HEALTH LEGISLATION AMENDMENT (MIDWIVES AND PRACTITIONERS) BILL 2009
August 20, 2009
Mr CHESTER (Gippsland) (12.40 pm) — I rise to speak in relation to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related bills. I note at the outset the very diplomatic way in which the member for Blair concluded his speech in relation to the need for further negotiations. Without wishing to put words in his mouth, I think he was calling for some further consideration of the issue of choice, which I will get to a bit later on.
I note also at the outset that this is a complex and somewhat emotional issue for many people involved in the debate. Despite the fact that it is legislation which I do not believe adequately deals with the opportunity for Australian women to choose to have a homebirth in the future, I must say that I agree with most of the measures that are contained in the bills. During her second reading speech the minister highlighted the fact that the bills before the House will facilitate access by patients of appropriately qualified and experienced midwives and nurse practitioners to the Medicare Benefits Scheme and the Pharmaceutical Benefits Scheme. The bills seek to remove barriers to the provision of care and, like the minister, I am hopeful that this will lead to improved access to services for the community, particularly in regional areas, which I am most passionate about, where it is already very difficult to recruit and retain a range of health professionals. I see some opportunities coming out of these bills that may assist regional communities.
On that point, I would like to highlight an issue of major concern to residents of the Sale district at the moment, the impending closure of RMIT University’s nursing course in Sale. Like many other regional areas, Gippsland has a marked shortage of qualified health professionals. Just this week there was another letter to the editor in the local newspaper from a young mother who could not get her daughter in to see a GP in either Sale or Maffra. The baby was eventually diagnosed with pneumonia. Lack of qualified health professionals is causing health issues, which are always of great significance in regional communities. Causing great distress in my community is the news that RMIT University will end its partnership with the East Gippsland Institute of TAFE and no longer offer a nursing course in Sale. It will not accept any new students from next year, which is a cause for concern, but there is also a long-term impact on nursing resources in our region.
Of immediate concern, though, is the commitment which has already been made to the 40 students who are in their first or second year of study. These students have committed to the three years of the course and are now being told they will have to travel to Churchill or Bundoora to finish their studies. The students are coming to me most upset by the changes, which have been made mid-course. Many are mothers who need to be in Sale to collect children from school or who have part-time work commitments that will not allow them to make the trip to Churchill on a daily basis. Common sense would suggest that we need to do whatever we can as a community to make sure that these students get to complete their course at Sale, as we can benefit from having 40 or more qualified nurses with ties to our local community.
I have written to the state and federal health ministers to seek their support in this regard and I met with the minister’s office today. I must say in commendation to the minister and her staff that the process of having a drop-in centre regularly on the Thursday of sitting weeks is very much appreciated by backbenchers like me. It provides an opportunity to meet directly with her and her staff to raise issues of concern in our electorates. I commend the minister for taking the initiative and I encourage other ministers who may be listening today to consider the opportunity to do so themselves. It is a brief drop-in service, but the five minutes spent face to face with the minister can overcome a lot of concerns or issues within our communities. It helps to build a better bridge between the parties and also to inform the minister regarding issues on the ground, which I think is of benefit to her and her staff. As a backbencher I certainly appreciate the opportunity to raise those issues directly with her.
Looking to the future, I believe there is a very real threat of not having enough nurses to service our local health systems throughout regional Australia. MPs from regional areas all understand that the evidence reflects that with the opportunity to train our own kids in the health professions there is more likelihood that they will return to offer those services to our communities in the future. The cancellation of this particular nursing course has been compounded by the proposed changes to youth allowance, which will leave many locals unable to afford to attend university. We need to explore all the options we can to create more opportunities for our young people to be trained in the local community and to overcome the accommodation and cost-of-living pressures which place a disproportionate burden on rural and regional students. I urge the government to work with RMIT to allow those local nursing students to complete their studies at Sale and to work with the East Gippsland Institute of TAFE to secure future opportunities for nursing and other health studies at Sale.
Returning directly to the legislation before the House: as the minister has stated, it is long-overdue recognition of our nursing and midwifery workforce. Coming from a regional area, I have seen first-hand the amazing contribution our midwifery workforce makes in maternity services. We have seen a situation throughout regional communities where there has been a gradual closing of birthing centres right across regional Victoria. I reflect on the situation I have in my electorate in the far east of the region, at Orbost. At a time when there are a lot of birthing centres being closed down around regional Victoria, the Orbost Regional Health service is taking steps in a completely different direction by increasing the number of births at Orbost. It has a very strong team of midwives leading the service, with professional support provided, I believe, through the Bairnsdale Regional Health Service.
It provides a great opportunity for the mums in the Orbost community to not have to travel so much in order to give birth. I commend the Chief Executive Officer of the Orbost Regional Health service, Therese Tierney, and her approximately 150 staff based in Orbost and the services they provide to our community. I want to spend time—as I believe many others will—in this debate focusing on the one area where the bills do not really accommodate my real concerns, which relate to the issue of midwife assisted home births. Under the maternity reforms, the government is refusing to extend these new arrangements for midwives to include home births. I quote directly from the minister’s speech:
Medicare benefits and PBS prescribing will not be approved for deliveries outside clinical settings, and the Commonwealth supported professional indemnity cover will not respond to claims relating to homebirths.
I accept again from the outset that there are many complex and competing issues to be addressed in this entire debate but we must, I believe, begin by setting aside our own personal prejudices. I come to this debate with only a small level of experience—four times in hospital for four healthy, beautiful young children.
Our birthing experiences were very positive. I would suggest my wife and I did not even give a second thought to the idea of home birthing. It is something that certainly would not have crossed our minds as a personal choice. In both Sale and Bairnsdale, where we had our children, we had access to highly regarded obstetricians and an excellent team of nurses and midwives throughout the entire experience. As much as you can enjoy the experience, we did—perhaps me more so than my wife, I would have to admit. My wife certainly enjoyed the continuity of care that was provided. Being in a regional setting, we had close contact with the staff at all times, and the obstetrician was available at various stages during the labours. But the midwives in particular were on hand throughout each of our children’s births, and we could not have been happier with the outcomes.
But this is not always the case. I respect the right of a woman to choose, within reason, when, where and how she decides to give birth. This is a complex and— I agree—an emotional issue, and far be it from me, particularly as a man, to be telling women what is best for them or how they should plan to give birth; I see that the member for Ballarat, who is in the chamber, is nodding in agreement. Unfortunately, that is exactly what these bills before us seek to do. The bills effectively rule out home births as an option in the future.
There is a very real risk, I believe, that such births will continue and that they will be forced underground. I think that is a less than ideal scenario, which I believe the minister herself has publicly acknowledged. It is a genuine concern for the mothers, babies and the government itself. I do acknowledge the minister has been questioned on the topic in the media. I think she is very conscious of the concern in the community that, if this results in the practice of home births being forced underground, that is not a desirable result for anyone— certainly not the minister or the government. The question before us is how we can prevent getting ourselves into a mess in this regard.
Under the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill, the minister claims that the bill will improve the choices that are available to women in relation to maternity care. As others have indicated already—and I do again today— the one choice that is effectively being ruled out is home birthing. The bill establishes a scheme to provide professional indemnity insurance cover for eligible midwives at an affordable cost, and I think that is a positive move. For the purpose of the bill, the definition of an ‘eligible midwife’ is one who is licensed, registered or authorised to practise midwifery under a state or territory law. The failure to extend the cover to midwife assisted home births needs further explanation, I believe, by the government. Has that decision been made on the basis of cost alone? If so, what modelling has been done to support that decision and has it been released publicly? But if the decision is based on the issue of medical risks then that argument needs to be debated more in public. Like many others, I have read information from both sides of the debate and I am not convinced that the risks are as great as some people in the medical profession like to present. I believe there is an element of a medical turf war behind some of the rhetoric that is used to discredit home births at the moment. Again I indicate that, as a personal choice, my wife and I would never have chosen to put ourselves in that homebirth situation but that is a choice we had the opportunity to make. I am not convinced that we are doing the right thing today by the women who choose to have a midwife assisted home birth.
I would like to spend a bit of time referring to the commentary about this issue as it has appeared in the popular press in recent times. In the Sunday Herald Sun there was a debate on the issue between a highly respected obstetrician, Peter Mourik, and the Homebirth Australia spokesperson, Justine Caines. Dr Mourik is, as I said, a highly respected obstetrician who has done some great work in regional Victoria. He supports the government’s position and believes the ruling will stop women from taking unnecessary risks.
Dr Mourik says:
Women who choose to give birth at home expect everything to be normal but they don’t consider how far they are
from expert help or even notify the ambulance service that they may need urgent assistance. 80 % of women can have their baby in a paddock but the problem is choosing these women. You just never know what will happen.
I am not for a second going to argue with Dr Mourik’s assessment. As I said, he is a highly respected obstetrician. But I will say that the midwives whom I have met with, and their clients, are also very aware of the potential risks. It is their belief that the continuity of care that they can provide allows them to follow a birth plan which acknowledges these risks and recognises when to seek further medical attention if required. They are absolutely passionate about the health of the mother and the baby and they make their assessments on whether it is appropriate to go ahead with a home birth at every step of the journey, in discussion with the family members.
Of course, things can go wrong—they go wrong in hospitals too—but the midwives I have met with would never proceed with a homebirth if they assessed the situation to be at a higher risk than normal. These women who choose a homebirth are so passionate about that choice that I believe they will go ahead with it anyway regardless of the government’s ruling on access to professional indemnity insurance for midwives.
As Justine Caines argued in that same article I referred to earlier:
Women will still choose homebirth. Many mothers have had bad experiences in hospital and won’t repeat that. Why does the government fund women who are choosing to have c-sections but not women who are choosing to give birth at home? Homebirth Australia would like the government to present a package for pregnant women that works a bit like the baby bonus. Every woman would be given a sum of money to spend on her pregnancy treatment, then it’s up to her whether she sees a midwife at home or an obstetrician in a hospital. It is putting the choice back into women’s hands.
Even under that scenario, there is no question in my mind that most women would still choose to give birth in a hospital, and that, of course, is their right. But I wonder: who are we to be taking away a woman’s right to choose a homebirth, as we are doing with this legislation before the House? By excluding midwives practising homebirths from the professional indemnity insurance cover and making insurance a condition of registration, we are effectively, if not technically, making it unlawful. Being subject to a $30,000 fine is certainly a huge discouragement to the midwives. I hold grave fears for the health and safety of women and their babies if we do in fact force homebirths underground.
The Senate Standing Committee on Community Affairs Legislation Committee received 2,000 submissions when it inquired into these bills. That is an amazing response, and it reflects, I believe, the level of community interest and the absolute passion in this debate. The submissions were primarily from midwives who provide homebirth services and from parents who described their experiences with homebirth and support for homebirths. The proposed legislation was generally supported in the submissions, but again the issue of the government’s failure to accommodate people who choose homebirths was a stumbling block for many of the people who made submissions. I quote from that Senate report:
Many submitters commented that homebirths will still occur but with an unregistered care provider who may or may not have qualifications or without any assistance.
One submission warned:
If homebirth is not available through registered midwives, the reality is that many women will still choose to birth at home either unsupported or with the help of non-registered midwives—this will likely worsen outcomes for mothers and newborns.
Concerns were also expressed by a number of witnesses to the inquiry that the proposed changes would lead to an increase in free birthing—that is, giving birth without a trained care provider on site. I would suggest that this would be the worst possible result. If a certain cohort of mothers feel their choices have been taken away from them and they are attracted to free birthing without any trained support, I fear for the safety of the mothers and their unborn children. I do not wish to be scaremongering on the topic by any stretch of the imagination, but that is a genuine and legitimate concern.
Mrs Elizabeth Wilkes, from the Australian Private Midwives Association, commented:
The disasters of women turning up bleeding, with babies unable to be born or whatever else that people are concerned about will certainly increase if this legislation goes ahead as it stands.
We cannot say that we have not been warned when we have people in respected positions within the industry— if it can appropriately be called an industry— coming out and giving quite cautionary tales to members both on our side of the House and within the government. It is also fair to say that, much as we have been warned, the medical profession is deeply divided on this issue.
The President of the AMA, Dr Andrew Pesce, stated to the inquiry:
The government was absolutely correct when it decided not to extend these bills to cover home births. The fundamental goal of maternity care must be a healthy mother and a healthy baby … It is not appropriate for the Commonwealth to introduce payment and insurance arrangements that encourage or sanction activities that inherently carry more risk.
That position that it inherently carries more risk is disputed by many on the other side of the debate. There are many competing views, but the one point that they all agree on is that the welfare of Australian mothers and their unborn children must be paramount in our considerations. That is why I am uncomfortable with the failure of these bills to recognise the right of a woman to choose a homebirth with a qualified and registered midwife. If we do force this practice underground, we will regret the day that we voted to make it harder for women to choose a homebirth.
In recommending that these bills be passed, the Senate committee acknowledged that the minister is currently working with the states and territories on potential options to prevent homebirthing from going underground. The committee says that this will include investigating indemnity options for homebirths that could be progressed without making the insurance unaffordable. But I repeat my earlier comments. I cannot recall the minister actually releasing any facts and figures to suggest that it is unaffordable or impossible to progress the issue immediately.
I note that the Victorian government is attempting to come up with its own solution, and a report in the Age newspaper on 9 August describes a pilot program where the state government will work with two Melbourne hospitals to provide for midwives assisting in homebirths to be covered by the hospitals’ own indemnity insurance.
That does sound like a positive move, and it may be a compromise position that can overcome this hurdle that we are confronted with. The Victorian scheme is expected to start next year, and homebirths will be restricted to low-risk pregnancies, although I must say that my understanding from discussions with midwives in my electorate is that homebirths are already setting that standard of working only with low-risk pregnancies. The pilot involves only two Melbourne hospitals at this stage and will not offer any comfort to the people in my electorate who are concerned by the legislation before the House. In any case, there are already midwives who have gone on the public record saying they do not want to work under that hospital system or situation again, so I believe it is an intractable position.
In conclusion, I would like to express my support for that fundamental right of choice in relation to this issue. I acknowledge, as do the registered midwives I have met with, that homebirthing is not an appropriate option for all women, nor is it the choice of the overwhelming majority of women, but it is the choice of a small number of Australian women and, if it were properly accommodated in the legislation, there would be the possibility, indeed, that more women would take up the option in the future. It is not something, as I said, that I would aspire to with my wife, but we are kidding ourselves as members of parliament if we think that homebirths will stop as a result of these bills going before the House. I am genuinely fearful of the impact the legislation will have if it forces the practice underground or leads to the more risky practice of free birthing. It is not in anyone’s interests for that to happen.
I think the member for Blair put it very well:
Childbirth is an intensely personal experience, and the decisions which are made by expectant mothers need to be supported within reason.
No disrespect intended, but I am unconvinced by the mainstream medical profession’s more extreme arguments against homebirths. I accept there is an element of increased risk in some circumstances, but it is entirely manageable in the majority of cases with the care and attention of a highly qualified and registered midwife. I cannot escape from the fact that women should have choice when it comes to deciding what they do with their bodies, and that extends to the issue of childbirth. I strongly urge the minister to continue working with the states and territories to resolve the issue of indemnity insurance and amend the legislation to allow existing services to continue to be offered.
I will give my final comments to the convenor of the East Gippsland Birth Support Group, Cath Lanigan, who has written to me in relation to these bills. Cath lives in Metung, a beautiful village on the Gippsland Lakes.
She says:
Only a small percentage of women currently seek homebirths but that doesn’t mean it’s not important or should be disregarded. It provides a choice which enables birth to be a very natural, normal event which in the vast majority of cases it is.
It provides women with the choice to involve other family members, midwives they know and trust, have their own autonomy, and the chance to have one of the most intimate moments in their life in the comfort of their own home surrounded by people who are invited to be there.
Cath continues:
I had a home birth with my second child, here in Metung, and I know what a beautiful and positive experience it can be for mother, baby and family. It would be an absolute travesty if this option was no longer available as a choice.
(Time expired)