letters from MIPP

About a month ago we reported on amendments to legislation applying to eligible midwives and Medicare.

The ability of a midwife to attend a woman giving birth in a hospital was a major item in the Medicare reforms, introduced more than three years ago.

Yet ...

• Despite many assurances that the Victorian government supports the federal government's maternity reforms, and has developed a framework for credentialing of midwives, no midwives in Victoria have made collaborative agreements with hospitals.  
• Midwives are able to buy insurance policies through MIGA, underwritten by Treasury, providing uncapped cover for women receiving midwifery services from eligible midwives for birth in hospital - yet they can't get access to the hospitals.
• Women would be able to claim up to approximately $1500 rebate for intrapartum midwifery services (2 midwives) - if the midwives could get access to the hospitals.
• Midwives are continuing to provide professional services for women in their communities, and accompanying them to hospital for birth or other specialist obstetric services if and when the need arises.
• Midwives report that some doctors who have previously agreed to collaborate with midwives have withdrawn, giving reasons such as "I don't think homebirth is a good idea" - when the collaborative arrangement covers only antenatal and postnatal midwifery services.

This is unacceptable.  What other profession would sit back and accept persistent exclusion from their usual places of practice?  Why are women who would prefer to give birth in hospital in the care of their known and trusted midwife being prevented from doing so? 


A new round of letters has been sent by MIPP to the public hospitals, respectfully requesting an update on progress.

A similar letter has been prepared, and is being sent to obstetricians and GPs who have agreed to collaborate with midwives, usually through a letter of referral, or in some instances, through a signed collaborative agreement.

The content of this letter is copied below:

Re:  Collaboration and hospital visiting access for Midwives

Dear Doctor

This letter is to inform you of recent changes in legislation governing the requirement for collaborative arrangements for eligible midwives, such as referral of women to the midwife for antenatal and postnatal midwifery services.  We thank you for your participation in collaborative arrangements to date, which have enabled women to claim Medicare rebate on the fees of midwives who have Medicare provider numbers. 

Since the introduction in April 2010 of amendments to the Health Insurance Act (1973), some midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare arrangements.

In recognition of this, at the 10 August 2012 Standing Council on Health (SCoH) meeting, the Commonwealth agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. On July 25^th 2013 the Health Insurance Amendment (Midwives) Regulation 2013 http://www.comlaw.gov.au/Details/F2013L01432 was introduced.

Accordingly, the purpose of the regulation is to enable midwives to demonstrate collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity. The regulation adds a new type of collaborative arrangement for an eligible midwife who is credentialed for clinical privileges within a hospital.  It is expected that the hospital will have a formal written agreement with such midwives, addressing consultation, referral and transfer of care, relevant clinical guidelines and locally determined policies.

Letters have been sent to the public maternity hospitals on behalf of MIPPS, requesting an update on the processes that are being implemented, by which the hospitals will provide eligible midwives the opportunity to have collaborative arrangements.  Until these new processes are established, midwives and our clients will continue to rely on the collaborative agreements and arrangements, such as referral, that have been used in the past couple of years.

Yours sincerely,

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, ..."
  
  
  

Midwifery under the spotlight at obstetric malpractice conference

The 5th annual obstetric malpractice conference will be held in Melbourne, June 20 and 21 this year.

Key issues to be covered:

• Developments of the National Disability Insurance and Injury Scheme and National Injury Insurance Scheme and implications for obstetric practice
• The Coroner's perspective on inquests involving perinatal death
• Lessons learned from the midwifery indemnity model in New Zealand
• Practical and legal implications of the Open Disclosure Standard
• Practical legal measures for when a baby is born with Hypoxic Ischemic Encephalopathy or other unexpected birth outcome
• Managing the Risks inherent in women's choice in obstetric care
• Perinatal Review Process
• Medico-legal risks of female genital mutilation and female elective surgery
• Race-based pregnancy care. Is that good medicine?
• Implications of new genetic technologies on prenatal diagnosis
• Wrongful birth damages - the first detailed damages judgment
• FACILITATED PANEL DISCUSSION: Awful Lessons I have learned by being an expert witness
• PANEL DISCUSSION: Medico-legal risks and ethics of female genital mutilation

This list of topics includes several of considerable significance to midwives who practise privately.  However, there is one major hurdle for anyone who may be considering making a booking: the cost!  Even with earlybird discount, $1,700, added to the potential loss of income if a baby in the midwife's caseload needs to be born, and accommodation costs, is a LOT of money in midwifery-land.

The opening address on Day 2 is 'Lessons to be learned from the Home Birth Cases in Vic and SA' - speaker is the coroner Judge Ian Gray. It would seem to me that we need to have midwives who are practising privately in Victoria and South Australia to hear what is said and to respond if appropriate. 

Midwives who face disciplinary hearings or coronial investigations find ourselves, our actions, and our 'outcomes' thrust into the spotlight, within a legal and professional framework that may seem quite foreign to contemporary midwifery philosophies.  Midwifery notions of informed decision making and partnership and choice can be discarded as meaningless by legal experts who rely on guidelines rather than professional clinical decision making. Click here and here for recent examples.

I do not wish to suggest that midwives always get it right - there will always be a need for unbiased outside review of serious morbidity and mortality, or unprofessional conduct in professional health care.
  

Issues around a woman's right to decline treatments (usually medical) that are considered 'evidence based', or 'best practice' will be reviewed from obstetric, legal, and consumer perspectives.   The management of breech births is a good example, and two consumer presenters, Rhonda Tombros and Ann Catchlove, who are also lawyers, will discuss:

Breech birth: consumers, choice and consent

• Women with breech presenting babies near term often find themselves with limited birth options. Some change care-providers, hospitals or even travel interstate to access the opportunity to attempt a vaginal breech birth
• This presentation will explore issues around consumer choice and consent in breech birth with a focus on the legal and ethical issues that arise when women are given no option for birth other than planned caesarean section
• How can care-providers and hospitals facilitate care that is both safe and respects women's decision-making autonomy?

Both women come with a proven track record, in challenging obstetric dominance of women giving birth.  See Breech Birth Australia and New Zealand, and the breech fb group, and Maternity Coalition.

Midwives discussing this conference via the Eligible Midwives facebook group have called for recordings of the proceedings to be made available after the conference.  I will keep readers informed.


Post script:
Midwives may apply for financial assistance via Government Scholarships (administered through ACN http://www.acn.edu.au/sites/default/files/nahsss_continuing_professional_development.pdf).

Progress report: 2 years

It has been two years since the federal government's maternity reforms became effective, with the political spin of  “Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives”, stating that "... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care." (for more detail click here)

Yes, 
consumer preference was very clear: thousands of submissions to inquiries, many from ordinary mums and dads and grandparents, many of whom had never previously made any attempt at political action.
But,
consumer preference in this instance was overwhelmingly in favour of the option of homebirth attended privately by a midwife.
And,
since current evidence supports planned homebirth, with access to suitable obstetric hospital services when required, as being at least as safe as hospital birth for most women, I fail to understand the action of the government in summarily excluding homebirth from any Medicare benefit.
(Many have made plausible suggestions about a paternalistic, nanny-state, socialist policy that seeks to provide a one-size-fits-all plan for maternity care.  'Informed decision making' has become a one of those hollow phrases that are used because they sound so fine.)


The package of maternity reform focused on professional indemnity insurance, Medicare, and PBS (pharmaceutical benefits scheme) for midwives, with provisions for midwives to attend our clients privately for birth in hospitals.  Looking at each of these elements:

• Midwives are now covered by professional indemnity insurance (PII) for all antenatal or postnatal services, and for intrapartum services provided in (just a few) hospitals.  Midwives attending homebirth have been granted an exemption from PII until June 2015.  The obvious problem with this arrangement is that if PII is a rational and reasonable product, cover for intrapartum care would be essential.  But, since noone in the insurance industry has been able to come up with an affordable insurance product for midwives, the exemption has been put forward as a stop-gap measure. (more here)  Perhaps the implementation of the government's National Disability Insurance Scheme will ease pressure on the insurance market, and bring some relief to this stalemate.  Independent midwives in the UK at present face loss of their ability to practise because PII has become mandatory.  This is definitely not in the public interest, and is an example of regulation of a profession being delegated to the insurance industry.
• Medicare provider numbers are being used by an estimated 150-200 midwives nationally.  The provision of Medicare rebates for women who receive part of or all their maternity care from privately practising midwives should lead to a reduced reliance on maternity hospitals, which are in may places overstretched, overbooked, and under-staffed.  Yet, midwives who have asked hospitals to refer women to them for shared antenatal care, or for primary care with a plan for hospital birth, have (almost uniformly) received negative responses.   Victorian midwives in private practice continue to experience roadblocks to implementing the promised reforms. 
• The PBS provisions of the reform package are yet to be fully implemented.  We know of one midwife in Victoria who has been endorsed by the Board for prescribing.  Other midwives will be applying now, having completed the Flinders University's Graduate Certificate in Midwifery (pharmacology and diagnostics).  The Victorian legislative changes have recently been gazetted (click here), enabling authorised midwives to become prescribers. 

The hospitals where intrapartum care is (or soon will be) provided by private midwives are Toowoomba, Gold Coast, and Ipswich, in Queensland.  The model has been established with My Midwives. 

Collaboration, the core requirement for Medicare funding to be accessed by the woman, continues to present huge challenges to midwives.  Most midwives who practise privately have women coming to them from many different communities.  These women see different doctors, and it is not possible for the midwife to have met or worked with most of these people.  Some doctors are ready and happy to refer women to midwives for private care; some refuse outright; and some go to extraordinary lengths to cover themselves, in case something goes wrong.  One doctor sent a letter by registered mail to the private midwife and the pregnant woman, informing them that she (the doctor) opposed home birth under any circumstances.  No evidence was given for this position.  In the discharge letter to the GP, the midwife wrote:

... I acknowledge receipt of your letter in which you stated that you do not endorse homebirths.  I would like to direct you to the Cochrane (2012) review of planned hospital versus planned home birth, in which the authors state “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.” 

Hospital visiting access has been the dream of some privately practising midwives.  There are many practical reasons why they would like to offer hospital birthing to their clients, the obvious one being that this is where most Australian women intend to give birth.  Homebirth can be seen as unusual, and not well understood.  

At present an investigation is being undertaken by the ACCC into specific cases of anti-competitive behaviour by obstetricians or hospitals, blocking access to midwives.  Any midwives who have documentary evidence that they believe would contribute to this inquiry may contact me by email, and I will give you the names and contact details for the case officers who are heading up this investigation. [Joy Johnston joy@aitex.com.au ]

Is there a way ahead?  Is there a light at the end of this next tunnel?

Midwifery is a legitimate option for women seeking maternity care.

Midwives are able to offer basic maternity services, regardless of where that birth is planned.

Fellow midwives, I encourage you to reconsider the way we provide midwifery care for mainstream women who intend to give birth in a hospital.  In the past we, the 'good girls', have entered shared care arrangements where possible, and provided private midwifery services in addition to the services provided by public hospitals, accompanied these women to hospital in labour, and done all in our power to protect, promote and support wellness, within the constraints of the system that would prefer us not to be involved.  

The new midwifery led primary maternity care model will be woman-centred, and community based.  The hospital will be excluded from the model until the time comes to use the hospital, whether that is during labour, or before or after birth.  Since independent midwives have been excluded from hospital collaboration, we have no choice but to act autonomously within the community, at the same time as collaborating with the specified medical practitioner for that woman, and providing a written handover to the hospital when hospital care is required.  

Women who choose this model of care may be classified as 'planned homebirth', when in fact they did not plan homebirth.  That doesn't matter - it's not about the setting, or the statistics.  The main goal of this proposal is that women are able to access midwifery primary care from a known and trusted midwife: 'more choice' from 'expanded models' of maternity care.

This post contains the opinions of the writer, which are not necessarily shared by all members of MIPP.

Your comments are welcome.

For those who like to read the advice given to Health Ministers

A Freedom of Information request was recently made by Homebirth Australia to the (federal) Department of Health and Ageing, for documents related to midwives and professional indemnity insurance under the government's reforms.

The documents are now available at this Disclosure log.

What can we learn from these letters and briefing papers?




A convenient 'reason' for delay: "to allow time for data to be collected ..."
With reference to the exemption granted to private midwives from having professional indemnity insurance when we attend homebirth, Health Minister Roxon wrote (May 2011) to her counterparts in State and Territory governments that:

"essentially this was to allow time for data to be collected on the safety of homebirths and to enable a private insurer to develop an appropriate insurance product."

Today I am exploring threads of information, about homebirth and the collection of data on the safety of homebirths, in some of these documents.

I would like to remind readers that homebirth had been the hot potato in the Maternity Services Review (2008), inspiring hundreds of impassioned submissions to the Review from women and midwives who attempted to convince the Health Minister that homebirth was an essential component of maternity services. 
Yet the Report (2009) side-stepped homebirth, giving preference to what it called ‘collaborative’ models, under obstetric control.

Homebirth, according to the Report (2009), was too much a hot potato, and was dropped! 

“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.” (Report Pp20-21)

[For more discussion on the Report and subsequent events, you can check through the archives of this and other blogs written by midwives and maternity activists.]

That was 2009.  And, it could be said that homebirth did polarise the professions!

2010 brought a reprieve for private midwives and homebirth, in terms of the 2-year exemption referred to in the opening paragraph of this post.


2010 also brought the National Maternity Services Plan, which was endorsed in November by the Australian Health Ministers' Conference (AHMC), committing all jurisdictions to, amongst other primary maternity care programs, publicly funded homebirth.

2011 saw homebirth on the agenda of the February AHMC meeting, with a briefing that drew attention to South Australian 'some' privately practising midwives (PPM) who were

"not practising safely.  This is in the context of at least one high profile case of a death in SA which is currently progressing through the courts.  As a result SA is seeking to strengthen the current monitoring arrangements for PPMs".

 2011: (June) The College (ACM) produced the first Homebirth Position Statement, which was rushed through the system, hastily adopted by the NMBA, endorsed by AHMC, posted on the NMBA website and became part of the regulation standards for midwives, drawing howls of dismay and rejection from midwives.  (See for example, APMA Blogs in mid-2011)

2011: (August) The Health Ministers meeting at ANMC agreed to a twelve month extension to the exemption from PII for private practice midwives attending home births.

2011: (November) The second (revised) ACM Position Statement on Homebirth Services was released, having undergone more constructive consultation with the profession than the previous one.  However, the first Homebirth Position Statement has been retained by the NMBA. 


Throughout this set of documents a recurring theme is data collection:
"allow time for data to be collected on the safety of homebirths ..."
 "the collection of sufficient data on the clinical safety of homebirths"

Data on actual homebirths and planned homebirths has been collected and reported on in Victoria for at least the past 20 years.  How much more is needed?

Each year a PROFILE: HOMEBIRTH document is published by the Perinatal Data Collection (PDC) unit of the Victorian government's Consultative Council on Obstetric and Perinatal Morbidity and Mortality (CCOPMM).  The statewide collection of perinatal data has, over the years, also developed and published Maternity Service Performance Indicators.  (Click here for the 2009 statewide set)

For example, in 2003-2007, there were 170 standard primiparae who planned homebirth, regardless of where the birth took place.  Of these,

MAT-1     none had labour induced (0%) [Statewide rate 2007 was 4.8%]
MAT-1b  11 had Caesarean births (6.5%) [Statewide rate 2007 was 14.8%]

Apart from individual cases that have been highlighted and possibly sensationalised in media reports, there is no reliable statistical evidence of poorer outcomes for either mothers or babies who give birth at home in the care of midwives.  Data supports the safety of homebirth: it is easy to argue the protective effect of many aspects of planned homebirth, for example, primary care by a known midwife, many aspects of social support, spontaneous onset of labour, and appropriate use of medical analgesics, anaesthetics, and uterine stimulants.

Plenty of time has transpired for data to be collected. 

There is no reason for homebirth attended by private midwives to be excluded from indemnity insurance products, and no reason for women to be discouraged from planning homebirth with an independent midwife.

a career in private midwifery

I was recently contacted by a journalist who was keen to write a story about private midwifery as a career. He told me his audience is people who are contemplating a career in health, and he hoped to shed light on the ins and outs of the particular career that was in the spotlight. He told me he wanted to present information in an informal, conversational manner, and even hoped for a bit of humor; that by the time a reader had read the piece they would have not only an idea of the particular career profile, but also know something about the person who had been interviewed for the article.

It all sounded good. Sure, I said, I'm happy for you to interview me.

With the wonderful technology of bluetooth in the car I was able to commit a 40 minute time slot as I drove from Vermont to Preston, between the homes of two new mothers. I talked passionately about the fact that birth is not an illness; that midwives form a trusting partnership with the individual women in our care; that our focus is the woman and her baby. But this did not seem to be useful information, as far as my interviewer was concerned. He told me the story shouldn't be about women who birth or midwives in general; it needed to be about what I was actually physically and mentally doing and feeling in my job. And it should be about the vivid little details involved in the processes you perform.  I came away from these interviews with a sense that I had not satisfied the journalist's investigative drive.  I felt that I was in one world, and he was in another, and that what I said was simply not making any sense.  I felt disappointed, because the more he plied his questions, the more my attempts at answers seemed to be unacceptable.

I write a lot about my experiences and feelings and the vivid little details of my job.  I hope any readers of this and other midwifery blogs are able to grasp the passion and values that midwives share with the women in our care.

Since the introduction of the Australian government's maternity reform package, new career opportunities are being opened up for midwives who want to practise privately. Midwives have obtained their Medicare eligibility notation, and hung up their shingles (set up web pages and social media sites). Here's a quick overview of what is required to get to this point in a midwifery career:

• Graduate from a university course that leads to registration as a midwife
• consolidate midwifery experience for at least 3 years full time employment across the full scope of midwifery practice
• undertake the Midwifery Practice Review through the Australian College of Midwives
• obtain a detailed reference that meets the AHPRA requirements, gather all the required documentation, have copies made and witnessed, and apply to AHPRA for notation as a Medicare-eligible midwife.  Expect this application process to take several months.
• purchase professional indemnity insurance
• join a private practice, or set up your own private midwifery business.  

Women can employ a midwife for any part or the prenatal, labour and birth, and postnatal care, or for the lot.  The midwife can charge as much or as little as she/he chooses.  If the midwife is participating in MBS, specific collaborative arrangements are required.  The Medicare rebate that the woman is able to claim varies according to factors such as the Medicare safety net.
 
Is private midwifery practice a realistic career option?

The Midwives in Private Practice (MiPP) collective has had between 20 and 30 active members since it was formed in 1989.  Most of these midwives have had other employment, such as casual work in a maternity hospital, in addition to their private work.  There have been a small number (estimated 5) for whom the private midwifery practice is their family's main source of income.  Most MiPP members over the years have had their own caseloads, with homebirth being an option for all midwives.

With the government's maternity reforms, time will tell if more midwives are able to sustain private practice.  Some who have Medicare are not experienced in homebirth, and it would not be wise for such midwives to offer homebirth care without first undertaking a program of learning and mentorship to extend their practice to homebirthing. 
    
Other midwives might want to offer an opinion on this.  

Joy Johnston

Mandatory reporting

There is a great deal of discussion and some dismay in the world of private midwifery, since we learned that a 'mandatory reporting' notification was made of a midwife who was deemed to be practising without insurance.

We understand that this midwife was in a public hospital with a woman who had planned homebirth. After transfer of care to the hospital, the midwife continued in a supportive role with the woman: the usual practice in Australia when women transfer from planned home birth to hospital care.