Keeping healthy pregnancies out of hospital is cheaper and lower-risk

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.

Instead of making hospitals the focus of care, community midwives are based in the community, offering pregnancy care in local clinics or women’s homes. Women keep the same “caseload” midwife throughout the maternity episode, with support from backup midwives. Midwives are publicly funded, and collaborate with medical and hospital services for women whose needs are beyond their scope of practice. Women are able to choose a hospital, birth centre or their home as the place of birth, depending on need and personal preference. Countries using this model tend to have higher rates of homebirth – The Netherlands has a 30 per cent rate, with excellent outcomes, and New Zealand has a rate around 7 per cent.

Midwives accompany mothers to hospital or other place of birth and care for them during labour and birth, then maintain their primary caregiver role for the first six weeks of motherhood, usually with home visits. The establishment of mothering and breastfeeding are supported in a way which is almost unheard of in Australia.

The focussed care of a single caregiver: “continuity of care”; is shown to produce better outcomes in all areas of health care, and birth is no exception. Lower rates of caesarean, lower demand on hospital bed-days, less need for neonatal special care, higher rates of breastfeeding and maternal satisfaction, all indicate better outcomes for babies and especially their mothers, making the transition to parenthood easier for women and their families.

Health policymakers often fear the expense of this high-quality care. “This is Rolls Royce care, but we can only afford a Toyota” was the response of one state health bureaucrat after seeing the NMAP. Fortunately, the Rolls Royce comes with a Hyundai price tag – research consistently finds caseload midwifery care to be cheaper than standard labour-ward care. Every medical intervention adds costs, with a caesarean costing on average 2 1/2 times as much as a normal birth. Even without the caesarean savings the midwifery model saves money, with fewer days spent in hospital, and increased efficiencies in midwives' use of work time.

Far from being “anti-obstetrician”, the push for midwifery models of care respects the valuable role of medical specialists in birth. In Britain and Europe obstetricians are comfortable with their status amid a midwifery model of primary care, respected for their expertise in difficult high-needs cases, rather than fighting midwives for the mundane work of normal birth care for healthy women.

The Maternity Coalition recently wrote to federal MPs proposing an end to doctors’ monopoly in normal birth care medicare funding. A “basic birth care provider payment” would be accessible to obstetricians, GPs or midwives accredited to provide normal birth care to a woman. Taking maternity care out of medicare, instead of letting midwives in, could save the Commonwealth millions, as it has in New Zealand, as well as reducing the pressure on hospital infrastructure. The Maternity Coalition also proposed that a proportion of health-care grants to the states be set aside for state-funded community-based midwifery services, to encourage state provision of cost-effective choices.

With all the current talk about primary, preventative models of health care, political parties could be expected to be embracing community demand for reform of maternity services. Despite the endorsement of the full range of consumer, midwifery and nursing groups, and strong academic and community support for the National Maternity Action Plan, the major federal parties have been cautious. Presumably ministers and shadow ministers are frightened of negative reactions from the doctors’ organisations, who have long occupied the best seats in the health stakeholders bus.

State and Commonwealth Health Departments have long claimed that they are focussed on providing cost-effective, evidence-based services to the community. Now that women are directly pointing out the failure of governments at both levels to meet this standard, it’s time for women’s choices, rather than old heirarchies, to determine maternity care policies.