I rise today in support of the Medical and Midwife Indemnity Legislation Amendment Bill 2021. This bill amends the Medical Indemnity Act 2002 and the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Act 2010 to expand eligibility for claims against privately practising midwives under the Commonwealth’s medical and midwife indemnity schemes.

Specifically, this bill amends the Medical Indemnity Act 2002 to ensure that claims made against midwives in private practice whose registration is not endorsed by the Nursing and Midwifery Board of Australia to prescribe scheduled medicines (registered only midwives) and covered under their own insurance contract are now eligible under the Allied Health High Cost Claims Scheme and Allied Health Exceptional Claims Scheme, where the claim relates to incidents that occurred on or from 1 July 2020.

This bill also amends the Midwife Professional Indemnity (Commonwealth Contribution) Scheme Act 2010 to expand the Midwife Professional Indemnity Scheme and the midwife professional indemnity run-off cover scheme, otherwise known as the midwife schemes, to remove criteria relating to the employment arrangements of midwives that have resulted in certain privately practising midwives being excluded from the midwife schemes.

Importantly, this amendment will enable key Aboriginal Community Controlled Health Services to choose to access professional indemnity insurance for their employed midwives who have been endorsed by the Nursing and Midwifery Board of Australia to prescribe scheduled medicines.

These changes support flexibility in arrangements & supports midwives to work in a variety of different engagements, without their indemnity insurance being a barrier.

This bill also provides certainty to insurers of the Commonwealth’s ongoing commitment to subsidise the costs associated with medical negligence claims against privately practising midwives, further incentivising insurers to provide professional indemnity insurance to midwives in private practice. The bill has been developed in consultation with the Australian College of Midwives.

I congratulate the Minister and his office on bringing forth this bill and  I want to note the Minister’s sharing with the House that he is the son of a nurse and midwife and I particularly want to note how this has truly informed his understanding of the role of midwives when he commented on this bill saying: 

“It’s about giving mums-to-be choice and control. That’s what’s so fundamentally important, as well as protection.”

He went on to say:

“This supports the principle that women are the centre of maternity care and that they should have access to a wide range of birthing choices.”

Discuss birthing on Country and why that matters 

Importantly this bill enables indemnity insurance for midwives working in ACCHOs. This is so important to ensure that culturally sensitive enabling maternity care can be provided by midwives working with ATSI women in these settings. Programs such as Birthing on Country. There is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. And Birthing on Country programs are a way forward.

The terms ‘Birthing on Country’ and ‘Birthing on Country Models’ are generally not well understood. The Australian College of Midwives describes Birthing on Country as ‘…a metaphor for the best start in life for Aboriginal and Torres Strait Islander babies and their families’ which provides an appropriate transition to motherhood and parenting, and an integrated, holistic and culturally appropriate model of care for all’

Birthing on Country Models then, can be described as maternity services that are designed, developed, delivered, and evaluated for and with Aboriginal and Torres Strait Islander women that encompass some (or all) of the following

  • they are community based and governed
  • provide for inclusion of traditional practices
  • involve connections with land and country
  • incorporate a holistic definition of health
  • value Aboriginal and/or Torres Strait Islander as well as other ways of knowing and learning
  • encompass risk assessment and service delivery and are culturally competent.

Accordingly, Birthing on Country Models can be incorporated in any setting.

I want to highlight here a study reported in the Lancet Glob Health 2021 May

A multi-agency partnership between two Aboriginal Community-controlled health services and the Mater Mothers Public Hospital designed, implemented, and evaluated a new Birthing in Our Community (BiOC) service.

Between Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. Women receiving the BiOC service were more likely to attend five or more antenatal visits, less likely to have an infant born preterm, and more likely to exclusively breastfeed on discharge from hospital.

This study has shown the clinical effectiveness of the Birthing in Our Community service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised.

I want to pay tribute to the Professor Sue Kildea, Professor Sue Kruske  who have an enormous cannon of work in this space and have contributed a significant evidence based to underpin public maternity services policy for First nations women

Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts. I congratulate the govt on the $15 million 21-22budget ATSI Mothers and babies Grant Opportunity – for indigenous led research that translates into culturally safe care pregnancy birth and post partum.

There has been a dramatic impact of COVID on women’s choice & how this bill could assist in increasing women’s access to models of care

Midwives are essential providers of public health care contributing to improved outcomes, especially for women who may not experience equitable access to maternity care. Midwives provide care, counselling, screening vaccination and sexual and reproductive health care in addition to pregnancy care. There is a lack of understanding about the impact and value of midwifery practice on public health outcomes. The  WHO 2021 State of the World’s Midwifery Report calls for the expansion of midwifery-led models of care, to promote the health and well-being of mothers and babies.  This has never been more evident than during the COVID pandemic.

To understand more about the impact of Covid on birthing women and their families , last year the ACM conducted a survey of women’s experiences of maternity care at the height of the COVID-19 pandemic. ACM wanted to explore and gain insight into women’s experiences as well as their challenges, uncertainties and fears. Almost 3000 women completed the survey.

Respondents reported feeling isolated, alone and unsupported by the evolving changes of the pandemic which led to anxiety, concern and distress. Many women expressed concern for their mental health. The results revealed that women were seeking alternative options to mainstream maternity care in an unprecedented way.

This included an exponential  shift in demand towards midwifery continuity of carer services such as Midwifery Group practice, Birthing centres and homebirth (either publicly or privately provided).

Despite seeking other options, a large proportion of women indicated that they hadn’t been able to source the care they were looking for.

Alarmingly 3% of the more than 1000 women who had reconsidered their care, were considering birthing without midwifery or medical assistance at home (i.e. “freebirth”).

It is imperative that the results of this survey, and the views expressed by the women who contributed, be considered in informing maternity policy both in the post-COVID-19 recovery phase and the longer-term future.

It is now clear that many low risk Australian women consider Homebirth a safe birthing option when attended by qualified clinicians. The evidence for whom homebirth is safest for is now well established. Large population-based studies and subsequent systematic reviews and metanalyses consistently demonstrate that planned homebirth is a safe option for women with low-risk pregnancies.

This evidence means there are real opportunities for service choice expansion and cost reduction.

However there remains many barriers to achieving this. Mr Speaker, in September 18, 2019 when speaking on the Medical and Midwife Indemnity Legislation Amendment Bill 2019, I highlighted the need to include intrapartum care for home birth in the indemnity cover for privately practicing registered/endorsed midwives. Unfortunately, this amendment has still not addressed this aspect of midwifery practice. Right now Section 284 of the National law has a transitional period of Exemption until 31 December 2021 . My understanding is that this will be extended to 2023 but that does not solve the fundamental issue of no insurance for intrapartum care in a home setting when women wish to choose this and what we know is that more women wish to choose this.

Meeting the needs of women is a hallmark of a high-quality maternity system. A decade of Australian maternity service reviews have highlighted that women want increased access to models of care, including homebirth.1 2 Despite this, the rates of homebirth in Australia are low.

The majority of women access homebirth options through engaging with privately practising midwives (PPMs). Accessing a PPM in Australia is expensive. Medicare is available for antenatal and postnatal care, but not the birth. The average out of pocket cost for women giving birth at home with a PPM is around $5000. The growth of publicly funded models across the country, and reassuring evaluations,37 38 also further demonstrate the safety of this model of care. Ultimately, the goal should be to ensure that all women who are suitable and would like a homebirth can access safe evidence-based care, thus bringing homebirth out into the mainstream.

Right now only low numbers of women can access it .

Continuity of care- MGP, Birthing centres, home birth 

This bill will certainly help optimise midwifery care but there is more policy tidying up to be done to ensure midwives can provide the care that women want in settings where they want it.

For example, there is a practical safety problem when it comes to the MBS item 82120 for the management of labour in a health service by a participating midwife. Anyone who has ever worked in a continuity of care  model for birthing women and I am someone who has, knows that the 12 hour rule  is problematic for any midwife who may have been working all day in antenatal or postnatal care and then is called to care for her client in labour. The midwife must fulfill the 12 hours before transferring care to another participating midwife. This could easily be remedied by a change to the regulations around that item number. I would be most pleased to work with the minister’s office to set that right.

So, in summary

This is a good bill & addresses some deficiencies in the last one.

But there is more to be done.

  1. A few more policy levers need to be pulled to ensure that women have access to the safest highest quality care and we know that for low risk women that it is continuity of care models. – overwhelming evidence lower stillbirth, lower intervention, higher breastfeeding, – midwifery Group practice, birthing centres and home birth
  2. We need more publicly funded models of home birth
  3. We need to continue to grow the Birthing on Country models in urban and rural settings
  4. We need to include indemnity cover and a Medicare rebate for intrapartum care in the home for PPM

I acknowledge the work of midwives as campions f public health  an guardians of safe birth and women’s health and well being

I commend this bill to the house

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