Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

Thank you, Mr Speaker. It is a rare occasion that the Speaker is in the chair when I am on my feet. It will give me great pleasure to speak while you are here. We are debating today important legislation which covers several areas. Most contentious of course is how it has dealt with midwives and homebirths, and as I am the first speaker to deal with the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills since the minister’s backflip on Friday I will be able to make some remarks on that. But firstly I will deal another aspect of the bill, the PBS and MBS access for midwives and nurse practitioners, which is included as part of the maternity services review which this government has undertaken. It is one of the many hundreds of reviews that the government has held since it came to office, particularly in the area of health, where it has had more reviews than days in office so far.

The coalition’s view is that there needs to be a more holistic approach to health care in Australia, especially in the areas of preventative health and chronic illness. The skills of all health and medical practitioners should be utilised to their full potential and in accordance with appropriate scope of practice. It is important that PBS and MBS access for all professionals is carefully restricted and monitored in accordance with professional qualifications and experience. Of course we are very fortunate in Australia to have a high-quality healthcare system. It has its challenges, particularly with state-run public hospitals. There are many challenges in all states at the moment, particularly in my home state of South Australia, and in regional areas such as mine it is a very challenging area of government policy, one where the state governments are clearly not up to the task. I note that the Rudd government, since coming to office and prior to being elected, have promised that if the states do not achieve certain benchmarks or certain standards they will take a full takeover of the health system to the Australian people. Whether that is the right or wrong approach, it will be dealt with at some other time; however, it is worth noting that their approach to that promise has been reduced since they have come to government and realised how challenging this area of policy is. The buck appears not to have stopped anywhere.

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

Ms Hall interjecting

Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

The member for Shortland is garbling something. It is important that there be appropriate guidelines for scope of practice ensuring patient health and the economic viability of the PBS and the MBS. Referral rights for nurse practitioners to specialise may give rise to inefficiencies. Currently, GPs refer only a very small portion of patients to specialists and are best placed to make such decisions.

While highlighting some of these concerns, the coalition will not oppose this legislation. We firmly believe that GPs are the cornerstone of primary care in Australia and it is important that there is genuine collaboration between other health professionals and GPs in managing patient health care. That is a fair summary of our position, a position that the shadow minister has pursued with some vigour since he took on that role. It is a position which is important particularly in outer suburban and regional areas such as mine, where there is limited access for people to medical services in some cases. There has been a centralisation of health services over many years, and there are challenges for regional health across this country in ensuring that people have access to appropriate healthcare services for both preventative and reactive health care.

We in the opposition are supportive of the government looking at these issues, but we do think it is getting to a point where the government need to start taking some action to fulfil some of the promises they made—which is, of course, what they are meant to do. When it comes to healthcare services in Australia, when the government promise that the buck will stop with them and they do not fulfil that promise, people have every right to be disappointed. The realm of health services also includes the aged-care sector, which in my electorate and also across a range of electorates around the country faces significant challenges.

That brings me to the other and more contentious aspect of this legislation, which is at the other end of the healthcare services spectrum, and that is homebirth. I think it is a disgrace that the government have handled homebirth in the way they have in this legislation. They are reducing choices for women. Not long ago I actually wrote a blog for The Punch about the whole issue of birthing and government putting its nose where it is not welcome. I suspect that is the best way to describe it. My wife and I were fortunate, with both of our children, in having very safe and happy births. We used a private obstetrician for both of them, and the services were first class. It is always very saddening to hear about stories of births that do not go so well, and it is a credit to the medical profession that, in the modern day, the rates of infant mortality are so much lower than they used to be. However, as a parliament I think we need to realise that birthing is a very personal and individual experience. For my wife and I, it was a very deep experience with the babies, and I think it is dangerous when governments start to intervene and restrict how that experience can be conducted, and that is exactly what this legislation seeks to do.

On Friday, the Minister for Health and Ageing performed a backflip, and she is seemingly allowing two more years for consideration of the homebirthing issue. I suspect that it is more of a bureaucratic battle with the health department and insurance rather than the actual health aspects of homebirthing, given that state governments run homebirthing services already. I suspect it is more the insurance angle, rather than the health aspects, that the government is trying to grapple with. I think that creates a very unfortunate situation, where the government has tried to outlaw something—by putting a significant fine on it and therefore outlawing it—because, it appears, it is beyond their wit to deal with what is mainly an insurance issue. As I said in the blog that I wrote in The Punch, it is a very poor excuse to send something underground, which is in effect what will happen, because there are a group of people in our community, even though it is a small percentage—

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

Ms Hall interjecting

Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

Currently it is able to, Jill. The member for Shortland says that is what the problem is currently. What your health minister has done in this legislation, Member for Shortland, is to try and make homebirths illegal. The Labor Party believe that government knows best and you can tell that to all the people out the front of Parliament House who have come here today to protest—the people the Labor Party will ignore, at their peril. Ultimately the individual knows best. Birthing is a very personal thing, and if the Labor Party try to tell women of Australia how they are going to do it, they will find that it is not a very practical or popular decision in the long run.

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

Ms Hall interjecting

Harry Jenkins (Speaker) Share this | Link to this | Hansard source

Order! I remind the member for Shortland that, as of yet, there are no interventions in this House. Even though that might lead to a better debate—and I am sure the member for Mayo would be able to handle interventions—at this point in time it is not allowed. The member for Mayo has the call.

Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

It is, I think, a good indication of the nervousness or the sensitivities on the other side to this issue, given the minister’s decision on Friday.

James Bidgood (Dawson, Australian Labor Party) Share this | Link to this | Hansard source

Mr Bidgood interjecting

Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

It would be interesting to know whether the member for camera shots on the other side, who interjects, went to the rally at the front of Parliament House earlier to explain to his constituents

James Bidgood (Dawson, Australian Labor Party) Share this | Link to this | Hansard source

I know more about homebirths than you’ll ever know.

Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

I am sure you do. You have probably taken some photos of it.

Harry Jenkins (Speaker) Share this | Link to this | Hansard source

Order! The member for Mayo will ignore the interjections. The member for Mayo will speak to the bills.

Jamie Briggs (Mayo, Liberal Party) Share this | Link to this | Hansard source

Thank you, Mr Speaker, for bringing me back to the legislation. Homebirth is a very personal issue and, as I said earlier, my wife and I were very fortunate. We have had two—and my wife plans more—birthing experiences which were very fortunately positive, and we are very lucky. However, others do not have such positive experiences, and they do need the best care available. There is no doubt about that. However, to rule out access to homebirths altogether rather than dealing with an insurance issue was an ill-thought-through decision. I am very pleased that the minister has listened to the concerns. She has undertaken a backflip for a two-year period, and we hope that in that time she will be able to get her mind across how to deal with the insurance issue.

I must say that this is probably the biggest issue which has driven contact to my office since I was elected 12 months ago. We have had more correspondence and contact about this issue than about any other single issue. It is a small group of people who are involved, but they are very passionate about their right to choose. That is something that we on this side of the House support. We support women’s right to choose. It was unfortunate that the government decided not to support that right of choice. We have fought against that and we are very pleased that the minister has seen it appropriate at this point to backflip for a two-year period. We hope that in that time she will be able to get across a better way to deal with the issue of homebirths and the issue of insurance, which is attached to it, and we certainly will have more to say as far as our policy going forward.

I thought I would give a snapshot of the emotion which is attached to this issue. A constituent of mine, Amy Sparshott, wrote to me again on Friday—she has written a couple of times. I think she describes the issue very well. She says:

Homebirth is not something that many women choose for themselves; however, it is important that women continue to have access to this choice of care. The South Australian state funded homebirth programs run from hospitals are a start but are not accessible to most South Australian women due to the strict guidelines and small geographical catchment areas.

My electorate of Mayo is not covered at all. The letter continues:

Midwives in private practice are experts in normal birth. Their skills will be lost once they either cease to work as midwives or find they have to work within a hospital system that is geared towards finding complications and introducing interventions during labour and birth that are not often needed.

That brings me to another reason for homebirths. There is, of course, choice but there is also circumstance. A couple of the ladies who have come to see me about this issue have said that they would never go back to a public hospital because of the experiences they had. So the government can slap a $33,000 fine on this and ban it outright—as the member for Shortland appears to want—but that will push these births underground and it will reduce access to the high-quality professionals that these people need, because they are going to do it anyway. Some will argue, ‘That is not taking much care of the unborn baby,’ but I do not think that is a fair characterisation of what these mothers and fathers are going through. The experiences they had in these public hospitals were so horrific that I can understand why they do not want to go back. It is only right and fair that they be able to choose another option which suits their needs better.

This is a very private and personal experience. It is a very important experience that many of us go through and enjoy. To tell someone that they cannot do it their chosen way because of an insurance issue is weak. It is right that the minister has backflipped, and we hope that she continues to. I support the sentiments of what Amy Sparshott, Joe Woods and others who have come to see me have said. It is about choice, but it is about choice for their reasons—whether it be the experience they have had previously in a public hospital or whether it be that they feel more comfortable to give birth in the home environment, it should be their choice.

The issue of care and responsibility for the unborn child raises its head in this debate. The situation is that homebirthing is not for everybody and few people choose it. There is no doubt that there are certain cases where homebirthing should not be undertaken—on medical advice—but I defy anyone to tell me that mothers and fathers would deliberately put their unborn babies at risk. It is quite an accusation to suggest that people would willingly put their unborn babies at risk and not think through the consequences.

We are very pleased that we have been able to get the minister to back down from the original intention of the bill, which was to outlaw homebirthing. It is as clear as day that slapping a $33,000 fine on midwives for assisting with homebirthing clearly rules that out as a possible option. We are glad that the government have backed down on that, because it would have sent homebirths underground, it would have reduced choice and it would have been a negative move for females in this country. We stand on the side of choice. We stand on the side of females being able to choose the healthiest and most appropriate way for them to give birth. We are glad the minister has backed down so far on this and we hope that she goes even further.

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

I would like to commence my contribution to this debate on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills by providing the member for Mayo with some information that might help him, so that next time that he makes a speech he can actually put factually correct information to the House. I have in my hand a letter from one of my constituents who wrote to a local health fund. This constituent is a midwife and is a person who is very supportive of homebirthing and somebody I have had a long association with. She wrote to a health fund asking them why they had removed homebirthing from the schedule that they paid insurance rebates for. Oh, the member for Mayo has left the chamber. He did not want to learn or get the information that showed that what he presented to this House was factually incorrect. The letter reads:

Thank you for your response to my inquiry. You have stated that the removal of the homebirth benefit is due to the fact that midwives in private practice are unable to source professional indemnity insurance for the homebirth of a baby.

And this is the really key point—

This has been the case since 1 July 2001

Who was in government then? That has been the case since 1 July 2001, when those opposite were in government. Those on the other side argue that they have supported homebirths for a long period of time—so how could it be that it was removed from medical indemnity insurance when they were in government? I find it sickening to see those on the other side of this House standing up and advocating homebirthing when they were the ones who removed it from medical indemnity insurance. They have never supported choice for women. They have always adopted a very patriarchal approach to birthing and other women’s health issues, where they feel that they have the right to tell women what they need and what is best for them. I hear speaker after speaker after speaker stand up and advocate homebirth, and that is really out of character for those on the other side of the House.

I have been associated with midwives in my electorate for a very long time. I have attended picnics on the foreshore in Newcastle with midwives where they advocated homebirthing, and I stated my support for homebirthing in that environment. It was many, many years ago—around 2001, I believe—when the then government decided that they would not offer medical indemnity insurance for midwives.

Listeners to this debate could actually be confused as to what it is about. They could think that this was a debate about homebirthing; that is not true. This is an excellent piece of legislation that supports the inclusion of nurse practitioners and appropriately qualified midwives under the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme in line with the 2009-10 budget measures. This will enable these health professionals to request appropriate diagnostic imaging and pathology services for which Medicare benefits may be paid and to prescribe certain medicines under the PBS. The MBS and PBS benefits will be available from 2010.

The professional indemnity, which has been discussed at great length and which I will come back to in a moment, will commence on 1 July 2010. Medicare benefits and PBS subsidised medicines will not be approved for delivery outside of clinical settings. The Commonwealth subsidised professional indemnity cover will not respond to homebirthing but, as has already been said in the debate today, an agreement was reached at the COAG meeting on Friday.

I heard the previous speaker refer to ‘backflips’. I would like to refer him, and all those members on the other side of this House who are not in the House now, to statements made by the minister consistently through this debate that there were negotiations taking place between the states and the Commonwealth and that this matter would be resolved. I refer to the communique that was released on Friday, which says:

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.

That is a far cry from what happened in 2001, when the Howard government removed that coverage from midwives. Professional indemnity insurance for midwives has always been quite an issue. I refer to the paper I have in my hand, from Australian and New Zealand Health Policy, which discusses the issue at great length—how Australian governments, particularly the Howard government, I have to say, appeared reluctant to protect the economic viability of the business of self-employed midwives. This legislation does give some protection to midwives, as does the agreement that was reached on Friday.

The government has committed $120.5 million over four years to maternity service reforms and $59.7 million over four years to expand the role of nurse practitioners. I might add that those on the other side of this House have always opposed the expansion of nurse practitioners. As a member of the House of Representatives Standing Committee on Health and Ageing over a very long period of time, I have seen many members on that side argue that nurse practitioners take away from the role of doctors. Last week I was in the Torres Strait Islands with the health and ageing committee and we visited Saibai, which is nearly the northernmost tip of Australia. There we saw firsthand just how vital the role of a nurse practitioner is, how essential it is for nurses working in very remote and rural locations to be able to work as nurse practitioners. They are delivering front-line services with doctors, hundreds or thousands of kilometres from where their health clinics are. That is the case in many areas throughout Australia. Mr Deputy Speaker—sorry, Mr Speaker; it is such an honour to have you in the chair.

Harry Jenkins (Speaker) Share this | Link to this | Hansard source

I am not sure where this flattery is going, but the member for Shortland will continue speaking to the bill.

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

Thank you. I have been a member of the health and ageing committee, as I mentioned, for some period of time. I was deputy chair when we brought down the report The blame game: report on the inquiry into health funding. When we did that inquiry, we looked extensively into the role of midwives and nurse practitioners. It has been my long-held belief that legislation like the bill we are discussing and debating here in this House today was needed. I did not see any moves from the then Howard government to act on those recommendations or to address that need.

In 2007 I was a member of the committee and we did an inquiry into the health benefits of breastfeeding, called The best start: report on the inquiry into the health benefits of breastfeeding. That inquiry really emphasised to me the vital role that midwives play, how their role needs to be expanded and how they need to have the rights that are being given to them in the legislation that we are debating here in the House today. It is a midwife who provides the support to a mother during pregnancy. Obviously, there is a very important role for obstetricians, but some women choose to have only a midwife’s support. After the birth is when a midwife provides the particular support that is needed in relation to breastfeeding. To hear those on the other side of this House sanctimoniously stand up and make the case that they support choice, they support midwives and they support women really turns my stomach.

I will get back to the legislation. This bill will support the inclusion of nurse practitioners and midwives under the Medicare Benefits Scheme and the Pharmaceutical Benefits Scheme, which is particularly important for those midwives who work in remote locations like Saibai Island and Thursday Island, as I mentioned earlier. These measures will help improve the efficiency, capacity and productivity of Australia’s health workforce, particularly in rural and remote areas, and it will make it so much easier for those nurse practitioners and midwives working in remote communities. When I was at Saibai Island last week, the nurse practitioner midwife there said that within the last month she had been required to assist in the birth of three babies whose mothers had come across from the Western Province of Papua New Guinea. Those births can be extremely difficult, and in those cases the excellent, highly qualified midwife can provide the assistance that is needed until the medical assistance of an obstetrician can be brought in.

These measures are vitally important for improving primary and maternal care. This legislation will allow nurse practitioners and advanced midwives to work in collaboration with doctors. I use Saibai Island in the Torres Strait as a very good example of where the skills of these midwives will be utilised. The new Medicare items covering these services will also be introduced, effective 2010. Specific Medicare items as well as PBS formulas specifying midwives and nurse practitioners will be managed through the minister’s determination. At this stage the government is not supporting funding of homebirthing. I have already referred to the communique that was released, and I can also refer to the transcript of the minister’s press conference on Friday, where she highlighted that there had been a breakthrough in the national registration and accreditation program. This has led to the resolution of the homebirthing issue. I hear people like the member for Mayo getting up and saying it is a backflip. It is not; it is the result of a lot of hard effort put in by the minister, who has worked constructively with the state health ministers to bring about a situation where this can take place. The Commonwealth signing on to the registration of the accreditation of 10 professions is about lifting standards, as the minister said. That is what it is all about.

I think this legislation has the ability to change the way nurse practitioners work. I should emphasise that, though I have talked a lot about those nurse practitioners working on Saibai Island, to a large extent it refers to nurse practitioners and midwives working in private practice. I felt the example of Saibai Island really showed how effective it was on the ground. In many areas throughout Australia there are no doctors on the ground. The simple fact that there are qualified midwives in those locations can really provide support that is needed. These midwives will need to meet advanced practice requirements and have collaborative arrangements with doctors. This is all about providing and ensuring the safety of those women who are giving birth and of their babies.

The reforms initiative supported by this legislation will allow for incremental reform with a strong framework of quality and safety. Quality, safety and being able to choose to have midwives and nurse practitioners when the time is right are what the Australian people should expect. It is expected that about 700 eligible midwives will participate in the measure over the next four years, so that will significantly expand the workforce and provide a lot of support to women throughout Australia. I have to emphasise that none of these bills have ever sought to make homebirthing unlawful—

Ian Macfarlane (Groom, Liberal Party, Shadow Minister for Energy and Resources) Share this | Link to this | Hansard source

That’s not right, is it?

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

yet those people on the other side of this House have said these bills are about making homebirthing illegal. Unlike the Howard government, we have not removed that professional indemnity that was in place.

I have to refer back, for the member who is going to speak following me, the member for Groom, to the fact that midwives not having medical indemnity insurance has been the case since 1 July 2001. What government was in power then? The Howard government. A large number of members on the other side of this House were members of the Howard government and I presume they supported that move, and now they sanctimoniously stand up in this parliament and argue that choice is being taken away by this legislation when in actual fact, through the hard work and the strong negotiating skills of the minister, we are in a situation where for the next two years there will be medical indemnity insurance. An agreement was reached on Friday and ongoing discussions will take place from there.

I would really like to congratulate the minister. This is groundbreaking legislation. This is legislation that does support choice for women. It is legislation that is not about telling women what they have to do but rather about providing choice. It is about recognising both nurse practitioners and midwives, and acknowledging that they have a significant contribution to make to our health system. I commend the bills to the House.

Ian Macfarlane (Groom, Liberal Party, Shadow Minister for Energy and Resources) Share this | Link to this | Hansard source

I listened carefully to the member for Shortland, but I must admit that at the end of the allocated time I was none the wiser as to whether she is actually a supporter of homebirths or not. What has been lacking in this debate all along—

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

Ms Hall interjecting

Ian Macfarlane (Groom, Liberal Party, Shadow Minister for Energy and Resources) Share this | Link to this | Hansard source

She interjects. She says she is. Well, why didn’t she say so in her speech? Why didn’t she come out and say to the midwives—

Jill Hall (Shortland, Australian Labor Party) Share this | Link to this | Hansard source

Ms Hall interjecting

Ms Anna Burke (Chisholm, Deputy-Speaker) Share this | Link to this | Hansard source

The member for Shortland has had her time, and the member for Groom will not provoke interjections.

Ian Macfarlane (Groom, Liberal Party, Shadow Minister for Energy and Resources) Share this | Link to this | Hansard source

I will not provoke, Madam Deputy Speaker, but I was interested in the answer because the member for Shortland claims now, after she has delivered her speech, that she is a supporter of homebirths. She said in her speech that she went to a rally a few years ago. If that is so, why was she so silent when the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills were introduced to the House? Why didn’t she, and every other member of the government sitting over there who say they support homebirths, speak up and say there is a flaw in this legislation, which couples homebirths to state registration requirements?

This government was on the verge of banning midwives attending homebirths, committing women to a situation where if they ask a registered midwife to attend then that midwife could not only face a massive fine but in fact be deregistered and lose her right to her livelihood. So where were all these people six weeks ago, before the minister did a massive backflip on Friday, before the minister changed her position to where she should have been? Where were all those people? Where have they been for the last six weeks? Why weren’t they speaking up? All those people who support choice, all those people on the government side who speak up for women’s rights—where were they on this issue? They were nowhere. They were silent.

The Minister for Health and Ageing changed her position last Friday because of the pressure that came from this side of the chamber, because of the pressure that came from those thousands of midwives who are standing out there in the rain as we speak. They went quietly to the minister for health. They said: ‘There is a flaw in what you are proposing. Because of the link to registration at a state level, there is going to be a problem in a registered midwife attending a homebirth.’ And what did we get from that side? Silence. They thought they could bluff it out. They thought it would not be an issue.

They should have been on the planes this morning, when babies and mothers—pregnant mothers, in some cases—were flying down here because the only time this government, this Prime Minister and that minister listen is when women go and stand in the rain, supported by their partners, to get a voice in this House. That should never be so. We need to see a more understanding government. We need to see a more compassionate government. We need to see a government that understands the detail of its own legislation. It took the minister nearly two months to realise the problem that was explained to her in words of single syllables by the midwives of Australia. They immediately knew that there were clauses in this legislation that were going to be a massive problem for midwives who operate in Australia.

Can I say categorically that every woman has the right to choose where she has her baby. It may not be the choice that my family makes. The birth of our two daughters is not something I would want to go through again. I know they say it is a wonderful experience, but the birth of our first daughter lasted 16 hours. It was not what you would call a quick delivery, and that daughter has been late most of the time ever since! Our second daughter was a little quicker, but it is not something that I would like to go through again. It was a wonderful experience and something that certainly leaves a memory, but whether my wife had decided to have those babies in hospital or whether she wanted to have them at home was, in the end, her choice. Whether my daughters make that choice, again, is their choice. But there are women now who are making that choice.

In my electorate, one birth in 15 is a homebirth. That is a staggeringly high statistic, for a whole range of reasons—lifestyle; experiences, perhaps with one birth in a hospital; personal beliefs. Whatever the reason, women need the right to have that choice. They need to be confident that if they make that choice they will then have access to the best care possible. As it originally stood, this legislation removed that right. It took away options that would have allowed women to make that decision or, more dangerously, to put them in a position where they would have to have a baby without a registered midwife. Imagine a government that says they care about the rights of individuals forcing women underground to have babies in seclusion, away from all the medical help. And do not think that they would not. There are some women who will do what it takes, as they say, to have their babies the way they want. In that situation the mother’s life, and the baby’s life, are being put in danger.

I am grateful for what the minister did on Friday. She has taken, as the member for Shortland said, an incremental step, but she has not come up with the solution. She has provided two years breathing space. That is not a solution. That smacks to me a little bit of, ‘Let us get this on the other side of the next election before we make a decision.’ That could be a cynical comment. I hope it is, because I hope the minister is committed to fixing this problem because she has not fixed it yet. She has said that you do not have to have indemnity insurance if you are a registered midwife attending homebirths. That is no solution. Everyone knows—and the Howard government started this process—that indemnity insurance is critical to protecting the professionals who operate not only in the medical area but everywhere. We as a government recognised that there would have to be assistance in some cases in paying those premiums. That is just the way the world is. No-one likes it, no-one believes that it should be this way, but that is the reality. A civil case now can amount to millions of dollars of damages and for a midwife often—in fact, in virtually every case—that would mean the complete destruction of her or his business.

As we move forward, firstly dealing with the whole area of obstetrics, the Howard government took steps to ensure that we filled the first major holes of assisting in indemnity insurance. I am not going to stand here and say that we got it right. What we did we got all right. We did not make a mistake. We did not exclude anything. We did not say to doctors, ‘If we provide assistance to you for your indemnity insurance you cannot do this or you cannot do that.’ We are not into specifying to professionals who know better what they should and should not do. There are other mechanisms for that. I do accept that we needed to go further, and in the fullness of time we would have. That baton has now been passed to the Labor government. As I say, I acknowledge that in this area, particularly for midwives and nurse practitioners, the government has introduced a number of very important pieces to this legislation: for instance, the right to request certain diagnostic imaging and pathology services, the right to prescribe certain medicines under the PBS, a new Medicare item and referrals under the Medicare benefits schedule for midwives and nurse practitioners working in collaborative arrangements with doctors. The bill goes on to cover a range of areas in regard to assisting with insurance and providing a tender process for indemnity insurance. There are within this legislation that we are talking on today provisions for the imposition of run-off cover support payments as a levy on insurers’ midwife professional indemnity insurance premium income—all good things that this side of the House supports. We support midwives. We support the work that they do. We see them as incredibly important.

I turn to my seat of Groom and my city of Toowoomba. Toowoomba is a very fertile place. In fact, in October last year it was shown to have 2.07 babies per woman over the preceding three years. The state average happened to be 1.92. I am sure it has got nothing to do with cold nights or anything else. We just see ourselves as living in a very fertile part of the world, both in growing crops and also babies. But, as I said, the interesting statistic that was not in that article and that has since surfaced is that one in 15 mothers chooses to have a homebirth. That is the principle that the coalition has forced this government to recognise: every woman has the right, whether they live in Toowoomba, in Canberra, in Nimbin or in the Riverina, to choose where they have their baby. Every woman has the right to choose whether or not they attend a hospital for the birth. This legislation, as it stood, undermined a woman’s right to choose how she would experience childbirth and limited her ability to decide what was in the best interests of her own body, her unborn child and her family. The minister knows that that is the case. That was proven by what she did on Friday. She accepts now that, through the link of state registration and the requirements of state legislation, she was taking away a right. She has not fixed it yet, and I guess our role between now and the next election is to ensure that she does not just prevaricate on this issue but actually gets down to doing something about it.

We need to ensure that women not only have the right to choose but have access to the very best of medical care when they do choose to have a baby at home. They need to have access to a fully registered indemnified midwife who can collaborate both with other midwives and with all the other doctors and obstetricians within the health service to ensure that that baby is born in absolute safety and is born in an environment to the choosing of the parents, particularly of the mother. If the mother decides to have the baby at home, then so be it. We as a parliament and we as a country should provide the support for a woman who makes that decision.

I must admit that when this debate about midwives started, around three years ago, I was not as passionate as I am now. I have always believed in the right of individuals to choose. That is a fundamental Liberal right. It used to be a fundamental Labor right, but they have stepped away from it. I believed that women could do what they chose to do—in fact, in my family they did anyway. I needed, though, to get my mind around the issue of homebirths. Coming from my background, slightly conservative, and from a family that, on my father’s side, has a history of birthing problems, I found the idea of homebirths certainly rang some alarm bells. That is when Liz Wilkes, who is not only a local midwife but also the national president of Australian Private Midwives Association, started coming to my office regularly to change my attitude towards homebirths. What she has done very successfully—not emotionally but very professionally—is to outline the facts relating to homebirths: the experiences in other countries, the process that takes place when a woman decides to have a baby at home, and the fact that, along with her right to choose homebirth, a woman should have the ability to make the right decision about every aspect of that birth—that is, that the baby be born not only in a home environment but in such a way that there is virtually no risk to both mother and child.

I acknowledge the work that Liz Wilkes has done, particularly in the last six months, to ensure that this legislation as it was originally framed did not pass this House and that concessions were gained from this government. Those concessions still have some distance to go, but people like Liz Wilkes and members of the midwives association right across Australia have brought this government to account and made it see the error of its ways. Just to make sure of that, the midwives association has also assembled the thousands of women out there in the rain today—women who will not be taken for granted on this issue.

This is not just about those women who want to have babies at home; it is about men and women who believe in the right of choice. They are the people being represented down there in front of Parliament House today: people who believe that women have the right to choose. We on this side believe that, but I sometimes wonder if those on the other side still do. It seems to me that their voices have become muted since they got into government. It seems to me that all the people who used to speak so freely when they were on this side of the chamber suddenly have been forced to toe the line. I will be interested to hear whether those who are left to speak in the debate speak up in support of the midwives who are assembled down there.

It seems odd to me that, with so many women and so many men who support the rights of women sitting on that side of the House, not one Labor member spoke to the midwives assembled on the lawn at the front of Parliament House. That says to me that perhaps they are not fair dinkum. I hope, as we go forward with this legislation, that I am wrong. The Senate will provide further information through its inquiry, which had over 2,000 submissions, a record number. Two thousand submissions should have been enough to tell the government that something was wrong, but they were not. It was not until those women prepared to assemble down there, started to book their flights and to travel to Canberra last week, that this government actually decided to do something about it.

The shame of all of this is not that a disaster almost occurred in the formation of this legislation; it is that professional men and women who are midwives have been distracted by the flaw in this legislation for the past six weeks. They have spent more time on this, in some cases, than they have on what they want to do, which is to deliver babies for Australians. This government needs to fix the problem. This government needs to ensure that women have not only choice but access to the full broad spectrum of birthing options when they deliver their babies. That is what this country is all about. It is what we who sit on this side of the House are all about. We believe in women having the right to choose. We do not believe in shutting off options that are safe. We believe that the government does not have to regulate everything to the point where it is impossible for people to deliver their babies in their own home.

I will be following this debate closely as we go forward from here. If those on that side of the House want to have any credibility in this matter they should be down there talking at the rally. They should be speaking up in this chamber. They should be saying to the people of Australia: ‘We realise there was a problem. We are going to fix it. We have not just deferred this for two years to get it on the other side of the election. Let’s fix it now. Let’s see the numbers from the health minister, see what it will cost and what we can do to fix the problem.’

Melissa Parke (Fremantle, Australian Labor Party) Share this | Link to this | Hansard source

I speak in support of the three bills before the House in this cognate debate: the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009.

There is widespread professional support for these bills and much community interest in them. They institute changes that have long been anticipated and that are greatly welcome. Yet in the way these changes were initially framed there were some consequences that, while not in themselves part of the bills’ overt purpose, were nevertheless of deep concern to some in the community, including within my electorate. These were the consequences for independent midwives practising homebirth deliveries.

I am extremely happy to say that, as of last Friday, 4 September, a solution has been found. So it is that in speaking to these bills I congratulate the Minister for Health and Ageing both for the reforms the bills represent and for acting so quickly and decisively to achieve a commonsense solution to an unintended consequence of the reform matrix. As with the adjustments made by the Deputy Prime Minister to the youth allowance reforms, this is another example of a government that is set on achieving the positive reform agenda it was elected to implement, but without the hubris or the arrogance to believe that its efforts cannot be further improved by listening to the community or by reasonable negotiation with its parliamentary colleagues.

At the outset, I think it is useful to set out a short history of some broad health system issues in Australia in relation to these bills. In the 2007 election campaign, the Australian Labor Party said we would consider a more expansive role for the skills and experience of suitably qualified health professionals, such as nurse practitioners and midwives. We also indicated our commitment to improved health services for women and children, including those in rural and remote areas. These commitments were informed in part by a 2006 Productivity Commission report in response to longstanding concerns about shortages and inflexibilities in the Australian health workforce. Key issues for the commission were: first, the critical need to increase the efficiency and effectiveness of the available health workforce and to improve its distribution; and, second, to develop a more sustainable and responsive health workforce whilst maintaining a commitment to high-quality and safe health outcomes. The commission also recommended the creation of a single national registration board for the 10 professional health occupations in Australia, including nurse practitioners and midwives.

In response to the Productivity Commission’s recommendations, the Council of Australian Governments resolved in March 2008 to devise and implement a new national registration and accreditation system to commence operation in July 2010. A core element of the national scheme is a condition that all registered health professionals carry professional indemnity insurance. Queensland was given responsibility for legislative development and enacted initial legislation in November 2008. An exposure draft of the second piece of legislation proposed for jurisdictions was released by the ministerial council in July 2009 and it addresses the nuts-and-bolts issues of accreditation and registration.

Parallel with those developments, and as a key step towards delivering the government’s commitment to a national maternity services plan, the minister charged the Chief Commonwealth Nurse with responsibility for a detailed investigation of maternity services—the outcome of which was published in February 2009 under the title Improving maternity services in Australia: the report of the maternity services review. Finally, earlier this year, the Rudd government gave life to this health reform agenda by providing a four-year, $120.5 million budget commitment to improving maternity services together with $59.7 million over four years to expand the role of nurse practitioners.

That brief summary of what has gone on before brings me to the bills that we are considering here—bills that give legislative effect to the government’s commitments. The first of the bills extends both the Medicare Benefits Scheme, MBS, and the Pharmaceutical Benefits Scheme, PBS, to participating eligible midwives and nurse practitioners so they can access or provide Medicare subsidised services, prescribe certain medicines and refer patients for diagnostic imaging and pathology. In the case of midwives, these measures resonate with recommendation 17 of the maternity services review, while in relation to nurse practitioners the government is legislating to further enhance the practice scope of these important health professionals. While nurse practitioners can already prescribe in most jurisdictions, their new access to the MBS and PBS will be a significant development and improvement. These are historical firsts for Australia. They are very significant measures indeed. They are measures conceived to enhance the efficiency, capacity and productivity of our health workforce, especially in rural and remote areas, and so they are measures that are consonant with the findings of the Productivity Commission report.

Now I want to touch briefly on the issue of professional indemnity insurance for midwives. This is the driver of the provisions in the second and third bills before the House. It is a great shame that there is no private sector insurer who will currently provide cover for midwife-led birthing. This constitutes a significant problem for both the registration and the accreditation of midwives and therefore in implementing an expanded role for midwives within maternal health services The maternity services review concluded that ‘lack of professional indemnity insurance will inhibit the expansion of collaborative models of midwifery care’ and it addressed the defect in recommendation 18, which called on the government to provide a subsidised insurance scheme for midwives operating in collaborative team based models. That is what is accomplished by these bills. They establish that scheme—a scheme that will be accessible by midwives practising in collaborative, team based models in clinical settings as recommended by the maternity services review.

But now, in the context of these positive developments, I want to acknowledge the strength of feeling and also the administrative difficulties that surround the issue of homebirth. As it originally stood, the model preferred by the maternity services review was one that excluded midwife led birthing in the home by virtue of the fact that the insurance scheme established under the legislation was not able to be extended to midwives who practice in the home. Last Friday, as part of a joint communique that emerged from the Australian Health Ministers’ Conference, a medium-term solution to this problem was announced. I can say in this place that it was an announcement celebrated in my electorate of Fremantle. At the conference, the health ministers agreed that the National Registration and Accreditation Scheme legislation would include a transitional clause providing an exemption through to June 2012 for privately practising midwives who are unable to obtain professional indemnity insurance. Requirements to access the exemptions include providing full disclosure and informed consent that they do not have professional indemnity insurance, reporting each homebirth and participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration accreditation process.

As noted by the health minister when the changes were announced, there will be more data on homebirthing, and there will be a process to work further on protocols that will either bring more homebirthing services into our public system or potentially open the way in the future for an insurance product to be extended to cover them. This is a fantastic, commonsense result and it will give comfort to midwives and families around the country.

On this point it is worth considering what the maternity services review actually said about homebirth:

While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time. It is also likely that professional indemnity cover support for a Commonwealth funded model that includes a homebirth setting would be limited, at least in the short term. It is likely that insurers will be less inclined to provide indemnity cover for private homebirths and, if they did provide cover, the premium costs would be very high.

One does not have to read too far between the lines to conclude that the issue of homebirth was a very difficult one for the review. It observed:

In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.

That view notwithstanding, there is an adamant and passionate minority of women who regard homebirth with a private midwife as their preferred birthing choice. I think their views are well illustrated by some words in a report released for the Western Australian Department of Heath in August 2008, entitled Review of homebirths in Western Australia. It had this to say:

It seems apparent that the maternity systems are, for some women, too medicalised and restrictive and do not meet their needs.

It also noted:

… developing systems to support safe and satisfying systems of care that provide childbearing women with a diversity of options is essential.

I recently met an impressive woman who is a very experienced, independently-practising midwife in my electorate of Fremantle—Sally Westbury. She told me that she is very supportive of the government’s initiatives in the area of midwifery. She sees them as a great step forward and feels she could be part of an incremental process of improvement, even if she cannot herself access the insurance scheme. After all, she has worked for many years as an independent midwife without such insurance and all her clients take on her service in the full knowledge that there is no insurance. She has relied on her judgement, her expertise and her commitment to sound professional practice. As a result of the exemption announced last Friday, Sally will be able to continue to provide those services, and the important choice that her services represent. As Sally pointed out to me, this is especially significant for women in regional, rural and remote areas who are not able to access community midwifery centres because of geographic restrictions on those services.

I want to say something on behalf of all those who have written to me and visited me—whether they be midwives, clients of midwives, couples who have chosen homebirth or maternal health practitioners who support independent midwives and the women they minister to. All these constituents of mine are committed and passionate people—they are people who care about health outcomes for themselves and for their families; they are people who have clear and substantial reasons for choosing homebirth; they are people who, in some cases, choose homebirth as a result of traumatic birthing experiences in hospitals; and they are people who care about choice as a matter of principle. I support all those people—my constituents in Fremantle—and I join with them in congratulating and thanking the health ministers, who have found a way to allow independent midwives to continue supporting those women and families who choose homebirth.

It should be noted that there are well-established independent midwife schemes in NZ and Europe. I understand that in New Zealand the independent midwives are covered by the comprehensive no-fault insurance scheme that applies there. Perhaps in the longer term there is something in this for Australia to consider.

I know that a significant number of women, even though they are in the minority, have chosen and continue to choose homebirth. I know they want that right of choice to remain. I know too that many women who do not themselves opt for homebirth nevertheless support the right of other women and their families to choose it.

On this issue we should recognise that there are other birthing choices, such as elective caesarean section deliveries, that are available to women even when there is no strict medical case for this kind of birth intervention. What is even more important is that we do not make the mistake of assuming that homebirth is necessarily a less-safe option than a hospital birth. I am aware that many people begin their approach to the question of homebirths by making that assumption, and I refer those people to the report undertaken by the Western Australian Department of Health in 2008, entitled Review of homebirths in Western Australia. It states:

For the years 2000-2006, the total perinatal deaths for babies born of all gestations was not statistically significantly different … between the planned homebirth and hospital birth groups.

Indeed, the perinatal mortality rate, or PMR, was 10.08 per 1,000 planned homebirths and 11.93 per 1,000 planned hospital births across that period. There were no perinatal deaths in the planned homebirth group for the years 2006 and 2007. Homebirth represents a tiny minority of all births but it is an important and valid birthing option, both personally and medically, and one that should be supported within the broader structure of our health system. I support these bills because they have been conceived to do good and they will deliver positive change. They are widely supported in the professional nursing and midwifery community, and they are reforms that are long overdue.

Alex Hawke (Mitchell, Liberal Party) Share this | Link to this | Hansard source

I rise today to support the thousands of women who have turned up to this parliament to protest, not to celebrate, the government’s proposed changes in this legislation that is before us today. The member for Fremantle gave a dry account of the bureaucratic processes of government, but I think she did outline a fantastic case as to why the health minister has got this legislation wrong and indeed ought to reconsider the position of the government in relation to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009.

The health minister has temporarily reversed her position on midwives in terms of homebirths. What we see there is an attempt by this government to acknowledge that they have indeed got it wrong. It is the case that only 0.2 per cent of births in Australia at the moment are homebirths. That is a very small proportion of births in this country, and yet when you look around the world the proportions are much, much higher. In the Netherlands, it is 30 per cent; in New Zealand, seven per cent; in the United Kingdom, 2.7 per cent—and this has been rising since 1988; in Australia, of course, 0.2 per cent; and in the USA, 0.6 per cent.

So I find it hard to understand why the government would introduce legislation which proposes that midwives who are present at a homebirth are engaged in some sort of criminal activity—and that is what it would become under this legislation. There would be a $30,000 fine, which is an odd signal to send to a professional midwife with their experience and their talent. I have met many midwives. Midwives who attend a homebirth would suddenly be guilty of a crime. I think this overlooks a series of very serious factors, including the fact that homebirths have been conducted throughout the centuries as a matter of course in human nature. And yet today we have only 0.2 per cent of births in Australia conducted in this fashion.

I cannot understand what problem the government is trying to solve. Of course the government says that this was an unintended consequence of this legislation. Indeed, it is the case that many midwives and nursing practitioners do support a national registration scheme. This is progress. Providing for the indemnity of midwives is a very important matter and something which all members in this place would agree upon. However, when you consider how small a fraction of births homebirthing represents, why exclude this category of activity from the legislation? Indeed, why then go further and say that homebirthing would become a crime under this legislation and midwives who were engaged in it would be guilty of a crime when it is a valid choice for an expectant mother to make?

I have had mothers from my electorate approach me and they are very passionate about the reasons why they may choose to have a homebirth. I find their reasons to be quite acceptable. The majority of people would also find those reasons to be quite acceptable. Sometimes it can be that they have had a very bad experience in the hospital system. I find that to be a valid argument. There are people who go through the hospital system who have genuinely bad experiences. Therefore, it may be the case that a person feels more comfortable in taking a homebirth option.

If you look at all the experience around the world, the argument that homebirth is somehow more risky does not seem to bear any significant weight when it is examined. In the United Kingdom, the largest study of its kind found that, for low-risk women, giving birth at home is as safe as doing so in a hospital with a midwife. The UK has a very workable scheme in place, which I think the government here ought to examine in relation to this legislation. This report did raise the issue of hospital transfers and noted that once complications arise after birth then the issue of transferring into hospital becomes more serious. But the experience of the midwives is such that, when a complication arises, they are the best placed people to determine when hospital care is needed. But, at the time of birth and in the arrangement of birth, there is no difference between hospital care and homebirth care, and that is the experience in the modern practice of this activity.

Therefore, it is mystifying that the government has taken this approach. I think it is very valid for people to be concerned and for women to be here today protesting outside the parliament in support of this. I get the sense that most people in the community accept that there ought to be this choice and that it is valid for a person to choose to have their own midwife present at their homebirth. Not knowing a lot about this topic and having spent time with experienced midwives who visited me, I can tell you I felt a lot more confident about it. Hearing from the women who had been through multiple homebirths with no complications reinforced to me the idea that there is just the same level of risk. When we consider that this is such a small fraction of all births, I cannot understand what the government is afraid of in relation to providing for extra indemnity insurance protection for this category of birthing. We have not heard any good arguments to date in relation to that matter. It may be something for the government to introduce as talking points so that their backbenchers could read them out for us, and then we may have an understanding as to why they specifically would seek to exclude homebirthing from professional indemnity insurance for midwives.

One of the government speakers, the member for Shortland, lamented the Howard government’s approach to this area, but we know that, if you look back in time after the collapse of HIH insurance, the availability and affordability of insurance in Australia went through a complete and utter overhaul. The member for Shortland ought to be very careful about saying that the Howard government did not support homebirthing because all the types of insurance available had to be re-examined and redefined after the collapse of that major insurer within this country.

Today I do not wish to speak for too long in relation to this topic except to record my absolute support for the right of a woman to have choice in her birthing options. In this case, the government needs to seriously re-examine its legislation because of the backflip that we have seen in the last week, saying that they will delay this by two years. The member for Fremantle described it as a ‘medium-term option’. Two years is not a medium-term solution to this problem. It is a very short-term solution. It puts at serious risk the professional and experienced midwives who attend homebirths. For them to then say to mothers, ‘I do not have insurance,’ and therefore raise a spectre of doubt in relation to their activity is, I think, an unacceptable outcome. I do not think this is a medium- or short-term solution. I think we need to look at something better.

If you look at the data or the facts from around the world, with such a small minority of women taking this option up in Australia, the government ought to seriously consider extending professional indemnity insurance to this field of endeavour—of course along properly conducted lines and of course with due examination of a register of women who are professional midwives. I think all members accept the need for those qualifications and that level of scrutiny but I do not see this as a major policy challenge. I do see this as a deep flaw within the government’s approach in relation to these bills in front of us and I would ask that the government seriously reconsider its position in relation to this legislation.

Tony Zappia (Makin, Australian Labor Party) Share this | Link to this | Hansard source

I too rise to speak in support of theHealth Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009. This package of bills provides the government’s response to the maternity services review, which I understand considered some 900 submissions. Just before I get onto my remarks on the bills, I will just say in respect of the comments previously made by the member for Mitchell that, even if he believes that the Howard government did not do the wrong thing in not providing professional indemnity insurance to midwives back in 2001 and even if he believes it was simply a case of an HIH debacle, the government had some eight or nine years after that to correct that particular anomaly and, in fact, chose to do nothing. For members to then come into this chamber and say the government ought to do it now raises the question: if it could be done and it was practical for it to be done, why didn’t they do it? They had so many years to do so.

These bills are important legislation because they respond to the Rudd government’s maternity services review. That review was undertaken because there were clearly flaws and problems in the birthing services throughout this country. It was not undertaken just to fill in time; it was undertaken because this government recognised that we could do things better, that we should do things better and that it was time that we did things better. These bills collectively go a long way to in fact doing things better when it comes to birthing throughout Australia.

The bills deliver on the government’s commitment of $120 million over four years to maternity services reform and $59.7 million over four years to expand the role of nurse practitioners. These bills do not make homebirthing unlawful. Importantly, following an agreement reached on Friday, 4 September—only last Friday—between the federal health minister and state health ministers, an exemption will apply until June 2012 for privately practising midwives who are unable to obtain professional indemnity insurance for homebirthing. June 2012 is not two years away; it is almost three years away. It gives ample time to the industry, the government and the state governments to look at what other measures need to be put in place. Three years is not insignificant, and I believe that it is a welcome move on the part of the federal health minister and the state health ministers working together. The exemption will enable homebirthing midwives to continue to provide their services in jurisdictions where that is currently allowed. The exemption comes with conditions requiring full disclosure by midwives that they do not have professional indemnity insurance and consent that each homebirth be reported. Those are reasonable and appropriate conditions to apply in order to get that extension until June 2012.

In summary, these bills implement three key measures relating to eligible nurses and midwives. Firstly, the bills support the inclusion of nurse practitioners and appropriately qualified and experienced midwives in the Medicare Benefits Schedule. Secondly, the bills support the inclusion of those same nurse practitioners and midwives under the Pharmaceutical Benefits Scheme. Thirdly, eligible nurse practitioners and midwives will be able to secure professional indemnity insurance under a government professional indemnity insurance scheme. I note that these measures have the support of both the Australian Nursing Federation and the Australian Nursing and Midwifery Council. I also note that the measures I have just referred to do not generally apply to homebirthing and that there has been some concern expressed by some sectors about that aspect. I understand that some state governments provide varying degrees of support for homebirthing. I also accept that there will be occasions when homebirthing will be a necessity. Overwhelmingly, however, births take place in a hospital because that is where the medical support services are available for both the mother and the child if a complication arises during the birthing.

I am aware that there has been some concern and some opposition to these bills because, as the measures contained within them do not apply to homebirthing, mothers wrongly believe that they are being denied choice. I just want to speak about the issue of choice, because it is an interesting matter. I ask those people who talk about choice: what choice does the newborn child have in the birthing and what rights should that child have? On other matters, I frequently hear members opposite talking about the rights of the newborn or unborn child. Today I have not heard one single member opposite talking about the rights of the newborn child. I accept and respect that mothers have choice, but I think that as a society we should also accept and respect the fact that the newborn child should have rights. If the newborn child is not in a position to express those rights then we collectively, as a society, also have an obligation and a responsibility to that newborn child. It is my view that every newborn child should have the right, wherever possible, to the best birthing services available at the time.

To quote Dr Andrew Lavender, President of the Australian Medical Association in South Australia:

Home birthing may appear to be an emotionally fulfilling option, but history has revealed it as clearly more dangerous for babies and mothers than birth in a hospital.

Current advocacy for home birthing fails to mention that even in highly selected cases—where the birth weight of the baby exceeds 2,500 grams and pregnancy exceeds 37 weeks—the mortality rate for babies is double that achieved in hospital.

It’s impossible to predict or safely manage birth complications such as an impacted shoulder, impaired oxygen supply to the baby, or massive haemorrhage in the home. The safest place to be is in a hospital.

Dr Lavender goes on to say:

Home birthing is a dangerous choice, which pays no regard to the rights of the unborn child to a safe and healthy birth with the best care available.

I am not a doctor and I am not prepared to make judgment on these matters, but I am prepared to say that if the President of the Australian Medical Association in South Australia—who, I assume, speaks on behalf of his profession—makes those statements then we should take note of them.

Enabling nurse practitioners and eligible midwives to prescribe necessary and appropriate diagnostic services or pharmaceutical products will not only ensure that mothers and newborns can be provided with better medical care but free up doctors, most of whom are already working long hours. It is also my view that it will give deserved and long overdue recognition to the nursing and midwife professions. The professional indemnity provided under the bills is essentially a government backed scheme whereby, for any claim between $100,000 and $2 million, the government will pay 80 per cent of the claim and, for claims above $2 million, the government will pay 100 per cent of the claim. Under those circumstances, it seems to me that all taxpayers would expect the government to minimise its risks by not covering homebirthing if the hospital option is available. It seems to me that this cover would not be feasible or affordable if homebirthing had been included.

In 2006, the latest year for which figures are available, there were 269,835 births recorded in Australia. Of those, 97.3 per cent took place in a hospital and two per cent took place in a birthing centre. Only 708 were recorded as deliberate homebirths, which is approximately one-quarter of one per cent of the total births in Australia for the year. What was particularly notable in those figures was that in that same year 886 mothers had intended having a homebirth but 178 of those, or one in five, needed to birth in a hospital, highlighting just how frequently complications arise with birthing. The South Australian government’s Children, Youth and Women’s Health Service estimate that every year around 50 women in South Australia choose to have planned homebirths. Homebirthing is by no means unlawful under these bills, and I understand that the minister is continuing to work with the states and territories on this issue following the meeting and agreement reached last Friday. However, the maternity services review did not recommend that mothers who choose homebirthing should expect the rest of society to bear the additional financial risks that come with it.

I take this opportunity to give special recognition to the Zonta women of Australia, especially Zonta women of the Para District Zonta Club in Adelaide, for the extraordinary support the members provide to midwives, nurses, mothers and babies both in Adelaide and overseas. The club has taken a special interest in supporting birthing services provided at home and abroad. Over the years club members have made and donated hundreds of beautiful baby quilts to local families in need of support. Their support for Third World countries comes through the provision of birthing kits that the club members fund and organise for distribution. Such simple kits can make so much difference to ensuring a much safer birth for mothers and babies in parts of the world where both maternal and infant mortality rates during childbirth are high. This program commenced in 1999 with the provision of 100 kits to Papua New Guinea. Zonta have since distributed in total 340,000 kits to 30 different countries in the Asia-Pacific and African regions. They have worked in partnership with 40 organisations including, since 2004, the federal government’s overseas development organisation, AusAID.

This project, which started small, has grown into the Zonta Birthing Kit Foundation, which runs community development programs where the local government or community establish their own midwifery training programs with the hope that eventually they will source, supply and make their own birthing kits. These kits make such a difference to the health and wellbeing of mothers and children in Third World countries, and I applaud the ambition to educate and empower the local communities to provide their own care and own birthing kits. This level of support and empowerment is a great example of a local community working to assist less fortunate mothers and babies who do not have the same access to maternity services and support covered under this legislation.

I would now like to elaborate on the further support and recognition for nurses and midwives that arise from this legislation. My own state of South Australia has been a leader in the provision of maternity services by midwives and nurse practitioners because of the Alternative Birthing Services Program, which was established in the early 1990s. Birthing units now operate at three of Adelaide’s hospitals—the Flinders Medical Centre, Lyell McEwin Hospital and the Women’s and Children’s Hospital. The consequence of this is that South Australia has a much higher proportion of births in birthing units—around seven per cent annually, compared to a national average of two per cent. The federal government’s maternity services review report found that demand for birthing units is growing. This legislation provides the support that midwives and nurses need to meet this demand from expecting mothers for birthing unit services. As a consequence, we should see the proportion of birthing unit births in other states rise to be closer to that in South Australia.

The organisations representing nurses and midwives have been very outspoken in their support for this legislation. On 13 May, the day after these measures were announced in the federal budget, the Chair of the Australian Nursing and Midwifery Council, Professor Mary Chiarella, said:

The Rudd Government and Minister for Health and Ageing, the Hon Nicola Roxon have shown their support and understanding of the contribution that nurses and midwives can and are making to the health system.

       …         …         …

In responding to the Maternity Services Review the Rudd Government has provided greater choice for women in maternity care by providing MBS and PBS for eligible midwives. It also supports midwives in being able to provide women with greater choice through a Government-supported professional indemnity insurance scheme for eligible midwives.

The secretary of the Australian Nursing Federation, Ged Kearney, said:

This represents a new era of health care and is a landmark reform of our health and hospital system.

She also said:

These changes will boost frontline healthcare across the community and make sure that those people who receive health care from nurse practitioners and midwives can do so without facing huge out of pocket expenses.

The support of these key industry organisations for the changes in this legislation shows that the Rudd government has gone about its reform of maternity services in the correct way. As part of the review the government consulted widely with all key stakeholders and the community. The report from the review was made publicly available in February 2009, before these changes were announced in the May budget. The reforms in this legislation will provide greater support and recognition for midwives and practitioners. They will meet the increasing demand for families to utilise birthing unit services. These reforms, arising from the recommendations of the report of the maternity services review, will mean Australia has a stronger and more equitable health system. Rosemary Bryant, Australia’s Chief Nurse and Midwifery Officer, said in her foreword to the review’s report:

There is a clear role for leadership by the Australian Government in concert with the state and territory governments to ensure that Australian women and their babies are provided with the best possible care.

I agree with the sentiments of Rosemary Bryant and I believe that the measures in this legislation are a significant step in creating a health system that provides the best possible care for Australia’s mothers and their newborn babies. I commend the legislation to the House.

Joanna Gash (Gilmore, Liberal Party) Share this | Link to this | Hansard source

I rise to speak to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and cognate bills in the interest of supporting freedom of choice for women. Whilst I applaud the move to expand the role of nurse practitioners and midwives, I cannot support the government in its long-term plans to exclude those who wish to assist in homebirths from the compulsory national registration and accreditation requirements, effectively disallowing the practice. It is pleasing to see that the Minister for Health and Ageing, Nicola Roxon, has recognised that she has made a big mistake on this issue in the past few days and offered some hope to homebirthing mothers and experts by allowing a two-year exemption from indemnity insurers for privately practising midwives, but it does not go far enough. While this does give the government two years to do its research and follow in the footsteps of other First World countries on this issue, there is still a long way to go in ensuring long-term certainty for private midwives and pregnant women.

I have been approached by many of my constituents as this debate has unfolded, who question why it is okay for a woman to choose whether she will abort a pregnancy, and how or whether she will undergo a caesarean or breastfeed, but not where she will give birth. Excluding midwives from indemnity insurance registration after a two-year indemnity period following the introduction of the national registration and accreditation in July 2010 will most certainly drive the practice of homebirth underground, with a potentially fatal risk to mothers and their babies.

Mums have reserved the right to give birth in their own home with experts they trust and feel comfortable with for hundreds of years. There is no one-size-fits-all approach to birth and the government should not legislate that there be just one or effectively make this so by putting question marks over the long-term viability of the practice and by refusing to offer Medicare support in any way. The law needs to take into account the feelings or preferences of women, who are ultimately the ones that will endure giving birth and live with the result. Over 18,000 women believe that a woman who is capable of making an educated decision about her child’s birth, and who is well aware of her options, should not be prevented from homebirthing by a well-meaning third party. This figure was found on the Homebirth Australia website, where 18,197 women have signed a petition to block the legislation that we are discussing here today.

While the number of homebirths only represents less than one per cent of all births in Australia, or approximately 700 births per year, this unique option still has a lot of support from women who reserve the right to choose, depending on their circumstances as the practice can also be quite expensive with no Medicare or private health fund rebates. Surely in this day and age of advanced skills, knowledge and technology it is possible to assist a woman in giving birth where she is most comfortable. There are several women in my area who are well qualified and who have set up their own private practice in this industry, providing a quality service to women and families in the Shoalhaven who choose personal care in their own homes. Moves to prevent these women from practising in the long term not only directly affect their business—the source of their wellbeing and passion—but also severely disadvantage the many women who would no longer be able to call on their services.

Pregnancy can be a time of intense stress and worry. Many women need the support that independent services provide, and any effort to make their experience as positive as possible is certainly worth while. In my view it is important for us to look at all the facts during this debate, as I would hate for us to perpetuate an existing culture of misinformation and a misunderstanding which often overrides the views of the very people that this legislation affects most, and that is women.

Some women may not be interested in homebirthing; I did not consider this option to be right for me. But the point is that it is a choice, a choice that women in a developed country like Australia should be entitled to. While the media has been known to focus on negative stories related to homebirthing, there is also ample research that indicates homebirth for low-risk pregnancies is as safe, or safer, than hospital births. All the facts need to be brought to the table in this discussion along with some consideration for all women, who deserve the right to go through the process of birth—a process they will remember for life—in a way they feel comfortable with.

It is actually quite alarming to me that we need to debate the legality of this age-old practice when, as I mentioned earlier, we live in an age of medical breakthrough, highly advanced technology and an accredited knowledge at our fingertips. It almost seems as though we are going backwards. If there are enough women who are always going to choose homebirth in the right situation, why are we not aiding them with the tools that we have? Why is the government leaving the door open to make things harder, as opposed to easier, for these women in the long-term, when the capability is certainly there? No one doubts that safeguards should be put in place; no one doubts that women need to be armed with the right advice and information. But, surely, providing the right resources for women instead of driving the practice underground is a better outcome for everyone involved.

The homebirth model of care has many points worth applauding: many women have reported feeling more prepared, safer and comfortable. I am not promoting it above hospital births, but I am simply pointing out that it is a viable option. This positive feedback highlights the professionalism and care provided by our nurse practitioners and midwives. I have the utmost faith in these professionals, and do not doubt their ability and judgment as the government apparently does. Some of them have helped successfully deliver homebirths for many years. We know that their representative body is extremely concerned about this legislation, warning that it would increase mortality rates, and although Minister Roxon has offered some concession the industry does need long-term certainty.

The Australian College of Midwives would like to see independent midwives exempt from indemnity insurance requirements full stop, not just for X amount of time, or would at least like to see the accreditation extended to them in the long run. This is certainly not an unreasonable request for those qualified homebirthing experts. The government does not have its hands tied: it can better equip women if it chooses. Friday’s backflip shows that the government recognises it made a mistake and, on behalf of the women in my electorate of Gilmore, I certainly encourage it to fully address the matter and not just offer a bandaid solution. The government is already showing some confidence in our Australian midwives and nurse practitioners with an increase in their powers to prescribe certain medicines, but it is treating them with contempt by leaving the door open to prevent those qualified to offer expert assistance in a homebirth from doing so.

I believe this issue boils down to several key factors that cannot be ignored. Firstly, it is about choice and the freedom to choose. Giving birth is a major event in a woman’s life, it affects her body and family for life and there are currently options for women, as it is acknowledged that one size does not fit all. Those options must remain in place for women. They can be added to as breakthroughs in research and technology are found, but never taken away from.

The second issue here is safety. There is a significant number of women who have done their research and have already decided that homebirthing is for them. They may even have been through the process before. These women are going to deliver this way whether they are supported by the government or not and qualified services must be available to them for the long term, without question, to make this practice as safe as possible and to reduce the possibility of unwanted consequences. The third point I emphasise is that our nurse practitioners and midwives are of world-class standard. Their professionalism and track record is the only reason we can have this debate today. I have every confidence in qualified midwives who are homebirthing experts and I stress the need for them to have the freedom to access the resources and services that they need. I am aware that the state Labor government has virtually made us a nanny state in New South Wales, treating the rights of mature adults with contempt, and surely any effort to assist the state government with easing the burden on its overcrowded, understaffed hospitals would be welcome.

Almost every day we read in the media stories about women who are sent home in the early stages of labour until a bed can be made available at a nearby hospital. While I would never denigrate the work of our medical personnel, I do criticise the lack of facilities provided and I certainly think that supporting other viable options such as homebirths would be in the public and government’s best interests. Not all women are happy for choices about their bodies to be left up to others, like the women I visited at this morning’s ‘Mother of all Birthing Rallies’ outside Parliament House. They are passionate about choice, as I am, and I speak for them today. I thank them for travelling from many far and wide places to be here today—it has not gone unnoticed. Well done to you all for being here. Your views have and will continue to be heard by the coalition.

Darren Cheeseman (Corangamite, Australian Labor Party) Share this | Link to this | Hansard source

I welcome the opportunity to speak on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and cognate bills. Having become a father recently, these are issues that I have given considerable thought to. It is great to see the government bringing some improved clarity and science to these issues, particularly to homebirthing and related insurance matters. It is also nice to be speaking on an issue that is at the leading edge of the delivery of health services across Australia, particularly the issue of nurse practitioners. I congratulate the Minister for Health and Ageing on these bills. Minister Roxon has shown a lot of resolve to deliver a greater level of certainty to the midwifery area and even more nerve to ensure that the rollout of nurse practitioners happens in a meaningful way. I cannot understate the importance of the role that nurse practitioners will play in the reform process in the delivery of health services right across Australia. This is indeed a very important change. In future years I think history will show that this reform was one of the most fundamental and important changes in our healthcare system.

Almost always when we make major change there is a push back within some elements of the community. The minister has stood up to this. I listened to the comments and the pressure put on by the various stakeholders in this debate. It was a real test that was passed with flying colours by the federal minister, who has taken the initiative in Victoria and nationally with these health reform bills. There are currently around 350 qualified nurse practitioners in Australia, generally working in public hospitals. I believe the role of nurse practitioners is a terrific one. It provides an important level of care, more flexibility and better integrated healthcare outcomes with our healthcare workforce. It also provides a fantastic new element to the nursing career structures and I think it will help contain costs within the Australian healthcare system. Nurse practitioners can already provide healthcare services and prescribe medications in the majority of jurisdictions around the world. However, the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill will enable their clients to access the Medicare benefits schedule and Pharmaceutical Benefits Scheme subsidised services and medications. In the budget, the government committed $120.5 million over four years to maternity services reform and $59.7 million over four years to expand the role of nurse practitioners. This bill is delivering on that commitment. These bills will support the inclusion of nurse practitioners and midwives under the MBS and PBS in line with the 2009-10 budget measures. In addition to these bills helping to drive the nurse practitioners reform issue, they will also enable the establishment of a professional indemnity scheme for eligible midwives. This is critical in supporting the new MBS and PBS arrangements that we have spelt out. The midwives and nurse practitioners bill will allow for nurse practitioners and advanced midwives to request or provide specific Medicare subsidised services and prescribe certain PBS subsidised medicines.

New Medicare items covering these services will also be introduced, effective from 1 November 2010. I think there is an important point to make in how the new arrangements will work. What we are seeking to put in place is a more effective and appropriate healthcare delivery structure that has all the proper checks and balances. Importantly, for midwives to be eligible to participate in the new arrangements they will need to meet advanced practice requirements and they will also have to work in collaborative arrangements with doctors. The minister and the Department of Health and Ageing will be working through exactly what is required and a comprehensive consultation process with midwives, doctors and other stakeholders will take place. The reform initiatives supported by this legislation will allow for incremental reform within a strong framework of quality and safety. It is expected that around 700 eligible midwives will be participating in the measure over the coming four years.

I want to go through a few details in relation to the professional indemnity for eligible midwives and, of course, to deal with the homebirthing issue. The three bills before the House improve choice and extend Commonwealth funding for a range of midwife and nurse practitioner services for the first time ever, including the provision of antenatal care in the community and attending births in clinical settings. But, very importantly, none of these bills make homebirth unlawful.

As we know, there is still a strong homebirth movement in Australia. Many Australian women and their families still take up this option. There are many women and men who favour homebirthing over the more clinical settings of hospitals. It is very important that in designing the new laws, the overall framework for midwifery, there are still choices available to women. We do not in any way want to establish a framework that makes homebirthing illegal or that drives it underground. That would be an absolute disaster in my view and most certainly might end in tragedy.

To avoid this, the Minister for Health and Ageing, after considerable consultation with state governments, has forged an agreement with all healthcare ministers around the country to add a transitional clause to the current draft national registration and accreditation scheme legislation. This transitional clause provides a two-year exemption for privately practising midwives who are currently unable to obtain professional indemnity. This clause will allow midwives who are currently practising to continue to do so, although they of course will not be insured. As most people are aware, there are currently no professional indemnity health products available for midwives working outside the state hospital system.

There are a couple of other important aspects to these bills that I think are very positive. These bills will improve disclosure and provide better information on services for users; provide better systems for collection of data, which will form the basis of future research so that we can continually refine and improve services; and provide better overall health standards systems for us to use. There will also be a requirement for homebirthing midwives to disclose fully to clients that they do not have professional indemnity insurance so that people can give informed consent. This is important and will ensure that clients are better informed about their rights and legal standing should things go wrong.

As well, each homebirth must be reported and disclosed. This is important because, in the past, the recording of data about homebirths has not been as good as what it should or could have been. There have previously been no reporting requirements. People will also be required to participate in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process. We will, for example, ask the national Nursing and Midwifery Council to provide advice on protocols for homebirthing outside the publicly funded and auspiced services.

Importantly, the collection of better data on homebirthing and the development of detailed protocols might actually bring more homebirthing services into our public system or potentially open the way into the future for an insurance product to be extended to cover them. Of course, we will have a fully operational nursing and midwifery board in place as a part of the changes that are established as a result of the registration and accreditation. So there are multiple benefits that are going to be introduced as a consequence of these bills. We are clearing up things that the previous government never got to. This has been achieved with a determined effort by the federal minister and with all governments working together to obtain an outcome that is progressive for our healthcare system.

Overall, the three bills before the House expand Commonwealth support for midwives and nurse practitioners in our community. They improve choice and extend Commonwealth funding for a range of midwife and nurse practitioner services for the first time ever, including providing antenatal care in the community and attending births in clinical settings. I underline again: none of these bills make homebirth unlawful. In fact, I believe they put in place foundations that may well lead to services of a sustainable nature with a long-term future.

The separate draft bill for the National Registration and Accreditation Scheme for the Health Professions currently carries a proposal that will require health professionals from the 10 professions covered to carry insurance as a condition of registration. This draft bill was prepared for all jurisdictions via a COAG agreement and is not yet before any parliament, but the bill goes hand in hand with some of the provisions of these bills and is another element in standardising accreditation requirements and a universally better healthcare system.

I think this legislation is very positive for my electorate. These measures will help improve the efficiency, capacity and productivity of Australia’s health workforce, but they are particularly important in rural and remote areas. As we know, many regional and rural areas struggle for GP services, and women giving birth sometimes have to travel a long way from their homes and their home communities. Whilst my electorate has recently taken some enormous strides in health service provisions under the Rudd government, as we build capacity at Deakin University’s medical school and provide a regional GP superclinic, there are still areas where it is hard to see a doctor or to get appropriate healthcare services when you need them.

These changes will help alleviate that problem. These changes will mean more people will be able to get timely medical advice when they most need it. These changes support the Commonwealth’s commitment to improve maternity and primary care services and they support the Council of Australian Governments health workforce reform agenda. These changes will also lift the standard of health care that people get in regional Australia. I commend the minister for her hard work and for her compassion in this area, and I commend these bills to the House.

Harry Jenkins (Speaker) Share this | Link to this | Hansard source

Order! It being approximately 2 pm, the debate is interrupted in accordance with standing order 97. The debate may be resumed at a later hour.