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Improving maternity services in Australia: the report of the Maternity Services Review
This Report presents for the consideration of the Minister for Health and Ageing, the Hon. Nicola Roxon, MP, the findings of the Maternity Services Review (the Review) conducted by the Australian Government Department of Health and Ageing, and led by the Commonwealth Chief Nurse and Midwifery Officer, Rosemary Bryant. The Review, including this Report, is a key step towards delivering the Government's election commitment to develop a National Maternity Services Plan (the Plan).
The aims of this Review were to:
elicit a range of perspectives on maternity services in Australia
identify key gaps in current arrangements
determine what change is required
determine what is needed for change to occur, and
inform the priorities for national action, and the development of the Plan.
It considered issues relevant to maternity services, including antenatal services, birthing options, postnatal services up to six weeks after birth, and peer and social support for women in the perinatal period.
Overview of Review Recommendations
The Review takes place at a time when the number of births in Australia is rising. The latest Australian Institute of Health and Welfare (AIHW) report on Australia's mothers and babies shows that, in 2006, the number of births in Australia was 282,169, an increase of 3.6 per cent from the previous year.1 Australia's increasing number of births, combined with growing workforce pressures, requires us to look at more effectively using our workforce to provide safe, high-quality maternity care, based on good evidence, to Australian mothers and their babies.
In conducting the Review, the Review Team was concerned to ensure that any changes it proposed built on the current strengths of maternity services in Australia, and that safety and quality must be the chief concern in determining appropriate models of care across Australia.
For women in rural areas, the range of choices available is constrained by safety and quality considerations and the availability of an appropriate workforce. Compared with obstetricians, other specialists and general practitioner (GP) obstetricians, midwives are more evenly distributed across rural areas of Australia. Even so, the mix of services that can be available in small communities is constrained; for example, if the number of deliveries is small, a viable and safe birthing service may not be possible. The desire for safety and quality also underpins requirements for education, registration and continuing education for the maternity workforce.
At the same time, it is important that safety and quality do not become the catch-cry to limit consideration of innovation and reform to care approaches. It is vital that approaches to change are evidence-based and take full account of consumer preferences.
The Report makes a series of recommendations in the key areas of:
Access to a Range of Models of Care
Inequality of Outcomes and Access
Information and Support for Women and their Families
The Maternity Workforce
Financing Arrangements.
In some instances, the recommendations identify specific areas where further collaborative work between the Commonwealth, states and territories, professionals and consumers is needed. In others, the recommendations identify areas where action could occur more quickly. A summary of the recommendations of the Review Team is provided at Attachment A.
Overall, the recommendations of this Report, if accepted and incorporated in the Plan, would continue to provide Australian women with safe, high-quality maternity care but would support an expanded role for appropriately qualified and experienced midwives and increase the range of collaborative models of maternity care available. Such changes would take place within a model of collaborative care
drawing on the expertise of the diverse health professionals involved in maternity care—and within an evidence-based safety and quality framework.
The processes undertaken by this Review have allowed us to identify current gaps, some priorities for action, and other, more complex, areas of policy reform requiring further development.
In summary, the Report recommends:
changes to improve choice and availability of a range of models of maternity care for Australian mothers by supporting an expanded role for midwives, including consideration of changes to Commonwealth funding arrangements and support for professional indemnity insurance for midwives
changes including an expanded role for midwives to take place within a strong framework of quality and safety
new national cross-professional guidelines be developed to support collaborative multidisciplinary care in line with best practice, along with a system for advanced midwifery professional requirements
improved national data collections and targeted research to support a safety and quality framework and allow the impact of changing models of care to be effectively monitored
changes to support the expansion of collaborative models of care, improved access for rural and Indigenous mothers and reduced workforce pressures (particularly in rural and remote areas of Australia): consideration of targeted additional support to attract and retain a rural maternity workforce—including midwives, GP obstetricians, GP anaesthetists—and improved access to specialist obstetric care
assisting Australian women in being better able to make decisions about their maternity care by accessing comprehensive reliable information: consideration of better access to a range of information on antenatal, birthing and postnatal care and options, including internet resources and the establishment of a single integrated pregnancy-related telephone support line.
Together, the recommendations propose changes that not only build on what currently works well for mothers and babies in Australia but also move to expand the range of available choices for mothers in a way that is informed by evidence, without compromising quality and safety, and having regard to workforce availability and resource implications.
The starting point for the Review was that Australia is one of the safest countries in which to give birth or to be born. At the same time, despite our strong record of safety and quality, maternity care in Australia is not meeting the needs of all Australian women. A significant part of Australia's maternity care is delivered in tertiary settings, rather than primary care settings, and by specialist obstetricians. Most women give birth in hospitals in a conventional labour ward setting—in 2006, 97.3 per cent of women gave birth in hospitals. Public hospitals deliver a significant proportion of antenatal care (55 per cent), as do private obstetricians (30 per cent), while GPs deliver 15 per cent of such care.2 At the same time, some Australian women are seeking, but have limited access to, other models of care such as birthing centres and antenatal and postnatal care in community settings.
In addition, Australia has a high rate of obstetric interventions including caesarean section; 31 per cent of births in 2006 were delivered via caesarean section, compared with the Organisation for Economic
Co-operation and Development (OECD) average of 22 per cent.3 While caesarean section rates are explained in part by factors such as maternal age and medical conditions such as obesity, diabetes and hypertension, there is debate surrounding this issue, suggesting further evidence is needed.
Moreover, while maternal and fetal mortality and morbidity rates have improved, the gains are not shared equally across the population; outcomes for Indigenous mothers and babies, in particular, are considerably poorer than for non-Indigenous mothers and babies.
High rates of smoking, alcohol consumption and poor nutrition in pregnancy are impacting negatively on the long-term health outcomes for Australian babies. While breastfeeding initiation rates in Australia are reported at around 92 per cent in 2006–07, the decline in exclusive breastfeeding continuation rates for infants up to six months of age (14 per cent) is of concern.4 Perinatal depression is estimated to affect around 15 per cent of women.5 While there is a range of clinical and non-clinical supports including from non-government organisations (NGOs) to support women and their families, these are not always well integrated or accessible.
As with many aspects of health care in Australia, maternity care is characterised by a mix of Commonwealth, state and private funding and service delivery. States and territories play a major role through public hospitals in particular. Currently, a significant proportion of Commonwealth funding is through the Medicare Benefits Schedule (MBS). The MBS is focused almost entirely on medical professional services, with a significant proportion channelled through the Extended Medicare Safety Net (EMSN). As a result, the range of maternity care options available outside the public system is limited. MBS financing is discussed in Chapter 6.1.
Conduct of the Review
The first step in the Review was the release of a Discussion Paper—Improving Maternity Services in Australia: A Discussion Paper from the Australian Government. The Discussion Paper identified a number of key themes and priority issues for maternity services in Australia and informed and guided the consultation process that followed.
The Review invited input from stakeholders through a call for written submissions responding to the Discussion Paper. In addition, the Review held a series of six round table forums to seek input from a range of key stakeholders. Further details on the consultations are provided at Attachment B.
Overall, feedback from stakeholders received through submissions and the forums confirmed the importance of the key issues identified in the Discussion Paper as the most pressing issues in the current Australian context:
Issues emphasised by consumers of maternity care included the limited availability of models of care consistent with their expectations; the impacts upon themselves, their babies and their families from the type of maternity care they experienced; difficulties in sourcing information and making informed choices on maternity care; their perceptions of risk; and, for many, their desire that pregnancy and birth be seen as a natural process.
Midwives, nurses and their representative organisations provided detailed accounts of their experience of providing maternity services in Australia and the constraints (including funding arrangements and indemnity insurance) on their ability to practise to the full extent of their expertise. They highlighted their desire for recognition as primary providers of maternity care and provided examples of successful collaborative models of care.
General practitioners (GPs), medical specialists and their representative organisations identified their highest priority as that of maintaining Australia's excellent record of safety in maternity care and emphasised the need for specialist expertise within the maternity care team. An issue of concern was the loss of skilled professionals and its impact on the provision of maternity care, most noticeably in rural and remote areas. These professional groups also expressed concern about moves towards homebirthing.
NGOs outlined the scope and the scale of service provided through this sector; the complementary nature of the services they provide in relation to clinical services; their specific areas of expertise; the need for recognition on the part of clinicians of the role NGOs can play; and the need for improved referral pathways between clinicians and NGOs. In particular, the role of peer support organisations in providing mothers with pregnancy information, breastfeeding and other parenting support, including dealing with perinatal depression and grief and loss, was identified to the Review.
Academics and researchers identified a number of issues: gaps in the current evidence base; limited opportunities to develop research in these areas; and the importance of evidence-based care built on a foundation of comprehensive national datasets. Priority research areas highlighted included identifying effective models for postnatal care, further examination of interventions, including caesareans, understanding of consumer expectations and experiences of different models of care and stillbirths.
Allied health professionals highlighted areas where their specific expertise contributed to the provision of maternity services and identified the importance of appropriate referral pathways and guidelines. Psychologists and other mental health workers, dieticians, physiotherapists and occupational therapists (particularly for women with a disability adjusting to caring for a new baby) were among those identified as members of the maternity team.
State and territory governments emphasised their support for Commonwealth leadership through a National Maternity Services Plan and their willingness to work with the Commonwealth on this Plan. State and territory submissions also highlighted current priorities—for example, to improve service integration and encourage more community-based care, where appropriate, as well as effective models and innovations within their jurisdictions
The findings and recommendations of this Review, if accepted, will inform the development of the National Maternity Services Plan. Development of the Plan will allow more detailed consideration of a number of issues than has been possible in this Review, including those that are solely or predominantly the responsibility of state and territory governments.
A number of other reviews of maternity services in Australia have been undertaken by jurisdictions and other stakeholders in the last decade; these previous reviews, which have informed this Review, will also be relevant to the National Plan.6
This Review has been conducted alongside other health reform processes currently under way, in particular those of the National Health and Hospitals Reform Commission, the Preventative Health Taskforce and the development of the National Primary Health Care Strategy. Maternity-related issues are being raised and considered in these reform processes. The Plan will need to take account
of the findings of these reform processes as well as the recommendations of this Review.
In the interim, the Review Report identifies a number of areas where actions could commence in the short term. Importantly, change will need to proceed with the effective engagement of a range of stakeholders, including consumers, health professionals, their representative organisations, professional indemnity insurers, private health insurers, state and territory governments, and the academic sector.
Structure of the Report
The Report considers key issues identified by the Review. It analyses the available evidence and data, describes the current context, summarises the feedback obtained through the consultation processes, and indicates related initiatives. All these factors have informed the Review Team's conclusions and recommendations. The Report also considers the issues of process and governance in moving forward from the Review to development of the Plan.
Key Issues for the Maternity Services Review
1. Safety and Quality
2. Access to a Range of Models of Care
3. Inequality of Outcomes and Access
3.1 Rural
3.2 Indigenous
4. Information and Support for Women and Their Families
5. The Maternity Workforce
6. Financing Arrangements
6.1 Commonwealth Funding
6.2 Professional Indemnity
Next Steps: Developing a National Plan
Figure 1: Number of women who die in childbirth, Australia, 1991-2006
Figure 2: Number of infant deaths to one year of age, Australia, 1996-2006, 5-yearly
Figure 3: Perinatal mortality, international comparison, 1996-2006
Figure 4: Maternal mortality, international comparison, 1996-2006
Figure 5: Rates of caesarean sections by hospital sector, Australia, 1991-2006
Figure 6: Rates of caesarean section by hospital, New South Wales, 2005
Figure 7: Homebirths, Australia, 1991-2006
Figure 8: Hospitals and birth centres, by number of women who gave birth, Australia, 1991, 1999 and 2006
Figure 9: Breastfeeding: the first 12 months
Figure 10: Indicative maternity services workforce
Figure 11: Obstetric benefits under Medicare, 2007-08
Table 1: Women who gave birth, by place of birth, 2006
Table 2: Models of maternity care
Attachment A - Summary of Recommendations
Attachment B - The Consultation Process