A Midwifery Success: Homebirth in the Australian Public Hospital System

Midwifery Today, Issue 145, Spring 2023.
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Matilda’s family sat in the garden enjoying a cup of tea while her contractions progressed. Members of her birth team showed up to offer steady support. Her midwife suggested a hot bath; her baby’s heart rate was quietly monitored and she visualized surrounding her baby with fresh air each time she took a breath. She gave birth in the bedroom that had been her husband’s in his childhood. Matilda’s peaceful homebirth, though it did not take place at a hospital, was entirely supported by the local public health system’s completely free midwifery and birthing services in Sydney, Australia.

I’m a 17-year-old DONA-certified doula from Denver, Colorado, USA. I spent the (Northern Hemisphere) summer in Sydney to learn more about the unique public hospital midwifery and birth system there. I enjoyed wide-ranging conversations with midwives, doulas, and birthing parents to get the full picture. As someone who is passionate about body autonomy, consent, and the reduction of obstetric violence, I was thrilled to learn about a public health system that addresses these issues, is available to all, and already exists in a major city.

In Australia, there are both public and private hospitals. In Sydney (in the state of New South Wales), the majority of people—around 75%—give birth for free in public hospitals, with a midwife as their primary care provider. Public hospital midwives work in rotational shifts on antenatal, birth, and postnatal wards, usually working in two out of the three units for an extended period of time. They are known as midwives who work in the “core system.” Most people who do not give birth in the public system hire a private obstetrician (at a substantial cost) and give birth at a private hospital. While the public system accepts women of all risk levels, some Australians opt for more monitoring and specialized care.

Julie Schiller is a former midwife who operated within the Midwifery Group Practice (MGP) system in South Australian public hospitals. The MGP model was founded about 20 years ago, but has grown substantially in recent years. It focuses on providing continuity of care throughout pregnancy, birth, and postpartum, assigning patients one lead midwife who will oversee all aspects of their care (and aim to be present at the birth if feasible).

“Most of us started in the group practice in 2006, but most of us had [already] been working in the birth center,” Julie said about her transition into MGP. “[W]e could see the advantages of having that relationship with women as a continuity.”

Often, midwives within an MGP will work in small groups for support and to ensure that the patient has a known provider at their birth. One of the most important differences between MGP midwives and core midwives in the public hospitals is their hours: core midwives work in a shift-based model, while MGP midwives are on call for their clients. Fifteen percent of Australian women have the option to receive care through the MGP, due to receiving care at hospitals that house MGP practices. The option is extremely popular and fills up fast; women are encouraged to register with a MGP at their local public hospital as soon as they have a positive pregnancy test (though their first intake appointment will usually be at 12–14 weeks).

MGP midwives have more autonomy within their practice, as it’s slightly more insulated from the wider hospital system. Often, they still give birth in normal obstetric rooms, but sometimes people will give birth in a birthing center that is based within the hospital. These birthing center rooms have large bathtubs designed for waterbirths, showers, a larger bed, birthing mats and balls, and other more home-like amenities. Women in labor in the birthing center are encouraged to bring in and play their own music, light electric candles, dim the lights, or use other birth-aids like TENS machines. So far, the outcomes associated with MGP programs have been impressive: as compared to the core midwifery care in the same hospital, patients are 20% less likely to have an assisted delivery, 13% less likely to be induced, and 30% less likely to have an epidural. While some MGP programs have low-risk health requirements, many are considered “risk blind,” meaning that they care for pregnancies of all risks.

All care that is given in this system is free for the patient, covered by Australia’s universal public healthcare system, known as Medicare. This system is paid for almost entirely by the Australian Federal Government and the individual state and territory governments. The only out-of-pocket costs to a pregnant woman are for the two ultrasound scans (at 12–14 weeks and 20 weeks) during the pregnancy; and, even for these, there are rebates for certain patients. The free care provided by the MGP midwives continues for two weeks postpartum, where the patient’s lead midwife will come and visit her in her home every day or two to check on how she and the baby are doing and help with breastfeeding techniques. This care continues for up to six weeks.

A smaller subset of MGP is the public homebirth program. This program is beginning to enter the mainstream health care system in Australia and is available in 17 hospitals across the country. Midwives working in this program support their patients in homebirths (as private midwives would be hired to do in other settings), but they have to adhere to strict risk guidelines set by the hospital. Patients in their care can risk out of having a homebirth if they develop gestational diabetes, don’t give birth within 42 weeks, or have consistently high blood pressure, for example. For some people, like Matilda, these clear rules are appreciated. She said that the rules “helped to not be totally fixed on the birth, like, I wanted it, but I held it lightly.”

The public homebirth system reaches birthing women who potentially would not otherwise have had a homebirth—which means that the security and rule-led procedure of the hospital is often welcome. For instance, Matilda had some spells of fainting shortly after giving birth. This was relatively normal for her, but her midwives thought it best that she get checked out at the hospital and facilitated those check-ups for her. One of the most unique things about this system is the collaboration between hospital and home. Matilda was considered a patient at the hospital and, while she was laboring at home, she also had a bed available in the hospital (in case she needed it). The hospital-based team had all of her medical records, a doctor available to see her, and quietly kept in contact with her homebirth midwife to receive updates. “When I was fainting they were immediately available [at the hospital],” Matilda said. “They weren’t having to try and find me a bed or anything.”

This sharing of knowledge and resources—and wider medical/hospital support for the public homebirth program—stands in marked contrast to mainstream American birthing health care providers’ animosity toward home-to-hospital transfers.

To find out more about the implications of the public homebirth system in Australia and why it has been able to thrive within the wider culture, I spoke to Hannah Dahlen, Professor of Midwifery and Associate Dean of Research at Western Sydney University. She said that access to supported public homebirth is a breakthrough in the Australian homebirth culture, and for Australian midwifery in general.

As someone who has been advocating for midwifery rights for over 20 years, Dahlen explained to me that the process of gaining insurance coverage for midwives had been long and arduous. In 2005, the first symbolic steps were taken after then Shadow Minister of Health (and later Prime Minister) Julia Gillard spoke about Medicare inclusion at a Bondi Beach Midwives Convention. In 2010, midwives were granted access to partial malpractice insurance.

While this was a massive leap in the right direction, as Dahlen says, “You never get everything that you want at once in politics.” The new insurance coverage came with a drawback: any homebirth midwife had to have a signed agreement with an obstetrician who was willing to assume responsibility in case something went wrong. While this arrangement did not take up much of the obstetrician’s time, and they were paid for their agreement, it held little benefit for the doctor. Worse, obstetricians had been advocating against giving power to midwives, so—as Dahlen says—giving them control over homebirth caseloads was like “putting the fox in charge of the henhouse.” Unsurprisingly, it became almost impossible for midwives to secure these partnerships. Although they were technically integrated into insurance systems, there were still significant barriers in the way of legal practice.

In 2010, the next round of the battle began to get homebirth midwifery covered by more comprehensive insurance. The policy that had come out ruled that midwives were covered until the start of labor and as of an hour after birth, but that there was no coverage during the homebirth. While advocating for this, Dahlen says that homebirth was almost ruled illegal: yet another example of the ebb and flow of policy-making.

Despite these restrictions, some midwives continued to practice and serve families without being fully insured. This meant that every time they went to a birth, they risked their homes, all of their assets, and their family stability. If they had been sued, or if there had been an emergency, they would have been unprotected from prosecution. Due to this massive risk, many homebirth midwives stopped practicing or practiced much more quietly, in the shadows. Over this time period, homebirth midwifery has remained steady but scarce, with numbers slowly starting to rise after Covid-19. Unsurprisingly, the scarcity of midwifery can be attributed to the significant barriers that the profession has faced.

Even now, while things have changed in very positive ways since then, the situation is still somewhat precarious. Australian regulation standards require that all health care providers have insurance coverage in order to practice, but there is no insurance coverage that is currently available to homebirth midwives. In order to oppose this, exemptions for homebirth midwifery have been put in place, making it legal for them to practice without the necessary insurance. These have been extended for periods of three years since 2009, but if the exemption is not renewed in 2023, it will once again be illegal for private homebirth midwives to practice in Australia.

This context makes the MGP and public homebirth system all the more special and important. It’s both a way for birthing women to have access to the sort of births that they want and a way for midwives to practice outside of the hospital in a controlled environment.

Hannah Croker, a former MGP midwife and midwifery specialist in Campbelltown, NSW, explained that she was taught in midwifery school that MGP “is the gold standard of midwifery care, that knowing caregiver, and how much that improves outcomes for women. Yeah, that just like, ignites a fire in your belly … you want to give that to women.”

Midwives generally love the autonomy and continuity of care that they’re able to give in these programs, which are more or less consistent with the values they’re taught to uphold as midwives. An MGP unit manager based in Sydney reinforced this satisfaction by telling me that “we want positions in midwifery group practice because there is a large degree of autonomy and we actually get to work across all aspects of midwifery care, which is what’s most satisfying. And that is, well, really important, too.”

Midwifery Group Practice isn’t widely prevalent in hospitals yet (as noted earlier, only about 15% of patients have the option to receive this care). After learning about how satisfied midwives are by the quality of care that they’re able to provide in MGP, I wondered why more midwives weren’t driving demand for and creating jobs. This factor, as well as the obvious demand from pregnant women, made me wonder: why are MGP programs still only available to a small percentage of patients?

According to Hannah Croker, the growth of MGP and hospital homebirth programs are largely dependent on the leadership within a given public hospital. She gave me an example of two sister hospitals that started their MGP programs at the same time. After a couple of years, one has 40 MGP midwives working within it, and one still only has six. When I asked her what accounted for this difference, her answer was “visionary leadership.” Advocacy for MGP within hospital administration is essential, and without it, it’s easy for an MGP program to stay stagnant.

When considering why MGP isn’t growing more quickly, it’s also important to note that while MGP midwives get a lot of satisfaction from working in the birth centers and at people’s homes, it’s challenging and emotionally taxing work. Being on call for clients makes it hard to plan for life events and, even on days off, midwives will often attend a client’s birth because of the personal relationship that they have built. While this speaks to the incredible and caring nature of so many midwives, it inevitably creates an environment of burnout and constant vigilance about the status of things at work. Being on call makes it hard to disconnect from work, hard to practice self-care, and hard to truly relax. It’s particularly tough for midwives who want to start their own families: being on call is exceedingly challenging with young children, and MGP midwives who have a child often leave the MGP program until their children are older and more self-sustaining.

This is difficult for a couple of reasons. Most midwives get to work for about 10 or so years before they have their own kids (because there is a direct entry midwifery program in Australia, they can begin training after high school, so they enter the midwifery workforce at a younger age). This means that many are hitting their professional stride just as they have to consider leaving for several years. It also creates a less stable workforce for MGP programs, because they have to rehire, retrain, and adjust to turnover. MGP midwives generally work in groups of four or six, so this change is felt even more acutely in these small groups.

One factor that makes rehiring even more tricky is that midwives face a tough transition to MGP after they secure a spot. This is not the fault of MGP but rather a reflection of the disconnection between MGP and the core midwifery system (the system that around 80% of midwives work in). The two models weren’t created to work together and there is some dissonance when switching from one to the other.

Hayley Moyes, an MGP midwife who works with teen moms, said that in the core midwifery system, “It’s really hard. People might be in the antenatal clinic for a few years, and then not have done a birth. And especially because there’s that expectation that if you’re an MGP midwife, you need to be on top of all your skills and be able to do everything by yourself.”

MGP midwives are responsible for all aspects of care regarding their clients, so they need to feel confident prenatally, in the birth room, and on postpartum wards. When they rotate responsibilities in the core system, it’s easy to only spend time working with patients in one of those stages. This means that when midwives make the transition to MGP, they don’t always feel as well-rounded as they perceive they should be, causing them a stressful adjustment period.

Despite the challenges, there are proposed solutions to these problems that hospitals are starting to take into consideration. Midwives I spoke to shared with me that they feel that many of these problems would be lessened if hospitals employed a time-share program, or allowed midwives to work part-time. This would help reduce burnout, as well as making juggling motherhood and a career as an MGP midwife feel more manageable. A part-time MGP midwife would be able to take on fewer clients and be on call for less time. Hayley Moyes said that hospitals push back on this proposal because of the “continuity of care” ethos, but she feels that “having two midwives working in unison and knowing the family that you’re looking after, that’s still better than having someone different every single time.” There is no simple fix to the acknowledged problem of midwife burnout, given the attachment-oriented nature of the job, but this could be the next positive step to address it.

While there are challenges to every system, the Australian Midwifery Group Practice is setting an positive example in maternity care, both in the hospital and at home. Eloise, a second-time mom in Sydney, told me the story of her homebirth in her little apartment. Despite her partner getting Covid and needing to isolate himself (within the apartment), she was able to give birth surrounded by her son, partner, and midwives. She asked them not to administer an internal check, strip her membranes, or be too invasive. The midwives listened to her wishes and made the space her own, even suggesting a sheet strung up for privacy. After a long and complicated first birth that had included a non-consensual episiotomy, Eloise said that she did some preparatory work around this birth, telling herself, “No, I’m not going to have this pain again.” She leaned into the space held by the midwives in her second birth and ultimately felt “so relaxed. The two midwives were so experienced, and they really made me feel super confident. They were like ‘you can do this.’ I could feel the faith that they had in me.”

The maternity and birth system that is slowly gaining ground in Australia is something that is completely foreign and unheard of elsewhere in the world, especially in the United States. While there are parts to it that only apply within an Australian context, the ethos of the MGP and private homebirth programs stands out as evidence-based, medically supported, positive outcomes-driven, full of heart, and a prioritization of intuitive and healing birth.

Over the course of doing these interviews, there was one comment that really stood out for me. Matilda’s husband is a doctor who has attended many births in hospital settings. After experiencing Matilda’s homebirth with the MGP midwives, he said, “I think the empowering nature of it, that was it. Birth became less fearsome, less medicalized, and more joyful. And it felt like we were actually creating a family in our home, rather than someone handing us a child. I think starting a family in a home … it just feels like how it should be.”

About Author: Sydney Leach

Sydney Leach is a 17-year-old birth doula who lives in Denver, Colorado. She is passionate about empowered birth, consent, and autonomy during the birthing journey (soulfulsummitdoula.com). On the side, she loves to mountaineer, ski, and rock climb in the beautiful Colorado mountains.

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