Monday, August 8, 2011

ACM Interim Homebirth Position Statement and Guidance for Private Practice Midwives

It is long overdue, a position statement on Homebirth for Australia from the ACM, well done: since 1987 RANZCOG has had an endorsed position statement that opposes homebirth: Since 2007 there has been a joint statement from the RCM & RCOG supporting homebirth for low risk women:

Now the ACM has an interim position statement that supports homebirth for the woman who has a 'low risk'; which is in line with the current Australian Legislation: The ACM cannot contradict the regulatory authority which created the Quality and Safety Framework.

This brings me to the Introduction of the Statement; yes 'women have the right to choose where and how they wish to give birth'..... as I have discussed before in previous blogs...women always have this choice...what they don't have is the right to a midwife to support that choice...because of how the legislation is set-up here.... for women that are in a 'risk category' a midwife needs to consult and collaborate with an obstetrician and this does not happen.... certainly not in WA....this is not from a lack of trying from private practice midwives / independent midwives to collaborate with doctors; As a privately practising midwife I have tried to no avail to get doctors to collaborate; they do not answer emails, letters phone calls. I have had some success with one doctor however the doctor is reluctant to put anything in writing.
A midwife owes the woman a duty of care to provide a safe environment and work within the defined scope of practice...very few obstetricians will support a homebirth for any risk category....and here we have a quandary; unlike the UK that supports midwives to support women in whatever choices they make.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG) does not endorse Home Birth.

In Australia about 0.2% of women deliver their babies at home. However this may be an underestimate, as it is unlikely that all babies born at home are recorded in perinatal data collection statistics.
Whilst mindful of a women’s right to personal autonomy and decision making, RANZCOG
cannot support the practice of Home Birth due to its inherent risks and the ready availability of safer birthing practices. Where a woman chooses to pursue Home Birth, it is important that this is an informed choice, considering all the benefits and possible adverse outcomes.

RCOG and Royal College of Midwives joint statement
The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.

The ACM is the professional body for midwives and I urge midwives to comment on the Position statement: contact the college and express your point of view, do you agree with it? How would you change it? give a balanced view:
Send submissions by email to or by post to PO Box 87, Deakin West ACT 2600. Only submissions with identified senders and a return address will be considered, you have until 23rd September 2011.

As for me I've read lots of comments on the Statement and the guidance document, one comment that keeps appearing is that a scarred uterus is a 'new concept' or 'new rule'.... this is nothing new.... a scarred uterus has always been considered 'high risk' I suppose what is new is the terminology of a scarred uterus...but the concept is old...

My objection with the Guidance Document is the fact that as a private practising midwife we are required to consult with an obstetrician prior to or at booking-in: this is an unrealistic expectation; I am usually booking a woman at anywhere from 8-12 weeks: I would prefer a booking visit with the obstetrician at 20 weeks to discuss the plan of care: The Woman is encouraged to attend this appointment with her midwife and create a plan of care...if the woman chooses a different pathway this also needs to be discussed and a plan made to facilitate this choice: this is clearly documented and all parties sign the document understanding all the risks associated with it: however I am not sure that this will be enough to protect the midwife in a court of law: What we need to be working towards is a continuity of care model...supporting high risk women to birth in hospital with her private midwife having visiting rights to all hospitals.

Remember please to send your comments to:


Bren harrison said...

Midwives with visiting rights to all hospitals is the way to go.!

Ann said...

Could you please point me to the legislation that says that for "women that are in a 'risk category' a midwife needs to consult and collaborate with an obstetrician"? I am most interested to examine it further.

Kind regards,

Ann said...

Good news! You don't actually have any objections to the guidance because you have misinterpreted what it is saying.

It says: Women must be made aware of the midwife’s obligation to consult at – or prior to – booking-in.

You are not obliged to actually consult at or prior to booking in. You are required to make the woman aware (either at booking in or before this) of your obligation to consult.

I think wherever we stand on the substance of the documents, we can all agree that they would benefit from some professional editing!

InfoMidwife said...

Thank you Ann for your comments: The Quality and Safety Framework clearly states: "Women with a singleton pregnancy, cephalic presentation, at term and free from any significant pre existing medical or pregnancy complications are those identified in the ACM guidelines as clearly meeting criteria for midwifery led care".
s38 & s39 of the Health Practitioner Regulation National Law - The Board may develop the codes and guidelines "(b) the scope of practice of health practitioners registered in the profession;" The Board as ratified the Quality and Safety Framework. The Q&SF also refers to the ACM consultation and referral guidelines which state....risk category need consult and collaborate....enjoy examining it further.

Ann said...

Thanks Pauline - I have examined those documents thoroughly on many previous occasions. As a solicitor and mother I have a keen interest in these issues. Your statement implies that the obligation to consult and collaborate is a legislative requirement which was news to me. I am relieved to know that I haven't missed some vital piece of legislation. Guidelines while set up under legislation are clearly not legislative in nature. Sorry to nitpick but we lawyers like precision.

There is also a large difference between saying certain women clearly meet criteria for midwifery care (and then going on to address the situation where care is provided to other women) and stating categorically that certain issues are contraindications to homebirth and cannot be supported.

Both the QSF and the College's guidelines on consultation and referral clearly recognise the situation where women refuse consultation and referral or other advice and midwives continue to provide care.

The interim guidance to privately practising midwives fails to engage with these issues other than by a passing reference to Appendix A. It needs to be comprehensively and consistently addressed.

InfoMidwife said...

thanks Ann, it’s good to see someone so passionate for the cause of women and their right to choice, something we both agree on.

Please forward your comments to the ACM and any recommendations you have:

You may also like to look at the National Health (Collaborative arrangements for midwives) Determination 2010 which also states that we need to collaborate; There are a suite of documents that regulate the midwife and the scope of practice of a midwife of which I have alluded to: You may like to also suggest a way forward to support midwives and enabling women’s choices in the current legislative framework:

Whilst I acknowledge there are midwives that continue care which is deemed outside the scope of practice (by the ACM & NMBA) I want to point out that this practice happens it leaves midwives at risk on many levels;
I just want legislative protection as a midwife to provide the choice for women which we currently do not have and I certainly do not want to be a test case to establish the case law on this issue.
There are “categorically that certain issues are contraindications to homebirth and cannot be supported”. How to overcome this issue is to provide continuity of safe midwifery care in collaboration with an obstetrician.
As a lawyer you will also know that there is always someone going to argue the opposite point of view which is a positive thing as it allows for reflection and a way forward.

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