Midwives damn AMA-induced amendments to maternity reform
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Senior midwifery research academics, including 19 professors and associate professors of midwifery, have signed an open letter raising serious concerns about the newly proposed amendments to Health Legislation (Midwives and Nurse Practitioners) Bill and the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill. These amendments are ill-informed, conflict with current regulation of the practice of midwives, and were promoted by a medical union (the AMA), rather than the craft groups most concerned and knowledgeable about women’s needs and safety at birth. We and our colleagues are surprised and disturbed that pressure from a union rather than our medical colleagues has persuaded the government to make changes that are not informed by evidence, but appear to be based on protection of income and power. We support reform of Australian maternity services — an area of long neglected policy by previous governments and health ministers. We have serious concerns, however, about the proposal that midwives be required by Commonwealth law to have “collaborative arrangements” with “one or more medical practitioners” before they are eligible for Commonwealth-funded professional indemnity and before their services are eligible for Medicare rebates. This will effectively institute medical control over individual women’s access to Medicare-funded midwifery care. It can also institute medical control over the registration of eligible midwives. This could lead to doctors unilaterally withdrawing from collaborative agreements with a midwife, leaving the midwife uninsured, and legally unable to practise in a private professional capacity. This could also leave a woman without her known and chosen carer in the middle of pregnancy. There is no current published research that supports an arrangement anywhere in the world where a medical doctor has the power of veto over the regulated professional practice of a midwife. In the models of care that are supported by the best evidence of quality and safety there has never been the need for written agreements or contracts binding midwives to certain medical practitioners — especially privately practising medical specialists. We acknowledge the necessity for regulation to maintain safety and standards; however we fail to see how the amendment can provide a net public benefit. The amendment introduces another level of regulation of the profession of midwifery, which is unprecedented nationally or internationally. This move contravenes the international definition of the midwife approved by the International Confederation of Midwives, the International Confederation of Gynaecologists and Obstetricians and accepted by the World Health Organisation. International evidence shows how midwifery care has received the highest scientific endorsement. A Cochrane systematic review of 11 randomised controlled trials published recently involving more than 12,000 women from worldwide demonstrates that outcomes for women receiving continuity of care from known midwives were better than for women who received fragmented care from multiple midwives and doctors. The amendment proposed by the AMA ignores and throws out advice provided by high level technical working groups drawn together to provide expert advice to the Commonwealth Department of Health & Ageing on Medicare eligibility and access to the MBS for participating midwives. While restrictions imposed by legislation are not within the power of the Trade Practices Act, we believe the amendment encourages restrictive practices that contravene the anti-competitive working relationships in Australia. One professional body being given authority to limit the ability of another profession to practise is totally unprecedented and unacceptable, particularly so in this case when there is no guarantee that the generic professional given dominance has relevant knowledge or skill to do so. A legal commitment preventing midwives from working in competition with doctors negates opportunities for mutuality and collaboration. If midwives are required to form collaborative agreements with individual doctors rather than area health services in rural and remote Australia, the reforms will be unworkable. Well supported home-birth midwifery care has already been marginalised and the proposed amendments are likely to outlaw home birth. Driving unregulated home birth underground, or having a “free birth”, unattended by qualified personnel could result in potentially catastrophic covert practices where women will not be able to access the care of a registered midwife. It appears that the powerful vested interests of one professional unionised group has the potential to completely derail the government’s long-awaited maternity reforms. The proposed amendment creates a real risk that qualified, competent midwives will lose their licence to practise — at a time when we have acute shortages of qualified midwives in many areas of Australia. This is likely to further reduce access to optimal or even safe care for women and families who are currently disadvantaged and for whom recent reforms offer most promise. |
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13 Comments
When are the medical profession and the public service going to grow up in Australia and catch up with the rest of the world and allow midwives autonomy of practice? Midwives were practicing as autonomous practitioners when doctors were still using leeches to bleed their patients and surgeons were in barbers shops. Yes there are risks in Midwifery as there are in Obstetrics and Gynaecology and those risks need to be insured against for doctors and for midwives. I would much rather be looked after by a skilled, experienced, cautious, professional midwife than a new graduate doctor or an out of date country GP.
The missing part of the equation here is the rights of the unborn child. While passionate home birth advocates are beating their chests about their individual rights, the needs of the unborn child are being given second place. Nobody cares about the 98% of births that proceed safely without any requirement for medical intervention. It is the small proportion of complicated births where the intervention of qualified medical specialists is required that cause the problem. Under such circumstances the professional responsibilities on the attending medical practitioner exceed those of any midwife, and accordingly the medical medical specialist’ s capacity is the one that is to be heeded. If midwives are so passionate about becoming medical specialists, get a medical degree and then specialises as midwives if that is your passion. Then you can run a one stop shop.
The problem here is medical indemnity. Indemnities cover risk and risk has a cost. If you want to engage in risky behaviour the cost of indemnity must rise. This is only the financial cost. We do not hear midwives responsible for botched home births publicly bearing responsibility for the complications, some of which a rise from the delay involved in transporting the mother and child to a suitable hospital for treatment. Furthermore as these are emergency cases, these must be accommodated within the hospitals at very short notice, sometimes displacing the needs of others who have planned to have their children born in a safer environment. Notwithstanding the personal suffering of the parents involved, remember that it is the community that ultimately picks up cost of treating brain-damaged children through the provision of social security support. Accordingly the community has some right to control risk in this situation, and this is more important than the personal feelings of home birth advocates.
Greg you are completely uninformed - you claim 98% of births proceed intervention free??? on what planet? not here in Australia.
More than 40% of women who gave birth in Australia in 2006 had an operative birth (forceps/vacum extraction or casarean) - these carry serious risks for the baby - and the mother.
I suggest you check the latest statistics here http://mybirth.com.au before you take part in a debate you clearly know nothing about.
The issue here is choice and a woman’s right to be in control of her own body. In a country where woman have supposedly won the rights to reproductive choices they are losing the right to have a natural birth without unnecessary interventions.
Women have to fight to have a natural birth in our current system and these ‘reforms’ if passed will only make it worse.
For heaven’s sake, Greg Angelo. An professional midwife practicing home birth midwifery is going to know when to refer to a doctor, just as much as any other doctor!! Probably more so in some circumstances. Midwives do bear responsibility for their actions just as much as any doctor, in the civil and criminal courts and before professional tribunals. Midwives can’t be covered for their liability if politicians pass laws preventing them being covered!! Your professed concern for the rights of the unborn child seems to be a fig leaf for your concern for the income of the Obstetrics profession.
What a fear-filled world Mr Angelo inhabits. A home birth is “engaging in risky behaviour”? Women giving birth in hospital because it’s “a safer environment”? Home births resulting in “brain damaged children”, “social security support”? The community should “control the risk (of homebirths)”? Crikey, mate, I reckon these women who simply want to make an informed choice about giving birth have a helluva lot more balls than you.
Greg Angelo,
Getting out of bed every day exposes us to increased risk…who is indemnifying you against that ‘risky behaviour’?
Get a life.
Greg you are obviously unaware of the statistics, and numerous studies, which clearly show that women and BABIES TOO are FAR more likely to suffer an injury IN HOSPITAL than at home. Women who birth at home do so to protect their babies from unnecessary medical interventions and dangerous highly interventionist “birth” practices which are damaging to both parties. I suppose you also don’t know that less than 5% of Australian women leave hospital after an intervention free birth … are you going to tell me that 95% of births require intervention, or are you going to do some research before you comment on subjects you clearly know nothing about. Being born in a factory … I mean a hospital, is not as safe as being born at home, and no reputable study has EVER shown it to be safer.
Thankyou for the clarity you have brought to this struggle against the power politic of the AMA against midwives. It’s so immature, and distrustful, disrespectful against the qualification and experience of the midwife.
You are absolutley right about continuity of midwife care throughout pregnancy and child birth itself. I had the priviledge of this at a Melbourne birth centre in 1985 and 1986!
I thought by now every woman would have access to this service Australia wide.
Its important that everybody let their Fed. MP’s know that it’s about time we give our midwives what they need to get on with the job of assisting women to give birth. It is the most precious of relationships a woman can have.
Greg obviously watched Nicola Roxon on Q&A where she allowed the conversation to mislead the public into believing that homebirthers cost society money due to ‘hugh risk behaviour’ which requires high insurance premiums and that we should birth in hospital for the safety of our children. I choose to birth at home for the safety of my children and myself. I’ve got 5 children and cannot afford the time to recover from a traumatic hospital birth (nor do I want to). If I had have had my third baby in hospital I would most likely have had a second caesarean, so i changed to a homebirth to ensure continuity of care and the very best care and advice for me and my babies. If you want a normal birth, employ an expert in normal birth…a midwife. This intelligent, experienced and educated expert, will also be able to advise you when things are not normal and support you to make appropriate choices for the safety of your baby and you. You have to be an expert in normal to know when things are not…wouldn’t you?
Lets talk here about the impact of interventionist births.
To intervene in a birth unnecessarily sends a message to the woman that somehow her body is faulty and that she is less than capable. This message often leaves a woman with physical pain experienced at a higher level than expected, it leaves her with breast feeding problems and leaves her feeling unequipped for motherhood. If we are talking here about safety then let us focus on a process that empowers women as mothers and leaves them feeling strong and confident. This process should include a practitioner the woman has a relationship with, someone she trusts. The process should include her preferences being listened to and her choices being well informed.
Currently in Australia suicide is the biggest post partum killer. The levels are rising on a par with the caesarean rate.
Look to the Australian Institue of Health and Wellbeing (AIHW) for reliable stats about maternal mortality and morbidity.
“It is the small proportion of complicated births where the intervention of qualified medical specialists is required…Under such circumstances the professional responsibilities on the attending medical practitioner exceed those of any midwife” No argument Greg, midwives and women know how skilled you are and when your skills are required.
“Indemnities cover risk and risk has a cost.” No argument here either Greg, life itself is a risk. If you wake up to the sun rise you are one day in front of potential risk. In fact there are risks while you sleep. No professional, can guarantee another person a 100% outcome in life, not even for our children, it’s same for any species on earth. How many small creatures do you walk on every day? We all do our best to protect. Rarely do professionals provide services with the intention to do harm. Unexpected events do happen that is the risk we take in professional lives. Read the Annual Sentinel Events Report. Maybe you are feeling anxious because you haven’t had the opportunity to be part of a birth at home or maybe you haven’t worked with skilled midwives for a long time?
“We do not hear midwives responsible for botched home births”. No argument again Greg, midwives like obstetricians are not perfect in every way, no 100% guarantees for anyone. Can you produce evidence that demonstrates the facts of your risky hearsay comments?
“emergency cases, these must be accommodated within the hospitals at very short notice.” No argument at all Greg, the role of tax payers hospitals is to provide services for the sick and deal with a whole range of human emergencies.
“the community has some right to control risk in this situation”. Absolutely no argument Greg, women are controlling risk/s, when they decide what is best for their individual health and wellbeing (just the same as you would for yourself) and midwives support women in their decision to control their risk/s and work with supportive medical colleagues to minimise those risks.
Dear All
Greg I am a ‘homebirth rights chest beater’ but I am also a staunch advocate of quality and safety and a taxpayer who funds medical (including obstetric) indemnity premium support that has cost the taxpayer $1 billion since 2002.
It is intellectually dishonest to assume that obstetrics is safer, homebirth is risky, midwives don’t collaborate and women are unable to grasp all of these issues.
Hopsital based, medically controlled care brings with it it’s own level of risk. In some circumstances this is warranted in others it is not.
When we drive a car we accept MUCH greater risk. We travel with our precious children, we maximise the safety and understand the benefits as to the risk.
I am a mother of seven who will make thousands of decisions for my children. I have that right. I also have a responsibility to ensure some basic requirements for them (hopefully some higher order needs as well). I am responsible and answerable to authorities for the care I provide. How is this different in birth? I have grown a baby for 40 weeks, taken care of my health and am planning the safest birth possible (with contingenies for other care as needed- something my midwife supports). Oh and by the way being in Royal North Shore or any other major hospital in no way guarantees quicker access to medical care and it certainly DOES NOT provide the 1-2-1 care of a homebirth midwife, where complications are far likely to be detected early and the high rate of undisturbed birth negates the risk of many procedures in medicalised birth (namely induction, augmentation, epidural anaesthesia)
Thanks Lesley and Sally for shining a light onto the politics of health policy for the entire community to see.
But this debate is not just about homebirth. It’s about ALL maternity care. The promise of the reforms was to deliver better access and affordable maternity services for ALL Australians by giving more women more choice - including to choose a privately practising midwife.
I gave birth to a son 15 days ago and chose to employ a midwife in private practice. The ante-natal care my family received was second to none - it included all the monitoring and ‘checks’ but also included so much more - wholistic care for me, my growing baby and our family. My husband and I did a ‘couple care program’ developed by Griffith Uni to help parents transition into parenthood (useful even if this isn’t your first child), we attended a weekend workshop run by our midwife (at no cost to us) where we discussed the actual birth, sex after birth, relationships, and our expectations of each other following the birth, and any fears/anxieties we might have been feeling etc.
The day our baby was born, our midwives never left our side, ensured that our baby was well and was breastfeeding well, and ensured I was well, nourished, and confident in mothering. As he was born at 6am, one of my two midwives came back to our home early in the evening to again check we (mum and baby) were doing well.
Our post-natal care has been exceptional. Our midwives have visited us 8 times in the past 15 days in our home. How fantastic is that! Plus we have more visits to come.
The benefits of getting care from a known midwife who you have chosen are great - it’s supported by evidence and research but it’s the intangible benefits which are the best.
It is this care that will probably be denied to the vast majority of Australian women if midwives are forced, through legislation to ‘collaborate’ with a doctor. Midwives already collaborate with and refer to doctors, it doesn’t need to be legislated to make it ‘better’ or ‘safer’.
I’m sure every Australian woman, if given the choice and the information, would choose to receive care like I am receiving. I just happened to also birth my baby at home, but the midwifery reforms will open up this kind of care to women who also want to birth at a hospital. More Australian families should be able to start family life feeling loved, supported, safe - in the way my family has felt for the past 15 days.
This is why politicians need to listen to families, and not to powerful medical trade unions. They need to ask what is best for mums, babies and their families? And make policy according to that - not to the pressure being brought to bear by one trade group to have power and control over another.