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Thursday, 20 August 2009
Page: 8561


Mr LAMING (3:52 PM) —The cruel subtext of the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 is that you are consigning homebirths to the underworld of health service delivery. That is the ridiculous position this legislation places us in. It will effectively do four things: (1) it will oblige registered midwives to sneak off and assist with home deliveries without anyone knowing and, in so doing, potentially make them reluctant to refer young mums for hospital care when needed; (2) it will potentially place registered midwives at risk of $30,000 fines purely for attending a homebirth; (3) it will lead to midwives not becoming registered, not falling under indemnity protection and continuing to deliver at home at greater risk, without hospital support; and (4)—worst of all—it will mean non-registered midwives operating parallel to if not in isolation from the health services.

The one thing that we know is that the best way to incorporate homebirths in an overall obstetric plan for a nation is to have them supported by a functioning hospital system. Let us remember that Australia is not the Netherlands and it is not Denmark; Australia is the second most sparsely populated country in the world. Yes, that presents certain challenges in health service delivery and it means that often mothers are not delivering just around the corner from a fully equipped hospital. As was said by my colleague Senator Eggleston, who has also worked in the area, we need to remember that in this debate about homebirthing there is a third party involved—the baby.

At a birth there is the clinician or the helper—the doula or whoever is involved; perhaps a midwife—there is the mother and the family, and there is also the baby. Australia stands proud in having some of the lowest morbidity and mortality statistics in the world for birthing. If we look purely at the intrapartum neonatal mortality statistics for healthy full-term babies, Australia compares very well. Overall statistics for neonatal deaths around the world usually sit between one and two per thousand.

In this debate we are excluding the high-risk pregnancies—women delivering earlier than 34 weeks, breech deliveries, twins, someone with a history of a caesarean attempting a normal delivery—from analysis. What you have left are what we call low-risk deliveries. You can read the volumes; you can go right through Cochrane, de Jong and Jules, and every one of the world’s leading experts in this area say the evidence in this area is inconclusive—and I do need to note the exception of a recent Dutch study, which did have its own weaknesses—or that at best there are virtually comparable mortality statistics for low-risk children born at home.

So we all need to cool down a little bit about the safety debate, because we in this chamber have access to the best possible studies and most of them are inconclusive. I have already referred to one that showed a slightly higher neonatal death or stillbirth rate, but overall through these huge studies—I am talking national cohort studies; I am talking anonymised meta-analyses; I am talking the US homebirth study—we can be fairly confident that we can send the actuarial analyses out to look at homebirthing and make a dispassionate decision on whether it is safe.

Can I now approach this debate from the provider’s point of view—and I need to acknowledge, Mr Deputy Speaker Washer, your long involvement in medicine and obstetrics. Fundamentally, providers are not out there trying to do wacky things with high-risk mums. Intrinsically, what midwives are doing, be they community midwives or working in a hospital, is looking after the interests of both mum and the baby. We do not have to fear that we will be promoting high-risk deliveries in the furthest corners of Australia. That is not what we are talking about. What we are talking about is making provision for mothers in Australia who want a homebirth to be able to have one.

Can I cast some light on two concerns that we have not yet mentioned. The first one—and it sounds awfully callous and very focused on cost-effectiveness—is that mums who deliver at home deliver an enormous saving to the healthcare system. That is not the pervasive consideration here, but let us remember that the thousands of dollars in bed days, the enormous risks of high-intervention deliveries—the use of forceps and vacuum extraction—and the ballooning number of caesarean sections come at a cost. The savings from homebirths would more than pay for extending indemnity to those mums who seek it and who are low-risk. We are following a common-sense approach so that we pull home deliveries into the warm embrace of high-quality, hospital-supported obstetric care. I do not think, Minister Roxon, that that is too much to ask.

I will make a second point that has not yet been made in this debate. In 1992 I walked the corridors of an obstetrics ward in Farnborough and Orpington in the UK fearful of my senior registrars, who brooked absolutely no deviation from obstetric protocols, and knowing that we operated there on a margin for error of 0.6 in a thousand deliveries. That is not a great deal of room for error. The term ‘margin for error’ sounds very clinical, but what it means is that we do not want to lose a single life. When, as you have in Australia over the last decade, you have reduced mortality in low-risk deliveries from 1.2 to about 0.8 per thousand it seems only small but it is 224 babies every year, out of an enormous number of deliveries. So it is absolutely imperative that with every delivery we are thinking: how can we maximise safety in mum and baby, No. 1?

We need a system that pulls homebirths into that view and says: what is going to work at home and what is simply too risky? I have outlined what is too risky, but quite often mums will say, ‘I can’t handle the pain anymore; can I be transferred?’ or, ‘Things are moving slowly with the dilation and in the progress of the second stage; can we transfer to a hospital? I think that common sense would dictate that if you were to provide indemnity to midwives they would simply say, ‘I accept the indemnity on the condition that I will do the following things.’

I used to be a high-risk clinician and surgeon myself—not because I was not terribly good at it but because I did high-risk operations—and I was told, ‘If you move into this clinical area you will pay more for your indemnity.’ So it is only reasonable that in homebirthing, were you to choose to deliver high-risk mothers at home or to deliver further from a hospital obstetrics unit, your premiums would rise. My point to those on the other side of the chamber is a simple one: let risk be paid for; let risk find its level in the healthcare system, as it does for every other clinician.

Think of what the other side are achieving in government. They are effectively proposing that any clinician can practise at home except for a midwife. It is an extraordinary proposition: a doctor can prescribe and any other allied health professional can practise from home but a midwife cannot; it is all because of some confected idea that it is either unsafe, that it needs to be driven underground or, most concerning off all, that it cannot be afforded. I think that is the subtext of this legislation—for some reason they believe they cannot afford to extend indemnity across to midwives.

I want to go back to 2001 for a moment. Back in those days, when we used to work under claims incurred rather than claims made, we basically had doctors being indemnified through mutual organisations. They did not fall under APRA and they did not fall under the Insurance Act 1973. Over the nineties the gradual demand for state tort law reform, which never came, meant that premiums started to rise. Eventually clinicians had calls made upon them by their insurers to try and pay for an explosion in payouts.

Let us go back a step. There are 2,000 payouts a year. The majority of them are under $100,000. About five per cent of medical indemnity cases where a plaintiff takes a doctor to court are for over half a million dollars. Those massive cases comprise about 40 per cent of indemnity cases. So it is no easy task to be able to work out the number or the size of claims in any one year. That is why you cannot leave a small number of midwives out on their own. It makes eminent sense to incorporate midwifery with medicine and with the range of other indemnities available, as it does to include homebirths.

Back in 2001 I was flying across the Gulf of Carpentaria when our party received a satellite phone call saying that United Medical Protection had gone into liquidation—that it had collapsed. That was a turning point—a lightning rod for the reform of medical indemnity, which many thought could never be fixed. This problem festered like a sore under both governments for over a decade until it was fixed in 2001, and I give credit to Kay Patterson, former Minister for Health and Ageing, and the state ministers who brought in tort law reform. What we knew was that the incurred but not reported cases had to be covered; that the ultra-high costs had to be covered; and that we needed a provision for practitioners who had retired, become ill or taken maternity leave. We needed a roll-on cover provision for those who were no longer covered. Of course in the old days it was simple: the practitioner, when they were potentially being sued, simply phoned up their insurer and said, ‘I used to be a member when the case occurred. Can you cover me now?’ And that was usually obliged. No longer.

The government stepped in in 2002 and said, ‘We need to have roll-on cover and it needs to be at a cost that does not actually make insurers unviable.’ The result again was roll-on cover that protected all practitioners, as it does to this day, even after they finished practising. That is important, as I said, because it is very difficult to determine when these cases are going to come forward and how large they will be. It is impossible to forecast how litigation changes over time. Cases that may not be prosecuted now may well be in years to come. It is very challenging for insurers. But we know that a study has been done—the actuarial analysis of covering homebirths has been done but has not been released by this government. It is truly disappointing that we cannot actually have informed debate of that actuarial analysis of homebirths.

What has become more important than anything for mums in the last two decades, if I can make an observation firsthand, is the emergence of perinatal testing, neonatal evaluation and birthing plans in the suite itself. Can I say that the one strong signal that was always there for me as a clinician was, when that mum was sitting there, often surrounded by family, in those final moments of labour—and they are often of course forgotten in that miasma of celebration when a healthy baby arrives—just how important it is to adhere to that birth plan. Families go to great trouble to develop a plan, and I recognise hospitals in this country for making sure that they are carried out to the letter for mums. We know that by doing that we improve the odds of a successful second stage. Reducing stress often means a more successful labour, less need for surgical and other forms of medical intervention, and less pain relief. That has always been the banner flown high by supporters of homebirth—that, no matter what study you look at around the world, the degree of intervention and the need for pain relief is far lower. A mother is far more likely to have a normal, uncomplicated delivery when birthing at home. We tend to take our focus away from that and shift it onto neonatal death and stillbirth, issues which are still very difficult to prove. One thing is clear: the importance of delivery at home for mothers who choose it—for mothers who are mentally ready to deliver at home and who actively seek out that kind of service.

I can see people thinking, ‘Would that be me? Would I choose to deliver at home?’ The thing is that Australia is a nation of choice. But this is a Labor government taking the choice away. I cannot put it any more simply than that. Delivery at home should be a right. We have the hospital service that can support it and we should be fighting hard to make sure that indemnity is extended to the low-risk deliveries cohort. Of course we need provisions for high-risk deliveries. I acknowledge that. We may have to look at ways to achieve that in a large nation like this. But let us not become the first country in the world to effectively liquidate, to effectively airbrush away or to effectively snuff out the right to deliver at home. For those who choose it and know they can do it successfully, and for the professionals who make it as safe as it is anywhere in the world, we on this side of the chamber stand up for the rights of women to decide.