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Monday, 7 September 2009
Page: 8632


Ms PARKE (12:58 PM) —I speak in support of the three bills before the House in this cognate debate: the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009.

There is widespread professional support for these bills and much community interest in them. They institute changes that have long been anticipated and that are greatly welcome. Yet in the way these changes were initially framed there were some consequences that, while not in themselves part of the bills’ overt purpose, were nevertheless of deep concern to some in the community, including within my electorate. These were the consequences for independent midwives practising homebirth deliveries.

I am extremely happy to say that, as of last Friday, 4 September, a solution has been found. So it is that in speaking to these bills I congratulate the Minister for Health and Ageing both for the reforms the bills represent and for acting so quickly and decisively to achieve a commonsense solution to an unintended consequence of the reform matrix. As with the adjustments made by the Deputy Prime Minister to the youth allowance reforms, this is another example of a government that is set on achieving the positive reform agenda it was elected to implement, but without the hubris or the arrogance to believe that its efforts cannot be further improved by listening to the community or by reasonable negotiation with its parliamentary colleagues.

At the outset, I think it is useful to set out a short history of some broad health system issues in Australia in relation to these bills. In the 2007 election campaign, the Australian Labor Party said we would consider a more expansive role for the skills and experience of suitably qualified health professionals, such as nurse practitioners and midwives. We also indicated our commitment to improved health services for women and children, including those in rural and remote areas. These commitments were informed in part by a 2006 Productivity Commission report in response to longstanding concerns about shortages and inflexibilities in the Australian health workforce. Key issues for the commission were: first, the critical need to increase the efficiency and effectiveness of the available health workforce and to improve its distribution; and, second, to develop a more sustainable and responsive health workforce whilst maintaining a commitment to high-quality and safe health outcomes. The commission also recommended the creation of a single national registration board for the 10 professional health occupations in Australia, including nurse practitioners and midwives.

In response to the Productivity Commission’s recommendations, the Council of Australian Governments resolved in March 2008 to devise and implement a new national registration and accreditation system to commence operation in July 2010. A core element of the national scheme is a condition that all registered health professionals carry professional indemnity insurance. Queensland was given responsibility for legislative development and enacted initial legislation in November 2008. An exposure draft of the second piece of legislation proposed for jurisdictions was released by the ministerial council in July 2009 and it addresses the nuts-and-bolts issues of accreditation and registration.

Parallel with those developments, and as a key step towards delivering the government’s commitment to a national maternity services plan, the minister charged the Chief Commonwealth Nurse with responsibility for a detailed investigation of maternity services—the outcome of which was published in February 2009 under the title Improving maternity services in Australia: the report of the Maternity Services Review. Finally, earlier this year, the Rudd government gave life to this health reform agenda by providing a four-year, $120.5 million budget commitment to improving maternity services together with $59.7 million over four years to expand the role of nurse practitioners.

That brief summary of what has gone on before brings me to the bills that we are considering here—bills that give legislative effect to the government’s commitments. The first of the bills extends both the Medicare Benefits Scheme, MBS, and the Pharmaceutical Benefits Scheme, PBS, to participating eligible midwives and nurse practitioners so they can access or provide Medicare subsidised services, prescribe certain medicines and refer patients for diagnostic imaging and pathology. In the case of midwives, these measures resonate with recommendation 17 of the Maternity Services Review, while in relation to nurse practitioners the government is legislating to further enhance the practice scope of these important health professionals. While nurse practitioners can already prescribe in most jurisdictions, their new access to the MBS and PBS will be a significant development and improvement. These are historical firsts for Australia. They are very significant measures indeed. They are measures conceived to enhance the efficiency, capacity and productivity of our health workforce, especially in rural and remote areas, and so they are measures that are consonant with the findings of the Productivity Commission report.

Now I want to touch briefly on the issue of professional indemnity insurance for midwives. This is the driver of the provisions in the second and third bills before the House. It is a great shame that there is no private sector insurer who will currently provide cover for midwife-led birthing. This constitutes a significant problem for both the registration and the accreditation of midwives and therefore in implementing an expanded role for midwives within maternal health services The Maternity Services Review concluded that ‘lack of professional indemnity insurance will inhibit the expansion of collaborative models of midwifery care’ and it addressed the defect in recommendation 18, which called on the government to provide a subsidised insurance scheme for midwives operating in collaborative team based models. That is what is accomplished by these bills. They establish that scheme—a scheme that will be accessible by midwives practising in collaborative, team based models in clinical settings as recommended by the Maternity Services Review.

But now, in the context of these positive developments, I want to acknowledge the strength of feeling and also the administrative difficulties that surround the issue of homebirth. As it originally stood, the model preferred by the Maternity Services Review was one that excluded midwife led birthing in the home by virtue of the fact that the insurance scheme established under the legislation was not able to be extended to midwives who practice in the home. Last Friday, as part of a joint communique that emerged from the Australian Health Ministers’ Conference, a medium-term solution to this problem was announced. I can say in this place that it was an announcement celebrated in my electorate of Fremantle. At the conference, the health ministers agreed that the National Registration and Accreditation Scheme legislation would include a transitional clause providing an exemption through to June 2012 for privately practising midwives who are unable to obtain professional indemnity insurance. Requirements to access the exemptions include providing full disclosure and informed consent that they do not have professional indemnity insurance, reporting each homebirth and participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration accreditation process.

As noted by the health minister when the changes were announced, there will be more data on homebirthing, and there will be a process to work further on protocols that will either bring more homebirthing services into our public system or potentially open the way in the future for an insurance product to be extended to cover them. This is a fantastic, commonsense result and it will give comfort to midwives and families around the country.

On this point it is worth considering what the Maternity Services Review actually said about homebirth:

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.

One does not have to read too far between the lines to conclude that the issue of homebirth was a very difficult one for the review. It observed:

In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.

That view notwithstanding, there is an adamant and passionate minority of women who regard homebirth with a private midwife as their preferred birthing choice. I think their views are well illustrated by some words in a report released for the Western Australian Department of Heath in August 2008, entitled Review of homebirths in Western Australia. It had this to say:

It seems apparent that the maternity systems are, for some women, too medicalised and restrictive and do not meet their needs.

It also noted:

… developing systems to support safe and satisfying systems of care that provide childbearing women with a diversity of options is essential.

I recently met an impressive woman who is a very experienced, independently-practising midwife in my electorate of Fremantle—Sally Westbury. She told me that she is very supportive of the government’s initiatives in the area of midwifery. She sees them as a great step forward and feels she could be part of an incremental process of improvement, even if she cannot herself access the insurance scheme. After all, she has worked for many years as an independent midwife without such insurance and all her clients take on her service in the full knowledge that there is no insurance. She has relied on her judgement, her expertise and her commitment to sound professional practice. As a result of the exemption announced last Friday, Sally will be able to continue to provide those services, and the important choice that her services represent. As Sally pointed out to me, this is especially significant for women in regional, rural and remote areas who are not able to access community midwifery centres because of geographic restrictions on those services.

I want to say something on behalf of all those who have written to me and visited me—whether they be midwives, clients of midwives, couples who have chosen homebirth or maternal health practitioners who support independent midwives and the women they minister to. All these constituents of mine are committed and passionate people—they are people who care about health outcomes for themselves and for their families; they are people who have clear and substantial reasons for choosing homebirth; they are people who, in some cases, choose homebirth as a result of traumatic birthing experiences in hospitals; and they are people who care about choice as a matter of principle. I support all those people—my constituents in Fremantle—and I join with them in congratulating and thanking the health ministers, who have found a way to allow independent midwives to continue supporting those women and families who choose homebirth.

It should be noted that there are well-established independent midwife schemes in NZ and Europe. I understand that in New Zealand the independent midwives are covered by the comprehensive no-fault insurance scheme that applies there. Perhaps in the longer term there is something in this for Australia to consider.

I know that a significant number of women, even though they are in the minority, have chosen and continue to choose homebirth. I know they want that right of choice to remain. I know too that many women who do not themselves opt for homebirth nevertheless support the right of other women and their families to choose it.

On this issue we should recognise that there are other birthing choices, such as elective caesarean section deliveries, that are available to women even when there is no strict medical case for this kind of birth intervention. What is even more important is that we do not make the mistake of assuming that homebirth is necessarily a less-safe option than a hospital birth. I am aware that many people begin their approach to the question of homebirths by making that assumption, and I refer those people to the report undertaken by the Western Australian Department of Health in 2008, entitled Review of homebirths in Western Australia. It states:

For the years 2000-2006, the total perinatal deaths for babies born of all gestations was not statistically significantly different … between the planned homebirth and hospital birth groups.

Indeed, the perinatal mortality rate, or PMR, was 10.08 per 1,000 planned homebirths and 11.93 per 1,000 planned hospital births across that period. There were no perinatal deaths in the planned homebirth group for the years 2006 and 2007. Homebirth represents a tiny minority of all births but it is an important and valid birthing option, both personally and medically, and one that should be supported within the broader structure of our health system. I support these bills because they have been conceived to do good and they will deliver positive change. They are widely supported in the professional nursing and midwifery community, and they are reforms that are long overdue.