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Maternity Services Review

Improving Maternity Services in Australia

Discussion Paper:

Improving Maternity Services in Australia: A Discussion Paper from the Australian Government (PDF 1468 KB).

Foreword

As a recent new mother myself, I am acutely aware of the significance - to mothers, fathers and families - of the experience of pregnancy and childbirth, of introducing a new member to our families and our lives. For most it is a joyous occasion, for some it is more difficult and for others it is a time of tragedy rather than a time of joy.

As Health Minister, I recognise that Australia is one of the safest places to give birth or to be born, but I also feel that current arrangements for the delivery of maternity services in Australia are not serving all Australian women as well as they should.

This is why the Rudd Labor Government made a commitment to developing a National Maternity Services Plan to ensure national coordination of maternal services.

While major changes in how we deliver and fund maternity services are not something that can happen overnight, this is an area where the Rudd Government considers change is warranted and is being actively sought by many in our community.

I have therefore asked the newly appointed Commonwealth Chief Nurse and Midwifery Officer, Ms Rosemary Bryant, to lead a Review of Maternity Services in Australia.

This discussion paper is the first step in this important review. I invite you to consider carefully and comment on the issues raised in the paper. I have asked my Department to take into account all of the comments made and report to me by December 2008 so that we can move forward and fulfil the commitment I made last year.

It’s my expectation that this review will help inform a national approach to change, and the development of a National Maternity Services Plan as a road map for the future.

Nicola Roxon

Participating in the Review

The Maternity Services Review (the Review) will canvass a range of issues associated with services across the spectrum of care including antenatal services, birthing options, postnatal services up to six weeks after birth, and peer and social support for women in the prenatal and postnatal periods.

The success of the Review depends largely upon the participation of people and organisations in the community. The Review aims to provide the opportunity for all points of view in the community to be heard and considered. All individuals, groups and organisations with an interest in maternity services are invited to participate.

All comments and submissions will be taken into account by the Department of Health and Ageing in the Review and the National Maternity Services Plan which follows.

While the review team will not respond individually to all submissions and comments received, it is important that these are made publicly available. Unless otherwise indicated in the submission, all submissions will be published on the Department of Health and Ageing website. In addition, where submissions focus on the issues relevant to the states and territories, this information will be forwarded to the relevant jurisdiction(s).

The Department of Health and Ageing will draw on the information it receives from participants and information, research and expertise assembled from other sources to formulate a report to the Minister for Health and Ageing, the Hon Nicola Roxon, MP.

The Department of Health and Ageing welcomes comment on the content of this discussion paper, which poses some indicative questions in regard to key issues.

Comments can be made via the following:
Email:Maternity.Services.Review@health.gov.au
Mail:The Secretariat
Maternity Services Review
MDP 94, GPO Box 9848
CANBERRA ACT 2601
Closing Date:Friday 31 October 2008.

Introduction

In 2005, 267,793 women gave birth to 272,419 babies - a dramatic jump of 5.9% from the number of babies born in 2004.¹ The number of births in Australia is now the highest it has been since 1971. It seems likely that Australia is at the start of a new baby boom.

Women and their babies must be the focus of maternity care. They should be able to feel they are in control of what is happening during pregnancy, childbirth and the postnatal period, based on their individual needs and having discussed issues fully with their care providers. In order for women to feel this control, we must recognise that pregnancy and childbirth, while requiring quick and highly specialised responses to complications, are normal physiological processes, not an illness or disease.

Australian women and their babies should be able to access high quality safe maternity services, as close to home as possible, in line with their assessed level of risk. These services should be available for the continuum – from early pregnancy, at the time of birth and during the postnatal care period. Where it is necessary for women to travel away from their families and communities to access care, it is important that transport and accommodation arrangements are also addressed.

Services should recognise the differing needs and preferences of women in relation to pregnancy, childbirth and the immediate postnatal period as well as the variable levels of risk. The risks associated with birthing should be kept as low as possible.

For women who experience significant emotional and psychological consequences, there needs to be a range of accessible, integrated and culturally appropriate peer and professional support services.

The Australian Government is undertaking a Review of Maternity Services, which will aim to elicit a range of perspectives, to identify the key gaps in current arrangements, determine what is needed for change to occur, and inform the priorities for national action. With its commitment to the development of a National Maternity Service Plan, the Australian Government recognises the need for national leadership in maternity care in order to address issues, gaps and priorities which concern Australian women and their families.

The context of maternity reform

The need for reform of maternity services in Australia is not a new issue. Over recent years, state and territory governments have reviewed their maternity services and identified the need for improvement. Maternity related issues have also been the subject of a number of inquiries, commissions and reviews (see Attachment 1). More recently consumers, governments and professions have developed frameworks to guide the planning of maternity services in the future.In April this year, Health Ministers across Australia collectively endorsed A Framework for Implementation for Primary Maternity Services in Australia² which focussed primarily on State funded and delivered primary maternity services, which provide care for women with uncomplicated pregnancies. The framework endorsed a set of principles to underpin services across Australia which included:

• ensuring that services enable women to make informed and timely choices regarding their maternity care and to feel in control of their birthing experience;
• ensuring that maternity services and care are provided in a culturally appropriate and responsive manner according to the individual needs of each woman;
• maximising the potential of midwives, obstetricians, general practitioners (GPs) and where appropriate other health professionals such as paediatricians and Aboriginal Health Workers specific knowledge, skills and attributes to provide a collaborative, coordinated multidisciplinary approach to maternity service delivery;
• offering continuity of care and, wherever possible continuity of carer, as a key element of quality care;
• ensuring that maternity services are of a high quality, safe, sustainable and provided within an environment of evidence-based best practice care;
• ensuring continued access to best practice maternity services and care at the local level, while recognising that the benefits of local access must be considered within a quality and safety framework;
• providing the right balance between primary level care and access to appropriate levels of medical expertise as clinically required; and
• working to reduce the health inequalities faced by Aboriginal and Torres Strait Islander mothers and babies and other disadvantaged populations.

In addition, key professional groups developed the National Consensus Framework for Rural Maternity Services in 2007.³ The framework established a consensus of the key principles among the professional organisations representing the core disciplines that provide rural maternity care. A series of strategies were identified to address the issues associated with quality and safety, access to care, team based models of care, health infrastructure and workforce shortages, and funding for maternity services.

Key consumer groups, such as the Maternity Coalition, have called for urgent reform to promote access to community midwives, including funding, legislation, standards of care, and indemnity arrangements.⁴

What are the issues in Australia?

All over Australia, women have made it clear that safety for themselves and their babies is of paramount importance.

Over the course of the last century Australia’s progress in making pregnancy and childbirth safer for women was spectacular. In 1936 there were 600 maternal deaths per 100,000 live births. By 1950 this had dropped to 109 per 100,000 live births and by 1980 this figure had dropped below 10 per 100,000 live births.⁵Graph 1: Maternal deaths per 100,000 live births, Neonatal deaths per 10,000 live births Australia 1908 to 2004


Source: Australian Bureau of Statistics⁶Today, Australia is one of the safest countries in the world in which to give birth or be born. Data from the Organisation for Economic Cooperation and Development (OECD) shows that over the past decade Australia has had consistently lower maternalⁱ and perinatalⁱⁱ death rates than the majority of comparable countries.<sup>7

i</sup> Number of maternal deaths, all causes, per 100,000 live births
ⁱⁱ The ratio of deaths of children within one week of birth (early neonatal deaths) plus foetal deaths of minimum gestation period 28 weeks or minimum foetal weight of 1000g, expressed per 1,000 births.

Inequalities

While mortality and morbidity rates in maternity care have improved, these gains in health outcomes are not shared by all Australian women. Most notably, risk factors and health outcomes for rural and Indigenous women and babies are considerably poorer.

Maternal mortality rates for Indigenous women are more than two and a half times as high as for other women.⁸ Indigenous women are more likely to smoke during pregnancy, have a higher rate of foetal death (stillbirth) and neonatal death ⁹(death of a newborn within 28 days of birth). In addition, Indigenous women are more likely to have preterm babies and have a higher proportion of low birth-weight babies than non-Indigenous women.¹⁰ Indigenous women have more than four times the teenage birth rate of non-Indigenous women.¹¹

In addition, pregnant Indigenous women generally access antenatal care later in pregnancy and with less frequency. In Queensland, South Australia and the Northern Territory, 73%-74% of Aboriginal and Torres Strait Islander mothers access five or more antenatal sessions, compared with over 90% of other mothers. Late presentation for antenatal care has been shown to be a risk factor for poor birth outcomes among Indigenous women.¹² Case studies of targeted programs show that increased antenatal visiting can translate into reduced infant mortality. For example, the Nganampa Health Council program reduced perinatal mortality from 45 per 1000 to 9 per 1000.¹³

In terms of health outcomes, rural women have significantly higher neonatal deaths and remote women had higher foetal death rates.¹⁴ Rural and remote families also experience higher rates of maternal death. Outer regional Australia accounted for 10% of the population, 10% of births and 16% of maternal deaths with remote and very remote areas accounting for 3% of the population, 3% of births and 7% of the deaths.¹⁵

Rural women also have poorer access to maternity care arising from the reduced availability of rural maternity units, and GPs and obstetricians. While it is generally accepted that women should have access to safe maternity care, consistent with their assessed level of risk, as close as possible to where they live,¹⁶ the options available to women differ according to where they live. In practice, this may mean differences in the models of maternity care appropriate to rural and remote communities, compared to urban settings.

Also, importantly, mortality rates alone do not tell the full story. Issues such as caesarean rates and other intervention rates, poor nutrition, smoking and alcohol consumption during pregnancy, breastfeeding rates and the rates of postnatal depression also need to be considered.

Intervention rates

Compared to a number of similar overseas countries, Australian maternity services have higher rates of intervention. This is evidenced by the higher proportion of hospital births, compared to birthing centre or home based births and the higher rate of interventions including caesarean section.

Australia has a very high rate of caesarean section (30.3% of births in 2005¹⁷compared with the 2004 OECD average of 22% of births).¹⁸ This proportion has increased markedly over the last fifteen years (up from 18% in 1991). This is well above the World Health Organization’s recommendation that caesarean sections should only be necessary for fewer than 10% of women, with 15% being an upper limit for surgical intervention.¹⁹

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% compared with 27.1% in public hospitals), as well as higher use of forceps (5.1% compared with 3.0%) or vacuum extraction (9.7% compared with 6.4%) for vaginal births.²⁰

Across Australian states and territories there are also substantial differences in the intervention rates. Use of forceps varies from 1% of births in Tasmania to 6% in Victoria. The caesarean rate in Western Australia (33.9%) is considerably higher than that in Tasmania (26.4%), and in Western Australia 22% of caesarean births take place with no labour, compared with only 12.6% in Tasmania.²¹

There is no consensus as to whether rising rates of caesarean section reflect the increasing risks associated with older mothers, decreasing procedural skills or defensive medical practice amongst clinicians, or increasing rates of women electing to give birth by caesarean section when it is not medically required. Although differences can sometimes be explained by demographic and other differences, the degree of some of this inconsistency suggests a need for further consideration. There has also been some evidence of poorer health outcomes for both mother and baby from planned caesarean section at term, and further research in this area is required.

Rising caesarean and other intervention rates also imply an additional burden on the health system and pressure on scarce hospital resources such as operating theatres.

Part of the challenge lies in our ability to monitor changes in health status and health outcomes through robust, comprehensive data collection and reporting. There have been calls for more sustainable investment at the national level in order to more effectively monitor the performance of maternity services in terms of safety, accessibility, sustainability and responsiveness.

Maternal nutrition, alcohol consumption and smoking

While there is limited population data available, good nutrition in pregnancy is essential for maintaining the mother’s health and for the healthy growth and development of the baby. Nutrients of particular importance to pregnant women include protein, iron, folate (folic acid), calcium and iodine. There is also a significant amount of research to indicate that smoking is associated with poor perinatal outcomes and is a risk factor for complications in pregnancy. In the period 2001 to 2003, 17.3% of women who gave birth reported smoking while pregnant, with smoking during pregnancy most prevalent in teenage mothers (42.1%).²² Aboriginal and Torres Strait Islander mothers were of particular concern, with 52.2% reporting that they smoked during pregnancy.²³
Rates of alcohol consumption during pregnancy and lactation by Australian women are also high with surveys showing half of the respondents drank alcohol during pregnancy.²⁴ In one survey, 15%²⁵ drank above the National Health and Medical Research Council 2001 guideline levels (1 standard drink per day) during the first trimester.²⁶

Breastfeeding rates

Breastfeeding rates are another issue to consider. The report of the recent Inquiry into the health benefits of breastfeeding in Australia indicated that while Australia compared well with other countries in breastfeeding initiation, the continuation rate lags behind other countries.²⁷

Table 1: Breastfeeding rates around the world 2002

	% of mothers who start	% who continue 6 months or longer
Sweden	98	53
Norway	98	50
Poland	93	10
Canada	80	24
Netherlands	68	25
UK	63	21
USA	57	20
Australia	83	18

Source: Inquiry into the health benefits of breastfeeding in Australia 2007²⁸

In addition, there are differences in breastfeeding rates across the population. According to the Australian Institute of Health and Welfare (AIHW) report on the Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, in 2004/05, 66% of Aboriginal and Torres Strait Islander children 0-3 years had been breast-fed compared with 72% of non-Indigenous children.²⁹ Although Aboriginal and Torres Strait Islander women living in remote areas are more likely to have breast-fed than those in non-remote areas, there is a risk of declining rates of breastfeeding in these Aboriginal and Torres Strait Islander women which is of concern.

Antenatal and postnatal depression

Another key consideration for maternity services is the rate of antenatal and postnatal depression. Depression affects around 15% of all women during the perinatal period. As there are about 267,000 women who give birth each year in Australia, approximately 40,000 women are likely to be affected every year.³⁰ It is important that women are screened for perinatal depression, and, if diagnosed, referred for treatment and support. Clinical and non-clinical services are available to support women experiencing antenatal and/or postnatal depression.

Social and emotional responses to pregnancy and birth

Women may be affected by psychosocial or other normal emotional reactions to pregnancy or to grief and loss following miscarriage or stillbirth. Peer, social and other support services play an important role in supporting women during the perinatal period. These services are often provided through not for profit organisations and include pregnancy counselling, grief and loss counselling, and breastfeeding support, as well as general support in adjusting to the demands of a new baby. Particular issues can arise where a pregnancy is unplanned. A key challenge is that there is variable access for women to these support services. A comprehensive national approach would ensure support services, including peer support services, are well integrated and women receive effective information and peer support, and are referred to clinical services as required.
As with many aspects of the Australian health care system, maternity services are a combination of Commonwealth, State and Territory Government and privately funded and delivered services. Maternity services are provided in multiple settings by a range of different providers. For Australian women and their babies, this often means a range of different health care providers are involved across the course of their pregnancy. From the woman’s perspective, maternity services often appear fragmented. They often have different care givers involved in different stages. For example, in many instances a woman will be in labour in hospital attended by a midwife (or more than one midwife if shifts change), whom she has never met before. This is despite international and national studies which have consistently demonstrated that continuity of care/r improves satisfaction for both women and health professionals, boosts health outcomes, and reduces intervention rates.³¹

Overall expenditure
The AIHW report Australia’s Health 2008³² indicates that $1,672 million was spent on maternity services in 2004/05, not counting the $456 million spent on neonatal care. Over $1,539m (92% of the total) was spent on admitted patient services. Therefore, the vast majority of maternity services expenditure is associated with deliveries taking place in hospital.³³Graph 2: Maternity Services Expenditure 2004/05

Source: Australian Institute of Health and Welfare³⁴
Percentages do not add up to 100 due to rounding.

The Commonwealth makes a substantial funding contribution through the Medicare Benefits Schedule (MBS) rebates (including the Extended Medicare Safety Net (EMSN)), contributions through the Private Health Insurance Rebate, support for public hospitals through the Australian Health Care Agreements (AHCAs) as well as a range of targeted workforce and other maternity related services (described in more detail in Attachment 2).

Outlined below are the maternity services covered by the MBS as at 1 November 2007. In addition to the obstetric services listed below, where treatment is provided by a medical practitioner to manage a concurrent condition during maternity care, these services would be covered under general MBS items.Table 2: Maternity Services currently covered under the MBS

Type of care	Description	Examples of MBS Item Numbers
Antenatal Care	A range of antenatal care items for both uncomplicated pregnancy and for women with particular pregnancy health needs, provided by a medical practitioner. Antenatal services provided by appropriately trained and qualified midwives, nurses and registered Aboriginal Health Workers, on behalf of medical practitioners, in rural and remote areas. An item for planning and management of a pregnancy, by a medical practitioner.	16500, 16501, 16502, 16504, 16505, 16508, 16509, 16511, 16512, 16514 16400 16590
Labour and Delivery	A range of items covering labour and delivery, including caesarean section, provision for high risk births and births where the patient’s care has been transferred to another medical practitioner.	16515, 16518, 16519 16520, 16522
Postnatal Care	A range of items covering postnatal surgical services, such as repair of cervix or third degree tear. There are no consultation items specific to postnatal care. The 6 week postnatal check and any other postnatal attendances provided by a medical practitioner are covered under existing specialist/GP consultation items.	16564, 16567, 16570, 16571, 16573
Diagnostic Services	A range of diagnostic imaging and pathology services specific to maternity care, such as pregnancy related ultrasound, pelvimetry, pregnancy test and glucose testing for gestational diabetes.	55700, 59503, 66545, 73527.

State and Territory Governments also make a substantial contribution by providing antenatal and birthing services, delivered for free through public hospitals, including birthing centres, to the majority of Australian mothers. Individuals and families also fund a significant proportion of maternity services through their private health insurance arrangements and with out-of-pocket contributions for particular services.

Expenditure across antenatal, birthing and postnatal care
Antenatal care is funded both publicly and privately. Private antenatal consultations are available through private practitioners, such as GPs, obstetricians and midwives. These services are subsidised through MBS rebates (in the case of midwives these are limited to certain services provided on behalf of, and under the supervision of, a medical practitioner) and by private health insurance rebates. Rebates do not always cover the full cost, leaving ‘gap’ payments for some services. In addition, some private hospitals provide some antenatal services such as exercise classes and classes to prepare for childbirth.

The funding of private antenatal services has been impacted by the introduction of the EMSN in 2004, and the associated introduction of a new item for the planning and management of a pregnancy (MBS item 16590). The planning and management fee has largely taken the place of a booking fee for which no Medicare rebate was previously payable. Anecdotally, whereas the booking fee was an exception, it appears that the charging of a planning and management fee is now widespread.

Between the 2006 and 2007 calendar years the average fee that doctors were charging for the planning and management of a pregnancy increased 16.2% from $1,088.55 to $1,264.86. By July 2008, the average fee charged was $1,980.51 and the highest fee charged was around $9,000.

These costs are heavily subsidised by the EMSN. In 2007 safety net payments for obstetric services cost $98.6m, making up 31% of total safety net expenditure.

Antenatal services are also provided through the public system via outpatient clinics in public hospitals. The available data suggests that there were around 3.2 million antenatal services in 2005/06, equivalent to around 12 per pregnancy. Just over half of these antenatal services are provided by outpatient clinics in public hospitals. Unfortunately there is limited data on how equitably these services are provided, including how many women are accessing antenatal care in the first trimester.

Graph 3: Provision of antenatal consultations 2005/06

Source: Department of Health and Ageing analysis³⁶

Nearly all births in Australia occur in hospital. Graph 4: Place of Birth, Australia, 2005

Source: Australian Institute of Health and Welfare³⁶

This contrasts with some other countries, which have considerably higher rates of home births and births in midwife-led environments equivalent to Australian birth centres. In New Zealand, 2.5% of women had a birth at home,³⁷ compared with 1.9% of women in the UK³⁸ and 0.2% of Australian women.³⁹

The majority of women giving birth in hospitals did so as public patients in public hospitals.

Table 3: Hospital Births: Public vs Private, 2005

	Type of hospital		Patient election status
	number	%	number	%
Private	78,809	30.2	88,375	33.9
Public	182,216	69.8	166,884	63.9
Not stated			5,766	2.2

Source: Australian Institute of Health and Welfare⁴⁰
Private health insurance arrangements cover some or all of the accommodation and labour ward costs of births in private hospitals (and private births in public hospitals), with the MBS helping to subsidise the medical costs. For midwives, as there is no MBS benefit payable for the management of labour and delivery, support for midwife services through private health insurance is limited.If a mother chooses to have her baby outside a hospital, at home or elsewhere, her insurer may pay a benefit for the services of a midwife to manage the delivery. However, in the majority of cases mothers choosing to have their babies outside hospital pay the full cost of midwife services.

Public hospital services are provided free to patients, jointly funded by State and Territory Governments and by the Commonwealth through the AHCAs. Some public hospitals offer birthing centres which offer midwifery led models of care, an option not generally available in private hospitals.

Expenditure on postnatal services is also a mix of public and private funding. Postnatal services are provided primarily by states and territories, with considerable variation in exactly what level of services are provided. Generally, private hospitals do not provide postnatal care beyond the delivery and the days immediately following. A mother may choose to consult a midwife privately for postnatal care. There is no Medicare benefit payable for postnatal care provided by a midwife. Some private health insurers pay benefits from general treatment cover, otherwise the mother pays for this care herself.

What about workforce and infrastructure?

As with other aspects of health care, workforce issues are central to ensuring access to the maternity services for all Australian women and their families.

There are currently around 12,000 midwives in Australia, who work predominantly in State and Territory Government employment.⁴² There were approximately 1160 practising medical specialists in obstetrics and gynaecology in 2003 (of which approximately 25% did not work in obstetrics).⁴³ Along with obstetricians and midwives, a range of other health workers can be involved in the provision of maternity services. These include GPs, nurses, paediatricians, anaesthetists, physiotherapists, doulas, dieticians, social workers, mothercraft nurses, lactation consultants and Aboriginal Health Workers.

The skills, qualifications and scope of practice of different health workers involved in the provision of maternity services vary. However, health workers providing maternity services cannot work in isolation from each other. For example, quality and safety cannot be ensured if there is no access to an anaesthetist in an emergency situation.

The maternity workforce, as with the overall health workforce, is faced with existing and worsening shortages. Workforce shortages are more acute in rural and remote areas. The ageing of the population is expected to exacerbate workforce supply issues in coming years, with increasing retirement rates, changing work patterns and growing demand for services impacting on the overall capacity of the health workforce. Inflexibilities and inefficiencies in workplace arrangements are further contributing to workforce issues and health outcomes, particularly in certain regions and for particular groups. As a result, there is a need to consider workforce and service delivery models in the provision of maternity services. There is increasing interest in the use of non traditional models such as multi-disciplinary care based on the needs of the individual. Such models require appropriate training of all health workers and increased collaboration among health disciplines. While each profession has professional standards and protocols, there is a need for protocols which guide multi-disciplinary practice. The introduction of new models of care also requires consideration of funding and service delivery mechanisms. Importantly, in the context of maternity services it will not always be appropriate, safe or effective to provide all models of care in every community.⁴⁴ It should also be noted that some women may prefer more traditional models of care for their childbirth experience. Likewise, some health workers prefer to work in a more traditional care environment.

Alternative models of service delivery, including those which support a comprehensive midwife role, have been introduced across parts of Australia. For example, in a number of states and territories, birthing centres which allow a midwife led delivery are developed adjacent to public hospitals, as well as community based models in some rural areas. However, for many women, the choices are limited to delivery in a public or private hospital setting, with potentially less flexibility for women seeking private arrangements.

Midwives can play an important role in improving the quality of primary maternity care in Australia. For such models to develop, there are a number of factors to be addressed. Funding is one factor, however, funding options alone will not enable the expansion of midwife led care or alternative shared care models. The current lack of access to appropriate and affordable professional indemnity insurance products is an obstacle to comprehensive midwife practice. At the same time, to provide a comprehensive service, midwives, as is the case with GP obstetricians, require rights in the hospital setting to enable them to visit and refer their clients, and to order and interpret diagnostic tests and initiate use of pharmacological substances for them, and the related Pharmaceutical Benefits Scheme and MBS access for these services. In addition, midwife-led care needs to be developed in the context of appropriate referral pathways to secondary or tertiary level services that provide a higher level of medical care for unplanned, high risk and complicated births. These pathways need to be supported by shared care protocols which are endorsed by all health professionals involved.

In tandem with a sustainable workforce is the need to ensure service infrastructure is in place to support services. Infrastructure can include hospital beds and diagnostic and monitoring equipment; reliable communication technology to facilitate specialist advice and support; evidence-based risk management protocols to support referral; and access to transport for the safe and timely transfer of women and their babies where referral to another facility is necessary.

What are the ways forward?

Improving the delivery of maternity services in Australia will require a comprehensive approach which recognises and builds on the mixed funding and service delivery arrangements which currently exist. Importantly, particularly in rural Australia, arrangements also need to allow flexibility to support a range of models responsive to the needs and circumstances of local communities.

At the same time, changes to service delivery arrangements will need to take place in a way that maintains safe services for both women and their babies. This will include protocols for women and their babies transferred from the care of one professional to another, or one hospital to another. On the ground, this means agreed models of care which involve close collaboration and agreed protocols between the range of health care professionals including midwives, GPs and obstetricians.

A key area is to expand the scope, within both public and private sectors, for women to achieve greater choice and increased continuity of care. This includes being able to choose, where clinically appropriate, a midwife-led service.

Unless such services can be developed in collaboration with GPs and obstetricians there are potential safety risks. At the same time, there could be potential opportunities for private health insurers and private hospitals to more actively support alternative choices for women.

Importantly, any changes in private sector services should not take place to the detriment of services provided by State and Territory Governments. New arrangements will need to take into account the potential impact on the availability and distribution of the limited workforce, and the ongoing viability of health services, particularly in smaller communities.

Another issue for consideration is achieving greater continuity and integration of care for those women who currently receive the bulk of their antenatal care through primary health care settings, including general practice and Indigenous and remote health services, but give birth in a public hospital setting with a different set of caregivers and health professionals. This is an area where a realignment of funding and responsibilities between State and Territory Governments and the Commonwealth has been mooted by some.

There is a need for better utilisation of existing nursing and midwifery skills particularly in rural and remote areas. While there is potential to increase the community based services, it is not possible to provide all services, for all levels of risk, in every community. Where women and their babies need to travel away from families and communities to access services consistent with their assessed level of risk, adequate transport services and accommodation options need to be in place.

It is also important to consider the need to provide access to postnatal services, such as information and support, for parenting and infant feeding. There have been concerns that breastfeeding rates have declined and postnatal depression rates have increased as a result of shorter hospital stays and fragmented community services. Strategies for Indigenous women and other groups of ‘at risk’ women will need to be tailored to their needs.

It is important to consider the range of social support services provided to help women who are under stress, dealing with postnatal depression or grieving over the loss of a baby.

In the longer term, initiatives to support and expand the available and future workforce will need to be part of any response, as will adequate information systems to monitor performance and support research.
Conclusions

Improving the delivery of maternity services in Australia is not the responsibility of any single party. While there are actions which could be undertaken by the Australian Government on its own, substantial change requires a combined approach.

Meaningful changes in maternity services require the engagement of:

• Health professionals and their professional organisations - to support cooperative and safe models of shared care, including education, training and credentialing;
• Insurers - to address issues of medical indemnity and access;
• Private hospitals and Private Health Insurers - to encourage and support new service models;
• Non-government organisations providing peer and social support to women;
• State and Territory Governments,
  • to support greater innovation in services they deliver;
  • to support patient transfer;
  • to address any legislative constraints;
  • to identify models to increase take up by disadvantaged and hard to reach groups; and
• Universities and professional organisations - to support education and training for health professionals as well as research and evaluation.

Through the development of a National Maternity Services Plan, the Australian Government seeks a way forward from the parties involved.

Attachment 1: Previous reviews

State and territory government reviews and plans
State and territory governments have played a major role in maternity reform to date. In the late 1980s and the early 1990s a number of states and territories, such as New South Wales and Victoria, reviewed maternity services, and for the first time described current practice, consolidated consumer views and provided a platform for further planning and research. As a result, a number of the States and Territories have maternity frameworks or plans, or outline role delineation of maternity services through overarching planning documents. These include:

• The NSW Framework for Maternity Services;
• Future Directions for Victoria’s Maternity Services;
• Improving Maternity Services: Working together across Western Australia;
• Tasmania’s Health Plan;
• South Australia’s Health Care Plan 2007-2016;
• Maternity Services Review in the Northern Territory; and
• A range of activity in response to Re-birthing: report of the review of maternity services in Queensland.

Inquiries, commissions and reviews

• Commonwealth of Australia. 1999. Rocking the Cradle: a report into childbirth procedures.
• National Health and Medical Research Council 1996. Options for effective care in childbirth.
• National Health and Medical Research Council 1998. Review of services offered by midwives.
• Australian Health Ministers Advisory Council 2008. Primary Maternity Services in Australia - a Framework for Implementation.

Frameworks

• Rural Health Workforce Australia, Royal Australian College of General Practitioners, Rural Doctors Association of Australia, Australian College of Midwives, Australian College of Rural and Remote Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists. 2007. National Consensus Framework for Rural Maternity Services.
• Maternity Coalition 2002. National Maternity Action Plan Birth Matters Journal of the Maternity Coalition. Vol 6.3.
• National Rural Health Alliance 2006. Principles for maternity services in rural and remote Australia.

Attachment 2: Australian Government initiatives in maternity care

New Directions: Mothers and Babies Services
Through New Directions: An Equal Start in Life for Indigenous Children the Australian Government will provide comprehensive maternal and child health services, including home visiting, for Indigenous people. The Child and Maternal Health Services component of New Directions commits $112 million to improve the health of Indigenous mothers and babies, including:

• $90.3 million over five years for comprehensive mothers and babies services, including home visiting;
• $11.2 million over five years for a Rheumatic Fever Strategy; and
• $10 million for an Indigenous Mother’s Accommodation Fund to be managed by the Department of Families, Housing, Community Services and Indigenous Affairs.

New Directions Mothers and Babies Services will provide Aboriginal and Torres Strait Islander children and their mothers with access to antenatal care; standard information about baby care; practical advice and assistance with breastfeeding, nutrition and parenting; monitoring of developmental milestones; and health checks and treatment for Indigenous children before starting school.

$85 million Plan for Perinatal Depression
The Australian Government is implementing an $85 million plan for perinatal depression, in partnership with the states and territories, to improve the prevention and early detection of antenatal and postnatal depression and provide better support and treatment for women experiencing depression during the perinatal period.

Specialist Obstetrician Locum Scheme
The Specialist Obstetrician Locum Scheme (SOLS) provides much needed locum relief to rural obstetricians so they can take a break from work to rest and undertake professional development. The objective of SOLS is to maintain and improve the access of rural women to quality local obstetric care and sustain safety and quality in rural practice.

The Government will invest $5.9 million to support the SOLS on a continuing basis, and expand it to provide support to GP obstetricians and GP anaesthetists. Funding will be provided over three years from 2008/09 when the Scheme’s current funding will run out. This will improve access to quality obstetric care for rural women by increasing the locum support available to the rural obstetric workforce.

Support Scheme for Rural Specialists
The Support Scheme for Rural Specialists (SSRS) supports specialists to stay in rural areas by reducing their professional isolation and providing access to Continuing Professional Development (CPD) and peer support activities. SSRS also encourages specialist medical colleges to develop CPD activities for their rural members.

Medical Specialist Outreach Assistance Program
The Medical Specialist Outreach Assistance Program (MSOAP) aims to improve rural and remote community access to a range of medical specialist services, including obstetrics, by complementing outreach specialist services provided by State and Northern Territory Governments. This is achieved by addressing some of the financial disincentives to specialists providing outreach services.Development of a National Women’s Health Policy
The Australian Government has made a commitment to develop a national policy on women’s health in consultation with State and Territory Governments, health service providers, consumers and advocacy groups that will encourage specific health services for women and actively promote participation of women in health decision making and management. Community and women’s health stakeholder groups will have opportunity to provide input into the policy as it is developed.

National Pregnancy Support Helpline
The National Pregnancy Support Helpline provides professional, non-directive counselling on all three options (that is, proceeding with the pregnancy and parenting, proceeding with the pregnancy and adopting, and terminating the pregnancy) to women with unplanned pregnancies who wish to explore pregnancy options, and to their partners and affected family members. The Helpline is available 24-hours, seven-days-a-week across Australia.

Initiatives to address smoking in pregnancy
The former Australian Government provided $4.3 million over three years to encourage doctors, health workers and practice nurses to give advice to pregnant women — particularly Indigenous women — about the damage caused by smoking, and to assist these women to quit smoking and not commence again after giving birth. The smoking and pregnancy initiative will cease in June 2009. An example of funding from the initiative is the development and distribution of a Pregnancy Lifescripts Kit which targets the key risk factors for pregnancy including smoking, alcohol use and nutrition. The Kit is used by GPs and practice nurses to help women have healthier pregnancies and healthier babies. Another example is the National Smoke-Free Pregnancy Project which provides brief interventions for pregnant smokers who attend participating public birthing services.

Nursing Scholarship Program - Royal College of Nursing Australia
The Nursing Scholarship Program (NSP) was developed as one of a range of scholarships in medicine, nursing and midwifery, pharmacy, and other health professions that were designed to encourage students to undertake a health career or upgrade health qualifications in rural and remote Australia.

The NSP provides direct financial assistance to individuals undertaking professional development, and other assistance through establishing support measures. The underlying objective of the NSP at a national level is a sustainable workforce of nurses and midwives. The NSP comprises of the following:

• Rural and remote undergraduate scholarships;
• Rural and remote continuing professional education scholarships;
• National Nurse re-entry scholarships for rural and metropolitan applicants; and
• Nurse Mentor Program as a support measure for all scholarship recipients.

Bringing Nurses Back to the Workforce
This program is available to registered nurses/midwives and enrolled nurses to encourage them to return to the workforce. The program aims to provide relief for nurses currently in the workforce by increasing workforce numbers, reducing the need for excess overtime and casual replacements and, in turn, allowing nurses to undertake more professional development opportunities. The recognised need for better clinical supervision of new graduates is also being addressed by building the numbers of nurses in the workforce and thus increasing the capacity to provide trained clinical placement supervisors of new graduates.Antenatal training support for Rural Practice Nurses Project - Royal College of Nursing Australia
On 9 January 2006, a new Medicare item 16400 was announced, under which practice nurses, midwives and Aboriginal Health Workers are able to perform antenatal care under the supervision of a GP or specialist obstetrician in rural and remote areas. The project enables these health professionals to be effective in their role and supports them to up-skill in the delivery of services under the Medicare Benefit Schedule (MBS) on behalf of GPs. The project outcomes are to:

• increase awareness of Australian Government support for practice nurse training in antenatal care;
• develop a practice nurse training package to support registered nurses, with varying levels of experience to deliver services under the antenatal MBS item number 16400;
• increase the number of practice nurses accessing MBS item number 16400;
• increase the training support available to practice nurses in rural areas; and
• promote safe, quality antenatal care to women living in rural areas.

Cross government initiatives

National Partnership
In July 2008, the Council of Australian Governments (COAG) agreed in principle to joint funding of around $547.2 million over six years for a National Partnership Agreement to improve outcomes for Indigenous children from birth to age three. This includes joint Commonwealth/State investment of around $165 million to improve antenatal, postnatal, child and maternal health services for Indigenous families, which is linked to the Commonwealth’s New Directions for Indigenous Children. In addition, the Commonwealth will be investing $107m in funding for states and territories to increase access to, and use of, antenatal services in the first trimester by young Indigenous mothers under 20 years, and support young Indigenous teenagers to delay first pregnancy and make informed decisions about family planning; and $275.2m for integrated services that will offer early learning, child care and family support programs, and facilitate access to child and maternal health services in urban, regional and remote areas with high Indigenous populations.

Early childhood development
Through COAG, all governments are working together on a range of initiatives that will enhance access to services and improve child health and development outcomes in line with the COAG agreed aspiration "that children are born healthy and have access to the support, care and education throughout early childhood that equips them for life and learning, delivered in a way that actively engages parents, and meets the workforce participation needs of parents."

Antenatal care

References

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