Andrew Laming (Bowman, Liberal Party) Share this | Link to this | Hansard source

The cruel subtext of this bill is that you are consigning homebirths to the underworld of health service delivery. That is the ridiculous position this legislation places us in. It will effectively do four things: one, it will oblige registered midwives to sneak off and assist with home deliveries without anyone knowing and, in so doing, potentially be reluctant to refer young mums to the hospital care they need; two, it will potentially place registered midwives at risk of $30,000 fines purely for attending a homebirth; three, it will lead to midwives not becoming registered, not falling under indemnity protection and continuing to deliver at home and at great risk; and four—worst of all—it will mean non-registered midwives operating parallel to if not in isolation from the health services.

The one thing that we know is that the best way to incorporate homebirths in an overall obstetric plan for a nation is to have them supported by a functioning hospital system. Let us remember that Australia is not the Netherlands and it is not Denmark; Australia is the second most sparsely populated country in the world. Yes, that presents certain challenges in health service delivery and it means that often mothers are not delivering just around the corner from a fully equipped hospital. As was said by my colleague Senator Eggleston, who has also worked in the area, we need to remember that in this debate about homebirthing there is a third entity involved.

At a birth there is the clinician or the helper—the doula or whoever is involved; perhaps a midwife—there is the mother and the family, and there is also the baby. Australia stands proud in having some of the lowest morbidity and mortality statistics in the world for birthing. If we look purely at the intrapartum neonatal mortality statistics for healthy full-term babies, Australia compares very well. Overall statistics for neonatal deaths around the world usually sit between one and two per thousand.

In this debate we are excluding the high-risk pregnancies—women delivering earlier than 34 weeks, breech deliveries, twins, someone with a history of normal delivery attempting a caesarean or vice versa—from analysis. What you have left are what we call low-risk deliveries. You can read the volumes; you can go right through Cochrane, de Jong and Jules, and every one of the world’s leading experts in this area say the evidence in this area is inconclusive—and I do need to note the exception of a recent Dutch study, which did have its own weaknesses—or that at best there are virtually comparable mortality statistics for low-risk children born at home.

So we all need to cool down a little bit about the safety debate, because we in this chamber have access to the best possible studies and most of them are inconclusive. I have already referred to one that showed a slightly higher neonatal stillbirth rate, but overall through these huge studies—I am talking national cohort studies; I am talking anonymised meta-analyses; I am talking the US homebirth study—we can be fairly confident that we can send the actuarial analyses out to look at homebirthing and make a dispassionate decision on whether it is safe.

Can I now approach this debate from the provider’s point of view—and I need to acknowledge, Deputy Speaker Washer, your long involvement in medicine and obstetrics. Fundamentally, providers are not out there trying to do wacky things with high-risk mums. Intrinsically, what midwives are doing, be they community midwives or working in a hospital, is looking after the mum and the baby. We do not have to fear that we will be promoting a whole lot of high-risk deliveries in the furthest corners of Australia. That is not what we are talking about. What we are talking about is making provision for mothers in Australia who want a homebirth to be able to have one.

Can I cast some light on two concerns that we have not yet mentioned. The first one—and it sounds awfully callous and very focused on cost-effectiveness—is that mums who deliver at home deliver an enormous saving to the healthcare system. That is not the pervasive consideration here, but let us remember that the thousands of dollars in bed days, the enormous risks of high-intervention deliveries—the use of forceps and vacuum extraction—and the ballooning number of caesarean sections come at a cost. The savings from homebirths would more than pay for extending indemnity to those mums who seek it and who are low-risk. We are following a common-sense approach so that we pull home deliveries into the warm embrace of high-quality, hospital-supported obstetric care. I do not think, Minister Roxon, that that is too much to ask.

I will make a second point that has not yet been made in this debate. In 1992 I walked the corridors of an obstetrics ward in Farnborough in Orpington in the UK fearful of my senior registrars, who brooked absolutely no deviation from obstetric protocols, and knowing that we operated there on a margin for error of 0.6 in a thousand deliveries. That is not a great deal of room for error. The term ‘margin for error’ sounds very clinical, but what it means is that we do not want to lose a single life. When, as you have in Australia over the last decade, you have reduced mortality in low-risk deliveries from 1.2 to about 0.8 per thousand it seems only small but it is 224 babies every year. It is an enormous number of deliveries. So it is absolutely imperative that with every delivery we are thinking: how can we maximise safety in mum and baby, No. 1?

We need a system that pulls homebirths into that view and says: what is going to work at home and what is simply too risky? I have outlined what is too risky, but quite often mums will say, ‘I can’t handle the pain anymore; can I be transferred?’ or, ‘Things are moving slowly with the dilation and in the progress of the second stage; can we transfer to a hospital? I think that common sense would dictate that if you were to provide indemnity to midwives they would simply say, ‘I accept the indemnity on the condition that I will do the following things.’

I used to be a high-risk clinician and surgeon myself—not because I was not terribly good at it but because I did high-risk operations—and I was told, ‘If you move into this clinical area you will pay more for your indemnity.’ So it is only reasonable that in homebirthing, were you to choose to deliver high-risk mothers at home or to deliver further from a hospital obstetrics unit, your premiums would rise. My point to those on the other side of the chamber is a simple one: let risk be paid for; let risk find its level in the healthcare system, as it does for every other clinician.

Think of what you on the other side are achieving in government. What you are effectively proposing here is that any clinician can practise at home except for a midwife. It is an extraordinary proposition: a doctor can prescribe and any other allied health professional can practise from home but a midwife cannot; it is all because of some confected idea that it is either unsafe, that it needs to be driven underground or, most concerning off all, that it cannot be afforded. I think that is the subtext of this legislation—for some reason they believe they cannot afford to extend indemnity across to midwives.

I want to go back to 2001 for a moment. Back in those days, when we used to work under claims incurred rather than claims made, we basically had doctors being indemnified through mutual organisations. They did not fall under APRA and they did not fall under the Insurance Act 1973. Over the nineties the gradual demand for state tort law reform, which never came, meant that premiums started to rise. Eventually clinicians had calls made upon them by their insurers to try and pay for an explosion in payouts.

Let us go back a step. There are 2,000 payouts a year. The majority of them are under $100,000. About five per cent of medical indemnity cases where a plaintiff takes a doctor to court are for over half a million dollars. Those massive cases comprise about 40 per cent of indemnity cases. So it is no easy task to be able to work out the number or the size of claims in any one year. That is why you cannot leave a small number of midwives out on their own. It makes eminent sense to incorporate midwifery with medicine and with the range of other indemnities available, as it does to include homebirths.

Back in 2001 I was flying across the Gulf of Carpentaria when I received a satellite phone call saying that United Medical Protection had gone into liquidation—that it had collapsed. That was a turning point—a lightning rod for the reform of medical indemnity, which many thought could never be fixed. This problem festered like a sore under both governments for over a decade until it was fixed in 2001, and I give credit to those health ministers and the state ministers who brought in tort law reform. What we knew was that the incurred but not reported cases had to be covered; that the ultra-high costs had to be covered; and that we needed a provision for practitioners who had retired, become ill or taken maternity leave. We needed a roll-on cover provision for those who were no longer covered. Of course in the old days it was simple: the practitioner, when they were potentially being sued, simply phoned up their insurer and said, ‘I used to be a member when the case occurred. Can you cover me now?’ And that was usually obliged. No longer.

The government stepped in in 2002 and said, ‘We need to have roll-on cover and it needs to be at a cost that does not actually make insurers unviable.’ The result again was roll-on cover that protected all practitioners, as it does to this day, even after they finished practising. That is important, as I said, because it is very difficult to determine when these cases are going to come forward and how large they will be. It is impossible to forecast how litigation changes over time. Cases that may not be prosecuted now may well be in years to come. It is very challenging for insurers. But we know that a study has been done—the actuarial analysis of covering homebirths has been done but has not been released by this government. It is truly disappointing that we cannot actually have informed debate of that actuarial analysis of homebirths.

What has become more important than anything for mums in the last two decades, if I can make an observation firsthand, is the emergence of perinatal testing, neonatal evaluation and birthing plans in the suite itself. Can I say that the one strong signal that was always there for me as a clinician was, when that mum was sitting there, often surrounded by family, in those final moments of labour—and they are often of course forgotten in that miasma of celebration when a healthy baby arrives—just how important it is to adhere to that birth plan. Families go to great trouble to develop them, and I recognise hospitals in this country for making sure that they are carried out to the nth degree for mums. We know that by doing that we improve the odds of a successful second stage. Reducing stress often means a more successful labour, less need for surgical and other forms of medical intervention, and less pain relief. That has always been the banner flown high by supporters of homebirth—that, no matter what study you look at around the world, the degree of intervention and the need for pain relief is far lower. A mother is far more likely to have a normal, uncomplicated delivery when birthing at home. We tend to take our focus away from that and shift it onto neonatal death and stillbirth, issues which are still very difficult to prove. One thing is clear: the importance of delivery at home for mothers who choose it—for mothers who are mentally ready to deliver at home and who actively seek out that kind of service.

I can see people thinking, ‘Would that be me? Would I choose to deliver at home?’ The thing is that Australia is a nation of choice. But we have a government taking the choice away. I cannot put it any more simply than that. Delivery at home should be a right. We have the hospital service that can support it and we should be fighting hard to make sure that indemnity is extended to the low-risk deliveries cohort. Of course we need provisions for high-risk deliveries. I acknowledge that. We may have to look at ways to achieve that in a large nation like this. But let us not become the first country in the world to effectively liquidate, to effectively airbrush away or to effectively snuff out the right to deliver at home. For those who choose it and know they can do it successfully, and for the professionals who make it as safe as it is anywhere in the world, we on this side of the chamber stand up for the rights of women to decide.

Arch Bevis (Brisbane, Australian Labor Party) Share this | Link to this | Hansard source

This has been a very interesting debate to listen to on the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and related bills. I think there have been a number of very good contributions made on both sides of the chamber. Indeed you yourself, Mr Acting Deputy Speaker Washer, are someone who is well regarded on both sides of this chamber, for a lot of very good reasons not least of all being your expertise and judgment in matters to do with health. A lot of the debate, perhaps understandably, has focused on homebirthing—and I too will be making a comment about that. But before I turn to that I think it is important to recognise that this bill contains very significant positive improvements in the recognition of midwives.

If you listened to much of the debate from many of those opposite, you would have the impression that this bill somehow attacks the standing of midwifery in this country. Nothing could be further from the truth. This bill is a significant advancement in the recognition of midwives and providing them with access to the necessary support mechanisms to enable them to do their work. This is a bill which has been crafted after a good deal of consultation, and I want to congratulate the Minister for Health and Ageing, Nicola Roxon, on her preparedness to engage in very extensive consultations, across her portfolio but particularly in respect of this bill, with those engaged in the birthing process.

The maternity services review which she oversaw had more than 900 submissions, and that is an indication of the interest in Australia in the laws governing the arrangements for birthing. But the bill contains major acknowledgements of and improvements for midwives. For the first time, it will grant access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme to provide benefits for services from eligible midwives. This has been a major issue for many in this section of the health industry. Like, I suspect, most members of this parliament, I have had regular and longstanding discussions with midwives in my electorate, with mothers in my electorate and also, in a related sense, with breastfeeding mothers, and in some cases there is an overlap. Some of the people who come before you to talk about these issues of access to midwifery are also engaged in activities associated with the Breastfeeding Association. I think it is a substantial recognition of the importance of the work of midwives that this bill will ensure access to medical benefits and also to the Pharmaceutical Benefits Scheme.

The bill also sees a government supported professional indemnity insurance scheme for eligible midwives being put in place. The previous speaker, the member for Bowman, concluded his contribution here by referring, quite rightly, to the problems that occurred with the entire professional indemnity industry—and indeed the insurance industry as a whole—after 9-11. Those of us who were in this place at that time, and indeed those who were in one of the professions affected, realised that indemnity insurance was becoming unattainable. It did not matter whether it was indemnity insurance for a midwife, a doctor or a lawyer, or if it was some small town country hall that the CWA wanted to operate. To get indemnity insurance of any kind was a major obstacle in the aftermath of 9-11. It is a serious issue and a complex issue, and this bill addresses many of the problems which confront midwives which are associated with that issue. It does not address all of the problems, but we should acknowledge that it does address many of them.

Importantly, the government has also committed to extra scholarships both for GPs and for midwives, and that is going to expand the maternity workforce. That is going to be a benefit for all Australians. As the member for Brisbane, in an inner city area, I want to acknowledge that I think it is going to be of particular benefit to those in rural and remote areas who presently do not have the sort of access that many of my constituents do—who invariably have a choice of hospitals, a choice of specialists and a choice of midwives. This is an important improvement in genuinely providing access and choice for women in many parts of Australia.

Providing access to the Medicare Benefits Schedule, the MBS, and also the Pharmaceutical Benefits Scheme, the PBS, for nurse practitioners is going to cost somewhere in the order of $60 million over the next four years. That is a substantial commitment from this government to ensure those new procedures are put in place. That is going to improve the flexibility and the capacity of Australia’s health workforce and it is going to improve patient access to services that in the past would not have been available. The government is also committed to providing eligible midwives with access to those two schemes for the first time, expanding choice for women, at a cost of some $66 million over four years. These are substantial commitments.

I was a bit annoyed, I have to say, at some of the contributions from those opposite, who tried to focus on other areas that for 12 years they took no action to fix and, in the process, ignored the improvements that this bill does make. There can be no question that the commitment this government has made and the provisions that are in this bill and in this budget are a dramatic improvement in ensuring the availability of midwifery to more Australians than would otherwise be the case.

In the second reading speech, the Minister for Health and Ageing said:

At this stage, the Commonwealth is not proposing to extend the new arrangements for midwives to include homebirths.

That has been the focus of a good deal of comment from a number of people opposite. Understandably, the nature of debate in this place tends to mean that we focus on the things we disagree about rather than the things we find in common, but it is nonetheless a serious issue. I have had a number of meetings with constituents in my electorate concerned about the homebirthing option and I think there is genuine cause for concern. We need to look at some additional adjustments to ensure safe, viable homebirthing options are available. At the moment, homebirthing is done at some financial risk to the midwife engaged in the activity. It is not as though the current system is a desirable final outcome.

I received a letter from one of my constituents a month or so ago that I think puts the case that many have put to me, and it puts the case quite well. I want to read a couple of paragraphs from that letter. My constituent said:

The intersection of this legislation with the national registration and accreditation of health professionals from July 2010 will prevent registered midwives from attending homebirths. I believe this to be an unintended consequence and ask that you, as my representative, take steps to ensure home birth remains a viable option.

Interestingly, she then referred to the experiences of some of her friends. It draws, I think, a useful comparison. She said:

Two days ago a friend of mine gave birth via a planned—

that is, from conception—

elective caesarean section. Her first child’s birth some seven years ago caused her great psychological distress. She grappled with depression and her desire to have more children for five years before finding an obstetrician who would provide her with an elective caesarean birth, giving her choice and control.

She has now experienced two planned caesarean births in 18 months with the same care provider and is a very happy woman. Society has supported her choices through taxpayer funds for surgery, hospital stays and by indemnifying her health carer.

She went on in her letter to say:

Next Friday, the wife of an employee of my husband will give birth by a primary planned elective caesarean section for no medical reason. It’s their first child. She doesn’t like the idea of labour and vaginal birth so she found an obstetrician who would support her right to the birth she wants. As a society we support her right through taxpayer funds for surgery, hospital stay and possible special care nursery for her baby and by indemnifying her carer. Any day now I’ll give birth too. All going to plan my baby will be born at home, as my daughter was eight years ago. I will be attended by two registered midwives. While currently society accepts my right to birth at home, I am not supported by taxpayer funding, nor are my midwives indemnified. And yet I’ll save those same taxpayers thousands of dollars.

She concluded by saying:

Women should be at the centre of their care and hold primary responsibility for the decision making. It’s not that the baby is unimportant or doesn’t have needs, but no-one has a greater interest in a healthy baby and a happy outcome than the pregnant woman herself.

I share those views. I think she has quite fairly put the case and drawn the comparison from her own personal experience. And I think it is time that we recognised in Australia the validity and importance of homebirthing. The sort of statistics that the previous member spoke about, which I have to say the people who have come to lobby me have also inundated me with, do demonstrate that there is a lot of empirical evidence to support the view that homebirthing in most circumstances, under proper supervision, is no more a health risk than birthing in a hospital environment. For some of us that may seem an alternative that we do not wish to consider and that is fine. But it is clear that homebirthing is very much the option that some women choose, and choose very strongly. Indeed, I have met with women who have had homebirths and who are now pregnant—I am thinking of one lady in particular who is now pregnant and intends to have a second child by homebirth. She is—I hesitate to use the word but I think it is the appropriate one—actually scared of going to hospital. She does not want to give birth in hospital.

For some of us that may seem odd, but I am reminded of when my first child was born. My eldest son is now 30 and when my wife was pregnant and we were considering the options for the birth of our first child, we wanted both to be in the labour ward together—it was a hospital birth. It was not easy to find obstetricians and hospitals that would let you do that. That may seem strange—and 30 years ago is really not that long a time—but 30 years ago a number of doctors would refuse to have the father in the delivery room. Some hospitals would refuse to allow you to be there. The expectation was that you would wait down the corridor in a room doing the sorts of things that you saw in movies from Hollywood for decades prior to that. We did actually thankfully have a very good obstetrician who was quite welcoming at the thought that I should be there, and not long before that one of the major hospitals in Brisbane had changed its policy to allow partners to be present in the labour ward. (Quorum formed)

Quorums are indeed a very small price to pay for government; I am more than happy to sit on this side of the chamber and endure quorums as often as you like. If the tactical high point for those opposite is to call quorums and get their happies and jollies out of doing that, long may it stay the same. The only sad thing about this particular quorum is that a number of members were engaged in a function paying respect to a former Speaker, who was acknowledged here at question time. It is a pity that the tactical team on the other side of the chamber could not comprehend that perhaps quorums could have been called at a time that did not involve disruption to what is a proper function in the Speaker’s suite to acknowledge the outstanding contribution of the first female Speaker of the Parliament of Australia. People can make their own judgments about the efficacy of those opposite in doing that at this time.

Before the quorum was called I had just completed reading a passage from a constituent of mine. I think the points made by my constituent are legitimate. There will still be many women who seek to have homebirths and we are going to need to look at the best way of dealing with that. This is part of a much broader issue. Yes, there are complexities with indemnity—which even the previous speaker on the other side of the chamber raised—which cannot just be swept away or ignored. The indemnity risks involved with homebirthing are different to those involved with hospital birthing. But these are not insurmountable problems. We need to ensure that women do have proper choice and that homebirthing is properly supported.

Another thing that has concerned me is the number of caesareans that occur in Australia. When you look at the statistics, it is hard to believe that they are all performed for medical reasons. The OECD average number of caesarean sections for every 100 live births is 22. In Australia that figure is 29. Only three countries have a higher rate: Korea, Italy and Mexico. In countries like Sweden, Belgium, France and Finland the figure is 17. There is a substantial difference between the rate of caesarean births in Australia and other countries that makes me wonder whether or not all of those caesareans are done for good and proper reason.

This was one of the issues that were looked at as part of the national study that was overseen by the Minister for Health and Ageing. I think it is also part of the mix of options that we need to look at. At the moment, as my constituent correctly points out, the arrangements allow indemnity, public funding for hospitalisation and all of those services to be supported by the public purse. We need to look at doing the same for homebirthing. But we should not forget that this bill provides very substantial improvements in the recognition of midwives. It is a good bill and it deserves to be supported by both sides of the chamber.

Debate interrupted.