'private in public' midwifery

A message today from Katy Fielding, Manager Acute Programs, Victorian Department of Health

Dear colleagues

I would like to inform you that the Minister for Health has recently approved the release of Eligible midwives and collaborative arrangements:

An implementation framework for Victorian public healthservices (the framework).

You will recall that the framework aims to assist public health services to assess how private midwifery services can operate at their service. As the “private in public midwifery” service model is relatively new in Victoria, the framework provides direction for public health services wishing to establish collaborative arrangements with eligible midwives.  The Department plans to evaluate the framework once this new model of care has been in operation for a sufficient period of time.

A hard copy of the framework has been distributed to CEOs of public health services and is available on-line at www.health.vic.gov.au/maternitycare

I am grateful to all of you for your valuable contribution to the development of this framework and welcome any feedback you may have. ...

 

Midwives who have Medicare numbers, and Prescriber numbers (ie achieved notation on their registrations as 'eligible', and endorsement as authorised to prescribe scheduled medicines) are well positioned to move into the new models, in cooperation and collaboration with mainstream public maternity hospitals.

How many midwives are we talking about?

Registration data published by the NMBA for June 2013 noted that 48 (of 212 nationally) midwives in Victoria had notation as eligible midwives, and 8 (of 22 nationally) had endorsement to prescribe scheduled medicines.  Those numbers are out of date, and we know that they are increasing each week.   For example, a social media group set up for eligible midwives (nationally) has more than 200 members, and another group recently set up for midwife prescribers has 100 members.

The conclusion I must draw is that there are many midwives who are ready to move out of employed models into private midwifery practice, as private practice has been redefined by the last federal government.  I believe as midwives leave the mainstream system, it will become increasingly difficult for hospitals to staff their maternity units within the old fashioned shift work models.  They will need to employ core staff only, and have midwives provide the basic care for their own clients, especially in labour, with early discharge wherever possible.  Hospitals will become more and more restricted to providing acute care only.

What will 'private in public' midwifery look like?
From the woman's point of view, it will be similar to the option that some women have, by which they have a private doctor within a public hospital.  Only this way they will have a private midwife who oversees and coordinates their care while they're admitted to a public hospital.

From the midwife's point of view, the care provided will be similar to the option that some midwives have, by which they work in a caseload/continuity of care/'know your midwife' model.  Midwifery practices will make their own decisions as to how they provide 24/7 midwifery cover - whether in a simple 'one to one' model, or having a named midwife on call covering a particular period, then off call at other times.  All midwives providing this 'private in public' midwifery option will be notated as eligible, will have government supported professional indemnity insurance covering intrapartum midwifery services in hospital, and will be credentialed by the hospital for clinical access.

From the hospital's point of view, the specified medical practitioner who will act as the collaborating consultant obstetrician at any time when a visiting midwife seeks discussion, consultation, or referral of women under the 'private in public' agreement will be the doctor authorised by the hospital to do so. 

When will the new 'private in public' midwifery options be available?

Good question.  The short answer is that we don't know.  However, the release of this framework document is an important step in the right direction.  Midwives who seek visiting access are making appointments to meet with hospital administrators.  Mothers who would like to use the 'public in private' midwifery options would do well to write to their local hospitals and request information.

Where do homebirths fit in?

Prior to the introduction of the federal government's maternity reforms, the only setting for private practice was the community, and the only place a privately practising midwife had professional autonomy was the home.  This has changed.

Private midwifery is no longer synonymous with homebirth.   

However, unless the 'private in public' midwifery options are facilitated quickly, many midwives will have no choice but to get into homebirth if they want to practise privately.

The 'private in public' midwifery framework seems obsessed with distancing itself from homebirth. I hope midwives can negotiate agreements with the public hospitals to cover the care we provide for homebirths, but I have no idea how amenable the hospitals will be.

When midwives attend women for planned homebirth one of the most significant decisions that can be made is to transfer from home to hospital.  The way this needs to happen, when it does happen, is without delay, in a seamless and professionally accountable way.  The writers of the reform legislation and the linked documents seem to believe - against all the evidence - that homebirth is dirty.  A lawyer commented on social media: "The more they try to integrate private midwives into the hospital system, the more homebirth becomes isolated and tied up in endless red tape which it becomes more and more impossible for midwives to satisfy."

Homebirth is not going to go away.  In a maternity world of machines that go 'ping', many women and midwives know that there is no better way to give birth than within the woman's own normal physiology, and that this can be achieved within the privacy and safety of the woman's own home, unless a valid reason exists to interrupt the natural process.


Opinions expressed are those of the author, Joy Johnston, and are not necessarily shared by all members of Midwives in Private Practice.

Your comments are welcome.

Maternity care plan

Midwives who are eligible to participate in Medicare, and offer Medicare rebates for women in their care, have this item in the Medicare schedule:

Item 82115

Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks, if:

(a) the patient is not an admitted patient of a hospital; and

(b) the participating midwife undertakes a comprehensive assessment of the patient; and

(c) the participating midwife develops a written maternity care plan that contains:

(i) outcomes of the assessment; and

(ii) details of agreed expectations for care during pregnancy, labour and delivery; and

(iii) details of any health problems or care needs; and

(iv) details of collaborative arrangements that apply to the patient; and

(v) details of any medication taken by the patient during the pregnancy, and any additional medication that may be required by the patient; and

(vi) details of any referrals or requests for pathology services or diagnostic imaging services for the patient during the pregnancy, and any additional referrals or requests that may be required for the patient; and

(d) the maternity care plan is explained and agreed with the patient; and

(e) the fee does not include any amount for the management of labour and delivery (Includes any antenatal attendance provided on the same occasion) Payable only once for any pregnancy

[Schedule 1 Part 1 of

Health Insurance (Midwife and Nurse Practitioner) Determination 2011]


It's clear from the legislation that a 'maternity care plan' is an important aspect of the antenatal care  provided by a participating midwife.  The professional attendance linked to Item 82115 is to take at least 90 minutes, and the scheduled fee is $319.00.  This compares with other antenatal attendances of at least 40 minutes, with a scheduled fee of $53.40.  Clearly, someone who advised the writer of this piece of legislation considered that the writing of a maternity care plan, and the other tasks (listed above) are very significant.


A midwife who has recently received her endorsement as an eligible midwife wrote to a social media site "I wonder if anyone could share their written maternity care plan format? Just want to know what you include and how to set it out ..."

This is a good question.  What does a maternity care plan look like?


It has occurred to me that the ICM Definition of the Midwife is a clear statement of a midwife's maternity care plan:

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.
...

The insurance company MIGA, in consultation with ACM and APMA, has developed a care plan that some midwives have adopted.  This care plan has a lot of boxes to tick, and much of the information would be collected routinely by midwives in taking a history and discussing care options with each woman.  Those who are using specially designed software would have many of the points of this care plan covered in entering the client information, and would be able to generate a maternity care plan printout when required.


The maternity care plan is to be kept with other professional records for each woman and baby, by the midwife.  The care plan usually does not need to be shared with anyone, unless asked for, for example, in a Medicare audit or an investigation.

There is ongoing discussion and concern about the relationship between midwives and public hospitals, particularly those hospitals that have, to date, refused to discuss any collaborative arrangements with midwives. MIGA states that, in order to meet the legislative requirements, a midwife is required to have:

• A Collaborative Arrangement with a doctor or Hospital, or

• A Care Plan communicated to a public Hospital providing obstetric services

• You should ensure this is acknowledged by the Hospital either in writing or as a record in your notes of an oral acknowledgement

  
  
  We note here that midwives in Melbourne, and many other places, who have attempted to comply with this requirement of acknowledgment (written or oral) by a hospital have had no success.  The hospitals have, to date, not been interested in collaborating with midwives.  Some hospitals have returned care plans to the midwife, and instructed her not to send them.   This problem seems to be ongoing, as was discussed in a previous post on this blog.
  
  XXX
  
  
  The MIGA maternity care plan seems to attempt to cover the 'what if' situations, in which a midwife might be required to defend her or his actions.  That makes sense - that's the job of insurance companies.
  
  But, ...
  
  Midwifery is not, primarily, about defensive practice.  It's about the midwife acting in a way that protects the wellbeing and safety of mother and baby.  It's about being 'with woman', in a special professional relationship.  It's about health promotion: healthy mothers and babies.  Midwives should not be instructed by an insurer, an entity that exists to make a profit for shareholders, as to the care plans they make.
  
  Midwives are encouraged to make a positive statement in each woman's maternity care plan, such as:
  
  "When providing primary maternity care for a well woman, the plan is to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. If illness or complications are suspected, a transfer to the planned hospital would be arranged without delay for urgent obstetric concerns, ..."
  
  
  

Publicly funded homebirth in Australia

Publicly funded homebirth in Australia: a review of
maternal and neonatal outcomes over 6 years

Authors: Christine Catling-Paull, Rebecca L Coddington, Maralyn J Foureur and Caroline S E Homer, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium

From the Medical Journal of Australia (Med J Aust 2013; 198 (11): 616-620.):

Results: Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%.

Conclusion: This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia.

These results are consistent with the large Dutch study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

The two Victorian publicly funded homebirth programs, at Sunshine and Casey hospitals, were not included in this study, which took data from 2006-2010. 

For more discussion about risk and homebirth, go to villagemidwife blog.

Questioning a midwife about women and risk

I am reluctant to make any broad statements about privately practising midwives and the way each one approaches a professional situation in which the woman has risk factors.  Each midwife, and each woman, is unique.  In fact, that's what the often repeated phrase 'woman centred care' points to: that the care for each woman is approached by her midwife from an individual perspective.

A midwife whose practice is under the regulatory spotlight for events that led to allegations that she has engaged in unprofessional conduct when she agreed to provide homebirth care for women in a risk category* is on the stand, under oath, and quizzed by the Barrister acting on behalf of the statutory body.  Here are a selection of the questions that this midwife may be required to answer.  Perhaps other midwives will take a moment to reflect on how we would answer these questions.

* The 'risk' profile could include, for example, postmaturity, prematurity, birth after caesarean, multiple pregnancy, breech presentation.  

With reference to a woman who wishes to give birth at home, the midwife is asked:

"Do you accept that you have a professional responsibility to inform the woman of risks?"
"Do you consider that after you have informed the woman of risk, such as post maturity, or previous caesarean, that it is appropriate for you to agree to homebirth?"
"Do you accept that homebirth after caesarean (hbac) entails higher risk than homebirth without previous surgery?"
"Do you agree that risks in a vaginal birth after caesarean (vbac) birth are better managed in hospital if they occur?"
"If as you say there are some risks for the vbac at home, why did you not record this in your notes?"

"What evidence do you rely upon for permitting vbac at home?"
"What special preparations did you make for a high risk birth at home?"

"Did the mother lead the decisions about homebirth, or did you give her the green light?"
"Did you consider saying no to homebirth, and sending the woman to a doctor?"
"In your midwifery practice, do you follow the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (ACM Guidelines)?"
"Do you accept that the ACM Guidelines state that the pathway for birth after caesarean is to at least consider referral and transfer to obstetric care?"
"Do you accept the first guiding principle of the ACM Guidelines, that 'As a primary caregiver, the midwife, together with the woman, is responsible for decision making.'?"
"Do you as midwife accept that you and the woman are jointly responsible for the decision to give birth at home?"
"On reflection, with the wisdom of hindsight, do you agree that you made a poor decision in providing home birth care in this situation?"
"Are you able to give the panel the assurance that if you were faced with a similar situation again, you would act differently?"
"Don't you think that a woman who is more than 10 days postmature, and unable to give birth in a small hospital, is too high risk for homebirth, where there are even fewer resources on hand than at a small hospital?"

The main 'requirement' for homebirth is that the woman is able to labour spontaneously without medical stimulation of labour or pain relief.  Midwives attending homebirth use no drugs to stimulate labour or to ease pain.  The only stimulation of labour available for homebirth is natural processes, such as walking, nipple stimulation, sexual intercourse, and perhaps a special meal.  If a woman who has had a previous caesarean, or whose baby is in a breech presentation, intends to give birth spontaneously, she usually accepts the requirement for spontaneous onset and good unmedicated progress in labour. 

The polarisation of midwifery care into 'planned homebirth with a private midwife' and 'standard hospital care for birth' is in itself unreasonable.

Physiological birth is a basic function of the female of the species.  In our world today we have the opportunity to interrupt physiological processes if we think they are progressing in a way that would lead to poor outcomes.

Consider any other physiological process: breathing, for example.
I breathe because that's what my body does.
I continue to breathe whether I am conscious of the fact or not.
If breathing becomes difficult, this can be a warning sign that prompts me to seek medical attention.

In the same way, a physiological labour will proceed because that's what the woman's body does.
She will continue to labour whether she is paying attention to it or not.
If labour becomes difficult, this can be a warning sign that can prompt transfer to another level of care.

Planned homebirth is 'Plan A'.  The midwife checks the fetal heart, or records signs of progress, or monitors the woman's vital signs in preparation for intervention if that becomes necessary.  The midwife has (or should have) no intention to interrupt the natural processes without a valid reason.  A transfer to hospital, 'Plan B,' is a change in the plan.   There are different rules in operation under 'Plan B' than 'Plan A'.

Effective decision making in labour requires a shared responsibility for the decisions that are made.  The midwife has a certain body of knowledge, and familiarity with the processes, and the woman has other knowledge about herself, her values, and her life direction.  Together they are able to navigate the often unpredictable journey of bringing a baby into the world.  A midwife is not a hired help, employed to facilitate a certain preferred option.  Active participation in decision making protects the wellbeing and safety of mother, baby(ies), and the future of the midwife.

Birth is a highly contested zone.  Our society takes a paternalistic attitude towards birth, through the regulation of the midwifery and medical professions, and the oversight of institutions such as hospitals.  This is good - to a degree.

However, the one who is literally 'holding the baby' at the end of the day is the mother, and she is usually within an immediate family and broader community.  Unless the mother-family-community relationships are broken down beyond repair, the best place for a child to be cared for and to grow is within that network.  A midwife works in partnership with the woman, for the childbearing period, promoting health, protecting wellness, and supporting the development of healthy families.

There will always be aspects of risk that either exist prior to the onset of labour, or that develop during labour.  The midwife who recognises and acts appropriately in the care relationship, and the woman who engages in an intelligent way in decision-making, will have a high level of safety built into their care plan.  There is no safer way than Plan A for a well woman to approach birth.  When complications are present the care decisions become more complex, and the need for medical attention becomes more urgent.  A midwife and woman working together in a trusting relationship bring strength and confidence to the decision making process.



Your comments are welcome.

Colalboration gone wrong!

The Australian Government’s $120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives, promised that Australian women would have

“more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services.” 

The National Maternity Services Plan (the Plan), endorsed by the Australian Health Ministers’ Conference in November 2010, provided governments with a strategic national framework to guide policy and program development.  The plan declares that primary maternity services will be  

“woman centred, reflecting the needs of each woman within a safe and sustainable quality system."

Year one of the Plan committed jurisdictions to developing 

“consistent approaches to the provision of clinical privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners.”

How is implementation of the Plan progressing?

Midwives report little action or hope of conclusion, on matters to do with provision of clinical privileges for Medicare-eligible midwives within public maternity services, except in Queensland.  Anecdotally we are aware of instances of increasing resistance within some public hospitals to the implementation of programs of clinical privileging for private midwives.


Earlier this week I received an early morning call from a distressed colleague.  Having worked with a woman who was planning homebirth for some hours, this midwife arranged to transfer the woman's care to a major public maternity hospital in Melbourne, where the woman had made a back-up booking.

The midwife, who believes she has had a good relationship with the hospital for many years, was distressed that the doctor who admitted her client refused to accept any verbal hand-over, and rudely walked away when the midwife attempted to carry out a professional conversation with him.

It would appear that efforts are being made within public maternity hospitals to derail any plans to enable admitting and practice rights for eligible midwives.

Within the obstetric community there is a strongly held position that a doctor or midwife who is willing to assist women in 'bad choices' is seen as encouraging 'bad choices'.  Women who have attempted to make arrangements with hospitals to facilitate normal birth in situations of acknowledged complexity, such as twins, breech babies, or even birth after a previous caesarean, have been given no choice.  "If you come here, this is what will happen!"  This is an often repeated scenario in both public and private hospitals.  These women have often sought private midwives to attend them in the relative 'safety' of their own homes.


This post is just skimming the surface of a complex issue.

Collaboration with medical and nursing colleagues, within hospital systems, is a basic expectation in all midwifery. 

Midwives are required, by regulation and by definition, to collaborate. 

“... 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 (emphasis added) and the carrying out of emergency measures.   ” 

(From ICM Definition of the Midwife, 2011)



Midwives also have an expectation of ethical professional behaviour towards those in our care.  The current Code of Ethics for Midwives lists 'values' - which in themselves describe the standard to which we aspire.  There is no place for bullying and domineering behaviours in midwifery.

1. Midwives value quality midwifery care for each woman and her infant(s).
2. Midwives value respect and kindness for self and others.
3. Midwives value the diversity of people.
4. Midwives value access to quality midwifery care for each woman and her infant(s).
5. Midwives value informed decision making.
6. Midwives value a culture of safety in midwifery care.
7. Midwives value ethical management of information.
8. Midwives value a socially, economically and ecologically sustainable environment promoting health and wellbeing.

 (From Nursing and Midwifery Board of Australia)

Midwives need a system that recognises us and treats us fairly.

We call on midwives to continue to stand in partnership with women, demanding equity and fairness in all maternity services provided by our governments - federal and state. Collaboration requires both parties to participate, the hospital and/or doctor, as well as the midwife.  There is no such thing as one-way collaboration.  Midwives are committed to the wellbeing and safety of mothers and babies in our care, and it is our duty to demand that the health care systems support us in achieving this goal.

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.

Transfer to hospital from planned homebirth in the Melbourne area

Midwives in and around Melbourne have received a letter from the Women's Hospital in Parkville, telling us that backup bookings for women planning homebirth will now restricted to the local area. Women outside the catchment area for the Women's, who require transfer of care, are to "present to the local maternity hospital closest to your client's home."

homebirth position statement

Members of MIPP who are also members of the Australian College of Midwives (ACM) will be aware that "ACM is working with both the NMBA and the Commonwealth to develop a contemporary homebirth position statement within the next three months."
(Australian Midwifery News, Autumn 2011 issue, page 3.)