Birthing after July 1, 2010?

Here's the full text of an article I have written for Essential Baby. Melissa Maimann July 22, 2009

Currently, all health professionals are registered by their own State Board. There are approximately 90 Registration Boards throughout Australia. Come July 1, 2010, all of these Registration Boards will be merged into one National Registration Board.

The benefits of National Registration include:

• Health professionals will be able to work between States and Territories, without having to register in each State or Territory prior to practicing • Consistency of registration requirements and implementation of national standards • Cost savings for both government and professionals with the elimination of unnecessary complexity and duplication • A framework for maintaining consistency of state and territory regulation for individual professions • Admission to professional practice (restrictions on professional practice by non-professionals) • Regulation of professional practice (through consistent standards for accreditation and registration) • Consumer protection (through complaints processes, insurance of professionals, criminal record checks of professionals and so on).

Alongside the changes to the registration of health professionals, there was a recent review of maternity services in this country (the Maternity Services Review, or MSR). There were several recommendations from this review.

What does all of this mean for pregnancy and birth?

The intersection of these changes has significant meaning for women, midwives and obstetricians.

Insurance will be a requirement for general registration after July 1, 2010. This is in place to protect the public, so that in the event of negligence that results in a baby or woman being harmed, the family may access a pool of funds to support medical and other expenses. That is fair and reasonable, however insurance is not available for midwives who are self employed.

To explain this further, most midwives are employed by a hospital and are covered by insurance through their employment. Midwives who work in private practice attending home births or hospital births do not have access to insurance. These midwives perform a very special role. Since they are contracted by women and are not employed by hospitals, they are uniquely placed to provide families with evidence-based and independent advice. This is significant for families, and often means the difference between a surgical birth and a natural birth. Currently, independent / private midwives may attend women at home or in hospital.

After 2010, all midwives will be required to have proof of insurance in order to register on the general (practicing) register. There will be different levels of registration, such as general (ie, a practicing health professional), non-practicing (in which case the professional cannot practice or give advice), student, and so on. All midwives will be able to register, but those who do not have insurance may only register as a non-practicing health professional. In that case, they may not attend births, provide advice and so on.

This affects all women! Yes, that includes you.

It is thought that these changes only affect families who want home births. This is not true! The changes affect all women who seek private midwifery care. Women consult with private midwives on a range of matters, regardless of the place of birth or chosen care provider. Things like, “My doctor / hospital said I have to have an induction / caesarean / epidural because… Do I have any other options?”

Private midwives give second opinions, run independent childbirth education classes, attend women who are birthing in hospital, and also attend home births. All of this will be affected by the changes to Registration come July 1, 2010. If midwives cannot secure insurance, your ability to seek private midwifery care and impartial advice will be impacted.

Which midwives will be able to access insurance?

Private midwives will need to show proof of insurance in order to practice. With insurance, private midwives will be able to birth with women in hospital, but not at home. Employed midwives working in hospitals will not need insurance.

In order for a midwife to access insurance, the midwife must work in a collaborative team with a doctor. Currently in Australia, midwifery is still seen by some as a profession that is only practiced under the direction and supervision of an obstetrician or obstetric guidelines. Although the Maternity Services Review does much to provide a framework through which midwifery may be seen as a profession in its own right, we have some time to pass before this is realised in the wider community. In the meantime, it is hard to say what will become of women’s choices when their choices are not within obstetric guidelines.

The midwife must be credentialed. This means participating in annual Peer Review and being up-to-date with continuing professional development.

S/he must have completed a certain amount of practice in a setting such as a hospital (eg one year) prior to entering private practice.

Then - the private midwife may apply to have access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Schedule.

What does this mean for hospital birth?

Currently, a mere 3% women Australia-wide are able to access continuity of care with a midwife. The good news is that after November 2010, it may be possible to contract a private midwife to attend you for a hospital birth. The details in this instance are a bit hazy. It would seem that you will be able to choose your own midwife, have your antenatal (pregnancy) consultations in your home, birth in hospital with your midwife, and then continue postnatal care at home with your midwife for up to 6 weeks. As well as this, you will be able to claim a Medicare benefit for midwifery services (in other words, midwifery will be bulk-billed). And your midwife will be able to order blood tests and ultrasounds, and s/he will be able to order medications such as Syntocinon, Vitamin K, Anti-D and Hepatitis B vaccines.

There are, however, a lot of unknowns, such as: • What is the process by which a midwife becomes eligible for MBS and PBS, and how long does this process take? • Can midwives access any hospital, or only a select few, and can a hospital refuse visiting rights to the midwife? • What are the hospital’s requirements for granting private midwives with visiting rights? • If a doctor is required to intervene in the labour or birth, does the midwife forego her / his payment to the doctor? • What are the $ values of Medicare benefits for antenatal and postnatal consultations?

These questions remain unanswered. The current Medicare fee for midwives to attend to antenatal care is approximately $23 per antenatal consultation. Private midwives typically book 4 women each month, so they do not spent a full eight hours a day seeing women in 20-minute time slots. More likely, private midwives drive an hour to consult with a family in their home for one or two hours, and then drive home for another hour. $23 remuneration for this service will not make ends meet for the midwife.

Likewise, if the midwife forgoes the birth fee because she has needed to call a doctor to intervene, it will not be economically viable for the midwife to continue practice.

I have no doubt that the Health Minister would not put the energy into making these changes if they could not work, however, the detail that is missing is the essential “nuts and bolts” that will see private practice flourish or die.

What does this mean for home birth?

Currently, there are two ways to have a midwife-attended home birth: you may have a home birth through a government-funded program, or you may access a private / independent midwife. Women who choose a private midwife generally experience more choice and control over their pregnancies and births. Care is usually provided in the woman’s home, and consultations are one to two hours long. Publicly-funded programs usually see women going to the hospital for antenatal consultations, which are around 20-30 minutes long. The programs have strict inclusion criteria and generally have high transfer rates. What this means is that if you are accepted onto the program, you have a reasonable chance - up to 40% or 50% - of being transferred out of the home birth program at some point in your pregnancy or labour and birthing your baby in delivery suite.

If a woman contracts a private midwife to attend the home birth, she generally has a higher chance of being accepted for homebirth, and the transfer rate is lower: around 20%. Publicly-funded home birth is not possible for women having vaginal births after a caesarean (VBAC), breech babies, twins, women who have their babies after 42 weeks or before 37 weeks, women with gestational diabetes, previous bleeding after birth, previous shoulder dystocia, women whose BMI is over 35 (or who are over 100Kg in weight) and so on. Come July 1, 2010, all of these women will have no choice but to birth in delivery suite if they are to be professionally attended.

What about women who do not meet the criteria for publicly-funded homebirth programs, or those women who cannot access a public home birth program?

There are two options for women who wish to birth at home but either cannot access a publicly-funded home birth program, or are not accepted into such a program.

One option is to freebirth, and the other option is for a midwife to attend the woman.

1. Freebirth The safety of freebirth (home birth without a midwife) has not been researched, and indeed, it would be unethical to have a randomised controlled trial of freebirth. So it is impossible to say that it is safe, or that it is not safe. However, it remains an option for women.

2. Midwife-attended home birth Midwives who attend home births outside of the publicly-funded models cannot access insurance. It is a requirement of registration that everything a health professional does in the course of their practice, is indemnified. Since insurance will not cover home birth, the midwife will be in breach of her / his registration by attending a home birth. This may lead to disciplinary action, up to and including de-registration.

If a midwife lets her / his registration lapse, planning to perhaps work as a doula or in some other capacity and attends a birth, s/he can be charged with practicing midwifery without registration. This carries a jail term or a fine.

It is important to note that there are no penalties for women and families who ask midwives to attend their births. Consumers of health services can never be charged for inciting professionals into unprofessional behaviour.

If midwives decide to work “under the radar”, although s/he may not be “found out”, there are important considerations for women and families:

• A midwife working under the radar will most likely not have the same access to continuing professional development as a registered midwife working legally. This can compromise safety as the midwife will not be up-to-date in her / his practice. • Midwives working under the radar will not be able to report their births to the government for statistical analysis. • Midwives working under the radar will not be able to register births or sign Medicare and Tax forms. • Midwives working under the radar will only be able to take cash payments and they will not be able to declare their income. • Women who experience complications at home with a midwife working under the radar will have to front up to hospital alone, without the ongoing support and advice of their midwife, and lie about all prior antenatal and birth care.

Additionally, there is a requirement of registration that includes mandatory reporting of health professionals. This means that health professionals must report other health professionals who place the public at risk of harm, for example by practicing the profession in a way that constitutes a departure from accepted professional standards. Hence, the midwife who attends home births without insurance risks being reported by her / his peers.

Clearly, the options of freebirth or midwife-attended home birth (if the midwife works under the radar) are not acceptable to women and families and have the potential to severely compromise safety for women and babies.

Although home birth is not every woman’s cup of tea, many people accept that it is the right of every family to choose where and with whom they will birth their baby. Forcing women to birth in hospital is no different to forcing women to accept other birth choices that they find unacceptable. Currently, your right to an elective caesarean, elective epidural, or elective induction is not questioned. Yet your right to home birth and private midwifery care is compromised, quite severely, by this new legislation. Imagine the outcry if hospital birth or epidurals were no longer possible for women!

Wow! That’s serious. What can I do to help?

• Increase awareness of the issue. Tell everyone you know, send an email to everyone in your address book, place a note about this in your email signature. • Visit Save Birth Choices for information on what you can do. • Attend the rally on September 7, 2009 in Canberra. See and scroll to the bottom of the page. • Talk to the media. • Talk to your local MP. These changes need to be accepted by every State and Territory in order to go ahead.

Author Melissa Maimann is an Essential Baby member and a private midwife.