Saturday, January 18, 2014

A new vision for maternity care

ARM 2013 - click to enlarge
The mother-midwife relationship:
"central to maternity care: the midwife caring for the mother and providing a safe space in which she can develop confidence in her own ability to give birth and mother her baby."  (ARM 2013, p3)

Last year, 2013, the UK Association for Radical Midwives (ARM) published its New Vision for Maternity Care.

The basic principles are copied in this post.  The Vision document is only 16 pages, and well worth the read.  In the Conclusion, ARM states:
"This is our New Vision for the maternity services of the future.  We wish to change the perceptions of the general public about birth and about midwives so that we can practise the profession for which we have been trained.  Organisational change and financial and educational input is needed to start the process.  Once women know other women who have experienced birth with continuity of care and real autonomy, whether at home or in hospital, this care will be expected.  This new standard of care will bring about improved clinical outcomes for mother and baby, substantial savings for the NHS and positive cultural change within maternity services and the wider public.  Babies whose mothers have a more confident start to motherhood will have a happier and healthier start to life.
Midwives are unique in their combination of skill, sensitivity and training to be 'with woman' through one of life's landmark experiences which has long-term effects on the individual, the family and society as a whole.  We must generate a new respect for both motherhood and midwifery.  We owe it to ourselves and to future generations."

Australian midwives have for many years looked to the United Kingdom for inspiration, as we attempt to survive professionally in a climate of extreme medical dominance.  The UK Changing Childbirth: Report of the Expert Maternity Group (1993) declared the 3C's loudly and clearly: that women want, and deserve, Choice, Continuity, and Control.

Reviews of the best available research have consistently declared that continuous care from a known midwife brings significant advantages in terms of improved outcomes, and better satisfaction by the woman and the midwife. 

The question that comes to mind as I read the ARM New Vision for Maternity Care is, what vision do we have in Australia?  How does Australian maternity vision care compare with that of the UK?

Back in 2002, a group of  Australian mothers, midwives, and maternity-philes, working under the auspices of Maternity Coalition (MC), published the National Maternity Action Plan NMAP.
This project, developed under the joint leadership of Tracy Reibel, who was Program Manager of the Community Midwifery Program in Perth and Freemantle, WA, and Barb Vernon, at the time national president of MC.  Using our relatively newly acquired skills with internet communication, this national collaboration came up with a vision for reform of Australian maternity services, changing from a 'top-down' obstetric dominated model, to a 'bottom-up' model that placed the woman-baby duo as the focus and centre of care.  

NMAP called on our government to enable choice: that each pregnant woman would be free to choose a midwife as her primary care provider; and access: that the woman would be free to give birth at home or in a public hospital, in the care of her known midwife, and all within public maternity funding.

There were little ripples that went out from NMAP, with caseload midwifery programs being established in various public hospitals, and a few new homebirth programs introduced.  Worthwhile, but too few and far between.  Competition for bookings was often fierce.  Women who applied to be cared for within caseload models were often disappointed.  Furthermore, 'modified' arrangements, apparently designed to improve cost/productivity reduced the likelihood of women being attended in labour by their known and trusted midwife.  Midwives who challenged the status quo were informed that a woman who used public maternity services should not expect the 'Rolls Royce' model! (Meaning that if choice and continuity of care was the best, it was not going to be offered to women who paid nothing for their care).  In the meantime, private obstetrics accounted for the care of one woman in three, most of whom were classed 'low risk', with consistently high rates of medical interventions such as induction of labour and caesarean birth.

Then, in 2008, after lobbying and huge efforts on many fronts, the federal government announced its Maternity Services Review.  I was personally delighted to see, in the Discussion Paper, Improving Maternity Services in Australia,  reference to NMAP.  The Discussion Paper noted Australia's low rate of home birth and midwife led models, and in the context of the review it appeared that the reference was favourable towards home birth:
"This contrasts with some other countries, which have considerably higher rates of home births and births in midwife-led environments equivalent to Australian birth centres. In New Zealand, 2.5% of women had a birth at home, compared with 1.9% of women in the UK and 0.2% of Australian women." (p11)
The Discussion Paper discussed primary maternity care, with statements about continuity of care and greater choice, such as:
"A key area is to expand the scope, within both public and private sectors, for women to achieve greater choice and increased continuity of care. This includes being able to choose, where clinically appropriate, a midwife- led service."(p14)

Many who had held the vision of continuity of care and choice where delighted.  We all wrote submissions to the Maternity Services Review; hundreds were received, and placed on the government's website for public access.  Comments were recorded at this blog site, such as here.


The report of the review, while repeating phrases such as 'informed choice', categorically prevented the NMAP vision of choice of place of birth from progressing. While many of the consumer submissions, as well as midwives' responses, pleaded for publicly funded homebirth options, the report deftly dodged the issue:
"Issues raised 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." (Report, p4)

Maternity reform since 2010 has brought into maternity services a mixed bag - some would call it a 'dog's breakfast'.  For example:
  • Homebirth is still the main setting for private midwifery practice, as most midwives are NOT able to access visiting privileges at hospitals.
  • Scores of experienced midwives have achieved notation as eligible, and have resigned from their hospital jobs and set up private practices, with the intention of providing Medicare-rebated midwifery continuity of care.  Most of these midwives have not been able to achieve hospital visiting access, and have joined the ranks of the independent homebirth midwives who travel great distances to visit clients and compete strongly with each other for enough business to keep the wolf from the door. 
  • Midwives practising privately are now able to purchase professional indemnity insurance that covers pre- and post-natal services, but NOT homebirth.  Surely the birth is the main event of maternity care! 
  • Midwives practising privately are able to purchase professional indemnity insurance for births in hospitals, BUT (more than three years after the reforms were implemented) there are only a small handful of hospitals in South-East Queensland where this is an option.
  • Midwives who are eligible for Medicare rebates on their services are required to have a signed collaborative arrangement with a medical practitioner.  BUT, doctors are not obliged to enter a collaborative arrangement. 
  • Instead of improving choice and continuity of care for women, the Medicare reforms have increased the complexity of care for well women who are quite within the scope of the midwife as primary carer.  Women receive the 'carrot' of some Medicare rebate, but most who plan homebirth continue to be out of pocket by approximately $4000 for an episode of care from eligible midwives.

In conclusion, I would like to quote again from ARM's New Vision (2013):
"... that services would be funded and organised from the bottom up around individual women and their families and within the communities in which they live.  Birth at home or in a local birth centre should be the preferred option for all low-risk women.  Community maternity care needs separate funding to promote, enable and support normal birth where possible.  This is a more efficient, less costly, friendlier and safer way to provide maternity care.
Instead of being the default place of birth, the consultant-led obstetric unit would become the place to care for women at higher risk of complications and a place for transfer in labour for emergency care ... [with] continuity of care from a known midwife." (p3)

I would encourage everyone who has an interest in maternity care to maintain the hope that the vision, of the woman at the centre having choice and continuity from a known midwife primary carer, will one day be achieved for all women.

The opinions expressed here are those of the author, Joy Johnston
Your comments are welcome.

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