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Backsliding in Oz: A letter from AIMS Australia and Homebirth Canberra to Dr Carmen Lawrence at Parliament House

A History of Community Midwifery Funding in the ACT

During the early 1970s the ACT (Australian Capital Territory) health system offered no alternatives to women wanting to choose how, where and with whom they wanted to give birth. From 1976, a few women, assisted by a registered midwife and two doctors, began to choose to give birth at home. By 1980 the practice of midwives, assisted by doctors, providing care during pregnancy, birth and the postnatal period was well established here, although only on a private fee for service basis. Women could not receive care from their independent (private) midwife in any ACT hospital. There were no publicly funded community midwives. Women choosing independent midwives had no access to public reimbursement or to private health fund cover.

Around the country, birth centres were established in public and private hospitals. Sydney's Crown Street Hospital For Women opened its birth centre in 1979.

In 1984 the Medicare Benefits Review Committee, chaired by Justice Robyn Layton, heard evidence from women, midwives, doctors and other groups. Homebirth Australia (which included the Canberra Homebirth Association) presented to the Committee a large folder containing every available current research article (hard copy) on the benefits, safety and philosophy of birth at home compared with hospital and care by midwives. The Royal Australian College of Obstetricians and Gynaecologists presented four references, of which three were on the dangers of birth at home and the need for obstetric care.

The Committee found that, although midwives working within the home environment were not irresponsible or unsafe, and despite "exhaustive canvassing of the issue" (Senator Cook, 1989), a simple extension of the fee for service arrangements to their services was not favoured (nor to the services of dentists, chiropractors and others).

In 1986 the National Health and Medical Research Council (NHMRC) Women's Health Committee acknowledged that

homebirths and alternative birth centres were well established and that there should now be a focus on establishing formal National standards of care and ensuring the existence of adequate support facilities in order to give women assurance of quality of care (quoted in the National Health and Medical Research Council, 1987, Report of the Working Party on Homebirths and Alternative Birth Centres).

The Committee recommended that a working party on home births and alternative birth centres be established.

In 1987 the NHMRC released the Report of the Working Party on Homebirths and Alternative Birth Centres. The authors recognised that "although birth centres have been established around Australia the demand for homebirths is not lessening and in recent years the number of births taking place at home has continued to rise" (1). The NHMRC Statement on Homebirths (1989) recommended that:

women who choose to give birth at home should have access to an integrated team of appropriately trained health professionals with adequate resources. This team should include both community-based (e.g. registered midwife and/or GP) and hospital-based (e.g. obstetrician and paediatrician) personnel (2).

Assistance for women choosing home birth was proposed after questions and speeches in the Federal Parliament by several Members and senators (Jean Jenkins, Rosemary Crowley, Peter Shack and Peter Cook) and an amendment to ensure funding for home birth midwives was proposed:

the Senate is of the opinion that women who choose to give birth at home are disadvantaged because of their ineligibility...(3).

Finally, it seemed, home birth funding had arrived. The Community Services and Health Legislation Amendment Bill (1989) was debated thus:

Senator Jean Jenkins (Democrat, WA), supporting an amendment to the Bill in favour of midwives' fees for births at home:

Because there is no Medicare rebate, midwives tend to charge minimal fees (or none) for a homebirth ... Nonetheless, the result of this situation is a case of discrimination against women who cannot afford to have a homebirth.
I point out to the Senate that an increasing number of women are recognising the advantages of a homebirth. ... Homebirth is not for everyone but some women want this.
...(in WA the aims of a task force which is currently reviewing obstetric...services) "are to assess the quality of care currently...and to investigate the possibility of alternative types of services which will allow for increased consumer choice. That is what I am talking about: the ability of women to give birth at home if they want (4).

Senator Cook (WA - Minister for Resources), supporting the legislation, replied:

The Government does not disagree with the intent of the Democrats' amendment ... This issue was again raised extensively during the consultations on the development of the national women's health policy. The Department of Community Services and Health has been considering several options ... The Government would like to see a wider range of birthing options available to women ... safety issues must be considered...hospital admitting rights available to midwives... The Government would like to provide financial assistance for those women who choose an appropriate home birth. I suggest 'the Government should take action to provide financial assistance for midwives associated with home births'.(5).

This acceptance by the Government of the principle of the Democrats' amendment led directly to The Women's Budget Statement 1989-90 (Budget related Paper No. 6), which included the following:

Birthing Services

The Birthing Services Options will provide an incentive package to assist States/Territories to reorganise their services to achieve more cost-effective delivery and longer term improved use of health resources. Current funding arrangements promote specialist dominated hospital birthing services. Developing alternative and more cost-effective services will improve resource utilisation and offer women choices. States will be encouraged to provide a comprehensive range of birthing services and midwife assisted homebirths to supplement the existing hospital programs (6).

To date, this money has been used to establish pilot home midwifery programs in only two States, South Australia and Tasmania.

In the ACT a strong group, ACT For Birth, took up the public demand for midwife assisted births and used the Commonwealth funds to create the in- hospital, doctor-dominated Birth Centre within Woden Valley Hospital. Those women who wanted to give birth at home, with a known midwife who had provided their antenatal care, chose not to utilise the Birth Centre even though the care there was, in relative terms, free. The homebirth community waited, hoping that some funds would eventually become available after the needs of the "middle ground" had been met. Home birth and the practice of community midwifery, after all, is safe, legal and federally funded.

In 1993-4 the renewal of the funding for a further four year phase to 1996-7 came as a great relief to home birth groups around Australia, and particularly to those in the ACT, where twice as many women (per head of population) give birth at home compared with other States.

The Alternative Birthing Services Program aims to promote greater choice in birthing services in the public health system and to provide an incentive to States and Territories to establish low intervention birthing services managed primarily by midwives...
The program contributes to the establishment of services which are: midwife based; recognise that pregnancy and childbirth are, in the majority of cases, normal life events requiring minimal intervention; involve women as active partners; and provide continuity of care (7).

Supporting the Program in 1993/94, Senator Crowley said:

This program allows women to have the support of a midwife at home if they so choose or to have the baby born in an alternative birthing room in hospitals (8).

Later in 1993, Senator Crowley drew attention to the fact that, in Western Australia, the implementation of the Program had been obstructed by the AMA.

It is a concern that many women who have contacted me directly...are not able to have the option of a choice of birth...because of the unspent money under the alternative birthing program and because of obstruction by the AMA...

Senator Crowley was pleased to propose that, under the allocation of alternative birthing money,

salaried midwives can be appointed to hospitals with the opportunity to work in the hospital and also in the community to assist women to have homebirths if that is their choice. I am very pleased to have the opportunity to assist the women of Australia to be able to make that choice (9).

In 1994 the ACT Department of Health lodged an application for an ABSP grant, proposing, inter alia, to provide "support for women during her birth in whatever setting she chooses" (sic) and was awarded $58,000 per year over four years.

A press release issued by the Federal Minister for Health, Dr Carmen Lawrence, on 21 November 1994 announcing the award of the grant stated that:

In the ACT funding will be used to employ midwives...to provide antenatal care, support for women during birth in whatever setting they choose, and postnatal care.

ACT health consumers strongly supported this proposal and continue to do so.

There is no question that the original primary intention of the Members and Senators who proposed and supported the provision of the ABSP funding was to provide high quality midwifery care for women choosing to give birth at home. In the ACT, this intention has been effectively negated by the establishment and siting of the Birth Centre within Woden Valley Hospital. The Birth Centre represents a continuing adherence to the dominant medical model. The cost effectiveness of the Birth Centre has not been proven; at the very least it is questionable. By contrast, the cost effectiveness of home birth is obvious. Politically the Birth Centre is a soft option which ignores the fact that women continue to choose to give birth at home. As there is targeted Federal money for midwives' services in the community, it is imperative that the ACT utilise it to the best advantage for the purpose for which it was intended, not for services that are anything but home birth or even community based.

Pregnant women are often asked to wait and be patient. Women who want to give birth at home have waited almost twenty years. When will their patience be rewarded


References

1. National Health and Medical Research Council, 1987, Report of the Working Party on Homebirths and Alternative Birth Centres

2. National Health and Medical Research Council, 1989, Statement on Homebirths

3. Commonwealth of Australia, Hansard, 13 June 1989, Community Services and Health Legislation Amendment Bill (1989) p.3900

4. Commonwealth of Australia, Hansard, 13 June 1989, Community Services and Health Legislation Amendment Bill (1989) p.3894

5. Commonwealth of Australia, Hansard, 13 June 1989, Community Services and Health Legislation Amendment Bill (1989) p.3899

6. Commonwealth of Australia, Women's Budget Statement 1989-90 (Budget related Paper No. 6), p.84

7. Department of Health and Human Services, Annual Report 1993-94 p.77

8.Commonwealth of Australia, Hansard, 30 August 1993, Questions without notice, p.472

9. Commonwealth of Australia, Hansard, 19 November 1993, Questions without notice, p.3284

Shane Marsh
23 March 1995


For more about homebirth in Australia, read Backsliding in Oz, letter from AIMS Australia and Homebirth Canberra to Dr Carmen Lawrence at Parliament House.

To: Midwifery Today - Birth Index - Midwifery information

Last updated 7/23/95 by Donna Dolezal Zelzer, djz@efn.org