Nick Xenophon (SA, Independent) Share this | Link to this | Hansard source

I commenced my contribution last night before the adjournment and I am pleased to continue today. Essentially, this is an important piece of legislation. There is an enormous amount of debate in the community about this in terms of what role midwives should have in our health system and in the delivery of children in this country. I think it is an issue that deserves ongoing debate and close scrutiny in terms of what the government is proposing to do.

As I said last night, over the past few months I have been contacted—as I am sure my colleagues have also—by many dozens of families who want to share their experience of their pregnancy and of delivering their baby at home with a midwife. In fact there have been hundreds of emails about the trust and bond they shared with their midwife throughout their pregnancy and how safe they felt during the delivery of their child. Some have also told me that they have had previous experience of such traumatic hospital deliveries that they would rather not have another child than be ‘forced’ to deliver their baby in a hospital situation. Indeed many wrote that ultimately it is their right to choose and removing that choice is fundamentally unfair.

There is no question that homebirth and/or midwives is not for everyone, but for those who choose it, it is fair to argue that that choice should be available to them. As I understand it, the statistics show that about one per cent of births are homebirths in this country compared to about 30 per cent in the Netherlands, and I will refer to that shortly.

Similarly and scarily, I have heard from women who had a ‘normal’ or textbook case low-risk pregnancy but because of an unexpected complication during labour they almost lost their child and, but for the intervention of the hospital’s doctors, would have lost their son or daughter. I have been advised by medical professionals about the risks of delivery without an obstetrician and how every second counts and that in some instances by the time the midwife realises there is a complication it might be too late to get the mother to a hospital. However, I emphasise that that contrary position has been put to me by those who argue that homebirths are something to be avoided.

I must stress that I do not believe any mother would knowingly make a decision that would risk her baby’s life. I have full confidence that the priority of midwives is to look after the mother and baby, as is the case with the medical profession. I would hope that a mother who is considering having her baby with a midwife would do all of the research and ask all the appropriate questions to ensure that it would be a safe decision for her to have her baby without an obstetrician present. Of course, these are the sorts of questions that need to be asked about a so-called conventional delivery through a hospital model and I am sure the same would go for a mother considering delivering her baby in a hospital.

Since the medical indemnity crisis of 2001, insurers have refused to give professional indemnity insurance to midwives who attend homebirths. But from 1 July 2010 the single National Registration and Accreditation Scheme for Health Professions will be introduced, which means that without indemnity insurance it will be illegal for privately practising midwives to provide antenatal care, labour and birth support, and postnatal care to women at home. I understand and I have heard the concerns of women who fear that this will result in homebirths being ‘forced underground’, and from a public policy and individual point of view this is in no way desirable. This should not be seen as an attempt to ban midwifery by stealth. One of the roles of parliament is to establish measures that ensure the safety of all Australian mothers and their babies. This legislation, although it may be seen to be punitive against midwives, does not need to be, and I believe it does not intend to be so.

The government’s amendments to the legislation include transitional arrangements for privately practising midwives through the provision of a two-year exemption until June 2012, and collaborative arrangements are an indication of this. Again, I acknowledge the fears of midwives who argue that this may in time undermine their role and the requests of intending mothers. Once again, it must all be balanced up against the safety of mother and child. Whatever decision is made in this place I hope that Australians and midwives know that it is to ensure that there are appropriate safeguards in place so that the health of a baby and the health of a mother are protected no matter where they give birth.

In Australia, demand for homebirths is about one per cent of all deliveries nationwide. Compare this to the Netherlands, where some one in three babies are born at home. Indeed, last year a review of 500,000 births in the Netherlands revealed no difference in survival rates between hospital births and homebirths, for low-risk pregnancies. In terms of adverse outcomes that is a very telling statistic. However, it is important to keep in mind that in the Netherlands they have in place a streamlined system that allows women to plan a homebirth and to access specialist emergency obstetric care in hospital should complications arise.

Under the scheme proposed in these bills, however, midwives will be unable to access Medicare unless they are sponsored by a doctor or obstetrician, by a medical practitioner, and therefore will be unable to admit a patient to a public hospital. It is for those occasional instances where an otherwise normal, safe and supposedly predictable low-risk pregnancy becomes, at the very last minute, for whatever reason, risky for the survival of the baby that I feel I have to support these bills. Having said that, I want to stress that I do believe midwives play a very important role in our health system. The services and support that they provide make a significant difference to women and families around Australia. It is important that we recognise that individual women and individual pregnancies have individual needs. Given this, I believe an independent inquiry should be conducted into midwifery in Australia, with the key focus on safety but also addressing the demand, the cost benefits for the public hospital system and international best practice, such as the system that exists in the Netherlands. I do not think we have had a level of scrutiny of midwifery and homebirths in this country to that extent. I think there is a demand for it. I think more women would avail themselves of midwives if we had systems in place similar to those in the Netherlands and other countries.

It is interesting to note that a review of homebirths in Western Australia was undertaken for the Western Australian Department of Health in August 2008. The review team members and report authors were Professor Caroline Homer and Dr Michael Nicholl. That was a very positive report about homebirths in Western Australia. There is no reason why it would be any different anywhere else in the country. It indicated that homebirths, as practised in WA, compared very favourably with hospital births in the Western Australian hospital system. There were specific terms of reference. The first term of reference was to:

Investigate the clinical experiences and health outcomes of mothers and babies accepted for homebirth by the Community Midwifery Program or midwives acting independently in Western Australia between 2000 and 2007. As a minimum, the investigation is to include mortality of mothers and babies; and emergency transfer of mothers or babies to hospital care at any stage of pregnancy, including during the post-partum period.

I think that indicates the sort of thing that should be done at a federal level. The national health and hospitals review did not specifically look at this very important issue because the government had already undertaken a maternity services review, and that report was provided in February 2009. However, the concern that has been expressed to me by midwives and those who are advocates for homebirths is that there has not been an adequate and robust study of the benefits and risks of homebirths, integrating that into our health system and looking at international best practice, such as in the Netherlands.

Let us look further at the international experience. Midwifery became a regulated profession in Canada in the 1990s. Midwives are today the lead healthcare professionals attending the majority of births, albeit mostly in a hospital setting. There is a different attitude to the role of midwives at births in Canada. Under legal recognition, Canadian midwives have access to hospital privileges, the right to prescribe medications commonly needed during pregnancy, birth and post-partum, the right to order blood work and ultrasounds for their patients and full consultation access to their own physicians. That, to me, seems to be a sensible way forward. Many would say that the Canadian system is leaps and bounds ahead of the US health system just south of the border. In 1990 New Zealand restored the professional and legal separation of midwifery from nursing. About 78 per cent of women choose a midwife in New Zealand. That is a dramatically different statistic from here in Australia.

Midwifery is a long-held practice, going back centuries. Midwives are educated and trained providers who care for child-bearing women throughout their pregnancy, during the delivery process and in the post-partum period. I think we have not availed ourselves of the resource and professionalism that midwives can offer. The fact that so few women choose to go down the path of using a midwife says something about the structural imbalances in our health system. I do not think we have had a robust enough analysis of that, even with the report of the maternity services review. That is something that ought to be looked at.

This is not easy legislation to decide on. I am sure that I am not the only one in this chamber who has been deeply concerned about this issue. As I said at the start of my contribution, there are so many aspects and arguments to this debate. In so many ways it is not a black and white issue; there are shades of grey in relation to this. I need to support measures to ensure the safety of all Australian mothers and babies, and for that reason I give my support to this package of bills. However, I believe ultimately that the fair and right thing to do is to have an independent inquiry into this area of practice. I think it is crucial to ensure that all Australian child-bearing women have access to the best care and the most appropriate care for them, whether that is in a hospital or clinic with an obstetrician or in a hospital with a midwife or at home with a midwife. The fact that other nations, such as Canada, New Zealand and the Netherlands, and a number of states in the US, have a different approach I think indicates that we have a long way to go. I hope that the regulations that will be set up under this legislation will not prejudice midwives and will look fairly at the importance of their contribution to our health system. Until we have that robust, independent inquiry, I do not think we will get the best policy answers. So I urge the government to go through the process of an independent review, particularly during this transition period. I think that in the absence of that we will not make the best decisions for the mothers and babies of this nation. Families need to be able to make an informed choice as to what is best for them.

Carol Brown (Tasmania, Australian Labor Party) Share this | Link to this | Hansard source

I am very happy to contribute to the debate on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009, the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009 and the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009, which introduce significant changes for Australia’s nurses and midwives. These bills are an important component of the government’s maternity reform package. I would like to make a short contribution and put a number of issues on the record.

The purpose of the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 is to amend the Health Insurance Act 1973 and the National Health Act 1953 to support the inclusion of nurse practitioners and appropriately qualified and experienced midwives under the Medicare benefits schedule, MBS, and the Pharmaceutical Benefits Scheme, PBS, in line with the 2009-10 budget measures. The midwives and nurse practitioners bill will enable those 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 2009-10 budget measure also provides for the creation of new Medicare items and referrals under the MBS from these health professionals to specialist consultant physicians. The Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009 will support the new MBS and PBS arrangements by enabling the establishment of a government supported professional indemnity scheme for eligible midwives. These bills will commence on 1 July 2010.

The bills before us expand support for midwives and nurse practitioners in our community, improving choice and extending funding for a range of midwife and nurse practitioner services for the first time ever. The bills will enable patients of appropriately qualified and experienced midwives and nurse practitioners to access benefits under the Medical Benefits Schedule for improved access to maternity services and improved choice for women. The government was supported in their commitment to better services by witnesses to the Senate Standing Committee on Community Affairs inquiry into the bills, and I quote from the report:

The government’s commitment to increase women’s access to midwifery care by providing midwives with access to the MBS, PBS and affordable indemnity insurance was supported by witnesses. The Australian College of Midwives (ACM) stated:

Evidence confirms that women and babies benefit from continuity of care by a known midwife. We welcome the Minister’s recognition of this evidence and commitment to expanding women’s access to the choice of primary continuity of care by midwives in both hospital and the community.

It is fair to say that the two community affairs inquiries held into these bills, which recommended the passing of the bills, generated considerable interest. The committee received over 1,000 submissions.

It is important to note that these three bills do not take away any rights and that none of these bills make homebirth unlawful. The indemnity insurance issue as it relates to privately practising midwives—raised by community members and organisations with many members and senators—is dealt with.

I am pleased that the Minister for Health and Ageing, Nicola Roxon, announced back in September 2009 that she was able to achieve agreement from all state and territory health ministers to a transitional clause. The clause provides a two-year exemption, until June 2010, from holding indemnity insurance for privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth. This issue was raised with me prior to the transitional arrangements being put in place, and after. I am pleased to say that the women I have spoken to have supported Ms Roxon’s approach.

At a recent meeting I had with representatives from the homebirth rally on their ‘national day of action’, they agreed that the exemption approach was a positive outcome. I spoke at the homebirth rally, which was held in Hobart on 18 February. It was attended by homebirth supporters, midwives and children. I had a meeting prior to the rally with rally representatives: Ms Jo Durdin, Director, Australian College of Midwives, Tasmania; Ms Lalita Holmes, one of the rally organisers; and an expectant mother, Ms Chernov. I also have had meetings with other individual midwives and interested individuals. The rally meeting was very constructive, and a number of issues were raised at the meeting which also have been raised by witnesses at the community affairs committee hearings.

An issue of concern was the impact of the requirement for midwives to have collaborative arrangements with medical practitioners. And, as the committee reported noted and has been repeated by interested parties that I have spoken to, the concept of collaboration to ensure appropriate care for women and their babies is supported. This was echoed by the Australian College of Midwives in their comment, ‘midwifery is a profession committed to the provision of collaborative care.’ They also stated that:

… there is no argument that women choosing the care of a private MBS funded midwife must have ready access to appropriate medical care if and when the need arises for themselves or their baby.

The ACM and others saw the issue as being how collaboration is ensured. The community affairs committee noted:

… effective collaborative arrangements amongst health professionals ensures the delivery of safe and high quality care. Collaborative arrangements are at the heart of the midwives and nurse practitioners reforms introduced by the Government and thus the Committee supports the principle of collaborative arrangements in legislation.

The details of the collaborative arrangements will be included in subordinate legislation and will continue to be the subject of consultations with health professionals. The majority report from the community affairs committee believes:

This consultation is critical to the effectiveness of the process and reflects the shared commitment and professional skills focused on safe birth practice.

These bills, as I have said, are a significant step towards improving access and services. I commend the bills to the Senate.

Alan Eggleston (WA, Liberal Party) Share this | Link to this | Hansard source

I would like to make a few remarks about these bills, 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. I see the most important part as being the suggestion that there should be collaborative agreements between doctors and midwives, and I think that should occur. But I note that there has been some opposition to this from some midwives who feel professionally threatened by having to work in collaboration with a medical practitioner—one trained in obstetrics, one presumes.

It is interesting to look at the figures over the years. Since the beginning of last century we have had quite a dramatic drop in the infant mortality rate. In 1907 the infant mortality rate was about 8,945 a year, whereas today it is around 1,200. There has also been a dramatic drop in maternal mortality rates associated with deliveries. In both cases, that is largely due to the fact that most babies are born in hospitals now and children are in hospitals under medical care—that is, with medical doctors as well as midwives caring for the mothers and babies.

But the one thing that has gone up over that time is the incidence of litigation. Medical litigation in Australia has skyrocketed, and that, I would suggest, is why the idea of having a collaborative arrangement between doctors and midwives is very important and in fact essential. Litigation can occur for many reasons, often quite trivial reasons such as failure to do a test in an antenatal clinic or failure to manage complications during delivery. I think, for the benefit and protection of midwives, having a qualified obstetrician or at least a general practitioner with a diploma in obstetrics overseeing what is done will protect them from the risk of litigation which might otherwise occur. I know that many GP obstetricians have ceased practising obstetrics because of the fear of litigation and because the cost of the insurance premiums is so high that the income from the deliveries they do does not at all cover the cost of the insurance.

As I said, litigation can follow from quite trivial events, such as failing to do a blood sugar test on an Indigenous woman who might only come into a clinic once or twice before she delivers. Then she turns up at the hospital with gestational diabetes, causing a very large baby, and then has complications because it is often very difficult to deliver large babies without surgical or other intervention. If there was an adverse outcome there, the midwife might find that, because she failed to order a blood sugar test very early in the pregnancy, which might have indicated that the patient was in danger of developing gestational diabetes, she could be liable for that adverse outcome of the pregnancy.

In fact I know of a doctor who was in exactly that situation in the north-west. He saw a patient only twice during her antenatal period and did do a blood sugar test, but the patient never came back and disappeared into the unknown. But in due course she turned up in a hospital with diabetes in pregnancy and a very large baby, and there were some complications. The doctor found that his insurance had to pay out damages of nearly $1 million to that patient. So I think a formal collaborative arrangement is very wise in terms of protecting the interests of midwives so that they are not subject to unnecessary litigation, and also of course to protect mothers and babies.

I note that the AMA has supported the requirement for inclusion of collaborative arrangements in legislation. Dr Andrew Pesce, the president of the AMA, stated in the Senate committee inquiry:

If collaborative care is essential, then it must be enshrined in the legislation. It is simply too risky to say that health professionals can use their discretion as to when, where and in what circumstances they will collaborate—and that works both ways. It is essential that the primary legislation encapsulates a requirement for collaborative arrangements so that the most important goal, quality and safety of patient care, is achievable.

The midwives who have objected to the suggestion that there should be a legislative requirement for collaborative agreements have said that in some way this questions their competence. But, as the AMA President said, addressing the issue of a perceived power imbalance between midwives and obstetricians:

If there is an imbalance, I suspect that it emerges from the fact that midwives can care for a patient to a certain point and then, if something goes beyond that, they need to enlist the services of a collaborating obstetrician. But that obstetrician obviously is hesitant to just become a technician and say, ‘I will just step in when I am asked to.’ They would like to step in at the right time. So, if there is a power imbalance, it arises from the different competencies of the people who work in the team, and I do not think it is one which stems from a desire to deal with the competition.

In other words, I think most doctors are very happy to see midwives involved in delivering babies and ongoing obstetrics, but they do feel there is a point at which it may be necessary for people with a higher degree of competence, a greater degree of knowledge, to step in and manage the delivery. That requirement can be achieved and protected through having written collaborative agreements. So I very much agree with the need for these sorts of agreements.

Senator Xenophon talked about the fact that in the Netherlands there are a great number of home deliveries. That is also the case in the United Kingdom, but fewer than there used to be in that country. Of course, the difference is that in both the Netherlands and the UK the population is fairly concentrated and it is never very far from someone’s home to a major hospital where there is an obstetrics team. And in both of those countries they have flying squads to go out and pick up ladies who are having babies and get into trouble such as having an unexpected haemorrhage or obstructed labour. Unfortunately, in Australia, where the distances are so much greater, that kind of service is more difficult to set up. Again, I think it is very important in the case of rural obstetrics that these collaborative agreements with local doctors who do have diplomas in obstetrics should be set up. That would then protect the mothers and babies as well as the midwives from later allegations of incompetence and from damages being awarded for matters which could have been otherwise avoided. So I strongly support the conclusion that the Senate Community Affairs Legislation Committee reached in its report, which was that the committee ‘supports the principle of collaborative arrangements in legislation’ and:

The Committee considers that the collaborative arrangements as envisaged will enable a flexible approach to meet the different circumstances of practice across Australia, particularly in remote and rural areas.

Joe Ludwig (Queensland, Australian Labor Party, Manager of Government Business in the Senate) Share this | Link to this | Hansard source

It seems that everyone has provided their contribution on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills. I thank the senators and I table a replacement explanatory memorandum relating to the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009 and the Midwife Professional Indemnity (Run-off Cover Support Payment) Bill 2009. I am pleased today to have the opportunity to sum up debate on these bills because they do introduce landmark changes for Australian nurses and midwives.

Since the election the government has been working to boost our workforce piece by piece. This legislation is a key part of the puzzle which has already seen funding for over 1,000 additional undergraduate nursing and midwifery university places a year and funding to provide new nurse practitioner and midwifery scholarships to build the workforce for the future. And just yesterday the Prime Minister and the Minister for Health and Ageing announced a major investment to tackle the doctor shortage.

These bills deliver access to the Medicare Benefits Schedule, the MBS, and the Pharmaceutical Benefits Schedule, the PBS, for midwives and nurse practitioners for the first time in Australia. These bills will also provide Commonwealth support for indemnity insurance for midwives who, as we are aware, have been unable to access insurance since 2002. This opens the way forward for improving access to maternity services, improved choice for women in maternity services and improved access to services provided by nurse practitioners. Put simply, this recognises the skill and expertise of nurse practitioners and midwives, which is long overdue recognition, and provides better services to the community.

The government has always been clear about the fact that these arrangements will need to be provided collaboratively with other health professionals. The Minister for Health and Ageing circulated amendments that reflect this intention, and I can confirm that we will not be proceeding with the amendment on the insurance bill and I will formally withdraw that at the appropriate time. The arrangements that these bills bring in do not cover homebirths. However, they do not take away any current right and they do not make homebirths unlawful. Privately practising midwives who are unable to obtain professional indemnity insurance for attending a homebirth will benefit from an exemption from the requirement under the new national registration and accreditation scheme to hold indemnity insurance for a two-year period, until June 2012. The framework for accessing the exemption is being developed by the Victorian government and has just been the subject of consultation.

The government recognises the importance of these arrangements to midwives, women and their families around the country. It also recognises the significant time and effort put in by their representative stakeholders. The government is looking forward to continuing to develop the details of the collaborative arrangements with stakeholders and to implementing this exciting reform in the coming months. It is vital to emphasise a point which I think the opposition has now acknowledged: that to vote against this package of bills would prevent a major expansion of services to many hundreds of thousands of women and prevent the establishment of any type of indemnity insurance for midwives. The government is committed to supporting Australia’s nurses and midwives who, quite frankly, are the backbone of our health workforce. The changes in these bills are significant and are a practical step in improving access and choice for Australians. We remain extremely proud that we are providing new and innovative options for thousands of women across the country.

In addition, I can provide some response to the second reading amendment moved by the Greens. The government do not accept that amendment. We have been clear about the coverage of these arrangements, as I have said in the summing-up, and we have been instrumental in gaining agreement to a transitional arrangement in the national registration and accreditation arrangements. This means that homebirth will not be outlawed or driven underground. We will continue to work with all stakeholders on these significant maternity services reforms and closely monitor the effectiveness of the new arrangements. With these closing remarks can I again thank all the senators for their contributions to the second reading debate. I commend the bills to the Senate.

Annette Hurley (SA, Australian Labor Party) Share this | Link to this | Hansard source

The question is that the second reading amendment moved by Senator Siewert be agreed to.

Question negatived.

Original question agreed to.

Bills read a second time.