Minority report by Coalition senators
Health
Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and Two
Related Bills
Introduction
1.1
The
Legislation considered by the inquiry seeks to reform the provision of
maternity services in Australia by providing midwives access to the Medical
Benefits Schedule (MBS), the Pharmaceutical Benefits Scheme (PBS), and a
Commonwealth-supported Professional Indemnity Insurance (PII) scheme. However,
the legislation will exclude midwives who attend homebirths from accessing
these schemes and, as such, from being registered on the National Registration
and Accreditation Scheme.
1.2
Coalition Senators believe that the Chair's Report addressed a number of
issues within the legislation, but drew the wrong conclusions from the evidence
and misrepresented some of the submissions made. For instance, the Chair's
report states that the legislation was generally supported by submitters, and
the Maternity Coalition are provided as an example of this support.[1] However,
the Maternity Coalition and similar submissions, whilst supporting the Bill's
policy towards midwives in general, were very critical of the consequences the
legislation will have towards midwives involved in homebirths.[2]
1.3
Coalition Senators have approached this inquiry with two principles.
Firstly, that expecting parents should have a right to choose where their child
is born. Secondly, the Parliament must not allow the practice of home-birthing
to go underground. By essentially outlawing homebirths, the Government will
force many mothers to give birth in potentially unsafe environments.
1.4 The
Committee took submissions and heard evidence from numerous groups and
individuals seeking to comment on the exclusion of homebirth midwives. This
Minority Report outlines these concerns with comments on the Government discrimination
against home birth practitioners, Professional Indemnity Insurance for them,
and the family's right to choose a birthplace. Coalition Senators also wish to
comment on the measure that allows a midwife or nurse to refer the patient
directly to an obstetric specialist without consulting the patient's General
Practitioner (GP), and the availability of a hospital place for all women
giving birth.
Discrimination
of midwife practitioners
2.1 The
incidence of homebirths in Australia is relatively small when compared to other
types of births available. In 2006 there were 832 births in homes, compared to
269,945 births in hospitals.[3]
Homebirths only accounted for 3 of every 1000 births. The Minister for Health
and Ageing has used an even lower figure, stating that 708 babies were
homebirthed in 2006 out of 282,000 total births.[4]
The reason for such a small percentage of homebirths is not necessarily due to
the choice made by families. State regulations already prevent midwives from
practicing unless they are a registered midwife or medical practitioner.[5] Such
regulations have already minimised the availability of midwives who are
eligible to perform homebirths.
2.2 Despite
the small number of midwives assisting homebirths in Australia, the sector is a
vocal group and strongly passionate about the practice. This inquiry received
over 2000 submissions, many from women hoping to share their homebirth stories.
The Australian Private Midwives Association was formed from a number of
independent groups in response to the Bills "impacting upon the private
practice midwifery workforce and through a desire to have an input into the
maternity reform agenda."[6]
2.3 The
Government appears to have discriminated against midwives when seeking advice
concerning midwife reforms. For instance, the Department of Health and Ageing
has formed the Maternity Services Advisory Group which includes industry groups
but includes very few representatives of midwives and does not include any
representatives of midwives involved in homebirth.[7] Professor
Sally Tracy of the Australian College of Midwives made the following statement:
I have to put on the table my objection
to the maternity services advisory group, too, because it looks like I might be
the only midwifery voice at it who can speak for midwifery. We do have other
midwives who are representing other big organisations and they will not
actually be wearing a midwifery hat. We do have 13 doctors’ organisations on
that advisory group.[8]
2.4 Coalition
Senators agree with Professor Tracey that any group formed for the purposes of
informing and reviewing government policy in the area of maternity services
must include adequate representation from the midwives profession. As such,
Coalition Senators recommend that the Department reorganise the Maternity
Services Advisory Group to ensure that midwives organisations make up at least
25 per cent of the Group.
2.5 The
legislation is in response to the National Maternity Services Review conducted
by the Department. The reason for excluding Midwives from the legislation is
explained in the Department's submission as follows:
The review did not recommend
Commonwealth funding for homebirths at this stage. Accordingly, the Government
is not proposing, to extend the new arrangements for midwives to homebirths.[9]
2.6 However,
the Department's submission also stated that the legislation 'delivers a range
of measures aimed at providing Australian women with more choice in their
maternity care.' Coalition Senators are confused as to how the immediate
exclusion of homebirth midwives from both the consultation process and the legislation
will provide Australian women with more choice in maternity care. The
legislation follows a worrying trend in Government policy being produced with
inappropriate industry and stakeholder consultation.
2.7 The
number of issues raised by homebirth advocates to this inquiry highlights the
complexities surrounding policy with regards to homebirthing in Australia.
Coalition Senators believe that these issues should be canvassed in an inquiry
with a wider scope. As such, Coalition Senators are recommending that a
reference be made to the Community Affairs References Committee for a full
inquiry into Homebirthing in Australia.
Professional
indemnity insurance
3.1 Professional
indemnity insurance for private midwife practitioners is not currently
available. Homebirth Access Australia submits that the unavailability of
insurance is due to the relatively small number of private practitioners
registered to practice under State regulations. The system cannot support
"a market-priced premium level that is affordable."[10]
Nonetheless, practitioners who meet the State requirements are currently able
to practice.
3.2 The Medical Indemnity
Insurance Association of Australia submitted that it is essential midwives who practice
independently be provided with appropriate professional indemnity insurance.
The MIIAA states that, "otherwise, this could potentially create an
incentive to sue medical practitioners preferentially over midwives based on
their insurance coverage."[11]
Coalition Senators believe that this is a reasonable position.
3.3 Many
submissions to the inquiry made by supporters of private practitioners agreed
that private practitioners should be obligated to hold professional indemnity
insurance. Ms Justine Caines of Homebirth Australia gave evidence that:
We have no problem with the national
registration. Some in our world have said, 'there shouldn't be a requirement to
have indemnity insurance.' Well, to me, indemnity insurance is a professional
requirement but also, very much, a consumer right.[12]
3.3 The
requirement to hold professional indemnity insurance did not appear to be a
significant issue in the inquiry. As such, the exclusion of private midwives
from being eligible midwives under the Commonwealth's PII scheme proved to be
the biggest concern for those making submissions or appearing as witnesses. The
Australian Nursing and Midwifery Council note in their submission, that:
...although only a small minority of women
choose homebirth, women will continue to make this choice. Application of an
insurance requirement that cannot be met by midwives is likely to result in
women giving birth without a midwife in attendance. This will make homebirth
very dangerous, even for low risk health women for whom homebirth is currently
a safe option.[13]
3.4 The Government’s PII scheme
will operate by inviting insurance companies to tender for the right to provide
indemnity insurance to midwives. A company will be chosen which can best carry
out the policies supported by the Government. However, it is clear from the
submissions made and evidence given to the inquiry that the Department has not
reviewed the risk profile involved in insuring midwives and has not provided
the insurance industry with enough information relating to the proposed tender
process. For instance, Dr Vernon of the Australian College of Midwives pointed
out that insurers are telling the College that they are unsure “...from the
documentation the government has currently provided as to what it is that they
are being asked to tender for...there is no information about the collaboration
and how that will occur between midwives and doctors and between midwives and
hospitals.”[14]
3.5 In
giving evidence to the committee, the Department was unable to give a clear
picture of how the tender process would operate and what information would be
available to tenderers. Professor Rosemary Calder of the Department stated:
The process looks confusing – I agree –
but the intention is that, as we work towards identifying the insurer that is
appropriate for this, we will also be working on the issues around eligibility,
noting that it is initially defined by registration and scope of practice. That
is an assurance to the insurance industry of where this will go and that, as it
reaches the point where insurance products need to be developed, the
eligibility criteria will have firmed up.[15]
3.6 The
fact that insurers are unsure as to the costs involved in providing indemnity
insurance and tendering for the government contract was made clear by Mr David
Nathan of the Medical Indemnity Insurance Association of Australia. Mr Nathan
points out that “there is not a great deal of compelling data that one can
point to as to the relative risks of homebirths versus birthing centres and
this and that...the sense is that there is more risk associated with homebirthing
than there is in terms of the independent midwife model that is being mooted as
we speak.”[16]
3.7 Coalition
Senators believe that the Department has not undertaken adequate modelling of
the risk factors and profile of different classes of homebirthing and an
immediate review would allow potential tenderers to consider the costs involved
in tendering for the Government scheme, as well as allow the Department to
draft appropriate selection criteria for the tendering process.
3.8 With
regards to homebirthing, the Chair's report takes note of comments made by the
Minister which stated:
I recognise that a very small proportion
of women would like to have home births and am currently investigating if there
is some way that we can provide this as an option without making the proposed
midwife indemnity insurance unaffordable.[17]
Given the small amount of homebirths
being performed in Australia each year, Coalition Senators would like the
Government to prove that the costs of insuring homebirth midwives would be
prohibitive. Coalition Senators believe that further modelling of the risk
profile of both midwifery, including homebirthing, and the costs of indemnity
insurance should be formally undertaken by the Department to ascertain the
feasibility of including private homebirth midwives in the scheme considered.
The
right to choose a birthplace
4.1 As
noted above, the Department's reasons for legislating the Midwife policies are
that the measures will provide "Australian women with more choice in their
maternity care, while maintaining Australia's strong record of safe, high
quality maternity services.[18]
4.2 However,
many submissions and witnesses noted that the legislation will not expand
choice, but will reduce choice by removing the option of undertaking a
homebirth for the majority of Australian women and families. The personally
enabling nature of allowing women to make such a choice should not be
underestimated. As Dr Barbara Vernon of the Australian College of Midwives
stated in evidence: "What we need to do is say we have a particular views
on whether or not women's choices are good choices but we respect that women
can make those choices".[19]
Bruce Teakle of the Maternity Coalition made similar sentiments:
...I think (this) is a strong reminder
that we must respect women's choices in the development of care rather than
take a patriarchal, advice-giving approach where we decide what choices women
must make otherwise they do not get any care.[20]
4.3 Coalition
Senators believe that women and their partners should be free to choose the
venue for their birth, so long as that venue is appropriate given the health of
the woman. There will always be a small amount of women who choose to give
birth at home. As such, Coalition Senators believe that the inclusion of
private homebirth midwives within this legislation would increase the safety of
women choosing homebirths.
4.5 The
Chair's Report notes the amount of criticism made by submissions about an
increase in unattended homebirths if the proposed changes went ahead. For
instance, Ms Elizabeth Wilkes of the Australian Private Midwives Association
pointed out:
If this is forced underground...midwives
will be deregistered, and not providing that care – will step out of home birth
care – and women will be cared for by unregulated, unregistered care providers
or no care providers at all. The disasters of women turning up bleeding, with
babies unable to be born or whatever else will certainly increase if this
legislation goes ahead as it stands.[21]
4.6
The Chair's Report does not offer any solutions to how the safety issues
of unattended homebirthing can be resolved. Coalition Senators believe that the
health consequences in outlawing private midwifery should have been considered
by the Government and addressed by the Department before this legislation was
introduced.
References to a
specialist
5.1 The legislation also contains
provisions which allow midwives to refer patients to obstetric specialists
without the patients being assessed by the patients' general practitioner. Many
submissions highlighted the potential problems caused by allowing nurses and
midwives to make a direct referral. For instance, the Rural Doctor's
Association of Australia (RDAA) submitted:
-
The
training that midwives have undertaken does not include specific training in
medical diagnosis and assessment and, in particular, does not include training
on what conditions are appropriately managed in general practice;
-
Unnecessary
referrals will take place causing significant additional costs to patients,
communities and to the taxpayer; and,
-
The
arrangements that were supported by the maternity services review envisaged the
midwife working in a collaborative team with a GP or specialist obstetrician
which would remove any need for the midwife to make referrals.[22]
5.2 As
mentioned by the Chair's Report, Dr Barbara Vernon of the Australian College of
Midwives noted concerns that a woman's General Practitioner may not understand
what kind of care the woman will need after birth if the woman is referred
directly to a specialist without seeking the General Practitioner's advice.
However, Dr Vernon believes that "midwives make safe and responsible
decisions for engaging with GP obstetricians or specialist obstetricians and
that if you had a woman in labour and something emerged where she would need
medical input it is a nonsense to think that we would build in some kind of
additional layer of referral before we could bring the doctor in to provide
assistance to that woman." [23]
5.3 Coalition
Senators agree that there are potential problems with allowing midwives to
refer their patient to a specialist without consulting a General Practitioner.
However, the fact that a woman giving birth may need immediate attention
without time for a referral to the GP before a specialist adds weight to the
argument that the additional referral is superfluous and potentially dangerous.
Coalition Senators believe that the operation of the legislation aims to ensure
that practicing midwives have the professional skills needed to decide upon
when to call in a specialist. However, we believe that the operation of this
measure needs to be monitored and reviewed in due course in order to ensure
that the health of women is not put into jeopardy by allowing direct referrals
to specialists.
Access to a
hospital bed
6.1 Some
submissions to the inquiry raised the issue that women choosing to undertake a
birth outside of hospital are doing so without available immediate access to a
hospital in the case that their health becomes at risk. Dr Kathryn Dwan shared
her experience as follows: “After 22 hours of labour, my husband and I made the
decision, in collaboration with our independent midwife, to transfer to the
hospital...Narayan (the born child) had to spend the first five days of his life
in intensive care at the Canberra Hospital, and during this time Marie, my
midwife, was our advocate and our most trusted source of information.”[24]
Unfortunately, Dr Dwan’s son had a problem with his lungs and needed to spend
the first five days in an intensive care unit.
6.2
Dr Dwan’s story highlights the importance of a woman giving birth having
immediate access to a hospital if something goes wrong with the birth. Dr
Dwan’s midwife had registered with Canberra Hospital to ensure that a bed be
‘on-call’ if anything had gone wrong and she was able to be transferred quickly
and easily. Unfortunately, it is not always common practice for midwifes who
operate outside hospital to ‘pre-book’ a bed. Ms Caines gave evidence that
“For every woman who has a normal
vaginal birth – but of course, more so a homebirth, because the outcomes are
even better – we reduce an amazing level of cost. For a start, we do not even
have a hospital admission, so we do not have a bed day stay”.[25]
6.3 Coalition
Senators believe that Dr Dwan’s story is an example of why all practicing
midwifes should be required to ‘pre-book’ a hospital room in the chance that
the mother or child requires hospital treatment. Some of the purported risks of
homebirthing might be mitigated if a hospital bed was immediately available.
Coalition Senators believe that ensuring access to a hospital bed should be a
requirement for private midwives to practice and are recommending that the
Government legislate such a requirement.
Recommendations
7.1
Coalition Senators recommend that the Department reorganise the
membership of the Maternity Services Advisory Group to ensure that midwife
organisations make up at least 25 per cent of the Group, and that homebirth
midwives are represented.
7.2 Coalition
Senators recommend that the Department of Health and Ageing undertake an actuarial
analysis on the risk profile of home births 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.
7.3
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.
7.4 Coalition
Senators recommend that Medicare Australia monitor and make a review after 12
months, of the ability of nurse practitioners and midwives to be able to refer
a patient to a specialist without first referring the patient to their General
Practitioner.
7.5 Coalition
Senators recommend that the Government legislate to ensure any eligible midwife
performing a birth outside of hospital be required to register with a hospital
to ensure that a bed be made available for the patient in the case that medical
attention is required during or after the birth.
7.6 Coalition Senators recommend that a reference be made to the Community Affairs
References Committee for a full inquiry into Homebirthing in Australia.
Judith Adams
Senator for Western Australia
Sue
Boyce
Senator
for Queensland
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