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Monday, 7 September 2009
Page: 8708

Mrs VALE (6:23 PM) —According to the explanatory memorandum, the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 supports the government’s 2009-10 budget measures purportedly by facilitating new arrangements to enhance and expand the role of nurse practitioners and midwives which allow them to take a greater role in providing quality health care.

For eligible nurse practitioners and midwives the bill will provide the right to request certain diagnostic imaging and pathology services for which a Medicare benefit may be paid, the right to prescribe certain medicines under the Pharmaceutical Benefits Scheme, and new Medicare items and referrals under the Medicare Benefits Schedule for midwives and nurse practitioners working in ‘collaborative’ arrangements with doctors.

The Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009 provide for the Commonwealth to contract with an insurer through a national tender process to provide indemnity insurance for independent midwives and the imposition of a run-off cover support payment as a levy on insurers’ midwife professional indemnity insurance premium income.

I note the coalition supports the referral of these bills to a Senate committee inquiry. The committee was due to report by 7 August 2009, but I understand that the committee’s report has been delayed for the time being. I look forward to seeing the committee’s ultimate report, because I share the concerns of many Australian women about the kind of health care they and their babies will receive at a most vulnerable time in their lives—that is, when giving birth.

I understand that the provisions in these bills regarding midwifery were recommended by the Maternity Services Review. New medical benefits items and pharmaceutical benefits provisions are to be available from 1 November 2010. The new MBS items will provide for collaborative working arrangements between nurse practitioners and midwives and doctors, although there is a lack of certainty as to what form ‘working collaboratively’ will take in practice. It is expected that for participating midwives it will include antenatal, birthing and postnatal care arrangements between those midwives, obstetricians and GP obstetricians. The government points out that nurse practitioners will be limited to providing those services within their competency and authorised scope of practice. However, there is still no detail on exactly what this means. The legislation does provide that both nurse practitioners and participating midwives will be able to refer their patients under the MBS to specialist consultant physicians, and these measures are welcome.

Many of my constituents will be aware that private midwife practitioners are unable to access professional indemnity insurance in Australia. The insurance industry says that this is because, firstly, there is no accurate and up-to-date data with which to make an actuarial assessment of liability and, secondly, the potential premium pool is too small to support a market priced premium that would be affordable for midwives. Pursuant to the national accreditation and registration scheme, it will be a requirement of registration from 1 July 2010 that all health professionals have indemnity insurance. The government plans to contract with an insurer to provide professional indemnity insurance to certain midwives. In doing so, a database will be established and maintained to allow the insurance industry to then develop appropriate insurance products in the future. This is a sound provision.

Provisions in the Commonwealth contribution bill will allow the government to pay certain amounts for claims against an eligible midwife and, in the case of practising eligible midwives, these are as follows: (1) for each claim, the insurer will pay the first $100,000; (2) for each claim over $100,000 the government will pay 80 per cent of the cost that exceeds that threshold, up to a ceiling of $2 million—claims between $100,000 and $2 million are classed as level 1 Commonwealth contribution payments; and (3) for each claim that exceeds $2 million, the government will pay at the level 1 rate for the first $2 million plus 100 per cent of the cost of the claim above that threshold, which is classed as level 2.

This bill also provides for the government to change the $100,000 threshold, the $2 million threshold and the rate of subsidy applying to both levels by the rules. Provision is also made for ‘run-off’ cover for an eligible midwife who has ceased to practise. I note that these amendments providing for insurance cover for eligible midwives are largely in response to the recommendations of the Maternity Services Review and are welcome amendments. However, the main concern that I and many of my constituents have is that this legislation does not provide any indemnity insurance cover for midwives supporting mothers at homebirths. I note that the minister has been persuaded to change her mind on this point. She has extended the time frame for the next two years. This extension of time will allow for discussion and debate and examination of the issue, which I know will be welcomed by the midwives association. It is a reversal that is welcome, and I acknowledge the work of the shadow minister in this regard.

The concerns raised state that privately practising midwives will not be able to provide homebirthing services after the introduction of the national registration and accreditation mandatory requirements for indemnity insurance in July 2010. It is claimed that this will drive the practice of homebirthing underground and increase the risks for mothers and babies. I understand that in 2006 less than 0.3 per cent of all births in Australia, approximately 700, were homebirths, so the minister’s reversal, allowing the debate and discussion to continue, is welcome. There are some jurisdictions in Australia that provide public midwifery homebirthing services in a limited number of locations, and that was never intended to be affected by the introduction of the national registration and accreditation scheme.

While many of the provisions of these bills are welcome, there is much confusion in some of the provisions as well as a real concern amongst women that this legislation denies them the choice of a homebirth for their baby. Firstly, the concept of ‘collaboration’ needs to be explained. The AMA says it needs to be clearer and that there needs to be genuine collaboration. Medical practitioners should refer patients to nurse practitioners and midwives but do not need to be co-located.

The Rural Doctors Association of Australia gives its broad support for greater PBS and MBS access for nurses and midwives and also expresses concerns that there needs to be a clearer protocol to: establish for midwives, hospitals and obstetricians how collaboration will work; articulate the circumstances when obstetricians and medical practitioners will be called in; ensure that the medical practitioner has knowledge of the history of the patient; and establish how the medical record of the patient will be managed.

The Australian College of Midwives welcomes the introduction of indemnity insurance, strongly supports the MBS and PBS access for midwives and suggests that an electronic health record for mobile health records needs to be developed to enable collaborative arrangements to work effectively. The college also suggests that there will need to be clear guidelines and principles established regarding consultation between patient, midwife and medical practitioner, for example, in those circumstances when a patient is transferred from a midwife to a doctor. The college also suggests that it is essential that midwives have visiting rights—that is, admitting privileges—at hospitals to enable continuity of patient care and that the concept of collaborative should not be too prescriptive as there needs to be a flexibility to adapt to varying circumstances in different regions and centres.

However, the real concern that many women have with this legislation, despite the welcome provisions and the two-year stay on the licensing of midwives who offer homebirthing, is that it will ultimately outlaw the traditional practice of homebirthing in Australia. We have this two-year gap, which the minister has agreed to extend, but there is still a real concern about afterwards, and I welcome the opportunity for debate on that.

The shadow minister for health pointed out that the coalition strongly believes that women should be able to make their own decisions about such a private matter and that this government is effectively putting a $30,000 fine on midwives who practise homebirthing. That is just not acceptable. At least, that was the government’s plan. My concern is that this legislation would have driven homebirthing underground and would have presented risks to the mother and baby in such circumstances. The legislation initially took an extreme position on homebirthing but there is a middle ground and now hopefully this middle ground can be explored over the next two years.

Apart from the important issue of freedom of choice for Australian mothers, which has been comprehensively addressed by other colleagues in the chamber, there is a case to be made, as the Australian College of Midwives points out, for being in a position to provide safe options for those women who wish to homebirth. While some jurisdictions already provide limited public homebirthing midwifery services, there is already a large unmet demand for these services. I understand that this will certainly be canvassed over the next two years.

Not every mother-to-be is an appropriate case for home delivery. Personally, I never would have chosen it for any of my four confinements. Indeed, I was not an appropriate candidate, as all my four children were premature. I was very grateful to my obstetrician, the late Dr Alexander Mackay McIntosh from Sutherland Hospital. And, on the occasion I did have a second obstetrician in attendance, my thanks and deep appreciation will forever remain with Dr John Mathews of Engadine.

I think that we all clearly understand that homebirthing is not appropriate for complex cases where the mother is known to have great risks. That is plain commonsense. That being said, there are many cases where homebirthing is appropriate and, given that there are many women who have had negative experiences giving birth in hospitals, they should be able to choose to give birth at home under the safe supervision of health professionals working in a cooperative and collaborative manner for their protection. Many women have expressed a need to have a greater input into and ownership of their own birthing experience. It is not rocket science. It is done in other jurisdictions and in other countries—for example, in New Zealand and England—and done very well. So why can’t it also be done in Australia?

The new national registration and accreditation regime will address the concerns of the present inconsistent registration requirements across states and ensure that midwives throughout the country meet requisite education, training and currency of experience requirements for the better protection of their patients. The Australian College of Midwives wants mothers to continue to have access to qualified homebirthing services and suggests that the government consider a number of options, which include: exempting independent midwives from indemnity insurance requirements under the national registration and accreditation for a transition period; extending the Commonwealth subsidy for indemnity insurance to midwives providing homebirthing services; or encouraging state and territory governments to increase provision of public homebirthing midwifery services. I am sure the Australian College of Midwives will clearly articulate their concerns and will have a major role in the considered examination and debate, as promised by the minister, over the coming two years.

However, the real issue for me with this particular legislation is that the provisions to ban homebirthing do not appear to take into account some very relevant considerations that constitute the reality for expectant mothers today. One is that there are fewer and fewer obstetricians amongst the medical profession today than there were even five years ago, and this seems to be a direct result of the extremely high indemnity insurance costs that obstetricians today must pay. My own obstetrician, Dr Mathews of Engadine, worked until he was well over the usual retirement age because he could not get another obstetrician to buy his practice.

The other reality about which mothers are genuinely concerned is the current state of our hospitals. When they read recent newspaper articles about the terrible neglect of women presenting in some of our local hospitals, many are simply horrified. Many are intent on having a homebirth mainly because of such reports. As a case in point I refer to an incident in my electorate at my own local Liverpool Hospital that occurred in July. After headlines in the local Liverpool Champion dated 29 July this year which read ‘Hospital sent home pregnant woman’ and the Daily Telegraph dated 24 July 2009 which read ‘Mum gives birth at home after being sent away by hospital’, why wouldn’t any mother want to arrange a homebirth with a registered and accredited midwife if she was assessed as being an appropriate patient.

The mother from Liverpool Hospital claimed she was forced to give birth on her bedroom floor after being turned away from the hospital because there were not enough beds. The mother was bleeding and in labour when she first arrived at Liverpool Hospital but was told the hospital did not have enough room on the night. She was told to go home because she would not be in labour for another 24 to 48 hours. Five hours later her baby was born on the bedroom floor of the family home, with the assistance of the shocked father and watched by her 18-month-old toddler. Is this the kind of experience the government offers to the mothers of Australia?

Then there are the horrific stories of young mothers waiting long hours in the hospital waiting room only to be left alone to miscarry in the public toilet of the hospital. What a disgrace to have such events occur in Australia. How do we defend such a hospital system, which we would expect to find in a Third World country, and, to add further insult to injury, then deny young women the right to choose a homebirth in a safe environment with professional assistance?

We can do better, and the advice from the Australian College of Midwives has some very sound suggestions whereby the provisions for collaborative, cooperative birthing support in these bills could well be the foundation by which all our health professionals work for the benefit and protection of Australian mothers and their babies—and not engage in what appears, to those of us outside the profession, to be a turf war. I do welcome the minister’s reversal of a former decision which will allow a further two years regarding the practitioners of midwifery for homebirthing. I think that is a very positive move and I know that it is one welcomed by the mothers and babies in my electorate.