Improving maternity services in Australia: the report of the Maternity Services Review

2. Access to a Range of Models of Care

Page last updated: February 2009

Current Context

Currently, the great majority of Australian women deliver their babies in hospitals in a conventional labour ward setting (Table 1 below). The AIHW reports that, in 2006, a total of 269,835 women gave birth in hospitals (97.3 per cent) while 5,460 women gave birth in birth centres (2.0 per cent). Planned homebirths and other births, such as those occurring unexpectedly before arrival in hospital or in other settings, accounted for the smallest proportion of women who gave birth (2,053 women, 0.74 per cent). There has been little change in these percentages over the last decade: the proportion of women giving birth at a birth centre increased from 1.84 per cent in 1996 to 1.97 per cent in 2006 while the number of homebirths fell from 0.35 per cent of women in 1996 to 0.26 per cent in 2006 and hospital births fell from 97.45 per cent in 1996 to 97.26 per cent in 2006. 24

The AIHW also reports on the place where a woman intended to give birth. 25 In 2006, a total of 9,368 women intended to use a birth centre but only 5,460 women actually gave birth in a birth centre; the large difference may be due to difficulties in accessing birth centre care, or births being escalated to hospital care. Furthermore, 886 women intended to have a homebirth but only 708 actually had a homebirth. 26

Table 1: Women who gave birth, by place of birth, 2006

 

NSW

 

Vic.

 

Qld

 

WA

 

SA

 

Tas.

 

ACT

 

NT

 

Aust

 

Mothers
(number)

91,303

68,547

55,719

28,253

18,518

6,053

5,354

3,689

277,436

Place (%)

 

Hospital

97.3

97.3

98.5

98.0

92.3

97.8

95.8

96.6

97.3

Birth centre

2.0

1.9

0.8

0.9

6.9

1.4

3.8

0.0

2.0

Home

0.1

0.3

0.1

0.7

0.5

0.2

0.2

0.9

0.3

Other

0.5

0.5

0.5

0.4

0.4

0.6

0.2

2.5

0.5


[Top of page<p class="footnote">]Source: Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney, p. 20.


South Australia has had a much higher number of deliveries in birth centres since its Alternative Birthing Services Programme was set up in the early 1990s. Birthing units opened at the Women’s and Children’s Hospital in 1992, at Lyell McEwin Health Service in 1993 and at Flinders Medical Centre in 1996. 27

Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28 compared with 2.7 per cent in England and Wales,29 2.5 per cent in New Zealand,30 and 0.6 per cent in the United States. 31

Figure 7: Homebirths, Australia, 1991–2006

Figure 7: Homebirths, Australia, 1991–2006


Source: Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney.


In 2004, the Australian Medical Workforce Advisory Committee (AMWAC) reported on the specialist obstetrics and gynaecology workforces in Australia. It found that, while there were a number of care options available to pregnant women in Australia, access to these models varied. Obstetricians, midwives and GPs may all be lead carers during a woman’s pregnancy, or care may be shared by a combination of providers, who may work in a range of settings, from private practice to public hospitals. Table 2 summarises the different models of maternity care available in Australia, which AMWAC drew from work prepared by the Centre for the Study of Mother’s and Children’s Health, School of Public Health at La Trobe University.

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Table 2: Models of maternity care


Model

Features

Private Maternity Care

Private patients of an obstetrician or GP obstetrician; attend private rooms for care in pregnancy and attended by the same obstetrician/GP for labour and postnatal care.

Public Hospital Clinic Care

Antenatal care in a public hospital outpatient clinic; attend the same hospital for labour and postnatal care; pregnancy and intrapartum care provided under the supervision of medical staff, uncomplicated births usually attended by midwives.

Public Hospital Midwives' Clinic

Antenatal care is provided by a public hospital midwives' clinic, with one or more visits to a consultant or registrar; intrapartum care is provided under the supervision of medical staff, uncomplicated births usually attended by midwives.

Birth Centre Care

Team midwifery care within a separate section of a hospital where midwives provide antenatal, intrapartum and postpartum care.

Shared Maternity Care

Formal arrangements between a public hospital and local practitioner (GP, obstetrician, midwife); the majority of pregnancy care is provided by a local practitioner, with visits to the hospital at the beginning and latter part of pregnancy; public hospital intrapartum care.

Combined Maternity Care

Similar to shared maternity care but does not involve pregnancy check-ups at a public hospital clinic.

Team Midwifery Care

 

Small teams of public hospital midwives care for women throughout pregnancy, labour, birth and the hospital stay, with one or more visits to a consultant or registrar.

Caseload Midwifery Care

Ongoing care with the same public hospital midwife for the majority of antenatal, labour, birth and postnatal care.

GP/Midwife Public Care

GPs and hospital-employed midwives jointly provide antenatal care to women enrolled for public hospital intrapartum care.

Outreach Midwifery Care

Midwife care for women with high social or obstetric risk, focus on support and education; intrapartum and postnatal care provided by a public hospital.

Planned Homebirths

Pregnancy check-ups, intrapartum and postnatal care provided by the same midwife; transfer to hospital in the case of complications as a private patient of a GP or obstetrician; may require a number of visits with a medical practitioner.


Source: Australian Medical Workforce Advisory Committee (2004), The Specialist Obstetrics and Gynaecology Workforce—An Update 2003–2013, AMWAC Report 2004.2, Sydney, pp 18-20.


The Victorian Government issued a report in 1999 on models of antenatal care. It examined 18 models of care and the percentages of women who used each model. If the categories set out in Table 2 are matched up against those in the Victorian study, it can be estimated that four models of care were used by 92.7 per cent of women. Private maternity care was used by 31.8 per cent of women at the time they gave birth, followed by combined maternity care (24.3 per cent), public hospital clinic care (22.4 per cent) and shared maternity care (14.2 per cent).32

A survey of the views of women in Victoria on their intrapartum care found the highest levels of satisfaction among women who were private patients of specialist obstetricians or GP obstetricians (83.4 per cent rated care as very good). These results may be considered unsurprising, given that private patients are more likely to have chosen the particular specialist as their health provider. Furthermore, they may indicate a preference for continuity of care from a known health provider. The next highest satisfaction rates (68.3 per cent) were reported by women who attended birth centres. 33 La Trobe University is leading a study building on the Victorian survey. It is currently analysing data on recent mothers in South Australia and Victoria and is due to report in 2009.

The Commonwealth and states and territories, through the Australian Health Ministers’ Conference have, as a principle, committed to continuity of care—and, wherever possible, continuity of carer—as a key element of quality maternity care. Continuity of care enables women to develop a relationship with the same caregiver (or team of caregivers) throughout pregnancy, birth and the postnatal period.34 There is some evidence to show the benefits of continuity of maternity care, which include reduced interventions in labour, enhanced experiences and satisfaction with care during pregnancy and childbirth, greater preparedness for birth and early parenting, and reduced health care costs.35 Research also supports the benefits of midwifery-led continuity of care.36

Of the range of models of maternity care shown in Table 2 above, including those that provide continuity of care, not all models are available to all women. The choice and type of options vary within and between states and depend on a range of factors including the available workforce, available facilities and community needs.

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What the Review Team Heard

  • A key area of consensus was that maternity care should be multidisciplinary and involve a collaborative, team-based approach.

    I strongly believe that the path to providing women a better service is through the development of effective, functioning women’s healthcare teams, and that this should be supported from both an educational perspective and a business model that rewards a collaborative model of care. I believe that overemphasis of who the leader of the care is (be it either GP-led, midwifery-led or obstetric-led) is unhelpful and only reinforces public perceptions of professional silos. Please can we change this to collaborative care? 37

    The Rural Doctors Association of Australia believes that this care is best provided by a collaborative model that involves all members of the core maternity care team—GP obstetricians, midwives and specialist obstetricians—according to the needs and wishes of the woman. 38


  • Numerous submissions identified the need for national guidelines for maternity care to assist collaborative multidisciplinary care and support evidence-based practice.
  • Many submissions referred to the difficulty in accessing birthing centres, some referring to possible access via a lottery or ballot system.

    Private and public midwifery care models exist in Australia, but due to a variety of barriers, operate at a very small scale … Nearly all primary midwifery models are very popular with women and unable to meet demand. 39

  • Consumer submissions voiced concerns about an absence of choice in relation to maternity services, in both rural and metropolitan areas. In their submissions, some consumers expressed feelings of being subject to coercion, lack of control over the birth process, and dissatisfaction with the outcomes. In some instances, consumers advised that this has led to them giving birth at home on their own without any health professional providing assistance.40 Many of the consumer submissions demonstrated a clear preference for care by midwives, either in birthing centres or in the home setting.
  • Many submissions to the Review were from women advocating homebirth and requesting government funding in this area. For a proportion of women, the desire for a known midwife through the course of their pregnancy, and the inability to access this type of service through mainstream maternity services, was at least part of the reason for their choice of homebirth. Some submissions also expressed a concern at the lack of choice for women who were excluded from alternative models of care options as a result of being assessed as ‘high risk’. For example, women wishing to have a vaginal birth after caesarean (VBAC), those who have had multiple pregnancies and those with breech presentation were identified as not meeting criteria for some alternative models of care.
  • Alongside consumer submissions, a number of organisations and academics advised of the benefits to women of continuity of care (and carer) midwife-led models and the limited access to these models in Australia. Differing views were raised with the Review Team about the New Zealand experience of moving to midwife-led models of care and the reported benefits and outcomes of those changes, including their impact on collaborative arrangements between midwives and other medical professionals.
  • There were numerous examples provided to the Review of existing effective collaborative models of maternity care operating in Australia. Examples included:
    • Belmont Birthing Service: women are cared for by a small group of midwives with referral to John Hunter Hospital.
    • The Kilmore Model: a team of midwives, GP obstetricians, specialist GPs and shared care GPs operate an antenatal clinic and collaborative obstetric care model.
    • Northern Women’s Community Midwifery Program: a publicly funded midwife-led continuity of care model that offers women in Adelaide’s northern suburbs access to a team of six community midwives.
    • Ryde Midwifery Group Practice: a caseload, midwifery-led unit associated with Ryde Hospital that offers the benefits of continuity of midwifery care to women with low-risk pregnancies.
    • Community Midwifery Program in Western Australia: provides caseload midwifery homebirthing service.
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Recent Related Initiatives

Through AHMAC, work to develop antenatal guidelines has commenced.

Discussion

The dominant models of maternity care currently available in Australia involve a conventional medical model in either a public or private hospital setting. Feedback provided to the Review and other state and territory maternity reviews indicates that the demand for other models of care, such as delivery in a birthing centre, greatly exceeds their availability. Where a range of models of care operate, they generally offer midwifery-focused models within the public sector. In the private system, options for midwifery-focused models are limited.

The Review received many accounts from consumers about their positive experiences in midwifery-focused models of care, including care provided antenatally, during delivery and in the postnatal period.

Similarly, the Review heard from health professionals—GPs, GP obstetricians, obstetricians, midwives, nurses and other health professionals—who spoke of their job satisfaction and the observed benefits to women and their families when working in collaborative care models. The types of collaborative care models varied depending on location and circumstance, but similar elements were identified in these models, including interprofessional respect, team work, clear communication and referral pathways, feedback mechanisms, consumer involvement and responsiveness to local environments.

Frequently highlighted to the Review Team was the value of collaborative models of maternity care that supported continuity of care and drew on the knowledge and skills of different health professionals. Related to this was the need for interdisciplinary national guidelines for maternity care. While work has begun to develop national antenatal guidelines, there are no nationally consistent, interdisciplinary guidelines covering the spectrum of maternity care: antenatal, birthing and postnatal services. While the Australian College of Midwives has developed National Midwifery Guidelines for Consultation and Referral, it was clear to the Review Team that these did not have unanimous cross-discipline support. Agreement between professions on the management of referral is a critical component to achieving effective collaborative multidisciplinary care.

The Review Team considered that greater choice for women would be provided by broader acknowledgment of the role that midwives can play as a member of a collaborative maternity team, potentially in a number of different care models. This role may not always be the same in all settings, as there are a variety of different models of care involving midwives (refer for example to Table 2 above). It was noted that, depending on the particular model, midwives may require different levels of qualification and experience.

Many of the consumers who participated in the Review consultation process had strongly held views about government funding for models of care that included birthing in a home setting. A number of submissions to the Review referred to the evidence of positive outcomes for homebirths for low-risk pregnancies. The Review concluded that, while homebirth is the preferred choice for some women, they represent a very small proportion of the total.

Even in countries such as New Zealand where homebirth is government funded, homebirth accounts for a very small number of births in comparison with other models of maternity care. New Zealand maternity data for 2004 found that, while 4.5 per cent of mothers had planned a homebirth, only 2.5 per cent actually experienced a homebirth. 41

In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.

The Review Team noted that a number of state and territory governments have developed programs and policies to allow for publicly funded homebirths, under specific conditions. For example, New South Wales Health prescribes comprehensive requirements for homebirths, including safety, monitoring, evaluation, credentialing of the midwife and compliance with incident reporting requirements. 42

While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time. It is also likely that professional indemnity cover support for a Commonwealth-funded model that includes a homebirth setting would be limited, at least in the short term. It is likely that insurers will be less inclined to provide indemnity cover for private homebirths and, if they did provide cover, the premium costs would be very high. Indemnity issues for midwife care more broadly are considered in Chapter 6.2.

Of concern to the Review Team is the number of submissions and other evidence that suggests a small number of Australian women are choosing homebirths without the support of an appropriately trained health professional. Accordingly, as with any other maternity care model, the Review Team considers that appropriate standards, monitoring and evaluation should be integral components of any service involving homebirth.

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Conclusions

The Review Team concluded that:

  • Continuity of care relies on the ability of practitioners to work together and on the capacity of services to link together as the woman moves through pregnancy to childbirth.
  • Greater choice in maternity care could be provided by collaborative care models, which draw on the expertise of the range of health professionals involved in maternity care.
  • It is clear that increased choice for women could be provided if there were greater recognition of the role that midwives can play in collaborative care models. Options should be explored for increasing the availability of birthing centre programs.
  • Interdisciplinary national guidelines for maternity care that are agreed by the relevant professional disciplines would support the maternity care team in the provision of safe, quality, collaborative care for women and their babies.

Recommendations

  1. As a priority, that the National Health and Medical Research Council (NHMRC) develop national multidisciplinary guidelines for maternity care to promote consistent standards of practice, quality and safety in collaborative team models. These guidelines are to be agreed by the professions involved, in consultation with consumers and state and territory governments.
  2. That, in developing the National Maternity Services Plan, consideration be given to the demand for, and availability of, a range of models of care including birthing centres.