My public comment on the draft - National Guidance on Maternity Care

or as I like to call it, Sharing the Maternity Habitat.

It's a bit long, but I've been too unwell to write anything more substantial than a tweet for ages, so I thought I'd put it up. It's terrible, but the best I could do in three hours :-\

To Whom It May Concern:

I’m an over educated mother of two having two degrees and a philosophy honours. I have been interested in reproductive autonomy ever since I had to fight to get it during the births of my two children. I have maintained an active interest ever since. My activities include writing to MPs and supporting and advising friends of their rights during their pregnancies and births. My primary reason for penning this contribution is that I believe that home birth midwives are professionals in their own right and thus should have indemnity insurance etc without the rather draconian necessity for collaboration.

Details are below. I humbly apologise for any errors of expression or formatting. I’m rather busy and vague and I was reminded of this deadline today - I only started at 9.00 pm! Obviously I feel very strongly about it if I’m willing to sweep all other commitments aside to work on it.

Reading through 1.1 Collaboration in health care, I am reminded that the hospital environment has its origins in the military and still has a rigorous ‘chain of command’ environment with doctors at the top and unquestioning nurses at the bottom. I was pleased to see your acknowledgement of the current health care culture in 2.6 Mutual trust and respect:

“For maternity care collaborations to be successful in Australia, the culture in maternity services will need to change. The current lack of trust is proving a major barrier. Trust and respect must be earned, rather than just assumed (Box 2.8; NHMRC consultations 2009).”

Collaborative care challenges that culture and you are to be congratulated on your efforts in this regard.

Summary of my points

We need to be sure that the people determining what is best evidence are capable, discerning and impartial. That is, they know how to read a paper and have some grasp of statistics.

Despite assertive wording in this document to the contrary, a power imbalance will continue between doctors and midwives. That this power imbalance remains illustrates that midwives are still not identified as independent maternity care professionals.

Private midwives must be able to enter metropolitan hospitals as the birthing woman’s chosen maternity care coordinator and be able to act with appropriate authority in this position.


Box 1.2 Point 2

“Collaboration empowers women to choose care that is based on the best evidence and is appropriate for themselves and for their local environment.”

During my experience in science I found that “best evidence” is always open to debate, and often what is best evidence is dictated by those who are perceived as more knowledgeable or experienced. In this case, the perceived voice of experience is the AMA. If the people dictating “best evidence” are doctors (well meaning, but fallible, reluctant to be sued, and an amazing number of them can’t do statistics) then there will be no improvement in maternity care and women will not be empowered because they will not be fully informed. Recently, the head of the AMA used a South Australian study to show that home birth was dangerous. If one reads the research paper it is perfectly clear that he misunderstood it, and if one removes the problematic births (premature, fatal birth defects) home births are just as safe as hospital births for normal pregnancies. We need to be sure that the people determining what is best evidence are capable, discerning and impartial. This needs to be explicitly stated in the guidelines as evidence guides risk assessment policies and it is these policies that will directly affect pregnant women.

Box 1.3

“Collaborating partners are independent maternity care professionals who are actively collaborating (i.e. not in an employee–employer relationship). Collaborating partners refer women to each other as the need arises.”

Despite your emphasis on there not being an employer-employee relationship, the power imbalance between doctors and midwives remains. A doctor will not lose insurance and Medicare access if a midwife refuses to collaborate with him/her, but a midwife stands to lose all of these things if a doctor refuses collaboration. That this power imbalance remains illustrates that midwives are still not identified as independent maternity care professionals. The power relationship is the same as that of an employer/employee in this respect.

I am saddened to see the assertion repeated here in 2.3 Awareness of disciplines and autonomy:

“Importantly, maternity care professionals should fully respect each other's professional autonomy. As regulated health practitioners, each clinician is responsible for working within and to their scope of practice, as defined by their profession, and in line with their professional and organisational codes and guidelines. Maternity care collaboration does not include one profession controlling the practice of another.”

Until midwives can access insurance etc without a collaborative arrangement, these mentions are mere lip service to the idea that one profession does not control the practice of the other.

Back to Box 1.3:

“A collaborative agreement or arrangement is an informal or formal recognition of the terms of a collaboration.”

How are midwives going to qualify for insurance etc if agreements are informal?

3.3.3 Metropolitan public hospitals - Access to Hospitals

You state that “access may be problematic at metropolitan hospitals”. This is something that must be addressed in the legislation to prevent situations where the birthing woman has chosen her maternity care coordinator, but this coordinator cannot attend the patient in any meaningful way if a transfer to hospital becomes necessary.

I note that you address some of the issues in 3.2.6 Credentialing, however, I believe that the emphasis on allowing privately practicing midwives access to hospitals should be stronger. Below I emphasise my concerns regarding outcomes if a midwife is not allowed to practise at the hospital of her client’s choice.

If a privately practicing metropolitan midwife cannot be credentialed at several hospitals then this will restrict choice of hospital for anyone she cares for and 1.2.1 Definition of maternity care collaboration:

“They support the person the woman has nominated as her maternity care coordinator, and recognise clearly defined roles and responsibilities for everyone involved in the woman’s care.”

is not remotely possible. Private midwives must be able to enter metropolitan hospitals as the birthing woman’s chosen maternity care coordinator and be able to act with appropriate authority in this position. In order to act with appropriate authority they must also have clinical privilege. Clinical privilege is something that can be established during the organisation of transfer plans.

I note this also comes up in 2.1 Women centred care and communication:

“Women have the right to decline care or advice if they choose. Therefore, if a woman refuses care or advice based on the information provided, her choice must be respected. Importantly, women should not be ‘abandoned’ because of their choice (NHMRC consultations 2009). Having a coordinator of care to provide a consistent, clear point of contact is integral to this approach (NHMRC consultations 2009).”

Again, if a private midwife has appropriate authority in a hospital setting the issue of abandonment becomes null and void. I know women who have elected not to have a private midwife because the thought of being in a hospital where their primary carer would have to leave their qualifications at the door was too daunting.

3.2.7 Hospital bookings

It is my opinion as a consumer that booking into hospital ought to be compulsory, and that the hospital should be notified of beginning of labour, particularly for a home birth. Making this compulsory would facilitate communication between home birth midwives and doctors and also act as a gesture of goodwill. Even the most belligerent OB can muster some respect for a safety conscious home birth midwife.


Again, I admire your efforts to change the culture of maternity care in Australia. But I reiterate that home birth midwives and models of care need more support than they currently get in these guidelines.

Yours sincerely,