Rachel Siewert (WA, Australian Greens) Share this | Hansard source

The Australian Greens broadly welcome the initiatives contained in 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. These initiatives have the intention of enabling nursing practitioners and some, though not all, appropriately qualified midwives to request appropriate diagnostic imaging and pathology under Medicare, prescribe certain medicines under the Pharmaceutical Benefits Scheme and make referrals under the Medicare Benefits Scheme. However, there are two aspects of these bills that we find unsatisfactory: the right of a woman to have the choice to give birth outside the hospital system is not appropriately or adequately dealt with and the provisions in the bills regarding collaborative arrangements between midwives or nursing practitioners and doctors.

A lot of the debate around these bills has centred on home births and quite rightly so. I am not diminishing the other important issues that are dealt with in these bills, and I will come to those, but this is an area that has attracted a lot of attention. As noted by many submissions and witnesses to the initial Senate Community Affairs Legislation Committee inquiry last August—we have had two inquiries into various provisions of these bills—the scheme outlined in these bills does not address the needs of many Australian women who wish to have the choice of a home birth. Initially, the effect of the concurrent introduction of these bills and the national registration for health practitioners scheme, referred to commonly as ‘bill b’ as part of the NRAS scheme, was that independent midwives would not be able to practise with registration as there was no available insurance product on the market to provide them with indemnity cover. There has been no professional indemnity insurance for independent midwives in Australia since 2001. Midwives in private practice have not been able to obtain insurance and have been practising uninsured. We are pleased that the government has recognised this for certain categories of midwife—I think that is extremely important, and I should have said that at the outset—but the effect of the legislation when it was initially introduced was to make it essentially illegal for independent midwives to provide midwifery services for home births.

On 4 September, the Australian health ministers met in Canberra and announced a transition clause in the draft national registration and accreditation scheme legislation. This provided a two-year exemption until June 2012 for privately practising midwives requiring indemnity insurance. As part of a package of measures, private practising midwives were required to participate in a quality and safety framework being developed in consultation by Victoria through the finalisation of the registration and accreditation process. The process of this legislation, which has sought to bring about significant changes to midwifery practice in Australia, has been undertaken in a fragmented and uncoordinated manner. We are very concerned about the fact that the government seems not to have foreseen some of the issues here, has made a series of amendments and that there has been a series of ongoing negotiations around the safety and quality framework which seem to be separate from some of the other collaborative arrangements and some of the other negotiations that have been undertaken.

The lack of initial consultation with the key stakeholders and the failure to identify the overlap and contradictions between these two major legislative measures at the outset of this process made it unnecessarily complicated and chaotic. To pick up some of the comments that Senator Parry made, if some of these issues had been dealt with by the government in the first place we would not have seen this legislation delayed as long as it has been. The Greens shared the concern raised by a number of witnesses to the Community Affairs Legislation Committee inquiry that, under the provisions of these bills, if registered midwives were unable to attend a home birth there was a very real potential that many women would still choose to give birth at home. The government saying that there should not be home births does not mean that Australian women will not make that choice. In fact, I had a number of mothers and expectant mothers say to me: ‘We want a home birth. The fact that the government thinks that it can make it virtually illegal does not mean that we are not going to choose to have a home birth.’ Unfortunately, they would have had to have made the choice of it being unsupported or done with the help of non-registered midwives.

When this issue was raised, some people in the government did not seem to think that it was a problem that people would be using non-registered midwives. It seems to me that it was a complete contradiction that the government wanted to set up a national registration scheme and certain people from government were saying, ‘What’s the problem with non-registered midwives? As long as they don’t call themselves midwives, it’s not a problem.’ This would increase the risk of negative outcomes for mothers and newborns. The government mitigated the immediacy of this problem when the announcement was made about the two-year exemption, but it is yet to indicate how it intends to solve the problem of access to midwifery care for homebirth in the long run. It seems to have delayed the successful outcome of negotiations and a resolution of the problem, as it sees it in terms of dealing with homebirths, to just two years down the track.

The government has done nothing to allay the fears of those who believe the future of homebirthing and the ability of women to choose the location of their birthing is being undermined by the ideology of some sections of this country’s medical profession. The Greens believe that the choice of having a low-risk homebirth should be available in Australia. The government needs to recognise that there are a significant number of women who want to birth at home. I do not know when the government is going to take this message on board and realise that women want the choice. They want to be able to birth at home. There are a number of women who want to be able to birth at home. There are a number of women who have birthed at home and want to have their next birth at home. There are a number of women who may not even want a birth at home but they absolutely support the right of women to have the choice of birthing at home.

The Greens support the requirement that practitioners hold adequate indemnity insurance. The exemption of private practice midwives providing homebirth care from this requirement should only be considered as a temporary measure until access to professional indemnity insurance has been resolved. We are very concerned about this legislation. As I said, we are pleased that an indemnity insurance scheme is being introduced. It is long overdue. What we have concerns about is the fact that midwives providing homebirths have been excluded. The insurance scheme should not be dependent on the location where a woman and her family choose to birth. Research indicates that well-integrated models of homebirth care are safe. However, homebirth, predominantly in the private sector, has been marginalised by some medical profession bodies and lobby groups. This marginalisation has made it extremely difficult for individual private midwives to integrate their care into hospital based maternity services.

I have lost count of the number of women and midwives I have spoken to who have had very significant difficulties in talking to hospitals to integrate their care. Midwives are very keen to integrate their care into the hospital system, but in many, many cases they have been denied that access. It is important at this juncture of the reform process that consideration is given to ways of better integrating private homebirth care into the delivery of maternity services rather than taking an approach that could potentially drive homebirth underground. The Greens consider that the model of homebirth proposed by the Australian College of Midwives has particular merit. This model ensures that quality practitioners who are experienced, credentialed and completing continuing professional development will use collaborative processes for consultation and referral according to nationally agreed guidelines to provide care for low-risk women. Under this proposal, indemnity insurance would only be extended to midwives who are Medicare eligible. These midwives will have already undertaken a credentialing process, will be linked to models of professional development and will work in collaboration with medical practitioners.

Evidence based guidelines should be used by midwives in making decisions regarding consultation and referral of the care of women. There is a need for nationally endorsed guidelines to support midwifery care. These guidelines should be for all areas of maternity care, including antenatal care, minimum standards of care in labour, caesarean section birth care, after caesarean section care and care for women with twins and breech birth babies. Such guidelines exist in other developed countries and inform practice. The maternity review recommended the development of guidelines, and this should be progressed as a priority. The adoption of a policy or a framework for private practice midwives providing homebirth care could be a way to progress the issue of indemnity while addressing insurance risk concerns.

One of the issues that have been a central part of this discussion is collaborative arrangements. This issue has been debated at length and it is one of the other areas that delayed the legislation. When the government realised that there were still some issues with the legislation, they introduced another amendment requiring collaborative arrangements. That had to be reviewed because we felt that there were significant changes. We had deep concerns. Also, countless women made representations, certainly to the Greens. I am sure all the other politicians in this place also got representations from mothers and midwives raising concerns about the government’s amendment that was introduced late last year.

On 28 October last year the government circulated amendments to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009. These amendments were designed to clarify in legislation that eligible midwives and nurse practitioners wishing to access the new arrangements would be required to have collaborative arrangements with medical practitioners. The details of the arrangements were to be specified in secondary legislation. The Greens were alarmed at the implications of these changes. A midwife or nurse practitioner would not be able to their job without the threat of veto from a doctor. In other words, it put a doctor in the position of having power of veto. If unamended, the only midwives who would be able to participate in the new arrangements would be those working directly in the rooms of obstetricians. This would be a long way from fulfilling the vision articulated by the minister of enhancing women’s access to care from midwives across all communities in Australia. For midwives who want to work in obstetricians’ rooms, that would not be a problem, but it would be a problem for a large number of other midwives.

19:52:01

The Greens referred the amendments to a second Community Affairs Legislation Committee inquiry to specifically look at the implications of the amendments. On 8 December, the Minister for Health and Ageing, Ms Roxon, wrote to the committee’s chair indicating that the circulated amendments were intended to clarify in legislation the collaborative intent that had been articulated. The minister went on to advise that after further consideration of the issues raised by stakeholders in relation to access to professional indemnity insurance—in other words, there were problems with the amendments, so this is the second lot of amendments that the government has to make to its legislation or to the process—and subsequent registration under the NRAS, she was persuaded that it was not necessarily desirable to just proceed with the collaborative arrangements in one of the bills, which was the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Bill 2009.

In the second community affairs committee inquiry into the bills, Dr Barbara Vernon, the Executive Officer of the Australian College of Midwives indicated to the committee that all stakeholders had largely agreed on the issues around eligibility. She said:

The key issue around eligibility that is problematic is whether or not we add this additional requirement of an arrangement with a doctor as to whether or not the midwife is going to be a capable, safe and competent practitioner in providing this care, and that is where there is a difference of opinion. But the material on midwives and their qualifications et cetera has been largely agreed upon, and it is likely that the Nursing and Midwifery Board of Australia would have carriage of administering that; they would have some kind of mechanism for identifying these midwives and maintaining their eligibility over time.

The department also commented on the progress to establish what was meant by eligible midwives and informed the committee that a very broad consensus had been reached around the level of experience that would be expected of an eligible midwife and that the midwife would need to have practised in a number of settings. We are yet to be informed of the outcome of these discussions that the department started.

The Greens acknowledge and support the minister’s intention that Medicare funded midwives should work collaboratively with medical and other health professionals as needed in the care of women and their babies. That issue is absolutely not in dispute. We completely agree. We do not, however, agree that it is necessary to legislate for collaborative arrangements in order to achieve this goal. Collaboration with medical and other health professionals is already encoded in the regulatory framework within which midwives work in Australia. Disciplinary action may be taken by regulatory boards if midwives are found to practise in a non-collaborative manner.

The Greens agree with the Australian College of Midwives that midwifery is a profession committed to the provision of collaborative care. We believe it is essential. 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 issue is how collaboration is ensured. The Greens believe the inclusion of collaborative arrangements in the manner in which it is proposed in this legislation may undermine how midwives work collaboratively with the medical and other health professionals. The Australian College of Midwives says that midwives should be able to demonstrate their adherence to safe, collaborative practice through the use of formalised maternity care notes for each woman for whom they provide care, which can be audited by Medicare Australia or the Nursing and Midwifery Board of Australia as appropriate. This seems to us to be a very sensible way forward.

The Greens agree with the Australian Nursing Federation that the consequence of the government’s amendments to the bills will mean that a medical practitioner could have veto over the ability of a midwife to practise. The Greens agree with the Australian Nursing and Midwifery Council, who have argued that collaborative practice between midwives and nurse practitioners and other health professionals is already legislated through the professional framework developed by the Australian Nursing and Midwifery Council. We remain concerned that the legislation should be presented to parliament before advisory groups have been able to complete their work—the very groups that the minister has set in place—and believe that this has contributed to the confusion and concern felt by many, not least by the public themselves.

The Greens support the minister’s intention that Medicare funded midwives should work collaboratively with medical and other health professionals as needed, as I have said. We do not agree that these legislative practices are necessary. We believe having collaboration in the legislation is not necessary. Collaboration with medical and other health professionals is already encoded, as I said, and there is provision for disciplinary action. In order for midwives to do their job, it is absolutely essential that they are involved in collaborative care. I have certainly had extensive consultation that I have undertaken with midwives and with mothers—and I have been ignoring fathers—and with fathers. When you go to a rally on homebirth, the fathers are always there as well. They are totally supportive and they want homebirth as well. We should not—and I should not—keep referring just to mothers. Fathers and families want the provision of homebirth. They support the indemnity insurance scheme and they want it extended to homebirths. They have very strong concerns about collaborative arrangements.

As I said, it is the midwives who are always talking about collaborative arrangements. It is the midwives who raise concerns with me about the fact that they have not been able to get collaborative arrangements with doctors. That is particularly important in regional centres. I note the number of emails, telephone messages and conversations I have had from women and men in Australia, particularly from regional centres, who have said that they have not been able to get a homebirth in their centre because their midwife has not been able to access collaborative arrangements.

As a Green, I do not want any mistake made; we do support collaborative arrangements and provisions. We do not support the way the amendments that have been proposed for this legislation enable a doctor to have a power of veto. That puts limits over a midwife being able to practise. That in itself starts to suggests to me that that is no longer a collaborative arrangement. That is a power imbalance between a midwife and a doctor. It is likely, unfortunately, that in many cases doctors will exercise that power of veto. That is why the Greens are proposing some amendments to provide for collaborative practice but not mandate collaborative arrangements as is articulated in this legislation.

The government made some mistakes in this legislation. We support the intent of the legislation but not some of the provisions. The government got it wrong twice. That is what held up this legislation. I do not always agree with Senator Parry but I agree with him on this one. It is disingenuous for the government to blame the Senate for this legislation being held up. In fact, we have helped you make it better, Guys. We have identified the problems with this legislation and we have been communicating with the public. If it was not for the pressure from the various people in this place and the public, you would still be going ahead with that flawed NRAS legislation which effectively outlawed homebirths. So stop having a go at the Senate about this particular legislation and look at the changes that were made.