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From little things, big things grow: a local approach to system-wide maternity services reform in the absence of definitive evidence

From little things, big things grow: a local approach to system-wide maternity services reform in... Background: For nearly two decades calls have been made to expand the role of midwives within maternity services in Australia. Although some progress has been made, it has been slow and, at system-wide level, limited. There are many barriers that prevent the expansion of midwifery-led services in Australia including funding arrangements for midwifery care, a lack of political will and resistance from powerful medical interest groups. The ongoing debate that exists about the evidence for the safety of midwifery-led care, particularly for the intrapartum phase, is likely to be an important reason why policy-makers are reluctant to implement system-wide reforms of maternity services. Discussion: Those opposed to the expansion of midwifery-led care argue that these services are only appropriate for low-risk women. They claim the evidence in support of midwifery-led care has too many holes in it to guarantee that services are safe for higher risk women. Midwifery advocates, however, argue there is no evidence to support the claim that midwifery-led services lead to poorer outcomes in any risk group. Despite this, funding for midwifery-led care outside hospitals remains limited. This article contends that calls for the system-wide expansion of midwifery-led care (such as through funding independently practising midwives) based on the available evidence are unlikely to succeed. There are too many methodological challenges in this area to ever "prove" that midwifery-led services are safe – except for the lowest risk women – and when there is doubt, policy-makers are likely to err on the side of caution. Summary: In order to expand access to midwifery care, advocates should abandon the idea of system-wide reform for now. Instead, they should concentrate on implementing small-scale, locally based changes because it is at this grass roots level that health professionals can work together to resolve the major sticking points – accurately assessing risk, identifying when it changes and responding appropriately. While a lack of political will is a major obstacle to reform it is amenable to change. We argue that system-wide reform is most likely to occur when policy-makers can reference examples of successful locally-based midwifery-led programs across Australia. Background wifery is practised in various settings – hospitals, birth The term midwifery-led care can be confusing as mid- centres and community clinics – and is organised in dif- Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 ferent ways – including standard midwifery, team mid- The What Women Want Party is not the only group inter- wifery and caseload (or one-to-one) midwifery. In this ested in expanding access to midwifery care in Australia. paper, midwifery models of care are considered to be The Maternity Coalition Inc. is a national umbrella organ- those that involve midwives as primary carers for women isation for midwives and mothers. They argue that com- in at least one of the perinatal stages. munity midwifery is commonly practised in other countries, including the United Kingdom, New Zealand There have been many state and federal reports and and the Netherlands, and services are easily accessed there inquiries into maternity services in Australia [1-6]. One of through public health systems. In 2002, they published a the first and most influential was the report of the Minis- National Maternity Action Plan (NMAP) that called on fed- terial Taskforce on Obstetric Services in NSW [1](known as eral and state/territory governments to radically reform the Shearman Report). It recommended granting hospital the way maternity services are both funded and delivered visiting rights to suitably qualified, independently practis- in Australia. They argued in particular that governments ing midwives as a means of expanding access to mid- "work as a matter of priority towards ensuring women wifery-centred maternity care in NSW [7]. It also suggested have universal access to primary midwifery care"[11]. expanding access to birth centres in order to "fulfil women's desire for a less medicalised approach to child- In this paper, we argue that such calls for wide-scale birth without sacrificing the benefits which medical reform are unlikely to succeed because there are too many advances have made possible"[1]. barriers to reform in Australia. Amongst them are the pro- hibitive costs of personal indemnity insurance for mid- Since then, the National Health and Medical Research wives working outside the public hospital system. A Council (NHMRC) has also reviewed midwifery services. further disincentive is the exclusion of independent mid- Their report, entitled Review of Services Offered by Midwives wifery services from the Medical Benefits Schedule, so that [2] examined evidence from nine randomised trials, women using these services must pay the full cost with no including three from Australia, and noted the findings of government funding contribution. There has also been a recent reviews of birth services in NSW, Victoria and West- history of hospital-based childbirth in Australia since the ern Australia. All favoured the introduction of midwifery- Second World War, which the medical profession domi- led models, which had been found to lead to lower rates nates (both numerically and hierarchically). Its position of medical intervention during birth and greater reported has been reinforced by recent advances in technology and satisfaction with care, both of which are highly valued by the greater reliance on hospital-based tests and interven- many women. The NHMRC report concluded that there tions in maternity care. The medical profession also has a was sufficient evidence from both international and powerful and well-established representative group national literature and experience to justify support for (RANZCOG – the Royal Australian and New Zealand Col- the introduction of midwifery models of care. To make lege of Obstetricians and Gynaecologists) that capably this a realistic option in Australia, however, it pointed out protects their interests. Aside from the difficulties within that midwives would need to be given legal responsibility maternity services itself, major health policy reforms in for ordering tests and initiating drugs [2]. Australia are always complicated because responsibility and financing is shared between federal, state and territory Despite the evidence in favour of midwifery care and governments. high-level backing from various bodies, access to mid- wifery care remains limited in Australia. It is especially Some commentators argue that lack of political will is the problematic in rural areas because many small maternity main reason there has not been a system-wide response to units, which were staffed by midwives and general practi- improve access to midwifery-led care in Australia. In tioners, have been closed in the past two decades. In NSW 2005–06, the Maternity Coalition Inc. produced a Cam- alone, 32 out of 67 rural maternity units have closed since paign Kit designed to influence the federal government on 1995 [8]. Women are often required to travel long dis- funding for maternity services. It argued specifically for tances to access any form of maternity care, let alone mid- the introduction of tied grants for community-based mid- wifery care [9]. The perceived failure of federal and state wifery care as part of the Australian Health Care Agree- governments to address maternity services issues has ments and a Basic Birth Care Provider Payment made spawned a new political party in Queensland, which aims available to both doctors and midwives through the Medi- to field candidates in both houses of the federal parlia- care Benefits Schedule. In their briefing to the federal gov- ment. According to party leader Justine Caines, the What ernment they argued: Women Want Party believes "the states share the same issues – soaring caesarean rates, the closure of rural mater- Community groups and caregivers are unanimous on the nity units and absolutely no choice for women" [10]. need for reform of Australia's maternity care services. Con- sumers and midwives have developed a tested and viable Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 vision of where we need to go. This vision has received particularly when they threaten to upset the established strong support from some areas of the medical community practice of medicine. As it stands, the evidence base for who recognize the evidence based benefits to women from midwifery-led care is strong. No studies have shown any having access to continuity of care by midwives during preg- increased risk of perinatal mortality or maternal compli- nancy and birth, with referral to medical care only if cations associated with midwifery-led care, and none have needed. The missing element has so far been the political shown that midwifery-led care had a detrimental impact leadership to bring about reform. We urge you to take this on other neonatal outcomes, such as Apgar scores at 1 and role [12]. 5 minutes post birth or birth weight. Some studies, in fact, have found that babies born in midwifery-led services We do not disagree that political will is an important fac- were less likely to need resuscitation [18], and that fewer tor in the reform process but argue that uncertainty sur- were admitted to NICU following birth [15,18-20]. rounding the evidence on the safety of midwifery-led care, Despite this, those who oppose proposals for expanding especially during the intrapartum phase, is an important access to midwifery care still refer to evidence to support underlying reason for policy-makers' reluctance to imple- their case. This paper looks at the evidence base in one of ment major reforms. Evidence on the safety, popularity the most controversial areas of midwifery care – birth cen- and feasibility of midwifery models of care for low-risk tres – and explains why it does not help put an end to the women is solid [13-15]and largely uncontested by medi- argument about the safety of midwifery care. cal professionals. It is the evidence on the safety of mid- wifery-led care for higher risk women, however, that Discussion brings the debate on expanding access to midwifery care How useful is the evidence? A case study on the safety of to a standstill. birth centres Despite the evidence in favour of expanding access to Groups such as RANZCOG accept that "some women midwifery-led care, critics continue to argue that it is not who have been carefully assessed as being at lower risk of safe. Their claims tend to focus on the evidence concern- pregnancy complications will choose to labour in rela- ing maternal and neonatal safety in birth centres. The tively low-technology primary care units". However, they highest level of evidence available is a 2005 Cochrane are quick to point out that just because childbirth in Aus- Review of birth centres. In this review of six randomised tralia "has never been safer" it "does not mean it is with- controlled trials (RCTs) involving 8,677 women, out- out risk of serious complications". They say that because comes in home-like care were compared to those in con- complications often occur "with frightening rapidity" and ventional labour wards. They found that women there "is at times no margin for unnecessary delays", birth delivering in a home-like setting were significantly more centres should be co-located with 24-hour obstetric facili- likely to require no intrapartum analgesia/anaesthesia, ties wherever possible [16]. have a spontaneous vaginal birth, choose the same setting again, be satisfied with intrapartum care, initiate and con- On the other side of the debate, groups like the Maternity tinue breastfeeding, and have perineal/vaginal tears, but Coalition Inc. argue that "it is time to break the current doc- not episiotomies. Importantly, there was also a non-sig- tor-led monopoly on childbirth by giving midwives their nificant trend towards higher perinatal mortality in home- proper place in maternity services". They state that "med- like settings [21], which is enough to sow the seed of ical evidence supports the good outcomes achieved in doubt in some critics' minds. midwifery led units and birth centres" and that "general practitioners and specialist obstetricians should not have This systematic review is particularly useful in highlight- the sole right to provide basic maternity care" because it ing the weaknesses in the evidence base for midwifery denies women choice and "their basic human rights". care. One is the definition of what constitutes midwifery- They claim that women object to the domination of led care, as it tends to vary from study to study. While all maternity services by medical practitioners because they the studies included in the Cochrane review offered intra- are aware that this exposes them to higher risk of partum care in a home-like setting, some birth centres "unwanted medical intervention"[17]. provided a high level of continuity of care over the ante- natal, intrapartum and postnatal period [22-24], but oth- At the heart of the debate about expanding access to mid- ers did not [25]. Some birth centre models had the routine wifery care is the issue of risk and the available evidence involvement of medical practitioners [23,25], while oth- cannot help resolve this problem. While many advocates ers did not [24]. This variability makes it difficult to com- protest that the evidence base underlying obstetric-led pare studies and be certain about what aspects of care is rarely questioned, this is true for many areas of con- midwifery care are important. It is impossible to know, for ventional practice. The burden of 'proof' mostly rests with instance, if it is the home-like setting that matters or the those seeking to reform the delivery of health services, continuity of care. The variability between models of care Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 is particularly important in this area of research because models are developed that are safe, effective and provide adverse outcomes are quite rare, which means study women with the choice they want. results often need to be pooled in order to reach statistical significance. This is impossible when the type of service There are several examples of successful programs where being examined differs between studies. advocates have begun by trialling a new model of care, which has then gone on to become an established service. Another difficulty in interpreting the data arises from the One such program is the St George Outreach Maternity high transfer rates from birth centres to standard care seen Program (STOMP) in suburban Sydney. STOMP offers in many studies. Some argue that this means existing cri- team midwifery for community-based antenatal clinic teria for admission to birth centre care are inadequate care, hospital intrapartum care and combined hospital [21,24]. In Australia, however, national midwifery guide- and home-based postnatal care. This popular program lines for referral and consultation have been developed caters for 720 women per year and can cover women who [26] but to date, they have failed to allay concerns about develop risk factors during their pregnancy through col- the safety of midwifery-led care. Classifying risk and laboration with obstetricians who also attend the developing referral guidelines can only go so far towards clinic[29]. assuring safety. Childbirth never comes with absolute assurances and the evidence base underlying service deliv- Other examples include the two successful small scale ery (like many other health services) will never be rock state-funded community midwifery programs currently solid. Because of the difficulties of producing irrefutable operating in Australia: one in the Perth metropolitan area evidence on the safety of midwifery-led care, debates of Western Australia and the other in northern suburbs of about it will continue. Adelaide in South Australia. Both offer one-to-one care throughout all perinatal phases, with the Perth program Is the lack of evidence enough to prevent reform? providing mainly home birth services and the Adelaide In discussing how difficult decisions are made, health program targeting young, Aboriginal or low socioeco- economist Anthony Culyer describes the 'weighing up' of nomic status women. Midwifery care continues, with different kinds of evidence including the more colloquial medical support, if women become high risk [29]. use of professionals' experiences when more than one profession is involved and stakeholders have conflicting In 2005 in far north Queensland, the planned closure of a interests [27]. In their recent analysis of the role of evi- midwifery-led service at Mareeba Hospital was averted dence in policy-making on obesity, Nathan et al. showed because of community protest. In response, the state gov- that it is possible to make progress in the absence of com- ernment agreed to let the unit operate as a trial midwife- pelling evidence [28]. The authors found that in some led birthing facility. Subsequent reviews commented on cases when empirical evidence was lacking, policy-makers the high standard of care, quality and safety [30]. The were prepared to make decisions based largely on opinion Mareeba model has been commended because it and ideas. However, importantly, they found that in more addresses the major priorities for change outlined in the contentious policy areas which involve interventions that Rebirthing report [6]namely "poor outcomes for Aborigi- affect everyone and require the development of a national nal and Torres Strait Islander babies, care for women in policy (such as food advertising to children), a lack of rural and remote areas; and the dearth of post-birth care" compelling evidence gave policy-makers good reason to [30] and serves as a clear example of the power of commu- avoid taking action. The lesson to be learnt from the nity-level advocates to overcome inadequacies in state- Obesity Summit in NSW is that governments will need a based services. substantial evidence base before they will take action in maternity services. Given the power of medical represent- Another example of a local trial of midwifery-led care has ative organisations in Australia, and their strong opposi- been operating in rural Victoria. This service was designed tion to the extension of midwifery-led services on the to capture those women in the community not accessing grounds that it puts mothers and babies at risk, policy- antenatal care, especially very young women, but also makers are likely to take an extremely cautious approach. those with drug or alcohol dependence or abuse, mental health problems, the homeless or those with previous Where does this leave midwifery-led care? experience of a neonatal death and/or difficult pregnancy Midwifery advocates' best hope for eventual system-wide and birthing [31]. While the Mareeba and rural Victorian changes to maternity care is to focus in the short term on trials may not yet have obtained a commitment to ongo- local level reforms. This will allow them to include critics ing funding, such trials provide proof of the feasibility and and sceptics in trials of midwifery care, thereby ensuring value of these programs to the local community. Evidence their concerns about safety are addressed and that new of their successful operation may in turn be used as a pow- Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 erful tool for influencing policy-makers' decisions to con- References 1. NSW Health Department: Maternity Services in New South tinue and/or expand these trials. Wales. Final Report of the Ministerial Taskforce on Obstetric Services in NSW (Shearman Report) Sydney 1989. Although this incremental approach to system-wide 2. National Health and Medical Research Council: Review of Services Offered by Midwives. Australian Government Publishing Service, reform may be frustratingly slow, it is much more likely to Canberra; 1998. succeed. At the local level, clinicians from various profes- 3. Senate Community Affairs References Committee: Rocking the cradle. In A report into childbirth procedures Commonwealth of Aus- sional backgrounds routinely work together. It is from this tralia, Canberra; 1999. basis of collaboration and cooperation that alternative 4. Victorian Health Department: Having a Baby in Victoria. Ministe- models of care that are safe and effective are most likely to rial Review of Birthing Services in Victoria, Melbourne 1990. 5. West Australia Health Department: Ministerial Task Force to emerge. Reforming services at the local level means sys- Review Obstetric, Neonatal and Gynaecological Services in tem-wide reforms, such as facilitating independent mid- Western Australia, Perth. 1990, I–III:. wifery practice, are less likely to be 'stonewalled' from the 6. Queensland Health Department: Re-Birthing. Report of the Review of Maternity Services in Queensland. Brisbane. 2005. outset by critics using evidence, or at least doubts about it, 7. Bennett C, Shearman R: Maternity services in New South Wales to convince decision-makers that more caution is st – childbirth moves toward the 21 century. Medical Journal of Australia 1989, 150:673-76. required. Advocates wishing to improve access to mid- 8. Hall L: Closure of maternity wards puts country mums at risk. wifery-led care need to resist the temptation to campaign The Sun Herald . 18 March 2007 for reform at a system-wide level and focus their attention 9. The Maternity Coalition: Breaking the childbirth monopoly. [http://www.maternitycoalition.org.au]. Press release 24 August instead on implementing change slowly, and at the local 2005, Accessed 13/3/2007 level. 10. Wenham M: Women's party is born. Courier Mail . 2 April 2007 11. Reibel T, Vernon B, Tracy S, Key B, Payne R, Leap N, Nixon A, Rob- inson J, Johnston J, Parratt J, Donnellan-Fernandez R: National Summary Maternity Action Plan for the introduction of community Advocates seeking to expand women's access to birth cen- midwifery services in urban and regional Australia. Birth Mat- ters 2002, 6.3:. tres, or midwifery care in general, need to be mindful of 12. The Maternity Coalition Inc: Briefing to the Federal Govern- the various obstacles to reform in maternity services. ment: Safe, Sustainable Maternity Care in Australia. [http:// Although a lack of political will is often blamed when www.maternitycoalition.org.au/home/modules/campaigns/ index.php?id=1]. Accessed 29/6/2007 there is no progress on a system-wide level, it is important 13. Turnbull D, Holmes A, Shields N, Cheyne H, Twaddle S, Gilmour to recognise the underlying role that evidence plays in WH, McGinley M, Reid M, Johnstone I, Geer I, Mc Ilwaine G, Burnett determining whether or not policy-makers are willing to Lunan C: Randomised, controlled trial of efficacy of midwife- managed care. The Lancet 1996, 348:213-18. implement changes. It is difficult to "prove" that mid- 14. Haertsch M, Campbell E, Sanson-Fisher R: Who can provide ante- wifery care is safe because methodological holes in the natal care? The views of obstetricians and midwives. Austral- ian and New Zealand Journal of Public Health 1998, 22(4):471-75. evidence reported in the literature mean there will always 15. Biró M, Waldenström U, Pannifex J: Team midwifery care in a be an element of doubt, to which critics will undoubtedly tertiary level obstetric service: A randomised controlled draw attention. Local examples of midwifery-led services trial. Birth 2000, 27(3):168-173. 16. The Royal Australian and New Zealand College of Obstetricians and that are feasible and popular are, we believe, the best form Gynaecologists: College statement on 'stand-alone' childbirth of evidence to persuade policy-makers of the need for units. [http://www.ranzcog.edu.au/media/pdfs/MR-Stand- alone%20childbirth%20units.pdf]. Press release 4 August 2005. change. Advocates should attempt to improve access to Accessed 6/4/2007 maternity-led care through a grass roots approach to 17. Maternity Coalition: Response to the Productivity Commis- reform. Then, region by region, the expansion of mid- sion's Position Paper on Australia's Health Workforce. 2005 [http://www.pc.gov.au/study/healthworkforce/subs/subpp185.rtf]. wifery-led services in Australia may at last get underway. 18. Rowley MJ, Hensley MJ, Brinsmead MW, Wlodarczyk JH: Continuity of care by a midwife team versus routine care during preg- nancy and birth: a randomised trial. Medical Journal of Australia Competing interests 1995, 163:289-93. They author(s) declare they have no competing interests. 19. Kenny P, Brodie P, Eckermann S, Hall J: Final Report Westmead Hospital Team Midwifery Project Evaluation Final Report. Centre for Health Economics Research and Evaluation 1994. Authors' contributions 20. Homer CSE, Davis GK, Brodie PM, Sheehan M, Barclay LM, Wills J, AB and KF both contributed to the review of literature that Chapman MG: Collaboration in maternity care: an rand- forms the basis of this argument and the preparation of omized controlled trial comparing community based conti- nuity of care with standard hospital care. British Journal of the manuscript. Both authors have read and approved the Obstetrics and Gynaecology 2001, 108:16-22. final manuscript. 21. Hodnett ED, Downe S, Edwards N, Walsh D: Home-like versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews 2005:CD000012. Acknowledgements 22. Hundley VA, Cruickshank FM, Lang GD, Milne JM, Turner M, Blyth D, The authors would like to thank Professor Stephen Leeder for his help Mollison J, Donaldson C: Midwife managed delivery unit: a ran- developing this paper. domised controlled comparison with consultant led care. British Medical Journal 1994, 309:1400-1404. 23. Jackson DJ, Lang JM, Swartz WH, Ganiats TG, Fullerton J, Ecker J, Nguyen U: Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Centre Program Compared With Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 Traditional Physician-Based Perinatal Care. American Journal of Public Health 2003, 93(6):999-1006. 24. Gottvall K, Grunewald C, Waldenström U: Safety of birth centre care: perinatal mortality over a 10-year period. British Journal of Obstetrics and Gynaecology 2004, 111:71-78. 25. MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M, Kennedy J: Simulated home delivery in hospital: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 1993, 100:316-23. 26. Australian College of Midwives: National Midwifery Guidelines for Consultation and Referral. Canberra. 2003. 27. Culyer AJ: NICE's use of cost effectiveness as an exemplar of a deliberative process. Health Economics, Policy and Law 2006, 1:299-318. 28. Nathan SA, Develin E, Grove N, Zwi AB: An Australian Childhood Obesity Summit: the role of data and evidence in 'public' pol- icy making. Australia and New Zealand Health Policy 2005, 2:17. 29. Maternity Coalition: National Maternity Action Plan. Birth Mat- ters 2002, 6(3):1-26. 30. Wenham M, : Reborn maternity unit is thriving in the north. The Courier Mail . April 10, 2007 31. Ponton K, Chapman Y, Francis K: Innovative model of maternity care supporting vulnerable rural populations. Australian Journal of Rural Health 2005, 13:368-72. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

From little things, big things grow: a local approach to system-wide maternity services reform in the absence of definitive evidence

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Springer Journals
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Copyright © 2007 by Boxall and Flitcroft; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
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1743-8462
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1743-8462
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10.1186/1743-8462-4-18
pmid
17903272
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Abstract

Background: For nearly two decades calls have been made to expand the role of midwives within maternity services in Australia. Although some progress has been made, it has been slow and, at system-wide level, limited. There are many barriers that prevent the expansion of midwifery-led services in Australia including funding arrangements for midwifery care, a lack of political will and resistance from powerful medical interest groups. The ongoing debate that exists about the evidence for the safety of midwifery-led care, particularly for the intrapartum phase, is likely to be an important reason why policy-makers are reluctant to implement system-wide reforms of maternity services. Discussion: Those opposed to the expansion of midwifery-led care argue that these services are only appropriate for low-risk women. They claim the evidence in support of midwifery-led care has too many holes in it to guarantee that services are safe for higher risk women. Midwifery advocates, however, argue there is no evidence to support the claim that midwifery-led services lead to poorer outcomes in any risk group. Despite this, funding for midwifery-led care outside hospitals remains limited. This article contends that calls for the system-wide expansion of midwifery-led care (such as through funding independently practising midwives) based on the available evidence are unlikely to succeed. There are too many methodological challenges in this area to ever "prove" that midwifery-led services are safe – except for the lowest risk women – and when there is doubt, policy-makers are likely to err on the side of caution. Summary: In order to expand access to midwifery care, advocates should abandon the idea of system-wide reform for now. Instead, they should concentrate on implementing small-scale, locally based changes because it is at this grass roots level that health professionals can work together to resolve the major sticking points – accurately assessing risk, identifying when it changes and responding appropriately. While a lack of political will is a major obstacle to reform it is amenable to change. We argue that system-wide reform is most likely to occur when policy-makers can reference examples of successful locally-based midwifery-led programs across Australia. Background wifery is practised in various settings – hospitals, birth The term midwifery-led care can be confusing as mid- centres and community clinics – and is organised in dif- Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 ferent ways – including standard midwifery, team mid- The What Women Want Party is not the only group inter- wifery and caseload (or one-to-one) midwifery. In this ested in expanding access to midwifery care in Australia. paper, midwifery models of care are considered to be The Maternity Coalition Inc. is a national umbrella organ- those that involve midwives as primary carers for women isation for midwives and mothers. They argue that com- in at least one of the perinatal stages. munity midwifery is commonly practised in other countries, including the United Kingdom, New Zealand There have been many state and federal reports and and the Netherlands, and services are easily accessed there inquiries into maternity services in Australia [1-6]. One of through public health systems. In 2002, they published a the first and most influential was the report of the Minis- National Maternity Action Plan (NMAP) that called on fed- terial Taskforce on Obstetric Services in NSW [1](known as eral and state/territory governments to radically reform the Shearman Report). It recommended granting hospital the way maternity services are both funded and delivered visiting rights to suitably qualified, independently practis- in Australia. They argued in particular that governments ing midwives as a means of expanding access to mid- "work as a matter of priority towards ensuring women wifery-centred maternity care in NSW [7]. It also suggested have universal access to primary midwifery care"[11]. expanding access to birth centres in order to "fulfil women's desire for a less medicalised approach to child- In this paper, we argue that such calls for wide-scale birth without sacrificing the benefits which medical reform are unlikely to succeed because there are too many advances have made possible"[1]. barriers to reform in Australia. Amongst them are the pro- hibitive costs of personal indemnity insurance for mid- Since then, the National Health and Medical Research wives working outside the public hospital system. A Council (NHMRC) has also reviewed midwifery services. further disincentive is the exclusion of independent mid- Their report, entitled Review of Services Offered by Midwives wifery services from the Medical Benefits Schedule, so that [2] examined evidence from nine randomised trials, women using these services must pay the full cost with no including three from Australia, and noted the findings of government funding contribution. There has also been a recent reviews of birth services in NSW, Victoria and West- history of hospital-based childbirth in Australia since the ern Australia. All favoured the introduction of midwifery- Second World War, which the medical profession domi- led models, which had been found to lead to lower rates nates (both numerically and hierarchically). Its position of medical intervention during birth and greater reported has been reinforced by recent advances in technology and satisfaction with care, both of which are highly valued by the greater reliance on hospital-based tests and interven- many women. The NHMRC report concluded that there tions in maternity care. The medical profession also has a was sufficient evidence from both international and powerful and well-established representative group national literature and experience to justify support for (RANZCOG – the Royal Australian and New Zealand Col- the introduction of midwifery models of care. To make lege of Obstetricians and Gynaecologists) that capably this a realistic option in Australia, however, it pointed out protects their interests. Aside from the difficulties within that midwives would need to be given legal responsibility maternity services itself, major health policy reforms in for ordering tests and initiating drugs [2]. Australia are always complicated because responsibility and financing is shared between federal, state and territory Despite the evidence in favour of midwifery care and governments. high-level backing from various bodies, access to mid- wifery care remains limited in Australia. It is especially Some commentators argue that lack of political will is the problematic in rural areas because many small maternity main reason there has not been a system-wide response to units, which were staffed by midwives and general practi- improve access to midwifery-led care in Australia. In tioners, have been closed in the past two decades. In NSW 2005–06, the Maternity Coalition Inc. produced a Cam- alone, 32 out of 67 rural maternity units have closed since paign Kit designed to influence the federal government on 1995 [8]. Women are often required to travel long dis- funding for maternity services. It argued specifically for tances to access any form of maternity care, let alone mid- the introduction of tied grants for community-based mid- wifery care [9]. The perceived failure of federal and state wifery care as part of the Australian Health Care Agree- governments to address maternity services issues has ments and a Basic Birth Care Provider Payment made spawned a new political party in Queensland, which aims available to both doctors and midwives through the Medi- to field candidates in both houses of the federal parlia- care Benefits Schedule. In their briefing to the federal gov- ment. According to party leader Justine Caines, the What ernment they argued: Women Want Party believes "the states share the same issues – soaring caesarean rates, the closure of rural mater- Community groups and caregivers are unanimous on the nity units and absolutely no choice for women" [10]. need for reform of Australia's maternity care services. Con- sumers and midwives have developed a tested and viable Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 vision of where we need to go. This vision has received particularly when they threaten to upset the established strong support from some areas of the medical community practice of medicine. As it stands, the evidence base for who recognize the evidence based benefits to women from midwifery-led care is strong. No studies have shown any having access to continuity of care by midwives during preg- increased risk of perinatal mortality or maternal compli- nancy and birth, with referral to medical care only if cations associated with midwifery-led care, and none have needed. The missing element has so far been the political shown that midwifery-led care had a detrimental impact leadership to bring about reform. We urge you to take this on other neonatal outcomes, such as Apgar scores at 1 and role [12]. 5 minutes post birth or birth weight. Some studies, in fact, have found that babies born in midwifery-led services We do not disagree that political will is an important fac- were less likely to need resuscitation [18], and that fewer tor in the reform process but argue that uncertainty sur- were admitted to NICU following birth [15,18-20]. rounding the evidence on the safety of midwifery-led care, Despite this, those who oppose proposals for expanding especially during the intrapartum phase, is an important access to midwifery care still refer to evidence to support underlying reason for policy-makers' reluctance to imple- their case. This paper looks at the evidence base in one of ment major reforms. Evidence on the safety, popularity the most controversial areas of midwifery care – birth cen- and feasibility of midwifery models of care for low-risk tres – and explains why it does not help put an end to the women is solid [13-15]and largely uncontested by medi- argument about the safety of midwifery care. cal professionals. It is the evidence on the safety of mid- wifery-led care for higher risk women, however, that Discussion brings the debate on expanding access to midwifery care How useful is the evidence? A case study on the safety of to a standstill. birth centres Despite the evidence in favour of expanding access to Groups such as RANZCOG accept that "some women midwifery-led care, critics continue to argue that it is not who have been carefully assessed as being at lower risk of safe. Their claims tend to focus on the evidence concern- pregnancy complications will choose to labour in rela- ing maternal and neonatal safety in birth centres. The tively low-technology primary care units". However, they highest level of evidence available is a 2005 Cochrane are quick to point out that just because childbirth in Aus- Review of birth centres. In this review of six randomised tralia "has never been safer" it "does not mean it is with- controlled trials (RCTs) involving 8,677 women, out- out risk of serious complications". They say that because comes in home-like care were compared to those in con- complications often occur "with frightening rapidity" and ventional labour wards. They found that women there "is at times no margin for unnecessary delays", birth delivering in a home-like setting were significantly more centres should be co-located with 24-hour obstetric facili- likely to require no intrapartum analgesia/anaesthesia, ties wherever possible [16]. have a spontaneous vaginal birth, choose the same setting again, be satisfied with intrapartum care, initiate and con- On the other side of the debate, groups like the Maternity tinue breastfeeding, and have perineal/vaginal tears, but Coalition Inc. argue that "it is time to break the current doc- not episiotomies. Importantly, there was also a non-sig- tor-led monopoly on childbirth by giving midwives their nificant trend towards higher perinatal mortality in home- proper place in maternity services". They state that "med- like settings [21], which is enough to sow the seed of ical evidence supports the good outcomes achieved in doubt in some critics' minds. midwifery led units and birth centres" and that "general practitioners and specialist obstetricians should not have This systematic review is particularly useful in highlight- the sole right to provide basic maternity care" because it ing the weaknesses in the evidence base for midwifery denies women choice and "their basic human rights". care. One is the definition of what constitutes midwifery- They claim that women object to the domination of led care, as it tends to vary from study to study. While all maternity services by medical practitioners because they the studies included in the Cochrane review offered intra- are aware that this exposes them to higher risk of partum care in a home-like setting, some birth centres "unwanted medical intervention"[17]. provided a high level of continuity of care over the ante- natal, intrapartum and postnatal period [22-24], but oth- At the heart of the debate about expanding access to mid- ers did not [25]. Some birth centre models had the routine wifery care is the issue of risk and the available evidence involvement of medical practitioners [23,25], while oth- cannot help resolve this problem. While many advocates ers did not [24]. This variability makes it difficult to com- protest that the evidence base underlying obstetric-led pare studies and be certain about what aspects of care is rarely questioned, this is true for many areas of con- midwifery care are important. It is impossible to know, for ventional practice. The burden of 'proof' mostly rests with instance, if it is the home-like setting that matters or the those seeking to reform the delivery of health services, continuity of care. The variability between models of care Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 is particularly important in this area of research because models are developed that are safe, effective and provide adverse outcomes are quite rare, which means study women with the choice they want. results often need to be pooled in order to reach statistical significance. This is impossible when the type of service There are several examples of successful programs where being examined differs between studies. advocates have begun by trialling a new model of care, which has then gone on to become an established service. Another difficulty in interpreting the data arises from the One such program is the St George Outreach Maternity high transfer rates from birth centres to standard care seen Program (STOMP) in suburban Sydney. STOMP offers in many studies. Some argue that this means existing cri- team midwifery for community-based antenatal clinic teria for admission to birth centre care are inadequate care, hospital intrapartum care and combined hospital [21,24]. In Australia, however, national midwifery guide- and home-based postnatal care. This popular program lines for referral and consultation have been developed caters for 720 women per year and can cover women who [26] but to date, they have failed to allay concerns about develop risk factors during their pregnancy through col- the safety of midwifery-led care. Classifying risk and laboration with obstetricians who also attend the developing referral guidelines can only go so far towards clinic[29]. assuring safety. Childbirth never comes with absolute assurances and the evidence base underlying service deliv- Other examples include the two successful small scale ery (like many other health services) will never be rock state-funded community midwifery programs currently solid. Because of the difficulties of producing irrefutable operating in Australia: one in the Perth metropolitan area evidence on the safety of midwifery-led care, debates of Western Australia and the other in northern suburbs of about it will continue. Adelaide in South Australia. Both offer one-to-one care throughout all perinatal phases, with the Perth program Is the lack of evidence enough to prevent reform? providing mainly home birth services and the Adelaide In discussing how difficult decisions are made, health program targeting young, Aboriginal or low socioeco- economist Anthony Culyer describes the 'weighing up' of nomic status women. Midwifery care continues, with different kinds of evidence including the more colloquial medical support, if women become high risk [29]. use of professionals' experiences when more than one profession is involved and stakeholders have conflicting In 2005 in far north Queensland, the planned closure of a interests [27]. In their recent analysis of the role of evi- midwifery-led service at Mareeba Hospital was averted dence in policy-making on obesity, Nathan et al. showed because of community protest. In response, the state gov- that it is possible to make progress in the absence of com- ernment agreed to let the unit operate as a trial midwife- pelling evidence [28]. The authors found that in some led birthing facility. Subsequent reviews commented on cases when empirical evidence was lacking, policy-makers the high standard of care, quality and safety [30]. The were prepared to make decisions based largely on opinion Mareeba model has been commended because it and ideas. However, importantly, they found that in more addresses the major priorities for change outlined in the contentious policy areas which involve interventions that Rebirthing report [6]namely "poor outcomes for Aborigi- affect everyone and require the development of a national nal and Torres Strait Islander babies, care for women in policy (such as food advertising to children), a lack of rural and remote areas; and the dearth of post-birth care" compelling evidence gave policy-makers good reason to [30] and serves as a clear example of the power of commu- avoid taking action. The lesson to be learnt from the nity-level advocates to overcome inadequacies in state- Obesity Summit in NSW is that governments will need a based services. substantial evidence base before they will take action in maternity services. Given the power of medical represent- Another example of a local trial of midwifery-led care has ative organisations in Australia, and their strong opposi- been operating in rural Victoria. This service was designed tion to the extension of midwifery-led services on the to capture those women in the community not accessing grounds that it puts mothers and babies at risk, policy- antenatal care, especially very young women, but also makers are likely to take an extremely cautious approach. those with drug or alcohol dependence or abuse, mental health problems, the homeless or those with previous Where does this leave midwifery-led care? experience of a neonatal death and/or difficult pregnancy Midwifery advocates' best hope for eventual system-wide and birthing [31]. While the Mareeba and rural Victorian changes to maternity care is to focus in the short term on trials may not yet have obtained a commitment to ongo- local level reforms. This will allow them to include critics ing funding, such trials provide proof of the feasibility and and sceptics in trials of midwifery care, thereby ensuring value of these programs to the local community. Evidence their concerns about safety are addressed and that new of their successful operation may in turn be used as a pow- Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 erful tool for influencing policy-makers' decisions to con- References 1. NSW Health Department: Maternity Services in New South tinue and/or expand these trials. Wales. Final Report of the Ministerial Taskforce on Obstetric Services in NSW (Shearman Report) Sydney 1989. Although this incremental approach to system-wide 2. National Health and Medical Research Council: Review of Services Offered by Midwives. Australian Government Publishing Service, reform may be frustratingly slow, it is much more likely to Canberra; 1998. succeed. At the local level, clinicians from various profes- 3. Senate Community Affairs References Committee: Rocking the cradle. In A report into childbirth procedures Commonwealth of Aus- sional backgrounds routinely work together. It is from this tralia, Canberra; 1999. basis of collaboration and cooperation that alternative 4. Victorian Health Department: Having a Baby in Victoria. Ministe- models of care that are safe and effective are most likely to rial Review of Birthing Services in Victoria, Melbourne 1990. 5. West Australia Health Department: Ministerial Task Force to emerge. Reforming services at the local level means sys- Review Obstetric, Neonatal and Gynaecological Services in tem-wide reforms, such as facilitating independent mid- Western Australia, Perth. 1990, I–III:. wifery practice, are less likely to be 'stonewalled' from the 6. Queensland Health Department: Re-Birthing. Report of the Review of Maternity Services in Queensland. Brisbane. 2005. outset by critics using evidence, or at least doubts about it, 7. Bennett C, Shearman R: Maternity services in New South Wales to convince decision-makers that more caution is st – childbirth moves toward the 21 century. Medical Journal of Australia 1989, 150:673-76. required. Advocates wishing to improve access to mid- 8. Hall L: Closure of maternity wards puts country mums at risk. wifery-led care need to resist the temptation to campaign The Sun Herald . 18 March 2007 for reform at a system-wide level and focus their attention 9. The Maternity Coalition: Breaking the childbirth monopoly. [http://www.maternitycoalition.org.au]. Press release 24 August instead on implementing change slowly, and at the local 2005, Accessed 13/3/2007 level. 10. Wenham M: Women's party is born. Courier Mail . 2 April 2007 11. Reibel T, Vernon B, Tracy S, Key B, Payne R, Leap N, Nixon A, Rob- inson J, Johnston J, Parratt J, Donnellan-Fernandez R: National Summary Maternity Action Plan for the introduction of community Advocates seeking to expand women's access to birth cen- midwifery services in urban and regional Australia. Birth Mat- ters 2002, 6.3:. tres, or midwifery care in general, need to be mindful of 12. The Maternity Coalition Inc: Briefing to the Federal Govern- the various obstacles to reform in maternity services. ment: Safe, Sustainable Maternity Care in Australia. [http:// Although a lack of political will is often blamed when www.maternitycoalition.org.au/home/modules/campaigns/ index.php?id=1]. Accessed 29/6/2007 there is no progress on a system-wide level, it is important 13. Turnbull D, Holmes A, Shields N, Cheyne H, Twaddle S, Gilmour to recognise the underlying role that evidence plays in WH, McGinley M, Reid M, Johnstone I, Geer I, Mc Ilwaine G, Burnett determining whether or not policy-makers are willing to Lunan C: Randomised, controlled trial of efficacy of midwife- managed care. The Lancet 1996, 348:213-18. implement changes. It is difficult to "prove" that mid- 14. Haertsch M, Campbell E, Sanson-Fisher R: Who can provide ante- wifery care is safe because methodological holes in the natal care? The views of obstetricians and midwives. Austral- ian and New Zealand Journal of Public Health 1998, 22(4):471-75. evidence reported in the literature mean there will always 15. Biró M, Waldenström U, Pannifex J: Team midwifery care in a be an element of doubt, to which critics will undoubtedly tertiary level obstetric service: A randomised controlled draw attention. Local examples of midwifery-led services trial. Birth 2000, 27(3):168-173. 16. The Royal Australian and New Zealand College of Obstetricians and that are feasible and popular are, we believe, the best form Gynaecologists: College statement on 'stand-alone' childbirth of evidence to persuade policy-makers of the need for units. [http://www.ranzcog.edu.au/media/pdfs/MR-Stand- alone%20childbirth%20units.pdf]. Press release 4 August 2005. change. Advocates should attempt to improve access to Accessed 6/4/2007 maternity-led care through a grass roots approach to 17. Maternity Coalition: Response to the Productivity Commis- reform. Then, region by region, the expansion of mid- sion's Position Paper on Australia's Health Workforce. 2005 [http://www.pc.gov.au/study/healthworkforce/subs/subpp185.rtf]. wifery-led services in Australia may at last get underway. 18. Rowley MJ, Hensley MJ, Brinsmead MW, Wlodarczyk JH: Continuity of care by a midwife team versus routine care during preg- nancy and birth: a randomised trial. Medical Journal of Australia Competing interests 1995, 163:289-93. They author(s) declare they have no competing interests. 19. Kenny P, Brodie P, Eckermann S, Hall J: Final Report Westmead Hospital Team Midwifery Project Evaluation Final Report. Centre for Health Economics Research and Evaluation 1994. Authors' contributions 20. Homer CSE, Davis GK, Brodie PM, Sheehan M, Barclay LM, Wills J, AB and KF both contributed to the review of literature that Chapman MG: Collaboration in maternity care: an rand- forms the basis of this argument and the preparation of omized controlled trial comparing community based conti- nuity of care with standard hospital care. British Journal of the manuscript. Both authors have read and approved the Obstetrics and Gynaecology 2001, 108:16-22. final manuscript. 21. Hodnett ED, Downe S, Edwards N, Walsh D: Home-like versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews 2005:CD000012. Acknowledgements 22. Hundley VA, Cruickshank FM, Lang GD, Milne JM, Turner M, Blyth D, The authors would like to thank Professor Stephen Leeder for his help Mollison J, Donaldson C: Midwife managed delivery unit: a ran- developing this paper. domised controlled comparison with consultant led care. British Medical Journal 1994, 309:1400-1404. 23. Jackson DJ, Lang JM, Swartz WH, Ganiats TG, Fullerton J, Ecker J, Nguyen U: Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Centre Program Compared With Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:18 http://www.anzhealthpolicy.com/content/4/1/18 Traditional Physician-Based Perinatal Care. American Journal of Public Health 2003, 93(6):999-1006. 24. Gottvall K, Grunewald C, Waldenström U: Safety of birth centre care: perinatal mortality over a 10-year period. British Journal of Obstetrics and Gynaecology 2004, 111:71-78. 25. MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M, Kennedy J: Simulated home delivery in hospital: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 1993, 100:316-23. 26. Australian College of Midwives: National Midwifery Guidelines for Consultation and Referral. Canberra. 2003. 27. Culyer AJ: NICE's use of cost effectiveness as an exemplar of a deliberative process. Health Economics, Policy and Law 2006, 1:299-318. 28. Nathan SA, Develin E, Grove N, Zwi AB: An Australian Childhood Obesity Summit: the role of data and evidence in 'public' pol- icy making. Australia and New Zealand Health Policy 2005, 2:17. 29. Maternity Coalition: National Maternity Action Plan. Birth Mat- ters 2002, 6(3):1-26. 30. Wenham M, : Reborn maternity unit is thriving in the north. The Courier Mail . April 10, 2007 31. Ponton K, Chapman Y, Francis K: Innovative model of maternity care supporting vulnerable rural populations. Australian Journal of Rural Health 2005, 13:368-72. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: Sep 30, 2007

References