Tuesday, March 10, 2009

No more homebirth?

The Maternity Services Review Report: no more homebirth?
Bruce Teakle 8 March 2008
[Bruce is a leader in Maternity Coalition Queensland Branch, and has given permission for this article to be displayed]

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.

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, compared with 2.7 per cent in England and Wales, 2.5 per cent in New Zealand, and 0.6 per cent in the United States.”
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.


Fiona said...

Can you please explain why, if a midwife took out indemnity insurance, she/he would be compelled to work only within the areas that they were indemnified for?

I am a homebirth 'consumer' and whilst I support your 'push' I am not sure how this will make homebirth 'illegal' (although it is clear that they are not supporting it).

My husband is a GP and believes that while he would not be indemnified for attending homebirths, undertaking work outside his insurance (but not his skills) would not preclude him from registration.

While I can see that not being indemnified for homebirth isn't a good thing, it is the status quo at this time, and I'd like to know how this would change.

If you can clarify this we would be happy to contact our MP.


Joy Johnston said...

Hi Fiona
Thanks for asking this question.

The brief answer is that while at present midwives are currently practising (legally) without insurance, a new national law http://www.nhwt.gov.au/natreg.asp is to be introduced 1 July 2010 which will make indemnity insurance mandatory for registration of all health professionals. The only health professional for whom indemnity is inaccessible is the midwife. Since the main work self employed midwives do is attending homebirths, and there are very few publicly funded homebirth models (none in Victoria), the effect will be to make it illegal for a midwife without insurance to practise midwifery. So although homebirth may still be legal if provided by public health services (as in WA, SA, NT), women's access to homebirth in areas where independent midwives have practised with excellent outcomes for many years, could be denied.

The indemnity situation is different for doctors, who are able to get government assistance with the cost of insurance.

Please do visit your federal MP and join our big push.

Fiona said...

Hi Joy,

I think you misunderstand my question. I understand that many homebirth midwives also attend hospital births as independent midwifes (I know mine does).

Even if you were practicing as a homebirth midwife, what is the reason that you couldn't become registered for other work that you did supporting women in hospitals, and get indemnity for that? (presuming that they make indemnity accessible).

Do you think that you wouldn't be able to take out insurance for a small part of your work to receive registration and then work unindemnified (but registered) as a homebirth midwife outside of this?

kind regards

PS we will probably go ahead and support this but it would be good to be speaking from a position of clarity on this aspect as it seems to be your crucial point.

Joy Johnston said...

Fiona we don't know yet how the government intends to police the requirement for insurance. But we know that the government has committed to reforming health practitioner registration and accreditation, and one aspect of the reform is to ensure that you, the consumer, can be sure that any health professional who provides a service for you will be covered by indemnity insurance. That means if something goes wrong, and you successfully sue, the insurance company will have the funds to make the pay out.

You ask "what is the reason that you couldn't become registered for other work that you did supporting women in hospitals, and get indemnity for that?"

A midwife who is employed by a hospital has vicarious liability cover, but of course is working for the hospital, not the individual woman.
When independent midwives go to hospital with our private clients, that's within our private arrangement, and is not indemnified.

"Do you think that you wouldn't be able to take out insurance for a small part of your work to receive registration and then work unindemnified (but registered) as a homebirth midwife outside of this?"
The answer is 'No' - this would not be possible.

Thanks again for exploring this further to make it clear. The service that independent midwives aim to provide is one that is focused or centred on the individual woman and her baby.