what will happen if her midwife advises transfer of care to an obstetric unit.  This is not new or unusual in midwifery.  Every woman who comes into spontaneous labour has to make decisions about when to go to hospital, or when to ask the midwife to attend, if home birth is planned. 

In conclusion, I do not want to seem to encourage midwives to encourage 'at risk' women to see home birth as their only option.  In my experience, a woman with twins, or breech presentation, or BAC, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing.  This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

The midwife is also enabled to fulfill her duty of care to the woman, without exposing herself unnecessarily to potential investigations for professional misconduct.

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Midwives in Private Practice (MiPP) is a participating organisation, under the Maternity Coalition 'umbrella', and all members of MiPP are also members of Maternity Coalition.
Maternity Coalition members receive the excellent quarterly journal, Birth Matters, pictured here. 

To become a member of Maternity Coalition, click HERE

Midwives in Private Practice

Each member of Midwives in Private Practice (MiPP) is

• a registered Midwife in Victoria 
• who derives some income from private midwifery practice 
• and provides primary care for pregnancy, birth & postnatal period  

 
PRACTICE STATEMENT
Midwives In Private Practice (MIPP) is a collective of qualified midwives, providing support, education, and promotion of best practice midwifery in any setting. Each member is responsible for her/his own practice of midwifery, maintenance of professional standards, and appropriate record keeping.
MIPP is a member group of Maternity Coalition Incorporated.

Principles:
The midwife joining or renewing membership agrees to:

• Practice in a way that is consistent with the International Confederation of Midwives' Definition of the midwife 
• Attend MIPP meetings. If this is not possible at any time, the midwife sends an apology, and contributes to current discussion by other means. 
• Contribute to the activities and work of MIPP. 
• Participate in professional standards peer review within the collective.
• Contribute to periodic reviews, providing quantitative and/or qualitative data as appropriate. 

Note: A midwife who wishes to commence private practice, ie ‘fee for service’ outside the acute health sector/hospital, is encouraged to seek mentoring with experienced independent midwives.

The MIPP list at the Maternity Coalition website has been updated recently.  The following midwives are listed, with phone and email addresses:

Alice Barden, Eltham
Amy Gillies, Wantirna South
Andrea Quanchi*, Echuca
Fiona Hallinan, Clifton Hill
Belinda Henkel*, Rosanna
Clare Lane* Mitcham
Helen Barrington, Ferntree Gully
Helen Brown, Heathmont
Helen Sandner, Strathdale
Jan Ireland*, Bentleigh East
Jennie Teskey*, Clifton Hill
Joy Johnston*, Blackburn South
Juliana Brennan* Gruyere
Kelly Langford*, Kensington
Leanne Chapman* Mildura
Louise Norbergen* Montrose
Malinda Morieson, Croydon
Melody Bourne, Brunswick
Nicola Dutton, Bayswater
Sally McCrae, Castlemaine
Sally-Anne Brown, Apollo Bay
Seneka Cohen, Croydon North

Note: Midwives with * after their names are able to provide Medicare rebates.

the death of a mother who gave birth at home

There is no easy way to present this issue. The word 'death' confronts us with an absolute reality.  A maternal death is shocking. A baby and her sister have lost their mother, a man has lost his beloved wife and the family have lost a daughter, sister, friend ...

Here's the story so far, as it has been presented in the online and print media and television today.

Herald Sun, Lucie van den Berg - Mum dies in home birth tragedy
The Age, Megan Levy - Home birth mum's tragic end
Channel 7 News
Mia Freedman at mamamia
Herald Sun blogger Susie O'Brien - Homebirthing is just too risky
The Punch blogger Tory Shepherd Home births are prone to many complications 
[and hundreds of comments to these blogs]

The submission made by Caroline Flammea, Nick Lovell and daughter Lulu Lovell to the federal government's Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills


The opportunity for sensational headlines was not lost.  'Home birth death' filled half the front page of the Herald Sun today. 

Victoria's Health Services Commissioner Beth Wilson is reported as having said she had "long held concerns about home births when medical back up may not be immediately available."  Perhaps Ms Wilson is unaware of the usual practice of homebirth midwives to arrange transport to hospital, and collaboration with specialist medical services when complications are detected. 

One would wonder if there are also "long held concerns" about the many smaller public hospitals and private hospitals that do not have medical personnel on site 24/7.  Surely no-one imagines that all pregnant women should be herded into large baby-factory hospitals that process births like cars off a production line?

One would wonder if the thankfully infrequent examples of sudden and unexpected death of a previously well mother who gives birth spontaneously in large tertiary level hospitals also lead to knee-jerk reactions and pronouncements before all the facts of the case have been considered.

This is not the time to argue the safety of home birth.  The sympathy of every midwife and every person who cares about working for better births is with this family, the midwives who attended the birth, and all the health service personnel and paramedics who provided care to a woman and her family in her last hours. 

Birth has never been safer, for mother or baby, than it is in this country today.  As rates of caseareans increase, and rates of complications related to placental implantation increase, new life-threatening risks will arise for those women.  The midwife's challenge, to work in harmony with natural physiological processes, is as real and as important today as it has ever been.


Link to the report Maternal Deaths in Australia 2003-2005 (AIHW 2008)

[Any opinions given in this article are those of the writer, Joy Johnston, and are not necessarily those of other members of the collective, Midwives in Private Practice.]

hospital access for Medicare-eligible midwives

A few months ago I reported on the work of a reference group set up by the Victorian Health Department to develop consistent approaches to the provision of clinical privileges for midwives within public maternity services, to enable admitting and practice rights for eligible midwives, and a new option for women who seek maternity care that protects continuity between the woman and her midwife.

Midwives in Private Practice (MIPP) was represented at the three meetings of the expert reference group. The 'deliverable' of this initial consultation process, which has been managed by the 3Centres Collaboration, is a draft document which provides a framework, and templates for paperwork and various records. This document will progress through careful checking by the Health Department, before it is able to be released. It is hoped that this document will provide a reliable process whereby public maternity hospitals in Victoria will be able to proceed with making arrangements whereby midwives are able to attend women privately for birth and other maternity care in the hospitals.

Readers may wonder how many women would want to be attended privately for birth in public hospitals? How many midwives would apply for visiting privileges, and what number of private clients/births would they be able to expect in a year? It is not known how many women in Victoria employ a midwife privately to attend them in labour in a public hospital. An estimate would be 100-200. Many more employ unregulated birth support people. Some midwives would attend 10-20 planned hospital births each year; others only occasionally.

For many years the predominant focus of private midwifery practice throughout Australia has been homebirth. However, since the introduction of notation as a Medicare-eligible midwife, the options for private midwifery practice have been extended. Some midwives who have achieved their Medicare notation/provider numbers have no experience in, and no intention of attending home births. Their plan is to provide continuity of care (and carer) for women giving birth in hospital. This suggests that as the number of Medicare-eligible midwives increases, the demand for hospital admitting and practice rights will also increase. If 10 newly eligible midwives were each taking 40 caseload bookings for planned hospital births, the estimated 100-200 per year could be 500-600.  It's still a tiny proportion of the State's annual number of births, but it's a potential growth area.

In order for a midwife, or doctor, or anyone, to be allowed to practise in a hospital facility, there are basic instructional and policy matters that need to be communicated. Routine fire evacuation plans and other emergency procedures are essential for safety of patients and staff and all concerned. Everyone needs to be skilled in use of the hospital's computer systems, entry of data, admission and discharge, reporting of incidents, ... just to name a few examples.

A midwife who is employed in a hospital, who also has a private practice, or who has recently moved from hospital employment to private practice, would be able to quickly meet the requirements for emergency procedures, IT processes, &c. This midwife would be ideally situated to take up admitting and practice rights. The hospital knows the midwife, and the midwife knows the hospital.  The process might be more challenging for a midwife who has not practised recently in the hospital.

It is important to remember that there is a woman and a child behind every episode of maternity care.  Private midwifery care for birth is a model that focuses on the woman and her baby, not on the care provider or the facility.  MIPP members look forward to the day when the options and arrangements for maternity care will truly value the woman, and thereby promote healthy outcomes.

Questions and answers 2: VBAC

The questions for today are focused on vaginal birth after caesarean surgery, VBAC.

This is the second post in the current series

• about midwives who have (or plan to obtain) Medicare provider numbers 
• about planned homebirth 
• about planned hospital birth 
• about vaginal birth after caesarean surgery (VBAC) 
• about women who have certain 'risk' factors 
• about ... 

I have shaded the 'planned homebirth' and 'planned hospital birth' lines as well as the VBAC line, because the place of birth, home or hospital, is a *setting* - not an outcome.

Women often ask independent midwives:
"Will you be my midwife for a HBAC?", or HBA2C (where H=home, and 2=2, and where, because it's at H, it's obviously V)
(and yes, we use abbreviations freely!)

The only truthful answer is "I have no idea, because it's impossible for me to know where your baby will be born!"


But, what is implied in the question "Will you be my midwife for a HBAC"? is,

"If you are my midwife, 

• are you willing and able to provide the professional services I am likely to need in order to give birth safely at home, and 
• do you have the skill to recognise situations in which you would advise me to transfer to hospital, and 
• do you have the wisdom to guide me?"

Planning VBAC at home is perhaps the simpler option from the woman's and midwife's point of view, because it's clear that in order to give birth the woman and her baby need to be well, at Term, and come into strong labour *naturally* - without induction or augmentation of labour, and without relying on medical strategies for pain management. It's clear that if a decision point is reached when medical expertise, or technology, are recommended, these are accessed by transferring care to the medical/obstetric/midwifery/nursing team in hospital. Transferring to hospital does not mean that the plan for VBAC is given up.

Yet planning VBAC at home may be considered by some to be unreasonable risk-taking.  Midwives attending homebirths are required to comply with various guidelines that have been approved by the regulatory authority, such as the Safety and Quality Framework.[Open this link and scroll down to 'Eligible Midwives'].  The Safety and Quality Framework seeks to ensure that women understand that the midwife has no professional indemnity insurance for homebirth, and requires a midwife providing homebirth services to

adhere to recognised consultation and referral guidelines developed by the Australian College of Midwives (ACM) and to have processes and relationships in place to demonstrate compliance with the guidelines.

The ACM Guidelines list Casearean Section as

6.3      Previous Obstetric history
6.3.11  Caesarean Section
CODE B = CONSULT [Evaluation involving both primary and secondary care needs.  The individual situation of the woman will be evaluated and agreements will be made about the responsibility (medical or midwifery) responsibility for maternity care]

The journey to homebirth for a midwife and woman, using the ACM Guidelines, may then proceed to Appendix A: WHEN A WOMAN CHOOSES CARE OUTSIDE THE RECOMMENDED ...
This process seeks to ensure that the midwife and other maternity professionals are advising the woman clearly, and the woman is making an informed decision.

If the midwife is Medicare-eligible, there are other requirements for collaborative arrangements before the midwife's fees can be rebated through Medicare.  This is the case whether the plan is to give birth at home or hospital.


When planning VBAC in hospital, many of the same issues arise for women who intend to proceed without medical intervention, unless there is a valid reason.  Most hospital guidelines require midwifery staff to obtain continuous electronic monitoring.  The woman in this situation is able to decline, if she makes that decision.  

A VBAC in hospital can proceed with continuous electronic fetal monitoring, epidural anaesthesia, IV fluids, a urinary catheter, forceps or other assistance that is available within the scope of a medically managed vaginal birth. Or a VBAC in hospital can proceed without any of these interventions.

Women planning VBAC in hospital would do well, if they can, to find a hospital that has a track record that demonstrates an understanding of VBAC. When you inquire about making a booking at the hospital, ask if the hospital has a clinical practice guideline or other written document that you can take away to read. Some hospitals have this material on the internet - click here for the Women's VBAC guideline.    This will give you an idea of what you are likely to experience.  Your midwife can help you understand the detail.

Specific questions can be asked of the hospital such as what is their current rate of planned vbac (out of all women who have had previous C/s surgery), and actual vbac. The denominator in the actual vbac rate is usually the number who planned vbac, or who commenced spontaneous labour.  So if a hospital says "We have a 65% VBAC rate" it probably means that of all women with a previous C/S who intend to undergo a 'trial of scar' and commenced labour, 65% had vaginal births." 

The decisions that need to be made in any pregnancy and labour (bac or not) are the same. Plan A. If mother and baby are well, and there is no valid reason to interfere with the natural process, the authentic midwife will act in a way that supports and protects natural physiological processes that lead to safe birth. This includes minimising any interruption or interference with the labouring woman.

Questions and Answers - Medicare-eligible midwife starting up private practice

Hello dear reader,
I am preparing a series of posts on general questions asked by women and midwives about private midwifery practice. If you have questions, please add them in the comments section, or send me an email joy@aitex.com.au

In preparing questions and (attempting) answers, please note that questions on clinical conditions can only be addressed in a general way, and cannot replace the face-to-face discussion and decision-making between a woman and her midwife or other care provider.  Also readers are welcome to provide additional information or discussion via the 'comments' section, or to write guest posts.

Frequently asked questions can be grouped, and colour-coded to help organise:

1. about midwives who have (or plan to obtain) Medicare provider numbers
2. about planned homebirth
3. about planned hospital birth
4. about vaginal birth after caesarean surgery (VBAC)
5. about women who have certain 'risk' factors
6. about ...

Today's question, to get the ball rolling, is:

Q. I wish to practise as an eligible midwife providing antenatal education and postnatal care.  How do I go about getting started?

A.  The short answer is that there is a great deal of scope for Medicare participating midwives to offer private midwifery services, including antenatal care and postnatal care.

When commencing private practice, a midwife is advised to find an experienced mentor, who is willing to support the midwife's entry into private practice. You may avoid a few headaches!



The longer answer ...

Women who receive midwifery care from a chosen midwife in private practice who is Medicare-eligible, and who has fulfilled the requirements such as collaborative arrangements and indemnity insurance (these have been written about previously on this blog. Use the search function if you want to check out previous posts) will receive rebate on the midwife's fees for services that have a Medicare item number.  The amounts of rebate are set out in legislative tables that are available for anyone interested.


The following brief summary is quoted from the government's ComLaw website.

Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162

Schedule 1 Midwifery services and fees

Part 1 Midwifery services and fees

Part 1 of Schedule 1 of the Determination sets out the relevant general midwifery services, assigns applicable item numbers, item descriptors and fees for the services. These items enable the payment of Medicare benefits to patients of participating midwives for antenatal, birthing and postnatal care: ·

• an initial antenatal attendance of at least 40 minutes duration (item 82100); · 
• a short antenatal attendance of up to 40 minutes duration (item 82105); · 
• a long antenatal attendance of more than 40 minutes duration (item 82110); · 
• development of a maternity care plan for a pregnant woman, where the pregnancy has progressed beyond 20 weeks (item 82115); · 
• management of a confinement for up to 12 hours (item 82120); · 
• management of a confinement in excess of 12 hours, where care of the patient is transferred from one midwife to a second midwife (item 82125); · 
• short postnatal attendance of up to 40 minutes duration (item 82130); · 
• long postnatal attendance of at least 40 minutes duration (item 82135); and · 
• six week postnatal attendance (item 82140), after which the woman would see her general practitioner. 

Antenatal and postnatal services may be provided in a range of settings including in consulting rooms, community clinics and the woman’s home. Medicare benefits for the management of labour and delivery are only payable where the service is provided to an admitted patient of a hospital, including a hospital birthing centre.

Please note that there is no Medicare item number for antenatal education.  However, midwives provide education for each woman in their care, relating the science and art of midwifery to that woman's personal situation, and guiding the woman in her preparation for birth and mothering.

A midwife who intends to provide Medicare-rebated prenatal (items 82100, 82105, 82110, 82115) and postnatal services (items 82130, 82135, 82140) is able to charge a fee, or bulk bill.  The amount of rebate the woman receives will depend on her status with the Extended Medicare Safety Net (EMSN) capping system.

For example, if the midwife's charge for a 1-hour postnatal visit (Item 82135) in the woman's home is $120, the scheduled fee for that item is $75.05, and the EMSN (if applicable) is $20.65

The rebate a woman who has passed the Safety Net threshold is $75.05+$20.65=$95.70.
Out-of-pocket expenses for that consultation are $24.30.

On the other hand, if the midwife chooses to do so, she may 'Bulk Bill' for that item.  The midwife receives the 'Benefit 85%' (of the scheduled fee) payment of $65.60 into her nominated bank account, from the public purse.  The midwife may consider the ease of bulk billing, and the opportunity to provide a greater number of postnatal visits without increased cost to the woman, to outweigh the lesser unit payment.

Midwives participating in Medicare are able to obtain portable EFTPOS machines from their bank, which enable easy and quick credit card payments (swipe the credit card), Medicare rebates into the client's debit card account, and bulk bill payments (swipe the Medicare card). 


Where to go for more information:
Midwives Australia
has a wealth of information and links at its website. Midwives Australia is a not-for-profit organisation supporting midwives through these changes with practical hands on initiatives, programs and resources.

Your comments are very welcome.
Please note that any opinions expressed in this blog are the opinions of the writer, Joy Johnston, and may not necessarily be shared by other members of MiPP.