National Maternity Services Plan

The current environment

Australia has made significant gains in improving the safety of pregnancy and childbirth over the past century. It is now one of the safest countries in the world in which to give birth or to be born. However, this is not the case for Aboriginal and Torres Strait Islander people.

Page last updated: 2011

Maternal and perinatal outcomes
Aboriginal and Torres Strait Islander outcomes
Fertility
Interventions
Age of mothers
Obesity
Smoking, alcohol and drug use

Maternal and perinatal outcomes

Australian women have experienced substantial decreases in maternal mortality rates over the past century. The rate stabilised in the 1980s to approximately 10 deaths per 100,000 live births.4

Table 1: Maternal mortality rate in Australia (1973–75 to 2003–05)


1973-75

1976-78

1979-81

1982-84

1985-87

1988-90

1991-93

1994-96

1997-99

2000-02

2003-05

Maternal mortality ratio per 100,000 women giving birth

12.7

12.8

12.9

9.4

8.5

9.3

6.2

9.1

8.4

11.1

8.4
Source: AIHW 2008, Maternal deaths in Australia 2003–056

Australia’s perinatal mortality rates have declined from 21.7 perinatal deaths per 1,000 births in 19737 to 10.3 perinatal deaths per 1,000 births in 20078 9 — a decline of 53%.

Table 2: Perinatal mortality rate in Australia (1994–2007)


1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Perinatal death rate per 1,000 live births

8.0

8.1

8.5

9.2

10.1

10.1

10

10.1

9.8

8.0

8.0

8.5

10.3

10.3
Source: AIHW Australia’s mothers and babies 1994 to 2007 (multiple)10-19

Compared to other OECD nations, Australia’s maternal and perinatal mortality rates remain relatively low. Nevertheless, valid and reliable comparisons between OECD nations may be constrained by variations in definitions, such as the gestational age and weight thresholds of infants.

Aboriginal and Torres Strait Islander outcomes

The exception to these positive outcomes are those for Aboriginal and Torres Strait Islander women, who continue to experience substantially poorer maternal and perinatal outcomes — characterised by higher rates of death, preterm birth and a higher proportion of low birthweight babies9 13-19 — compared with their non-Indigenous counterparts. In 2007, 1.3% of Aboriginal and Torres Strait Islander mothers experienced perinatal death, compared with 0.7% of non-Aboriginal and non-Torres Strait Islander mothers.

Numerous initiatives designed to provide culturally competent services have been developed in recent years, including many strategies under the Closing the Gap initiative of COAG.Top of page

Fertility

Australia is currently experiencing a ‘baby boom’. The total fertility rate in 2008 was 1.97 babies per woman, up from 1.92 babies per woman in 2007.20 The most recent increase in total fertility rate, between 2007 and 2008, was chiefly due to births by women aged 30 to 39 years who accounted for 55% of this increase. The total fertility rate also increased in five states and territories during 2008. The exceptions were Victoria and the Australian Capital Territory, where rates were similar to 2007 levels, and the Northern Territory, where the total fertility rate was slightly lower.21

While the high fertility rate is heightened by Australia’s increasing population, particularly in women of reproductive age, the intergenerational report by the Australian Government Department of Treasury22 projects that the total fertility rate in Australia will fall marginally to 1.9 babies per woman by 2013, and remain at this level to 2050.22

Interventions

Although the majority of Australian women have vaginal births (i.e. vaginal births including vaginal breech, forceps and vacuum), there appears to be a trend away from normal birth. Australia has high rates of births by caesarean section (30.9% of births in 2007) compared with the OECD average of 25.7% of births. This rate is increasing in both the public and private sectors, but continues to be substantially higher in the private sector (Figure 3).13-19

Figure 3: Proportion of births by caesarean section operation by hospital sector (1998–2007)
Proportion of births by caesarean section operation by hospital sector (1998-2007)
Text from image shown above. Numbers are approximated from the graph shown.
Public Hospitals


1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Percentage of births by caesarean section

18

19

20

23

24

26

27

27

27

28

Private Hospitals


1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Percentage of births by caesarean section

13

30

33

34

36

37

38

40

41

42

Australian Average


1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Percentage of births by caesarean section

27

22

23

25

27

28

30

31

32

32
Source: AIHW Australia’s mothers and babies 1998 to 2007 (multiple)10-19Top of page

High rates of caesarean section are often compounded by a lack of support for vaginal births after caesarean section, emphasising the need to prevent the primary caesarean section.23 For example, 83% of women giving birth by caesarean section in 2007 had previously given birth by this method.9 The proportion of women having caesarean section without labour has also increased from 11.9% in 1998 to 18.1% in 2007.9

In 2007, 7.4% of all births in Australia were preterm, with an almost 20% increase in the proportion of normal risk women having a preterm birth from 1994 to 2004, and a 12% rise in preterm birth overall.23 Concerns have been expressed in other countries that the rising rate of late preterm birth (from 34 weeks gestation) may be associated with increasing obstetric intervention,24 particularly increasing rates of induction of labour and caesarean section operation.25 26

Other forms of intervention, including induction of labour, are also high: 25.3% of mothers had an induced labour in 2007, while a further 20% of all mothers had augmented labour.9 Unfortunately, the data on reasons for interventions cannot be examined at a national level, as it is not captured consistently across the jurisdictions.

The rise in interventions, including the reason and their impact on women, babies and the health system, is the subject of considerable debate among health professionals and consumers. Issues requiring further investigation include:
  • agreement of identified clinical indicators for specified interventions that are compared across maternity services of the same service capability
  • dissemination of evidence for interventions, including support such as education strategies, for both consumers and clinicians

Age of mothers

Australian women are, on average, giving birth at a later age. The percentage of women giving birth who were aged 35 years or older increased from 16% in 1998 to 22.3% in 2007, while the ages of women who gave birth that year ranged from younger than 15 years to 56 years.9 The mean maternal age has also progressively increased over the past 10 years from 28.9 years to 29.9 years.

From 1998 to 2007, the proportion of women giving birth in the 30–34-year age group has grown, while the proportion of women giving birth in the 25–29-year age group has declined. The proportion of women in the under-20-year and 20–24-year age groups has remained relatively stable during this period (Figure 4).
Figure 4: Maternal age by age groups (1998–2007)
Maternal age by age groups (1998-2007)
Text from image shown above.


1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

age <20

5

5

5

5

5

5

5

4

4

4

20-24

17

16

16

16

15

15

15

15

15

15

25-29

33

32

31

30

29

28

27

27

27

27

30-34

30

30

31

32

33

34

34

34

33

32

35-39

14

14

15

15

15

16

16

17

18

19

40+

2

3

3

3

3

3

3

3

3

4
Source: AIHW Australia’s mothers and babies 1998 to 2007 (multiple)10-19

Adverse maternal and perinatal outcomes are associated with younger and older mothers.9 The general trend towards an older population of women giving birth has implications for maternity and neonatal services, including the capability of services to respond to complex pregnancies. While numbers of adolescent mothers have declined over the past decade from 5.1% to 4.1% in 2007, there has been an increase in the number of adolescent mothers in some vulnerable groups, particularly Aboriginal and Torres Strait Islander people. Pregnant adolescent mothers continue to require specialised support and tailored service provision.9Top of page

Obesity

An obesity epidemic in Australia is affecting all sectors of the health system, including maternity services. Obesity rates for pregnant women are not reported at a national level, and there are limited numerical data on mortality and morbidity outcomes for obese women and their babies.

Maternal obesity is a significant risk factor for adverse outcomes and comorbidity during pregnancy and childbirth. Medical risks include maternal conditions such as diabetes, thromboembolism and hypertension,27 and a threefold risk of operative births, including caesarean section operation.28 For babies, maternal obesity carries a higher risk of stillbirth, birth injury, admission to neonatal intensive care, and a higher risk of childhood obesity.29 30

The increase in obese pregnant women requires a response that incorporates an increased capability for maternity services to provide appropriate care to both the mother and baby. While maternity services have a limited capacity to address the factors leading to women being overweight or obese in pregnancy, broader health strategies were proposed by the Preventative Health Taskforce in the National Preventative Health Strategy. The Australian Government’s response to the National Preventative Health Strategy outlines how the proposals will be progressed.31

Smoking, alcohol and drug use

The consumption of cigarettes, alcohol and illicit substances by pregnant women increases the likelihood of adverse outcomes during pregnancy and birth.

Mothers who smoke during pregnancy have higher proportions of babies with poorer perinatal outcomes than mothers who do not smoke. In 2003, the proportion of liveborn, low birthweight babies (less than 2500 grams) of mothers who smoked was 10.6% — twice that of babies of mothers who did not smoke (5.1%). The odds of preterm birth at less than 37 weeks gestation was 60% higher in babies of mothers who smoked than in babies of mothers who did not smoke.32

Maternal alcohol consumption can harm the fetus in a number of ways. Although the risk of birth defects is greatest with high, frequent maternal alcohol intake during the first trimester, alcohol exposure throughout pregnancy (including before pregnancy is confirmed) can have consequences for development of the fetal brain.33

Women who are pregnant and use illicit drugs have increased maternal and fetal morbidity. These women sometimes find it difficult to access traditional referral services to maternity care, and often present late in pregnancy for antenatal care, or wait until labour to access health services. They are also unlikely to disclose their drug use. While maternity care provision is complicated by legal, social and environmental problems, as well as a prevalence of negative attitudes of health professionals, pregnancy can be seen as a window of opportunity for the provision of education, choices and support.34

These factors therefore require a specialised response to manage their associated risks. Preventative strategies, including pre-pregnancy education, are currently being implemented through the National Preventative Health Strategy.31 Women who consume these substances also need earlier access to antenatal care and a maternity care pathway that provides appropriate links to specialised clinical services, particularly allied health and social support services, and including neonatal services. Top of page