When 'safety' makes care impossible: the new insurance threat to private homebirth

Women who choose homebirth are often portrayed as moving away from safety. The research tells a different story. Many are moving towards the kind of safety they value: a known and trusted midwife, bodily autonomy, privacy, protection of birth physiology, freedom from unwanted intervention, and emotional, psychological, cultural and spiritual security.

Women choosing to birth at home in Australia more than doubled from 923 in 2019 to 2,081 in 2023. This number is still only 0.7% of births, but the trend matters. Women are seeking relational, midwife-led care that the mainstream system does not reliably provide. Australian research has found that women choose homebirth to avoid unnecessary intervention, remain in the comfort of home, make their own decisions and receive continuity of care. A 2025 systematic review similarly found that women understand safety more broadly than institutions commonly do: physical safety matters deeply, but so do dignity, trust, autonomy and protection from psychological harm. Midwives' expertise was central to their sense of physical safety.

A long-awaited solution: with a fatal gap

Since national registration began on 1 July 2010, privately practising midwives attending homebirths have operated under a specific exemption from holding professional indemnity insurance for intrapartum care. The exemption was necessary because no insurer offered a suitable product. Midwives still required insurance for antenatal and postnatal care and had to comply with the Nursing and Midwifery Board of Australia’s safety and quality requirements.

From 1 July 2025, the Commonwealth-funded Midwife Professional Indemnity Scheme was expanded to cover eligible claims against endorsed midwives providing out-of-hospital labour and birth care. MIGA is the sole insurer participating in the scheme. This reform was important and overdue. The exemption was extended one final time but will end on 31 December 2026.

The difficulty is that a planned homebirth requires a second registered health practitioner who is educated and current in maternal and newborn emergency care. The second midwife has not historically needed endorsement for scheduled medicines and does not need prescribing or diagnostic-ordering authority to perform the second-midwife role. Yet from 1 January 2027, a second midwife practising privately at a homebirth must also hold appropriate intrapartum insurance, while the only government-supported product is available to endorsed midwives. This requirement creates a practical, even if indirect, endorsement requirement. A registered midwife may be legally and clinically capable of acting as the second practitioner, but unable to obtain the insurance required to do so.

The NMBA’s 2026 draft revised Safety and Quality Guidelines compounded the concern by proposing that the second practitioner hold appropriate insurance and be prepared to assume the primary-midwife role if required. The consultation has closed, and the NMBA is considering feedback. Homebirth Australia and the Australian College of Midwives have warned that no fit-for-purpose product exists for the non-endorsed or occasional second midwife. MIGA is not the sole cause of this conundrum. It is a systems-design failure produced by the interaction of Commonwealth funding rules, National Law and NMBA requirements, and the terms of the sole available insurance product. Each part may be presented as a safety measure. Together, they may make compliant practice impossible.

Rural women will pay first

The consequences are already visible. ABC News reported in May 2026 that Geraldton’s last privately practising homebirth midwife planned to pause her practice. The small number of endorsed midwives in the region were largely public employees and could not justify paying approximately $2,400 for insurance to attend only a handful of births as a second midwife. Without a second, the primary midwife cannot offer homebirth. These changes to insurance rules and the shortage of qualified midwives may force families to make difficult decisions about their care. See the Channel 7 News New England Regional video on the story: 

Award-winning midwife is sounding the alarm about access to safe homebirth services in the bush.

Links to an external site.

The economics are stark. Public homebirth midwives are indemnified through their employer. A self-employed midwife must assemble, coordinate and finance the same two-practitioner safety structure birth by birth. The Australian College of Midwives has also identified the absence of a Medicare item for intrapartum homebirth care, run-off cover costs that may total up to $15,000 over three years when a midwife leaves private practice, and unaffordable entity insurance for many midwife-led practices.

This convoluted bureaucracy is how reproductive inequality is produced: not usually through an explicit prohibition, but through accumulated costs, qualifications, exclusions and administrative conditions that make a service unviable. Metropolitan women may retain some options as there are more midwives in metropolitan areas. Rural, regional and remote women will lose their options first as the Geraldton and Tamworth stories indicate.

When regulation intended to create safety increases risk

Homebirth care must be well governed. Registered midwives must practise competently, communicate risk honestly, consult and refer appropriately, recognise deterioration, and transfer care when indicated. Serious adverse events warrant rigorous, fair examination. Women and babies deserve nothing less. But an insurance eligibility rule is not a clinical safety intervention. Requiring a second midwife to obtain an endorsement designed primarily for prescribing and diagnostic authority does not necessarily make her more capable of neonatal resuscitation, managing an obstetric emergency or assisting a timely transfer. It may simply remove her from the available workforce. That eligibility rule can produce the opposite of the intended result. In an Australian survey of 1,681 women who had planned a homebirth, most preferred care from a registered midwife. If there was no midwife available, half said they would freebirth or engage an unregistered birth worker. Almost 60% reported a factor that would have excluded them from a publicly funded homebirth program. As a privately practising homebirth midwife, I often ended up the default choice for women denied publicly funded midwifery care because they were 'too old and too fat' and 'outside' guidelines. More recent media coverage continues to document women turning away from the formal system following trauma, coercion, lack of consent or inability to access midwifery care.

Homebirth with a registered midwife and freebirth are not the same. Removing access to the former is not a credible strategy for preventing the latter. For healthy women with uncomplicated pregnancies, Australia-wide linked data found planned homebirth was associated with substantially more normal labour and birth and fewer interventions than planned hospital birth, without a statistically significant difference in perinatal mortality. More broadly, the 2024 Cochrane review found that midwifery continuity models improve women’s experiences and reduce caesarean and instrumental birth. Safety policy should build on these benefits through integration, reliable consultation and respectful transfer pathways, not dismantle the workforce that provides them.

Regulation, notifications and the chilling of woman-centred care

A wider regulatory climate also matters. Notifications to Ahpra are essential when there is a genuine concern about unsafe or unprofessional practice. A notification, however, is an allegation requiring assessment, not a finding of wrongdoing. Notifications about midwifery practice in 2024–25 involved about 0.5% of the profession. Publicly available data doesn't adequately separate private homebirth practice from other midwifery settings. Although notification numbers are small, regulatory processes clearly cause harm. A 2021 feminist qualitative study of eight privately practising midwives found that other health professionals mostly made the reports after the midwives supported women choosing care outside recommended guidelines. None of the reports in that study was made by the women receiving care. Participants described being “caught between women and the system”, experiencing profound distress and changing or leaving practice. A 2025 study across midwifery settings similarly found serious personal and professional effects, poor communication, protracted investigations, loss of confidence and inadequate support.

Accountability and procedural justice must coexist. A process that takes months or years can become a punishment before any adverse finding is made. It can also encourage defensive practice: declining women with complexity, transferring responsibility prematurely, or abandoning private practice altogether. In maternity care, that chilling effect falls not only on midwives but on women’s access to relational care and informed choice.

Choice without infrastructure is not choice

Australia’s national maternity strategy says women should have access to continuity of care with the provider of their choice. The Australian Charter of Healthcare Rights protects access, respect, partnership, information and informed decision-making. These principles do not create an unlimited entitlement to every requested service regardless of clinical circumstances. They do require governments and regulators to avoid making safe, evidence-informed options structurally unattainable. The gendered pattern is hard to miss. A predominantly female profession providing intimate, relational care to women is required to absorb growing layers of personal financial risk, regulatory surveillance and unpaid coordination. Meanwhile, the hospital-centred system remains institutionally funded and treated as the default, even when women describe that environment itself as a source of risk and trauma.

Midwifery is repeatedly asked to prove itself within structures designed around medical institutions, rather than being resourced according to its own evidence, philosophy and scope. The result is not neutral regulation. It reproduces professional hierarchy through policy.

What must happen before 1 January 2027

The Commonwealth, NMBA and MIGA need an urgent, jointly designed solution. At minimum, this should include:

• a fully underwritten, low- or no-cost, scope-limited insurance product for non-endorsed second midwives;
• extension of the primary midwife’s policy to cover a second midwife working within a documented peer or mentoring arrangement;
• no endorsement requirement for a second practitioner unless she actually assumes the primary role;
• a Medicare item for intrapartum homebirth care, together with equitable run-off and entity-cover arrangements;
• funded rural loadings, mentoring pathways and workforce development;
• integrated, respectful hospital consultation and transfer pathways;
• early triage, transparent timeframes and meaningful support for midwives subject to regulatory notifications; and
• national reporting of notifications by practice setting, source, duration and outcome, so claims about risk and regulation can be tested rather than assumed.

Insurance should protect women and midwives when something goes wrong. It should not be designed in a way that prevents a safe workforce from existing.

If reform drives registered midwives out of homebirth and women out of regulated care, it cannot honestly be called a safety success. Women do not have meaningful choice simply because no law expressly forbids homebirth. Choice exists only when a safe, skilled and sustainable service is genuinely available.

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Selected sources

Australian Health Practitioner Regulation Agency. (2025). Annual report 2024–25: Notifications.

Australian College of Midwives. (2026). 2026–27 Federal Pre-Budget Submission.

Australian Government Department of Health, Disability and Ageing. Midwife Professional Indemnity Scheme.

Australian Government Department of Health. (2019). Woman-centred care: Strategic directions for Australian maternity services.

Australian Institute of Health and Welfare. (2026). Australia’s mothers and babies: Place of birth.

Chauncy, C., Dawson, K., & Bayes, S. (2025). What do safety and risk mean to women who choose to birth at home? A systematic review. Midwifery, 144, 104340. https://doi.org/10.1016/j.midw.2025.104340

Gordon, F., Whitburn, L. Y., & Newton, M. (2025). Understanding the impact of AHPRA notifications on midwives’ wellbeing, practice and career. Midwifery, 148, 104471. https://doi.org/10.1016/j.midw.2025.104471

Homer, C. S. E., et al. (2019). Maternal and perinatal outcomes by planned place of birth in Australia 2000–2012. BMJ Open, 9, e029192. https://doi.org/10.1136/bmjopen-2019-029192

Homebirth Australia. (2026). Response to the NMBA consultation on Safety and Quality Guidelines for privately practising midwives.

Hunter, J., Dixon, K., & Dahlen, H. G. (2021). The experiences of privately practising midwives in Australia who have been reported to AHPRA. Women and Birth, 34(1), e23–e31. https://doi.org/10.1016/j.wombi.2020.07.008

Melville, B. (2026, May 21). Birth choices dwindle as new laws push Geraldton’s last private midwife to press pause in WA. 

ABC News.Nursing and Midwifery Board of Australia. Professional indemnity insurance arrangements.

Sandall, J., et al. (2024). Midwife continuity of care models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667. https://doi.org/10.1002/14651858.CD004667.pub6

Sassine, H., Burns, E., Ormsby, S., & Dahlen, H. G. (2021). Why do women choose homebirth in Australia? A national survey. Women and Birth, 34(4), 396–404. https://doi.org/10.1016/j.wombi.2020.06.005

We Have Changed the World Faster Than We Have Changed Ourselves

 There is something increasingly obvious about modern life. We have built a world that asks human beings to function in ways they were never designed to. Our technology has evolved at breathtaking speed. Our biology has not. The human nervous system that responds to a notification on a smartphone is fundamentally the same nervous system that once listened for the sound of a predator in the long grass. Our brains still scan constantly for danger. Our hormones still respond to uncertainty. Our bodies still seek safety through connection, rhythm, familiarity and belonging. Evolution takes tens of thousands of years. The digital revolution took less than fifty. The result is a profound mismatch between the world we have created and the bodies we inhabit. We often assume anxiety, exhaustion, burnout and chronic stress are personal failings. Yet perhaps they are entirely predictable physiological responses to environments that continuously signal urgency, uncertainty and threat.

A nervous system living in the future

Our ancestors experienced stress as relatively brief episodes. A predator appeared. A storm arrived. Food became scarce. The threat resolved. The nervous system returned to balance. Today, there are few lions or sabre-toothed tigers hiding in the bushes. Instead, we have overflowing inboxes, performance targets, staffing shortages, endless notifications, financial pressures, constant news updates, social comparison and the expectation that we are permanently available. Our stress response was designed for acute danger. We are asking it to cope with chronic activation. No wonder so many people feel exhausted.

We cannot out-think physiology

One of the greatest misconceptions of modern society is that knowledge alone changes behaviour. It doesn't. The nervous system responds first. Long before the thinking brain evaluates a situation, the body has already begun deciding whether it is safe. This matters everywhere. It matters in schools. It matters in workplaces. It matters in hospitals. And nowhere is it more obvious than maternity care.

Birth is one of the most profound neurophysiological events in human life. The hormones that support labour are exquisitely sensitive to the woman's environment. Privacy, trust, familiarity and continuous support help the body release oxytocin and endorphins. Fear, surveillance, uncertainty, and interruption activate stress pathways that can slow labour and increase the likelihood of intervention. For decades we have measured labour against clocks while paying remarkably little attention to the neurobiology that actually drives it. Perhaps we have been asking women to adapt to systems rather than asking systems to adapt to women's physiology. The same question could be asked of healthcare workers. And teachers. And parents. And children.

The cost of constant adaptation

Modern life rewards speed. Biology rewards regulation. Health services ask clinicians to move faster while expecting compassionate care. Universities demand greater productivity while encouraging innovation. Parents juggle work, childcare and ageing relatives. Children grow up immersed in digital stimulation before their nervous systems have developed the capacity to regulate it. Many workplaces now operate as though human attention is infinite. It isn't. Attention is a biological resource. Recovery is biological. Relationships are biological. Even creativity depends upon periods of rest, reflection and psychological safety. The answer to overload cannot be resilience training alone. A nervous system cannot meditate its way out of an unsafe environment.

The disappearing medicine around us

At precisely the time we most need environments that calm the nervous system, we are removing them. We cut down forests. We fragment ecosystems. We replace natural sound with traffic. Dark skies with artificial light. Birdsong with notifications. Yet research continues to show that nature is not merely beautiful; it is biologically active. Time spent among trees lowers cortisol, reduces blood pressure, improves immune function, enhances mood and supports cognitive restoration. Green spaces encourage movement, social connection and emotional regulation. Exposure to natural environments appears to strengthen the very physiological systems that chronic stress weakens. The natural world is not simply scenery. It is part of humanity's regulatory system. When we destroy ecosystems, we are not only driving biodiversity loss. We are dismantling one of our oldest forms of medicine.

Technology is not the enemy

Technology has transformed healthcare, education and communication in extraordinary ways. Generative AI has enormous potential to reduce administrative burden, improve access to knowledge and free clinicians to spend more time with people. Social media can connect isolated communities, amplify unheard voices and spread important ideas. The challenge is not technology itself. The challenge is allowing technology to become the environment in which we spend most of our lives. Every new technology changes behaviour. Every behavioural change influences physiology. The question is no longer whether technology changes us. It is how consciously we choose to shape that change.

Designing systems that fit human beings

Perhaps the future is not about making people increasingly efficient. Perhaps it is about making systems increasingly human. Imagine workplaces designed around recovery rather than relentless productivity. Schools designed around attention rather than distraction. Cities with trees, parks and quiet spaces recognised as public health infrastructure rather than optional amenities. Hospitals that understand psychological safety as seriously as physical safety. Maternity services organised around relationships, continuity and trust because they align with human neurophysiology rather than because they are simply kinder. This is not a return to the Stone Age. It is the application of twenty-first-century science to understand bodies that still carry hundreds of thousands of years of evolutionary wisdom.

A different kind of progress

For much of modern history, progress has been measured by speed. Faster transport. Faster communication. Faster healthcare. Faster work. But biology asks a different question. Not "How fast can we go?" Rather, "What allows humans to flourish?" The answer has changed remarkably little. Safe relationships. Meaningful work. Connection with nature. Time for recovery. Communities that care for one another. Environments that support rather than fight our physiology. Perhaps genuine progress is not asking humanity to become more machine-like. Perhaps it is having the wisdom to build a world that remembers we are still beautifully, wonderfully and irreversibly human.

Many of our institutions- healthcare, education, workplaces, and even cities- were designed around efficiency, control and production rather than around human neurophysiology. The challenge is therefore not simply to make individuals more resilient, but to redesign environments so they work with human biology rather than against it. Continuity of midwifery care is an inspiring example of a system deliberately designed to align with human physiology rather than forcing physiology to conform to the system.

Continuity of midwifery care is an ecological model of healthcare

I've been thinking more and more about the distressing, heartbreaking and avoidable tragedies for mothers, babies, their families and their communities in the various reports from the UK.  I've also been thinking about the fixation on 'normal birth ideology' and the idea that individuals are to blame for the horrific morbidity and mortality exposed in these reports, rather than highlighting how the system needs to change. I've lamented that the 'system is broken', but I'm realising that saying the system is "broken" implies that it has failed to do what it was intended to do. Many of the characteristics we now criticise in maternity care: fragmentation, hierarchy, surveillance, standardisation, control and efficiency, are not accidental. They arise from a worldview that has historically privileged control over relationship, production over care, and certainty over complexity. The maternity care system reflects patriarchal values and assumptions that have shaped institutions over centuries.

 What if maternity care reflects our relationship with the living world?

I am proposing another idea. Perhaps the maternity scandals are not only telling us something about healthcare. Perhaps they are revealing something much deeper about our culture. Across the world, we have inherited systems built upon a particular way of seeing the world. A worldview that values certainty over uncertainty, control over relationship, measurement over meaning, and production over care. It is a worldview that has delivered extraordinary scientific and technological advances, but it has also encouraged us to see living systems as something to be managed rather than understood and valued.

The natural world has long been treated this way. Rivers have been straightened. Hills levelled. Forests cleared. Wetlands drained. Predators eliminated. Landscapes divided into parcels that can be measured, controlled and exploited. Complexity is often viewed as a problem to be simplified, rather than a source of resilience. Wildness is regarded with suspicion because it cannot always be predicted.

Women's bodies have frequently been approached in remarkably similar ways.

Pregnancy becomes a condition to monitor. Labour becomes a process to manage. Birth becomes a production line with predefined timelines, protocols and performance indicators. The extraordinary intelligence of physiology, the intricate orchestration of hormones, emotions, relationships and environment, is often reduced to a series of variables to control.

Yet physiology is not a machine. It is an ecosystem.

Like every ecosystem, it responds continuously to its surroundings. A forest cannot be understood by measuring a single tree. A coral reef cannot be understood by studying one fish. Likewise, birth cannot be understood simply by monitoring cervical dilatation, contraction frequency or fetal heart rate. These are important, but they are only fragments of a much larger living system. Birth unfolds within an ecological network of hormones, relationships, emotions, history, culture and environment that interact continuously with one another. Modern science is increasingly confirming what experienced midwives have always observed: physiology is exquisitely sensitive to context. Oxytocin is influenced by safety. Stress hormones respond to fear. Labour can accelerate when a woman feels protected, or slow when she feels observed, threatened or alone.

The environment is not merely the backdrop to birth. 

The environment becomes part of the physiology itself. This is why relationships matter so profoundly. A trusted midwife is not simply another member of the workforce. She becomes part of the woman's physiological environment. Her calm presence can reduce fear. Her familiarity allows subtle changes to be recognised early. Her relationship creates the conditions in which women feel safe enough to labour, ask questions, express uncertainty, and trust their own bodies.

Continuity of midwifery care is therefore much more than a model of service delivery.

It is the deliberate creation of the ecological conditions in which physiology is most likely to flourish. This way of thinking also helps explain why so many dedicated midwives find themselves working in ways that do not reflect their own values.

People adapt to the systems they inhabit.

When success is measured primarily through efficiency, throughput and compliance, relationships inevitably become secondary. Time spent listening appears unproductive. Knowing a woman deeply becomes an unaffordable luxury rather than a cornerstone of safe care. Compassion is squeezed into the spaces left between competing demands. It is hardly surprising that many midwives experience moral distress. They entered maternity care to care for childbearing women, yet often find themselves working within structures that reward the management of processes more than the nurturing of relationships.

The same worldview that has contributed to ecological degradation also shapes the way many societies organise maternity care. Both assume that living systems perform best when they are tightly controlled. Yet ecology teaches the opposite. The healthiest ecosystems are not those subjected to the greatest control. They are those with the greatest diversity, adaptability, connection and resilience. Their strength lies in relationships. Human beings are no different. Birth is one of nature's most sophisticated biological processes. It evolved, not in brightly lit clinical environments governed by clocks and protocols, but within relationships, communities and environments that promoted safety, connection and trust. This is not an argument against medicine. Medicine is one of humanity's greatest achievements and has transformed the survival of women and babies when complications arise. The question is not whether medicine belongs in maternity care. It unquestionably does. 

The question is whether medicine should define the entire philosophy of maternity care. 

When intervention becomes the organising principle rather than the response to need, we risk treating every birth as though physiology is inherently suspect. Perhaps that is the deepest lesson emerging from the maternity inquiries. Not that physiology has failed. Not that women have failed. Not that clinicians have failed. But that we have created systems shaped by assumptions that privilege control over connection, hierarchy over partnership, and surveillance over trust. If we genuinely want different outcomes, we may need more than organisational reform. We may need a different story about birth itself. One that recognises birth not as a process to be controlled, but as a living ecological event requiring knowledge, humility, relationship and respect. Because how we treat birth ultimately reflects how we understand life. If we continue trying to dominate living systems, whether forests, rivers or women's bodies, we should not be surprised when those systems lose their resilience. But if we learn to work with them instead of against them, supporting rather than controlling, partnering rather than overpowering, we may discover that the future of maternity care is inseparable from the future of our relationship with the living world.

 Every woman needs a midwife.

Not simply because she may need clinical care. But because every living system thrives through relationship. And some women need doctors too. Not as controllers of physiology, but as valued partners when physiology asks for more than nature alone can provide. That is not a compromise between two philosophies. It is the wisdom of recognising that both nature and medicine are at their best when they work in relationship rather than in opposition. 

The recognition that continuity of midwifery care is an ecological model of healthcare and one where women and babies are safest is an idea that sits at the intersection of maternity care, systems thinking, ecofeminism, salutogenesis, physiology, and relational care, aligning contemporary complexity science and ecological thinking with the physiology of birth rather than treating continuity simply as a service model.

 

Maternity scandals commentary keeps blaming 'normal birth' ideology. The real problem is broken systems

Another damning report into a maternity unit, another round of the same argument. Last month, Donna Ockenden's review into Nottingham's maternity services found 520 families had suffered avoidable harm, including 162 deaths. It is the latest in a tragic line of UK inquiries stretching back to Bill Kirkup's 2015 report into Furness General Hospital, where 11 babies and one mother died avoidably—among them Joshua Titcombe, son of patient-safety campaigner James Titcombe. Writing in the BMJ, Titcombe argued that a "damaging ideology" that prizes natural, "normal" childbirth over safety continues to cause preventable harm, and that inquiry after inquiry reports the same symptoms without confronting the root cause. I responded in the same pages. I don't think he's wrong that ideology causes harm. But I don't think the ideology in question belongs to midwifery. 

Shifting the Battlefield 

I wrote a paper 20 years ago about the politics of Australian midwifery. Back then, the fight was over whether midwives should be allowed to practise autonomously at all. That fight is largely over. Midwives here can prescribe, order tests, and bill Medicare; every state and territory now has a senior midwife advising government. What hasn't changed nearly as much is what happens to the small number of women each year for whom something needs to go differently, and that's exactly where the harm in these UK inquiries keeps turning up. If you read what the inquiries say, rather than what popular commentary claims they say, they don't conclude that "midwives got it wrong" or "obstetricians got it wrong." Instead, they describe: 

• Wards operating without safe staffing thresholds. 
• Fragmented multidisciplinary teams that do not communicate. 
• Toxic workplace cultures where clinicians are too afraid of blame to say, "I think something's wrong here." 
• Critical warning signs missed because nobody has the time, continuity, or standing to notice them.  

Occasionally, a report finds a rigid determination to achieve a vaginal birth that overrides a woman's or baby's obvious need for medical escalation. Yet both failures share a root cause, a system that doesn't give the people inside it the room to notice change and respond to it. That is a textbook definition of organisational failure. It is not a verdict on a philosophy of birth. 

The Best-Evidenced Infrastructure We Aren't Using 

This distinction matters because arguing about "normal birth versus medical intervention" distracts from the one intervention the evidence says reliably works: continuity of midwifery care. This is a model in which the same midwife or small team cares for a woman throughout pregnancy, birth, and the postpartum weeks. It sounds like a nice-to-have, but the data proves it is safety infrastructure. Recent studies, including work covering disadvantaged and First Nations communities, link continuity of care to fewer premature births, fewer unnecessary interventions, and fewer babies needing intensive care (Kuipers et al 2026, Lundborg et al 2025; Forster et al 2026). It works for much the same reason a GP who has known you for years notices subtle health shifts that a stranger in an emergency department might miss. Someone who knows your baseline can detect changes earlier, allowing for intervention before they become a catastrophic emergency. Yet, most Australian women still don't get this care. Not because the evidence is thin, but because our funding models, rosters, and hospital structures were built around short, disconnected appointments rather than relationships. Rebuilding a public hospital system around relationships is genuinely hard organisational work. It is not an ideological debate.

Understanding Physiology is Not an Ideology 

Supporting normal physiological processes is fundamental biology. Every area of medicine seeks to preserve normal physiology whenever possible: 

• Cardiology supports normal cardiac function. 
• Endocrinology supports normal glucose regulation. 
• Neonatology supports normal transition after birth. 

Maternity care should be no different. Understanding physiology does not mean refusing intervention. It means recognising how the body functions normally, creating environments that support those processes, and intervening promptly when physiology is no longer sufficient. Unfortunately, this distinction has become deeply blurred in public debate. The phrase "normal birth ideology" has become a convenient shorthand that conflates two entirely different concepts: 

1. Supporting physiological childbirth based on biological science. 
2. Pursuing a vaginal birth despite emerging clinical evidence that intervention is required. 

They are not the same thing. Indeed, one of the defining skills of expert midwives and obstetricians is recognising when physiology is progressing normally and when it is beginning to deviate. Good maternity care is not about avoiding intervention; it is about intervening at the right time, for the right reasons, in genuine partnership with the woman. 

The Cost of a Misguided Debate 

If the public is led to believe that birth physiology itself is inherently unsafe, confidence in continuity of midwifery care, birth centres, and community-based services will be undermined, despite decades of evidence demonstrating their safety for appropriately selected women. We risk dismantling the very models of care associated with better outcomes because they have become caricatured. 

Complex systems rarely fail for a single reason. Aviation accidents, nuclear incidents, and major industrial disasters are seldom caused by one mistake; they arise when multiple layers of defense fail simultaneously. Maternity care is no different. The UK reports describe complex systems failures, not a single flawed philosophy. Perhaps the greatest lesson from these inquiries is not that maternity services over-supported physiology, but that they failed to create the organisational conditions in which physiology could be safely observed, understood, and supported. 

Reframing the Path Ahead 

To fix this, we need to completely reframe the debate: The opposite of intervention is not normal birth. The opposite of intervention is neglect. Good maternity care lies precisely between those extremes: understanding physiology well enough to support it when it is healthy and recognising early when it is no longer safe. This perspective moves us beyond the polarising language of "normal birth versus intervention" and towards what the inquiries consistently point to. Safer maternity care depends on well-functioning systems staffed by professionals who work collaboratively, listen to women, and act decisively when circumstances change. 

We already know what makes maternity care safer: continuity of relational midwifery care, adequate staffing, psychologically safe teams, respectful multidisciplinary collaboration, informed decision-making by the woman, and organisations that learn rather than blame. 

These elements are not in competition with physiological birth; they are the very conditions that enable physiology to be supported safely and intervention to occur when needed.

Reorienting Safety Culture in Maternity Care

Why “Patient Safety” Falls Short and What We Must Do Instead

Introduction: Time for Change

In healthcare, 'patient safety' is a foundational concept (Institute of Medicine, 2000). Preventing harm and promoting high-quality care are essential. In maternity care, the term patient safety is embedded within a medicalised, hospital-centric model that can be at odds with midwifery philosophy and the experiences of birthing women.

We must ask: Safe for whom, and by whose definition? This blog post argues for a shift in safety culture; from a focus on protocols and risk aversion to one that centres each woman’s wellbeing and safety in all its dimensions.

Please note: throughout this blog post, I use gendered language (e.g. “maternal,” “mothers,” “women”) with the acknowledgement that some who give birth do not identify as women.

The Problem with 'Patient Safety' in Maternity Care

The term 'patient safety' emerged from a hospital risk-management paradigm focused on preventing clinical error (Institute of Medicine, 2000). It assumes that the care recipient is ill, passive, and dependent, and that safety is achieved through compliance and protocol.

This framing is a poor fit for maternity care. Childbirth is not an illness. The majority of women are well, and the birthing process, when supported physiologically and respectfully, often unfolds safely without intervention (Consensus statement, 2013).  The term patient strips women of agency, embedding a power imbalance, positioning them as objects of care, rather than autonomous participants. It reinforces a culture where decision-making is top-down and where deviation from protocol is seen as dangerous, regardless of the woman’s values or the context. Safety in this context is too often reduced to physical outcomes alone. While survival is of course paramount, the ‘patient safety’ focus on physical outcomes neglects emotional, psychological, cultural, and relational safety, all of which profoundly impact a woman’s experience and recovery (Bohren et al., 2015).

Consequences of a Misaligned Safety Culture

• Over-medicalisation: Risk-averse environments may lead to unnecessary interventions that increase morbidity and trauma (Birthrights, 2013).
•  Disempowerment: Women may be coerced, ignored, or denied informed choices “for their own safety” (Keedle et al., 2022).
• Moral injury among midwives: Midwives may be unable to practise in ways that align with their professional knowledge and values (Kendall‐Tackett & Beck, 2022)
• Structural harm: Racism, cultural insensitivity, and obstetric violence are often overlooked in traditional safety audits (Hailu et al., 2022).

A Midwifery-Informed Vision: Woman’s Wellbeing and Safety

• Holistic: centring the whole person, physical, emotional, cultural, and social (O’Reilly et al, 2025).
• Embracing partnership and informed decisions (Esteban-Sepúlveda et al., 2022)
• Valuing continuity of care and trust (Homer, 2016).
• Recognising women’s right to define their safety. (Rönnerhag et al., 2018)
• Safety, in this sense, is not the absence of clinical error: it is the presence of respect, choice, connection, and support (Lyndon et al, 2018)

Practical Steps Toward Reorientation

1. Replace “patient safety” with “woman’s wellbeing and safety.”
2. Value relational safety and continuity of care.
3. Embed emotional, psychological safety and Cultural Safety as essential elements.
4. Foster reflective, non-punitive team cultures.
5. Involve women in defining what safe care means.

Conclusion

True safety in maternity care cannot be achieved by clinging to a model that sees women as patients and care as something done to them. We must shift from a safety culture of control and compliance to one of trust, relationship, autonomy, and respect. Language is not neutral and by choosing to centre each woman’s wellbeing and safety, we take a meaningful step toward care that is not only safer but also more just, more respectful, and more human. Safety in maternity care must move beyond checklists and compliance. It must be woman-defined, relational, and holistic. The term “patient safety” no longer serves us — if it ever did. By reorienting our language and our culture toward each woman’s wellbeing and safety, we honour not only midwifery values but the human dignity of every woman giving birth.

Let us choose our words and our paradigms wisely. They shape the care we give.

What do you think? Do you agree? Do you disagree? 

References

Birthrights. (ND). Human rights in maternity care: the key facts. https://www.birthrights.org.uk

 Bohren, M. A., et al. (2015). The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review. PLoS Medicine, 12(6), e1001847. https://doi.org/10.1371/journal.pmed.1001847

Chauncy, C., Dawson, K., & Bayes, S. (2025). What do safety and risk mean to women who choose to birth at home? A systematic review. Midwifery, 144, 104340. https://doi.org/10.1016/j.midw.2025.104340

 Esteban-Sepúlveda, S., Fàbregas-Mitjans, M., Ordobas-Pages, L., Tutusaus-Arderiu, A., Andreica, L. E., & Leyva‐Moral, J. M. (2022). The experience of giving birth in a hospital in Spain: Humanization versus technification. Enfermería Clínica (English Edition), 32, S14-S22. https://doi.org/10.1016/j.enfcle.2021.10.007

Hailu EM, Maddali SR, Snowden JM, Carmichael SL, Mujahid MS. Structural racism and adverse maternal health outcomes: A systematic review. Health Place. 2022 Nov; 78:102923 https://doi.org/10.1016/j.healthplace.2022.102923

Homer, C. (2016). Models of maternity care: evidence for midwifery continuity of care. The Medical Journal of Australia, 205(8), 370-374. https://doi.org/10.5694/mja16.00844

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington. DC: The National Academies Press. [Link](https://doi.org/10.17226/9728)

Keedle, H., Keedle, W., & Dahlen, H. (2022). Dehumanized, violated, and powerless: an Australian survey of women's experiences of obstetric violence in the past 5 years. Violence Against Women, 30(9), 2320-2344. https://doi.org/10.1177/10778012221140138

Kendall‐Tackett, K. and Beck, C. T. (2022). Secondary traumatic stress and moral injury in maternity care providers: a narrative and exploratory review. Frontiers in Global Women's Health, 3. https://doi.org/10.3389/fgwh.2022.835811

Lyndon, A., Malana, J., Hedli, L. C., Sherman, J., & Lee, H. C. (2018). Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 324-332. https://doi.org/https://doi.org/10.1016/j.jogn.2018.02.008

O'Reilly, E., Buchanan, K., & Bayes, S. (2025). Emotional safety in maternity care: an evolutionary concept analysis. Midwifery, 140, 104220. https://doi.org/10.1016/j.midw.2024.104220

Rönnerhag M, Severinsson E, Haruna M, Berggren I. Qualitative study of women's experiences of safe childbirth in maternity care. Nurs Health Sci. 2018; 20: 331–337. https://doi.org/10.1111/nhs.12558

Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. (2013). The Journal of Perinatal Education, 22(1), 14–18. https://doi.org/10.1891/1058-1243.22.1.14

Have you registered for International Day of the Midwife yet?

Registrations are open to join the most amazing and virtual midwifery conference! 

Midwives Making Connections

Here's the link to theVirtual International Day of the Midwife Conference 2025

Starts on Mon, 5 May 2025 10:30 AEST

Free, 24-hour virtual conference with global speakers and posters! 

The Virtual International Day of the Midwife (VIDM) is an annual online FREE conference that celebrates the International Day of the Midwife. It is held on or around May 5th each year to be as close to the International Day of the Midwife as possible.

VIDM runs for 24 hours and covers a wide range of subjects with speakers from around the globe. It uses online conferencing software to bring together people who have an interest in childbirth matters – midwives, students and consumers — all completely free.

Skin to skin contact at birth reduces the woman's probability of PPH

 Did you know that a newborn baby, having skin-to-skin with its mother at birth and access to her breast for feeding, reduces the woman's probability of experiencing postpartum haemorrhage?

This new study

https://www.webofscience.com/wos/woscc/full-record/WOS:001396687100001?AlertId=dbfbdef5-f56a-4576-9b3c-1250a8dc74ea

found that it does, as we did ten years ago!

https://www.sciencedirect.com/science/article/abs/pii/S026661381500203X?via%3Dihub

Art by the wonderful Amanda Greavette from her Birth Project

#evidencebasedpractice

#reducePPHrate

#skintoskincontactatbirth

What does ChatGPT know about Maternal Health?

 ChatGPT is a phenomenon that is causing both concern and excitement in academic circles.  The concern is about students being tempted to use the AI to write their essays.  The excitement is about students learning to critique what the AI program writes in response to questions.  There is also conversations about whether AI can mark students assignments!  I enjoyed reading this article by Mark Schaefer on Medium outlining 20 Entertaining Uses of ChatGPT You Never Knew Were Possible. 

I like asking the AI questions, to see what comes up.  I am teaching a course about Global Maternal Health so thought I'd ask it "what's happening with Global Maternal Health".  The response was: 

Maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period. While progress has been made in improving maternal health globally, there are still significant challenges that need to be addressed.

According to the World Health Organization (WHO), approximately 810 women die every day from preventable causes related to pregnancy and childbirth. Most of these deaths occur in low-income countries, and the majority of them are due to complications such as severe bleeding, infections, high blood pressure, and unsafe abortions.

In addition to the high maternal mortality rates, many women also suffer from complications and long-term health problems related to pregnancy and childbirth, such as obstetric fistula, which can cause incontinence and social stigma.

To address these issues, efforts are being made to improve access to quality maternal healthcare services, including skilled birth attendants, emergency obstetric care, and family planning. The WHO has set a target of reducing the global maternal mortality ratio by at least 70% by 2030, and many countries are working towards this goal.

However, the COVID-19 pandemic has had a significant impact on maternal health, with disruptions to healthcare services and increased health risks for pregnant women. It is essential to continue prioritizing maternal health and to address the ongoing challenges and inequalities that affect women's health and well-being globally.

A reasonable overview but no mention of the Sustainable Development Goals, although the WHO goal to reduce maternal mortality ratio by 2030 is a nod in their direction. 

I then asked 'What can we do locally to improve maternal health?' The response was: 

Improving maternal health requires a multi-faceted approach that involves various stakeholders, including healthcare providers, policymakers, community organizations, and individuals. Here are some actions that can be taken locally to improve maternal health:

1. Increase access to quality maternal healthcare services: Pregnant women should have access to affordable and high-quality healthcare services, including antenatal care, skilled birth attendants, emergency obstetric care, and postnatal care.

2. Promote maternal health education: Educating women and their families about healthy pregnancy practices, including proper nutrition, exercise, and prenatal care, can help prevent complications and improve maternal and fetal health.

3. Address social and economic factors: Social and economic factors, such as poverty, lack of education, and gender inequality, can impact maternal health. Addressing these factors through programs that promote economic empowerment, education, and gender equality can improve maternal health outcomes.

4. Encourage family planning: Access to family planning services can help women plan and space their pregnancies, which can reduce the risk of maternal and infant mortality.

5. Support community-based initiatives: Community-based initiatives, such as support groups for pregnant women, can help provide emotional support, promote healthy practices, and address cultural and social barriers to maternal healthcare.

6. Advocate for policy change: Advocating for policies that promote maternal health, such as laws that improve access to healthcare services and promote gender equality, can help improve maternal health outcomes.

By taking these actions, individuals and organizations can work towards improving maternal health locally and contribute to the global effort to reduce maternal mortality and morbidity

Again, a good general response. Interestingly skilled birth attendants are mentioned but not continuity of midwifery care which actually has been found to tick all the boxes outlined in the list of the multifaceted approach.  The Millennium Development Goals (MDG's) focused on the provision of skilled birth attendants and in terms of global maternal health, the ratio has worsened in many regions. 

So I asked "how can continuity of midwifery care contribute to global maternal health? 

This was the response: 

Continuity of midwifery care refers to the provision of care by the same midwife or a small group of midwives throughout pregnancy, birth, and the postpartum period. This approach has been shown to have several benefits for maternal and newborn health, including:

1. Improved outcomes: Continuity of midwifery care has been associated with reduced rates of preterm birth, low birth weight, and neonatal mortality. It can also reduce the need for interventions such as cesarean (US spelling) section and epidural anesthesia (US spelling).

2. Improved maternal satisfaction: Women who receive continuity of midwifery care report higher levels of satisfaction with their care, as they develop a relationship of trust and familiarity with their midwife.

3. Cost-effective: Continuity of midwifery care has been shown to be cost-effective, as it reduces the need for interventions and hospitalizations.

4. Increased access: By providing care in the community, continuity of midwifery care can increase access to care for women who live in rural or remote areas.

Implementing continuity of midwifery care can be challenging, especially in low-resource settings where there may be a shortage of midwives or other healthcare providers. However, this approach can contribute to improving maternal health globally by providing women with high-quality, personalized care that addresses their individual needs and preferences. It can also help reduce the global burden of maternal and newborn mortality and morbidity, particularly in low-income countries where access to quality maternal healthcare services may be limited.

Rather good overview by ChatGPT of continuity of midwifery care, don't you think?  If ChatGPT knows the benefits, then we must make sure that our politicians and policy makers know too.