Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills
I am opposed to the amendments that have been introduced to the above bills that would require midwives to enter into formal collaborative arrangements with medical practitioners.
I deplore the actions over many years by the AMA to establish a medical monopoly over maternity services. They are copying the example of the AMA in the US, and ignoring the examples set by the UK, NZ and other developed countries. They are reducing the role of midwives to that of obstetric nurses. They are pushing a hierarchical system that will make midwives subordinate to obstetricians instead of being autonomous professionals. This promotes the medical model of childbirth and marginalizes the midwifery model of childbirth. This makes it much harder for consumers to access true midwifery model care and natural birth alternatives, including homebirth. Homebirth is a bastion of natural birth skills and knowledge, it is being targeted by the medical lobby not because it is ‘unsafe’ but because as long as homebirth exists, its excellent results show up how sub-standard medicalised, institionalised birth services are. Consumers in a democracy deserve a choice. Do not allow our choices to be eliminated or reduced. The midwifery model of care must remain as an option for Australians, including homebirth and continuity of care with a care provider of our choice.
This document is entitled Improving Maternity Services in Australia - A Discussion Paper from the Australian Government. It is dated 31 October 2008.
The paper poses this question:
"What are the key workforce barriers to integrated models of care?"
And states,
"All facilities should offer women choice of carer and place of birth, more education and should promote midwife-led care across the continuum. An enormous obstacle is private obstetric charges, as obstetricians may be hesitant to forgo lucrative incomes of up to $9,000 per pregnancy, with some Sydney doctors reported to be charging up to $12,000 and earning collectively up to $1.4 billion per year."
It also recommends the following:
"The state and national governments must shift the emphasis from a medical model of care to a social model of care in childbirth that encompasses women's needs holistically rather than focussing on the clinical aspects of pregnancy and labour."
and
"Women and families should be actively encouraged to take control of their pregnancies and be supported in their decision making."
It is of extreme concern that the points high-lighted in this paper seem to have been ignored and dismissed by government in recent legislation. The well-being of babies and mothers and the right of women to choose the midwifery model of care as an alternative to the obstetric, institutionalised model, is being dis-regarded in favour of enabling a medically dominant system similar to what we see happening in the USA.
The attitude of Australian obstetricians as seen in the following statement, makes it clear that this government is being cultivated to prefer the interests of obstetricians over the interests of mothers and midwives:
"The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) does not endorse Home Birth. Home Birth is not endorsed as it is associated with an unacceptably high rate of adverse outcomes."
This is a flat lie.
In 2006, 282,169 babies were born in Australia. There were 2091 foetal deaths. 30.8% of the 277,436 women who gave birth had caesareans. Only 58% had spontaneous vaginal births. 708 women had homebirths. No foetal deaths occurred during these 708 homebirths. The infant mortality rate for homebirth in 2006 was ZERO. The main reason for the caesareans was previous caesarean. 83% of women in Australia who have a primary caesarean will have a repeat caesarean. (AIHW National Perinatal Statistics Unit 2006)
So why is the AMA demonising and marginalising homebirth?
And why is the government playing into their hands?
Perhaps it is less to do with this:
"Home Birth is not endorsed as it is associated with an unacceptably high rate of adverse outcomes."
and more to do with this:
"An enormous obstacle is private obstetric charges, as obstetricians may be hesitant to forgo lucrative incomes of up to $9,000 per pregnancy, with some Sydney doctors reported to be charging up to $12,000 and earning collectively up to $1.4 billion per year."
This government must stop ignoring the voices and interests of women, mothers, families and midwives, and stop enabling the greed and monopoly of insurance companies and doctors.
80% or more of women in the UK and NZ access the midwifery model of care as an alternative to the obstetric model. The AMA website states that obstetricians are the most appropriate careproviders for women. Not 'high risk women'. Just - 'women'. This is indicative of their agenda to secure a monopoly over the billion-dollar industry of birth services, to eliminate the competition, and to use the birthing population of Australia as fodder for a massive obstetric/caesarean industry, pushing up rates of induction, and therefore primary caesareans - which generates guaranteed repeat business, as less than 20% of women who receive a primary caesarean are able to achieve VBAC in our hospitals.
Meanwhile, 96% of primips who plan homebirths achieve a spontaneous vaginal birth. (25% of the 708 women who gave birth at home in 2006 were primips.)
95% or more of women who engage the care of a homebirth midwife for a VBAC birth achieve a successful VBAC.
The AMA would have you believe that homebirth, with its 4% caesarean rate, is "unsafe", and that midwives operating outside of an obstetric hierarchy must be excluded and criminalised. They would also have you believe that even if there is a publically funded homebirth system, VBAC women must be excluded from this as being too 'high risk".
Do you not see any selfish, profit-driven agenda here?
The caesarean rate has increased by more 10% in 10 years, from just over 20.3% per cent in 1997 to 30.8% in 2006.
The following 2005 article indicates that clinical safety is NOT the driving factor behind the rising rates of induction, intervention and surgery for birthing women:
"The AMA said there was no need to be concerned by the record high and women should always choose what is right for them.
Dr Pesce said litigation was a major factor in the jump in caesarean rates.
"No obstetrician has ever been sued for performing a caesarean section, when they get sued it's because they didn't perform one," he said."
The fact that Pesce also patronisingly states that we should NOT BE CONCERNED about the rising c/s rate hints that Pesce et al (whose patients have an 80% caesarean rate) have a vested interest in eliminating natural birth alternatives and any competition to what is a lucrative trade for them.
An unprecedented number of submissions were received on this issue. It is clear and plain that Australian women demand and deserve a choice between the obstetric management of birth and autonomous midwifery model care that supports natural birth.
“It is encouraging that the latest state government policy document is supportive of a direction that is woman centred and in line with national and international evidence and trends. It is our impression however that some women are choosing homebirth in WA as there are limited options in relation to access to midwifery continuity of care, waterbirth, support for vaginal birth after caesarean section or access to birth centre environments. It seems apparent that the maternity systems are, for some women, too medicalised and restrictive, and do not meet their needs. It is our impression that some women, who in other models and systems would not be ‘eligible’ or recommended for homebirth, seem to be choosing this option as a surrogate means to access midwifery continuity of care and waterbirth. This issue was apparent in both metropolitan and rural areas. The reviewers believe that the choice to give birth at home or in water will continue, as will the choice to have a vaginal birth after a caesarean section. Therefore, developing systems to support safe and satisfying systems of care that provide childbearing women with a diversity of options is essential.”
This government has a responsibility to ensure that a diversity of birthing options, including waterbirth, midwifery continuity of care, midwife-led care, homebirth including home VBAC, are available and accessible, funded and supported, for all consumers of maternity services.
It is not the role of this government to be lackeys for the AMA, promoting the interests of the 27,000 members of the AMA, over the well-being and preferences of Australian women and babies. Reducing midwifery and natural options so that fewer and fewer women even realize they are are options is manufactured consent – even coerced consent in some cases - not informed consent, and I deplore these unethical tactics to herd an unsuspecting population of birthers into the medicalised system by reducing their awareness of, and their access to, their rights and choices.
A “collaborative team approach” does not mean: "obstetricians in charge, who set obstetric policy driven by insurance stipulations, who have the authority to force midwives under their hierarchy to conform to obstetrically-set policy, thereby making it impossible for midwives to deliver the midwifery model of care, so that consumers have no alternative to the obstetric model, it is the only reality they know, so obstetricians get most of the money and hold most of the power, and the only way women can access the midwifery model is to go underground." That is not team work. That is distortion of a healthy and just balance of power. That is corruption.
Collaboration means midwives are autonomous professionals delivering the midwifery model of care to the low-risk women who choose them, who consult with and refer clients to obstetricians if/when necessary. It means obstetricians being required to up-skill on normal birth practices, such as attending homebirths with private midwives as a pre-requisite to joining a collaborative team with midwives. Collaboration means it is not obstetricians who assess who is low risk and who is high risk. It means obstetricians are specialists in high-risk obstetrics who respect midwives as equal professional who are specialists in normal birth. What's good for the geese is good for the gander; the power hierarchy must end and obstetricians cannot be allowed to continue to call the shots on what is good for women in Australia.
"Home Birth should not be offered as a model of care as there is a reasonable public expectation that any model of care that is offered has a margin of safety that would be acceptable to most women. This is not present in the setting of Home Birth ... women who choose to prioritise this aspect of their birth experience above that of risk minimisation."
This implies that women planning homebirths selfishly place their desire for a gentle and humane birth experience above the safety of themselves and their babies, perhaps because they are ill-informed of the risks, as this sentence implies:
"Women contemplating Home Birth must be provided with accurate information about the risks involved."
(This inference that homebirth women are ill-informed, risk-taking mavericks contrasts with the fact that most women planning homebirths are older, educated, highly-informed, affluent city-dwellers.)
The AMA cannot have any concept of what is ‘acceptable to most women’, as within the dynamic of ‘manufactured consent’ that is the norm within the medical system, and the dearth of any system of collecting and analyzing feedback from women as consumers of maternity services, as per the mandatory Birth Review in New Zealand, the preferences and needs of ‘most’ women are being ignored.
Of 1000 women, 170 matched the criteria for a 'standard' primip woman.
170 first-time mothers (primips) planned to have their first babies at home during the period 2003-2007.
Of these 170 women, none were induced. (Compared to a 25% induction rate in Australian hospitals.)
Of these 170, 11 women were transferred and had caesareans in hospital - a 6.5% caesarean rate. (Compared to a 15% primip c/section rate in public hospitals; and a 27% primip c/section rate in private hospitals.)
Of these 170, 1 woman sustained a 3rd or 4th degree perineal laceration (0.6%) - after transfer to hospital.
138 of these 170 actually gave birth at home.
None of these 138 were induced.
None of these 138 sustained a 3rd or 4th degree perineal laceration.
30 women planned VBACs at home between 2003 and 2007.
Of these 30, 100% achieved vaginal birth after previous ceasarean (VBAC). (Compared to a 30% VBAC rate in public hospitals, and a less than 20% VBAC rate in private hospitals.)
These are key performance indicators according to the Victorian Government.
These results were delivered by midwives who provide care according to the midwifery model of care. These births were not 'supervised' by medical doctors, as stated by the AMA in this September 2008 article: “Medical Supervision Key to Safe Maternity Services”
Medical practitioners did not attend these births as recommended in the RANZCOG statement on homebirth:
"Women choosing Home Birth should be cared for by both an experienced medical practitioner and a registered midwife..."
Homebirth midwives consult with, and refer clients to, specialist care when necessary, however, these births occured outside of the control of and supervision of the medical hierarchy, and these results were achieved without the supervision the AMA deems necessary ostensibly for .... safety reasons? Is it really “safety” that is the driving motive behind their policy of 100% medical involvement in, supervision of and management of ALL births, even low-risk ones that are managed by midwives in all developed countries except the USA?
I would like to contrast these statistics from the Department of Health with the following comments from Daniel Andrews, Victorian Minister for Health:
(To homebirth midwives who met with him in his office):
"You're cowboys. There is no place for independent midwives in Victoria. You'll get an exemption from the legislation over my dead body. Homebirthing women are not representative of women in Victoria. I don't care about the 700 or more women in Victoria who had homebirths last year."
This sentence (below) in the RANZCOG homebirth statement indicates that the plan to use compulsory indemnity insurance to eliminate homebirth midwives and homebirth as a natural birth option for women, was an intentional strategy. It is well known to RANZCOG that midwives have been uninsured since 2004, when Lloyds of London ceased to cover midwives worldwide because it was not financially viable as the pool was too small. It is well known that no insurance is available for homebirth midwives.
"Health professionals supervising Home Birth should have appropriate indemnity insurance. Indemnity insurance premiums must reflect the associated increased risks."
By falsely claiming that:
- homebirth is risky
- homebirth must be supervised by doctors
- homebirth midwives must have insurance
and by pressing these arguments on the government, the AMA have created a situation by which all competition to their monopoly may be eliminated, and women will have no means by which to compare the highly promoted medical model, touted as being the 'safest in the world' by the AMA, with safer, gentler and less traumatising care delivered by autonomous midwives.
This is a wrong that must be righted. This government should not collaborate with a plan to eliminate autonomous midwifery and thus restrict safe normal birth options for Australian consumers. Any service providing a 6% caesarean rate for first time mothers, a 100% successful VBAC rate, and a less than 1% perineal laceration rate, deserves the attention and support of our government. It does not deserve to be maligned, stitched up, marginalised, muzzled, and driven undergound.
Roxon's amendment states,
"For midwives to be eligible to participate in the new arrangement they will need to meet advanced practice requirements and have collaborative arrangements with doctors."
What guarantee does this government offer that obstetricians will collaborate with independent midwives who provide homebirth services, when RANZCOG has blatantly stated that they refuse to support homebirth? What pressure will this government bring to bear on obstetricians who have already stated that they do not support homebirth, to ensure that they willingly collaborate with homebirth midwives?
How is this viable? How will this government guarantee that Obstetricians will support and collaborate with midwives providing services for women wanting home VBACs?
What advanced practice requirements will obstetricians need to undergo in order to be adequately skilled-up in natural birth practices? Most have never seen a normal birth in a homebirth setting, and don't believe it is possible for women to give birth safely without intervention. Obstetricians will need to be required to attend homebirths apprenticed to midwives in order for them to be safe enough to collaborate with midwives providing homebirth services. Collaboration is a two-way street – not a tool of dominance and hierarchy.
How will the government ensure that obstetricians WILL collaborate with midwives - without coercing these midwives to conform to obstetrically-set policy, so that the midwifery model of care is not compromised - and that obstetricians will be sufficiently trained and experienced in the midwifery model that they do not jeopardise it?
It seems to me that if it is a condition that midwives have collaborative arrangements with obstetricians, and obstetricians refuse wholesale to support homebirth midwives, then you have the homebirth midwives nicely stitched up, you've played into their hands, and homebirth families and midwives are wrecked.
I urge you to take a stand against the selling out of the womanhood of Australia and take all measures necessary to ensure that midwives are treated with the same equity as obstetricians in all regards, and that we as consumers can access natural birth options (including homebirth) and the midwifery model of care as easily as we can access obstetric models of care.
The fact that Pesce is blatantly bragging about his ability to manipulate Nicola Roxon and his success in forcing an untenable and unviable amendment demanding unilateral collaboration and unilateral right of veto for doctors as his greatest success in this article:
should be adequate evidence that the holisitic welfare of birthing women and our right to democracy is not his prime consideration. Members of the public raised their objections in these letters to the Editor (one of which was sent in by my husband): An Attack on Women's Rights
How dare this government enable Pesce and his ilk to place them in a position of power over midwives and women, with punitive powers to force our compliance to a system that rising rates of PTSD reveal are damaging to women, and empower them to demonise a gentle, safe alternative like homebirth? This government is duty bound to observe the example of the UK and other nations in guaranteeing midwifery-led care, including homebirth is available to all consumers, including Indigenous women and those in remote areas.
The Royal College of Midwives (RCM) and the Royal College of Obstetricians and
Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There
is no reason why home birth should not be offered to women at low risk of complications and it
may confer considerable benefits for them and their families. There is ample evidence showing that
labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with
implications for her health and that of her baby.
My submission to the Senate Committee
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