Position Statement on Home Birth

Midwives and other interested parties are preparing critiques and responses to the ACM ‘Interim’ homebirth documents .   The College is inviting comments on the documents, which are an interim position statement, guidance for privately practising midwives providing midwifery care for planned homebirth, and a literature review.  None of these documents have undergone academic peer review.  The closing date for submissions is 23rd September 2011.

The Nursing and Midwifery Board of Australia has "endorsed the Australian College of Midwives position statement on Homebirth." The full significance of this rapid endorsement by the regulatory body, of an 'interim' document, prior to consultation with the profession, is not clear. 

We refer readers to the International Confederation of Midwives' (ICM) Position statement on homebirth

It states, after a brief introduction:

POSITION:

The ICM supports the right of women to make an informed decision to give birth at home. The midwife who elects to provide professional services for women in their homes should be able to do so within a nation’s health service. The ICM recognises that not all nations have the legislation or health service structure which supports home birth, and urges national governments to review the scientific literature on the subject and progress to a maternity service which includes it as an option for women giving birth. 

GUIDING STATEMENT TO MEMBER ASSOCIATIONS: 

Member Associations based in countries where women do not have access to a full range of options as to where they can safely give birth, are encouraged to negotiate with their governments for this to occur. 

The Australian College of Midwives (ACM) is a member association of ICM. Any position statement of the ACM should usually be consistent with, and reflect, the Position Statement of the ICM. The professional College for midwives in Australia is expected to negotiate with our government to provide a full range of options, including homebirth, where women in this country can safely give birth. Please remind the College of this ICM position and guiding statement in your submissions.

insurance and private midwives

All regulated health professionals have been required, since 1 November 2010 when the new National Health Practitioner Regulation law came into effect, to have professional indemnity insurance.

There is no insurance product that covers homebirth, which is the mainstay of private midwifery practice. An exemption from indemnity insurance for homebirth has amended the requirement for insurance, and this is in effect until 30 June 2013.

Midwives who practise privately have the choice of two insurance products. One of these, from MIGA, is the only one that will provide intra-partum cover for Medicare-eligible midwives to attend certain hospital births, as it has government backing. The other product, from Vero Mediprotect insures midwives for provision of private prenatal and postnatal services and education, but excludes birth. [These links are included for information only, and this statement should not be construed in any way to direct midwives to one particular product.]

Recent developments with regard to insurance have been outlined at the MiPP blog, since we learned that a 'mandatory reporting' notification was made of a midwife who was considered to be practising without insurance. We understand that this midwife was in a public hospital with a woman who had planned homebirth. After transfer of care to the hospital, the midwife continued in a supportive role with the woman: the usual practice in Australia when women transfer from planned home birth to hospital care.

There seems a small window for those with MIGA insurance if the woman is admitted ‘private’. The MIGA-insured midwife then may be covered. Most hospital backup booking arrangements that are made by or for women who are planning homebirth are with public hospitals. The possible pathway that is being looked at is that the woman is admitted as a 'private' patient in the public hospital. Some larger hospitals have 'in house' obstetricians. In this case the obstetrician on call at the time of admission will assume responsibility for the care of the woman and baby. Other hospitals have local obstetricians, paediatricians, and obstetrically qualified GP's on roster, to be called in for public as well as private patients. 

ACM Position Statement on Homebirth, "endorsed"

From the AHPRA website

“The Nursing and Midwifery Board of Australia has endorsed the Australian College of Midwives position statement on Homebirth. The College is inviting comments on the position statement; the closing date for submissions is 23rd September 2011. The position statement is available from the Australian College of Midwives website.”

totally flawed research

Listed as a top article in today's Age, readers are confronted with the question: 'Caesarean births a better option for mothers? ' The article tells us that "Dr Stephen Robson, an associate professor of obstetrics at Australian National University, is recruiting 1000 pregnant women to test the long-held view that vaginal deliveries are better than caesareans for healthy women with uncomplicated pregnancies."

This 'study' requires well women who are expecting their first child, of whom 500 choose a caesarean (for no medical reason) and 500 plan a vaginal birth, and will look at "psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates."

"Good luck!" I say. Good luck to the mothers and babies - they will need it.

This research is not good science - whatever results are achieved will not come anywhere near testing the safety of vaginal vs surgical births for healthy women with uncomplicated pregnancies.

What sort of ethics committee would give approval to this research? Anyone who has studied basic health science will know that the numbers in this study are so small that confounding variables will make the data useless.

Of the 500 women planning vaginal birth, assuming that they are standard pregnant women who receive standard maternity care, at least 30%, and possibly up to 50% will experience a Caesarean birth. That leaves the vaginal birth cohort of 250-350. Many of these women will receive powerful narcotic drugs either by injection or epidural; drugs that are kept locked up in the 'dangerous drugs' cupboard. A considerable number of the 'vaginal birth' cohort will have their labours stimulated artificially with synthetic prostaglandins and oxytocin; and many will be 'assisted' to give birth by obstetricians wielding forceps or ventouse caps. All of these interventions carry potentials for harm to the mothers and babies, with a potential to influence depression and breastfeeding rates.

Of the 500 women planning elective pre-labour Caesarean, there will be other variables. A few may even labour spontaneously and quickly, and give birth vaginally! A considerable number of the surgically delivered babies will experience difficulties with breathing, and require special care for the first day or so. A few of these babies may be very ill.

A few mothers in the elective Caesarean cohort will develop wound infection, and many will develop internal adhesions that may complicate future births. A few may experience serious iatrogenic complications of the surgery, including accidental surgical damage to uterus, bladder, ureters, or bowel; drug administration errors; harm resulting from spinal anaesthesia; and haemorrhage. Subesquent pregnancies for these women also bring the potential for abnormal placenta formation, with placenta accreta and percreta placing a woman at great risk of serious haemorrhage requiring urgent hysterectomy as a life-saving measure.

In 1996, World Health Organisation made the profound statement that "In normal birth there should be a valid reason to interfere with the natural process." (in Care in Normal Birth: a practical guide, p4)  It's a no-brainer.

Today, Australian women are being enlisted into research that pretends to address the question of which is better, vaginal birth or abdominal surgery. It's a stupid question. If the safety of vaginal birth for the primigravid well woman is considered anywhere near the risk of a Caesarean, it's an indigtment on what happens to women planning vaginal birth.   The researchers need to find ways to protect and promote the natural processes in birth, while reserving surgical intervention for those who have a 'valid reason'.

I hope there are midwives and doctors whose critical thinking alarm bells start sounding when they are asked to enlist women in this study, and I hope the women who are approached tell the researchers what they can do with their trial.

This is a personal opinion, and is not a policy statement for Australian Private Midwives Association.

Your comments are welcome.

News for privately practising midwives and women planning homebirth

from
Australian Health Ministers’ Conference
COMMUNIQUÉ
5 August 2011

Professional Indemnity Insurance Exemption for Independent Privately Practising Midwives
"Ministers agreed to a further 12 month extension of the exemption to 1 July 2013 while further options are explored with a report back to the next Health Ministers meeting."

Your comments are, of course, welcome.

MotherBaby Childbirth Initiative

[click image to enlarge]

In 1996 the Coalition for Improving Maternity Services (CIMS) created the Mother-Friendly Childbirth Initiative (MFCI): 10 Steps to Mother-Friendly Hospitals. Although designed specifically for the U.S, the MFCI had global impact. In response to strong international pressure, the CIMS International Committee was formed with the goal of creating an international initiative that would be applicable in all countries and settings. It became the International MotherBaby Childbirth Organization (IMBCO) in 2007. In collaboration with grass-roots representatives from every world region and an international Technical Advisory Group (consisting of representatives from WHO, UNICEF, ICM, FIGO, Lamaze International, and many others), IMBCO created the International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal MotherBaby Maternity Services and launched it in 2008.

The purpose of the IMBCI is to call global attention to the importance of the quality of the mother’s birth experience and its impact on the outcome, the risks to mother and baby from inappropriate medical interventions and lack of access to appropriate emergency care, and the scientific evidence showing the benefits of optimal MotherBaby care based on the normal physiology of pregnancy, birth, and breastfeeding. The IMBCI 10 Steps set the gold standard for excellence and superior outcomes in maternity care. The IMBCI has been translated into over 20 languages and is being put to many uses in the developed and developing worlds. Its 10 Steps are currently being implemented in 3 pilot/demonstration sites--hospitals in Quebec, Brazil, and Austria. This presentation will describe the IMBCI and the multiple ways in which it is being put to work around the world. A critical component of the IMBCI is that it highlights the fact that “women’s and children’s rights are human rights” and that “access to humane and effective health care is a basic human right.”

The Asia-Pacific Regional Representative of the International MotherBaby Childbirth Organization is midwife Rachael Austin, dnraustin[at]bigpond.com from Theodore, Queensland.