Before that, most people came into the world thanks to a midwife. But the bonus, which was more than enough to cover a doctor's fee, vastly increased the numbers of people, especially poorer people, who could afford to engage doctors - who were then angling for a bigger slice of the birthing action. By 1923 the bonus was only payable if the birth had been handled by a doctor.
Today's midwifery advocates look back at that point as ``the death knell for midwifery'', and the Act certainly made Australia a world leader in the race to sideline midwife-led birthing - which continued to have a significant, if shrinking, role in Britain for two or three more decades as hospital infection rates continued to pose a threat.
But the end result was largely the same - the invention of antibiotics in the 1940s transformed infection control, and by the 1970s hospital birth was becoming de rigeur, even in Britain.
In Australia, hospitals now have cornered the market in birthing: 97.2 per cent of the 250,758 births in 2002 took place in hospital wards. Only 2.1 per cent, or 5379 births, took place in midwife-run birthing centres attached to hospitals, and almost none - just 522, or 0.2 per cent of the total - took place at home.
The recent controversies about midwives have focused on the safety of stand-alone midwife-led units - those not sited adjacent to fully equipped hospitals. But while midwives and some obstetricians continue to argue that issue, pressures are growing here and overseas for a greater use of midwife services.
Some state Governments, led by NSW, are expanding midwife-led centres, and the federal Government is also considering creating a Medicare rebate for midwife care.
Talk to almost any woman who has had a midwife manage their birth and it's hard to see why this has not happened already. Most new mothers have little but praise for them.
Heather Hillam, of Sydney, gave birth one week ago to her and husband Howard's first child, Emily, at the delivery suite of her local public hospital. The delivery was handled entirely by a midwife, and Hillam says it was the midwife's support that allowed her to give birth without any pain relief.
She was so impressed she says she'll ``definitely'' choose to have a midwife deliver her next child (although she will again opt for a hospital setting where back-up is available).
``The surprise for me was that I just didn't realise the level of skill that midwives had,'' she says. ``I pictured them almost as womanly support, but the midwife who was with me throughout the whole birth ... she left me feeling secure and safe. I think it's easy to underestimate the skill and knowledge that they have.''
Such enthusiasm is reflected by experience in Britain, which has been actively encouraging midwife-led care since the government published an influential report, Changing Childbirth, in 1993.
Consultant obstetrician Rick Porter is director of maternity services at the Royal United Hospital in Bath, southwest England, and runs one of the country's most developed midwife-led services. His one service, which has several midwife-run stand-alone units in surrounding communities, accounts for 16 per cent of the 10,000 births in British community midwife units annually.
A strong supporter of midwife care, he says the Bath service has ``extraordinary'' public backing: for every patient who complains, there are between 40 and 60 others who have taken the trouble to compliment the service in writing. (As Porter drolly adds, thanking people is ``not an English habit''.)
He thinks birthing passed from midwives into hospitals in Britain, Australia and other places as a result of ``an abuse of the concept of cause and effect''.
According to Porter the obstetricians and policy makers of the day noted that as more births were being done in hospitals, perinatal mortality rates continued to fall, and ``made the jump'' to saying the move to hospital birth was responsible for bringing death rates down.
``So by 1970 ... they said `if we completely expunge community births, then we're going to be even better'. And of course they were right - over the next 30 years maternal and perinatal mortality did fall, but what they forgot to work out was whether it had anything at all to do with universal hospitalisation,'' he says.
``There isn't a causal relationship, or at least there is, but it's not half as strong as those who started the policy actually believed.''
Interestingly for Australia, Porter says a crucial factor that shaped the 1993 Changing Childbirth report was that doctors were unable to provide a shred of evidence to the parliamentary committee to justify universal hospitalisation for women in labour. Since the report, Porter says the number of midwife-run birthing centres alongside British hospitals has "mushroomed". But it proved a turning point in other respects.
"What it did was make people realise that midwives could call the shots in many respects, and I think it did in many (if not most) maternity units change the relationship between midwives and obstetricians forever.
"It became unacceptable for obstetricians to adopt this condescending posture as regards midwives. It would be wonderful if I could say that was universal, and it certainly isn't – because just as is here, there will be obstructive obstetricians anywhere you care to mention."
In Australia, some believe there is another potential driver that may explain the reluctance of some obstetricians to cede a greater role to midwives – unlike in Britain a large proportion of births in Australia are handled in the private sector, 31 per cent in 1996-97.
A paper published in the British Medical Journal five years ago (2000;321:137-41) compared the experiences of low-risk women giving birth as public and private patients, and found rates of obstetric interventions – such as forceps or vacuum deliveries, epidurals and caesareans – were significantly higher among private patients.
Among low risk private patients between 10.9 and 12.3 per cent of births were delivered by caesarean, while among public patients the rate was 8.5 per cent. The epidural rate was between 35.2 and 50.8 per cent among private patients, and 25.1 per cent in the public sector. The authors noted that while "a rate of intervention that is appropriate or reasonable is unknown, there are no obvious clinical reasons for intervention rates to be higher in private than in public patients".
Doctors in the private sector are paid on a fee-for-service basis for each consultation and procedure, usually a mix of money from Medicare, private health funds and patients themselves. By contrast, public hospital staff specialists are paid a salary and have nothing to gain by carrying out more procedures.
Andrew Bisits, a staff specialist and director of obstetrics at John Hunter Hospital in Newcastle, NSW, was one of the driving forces behind the setting up of the second stand-alone midwife-led birth centre in NSW, at Belmont just south of Newcastle.
He says a single caesarean might be worth about $1000 in the pocket to a private obstetrician.
But while he agrees there were "blatant" cases of overservicing 10 to 15 years ago, these days he thinks by far the major driver is a fear of being sued and doctors' wishes to "cover your backside, just in case something bad happens".
"Obstetricians are being more and more paralysed and paranoid (fearing litigation) – the caricature is that all they feel they can do is a caesarean," he says.
Bisits says midwives will "absolutely" be used more in the health system generally and agrees the attitudinal shifts that started to happen in the UK after Changing Childbirth are increasingly evident here.
But overseas examples may carry some warnings for Australia when it comes to expanding midwife care.
In New Zealand, over 70 per cent of births are handled by midwives after legislative changes turned private midwifery into an attractive option for midwives and patients.
But Bisits says the downside was that GPs were sidelined, and now had a fraction of the role in antenatal care they once did. The risk
was that some problems or risks might be missed, he said.
More seriously, the New Zealand system had created financial incentives for midwives to initiate interventions, with the result that some midwives "are almost behaving like obstetricians", he says. "The curious thing in New Zealand is that despite a midwifery-focused maternity service, the caesarean rate is higher than ours," Bisits says.
Porter says Bath's midwife services, for all their success, cannot demonstrate a much lower caesarean rate either. But he thinks the shortage of medical specialists, including obstetricians and paediatricians, will continue to drive increased use of midwives, here as in Britain.
Hospitals in areas with the worst shortages, he says, are "faced with a stark choice . . . either close, or reinvent the unit".
This is the sort of choice facing Camden in southwestern Sydney, where another midwife-led unit is under consideration.
"In many respects the far easier option, is to close . . . and say to the community, 'well tough – we can't staff it'. As you can imagine that goes down not terribly well with anybody.
"Civic pride is so deeply embedded and connected to your hospital, that if you start ripping out the entrails of that, by taking away something as emotive as the maternity unit, you seriously are getting at the soul of a community."
In London, even the biggest, most advanced hospitals seen as the bastions of specialist obstetricians such as Queen Charlotte's, have set up midwife-led units, which now handle up to 800 births a year (compared to about 200 at Belmont and Ryde, set up in Sydney last year).
"Now what this is showing is that really the idea of midwife-led units just being little diddly units where they deliver a woman every other Thursday in a month with an R in it, is an outmoded concept," Porter says. "These can be busy units, but they can still retain the flavour and the concept of midwife-led centres. I think it's really exciting."
