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Tuesday, 16 March 2010
Page: 1869

Senator XENOPHON (12:31 PM) —I commenced my contribution last night before the adjournment and I am pleased to continue today. Essentially, this is an important piece of legislation. There is an enormous amount of debate in the community about this in terms of what role midwives should have in our health system and in the delivery of children in this country. I think it is an issue that deserves ongoing debate and close scrutiny in terms of what the government is proposing to do.

As I said last night, over the past few months I have been contacted—as I am sure my colleagues have also—by many dozens of families who want to share their experience of their pregnancy and of delivering their baby at home with a midwife. In fact there have been hundreds of emails about the trust and bond they shared with their midwife throughout their pregnancy and how safe they felt during the delivery of their child. Some have also told me that they have had previous experience of such traumatic hospital deliveries that they would rather not have another child than be ‘forced’ to deliver their baby in a hospital situation. Indeed many wrote that ultimately it is their right to choose and removing that choice is fundamentally unfair.

There is no question that homebirth and/or midwives is not for everyone, but for those who choose it, it is fair to argue that that choice should be available to them. As I understand it, the statistics show that about one per cent of births are homebirths in this country compared to about 30 per cent in the Netherlands, and I will refer to that shortly.

Similarly and scarily, I have heard from women who had a ‘normal’ or textbook case low-risk pregnancy but because of an unexpected complication during labour they almost lost their child and, but for the intervention of the hospital’s doctors, would have lost their son or daughter. I have been advised by medical professionals about the risks of delivery without an obstetrician and how every second counts and that in some instances by the time the midwife realises there is a complication it might be too late to get the mother to a hospital. However, I emphasise that that contrary position has been put to me by those who argue that homebirths are something to be avoided.

I must stress that I do not believe any mother would knowingly make a decision that would risk her baby’s life. I have full confidence that the priority of midwives is to look after the mother and baby, as is the case with the medical profession. I would hope that a mother who is considering having her baby with a midwife would do all of the research and ask all the appropriate questions to ensure that it would be a safe decision for her to have her baby without an obstetrician present. Of course, these are the sorts of questions that need to be asked about a so-called conventional delivery through a hospital model and I am sure the same would go for a mother considering delivering her baby in a hospital.

Since the medical indemnity crisis of 2001, insurers have refused to give professional indemnity insurance to midwives who attend homebirths. But from 1 July 2010 the single National Registration and Accreditation Scheme for Health Professions will be introduced, which means that without indemnity insurance it will be illegal for privately practising midwives to provide antenatal care, labour and birth support, and post-natal care to women at home. I understand and I have heard the concerns of women who fear that this will result in homebirths being ‘forced underground’, and from a public policy and individual point of view this is in no way desirable. This should not be seen as an attempt to ban midwifery by stealth. One of the roles of parliament is to establish measures that ensure the safety of all Australian mothers and their babies. This legislation, although it may be seen to be punitive against midwives, does not need to be, and I believe it does not intend to be so.

The government’s amendments to the legislation include transitional arrangements for privately practising midwives through the provision of a two-year exemption until June 2012, and collaborative arrangements are an indication of this. Again, I acknowledge the fears of midwives who argue that this may in time undermine their role and the requests of intending mothers. Once again, it must all be balanced up against the safety of mother and child. Whatever decision is made in this place I hope that Australians and midwives know that it is to ensure that there are appropriate safeguards in place so that the health of a baby and the health of a mother are protected no matter where they give birth.

In Australia, demand for homebirths is about one per cent of all deliveries nationwide. Compare this to the Netherlands, where some one in three babies are born at home. Indeed, last year a review of 500,000 births in the Netherlands revealed no difference in survival rates between hospital births and homebirths, for low-risk pregnancies. In terms of adverse outcomes that is a very telling statistic. However, it is important to keep in mind that in the Netherlands they have in place a streamlined system that allows women to plan a homebirth and to access specialist emergency obstetric care in hospital should complications arise.

Under the scheme proposed in these bills, however, midwives will be unable to access Medicare unless they are sponsored by a doctor or obstetrician, by a medical practitioner, and therefore will be unable to admit a patient to a public hospital. It is for those occasional instances where an otherwise normal, safe and supposedly predictable low-risk pregnancy becomes, at the very last minute, for whatever reason, risky for the survival of the baby that I feel I have to support these bills. Having said that, I want to stress that I do believe midwives play a very important role in our health system. The services and support that they provide make a significant difference to women and families around Australia. It is important that we recognise that individual women and individual pregnancies have individual needs. Given this, I believe an independent inquiry should be conducted into midwifery in Australia, with the key focus on safety but also addressing the demand, the cost benefits for the public hospital system and international best practice, such as the system that exists in the Netherlands. I do not think we have had a level of scrutiny of midwifery and homebirths in this country to that extent. I think there is a demand for it. I think more women would avail themselves of midwives if we had systems in place similar to those in the Netherlands and other countries.

It is interesting to note that a review of homebirths in Western Australia was undertaken for the Western Australian Department of Health in August 2008. The review team members and report authors were Professor Caroline Homer and Dr Michael Nicholl. That was a very positive report about homebirths in Western Australia. There is no reason why it would be any different anywhere else in the country. It indicated that homebirths, as practised in WA, compared very favourably with hospital births in the Western Australian hospital system. There were specific terms of reference. The first term of reference was to:

Investigate the clinical experiences and health outcomes of mothers and babies accepted for homebirth by the Community Midwifery Program or midwives acting independently in Western Australia between 2000 and 2007. As a minimum, the investigation is to include mortality of mothers and babies; and emergency transfer of mothers or babies to hospital care at any stage of pregnancy, including during the post-partum period.

I think that indicates the sort of thing that should be done at a federal level. The national health and hospitals review did not specifically look at this very important issue because the government had already undertaken a maternity services review, and that report was provided in February 2009. However, the concern that has been expressed to me by midwives and those who are advocates for homebirths is that there has not been an adequate and robust study of the benefits and risks of homebirths, integrating that into our health system and looking at international best practice, such as in the Netherlands.

Let us look further at the international experience. Midwifery became a regulated profession in Canada in the 1990s. Midwives are today the lead healthcare professionals attending the majority of births, albeit mostly in a hospital setting. There is a different attitude to the role of midwives at births in Canada. Under legal recognition, Canadian midwives have access to hospital privileges, the right to prescribe medications commonly needed during pregnancy, birth and post-partum, the right to order blood work and ultrasounds for their patients and full consultation access to their own physicians. That, to me, seems to be a sensible way forward. Many would say that the Canadian system is leaps and bounds ahead of the US health system just south of the border. In 1990 New Zealand restored the professional and legal separation of midwifery from nursing. About 78 per cent of women choose a midwife in New Zealand. That is a dramatically different statistic from here in Australia.

Midwifery is a long-held practice, going back centuries. Midwives are educated and trained providers who care for child-bearing women throughout their pregnancy, during the delivery process and in the post-partum period. I think we have not availed ourselves of the resource and professionalism that midwives can offer. The fact that so few women choose to go down the path of using a midwife says something about the structural imbalances in our health system. I do not think we have had a robust enough analysis of that, even with the report of the maternity services review. That is something that ought to be looked at.

This is not easy legislation to decide on. I am sure that I am not the only one in this chamber who has been deeply concerned about this issue. As I said at the start of my contribution, there are so many aspects and arguments to this debate. In so many ways it is not a black and white issue; there are shades of grey in relation to this. I need to support measures to ensure the safety of all Australian mothers and babies, and for that reason I give my support to this package of bills. However, I believe ultimately that the fair and right thing to do is to have an independent inquiry into this area of practice. I think it is crucial to ensure that all Australian child-bearing women have access to the best care and the most appropriate care for them, whether that is in a hospital or clinic with an obstetrician or in a hospital with a midwife or at home with a midwife. The fact that other nations, such as Canada, New Zealand and the Netherlands, and a number of states in the US, have a different approach I think indicates that we have a long way to go. I hope that the regulations that will be set up under this legislation will not prejudice midwives and will look fairly at the importance of their contribution to our health system. Until we have that robust, independent inquiry, I do not think we will get the best policy answers. So I urge the government to go through the process of an independent review, particularly during this transition period. I think that in the absence of that we will not make the best decisions for the mothers and babies of this nation. Families need to be able to make an informed choice as to what is best for them.