Birth Control

My girlfriend is a midwife. On July 1, 2010, new legislation (called the “National Registration and Accreditation Scheme”) comes into force, affecting all health professionals, including midwives. One of the provisions of this legislation is that to register as a midwife, you need to show that you have insurance that indemnifies your practice. Without registering as a midwife, you cannot practice as one.

OK, so what? It’s a little illiberal to force people to have liability insurance, but it’s hardly an unusual step. The problem is that insurance to indemnify midwives who practice individually is simply not available. One of the reasons is that the statute of limitations on legal action is extremely long, since the baby’s right to sue doesn’t even begin until 18 years after birth. It may also simply be too risky to indemnify individual midwives of uncertain ability, given the massive payouts that are likely to result from negligence. In any case, liability insurance for individual midwives cannot be bought for love nor money.

If midwives can’t practice individually, that has a number of consequences. Obviously it restricts the ability of midwives to practice as they please. It also reduces a woman’s chance of having the same midwife throughout pregnancy and thereby developing a personal relationship before the birth. But most importantly, it makes it essentially impossible for women to choose home birth in practice. Obviously hospitals don’t send out midwives to carry out home birth – women have to come to the hospital for that. And since midwives can only be indemnified when attached to hospitals or other large health practices, that means there are no midwives available to assist in a home birth. Anyone a woman recruits to help with a home birth will be acting as a midwife while unregistered, which attracts a $30,000 fine. (Bizarrely, the woman giving birth also gets fined for “enticing” the midwife to practice).

It’s a regressive step towards a monopoly health services system – where people don’t get to choose how medical care is provided, even for something as personal as birth.

26 thoughts on “Birth Control

  1. This issue is not about thome births, it’s about the government forcing certain people to take out insurance.

    Insurance is a private sector invention that was developed to manage risk. It has always been an individual decision whether to reduce the risk or remain exposed. The idea that governments can make it compulsory is outrageous unless the government is itself exposed.

    If a midwive wants to practice without insurance, because the insurance companies refuse to offer cover, that’s her/his choice. It should be their choice and not the government’s.

  2. Paying a fine of $30,000 out of your after tax income is a long period of enslavement to the state for most people, especially given that even slaves are usually allowed to eat. It is incredibly draconian. So if you’re in a remote area and you encounter a woman struggling to give birth the state effectively wants you to run away and hide rather than stay and render assistance. How kind and considerate of the state. Arsholes!

    Still it’s not as bad as the prison sentence you can face for merely owning certain types of firearm without the right bits of government paper.

    It bemuses me that people point to the ALP or the Liberal party, depending on tribal inclination, and proclaim them more liberal than the other mob. The reality is that they are both somewhat liberal but they both serious ration the occasions on which they demonstrate it.

  3. Seriously, if an adult wants to have open heart surgery in his garage performed by a witch doctor I’d be all for it.

    However the problem with home birthing and a midwife is that a kid is involved who doesn’t quite have the smarts at that young age to decide if a home birth is risky for him/her.

    There’s a lot that can go wrong in a birth and one reason why the birth survival rate has gone up in Western countries is because childbirth is handled by doctors in a operating/birth theater.

    Home birth is a dangerous exercise putting the life of the kid at risk who isn’t quite able to say if s/he is willing to take that risk.

  4. I’m not sure less home births is such a bad thing to be honest.

    As JC says the baby doesn’t get a say in it, even though it’s 100% true that hospital births are much safer. Babies shouldn’t be put at risk because their parents are retarded hippies.

    That said forcing people to have insurance is morally suspect for the reasons David points out. There’s no reason at all to require people to be insured against being sued, they can always simply take the risk on themselves. If insurance companies offered a fair payment for the risk they took on, they wouldn’t make any money.

  5. An insurance company makes money because they charge a small premium. I think that is still “fair”.

    I don’t think it’s the role of the government to tell parents how to give birth. I accept that different approaches may have a different level of safety… but that’s true of nearly every decision in life. Including decisions that parents make for their children every day.

    I think people should be allowed to enter a contract saying “if I make a mistake, I’m sorry, but you can’t sue me”. I think people who accept responsibility, or comply with a regulatory standard, or have an endorsement etc would get more customers. But that’s up to each buyer to decide.

  6. John:

    The kid can’t make a decision in terms of where it comes out.
    Given birth is serious issue fraught with risk and while I don’t give a toss what risky behavior adults indulge in this is altogether different because another kid is involved.

    A hospital is the safe right place to have a kid.. not the bedroom or a freaking swimming pool as some idiots do.

  7. Everything is hunky dory in a birth until something goes wrong and there’s a lot of shit that goes wrong that midwives are not competent to perform.

    There’s a good reason doctors/specialists assist deliveries. That’s because they are trained in science based medicine to reduce the chances that when something goes wrong, even a little bit wrong, the life of the mother and the child are not at great risk the way it used to be before modern western medicine was introduced.

  8. Yes. Risk exists. Always. But who is best to manage it?

    In this case doctors. John if you’re comparing risky behavior is say sports, I’d say it doesn’t compare as the risk of losing a mother, child or both in child birth is planes higher.

    Arguing that risk exists doesn’t mean that with a limited approach we can’t reduce risk for those that don’t have a say in the matter because they can’t speak.

  9. We have had three kids and the process was never handled by a doctor. We were in a hospital so there were doctors available if an emergency had occured but they didn’t run the process. The process was run by midwives and they were extremely competent. A doctor did visit to inspect the child briefly but this was some time after the birth process was all over and done with.

  10. JC,

    why does home birthing rate above the litany of other things that mothers can do that are harmful to their child (alcohol, etc. )? It would be easy to reduce many of those other risks, but we don’t.

  11. Conrad:

    There’s really not that much you can do about a mother that drinks , smokes or does alcohol during a pregnancy short of sticking the woman in a padded cell. And no one advocates that.

    However you can ensure that a kid gets the best advantage in surviving a birth by applying reasonable standards brought about with scientifically based western medicine.

    Terje:

    The doctor was possibly 30 seconds away. The issue is in case something goes wrong.

    Home birth is a stupid idea and it’s anti-science in way. Hospital is the right place to drop a kid.

  12. My 2c:

    1. Childbirth is risky. It was the most common cause of death
    in women a century ago.

    2. It is not just the woman, but also a non-consenting child at risk.

    3. It should normally be the choice of the parents of the child to assess risks about their children, unless the parents are unfit.

    4. Choosing an uninsured midwife over a modern major hospital calls a woman’s fitness. Frankly it’s up there with the pure water starvation diets. It’s just stupid.

    There is another line of reasoning too:

    1. If permanent damage is caused to either the mother or the child, the taxpayer is forced to pay for the rest of their lives.

    2. Any morality which says that someone should be forced to play for someone else’s self-inflicted medical bills, will inevitably also say that people should be stopped from running the risks that are likely to incur those bills.

    3. Hence this is an argument which is not winnable. You have to first argue that no-one is responsible for their own decisions – even if we don’t agree with those decisions.

    Then we can argue about compulsory insurance.

  13. Ah, forgot to check in on the comments here.

    You all probably think, as I did, that home births are much riskier than hospital births. I see Yobbo for instance says it’s “100% true that hospital births are much safer”. Here’s what Wikipedia has to say on the subject:

    A study of 529,688 low-risk planned home and hospital births was reported in the British Journal of Obstetrics and Gynaecology in 2009. The study concluded:

    A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system.

    The thing is that if complications do occur, the women can be moved to hospitals very quickly. With a competent midwife who knows when to make the emergency trip, the increased risk is negligible; the concerns insurance companies have would be to do with the capabilities of the midwives, I would wager. I would share jc’s concerns if home birthers were of the Jehovah’s Witness school of refusing any medical intervention, but the overwhelming majority intend to seek hospital care if there are serious problems.

    conrad’s point about not making it illegal for mothers to smoke and drink during pregnancy is also well-taken. jc’s response that it is simply an enforcement issue is a little dubious. Would we really force mothers to not smoke and drink at all if we could enforce it? OK, so taking folic acid during pregnancy has been shown to be beneficial, do we enforce that? What about other dietary issues? What about breastfeeding during infancy, that’s extremely beneficial, should that be forced too? Obviously there’s a dividing line here. Some actions incur such harm to the fetus that we really would prevent them. I don’t think the evidence is there that home birthing is such an action.

    John’s point is similar – parents make decisions for their children every day that involve a judgement on risk. Should children be allowed to go swimming in the surf? Bike riding? etc etc etc.

  14. Chrisjv:

    I’m actually not advocating any form of enforcement in terms of making mother do things by the force of law. I’m suggesting that supporting home birth is a silly idea.

    A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system.

    There are a lot of caveats is that statement to the extent that it makes it basically worthless.

    There’s a bloody good reason why medical insurance carriers don’t insure home birth. The reason is that it could seriously hurt them. In that sense the market has spoken.

  15. I think there are an awful lot of presumptions about the risk of home birth being made here. I suspect the lack of insurance for this market reflects more on the size of the market, the lack of good statistical data and such factors rather than the actual higher risks. JC I don’t think there are that many caveats in the piece you quote above from Chrisjv.

    One of my neighbours is a neonatal doctor and he is always banging on about how brilliant the Cochrane systemic review process is. He says we should use this approach to the review of medical evidence for public policy. The wikipedia article on home birth has this from the Cochrane database:-

    The most recent research contained in the Cochrane systematic review of the literature, (published on the Cochrane database; the source from which hospital policies are usually created), states that there is not enough evidence to decide one way or another, whether home or hospital birth is safer (Olsen & Jewell: 2000 (CD000352) in Hofmeyr et al:2008:252).

    However, Hofmeyr goes on to say, on behalf of the Cochrane database; “The relative benefits and risks of different settings are difficult to quantify. For a woman and her baby with no complications, the risk of an unexpected adverse event during a home birth may be smaller than risks specific to hospitalization, such as hospital-acquired infections” (Hofmeyr et al:2008). Olsen and Jewell (2000), the authors of the systematic review also state: “In countries where it is possible to establish a home birth service backed up by a modern hospital system, all low-risk women should be offered the possiblity of considering a planned home birth….” (Olsen & Jewell: 2000 (CD000352) in Buckley:2005:230).

    On reflection however I would expect that the conseqence of this legislation is likely to be the creation of more birthing centres outside the traditional mould. That’s no bad thing because the traditional mould found in most hospitals was not always that great. In particular there is lots of evidence that doctors are far too interventionist (a bit like governments) and in most instances it is good to keep them away from mothers that are delivering.

  16. It’s really not so much about the manner of the birth, but the distance to a hospital if something does go wrong.

    When you are giving birth at home and something goes wrong, it could be 1-2 hours depending on traffic before a doctor can try to help you.

    I don’t have any problem with people giving birth using the services of a midwife if they are still in close proximity to a hospital in case of the worst case scenario.

  17. “Do it for the children!” Who’d have thought that a libertarian would ever fall for that argument?
    I believe that we should be free to take out insurance for most things. A part of such insurance might be that the Insurance agent insists that you enter a hospital, or a privately-run birth clinic. That would be compatible with freedom and care.
    Or you should be free to bear and raise your chilrden as you choose, come what may.

  18. There are lots of things you can do in life to reduce risk, both for you and your dependents, family & friends. Choosing to live far from medical care increases your risk (and for your children). Job choice impacts on risk. Which country you live in impacts on risk (and for your children).

    Your behaviour before and during and after your pregnancy impacts the health of your child. How your treat your child, which school you send them to, which rules you enforce, which morals you teach, which sports you let them play, etc all have a huge impact on the future health and welfare of your children. And of course, passing on any religion is “child abuse”. 🙂

    The argument that “the experts know best” I think is dangerous. Yes, sometimes experts know best. If this is all that matters, then the logical conclusion is that our lives should be run by a bunch of smart bureaucrats who are experts in their field. Allow health bureaucrats to make our health decisions. Allow education bureaucrats to make our education decisions. Allow “consumer rights” bureaucrats to make our general consumption decisions. The list goes on. Our decisions would be “better” and we wouldn’t be bothered with all that annoying freedom.

    I think it is preferable to leave the decisions with free individuals.

  19. John:

    Science based medicine is a case of the experts know best. That’s not to say we need to live under the boots of experts. They are worth listening to.

  20. I agree that experts are often worth listening to. My instinct would be to use a hospital.

    But I don’t think a home-birth constitutes child abuse, so I don’t think there is a role for government in making the decision, or regulating one option out of existence.

  21. I always felt there is a market for birthing centres, near or attached to hospitals, but run by midwives and based around not medicalising the birth – unless something goes wrong. I’m sure it is a premium service many will be willing to pay for.

    I agree many of these home birthers are mad. Coming from a farm I have a somewhat clinical approach to the whole thing – there will be a percentage of complications, which on the farm translates into death for mother and baby. You can be damn sure that when my wife is having kids it will be within shouting room of qualified doctors with cesaerian facilities.

  22. Even football matches in the country have regulations that require a doctor (or at least an Ambulance) to be present.

    And far less people die playing football than die giving birth.

    Personally I think anyone who tried to give birth at home without a doctor present is a fucking idiot. Should they be allowed to anyway? It’s the same as the abortion argument I guess. Do the rights of the baby trump the rights of the mother or vice versa?

    In any case, Darwin’s law wins.

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