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homebirth position statement

Members of MIPP who are also members of the Australian College of Midwives (ACM) will be aware that "ACM is working with both the NMBA and the Commonwealth to develop a contemporary homebirth position statement within the next three months."
(Australian Midwifery News, Autumn 2011 issue, page 3.)

Join the global webinar to celebrate International Midwives' Day 5 May

Plans are set for the Virtual International Day of the Midwife on May 5th. The program, which spans the 24-hour period, with speakers from the various continents, has now been finalised, and it looks to be a very interesting and diverse program: http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2011

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.

A flawed analysis

This week's leading story on Medscape OB/GYN and Women's Health [Medscape_OBGYN@mp.medscape.com]
Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong

A Flawed Analysis

The highly charged debate over the safety of home birth was inflamed by the publication of a meta-analysis by Joseph R. Wax and coworkers,[1] which concluded that "less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate." The statistical analysis upon which this conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings,[2-6] this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion,[7] meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research.

In this article we describe in detail numerous mistakes in design, methodology, and reporting in the Wax meta-analysis that place clinicians and patients at risk for being misinformed.

Soon after the Wax et al article was published, the Midwives Alliance of North America published a similar critique.

Click here for the MANA press release, published by midwivesVictoria blog at the time.


Wax and colleagues were mirrored at about the same time by a similarly outrageous 2010 publication by Kennare et al in the Medical Journal of Australia.
Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (MJA 2010;192:76-80)

The authors of the Australian study, which looked retrospectively at data, claimed that "planned homebirths had a perinatal mortality rate similar to that for planned hospital births, but a sevenfold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia." Huge confidence intervals and small numbers were clear limitations, as well as decisions about inclusions and exclusions, yet the flawed conclusions have been circulated widely in a shrowd-waving "doctor knows best" campaign.

Homebirth via public hospitals

A midwife from Casey Homebirth service, at a maternity conference, with the 'gear' that she takes to a home

In December 2009 we noted at this blog the announcement that some Victorian women would be able to access homebirth via a publicly funded pilot scheme.

Two metropolital hospitals, Casey in the South-East and Sunshine in the West, have their homebirth programs up and running. We have also been told by a reliable person that Monash Medical Centre, a level 5 hospital in Clayton, is planning to offer homebirth as part of comprehensive maternity services this year. [Click on the highlighted words to go to the websites of the hospitals mentioned]

I have recently met up with a group of the midwives employed at Casey. I was impressed at their enthusiasm for their work. They told me they are loving the work.

Homebirth is a basic aspect of midwifery practice. It allows the practitioner an opportunity to develop a strong midwife identity, accepting the authority in decision-making at any time in the episode of care, and particularly at the time of birth. Homebirth is 'PLAN A' - the woman giving birth spontaneously, without medical intervention, and the midwife acting in harmony with normal physiological processes.

Working in a public hospital homebirth program enables midwives to practise one-to-one (caseload) primary maternity care without taking on the professional marginalisation that is experienced when midwives go into private practice.

Midwives who have moved into private practise may not value this aspect of the hospital program to the same degree as those who take the hospital caseload-homebirth positions.

Hospital midwives are able to provide care for the group of women booked in their caseload, with structured 'backup' processes from other midwives in the program, and arrangements for handing over care if a labour is very long. These midwives value their employment contracts, through which they have a reliable income, employment benefits such as sick leave and long service leave, and their relationship with their clients is separate from their ability to earn a living.

By way of comparison, independent (private practice) midwives value the strong commitment they make to individual women, and very rarely ask another midwife to take over. The 'employment' arrangement is a private one, between the individual woman and her private midwife or midwives.

Both options - private and public - have potential advantages and disadvantages.

‘Hospital at home’ is a reality. Hospitals are over-crowded, and it makes sense to provide services in the home when possible. The hospital risk management includes the latest gadgets that may be useful, such as the 'Neopuff TM' machine shown in the picture above. With the strict policies on inclusion in the program, it’s very unlikely that the midwives will need to use the neopuff. That will come out in audits down the track.

The inclusion by hospitals of this item should not be seen as suggesting that all midwives attending homebirths need to carry such equipment. There would need to be some compelling evidence that babies born at home would be better off. Hospital babies, many of whose labours are induced when they not quite ready to be born, depressed by narcotics, and premature, ... are the ones that would clearly benefit from the Neopuff TM.

Homebirth via public hospitals is a valuable addition to publicly funded maternity services. Women and their babies benefit, as homebirth requires the promotion of normal physiological birthing, feeding, and nurture processes. Midwives benefit in being separated from reliance on unnecessary medical interventions.

I anticipate that there will, in time, be an exchange of midwives between the public and private homebirth options. This will be good for midwifery, and good for birthing women.

Comments by readers are most welcome.

NMBA and Professional Indemnity Insurance

The Nursing and Midwifery Board of Australia is seeking feedback from all stakeholders on the revised Professional Indemnity Insurance Arrangements Registration Standard, and Guidelines. Click here for the link.

Submissions are due by 6 May.

The Board is seeking feedback on the following two approaches:
Approach 1:
The Board specifies a minimum amount of cover for professional indemnity based on advice from the insurance industry.
Approach 2:
The Board does not specify a minimum amount of cover for professional indemnity.

Two approaches are outlined because the Board has received some feedback that the draft Guideline should include advice about the minimum dollar value of quantum of cover for midwives wishing to practise independently. The Board realises however that there are potential drawbacks to both approaches, and is therefore keen to provide the most useful advice to practitioners seeking PII cover.

Blog readers are invited to share your views on professional indemnity insurance generally, and any points that you think ought to be included in submissions to this inquiry.