regulation of midwives

Several MIPP midwives were amongst 60+ national attendees at a meeting this week in Melbourne, hosted by AHPRA.
The meeting was called 'The Light at the End of the Tunnel Midwifery Workshop', and presentations were made by various midwifery leaders and regulatory people.

The aim of the Workshop was:

1. To improve and foster understanding between the NMBA, midwives and stakeholders regarding midwifery issues incorporating:

a. Accreditation & education
b. Midwifery Practice
c. Association
d. Workforce 

2. To move closer to the intent of the National Registration and Accreditation Scheme by ensuring that there is a common understanding about midwifery practice.

Mary Chiarella from the NMBA chaired the workshop.  The round table discussions and feedback were well organised.  Attendees will receive summary notes and powerpoint slides, and the Board is committed to using the information gathered in the workshop as policies are developed.

Separate midwifery regulation
There will be a review of the national law (? next year - not sure) and there is support amongst midwives for a separate Midwifery Board to be established.  Although the current NMBA can be seen as an improvement on its preceding state and territory nurses boards, many midwives believe that the profession of midwifery is not well served by the current arrangements.  In the meantime the need for midwives to be on each of the state and territory Boards (members appointment by jurisdictional health minister), and to be on panels hearing complaints regarding midwives practice, were stressed by several attendees.


Quality and Safety Framework, and practice review
It was noted that a new quality and safety framework is being developed and will be distributed for comment in the near future. It will cover all midwifery practice - not just homebirth/private practice. There seemed strong support for midwifery practice review by all midwives. 

Home birth after caesarean, and mandatory notifications
One issue that was raised, which some readers may be interested in, is that independent midwives in some areas have been 'reported' for planning vaginal birth after caesarean (VBAC) homebirths. They have been told by the hospitals that notifications have been made under mandatory reporting: meaning that the person who made the report believes that a midwife who plans HBAC has departed from accepted professional standards, and is thereby placing the public at risk. The members of the national Board who were at this workshop were emphatic that this sort of action does not have the support of the NMBA . It's a practice issue, and the Board does not have any policy in regard to HBAC.

Making a 'mandatory notification' is a serious step that is aimed at preventing members of the public who receive professional services being placed at risk of harm, and should only be taken with sufficient reason.  Making a notification that is vexatious or not in good faith may expose the reporting practitioner to proceedings for defamation. Women who ask midwives to attend them for planned homebirth after a previous caesarean usually do so believing that this care plan gives them the opportunity to come into spontaneous labour, and establish labour without interruption. 

There was some discussion around the impact on the midwife of notifications and investigations into professional conduct.  Participants requested that the Board provide support for midwives who face proceedings by NMBA and AHPRA, as they defend their professional position.  The public interest is served not only by punitive measures for professionals who have misbehaved, but by ensuring that everyone is treated with respect and natural justice and their cases are dealt with in a timely, transparent and accountable manner.

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.

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.

choice of home birth: a human right?

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

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

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


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

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

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

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

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

“The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. ... A midwife may practise in any setting including the home, community, hospitals, clinics or health units.”  [Note that this paragraph is unchanged in the revised (2011) ICM Definition of the Midwife.]

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

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

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

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

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

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

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

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

MIPP submission to Senate Inquiry

Inquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency (AHPRA)

MIPP has made a joint submission with Australian Private Midwives Association (APMA). To access all the submissions received by the committee,
click here

The matters addressed in this submission are in response to our experiences during the recent transition from individual State and Territory-based regulation of the midwifery profession to the national regulation of the midwifery profession under AHPRA.

We draw to the attention of the Inquiry the following matters, which will be discussed in more detail in the body of this submission:
1. AHPRA’s administration of the registration process for Medicare benefits
.1 Midwives are required by AHPRA to provide a reference from hospital midwife manager or obstetrician when applying for notation as eligible for Medicare benefits. This is an unreasonable request for many privately practising midwives.
.2 ‘Prescribing’ course. Midwives who apply to AHPRA for notation as eligible for Medicare benefits are required to sign an undertaking to complete within 18 months of recognition as an eligible midwife, an accredited and approved program of study determined by the Board to develop midwives’ knowledge and skills in prescribing ...” There is at present no such course available for midwives.
.3 Some midwives have experienced unacceptable delays and a lack of fairness in processing applications for notation as eligible midwife.
.4 We draw to the attention of the Inquiry the implications for consumers/ private clients of midwives whose applications have been delayed without good reason.
.5 We assert that there is a strong potential for misunderstanding in the obstetric and hospital midwifery communities as to the meaning of collaboration. Legislation that privileges obstetricians, placing them in a supervisory role for midwives, must be repealed.

2. The administration by AHPRA of complaints against privately practising midwives
.1 A privately practising midwife’s registration had been suspended prior to the changeover to the new legislation. This midwife has been unable to work and earn a living, yet she has not yet been given an opportunity to present her case in person, or to have her suspension lifted.
.2 At least two midwives have recently had conditions (supervised hospital practice) placed on their registrations without any investigation into the complaint. This is as effective as a suspension, with the midwife losing her ability to earn a living while the conditions apply.

3. Professional Indemnity Insurance. AHPRA, through the Nursing and Midwifery Board (NMBA), is currently in the process of drafting requirements for insurance for midwives. We wish to draw this to the attention of the Inquiry, as midwives in private practice are the only professional group unable to purchase indemnity insurance to meet the requirements of the national legislation.