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Tuesday, 16 March 2010
Page: 1874


Senator EGGLESTON (12:51 PM) —I would like to make a few remarks about these bills, 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. I see the most important part as being the suggestion that there should be collaborative agreements between doctors and midwives, and I think that should occur. But I note that there has been some opposition to this from some midwives who feel professionally threatened by having to work in collaboration with a medical practitioner—one trained in obstetrics, one presumes.

It is interesting to look at the figures over the years. Since the beginning of last century we have had quite a dramatic drop in the infant mortality rate. In 1907 the infant mortality rate was about 8,945 a year, whereas today it is around 1,200. There has also been a dramatic drop in maternal mortality rates associated with deliveries. In both cases, that is largely due to the fact that most babies are born in hospitals now and children are in hospitals under medical care—that is, with medical doctors as well as midwives caring for the mothers and babies.

But the one thing that has gone up over that time is the incidence of litigation. Medical litigation in Australia has skyrocketed, and that, I would suggest, is why the idea of having a collaborative arrangement between doctors and midwives is very important and in fact essential. Litigation can occur for many reasons, often quite trivial reasons such as failure to do a test in an antenatal clinic or failure to manage complications during delivery. I think, for the benefit and protection of midwives, having a qualified obstetrician or at least a general practitioner with a diploma in obstetrics overseeing what is done will protect them from the risk of litigation which might otherwise occur. I know that many GP obstetricians have ceased practising obstetrics because of the fear of litigation and because the cost of the insurance premiums is so high that the income from the deliveries they do does not at all cover the cost of the insurance.

As I said, litigation can follow from quite trivial events, such as failing to do a blood sugar test on an Indigenous woman who might only come into a clinic once or twice before she delivers. Then she turns up at the hospital with gestational diabetes, causing a very large baby, and then has complications because it is often very difficult to deliver large babies without surgical or other intervention. If there was an adverse outcome there, the midwife might find that, because she failed to order a blood sugar test very early in the pregnancy, which might have indicated that the patient was in danger of developing gestational diabetes, she could be liable for that adverse outcome of the pregnancy.

In fact I know of a doctor who was in exactly that situation in the north-west. He saw a patient only twice during her antenatal period and did do a blood sugar test, but the patient never came back and disappeared into the unknown. But in due course she turned up in a hospital with diabetes in pregnancy and a very large baby, and there were some complications. The doctor found that his insurance had to pay out damages of nearly $1 million to that patient. So I think a formal collaborative arrangement is very wise in terms of protecting the interests of midwives so that they are not subject to unnecessary litigation, and also of course to protect mothers and babies.

I note that the AMA has supported the requirement for inclusion of collaborative arrangements in legislation. Dr Andrew Pesce, the president of the AMA, stated in the Senate committee inquiry:

If collaborative care is essential, then it must be enshrined in the legislation. It is simply too risky to say that health professionals can use their discretion as to when, where and in what circumstances they will collaborate—and that works both ways. It is essential that the primary legislation encapsulates a requirement for collaborative arrangements so that the most important goal, quality and safety of patient care, is achievable.

The midwives who have objected to the suggestion that there should be a legislative requirement for collaborative agreements have said that in some way this questions their competence. But, as the AMA President said, addressing the issue of a perceived power imbalance between midwives and obstetricians:

If there is an imbalance, I suspect that it emerges from the fact that midwives can care for a patient to a certain point and then, if something goes beyond that, they need to enlist the services of a collaborating obstetrician. But that obstetrician obviously is hesitant to just become a technician and say, ‘I will just step in when I am asked to.’ They would like to step in at the right time. So, if there is a power imbalance, it arises from the different competencies of the people who work in the team, and I do not think it is one which stems from a desire to deal with the competition.

In other words, I think most doctors are very happy to see midwives involved in delivering babies and ongoing obstetrics, but they do feel there is a point at which it may be necessary for people with a higher degree of competence, a greater degree of knowledge, to step in and manage the delivery. That requirement can be achieved and protected through having written collaborative agreements. So I very much agree with the need for these sorts of agreements.

Senator Xenophon talked about the fact that in the Netherlands there are a great number of home deliveries. That is also the case in the United Kingdom, but fewer than there used to be in that country. Of course, the difference is that in both the Netherlands and the UK the population is fairly concentrated and it is never very far from someone’s home to a major hospital where there is an obstetrics team. And in both of those countries they have flying squads to go out and pick up ladies who are having babies and get into trouble such as having an unexpected haemorrhage or obstructed labour. Unfortunately, in Australia, where the distances are so much greater, that kind of service is more difficult to set up. Again, I think it is very important in the case of rural obstetrics that these collaborative agreements with local doctors who do have diplomas in obstetrics should be set up. That would then protect the mothers and babies as well as the midwives from later allegations of incompetence and from damages being awarded for matters which could have been otherwise avoided. So I strongly support the conclusion that the Senate Community Affairs Legislation Committee reached in its report, which was that the committee ‘supports the principle of collaborative arrangements in legislation’ and:

The Committee considers that the collaborative arrangements as envisaged will enable a flexible approach to meet the different circumstances of practice across Australia, particularly in remote and rural areas.