RALLY Tues 4 August, 10.30am

A protest is planned outside Nicola Roxon's office.

10.30am to 11.30am next Tuesday AUGUST 4.

1 Thomas Holmes St
Maribyrnong 3032

LEAVE YOUR CALLING CARD WITH THE MINISTER
Every woman, or midwife, or other interested person is asked to make a calling card to leave with Minister Roxon. It is unlikely she is going to come out, that's OK you all need to leave a 'calling card'. [see attached examples]







With a short caption re who they are etc and a photo. For women that have stark differences in birth outcomes they could include pics of these. Midwives could highlight who they are, Mother, Grandmother, Midwife for X years etc.

This rally is being organised by Homebirth Australia, Maternity Coalition, Midwives in Private Practice, and other maternity interest groups.

Rogue midwives

I have to tell you, dear reader, that midwives like me have now been called 'rogue midwives'. Our governments, both state and federal, are attempting to make private midwifery practice for homebirth unlawful. As one of the midwives who faces this fate, I must assume that I am being considered a rogue midwife.

How does one answer such a charge?

My husband received an email yesterday from a friend who lives in an Asian country, and whose only contact with childbirth is that which is common to all who have been born. With reference to my blog of 26-Jul, , he wrote that: "I remember very well that Joy told us in 2002 in Melbourne that private midwives cannot easily use anymore the official health insurance channel.

"Now it is being outlawed. We deeply regret this process as midwifery is a nice and biblical profession. [See previous post]

"I especially came across the sentence:
“An outsider looking at the list could conclude that midwives are not all that important in maternity services.”
...
"What is the situation of private midwifery in other countries, e.g. certain European countries?"



The message that those who want midwives to accept the outrageous new restrictions to autonomy in midwifery practice are giving us is that midwives in Netherlands, New Zealand, Canada, UK, Denmark, Switzerland ... are also being prevented from working without indemnity insurance, and that acceptable levels of indemnity insurance are not able to be purchased for private practice. Independent midwives in the UK face similar restrictions.

However, midwives in most of these countries are able, under government schemes, to access suitable indemnity insurance. The proposed actions of the Australian government in making independent midwifery practice unlawful is unprecedented across the developed world. It is good to see a politician, Jamie Briggs who is willing to speak out, 'defending the right of mums to have a safe home birth'.

I am aware that people from many countries are reading this blog. If there are other sites that I don't know about, please leave a comment, with the links.


**********
On a lighter note, here's what the 'Village Midwife' does on Thursday mornings, births permitting. With a group of friends, I can hit the ball as hard as I please, occasionally hitting it well, and enjoying the fresh air and beautiful garden setting of a suburban home.

Who will be advising the Minister?

The Maternity Services Advisory Group is a new advisory committee of the federal health department, in preparation for implementation of the government's current group of maternity reforms.

These reforms include professional indemnity insurance, Medicare and prescribing rights for midwives, as well as the outlawing of private midwifery practice as we, and the rest of the developed world, know it. That is, women employing a midwife as their primary care provider for their complete maternity care, including birth in the place the woman chooses.

The advisory committee of approximately 25 is topheavy (to put it mildly) with medical stakeholders in maternity care.

The list includes two highly respected midwife academics, Sally Tracy and Pat Brody. Barb Vernon, who is executive officer (with a background in politics, not a midwife) of the Australian College of Midwives (ACM), will also sit on the committee. There are three consumer places, two of which are taken by leading Queensland Maternity Coalition activists, Joanne Smethurst and Bruce Teakle. I see NO name on the list of any person who might have substantial recent midwifery practice on their CV. (please correct me if I am missing something here!)

An outsider looking at the list could conclude that midwives are not all that important in maternity services.

Yet the government's proposed reforms are all about midwifery practice.

The picture I get is a big table with some of the big obstetric names: Ted Weaver, Andrew Foote, Andrew Pesce, David Elwood (you can google them if you want to know more about them). There is one female doctor, Marilyn Clarke from Australian Indigenous Doctors Assn. Other medical names are Steve Sant, Steven Katz, Ross Wilson, Dennis Pashen, and a representative of the Medical Deans of Australia and New Zealand. The Nursing College and union are represented, along with several hospital associations.


I am going to stick my neck out here, and comment on the obvious MALENESS of this committee. Every reader can draw her (or his) own conclusions about what that means. Is this the battleground, at which the boundaries of 'women's business', or what is allowed in the quintessential female acts of bearing and nurturing a child, are decided?


A midwife is a guardian of physiologically normal birth, and an expert who works in harmony with the natural processes in pregnancy, birth, postnatal, and breastfeeding-nurture of the infant.

The focus of 'maternity' has shifted, from the primary care which protects, promotes, and supports wellness, with access to specialist levels of care when appropriate, to the highly medicalised world that treats pregnancy as a condition to be managed, treated, and eventually have the growth extracted. The midwife is the forgotten maternity professional, now on the verge of extinction.

Informed Choice: a privilege but NOT a right

There are some phrases that wend their way into the conversations of groups of people, and noone really remembers when that phrase first came up, or what it really means.

'Informed choice' is one of those phrases, and it has come into general acceptance in midwifery along with 'evidence based practice'. It is meant to refer to the consumer's ability to choose from a range of reasonable options. Sounds fair enough!

What information does a young woman who is pregnant for the first time have access to, so that she can make a choice?
The local GP says "Do you want to go private or public?" - Choice #1
"Which hospital do you want to book with?" Choice #2

... and so on. Informed choices, if you look at the information provided, and the choice made. It's unlikely that any evidence will be offered, unless this green newbie to the birthing market talks about homebirth! At this point we can skip information, choice, research and evidence, and go directly to emotional manipulation and downright bullying.

There is only one basic choice in childbearing - either do it yourself, or find someone else who will do it for you. I can not stand under the 'every woman, every choice' banner. I will wave a banner 'every woman: one choice'. And the one professional attendant who has the duty to promote normal birth, and has the skill to harmonise with the natural physiological processes is the midwife.

I live and work amongst women who are enormously privileged in access to information, options, and services. But there are some even within metropolitan Melbourne, and definitely in other parts of this vast land, who are less able to access what most take for granted.

What 'informed choice' is available to the mother who lives on a cattle property 60k out of the nearest town; where the internet connection doesn't always do the job; where midwives are nurses who assist at hospital births; where the hospital is run like a military outpost to train new doctors, and the folk are told they should consider themselves lucky that they even have doctors? Her choice is to get to the local hospital to give birth, and to do as she is told and hope for the best, or to make a booking in the city and get to the city hospital to give birth, and to do as she is told and hope for the best. Even if she is philosophically committed to 'natural' birthing, it's likely that a 'choice' will be presented that subtly but effectively removes that option.

Yet there's one key decision she has to make: either do it yourself, or ask someone else to do it for you.

AND - in case anyone reading this is not sure of the facts, if you ask what would be the safest way; what is the 'evidence based' way? In almost every case, the safest way for mother and baby is that they do it themselves, with a midwife as primary care provider, UNLESS there is a valid reason to interrupt/intervene/interfere with the natural process.

labour IS a right of passage

At a time when every spare moment has been put to preparing submissions and impact statements in an effort to prevent disastrous legislation from being enacted federally, I have noticed a couple of media comments on the statement by Dr Dennis Walsh, a MAN, and a midwife academic, who says that “labour agony is a ‘rite of passage’ and pain relieving epidurals weaken the mother’s bond with babies”.

I agree.

[I have met Denis. He comes from my home town, Brisbane, not that that makes him right. I really don't get the man midwife thing, but a few men have made midwifery their calling, and a few of them seem to be OK.]

A very useful commentary can be found at a feminist philosophers link, posted by SA midwife Lisa Barrett.

ps - there are some in every walk of life who are perfectionists, and when reading a statement by midwives about protecting and promoting the physiological, normal processes in birth, and avoiding the surgical and medical alternatives, become defensive because they know someone (or they themselves) did not achieve what they perceive to be the ultimate, perfect birth. Please remember, noone gets it right all the time. Most of us are good enough most of the time. Ponder this, and apply it to decisions in bearing a child, bringing a precious new life into this world.

Our natural law rights in childbirth

Australia's independent midwives and mothers are now working against time in a concerted effort to protect normal birth, including homebirth and the mother's right to employ a midwife privately.
(please see previous posts on the draft health practitioner legislation if you want more information)

I have received hundreds of emails and phone calls, some from people who have experience in maternity activism, and others from bewildered people who wonder what they can do to help. One email, which was forwarded from someone I have never met, held the key that helped me develop a new line of defence. The email contained personal advice from a lawyer, who pointed out that the Austrlian constitution has clauses that can be used in defence of women's rights to homebirth as a "natural law right".


The legislation denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing.

The only requirement for physiological birth is that the woman is able to proceed without medical or surgical assistance. Since pregnancy and birth are truly natural states, and are not, per se, reliant on outside management, it is reasonable to protect the woman’s natural law right to maintain personal control over such decisions, including if and when she goes to hospital.

I believe that having a baby at home instead of a hospital is a natural law right , given by GOD rather than by government, and covered under the freedom of religious belief provisions of the Australian constitution. Many religious codes have ancient guidance that can be applied to the birth of a baby. The Christian Scriptures, which are my personal supreme guide to faith and action, teach that children are a blessing from God, to be valued and protected, and give many examples of people who protected and supported the mother and child, even in defiance of government (eg Exodus 1:17). Section 116 of the constitution says that the parliament shall make no laws to restrict your religious belief, practice, and observance.

By denying midwives insurance, and denying midwives the right to practise privately in any geographic location, the government would deny a woman's right in physiological childbirth.


I think we need to stress the difference between physiological and medically managed childbirth. No person can predict a particular outcome in maternity care: the care of the midwife is a partnership with the woman, that develops as time passes and decisions are made. The best/safest/uniquely normal default position, which I call 'Plan A', is to proceed naturally without outside stimulation or pain management, as long as there is no valid reason to interrupt, interfere, intervene, or disturb that physiologically natural process. Even so-called natural therapies, and emotional 'support' can also disturb the natural process. The woman's and baby's body's subtle orchestration of hormones and physical activity cannot be replicated in managed birth. Medically managed birth - whether induction of labour, or pain relief with drugs, or anything else that the birthing woman can't do for herself, should be considered iff (if and only if) the natural process is more likely to harm mother and or child than the medical intervention.

My message today to all who read this blog is that we are fighting for something that is truly worth fighting for! But you probably wouldn't be reading this if you didn't already know that.

Be strong and courageous.
Joy Johnston

beautiful birthing montage

Homebirth Rights Rally

please write your submissions today!

TWO VERY IMPORTANT OPPORTUNITIES EXIST RIGHT NOW.
THE PUBLIC (THAT'S YOU AND ME) ARE INVITED TO COMMENT ON:

*1. Exposure draft of Exposure draft of Health Practitioner Regulation National Law 2009 (Bill B) by 17 July 2009.

"If you wish to provide comments on the exposure draft, please lodge a written submission in electronic form, marked Exposure draft, at nraip@dhs.vic.gov.au by close of business on Friday, 17 July 2009. Please note that your submission will be placed on the website after the closing date for all submissions unless you indicate otherwise." Communique - Ministers release draft legislation for National Registration and Accreditation Scheme.


*2. Senate Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills.
The Committee invites you to provide a written submission which should be lodged by 20 July 2009. A public hearing will then be held later in July. The Committee prefers to receive submissions electronically as an attached document – email: community.affairs.sen@aph.gov.au – otherwise by fax (02 6277 5829).


A couple of days ago I was speaking with a mother of four children, all born at home, who lives in a small rural Victorian town. An independent midwife in that town has been attending about 25 homebirths each year, and is loved and respected by her community. Without change to the Health Practitioner legislation and related Bills, these women will not be able to access homebirth from 1 July next year. Even though the Victorian Health Minister has made a public statement about publicly funded homebirth services to be offered in the near future, the only women who will be able to apply for that service will be those within a small radius of the city hospitals from which the model is managed.

This story is repeated time and again across the country. We must prevent the legislation denying midwives the right to practise independently in our communities from progressing any further without crucial changes being made.


We have just a few days in which to prepare our submissions. If my ideas or anything I have written on this blog, or at other sites, is of use in arguing these important points to the Senate or the government, please feel free to borrow liberally.

When you have prepared your submissions, please also send a copy to your State or Territory Health Minister, and your local MPs. Let them know how important the choice of a midwife who can work autonomously in the community, within her scope of practice, is to you.
Joy Johnston

the personal side of midwifery

I know many of the readers of this blog are interested and very concerned about the matters that I and other Australian midwives have been highlighting in the past months.

On Tuesday I went with several like minded colleagues, including Clare Lane from Midwives Naturally, to the Victorian stakeholders forum on the government's National Registration and Accreditation Scheme for health professionals. A report is being prepared, and I will let you know when it is available. Within the limitations of a large forum's question and answer session, we made every attempt we could to ask the Health Minister to provide a means for the continuing practice of independent midwives.

How did it go? The short answer is that we came away feeling emotionally drained, having banged our heads against a bureaucratic brick wall. The minister clearly stated that the government does not want to support the indemnity insurance for ‘a small pocket of women and midwives’, when there are what he said are ‘better ways to spend the public dollar across the whole health system’ (as he waved his arm across the room at all professionals). I asked what would happen if it was decided that all private GP practices should close, and they be required to work under the supervision of hospitals. (see previous post) The Minister assured the audience that that would not happen. That's a relief, isn't it! After the initial response on questions of homebirth, there was an audible sigh in the room every time another independent midwifery or homebirth question was asked.


Many women choose an independent midwife as their care provider because they value the fact that they have personally chosen that midwife. The same could be said for any other health practitoner - or even the hairdresser or the vet who treats your dog.

Tuesday night was the coldest night for many years in Melbourne. When the phone rang at 2.30 am, and I got into the car to head out, I was shivering a little until the car's heating kicked in. I had a distance to drive - about 35 kilometers. The mother was labouring well, and her baby was born about an hour after I, and the other midwife, Clare, arrived.

The parents of this baby do not appear to be wealthy, yet they chose to engage the private services of two midwives, and pay our fees. Clare and I are not the closest independent midwives to their home, yet they chose to employ us. The main reason the mother gave was that we had attended the birth of their first child several years ago when they lived closer to our homes. Clare and I were more than happy to travel the extra distance and be 'with woman' that night.

This particular mother would probably be eligible for a publicly funded homebirth program, if one existed. Yet should she not retain the right to employ a midwife privately?

The loss of a midwife's right to private practice from 1 July next year will impact on families in subtle and personal ways. Clare and I had both been at the forum the previous day when the Health Minister dismissed our practices as being insignificant, and the women who employ us as being unimportant. We reflected on the deeply personal side of private midwifery practice and homebirth, and will remember this and every birth we attend, as something to treasure.

The personal is political. We cannot allow our elected representatives to ignore our rights to self determination, and evidence supporting the safety of the very model of care that independent midwives offer.

Remember, birth is not an illness.

[for notes on the stakeholders forum, please go to the MiPP blog]

Bill B

Tomorrow (Tues 7 July) I am planning to attend the Victorian stakeholders forum on 'Bill B', the exposure draft of the National Regulation and Accreditation Scheme for health professionals.

I have prepared a couple of documents exploring the clauses in the new legislation, and the impact that this is likely to have on midwives' private practices. Included is a list of questions to ask the representatives from the Department of Human Services at the forum tomorrow. If anyone would like me to send this information to you, please contact me by email joy@aitex.com.au. You will need to introduce yourself if I don't already know you, because I don't want to share my work with people who might abuse it.

You may wonder why I have included a picture of a Bilby, a small mouse-like marsupial with big ears?

Midwives share a lot with the Bilby. I'm suggesting that the Bilby be adopted by midwives as our little animal mascot.

The Bilby is at present being brought back from near-extinction. The midwife in private practice is also an endangered species. We need big ears, like the Bilby, to stay alert to any danger. We need to scurry for cover at the slightest sign.

Let's hope we have the resillience and intelligence to overcome the threats to our existence, and continue providing expert one-to-one midwifery care for women in our communities.


In the interests of best practice, and safe choices for all women, I believe:
• Midwives must be able to practise midwifery without government or outside professional interference
• No group of midwives should be subjected to greater levels of regulation than any other group of midwives – independent midwives expect the same degree of regulation as any other midwife
• The midwifery profession expects the same level of regulation as other health professions
• Peer counselling and confidential review of cases should be implemented. Midwives who are acting in a way that may be unprofessional or incompetent or putting their clients at risk should be reported to the regulatory body for investigation – as for any other professional.
• Risk assessment and response to development of complications is a normal aspect of a midwife’s professional capability. Risk assessment is an ongoing process throughout the episode of care. (WHO 1996 Care in normal birth)
• Women who seek the services of independent midwives will sometimes have complex social and obstetric histories, and this makes the dedicated care of a skilled midwife essential. This option is often not available in hospital based models of care, private or public.
• We need urgently to demolish the barriers that exist in maternity care, preventing midwives from attending their clients privately in hospitals.
• The protection of the midwife’s right to attend a woman privately for maternity care in any setting is strongly in the public interest.

ABC Radio - Life Matters

As if to celebrate the expected demise of private midwifery and homebirth by this time next year, the ABC Radio's Life Matters program has presented an outrageous interview with Dr Hilary Joyce, the new president of the College of Obstetricians and Gynae's.

You can listen to the podcast here.

I have left a comment at the guestbook.

I would like to suggest that midwives working privately should be treated no differently from doctors or other professionals working privately.

Many women who employ a midwife want to know the person who will be with them throughout their active labour, promoting normal birth, and supporting them to make informed decisions. This is best practice in midwifery, yet it's as scarce as hen's teeth in the public system. That's why women employ midwives privately. There is nothing synister about homebirth. Evidence from international and Australian homebirths shows clearly that homebirth is a reasonable choice for well women with a midwife primary carer who is able to refer to obstetric specialists if and when complications arise.

Most midwives in private practice are highly competent midwives, and we have excellent outcomes. I am one. I have practised privately for the past 15+ years, and I stand to lose my livelihood next year because I can't purchase professional indemnity insurance.

The bias of the guest Dr Hilary Joyce in this interview was not explored. The claims linking Australia's maternity obstetrics with obstetric oversight of birth cannot be supported. An outcome for which obstericians are primarily responsible is that more than 30% of Australian babies are born by caesarean surgery.

Obstetricians do not practise midwifery; midwives do not practise obstetrics. The midwife has, by definition, a duty to promote normal birth. The obstetrician is a surgeon, who should be consulted only when illness or complication arise in pregnancy or birth.

Remember, pregnancy and birth are not an illness.

You can read comments, and leave your own at Life Matters Guestbook.

1 July 2009

I want to mark this day, 1 July 2009.

In just twelve months from today privately practising midwives who don’t have insurance will be called ‘non-practising midwives’ under the new national Health Practitioner Registration laws. New arrangements will provide indemnity insurance for eligible midwives to practise other parts of midwifery, but NOT homebirth. Homebirth is the livelihood of self employed, privately practising midwives.

The new laws and provisions will potentially open up new freedom for midwives employed by hospitals; an item for celebration. Even homebirth may be provided by the hospitals - the insurance will be provided as part of the employer's vicarious liability arrangements.

It will be confusing and dangerous for consumers, and we need to do all we can to prevent this ill-thought-out health reform from progressing without amendment to enable a midwife to practise midwifery in any setting, which is fundamental to the international definition of the midwife.

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

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.

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.

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?
Sure.
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?)

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.

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 joy@aitex.com.au

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!

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:
WHAT ABOUT HOMEBIRTH?

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.

and


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

breastfeeding difficulties in the first fortnight

Today I want to reflect on the journeys of two first time mothers and their babies. Although these 'cases' are based on two actual babies and their mothers, the situations are not uncommon, and I hope this account will assist readers in understanding better the complexity and the wonder of the natural processes in nourishing and nurturing newly born babies.

I will call the babies Baby Boy (BB) who weighed about 3.4 kilos, and Baby Girl (BG) who weighed about 4 kilos at birth. Both were born in public hospitals in Melbourne, receiving good midwifery care. Both mothers pushed their babies out under their own steam, so to speak - spontaneous vaginal births. The mother of BG had received an injection of a narcotic a few hours prior to the birth, and the mother of BB received several doses of an oral narcotic after the birth.

Both babies remained skin-to-skin with their mothers for their first hour or so, but neither breast fed in that period. BG's mother was taken to the operating theatre for removal of her placenta, and BB's mother was taken to the operating theatre for repair of a perineal tear. Both babies slept while separated from their mothers.

By 24 hours -
Baby BB had had a couple of brief breast feeds but was still quite sleepy most of the time.
Baby BG had been to the breast several times, without attaching well. She was sucking her lower lip when awake, and seemed content with that.

By 48 hours, second day -
Both mothers and babies had gone home from hospital. Neither of the babies was feeding effectively.

I was in contact with both mothers. I encouraged each to work on learning to express milk by hand, to 'reward' any effort made by her baby with expressed milk, and to give baby as much as she was able to express. This amounted to not much more than a few mililitres. The mother was encouraged to persevere with massaging and expressing her breasts every few hours until her baby's efforts at suckling became strong and effective.

Third day -
Baby BG was checked by hospital midwife. Although she had not yet breastfed effectively, she was receiving about 5 ml of expressed colostrum milk whenever she was awake. Both mother and baby were well. Mother was encouraged to continue, and to give BG access to her breast when ever she was awake.

Baby BB had not woken much, and his mother had kept to the plan of expressing her colostrum every 3-4 hours, and giving him the milk using a syringe or tea spoon. However, that evening the result of BB's serum bilirubin test indicated moderate jaundice, which was at the lower end of the range for which babies of his age are nursed in phototherapy. The hospital nurse called BB's mother, and asked her to bring him to the special care nursery, to be admitted. BB's mother asked if she would be able to stay to continue breastfeeding, and was told 'no'. There was no bed available. The hospital would use any expressed breast milk she provided, as well as artificial formula milk to feed BB while he was in their care.

At the same time, I was visiting BB and his mother. We worked at stimulating little BB, using olive oil to massage him, and co-bathing in the bath tub. We were delighted when he cooperated, and took both breasts better than he had done previously. The mother was not willing to be separated from BB without good reason, and we felt we had turned a corner. With my support the parents made the decision to stay at home, and have BB's jaundice checked again at the hospital the following day.

I had noted that BB was tongue tied, and arranged for the hospital breastfeeding support unit to review that too. BB did a lot of serious breastfeeding overnight, and when his serum bilirubin (jaundice) level was checked the next day he was out of the range requiring admission.

Fourth day -
Baby BG had found the breast, to the delight of her parents. However her mother's nipples were grazed and ridges were forming across the nipple when she nursed. When I visited them I guided mother with a few tips on improving the positioning and attachment - fine tuning the success that they had achieved on their own.

Baby BB also seemed to be progressing well. He and his mother spent the day with the breast feeding support midwife at the hospital. The frenulum (tongue tie) was snipped; the jaundice was settling; the number of wet and pooey nappies increased; and he was settling and sleeping between feeds.

Baby BB's mother was confident to cease expressing milk by about Day 5. However, over the next few days it became clear that his breastfeeding was not as effective as BB needed, as he did not gain any weight from the fourth to the tenth day. He was going to the breast frequently, but often unsettled after feeds. The Maternal and Child health nurse assessed him as dehydrated, considered that the tongue tie was continuing to interfere with BB's sucking, and insisted that he be given baby formula milk supplements. Attempts to express milk by hand and using an electric breast pump resulted in small amounts - about 10 ml.

That evening I visited baby BB and his mother, and once again we devised a plan. This included learning a more effective bi-manual compression of the breast, and regular expressing to stimulate milk production. All expressed milk was given to BB after he had worked at the breast. The record of feeds showed a steady increase in the volume of breastmilk that was given as a supplement to BB.

By about 12 days of age BB's efforts at the breast continue to be supplemented with expressed milk. The tongue tie is to be reviewed by another doctor who is expert in such matters. Mother continues to work consistently on increasing her milk supply. Her beautiful baby boy is responding well: the more milk she gives him, the more he wants.


As I reflect on these real life situations that real mothers and their babies face I am very pleased to record the stories. The issues in getting breastfeeding right are as multi-faceted as any other aspect of life. Each mother-baby pair have their own set of challenges; some expected, and some out of the blue. Each mother-baby pair who manage to overcome their challenges and make the best choices that are available at the time are learning about life and becoming more strongly bonded together. The resulting emotional attachment supports them in dealing with the life challenges that lie ahead.