Friday, December 31, 2010

listing of sites for Australia's maternal and perinatal statistics

AIHW National Perinatal Statistics Unit
The most recent general report is Australia's Mothers and Babies 2008

Maternal and Perinatal Health Series 45

New South Wales
2007 Mothers and Babies

For 2007, there were 144 planned homebirths across NSW with 31 planned homebirth/hospital admissions, so a transfer rate across the state of 21.5%. The highest homebirth rate was North Coast NSW (Port Macquarie to Tweed Heads) with 44 planned homebirths but it also had the highest reported transfer rate of 25.5%. This rate included the Natural Birth Education and Resource Centre (now closed) which registered its births as homebirths and transfer as homebirth transfers, not birth centre births.

There were also 490 babies Born Before Arrival (BBA) which may include some babies who were born unassisted but went to hospital for their paperwork.

Perinatal Statistics Queensland

Northern Territory
Mothers and Babies 2006

Western Australia
Perinatal Statistics in WA 2007

South Australia
Pregnancy Outcome in South Australia 2008

[report not found at ]

Publications of  the CCOPMM
also, see Maternity and Neonatal Performance Indicators.
Further summaries of home birth, and discussion at this blog.

Wednesday, December 29, 2010

Outcomes for planned home births 2008 (Victoria)

    Click on picture to enlarge

The two pages copied above are from the Victorian government's perinatal data statistics unit, which is part of the Consultative COuncil on Obstetric and Paediatric Mortality and Morbidity (CCOPMM). The publication is:
Hospital profile of maternal and perinatal data
Homebirths for the year 2008

Each hospital receives a copy, and homebirth data are aggregated into a virtual 'hospital' for statistical purposes.

These data are not published on the internet, but are sent to each Victorian maternity hospital, and to independent midwives who provide the data.

This report, for the first time, "reports on all births that were planned to occur at home, regardless of whether they actually occurred at home or in hospital. Previous Profiles reported only on outcomes for achieved home births. This new format will provide more useful information, for example for informing women who are considering homebirth." (page 2)

Saturday, December 18, 2010

Survey on prescribing courses for midwives

The following message has been forwarded by Liz Wilkes, a leader in APMA and Midwives Australia

Re: Prescribing courses for midwives

From 1 Nov 2010, Eligible Midwives are able to prescribe certain medicines under the PBS. One of the requirements to become an Eligible Midwife is the completion of a “program of study or equivalent — prescribing” meeting the requirements of the Nursing and Midwifery Board of Australia (NMBA).

The Department of Health and Ageing (DoHA) has asked NPS: Better choices, Better health to undertake a project to look at the feasibility of prescribing courses for midwives to prepare them for this additional role. As part of this project, we have designed the following survey to help us better understand the perspective and expectations of potential students of prescribing courses. Below is some information about the survey.

What is the purpose of the survey?
The purpose of this anonymous survey is to consult prospective students who may be thinking of undertaking a prescribing course to fulfil one of the requirements in becoming an Eligible Midwife. We encourage you to complete the survey if you are currently practising as a midwife, or you have a midwifery degree and you are planning to practice as a midwife. This information will be invaluable to the Department of Health and Ageing and NPS in considering how best to support and assist midwives and/or potential course providers in the future. The idea of a survey came from the project reference group comprising representatives from the NMBA, the Australian Council of Nursing and Midwifery, and the Australian College of Midwives, as well as representatives from groups with expertise in prescribing education and drug therapy education.

Why has the survey come to me?
We are seeking to understand the perspective and expectations of potential future students of prescribing courses. This is an emerging area of practice and it is important to gain as much information as possible to assist midwives and/or potential course providers.
The Australian Private Midwives Association has kindly agreed to assist us by sending the survey to its members.

Who should complete the survey?
We invite all currently practising midwives, or those with a midwifery degree who are planning to practice as a midwife to complete the survey. Feel free to pass on the survey to relevant colleagues. We ask that each person only completes the survey once.

How do I access the survey?
Please click on this link
( and you will be taken to the survey directly.

What is the timeframe for completion?
The survey will take approximately 15 minutes to complete. The survey is open from now until 10 January 2011. We would appreciate it if the survey could be completed as soon as possible.

What will happen to the findings from the survey?
The data will be collated and analysed by NPS, and the findings will be reported to DoHA.

Who do I contact for further information?
If you would like further information, please contact Dr Michelle Koo, Manager, Educational Design and Support, NPS on 02 8217 8742 or via email at

Who is NPS: Better choices, Better health?
NPS is a not-for-profit organisation funded by the Australian Government of Department of Health and Ageing to enable better decisions about medicines and medical tests. For more information, visit

Thank you and kind regards,
Dr Michelle Koo
Educational Design and Support team
Innovation and Learning

Thursday, December 16, 2010

A GP practice withdraws collaboration

click to enlarge

The letter copied above, with the name of the doctor who wrote it blocked out, was sent to this blog by its recipient. This letter was written by one of the GPs in Bendigo who, in the past, had been willing to support women choosing homebirths.  The main 'support' received in such cases is that the doctor orders routine blood tests and investigations, and facilitates access to the blood bank for women with Rhesus Negative blood to receive prophylactic Anti-D.  One would wonder what 'Duty of care' this doctor perceives is appropriate for these women once this facility is no longer available?

The writer makes reference to a paper comparing planned home births with planned hospital births, published in the American Journal of Obstetrics and Gynecology 2010, by Joseph R. Wax and colleagues.
[Maternal and Newborn Outcomes in Planned Home Birth Vs. Planned Hospital Births: A Meta-Analysis, Wax JR, Lucas FL, Lamont M, et al., Am J Obstet Gynecol 2010]

Using various statistical analyses, this author claimed that there is a three times higher neonatal mortality rate of babies in the planned home birth group than in the hospital birth group. This paper has a familiar ring to it: readers will recall the AMA publication of Kennare et al's retrospective analysis of data from South Australia, and the outrageous conclusions made by the authors. For links and comment, go to the MIPP blog.

A voice of reason has been published by Medscape Ob/Gyn & Women's Health, a respected online medical review site.

Medscape convened a 'Roundtable' in Ob/Gyn & Women's Health,
Experts Argue the Continuing Home Birth Issue
Perspectives on the Joseph R. Wax and Colleagues Home Birth Study in AJOG

The following excerpt is copied from Section 6: Eugene Declercq, PhD

After a long decline,[10] the number of home births has started increasing in the United States. ... Four years do not make a trend, but the rate of home birth is the highest it has been since 1994 and the total number of home births (26,667) is the highest since 1991.

It is in this context that we confront numerous problems faced by researchers trying to resolve the question of safety of home birth. Limited space prevents a full discussion of the barriers to such research, but 3 important ones are:
  1. Design. The gold standard -- a randomized trial -- is not feasible because women will not let themselves be randomly assigned to a given birth site. To argue that the safety of home birth can only be established by a randomized trial presumes that home births are unsafe. Because a randomized trial is impossible, then logically home birth can never be shown to be safe.
  2. Measurement. Because our focus is on planned home births, how do we define such births to make sure we exclude accidental home births (eg, precipitous labor) and include home births that result in transfers to the hospital? Current US data systems do not facilitate such tracking, although some US studies have tried to address this problem as have several recent studies from other countries.
  3. Statistical power. Because planned home births typically involve healthy women, poor outcomes are rare, and hence very large samples are needed to identify differences.

These limitations are among the constraints that Wax and colleagues[1] tried to overcome with their meta-analysis of studies that met certain criteria. The dearth of appropriate studies resulted in inclusion of some studies that are old (data from the 1970s),[25] studies that inferred rather than documented planning status, and studies that were primarily from other countries (only 2 of the 12 were US-based). The decisions that have drawn the most criticism have involved the largely unexplained inclusion and exclusion of certain studies. The inclusion of data from Pang and colleagues' study,[26] done in Washington state, drew fire because it was the source of most of the reported neonatal deaths and it could only infer planning status, which was defined as "home births of singleton newborns of at least 34 weeks' gestation [with] a midwife, nurse or physician listed as either the birth attendant or certifier..." The difficulty with that definition is seen in a recent 19-state study of births occurring at home in which planning status was indicated.[27] In that study, I and my colleagues found that 87% of the unplanned home births occurred after 34 weeks and 69% of the home births attended by physicians were unplanned. In addition, 22% of the planned home births were attended by "other" attendants; these would have been excluded by Pang and colleagues.[26] This means that Pang and colleagues probably both erroneously included physician-attended full gestation home births in the planned home birth category and excluded "other" attended planned home births. In fairness, our study was published in the same month as Wax and colleagues' study and years after Pang and colleagues' study, but one cannot now claim that the potential problems with selection bias simply cancel each other out.

Of greater consequence was Wax and colleagues' exclusion of the largest study of planned home births ever done: that by de Jonge and colleagues[7] in the Netherlands, with more than 300,000 planned home births. Wax and colleagues' decision to use neonatal mortality at 28 days as their primary outcome unfortunately led them to exclude that study, which reported on perinatal and neonatal mortality up to 7 days. After controlling for confounders, de Jonge and colleagues reported no added mortality risk in planned home births. The size of their study overwhelms that of Wax and colleagues' meta-analysis and was the basis on which the meta-analysis found no difference in perinatal mortality. Perinatal mortality, which includes fetal deaths, would seem a more appropriate outcome measure. Neonatal mortality is also widely used, but how important is the distinction between 7 and 28 days? Over the past decade in the United States, about 80% of all neonatal deaths up to 28 days have occurred in the first 7 days. Apparently, de Jonge and colleagues are now examining their data out to 28 days. Would anyone seriously suggest that such a great concentration of home birth-related deaths occurring between 7 and 28 days would alter their core finding of no added risk? If de Jonge and colleagues find no difference at 28 days, Wax and colleagues' meta-analysis would also most likely find no overall difference in neonatal mortality. What happens then -- are their findings withdrawn? Does the journal publish a retraction, even after it made Wax and colleagues' article an "editor’s choice"?

Currently under way is the Birthplace in England study, another large, well designed study of home, birth center, and hospital births. The fact remains, however, that the debate over home birth will not be resolved by this or any study, no matter how well designed. At its core, the home birth debate is ideological, centering on 2 diametrically opposed perspectives on birth held by groups that generally do not communicate with each other and unfortunately often hold each other in disdain. Perhaps the question we should be asking is not what is right or wrong about any study on this topic. Rather, why are increasing numbers of US women who are experienced in birth (80% with parity 2 or higher) choosing to reject hospital-centered systems of maternity care that so many well-meaning clinicians want to make better?

Saturday, December 4, 2010


Congratulations to Liz and the family of baby Eli.

The Chronicle [Toowoomba, Qld] article announces:

Baby Eli is an Australian first

Baby Eli may wonder what all the fuss is about but he really is a very special little boy.

The third son of Stacey and David Silver is the first to be born under the care of Australia’s first Medicare eligible midwife, Toowoomba resident, Liz Wilkes.

Medicare payments for midwives were introduced on November 1 as part of National Health reforms.

Ms Wilkes along with others, has established the new clinic My Midwives in Toowoomba.

The clinic will employ 5 midwives, mentor midwifery students and provide outreach services. ...

Wednesday, November 24, 2010

Australia’s mothers and babies 2008

The Australian Institute of Health and Welfare has released a new report today:

In 2008, 292,156 women gave birth to 296,925 babies in Australia. The increase in births continued, with 2,720 more births (0.9%) than reported in 2007. This is the second year that the rate of caesarean section has not significantly increased with a 0.2% rise from 30.9% in 2007 to 31.1% in 2008.

Click on the link to view the media release and report.

Baby boom slows, but more births to older mothers

A fall in the rate of women giving birth suggests the baby boom may have peaked, according to a report released today by the Australian Institute of Health and Welfare (AIHW).

The report, Australia’s mothers and babies 2008, shows there was a 0.6 percentage point fall in the overall rate of women aged 15 to 44 years giving birth, from 64.9 per 1,000 women in 2007 to 64.4 per 1,000 women in 2008. Of these, an estimated 3.2% of women who gave birth received assisted reproductive technology (ART) treatment.

‘The proportion of older women giving birth has continued to rise over the past 18 years,’ said Associate Professor Elizabeth Sullivan, of the Institute’s National Perinatal Statistics Unit located at the University of New South Wales.

‘The proportion of mothers aged 35 years and over increased from about 11% in 1991 to about 23% in 2008. Mothers aged 40 years and over made up almost 4% of all women giving birth in 2008 compared to 1.4% in 1991.’

The average age of mothers in 2008 was 29.9, up from 27.9 in 1991, and the average age of first-time mothers increased from 25.8 years in 1991 to 28.2 years in 2008.

‘There are a number of factors that contribute to delayed childbearing, including social, educational and economic factors and increased access to assisted reproductive technology,’ Associate Professor Sullivan said.

Indigenous mothers were younger, with an average age of 25.1 years in 2008, compared with 30.1 years for non-Indigenous mothers. The average age of first-time Indigenous mothers was 21.0 years.

For a second year in a row, the rate of caesarean section did not increase, with 31% of women who gave birth doing so by caesarean section. A further 57% had a non-instrumental vaginal birth.

Indigenous mothers had a lower caesarean rate than non-Indigenous mothers (25% compared with 31%). Advancing maternal age was associated with higher rates of caesarean section.

About 11% of mothers had an instrumental (forceps or vacuum extraction) assisted vaginal birth. This rate has remained stable over the last decade.

Instrumental birth was more prevalent in major cities, and a larger proportion of women who had instrumental deliveries were first-time mothers.

The proportion of women who smoked while pregnant was 16%. Over half of Indigenous mothers reported smoking during pregnancy (51%), compared with 14% of non-Indigenous mothers.

Of babies born in 2008, 6.1% of live births were of low birthweight (less than 2,500 grams). This rate of low birthweight was the lowest in the decade 1999–2008.

Monday, November 22, 2010

Letters to public hospitals requesting collaborative arrangements

Midwives practising privately are now able to apply to be noted by the Nursing and Midwifery Board of Australia as eligible for Medicare, and clients of these midwives are now able to claim rebate on the midwife's fees.  Women enquiring about private midwifery services are now asking midwives, "will I be able to claim Medicare rebate on your fees?"

There are just a few midwives in the country who are able to offer Medicare rebate.  Others are working towards it.

One of the hurdles that a midwife needs to successfully negotiate in order to achieve this status is to comply with the National Health (Collaborative arrangements for midwives) Determination 2010.

Midwives who are continuing to provide private midwifery services for women planning homebirth are seeking an arrangement to cover collaboration in situations when women in their care are referred to a public hospital for obstetric review, such as for prenatal assessment or monitoring when indicated, or transfer of care.

With reference to the (Collaborative arrangements for midwives) Determination, the pathway which we have been advised is suitable for public hospitals providing collaborative arrangements for midwives whose clients are planning home birth is as follows:

[Excerpts from National Health (Collaborative arrangements for midwives) Determination 2010]
4 Specified medical practitioners
For the definition of authorised midwife in subsection 84 (1) of the Act, the following kinds of medical practitioner are specified:
(c) a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.

5 Collaborative arrangements — general
(1) For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:
(b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;
(c) an agreement mentioned in section 6 for the midwife;
6 Agreement between eligible midwife and 1 or more specified medical practitioners
(1) An agreement may be made between:
(a) an eligible midwife; and
(b) 1 or more specified medical practitioners.
(2) The agreement must be in writing and signed by the eligible midwife and the other parties mentioned in paragraph (1) (b).

In the case of an authorised midwife providing care for a woman ‘W’, having a collaborative arrangement under section 4(c) above with the director of obstetrics or another doctor ‘D’ authorised by the hospital to participate in a collaborative arrangement, the midwife would write a letter to the doctor, and keep a copy of the letter in the woman’s notes, stating that Doctor D is the specified medical practitioner under whom the woman would be admitted if admission to hospital was indicated. The letter would say something like
“Dear Dr D, Ms W is a woman in my care who is planning home birth, who has booked in to your hospital for backup if indicated. At present there is no indication, and I will contact you should any problems or concerns arise. This collaborative agreement is required so that Ms W can claim Medicare rebate on my fees.”

Please note that this collaborative arrangement does not apply to intrapartum care, after transfer of women who had planned home birth from private care in the community to a public hospital. There is no Medicare item number for intrapartum midwifery care for planned homebirth. The intrapartum options for midwives, covered by Medicare are outlined in the Federal Register of Legislative Instruments F2010L02640. These items refer to planned hospital births at which the midwife is in attendance, privately employed by the woman. This option requires visiting access arrangements to be in place, including collaborative arrangements for intrapartum obstetric referral.

Wednesday, November 17, 2010

Towards Normal Birth in NSW

Towards Normal Birth in NSW, a policy directive, with a requirement for mandatory compliance, was released earlier this year.
"This policy provides direction to NSW maternity services regarding actions to increase the vaginal birth rate in NSW and decrease the caesarean section operation rate; to develop, implement and evaluate strategies to support women and to ensure that midwives and doctors have the knowledge and skills necessary to implement this policy."

Carolyn Hastie has listed her 21 strategies to keep birth normal at her thinkbirth blog.

A NZ midwife, Sarah Stewart, has provided the link to the RCM list of ten top tips.

Midwives around the world have in recent years been promoting normal birth as a definitional duty of care, rather than a default position.

The policy directive Towards Normal Birth in NSW contains many parallels with the global Baby Friendly Hospital Initiative (BFHI), in the protection, promotion and support of breastfeeding. It is a simple step from BFHI to the protection, promotion and support of the normal physiological processes in the whole birthing continuum, rather than waiting until the baby has been born and needs food. The '10 steps to providing woman centred labour and birth care' (p8) parallels the BFHI '10 Steps'.

The NSW Health Department has taken a brave step in the right direction with this document. Time will tell whether 'mandatory' means just that, or something else. The implementation check list (Attachment 1) states that "All Area Health Services must achieve the measures by 2015."

We would love to hear from any readers in NSW. How's it going?

Saturday, November 13, 2010


Midwives Rosie and Joy
After a Skype conference call that linked midwives in locations around the country for the APMA annual general meeting, the group at my house had a very valuable time of *listening* to each other. We sat around the table and we ate sandwiches and boiled fruit cake and drank our tea or coffee.

Our little group included those who have been in private practice from anything from five to 20 years. We also covered a wide spectrum of positions as far as Medicare and particularly the Collaboration arrangements are concerned.

Listening was so useful, and we asked ourselves to not try to debate or challenge the person who was speaking. (that’s quite a challenge in itself). We asked each person to talk about their current status with the Medicare eligibility application, and their plans.

I have recently had an in-depth conversation with a midwife who believes that no midwife should even attempt to take up the Medicare eligibility because “only women who consent to referral will be eligible for Medicare”, and that in supporting the Government’s Medicare reform a midwife is supporting discrimination against women. I have heard calls for midwives to stand together. I have read on a midwife’s blog “APMA representing private medicare midwives, and once again the rest of the midwives and the women who want a no fuss homebirth are left wondering ....”

Another midwife has written publicly “While women in Ireland, Hungary and the USA are being shackled physically we certainly are being shackled metaphorically here in Australia not just by legislators, hospitals and obstetricians but some of our own midwives and women who accept this treatment without even raising a pen to paper to object.”

These statements come after years of distress and fear amongst midwives and women who employ us, about the future.

Now that the legislation has been set down midwives have a clear choice as far as Medicare is concerned – either to do what we can to work within the ‘system’ as it is, or not. While we have the exemption for homebirth, we can continue attending women in their homes.

I believe we need to stay together as much as possible, or face further marginalisation of private midwifery practice as we know it. I hope that those among us with political skill will continue to work to improve equity and access for all women, and protect the scope of practice of the midwife.

A colleague who joined in our discussion yesterday spoke in very clear terms, differentiating between a midwife’s issues and a woman’s issues. I wish I had recorded what she said, but of course we were not recording anything.

I would encourage independent midwives to meet with your colleagues, and take time to *listen* to each other.

Tuesday, November 2, 2010

Collaborative arrangements for midwives

Earlier posts on this blog and others have sought to tease out some of the issues that have been brought to light with the Australian government's attempts at reform of maternity care.

Since mid-2008, with the announcement of the Maternity Services Review, midwives and birthing activists have written and argued and pleaded for improvements that are based on evidence and women's rights.

That campaign is ongoing. There is plenty of work to be done.

Some midwives are now seeking to take up the offer of Medicare (MBS) and limited prescribing rights (PBS) that have progressed through legislation, and are now being implemented.

Each midwife has some serious hurdles that we will need to overcome in order to be granted these 'privileges', and enabling our clients to claim Medicare rebates on services that are linked to Medicare items. Perhaps the most challenging is the requirement, spelt out in the National Health (Collaborative arrangements for midwives) Determination 2010 for an authorised midwife to have a signed collaborative arrangement with a doctor, or alternatively to follow a lengthy and prescriptive documentation process.

Of the options for signed arrangements, the first option is that the midwife is employed by the doctor or doctors. This is not a likely option for midwives who practise privately in communities. Obstetric group practices already employ midwives in their rooms, and these midwives probably provide valuable assistance in seeing the large numbers of women who pass through the rooms. But it is doubtful whether, even if these midwives are granted eligibility for MBS and PBS, they will be encouraged by their bosses to practise authentic midwifery, including practising on their own authority, promoting normal birth, and working in partnership with women throughout the episode of care. These midwives are likely to continue as obstetric assistants: some may scrub to assist at caesareans; some may even take on a caseload. But unless they are practising in true co-labor, as professionals in their own right, the 'reforms' are unlikely to make any changes to maternity care standards or outcomes.

The second option for signed arrangements is that the woman is "referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner". This option is quite fascinating. The obvious question is, why would a "specified medical practitioner" - a doctor who makes a living that is proportionate to the number of women who receive private maternity services from him or her, refer a woman to a midwife? This option will require strong women who approach these doctors, armed with their own plan, and request a referral that meets the requirements for collaborative arrangements.

The third option for signed arrangements appears to be the one that may be suitable for midwives who are practising privately and attending home births. This option will require the specified medical practitioner to be "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement." In this scenario the doctor who signs the arrangement may not be the doctor who provides collaboration in situations when women in our care, who are planning home birth, are referred to the hospital for obstetric review, such as for prenatal assessment or monitoring, or transfer of care. The doctor who signs the agreement with the midwife may be the medical director or head of obstetrics in a public hospital, who delegates the "authority to participate in collaborative arrangements" to the obsterics registrar. Such collaboration is applicable to the midwife’s provision of private prenatal care, and postnatal care. There is no Medicare item number for intrapartum midwifery care in the community (homebirth), so collaborative arrangements are not required to cover home birth.

Midwives who contact their local public hospitals with the purpose of seeking a signed collaborative arrangement are encouraged to communicate with APMA, or MIPP, in reporting the responses of the hospitals. These responses will be important information that will be used in reviewing and revising the legislation in the coming year(s).

Monday, November 1, 2010

Press release from Minister Roxon


The Health Minister says:
[Comments and highlighting added by the blogger]

Nurse Practitioners and Midwives will from today be able to access the Medicare Benefits Schedule and provide Pharmaceutical Benefits Scheme medicines in the community.

For the first time highly skilled Nurse Practitioners and Midwives will be able to provide taxpayer subsidised services to patients outside of the public system in medical practices and the community.
[Blogger: We don't know of any midwives who have been successful in their applications for Medicare and PBS.  Readers are asked to provide links to any press releases that may identify midwives who have been awarded Medicare provider numbers
ps - one midwife has informed APMA that she is now 'eligible'/]

This is a momentous day for the nursing and midwifery professions and a great day for patients who will be able to claim a rebate, and benefit from better access, closer to home in a wider range of settings.

[Blogger: Home birth is not included in the Medicare reforms.  Women planning home birth may be able to get Medicare rebates on midwives' charges for prenatal and postnatal care, but not for birth.  The only Medicare  rebates for birth are for birth in hospital, attended privately by the midwife who has visiting access arrangements with the hospital, and collaboration arrangements with a named medical practitioner.]

Midwives will be able to deliver maternity care, including antenatal and postnatal care in the community, and undertake deliveries in a hospital.
Nurses and Midwives will be required to work in collaboration with medical practitioners when providing MBS services and PBS prescriptions.

[Blogger: Medical practitioners are not required to work in collaboration with midwives.]   

For today's article Medicare extended to nurses, midwives by Mark Metherell in The Age, click here.

Wednesday, October 27, 2010

Minister Roxon's advice: "suck it and see"

Women’s Right to bodily autonomy and a midwife’s right to practice: We’ll just have to “suck it and see”

Writer: Anonymous

Historic times yet I get the distinct feeling they won’t want to be remembered. Julia Gillard, a declared feminist and yet we are on the cusp of the most draconian midwifery regulation dressed up as reform. From November 1 midwives will be able to claim Medicare funding but only when controlled by a doctor. Midwives are educated and registered to provide complete care for healthy women. Despite common misconception midwives are not handmaidens to doctors, but professionals in their own right.

Naturally it is appropriate for midwives to have established links to a range of other health professionals, this enables a woman to receive timely advice and care. When a midwife and obstetrician are respected for their role and a woman is recognised as the primary decision maker, best practice care is possible. This does not happen in Australia. Many women have been led to believe that their bodies are revolting, faulty with birth a barbaric process that should be managed. Couple this with a system that has financially rewarded huge increases in surgery with little scrutiny, indeed one that saw the likes of Graeme Reeves [NSW the 'Butcher of Bega'] continue to practice. It’s easy to see why obstetrics controls childbirth’s billion-dollar industry.

Maternity reform was the first cab off the health reform rank. Considering it’s the highest volume area, accounting for the greatest number of bed stays, that seemed appropriate to reform advocates. Perhaps this was Minister Roxon’s first mistake, she was overheard saying ‘I want to get maternity over with first and then move onto chronic disease’. I am sure she understood the turf war and passionate consumer advocates it seems she had little understanding of how political (read profitable) pregnant woman are.

Allegedly the AMA threatened a $7 million anti-government campaign pre election if midwives were able to claim Medicare in their own right. Their deal that individual doctors controlled midwives access to funding and the decisions of the birthing woman. If a woman makes a decision not supported by an individual doctor access to funding and midwifery care is likely to be withdrawn.

It is possible that the Gillard Government is contravening its responsibilities under the Convention of the Elimination of all forms of Discrimination Against Women (CEDAW). If international convention is too abstract then perhaps the plight of rural and remote women is more convincing. In rural areas, GP’s control maternity care, even when a GP has ceased obstetric practice the establishment of midwifery models has been vigorously opposed.

Women are forced to relocate or risk travel in labour rather than access local midwifery models. The cultural damage for Aboriginal women is considerable. If Medicare funding was not shackled to the permission of an individual medical practitioner midwives could establish rural clinics. This could have enhanced safety and removed the financial and emotional burden of many rural families.

These and many other issues were formally raised. The Maternity Services Review received 950 submissions, nearly double that of the National Health and Hospitals Reform Commission. The consumer led juggernaut then continued to achieve the nigh impossible, 2 Senate enquires into the same bill (something only seen a handful of times) coupled with a Senate record number of submissions, 2507. Over three thousand gathered outside Parliament House to protest the way the reform in September 2009.

The political cost has been high with Minister Roxon embarrassed by poor advice. It is unclear why but a senior bureaucrat and ministerial adviser both with carriage of maternity reform have both ‘moved on’.

Last week ‘reform representatives’ met with the Minister, the meeting was only achieved after the same women ran in ultra marginal seats in the recent federal election. While seemingly having an open door policy to the AMA, maternity consumers have been repeatedly refused access.

Many criticised the Rudd/Roxon health reform citing it was rather hospital reform, with little focus on health, wellness or consumer engagement. Perhaps that can be explained with yet another medical practitioner appointed by the Minister. Dr Judy Searle, an Obstetrician, seemed unmoved by the participants pleas regarding rural maternity services citing it as ‘a hard area’ but the quote of the meeting must go to the Minister herself who is reported to have responded to the participants comments regarding women’s rights to self determination rather than proposed medical control by saying we will just have to “suck it and see”. So that’s how Labor feminists do women’s rights.

Note:  This essay was sent anonymously to APMA. 

Thursday, October 21, 2010

Disrespect and abuse of women in childbirth

Rally outside AMA House in Melbourne
We would like to hear stories from women and midwives who have encountered disrespect and/or abuse in maternity care.

Many anecdotal accounts are available. Many women and midwives wrote their stories in submissions to the Australian government's Maternity Services Review.

Two well known academics in the field of women's studies have asked that midwives and mothers who are willing to share their stories contact them. This is not, at this stage, funded research. The aim is to make up a collection of accounts that demonstrate issues of women's autonomy and rights in birthing - as both birthgivers and the women workers who care for them. These accounts will be useful in presentations to human rights advocates, and women's health networks.

If you would like your story considered for this project, please send a message to Joy  [].

Click here to read of the US

Thursday, October 14, 2010

WA Health Department statement on Home Birth

Home Births

In Australia there are a small number of women who elect to have home births. In WA, approximately 200 women have a homebirth each year representing between 0.65-0.8% of all births.

Some countries have higher rates of planned homebirth. For example around 2% of all births in the UK are homebirths and in the Netherlands this is much higher at around 30%. In these countries the infrastructure for safe home birthing is well established and outcomes are usually positive.

There has been controversy about the safety of births at home with differences in opinions between health professionals and sometimes it may be difficult to obtain a balanced view.

In 2007 WA Health commissioned a review of evidence into Models of Maternity Care. This review discusses the safety of planned home births by women of low obstetric risk.

The review concluded that
"Planned home birth with a qualified home birth practitioner is a safe alternative for women determined to be at low risk of pregnancy complications." view full review-see page 11 (external site) (PDF 1.22MB)

You should be aware that your midwife will advise transfer to hospital if complications arise and that there should be a clear plan in place with your local hospital to allow a smooth transition to hospital care, should it become necessary, at any point during your pregnancy, labour or birth.

Some women opt for homebirth after a prior birth experience within a hospital environment that may have not met their expectations. For a few of these women homebirth is not a safe choice due to pre-existing medical problems or previous pregnancy or birth complications. If this applies to you we encourage you to make an appointment with senior members of midwifery and medical staff at the hospital to discuss your concerns. They will then be able to support you to ensure your next birth experience will be more rewarding.

If you are considering a homebirth make sure you are fully aware of the potential and often unpredictable complications that may arise during labour and birth before you make your choice.

Community Midwifery Program WA (external site) provides continuity of midwifery care for low-risk women who are planning to birth at home.
Royal Australian and New Zealand College of Obstetricians and Gynaecologists Homebirth statement (external site) (PDF 520KB)
Royal College of Obstetricians and Gynaecologists Homebirth statement (external site) (PDF 84KB)
Report: Review of home births in Western Australia (August 2008) (external site) (PDF 445KB)

News from the West

From Western Australia

RESPONSE [to the article below] by Community Midwifery WA
“In response to their objections we have updated the website to include a Research page – we are all for transparency and our aim is to provide women with evidence-based information to enable women to make an informed choice. See our new update page

The report was picked up by the ABC and the AMA and Simon Towler (Chief Medical Officer of WA Health) were interviewed. Dr Towler stood by their support of CMWA, the CMP and their own website “Having a Baby”.

Later on, Consumer spokesperson spoke on 6PR along with the AMA and – again – Dr Towler provide some comment. Again, the support of CMWA and CMP was very welcome.”

The following Article was published in The West Australian newspaper, Oct 13th page 17. Medical reporter Cathy O’Leary
Leading WA doctors have attacked the Health Department's promotion of home births on its website, saying it has biased information and fails to acknowledge the risks to women and their babies.

Dr Louise Farrell, the former WA head of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Australian Medical Association wants the information changed or a link to the Community Midwifery Program removed .

The department's webpage on home births refers to an external website detailing advantages and disadvantages.

Last year, the department released findings of an independent review of home birth safety that found they were generally no riskier when well supported, but doctors maintain they are riskier.

Dr Farrell said the department should promote the safest and best options for women yet was publicising a practice that had poorer outcomes.

It already had to remove information promoting home birth for women who previously had a caesarean after doctors complained. "But it still seems to promote home birth as an equally safe option compared to other models and I think there's a problem with that," Dr Farrell said.

AMA WA president Dave Mountain said the department should remove the website's content until it had more balanced information.

"Choice is a good thing, but I'm against ill-informed choice and the problem with the site is that it's extremely unbalanced and portrays home birth in a way which is highly supportive and uses biased language," he said. "Although there's some research suggesting that in very well-selected people home birth can be reasonably safe, there have been significant concerns about the rates of neonatal deaths and poor outcomes."

Chief medical officer Simon Towler said the department recognised some women wanted a home birth and referred them to the CMP, a publicly-funded service for low-risk women.

He said the recent review found a planned home birth with a qualified practitioner was a safe alternative for women at low risk of complications.

But the site was being changed to include references to the review and the RANZCOG policy on home birth.

Monday, October 11, 2010

APMA Position Statement on Collaborative Arrangements

Australian Private Midwives Association (APMA) represents midwives in private practice.

The National Health (Collaborative arrangements for midwives) Determination 2010

  • requires written agreement or acknowledgment by a medical practitioner for Medicare funding to be available for services provided privately by a midwife
  • defies the International Confederation of Midwives (ICM) Definition of the midwife - it prevents autonomous practice for Medicare funded midwives.
  • defies the ICM Declaration (Glasgow 2008) which states that legislation developed in member countries must enable midwives to practice in their own right.
  • prevents most current private practice midwives from accessing Medicare funding.
The impact of the National Health (Collaborative arrangements for midwives) Determination 2010 on ALL of midwifery is likely to include:
  • Low uptake of these reforms by midwives
  • Minimal benefit to women whose seek a midwife as their primary maternity carer
  • Uptake only by midwives working for obstetricians as they will be able to access the required arrangement
Midwives working for obstetricians are likely to practice within the medical model, rather than a midwifery model. This will lead to progressive erosion of midwifery as a profession, and progressive loss to women of access to midwives who are skilled in the art of midwifery

As midwives become more entrenched in the medical model, midwifery skills will be lost and women's access to normal birth will be diminished even further than it is now

Private practice midwifery will become known as the model whereby midwives are working in private medical practices, with little regard for those self employed midwives who currently provide true midwifery care at this current time

Acceptance within the maternity workforce that midwives require medical sign off for Medicare and therefore further erosion of opportunity for midwives to work autonomously

APMA is opposed to Parliamentary progress of the National Health (Collaborative arrangements for midwives) Determination 2010 in its current form.

APMA will continue to lobby for the National Health (Collaborative arrangements for midwives) Determination 2010 to be disallowed, withdrawn and rewritten in an acceptable form.

The NHMRC Draft National Guidance on Collaborative Maternity Care document is at

Sunday, October 10, 2010

'midwifery models of care' in rural Queensland

[This account has de-identified the midwife and location.  It is a clear example of the ridiculously restrictive environment in which midwives are required to practise.]

I have had various discussions with managers/project officers who are attempting to roll out hybrid 'midwifery models of care' for the rural sector. From my own personal observations -

  • It is clear that GP's are the primary carer with the midwife as the after thought so as not to upset them.
  • GP's are scared they will lose an income stream to their rural practice often with the right to private practice to the local hospital.
  • Managers do not want to lose the doctor as the rural community backlash will be fast and vicious (rightly so).
  • Higher places of office are providing non-reassuring advice to the facility managers, happy to provide details specific to my application verbally.
  • It is clear managers are thinking they can switch a midwife's hat on for a few hours of the day to provide antenatal care or birth care. Essentially they are employed as a nurse first.
  • It is clear until nursing workforce shortages are addressed there will be no change in practice in rural areas that ensure continuity of care with a known midwife as midwives 'offering' themselves to be in these new models are still being put on rosters and not annualised salaries plugging up nurse shortages. Burn out for midwives will occur rapidly.

Geographical boundaries in keeping care within local communities to ensure the care is local, owned by the consumer and feels safe (Rebirthing Report) are being ignored in the drive for efficiencies in combining some projects when viewed in a remote office in some districts.

Collaboration for homebirth with a General Practitioner

A well known Melbourne GP, Peter Lucas, has attended homebirths with midwives for many years.

An excerpt from his website:

“For some 35 years Dr Peter Lucas and Wattle Park House has offered collaborative care with home birth families and the midwives they have chosen to assist them with their experiences.
"This will continue but assumes that the Wattle Park House medical practitioner attends the birth.
"Until midwives obtain full indemnity cover which includes the labour and delivery, collaboration at a distance is fraught with uncertainty in a medico-legal sense, and cannot be seriously entertained.”

Midwives are concerned that although this doctor is willing to enter what has been called a "collaborative" arrangement with a midwife, he (or his insurance company) are setting conditions on his collaboration and transferring the primary carer role from the midwife to himself. If midwives were to enter into agreements with Peter, they would no longer be the primary carer for their own clients. The arrangement negates the notion of continuity of care from the midwife who practises on her own authority, and renders useless the process of applying for Medicare/PBS eligibility for these women for their antenatal care, as the doctor will be providing that.

Saturday, October 9, 2010

Examples of lack of collegiality by some doctors

In preparation for the implementation of Medicare reforms, commencing 1 November, midwives and maternity consumers have been asked to record evidence of any obstruction to collaboration.

The following message has been received from a midwife in Melbourne:

"A number of my clients have been advised by the GP, when going to their office requesting blood tests, ultrasounds etc, that if they are having a midwife attended home-birth then the GP does not want to be involved in their care beacuse of the lack of insurance for midwives in private practice. This is a major barrier to collaboration in my opinion. I have been searching RACGP websites for some confirmation of this issue and have found some. The attached document (the RACGP submission to government) states:
"What are the workforce barriers to integrated models of care?
• Insurance
As stated previously the RACGP finds the present unavailable of insurance for
privately employed midwives a deterrent. Some GPs want to access midwives on a
sessional basis as they do for other doctors, but find this not possible in the current

"Do any of the Midwives/clients have it in writing that GP's are refusing to collaborate already? I have personally found this to be a frustrating and potentially negilgent treatment of women. They [the women] ask for a simple test and the GP refuses - what if there IS an undetected problem because of the GP's refusal to provide care?"

The Australian Medical Association has published a document Collaborative Arrangements: What you need to know in preparation for the inclusion of eligible midwives and nurse practitioners in Medicare funding from 1 November 2010.
This guide is intended to provide you with guidance on important information to consider when entering into a collaborative arrangement with a midwife or nurse practitioner.
  • The legislation
  • Effective collaboration is good for patients
  • What is a collaborative arrangement?
  • Does the midwife/nurse practitioner meet the relevant MBS/PBS requirements?
  • Indemnity insurance
  • Is there any obligation to participate in a collaborative arrangement?
  • Are there any restrictions on which medical practitioners can participate in a collaborative arrangement?
  • Can more than one medical practitioner be a party to a collaborative arrangement?
  • Is a collaborative arrangement required for every patient?
  • Do you have confidence in the midwife or nurse practitioner?
  • Remuneration
  • Should you insist on a written agreement?
  • Clinical settings where services will be provided
  • What matters should be included in a collaborative arrangement?
  • Best practice guidelines
  • What should you do when a patient does not want to follow agreed clinical guidelines?
  • What happens if things do not work out?
  • Where can you obtain more information about relevant MBS and PBS arrangements?

Link to Medicare information: Midwives and Nurse Practitioners

New blogger

That's me at a rally outside the Health Minister's office
Hello, this is Joy Johnston.  

I would like to introduce myself, as I have put my hand up to work with this blog. My blogs are perhaps the best way of telling you how I use this valuable medium.

Through the villagemidwife blog I share my own midwifery stories and make critical comment on current issues.

midwivesVictoria is a site I manage for the Midwives in Private Practice (MiPP) group, a collective of independent midwives in Victoria.

Private Midwifery Services is a more recent blog, in which I have addressed the very complex and often vexed issue of reform of maternity services, particularly as it has impacted on independent practice including homebirth.

My blogging experience goes back several years. On my blogger dashboard I have about a dozen sites, and there's a Word Prss quilt blog out there too! I use blogs as records that are maintained in a systematic fashion over time, and easily retrieved. A blog is like a magazine that, instead of having pages that you turn, has pages that continue on down the screen and into the past. The links on the side bar of the blog invite the reader to explore further. Documents and posters can be posted on the blog as images, and enlarged by a right click from the mouse.

Anyone who is older than about 40 will remember the pre-digital, pre-internet era. As a budding activist for maternity reform as recently as the early 1990s, I did cutting and pasting of articles that were put together into a photocopied magazine, or a single page. We had a computer and a printer, but there was no ability to do special page layouts. Instead of mail merge for addresses, we addressed envelopes by hand. The marvel of fax could be used then to get messages out quickly to hospital maternity units.

Then came email, firstly through the Uni, and then at home. What emancipation!

The world of midwifery, and maternity activism, has groups that connect with each other through direct email, Yahoo! groups, and in recent years other social networks such as Facebook and Twitter. In those groups it's very easy to become inwardly focused, with pretty well everyone speaking the same language, or at least those who engage in discussion are. And there is usually, in my experience, a silent majority.

A blog enables information to be shared with anyone who is interested. The networks formed by blogs, with links to other similar blogs and websites, can lead readers down interesting and complex pathways. This crossing of professional and cultural boundaries is useful as an adjunct to the more restricted group discussions.

Blogs enable tracking of numbers of visitors to the site: a sort of statistical self-worth meter. Comments are useful, sometimes agreeing, and sometimes putting an opposing view. The hardest thing for a blogger to face is the doldrums, when noone out there seems interested in all the fascinating material that one has collected and shared. Photos can be used too, and will often draw attention to an otherwise bland page of text.

Australian Private Midwives Association welcomes our readers. Comments that address issues of interest to our group are welcome.