The Future of Midwifery and Homebirth in Australia?

http://king-animal.blogspot.com.au/2012/07/wolf.html#.UsTquXn5i04A lot of changes have occurred in Australian midwifery over the last few years, and I think many midwives and women are unsure or confused by them. I am going to attempt to make a clear and coherent summary of the changes, and discuss the impact of them now, and in the future for midwifery and homebirth. There are going to be a lot of acronyms in this post which may be new to some and familiar to others. So here is a glossary before I begin:

  • ACM – Australian College of Midwives
  • AHPRA – Australian Health Practitioner Regulation Authority
  • AMA – Australian Medical Association
  • ANMC – Australian Nursing and Midwifery Council
  • ICM – International Confederation of Midwives
  • NMBA – Nursing and Midwifery Board of Australia
  • PII – Professional Indemnity Insurance
  • PPM – Privately Practising Midwife
  • RANZCOG – Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Before AHPRA and PII (pre 2010)

The following is an overview of how PPMs worked based on myself and other midwives I know. I realise there will be some variation across individual midwives…

Before AHPRA PPMs were regulated in the same way as any other midwife – at the time this was by ANMC. They collaborated with GPs, hospitals and other health care practitioners, referring and transferring care when needed. The ACM’s ‘consultation and referral guidelines’ were freely available online which meant women could access them, and they formed the basis of discussions around scope of practice and consultation/referral. If a woman transferred to hospital during labour the PPM could no longer act as a ‘midwife’ – instead handing over the professional role and responsibility to the hospital midwife. This allowed the PPM to focus on the woman’s emotional, physical and advocacy needs rather than on the needs of the institution. Hospital midwives are well placed to work within their environment – they know how to deal with the obstetricians, equipment, medications, policies and paperwork. There was no indemnity insurance available for PPMs (since 2001) – so they worked without it. PPMs were employed directly by women and worked directly for women. The above factors were discussed and stated in a signed mother-midwife contract

Meanwhile consumer groups such as Maternity Coalition and the ACM were pushing for medicare funding for PPMs. I supported this, and still believe that the health care system should fund homebirth, and that all women should have access to PPMs regardless of their financial situation. There was/is also a government commitment to increasing access to continuity of care for all Australian women.

In 2009 AHPRA was formed in order to have one National registration body rather than individual State registration boards. This was to prevent dangerous healthcare practitioners switching states to continue practising. The ANMC was absorbed into this new registration body. The role of AHPRA is to register and regulate all health care professions including midwifery. Each profession has their own Board within AHPRA – and the Nursing and Midwifery Board of Australia (NMBA) is responsible for midwives and nurses. To understand why midwifery is so entangled with nursing in Australia see Fahy’s (2007) article ‘an Australian history of the subordination of midwifery’ . The perception of midwifery as a branch of nursing underpins the ongoing medical control of the profession described below. Anyway – back to the NMBA. The primary role of the Board is to ‘protect the public’ ie. these are the people who deal with misconduct hearings and ensure midwives are undertaking continued professional development. The formation of AHPRA brought with it two key changes to PPM practice – eligibility and indemnity insurance.

Eligible midwives

In 2010 the ‘eligible midwife registration standard’ came into effect. The aim of this was to enable women to access medicare rebates for PPM care. In order to get rebates women need to engage the services of an ‘eligible midwife’. Note that rebates are not available for homebirth – only antenatal care, birth in a hospital/birth centre (where the PPM has visiting rights) and postnatal care. To become eligible, the midwife must apply to AHPRA for notification and demonstrate that she mets the requirements which are:

  • current general registration as a midwife in Australia with no restrictions on practice
  • midwifery experience that constitutes the equivalent of three years’ full-time post initial registration as a midwife
  • current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
  • successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
  • 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
  • formal undertaking to complete within 18 months of recognition as an eligible midwife, or the successful completion of a course to acquire the skills required to order diagnostic tests and prescribe scheduled medicines

You can download the ‘guidelines and assessment framework for the registration standard for eligible midwives‘ for further details about the requirements. It could be argued that these requirement (excluding prescribing – which is whole other rant/issue) merely reflect the normal scope of midwifery according to the ICM. However, in Australia most midwives are unable to practise to their full scope due to constraints imposed by the structure of the medicalised maternity system.

The ‘eligible’ classification is often misunderstood, with many believing that you must be eligible to be a PPM or attend homebirths. This is untrue, and many of us continue to work as described above, choosing not to be ‘eligible’ for a number of reasons. There is also an assumption that an eligible midwife is ‘better’ and ‘more experienced’, and again this is not necessarily true. For example, a midwife can gain eligibility without any experience in attending homebirths. The point of eligibility was/is for women to access medicare rebates – not to create a separate and higher class of midwife.

Medicare eligibility has resulted in a number of changes. Firstly, it has increased women’s access to continuity of care and given them access to rebates for maternity care via a PPM. Many midwives have set up as PPMs and midwifery group practices are popping up everywhere – again this increases women’s choices. Some midwives are continuing their homebirth practice with the additional benefit of women being able to claim rebates if they wish. Other midwives are setting up new practices. There are so many different ways in which eligible midwives are working… I am not going to attempt to list them all. In my local area maternity service options for women have increased from hospital (public or private) or PPM in 2009; to hospital, midwifery led birth centre (medicare rebates), midwifery group practice (medicare rebates), non eligible PPMs and eligible PPMs. And for those who do not want to engage with standard maternity services there are birth workers, doulas and the option of freebirth.

However, medicare rebates come at a price…

Collaborative arrangements

In order for a woman to claim medicare rebates for care by a PPM, the PPM must have a collaborative arrangement. The nature of this arrangement has evolved since 2010…

Initially, during negotiations with AHPRA about eligibility, the requirement was going to be that the midwife must ‘demonstrate’ collaboration with medical practitioners and health services. This would have been easy – PPMs were doing this anyway (see above), and documentation would have provided evidence. However, the AMA and Rural Doctors Group ensured that the requirement became a signed collaborative arrangement with a medical practitioner. Interesting that doctors got the final say in midwifery practice. I doubt there are any midwives involved in negotiations with AHPRA about how obstetricians practice. Disappointingly midwives and consumers (the ones at the table) agreed to this requirement in order to gain eligibility, maintaining that they would work to change the requirement in the future. Personally, I think they should have refused to allow medicine to control midwifery practice in this way, even if it meant losing eligibility. Instead, the types of collaborative arrangements midwives were required to have were determined as (Dept of Health):

  1. being employed or engaged by a medical practitioner or an entity that provides medical services; OR
  2. receiving patients on written referral from a medical practitioner; OR
  3. a signed written agreement with a specified medical practitioner/s; OR
  4. an arrangement in the midwife’s or nurse practitioner’s written records

There was/is no obligation for doctors to collaborate. And in case there is any confusion about this, the AMA published a handy  guide for doctors ‘collaborative arrangements – what you need to know’ stating clearly that: “If you do not want to be part of a collaborative arrangement, or you are unable to reach agreement on the appropriate terms of a collaborative arrangement, then there is no obligation to be part of one. You do not have to commit to being part of a collaborative arrangement for any particular period.”

The collaborative arrangement was the equivalent of requiring the manager of Woolworths to agree in writing to allow customers to buy vegetables directly from a local farmer.  Not surprisingly, getting a collaborative arrangement, and therefore claiming medicare rebates was fairly impossible. In 2013 in response to the predictable ‘difficulties with establishing collaborative arrangements’ an amendment was made to the requirement expanding the types of collaborative arrangements. Now, in addition to a collaborative arrangement with a doctor who provides obstetric services (as above), a PPM has two further options for collaboration:

  1. That she is credentialed for a hospital, having successfully undergone a formal assessment of his or her qualifications, skills, experience and professional standing. It is expected that appropriately qualified medical practitioner/s would be involved in the assessment; OR
  2. That she has a written agreement with an entity other than a hospital that employs or engages at least one obstetric specified medical practitioner.

Effectively medical practitioners, individually or via the institutions they work in still control access to medicare for PPMs.

Midwives are pretty resourceful, and many have found ways to make this work for them and the women they care for. However, it is very dependent upon the people and organisations providing collaborative arrangements. Because it is so complex, there is a lot of confusion and misunderstanding. For example, some believe that a medicare eligible midwife cannot care for a woman having a VBAC. This is not true. She can – just as any PPM can. She may not be able to secure a collaborative arrangement to do so ie. there will be no medicare rebate for that care. However, in some cases medical practitioners or hospitals will agree to antenatal and postnatal care by a PPM for VBAC women. Women need to discuss options and boundaries with their individual PPMs… regardless of eligibility. This is part of negotiating the mother-midwife relationship.

Currently eligibility and collaboration remain an ‘opt in’ choice for both midwives and women. Personally I have chosen not to ‘opt in’ because I feel that the current collaborative arrangement requirements are not aligned with my philosophy of midwifery and ‘with-woman’ care… and I won’t compromise. There are women who also feel this way, and specifically want a non-eligible midwife. Or, who do not want to jump through the hoops required to access a medicare rebate (eg. booking into hospital). While both options are available – eligible and non-eligible PPMs – women can choose the option that works best for them.

However, this choice may disappear in 2015…

Professional Insurance Insurance – the wolf at the door

AHPRA registration standards require that all health care professionals have ‘professional indemnity insurance’ (PII) for all aspects of their practice. No big deal for midwives working within the system because they are covered vicariously by the organisations they work for. But this left PPMs with a problem. There was no insurance product available for them, and to practice without insurance breached their registration standards. Long story short, following a lot of protests and negotiations a compromise was found. Two insurance companies stepped in with PII and we now have two products, both excluding homebirth. MIGA only provides insurance to eligible midwives and covers antenatal care, labour in hospital/birth centre and postnatal care. Medisure will insure any PPM for antenatal and postnatal care only. 

Because there is no cover available for homebirth an exemption for PII during a homebirth is in place until June 2015. Not surprisingly, neither insurance company is jumping at the chance to offer PII for homebirth. The NMBA recently published a report on PII for midwives which analyses the issues involved with offering an insurance product that covers homebirth with a PPM. The difficulties centre on the size of the market (ie. number of homebirths/PPMs buying the product); working out the probability of a claim; and working out the size and type of a potential claim. The report includes a lot of discussion about ‘risk’ and ‘risk assessment’. It also suggests that an option could be to make any PII product only available for medicare eligible midwives to ensure ‘confidence and certainty’ within the insurance market about PPM practice. It is likely they will also dictate further requirements for cover such as women must undergo particular screening tests (bloods, u/s, etc.) and be classified as ‘low risk’. These issues are already being faced in the United Kingdom by women and PPMs.

So far there has been no official response to the insurance report from the ACM. The recent Maternity Coalition magazine included this divisive statement in relation to protecting midwives and women’s choices:

“Many midwives feel that they are in a vulnerable legal position. This is often because they are not doing these things [following professional standards re. scope, information giving and documentation]. If we could confidently demonstrate that homebirth midwives as a group were practising in this manner then it would be easier to secure insurance for intrapartum homebirth care and resist the push to regulate homebirth more strictly.” (Ann Catchlove)

It is the NMBA’s role is to regulate midwives… all midwives, including homebirth midwives. All midwives must follow professional standards, provide adequate information, and keep adequate documentation. Yes, individual homebirth midwives may fail to do this… and so might individual hospital midwives. Some would argue that information giving by hospital staff is often below the legal standard for consent (e.g. ARM, induction). Either way, there are already mechanisms in place to hold midwives accountable for their practice via NMBA and civil law. Indeed, considering the number of vexatious reports submitted to the NMBA against PPMs, it could be argued that the mechanisms are working too well (Jo Hunter is presenting about this issue at the Homebirth Conference in March). Unfortunately, we are never going to ‘confidently demonstrate’ that all midwives within any model of care or birth setting are practising in a particular way. Aligning midwifery with medicine and allowing medicine to regulate midwifery practice will not reduce risk. Evidence-based, woman-centred care will reduce risk. How about requiring all midwives to undergo a regular consumer-led ‘midwifery practice review’ assessing their practise against evidence and midwifery philosophy?

The future of midwifery and homebirth?

The following predictions are from my own crystal ball, and some optimists may consider them pessimistic. I think that in 2015 a PII insurance product will be made available that will cover homebirth, but only for eligible midwives accredited by hospitals, and for women booked into the hospital system for shared care and who meet particular ‘low risk’ criteria. PPMs without eligibility will no longer be able attend homebirths – to do so would mean practising without insurance ie. breaching their registration. Women who are not classified as ‘low risk’ will be unable to have a registered midwife at their homebirth (eg. previous c-sectiongestating beyond 41 weeks). I think that the professional midwifery organisations will go along with this in order to gain the mandatory insurance and protect private midwifery practice (limited) at homebirth. These changes will have a significant impact on a minority of midwives and women:

Midwives: Non eligible midwives will either become eligible; or stop providing PPM services; or hand in their registrations and become unregulated ‘birth workers’ (however, in South Australian this could lead to criminal charges). Newly qualified midwives will struggle to gain the experience required to become eligible due to limited continuity of care within the maternity system. PPM practice will be dictated by the constraints of an insurance product who’s focus will be on eliminating risk based on medicalised notions of ‘risk’.

Women: Access to midwives and options for care will be limited. Women who do not meet the requirements for insurance cover will be unable to have a registered midwife at their birth. Many women will go along with the requirements (including to switch to hospital birth) but others will not, and their only option will be to freebirth (this is already happening in Ireland). There is a big difference between choosing to freebirth and feeling there is no other choice.

I think we have lost sight of what is important – the essence of midwifery, being ‘with woman’ regardless of where or how the woman chooses to birth, or with whom she chooses to birth. Unfortunately, I think we have come too far down the track and midwifery has become entangled with medicine and the needs of insurance companies. I can’t see a way out of this mess can you? What I find most frustrating is the lack of discussion about these issues within the Australian midwifery profession. In contrast, in the UK where PPMs face the same insurance issues there are protests, marches and campaigns – even support from a Professor of Obstetrics and Gynaecology. Either, Australian midwives don’t know what is going on, or they agree with the changes, or they don’t care – I’m not sure which. I’d love to know your thoughts.

About midwifethinking

independent midwife, lecturer and student of all things birthy
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82 Responses to The Future of Midwifery and Homebirth in Australia?

  1. Disillusioned says:

    I just want to cry. How can it have come to this?

  2. A fantastic post thank you Rachel! I’m not a midwife but an independently practicing childbirth educator with a PhD in Psychology who refuses to participate in the Medicare system for all the reasons you have outlined. The Medicare system has left mental health in Australia struggling with experienced and well regarded counsellors and psychotherapists now seen as second best to recently graduated Medicare registered psychologists, who so often have only their training placements as experience. Registration, accreditation and the Medicare system were introduced to protect consumers, but all that is happening now is that they are ‘protecting’ people from making their own choices. May all strong and empowered midwives and the women they support be brave enough to stand up for freedom of choice and see the medical and insurance systems for what they are – delusion and ignorance of what is real and important.

  3. Ana says:

    I find this a profoundly depressing state of affairs. I’ve had both my children at home but am unsure whether that will be an option if I have any more. I cant imagine birthing in hospital or free birthing. It seems ridiculous to me that I’m being cut off from a model of care that has been shown to have as good or better outcomes and it frustrates me that I’m not able to get any interest from politicians in changing it.

  4. Jess says:

    Challenges such as these will hopefully become the great catalysts for the positive changes that we all agree are desperately needed! That is IF, and only IF; we rise to the challenge. Rachel, you are right, there is a lack of discussion within our professional bodies about the profound importance of this issue. I believe hard lobying needs to happen, from the ground up, supported by our professional bodies and taken all the way to government and insurance companies that seem to have so much power over us/them/ and our women. I think the key here is lobying for a serparation of birth as a “non-medical” life event, and attaching legistltion that protects it as being so. I am newly graduated and awaiting my new job within a major hospital to begin, I cannot imagine a career worth striving for if I may have the option of becoming a homebirth midwife taken away from me. I simply won’t stand for it! However, ‘HOW’ and were to from here are the key questions…. We must keep the faith!

  5. Anna Mae says:

    Medicare is designed for MEDICAL care… Midwifery care is not medical care, so why the complaints and trying to get around legislation? If you don’t want to do the training or meet minimum requirements to be a registered HEALTHCARE professional (like everyone else has to – physios, nurses, psychologists etc) then don’t complain you can’t get government HEALTHCARE funding.

  6. Kate says:

    This article is put together so well, thank you for sharing, its a shame the info your sharing is so disappointing :( I dream of a change in the government legislations for things like homebirth and independant midwifery but my fears tell me nothing is going to change :(

  7. Gypsy says:

    Thank you Rachel, for cohering this complex situation into one article. I agree with your crystal ball, and unfortunately I don’t have any clever solutions to add. Just heart break, anger and some choice expletives (but this won’t change the current trajectory).

    Salt upon the wound – this very situation was predicted well by those (women and midwives) who, back in 2009/2010 etc., saw collaborative agreements as a death knell for women-centred homebirth midwifery. AND HERE WE ARE.

    Yet in amongst it all, I know too that historically midwifery knowledge/wisdom/skill has survived far worse than what we are currently facing here in Australia. There is surely strength in lineage.

    Maybe it’s about building to a tipping point (of patriarchal insanity), that we haven’t quite yet reached. Or maybe, through the final absorption of Australian PPM’s into medical control we will see this precious knowledge returned, by necessity, into the hands of the people. Or perhaps the outcome will be beyond anyones control, I have seen midwifery listed as a ‘post-peak oil profession’ many times!

  8. lindajstegeman says:

    Well it’s going to take unity and bravery – as you know. Unfortunately there are different things at stake for the medical profession and the midwifery profession and women. The fight is worldwide really. Even where the situation is different there is an ongoing tussle.

  9. Denise Hynd says:

    NZ LMPC (self-employed) midwives have PII cover through a combination of levies (based on thier Caseloads) to the national Accident Compensation Commission and increased membership fees to the NZ College of Midwives. Bill Shorten tried to get a National Injury Insurance Scheme as well as the National Disability Insurance Scheme up but had to be satisfied only with the later with-n the term of Gillard government! If both of these had, or do eventuate (with a Shorten government) then Australia will have the equivalent of NZ’s ACC ( http://www.acc.co.nz/). Senator Rachel Swiert’s cheif policy advisor said to me last June in Perth ‘this could be a means of part cover for Homebirth in Australia as it is in NZ! Please follow this up with Bill Shroten’s or Rachel’s offfice. I have tried to get other Australian midwives to check this out, lobby and spread the word!

  10. Shara says:

    Thanks Rachel, I was one of the Facebookers who wanted to hear your thoughts on this topic! I am coming from a consumer standpoint. We had our 3rd baby mid 2013, our first homebirth. I was really excited to finally be pursuing a homebirth here on the Sunshine Coast. I contacted 2 PPM, both were unavailable, but gave me some names of other midwives. Those midwives were also unavailable. I felt pretty deflated then. 5 midwives all unavailable at the exact same time, maybe it was a conspiracy 😉 I decided then that rather than putting my tail between my legs and booking in at the hospital or engaging the services of an eligible midwife – a system I didn’t agree with, I would just have to freebirth. I continued through my pregnancy with no prenatal care, planning to birth DIY style, until at around 32 weeks my husband felt that he couldn’t support that decision anymore. (It turns out he naively mentioned it to some co-workers who completely freaked out at him). So I felt that my only option was to contact an eligible midwife. I did, and met with her twice before my baby was born at home at 38 weeks. Although I was extremely apprehensive about this relationship, I thankfully found her to be very supportive of my decisions, never once questioning my lack of pre natal care or my desire to only have the bare minimum with her. So I had him at home, and feel like I should be happier than I am, after all I’ve got a healthy baby and all that 😉 But I can’t help but feel “robbed” of the opportunity to have developed a relationship with someone, who was completely on my side, and the opportunity to share my excitement about my pregnancy and upcoming birth with someone who would get ‘it’ ! I was so fearful (I’m not sure why really) that an eligible midwife would risk me out of homebirth at the eleventh hour. That I perhaps missed out on what I truly wanted because of that fear/// all that to say: it is not a system I agree with at all, but I’m sure glad it was there for me when I needed it. And I’m grateful to midwives like yourself who continue to bring the facts to any woman who wants them. X

    • Hi Shara
      There is a problem with the number of PPMs and women wanting homebirth on the Sunshine Coast. Most of the non-eligible PPMs cannot take a large client load due to other full time jobs and/or children. The eligible PPMs have a bigger practice and more availability… and their practice in terms of care at a homebirth is the same. I am sorry you felt apprehensive about the relationship. This is one of the reasons I wrote the post. There is a bit of ‘them and us’ about eligible midwives as if they are ‘different’ but they are generally not. It is not the eligibility that will ‘risk you out’ it will be the insurance come 2015.

  11. Nicola Philbin says:

    Great article setting out the reasonsmbehind the decline of midwifery in Australia, I learnt a lot. The idea that indemnity insurance protects women is so dangerous – it does not protect at all, just forces women into particular care patterns that have no research basis and often have worse outcomes. The same is happening in Europe.

    However, the article you refer out to does not illustrate that freebirthing is happning in the UK – although it may be – because at article refers to Ireland. In some ways the Irish situation is morre analagous to Australia – the medical establishment has a complete stranglehold over childbirth, and the value of midwifery is little recognised by society at large. Aja Teehan herself did not freebirth – she went to the UK and birthed with a midwife!!

    • I’ve amended the post because it was Ireland… and you are correct, the UK is not quite as stuffed as Ireland and Australia. However, they are struggling with the requirement for insurance.
      Thanks for the update on Aja :)

      • G King says:

        UK women not quite so stuffed though as the community midwives there carry out homebirths so the women do have more choice than here where it seems women can have private hospital birth, public hospital birth or uninsured midwife for home birth or free birth :(

        • Teresa Walsh says:

          Maternity services are far from perfect in the NHS at the moment!!! Through chronic underfunding, there is a shortage of around 5000 midwives in the system – if there is noone available to attend a woman who wants a homebirth, she is informed that she will have to come to hospital in some areas.

          • Yes – this is what my mw friends in the UK tell me. The financial collapse changed things a lot. It was already stretched when I left. Community mws (myself) being called in to hospital shifts leaving no cover for homebirth.
            And there was not guaranteed continuity of care re. Homebirth. It would be whichever community mw was on call at the time. Not necessarily the one you saw in pregnancy.

  12. Mamaof5 says:

    I have freebirthed twice now, and the reason was combo of didn’t have a choice/actually wanted to. I am freebirthing again this year, despite being labelled as high risk by the hospital system. I was also labelled a type 2 diabetic 20 years ago by the western medical system – something that is a hard thing to reverse, but taking the responsibility upon myself, i’ve been able to do so. In the same vein, taking responsibility for my births and choosing freebirth, i’ve had to educate myself more than most women – this is a slippery slope – when you decide to take this responsibility upon yourself, you start to see other areas where freedom means more than any regulated official (government=private corporation) body could ever provide. It is family members, mothers, grandmothers, sisters, friends that NEED to be well educated on the matter of birth, so THEY can help the birthing mother, otherwise natural birth as we know it will be gobbled up by all these useless regulations.

  13. It’s interesting that the NHS in the UK give women the choice between home birth, midwife-led units or maternity units in hospitals. Home births are cheaper so it’s no surprise they are keen to promote them but then regular readers of this blog are well aware of the additional benefits. Also the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists work together and are supportive of home births.

    http://www.rcog.org.uk/womens-health/clinical-guidance/home-births

    Come on Australia! Don’t lag behind. This is a shocking breach of women’s choices. We have choice when it comes to sex, conception etc etc so why are choice and and dignity stripped away at birth?

    • I worked in the NHS for years. And it was much better re. choice. However, there was also a duty of care ie. a woman could decide to homebirth against recommendations/guidelines and the midwife had to attend and provide the best care possible in the situation. This meant that women took responsibility for their own decision ie. to have a VBAC or breech birth at home. The midwife was protected by the ‘duty of care’ and vicarious liability through the NHS. The culture is also totally different. In the hospital where I worked the Consultants wife had homebirths.

  14. sneetchgirl says:

    Great post Rachel. Thank you for breaking down a lot of confusing & I believe, unknown, information. Thanks for shining the light once again.
    In my honest opinion..it’s going to take a clear separation between midwifery and the medical profession, rather than aligning with it & this needs to come from yes, midwives, but ultimately, the women demanding it too. I mean, what do they want in a midwife? For their birth? For their children’s births? Where are their voices in all of this? They are the heart & soul & why one works with birth. Can midwives not create relationship with women & in true partnership create change in this? One thing is for sure, there needs to be far more dialogue. Thank you for opening it up. X

    • Claire Hall says:

      I think you are right. But I think it will have to come from women. I think it is too late for midwives to have much effect

    • I agree it does need to come from women. However, many women are unaware of what is going on. And most women do not want a homebirth and feel that medicine = safety. I think there is a drive towards physiological birth within hospital ie. ‘delayed’ cord clamping, etc. But, in general women are scared and do not trust their own bodies…
      The maternity systems are set up to avoid true relationships/partnerships between mothers and midwives. It is fragmented and most women do not see the same midwife throughout. Perhaps continuity of care for all would be a start?

      • sneetchgirl says:

        Yes continuity of care & continuity of carer I believe. So relationship, trust & education can be built.

      • Claire Hall says:

        Yes, it would be a start. RNZCOG and the AMA have done a good job on he public though – – -it will b a long battle

        • Denise Hynd says:

          Sarah Buckley and Michel Odent are leading the doctor vanguard explaining that we put women into hospital before we understood about the hormonal drivers of labour and birth, and that the loss of natural hormonal flows is a life-time defecit that has societal implications. So manitaining and increasing a Homebirth Movement is vital for our species and one day that message will reach our politicians and so called health bureacrats. And if you do not know what I am talking about read their books – particualrly ‘Gentle Birth Gentle Mothering’!

  15. Teresa Walsh says:

    Thanks Rachel. I am an eligible midwife and unfortunately I agree with a fair bit of your analysis. I feel quite sad that women and midwives lobbied so hard for changes to the Australian maternity services which would create choices and continuity – I became eligible asap so that women in my area would have access to affordable private midwife care with Medicare rebates. Now eligible midwives are being portrayed as part of the problem! It continues to be rediculous how difficult it is to establish collaborative arrangements – why are the medical profession not being held to account for this? Contrary to what you say however, I know many eligible midwives are stretching the system, taking every opportunity to collaborate with medical colleagues – and at the same time educating some of them about informed consent, right of refusal and woman-centred care. I too am really sad at the attitude of many midwives working within the system – happy with their subordinate role in the hospital pecking order, and choosing to be ignorant of developments in their profession – some are just as openly hostile towards midwives in private practice as the medical staff are. The prejudice towards homebirths in Australia is hard to tackle – the medical lobby worldwide have spent decades creating a culture of fear and negativity despite the evidence. I want women to be able to choose wherever they want to birth and with the care provider of their choice. Wrangling over indemnity insurance, professional regulation and defining risk will narrow those choices further. So, do you have suggestions Rachel as to how we can effectively unite our profession, respect the expertise of other professionals, and create true collaborative woman-centred maternity services?

    • Claire Hall says:

      Hi Teresa, can I just ask for a clarification? When you said “I want women to be able to choose wherever they want to birth and with the care provider of their choice. ” – does that include non registered lay birthworkers, freebirth etc?

      • Teresa Walsh says:

        Hi Claire. Of course – if they are truly making an informed choice, and not being forced into making a particular choice because the options available to them are otherwise unacceptable. And whatever choice a birthing woman makes should not exclude her from access to additional care in a hospital if she makes that choice during labour and birth. One of the best things for me (and for women) about being eligible with hospital visiting access is that women have the freedom to birth where they choose when they are in labour. I provide all their midwifery support at home or in the hospital. Sometimes they decide to stay at home instead of a planned hospital birth, and feel so empowered that their bodies could do this. Sometimes they choose to go to hospital from a planned homebirth for whatever reason. Either way they make the choice that is right for them – and my role is to provide information and advice, a safety net, support, advocate for and midwife them. Philosophically many hospital staff do not start from the same basic principle that women should always have the power – in fact some staff see private practice midwives as aliens mainly because of this! Actually I would prefer to attend only homebirths – because there is almost always conflict every time I support birth in hospital due to this different philosophy – but its not actually about what I want. Most women want to birth in hospital, and they too deserve fantastic midwifery care.

        • Claire Hall says:

          You bring up some good points. Most people think that a woman’s choice to choose a lay support person / freebirth means that they shun all medical help and put themselves in dangerous situations. That is not the case and the stigma and difficulties you highlighted when they seek help is what keeps them away, not their desire to reject modern medicine/obstetric help when it is appropriate.

  16. Claire Hall says:

    Thank you for this Rachel. Well written. It is a conversation that I tried to have 6-7 years ago, (and continued to try to have until 2010 when I gave up in frustration) but midwives would not listen nor discuss. I am so happy to see you bringing things into the open to be discussed honestly and in such a non-emotional and rational way. Go you!!

  17. Another consumer viewpoint: Shara I hear what you are saying. I have had three homebirths now with the same midwife and the last one in particular was a very deep and meaningful experience, given our long history together. I can’t imagine birth being any other way than with a deep mother-midwife relationship. I accessed medicare rebates….my collaborative arrangements consisted of nothing more than a referral from a GP (who grumbled a bit but acknowledged that my midwife knew much more about my case than he ever would), and a last minute book in at a hospital where the midwife had good contacts. I don’t know any more detail about her collaborative arrangements. I have been dismayed to observe midwives in Sydney seemingly one by one being ‘reported’ by hospital staff for one thing or another and instantly being banned from practising (presumed guilty and having to prove their innocence). I agree there is much silence about the future of PPM and the whole insurance issue. I would not freebirth personally, and feel concerned about my future options for birthing.

  18. Diane says:

    I hope midwives in the U.S. are paying attention.

    • What is happening in Australia is a shift to the way that American nurse-midwives often are forced to practice, and home birth faces similar obstacles here. There are different laws and regulations in each US state, and nurse-midwifery is often regulated by the state board of nursing or the medical board! with predictable results. Excellent article!

  19. Andrea World says:

    Thankyou Rachel for this analysis. I do hope your predictions do not come to light, but do indeed feel there is certainly an air of realism to them rather than pessimism. From my ‘consumer’ perspective these are certainly the conversations that need to be had. By midwives, yes, but by consumers AND midwives moreso. Over the last 2 and a half years I have been so priveliged to meet so very many midwives and consumers that are doing their absolute utmost to bring appropriate change for womens choices in maternity care. I come from the other side of the fence you see. Once ‘mainstream’ , having grown up in a family that always had private health insurance to “ensure the best care possible”….. Or that is what we are led to believe. My first two babies were born in a private hospital, my pregnancies under the care of a private OB. Not their births though – the OB never attended my labours. My third birth I intended to try the public system and find out why year after year at every baby expo there was this bunch of women telling all and sundry to ‘choose a midwife’. I was hopeful to have a birth at which I was ‘connected’ to a midwife. My experience by 20wks in a public obstetric model (due to GDM) had me feeling lost and disillusioned. It was at this desperate point I turned to researching homebirth. Something that ‘regular’ people like myself just don’t do – do they? I was in unfamiliar territory – fearful of what ‘might’ happen, but equally sure that my current circumstance was not right for me or my baby. Finding a Medicare eligible midwife was my saviour. Without any knowledge of ‘the system’ I found this medicare eligibility factor to be somewhat comforting and without it I do not know what I would have done. Hiring someone that had no official affiliation with some sort of agency or group seemed too ‘risky’ to my then ‘birth world ignorant self’ I do know a lot more these days, but the existence of medicare eligibility saved me when I needed it. My Medicare eligible midwife gave me options I had never had. She fought the system for me. She fought FOR ME. At possible risk to her own career she stood up and provided me the best damn birth experience of my life. In my home, surrounded by my husband, children, mother and another midwifery partner. The system labelled me as high risk and I disagreed. My midwife told me I could do whatever I wanted to, and she would support me. She gave me evidence/information, comfort, support, she gave me what I needed. I do understand that there is a long way to go and that the current system is not workable, but if not for the many midwives and consumers before me, joining together and attempting to bring in medicare eligibility I would not be in the same space I am now. Is the system ‘crappy’ right now? Hell yes. But please – everyone- do not write off the notion of eligible midwives being a good thing for many. It brings ‘us’ in. The women like me that previously didn’t understand the notion of ‘choice’ of real ‘care’ in a medical system that is failing women everyday. Midwives, be you eligible or not, please support womens access to better options and choice. That is the main thing here, not about which paperwork needs to filled out by who, but what each woman needs. I believe without doubt that those of you reading this article are here for the right reasons. My hope is that all of us, consumers, midwives whoever – can agree that the system needs to be greatly improved and we must continue to work towards that goal, together, and without any issue over who may or may not be ‘eligible’. When my third son was 3 wks old I attended my first Maternity Coalition meeting – at the suggestion of my midwife. I haven’t looked back. – Andrea World, MC QLD President.

    • Andrea
      I hope my post does not further reinforce the non-eligible/eligible PPM divide. I have no problem with eligibility as an ‘opt in’ for both midwives and women. In general there is no difference between the practice of eligible/non-eligible midwives… at least not the ones I know. My point is that it should remain AN option not THE only option.

  20. Babs says:

    Rachel, Once again you have drawn out the most fascinating and most frustrating parts of private midwifery and the reduced choices for the woman. Teresa has also responded so eloquently in drawing out the open hostility and obstruction from within our own profession to private practicing midwives.
    I am an eligible midwife who has been within the fight from the beginning. Through my industrial network in Queensland changes were made to the Nurses Award to enable different ways of employing midwives to ensure continuity beyond the typical nursing shift work model of care. Because of that role, reporting, negotiating and supporting other midwives and nurses, I have been vilified within those nursing structures. Any form of harassment and mobbing I have experienced. I gained eligibility to enhance options for woman having affordable care. I blindly thought once hospitals were ‘directed’ to play the game and collaborate they would do so. But guess what? These same decision makers – medical directors and NUM’s are these same nurse ‘leaders’ who are now blocking my access to these two hospitals I was connected with. Seems I am labelled difficult and obstructionist and would never fit in with their systemic control they have over their medwives.
    I elected to forget about hospital access and continue with home births to maintain eligibility but that reduced woman’s choices. That did not sit well with me. Not many choices left to consider. Either I move back to NZ and after 34 years working and living in Australia, married and having adult children born here where does that leave me for setting up retirement in 15 years? Or do I suck up my ‘eligibilty’ and return totally to the hospital system.
    I was recently chastised during a performance review in a rural hospital for being ‘too good of a midwife that women ask for you’. I don’t have too many ‘friends’ there as I practice in partnership with women. I enjoy working to high standards of care. I enjoy being ‘with woman’ in working with them to achieve the birth they want, I give so much of self that there isn’t much left to share at the end. I am diligent, I follow guidelines- ACM and Hospital yet I am being asked to lower my ‘popularity’ by reducing my standards and relationships. A rock and a hard place. You have written so well about the professional risk of following these changes and I hope I have written about the personal sacrifices and cost to self I have endured. Women need to know they will have much less choices if they accept what is currently on the table.

  21. Juli says:

    Thank you for this interesting but sad insight into the Australian system. I’m following your blog from the other side of the globe, from Germany. It seems to me, this phenomenon concerning the regulation of midwifery practice is a global one…
    You referred to Ireland and the UK. Here in Germany we experience something similar. Especially the involvement of insurance companies seems odd to me. Our midwives have to undergo the same training as hospital-midwives. The insurance contracts available do not cover twin or breech homebirths. Every birth more than 3 weeks before or 2 weeks after the estimated birth date, is also excluded from insurance.
    They are not obliged to have any insurance here, but most would not dare to practice without insurance. Any “leagaly approved mistake” could ruin their entire life. Again the hospital-midwife has the insurance via her hospital and hospitals don’t seem too have problems with their insurance rates…
    But the self-employed homebirth-midwife has to pay for her insurance and the insurance rates have exploded during the last years. The income of midwives has not changed at all. Here in Germany nearly everybody has a public-health-insurance (most ordinary people are obliged to pay insurance-rates to the public health-system). Therefore the state negotiates the prices for any medical treatments (and birth is mostly seen as a medical case…). All midwives attending homebirths are nowadays charging some extra-fee form the mothers they care for and that fee is rising from year to year. Several midwives have already closed their practise altogether or stopped in-labour-attendance for financial reasons.

    I’m sad, that women’s choices are cut short all over the world. But – being part of the freebirth movement – I also see women, not midwives, in the duty to stand up for THEIR rights. It is never good to start freebirthing without a free choice. But if there will only be the two options hospital-care or going unattended, it might also make people think. When at least some of the formerly attended homebirth mothers come to freebirth, the freebrith movement might grow to a recognized party. The worldwide connections via modern technology will also help a lot to encourage the mothers to choose freebirth and educate themselves. I wonder (and also fear) what authorities around the world will do with this group of strong women…

  22. Thanks everyone for your comments and discussion. I am so pleased we are putting this discussion ‘out there’.
    I think that a lot of the issues would not have arisen if midwifery had been aligned with social sciences (ie. sociology, psychology, anthropology from the beginning). Wouldn’t it be great if midwifery education was based in these disciplines?

    • Denise Hynd says:

      Interesting last comment as midwifery is older and before sociology etc but also older than medicine and nursing, but recognition of such does not fit in a patriachial cuture or world!!

    • virgo0921 says:

      Interestingly, my BSN was psych based and we took sociology, anthropology, etc. What midwives need is a course about feminism-took one as a graduate student; very enlightening.

  23. Haydee Cowper says:

    I am so disappointed that the word Collaborative has been used to undermine women’s choices not to improve those choices. In my experience it is possible for women to have a known midwife, choose either home birth or hospital birth and have a good team available to her and family no matter what level of risk she is for her birth as she needs. However it is all dependent on the willingness of the players ie dr, rm, and hospital system to recognise and support the woman’s rights to choose.
    Pregnancy and birth are not a disease to be cured, they are a normal physiological event required to maintain the survival of the species…so yes maternity care should have been aligned with the social sciences.

  24. Ros Beard says:

    Hi I am a fairly ‘normal’ eligible midwife who has read this with a sense of not believing what I am reading – I think it absolutely will increase divisions and is such a shame. Last night I provided care to a woman in a hospital, as my admitted client, a woman who had a vaginal birth after 2 previous c/s, who birthed her baby through water with no monitoring, no cannula, she wasn’t ‘risked out’ we had insurance, she had her baby for free (bulk billed) and would never have been able to have this type of care without us. So I don’t know, isn’t this what we are striving for?

    • I know a few ‘normal’ eligible midwives ;)
      In my post I write about how eligibility has increased choice for the type of care you describe. Yes this is what we a striving for… and the situation you described is not the one that will be effected. What if that same woman chose to have a homebirth with you in 2015 against the requirements of your homebirth insurer? It is this minority that will be effected. I hope you don’t think my post will increase divisions – that is the last thing I want to do. Midwives need to work together regardless of how they choose to practice. Unfortunately eligibility has resulted in further division. For example, forums and midwifery groups splitting off into ‘eligible midwife only’ groups… leaving the others without a forum to discuss the issues or keep up to date with what is going on. We need to come together to ensure choice for all women – the one in your scenario and the one who decides to have a vbac at home.

      • Liz Wilkes says:

        Hey Rachael, unfortunately I think it does increase the split. Ros is my colleague and we additionally do support women to VBAC at home and I think the situation described is exactly what we are talking about. The woman couldn’t have afforded to birth with a non-eligible midwife at home even now. Anyway, every one has a different view and thats ok.

        • lindajstegeman says:

          You must be working in a very enlightened hospital/district Liz and Ros. I could certainly say that you are very lucky as are the women you support. I would say that very few places in Australia would support those options. If women’s choices were supported to that extent mostly I wouldn’t think the concerns voiced so far would be there.

        • Did you read the paragraph where I discuss the benefits of eligibility and that eligible midwives do support high risk women… it was one of the myths I was trying to bust. Our local eligible midwives support ‘all risk’. I don’t have a problem with eligibility. I also state that I support government funding for homebirth. My own Homebirth was funded by the NHS and I would not have been able to afforded a PPM (and there wasn’t any).
          My point is that you may be unable to do this without insurance in the future. A women will be unable to have you at her vbac Homebirth. Eligibility is not the problem – insurance is… for all PPMs regardless of their eligibility.
          What do you see as the future in 2015? Do you think there will be a product that covers you to attend vbac at home?

  25. Aine Alam says:

    Hi Rachelthis is definitely and international struggle, it seems to be happening everywhere.it seems to me that the problem is the the midwife’s role needs to be revisited making it clear that we are not doctors or nurses but more like coaches, navigators and advocates. I am currently working on a project in a developing country where the midwives have been displaced for so long that they are doctors handmaidens and have lost any sense of maintaining normality never mind autonomy. the struggle now is that clients and doctors do not see them as credible professionals in charge of maternity care due to their complete loss of skills on mass. Because doctors are reluctant to go to areas of poverty(economic and insurances drivers in force here too), women are dieing in the thousands. This is a global problem and I feel Midwifery Associations and feminist social activists will have to make a stand. In UK Midwives deliver 80% of babies, struggled to regain this level, thanks mainly to our clients and social science researchers like Ann Oakley Active Birth Movement and Nation Child Birth Trust. The ICM should be at the fore front with this, but I feel they are busy spending aid money in large specific parts of the world rather than have a global single approach to the decline of the Midwife in real terms. We have to work with doctors, I agree but not under them!What to do?ine

    Date: Thu, 2 Jan 2014 04:42:47 +0000 To: fetwp@hotmail.com

  26. Hello Rachel and everyone, I am writing wearing my ACM hat. One of the things that will have a direct influence on the issue of insurance and PPMs is the upcoming NMBA review of supervision. It is really important that we respond to this review when it goes ahead, which should be any time now. The ACM will shortly be issuing an EOI for members to join a working group that will guide the ACM response to the review. Please keep an eye open for more information, and if you’d like to be involved and are not a ACM member, please feel free to join up now. This issue is important for us all, not just PPMs, because in the the tender document the NMBA indicates it wants recommendations for models of supervision for midwives, not just PPMs.

  27. Kathi Valeii says:

    “Collaborative agreement” is nothing but “Permission Slip to be Supervised” under a palatable-sounding cloak. We are facing many of the same issues in the States, though most states who have those requirements just call it what it is – Physician Supervision Requirements. At the root of all of them is the age-old control of women. Control not only of midwives, but of the women that they serve.

    As more and more restrictions are placed on midwives and more and more repercussion are set out for midwives who step out of line, hospital birth or freebirth is becoming the increasing polarity here, as well. Any time we pace stringent restrictions on a woman’s right to choose, her “choices” become anything but. Under the guise of “protecting women” (from whom? Ourselves?) these restrictions and guidelines work against women and make birth less safe.

    Thanks for the overview of what’s happening over in Australia. This was a hugely informative look at the situation.

  28. Thank you Dear Rachel for your comprehensive report on whats what now.
    And there will be benefits, phew! and there will be problems…
    So, where to from here…maybe we could create a map of whats available (in terms of birth options and midwifery care) and where around Australia and then go from there….
    Any one see any value in this and want to help with collating this info?
    Thanks so much Rachel for this conversation.
    Love Jane

    • Denise Hynd says:

      My Birth website (http://www.mybirth.com.au/) has tried to do this? Perhaps all Rachel’s readers could check if the information is current there??

      • janehcollings says:

        Great website Denise! Thanks!
        Re Bowral, near where I live, they don’t have a ‘birth centre’, its a public hospital, no midwifery group practices etc, 3 labour ward rooms, very standard. xxxxJane

    • Hi Jane
      Thanks for the link Denise. I think the problem is that what is available differs dramatically depending on location. Many women have not options between freebirth and obstetric hospital. It would be great to create a ‘map’ of what’s available in various local areas… big job though to compile it and keep it up-to-date! Unless women from each local area were responsible for the information in their part of the map….

  29. Francie van der Sluis says:

    Love following your blog Rachel! I also read your thesis, Midwifery practice during birth: rites of passage and rites of protection. Was a great read. I am a postgrad midwifery student on the Gold Coast and have almost finished my studies. I am hugely passionate about continuity of care and am hoping that once I get a few years experience I can head down that road and become a PPM. Our maternity system needs a huge overhaul and we definitely need more midwives like yourself spearheading the change….time will tell.

    Francie ;)

  30. Wild Leaf says:

    This is very helpful information. Albeit, very sad. I was born at home in the 70s Along with both my sisters. I have always had a particular passion for home birth. Not many children can say they were there when their siblings were born and can remember the birth. I consider it a great privilege and my knowledge (and less fear) about a home birth came about because I was a participant in it it, even as a child. To learn about birth so young, is very precious, and to have met some amazing strong midwives so young leaves a very indelible mark. I have followed much of the regulation and ‘restrictions’ over the years, with much interest (and anger!!). I have always planned to have a home birth myself. So when we recently found out we are expecting I was very excited, to be having a baby and because i can’t wait to experience home birth. That bubble was burst when I found that regulations and restrictions would probably force my hand to birth In a system I do not agree with. My husband and I cannot afford a privately practicing midwife as we do not have a high income. To be eligible for the community midwifery program I need to fit into their criteria, I fit into all but one. The BMI. So to birth at the birthing centre I need to fit into their criteria, and again I fit into all but 1. The BMI. To have a water birth, i need to fit the criteria, again i fit all but one. The BMI. Apparently, my weight makes me high risk and will cause complications. I point out: I do not have diabetes, I do not have heart disease, I have never had high blood pressure, i do not drink or smoke, I do not have risk of cancer and there are no major illnesses in either of our families which would be cause of concern. All women in both families have had healthy births. Every antenatal blood test has been very positive. So one would think I’d be a dream patient. But my couple of extra kilos (I am by no means grossly overweight, just have a bit of extra fat here and there, and silly big boobs!!) combined with my height, puts me in a situation, where I have few options. Which is silly, because isn’t the biggest requirement of giving birth the fact that you are pregnant and need to give birth????
    For one who grew up always associating birth with home birth and one who has been a staunch defender of home birth, attending rallies, writing letters etc. I almost feel let down by those who have sold out to the medical standards and regulations. My mum was in her 40s when she gave birth to my youngest sister. Nobody told her she was too fat to give birth, or said she’d have to meet requirements first to be able to give birth. Does the government realise by putting so many restrictions on it they risk causing unregulated, and risky ‘backyard brths’ (not freebirth) which people will associate as home birth? Gah, it’s infuriating. Where are my rights as a pregnant mother, to give birth how I want? Where are the rights of my unborn child to be born in a safe and loving environment and not prodded and poked and forced? It makes me angry, and fearful. I do not have good associations with hospitals, have always found I have had to fight them to get information. I’m fearful for my children and their right to give birth how they want.
    Something needs to change, because we are forced into a cookie-cutter health system where everyone is treated the same and only the medical people have rights.

    • I am sorry that you have found yourself ‘outside’ the restrictions of the system. Are there any medicare eligible midwives near you. They can still take you on under the current regulations but would have to do some documentation around it?

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  32. Andrea says:

    I am both saddened and thankful for this information. Saddened because the possible (and likely) future of homebirth results in the loss of me having an HBAC. Thankful because it is wonderful that people like yourself are working hard to at least make people aware of their choices (or lack of, in this case). I, like many others have mentioned, agree that leaving so few choices will result in an increase in freebirth, but freebirth should not be about choosing to do it because there was no other choice. I mourn the loss of my own right to choose how to birth my baby, and I will continue to mourn this loss after the probable hospital birth of my next child.

    on a side note, are there any organisations that ALL women can join to try to overcome the issues that we face? I would like to try, in any case.

    • It seems that women like you will become collateral damage for the ‘greater good’. The big organisations seem to accept that a minority of women will be left with few options.

      The Maternity Coalition is a consumer organisation… although I think they may be resigned to the status – perhaps contact them and ask what their vision/aims are and how they would support women like you. There is also Homebirth Australia.

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  34. Hildy says:

    If homebirth is so safe, why don’t homebirth midwives form a professional defense organisation and co-insure? Medical defense organisations have done this for centuries.

    Or do they not feel that it’s safe enough to risk the house over?

    • Homebirth midwives currently ‘risk the house’ as they have no insurance. Any claim will be paid by them. Recently a Homebirth midwife was directed to pay 6 million for negligent damages. In Australia obstetrians have their insurance subsidised heavily by the tax payer. Not sure where I said Homebirth was safe… it is not safe. Birth is not safe regardless of the setting. Different risks apply to different settings. Women decide which risks they want to take. Also please note that Homebirth midwives are not a homogenous group.

      • Hildy says:

        Obstetricians do not have their insurance subsidised heavily by the taxpayer. The premium support scheme subsidy scheme only occurs when the premium is greater than 7.5 % of gross billings, and then subsidises 60% of that. So an obstetrician billing 700,000 a year (100 women at 7k each) who pays 80k in premiums, above the line, gets a 16k subsidy (or 20%), and ends up paying 54k in insurance premiums.

        That is one midwife risking her assets; the family will be unlikely to recover the damages. Did the midwife make the fact that she did not have private indemnity insurance clear to the mother?

        My point is that a midwife-run insurance company (most of the medical defense organisations are doctor-run) would be able to assess its own risk and not be trapped in medical notions of risk. The fact that midwives are not doing this suggests that they don’t have enough faith in their colleagues to risk the house on them.

        • Your initial point was about midwives having faith in Homebirth… not having faith in the practice of a bunch of non-homogenous practitioners who they don’t personally know. Personally I wouldn’t put my house at risk for a stranger’s practice.
          And midwives have to disclose lack of insurance as part of the exemption agreement. I get women to sign a contract clearly stating I do not hold insurance for Homebirth. I don’t know the midwife who got sued so I have no idea what she did re. disclosure.

          • Hildy says:

            The MDOs, though, originally required doctors to have faith in the practice of a bunch of non-homogenous practitioners that they didn’t personally know. Given how much influence we have in the training of our colleagues, isn’t the correct answer to get together with your colleagues, write up a list of things which are acceptable or not acceptable, and sign up together?

            I will ask another controversial question:
            – if a child has hypoxic encephalopathy due to cord prolapse during a freebirth, should the child be eligible for NDIS? should the child be eligible to sue their parents for birth negligence?

            Essentially, what is the obligation upon mothers to minimise risk when accessing public succour for the consequents of said risk?

          • Doctors have a history of supporting each other… unfortunately midwives ‘eat their young’ and are often the ones causing problems via in fighting. I very much doubt that our College could advocate for midwifery in this way.

            As for your questions… interesting ethical/legal dilemma. A few thoughts: It would be difficult to prove that the outcome of a cord prolapse in hospital would have had a different result – might have, might not. There are many risky things a mother can do during pregnancy/birth that will effect her baby… smoke, take drugs, take antidepressants, be stressed, poor nutrition, domestic violence… should the child be able to sue for the outcome of these choices or circumstances? What about formula feeding and the known risks… can a child sue for not being given breastmilk? Slippery slope.

          • Hildy says:

            I’m not comparing midwife-attended homebirth to hospital, I’m comparing freebirth to non-freebirth. I’m imagining a situation where a husband disagrees with the decision to freebirth but is unable to do anything about it. It would be extraordinarily difficult to prove a cord prolapse in that situation, though – but if the child is disabled, and is temporally associated with freebirthing, should the husband (as the next friend of the child) be entitled to sue the (presumably now estranged) wife?

            The whole topic gives me the squicks because of the notion of controlling women’s bodies – but I also can’t say that I like paying higher taxes for things like the care of disabled children of consanguinous marriages, etc.

    • Claire Hall says:

      Hi Hildy
      there is not a large enough base for midwives to do as you suggest. The percentage of home birth midwives is very small and it is not a financially viable option. The college did in the past advocate in this way, and they lost that insurance in late 90’s? (can’t remember the dates).

      The “suing” that occurs is usually the only way a family of a disabled child can gain the extra funds that they need to care for that child. The idea of a husband suing the wife only makes sense if it is he that will be caring for the child and it is she who has all the money. I understand the thought about these higher taxes because of the disabled – especially since many might think the injury was “caused”. Aside form the fact that this is highly unproven and there are far more in the system suffering from these sorts of disabilities than from freebirth (you object to paying higher taxes for them too?), what about those left disabled from car accidents where there was no fault of the driver that caused the accident was uninsured? diving accidents? the surf? snow skiing? The list goes on and on and on.

      I think Australia going down the American route of only caring for themselves and ignoring the suffering of others is not the Australian way. Apart form the fact that any injury from free birth will not be a cause of higher taxes, (too miniscule to make a ripple), I am rather concerned at the increasing reluctance of Australians to care for the poor and disadvantaged.

  35. lara says:

    Hi Rachel, Could you please recommend an independt midwife in Melbourne? We are new to this country. I would like to have a homebirth. This is my second pregnancy. My first a natural birth at a hospital overseas. Thank you so much. Lara

    • Hi Lara – I haven’t worked with an midwives in Melbourne so can’t make a personal recommendations. I suggest linking in with mothers’ groups / homebirth groups and asking them for recommendations… then meeting up with a few midwives to find someone you click with. Good luck :)

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