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Homebirth in too-hard basket

Government inaction and insurance are two roadblocks in the way of private practice midwives, writes Joy Johnston.

On May 10 an Australian Greens senator, Lee Rhiannon, drew attention to serious obstructions to maternity reform when announcing the passage in the Senate of a motion calling for immediate action on the obstacles facing privately practising midwives.

“Roadblocks frustrating women’s right to choose a range of birthing arrangements need clearing … It is time governments across Australia joined together to enable midwives to properly do their work,” Rhiannon said.

Midwives who practise independently, working privately with women in our communities rather than being employed by hospitals, are familiar with social, professional, and financial obstacles that have restricted our practice to a tiny minority of women, those who plan homebirth, and prevented us from working to the full scope of our practice with women who give birth in hospital.

There have been significant roadblocks obstructing midwives from doing their work in recent years in the context of political and social developments related to midwifery.

The modern era in medical and hospital services in the developed world has brought improved outcomes for women and babies who experience complication or illness associated with pregnancy and birth. Hand in hand with medical progress we have experienced a loss of reliance on physiological processes, and, I believe, a decline in midwifery skill.

Yet there is no medicine or procedure that makes birth safer than the natural unmedicated physiological processes, for the majority of mothers and babies. There is no better way to prepare the woman and baby for the physical and emotional complexities of mothering and nurture, than in concert with the ancient natural processes.

Contemporary midwifery seeks to reclaim the protection, promotion and support of the finely balanced physiological processes in birthing, while working in respectful co-operation with medical and nursing teams when needed, in order to optimise health and wellbeing.

Midwives are able to provide primary maternity care and be the responsible professional attendant throughout the episode of care. Midwives each have a caseload, a small group of women, for whom the midwife intends to provide ongoing professional services until about seven weeks after the birth. Midwives arrange appropriate support and relief through group practices or other co-operative arrangements.

For many years in Australia, independent midwives have led the midwifery profession in primary care options, supporting women who intend to give birth at home, without medical assistance.

Immersion in water as a pain management strategy, and to aid progress in labour, is a usual practice in privately attended homebirth. Midwives become expert in reducing anxiety, and in protecting the space around the labouring woman so that she is not interrupted. Midwife means, literally, “with woman”. The setting in which the midwife works is a secondary issue to the practice of midwifery. Yet current obstructions to midwives being able to fully practise our profession, and to women being able to access us as the primary maternity care provider throughout their care episode, have polarised midwifery artificially into “homebirth” and “hospital birth” midwifery.

Obstructions to midwives being able to properly do our work include medical dominance, and insurance. A culture of medical dominance in maternity care today is so deeply ingrained that few are aware of it. For example, until as recently as 1995, Victorian Midwives Regulations required supervision of midwives by doctors. A midwife was required to have a doctor’s permission to carry out a vaginal examination of a woman. There was no mention of informed consent from the woman.

This culture was in direct conflict with professional developments in midwifery, organised and promoted globally through the International Confederation of Midwives (ICM), and articulated in the ICM Definition of the Midwife, which is a foundational document in all Australian midwifery education and codes of practice.

At the same time, in response to the tragic outcomes linked to loss of breastfeeding in developing countries, UNICEF and the World Health Organisation (WHO) introduced the global Baby Friendly Hospital Initiative. Protecting women’s and babies’ physiological processes in breastfeeding is an extension of such protection in birth, and is an ongoing challenge to the midwifery profession.

The federal government’s Maternity Services Review (2008), its report, and the 2009/10 budget package: Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives, ignored or side-stepped homebirth, the main practice area of privately practising midwives, and the main choice that women called for in their submissions to the review. Preference was given to “collaborative” models, under obstetric control, which often exclude midwife-led primary maternity care options.

In providing “more choice in maternity care”, the reform package actually gave veto power to a doctor, over the midwife’s ability to provide Medicare rebate to a woman in her care. The National Health (collaborative arrangements for midwives) Determination 2010 requires very specific signed collaborative arrangements to cover all aspects of a midwife’s practice. There is no requirement or onus on doctors to sign a collaborative arrangement, and in many instances women have experienced frustrating refusals by doctors, who refuse to collaborate with a midwife in the legislated way.

Midwives in most states have experienced the roadblock of outright refusal, when we have requested processes to achieve clinical privileges in public hospitals, despite government-guaranteed indemnity insurance for midwives insured with the Medical Insurance Group Australia (MIGA).

Midwives in some states have negotiated casual employment models in public hospitals, so that they are permitted to attend women in the public system, who have been their private clients for prenatal care, and who will return to their private care postnatally, after discharge from hospital.

Queensland alone is moving ahead, with Toowoomba, Ipswich, and Gold Coast public hospitals, and possibly others, offering visiting access to midwives. Finding an insurer willing to cover private midwives for homebirths is another obstacle. It had been known for at least a decade prior to the introduction of the 2010 maternity reform package, when professional indemnity insurance became mandatory for all registered health professionals, that no underwriter anywhere would indemnify midwives for private homebirth practice. The global insurance market had no interest in the small, disorganised remnant of midwives who provided primary maternity care for less than 0.5 per cent of Australia’s mothers and babies.

That minority group of midwives, and the women who employed us, found a strong voice during the government’s Maternity Services Review (2008), with thousands of written submissions to that and subsequent inquiries. The discussion paper of the review included reference to the call by Maternity Coalition* in 2002 for reform enabling all women to access one-to-one midwifery care, and choice of place of birth: home or hospital. Submissions from many midwives and women called for homebirth to be recognised and funded. Yet the call for “home” as a setting for birth, and as a funded practice setting for private practice midwives, was all but ignored in the discussion paper and the final report of the inquiry.

Insurance for private practice midwives since 2010 excludes homebirth, which is the main practice area for private midwifery. Insurance that covers prenatal and postnatal services, and excludes the birth, is incomplete. If there is truly benefit for the public in having mandatory indemnity insurance, it must be available to all aspects of professional practice. But it’s not all bad news. Midwives are resourceful people, and we have found ways around most of the roadblocks and obstructions that we have encountered. For more information read: Maternity Coalition 2002, National Maternity Action Plan, Birth Matters, journal of the Maternity Coalition, vol 6.3.

Joy Johnston is an independent midwife in Victoria and acting-president of the Australian Private Midwives Association. She is acting President of Australian Private Midwives Association (APMA) and a frequent blogger www.villagemidwife.blogspot.com.au

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