This month a group of mothers filled Brisbane’s King George Square with babies’ clothes hanging on Hills Hoists, drawing public and media attention to their frustration about the lack of places in the city’s only midwife-led birth centre. The “Airing Our Laundry” event was the first in a week of actions organised by groups of mothers in every mainland state of Australia, all asking for access to one-to-one maternity care from a known midwife.
While “choice in birth”, midwives and birth centres may seem an obscure issue in a health-care system with big problems and big bills to pay, not only are midwifery models of care popular with women, they are supported by strong evidence and extensive international experience as being more cost-effective and producing improved outcomes relative to Australia’s current system.
State and Federal policies over decades have produced a maternity-care system that not only offers women little choice but is unnecessarily expensive and is now failing to provide even basic services to increasing numbers of rural and regional women. We have followed the United States in restricting care options to a hospital-based system controlled by doctors, rather than providing community-based midwifery care as used in New Zealand and European countries.
The majority of Australian women receive their maternity care from public hospitals. Many receive some of their antenatal care from a preferred GP, with medicare funding, but it is now rare for GPs to attend births. Thus most women’s care is fragmented among up to 25 different midwives and doctors. Often a woman will not see the same person twice during pregancy.
Growing numbers of women, encouraged by the Commonwealth’s generous tax relief and rebates on private health insurance, have been turning to the private system, hoping to have their birth care from a practitioner they know, instead of in the anonymity of the public system. Unfortunately these women experience similar fragmentation of care and are often disappointed to find that their obstetrician’s role in the birth is restricted to brief check-ups while unfamiliar shift-working midwives still provide the majority of care.
Fragmentation, poor collaboration between professions, and high dependence on specialist doctors has led us to high and increasing levels of medical intervention in birth. While the World Health Organisation states that 10 to 15 per cent is the maximum rate of caesarean deliveries that can be justified by the pursuit of safety, Australia’s caesarean rate is around 30 per cent and increasing by 1 to 2 per cent of births a year. Claims by some private obstetricians that this is due to women’s request are unsupported by evidence, and contradicted by the available published research which shows that well over 90 per cent of women would prefer a normal birth.
Evidence is strong that avoidable caesareans carry significantly increased risks to both babies and mothers, including several times higher risk of death during birth, loss of fertility, and future stillbirths. Despite this, state governments have evaded rather than confronted the issue, making access to outcome statistics difficult – in Queensland the most recent publicly released maternity care outcomes are four years old.
Private hospitals have produced the highest caesarean rates. Although outcome statistics of private hospitals are kept secret in Queensland, several are known to have rates around 50 per cent. With taxpayers paying the 30 per cent private health insurance rebate, plus medicare payments to several doctors per birth, and the recent medical indemnity bailout packages being largely spent on obstetricians, private maternity care is developing into a public-health funding black hole.
While poor outcomes and high costs may be hard on mothers and taxpayers, the states have been quiet about the problems in the private hospitals. Every $10,000 private hospital birth saves their public hospitals around $3000, and scrutiny of overservicing is avoided to prevent unnecessary conflict with medical trade unions.
The blank cheque has, however, not been enough to keep the obstetric-focussed system providing necessary services. With obstetricians leaving practice due to insurance and lifestyle issues, more and more small hospitals are closing their maternity units. Increasing numbers of rural and regional women are being forced to find accommodation near a major hospital at 36 weeks pregnancy and wait it out – as Aboriginal women from remote communities have been doing for decades.
While Health Ministers have focussed on bandaiding the medical system, Australia’s consumer groups have been developing a big picture vision for reform. The National Maternity Action Plan (NMAP) has been developed by peak consumer group The Maternity Coalition, and proposes that all Australian women have the choice of continuity of maternity care from a community-based midwife.
The NMAP proposal is based on the maternity care systems of countries such as New Zealand, which made major reforms in 1990, and The Netherlands and Britain who have historically used midwives as primary caregivers.
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