On the morning of 24 June this year, Nicola Roxon entered the House of Representatives and proudly introduced three bills that amounted to a revolution in midwifery in Australia. Midwives have been able to access some limited Medicare items since November 2006, but Roxon’s bills would dramatically extend Medicare and Pharmaceutical Benefits Scheme funding to midwifery and nurse practitioner services.

The bills were the product of a review early this year by Rosemary Bryant, the Commonwealth Chief Nurse (a position established by Roxon), which argued what Australian women have been saying for years — that unless you’re a privately-insured patient, there’s not enough choice when it comes to giving birth, especially if you live in a regional community.

Roxon’s bill also gave effect to the growing push for collaborative care, making midwives more central in maternity care as part of a team-based approach.

It can’t be said that doctors are particularly enthusiastic about the reforms, which is usually a good sign.

But if Roxon was thinking this major reform might have attracted support from proponents of choice in “birthing”, as it’s now called, boy was she wrong. The reforms deeply offended homebirth advocates, partly by failing to extend Medicare funding to midwives providing services outside clinical settings like planned home births, and partly by requiring midwives providing homebirth services to have professional indemnity cover.

Roxon’s bills established a publicly-funded professional indemnity scheme for midwives, but it correctly doesn’t extend to services provided outside clinical settings where risks are much higher. Private insurers won’t provide indemnity cover for home birth midwives because there’s too few of them to provide a premium pool, and home births are too high risk.

This hasn’t stopped some women suing after bad outcomes. As Bryant’s report notes, if one practitioner can’t be sued — and many home birth midwives have stripped themselves of assets and required strict contracts to prevent litigation — then patients will try to sue other practitioners who have been involved — like the obstetricians who have been called in at the last minute when a home birth has gone horribly wrong. In such circumstances, other medical professionals are reluctant to become involved for fear of becoming the litigee of choice.

The reaction from homebirth advocates has been little short of hysterical. Roxon has been vilified across the blogosphere and deluged with letters and emails. One blogger, perhaps not understanding the meaning of the word, called Roxon’s failure to publicly fund homebirth “socialist”, which would make it the first socialist reform Miranda Devine has ever supported. While not all homebirth advocates are as extreme as Joyous Birth, which uses the term birth rape, there’s plenty of wingnuttery out there.

Including perhaps the ultimate nightmare of earnest Youtube songs:

Much of the debate has defaulted to the claim that the Government is seeking to ban homebirths, when it is doing no such thing, and the claim — at odds with considerable evidence — that homebirths are as safe or safer than deliveries in clinical settings, including birthing centres.

There’s a flatearther tone to such arguments, which might come as a surprise to women in developing countries who face far higher rates of maternal and peri-natal death — or for that matter to our ancestors.

But the missing fact in the froth-mouthed attacks on Roxon and her reforms — which the Coalition have eagerly taken up in Parliament — is that only a tiny fraction of Australian women choose home births – 0.22% of all births in Australia, according to Bryant’s report. Even in New Zealand, where taxpayers fund homebirths, the rate is only 2.7%. Moreover the rate was declining rapidly in Australia even in the 1990s, when home birth midwife insurance was available.

No one is stopping Australian women who want home births from choosing them. Roxon’s bills simply continues the current approach of not providing Medicare funding for home births and requires that midwives are either part of a professional, accredited, indemnified, collaborative care model or they’re not.

What should have been hailed as a major step forward for midwifery in the Australian health system — for too long characterised by a maternity care approach dominated by obstetricians (and usually male ones) — has been drowned out by the ideological attacks of a tiny and wholly unrepresentative minority.

Peter Fray

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