Independent midwife clients granted a brief reprieve – or are they?

The West this afternoon tells us: “Homebirth mothers win reprieve”:

Pregnant women wanting to give birth at home have won a reprieve after Federal Government and the States cut a deal today to allow midwives to continue practising without insurance.

Health Minister Nicola Roxon announced privately practising midwives would have a two year exemption from obtaining medical indemnity cover.

Two years. At least this may offer some women breathing space – the women who were trying to get pregnant right now to avoid the 2010 deadline at which their midwives were to become outlaws.

The article continues:

Homebirth advocates had feared homebirthing would be driven underground because midwives would not be able to get insurance – a requirement of the new National Registration and Accreditation Scheme for health professionals to come into effect mid next year.

While the Federal Government is planning to subsidise insurance for midwives who work in hospitals, it had refused to extend indemnity to homebirthing midwives because of the high cost of providing cover.

Private insurers have also refused to cover homebirths because of the perception homebirths are riskier.

This doesn’t accord with what I’ve read over the past few years at all. As far as I can tell, it is just an unreferenced, passive-voice/agent-deleted throwaway quote from the Maternity Services Review:

[…]the provision of birthing services by privately practising midwives is perceived to be a high-risk activity.

My understanding is that the lack of indemnity insurance in Australia isn’t because homebirths are higher risk or because homebirths are perceived to be higher risk than hospital births; it is based around the fact that there is a tiny pool of homebirth midwives, and on obstetric malpractice payouts being enormous. There is no feasible way to share risk between such a small number of midwives, nor do actuaries seem to have any idea of the actual likely risk and cost of payouts – all the stats the Australian Government have been working on have been based on obstetric litigation.

Note also that obstetric malpractice insurance has been heavily subsidised by government for quite some time via the Premium Support Scheme and High Cost Claims Scheme, without a whimper of complaint from the medical profession or the general population.

Back to the West:

Under the deal announced today following the Health Ministers conference in Canberra, midwives will be able to keep practising homebirths provided they warn expectant mothers they do not have insurance, they follow quality and safety guidelines being developed and each homebirth is reported to health authorities.

That second catch is a huge one. It sounds like a motherhood statement, but if you dig beneath the surface, “quality and safety guidelines” can be heavily proscriptive. The “quality and safety guidelines” I’ve seen so far have typically been extremely restrictive, including exclusion from homebirth for such things as being too young, too old, too fat, too thin, having a disability (poorly defined), having a previous C section (which we can see from the Canadian study needn’t be an exclusion), declining certain poorly-evidence-based prenatal screening (such as glucose tolerance, ultrasound, GBS testing), history of postpartum depression, previous baby in intensive care (regardless of cause), and so on.

The Sydney Morning Herald says that protocols – not guidelines, protocols – would be developed in consultation with the National Nursing and Midwifery Board.

And Roxon’s clinging to the Maternity Services Review not recommending public funding of homebirth midwifery yet – which the Review author herself, right in the review, said was purely based on political expediency (i.e. not pissing off the medical colleges and associations):

The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions. […]

So as long as the AMA and RANZCOG are hostile to homebirth -ideologically, not evidentially – the government is not prepared to stare them down.

More on the Maternity Services Review here: “Maternity Services Review: Medicare payments to OBs up from $77m to $211m since 2004.”

Bottom line? If there’s no “informed refusal to go to hospital” clause, this acclaimed change-of-heart really isn’t likely to improve things significantly for many women.

Addit 4 Sep @1709: Unfortunately, this sort of informed refusal doesn’t seem to be terribly likely, given stuff like today’s NSW Supreme Court decision – upholding the he right to refuse medical treatment, with the following caveat:

An exception could be made if a pregnant woman’s refusal of treatment would result in the death of her unborn child.

When are pregnant women going to be promoted to full personhood?

Categories: gender & feminism, health

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12 replies

  1. I agree with your analysis. It’s so insulting, the whole thing. Just leave us the fuck alone to give birth. My body=my birth.

  2. I got so hopeful for a minute there. It’s more a stay of execution rather than anything else. What is it with these people that they think women are so dead set on having a homebirth that they would risk the life of their child?

  3. It’s not even a stay of execution though, Mindy – forcing independent midwives and woman into a prescribed protocol is a substantial change from the current situation. To me it looks more like a smokescreen to try to get protestors to back off, pure PR spin.

  4. The “quality and safety guidelines” I’ve seen so far have typically been extremely restrictive
    Indeed, some of the pregnancy message boards suggest that the current Australian hoembirths with hospital midwives exclude women who had a previous vaginal birth with birthweight over 4kg.
    Regarding the Hunter and New England Area Health Service v A case that the SMH talked about, I looked up the decision. The case itself is about a (male, not pregnant) patient’s advanced directive refusing dialysis, here’s the mention of pregnancy related cases:

    19 There may be an exception to the principle that a capable adult’s right of self-determination is paramount. Lord Donaldson in Re T at 102 noted, as a “possible qualification” to the paramountcy of that right, “a case in which the choice may lead to the death of a viable foetus”.
    20 Brown P was faced with precisely that situation in Re S [1993] Fam 123. In that case, his Lordship said at 124, the medical evidence was “emphatic” that a particular operation was necessary to save the mother’s life, and the life of her unborn child. He said that the child could not be born alive if the operation were not carried out. In those circumstances, Brown P declared that the operation and any necessary consequential treatment could lawfully be performed despite the mother’s refusal of consent.
    21 That situation has been recognised in the American courts, including by the Court of Appeals of the District of Columbia in In re AC 573 A 2d 1235 (1990). Terry J, for the majority, noted at 1246 that there were “rare cases in which a patient’s right to decide her own course of treatment has been judicially overridden”. That was usually done “to vindicate the state’s interest in protecting third parties, even if in fetal state”. His Honour cited a number of authorities. In that case, Belson J dissented in part. The point of his Honour’s dissent was to emphasise, more than he thought the majority judgment had done, the State’s interest in protecting the interests of a viable unborn child (see at 1254-1255).
    22 Since the question does not arise in this case, it is neither desirable nor necessary that I should explore it further.

  5. Gah, as if we need to start mining US State laws on fetal personhood. Scary.
    Mary: I poked around for info on that forced C section case, and my first few hits were about how it should not be considered authoritative, and about how more recent decisions did not support it. A few examples:
    from a Tort Law book
    from a Healthcare Law book
    From a risk management article on obstetric consent
    I recognise that a lot of people want this to be a contentious issue, including those who recently incarcerated a pregnant woman in Florida, but I’ll fight that all the way to the end.

  6. Aarrrgggg. I am so sick of people assuming they desperately need to advocate for the unborn baby. I have no doubt that there exist situations in which a mother does not make what I would regard as a rational decision (I’m not big on refusal of treatment on religious grounds, for example), but these are neither common nor unequivocally wrong.
    If these terribly concerned people want to advocate for the ignored, under valued people, advocate for the mothers. After all, most mothers have been bullied and terrified into at least considering ignoring their own needs, if not actually disregarding them altogether.

  7. Lauredhel: yes the reference to the US cases was a particular worry. Thanks for the links on current thinking.

  8. I think the other place that the personhood of the foetus is being brought about via backdoor methods is in the possible model proposed by Roxon as “guidelines” for homebirth under state control.
    Staff are told they have a “separate duty of care” to the foetus during birth and also once the child is born.
    So this means that if they don’t like the decision a woman makes, or they think they know better than her, they can….what exactly? It’s not spelt out in the “guidelines” but what exactly are they going to do to women who refuse to do as they’re told? Will they lay their hands on us, put us in ambulances and carry us protesting all the way to a hospital where despite our protests we will be operated upon without any hint of consent? Will they call the police to escort us? Will our children be removed? (Please don’t cry EXAGGERATION, this is already happening.) I see enough dodgy consent bullshit in hospitals to know that consent is seldom freely given but more accurately coerced, bullied, forced or threatened.
    What does this all mean?
    Here’s my blog entry with the relevant parts pulled out for those who want to see for themselves.

  9. Oh and let me just add, I find it all extra interesting that personhood of the foetus is being broached in this way in a field that the normal feminist groups concerned with that issue won’t be paying attention. It’s just birth, and no one pays attention to what’s done to women except us small fringe lunatics. Well look over here, please women. If they get personhood through this way, abortion will be next.

  10. While I’m very concerned about what the framework will be that must be conformed to in order to get the exemption, I am not as pessimistic otherwise that the two year delay is just putting this in the too hard basket and making it someone else’s problem (though of course it may be). When the Greens suggested a temporary exemption this news was greeted enthusiastically in homebirth circles. I included it in my suggestions to my MP as one possible first step.
    The thing with the threat to homebirth midwifery is that the problem is on multiple fronts: the need for indemnity to register (and the need to be registered to practice), the apparent impossibility of the small pool of midwives arranging indemnity on their own, and the legislation, in the lower house on Monday, that provides for indemnity assistance to other midwives but not independent midwives.
    I saw the full communique from the health ministers posted on one of my groups, and it wasn’t “Roxon on homebirth”. It covered a lot of other issues unrelated to birth and was the health ministers on what they had met about.
    If Roxon is now trying to find a solution to retain homebirth midwifery, and it seems she has been moving a bit in that direction very recently, the beginning might look very much like this. It seems it would allow next week’s legislation to pass, which has other things the government wants to achieve, without including independent midwives if she does not have a solution ready right this minute, but without dooming independent midwifery.
    I’m imagining resolving indemnity is not something that can be done with the stroke of a pen. I imagine it will also involve work with insurers (probably after the “quality and safety framework” has been finalised (*dread*). I suspect that the state health ministers are just not involved in the process of resolving indemnity but their say is required in approving a delay in indemnity for registration.
    If homebirth had just been favoured in the maternity review indemnity recommendations as it should have been, and included from the beginning in the legislation on medicare and indemnity, it would likely be ready to be voted on in parliament next week – *sigh*.
    I will still be at the rally in Canberra on Monday, and in the meantime communicating with my MP on what else also needs to happen, but as far as it goes, I see it as good news.
    (There’s no certainty in it yet for the woman I know trying to conceive right now to have a baby before the deadline. Nor would there be for me if I plan another baby and a homebirth. Both our medical histories, and so many other women’s, would not fall within the kind of “low risk” models that get bandied about. But we would both fit comfortably into the Canadian criteria. Anyone have a beef with the Canadian criteria? At first glance to me they look like they would include most women whose own research would suggest they were homebirth candidates and whose midwives would support for homebirth. I would also like a guideline that includes an option for the woman to make a different choice.)

  11. “Anyone have a beef with the Canadian criteria? At first glance to me they look like they would include most women whose own research would suggest they were homebirth candidates and whose midwives would support for homebirth. I would also like a guideline that includes an option for the woman to make a different choice.”
    I object to any rules that attempt to intervene between me and my primary healthcare provider of choice. Any. I object to anyone trying to make rules which are decisions about MY BODY. (See above for the de fact personhood that this involves!)
    I note the MSR hasn’t resulted in trying to wrestle perfectly healthy women from the client pool of high risk surgeons which surely would happen if anyone in government was remotely serious about actual real reform? The surgical monopoly is merely being extended into the last frontier of births which were relatively free from their interference. And I only say “relatively” because the aggressive, inappropriate behaviours of registering bodies towards midwives in recent years mean that “guidelines” like these are already in position in a de facto sense.
    We have no culture of independent midwifery in this country unlike the UK where midwives are acknowledged as specialist, not handmaidens to surgeons or sort of like nurses who get to cuddle babies. Roxon is playing games with us, the press is playing along. Meanwhile our human rights get a bollocking.
    This is what was released yesterday wrt homebirth:
    Health Ministers agreed to a transitional clause in the current draft
    National Registration and Accreditation Scheme legislation which provides a
    two year exemption until June 2012 from holding indemnity insurance for
    privately practising midwives who are unable to obtain professional
    indemnity insurance for attending a homebirth.
    Additional requirements to access the exemption will include;
    – A requirement to provide full disclosure and informed consent that
    they do not have professional indemnity insurance.
    – Reporting each homebirth
    – Participating in a quality and safety framework which will be
    developed after consultation led by Victoria through the finalisation of the
    registration and accreditation process.
    These provisions will only apply to midwives working in jurisdictions which
    do not prohibit such practice as at the date of the implementation of the
    scheme. ”
    The other points in the release around homebirth are also furphies. Roxon keeps trying to make it sound like midwives don’t report homebirths to perinatal data. They do! That’s why homebirths are in the perinatal data!
    Midwives DO tell women they’re uninsured! And once you have a moment’s contact with homebirth communities you become immediately aware of it. Of course needing a Rule around it is merely to imply that those norty midwives aren’t telling their clients they have no insurance! Surgeons are insured up the wazoo and have outcomes that make me shudder. Maybe clients should be warned about that instead?
    We have no idea about the jurisdiction stuff nor about a “framework” but again the “framework” point only serves to indicate the lie that midwives are lacksadaisical, working without reference to safety and (what is mostly true), beyond the grasp of *gasp* hospitals. Hospitals don’t actually have any goddam legal right to know anything about anyone who’s not on their premises. None! They are not medical control groups which have the right to police women in the area around them.
    Roxon has just set up a false version of what’s happening, they’ve released this crap to look like they’re doing Something and yet what have women gained? Nothing! The AMA and their fellow travellers, on the other hand, have everything done to guarantee that their desire for an ideological stranglehold over women’s right is complete.

  12. I had been fearing but very much expecting criteria to be included in any indemnity solution, so I was quite ready to start thinking in terms of how to engage with a proposal of a framework, what to lobby for – it needs to be on the evidence based end of the spectrum, and there needs to be an option for informed choice to continue with homebirth with a midwife when not fitting the criteria. And so it wasn’t till after reading your reply, blessed, that I really connected with this being new rules without being a condition of indemnity (as there still is no indemnity). So what is the framework for, apart from “midwives UR doing it rong”? It does seem like they’ve taken the step from no political will to advance homebirth midwifery, to political will to restrict homebirth midwifery, with no indemnity excuse.
    Less optimistic now.

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