Sunday, 26 October 2008

My submission for the Maternity Services Review

Submission to the National Maternity Services Review
October 2008
Submitted by: Carolyn Hastie RM, RN, Grad Dip Primary Health Care, IBCLC, Master of Philosophy

The current system of maternity service provision in Australia disempowers women in both birth and motherhood (1). Modern maternity care is also plagued with communication failures and turf wars, none of which advantages women and their babies(2, 3). The history of maternity care in Australia is replete with stories of medical domination, midwifery subordination and women being left out or caught in the middle of the warring factions(4, 5). Adverse outcomes in health and maternity care are linked to poor communication (6, 7) and while efforts have been made to improve relationships through workshops and policies promoting teamwork between doctors and midwives, these strategies are insufficient on their own to change the culture (8). The way that the maternity care system is organised must be changed if there is to be any real benefit to childbearing women and their babies. That is because organisational factors are more important than the personalities of the individuals involved in providing maternity care. Organisational factors frame, direct and limit what discourses and therefore behaviours are possible(8). The problem is the underlying structure of health service delivery which gives preference and privilege to one group over another and the enormous power imbalance this system of preferential treatment creates. As the history of maternity services demonstrates, the enormous power imbalance inherent in modern maternity care creates tensions, underhanded practices, over inflated personalities and unsatisfied women. It also produces avoidable adverse outcomes for women and babies(8).

When there is a women centred approach to service delivery, then team work, collaboration, good interprofessional relationships and optimal outcomes for mother and baby are more likely to occur (8). A woman centred approach in maternity care means the care is individualised. The woman is regarded as an autonomous being who is the expert on herself and the best person suited to care for her baby. The woman has the right to be self determining and have control over what happens to her. She has the right to be fully involved in decision making about her care (9). When a woman feels in control, her stress hormones are reduced, enabling her physiology to work in optimal ways, keeping mothers and babies safer (10, 11). In this model, the midwife and doctor establish a partnership with the woman to meet her needs within the context of her childbearing experience. Australia needs a primary health care, woman and family-focused approach to maternity services, which addresses this empowerment issue while providing safe and effective maternity services. (1) A major challenge is that the concept of collaboration for doctors tends to mean midwifery cooperation and submission to medical authority (8). Midwives, however, view collaboration as meaning equal relationships based on professional recognition and respect with a common goal (8). For midwifery, that goal is women centred care. Any organisational effort designed to improve collaboration and outcomes of maternity care will fail unless or until we have a woman centred approach to care provision (8). For a true women centred approach to be made a reality, it must be coupled with successful interventions that move towards disbanding professional silos, instituting genuine dialogic relationships between midwives and doctors as well as addressing social and emotional intelligence and competence in both professional groups (8).

Barriers to equitable, effective and sustainable maternity care

Commonwealth policies and processes are contributing to the lack of women’s access to choice and quality in maternity care and reduced economic effectiveness in the following ways:
• The current organisation of maternity services is geared to the needs of the health professional, particularly medical, rather than the woman’s needs.
• Funding arrangements which perpetuate medical dominance in maternity services and subjugates other professional bodies, such as midwives
• Exclusion of midwives from access to Medicare provider numbers creates an inappropriate monopoly by GP and specialist Obstetricians in private maternity care and disadvantages health services which provide midwifery led options for care in public maternity care.
• The provision of Medicare rebates for medical intervention in birth creates financial incentives to intervene inappropriately in the private arena of maternity service provision.
• The health insurance rebate for private maternity care services provides large subsidies for a sector of maternity care providers who are unaccountable for their outcomes, and who are usually over-servicing clients (e.g. high rates of caesarean section in private hospitals) (12, 13).
• Allowing state expenditure of Commonwealth health funding on inadequate and expensive models of maternity care in public hospitals that deprive women of relationship based care which has been shown to be safer and more satisfying for women.
• State/Commonwealth cost shifting diverts resources and focus from the needs of women and their families.

Although these are only some of the elements obstructing women centered and therefore, equitable, effective and sustainable maternity services in Australia, it is clear that funding is the key element to solving the current crises in maternity care.


Promotion of a woman centered approach to maternity service provision

The Federal government should lead the way in promoting a woman centered approach to maternity service provision. Any and every policy document, guideline or announcement should articulate a women centered focus and approach to maternity service provision.

Access to continuity of midwifery care for all childbearing women in the public health system

Make available to all women the choice of having a community midwife provide continuous maternity care through their childbearing experience in the publicly funded health system. Access to continuity of midwifery care will ensure savings in health dollars and bring Australia into line with international best practice in addition to meeting community demands for a range of readily accessible and appropriate maternity services (10). Whatever the medical risk status of a childbearing woman, the provision of continuity of midwifery care is vital for her emotional and social wellbeing which translates into better physical wellbeing for the woman and her baby.

Remove Medicare item 16400.

Remove the payment for nurses to provide antenatal care. Antenatal care is outside the educational background and scope of practice of all nurses. They have neither the qualifications nor the experience of providing antenatal care to pregnant women. It is dangerous for women to receive antenatal care from a nurse who is being pressured to provide care outside the nurse’s scope of practice. Regulatory bodies for nurses and midwives have developed national competency standards and the provision of antenatal care is not one of the competencies of nursing. GP’s are often ill equipped to provide antenatal care as they do not have the necessary knowledge to do so and it is poor organisation to have them responsible for another health practitioner’s care when they themselves are not competent in that aspect of caring for a pregnant woman.

Medicare provider numbers for midwives

Medicare provider numbers for midwives will enable health services which provide midwifery led models of care to bulk bill Medicare for maternity services provided by midwives and pathology and ultrasonography services ordered by midwives in these models. It will also enable midwives to engage in private practice on a level playing field with medical doctors.

Medicare rebates for birth

Provide the highest rebate rate for normal birth and reduce the payment rate for every intervention performed, as the more women pay for maternity care, the more intervention they receive (12-14).


All services receiving direct or indirect taxpayer funding be required to provide timely and publicly accessible data on outcomes. Currently in many states no outcome information is available to the public from facilities providing maternity services. This secrecy is inconsistent with goals of safety, accountability or the control of costs.


1. Maternity Coalition, Australian Society of Independent Midwives, Community Midwifery WA Inc. National Maternity Action Plan: Maternity Coalition; 2002 September.
2. Reiger K, Lane K, Possami-Inesedy A. Childbirth and the culture of risk. Health Sociology Review 2006(Special Issue).
3. Reime B, Klein M, C, Kelly A, Duxbury N, Saxell L, Liston R, et al. Do maternity care provider groups have different attitudes towards birth? British Journal of Obstetrics and Gynaecology 2004;111:1388-1393.
4. Fahy K. An Australian history of the subordination of midwifery. Women and Birth 2007;20(1):25-29.
5. Reiger K. Domination or mutual recognition?:Professional subjectivity in midwifery and obstetrics. Social Theory and Health 2007;in press.
6. Hart E, Hazelgrove J. Understanding the organisational context for adverse events in the health services: the role of cultural censorship. Quality and Safety in Health Care 2001;10:257-262.
7. Douglas N, Fahy K, Robinson J. Final Report of the Inquiry into Obstetric and Gynaecological Services at King Edward Memorial Hospital 1990-2000”, (Five volumes), Western Australian Government.Inquiry into Obstetric and Gynaecological Services at King Edward Memorial Hospital Western Australia State Law Publishing. ; 2001.
8. Hastie C. Putting women first: Interprofessional Integrative Power. Newcastle: The University of Newcastle; 2008.
9. Powell Kennedy H. A model of exemplary midwifery practice: results of a Delphi study. Journal of Midwifery and Women's Health 2000;45(1):4-19.
10. Hatern M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4.; 2008.
11. Power ML, Schulkin J, editors. Birth, Distress and Disease. First ed. Cambridge: Cambridge University Press; 2005.
12. Fisher J, Smith A, Astbury J. Private health insurance and a healthy personality: new risk factors for obstetric intervention. Journal of Psychosomatic Obstetrics and Gynecology 1995;16(1).
13. Roberts C, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: population based descriptive study. British Medical Journal 2000;321:137-141.
14. Tracy S, Tracy M. Costing the cascade: estimating the costs of increased intervention in childbirth using population data. British Journal of Obstetrics andGynaecology 2003;110:717-224.

1 comment:

David Vernon said...

Carolyn, this is an excellent submission. I love the audacity of the proposal that rebates be tied to normal birth - viz, the fewer interventions the greater the rebate! This is an audacious suggestion and makes me smile.

I do wonder whether it may lead to some peverse outcomes - eg. those with high needs and likelihood of intervention would find it harder to receive assistance... This will give policy makers some interesting design headaches!

With best wishes,

David Vernon