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Baby deaths prompt call for crackdown on unregistered midwives

A South Australian coroner has called for a crackdown on unregistered midwives following findings that the deaths of three babies during homebirths could have been prevented.

17 Jun 2012

A South Australian coroner has called for a crackdown on unregistered midwives following findings that the deaths of three babies during homebirths could have been prevented.

In what could be a landmark case for the regulation of midwifery and homebirthing, Deputy State Coroner Anthony Schapel rejected the evidence of the unregistered midwife who attended all three births and recommended laws making it illegal to practice as a midwife without registration, and requiring formal notification of planned homebirths involving a heightened risk of complications.

The AMA has backed the recommendations, and South Australian President Dr Peter Sharley said more should be done to break down misconceptions about hospital births and improve the attractiveness of midwife-led birthing units.

The case has highlighted a loophole in national health regulations that enables and - according to the coroner, encourages – midwives to operate outside formal jurisdiction, with little or no protection for mothers or their infants in the case of complications.

The case centres of the activities of Lisa Barrett, an experienced midwife who let her registration lapse early last year to work instead as a ‘birth advocate’, and who attended all three fatal homebirths.

The coroner found that in each instance the babies – Tate Spencer-Koch, born in July 2007, Jahli Jean Hobbs, born in April 2009 and Tully Oliver Kavanagh, born in October last year – were “robust and viable” immediately before delivery, but died as a result of complications that would not have been fatal if they had been born in hospital.

He found that Tate was a large baby – a fact known by Ms Barrett before delivery – whose birth was obstructed by shoulder dystocia and died as a result of intrapartum hypoxia.

Jahli’s was a breech birth – also known by Ms Barrett before delivery – and delays in her delivery meant she too died of intrapartum hypoxia.

The third infant, Tully, was the second of twins and was delivered more than an hour after his sister. During the course of his delivery placental separation occurred, leading to fatal hypoxic ischaemic encephalopathy.

In each instance, the coroner found “as a matter of certainty” that each child would have survived had they been born by caesarean section.

The coroner heard evidence of a fourth death, of the second of twins during a home birth attended by Ms Barrett in July last year in Western Australia.

In her testimony, Ms Barrett argued that since she relinquished her midwifery registration she no longer attended births in a clinical capacity, and merely provided support as a birth advocate.

But Mr Schapel rejected Ms Barrett’s testimony, describing it as “disingenuous”.

“It is obvious to the court that Ms Barrett was performing the clinical duties and responsibilities of a midwife, and was not merely present as a birth advocate,” the Deputy Coroner said. “To my mind, Ms Barrett’s evidence that she was a mere birth advocate, not performing the duties and responsibilities of a midwife, has to be rejected.”

Ms Barrett told the court she had decided to relinquish her midwifery registration and practice because of new requirements that came into effect at the time of the introduction of the Health Practitioner Regulation National Law.

But, in a damning judgement, Mr Schapel rejected her testimony, and instead found that Ms Barrett had let her registration lapse in order to exploit the fact that there were no sanctions or restrictions on people practising as unregistered midwives.

Under the National Law, registered midwives can obtain an exemption from the requirement to have liability insurance while attending a homebirth, but the exemption is set to cease in mid-2013.

Ms Barrett denied suggestions she discontinued her registration because she would not qualify for the exemption, as she did not want to comply with the safety and quality requirements imposed on registered midwives.

“I find that Ms Barrett handed in her registration as a midwife because she well knew that in order to practise as a registered midwife with the benefit of an insurance exemption in respect of intrapartum care in homebirths, she would have to conduct her practice within the Nursing and Midwifery Board of Australia’s Safety and Quality Framework and the Australian College of Midwives Guidelines,” Mr Schapel said. “I further find that she was not prepared to do this as it would act as a hindrance to her homebirthing practice in respect of high risk homebirths.”

The Deputy Coroner recommended measures to crackdown on unregistered midwives, require notification of intended homebirths, improve information to parents and investigate the establishment of alternative birthing centres, as suggested by AMA South Australia.

In particular, Mr Schapel recommended laws that would “render it an offence for a person to engage in the practice of midwifery…without being a midwife or a medical practitioner registered pursuant to the National Law”.

The Australian College of Midwives warned such a measure could drive women wanting homebirths out of the health system entirely.

The Deputy Coroner said he had carefully considered this issue, and decided that the very availability of unregistered midwives made it possible for women to undergo homebirths that were of enhanced risk, and that the tendency to do so might be altered if patients were given full knowledge and understanding of the potential consequences.

Immediate past president of AMA South Australia, Dr Andrew Lavender, testified at the inquest, and said that although the AMA did not in principle object to home births, they most be conducted “within the parameters of the lowest potential risk to the baby and mother”.

“It must also be within the context of fully-informed consent must include the increased risks associated with delivery in a home environment away from acute medical intervention facilities,” Dr Lavender said.


Published: 17 Jun 2012