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.

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.

A scarred uterus

The Australian College of Midwives (ACM) has released an Interim Homebirth Position Statement for comment.


The ACM Interim Guidance for privately practising midwives providing midwifery care for a planned homebirth state:

"There are some contraindications to a planned homebirth which women should be informed of at booking. These are:
• Multiple pregnancy
• Abnormal presentation (including breech presentation)
• Preterm labour prior to 37 completed weeks of pregnancy
• Post term pregnancy of more than 42 completed weeks
• Scarred uterus"

Births after Caesarean

Is spontaneous natural labour and birth a realistic option?

The answer, in each case, depends on decisions made during the pregnancy and as the labour progresses.

Most midwives, and many doctors, would encourage women to give birth vaginally. Unless there is a specific and valid reason to avoid vaginal birth, there is no safer way for mother and baby than spontaneous, natural, unmedicated vaginal birth.