Friday, June 26, 2009

in summary ...

From Health Minister Nicola Roxon: Historic Step forward for Midwives and Nurse Practitioners

From Australian College of Midwives: Mothers and babies at risk: Access to qualified midwives for homebirth under threat

From Maternity Coalition (by email - website not updated at the time of writing this blog) "Maternity Coalition’s vision is for all Australian women to choose who, where and how they birth. We are about increasing women’s choices so they can make informed decisions about the type of care that is right for them and their family. We are facing the prospect of having an evidence-based model of care being removed – and why? It would be an understatement to say we are concerned about this. We are VERY concerned about this."

From Homebirth Australia: "Deaths will increase with new announcements" ... "We believe every woman has the right to choose how and where she gives birth. Please stop homebirth becoming illegal and sign our online petition."

From Midwives in Private Practice (MiPP): "Can the Australian maternity community accept government interference in defining the setting of practice of a midwife? Would the medical community accept such wanton interference in its professional boundaries?"

Midwife-blogger Lisa Barrett: "I am a failure to understand why all women and midwives are totally up in arms at this. I know they aren't because many see it as better than nothing. That's really all midwives are good for, scraps from the Obs table. If every midwife decided to stop work for the day in protest then it would soon change."

Blogger Hoyden About Town "Homebirth to become illegal in a year. ... And no matter how low-risk the woman nor how much she desires a homebirth, women will not be allowed to do so legally with a midwife. Because the legislation introduced this week will ban midwives from practising without insurance; and there is no insurance provider for homebirth midwives. So long, too bad, so sad. Good bye."

Save Homebirth blog: offering support for people travelling to Canberra to protest at the Homebirth Australia Mother of All Rally, Monday 7 September.

Blogger-midwife Melissa Maimann: Access For Pregnant Women To Medicare Funded Midwifery Care On The Way: But not for homebirths

Thursday, June 25, 2009

PLEASE sign a petition to save private midwifery and homebirth

GO to the petition

"... with planned national registration of all health professionals to take effect on July 1st 2010 midwives in private practice will be unable to seek registration on the basis of their inability to obtain professional indemnity insurance."
The petition asks that "the senate bring this issue to the parliament's attention and make a speedy redress to assist midwives in private practice to obtain professional indemnity insurance. We also ask that midwives in private practice enjoy the same funding mechanisms as procedural general practitioners and specialist obstetricians under the medicare benefits schedule."

The petition is at the excellent new Homebirth Australia website.

Saturday, June 20, 2009

not interested in anything less

I was preparing a reply to a comment in the next post, and have brought it to a new post, as the issue needs more critical exploration.

The writer stated that the care of a private midwife has suited her well, and she is not interested in anything less. That is understandable, and I believe many women - and many independent midwives for that matter, agree.

But in any society the choices that we have are defined by laws set down by government, and the Australian government - the previous Liberal one, as well as the current Labor one - have agreed that it's in the public's interest to require all health professionals to have indemnity insurance. After 1 July next year women will not be able to access independent midwifery for homebirth (unless changes are made to the legislation or to the accessibility of indemnity insurance for midwives).

The only profession for which indemnity insurance is not available for private practice is midwifery. This is a global phenomenon. Countries where midwives practise autonomously (and are not under threat as Australian midwives are) - Netherlands, Canada, and New Zealand, for example, have insurance schemes that are supported by government funds. New Zealand's system requires a percentage of the earnings of all health professionals to be placed in an accident compensation fund, from which payments are made to any patient or client who experiences harm. This is very different from Australia's system, in which anyone who claims they have been harmed in their health care has to sue their doctor/midwife/hospital in a court of law, or come to an arrangement (payout) prior to going to court.

It is unreasonable to ask that one section of the health care community, independent midwifery, have different rules than the rest. I believe a scheme similar to the New Zealand scheme, would bring equity into the maternity system, and take decisions about compensation out of the courts. Of course matters of professional misconduct or negligence would need to be dealth with at a higher level, as they are currently, and will be under the new Health Practitioner legislation.

The 'decision' that midwives providing homebirth independently should not be indemnified, and consequently the outlawing of privately attended homebirths is a decision of the current Health Minister, Nicola Roxon. She needs to hear from every person who cares, and she needs to change that decision. We, the public, have the right to tell our elected representatives, what we consider to be reasonable.

Friday, June 19, 2009

talking about homebirth

Thismorning I was woken by someone from ABC Radio 774 (the Melbourne local radio) at about 6.30. Would I speak to Red Simon about homebirth being outlawed?
They called back, and Red wanted to know about homebirth. In the next few minutes (cut short mysteriously by the phone line going dead) I was able to reassure him of the safety of homebirth.
Red sounded genuinely surprised that 30% of Dutch babies can be born at home in this century. I think he was wanting to paint a picture of homebirth being a vestige of a bygone era, that some of us are reluctant to part with. He told me his wife went to three different hospitals to have her three children, so that she could check out the cuisine. He asked me if my children were born at home. No - I didn't know about homebirth then. I learnt about homebirth from reading professional literature. It was the evidence that convinced me.

News articles discussing the future of homebirth have appeared in several papers thismorning.
Daily Telegraph (Sydney) informs us that "HOMEBIRTHS will become illegal under tough new laws that prevent women using midwives to have children outside hospitals. The move is set to drive homebirths underground, with expectant mothers and their babies at risk."
A similar article in Adelaide Now identifies "the draft Health Practitioner Regulation National Law, released last week, [under which] a midwife cannot be registered unless she has insurance."

For more detail, please go to the MiPP blog.

It's not true that *all* homebirth will be illegal after 1 July 2010, when the Health Practitioner Regulation National Law, which mandates professional indemnity insurance as a condition for registration, is set to come into effect.

Homebirth programs that are operated by hospitals and health authorities will be able to continue. The option that will become illegal is private arrangements between a woman and a midwife. That means midwives like me, and an estimated 150 others, will be out of work, and all the women who want to arrange homebirth privately will be denied that choice.

Depending on your perspective, here are some ideas. I present them as questions, because each person with an interest in homebirth will have to make the best decision they can when the time comes.

After 1 July next year:
Will a midwife agree to provide midwifery care 'underground', and ask the parents and anyone else involved to keep quiet about their role?
Will a midwife who continues 'underground' cease any reporting to governement authorities such as Registry of Births, Deaths and Marriages, and perinatal data collection units?
Will a midwife who continues 'underground' ask for cash payments, and cease reporting income to the Tax Office?
Will a woman who wants homebirth need to arrange her own documentation of the birth - either by statutory declaration, or by arriving at a public hospital with her baby, and stating that the baby was 'born before arrival'?
Will a woman who wants homebirth and who experiences complications at home need to go to hospital without her midwife's referral or support?
Will all the women who want to plan homebirth find doctors who will attend them at home?

The doctor issue is worth thinking about. It might sound like competitive rivalry for me to bring doctors into this discussion, but the fact is that independent midwives compete with doctors to be the primary carers for pregnant/birthing women. (it's a very unlevel playing field, but that's another issue!) While the midwife offers continuity of care throughout the pregnancy and birth, the local GP offers a variety of fragmented models of 'shared care', ensuring that the woman receives care from a midwife who is a total stranger in labour. The stranger-midwife is also a feature of models in which an obstetrician is the primary care provider.

There are doctors who support homebirth; some have given birth at home themselves, while others will agree to attend homebirths. Melbourne doctor Peter Lucas is well known and appreciated for his homebirth practice.

Doctors have indemnity insurance, so they will be able to continue practising after 1 July next year. Some have insurance that covers 'procedures' - including childbirth, while others are more restricted in what they are able to do. Doctors fees are rebatable through Medicare, and the Medicare Safety Net enables the doctor to charge a fee that he/she considers appropriate, knowing that the client will be able to get a lot of it back from the public purse.

Women could, en masse, require attendance at home from doctors for home births if midwives are not able to be called. Of course the doctors might refuse to attend, but what is their duty of care in such a situation?

Another question: will public hospitals set up homebirth services that will provide the required professional care for all the women who at present would book with an independent midwife? Will the hospitals provide employment (and indemnity) for independent midwives?

These questions are all in my mind. What will I do? How will I advise women who ask me? (And, from a practical point of view, How will I earn enough to keep food on the table?)

Monday, June 15, 2009

Being Baby Friendly

[Pic: Barb and Cassie, used with permission]

On Saturday I attended an update session for assessors and educators in the Baby Friendly Health Initiative (BFHI). I have been involved with BFHI since it was introduced to Australia in the early 1990s, and it was good to focus on the issues of promoting, protecting and supporting breastfeeding in our maternity care system.

The BFHI is an international project that aims to give every baby the best start in life by creating a health care environment where breastfeeding is the norm and practices known to promote the health and well-being of all babies and their mothers are followed.

The BFHI Ten Steps to Successful Breastfeeding are the global standard by which health services are assessed and accredited. A 'Baby Friendly' health service is one where mothers' informed choice of feeding is supported, respected and encouraged.

In Australia, the Australian College of Midwives administers the Baby Friendly Health Initiative.

The BFHI has released a new set of booklets which will be used for health facility (usually hospital) assessments in the future. A few issues that were open to interpretation in the past have been clarified. Acceptable medical reasons for the use of breastmilk substitutes, and Standards for compliance with the World Health Organisation International Code of Marketing of breastmilk substitutes (known as the 'WHO Code' ) are clearly stated. It is likely that some 'Baby Friendly' hospitals will need to improve their policies and practices before their next assessment in order to maintain the award.

Here are a few of *my* highlights taken from the revised BFHI assessment. Please note, this list is not exclusive:
(For the full wording of each Step, click here
Step 1: The facility's breastfeeding policy is supported by clinical protocols which are evidence based.

Step 2: At least 80% of staff who assist mothers with breast feeding are able to describe two issues that should be discussed with a pregnant woman or mother who indicates that she is considering feeding her baby with infant formula.

Step 3: The antenatal education includes the importance of skin to skin contact for all babies (not just those whose mothers plan to breastfeed!) for at least the first hour of life.

Step 4: The facility has procedures which keep mothers and babies together in skin to skin contact for at least an hour after a vaginal or caesarean birth. (medically indicated procedures which vary this policy are stated)

Step 5: Mothers who are not breastfeeding confirm that they have been given individual education about artificial feeding

Step 6: At least 80% of staff who assist with breastfeeding or who provide advice on breastfeeding are able to describe two pieces of information that they will discuss with a pregnant woman or mother who is undecided, but considering feeding her baby with infant formula.

Step 7: All babies stay with their mothers 24-hours a day. Documentation will be expected for any variation from this.

Step 8: Breastfeeding on demand (without restrictions or controls on frequency or length of feeding) is the standard, with emphasis on effective breastfeeding.

Step 9: Mothers can explain why dummy use is discouraged while breastfeeding is being established.

Step 10: The facility reports on how it works with local breastfeeding support groups and services.

Friday, June 05, 2009

We live in interesting times

I would like to add to my recent discussion and state here that I believe there is a positive future for homebirth, on a much larger scale than the Australian community has known.

Any major reform requires costings and processes to be carefully developed so that it is introduced in a responsible and transparent manner. I know that there is a lot of work happening behind the scenes at the national level to address the detail for the changes that were announced by the Health Minister in the Budget. Also state and territory health departments are working on policies for homebirth and water birth. South Australia has its policies published, and I think some of the other states are also moving ahead well in this area. If anyone reading this blog knows of web links for relevant policies, please pass them on either through the comments or by email

Although the midwifery reforms announced in the Budget (indemnity, Medicare and PBS) are hugely significant to independent midwives and the women who employ us, the reforms are a lifeline to the whole midwifery profession. The midwife's scope of practice in all settings will be freed from some of the unreasonable restrictions that have all but stifled the profession and prevented midwives from practising as defined in the ICM Definition of the Midwife.

I anticipate that, from November 2010, midwifery will move from the obstetrician's-assistant- shiftworker-nurse model to that of a distinct professional who has authority for a unique model of care in which the woman and her known midwife primary carer work in a special partnership, with the purpose of promoting health of both mother and baby through the promotion and protection of physiological processes linked to normal birth and nurture of infants.

I anticipate that Medicare payments will enable health services to set up a range of options that are attractive to both mothers and midwives, in which midwives provide primary maternity care for women, integrating their care with the specialist obstetric and other medical services in the hospitals as and when needed. There will be no need for the cost shifting that goes on now, with women being sent to doctors for the prenatal care to take pressure off the hospital budget.

I anticipate that university midwifery departments will celebrate the reduction of the theory-practice gap that has plagued them for many years. The career options for midwives who want to practise midwifery will be greatly expanded.

I have been in touch with Patrice Hickey, Victorian branch President of the Australian College of Midwives, (ACM Vic) and I would like to acknowledge the work of the ACM throughout this process on behalf of midwives and birthing women.

We live in interesting times!

Tuesday, June 02, 2009

HOMEBIRTH after July 2010???

I am writing today with a foggy brain that didn't assume the horizontal until after two thismorning. But that's what midwives do, after all. I do hope this brief discussion makes sense.

We (the community of independent midwives and homebirth parents) are all wondering what will happen to homebirth after July next year. If you are not aware of the issues, please scroll down in this blog, and go to the MIPP blog for more information and links.

I've been busy with a cluster of births, and haven't had time to be worried yet, but I know some of my clients are concerned. I just have lots of unanswered questions, such as ...

What will be the impact of the midwifery changes announced in the federal budget on my ability to practice midwifery (and make a living)?
(I am writing in the first person here - that's what people seem to do on their blogs - but I know it applies well beyond my personal situation!)

With the requirement for indemnity insurance for registration from 1 July 2010, and the government's provision of indemnity insurance &c for 'eligible midwives' from 1 November 2010, what happens to my ability to earn a living, and to the women who want me to attend them professionally, during those four months? (assuming that the announced time frame will be adhered to) How can I be sure that I will be an eligible midwife?

and the BIG question:

There are no publicly funded homebirth options in my area, and even if there were, some women would prefer to engage a midwife privately to come into their home to provide midwifery services. Some women booked with me would be excluded from any service that is 'risk managed' to current hospital standards - those who have had more than six babies (they should be considered super birthers by that stage), those who have had one or more previous caesareans, those whose babies don't want to be born before that magical 42 week mark, those who are a bit too old, a bit too young, to tall, too short, or whatever.

Does this mean that I am ignorant or careless about risk?
Does this mean that women who choose my care are being ignorant or careless about their own safety or the safety of their babies?

I'm not going to say a blanket no, or yes. It all depends. No life event, and particularly not birth, can be risk free. Home and hospital both have their own sets of risks and uncertainties.

I don't know what's going to happen about homebirth.

I would encourage anyone who is interested to work at keeping yourself informed, and to take action in whatever way you can.
Keep an eye on the blogs, forums, email groups, and professional journals that are writing about midwifery and homebirth.
Read everything with a critical eye.
Be prepared to ask how would [ ] affect me - the political is personal.

Think globally,
Act locally.


Plan if you can to attend the Homebirth Rights rally in Canberra, 7 September, and tell others about it.