In Part II, Kristin Beckedahl, explores the political debate that surrounds the fundamental human rights issue of where, and with whom a woman, chooses to birth her baby.
Although currently shrouded by uncertainty – due to national legislation, ongoing reforms and changing frameworks – homebirth within Australia is alive and well. In a handful of capital cities around the country, pregnant women who are categorised as ‘low-risk’ have access to limited places on publicly funded community homebirth programs. The midwives who work within these programs are often employed by their State’s Health Department. Also within the community (and the focus of this article), are midwives in private practice. These midwives are engaged by families, at their own cost, to provide the invaluable continuity of care across the pregnancy, birthing and postnatal periods. However, by preserving and supporting a woman’s agency, and her right to choose where and with whom she births her baby whilst ensuring the safest practices to do so, these midwives concurrently become personally vulnerable to litigation and ultimately, the loss of their livelihoods.
This article will explore four contentious issues that are placing homebirth in jeopardy. These include the scrapping of indemnity insurance for midwives attending homebirths, the federal government’s lack of support for midwives’ autonomy, enforced collaboration frameworks between midwives and doctors and the increasing rise in freebirth.
In Part I of this two-part article (in the Summer edition), I shared my personal homebirth story from 7th February 2009. Later that year, on 7th September, whilst breastfeeding in the same lounge room in which I had homebirthed my daughter seven months prior, I watched emotive media reports on the television. More than 2,000 homebirth supporters from all over Australia had braved the drenching rains in Canberra to congregate on the lawns of Parliament House at what had been termed the ‘Mother of All Rallies’. This rally was a vocal response to the Commonwealth Government’s Maternity Services Review (MSR) Report and the Health Minister’s announcement that medical indemnity insurance would not apply to homebirths – effectively making them illegal under new national registration laws, which took affect 1 July 2010. This change in the law was seen as a huge injustice to both private practising midwives and consumers. It also resulted in midwives being treated unfairly as they became the only health professionals denied indemnity insurance, despite a $500m support package provided for medical practitioners since 2001.
‘By preserving and supporting a woman’s agency, and her right to choose where and with whom she births her baby whilst ensuring the safest practices to do so, these midwives concurrently become personally vulnerable to litigation and ultimately, the loss of their livelihoods.’
1. INDEMNITY INSURANCE
Lets back track three months to June 2009. The Rudd government introduced national laws requiring midwives to hold professional indemnity insurance as a condition of practice as members of the National Midwifery Register. In other words, all midwives in private practice must hold registration – and indemnity insurance – to be legal practitioners. It sounded like a safe, reasonable requirement. The problem was that in 2001 with the collapse of insurance giant HIH – the only insurance product for midwives for homebirth was withdrawn. This occurred not because there had been claims, but because the global insurance market had seemingly deemed it not worth the risk. Why insure a small, fragmented group of midwives who provided primary maternity care for less than 0.5 per cent of Australia’s mothers and babies, when one claim could cost the insurer far more than the total revenue generated by the product? Essentially, the risk-benefit equation was not in the insurer’s favour. So since that time, private midwives have been practising without insurance.
In November 2010, through government reforms there was a small breakthrough with insurance for midwives in private practice. Although soon after, two serious flaws were called to be corrected in the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Act 2010. Insurance became available but it was forprenatal and postnatal care, or birth in hospital with that private midwife, but it did not cover the labour or birth occurring at home. Under the government’s policy and Medical Insurance Group Australia (MIGA), midwives needed to be assisting in more than 30 births per year, and also needed to have at least three years professional post-graduation experience before they were eligible to access the insurance scheme. The birth quota might be realistic in metropolitan Australia for a midwife to give assistance in more than 30 births a year, but in regional Australia many midwives are fully employed in doing a range of pre and postnatal support, but do not assist in more than 30 births a year. Therefore, under this MIGA scheme they are not insurable because they do not reach the eligibility quota of 30 births a year.
Fast forward to the end of the two-year exemption period on June 30, 2012, and the deadline for the exemption was again extended, to June 30, 2013. In other words, the problem remains the same; if midwives require insurance to stay registered (and able to practice legally), and no insurance company steps forward with relevant policies, then where does that leave these midwives and the families that choose to employ them? The bottom line is that homebirth is not going away, and women will continue to autonomously choose homebirth and it must be funded and indemnified like all medical births are.
2. GOVERNMENT’S LACK OF SUPPORT
As a result of these new national laws up to 200 midwives in private practice faced de-registration from July 2010, and if they continued to work they risked fines of up to $30,000 and the loss of their livelihood. However, following a distinct lack of interest from insurance companies, the then Health Minister Nicola Roxon announced a two-year exemption from holding indemnity insurance for midwives in private practice who cannot obtain cover for attending homebirths. Although welcomed by midwives and consumers, the exemption was a viewed as a reprieve only. A lasting solution was avoided and is still outstanding.
In the 2009/10 budget package: ‘Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives’, the Federal Government again ignored or side-stepped homebirth – the main practice area of private midwives, and the main choice that women called for in the submissions to the review. Preference was given to the development of collaborative models under obstetric control which often exclude midwifery-led primary maternity care options.
In May 2010, Australian Greens Senator, Lee Rhiannon, drew attention to serious obstructions to maternity reform when announcing the passage in the Senate of a motion calling for immediate action on the obstacles facing midwives in private practice.
“Roadblocks frustrating women’s right to choose a range of birthing arrangements need clearing … It is time governments across Australia joined together to enable midwives to properly do their work” Rhiannon said.
Although the government also opened up the Medicare Benefits Schedule (MBS) to midwives (which allows women to claim rebates for particular care) only a small proportion have become Medicare providers. To qualify for these rebates, midwives must enter into collaborative agreements (as per Determination 2010) with doctors, but doctors as a general rule do not support the initiative. Thus, even though the reform package intended to provide ‘more choice in maternity care’, it actually enables doctors to veto midwives’ ability to provide Medicare rebate to a woman in her care. As there is no requirement or onus on doctors to sign a collaborative arrangement, women have in many instances experienced doctors refusing to collaborate with midwives as the MBS intended. Some midwives virtually lobbied every obstetrician in their State to sign a collaborative arrangement – but to no avail.
Hannah Dahlen, Associate Professor of Midwifery at the University of Western Sydney acknowledged the small progress but continues to push for reform as the past president and current national media spokeswoman for the Australian College of Midwives.
“Yes, there have been some successful collaborative arrangements with obstetricians, which we must celebrate and continue to embrace when they are achievable, but on the whole with less than 150 midwives taking up eligibility in two years and less than 100 of these claiming Medicare and a tiny number of these claims being for birth care, we have demonstrated the arrangements, as we strongly argued in 2010, won’t work.”
Joy Johnston, a midwife in private practice in Victoria and Acting-President of the Australian Private Midwives Association (APMA) says;
“Obstruction to midwives being able to properly do our work include medical dominance, and insurance. A culture of medical dominance in maternity care today is so deeply ingrained that few are aware of it. For example, until as recently as 1995, Victorian Midwives Regulations required supervision of midwives by doctors. A midwife was required to have a doctor’s permission to carry out a vaginal examination of a woman.”
In July 2012 midwives were given the opportunity to get approval as PBS prescribers with the commencement of the first accredited course in administering scheduled medicines; the Graduate Certificate in Midwifery at Flinders University in Adelaide.
“The milestone is long overdue as midwives in private practice have been wanting prescribing rights since the 90’s, if not before” says Jen Byrne, the acting co-ordinator for midwifery programs at Flinders. For some it felt like another bureaucratic hoop to jump through as many have been practising competently for years. It will show that midwives are autonomous practitioners who can look after women in their own right, and women won’t need to double dip by visiting GPs for various scripts and tests. This way the midwife decides on the basis of her knowledge and scope of practice what medications to prescribe, store and administer” says Byrne. Most of those enrolled are eligible midwives who will study part-time, juggling their private practices and other commitments over two semesters of online study and portfolio submission.
Dahlen insists that doctors and governments simply do not understand that women will continue to birth at home regardless of whether health authorities sanction it or not.
“Every time women start marching for homebirth the government says, ‘Let’s give them birth centres’, but they don’t expand their birth centres or even build them in some states so very few women can use them and some women just don’t want to birth in a birth centre” says Dahlen. “We absolutely need more birth centres but they are not the whole answer and they will not take away the issue of homebirth. Women will continue to do what they want – exercising their right to chose – and if there’s not a professional around, they will do it anyway.”