Homebirth midwifery

In 2010, National Registration came in and required that all health practitioners carry professional indemnity insurance. Indemnity insurance had to cover every aspect of practice. Except there would be no insurance for homebirth. Threatened with the extinction of private homebirth services, the government inserted an exemption to the requirement of insurance for a homebirth. We still need insurance for pregnancy and postnatal care, but not the actual birth …. At home.

What about when we need to transfer women to hospital? It happens in 10% - 50% of cases, depending on how a midwife practices, how adherent she is to the ACM Guidelines, safety issues and so on.

Typically, we go with our clients to hospital and stay to support them when they are transferred. This has not been questioned until now.

Does “support” at a homebirth transfer constitute “midwifery practice” for which we need insurance? In considering the support vs practice issue, we should consider the sorts of situations that may arise while we are supporting a woman in hospital, and how we would respond. Please consider the following scenarios:

  1. A woman transfers from home to hospital and has a CTG (baby heart rate monitor) in progress. The private midwife is in the room with the woman and her partner. There is a concerning abnormality in the baby’s heart rate. The midwife rings the bell. Several minutes elapse. The midwife rings the bell again. Should she act (change the woman’s position, cease the Syntocinon infusion if it is in progress, increase fluids etc) or not? Because if the midwife did act she’d be practicing midwifery. Let’s assume the midwife did not act. Fast forward to the birth and there is a bad outcome. Will the midwife be considered to have been partly liable for failing to act? How will the woman see this scenario if the midwife didn’t act and her baby was harmed? Do you think the woman might try to sue her midwife who she has paid to attend her birth as advocate / support / immediate second opinion person and so on?
  2. A woman has had her baby. Hospital staff have left the room and it’s quiet time for the parents. The woman mentions to her private midwife that she feels a sudden warmth and dampness and asks her midwife to check. Should the private midwife check? Should she simply press a buzzer and wait? If she does check, she notices a concerning about of vaginal bleeding. She rings the bell and waits. Should she act to stem the flow of blood by massaging the woman’s uterus to a state of contraction? If the hospital staff come and it’s obvious that they’re run off their feet, should the private midwife assist them perhaps by preparing an IV infusion, locating equipment for them to use, reassuring the woman who is the midwife’s client as well as the hospital’s client? Who’s liable if the private midwife prepares the infusion incorrectly and the hospital staff administer it? You might think the hospital staff are liable; they might argue that the private midwife is.
  3. A woman is labouring and the hospital recommends a particular course of action which the woman does not want to follow. She looks to her private midwife for guidance. What should the private midwife say? Nothing? Because if she ventures to provide any advice, she is practicing midwifery.
  4. The hospital staff make an incorrect assessment, for whatever reason. They intend to act on this incorrect assessment with a management plan that the private midwife knows to be inappropriate for the woman. Should she speak up? If she does, she is practicing; if she does not and there’s a bad outcome, could she be liable?

So you can understand the dilemma that is faced by a midwife who “supports” her client in hospital, and why insurance is necessary whenever “the individual uses their skills and knowledge as a … midwife”. You can also understand the conflict experienced by all – the hospital, woman and midwife, when a midwife attends the hospital with her private client.

The homebirth exemption covers the birth at home; it does not extend to a home birth transfer. One insurance product covers labour and birth care, however it only covers the care of private patients. Obstetricians don’t – as yet – provide back-up care for home birth women, and midwives do not have admitting rights to be able to admit women. Hence, women are admitted as public patients when they transfer from a homebirth.

This has been known for a while now, that insurance does not cover the care of public patients, women who transfer from home to hospital are public, therefore the midwife is not covered. We didn’t think it mattered because we assumed that “support” requires no insurance. Right? Wrong!

We need to have insurance to practice, but how is practice defined? The Registration Board defines it:

Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a nurse or midwife. For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care. It also includes working in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery

In effect this means if you are a private midwife, you are a private midwife wherever you are and whomever you’re with. As soon as we use our knowledge or skills, we are considered to be practicing, and we cannot not use knowledge that we have.

Where does this leave homebirth and midwifery?

From the woman’s perspective, who would choose a private midwife for home birth care when faced with a possibility of transfer to hospital without the private midwife whose “support” / advice would be most valuable when faced with an unexpected situation?

From the private midwife’s perspective, who can sleep at night knowing she may have to leave a woman at the hospital gate right when the woman needs her midwife the most?

The absurd thing about all of this is that midwives can simply unregister and have none of these issues. And they are doing just that! So long as we don’t call ourselves “midwife”, we can do just as we please. You see, we have title protection (“midwife” is a protected title), but not practice protection. Anyone can assist a woman in birth. Unregistered midwives work with no practice and referral guidelines, no regulation, no compulsory hospital booking for homebirth clients, no insurance costs, no continuing professional development costs, no obstetric consultation if it is not desired - you can do what you want, so long as you don’t call yourself a midwife. It’s absolutely legal.

Is this a safe system of care? Is this meeting the needs of homebirth women and babies? Isn’t it far better to have a system whereby a private midwife can admit her client to hospital if need be, and continue her care in the hospital?

It seems that no-one can force hospitals to enable admitting rights for midwives, even though this is was the Health Minister’s intention when the reforms were rolled out. We have reached a situation that requires urgent resolution.

For now, I have taken the decision to cease my homebirth practice. I am no longer accepting homebirth bookings, however I am of course homebirthing with my booked clients who have chosen homebirth.

This has been a distressing and difficult decision. I love attending homebirths. There’s something special about being home with a woman in labour and welcoming a baby into the world gently and peacefully at home. It’s really special. Relaxed, calm, peaceful, joyous. No hospital noises or smells, no clinical store rooms, no hospital bed and stainless steel, no doors banging, phones / pagers ringing, people yelling down corridors. Just home furnishings, carpet, softness, warmth and love. The perfect way for a baby to journey into this world. My heart is very heavy with this decision. Once I have admitting rights, I will start homebirthing again. However for now, I feel incapable of dropping a woman at the hospital gate and not supporting her through labour; and I am not willing to be seen to be practicing without insurance as this is an offense.

I am continuing to birth with women in hospital as I am fortunate to be able to do so and we have had amazing feedback from women and their partners. I truly believe it represents the ultimate in private maternity care. No-one is ever “transferred” as we can accommodate all levels of care and care needs and women are supported by continuity of midwifery and obstetric care. This is a far superior model than home birth where any obstetric involvement entails the woman being seen by an unfamiliar obstetrician in a hospital clinic and any labour transfer entails moving to a new location to be cared for by strangers. I strive to give women and babies the very best care and in my heart, I know that our collaborative model of care is the very best in private care. I am, however, very sad to leave behind homebirth for now. It has been my passion and dream for most of my life.