This post was first published in 2014 during a time of big changes to Australian midwifery. I come back to update the content from time to time. Adding changes rather than editing the initial text. This post offers a timeline of a shift in the way homebirth midwives are able to work. There was and is a lot of confusion about what happened, and I have attempted to make a clear and coherent summary of the changes and discuss the impact of them now, and in the future for midwifery and homebirth. There are going to be a lot of acronyms in this post, which may be new to some and familiar to others. So here is a glossary before I begin: 

• ACM - Australian College of Midwives
• AHPRA - Australian Health Practitioner Regulation Authority
• AMA - Australian Medical Association
• ANMC - Australian Nursing and Midwifery Council
• ICM - International Confederation of Midwives
• NMBA - Nursing and Midwifery Board of Australia
• PII - Professional Indemnity Insurance
• PPM - Privately Practising Midwife
• RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists

The formation of AHPRA and the beginning of the end

 Before AHPRA (pre-2010), PPMs were regulated in the same way as any other midwife; at the time, that was by ANMC. They collaborated with GPs, hospitals and other health care practitioners, referring and transferring care when needed and/or requested by women. The ACM's Consultation and Referral Guidelines were freely available online, which meant women could access them, and they formed the basis of discussions around the scope of practice and consultation/referral. Women considered the information in the guidelines and chose whether to follow recommendations or not. The midwife supported their decisions. If a woman transferred to hospital during labour the PPM could no longer act as a 'midwife', instead handing over the professional role and responsibility to the hospital midwife. This allowed the PPM to focus on the woman's emotional, physical and advocacy needs rather than on the needs of the institution. Hospital midwives are well placed to work within their environment, and they know how to deal with the obstetricians, equipment, medications, policies and paperwork. There was no indemnity insurance available for PPMs (since 2001) - so they worked without it. PPMs were employed directly by women and worked directly for women. The above factors were discussed and stated in a signed mother-midwife contract. New graduate midwives were able to set up as PPMs upon qualification and worked alongside experienced PPMs for support.

Meanwhile, organisations such as the Maternity Coalition and the ACM were pushing for Medicare funding for PPMs. I supported this in principle and still believe that the health care system should fund homebirth and that all women should have access to PPMs regardless of their financial situation. There was/is also a government commitment to increasing access to continuity of care for all Australian women.

In 2009 AHPRA was formed in order to have one National registration body rather than individual State registration boards. This was to prevent 'dangerous' healthcare practitioners from switching states to continue practising. ANMC was absorbed into this new registration body. The role of AHPRA is to register and regulate all healthcare professions, including midwifery. Each profession has a Board within AHPRA, and the Nursing and Midwifery Board of Australia (NMBA) is responsible for nurses and midwives. To understand why midwifery is so entangled with nursing in Australia, see Fahy's (2007) article An Australian History of the Subordination of Midwifery. The perception of midwifery as a branch of nursing underpins the ongoing medical control of the profession. Anyway, back to the NMBA. The primary role of the Board is to 'protect the public'; i.e. these are the people who deal with misconduct hearings and ensure midwives are undertaking continued professional development. The formation of AHPRA brought with it two key changes to PPM practice: eligibility and indemnity insurance.

Eligible midwives and Medicare access

In 2010, the 'eligible midwife registration standard' came into effect. The aim of this was to enable women to access medicare rebates for PPM care. In order to get rebates women needed to engage the services of an 'eligible midwife' [now called 'endorsed' - see below]. Note that rebates were not available for homebirth, only antenatal care, birth in a hospital/birth centre (where the PPM has visiting rights) and postnatal care. To become eligible, the midwife had to apply to AHPRA for notification and demonstrate that they met the requirements, which were:

• Current general registration as a midwife in Australia with no restrictions on practice
• Midwifery experience that constitutes the equivalent of three years full-time post-initial registration as a midwife (5,000 hours)
• Current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
• Successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
• 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
• Formal undertaking to complete within 18 months of recognition as an eligible midwife or the successful completion of a course to acquire the skills required to order diagnostic tests and prescribe scheduled medicines

It could be argued that these requirements (excluding prescribing - which is a whole other rant/issue - and the post-grad experience) merely reflect the normal scope of midwifery according to the ICM. However, in Australia, most midwives are unable to practise to their full scope due to constraints imposed by the structure of the medicalised maternity system.

The 'eligible' classification was often misunderstood, with many believing that you needed be eligible to be a PPM and attend homebirths. This was untrue, and many of us continued to work as described above, choosing not to be 'eligible' for a number of reasons. There was also an assumption that an eligible midwife was 'better' and 'more experienced', and again this is not necessarily true. For example, a midwife can gain eligibility without any experience in attending homebirths. The point of eligibility was/is for women to access medicare rebates. Not to create a separate and higher class of midwives.

Medicare eligibility initially resulted in a number of changes. Firstly, it increased women's access to continuity of care and gave them rebates for maternity care via an eligible PPM. Many midwives set up as PPMs, and midwifery group practices began popping up everywhere. Some midwives continued their homebirth practice with the additional benefit of women being able to claim rebates if they wished. Other midwives set up new practices. There were so many different ways in which eligible midwives worked, and I am not going to attempt to list them all. In my local area, maternity service options for women have increased from hospital (public or private) or PPM in 2009 to hospital, midwifery group practice (medicare rebates), non-eligible PPMs and eligible PPMs. And for those who do not want to engage with standard maternity services, there are birth workers, doulas and the option of freebirth.

However, medicare rebates came at a price...

Collaborative arrangements and medical power

In order for a woman to claim medicare rebates for care by an eligible PPM, the PPM needed to have a collaborative arrangement. The nature of this arrangement has evolved since its introduction in 2010 (see updates below).

Initially, during negotiations with AHPRA about eligibility, the requirement was going to be that the midwife must 'demonstrate' collaboration with medical practitioners and health services. This would have been easy because PPMs were doing this anyway (see above), and documentation would have provided evidence. However, the AMA and Rural Doctors Group ensured that the requirement became a signed collaborative arrangement with a medical practitioner. As usual doctors got the final say on midwifery practice. I doubt there are any midwives involved in negotiations with AHPRA about how obstetricians practice. That this signed collaborative agreement made it through despite opposition from all of the midwives and consumers at the table is a testimony to the power of medicine in these negotiations. Some midwives thought that if they secured eligibility, they could change this requirement in the future. Personally, I think they should have refused to allow medicine to control midwifery practice in this way, even if it meant walking away and losing eligibility and Medicare. Instead, the types of collaborative arrangements midwives were required to have were determined as follows: 

1. being employed or engaged by a medical practitioner or an entity that provides medical services; OR
2. receiving patients on written referral from a medical practitioner; OR
3. a signed written agreement with a specified medical practitioner/s; OR
4. an arrangement in the midwife’s or nurse practitioner’s written records

There was no obligation for doctors to collaborate. And in case there is any confusion about this, the AMA published a handy guide for doctors titled Collaborative Arrangements - What You Need to Know stating clearly that: 

If you do not want to be part of a collaborative arrangement, or you are unable to reach agreement on the appropriate terms of a collaborative arrangement, then there is no obligation to be part of one. You do not have to commit to being part of a collaborative arrangement for any particular period.

The collaborative arrangement was the equivalent of requiring the manager of Woolworths to agree in writing to allow customers to buy vegetables directly from a local farmer. Not surprisingly, getting a collaborative arrangement and, therefore, claiming medicare rebates was fairly impossible. In 2013, in response to the predictable difficulties with establishing collaborative arrangements an amendment was made to the requirement expanding the types of collaborative arrangements. In addition to a collaborative arrangement with a doctor who provides obstetric services (as above), a PPM had two further options for collaboration:

1. That she is credentialed for a hospital, having successfully undergone a formal assessment of his or her qualifications, skills, experience and professional standing. It is expected that appropriately qualified medical practitioner/s would be involved in the assessment; OR
2. That she has a written agreement with an entity other than a hospital that employs or engages at least one obstetric specified medical practitioner.

Effectively, medical practitioners, individually or via the institutions they work in, still control access to Medicare for PPMs.

Midwives were pretty resourceful, and many found ways to make this work for them and the women they cared for. However, it was very dependent upon the people and organisations providing collaborative arrangements. Because it was so complex, there was a lot of confusion and misunderstanding. For example, some believed that a Medicare-eligible midwife could not care for a woman having a VBAC. This was (is) not true. She could, just as any PPM at that time could. However, the PPM may not have been able to secure a collaborative arrangement to do so, i.e. there would be no medicare rebate for that care. However, in some cases, medical practitioners or hospitals did agree to antenatal and postnatal care by a PPM for VBAC women. Women needed to discuss options and boundaries with their individual PPMs regardless of eligibility. This was (is) part of negotiating the mother-midwife relationship.

Eligibility and collaboration remained an 'opt-in' choice for both midwives and women. Personally, I chose not to 'opt-in' because I felt that the collaborative arrangement requirements were not aligned with my philosophy of midwifery and 'with-woman' care, and I won't compromise. There were women who also felt this way and specifically wanted a non-eligible midwife or who did not want to jump through the hoops required to access a Medicare rebate (e.g. booking into a hospital). While both options were available, eligible and non-eligible PPMs, women could choose the option that worked best for them.

However, this choice disappeared in 2015 (see update below).

Professional Indemnity Insurance

AHPRA registration standards require that all healthcare professionals have 'professional indemnity insurance' (PII) for all aspects of their practice. No big deal for midwives working within the system because they are covered vicariously by the organisations they work for. But this left PPMs with a problem. There was no insurance product available for them, and to practice without insurance breached their registration requirements. Long story short, following a lot of protests and negotiations, a compromise was found. Two insurance companies stepped in with PII, and we had two products, both excluding homebirth. MIGA only provided insurance to eligible midwives and covered antenatal care, labour in hospital/birth centre and postnatal care. Medisure insured any PPM for antenatal and postnatal care only.

Because there was no cover available for homebirth, the government put in place an exemption for PII until June 2015. Not surprisingly, neither insurance company jumped at the chance to offer PII for homebirth. The NMBA published a Report on PII for Midwives (2013) which analysed the issues involved with offering an insurance product that covers homebirth with a PPM. The difficulties centred on the size of the market (ie. number of homebirths/PPMs buying the product); working out the probability of a claim; and working out the size and type of a potential claim. The report included a lot of discussion about 'risk' and 'risk assessment'. It also suggested that an solution could be to make any PII product only available for medicare eligible midwives to ensure 'confidence and certainty' within the insurance market about PPM practice. It is likely they will also dictate further requirements for cover such as women must undergo particular screening tests (bloods, u/s, etc.) and be classified as 'low risk'. These issues were already being faced in the United Kingdom by women and PPMs.

There was no official response to the insurance report from the ACM. However, the Maternity Coalition magazine included this divisive statement in relation to protecting midwives and women's choices:

Many midwives feel that they are in a vulnerable legal position. This is often because they are not doing these things [following professional standards re. scope, information giving and documentation]. If we could confidently demonstrate that homebirth midwives as a group were practising in this manner, then it would be easier to secure insurance for intrapartum homebirth care and resist the push to regulate homebirth more strictly. (Ann Catchlove)

It is the NMBA's role to regulate midwives, all midwives, including homebirth midwives. All midwives must follow professional standards, provide adequate information, and keep adequate documentation. Yes, individual homebirth midwives may fail to do this, and so might individual hospital midwives. Some would argue that information giving by hospital staff is often below the legal standard for consent. Either way, there are already mechanisms in place to hold midwives accountable for their practice via NMBA, civil law and criminal law. Indeed, considering the number of vexatious reports submitted to the NMBA against PPMs, it could be argued that the mechanisms are working too well. Unfortunately, we are never going to 'confidently demonstrate' that all midwives within any model of care or birth setting are practising in a particular way. Aligning midwifery with medicine and allowing medicine to regulate midwifery practice will not reduce risk. Evidence-based, woman-centred care will reduce risk. How about requiring all midwives to undergo a regular consumer-led 'midwifery practice review' assessing their practice against evidence and midwifery philosophy?

The Future of Midwifery and Homebirth?

We have lost sight of what is important, the essence of midwifery, being 'with woman', regardless of where or how the woman chooses to birth, or with whom she chooses to birth. Unfortunately, I think we have come too far down the track and midwifery has become entangled with medicine and the needs of insurance companies. I can't see a way out of this mess, can you? What I find most frustrating is the lack of discussion about these issues within the Australian midwifery profession. Either, Australian midwives don't know what is going on, or they agree with the changes, or they don't care, I'm not sure which.

Updates

The following are updates added to the post over the years as the situation has progressed.

March 2015 – Changing practice

Anecdotally, from my own experience and contacts, private practice midwifery is shifting. There are increasing numbers of Medicare-eligible midwives/midwifery groups, and some are gaining visiting rights in hospitals. This is great for women who want continuity of care and a hospital birth. As these midwives are increasingly 'networked' into the mainstream maternity services, they are more and more 'risk adverse', particularly in relation to homebirth. Due to vexatious reporting and the involvement of hospital staff in the care of their clients, PPMs are being very careful about what they are seen to take on and how they practice. In addition, PPMs without medicare eligibility are in decline, either becoming eligible or stepping out of practice. The result is that many women are left without the option of midwifery care for a homebirth e.g. women seeking support for VBAC.

April 2015 – Eradication of non-eligible PPMs

The government have extended the PII exemption for homebirth until December 2016. Meanwhile Medisure (Vero) announced that they are withdrawing their insurance product for PPMs (antenatal and postnatal) from April 2015. PPMs who already have insurance with them can renew up until June 2015 i.e. ending in June 2016 at the latest. This is the only product available for non-eligible PPMs. MIGA will only insure Medicare-eligible midwives. All midwives must have insurance for antenatal and postnatal care to fulfil registration requirements. Without it, they cannot practice. This move will effectively prevent PPMs from practising without medicare eligibility and reduce women's options.

June 2016 – Yet another PII exemption

It looks like the PII for homebirth will be extended for another year (again). Meanwhile, non-eligible midwives have ceased practising because the only PII product available for antenatal and postnatal care is for eligible midwives only. The ACM is attempting to get a Midwifery Practice Scheme approved through Queensland Health, which potentially could provide all PPMs with insurance cover (in Queensland at least).

June 2017 – I'm out

I've tapped out of Private Practice Midwifery, and I'm tapping out of attempting to keep up with the constantly shifting landscape of increasingly complicated regulation. The following is my personal interpretation of what I am witnessing at this point in time.

Various frameworks, policies, guidelines and standards for PPMs have been issued by NMBA and ACM, a complex web of red tape that PPMs must navigate. This web is so complex that organisations have been set up to interpret and explain all the new rules to PPMs (for a fee). I take my hat off to those midwives who have stayed the course and are attempting to provide woman-centred care in the middle of this systems-focused bureaucracy. It seems that PPMs are increasingly being forced to 'tend to the needs of the institution' rather than the women who employ them.

The regulation changes have made PPM very difficult to sustain outside of a large-scale business model ie. private group practices based in premises rather than in women's homes. Many PPMs have headed back into the public sector, unable to sustain their PPM practice. The 'gap' payments are increasing for the homebirth element of care (not covered by medicare rebates), and it is now often more expensive for women to have a homebirth than it was before medicare rebates. This has decreased access to homebirth with a PPM for many women.

Small-scale PPM's days are numbered, particularly as two care providers are required at all homebirths. In many locations, there are simply not two care providers available - e.g. in rural and remote regions of Australia - again reducing women's access to homebirth with a midwife. PPMs without medicare eligibility can now only act as 'second midwives' at a birth, but only if they are not involved in any antenatal or postnatal care of the woman. Personally, I would not feel 'safe' attending the birth of a woman who I had not developed a relationship with nor had a good understanding of her pregnancy so far.

Because PPMs are now so heavily networked into the mainstream maternity services with collaborative agreements, hospital credentialing, etc., they are very much on the radar. There will be an audit of PPMs to ensure compliance with all of the new rules - an audit that is above and beyond that of any other healthcare provider on the AHPRA register. This places midwives in a very vulnerable position. Although there are pathways that PPMs can follow to support women outside of recommendations (e.g. VBAC homebirth) they are very complicated beauracracy-wise, and are risky professionally for the midwife who may be blamed for any outcome relating to the woman's decision. This has resulted in many PPMs refusing to take on any women for homebirth who are not entirely 'risk-free' as defined by the various frameworks, policies, guidelines, etc. The aim is to protect the midwife and the business. This has resulted in many women being unable to access midwifery care. Freebirthing is on the rise as not all women will change their personal perceptions of risk and head into the nearest hospital.

I often get asked if I miss private midwifery practice and/or attending homebirths. The answer is that I miss how it was. The simplicity of being employed directly by a woman, providing woman-centred, evidence-based care in alignment with clear professional standards and the law. However, those times are well and truly gone and I just don't have the energy or time to work within the new web.

August 2023 – Successful medicalisation of homebirth midwifery

Well, it's been a while! I thought I'd pop in with a brief update since we have just had yet another government exemption for PII for homebirth. Today, only endorsed PPMs can provide midwifery care outside of institutions. The term 'eligible' has been replaced with 'endorsed'. Only endorsed PPMs can access the PII for antenatal and postnatal care required to activate the homebirth exemption. Many of the old-school PPMs have left the practice (which was a goal), and the homebirth landscape is very different.

To be endorsed, PPMs must have completed a prescribing course and completed 5,000 hours of practice. Of course, most complete those hours in a hospital setting. So, we have PPMs who are new to homebirth but indoctrinated in hospital practice. They can struggle to unlearn practices, and to escape a sense of belonging to the institutions. In some cases, homebirths are being 'managed' like hospital births, resulting in hospital outcomes. However, women are adapting to this new landscape and there is a huge rise in freebirth and unregistered birth workers. I think the homebirth community is actually growing as women reclaim childbirth outside of institutions and regulations.

So, I'll leave you with a prediction for the future of midwifery and homebirth...

The PII exemptions will continue until public homebirth programs are more widespread. Of course, these publicly funded programs are heavily restrictive and overseen by obstetricians. Most women don't qualify. They must be deemed 'low risk' and agree to all routine antenatal testing. If anything changes during their pregnancy e.g. going postdates, they will be removed from the homebirth service. PPMs will only be able to continue working if they are controlled by medicine and the hospitals they have visiting agreements with.

Once women have more widespread access (on paper, anyway) to homebirth via the public system, the exemption will be removed. Any PII available will require PPMs to follow the public hospital guidelines for homebirth (i.e. low-risk only). Therefore, PPMs will be unable to attend homebirths unless women meet particular 'low risk' criteria. The argument will be that 'low-risk' women now have access to 'safe' homebirth via the public system and heavily regulated PPMs, and women who are 'high risk' should be birthing in a hospital anyway. I hope I am wrong.

June 2024 – The end-game

We are entering the inevitable end game.

In November 2024, the requirement for PPMs to have a collaborative arrangement with medicine to access Medicare funding will be removed (after 14 years!). There was much celebration of this, and the ACM stated that Endorsed Midwives (the only remaining PPMs) 'will be able to work autonomously and independently.'

Less than a month after that announcement, we had the news that there was finally a solution to the lack of PII cover for homebirth with a PPM. When the next exemption runs out on 30th June 2025, the Australian Government has declared that it will 'cover 100% of the cost of [legal] claims for low-risk home births and intrapartum services at home'. So, there will be PII for 'low-risk' homebirths only. Therefore, a PPM attending a homebirth for a woman who does not meet the criteria for 'low risk' throughout pregnancy and labour (postdates, VBAC, 'older' mother, etc, etc, etc.) will be uninsured. Being uninsured for any aspect of midwifery practice breaches registration requirements and the law. Can you see where this is heading?

So, here we go again—PPMs and homebirth consumer groups fighting and failing to be heard in tick-box consultations about a 'proposed' change. Just like in 2010, at the beginning of this strategic takedown of homebirth midwifery, medicine will have the biggest seat at the table and the biggest voice. The fact that the ACM was not consulted or even informed of the government plans for PII for midwives speaks volumes. I don't think there is any chance that the Government will agree to cover insurance claims for 'high-risk' homebirths. Why would they? And Medicare funding is limited in general. There are many treatments, tests, and services that are not funded by Medicare. Why would Medicare fund a service ('high risk' homebirth care) that is deemed unsafe when there is a 'perfectly appropriate option' of hospital birth?

I'm not suggesting consumers and midwives lie down and give up. We need to shout about what is happening and ensure our opposition is loud and public (and the birth community is good at activism; it has to be). But we also need to have a plan B. Plan A (engaging under their terms) has only resulted in where we are now. Maybe it is time for a different and more radical approach.

For the master’s tool will never dismantle the master’s house. They may allow us temporarily to beat him at his own game, but they will never enable us to bring about genuine change. And this fact is only threatening to those women who still define the master’s house as their only source of support. – Audre Lorde

August 2024 – Hospital in the home

Medicine has effectively controlled midwifery in Australia for centuries (see this article for the history An Australian History of the Subordination of Midwifery). However, until the changes documented in this post, homebirth midwifery remained autonomous. The systematic invasion of this last strong hold of midwifery is now complete. Obstetricians (experts in pathophysiology, not physiology) lead hospital homebirth programs and participate in the regulation of PPMs.

My local publicly funded homebirth program is now up and running for women who are low risk and remain low risk and agree to all the tests and parameters required by the hospital. I am looking forward to seeing the stats regarding how many women actually end up birthing at home without intervention.

I think the words and images in this article and report say it all. This is what homebirth midwifery has become. A midwife overseen by an obstetrician as she prepares an emergency medical bag for a physiological birth (not as it would appear a road traffic accident).

The future of homebirth in Australia.