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

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.