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.

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.

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.

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.