Are we there yet?

From the Australian College of Midwives Presidents report September 2010

“Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek.” (Barack Obama)

Are we there yet, is a phrase that seems to hum along in the back of my mind a lot these days. This inevitably conjures up memories from my childhood of sitting in the back of a car full of hot, bored siblings; elbows digging into sides with increased frequency and viciousness as we go on some long trip to some imagined and longed for destination. Back then as a child I felt increasingly like not believing my parents the longer the trip went, especially as they kept angling their heads over the seat in my direction and shouting with increased frustration, “not long now! Please be good!” “That’s what you said last time,” I would holler back as the elbows once again jabbed into sides and the squeals became ever more painful in the back seat. When we finally got to the longed for destination and all tumbled out - a jumble of eager limbs - the reactions were varied. The optimists amongst us shrieked with glee while the pessimists scowled with discontent; but the truth was it was never quite how you imagined it - some things were inevitably better and some things were worse. Even when returning to a well-loved holiday destination, there was that moment when imagination and dreaming met reality, providing the ultimate confrontation to the integrity of memory.

My, are we there yet question, could relate to the past exhausting two years of maternity reform; the last tedious ten years of lobbying for maternity reform; the last painful twenty years of writing and arguing for maternity reform; or perhaps the last slow and repetitive three hundred years of oppression, revolution and renewed oppression and revolution.

So, are we there yet? Will we ever get ‘there’? What does ‘there’ look like? Do we all have the same concept of what ‘there’ will or should look like? I would suggest here is where the tension and eternal nature of this question comes from. I don’t intend to give an answer to a question that is probably at least 300 years old - if not older - but I want to talk about what we have achieved as a profession in getting to where we are and what we need to achieve in order to get ‘there’.

What have ‘we’ achieved?

Firstly, I would like to make clear that when I say ‘we’ that I mean ‘we’ in the true sense of what being a midwife is - ‘with woman’. Without the powerful presence of consumers in maternity service reform we would never be where we are today and without the continued partnership we have with consumers we will not be where we want to be tomorrow. Most importantly, consumer input is the best guide we have to where we strategically want to be, because if we are not meeting the needs of our consumers then we will fail dismally as a profession.

Secondly, we have grown as a College with over 5000 members and this is climbing everyday. We are the leading professional voice for midwives in this country and we should be very proud of this hard won achievement. Midwives are firmly on the map. In the past couple of years there has not been one month when the Australian College of Midwives (ACM) was not in the media and the ACM have been cited 1006 times in the past two years with an average of 1.4 media citations per day. The terms ‘midwife/midwives, midwifery’ have been mentioned 8425 times in the past two years with an average of 12 citations per day. Remember we have a running newsfeed on the ACM website and so on any day you can look and see what is being said about midwives in the media. Much of this media is positive and also high-impact in its placement on news pages and as headlines.

From 1 November 2010, eligible midwives will be able to provide Medicare funded care to women in the community and in hospitals, thanks to major reforms legislated by the government in March this year.  Medicare funded midwives will be able to work in practices in the community, with other midwives, with doctors and with allied health professionals as well as in hospitals to offer more women the choice of having one-to-one care from a known midwife throughout their pregnancy, labour, birth and early parenting.   The Australian College of Midwives has been public about acknowledging the Health Minister Nicola Roxon’s role in giving women wider choice with these important reforms. Likewise eligible midwives will gain access to PBS.

Insurance has also been secured, something we have been fighting for since 2001. The Commonwealth’s insurance scheme involves a contract with an insurer (MIGA) who can now provide insurance policies to midwives. MIGA policies will cover pregnancy and postnatal care in the community, and labour and birth care in a clinical setting.  For midwives not intending to apply for eligibility there is another product available through VERO that may suit some midwives. Please read all the information about the insurance products carefully and make sure you understand the implications and limitations of the product you select.

The National Health and Medical Research Council will soon release the National Guidance on Collaborative Maternity Care. This multidisciplinary committee, that I was pleased to be part of, has developed a wonderful document that is evidence-based and will help clinicians to provide women with care that puts them at the centre, where they rightly should be.

The National Maternity Services Plan has had input from a wide range of key stakeholders and is looking strong and supportive of midwifery care. We look forward to its release shortly.

The Breathing New Life into Maternity care collaborative conference held in Alice Springs in July was a great success, with over 400 midwives, doctors and consumers attending. The evaluation survey the ACM sent out has just been completed and the responses were overwhelmingly positive. The Australian College of Midwives joined with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Australian College of Rural and Remote Medicine to promise to work together on several issues. These are;

  • To rejuvenate a joint services committee where the various Colleges can talk about maternity care issues
  • To work on workforce and education needs together
  • To look at partnership opportunities so we can support for our neighbouring countries in Asia and the Pacific where maternal and perinatal outcomes are poor; and
  • To seek funding and support for a pilot program of ‘birthing on the land’ for Indigenous women to be fully costed and evaluated.

These are important steps forward in collaboration.

So here is the optimist’s view of the destination after the long trip! From this summary one might say it feels like we are ‘there’. However……..

What do we need to achieve?

That I guess is the good news but we are certainly not ‘there’ yet in other ways. We remain very concerned that the recently released Determination - known as the National Health Collaborative Arrangements for Midwives - could hinder the Health Minister Nicola Roxon’s good intentions for maternity reform. Barack Obama said, “A good compromise, a good piece of legislation, is like a good sentence; or a good piece of music. Everybody can recognize it. They say, 'Huh. It works.’ It makes sense.”

The National Health Collaborative Arrangements for Midwives certainly get no ‘Huh!’ We are yet to see whether doctors will be willing to collaborate with midwives and whether they will use this arrangement to try and control midwifery practice and impact on women’s childbirth choices. We are most concerned about the effect of these collaborative arrangements on women living in rural and remote communities where there may be no doctors at all or doctors on short-term contracts that the midwife will constantly be trying to negotiate with. There is now a real risk that midwives will not be able to take up the government’s reforms and they will fail.

ACM will be watching the impact of this legislation closely and we have sent several E-Bulletins out to you, the members, on this issue. We are asking our members to report any cases where there is difficulty obtaining collaborative arrangements or where the medical profession use the arrangements to control midwifery practice or deprive women of choice so we can use this in future negotiations with the Government. Minister Roxon has made it clear that she has no desire to see a medical veto over midwifery practice and we will be making sure that she keeps her word on this.

States and Territories must now come to the party and develop state-wide clinical privileging and standardised hospital access agreements so midwives can provide care for women in hospitals without all the current barriers they face. We are encouraging them to facilitate this process and to assist midwives to make these collaborative arrangements work for the sake of women and for the future of evidence based maternity reform in our country. Some States, such as NSW, are well on the way, while others have not yet started. We are also seeking guidance from the Department of Health, Australia on how we can set up clinical privileging to meet requirements for collaborative arrangements and reduce the problems midwives will encounter with these.

Homebirth continues to be unfunded and uninsured and there is a two year exemption in place on the requirement for midwives to hold insurance for intrapartum care in order to be able to register. The Safety and Quality Framework should be out shortly and we will notify you when it is officially up on the NMBA website so you can examine the implications for your practice. We will continue to lobby for funded and insured access to homebirth. The Australian College of Midwives believes that women should be able to choose their place of birth and care provider. It is also within the scope of practice of a midwife to be able to provide this care.

So here is the pessimist’s view of the destination after the long trip! Looking at this one would be able to say it feels like we are nowhere near ‘there’. However, perhaps there is one more view we need to consider and that is the realist’s view.

Where to now?

Recently I joined other international midwifery leaders commenting on the cumulative global impact of the recent Lancet editorial and other international studies and reports criticising homebirth and midwife-led care in America, Australia, the Netherlands and elsewhere. Cathy Warwick, General Secretary of the Royal College of Midwives, said: “We are extremely concerned that there appears to be a worldwide anti-homebirth, anti-midwife and anti-normal birth movement.  We feel under attack and that there is a concerted and calculated global attack and backlash against homebirth and midwife-led care.”

The Australian College of Midwives sent in a supporting statement and an article was published in the UK Guardian on this issue. I outlined the complex events occurring in Australia for the journalist: on the one hand reform and on the other oppression. It made me contemplate history again and the wise words of change theorists like Thomas Kuhn who would say this is pretty much how it goes. When you change the state of play and power structures it is common to see backlash and claw back of power. I believe we are seeing this internationally now as the evidence mounts and the traditional power structures in maternity care are challenged and shifted. We can react with depression, anger and helplessness or with insight, bravery and strategy. I am determined to follow the latter option and I know I share this view with many of you. We cannot give up and we cannot simply accept whatever is given to us. We need to be clever, political, strategic and above all persistent. Change has come and is coming, but we must also be ‘the change that we seek.’

So for the past two years of the maternity service reforms we have been in the back of the proverbial car moving towards our destination calling out, are we there yet? There has been some major frustration and a few sharp elbows and sore ribs along the way. In two short months we will be rolling up to one of our planned destinations as eligible midwives with access to Medicare and PBS. As we spill clamouring out of the car there is inevitably an element of frustration, fear, longing, dreaming, disillusionment and excitement. More work is needed on the collaboration arrangements to change them or make them workable. Insured, funded homebirth remains an outstanding issue.

As the pessimists and optimists view our destination ahead and we debate each other around the pros and cons, the realist in me muses that perhaps we will never truly get ‘there’ on everything at the same time and perhaps we need to redefine ‘there’ as a journey and not a destination.

If history teaches us anything then perhaps it is this; that the road to consensus is arduous and we rarely get everything we want, but we most certainly can shape and influence much of what we get. Are we there yet? No. Have we come a long way and had an impact? Most certainly YES!

From the Australian College of Midwives Presidents report December 2010. Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is

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