Tuesday, June 30, 2009

NSW Coroner's plea for homebirth

A NSW Coroner's report dated 26 June 2009, on the death of a baby whose mother gave birth at home in the care of a midwife emphasises the fact that women need to be supported in their choice of homebirth.
An article in SMH today Insurance plea for homebirth midwives gives an overview of the case.

The FIRST of the Coroner's recommendations is:
"1(a) Great care should be exercised in drafting any proposed legislation along the lines recently forecast so as to avoid what may be anunintended consequence of making the practice of 'Home birth' itself unlawful."

Home birth will be unlawful in just 12 months from tomorrow (1 July 2010) if the federal legislation 'Health Practitioner Regulation Law 2009 (Bill B)', which is currently available as an Exposure Draft, passes through parliament without significant amendment and becomes law.

Monday, June 29, 2009

Maternity Service Core Competency Model

The public (that's you and me) have been invited to respond to a national draft document, 'Maternity Service Core Competency Model', which is being developed by an expert team described here.

There is a 20 page document pdf that sets out the core maternity competencies.
We are invited to complete a survey form which has nine questions with two areas for text entry.

The closing date for feedback is Tuesday 30th June.

Here's a comment left by the manager of this blog (Joy Johnston), in response to question 9. Would you like to make any other comments about the Maternity Service Core Competency Model?

The document explains collaboration (p3) from a service perspective - that no maternity service provider can work in isolation. This is true.
Yet the point that is not made is that primary maternity care for many women can be achieved, and is safely completed, within the competency and capability of the midwife who is primary care provider. In these cases, from a woman's perspective (woman centred care is the first over-arching aspect of the framework), the experience of maternity care is uniquely within the midwife's scope of practice.
I recommend that a statement to this effect be included.

This point may be obvious to many people, especially mothers who have experienced physiologically normal pregnancy and birth. Birth is not an illness. Pregnancy, birth, and nurture of the newborn infant are beautifully and wonderfully within normal healthy natural life processes.

The document under review states that "The underpinning philosophy of primary maternity services is that childbirth is a normal but significant physiological event and that different women have different needs in relation to pregnancy and childbirth." (p2) It continues, "One guiding principle of primary maternity services is to maximise "the potential of midwives, obstetricians, general practitioners and where appropriate other health professionals' specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery for women with normal pregnancy risk (reference given)." [emphasis added]

Discussion on midwife led models of care has frequently become bogged down over the meaning of collaboration and multidisciplinary approaches to maternity care.

The independent midwife who provides primary maternity care, employed privately by individual women, practises autonomously withing the midwife's scope of practise will collaborate with other maternity service provides if and when a complication or condition which is outside her competence or capability arises.

An midwife who provides primary maternity care as an employee of a hospital or health service is frequently required by the service to send women in her care for routine review by an obstetrician at intervals in the pregnancy. This is supervision, not collaboration.

This protocol has been introduced as part of a "collaborative, coordinated multidisciplinary approach to maternity service delivery for women with normal pregnancy risk" as recommended by the Australian Health Ministers Advisory Council 2008 (full reference in document under review p2).

The requirement for routine obstetric review in pregnancy of women with normal pregnancy risk is not based on evidence, and therefore does not meet the over-arching criteria (p5) for core competencies in maternity service provision.

Readers who have completed the survey form, or who wish to discuss issues raised above, are welcome to add your comments to this blog.

Saturday, June 27, 2009


Given the current political climate, both at a national and local level, an extraordinary meeting of MiPP has been called by members. This meeting is to be held in Melbourne.

Items for discussion and action include:
* Understanding of the current political environment and its implications for women and their families choosing homebirth and for independent midwives.
* Exploration of our legal position and right to practice professionally post July 1st, 2010.
* Clarification of status and developments in homebirth back-up referral process with public maternity hospitals
* Seek provision of opportunity for MiPPs to participate in confidential review and debriefing sessions in response to incidents
* MiPPs as an evolving organisation as we meet contemporary challenges- what are our aims and objectives? How do we support one another collegially? How do we stand in solidarity whilst respecting individual differences, variations in practice and beliefs?
* Representatives of MIPPs to attend protest rally organised by Homebirth Australia at Parliament House on Monday, September 7th from 11.30am.
* Request to Australian College of Midwives, as our peak professional body, to commit to supporting and defending a midwife's right to engage in the full scope of midwifery practice, in any setting.

If readers would like to comment on this agenda, or add your thoughts, please do so by using the Comments below.

A midwife wrote, in a letter to the Health Minister, Nicola Roxon,
"For me, working with homebirthing women is my income and my career. I have worked all my professional life to be where I am today, to provide the highest possible care to childbearing women. No other health profession has been outlawed by the government preventing them professional earning in the private sector. Why is private midwifery practice being outlawed when high quality research very clearly states that homebirth with a midwife is just as safe?"

Thursday, June 25, 2009

PLEASE sign a petition to save private midwifery and homebirth

GO to the petition

"... with planned national registration of all health professionals to take effect on July 1st 2010 midwives in private practice will be unable to seek registration on the basis of their inability to obtain professional indemnity insurance."
The petition asks that "the senate bring this issue to the parliament's attention and make a speedy redress to assist midwives in private practice to obtain professional indemnity insurance. We also ask that midwives in private practice enjoy the same funding mechanisms as procedural general practitioners and specialist obstetricians under the medicare benefits schedule."

The petition is at the excellent new Homebirth Australia website.

Wednesday, June 24, 2009

from the Health Minister

Press Release today from Nicola Roxon ("from the horse's mouth", so to speak, and it's a real 'mixed bag', to mix metaphors)

"... In line with the Maternity Services Review Report, Medicare benefits and PBS prescribing will not be approved for deliveries outside clinical settings, and the Commonwealth-supported professional indemnity cover will not respond to claims relating to homebirths." [emphasis added]

Since homebirth is the main practice setting for private midwifery practice, I wonder what the advisers to the Minister are thinking about. By accepting the government's offer of indemnity cover, we will be cancelling our commitment to homebirth. Where, and how, will we work? Are we to celebrate a pyrrhic victory?

State health departments are producing homebirth policies. That's great. Access to homebirth may be greatly extended for the majority of women and midwives WHEN the public hospital system gets its act together and offers homebirth. But access to homebirth will at the same time be severely curtailed if not removed for many of the women who at present are being attended by independent midwives.

Can the Australian maternity community accept government interference in defining the setting of practice of a midwife? Would the medical community accept such wanton interference in its professional boundaries? As discussed previously, a doctor is able to attend homebirths, with insurance, with clients claiming Medicare refunds and benefits.

Midwives please note, from the above press release:
"The new professional indemnity scheme for eligible midwives will be available from 1 July 2010 and the new Medicare and PBS arrangements will be available from 1 November 2010."
The Australian College of Midwives is calling for expressions of interest in private practice (see P7 of Australian Midwifery News Winter 2009)

Outcomes for births booked under an independent midwife in the UK

Readers of this blog may be interested in a new paper from the BMJ:
Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study

Authors: Andrew Symon, Clare Winter, Melanie Inkster, Peter T Donnan

To access the full paper and citation, click here.

<<Conclusions: Healthcare policy tries to direct patient choice towards clinically appropriate and practicable options; nevertheless, pregnant women are free to make decisions about birth preferences, including place of delivery and staff in attendance. While clinical outcomes across a range of variables were significantly better for women accessing an independent midwife, the significantly higher perinatal mortality rates for high risk cases in this group indicate an urgent need for a review of these cases. The significantly higher prematurity and admission rates to intensive care in the NHS cohort also indicate an urgent need for review.>>

Comment by Joy Johnston:
This paper adds to the significant body of literature supporting homebirth as a safe and reasonable option for well women who are assessed to be at low risk of complications. It also identifies a higher rate of death of babies born at home to mothers in higher risk categories, when compared with births in hospital.

In general the *low risk* woman is in good health; her pregnancy continues without medical complication to Term; she has one fetus who is lying longitudinally and whose presentation is cephalic; she comes into spontaneous labour and progresses to giving birth unassisted to a live healthy baby, without requiring uterine stimulants or pain relieving agents.

Many independent midwives in both UK and Australia would agree to attend a woman who would not meet hospital risk management criteria for low risk. While in the UK the principle of informed choice is a key aspect of government policy for maternity care, Autralian women are increasingly finding that they have little choice. For example, women who have had one or more caesarean births, and who want to plan a vaginal birth, often experience strong pressure to the point of bullying by midwives and doctors who attempt to enforce compliance with the plan of management considered 'best' by the maternity service providers.

Health is not black and white - there's always the possibility of shades of grey.

Independent midwives in Australia, and women who want homebirth, face enormous challenges as the changes to legislation regulating midwifery practice are implemented next year from 1 July. The women in 'grey' zones of risk - women who have had caesareans, or the grand multis - those who have given birth to six or more children, or the older or very young women, or those whose pregnancies are continuing beyond 41 weeks - these are the women for whom the independent midwife provides an invaluable personally refined service, whether they choose to give birth in hospital or at home. These are the women for whom the promotion of normal birth, working in partnership with a trusted and skilled midwife, becomes the key to protecting good outcomes. These are the women who will be most affected by the banning of independent midwives from professional practice.

Tuesday, June 23, 2009

from the College of Midwives

Media Release, June 2009

Mothers and babies at risk: Access to qualified midwives for homebirth under threat

Private midwives will no longer be able to attend homebirths under new national laws proposed for registering health professionals to have effect from 1 July 2010.

The national registration scheme for health professionals, which has been being developed by COAG and health ministers since 2007, released the draft laws last week. One of the requirements of the new scheme will be that all health professionals have professional indemnity insurance, as a measure to ensure consumers have access to compensation if they successfully prove negligence.

to read the full media release click here

Monday, June 22, 2009

carrot and stick approach

It's a brilliant strategy - particularly when working with donkeys.

The carrot is the 'promise' of extended practice, namely Medicare and prescribing rights, WITH indemnity insurance - removing some of the big restrictions that Australian midwives have struggled under for as long as any of us can remember. There's no 'promise' of access/practising rights for independent midwives in maternity hospitals, although that is implied. My memory goes back far enough to remember our efforts in the 1990s, when we DID have indemnity insurance. The big doors at the hospitals were securely shut to us then, and I haven't seen anything that makes me believe it will be any easier next year.

The stick is the clear statement in the draft legislation (see the previous entry in this blogsite) that a midwife will face disciplinary action if she engages in professional activity for which professional indemnity arrangements are not in force.

[Anyone who wonders if they would not mind disciplinary action - would just speak the truth without fear - perhaps you should speak to someone who has experienced it. The time and emotional effort demanded by the process, even if the complaint does not go to formal hearing, can be very draining.]

In a recent email discussion forum an experienced midwife colleague suggested that a new group be formed: a grassroots group set up specifically to protect homebirth. A group of guardians of the birthing woman and child. Midwives who can no longer practise the most basic and legitimate form of midwifery.

It appears that those midwives who are currently self employed, as well as those who are on extended leave from midwifery (such as maternity leave) will be registered as ‘non-practising’ midwives until we have insurance, (or, get a proper job).

I don’t look forward to disciplinary hearings, and will do all I can to avoid them, but imho that’s better than handing it all over to the police. As noted above, I expect that the carrot that will make many midwives toe the line is the ‘hope’ of being ‘eligible’ for the insurance, Medicare and prescribing when that is brought in. This will be particularly significant between 1 July, when the requirement for indemnity is enforced, and 1 November next year, when we anticipate the government's new indemnity plan for midwives to be available.

Will some midwives engage in civil disobedience?

Going underground, even with the possibility of disciplinary action if someone notifies the registration Board, may be the best option for those midwives and women who choose to continue to plan homebirth. It's not the first time authorities have set unreasonable rules that cannot be accepted by people with integrity. A skilled midwife who agrees to attend a labouring woman in her home will advise the woman appropriately if complications arise.

Going underground is not a long term strategy. It does not offer a solution in any sense of the word. It simply delays the inevitable. Home birth with a private midwife faces obliteration - extinction - annhialation.

There is a great deal of apathy in the midwifery profession. It appears that many of the influential midwives and nurses in this country believe in their hearts that there is no place for home birth in Australia. Is this through fear or ignorance?

I am challenging all midwives to stand up for MIDWIFERY. It's not about standing up for homebirth. I believe that the profession as a whole (not just independent midwives) should be objecting to our government's uninformed intrusion into the midwifery profession’s scope of practice, as defined internationally by ICM, and agreed to by all relevant peak bodies. Midwives practise midwifery in all settings, including the home. Birth is part, but not all, of midwifery. The setting for birth is a professional midwifery decision, made in partnership with the individual woman, and is not open to government fiddling.

Get real! My colleagues remind me "If we had the support of the midwifery profession as a whole, this wouldn’t be an issue! Imagine if ALL midwives threatened action in support of protecting the rights of birthing women and their own right to practice as midwives. The Government would soon find a way to resolve the issue…"

And where are the midwifery students, young and strong, waving placards??? A student commented: "The student body should be threatening action, but aren't. There is such an apathy amongst the majority of midwifery students."

So what can we do right now?

Stay well informed - join email groups, read and comment on blogs, read professional emails, newsletters and journals

Keep the issues in the public press - call in to radio talkback shows, send articles to local newspapers, write your own blogs and websites

Plan to attend the HBA Homebirth Rights Rally in Canberra September 7th, where you will be able to wave placards and demonstrate how important homebirth is to midwifery.

Wednesday, June 17, 2009

Questions about indemnity insurance and homebirth

As the time for the new health practitioner legislation in Australia approaches, many in the homebirth community have asked questions about how it will impact on them personally.

The timeline as I understand it at present is:
Early October 2009: women who conceive a child, and who would at present book a midwife to attend them privately for planned homebirth will need to know that, without government intervention, this will not be possible if their labour starts after 30 June 2010.

1 July 2010 - Midwives, who do not have professional indemnity insurance, will no longer be able to be registered, and therefore will no longer be able to provide midwifery services for homebirth. Independent, self employed midwives are the main provider of homebirth services in most of Australia.

1 November 2010 - *Eligible* midwives will be able to purchase indemnity insurance for their private practices, but NOT for homebirth, with government support. The services of these *eligible* midwives will also be rebatable through Medicare for the first time. Criteria for eligibility are not yet available.

Midwives have asked, will I be able to attend homebirths without insurance, if the parents agree?

Probably not. If after 1 July next year a midwife is not registered under the current legislation (Health Practitioners Regulation Bill), it will be illegal for that person to act as a midwife. If a registered midwife (eg someone employed in a hospital) were to attend a homebirth privately (rather than as part of the hospital's services), the note on clause 101 below states that this does not constitute an offence but may constitute behaviour for which disciplinary action may be taken! That's a big stick. How many most midwives will be willing to step out of line to continue to provide homebirth services???

Justine Caines, who is the leading activist and political commentator in Homebirth Australia, has reviewed the exposure bill (draft legislation).
"I read this to say that a registered midwife must not practice midwifery without professional indemnity insurance. Therefore in the case of a registered midwife that was providing hospital based care she would be prevented from providing homebirth unless she had indemnity insurance that covered homebirth."

Clauses from the draft legislation Health Practitioner Regulation Law 2009 below have been identified by Justine as being very problematic to homebirth practice.

69 Eligibility for general registration

(1) An individual is eligible for general registration in a health profession
(a) the individual is qualified for registration in the health profession,
(b) the individual has successfully completed:
(i) any period of supervised practice in the health profession required by the National Board established for the health profession, or
(ii) any examination or assessment required by the Board to assess the individual’s ability to competently and safely practise the profession, and
(c) the individual is a suitable person to be registered in the profession, and
(d) there is, or will be, in force in relation to the individual appropriate professional indemnity insurance arrangements, including a policy held, or arrangements made, by the
individual’s employer that will cover the individual

101 Conditions of registration

(1) If a National Board decides to register a person in the health profession for which the Board is established, the registration is subject to the following conditions:
(a) for a registered health practitioner other than a health practitioner who holds non-practising registration:
(i) that the registered health practitioner must complete the continuing professional development program required by the National Board, and
(ii) that the registered health practitioner must not practise the health profession unless professional indemnity insurance arrangements are in force in relation to the practitioner’s
practice of the profession,
(b) for a registered health practitioner who holds non-practising registration, that the person must not practise the health Profession,

Note. A failure by a registered health practitioner to comply with a condition of
the practitioner’s registration does not constitute an offence but may constitute behaviour for which disciplinary action may be taken.

Friday, June 12, 2009

updated list of MiPPs

Pic: L-R Back row: Kylie, Gaye, Helen, Joy. Front row: Andrea, Helen, Karen, and Patrice Hickey (President of Australian College of Midwives, Victorian Branch)

You can find the updated list of midwives in private practice (MiPPs) at the Maternity Coalition website. Click here

Thursday, June 11, 2009


The Rural Health Education Foundation (RHEF) has released a video of a panel discussion on birthing in rural and remote areas, looking at the latest research on the care of pregnant women and their babies and possible medical complications. The panel explores the implications of such research for rural women and their health caregivers. It examines models of patient care for women with low-risk pregnancies that enable them to give birth in local communities.

You can watch the video online through Rural Health Education Foundation's website. You will be asked to register your details at the site, which will then allow to you view the Video online or even download it as a podcast. It is free to register and it will also give you access to many other videos and resources.

Link http://www.rhef.com.au/programs/program-1/?program_id=355

Tuesday, June 2, 2009

Homebirth Rights: Rally - Parliament House Canberra - September 7

Homebirth Australia has announced that it plans to hold a MAJOR rally in Canberra (outside Parliament House) on Monday September 7 from 11.30am.

Justine Caines writes:
"There has been much discussion about the potential outlawing of homebirth and the continued lack of equity for women choosing homebirth.

"We need this to be BIG. When I met with the federal department of Health they commented on the huge number of submissions (900 of which over half came from homebirth consumers). Sadly I said if you outlaw homebirth I will lead 9000 angry women and babies to Canberra!

"The states close to Canberra will be called on to provide as many as possible to attend."

Details will soon be on the HBA website www.homebirthaustralia.org/

For any other info please email justine.caines@bigpond.com

If you would like to be involved more in the online discussion you can join the ozmidwifery list, or read the list archive.