The government has decided to scrap a proposed definition of “low risk” pregnancy for private practice midwives providing home birth services after stakeholders successfully argued the definition was too restrictive.
The Commonwealth will indemnify privately practicing midwives on claims related to intrapartum care during home births for what could be a wider range of patients than initially thought.
Where there was originally going to be a legislated clause dictating that homebirth candidates had to meet a “low risk” definition, this has now been dropped in favour of “trusting midwives’ clinical judgement within their scope of practice”.
There will still be rules specifying the intrapartum services covered by government insurance, just not in the legislation itself.
It comes just as nurse practitioners and midwives are released from collaborative arrangement requirements, and in the same week as the final report from the Scope of Practice Review recommended introducing a bundled payment for midwife-led maternity care.
The government will not be extending its indemnity offer to any other health professionals involved in maternity care, despite the fact that medical indemnity fees for obstetricians tend to be among the highest of the specialties.
The situation has come about simply because there are no private insurers willing to insure midwife intrapartum care (i.e. labour) during a homebirth.
For about 15 years, private practice midwives have been operating under an exemption allowing them to provide homebirth intrapartum care without AHPRA-mandated indemnity insurance.
They were still required to be covered for any care before or after labour.
The exemption was only intended to be temporary but has now been extended on five separate occasions.
Enter the proposed government indemnity scheme, which came up for consultation earlier this year.
The product was initially intended to cover low-risk births, defined as being at-term singleton pregnancies with cephalic presentation, where the birthing location is within 30 minutes of an obstetric hospital.
Women with certain conditions listed under level B or C of the Australian College of Midwives’ guidelines for consultation and referral would also be included, so long as the midwife consulted with other practitioners.
Stakeholders from both sides of the aisle were unimpressed with this definition.
The National Association of Specialist Obstetricians and Gynaecologists, which represents private practice obstetricians, argued that the definition was far too broad.
Its specific critique was that there were no clear protocols for which type of provider was to be consulted on or referred to in cases of medium- or high-risk pregnancies.
“Category C women … include those with multiple previous caesareans, BMI > 50, complex medical conditions including cardiac conditions, [pre-term birth] and abruption,” the organisation wrote in its submission.
“This group represents the highest risk women who give birth.”
The Australian Nursing and Midwifery Federation, meanwhile, had “significant concerns regarding the lack of autonomy afforded to midwives to perform their role in accordance with their regulatory obligations as proposed by the … definition for low-risk birth”.
This was ultimately the view formed by the government as well.
“Government agrees that by trusting midwives’ clinical judgment within their scope of practice, and leveraging these robust existing guidelines, we can effectively support homebirth care in a way that ensures public safety while avoiding the potential pitfalls of a restrictive definition,” it said in a communique published by the Australian College of Midwives last week.
“Government believes this change in approach, informed by extensive consultation and a thorough understanding of the complexities involved, represents the best possible outcome for all stakeholders.”
Instead of a definition of “low risk” being included in the Bill, there will be scope for rules that specify the intrapartum services covered under the expanded Midwife Professional Indemnity Scheme.
Related
The intent is that these will be closer to the Nursing and Midwifery Board of Australia’s safety and quality guidelines for privately practicing midwives, rather than the Australian College of Midwives’ National Midwifery Guidelines for Consultation and Referral which formed the basis for the original definition of low risk.
As some stakeholders pointed out, the college guidelines were not written for a homebirth context; the nursing and midwifery board guidelines were.
It’s also worth noting that the nursing and midwifery board guidelines themselves refer back to the midwifery college guidelines in several key places, including clinical risk management.
The current insurance exemption will be extended one more time, with a final end date of 31 December 2026.
Private practice midwives will continue to provide homebirth intrapartum care at their own risk up until that point.
