The Maternity Services Review Recommendations

For further information, please contact Melissa Maimann at Essential Birth Consulting. Below, you will find the recommendations of the Maternity Services Review. Of particular interest are Recommendations 17 and 18, which relate to private mdiwifery practice.

While private midwives support provision of access to the PBS and MBS, the requirement of working in collaborative, team-based models is in opposition to current private midwifery practice. Current practice is based on one-to-one midwifery care, and women prefer it this way. Sometimes women are happy to work with 2 midwives, knowing that one or both midwives will be present for the birth. It is difficult to speculate the definition of "collaborative" and "team-based". If it requires that each midwife team has a medical leader, this could work counter to the needs of homebirthing women. If each homebirth needs to be OKd by an obstetrician, I can see many women being disgruntled.

Insurance is a great thing. Currently, midwives around the world are not able to access insurance if they work outside of hospitals. We welcome the opportunity to work insured, and of course it is only fair that women have access to funds in the event of a serious injury to themselves or their babies during labour or birth.

However, insurance also brings with it 2 central problems.

First, the increased business expenses would need to be passed onto consumers. This might increase the cost of a homebirth by as much as 25%. So inevitably, homebirthing women are hit twice by this move – first there is a lack of access to Medicare, and second, they end up paying, pro-rata, for their midwife’s insurance.

Second, insurance might limit practice. The ACMI Guidelines for Consultation and Referral guide midwifery practice and determine whether a woman can be cared for solely by a midwife, whether she needs medical consultation, or whether her care needs to be transferred to a doctor. I cannot see a way for insurance to come into effect without the attachment of some sort of guidelines. Many women who want a homebirth come to their decision from past negative hospital experiences or a desire to experience a natural twin / breech / VBAC birth etc which is denied to them in hospital.

Many women who have homebirths have some sort of risk factor - post dates, big baby, small baby, prolonged ruptured membranes, too old, too young, previous postpartum haemorrhage, gestational diabetes etc. Under the guidelines, these women would not be able to have a homebirth and midwifery care. Not only do we have to have insurance, but the insurance needs to cover everything we do. Almost certainly, insurance will not cover “risky” situations as defined by ACMI. If it did cover “risky” situations, the premium would increase, and these costs would then again be passed onto the consumer.

The other recommendations are listed below:

1. That the Australian Government, in consultation with states and territories and key stakeholders, agree and implement arrangements for consistent, comprehensive national data collection, monitoring and review, for maternal and perinatal mortality and morbidity.

2. That the Australian Government, in consultation with states and territories and key stakeholders, initiate targeted research aimed at improving the quality and safety of maternity services in select key priority areas, such as evidence around interventions, particularly caesarean sections, and maternal experience and outcomes, including from postnatal care.

3. As a priority, that the National Health and Medical Research Council (NHMRC) develop national multidisciplinary guidelines for maternity care to promote consistent standards of practice, quality and safety in collaborative team models. These guidelines are to be agreed by the professions involved, in consultation with consumers and state and territory governments.

4. That, in developing the National Maternity Services Plan, consideration be given to the demand for, and availability of, a range of models of care including birthing centres.

5. That, given the role of the states and territories in the provision of maternity services in rural areas, the availability of rural maternity services is a priority area for the Plan, requiring the engagement of states and territories.

6. That provision of maternity services be considered in the context of all governments’ commitment to close the gap on Indigenous disadvantage, and be developed in partnership with Indigenous people and their representative organisations.

7. In consultation with relevant state or territory governments, that consideration be given to funding expansion of Indigenous maternity care programs, based on current successful models, within a research and evaluation framework.

8. That, in any initiatives that are aimed at supporting an expansion or upskilling of the maternity services workforce, particular focus is given to supporting an increased number of Indigenous people as members of the maternity workforce, across a range of roles.

9. That all professional bodies and employers ensure that all health professionals and other staff involved in the delivery of maternity care receive cultural awareness training.

10. That all professional bodies involved in the education and training of the maternity workforce ensure that cultural awareness training is a core component of their curricula.

11. That consideration be given to improving the range of birthing and other pregnancy-related information and resources, including those on the internet, that is made available to assist women in informed decision making; with any information materials specifically recognising the needs of population subgroups such as culturally and linguistically diverse communities, women with a disability, Indigenous and teenage mothers.

12. That consideration be given to the establishment of a single, integrated pregnancy-related telephone support line for consumers, possibly as part of the National Health Call Centre, providing both clinical and non-clinical support services, complemented by triage to a number of existing specialised support services.

13. That in order to lengthen the duration of breastfeeding, further evaluation be undertaken to identify the health care or community settings in which breastfeeding information and support are most effectively received, with a particular priority on consulting and supporting women from diverse cultural and socioeconomic backgrounds.

14. That the development of national maternity care guidelines (Recommendation 3 above) consider the Perinatal Society of Australia and New Zealand Clinical Practice Guideline for Perinatal Mortality Audit.

15. That consideration be given to support for the rural maternity workforce to obtain and maintain appropriate training and skills.

16. That consideration be given to identifying the competencies and credentialing required for advanced midwifery practice.

17. That, noting the potential issues to be resolved including the potential interaction with Private Health Insurance arrangements, the Australian Government gives consideration to arrangements, including MBS and PBS access, that could support an expanded role for appropriately qualified and skilled midwives, within collaborative team-based models.

18. That, in the interim, while a risk profile for midwife professional indemnity insurance premiums is being developed, consideration be given to Commonwealth support to ensure that suitable professional indemnity insurance is available for appropriately qualified and skilled midwives operating in collaborative team-based models. Consideration would include both period and quantum of funding.

"Many submissions to the Review were from women advocating homebirth and requesting government funding in this area. For a proportion of women, the desire for a known midwife through the course of their pregnancy, and the inability to access this type of service through mainstream maternity services, was at least part of the reason for their choice of homebirth. Some submissions also expressed a concern at the lack of choice for women who were excluded from alternative models of care options as a result of being assessed as ‘high risk’. For example, women wishing to have a vaginal birth after caesarean (VBAC), those who have had multiple pregnancies and those with breech presentation were identified as not meeting criteria for some alternative models of care.

"Many of the consumers who participated in the Review consultation process had strongly held views about government funding for models of care that included birthing in a home setting. A number of submissions to the Review referred to the evidence of positive outcomes for homebirths for low-risk pregnancies. The Review concluded that, while homebirth is the preferred choice for some women, they represent a very small proportion of the total.

"While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time. It is also likely that professional indemnity cover support for a Commonwealth-funded model that includes a homebirth setting would be limited, at least in the short term. It is likely that insurers will be less inclined to provide indemnity cover for private homebirths and, if they did provide cover, the premium costs would be very high. Indemnity issues for midwife care more broadly are considered in Chapter 6.2."

- Seems that homebirth with a private midwife may be a thing of the past come 2010, unless a solution can be found with respects to Commonwealth funding for private midwifery, that also respects each homebirth woman's right to autonomy.

Melissa Maimann, Essential Birth Consulting.