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Monday, 7 September 2009
Page: 8716

Ms MARINO (6:57 PM) —I rise to speak on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and cognate bills. The original intention of these bills was to provide Medicare benefits to eligible nurse practitioners and qualified, experienced midwives who request diagnostic imaging and pathology services as well as allowing them to prescribe certain medicines through the Pharmaceutical Benefits Scheme under a collaborative arrangement and protocols with doctors and hospitals. The government will provide, through a contracted insurer, for professional indemnity insurance to eligible private midwives.

However, just like the government’s proposed changes to youth allowance, these bills have not been thought through in practical terms and there has been a clear failure to consider the effects on women and families in rural and regional communities. As a result of sustained pressure, Minister Roxon and the government have done a partial backflip on the legislation and agreed to maintain the status quo, allowing midwives to continue to assist in homebirths for two years. It was clear that the bills, in the form presented by the government, are of particular relevance in regional and rural communities and demonstrated very directly how this government continuously and deliberately fails to understand how rural and regional communities actually function—communities like those in my electorate of Forrest, where we have a shortage not only of general practitioners but also of obstetricians and gynaecologists. We also have limited maternity care options. The Forrest electorate is located in a regional area where there is no birth centre or government funded community midwifery program such as those available to and accessed by women living in the metropolitan areas.

There are women who, by choice, have already experienced a homebirth and want to be able to do so in the future, as well as those who want to experience their first homebirth. All these women need to have access to a midwife who will provide a particular type of maternity care for them in their own homes: the homebirth. A number of very concerned and upset mothers in my electorate, from Busselton and Margaret River, have spoken to me about the effects the original bill would have had on them and on the midwives they currently have access to, who have already safely delivered their babies. I rise to speak on behalf of these women from my electorate, to give voice to their issues here in federal parliament. The mothers I refer to are those who want to be able to have a homebirth with the same type of care and service they have already had in delivering their babies—or, alternatively, to have their first homebirth. However, the legislation as originally presented would have prevented them from doing so, because the midwife would have been acting outside their registration by not having the requisite indemnity insurance.

The mothers and families whom I met are extremely angry that this legislation did not make provision for safe midwife home based maternity care in their own homes. However, by far the most important issue to them is the issue of choice. They absolutely and completely believe it is their right to choose their own birthing option. They made it very clear to me that this decision is their choice. They want to choose and they emphatically believe it is their right to do so. I met Jane, a homebirth mother of three from my electorate, and I quote Jane’s subsequent email:

I live in a regional area where there is no access to a community midwifery program and I therefore depend on the independent midwives in the area for homebirth support. With the introduction of the proposed legislation I will be unable to access a homebirth with a qualified midwife. For any future births I would then have to choose between birthing in a hospital and freebirthing.

In Australia, elective surgery is a government supported and subsidised choice. In the case of childbirth, the safety of both mother and child is the priority. To many women, the right to choose how and where to give birth is also a priority, as I found with the mothers I met in Busselton and Margaret River. Women are able to make a number of decisions regarding their birth options and maternity care, but women who choose to birth with trained midwives in their own homes will have no choice except to have a hospital birth or to have their babies in their homes without the support and presence of a trained professional to assist them should the government continue with this legislation in the future. I am extremely concerned about this. The health and wellbeing of both mother and child are paramount.

I recently met with Andrea, a mother from Margaret River, in my electorate. Andrea has a 10-month-old daughter who was born in the hospital system but she is pregnant again and intends to have a homebirth. In fact, she was very relieved that, had the government persisted with the legislation, she would have delivered her baby in a homebirth situation before the legislation took effect. Andrea is a member of the Margaret River homebirth mothers group called Birth Choice. This free support group has approximately 40 members and meets once a month. I understand that at least one of the mothers in the group is prepared to have a freebirth if, as a result of this or subsequent legislation, she does not have access to a registered independent midwife. Freebirthing is a homebirth without the care or attendance of an experienced midwife or medical professional. It is an extremely dangerous practice where the safety of mother and child can be compromised. A reduction in the number of independent midwives as a result of this or subsequent legislation not only would lead to an increase in the number of hospitals births but could potentially increase the number of freebirths.

Some of the mothers expressed serious concerns that, if legislation were passed either now or in two years time and home-birthing services were abolished, it would only take one freebirth complication or serious problem for home birthing to never be legalised again. At present, at least 35 women choose to give birth at home with a registered midwife in the south west. Many more would like to birth at home but simply cannot afford to do so. The costs of employing a registered midwife to provide a homebirth are directly borne by the woman or family who make the choice of the homebirth. Should indemnity insurance for independent midwives become available, it would need to be an affordable option because, in most cases, the cost would be passed on directly to the woman or family.

For the mothers I met in Busselton the cost of a homebirth, which cannot be reimbursed from either Medicare or private health funds, includes 10 to 12 antenatal checkups, the actual delivery of the baby and home visits for the first five days following birth, with direct contact and postnatal support for up to six weeks following the birth. As mentioned, postnatal support is given to new mothers for approximately six weeks after birth. For the mothers I met, this postnatal support and the ongoing friendship are almost as important as the actual birth. They have a personal belief that both the homebirth experience and the postnatal support actually lessened their potential for suffering postnatal depression. As we are all aware, postnatal depression is a very serious problem for women and their families.

I am concerned from reading this legislation, and given the minister’s backflip, that it appears to be yet another piece of this government’s rushed legislation, because it lacks detail on how this process will work on a practical level. There is no guidance as to what the definition of ‘eligible midwife’ is. If a midwife is not eligible, what further training or requirements will have to be completed for them to become eligible?

Another flaw is the lack of explanation as to what level of ‘consultation’ will be required between independent midwives and general practitioners. Independent midwives in my electorate tell me they have a very sound working relationship with local GPs and with other independent midwives. They believe that the collaborative care process between mothers, midwives, general practitioners and hospitals is imperative for the safety of homebirths. Homebirth mother of three Sharon said:

I felt safe and in capable care with all my children’s homebirths. My local GP was informed that I was in labour and phoned when my baby was born.

Will the existing collaborative approach used by the mothers in my electorate be considered adequate consultation under the legislation?

The intersection of the National Registration and Accreditation Scheme legislation with the midwifery and nurse practitioner legislation will make it impossible for independent midwives to register and practise as homebirth midwives. The NRAS, which is to be introduced on 1 July 2010, requires proof of professional indemnity insurance for midwifery registration. Under the original legislation, after 1 July 2010 any individual who practised as a midwife without registration was subject to a maximum penalty of $30,000. As we know, there is no professional indemnity insurance for independent midwives. Clearly, the government—until forced into a backflip—was deliberately excluding this choice for Australian mothers. It appears that homebirth midwives are the only health professionals who are unable to gain access to indemnity insurance.

Susan is an experienced midwife who has been living and working in my electorate for the last 7½ years. She has worked in a hospital maternity unit for over seven years, but during the last 3½ years she has shifted to the role of a privately practising midwife, or what is known as an independent midwife. Susan has said:

I find working as an independent midwife much more rewarding than working in the hospital system, as I am able to provide uninterrupted, continuity of care throughout the pregnancy, labour, birth and postnatal period. I am able to provide dedicated and thorough care to one woman at a time and because of this I believe it is SAFER, more COMPREHENSIVE and much more PERSONALISED than what I would be able to provide on the maternity ward.

I note that results from a comprehensive study conducted in the Netherlands released on 15 April 2009 concluded that planning a homebirth does not increase the risk of perinatal mortality and severe perinatal morbidity among low-risk women, provided a well-trained midwife is available.

I also note that at the Senate Standing Committee on Community Affairs hearings into this legislation, Associate Professor Hannah Dahlen from the Australian College of Midwives commented:

… what all this evidence tells us again and again is that homebirth for low-risk women attended by competent, networked, integrated midwives within a responsive system is safe.

Midwives in my electorate only take on low-risk women. This, along with the collaborative relationship between the midwives, GPs and hospitals contribute to providing homebirth as a birthing option in the south-west of WA.

I understand that in their current form these bills will enable Medicare funding, access to the PBS and professional indemnity support for midwives providing care for women giving birth in hospitals. However, this will not be available to midwives assisting the families in my electorate who choose to give birth anywhere other than in a hospital. The original legislation, in the form the government presented, would have abolished the independent midwives industry in my electorate and throughout Australia. Alternatively, as I said earlier, what concerns me greatly is the possibility of ‘freebirthing’—birthing at home without a midwife’s support. This legislation, in its original form, actually denied women the right to choose a homebirth.

I well understand, as do the women in my electorate, that homebirthing is not an appropriate option for all women. But this is an issue that is fundamentally about choice. The women I met believe very strongly that they should have the right to choose how, where and with whom they give birth to their children. They feel so strongly, in fact, that four of them—Susan Mildwaters, Sharon Scott, Jane Reynolds and Catherine Evans, came from the south-west of WA, at their own cost and with their beautiful babies, to rally in Canberra today with other women from right across Australia. They rallied for their right to choose and they rallied against this government and this legislation.

I note that a minority report by the coalition members on the Senate inquiry, Senators Judith Adams and Sue Boyce, made a number of very sound recommendations. Two of these are:

… that the Department of Health and Ageing undertake an actuarial analysis on the risk profile of homebirths in Australia, with a distinction between professionally supported homebirthing and unsupported free births, and a full analysis of the costs involved in including homebirth midwives within the Commonwealth’s Professional Indemnity scheme.


If the costs of including private homebirth midwives within the Commonwealth’s Professional Indemnity scheme proves to be feasible, Coalition Senators recommend that the Minister include midwives who perform homebirths as a category of ‘eligible midwife’ in the regulations and rules to be attached to the three Bills.

I commend all of the recommendations made by Senator Adams and Senator Boyce to the government.

The latest backflip by the government and Minister Roxon does not provide at this time any longer term certainty for independent midwives and mothers wishing to birth at home, and I call on the government to release the costing and the actuarial modelling for the provision of indemnity insurance for midwives.