JULIA MEDEWThe provision of state funded homebirth services is a welcome sign of change in attitude towards the normality of birth, at least in the eyes of politicians and health care service bureaucrats. However, this pilot scheme is funded for one year. What happens after that is anyone's guess. The skeptic in me is suspicious that this 'offer' is to mollify the insurgents and designed to keep people quiet. Given the groundswell of support from the community for privately practising midwives to provide homebirth services for women who want to birth at home, that is a reasonable suspicion.
December 23, 2009VICTORIAN women will be able to give birth at home - with hospital back-up for the first time - under a pilot project starting at three hospitals next year.
Health Minister Daniel Andrews said yesterday that the State Government had allocated $400,000 for midwife-led home births through Casey Hospital in Berwick and Sunshine Hospital in Melbourne's west. A regional health service will also participate, but the Government has yet to decide which one.
Those of you old enough to remember will remember the fanfare and Commonwealth money dished out to fund midwifery model of care pilot programs following the Shearman report in the late 80's. Many programs were funded in the early 90's. As soon as the money ran out, however, those models fell over and childbearing women across the country were left high and dry, with no midwifery service. The only model to survive those halcyon days was the Community Midwifery practice in Perth, Western Australia. The only reason that model continued was because the state government at the time agreed to fund it.
Time will tell if this is a Wizard of Oz or Emperor's New Clothes situation or not. The government may be sincere in wanting women to have true choice, however true choice means equity for all health professionals, not just those with the most money and the most power.
A disturbing aspect to this pilot project is that the government is hoping that private midwives will want to work in the program and become state funded employees. While that sounds good on the surface, the reality is that along with state funding comes state rules and regulations which is where the problems start for some people. Midwives who work privately do so because they want to work in their full scope of practice and be 'there' for those women who request their services. That means being on call for those women. With state run services there are rules about how many days you can work, how many hours you can work, who you can work with and how you do your work. Depending upon how the project is structured, women may or may not know who will attend them for their birth; they may not know the midwife on the other end of the phone when they ring in labour. Those rules and regulations are designed to protect the institution. Because the rules and regulations are designed for institutional needs, not the birthing woman's needs, they end up creating a 'cookie cutter' approach to maternity care work. A birthing woman does not necessarily fit neatly into a proscribed pattern of care provision. Privately practising midwives I know choose to work as a contracted employee of the woman, within their scope of practice and according to their professional requirements, not contracted by the state to have their working schedule dictated by rules and regulations for government purposes. Private midwives primary focus is on the woman and what her needs and desires for the birth of her baby were. Serving two masters never works.
An article which explored the ethics of caring for nurses in the health care system identified three ways that nurses align themselves. The first way is aligned with the institution, the second, aligned with doctors and the third, aligned with 'patients'. Midwifery ethics, as described by Fay Thompson, are clearly 'with woman'. While some privately practising midwives may be interested in working in state run institutions, others are not going to be interested in working for the state.
Apart from the right to work in way that is aligned with one's ethical and professional values, our profession needs privately practising midwives. Midwives in private practice demonstrate what midwifery care is at its essence and provides an inspirational role model for future midwives. Midwifery knowledge and wisdom, which has, in institutionalised maternity care, been subsumed under the technocratic approach to childbirth of the medical model, is held and passed on by privately practising midwives.
To sum up, this pilot study is welcomed, but this year long program, even if it continues, does not take the place of ensuring there are robust structures in place for the continuation and support of private midwifery and a woman's choice to birth with someone she knows and trusts.
Home-birth boost for expectant mothers
