Colalboration gone wrong!

The Australian Government’s $120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives, promised that Australian women would have

“more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services.” 

The National Maternity Services Plan (the Plan), endorsed by the Australian Health Ministers’ Conference in November 2010, provided governments with a strategic national framework to guide policy and program development.  The plan declares that primary maternity services will be  

“woman centred, reflecting the needs of each woman within a safe and sustainable quality system."

Year one of the Plan committed jurisdictions to developing 

“consistent approaches to the provision of clinical privileges within public maternity services, to enable admitting and practice rights for eligible midwives and medical practitioners.”

How is implementation of the Plan progressing?

Midwives report little action or hope of conclusion, on matters to do with provision of clinical privileges for Medicare-eligible midwives within public maternity services, except in Queensland.  Anecdotally we are aware of instances of increasing resistance within some public hospitals to the implementation of programs of clinical privileging for private midwives.


Earlier this week I received an early morning call from a distressed colleague.  Having worked with a woman who was planning homebirth for some hours, this midwife arranged to transfer the woman's care to a major public maternity hospital in Melbourne, where the woman had made a back-up booking.

The midwife, who believes she has had a good relationship with the hospital for many years, was distressed that the doctor who admitted her client refused to accept any verbal hand-over, and rudely walked away when the midwife attempted to carry out a professional conversation with him.

It would appear that efforts are being made within public maternity hospitals to derail any plans to enable admitting and practice rights for eligible midwives.

Within the obstetric community there is a strongly held position that a doctor or midwife who is willing to assist women in 'bad choices' is seen as encouraging 'bad choices'.  Women who have attempted to make arrangements with hospitals to facilitate normal birth in situations of acknowledged complexity, such as twins, breech babies, or even birth after a previous caesarean, have been given no choice.  "If you come here, this is what will happen!"  This is an often repeated scenario in both public and private hospitals.  These women have often sought private midwives to attend them in the relative 'safety' of their own homes.


This post is just skimming the surface of a complex issue.

Collaboration with medical and nursing colleagues, within hospital systems, is a basic expectation in all midwifery. 

Midwives are required, by regulation and by definition, to collaborate. 

“... 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 (emphasis added) and the carrying out of emergency measures.   ” 

(From ICM Definition of the Midwife, 2011)



Midwives also have an expectation of ethical professional behaviour towards those in our care.  The current Code of Ethics for Midwives lists 'values' - which in themselves describe the standard to which we aspire.  There is no place for bullying and domineering behaviours in midwifery.

1. Midwives value quality midwifery care for each woman and her infant(s).
2. Midwives value respect and kindness for self and others.
3. Midwives value the diversity of people.
4. Midwives value access to quality midwifery care for each woman and her infant(s).
5. Midwives value informed decision making.
6. Midwives value a culture of safety in midwifery care.
7. Midwives value ethical management of information.
8. Midwives value a socially, economically and ecologically sustainable environment promoting health and wellbeing.

 (From Nursing and Midwifery Board of Australia)

Midwives need a system that recognises us and treats us fairly.

We call on midwives to continue to stand in partnership with women, demanding equity and fairness in all maternity services provided by our governments - federal and state. Collaboration requires both parties to participate, the hospital and/or doctor, as well as the midwife.  There is no such thing as one-way collaboration.  Midwives are committed to the wellbeing and safety of mothers and babies in our care, and it is our duty to demand that the health care systems support us in achieving this goal.

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.

"homebirthing is a sensitive and controversial issue"

The report said “homebirthing is a sensitive and controversial issue”.
The irony of this statement was clear when it appeared in Improving Maternity Services in Australia – The Report of the Maternity Services Review (2009). Homebirth continues to be both sensitive and controversial today.

Maternity Coalition's Summer 2011 issue of Birth Matters devoted significant space to the extremely sensitive and controversial end of homebirth; "high-risk homebirth". MC President, Ann Catchlove, wrote a deeply personal and moving column referring to the death of a baby in a highly publicised homebirth, that "I hope that we will have realised that the way to respond to "high-risk homebirth" is not by prohibition and persecution but by seeking to understand why women make decisions and giving them real options within the system. Meanwhile, in the here and now, a mother is being treated in a most unfair and unjust manner. We need to stand up and say that is wrong."

In an article published in the (UK-based) AIMS Journal Vol 23 No3 2011, Joy Johnston (who is also the author of this blog) wrote:

The constant recurring theme in Australian and international midwifery regulation is the public interest. The Australian medical profession considers obstetric supervision of all maternity care to be in the public interest, and assesses midwifery as incapable of delivering optimal and safe maternity care in settings outside obstetric surveillance. The issue of home birth is the pimple on the end of the maternity system’s nose. It won’t go away, it hurts when touched, and it’s a real nuisance.

The large 'Birthplace' study [click here for link and comment] looking at place of birth in the UK is to:

effectively be replicated in Australia from 2012 with a NHMRC funded birthplace study led by Professor Caroline Homer from the University of Technology, Sydney. Feeding in to the Maternity Services Review recommendations for more research and national data collection, the study will investigate outcomes from about 45,000 births across public and private hospitals including birth centres, freestanding midwifery units and homebirths, both publicly and privately funded. “We need to continue to grow the evidence and what has to be unpacked are the important pieces of information for women – their chances of a normal birth versus a caesarean section or their chances of good outcomes versus bad,” Homer said. “We haven’t had a big national study which clearly defined intended place of birth at onset of labour, not at 12 weeks. Smaller studies have also been a bit vulnerable because of their low numbers.” (quoted from Nursing Review, 21 Dec 2011)

MIPP is currently undertaking a REVIEW OF PLANNED HOMEBIRTH FOR ‘AT RISK’ WOMEN IN VICTORIA, 1999-2009. The data for this audit is being prepared by the Victorian Perinatal Data Collection team. Women included in this audit are those identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories: Multiple pregnancy; abnormal presentation (especially breech); preterm labour prior to 37 completed weeks of pregnancy; post term pregnancy 42+ weeks; and previous caesarean birth. It is anticipated that at least one paper for publication in a professional peer-reviewed journal will come out of this review, and it is hoped that valuable information will be highlighted.