Rural and remote families experience higher rates of maternal death;43 rural women have significantly higher rates of neonatal deaths and remote women have higher rates of fetal deaths.44 While these outcomes are in part reflective of the poorer outcomes for that proportion of these populations identifying as Indigenous, this is not the entire picture.
People living in rural and remote areas face a number of health inequities, many of which result from, or are exacerbated by, problems in accessing health care services. Health inequities are demonstrated by higher incidences of chronic disease and disease risk factors, high rates of smoking, consumption of alcohol in quantities risking harm in the short term, obesity, and death rates that increase with remoteness. For example, females living in rural and remote areas were 1.3 times more likely to report diabetes than those living in major cities.45
For rural and remote communities, accessing appropriate maternity services raises particular issues. What exacerbates this is the need for ongoing care throughout the pregnancy and, for higher risk pregnancies, the requirement for a significant period of hospitalisation prior to and sometimes after the birth. Even in a low‑risk pregnancy where a woman has access to a GP, she may still have to travel a considerable distance in anticipation of the birth or for some aspects of her antenatal or postnatal care. Current supports and services, including travel and communication, are inadequate to cater for the needs of all women and their families in rural and remote areas.
As is the case for all health care, however, maternity services require access to an appropriately skilled workforce and associated infrastructure, not all of which can be provided in every community. The alternative to travel by women, for some aspects of care, is for fly-in fly-out services from maternity care professionals. The Medical Specialist Outreach Assistance Program (MSOAP) improves the access of people living in rural and remote Australia to medical specialist services by complementing outreach specialist services provided by state governments and the Northern Territory government. For its part, the Specialist Obstetrician Locum Scheme (SOLS) supports access of rural women to quality local obstetric care by providing locum support to the rural specialist obstetrician workforce, obstetricians and GP obstetricians.
Over recent years, there has been a decline in the availability of facilities providing maternity services in rural and remote Australia. The Rural Doctors Association of Australia (RDAA) reported in 2006 that over 130 small rural maternity units had closed across Australia in the 10 years since 1995.46 State government closure of these facilities has been the result of workforce shortages, safety and quality considerations and, inevitably, cost considerations.
The AIHW reports that the number of hospitals and birth centres fell by one-third between 1991 and 2006, from 617 to 416. Figure 8 shows that this reduction in hospitals and birth centres was greatest in hospitals that saw between 1-100 women who gave birth per year; the number of these centres almost halved from 325 to 159.47 Workforce considerations for rural and remote Australia are discussed in Chapter 5.
Figure 8: Hospitals and birth centres, by number of women who gave birth, Australia, 1991, 1999 and 2006
Source: Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney.
What the Review Team Heard
- Many submissions to the Review highlighted the growing impacts on communities and families of a lack of maternity services in rural communities. These included family disruption and costs associated with travel and accommodation, the physical and other impacts of long travel, and the risks including roadside birthing.
Women in rural and remote areas are no different from their city sisters in having the same wishes, but rarely are these wishes realised. If their preferred option is not available locally, they have to travel away from home, sometimes long distances to metropolitan centres, where they are dislocated from their support structures. They often have significant financial outlays for travel and accommodation. However, like most people who live in rural, regional and remote areas, they are pragmatic, and accept that they need to make some compromises for living in small communities. Nevertheless they have a right to access more options than currently exist for them. 48
- The Review heard of the critical role played by procedural GPs (obstetricians and anaesthetists) in providing maternity services in rural communities, the impact of their declining numbers on rural communities and the opportunities for developing collaborative models of care where procedural GPs were involved.
It is increasingly common for GPOs (general practitioner obstetricians) to work collaboratively with midwives, deliver only more complex cases and, where neonatal resuscitation skills are good, not necessarily attend the delivery. 49
- Also highlighted to the Review was the importance of focusing on a range of models of care that allowed services, as far as possible, to be close to home and sufficiently flexible to adapt to local circumstances.
It is important that maternity care is accessible close to home. An interesting outcome of the Rural Maternity Evaluation was that women were comfortable accessing labour services away from home providing that pregnancy and postnatal services were accessible close to home. 50
- An issue raised for rural women was the fragmented nature of their maternity care.
It is well known that adverse events increase when the patient moves between systems or hospitals. Transition between primary care sector and acute care sector whether in the postnatal, antenatal or birthing period requires excellent communication systems, referral processes and clinical guidelines. Clarity around when accountability ends and starts is also important. 51
The development of improved networks between rural and major centres will assist education and training, as well as the clinical management of individual cases, particularly high-risk women. Access to improved teleconference facilities will also assist rural centres in particular. 52
The Review process brought to light jurisdictional differences in the supports available for health professionals. In particular, access and linkages from rural and remote primary care providers to tertiary, specialist advice and retrieval services was highlighted. Activities being undertaken in some jurisdictions to redesign their health services to provide services locally when this can be done safely, effectively and efficiently and to better integrate services when they are provided across multiple settings were also relevant.
The sustainability of safe, high-quality services, particularly in rural and remote communities, will depend on the creation of formal networks of health professionals (midwives, GPs, obstetricians) who work as an integrated team to ensure a seamless and holistic approach to service provision along the continuum of care. Strong clinical governance, guidelines and clear transfer and referral protocols are required to support women and their babies. 53
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Recent Related Initiatives
As part of the COAG Indigenous Health National Partnership, the Commonwealth committed to the expansion of the Medical Specialist Outreach Assistance Program (MSOAP) to increase access to specialist services in rural and remote areas.
In the 2008–09 Budget, the Commonwealth provided $7.9 million over four years to support and expand the Specialist Obstetrician Locum Service (SOLS).
The provision of maternity services to rural communities will require trade-offs between access to services locally and considerations of safety and quality. What is more challenging is determining which services can and should be provided at the local level and what is not practical or appropriate to provide, taking into account considerations of quality and safety, availability of a suitably trained workforce and infrastructure, costs and consumer preference. These are complex issues, with a variety of different views existing in the community.
Planning of rural maternity facilities, under current arrangements, is primarily the responsibility of state and territory governments. The RDAA, in its submission, has called for standards to be established for access to rural maternity services. 54 As discussed in Chapter 6.1, the new National Health Care Agreement sets a target that all Australian babies are born healthy and remain healthy and will provide scope for increasing the range of maternity health care models available to Australian women.
As noted, submissions from a number of jurisdictions point to activity to redesign health services to provide services locally when this can be done safely, effectively and efficiently and to better integrate services when they are provided across multiple settings.
For maternity care, the development of collaborative care models, responsive to community needs, together with regionally integrated service systems, could significantly improve access to maternity care for rural women, their babies and families. As part of delivering care, the scope of outreach services is important. The Review Team considers that the inclusion of midwives and other appropriate health workers in existing outreach schemes, such as MSOAP, would assist in improving access for rural and remote women to maternity care.
A number of submissions identified existing services that pointed to the potential for midwives working within collaborative models of care to expand the provision of local ante and postnatal care within small communities. Such services, when combined with transfer of the mother to larger centres for delivery, supported by referral and communication networks and systems, may provide rural women with more options and reduce travel requirements.
In considering a range of models for rural communities, the need to allow flexibility to respond to community need and priorities and workforce availability was identified as critical, as opposed to the imposing of a ‘one size fits all’ model of maternity care for all communities.
Linked to the availability of maternity services for rural consumers is the availability of specialist advice for health professionals providing services on the ground in rural areas. For example, a number of states and territories operate integrated specialist phone advice systems comprising bed management, obstetric advice and support, and patient transfer/retrieval. Given the workforce shortages of health professionals in rural areas, these types of services are essential.
The Review Team concluded that:
- Mechanisms to improve maternity care networks so that systematic processes exist to link local, regional, and tertiary services with support and backup are vital.
- Collaborative care models developed for rural communities must reflect local circumstances, including the availability of appropriately skilled workforce.
The role of outreach services is an important component of the service mix.
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