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Homebirth models of care must be ‘safe and resourced’: RACGP

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Greater maternity choices for women and improved outcomes for Aboriginal and Torres Strait Islander people are part of current Government reforms underway.
 
On the table is the enablement of privately practising midwives to provide maternity care services in low-risk homebirth settings and during labour outside a hospital, and supporting Birthing on Country models of care.
 
Announced in the 2024–25 Federal Budget as a four-year investment to expand eligibility under the Midwife Professional Indemnity Scheme (MPIS), the changes include indemnity insurance cover for these services through the MPIS and MPIS Run-off Cover Scheme (MPIS ROCS).
 
Now, the Department of Health and Aged Care (DoHAC) is seeking input from GP, midwife and obstetrician organisations.
 
The RACGP’s submission to the DoHAC’s consultation on expanding MPIS for low-risk homebirths details recommendations for the proposed changes and criteria.
 
While recognising that women have a right to choose their place for giving birth, the college believes choices must be fully informed and options safe, and says the current proposed definition for low-risk homebirth is not appropriate and attempts to ‘address two issues with one solution’.
 
For Aboriginal and Torres Strait Islander people, there needs to be a clear distinction between Birthing on Country and homebirth, the college advises.
 
The RACGP supports Birthing on Country models of care to be made ‘as safe and resourced as possible’ to provide optimum outcomes for Aboriginal and Torres Strait Islander families who have access to and choose them.
 
This supports ‘positive birthing experiences’, RACGP President Dr Nicole Higgins writes in the submission.
 
‘We recognise that for some Aboriginal and/or Torres Strait Islander birthing mothers the hospital may not be a place they feel safe if inherent bias and racism are present,’ she said.
 
‘Culturally safe, trauma-informed approaches, available choices for women including spiritual choices that support social and emotional wellbeing and connection to culture are important.’
 
The college recommends the DoHAC consults Birthing on Country experts on what considerations need to be made for the MPIS, including indemnity insurance cover, as it relates to Birthing on Country models of care.
 
Additionally, homebirths as a preferred choice must be accompanied by ‘careful risk stratification process’, the college says, including all relevant checks and balances ‘at every step of the process’ to ensure informed consent, including financial consent.
 
While Tasmania is now the only jurisdiction in Australia that does not offer publicly funded homebirth programs, each has its own set of criteria to determine whether a birth is suitable for homebirth, using the best available safety evidence.
 
In the latest consultation, the DoHAC is proposing criteria to be used by the MPIS and MPIS ROCS to identify a woman’s safety to homebirth, based on ‘elements common to all jurisdictions’. The criteria stipulate:

• singleton pregnancy, not multiple, eg twins
• foetus head down (cephalic presentation)
• pregnancy term between 37 and 42 weeks
• a documented midwife plan for safe and timely transfer to a hospital with maternity services
• the midwife has documented no concerns that make homebirth unsafe for the midwife, woman or baby.

The RACGP suggests changes to the low-risk homebirth criteria, including that standard antenatal care ‘with best practice investigations’ must be incorporated, including ongoing communication with the patient’s usual GP to ensure continuity of care remains in place.
 
‘This will enable GPs to provide ongoing support, holistic care, and follow-up care,’ Dr Higgins writes.
 
Homebirth ‘safe plans’ must also be agreed on with local maternity hospitals, and she highlighted such plans in remote areas would be different to those in metropolitan areas
 
Notably in its submission, the RACGP strongly cautions against the de-medicalisation of maternity care, pointing to recent evidence from New Zealand where GPs were excluded from antenatal care and replaced with a model of midwife bundled care, leading to an increase in birth injuries, deaths, and poor perinatal outcomes.
 
Dr Higgins has warned about Australia not following the same model as New Zealand, and for the Government to consider the required practice models to reflect quality and safety processes present in the hospital setting.
 
‘GPs have an important role in antenatal care in Australia, supporting women and families from preconception, throughout their pregnancy, and often during birth in rural and remote communities,’ Dr Higgins recently wrote in her advocacy column.
 
‘We need to ensure it stays this way and Australian women have choice and access to get this care from their GP, no matter where they live.’
 
In her 2 August President’s Update sent to members, Dr Higgins also raised concerns that while full details of the next Scope of Practice review are not yet known, it has put forward bundled midwifery care, like the New Zealand model, as the ideal.
 
‘This is block-funding of midwives from conception to delivery, which has killed off shared care and GP obstetrics, especially in rural areas,’ she said.
 
‘This would be a disaster in rural and regional Australia, and we need GPs and midwives working together to get the best outcomes for our patients.’

Also in its submission on expanding eligibility under the MPIS, in relation to the proposed inclusion of a low-risk homebirth professional indemnity insurance product within the MPIS, the RACGP highlights the Government is agreeing to provide insurance cover through the scheme and MPIS ROCS because ‘private insurers are unwilling to provide cover due to the inherent risks and potential for litigation’.
 
Therefore, the college is urging the Government to extend funding MPIS ROCS for all providers of obstetric services to ensure costs to patients are reduced, regardless of their choice of obstetric provider and no provider is financially disadvantaged.
 
The DoHAC is expected to work with states and territories to determine the next steps, stating it is intended that the national definition will be specified in the MPIS Rules 2020, and referenced in a future contract with an insurer for the provision of these services.
 
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Aboriginal and Torres Strait Islander health homebirths midwives RACGP submission scope of practice shared maternity care

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