Hello, where are you a Professor of Midwifery?
In Western Sydney University, Sydney, Australia.
photo by Holly Priddis
What are the requirements to become a midwife in Australia?
There are two pathways to become a midwife in Australia. One pathway is that you do Nursing first and then you do a postgraduate qualification at university. All of the training is at university. The only way to be certified as a midwife in Australia is to do a university degree. So that’s one pathway. Sometimes Nursing and Midwifery are done together over a four year double degree.
The second pathway is what we call a Bachelor of Midwifery, which is where you come out of school or from a previous qualification and you do three years and come out with a Bachelor of Midwifery. So there’s only two pathways.
Can you practice as a home birth midwife with either degree?
So that’s now another level of complication. There’s legislation in Australia guiding this. There’s nothing to stop you from going out and setting up a practice, but there are all these hoops that actually mean you can’t do that.
As a midwife you need to have insurance. We have an insurance product for private midwives that covers them for antenatal and postnatal, but no insurance product for home birth. As a result of that there’s a whole safety and quality requirement that needs to be met, and part of the safety and quality requirements are that you need to be able to practice across the scope. You need to do so much professional development, you need to do professional reviews, etc. etc.
You need to produce your statistics and register births. In order to get the insurance, you need to have what we call ‘endorsement’ as a midwife. To become an endorsed midwife, you need to show three years of practice across the scope, you jump through many, many hoops, you then get a registration of endorsement. That registration then enables you to go on and do a further qualification in prescribing and ordering medications, and once you have got your prescribing and ordering qualification, then you can apply for the insurance.
So all these things stop people from coming straight out and going into providing home birth care.
There are two systems of home birth in Australia: a public system and private system.
The majority of births are in the private system with private home birth midwives. However, more and more publicly funded home birth programs are developing; They run out of a hospital, and they often run out of a group practice or a birth center. So there are fourteen now completely funded home birth programs where midwives are employed by the hospital to also provide home birth services.
Privately practicing midwives are self-employed and those ones have to get the insurance and the endorsement before they’re able to practice.
Is there public health insurance in Australia?
Will they cover the private midwives as well?
No. The public hospitals are insured by Treasury Managed Fund. It insures all public health workers. So midwives who work in the hospital who are part of a publicly funded home birth system are insured by the hospital under that. However, the hospital has very strict guidelines who can have a home birth and who cannot. We’re writing a book on this whole issue this year. For example, if you refuse to have a GBS swab for Group B Strep, if you refuse to have a Glucose Tolerance Test, you may be kicked out of the program.
I’ve just written about a woman who lived within 29 minutes of a hospital for her first publicly funded home birth, and then the hospital changed the system and even though she hadn’t moved and neither had the hospital, she now lived 31 minutes from the hospital and they refused to have her in the program due to having a 30 minute rule. So the public system is very rigid. You have to be super low risk, and if you go over 42 weeks you can’t have a home birth supported by them. They’ll literally ring up at 9 in the morning and go, ‘You are no longer covered and we won’t come for a home birth.’ So that’s a problem.
In the private system, the midwives do VBACs, and there’s much more flexibility around choice.
Because they are privately paid for?
Because it’s a private system you are not therefore regulated by the policies and procedures of the hospital organization. And the woman directly employs that midwife, and that automatically puts the midwife into a position of being a provider of a service rather than somebody who has the right to say ‘no’ to a woman’s choice.
Are there regulations on midwives in general?
Yes, so many…different to the U.S. where you have many different brands of midwives where you have Certified Midwives, Licensed Midwives,and then you have Certified Nurse Midwives who work mostly in the hospital system.
We have one registration so whether you do your Bachelor of Midwifery degree, or whether you’re a nurse that goes on to do 18 months of postgraduate Midwifery, you come out with the same registration. Then we have codes of conduct, we have registration and education standards, we have to complete audits every year around whether or not there’s been any notifications on your practice. There’s a lot of requirements around regulating midwifery in Australia.
As far as regulations on home birth, only the public ones are regulated. With private midwives, you can have a VBAC at home if you want, you can have a baby after 42 weeks at home, there’s no regulations for that?
Ok this is where it gets interesting. I’m writing a book that will be published this year called, ‘Birthing outside the system: The Canary in the Coal Mine,’ on the topic of why women are birthing outside the system. So we have laws that say women have the right to determine what will happen to their body. Theoretically. However, what they do is, because they can’t regulate a woman’s body and a woman’s choices, they target the midwives. So if a midwife transfers a woman who’s having a VBAC at home to the hospital, there’s a huge number of hospital personnel reporting those midwives to regulatory authorities. When that happens, the midwife has to go through six months to two years of writing reports, going through tribunals, explaining that the woman had made an informed decision and she was not coercing her. We’ve got a chapter in our book on this, it’s called ‘The Witch Hunt’, about how half the midwives in Australia have been reported to the regulatory authorities. Many of them have just left practice because it was too hard. So yes you can have a VBAC, yes you can have a baby at home after 42 weeks, but as a midwife you risk getting reported and penalized.
Do you personally deliver at home births now or are you teaching?
I do both. I take on around ten women a year in a caseload practice. I’m part of a team of private midwives called ‘Midwives at Sydney and Beyond’. There are six of us and we catch half the home birth babies in New South Wales.
How popular is home birth in Australia? Is it really stigmatized like in the United States?
Yes, it’s very stigmatized. The rate in Australia is 0.3%.
Wow, that’s very low.
Yes, but this is the interesting thing. This is another chapter in the book on research that we’ve done, that there are more people now probably free birthing at home without anyone in attendance or no registered midwife in attendance, than there are home births with registered midwives.
If you look at the whole of Australia and how many midwives are providing private home birth services, there are about 240 midwives. That’s a very small number for the entire nation, and they’re dropping every year because of this reporting and victimization that is happening. So we know there are more women who free birth, who choose to birth without a midwife, now than there are births with a midwife. This happens, because they either can’t find a midwife, they can’t afford them, or they’re too far away- they live in rural remote areas where there are no private midwives. They may also be so traumatized by the system and their experience with health providers that they don’t even trust midwives.
The U.S. has got the same situation of rising rates of free birth. Hence why we’re writing this book, ‘The Canary in the Coal Mine’. We’re not listening to the women who are telling us the system is traumatizing them. There are not enough options. They’re seeking midwifery care. They’re seeking relationship based care. We’re continuing to ignore it so they go off and they do their own thing. Then we turn around and we demonize them when it’s actually our fault for not meeting women’s needs.
Most midwives in Australia practice in hospitals?
Yes, 99% are practising in hospitals.
Are midwives doing primary care, like in England where pregnant women see a midwife and only see an obstetrician if there are any complications?
In Australia we have a system probably halfway between the U.S. and England. 25% of women have private insurance, which means that for their birth they have a private obstetrician who does their antenatal care and who comes in at the last moment to catch the baby; The midwives in the hospital do all the rest of the care.
The other 75% are cared for in a variety of models. Around 10% of those women now are in continuity of midwifery care programs where they have a known midwife who provides antenatal care, comes in for their birth, and does postnatal care. That’s 10% of women.
The remaining 55-60% of women are cared for in a variety of fragmented models. There might be shared care with a general practitioner. There might be shared care between a midwife and a midwife clinic, where one midwife catches the baby and different midwives do the postnatal care. Or it might be that they have risk factors so they go to the doctor’s clinic and midwives do the care and the birth.
We have a variety of systems including a public and private system. In our private sector, again I’ve done a lot of research on this, the intervention rates are so much higher, much higher cesarean, much higher epidural, episiotomy, you name it, because private obstetricians come from a very obstetric model.
What would you tell someone who wants to have a home birth but is afraid for her baby’s safety?
I think there’s a lot of discussion that needs to be had. I think it’s not as simple as is it safe or is it not safe.
We’ve just done a big systematic review where we looked at all of the studies of low risk women who intended to have a baby at home or birth it at hospital, and we’ve done a meta-analysis looking at all of that. There is no difference in babies’ outcomes if the woman is low risk and she has the attendance of a registered competent midwife.
But there is some trends going on, and certainly the biggest and best study ever done into home birth would be the U.K. Birthplace Study, which showed a slightly higher morbidity, remember it wasn’t deaths it was a morbidity, which included a whole lot of things, but it was slightly higher for women having their first baby. Our meta-analysis picked up a trend to it but it wasn’t statistically significant. However, the way I tend to put it is, there are probably slightly more complications for the baby at home if it’s your first; So we need to actually talk to women about a higher expectation that transfer is really normal with your first baby. We should think at least 20-30% of first time moms are going to be transferred. That’s normal. With subsequent mothers who’ve had a normal birth with their first baby, home birth is much safer. Those babies have less interventions, those mothers have less interventions, so what we can say is for first time mothers there’s slightly higher morbidity risk for the baby, but less risk for the mother. For subsequent mothers, lower risk for the baby, lower risk for the mother. And then really I think it’s a decision that women need to make with an understanding you’ll have more likelihood of a transfer with a first baby. Then you’ve got to think about where do they live? Australia, like the U.S., we have a massive land and we have hugely remote areas. So if you’re like 2 ½ hours from the nearest hospital, you’re going to make different decisions then if you live across the road from the hospital.
Women with risk factors like VBAC, breech, etc., we do know those risks are increased for the baby, however for the mother there’s less risk. So this is a discussion we never have. Society’s so focused on the baby they forget that that baby is not going to be in a good state if it has a mother in a poor state.
Yes, that’s right. It affects their bonding and it affects their relationship for a long time. It’s not so clear cut.
We don’t value that in society. We think only good mothers are mothers who sacrifice their needs for their baby. That’s society’s belief. However, good mothers are strong mothers, they’re competent mothers, they’re empowered mothers, and we’re not getting that with the way we are risking childbirth to the point where we’re devastating the hand that rocks the cradle. And we then sit there and wonder why we’re ending up with the dysfunctions that we’re seeing in children. We’re not valuing women enough. If we valued women, really valued women, we’d get it right.
I think unless you’ve had a home birth, or been at a home birth, it’s really hard for the general public to understand how different it is. Before I went in to do home births, I’d been a midwife for thirty years, and I had worked for twenty years in high risk maternity units, most of the time in the delivery ward. So I was a very expert midwife. I could suture in the dark, I could put venous access and take blood in my sleep, I was very skilled at emergencies, at all of those things.
But I moved out ten years ago doing mostly home births, primarily because I was so distressed at what I was seeing happen to women, and I was becoming a part of it. I found I thought I’d walk into there as the expert, but I walked into there having to unlearn so many bad habits. I found that the first few home births that I was at I could not sit still.
I was with really experienced home birth midwives who pulled out their knitting and knitted away, and I was used to running up and down delivery ward corridors being the efficient, competent midwife, and the efficient, competent midwife was the busy one. And suddenly I’m in a woman’s home for seventeen hours listening to Enya and smelling candles, and I was just beside myself, so I ended up having to take up crocheting (I’m not a good knitter), to stop myself, to take my adrenaline down and to make me present.
It took me a couple of years to unlearn the rush of midwifery and learn that the art of just simply being there is one of the most powerful tools a midwife has.
Now I love it. I love the lights all dim, the music’s playing, the dog’s sitting by the fire, the children are playing in their pajamas, and I am home.
I also had to relearn the way I related, because I was used to obstetric beds. I was used to the bright lights. I was used to women not functioning physiologically. So I had to relearn women’s progress signs as we weren’t doing vaginal examinations regularly. We were doing them if women wanted. I had to start learning the external signs a woman gives you, rather than always depending on how many centimeters she was. So for me, that expert midwife had a very hard lesson, that the most expert midwife was the one who sits and watches and learns from women.
That’s beautiful. Thank you. I love that and it’s true. That’s what it’s about. It’s about the woman and it’s about her journey.
It is. And every journey is so utterly unique, and I’d say I’ve become such an experienced midwife that I now no longer focus on how it’s going to be. Because I’ve learned that every woman can surprise you. And our job as midwives is to watch birth unfold. If it’s unfolding in a way that’s jeopardizing safety, our job is to step in, but not until then. We do so much stepping in in case. We think we are preventing but we’re just causing this cascade of problems.
I feel that unfortunately many women end up having home births after they’ve had a traumatic birth experience, which is sad. Women should know that there’s so much more out there than a hospital birth with a doctor who’s going to treat you like a patient, and you’re not a patient. You’re a woman giving birth.
So this is my argument when people say, ‘Well the risk is slightly increased for the first time mother.’ If you only look at the first time mother and you look at that in isolation, yes, perhaps for the baby the risk is slightly increased. If you look at a woman’s reproductive life journey, what happens in that first birth shapes the second, the third, the fourth. Potentially, what happens in that first birth is the morbidity that hits her in number three when she ends up with her placenta growing into her cesarean scar. So we can’t have this short term view of risk. We have to have a much broader look at risk, and we’re now doing research where we’re looking fifteen years after the birth. We’re looking at women who are low risk and who had a cesarean and we’re looking at women who are low risk and who had a normal vaginal birth. We’re looking at them fifteen years down the track at how many more interventions do they have, how many more morbidities do they have. What about when they’re starting to go through perimenopause and they’re starting to get very heavy bleeding; They’re more likely to lose their uteruses if they’ve had a cesarean. So until we take a long term view of physical outcomes, and until we take emotional and mental health as equally important as physical outcomes, we’re not going to change this discourse.
Thank you so much Professor Dahlen!