Friday, July 3, 2009

The Homebirth debate!

I'm a homebirth baby and I am not happy if my mummy does not have choice about my birth!

There is much debate around Australia amongst midwives and women, what’s it about? Homebirth! Now what brings about this discussion, yes it's National Registration: which means by 2010 all midwives in order to be registered with the Nurses and Midwives Board need to have indemnity insurance to conduct a homebirth.
It is interesting to note that within the profession of Midwifery there are many differing views on this subject. Historically nursing has been fractured and governed by the medical model; therefore this has carried forward into midwifery. You have midwives that consider themselves nurses as well as midwives who still follow a medical model. Then you have the midwives who consider themselves purely as a midwife. I do believe that the Bachelor of Midwifery will help change this perception within Australia. Try as it may midwifery battles with the medical model regarding health issues. We as a Nation hold a very medical model mentality; this is another reason why so many women choose obstetricians as opposed to midwives. However now with the proposed changes being made by the government which allows for midwives to have a Medicare provider number this is a huge step in the right direction. The introduction of the Nurses and Midwives Act 2006, further confirms the separating of the two professions, Nursing and Midwifery. Of course with every carrot there is a price to pay and in this case it is that the government will not provide indemnity insurance for private practice midwives (independent).

Midwives are highly skilled autonomous practitioners; however they may work in different ways. There are those who practice midwifery in every aspect, which is working with the women, antenatal, intrapartum and postnatal. You have midwives that only work in one area, so they choose either labour/birth suite or a ward area and only specialise in that area however they do know all aspects of midwifery care. When working within a hospital system (medical model) midwives can practice within a team model which is midwifery led care, referring to the medical model when a problem arises. Also midwives work providing high risk care in consultation with the obstetrician. Midwives always endeavour to keep labour as normal as possible for the woman. Even though midwives work within a hospital system there is also low risk normal labours and births with midwifery led care and without intervention.

As a midwife you can work in a birth centre and within the Community Midwifery Program which provides midwifery led care for low risk women. The only provision for Homebirth is in the community midwifery program. These midwives will be provided with indemnity insurance because they are attached to a health service. All other care is covered by Medicare or private health insurance.

Private Practice midwives (independent midwives) provide a homebirth service in which they will charge the women a fee approximately $4500.00. This fee will vary between midwives and is a reasonable fee as opposed to our medical doctors who charge much more, however the woman can claim this from her private insurance or Medicare.
Private practice midwives provide all facets of midwifery care and would refer to an obstetrician if there was a medical problem. The ideal is for private practice midwives to look after normal healthy women without any medical problems, therefore considered low risk. The Australian College of Midwives (ACM) provides National guidelines for midwives to assist them in which conditions are considered high risk. Remembering the definition of a midwife is to deal with the normal, anything abnormal is referred to an obstetrician for advice.
This is where some midwives differ in opinion; there are some who believe that all births should be in a hospital setting and those who believe anything goes. The most important point to remember is that it is the woman's choice as to where she wants to birth.
The conflict arises when a woman chooses to birth outside what is considered the ‘normal’ which is stated in the guidelines (AMC). A private practice midwife can choose to accept a woman even though she may be considered high risk. As long as the woman is well informed and has consulted an obstetrician for a medical opinion. The midwife needs to clearly document her discussion, care and plan of action; it is after all the woman's choice. However, the woman and midwife must accept the consequences of this action. The midwife has to remember to continue to work within his/her scope of practice as legislated by law. Fringe or radical midwives, whatever term you would like to call these midwives might accept any woman with what is considered a high risk pregnancy and this is where the problem lies. This is not an easy choice, because there are women that would go it alone rather than go to hospital. The question is who protects these midwives who choose to work with high risk women who are well informed and do not want medical intervention? Because the choice is that these women will go it alone.
I am pleased to work as a private practice midwife however I would not work outside the realm of 'normal' 'low risk' because that is what I consider the role of a midwife to be, anything that is abnormal is not considered for midwifery care within the home environment. There are midwives and women that would consider me to be conservative and not being ‘with woman’ because I choose only to take low risk women. I am happy to facilitate and care for a high risk woman within the boundaries of a hospital making her experience as much normal as possible.
I am sure that some women do not really understand the scope of practice of a midwife and that we are governed by legislation as to how we can work (Nurses & Midwives Act 2006). The big question is if the government does not provide indemnity insurance for private practice midwives, homebirths will no longer be allowed. This will surely push homebirth underground and more women will free-birth. This in fact will take us back to the dark ages, more women and babies will die. This is the last thing the government and society wants.
Change is slow - and maybe we need to take a step back to enable two steps forward. Medicare provider numbers are a step in the right direction; this will increase the visibility of the midwife and allow women to claim for the care provided by the midwife. Hospitals will give visiting rights to private practice midwives to birth women in the hospital under the care of the midwife and allow these women to go home a few hours later, continuing the care at home. Eventually the powers to be will see the value of birthing at home? 'It’s a nice dream'
I personally want to see women’s choice for homebirth being an option - by 2010 this may not be an option.

please contact your local politician and have your say!


Anonymous said...

Went to a talk by Paul Keating this week - interesting. He talked about "BIG picture" thinking, he related it to his governments initiatives around APEC. I felt it related to us and what is happening now.
It seems to me that women (and midwives) need to consider what they want for maternity care in 5 - 10 years time. Nothing happens quickly - in this state (WA) it took us 12 years of lobbying towards a clear "big picture" goal to get a change in legislations that meant we could provide a direct entry route midwifery course. This didn't come without some pain.
I can't help but think that this is what is needed now - "big picture" thinking. We need to develop a strategy in which homebirth becomes an option that is offered by mainstream maternity services - like in many other countries. If that means a little pain in the short term, particularly around the impact of the indemnity requirements for national registration on private practice - well that meay be the short term price we need to pay. As long as we keep our eyes on the "big picture" I feel we can weather the storm.
We need to grasp the medicare provider numbers and lobby STRONGLY - for homebirth and other models of midwifery care to be part of mainstream maternity services. One we have more runs on the board (yes I know the evidence is there already - but we are asking the majority of Australians to make a significant shift in their beliefs) - in terms of outcomes ....... then we launch our insurance offensive.
I think we need to acknopwledge that these are interesting political times for women and the midwifery profession - and we need to focus our energies in battles we can win - and then when things are progressing launch our next offensive.
My dream is that my sons and their partners will have greater access to a range of maternity models in which to birth their babies.

Sarah Stewart said...

Best wishes in your struggles in this area - Sarah, midwife, New Zealand

Anonymous said...

The changes to legislation for Midwifery are exciting and long overdue
However midwives in Australia also need to be ready for the realisation that with "rights" bear :
delegated responsibility ,accountability for decision making, clinical supervision ,peer review, appropriate referral in cases of deviation from the norm
This is an critical area for midwives and midwifery students who have been trained in a system where midwifery care is secondary to obstetric care and therefore accountability seems to rest with obstetricians.
In countries such as UK, Holland and NZ midwifery accountability is the accepted norm.
Midwives in these countries have not needed to “battle with obstetricians to keep birth normal (well not as much!)
The challenge now is for Australian midwifery to keep birth normal but equally accept the responsibility of firm guidelines and processes that support women and midwives in every setting

Anonymous said...
very relevant document

Save Homebirth

Home Birth Australia