Updated: August 2023
This post was first published in 2014 during a time of big changes to Australian midwifery. I come back to update the content from time to time. Adding changes rather than editing the initial text. So, this post offers a timeline of a shift in the way homebirth midwives are able to work. There was and is a lot of confusion about what happened and I have attempted 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 and/or requested by women. 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 and 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 needed to engage the services of an ‘eligible midwife’ [now called ‘endorsed’]. Note that rebates were 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 had to apply to AHPRA for notification and demonstrate that they met the requirements which were:
- 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 (5,000 hours)
- 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
It could be argued that these requirements (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 was often misunderstood, with many believing that you needed be eligible to be a PPM and attend homebirths. This was untrue, and many of us continued to work as described above, choosing not to be ‘eligible’ for a number of reasons. There was also an assumption that an eligible midwife was ‘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 initially resulted in a number of changes. Firstly, it increased women’s access to continuity of care and gave them access to rebates for maternity care via an eligible PPM. Many midwives set up as PPMs and midwifery group practices began popping up everywhere. Some midwives continued their homebirth practice with the additional benefit of women being able to claim rebates if they wished. Other midwives set up new practices. There were so many different ways in which eligible midwives worked… 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 came at a price…
Collaborative Arrangements
In order for a woman to claim medicare rebates for care by an eligible PPM, the PPM needed to have a collaborative arrangement. The nature of this arrangement 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 because 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. That this signed collaborative agreement made it through despite opposition from all midwives and consumers ‘at the table’ is a testimony to the power of medicine in these ‘negotiations’. Some midwives thought that if they secured eligibility they could change this 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 walking away and losing eligibility. Instead, the types of collaborative arrangements midwives were required to have were determined as (Dept of Health):
- being employed or engaged by a medical practitioner or an entity that provides medical services; OR
- receiving patients on written referral from a medical practitioner; OR
- a signed written agreement with a specified medical practitioner/s; OR
- 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. In addition to a collaborative arrangement with a doctor who provides obstetric services (as above), a PPM had two further options for collaboration:
- 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
- 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 controlled access to medicare for PPMs.
Midwives were pretty resourceful, and many found ways to make this work for them and the women they care for. However, it was very dependent upon the people and organisations providing collaborative arrangements. Because it was so complex, there was a lot of confusion and misunderstanding. For example, some believed that a medicare eligible midwife could not care for a woman having a VBAC. This was (is) not true. She could – just as any PPM at that time could. The PPM may not have been able to secure a collaborative arrangement to do so ie. there would be no medicare rebate for that care. However, in some cases medical practitioners or hospitals did agree to antenatal and postnatal care by a PPM for VBAC women. Women needed to discuss options and boundaries with their individual PPMs regardless of eligibility. This was (is) part of negotiating the mother-midwife relationship.
Eligibility and collaboration remained an ‘opt in’ choice for both midwives and women. Personally I chose not to ‘opt in’ because I felt that the collaborative arrangement requirements were 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 were available – eligible and non-eligible PPMs – women could choose the option that works best for them.
However, this choice disappeared in 2015 (see below)
Professional Indemnity 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 requirements. Long story short, following a lot of protests and negotiations a compromise was found. Two insurance companies stepped in with PII and we had two products, both excluding homebirth. MIGA only provided insurance to eligible midwives and covered antenatal care, labour in hospital/birth centre and postnatal care. Medisure insured any PPM for antenatal and postnatal care only.
Because there was no cover available for homebirth, the government put in place an exemption for PII until June 2015. Not surprisingly, neither insurance company jumped at the chance to offer PII for homebirth. The NMBA published a Report on PII for Midwives which analysed the issues involved with offering an insurance product that covers homebirth with a PPM. The difficulties centred 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 included a lot of discussion about ‘risk’ and ‘risk assessment’. It also suggested 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 were already being faced in the United Kingdom by women and PPMs.
There was no official response to the insurance report from the ACM. However, the 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, civil law and criminal 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. 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?
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. 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.
Update: March 2015
Anecdotally, from my own experience / contacts – private practice midwifery is shifting. There are increasing numbers of medicare eligible midwives/midwifery groups, and some are gaining visiting rights in hospitals. This is great for women who want continuity of care and a hospital birth. As these midwives are increasingly ‘networked’ into the mainstream maternity services they are more and ‘risk adverse’, particularly in relation to homebirth. Due to vexatious reporting and the involvement of hospital staff in the care of their clients, PPMs are being very careful about what they are seen to take on. In addition, PPMs without medicare eligibility are in decline – either becoming eligible or stepping out of practice. The result is that many woman are left without the option of midwifery care for a homebirth e.g. women seeking support for VBAC.
Update: April 2015
The government have extended the PII exemption for homebirth until December 2016. Meanwhile Medisure (Vero) announced that they are withdrawing their insurance product for PPMs (antenatal and postnatal) from April 2015. PPMs who already have insurance with them can renew up until June 2015 ie. ending in June 2016 at the latest. This is the only product available for non-eligible PPMs. MIGA will only insure medicare eligible midwives. All midwives must have insurance for antenatal and postnatal care to fulfil registration requirements. Without it they cannot practice. This move will effectively prevent PPMs from practising without medicare eligibility and reduce women’s options.
Update: June 2016
It looks like the PII for homebirth will be extended for another year (again). Meanwhile, non- eligible midwives have ceased practising because the only PII product available for antenatal and postnatal care is for eligible midwives only. The ACM are attempting to get a Midwifery Practice Scheme approved through Queensland Health which potentially could provide all PPMs with insurance cover – in Queensland at least.
Update: April 2017
I’ve tapped out of Private Practice Midwifery and I’m tapping out of attempting to keep up with the constantly shifting landscape of increasingly complicated regulation. The following is my personal interpretation of what I am witnessing at this point in time.
Various frameworks, policies, guidelines and standards for PPMs have been issued by NMBA and ACM – a complex web of red tape that PPMs must navigate. This web is so complex that organisations have been set up to interpret and explain the all new rules for PPMs (for a fee). The situation reminds me of Foucault’s concept of ‘power/knowledge’. I take my hat off to those midwives who have stayed the course and are attempting to provide woman-centred care in the middle of this systems-focused bureaucracy. It seems that PPMs are increasingly being forced to ‘tend the needs of the institution’ rather than the women who employ them.
The changes to regulation have made PPM very difficult to sustain outside of a large-scale business model ie. private group practices based in premises rather than in women’s homes. Many PPMs have headed back into the public sector unable to sustain their PPM practice. The ‘gap’ payments are increasing for the homebirth element of care (not covered by medicare rebates), and it is now more expensive (locally) for women to have a homebirth than it was before medicare rebates. This has decreased access to homebirth with a PPM for many women.
Small-scale PPM’s days are numbered, particularly as 2 care providers are required at all homebirths. In many locations there are simply not two care providers available – e.g. in rural and remote regions of Australia – again reducing women’s access to homebirth with a midwife. PPMs without medicare eligibility can now only act as ‘second midwives’ at a birth, but only if they are not involved in any antenatal or postnatal care of the woman. Personally I would not feel ‘safe’ attending the birth of a woman who I had not developed a relationship with nor had a good understanding of her pregnancy so far.
Because PPMs are now so heavily networked into the mainstream maternity services with collaborative agreements, hospital credentialing etc., they are very much on the radar. There will be an audit of PPMs to ensure compliance with all of the new rules – an audit that is above and beyond that of any other health care provider on the AHPRA register. This places midwives in a very vulnerable position. Although there are pathways that PPMs can follow to support women outside of recommendations (e.g. VBAC homebirth) they are very complicated beauracracy-wise, and are risky professionally for the midwife – who may be blamed for any outcome relating to the woman’s decision. This has resulted in many PPMs refusing to take on any women for homebirth who are not entirely ‘risk-free’ as defined by the various frameworks, policies, guidelines, etc. The aim is to protect the midwife and the business. This has resulted in many women being unable to access midwifery care. Freebirthing is on the rise as not all women will change their personal perceptions of risk and head into he nearest hospital.
I often get asked if I miss private midwifery practice and/or attending homebirths. The answer is that I miss how it was. The simplicity of being employed directly by a woman, providing woman-centred, evidence based care in alignment with clear professional standards and the law. However, those times are well and truely gone and I just don’t have the energy or time to work within the new web.
Update: August 2023
Well, it’s been a while! I thought I’d pop in with a brief update since we have just had yet another government exemption for PII for homebirth. Today, only endorsed PPMs can provide midwifery care outside of institutions. The term ‘eligible’ has been replaced with ‘endorsed’. Only endorsed PPMs can access the PII for antenatal and postnatal care required to activate the homebirth exemption. Many of the old-skool PPMs have left practice (which was probably a goal) and the homebirth landscape is very different.
To be endorsed, PPMs must have completed a prescribing course and completed 5,000 hours of practice. Of course, most complete those hours in a hospital setting. So, we have PPMs who are new to homebirth but indoctrinated in hospital practice. They can struggle to unlearn practices, and to escape a sense of belonging to the institutions. In some cases, homebirths are being ‘managed’ like hospital births resulting in hospital outcomes. However, women are adapting to this new landscape and there is a huge rise in freebirth and unregistered birth workers. I think the homebirth community is actually growing as women reclaim childbirth outside of institutions and regulations.
So, I’ll leave you with prediction for the future of midwifery and homebirth…
The PII exemptions will continue until public homebirth programs are more widespread. Of course, these programs are heavily restrictive and overseen by obstetricians. Most women don’t qualify. However, once women have access (on paper anyway) to homebirth, the exemption will be removed. There will be no PII available. Therefore PPMs will be unable to attend homebirths. The argument will be that women have access to ‘safe’ homebirth via the public system so don’t need PPMs. I hope I am wrong.
I just want to cry. How can it have come to this?
Thanks Rachele for your skilled writing. Crying is good “disillusioned” releases tension and helps with some of our fears. However, standing strong together and doing what we do best regardless, is the strongest way to show we will not be put down, our skills will not be wasted and the women who choose our services will have their needs met.
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.
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.
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!
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.
Did you even read the article?
Clearly not 🙂
You have just embarrassed yourself on the world wide web. If you don’t read the article, you should not comment.
Are you kidding, they are complaining because they know it means they won’t be able to help women the way they want to! So many women who want home births won’t be able to because independent midwives, registered or not will not be allowed to attend home births without breaching their license( or whatever it is that makes them legally able to practice). They are trained qualified midwives, went through the same education as hospital employed midwives, who have decided to work independently rather then in a hospital setting, they are (some aren’t) registered, the no registered ones firmly believe in women’s rights and are not willing to budge or compromise, and the ones who are registered are simply so in order to provide more option’s for low income women etc, but even registered midwives will be affected by this, so you just sound ignorant and stupid right now, read the whole article and understand it before you comment
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 🙁
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!
For it to be post peak oil we’ll need better coverage – my midwife drove for 3 hours to get to me!
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.
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!
Have you contacted the ACM about this? I am unfamiliar with NZ but it seems like a different world despite it’s geographical closeness to Australia
As I said I have tried ……………………..
It is so frustrating that our College seems to be ambivalent about all this. 🙁
Sarah Stewart at ACM has practiced in NZ so does understand and will follow -up!!! Yes!!
Hello Denise and Rachel, just a quick note to say the ACM is following up this information from Denise. We’ll let you know what the response from Bill Shorten is. cheers Sarah
Thanks Sarah
I look forward to hearing the response.
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.
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 🙂
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 🙁
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.
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.
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.
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
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?
Yes continuity of care & continuity of carer I believe. So relationship, trust & education can be built.
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
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’!
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?
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?
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.
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.
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!!
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.
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!
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.
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.
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…
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?
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!!
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.
great idea Virgo…feminism and human rights.
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.
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.
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.
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?
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
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.
“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.
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
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??
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….
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 ð
Thanks Francie
Our maternity system needs passionate new graduate midwives who won’t accept the status quo ð
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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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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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.
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.
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.
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.
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.
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 ð
As a midwifery student at Maternidad La Luz in El Paso, TX, USA I see a lot of mirrors to the progression of midwifery in the US and Austrailia. It makes me want to scream inside the way that women’s ACCESS to birth providers outside of the medical system is what is threatened, not to mention the livelihoods of those of us who dedicate our lives to protecting the portal of birth. The Medicare system here has likewise put many regulations on who can receive assistance for home births and the midwives receive 1/4 of what they usually charge if they want to take medicare clients. Also, each states laws are different and in particularly bad states home birth midwifery has been all but driven out entirely and MULTIPLE MIDWIVES CHARGED WITH MURDER in the past 5 years. Depending on which state we work in our rights to give care at home is faced with jail time and more and more rules are becoming LAW rather than REGULATION making offenses criminal.
And the real truth, outside of all this banter and men writing laws is this: Each women has the fundamental right and ability to choose for herself who will attend her birth. There is no one outside of her who needs to step in and dictate who is suitable to do that and who is not. If we have to go underground to offer women what they deserve, that may well be what happens- but it will leave many many women out of a better option. There is a lot of activism in the form of documentaries being made of late, and i pray everyday that they lead to the type of activism and protests you speak of. Also I will dedicate my work to connecting with sister midwives and forming a network of solidarity and protection for one another! A new era is upon usâ¦
Thank you for your post!
So sad to know that these issues are international ð
“And the real truth, outside of all this banter and men writing laws is this: Each women has the fundamental right and ability to choose for herself who will attend her birth. There is no one outside of her who needs to step in and dictate who is suitable to do that and who is not.”
So true! ð
Hi Rachel,
Thanks for your post, much of which is insightful. You are brilliant and a huge asset to midwifery in Australia.
However some of what you have written above is not fact. In regard to “collaborative arrangements”, you accuse:
“Disappointingly midwives and consumers (the ones at the table) agreed to this requirement in order to gain eligibility”
I was at the table and this is simply not true. Consumer, midwifery and nursing stakeholders united against the âcollaborative arrangementsâ amendment and lobbied hard, but were unsuccessful. We got a Senate review on this and made submissions and spoke at the hearings (all recorded in Hansard). Some of us worked for months on this issue. There was no point at which the non-medical stakeholders agreed to this. Please edit what you have written about this.
I would also like to challenge your statement that:
“Personally, I think they should have refused to allow medicine to control midwifery practice in this way, even if it meant losing eligibility.”
This wasnât an option in our power. We (the non-medical stakeholders) did not have the power to refuse, veto, stop the reform process. Perhaps we could have walked away from the table and let a practice nurse model be developed, as the AMA proposed. Perhaps we could have become such a political liability that the Minister gave up and dropped the whole thing.
How would your proposition have improved things for women or midwives now?
It’s not hard to see what’s wrong in Australian maternity care, and it’s easy to be critical. However, trying to make things better is risky. You have to work very hard, for a long time, and you never get all of what you want, sometimes none. But if people don’t try, you can be sure that the big end of doctor town will take the lot.
Be cautious about the language of powerlessness – which I think you have indulged in above. What we need is real strategies which propose solutions in the real world, and people willing to do the work to make them happen. Look at what the New Zealanders achieved, with strategic thinking, strategic partnerships and political engagement. We can achieve something like the NZ model in Australia, but we’ll need to get onto it quick.
Best wishes from Bruce.
Hi Bruce
Thanks for putting your concerns in writing, I know we have discussed some of these issues face-to-face. I have a amended some of my post based on your information. I rely on information given to me about what happens ‘behind closed doors’ – clearly I was misinformed about some details. Although I am not sure what nursing stakeholders were doing at these meetings… medicine and nursing having a say in midwifery – it doesn’t happen the other way around.
I was told to my face by more than one member of ACM that they accepted the signed agreement thinking that they could change it afterward… so I’m leaving that bit in. I had already linked to your article in the post.
I do think that if ALL of the midwives had walked away from the table and carried on as before (without eligibility) AMA would have had less power. They could develop their practice nurse model – we could ignore it. “Dropping the whole thing” may indeed have improved our current situation – all PPMs would be equal. The ‘non-eligible’ would not have been cut free alone with this insurance withdrawal. Eligibility has divided PPMs and left the small group who continue to practice (as they always did) vulnerable and the women they care for with less choice.
“Be cautious about the language of powerlessness” – I do feel powerless and I don’t have the answers. I have witnessed first-hand the fall out of these reforms for both women and midwives. I can no longer practise midwifery myself. This is a very personal issue for me and many of my friends. Most do not understand what is going on… many don’t care because it does not impact on their choices or their way of practising. I’m not sure we can back out now and recreate a woman-centred, rather than medicine-centred/insurance-centred PPM system – which is where I see us heading. If you can think of any way in which I can help please let me know.
Dear Bruce and all,
Thank you for your years of effort! Be ware of blindly emulating the New Zealand model as their Intervention rates are almost as high as Oz because most women labour & deliver in secondary and tertiary units even with a LMC midwife. In 2012 Homebirth was only 3% of all NZ births, plus 10% used a primary unit and there is no way of knowing how many of these had physiological births? Statistically a ‘Normal birth here can be induced, augmented, have an epis or haemorrhage and most have active 3rd stage ! Midwives, doctors nay everyone here, back in Oz, the world over needs to unlearn medical care of pregnant women especially in Labour. If we appreciated the importance of the labour hormones, that where and how the woman labours strongly influences outcomes via their impact then we would encourage most women to nest, is stay home with a true midwife! The impact of Place of Birth needs to be added to the change agenda in Australia along with a National Injury and Disability insurance scheme as I said before then emulate the New Zealand model!
Language is very important. Open, transparent and being accountable doesn’t appear to be in the vocabulary of many of those sitting around that table and the subsequent consultations. Indeed Rachel what you have written is so very right. Sad you felt you had to change what you wrote.
Haven’t we got the Practice Nurse by default because so many of us have dropped out playing the ‘games’ of trying to meet the needs of the client, putting us at risk of dealing with AHPRA (2 weeks to respond is very stressful) when the existing system puts in a complaint or having to deal with AHPRA because the consumer complained to them for ‘not being able to give them home birth I wanted’ when, by following the guidelines, you transferred their care back to the hospital with the offer to remain with them as a support person. Taking 8 months to be cleared of ‘wrong doing’ for a solo practitioner is a heavy penalty. Access to a facility requires one to be able to declare ‘be of good character’ and have no ‘outstanding matters’.
The push for group practices, led perhaps by those sitting around these said tables, removed individualised care, holistic care and mutual respect for the woman’s decision making and autonomy.
Diversity of our practices has been targeted. Those who are knowledgeable around alternative complementary therapies which many clients seek and desire were seen as bad by the traditional medical hospital gate keepers. Medical and nursing domination? This debate is not about just home birth vs hospital birth. Informed choices and respect for clients decisions must be at the centre of all care provided by all practitioners.
Insurance companies are all about reducing risk. Child birth is risky business no matter how one practices. The insurance industry has had too much say on how midwifery practice is to be practiced. They totally dominate. Child birth is a healthy life changing event, it is not an illness.
The decision makers have effectively divided midwifery and midwives in private practice into eligible and non-eligible, based on $$$, collaboration (AKA conformity control) and insurance. Midwifery as a whole has been divided into hospital very controlled midwives practicing in a medical model and private practice based on practice ‘Guidelines’, medical dominance by collaboration and insurance ‘Guidelines’ rather than evidence based holistic care respecting clients autonomy we were once able to provide. Micro-management and control dominates.
Developing a strong midwifery workforce culture that is responsive to client needs is essential. Why is it that many changes to midwifery practice requirements only apply to private eligible midwives? Why is it that so much focus on requirements by regulators AHPRA, by ACM and by MC is on the eligible midwife and not applicable to ALL midwives?
New Zealand got what it has through Prime Minister Helen Clarke changing how women could decide who their LEAD carer was to be virtually overnight. Women were not unrealistic in their wishes. Child birth was seen as normal and not based on illness. That culture was already there and didn’t require control or developing. Midwifery and midwives were already working to the full scope of practice. Their strength was their immediate knowledge, skill and practice professionalism was in evidence. They were engaged, valued and respected by the community. Australia has a system based around insurance and a Medicare rebatable item number for each single contact. Fragmentation of care exists. New Zealand has the funding based on the woman’s pregnancy journey with the woman the focus of care. Not based on risk.
Those that sat and perhaps still sitting around the table need to take a cold shower, reflect and just stop accepting second best for women and their families. Refocus and put women at the centre of the debate rather than secondary to the medical and nursing cultural divide influenced by workforce shortages. Walking away takes courage but is often better than accepting the alternatives. Women and midwives are paying the penalty of the decisions made prior to 2010!
Yes! Yes! Yes! (and thank you) ð
Maybe you were in NZ in 1990 but Funding is not that simple for example a DHB can use their funds for primary maternity care for everything but women. So there is no promotion for homebirth and lots of primary units being shut or areas with none! As for community regard for midwives in NZ; recently 2 women died of rare & hard to diagnose Amniotic Fluid embolism one in the care of an Obstetrician in the hospital the other started labour in a birth centre but transfered with her midwife to a tertiary hospital. Only the latter resulted in months of sensational media, a bias coroner’s case and more media, so the midwife has now left the city and possibly the country!
I hear you Denise. Media sells newspapers. I followed the ‘story’ on AFE. Such tragedy having only seen a handful that survived in my other life as an Intensive Care nurse at RBH. I was shocked at the Coroners comments. Medicine and law are never a good mix. Midwives make good targets. We, the public, never hear the medical misadventures. Who has an interest in health when people have Dr Google and Nurse Facebook as their resource these days.
The good work of the 90’s steps on maternity reform is slowly being eroded in NZ. Many of those primary units are being closed because of the lack of midwives confident in primary health care. The midwifery identity of being autonomous in decision making is being questioned & challenged. Recruiting to isolated, not attractive areas are not easy to solve.
I have first hand knowledge of some of the NZ Med-wives moving across here. They fit the medical culture of doing more with less, quick through put. One constantly questioned the work load of 40 clients FTE per midwife (written in the Award) in our team as she had a ‘wonderful’ time with 120 clients each year North Auckland. She got the ear of management. I left the Team as I could not work with poor quality care. Then you saw her practice – time limits, preference for multi’s, intervention, epis- as they were quicker – very superficial ‘care’ and poor relationship with woman and certainly none for this disadvantaged community our Team was set up for. She shared when she left NZ she threw her phone into the harbour to ‘enjoy’ freedom then at every step undermined efforts to ensure the Team providing quality care by manageable work load.
NZ midwifery has some good elements but sustainability with manageable workloads needs work. Learning from the experiences of others like yourself Denise will assist. The leaders around the table seem to have the eyes closed, ears covered and lost the tongue to speak and certainly domination by medical, nursing & insurance interests are the priority, not the woman and not the midwife!
Thanks for this passion. It is a refreshing read on the back of the confusing and expensive road to eligibility. I have recently become ‘Eligible’ and all that has changed for me is the weight of my purse. In order to help one of my friends to have a home birth this year I had to organise PII with MIGA. I work in a rural area with low birth numbers and a lot a beautiful people without much money. After I have fulfilled my Eligibility obligations and paid the PII I will have to care for another 3 women before I cover my costs. The rural woman is even less likely to have access to am MMP with the new system and unless there is some kind of low cost PII midwives like me…who were already providing homebirths on a shoe string will cease to exist. It saddens me that I have had to bring insurance expenses into a conversation with my friend and birthing mother who should at this stage of her pregnancy be focusing on all that is good and warm in her life.
Thanks for sharing your experience of the changes as a rural midwife
What do you think of this>
https://newmatilda.com/2016/06/10/gaye-demanuele-and-the-politics-of-homebirth/
A good breakdown of the current political situation of homebirth in Australia.
It is not that long ago that most Australians birthed at home supported by their families! My mother, her siblings and her cousins (my grandmother was the eldest of 5 girls) were all born in my great grand mother’s house with a midwife and supported by her aunts and grandma in the west of Sydney in between the wars! Some how Australian’s need to be reminded of how loving and safe this is compared to the production line of a hospital that how I think of everyone reusing the same clinical rooms and beds! Bring back the Sullivans with starting with a period homebirth on TV maybe?
hi,I read some of the article and some of the comments; only to add to my disappointment and frustration regarding the situation in India. Nearby is a government doctor, personally going around in a Jeep into the interior villages ,dragging out pregnant tribal women in the last trimester [who are hiding because they believe and practice natural birthing methods] to ‘deliver’ at the local government hospital. In India,even the rich and educated don’t have the option of a birth-plan or choice between Ob or Midwife. There are only 2 natural birthing centers in the whole country. In fact here, midwifery is like a demeaned profession- a 2-yr course for 17 yr-35 yr olds, in contrast to 4yr nursing and 5yr medical learning. Mommies cannot hope to learn. I graduated from the 2nd best institution in the country- as a physical therapist. Logic from Bio-mechanics indicated to me that something is terribly wrong with the way doctors conduct deliveries, when I was induced with pitocin for SROM, and assigned to a ‘delivery table’ in Dec,2009- baby # 1. Till then I’d been reading books written by the ‘western’ world and had no idea that Drs here did differently, or are 30 years behind their white counterparts. [They’ve moved into ‘mandatory’ institutionalized births only recently, where does a mother get to talk about ‘feelings’ or ‘preferences’!] Baby came 20 minutes after pitocin was withdrawn so as to post me for C-Sec, only 15 hours after ROM. Baby 2 [2011] and 3 [2012] had medically-unassisted natural labors but 10 minutes on that table to ‘be delivered’ again- and that was agonizing enough to make me cry out, and with it, of course, the ‘fashionable’ episiotomy which is handed out to every woman, like it or not, for daring to get pregnant ! Husband AV and I, prayed a lot and and decided to labor at home for baby 4, then went on to birth him at home- unplanned, unassisted [Oct 2014]. We had a cord prolapse: I felt my ring of fire [1st time!], then heard AV say,it looks like cord. I paused for 2 seconds asking heavenwards, “Now what?”, then I pushed, [contrary to what I had desired after reading about Dr.Odent’s Fetal ejection Reflex,] and baby’s head was out. Next contraction, he slid out, next- the placenta. The kid actually smiled at me !!! BUT…….our doctors were not so pleased. Hmm, now baby 5 is due in Nov- and many have freaked my husband ‘out of’ home-birthing again. An electronics engineer-turned-computer-professional, he has no knowledge of Anatomy , let alone Birthing complications.But he has been a wonderful birth-partner, unlike most men in India. All i was trying to say- the cord prolapse only reminded me about O2 compromise and set me pushing, instead of breathing out the baby- had a tiny tear therefore. And I was on hands and knees for most part of labor, stood up at 2.45 am to birth- afraid that AV would not know which is what!! Anyways, baby was in my arms at 3.02 , I had a yummy,quick hot water bath at 3.10am and we were at the nearby hospital for postnatal care by 3.30am. It was the best experience- I am wishing baby 5 is also birthed naturally next month.
But many, many thanks to you, Dr Rachel Reed, We were both reading your articles from Jun to Sept 2014 which changed our perspectives regarding nuchal cord,amniotic fluid,etc. Blessings to you for sharing valuable information with parents like us. Hope you’ll think about India too, while you strive for justice in Australia.
The maternity systems are broken worldwide – and far worse in places like India than in Australia (unfortunately). We all need to work together to make worldwide change for women. Thank you for sharing your amazing instinctive birth story. Good luck for baby number 5 ð
Thanks for putting this together, great read. Are you familiar with the Community Midwifery Program here in WA? Seems like a great option for women looking for continuity of care with the option to birth at home all covered through the public health system… would be great to hear your thoughts ð
Yes I am and have heard great things about the program! :). This type of service should be available to all women. I’m guessing there are parameters regarding who can birth at home eg. no VBAC or post-term? I’d like to see something like in the UK where maternity services meet the demands of women even if the woman chooses options that are against recommendations. The woman should take responsibility for her decisions rather than the care provider. Those are my thoughts ð
There is screening involved, from what I understand they do VBAC on a case by case ð It would be great to have some kind of system like that, seemingly the restrictions on home birth and other choices are driven by fear (of being sued) and not by research or evidence. We would need some kind of disclaimer signed by the mother to negate the midwifes duty of care right?
I also think a lot of it comes down to culture and education of mothers, knowing the facts and research about the interventions that are offered and being able to weigh up the risks of not having that intervention vs the risks of having it, the latter seems to not be up for discussion as much! Ideally this education would come from whatever provider you choose not just a birth centre/homeburth midwife who’s into “alternative” methods.
Would also be interesting to know the history/beginnings of the CMP, is there scope to have it implemented in other states…
I meant HBAC rather than insisting the women go to hospital to attempt a VBAC which I understand it what happens now on the CMP? ( I maybe wrong) For women who have been traumatised in a hospital labour which ended in a C/S it is hard for some women to go back there!
As someone who was supportive and involved with and on the Community Midwifery Program in Perth when it was run by women and midwives, it did take women who wanted VBAC and other situations which do not meet the current restricted parameters! But that was when the midwives brought their own PI Insurance which became unattainable after 9/11 when Lloyds withdrew underwriting of this policy from a Queensland company! It was this situation and midwifery politics which saw it eventually come more directly under the management and control of the WA Health department and it is not coincidental that concurrently WA homebirth midwives became to object of various forms of litigation and restrictions whilst the transfer and other outcomes of this program also changed!
Yes women need to be encouraged and supported to take responsibility for their actions and decisions as per the Code of Homebirth Australia! One of the problems of practice in NZ is that there is no community acknowledgement for example in the NZ Health and Disability Code of Consumer Rights there is no mention of any responsibilities for the consumers. I feel lack of discussion about the need for women to take responsibility is not only disrespectful of women’s agency, but also inconsistent with the reality that it is or should be women who give birth; healthy babies are not naturally delivered by midwives, doctors or anyone else! And women who “want” a natural labour and birth need to believe in or surrender to their instincts, and for most this takes trust that their bodies do and can work as needed rather than reliance on another person that he or she will get her through the process! I am saddened when a women gives birth before getting to a hospital or other situations where some-one unexpectedly catches the baby and they the catcher are lauded as having delivered or saved the day but not the women who gave birth!!
Many Blessings and a Huge Bear Hug for everything you have donde and will continue to do; your work has more impact that you know; please do continue writting; your blog had teached me a whole lot; thank you very very much!
Thanks Diana. Yes I will continue to write my blog x
Hi Rachel. So sorry to hear you will no longer be serving women as an expert midwife. Such a sad loss for women, and for midwifery. We are still keeping going in our area, and we thankfully have a wonderful Director of O&G locally who is absolutely supportive of women’s right to choose, and home birth. Many families are thrilled with their empowering births, and our clinical outcomes are enviable by anyone’s standards. Yet…. the local hospital midwives who see us at work continue to be the strongest and loudest critics of private practice midwives and the women who choose to use our services. This I find really heart-breaking for our profession. We will no doubt be audited in this latest round of regulatory control as you discussed….sigh. Take care and best wishes. xx
I hope you can keep making a difference for the women you care for. And I hope to see the day when midwives support each other rather than oppress each other.
I’ll be focussing my energy in this direction ð x
Hi Rachel, What a loss for birthing women and your community. To have tried is much better than those that never had a go. The outlook is pretty grim when I read women being risked out or even worse being deceived by the newer ‘type’ of midwives who are clearly not engaged to the true spirit of simplicity and being with women, being guided by women. Recently read ‘these midwives were selected for their …’ as another medically co-located practice commences. Sadly the resistance within and oppressive culture is what is killing midwives love of their practice. Enjoy your new direction no matter where it leads you. Taking time to smell the flowers and knowing the joy you have given many families is indeed an honour to be cherished.
So sad. My own homebirths (vbac) with midwife Elaine Davis were in the late 80’s & I continued my connection with the Home Midwifery A Assn (Qld) for many years along with Julie Wimberley (Julie Ann Young) & others. We certainly hoped for better in those days.
I’ve stood as doula ‘with’ many birthing women since, but it does concern me to see the rise in freebirthing when these women could have so much more.
Good read. Thank you for sharing this.
Thanks for tagging me on this, Virginia. I’ve read a lot of it but not all. It’s very timely since I’m presenting on the subject of “Responsible and Radical” in November at the Homebirth Australia Conference. The birth scene in Canada has been altered by the Covid situation. Among many other things, Covid has exposed the difficulty of working within a system that can demand the practitioner take medications that the practitioner chooses to decline. Because I’m going to be speaking in Australia, I’m reviewing the devastating “trial by press” that has happened over the past 40 years. Not only midwives but also the terrible trial of a pregnant woman that was depicted in the Meryl Streep film “A Cry in the Dark”. That story should be compulsory viewing by every person interested in midwifery. . . how “evidence” and “forensics” can be corrupted. How once the press decides a person is a monster, they build their stories around that premise because it sells ad space. It’s not unique to Australia, it’s all over the world. I’m looking forward to being there in November. Gloria in British Columbia, Canada.
Dear Rachel,
So many of todays midwives and women have lost sight, nay have no realisation or awareness of the importance of Homebirth, based on a relationship between women and their midwife, has for them both individually, and for Humanity in optimally creating the next generation. Because we can not perceive or explore the wonders and benefits of our physiology when we labour and birth in an environment , that is not centred in the promotion, protection and support of our hormonal physiology. Sadly I do not think it is coincidental and unrelated that we are struggling to maintain true homebirth in this time of environmental crisis, but thank for putting this information on the record.