Doing what comes naturally

Some women just know…others are taken by surprise. Either way, when you receive confirmation of your pregnancy you will be faced with a number of decisions. How will you prepare for the birth? Who will provide medical care for you throughout your pregnancy, birth and post-natal periods? Where will you birth? How much will it cost?

In our mother’s generation most Australian women started with their GP and most opted for a hospital birth. This is still the case but there are significant changes occurring in maternal care based on a greater respect for a woman’s right to control her birthing experience and for the role of qualified midwives becoming central in providing continuity of care.

Recent government legislation opens up a much wider range of affordable choices for pregnant women and recognises midwives as the most appropriate primary carers in normal pregnancy and birth.

Overdue for review

The need for a new approach to maternal care became obvious around ten years ago. With the number of births rising rapidly, shortages in the maternity workforce, concerns about high rates of intervention in hospital births and urgent calls for improved maternity services, particularly for rural and indigenous mothers, the government decided to act.

A Government Discussion Paper (2008) set the agenda:

“Women and their babies must be the focus of maternity care. They should be able to feel they are in control of what is happening during pregnancy, childbirth and the postnatal period, based on their individual needs and having discussed issues fully with their care providers. In order for women to feel this control, we must recognise that pregnancy and childbirth, while requiring quick and highly specialised responses to complications, are normal physiological processes, not an illness or disease.”

The Maternity Services Review that followed in 2010 made a number of recommendations, one of which was to expand the role of midwives in a collaborative team model. Commonwealth Chief Nurse and Midwifery Officer Rosemary Bryant, who led the review, identified the major problem in working “collaboratively” in hospitals.

“There is a lack of unanimity within and between some groups of the medical and midwifery professions on the issue of how to deal with risk and consumer preferences. While it is acknowledged that safety and quality of care is an overarching goal, it would be remiss to always use it as an excuse not to change practice.”

Things look better now

As a result of the review the Australian Government announced a package of reforms to improve maternity care in November 2010. Midwives who meet advanced requirements in regard to experience, competence and continuing professional development are now able to access the Medical Benefits Scheme, the Pharmaceutical Benefits Scheme and enter into a “collaborative” arrangement with a Doctor. This means that women are able to claim Medicare benefits for specific midwifery services and an authorised midwife may order and interpret tests, prescribe medications on a client’s behalf, and access visiting rights to hospitals.

Mary Young is the founder of Know Your Midwife and a Medicare-eligible private midwife, one of two currently practising on the Sunshine Coast. Mary believes the care that a midwife can provide for a woman through antenatal, labour, birth and post-natal periods leads to the best possible outcomes for mother and child.

Research shows that continuity of midwifery care can lead to reduced intervention in labour and higher satisfaction with the birthing experience, breastfeeding and a reduction in post-natal depression.

“We have to swing the culture of birth around so that women see that birth is a natural process. Doctors and obstetricians are there for the abnormal. Midwives are the experts when it comes to a normal pregnancy and birth. Women have to take back their power,” Mary says.

Women become empowered when they can make an informed choice but too often the first person the mum-to-be goes to for help presents a very limited range of options.

“GPs are the gatekeepers,” Mary says. “The doctor asks if the woman has private medical insurance. If so, she is referred on to an obstetrician. If the answer is no, she is referred directly to a public hospital. Other options, such as private midwifery care are not presented.”

Under the new legislation expectant mothers can claim some midwifery services from Medicare. Some private health insurance funds also allow claims for private midwifery services. “Cost is no longer such a barrier to helping mothers-to-be experience the benefits of continuity of care with a private midwife, and the impact this has on their birthing experience if they are birthing in a hospital,” Mary says.

The home birth debate

Not everyone is happy with the new provisions. Home birth midwives and the women who choose to birth in their own homes have missed out on government support.

It is a requirement for registration that health practitioners hold professional indemnity insurance. No insurance is available to cover birth care at home, though insurers will cover midwives for ante-natal and post-natal care. Home birth advocates want the government to provide appropriate funding and insurance protection for private midwife homebirth care.

The decision has reignited debate about quality and safety issues in a long-running ‘turf war’ between midwives and obstetricians.

The Spokesperson for Homebirth Australia and mother of eight home birthed children Justine Caines OAM rejects the suggestion that mothers are gambling with the health of their babies by choosing a home birth, and the presumption that a hospital birth equals a safe birth.

“There is no reliable evidence to demonstrate that hospital is safer than home. There is (strong) evidence that shows intervention is taking place for no clinical reason especially if a woman is a private patient in a private hospital.”

Justine says that any evaluation of homebirth versus hospital birth safety should include data on the considerable number of women and babies who suffer poor health outcomes as a consequence of intervention, especially in private hospitals which are known to have higher rates of intervention than public hospitals. Interventions include caesarean section, epidurals and episiotomies.

“Homebirth keeps birth normal unless absolutely clinically necessary. Hospital birth intervenes and schedules birth according to the needs of the organisation and the practitioners,” Justine says.

Continuity of care is known to increase the chances of a normal birth.

“The vast majority of homebirth women receive care from one known midwife while the vast majority of hospital birthing women receive care from a number of providers including some they have never met. Birth is intimate (like sex) so it is no wonder that when women are forced to share this intimacy with total strangers, things don’t work. Imagine ‘performing’ while being watched.”

In an interview on Radio 2GB in August 2010 Justine told listeners that the Australian Medical Association (AMA) ‘has a gun to the head of government’. The AMA has certainly been very influential in setting the framework for maternity reform. In the same interview obstetrician and gynaecologist, and President of the AMA, Doctor Andrew Pesce explained the AMA’s position. He pointed out that less than 1% of women in Australia choose a home birth.

“We should be focussing on improving hospital-based maternity units rather than going outside the hospital system.”

Dr Pesce said that rather than allowing midwives and obstetricians ‘to go their own way and do what they want’ as he says has happened in New Zealand over the past ten years, the AMA has insisted that obstetricians and midwives need to work together and agree on how care will be shared.

“If we are going to consider home birth within the maternity care system we have to consider it within the hospital system,” Doctor Pesce said.

Affordable maternity care options

• The Government is making changes to the MBS and PBS so that maternity care options are more affordable.

• From 1 November 2010, eligible midwives in Australia will be able to access the MBS and PBS.

• For the first time, you can claim Medicare rebates for specific services provided by an eligible privately practicing midwife.

• You will have more choice in the type of care you wish to receive when having a baby

Source: http://www.health.gov.au

Making the best maternity care choices for you

There are many things to consider when deciding where to have your baby and who should care for you. What facilities and types of care are available in your area? What is important to you in your pregnancy and birth? What costs are involved and what rebates can you claim?

The majority of Australian women still opt for pregnancy care by a GP or obstetrician and a hospital birth (98%). This may change substantially as women come to understand the services that private midwives can provide and as costs of such care become more affordable under government subsidy.

At present the main choices are:

Private hospital - If you wish to have your baby as a private patient you can either choose your hospital first and find out which obstetricians work there or choose your obstetrician first and find out which hospitals he has admitting rights to. Check what your private medical insurance will cover as substantial costs are involved.

Public hospital facilities - If you choose to use a public hospital you will need a referral from your local GP. There are usually no costs to you if you have valid Medicare cover. The following options may be available for continuing care, provided yours is a low-risk pregnancy:

• maternity clinic at a hospital

• midwife managed ‘birthing centre’ at a hospital

• community based midwifery program

• shared care with your local GP (some costs involved)

• community based ante-natal clinic with a hospital birth

Private Midwifery Care - As a primary carer your midwife works to provide normal maternity care from early pregnancy through birth and early parenting. She is trained to detect complications or illness in mother or baby and will refer and collaborate with specialist medical and nursing providers as needed. Contact your choice of private practice midwife to enquire about services and costs.

For more detailed information on care choices see www.bubhub.com.au, pregnancy tab, look under pregnancy info sheets and articles.

Need help? National Pregnancy Support Helpline 1800 422 213 is an integrated national pregnancy and perinatal support helpline. It is a 24-hour-a-day, seven-day-a-week telephone helpline that women can use during pregnancy and for up to 12 months after the birth of a child.

Helpful websites: www.knowyourmidwife.com.au, www.homebirthaustralia.com.au and www.health.gov.au (Information by topic dropdown box)