for the record ...

A couple of dodgy situations have arisen in the Melbourne private midwifery world this past week, and I am noting them here, for the record.  People will not be named, but be assured, these stories are not fictional.

Story #1 - Woman W1 and doctor GP:

W1: (39 weeks pregnant, planning homebirth) "My midwife told me to ask you for the paperwork I will need to register the baby's birth, and get the baby bonus."
GP: "I have never been asked for that paperwork.  In fact I don't know where to get it."

For readers who are unfamiliar with the process, this paperwork is issued after birth by the midwife who attends a birth at home, or by the hospital where the baby was born. 

The GP phoned a well known and respected midwife to inquire as to how to obtain the paperwork.  That midwife immediately questioned the request.  If W1 is in the care of a midwife, that midwife should issue the paperwork, and sign the declaration to enable registration with Centrelink, baby bonus or paid parental leave, adding the baby's name to Medicare card, and other standard processes including obtaining a birth certificate.  Simple as that!

In this case W1 is probably planning homebirth without a registered midwife in attendance.  Call it freebirth or pure birth or attended by a birth worker or whatever you like.   A GP would be unwise to issue the birth paperwork, unless she or he was also prepared to attend the birth and sign the professional declaration.

Story #2 - Lay birth attendant LBA phone call to midwife M2:

LBA: "I am looking for a midwife who will visit the woman W2 in her home once labour has started, and do an assessment so that we can be sure she is at least 4 centimeters dilated."
M2: "Why do you want this?"
LBA: "Because W2 had a caesarean birth last time and she does not want to go to hospital until she is in established labour ..."
M2: "Let me get this straight.  You are asking me to visit when you call me, check mother and baby, give you that information, then go away?"
LBA: "Yes."

A midwife is immediately wary of this request for a number of reasons.  Here are a few:

• the professional relationship is between a midwife and a woman; not the woman's friend, or partner, or employee.

• information obtained in an assessment (maternal observations: frequency, strength and duration of contractions; fetal observations including lie, presentation, position, heart rate; and dilatation of the cervix) will not necessarily give the information that W2 or LBA are after.  The skill of midwifery includes interpretation of clinical observations over time.  

• the midwife cannot delegate professional responsibility for midwifery care to an unqualified, unregulated person.

 A midwife would be unwise to attend a woman in labour unless she or he was also prepared to attend the birth and take professional responsibility for decisions made.  An exception would be if another midwife who was unable to attend a client who said she was in early labour, asked the midwife to provide a 'locum' service and report back.

 One of the realities of physiological birth is that the labour must begin spontaneously - in the woman's own time.  Most women make the decision themselves as to when to ask their midwife to attend, or when to go to hospital.  Sometimes they get it wrong - too early, too late!  Sometimes just right. 

This dilemma will not be resolved by having a private midwife provide a one-off consultation.  If people want that sort of information, they could 'do it yourself' DIY.  They could get hold of a fetal monitor and listen to the baby's heartbeat as much as they want to.  They could get hold of a little internal camera that takes pictures of the cervix.  The technology exists.  Also blood pressure monitors, a thermometer, ...  

'DIY' will never replace the midwife, who is 'with woman' in a partnership that requires trust and reciprocity throughout the episode of professional care.  

'free birth'

Birth is, and probably always will be, a contested territory.

An unknown number of women have made the choice to 'free birth': to give birth without professional attendance.  This phenomenon is happening in Australian communities, at the same time as the independent/homebirth midwifery profession is undergoing increasingly demanding levels of regulation from statutory bodies and by way of professional expectations set by our peers. 

While any competent individual has autonomy for their own actions and their own bodies, the issue becomes more complex when that body is a woman's body, which is carrying an unborn child.  And although courts in various countries have upheld the right of a woman to refuse, for example, caesarean surgery that is intended to protect the life of the child, there are many subtle forces that direct a woman in to compliance with social norms.  

Why 'free birth'?
... access? 
Women who proceed with a plan for 'free birth' are not necessarily unable to access a midwife privately to attend homebirth, although this is sometimes the case. 
... cost?
the cost of private midwifery services for homebirth may be prohibitive.
... belief?
the woman who has formed a strong belief that the presence of any qualified person (ie midwife) will inhibit her ability to proceed naturally with birth, considers that she is better off without any professional attendant.
... objection?
A woman may object to some practice, such as listening to the fetal heart sounds, that a midwife may consider to be a basic requirement for safe practice.
... substitution?
an unregulated birth attendant may be willing to act in supporting the woman, and guiding her through her birth, effectively substituting for the midwife.

Whatever the reason, each woman / each situation, is unique.

Here is a hypothetical example.

Ms A and her partner have had two children previously.  Baby #1 was born in hospital, after a long and painful labour, in which Ms A had augmentation of labour, an epidural, and a forceps birth. 

Ms A felt traumatised after that birth, and in her second pregnancy decided that she wanted homebirth.  The midwives who attended her in labour were unhappy with her progress, and recommended that she transfer in labour to hospital.  Baby #2 was born in hospital: a big baby; and another difficult birth. 

Ms A reflected on her experience, and believed that the midwives were fearful, and that she would have been better off without them.  She therefore chose 'free birth' for her third child, and invited two friends who worked as doulas to be with her to support her for the birth.

Ms A's complex process in choosing 'free birth' included her belief that the presence of midwives for baby #2 had inhibited her progress, and the availability of a substitute for professional attendants.

In recording this hypothetical example, I would like to be very clear that I understand that Ms A made choices and decisions that she believed would be in the best interests of herself and her baby. 


The issue of 'free birth' was addressed in a Victorian ABC TV story 7.30 report last Friday.

Several of the people interviewed for this story were asked if they supported the recent recommendation by the South Australian Coroner that it should be an offense for a person to attend birth without having the qualification of midwife or doctor.  The response from Hannah Dahlen, on behalf of the Australian College of Midwives, included a statement that the answer to 'free birth' is not to be found in cracking down, to 'exterminate' its practitioners, as it will only be driven underground.

I concur with this.  Although the events that led to the recommendation by the SA Deputy State Coroner are tragic, I do not consider that legislation to protect midwifery practice in South Australia would or could achieve the desired aim of improved public safety.

The choice that some women make, to give birth to their babies at home, takes into account individual social preferences and reasons. Since birth at home is the outcome of a spontaneous physiological natural process, there is no legislation that can control who a woman consults in pregnancy, or who is with, or not with, a woman who is labouring or giving birth spontaneously.

A woman’s right to self-determination in making decisions such as where she gives birth, and with whom, will not be controlled or altered by legislation designed to protect midwifery practice.

It is my belief that the government’s support for the regulated midwifery profession, with funding for homebirth programs, protection of the full scope of private midwifery practice including hospital visiting access, and education for the public in maternity choices, will result in greater protection of public interest than the proposal to protect midwifery practice.

Joy Johnston