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.
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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.
• Lesley Barclay is head of the Northern Rivers University Department of Rural Health at the University of Sydney, and Sally Tracy is Professor of Midwifery Research at the University of Sydney.