Midwife professional indemnity scheme for low risk homebirth
Background
Primary Health
The World Health Organisation (WHO states) all people everywhere deserve the right care right in their community. This is the fundamental premise of primary health care. Primary health care addresses the majority of a person’s health needs throughout their lifetime. A primary health care approach includes three components, meeting people’s health needs throughout their lives, addressing the broader determinants of health through multisectoral policy and action and empowering individuals, families and communities to take charge of their own health by providing care in the community as well as through the community. Maternity Care founded on the principles and practices of primary health benefits the individual and the community.
Midwifery
The Lancet Midwifery Series in 2014 states that midwifery is the vital solution to providing high quality maternal and newborn care. This extensive body of work found maternal and neonatal outcomes can be improved within the scope of midwifery practice by normalising optimal physiological processes.
This was reaffirmed at the 5th Global Midwifery Symposium in 2023, the United Nations Population Fund (UNFPA), the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the International Confederation of Midwives (ICM), and over 20 global highlighted the critical role midwives play in ending preventable maternal and newborn deaths and stillbirths, and leading the way in improving quality maternal and newborn care worldwide. Jointly, they committed to improving access to skilled midwives to ensure universal and equitable access to comprehensive maternal and newborn healthcare services.
There is solid evidence that midwives play an important role in stopping preventable maternal and newborn deaths. Well-trained and supported midwives have the potential to provide 90 percent of all essential sexual, reproductive, maternal and newborn health services. Midwives also improve women’s birthing experiences and reduce healthcare costs.
Midwifery care in the community is safe. We know when care is accessible and it’s near where people live or in their homes, when it’s focused on them and their needs, that’s the best care. It gives women the best chance of having a safe pregnancy and birth and a really positive experience, which is what we want for every single woman, every single baby.
The International Confederation of Midwives, Model of Midwifery Care adopted by the Australian College of Midwives is founded on the principles and practices of primary health. Midwives promote and respect women’s and newborn’s health rights. Midwives respect and have confidence in women and in their capabilities in childbirth. Midwives promote and advocate for non-intervention in normal childbirth. Midwives provide women with appropriate information and advice in a way that promotes participation and enhances informed decision making. Midwives offer respectful, anticipatory and flexible care, which encompasses the needs of the woman, her newborn, family and community and begins with primary attention to the nature of relationship between the woman seeking maternity care and the midwife. Midwives empower women to assume / take on responsibility for their health and well-being and for the health of their families, midwives practice in collaboration and consultation with other health professionals to serve the needs of the women and her newborn, family and community. Midwives maintain the competence and ensure their practice is evidenced based. Midwives use technology appropriately and affect referral in a timely manner when problems arise.
Issues
Medicalisation of pregnancy
It is not an illness to have a baby — pregnancy, labour, birth and breastfeeding are normal physiological processes and there should be no intervention in that process without a valid reason.
The current medicalisation of pregnancy most especially for the normal, healthy woman is at odds with the reliable evidence that pregnancy and childbirth are normal physiological events for most women. Technological advances and surgical skills, used appropriately, can save lives. However, without valid indications, routine use can transform childbirth from a normal biological process into a potentially harmful medical procedure. That said when the medical model is applied to women and their infants who need intervention, it is medicine at its best, it is beautiful medicine, it transforms lives, it save lives. When applies to all women however, it has the potential to cause harm and it violates an underpinning principle of medicine itself – above all do no harm.
In pathologized maternity care the same approaches apply to all pregnant women, rendering the woman invisible. It engages in practices that are not supported by reliable evidence, are unnecessary or unwarranted, are unfamiliar and often undesirable for women. Do not improve the health outcomes for mother and baby and may cause harm. They prioritise the needs of providers over the needs of women and encourages the use of technologies or interventions without proven benefit. Despite the evidence that the best and safest care is care that is at the level of care required, available, accessible, affordable high quality and provided close to where the consumer of care lives. Many maternity care providers continue to believe that women need specialist medical care and sophisticated technology to ensure their safety in what is interpreted as a high-risk event.
We question why women are expected to trust obstetricians and other health professionals to do the “right” and “safe” thing yet obstetricians and other health professionals are unable to trust midwives to also have the best interests of the woman as the focus of their care and work with women to ensure the best outcomes for the woman and her baby
Risk
In relation to Professional Indemnity for home birth and the associated risks it is essential to be mindful of the World Health Organisation (WHO) statement that in normal birth there should be a valid reason to interfere with the natural process; 85% of births do not require interventions. As caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10%, there is no evidence that mortality rates improve, (WHO, 2015).
The evidence is clear on the safety of births planned at home across all states and territories in Australia by comparing cohorts of women with uncomplicated pregnancies. For healthy women with uncomplicated pregnancies, planned home births resulted in high rates of normal labour and birth, low rates of most maternal complications and no statistically significant differences in the rate of perinatal mortality or NICU admission.
Risk no matter how well defined is subjective and there is no sound evidence on what constitutes a risk. This gives rise to a tension between bodily autonomy and giving birth the way women want and the hospital and health professional’s desire to minimise their perceived risk. More importantly, risk factors have come to be seen as dangerous in themselves, even when they pose little threat to the women who have them. With limited reliable evidence making clear who is normal and who is at high risk, there is a tendency to “err on the side of caution”. The line is drawn so that the maximum number of people are labelled “at risk” and therefore are denied their right to choose the place of labour and birth and become candidates for inappropriate, unnecessary and potentially harmful interventions.
For maternity care to be woman-centred, efficient and cost-effective, the aim should be to deliver appropriate care in the right place, at the right time, with the right health professional. To limit access to home birth based on ill-defined risk factors is the deny women a choice in where to birth. The biggest risk factor for a women is not her personal risk, but the place she gives birth. The outcomes are better at home and more harmful in hospital.
Recommendations
MHM proposes the eligibility for home birth public and private to be consistent. We would prefer not to use the terms low risk or high risk as this engenders fear. We propose an all-risk model of professional indemnity. Surely it is preferable for all women to receive continuity of midwifery care in the community and for the place of birth to be reviewed as the pregnancy progresses in light of the individual’s health and preferences. As an example many women get labelled as high risk due to Glucose Tolerance Tests that are done too early with cut off values are contentious. Rather the focus should be not to label the women as high risk but rather place the emphasis on strategies to maintain wellness such as aiming blood sugars within a healthy range.
The provision of midwife professional indemnity scheme for homebirth is best informed by the National Midwifery Guidelines for Consultation and Referral (“The Guidelines”). The Guidelines are based on best evidence, providing guidance on best practice and therefore inform professional indemnity. The Guidelines have been a pivotal and essential resource for guiding clinical midwifery care. The Guidelines are applicable to all health care practitioners, across all contexts who will, or are likely to, provide care to women during the childbearing years. The Guidelines foster a collaborative, multidisciplinary approach to the provision of maternity care across Australia. They reflect the dedication and commitment of all Australian maternity care providers to achieving respectful, collaborative and woman-centred maternity practice. More importantly, they are evidence of the pivotal role that midwives play in the provision of safe, humanised, high quality, evidence-based care. The use of The Guidelines provides an all-risk model for expanding eligibility under midwife professional indemnity scheme homebirth.
It is essential in expanding eligibility under midwife professional indemnity scheme for homebirth that the evidence be considered by reflecting on intersection of the science (data/quantitative), the experience of care (qualitative) and ethics – doing right and minimising harm.