Briefing to the Federal Government: Safe, Sustainable Maternity Care in Australia

Background 

You would be aware of our concerns about the maternity care services available to the majority of Australian women:

• Diminishing access to maternity services for rural and regional women.
• Lack of access to evidence-based one-to-one midwifery care.
• Rates of caesarean section inconsistent with women's preference or the need for safety (at around 30% of births this is twice the maximum recommended by the World Health Organisation as necessary for safe childbirth)
• Rapidly increasing costs to the public health system, despite decreasing choices for women. 

Only a reform of the models of care offered to Australian mothers will be able to address these current serious problems. 
 
Australia's consumer and midwifery groups have developed the "National Maternity Action Plan for the introduction of community midwifery services in urban and regional Australia" (NMAP). The NMAP has been endorsed by the full range of consumer, midwifery and nursing stakeholder groups in Australia. The NMAP provides a clear vision of a reformed Australian maternity care system, focussed on the needs of women, their families and their communities.
 
The case for the safety, cost effectiveness and popularity of community-based midwifery models of care is well established by scientific research, its broad scale implementation in other countries, and its local implementation in parts of Australia.

Commonwealth Role 
Although we respect the role of the states and territories in delivering health care services to the community, we also understand the responsibility of the Commonwealth to ensure that funds raised through taxation are efficiently and effectively returned to the community as services. 
 
In the area of maternity care, current Commonwealth policies and processes are contributing to the lack of access to choice, quality and economic effectiveness in the following ways: 

• The creation of an inappropriate monopoly in private maternity care by GP and specialist obstetricians by excluding midwives from access to Medicare provider numbers. 
• Providing financial incentives via Medicare for high rates of medical intervention in birth.
• Providing large subsidies via the health insurance rebate for private maternity care services which are unaccountable for their outcomes, and are frequently manifestly over-servicing clients (e.g. extreme rates of caesarean section in private hospitals).
• Allowing state expenditure of Commonwealth health funding on unpopular, inadequate and expensive models of maternity care in public hospitals that give women no certainty or continuity in their care. 
• 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 modernisation of Australia's maternity services, it is clear that funding is the key to the development of a lasting solution.
 
Funding-driven Solutions 
Maternity Coalition urges you, and your party, to take a leadership role in coordinating a national response to reform. We propose the following elements of funding reform.

Community Maternity Services Funding 
The first element could be via the Australian Health Care Agreement process, by setting aside a proportion of state health care funding as tied grants for community-based midwifery care.
 
In the first year of implementation, directed funding could be for the equivalent of 2 to 5% of births, which would provide an adequate incentive, without undue burden on those states and territories which have not already developed community midwifery services. 
 
In following years directed funding could be increased at a prescribed rate, allowing for forward planning. A long term strategy would be necessary for this to be successful.

Basic Birth Care Provider Payment 
A second element could be the separation of private medical care for normal birth from the medicare schedule, and making these funds available to doctors and midwives on a level playing field. Of course the lack of access to professional indemnity insurance for midwives will obstruct this option in some circumstances in the short term, but the funding step needs to be taken.

Accountability 
Another move which is necessary to making safety of women and babies a genuine focus of services would be for the Commonwealth to require that 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.

Popular support 
While some resistance to these measures is predictable, midwife-led services such as birth centres are very popular with women, and re-establishment or retention of rural and regional maternity services is of great importance to communities. It will also be essential to have medical referral back up for midwifery managed services to ensure that all women receive the care they need. Such support is typically more forthcoming from salaried obstetricians than from obstetricians in private practice, as they do not have personal financial incentives to maximize the medical care women receive during pregnancy or birth.
 
Leadership in bringing a primary preventative family-focused approach to maternity services, while addressing the current disempowerment of women in birth and motherhood would, if well presented, have broad electoral appeal. 
 
The fact that these reforms could be made at a saving makes them even more attractive.
 
Conclusion 
Community groups and caregivers are unanimous on the need for reform of Australia's maternity care services. Consumers and midwives have developed a tested and viable vision of where we need to go. This vision has received strong support from some areas of the medical community who recognize the evidence-based benefits to women from having access to continuity of care by midwives during pregnancy and birth, with referral to medical care only if needed. 
 
The missing element has so far been the political leadership to bring about reform. We urge you to take this role. 
 
Yours sincerely

Leslie Arnott 
National President 
nationalpresident@maternitycoalition.org.au