NURSING AND MIDWIFERY PRACTICE BILL

Second Reading

Adjourned debate on second reading.

(Continued from 16 October 2008. Page 375.)

The Hon. SANDRA KANCK (17:43): I begin with three words: about bloody time. It has taken us too long to deal with legislation that recognises the professionalism of midwives in this state. This bill repeals the Nurses Act 1999. The recognition of midwifery in the title of the bill is a hugely symbolic act by the parliament. Midwives are increasingly undergoing very different and specialised training compared to nurses, and they are indeed a separate profession in their own right.

In 1999, the current Nurses Act was passed. I attempted at that time—and fortunately succeeded—to maintain a separate midwifery register. The proposal of the then Liberal government was to roll all nurses and midwives together as if they were the same. It was certainly a hard fight to get it to that point, but the one thing that really left me quite flat at the end was that I was not successful in being able to rename it the nurses and midwives act, despite the fact that there was evidence—indeed, government ministers put it on the record—that South Australia was moving to have the training of direct entry midwives, which meant that people would go straight into midwifery rather than the old-time method of training and getting a triple certificate in nursing, with midwifery as one of those add-ons.

At the time we debated the Nurses Act 1999, six overseas trained midwives were practising in South Australia. They were registered as nurses, despite the fact that it was very clear that they were not nurses and that it was absolutely inappropriate to label them as such. When I attempted to amend the act so that midwives were included in the title, the argument the government used was that only six midwives were registered in South Australia who had trained only in midwifery and therefore what I was asking for was not needed. The opposition took the industrial position of the Australian Nurses Federation at the time, which was that midwifery was, effectively, a branch of nursing and not a separate profession.

It was interesting that both the Liberal and Labor parties acknowledged that in South Australia we were in the process of establishing direct entry midwifery courses, but the Labor Party argued that we needed to wait and see what the impact of that would be. The first direct entry midwifery degree courses began at Flinders University and the University of South Australia in 2002, which was 18 months after the current act came into operation.

Those of us with some knowledge of midwifery knew that, upon graduation, the students would have to register and declare themselves to be competent as nurses when, in fact, there was no such competency and there never could be. Some of the limited number of direct entry midwives, and some of those who would be directly involved in the training of the direct entry midwives, told me at that point that, if you had put some of them into an accident and emergency department or a surgical ward, they would have been totally at sea and not competent to act as a nurse, yet they had to sign a form and state, 'I am proficient to act as a nurse.' So, they had to lie.

With those deficiencies in the current act, there was concern that the first midwife graduates would have to register in New South Wales, for instance. In the end, they were registered in South Australia but, when filling out their application forms, they had to lie about their competency to act as nurses.

Historically, 40 years ago, midwifery was an add-on after training to be a nurse. It might have been appropriate 40 years ago to have a Nurses Act but, at the end of the 20th century, our MPs ought to have looked a little further into the quite near future and at developments that were occurring in this field.

So, in frustration, and knowing that the first direct entry midwives were only seven months away from completing their studies, in May 2004 I had drafted for me and introduced into this place a Midwives Bill. Meanwhile, the Australian College of Midwives continued to lobby and negotiate with the Minister for Human Services, as the minister (Lea Stevens) was titled at that time. She told them that, although a separate Midwives Act was unacceptable to her, she would introduce a Nurses and Midwives Bill in mid 2005.

I point out that the midwives who were negotiating with the minister had to make concessions on this point, even though they specifically wanted a separate Midwives Act. In order to progress things along, they agreed to have a Nurses and Midwives Act. So, having made that concession, they expected that, as promised, this bill would be introduced in mid 2005. Was it introduced? Clearly not, otherwise we would not be dealing with it today.

I reintroduced my Midwives Bill in September 2005, in part as a message to the government that it was not following up on the promises it had made to the midwives and that it was taking much too long to progress a Nurses and Midwives Bill. Of course, it also reminded the minister that there were problems with the probably 40 or so midwives in the first lot of graduating students having to lie about their competencies in order to register as a nurse.

Before the end of 2005, history tells us that minister Stevens had to resign her portfolio due to ill health and that the Hon. John Hill was appointed to take on that position. I very quickly sought an appointment to meet with him in late 2005, and he quite graciously gave me an appointment fairly soon after my asking for it.

I took my own agenda along to that meeting, and at the top of that agenda was the recognition of midwifery as a profession. I spent some time explaining to him why it was important, and I told him about the importance of language in this regard, and I will talk about that a little later. Disappointingly, despite my meeting with minister Hill in late 2005, it has taken almost three years since then to get this bill into parliament.

I am disappointed by the comments of the opposition and its shadow minister about the term 'midwifery'. In her speech, she suggested that, as a term, it was out of date. I want to reassure her that it is absolutely not out of date. In fact, it is a term we must retain because it means 'with woman', and that is what the profession of midwifery is all about—working with pregnant and birthing women and then working with them, post birth, assisting in establishing breastfeeding and the bond between the mother and the newborn child.

I am also pleased that the definition of 'midwifery' in this bill includes postnatal care. Midwifery is a partnership between equals and, with its meaning of 'with woman', it can, and does, encompass the handful of male midwives in this state. It is a non-medical model and it is about wellness.

It is very different to the practice of obstetrics. Obstetrics is about the out-of-the-ordinary and about complications. Most pregnant women—something like 95 per cent—do not need obstetricians. Obstetricians, by virtue of their being doctors, have an entirely medical perspective on this process: it is about intervention; it is not about pregnancy and birthing being natural things for women to do. Obstetricians 'deliver' babies. It is a very doctor-centred term and process as compared with the mother-centred process which midwives facilitate.

In the midwifery model, women birth their children; they call the shots. There is no need for a doctor to deliver them as if they were being released from a prison. Delivery versus birthing—the language, the procedures and the underlying philosophies are very different. Women who choose to birth with a midwife are, we know, significantly less likely to have medical intervention, such as a caesarean or ventouse or forceps deliveries. The births are far more likely to be natural, occurring when the baby is ready to be born rather than to suit an obstetrician's golf timetable. The babies are more likely to be breastfed and the mothers are less likely to have postnatal depression.

The federal government's current National Maternity Services Review paper has some very interesting figures, and I will read from that discussion paper as follows:

Australia has a very high rate of caesarean section—30.3 per cent of births in 2005 compared with the 2004 OECD average of 22 per cent of births. This proportion has increased markedly over the past 15 years, up from 18 per cent in 1991. This is well above the World Health Organisation's recommendation that caesarean sections should only be necessary for fewer than 10 per cent of women, with 15 per cent being an upper limit for surgical intervention.

Within Australia there is also considerable variation in the caesarean rates between the public and private systems, between states and territories and between individual hospitals. Private hospital patients are more likely to have caesarean births (40.3 per cent compared with 27.1 per cent in public hospitals), as well as higher use of forceps (5.1 per cent compared with 3.0 per cent), or vacuum extraction (9.7 per cent compared with 6.4 per cent) for vaginal births.

In September 2001, I launched a conference on caesarean awareness held in North Adelaide. One of the speakers was Gus Dekker, who at that stage was an obstetrician at the Queen Elizabeth Hospital. Gus Dekker comes from the Netherlands, where obstetricians have a very different attitude towards birthing and interventions. He is now a professor of obstetrics and gynaecology at the University of Adelaide, and he gave some very interesting facts and figures about when caesareans occur. He was able to tell us from his own experiences in Adelaide that there is a dearth of caesareans on Wednesday afternoons and on weekends.

Given that foetal distress or prolonged labour can be some of the justifications for caesareans, it seems strange that this largely does not occur on Wednesday afternoons or on weekends (the days that doctors traditionally play golf), and one might conclude that this seems to coincide just too nicely with obstetricians being able to have the weekend off and being able to play golf on a Wednesday afternoon.

Gus Dekker also gave us some figures from 1999 compared to his home country of the Netherlands regarding caesareans. At that stage, the figure for South Australia was 24.9 per cent—again, significantly higher than the World Health Organisation suggests—compared to 7 per cent for the Netherlands, and one has to wonder why. It is to South Australia's shame that our caesarean rates are so high. I believe that this is something that we need to address as a matter of urgency.

I would like to use this opportunity to ask the minister if, on providing the second reading summing up, we can have a few answers to questions on current caesarean rates in South Australia and on the difference between the public and the private system. Again, if one looks at the figures provided in the current national consultation, there is a huge difference between caesarean rates in public and private hospitals.

I also note that there can be significant differences according to which hospitals we are talking about. So, I will ask whether the minister can provide that information, given that the private hospital system has a much higher caesarean rate than the public hospital system. What is the breakdown of the caesarean rate of one private hospital compared with another within South Australia? Also, is there any breakdown in figures based on whether the birthing was at the hands of a midwife or an obstetrician?

Independent midwives—that is, those who are not directly employed by a hospital or health service in this state—have no indemnity insurance, and that has been the position now for the last eight years.

I find it strange that 15 years ago the state government was able and willing to broker a deal with GP obstetricians in this state who were facing hefty increases in their indemnity premiums so that the state government would underwrite that system, but it has not been willing to offer a similar cross-subsidy to midwives. So, another question to which I seek an answer during the second reading reply by the minister is: how much is the state government currently paying per annum for the GP obstetrician indemnity scheme and, with the passage of this bill, will the government consider implementing a similar scheme for independent midwives?

This bill, in concert with the federal government's current consultation, will play a part in ensuring that birthing is considered the act of a well woman and produce better and more cost-effective outcomes than a doctor-led model. The next move must be to push (and I do not mean that as a play on words) for a national maternity policy that promotes normal birth first and foremost. Once we begin with that as our basis, everything else will flow, that is, we will see a reduction in interventions, we will get more midwifery-led care, we will see more mothers breast feeding and so on.

There is, and has been for quite some time now, a shortage of nurses and midwives, and the government has been actively recruiting nurses and midwives from overseas. I ask the minister to provide details during the summing up of the cost involved in this program and also information about which countries the successful applicants have come from.

Nurses and midwives have to demonstrate currency of practice, and more refresher courses must be provided for them. I was recently contacted by a midwife who has spent the last few years working overseas in Afghanistan, Burma and India. We have no reciprocal relationships with those countries for recognition of her practice in those countries, so she applied to do a refresher course. There is only one run per year at Flinders University, and only 10 of the applicants were able to be accepted to do this year's refresher course. She was eleventh on the list, so she missed out and now has to wait until next year for the next refresher course.

So, here we have an experienced midwife—and we have a shortage of midwives in this state—who is now working as a night-fill operator in a supermarket. This person wants to continue to work in South Australia but, because we do not have enough refresher courses (and this comes down, I believe, to the state government not funding them) she may be forced either to move interstate or back overseas again if she wants to continue to work as a midwife.

Clause 35 of the bill deals with this issue. It states that a limit can be placed on the nursing or midwifery care that the person can provide and, if the board is satisfied that they have not practised for a period of five years or more, it can impose a condition requiring the person to undertake a specified course of education or training or to obtain specified experience, and there are such other conditions as the board thinks fit. So, in this example, it seems to me that there could be provision for this woman to practise with a little bit of flexibility, if it could be exercised, under the terms of clause 35.

When one considers that the government has this recruitment program running overseas, one will see that it might be a cheaper option to provide more spaces in refresher courses and more frequent refresher courses so that nurses and midwives who are interested in re-entering the workforce and practising in South Australia are able to do so. When one considers that a recruitment program that operates overseas may or may not hit its mark, getting those who already have qualifications here in South Australia back working in the field would appear to be a much cheaper option.

I now turn specifically to nurses, because they are encompassed by this bill, although for nurses it is not, I suppose, with the same degree of triumph that they approach this legislation because it is not such a breakthrough for them. This is more an updating and bringing the legislation into the 21^st century for them.

I observe that nursing is an area where there seems to be a lot of bullying, particularly in the mental health area, from the contacts that are made with my office from time to time. Both bullying and nepotism seem to be complaints, although I do not hear much about this from midwives. I think it is really important that the government ensures that this sort of behaviour is brought under control so that nurses, in particular, will continue to be part of the nursing profession in South Australia.

In October 2005, the Social Development Committee, of which I was a member, tabled the results of its inquiry into rural health. There were two recommendations which I moved and which were successful. They referred to the federal government, but I considered them to be very important, particularly for people in country areas. No. 11 was that the federal government give nurse practitioners a restricted provider number to enable them to order an appropriate range of investigative reports, and No. 12 was that the federal government give nurse practitioners limited and appropriate prescription rights for pharmaceuticals.

There was not a huge amount of publicity on this but, within a week of that report being tabled, the AMA contacted me seeking an appointment to discuss this, and it basically told me that the world as we knew it would fall apart if nurse practitioners were given these sorts of rights. My response to the AMA at the time was to say, 'Well, there are many parts of this state where we cannot get GPs to go because they are more comfortable practising in the metropolitan area, and I do not see why people in the country should be disadvantaged by the fact that doctors in some cases are opting for a more comfortable life. If we can have nurse practitioners with these sorts of skills and the wherewithal to exercise them and this can be a benefit for people in country areas, I am all for it.' It is interesting to reflect on the fact that here in South Australia, eight years on, we now have five nurse practitioners with these sorts of rights, and I think that is a very positive step forward.

I will return to the topic of midwives and say how important those sorts of rights are for them. When midwives are working with mothers, there are some conditions that are very common amongst women who are pregnant, such as anaemia. How silly it is—and expensive for our whole health system—to require those women to go back and see a GP in order to get a referral for a pathology test to check whether they are anaemic. It is time wasting and not cost effective to be paying out for a GP or an obstetrician when a midwife should be able to order exactly the same test.

We have two classes of nurse in this state—enrolled nurses (ENs) and registered nurses (RNs). ENs make up about 20 per cent of the nursing workforce and, until about the mid 1980s, many of them were trained within the hospitals (on-the-job training). Registered nurses are the university-trained nurses. Any new ENs are those who go to TAFE and do an 18-month course or do a course with other registered training organisations. I know that TAFE SA offers an 18-month Diploma in Nursing.

In regard to salary, no matter how many years of practice they have under their belt and how much expertise they have, a top-of-the-range EN cannot earn more than $45,000. By contrast, a level 5 RN can earn more than $80,000 per annum. I know that a registered nurse does 18 months more training than an EN, but I question whether that 18 months extra training justifies an extra $35,000 a year in pay. To use a military term, the ENs are the 'grunts' of the nursing system. They are the ones at the coal face. They are the ones who empty the bedpans or walk around the Women's and Children's Hospital jiggling a snotty-nosed crying baby to try to pacify it and put it to sleep. The RNs direct the ENs. They work out patient care programs and have much more paperwork to deal with than an EN, but I wonder whether the different type of work justifies this level of stratification, especially in relation to pay.

The switch to university training for RNs was part of a very well orchestrated industrial campaign in the early 1980s to give more nurses greater professional standing—and, of course, if you have that greater professional standing you get increased pay. However, that process advanced one group of nurses to the detriment of another group of nurses. I am aware that, in many cases when the RNs complete their training and come into the workforce, very often the ENs who are being supervised by the RNs have to tell the RNs how to supervise them and what their instructions have to be.

There is certainly a public view that there needs to be a return to at least some of the on-the-job training that the pre-1980s system produced. There are definitely some failings of the university system in terms of the people it excludes. The cost of university study can be quite prohibitive. For some people, just in terms of where they come from in society, the whole concept of going to university is simply not within their way of thinking. There are many Aboriginal girls and women who would never see it as within their capacity, either financial or intellectual, to take themselves off to university to become a registered nurse.

I query whether the pecking order that exists within the system now between RNs and ENs is justified. At the present time there is no value given to enrolled nurses as educators and no recognition given to them in terms of the mentoring that they can do, particularly with the new registered nurses as they first come into the system. Maybe we need to create a new class of administrative nurse—the type who will do all of the filling out of forms and develop the patient plans, and that sort of thing. I question whether an ability to fill out forms makes one nurse more important than another type of nurse who does the face-to-face nursing.

I have not received any correspondence on this bill and, in particular, I would have been looking for correspondence from midwives about any concerns they might have. I spoke to one midwife a few days ago and asked whether they had any concerns with it, and she said: no.

In closing, I indicate that I welcome this bill because of the positive steps it takes to recognise the professional status of midwives. It has taken 10 years to get to this point—and that is 10 years too long. I salute the midwives of this state who lobbied back in the 1990s to get their professional recognition in legislation; and even when it did not come with the current Nurses Act they did not give up but, rather, kept lobbying. In no small way the legislation before us today is a tribute to the gutsiness and determination of the midwives of this state, and I congratulate them. It is with great pleasure that I indicate my support for this bill.

Debate adjourned on motion of Hon. T.J. Stephens.