Chapter 4 - Care during birth
The birth setting
4.1
Almost all Australian babies
are born in hospital. Most are born in traditional labour wards, now generally
known by the more politically correct term ‘delivery suites’. A small
percentage of hospital births take place in alternative birthing centres the
majority of which are located either within hospitals or very close to them.[103] The Australian Institute of Health
and Welfare estimated that in 1996 birth centres accounted for 2.5% of all
births, but the figures do not include Victoria and Tasmania, where
confinements in birth centres are not separately enumerated.[104]
4.2
A very small number of
Australian babies is born at home. The figure was 0.3% in 1996, although the
Australian Institute of Health and Welfare cautions that home births ‘are
underascertained in some State and Territory perinatal collections’.[105]
4.3
This pattern does not vary
significantly between States. Nor is it greatly influenced by the ethnic
background or health insurance status of the mother.
4.4
Irrespective of birth setting,
mortality outcomes are exceptionally good for Australian mothers and babies by
world standards (although this is not the case for Aboriginal mothers and
babies for whom mortality rates are double those of the non indigenous population,
as noted in chapter 2). Appendices 3 and 4 give international comparisons.
4.5
In the period 1991-93 there
were 3.5 maternal deaths per 100,000 confinements directly related to
childbirth.[106] However, the
underlying rate is higher than this. In 1994 the rate was 7.0 deaths per
100,000 births. Averaged over the period 1990-1994 it was 5.3.[107] The safety of childbirth in Australia
is reflected in Australian Bureau of Statistics figures on deaths from
complications in pregnancy, childbirth and the puerperium: 13 in 1989 and 1991,
15 in 1993, 24 in 1995, 11 in 1997 and 7 in 1998.[108]
4.6
Foetal, neonatal and perinatal
death rates were 5.5, 3.0, and 8.5 per 1000 births in 1996. By 1998 the foetal
death rate had dropped to 4.5, the neonatal rate to 2.7 and the perinatal rate to
7.2 per 1000 births.[109]
Foetal, Neonatal and Perinatal Deaths
![Rates are per 1,000 total relevant births.](/~/media/wopapub/senate/committee/clac_ctte/completed_inquiries/1999_02/child_birth/report/c04_1_gif.ashx)
Rates are per 1,000
total relevant births.
Source: ABS, Causes of Death Australia, Cat No 3303.0, Table 3.1 p.60.
4.7
Australian women value safety
for their babies and themselves above everything when making choices about
birth settings. For this reason the vast majority choose to birth in hospitals
where perinatal and maternal mortality rates are very low.
4.8
But while women may be happy
with the outcomes achieved, in terms of perinatal and maternal mortality, they
are generally not impressed by the measures adopted to achieve them. The
evidence suggests that they resent the way in which childbirth has been taken
over by the medical profession rather than treated as a natural process, with a
concomitant increase in the level of interventions and consequent morbidity
outcomes (described in the following chapters) and in the disempowerment of the
women giving birth. While acknowledging that the medical approach may be
necessary in a small number of cases they consider it inappropriate for most
women compelled or persuaded to submit to it without any medical justification.
They are further alienated by a system which too often fails to provide
continuity of carer so that they may be tended during birth by total strangers.
4.9
Hospitals have been slow to
respond to community pressure for a more holistc approach to birth, as have
governments and some elements of the medical profession. Some initiatives have
been adopted as noted. The Alternative Birthing Services Program has been an
important catalyst in this respect. But much remains to be done. Possible
future directions will be considered in connection with discussion of the
development of best practice guidelines for care during birth.
Birth in a hospital delivery suite
4.10
Although most maternity
hospitals (and maternity units within general hospitals) are relatively small
(half had fewer than 100 births in 1996), many births occur in large units. In
1996 more than 42% of all births were in hospitals conducting more than 2,000
confinements annually.[110]
Arrangements are normally made during pregnancy for women deemed at risk of
complications during birth to be admitted to large hospitals where obstetrical
specialists and a range of services are available. This policy has been a major
contributor to Australia’s current very low rates of maternal, and more
especially perinatal, morbidity and mortality.
4.11
Just over 30% of mothers giving
birth are privately insured. The figure ranges from 30.2% in Western Australia
to 35.5% in the Australian Capital Territory.[111]
(Figures were not recorded in Victoria and the Northern Territory at this time
and were not available for Tasmania.)
4.12
During birth in a hospital
delivery suite, a woman may be in the care of midwives, of a general practitioner,
of a registrar, of a specialist obstetrician or of any combination of these.
Usually she is cared for by midwives during labour, with an obstetrician or
registrar on call who then attends at the birth, at least in the case of
privately insured women. General practitioners rarely have the right to attend
hospital births in urban centres. A woman is more likely to be attended by a
specialist obstetrician during labour and birth if she is privately insured or
if she or her baby are deemed at risk of developing complications.
4.13
Even healthy women who give
birth in traditional hospital labour wards and have uncomplicated labours run a
high risk of some form of intervention (as discussed in the following two
chapters). They may or may not be familiar with the midwives attending them in
labour, depending upon the extent to which shared care arrangements are in
place which extend through pregnancy into birth and beyond into the post natal
period. (Shared care arrangements are discussed in chapter 2.)
4.14
Women who enjoy continuity of
carer right through pregnancy and birth express greater satisfaction with their
care than do women assisted by a range of professionals. A study by Brown and
Lumley suggested that while consumer satisfaction was highest among privately
insured women attended by a specialist during their antenatal care, women in
this group were no more or less likely to be happy with their care during birth
than women receiving standard public hospital or general practitioner care.[112] This is because in the former
situation it is rare for an obstetrician to be present throughout labour. So
women must rely on midwives or registrars with whom they are unfamiliar, and
who are not familiar with their histories and particular concerns.
4.15
Dissatisfaction with the medical
emphasis of hospital births and with discontinuity of care were major factors
driving consumer demand for alternative, more woman centred approaches to
birth, with midwives as the primary care givers. Some traditional hospitals
have responded to this demand by establishing team midwifery programs for
healthy women. Westmead hospital is one.
7% of women giving birth [at Westmead] in 1998 enrolled in this
programme. Though an obstetrician is ultimately responsible for these patients,
they are seen in a separate clinic and cared for by a team midwife in labour
ward. Team midwives only rarely need to care for more than one woman at a time
in labour ward because the numbers of women booked for this model of care are
limited to a number which makes this feasible. Women receiving team midwifery
care have a greater degree of continuity of care than other public obstetric
patients.[113]
* * *
At the John Hunter
Hospital in Newcastle, NSW, continuity of care provided by midwives was
demonstrated through a randomised, controlled study with 814 women to be as
safe as routine care. It also reduced the need for medical interventions
including induction of labour, analgesia use and need for neonatal
resuscitation. Women receiving team care were significantly more satisfied with
their experience and there was a significant reduction in cost. This model of
care has now become part of the routine options of care available for women who
choose to birth at this hospital.[114]
4.16
The Committee received many submissions
supporting the work of team midwives at John Hunter, whose system has been
adopted by many other hospitals. The Committee was therefore dismayed to learn
that the program is now under threat, with its funding to be diverted to other
hospital programs.[115]
4.17
The team midwifery approach is
only one of a range adopted by hospitals in response to consumer demand for a
less interventionist medical approach to childbirth for healthy women. Others
include the midwifery case load model and variations on the shared care model.
Aspects of the midwifery case load model were explained by a Victorian witness.
There are different midwifery models that provide total
continuity of care. An example is a caseload model. The midwives actually take
a caseload of about four women throughout their pregnancies and provide the
antenatal, intrapartum and postnatal care.[116]
Birth in an ‘alternative’ birthing centre
4.18
Although originally established
as alternatives to standard hospital models of birth care, birthing centres are
now accepted as mainstream services. They are therefore generally referred to
in the following discussion simply as ‘birth centres’.
4.19
A birth centre may be housed in
a self contained area within a maternity hospital. It may be a free standing
building in hospital grounds or adjacent to a hospital or, more rarely, it may
be located totally independently of a hospital.
4.20
Birth centres are a deliberate
attempt to move away from the medical model of care provided in labour wards,
and to replicate the atmosphere prevailing at home, while ensuring immediate
access to medical attention and services should they be required. Ideally, they
are designed to provide a home like atmosphere with rooms furnished like
bedrooms rather than hospital wards, for example with a double bed rather than
the usual hospital variety. They have ready access to shower and bath
facilities and some are completely self contained units. This is the position
at the Queen Elizabeth Hospital in Adelaide, for example, and at the King
Edward Memorial Hospital for Women in Perth. Many regular labour wards are
moving in the same direction.
4.21
Where hospitals or health
services have had no real commitment to them, the centres may in fact be no
more than a room at the end of a labour ward with no special facilities and no
attempt to introduce a non medical approach to birth.
The concept of birth centres has become murky in Australia as
many traditional labour wards have been decorated with curtains and bedspreads
and renamed birth centres without any fundamental change to the medical
protocols that still control woman and midwives. [117]
4.22
Birth centres are staffed and
run by midwives. Although obstetricians and registrars (or general
practitioners in some centres) may be on call they do not assist at labour or
birth unless requested by the midwives to do so. In some birth centres (and
some labour wards) where a team approach has been adopted midwives and general
practitioner-obstetricians both may be present during labour and birth.
4.23
Access to birth centres is
limited to women deemed at low risk. In most birth centres strict admittance
protocols apply. Women who are accepted by birth centres early in their
pregnancy will be transferred to regular hospital labour wards if they develop
complications during pregnancy. Similarly, low risk women who develop
complications during labour are immediately transferred to ‘mainstream’
hospital labour wards. Transfer rates are quite high. At the birth centre at
the King Edward Memorial Hospital for Women in Perth, for example, in the year
to January 1997 approximately 29% of women were transferred prior to the onset
of labour and a further 17% were transferred during labour.[118] ‘Nearly 30% of women who planned a
birth centre birth in NSW in 1997 were transferred to the labour ward for the delivery’.[119]
4.24
Although protocols govern both
admittance to birth centres and transfer out of them in the event of
complications, there is great variety in their content. In Melbourne, for
example, a woman who has had a previous Caesarean section is not permitted to
book into a birth centre. In Sydney she may be accepted.[120] In South Australia the position
varies from hospital to hospital.
We have produced guidelines for South Australia of the people
who should be in a birthing centre, or should be informed about birthing
centres, and who could go to a birthing centre. Individual hospitals interpret
those guidelines differently. For example, the Queen Elizabeth Hospital allows
women who have had a previous caesarean section to go to their birthing centre,
whereas this hospital [the Women’s and Children’s in Adelaide] does not.[121]
4.25
More research, especially
research using randomised trials, is needed on which to base best practice
guidelines governing the content of these protocols.
4.26
The earliest birth centres were
established in the 1980s, in response to consumer demand. They were funded by
State health departments. Later the Commonwealth, reacting to the same
pressures, funded the Alternative Birthing Services Program (ABSP). It began in
1989 and provided funds for the establishment of birth centres in the public
health system and for the payment of midwives attending at home births or in
birth centres. It has also funded a range of innovative outreach and antenatal
services. Commonwealth funding for the program in the period 1989-90 to 1996-97
was $15.4 million. Since 1997-98 ABSP funding has been broadbanded with general
public health funding provided to the States under the Public Health Outcome
Funding Agreements.
4.27
Birth centres account for only
a small proportion of total births. In 1996 there were 4,652 such births (2.5%
of all births), an increase from the 2,405 recorded in 1992. These figures
exclude Victoria and Tasmania where birth centre births were not separately
recorded.[122]
4.28
The objective of the ABSP was
to promote greater choice for women giving birth. It aimed to promote a
philosophy of care which emphasised the role of the midwife as a primary carer
and pregnancy and birth as normal life events for most women. It was also
intended to encourage State health services to trial a range of models of care.
4.29
The ABSP had a strong emphasis
on the provision of alternative services for Aboriginal and Torres Strait
Islander women. During its first phase, 25% of its funds were targetted to this
group. The focus has been on antenatal and post natal care rather than birth,
although Aboriginal programs include, for example, a community based birthing
service for Koori women in metropolitan Victoria, run by the Victorian
Aboriginal Health Services Cooperative and a similar project in Adelaide run by
the Northern Metropolitan Area Health Service. Both of these services provide
continuity of care for Aboriginal women through the antenatal period, the birth
and into the post natal period.
4.30
The birth centres have been an
outstanding success. Their maternal and perinatal morbidity and mortality rates
are comparable to, or better than, those of hospital labour wards. Even though
their client group is restricted to women in the low risk category, while that
of major centres includes most women considered at high risk, their results are
impressive, both in terms of medical outcome and in terms of consumer
satisfaction.
4.31
The cost of births at birth
centres is comparable to, or slightly higher than, the cost of uncomplicated
vaginal deliveries at public hospitals, at least in those centres for which
figures were supplied to the Committee. Queensland Health, for example, advised
that the cost of an uncomplicated vaginal delivery of a public patient at
Mackay Hospital was $1,473 in 1999. The cost at Mackay Birth Centre was $1,840.[123]
4.32
Birth centres have lower
intervention rates than labour wards and much higher levels of consumer
satisfaction. Women particularly report greater feelings of empowerment in
birth centres. Women in the centres are given greater flexibility than the
hospitals generally permit in the manner in which they give birth, and report
that they have more input to decisions taken during labour and birth.
4.33
Support for birth centres is
widespread. Demand exceeds supply in most centres.
The birthing centres are overfull in Adelaide and cannot provide
enough places for the women who want them.[124]
4.34
In the centre at the Royal
Women’s Hospital in Brisbane potential clients are selected by ballot every
month, with applications approximately double the centre’s capacity to respond.
4.35
Facilities have not been
expanded to keep pace with this demand. In fact, some very well supported
centres have recently closed, or are threatened with closure.
The average number of babies born every year in Western Australia
is 25,000. The state has only two Birth Centres in the Metropolitan Area, a
total of only five (5) beds...The only rural Birth Centre in Mandurah was closed
when the public hospital was privatised. This means that there are no Birthing
Centres outside the Metropolitan Area.[125]
* * *
As I understand it, the birth centre at Swan District was an
Alternative Birthing Services project and it was funded for the length of time
covered by the Alternative Birthing Services Program. I think the funding is
just about over.[126]
4.36
The Health Department of
Western Australia disputed this, claiming that ‘since 1994/95, Western
Australia has received over $230,000 annually from the ABSP, with broadbanding
under the Public Health Agreement having no effect on the ABSP allocation’.[127]
4.37
This is in part a funding
issue. The position was succinctly stated in a Northern Territory evaluation of
the ABSP.
The ability of the Alternative Birthing Services Program to
promote birthing as a normal life event is hindered by the lack of funds
available compared to those available to parties with an interest in keeping it
medicalised.[128]
4.38
The Commonwealth Alternative
Birthing Services Program was a pilot program. The intention was that projects
established by the program which proved successful in terms of safe outcomes
and consumer support would continue with State funding. While this intention is
certainly being fulfilled in some area health services the practice is by no
means uniform.
4.39
Funding considerations are not
the only barrier. Some midwives and consumer groups pointed to opposition from
obstetricians to establishment, retention or expansion of birth centres.
In 1995 consulting
obstetricians at KEMH prevented the establishment of a Commonwealth Alternative
Birthing Services Programme under the auspices of the hospital, by threatening
to withdraw their clinical services from all women, after hours and on
weekends.[129]
4.40
The success of birth centres
extends beyond the centres themselves. They have had an impact on attitudes and
practice in traditional labour wards.
...the birth centre culture has filtered out through the rest of
the practice of midwifery...I see the sorts of philosophies that the birth centre
brought in going through what one used to call labour wards - we call them
delivery suites these days.[130]
4.41
Their impact on the general
community can be expected to increase among groups not so far touched by their
development, according to some evidence to the Committee.
I think the multicultural society which we have may well increase
our numbers in the family birth centre. I think it is just the beginning of
perhaps a much larger input into and interest in the family birth centre type
of situation when the multicultural and perhaps the less educated or informed
people are becoming more and more informed of that option.
...I think that up to now the birth centre philosophy and birth
centre facility have not been exploited as much as they should have been with
some of the ethnic groups which we now have. There is a lot of potential for
that to become a very much more used option.[131]
4.42
Many recent reports[132] have favoured the further
development of birth centres provided they continue to attract consumer support
and continue to provide services that are equally safe to those provided by hospital
labour wards. The NHMRC did not support the expansion of birth centres remote
from hospitals, on safety grounds.
4.43
The Committee favours the
continuation and expansion of birth centres. As noted, they have received
support in many recent reports. Support was also expressed consistently in
evidence provided to the Committee by consumer and midwife groups. The
Committee considers that birth centres have demonstrated that they have
community support, are safe and are cost effective. They are now a widely accepted
mainstream component of birthing services in Australia rather than a fringe
alternative. It is therefore appropriate that they be maintained and extended
by hospitals, through hospital budgets, rather than through the Alternative
Birthing Services Program, which is now part of Public Health Outcome funding.
Recommendation
The Committee RECOMMENDS that the Commonwealth Government work
with State governments to ensure the continuation and expansion of hospital
birthing centres.
Home birth
4.44
Home birth represents a very
small proportion of total births in Australia. As noted, they accounted for
only 0.3% of total births in 1996.[133]
The number has been fairly consistent over recent years, although supporters
claim that more women would birth at home if current financial and other
constraints were removed.
4.45
The Australian Institute of
Health and Welfare suggested that women who favoured the non medical approach
of home birth were turning increasingly to birth centres and that this
accounted for the fact that there had been no increase in home births despite
increased consumer concerns over the medicalisation of pregnancy and
childbirth.
Women who sought to avoid what they would regard as unnecessary
intervention and may have chosen home birth for that reason and for the type of
care that they get are increasingly using birthing services linked to hospitals
for their care. So we are not seeing an increase in home births in Australia.[134]
4.46
A major inhibitor to growth in
the number of home births is concern about rapid access to medical expertise
and facilities in the event of unforeseen complications. Although most home
birth midwives accept only healthy women at low risk of developing
complications, such risks can never be totally predicted. This is borne out by
the fact that a significant number of women who begin their labour at home are
eventually delivered in hospital. The figure was said to be 12.9% in 1988-90.[135]
4.47
The medical risks of home birth
are cited by the medical profession as the reason for their opposition to it.
With infant and maternal mortality the lowest it has ever been,
people have begun to believe that childbirth is totally without risk, and that
all the medical intervention is both invasive and unnecessary. They advocate a
return to home-delivery, without medical management, and often without any
medical support. The end result of this can be deduced by comparison with the
situation in the Third World, where no woman has the chance of a hospital
delivery, and where 9 women in every 1000 die during or after labour.
...Home delivery survives only as an atavism. It can only be
justified in terms of personal gratification, and it has nothing to do with
best practice, or indeed any form of professional standard.[136]
4.48
The Royal Australian College of
Obstetricians and Gynaecologists is opposed to home birth on safety grounds
but, in recognition of the fact that it does occur, has developed best practice
guidelines to assist women contemplating this option.
The College recognises that a small number of women will chose
domiciliary confinement. While considering that homebirth exposes the mother
and child to unacceptable risks, the College has recommendations to guide
persons seeking home delivery.[137]
4.49
Another factor restricting the
appeal of home birth is its cost. This ranges from $1,500 to $2,500 according
to evidence provided to the Committee. These costs are not met by Medicare and
must therefore be borne by the woman and her family. For this reason home birth
is not an option for many women who might otherwise choose it. Few private
health funds cover the costs of home birth either.
Failure to make midwifery fees claimable through Medicare
discriminates against the midwife and the women who wish to choose this model
of care. With the WHO recommending the midwife as the most appropriate carer
for normal healthy women in pregnancy and birth, it is ironic that their fees
are the only ones not claimable
either through Medicare or most private health insurance funds.[138]
* * *
Midwifery care for homebirths should attract an equitable
medicare rebate. Many women from lower socio-economic areas are extremely
disadvantaged and discriminated by the lack of a medicare rebate for the
services of independent midwives. A more general application would see homebirth
made free to all women through
medicare taking up its public responsibility in rebating the care provided by
midwives.[139]
4.50
Women birthing at home
therefore tend to be of higher socio economic status than those who give birth
in hospital.
A SA study in 1990 found women who had planned homebirths were
older and of a higher socioeconomic group than women who gave birth in
hospital.[140]
4.51
Because of the small number of
women birthing at home, there is not enough work available to the independent
midwives who assist them. Such midwives have therefore to seek work in
hospitals or community based centres (where these institutions will accept them
- often will not). Here they have less responsibility and autonomy and may lose
some of their skills. Many of them are uncomfortable with the medical approach
adopted in hospitals where, they consider, their skills are undervalued.
4.52
Midwives are leaving the
profession and recruitment of new midwives is insufficient to replace them.
High attrition rates place great pressure on those remaining. There are
parallels here with the situation facing specialist obstetricians.
The general public is being swayed to think that the hospital is
more safe because of the technology, but many authors assert that the use of
technology is actually deskilling the midwives in this “technobirthing”
environment. The midwives are no longer ‘with’ women but are minders of
machines and reporters to doctors.[141]
4.53
The threat of litigation is
also a factor adversely impacting on the recruitment and retention of
independent midwives.
...medical insurance is having quite an impact on the way - at
least in the private sector - the options are available to women. Because there
is still an attitude by organisations such as the Medical Defence Union that
doctors and midwives should not be working together. Doctors should not be
providing backup for visiting midwives. This causes a problem, because it is
difficult for midwives to get the required amount of insurance in order to have
access to visiting rights in hospital.[142]
4.54
Home birth may be viewed as one
manifestation of the widespread reaction by women against the medicalisation of
pregnancy and birth. They resent the way in which hospitals treat healthy women
in labour as if they were sick and require medical intervention.
4.55
The Committee heard from many
advocates of home birth. Most had themselves given birth at home and were keen
to extend the benefits which they had received to other women. The following
excerpts are typical of many received by the Committee.
The degree of medical intervention practised in hospitals is
unnecessary and frightening and this led me to a search for different
approaches for the birth of my daughters...I wish to share these experiences with
the Committee to highlight the importance of informed choice, continuity of
care and respecting the normality of pregnancy and childbirth.[143]
* * *
From our experience, we know that birthing at home is good for
women, babies, families, communities and cultures and it is also cost effective
when compared to the expense of giving birth in hospital.[144]
4.56
Most advocates of home birth
recognised that it was not an option for women at risk of developing
complications during labour or delivery.
I wish to point out that I do not believe that giving birth at
home is somehow inherently ‘better’ than giving birth in hospital. I am well
aware of the fact that some women and babies require the type of medical care
only possible in a hospital setting, and I do not underestimate the importance
of such care. I am also aware of the fact that many women feel safer and more
comfortable labouring and giving birth at hospital than they would at home.
However, there are a number of women with low-risk pregnancies who, if given
the choice, would prefer to give birth at home and who could do so safely if
the type of care provided under the CIS [Childbirth Information Service] model
was more widely available.[145]
4.57
Home birth supporters
considered that the risks of home birth were exaggerated by the medical
profession, which saw it as a threat to their authority.
When I decided on birth at home, most medical practitioners I
spoke with abhorred my decision, branding it as unsafe and foolish. I felt that
I had made the right decision and set about informing myself about the practice
of home birth. What I discovered was that claims about the dangers of home
birth are based on opinion, not facts. These claims are also perpetuated by
those with the least motivation for encouraging women to access this model of
care. Their motivation is less about safety and more about politics, power and
money.
...I believe the silence on these issues [safety of home birth] is
testimony to the power of the medical profession generally in sustaining the
medical model of birth and suppressing the development of superior
woman-centred midwifery care.[146]
4.58
Independent research on the
safety of home birth in Australia is not conclusive. Where the numbers are so
small it is difficult to draw definitive conclusions. Some overseas studies
have shown that home births are not inherently less safe than hospital births.
It is concluded that no empirical evidence exists to support the
view that it is less safe for most low-risk women to plan a home birth,
provided that the pregnant woman is motivated and, furthermore, selected and
assisted by an experienced home birth practitioner, and provided that the home
birth practitioner, in turn, is backed up by a modern hospital system should a
transfer be needed. It is further concluded that home birth as managed in the
included studies may well have other advantages compared with standard hospital
care.[147]
4.59
Other studies dispute this. A
study by Hilda Bastian and others which compared data on 7,002 planned home
births in Australia during 1985-90 with national data on perinatal deaths and
outcomes of home births concluded that Australian home births carried a high
death rate compared with both all Australian births and home births elsewhere.
The largest contributors to the excess mortality were underestimation of the
risks associated with post-term birth, twin pregnancy and breech presentation,
and a lack of response to foetal distress.[148]
4.60
In view of these findings the
authors stated that:
While home birth for low risk women can compare favourably with
hospital birth, high risk home birth is inadvisable and experimental.[149]
4.61
Certainly, women birthing at
home undergo fewer invasive procedures so the morbidity rates associated with
these procedures are lower.
Women birthing at home between 1988-90 experienced mainly
spontaneous birth (86%) and only 12.9% were transferred to hospital during
labour or in the postnatal period...Of those women who birthed at home, 93%
required only non-medical or social support by the midwife and support persons;
1.5% required Pethidine and further 5% used acupuncture or homeopathy and
herbal remedies.[150]
4.62
Home birth pilot programs were
developed by some States using Commonwealth funding provided through the
Alternative Birthing Services Program (ABSP). This funding was used to pay the
fees of independent midwives attending low risk births. It has been suggested
that in States which did not take up these funds and where therefore, there
were fewer constraints on the women accepted for home birth, there has been an
increase in high risk births at home.
States which did not use the opportunity of developing a home
birth program based on low risk criteria (NSW, Victoria and Queensland) have
seen an increasing trend of midwives taking on women with high risk pregnancies
for delivery at home...The ABSP homebirth pilot programs have ensured safe home
birth practices with good access to hospitals. It is regrettable that no States
have taken up the challenge of on-going funding of home birth services.[151]
4.63
Home births are favoured by
only a small number of women in Australia. In other countries the situation is
quite different. In Holland, to which the Committee’s attention was repeatedly
directed, over a third of babies are born at home and perinatal and maternal
morbidity and mortality rates are low. The reasons for the difference in approach
are complex. Cultural and social factors are important.
4.64
Holland has a much more
integrated health system than does Australia, and provides greater continuity
of care through the antenatal period, birth and into the post natal period.
Home birth is much more widely accepted there, by the population generally and
by the medical profession. Midwives undergo a more rigorous training in Holland
than they do in Australia. Finally, because Holland is a small and densely
populated country, women giving birth at home are never far from hospital
support should this become necessary.
4.65
It seems likely that home birth
will remain the preferred choice for a minority of Australian women. Its
proponents suggest that their greatest impact will not be to increase the number
of home births but rather to ‘humanise’ hospital births by influencing hospital
staff to adopt a less interventionist, more holistic and woman centred approach
to birth. Moves in this direction are already evident in some hospitals,
although they have not gone nearly far enough in the view of many witnesses
before the Committee.
I have had discussions with a very prominent homebirth midwife -
I do not see any reason not to name her - Maggie Lecky-Thompson. I enjoyed my
discussion with her and she herself volunteered that the impact of the
homebirth movement was not going to be to move birth to the home but to
civilise hospital births. I think she is absolutely right. I think that in the
last 10 to 15 years, since it has become very apparent to any obstetrician that
obstetrics was being practised in a way which was not necessarily either
beneficial to mothers or making them happy, obstetricians have been changing
their practice.[152]
4.66
The Committee supports the
continuation of this option for healthy women. It considers that the available
evidence, both in Australia or overseas, is such as to justify its retention
and notes that in Holland, for example, where a third of all births take place
at home, morbidity and mortality rates are comparable to those in Australia.
Recommendation
The Committee RECOMMENDS that the Commonwealth Government
continue to fund midwives to assist at home births for women at low risk
through the Public Health Outcome Funding Agreements.
Birth in rural and remote locations
4.67
Women living in rural and
remote areas have fewer local options for care during birth than do those in
urban centres. Basically they can either give birth at their local hospital,
attended by a midwife and a general practitioner or, if there is no local
hospital, transfer to a regional or other urban centre offering the range of
services outlined earlier. Few women have access to the services of a
specialist obstetrician. Home birth is problematic in rural areas because of
the distance and time involved in transferring a woman to a major centre should
complications develop during labour.
4.68
Women with health problems or
considered at risk of complications during birth are normally encouraged to
give birth at a metropolitan or regional centre where specialist staff and
facilities are available if required. For women in remote communities this
requires transfer to urban centres well before the anticipated date of birth.
This practice, which is in place in all States and Territories, has been a
major contributor to Australia’s current very low rates of perinatal and
maternal morbidity and mortality.
...the regionalisation of perinatal care, whereby high risk
mothers and babies are transferred from smaller units to tertiary care centres,
has probably been the predominant factor in reducing perinatal death rates.[153]
4.69
Some evidence to the Committee
suggested that despite women’s reduced choices in rural areas, outcomes are
not compromised.
Clearly, it is not possible to have a range of options for women
in rural areas doing only 20 deliveries per year. On the other hand, the
doctors and hospital midwives in those districts offer a level of continuity of
care that city dwellers could only dream of.[154]
* * *
Although access to obstetric facilities for rural and remote
women is often limited, health outcomes for women choosing to deliver in rural
and remote locations are not necessarily worse than for metropolitan teaching
hospitals.
In fact, the converse is
true. Perinatal mortality and morbidity statistics from GP obstetric units in
rural areas in NSW and rural Canada have been identified as being among the
best in the world.[155]
4.70
Other evidence suggested that
high skill levels could not be maintained by staff in hospitals carrying out
only a small number of births each year. As noted, half of the maternity units
in Australia have fewer than 100 births a year. Almost all of these are in
country areas.
4.71
For healthy women giving birth
with the assistance of a midwife and a general practitioner in a country
hospital outcomes are comparable with those in metropolitan areas. It has been
suggested that in part this is because country general practitioners are
skilled at identifying possible problems in pregnancy and arranging for the
transfer of women at risk to metropolitan services.
The reasons for this [comparable outcomes for rural general
practitioner care] are complex but it is believed that experienced rural GP
obstetricians are good at identifying potential problems promptly and
transferring patients to a larger centre in a timely and appropriate fashion.[156]
4.72
There are generally lower
intervention rates in country areas than in metropolitan centres for comparable
populations. This may in part be because fewer options for intervention are
available. Anaesthetists are in short supply, for example, so that epidural
anaesthetic may not be available (and because women are less likely to have
their labour artificially initiated it may be less necessary). In these
circumstances there is greater need for alternative, less interventionist
approaches to pain relief and greater knowledge and skill in their use.
4.73
In country hospitals staffing
arrangements tend to be less hierarchical than in urban areas. Midwives and
general practitioners work as a team. The woman giving birth is likely to have
received her antenatal care from the midwife and/or general practitioner
attending at the birth. This continuity of care and familiarity with the people
attending at the birth have been demonstrated in many studies to increase
women’s confidence and sense of control during the birth, which in turn reduces
the need for intervention.
The best examples of the whole of the shared care model are in
the country...I refer, for example, to Geraldton...Kalgoorlie, and Collie, which is
where I come from. We have a population of only 10,000. We do not have a
resident specialist, but we have three GP obstetricians, a general surgeon and
anaesthetists and our intervention rate is low. It is currently about 10 per
cent...So it can be done, and it can be safely done.[157]
4.74
This pattern is not uniform.
The Committee was advised of a number of country hospitals with very high
intervention rates. They included, for example, the Coff’s Harbour Hospital
(23.8%), Tamworth Base Hospital (23.7%) and Lithgow (27.1%).[158]
4.75
While giving birth in country
hospitals is in many respects a more satisfying experience than giving birth in
metropolitan hospitals (at least for healthy women) there are significant
problems. Rationalisation of services in rural areas threatens the existence of
small country hospitals. Without them, healthy women in rural areas will be
forced to travel to major urban centres for their births and will lose the
benefits of giving birth close to their homes and families. The National Health
and Medical Research Council has cautioned against further centralisation of
hospital services.
While it is imperative that there is sufficient centralisation
of services to ensure that expertise can be maintained in each region, attempts
to reduce local services for healthy women with normal pregnancies should be
resisted unless clear and unequivocal advantages can be demonstrated.[159]
4.76
The Royal Australian College of
General Practitioners also pointed out that:
Once you close those units [obstetrical units in country
hospitals] you get this incredible downward spiral. Closing acute services in a
small rural hospital is a disaster because, once you lose your acute services,
you effectively turn many of these small rural hospitals into nursing homes.[160]
4.77
In country hospitals which have
closed their obstetrics units, but where births still occur, perinatal
morbidity and mortality outcomes have deteriorated.
The New South Wales study found that deliveries continue to
occur in hospitals without an
obstetric unit and will still present unbooked and often in preterm labour.
This often occurs in small towns where the units have been closed because of
low numbers of deliveries, lack of support services or proximity to larger
hospitals. Without the professional expertise of a functioning obstetric and
midwifery service, perinatal mortality and morbidity figures tend to be
suboptimal.
This highlights the need
to keep small rural obstetric units open and to staff them adequately. Rural
women will continue to want care closer to home and have every right to expect
a safe, accessible service.[161]
4.78
The greatest threat to the
quality and safety of the birth experience for country women is the shortage of
general practitioners qualified in obstetrics. Many of them are leaving country
practices. Of those who remain, many are refusing to undertake obstetrical
work. And new entrants are not moving to country areas in sufficient numbers to
replace them, despite Commonwealth incentives to encourage them (as described
in chapter 2).
4.79
Litigation or the perceived
fear of litigation, and the associated costs of insurance are major issues for
general practitioner obstetricians in country areas (although State governments
subsidise the costs of their insurance). They have contributed to the virtual
elimination of specialist obstetricians in rural areas.
The costs of indemnity for specialist obstetricians is
predicated on their seeing enough patients and earning enough income to cover
these costs. Especially, away from the big cities, specialist obstetric
practice rapidly becomes non-viable. The simple solution for Obstetricians is
to limit themselves to only Gynaecology, which is lucrative, has better hours
and smaller indemnity bills. This is not the best outcome for the community.[162]
4.80
However, a recent Victorian
study suggested that lifestyle issues were an equally important factor in the
drift of general practitioners with obstetric training from the country.
Personal/family reasons or interference with lifestyle were
chosen by 36% of respondents as the most important reason for ceasing obstetrics.
Rising insurance premiums was the reason for 16%, concern regarding the
management of unexpected emergencies for 10% and lack of remuneration for
8%...Both rural GPs and urban/provincial GPs considered personal, family and
lifestyle issues as the most important (29% v 40%).[163]
4.81
This view was supported by
general practitioners in submissions and public hearings.
Rural Obstetricians may not have the lifestyle, financial and
continuing educational opportunities of their city colleagues, so there need to
be incentives to keep them or we run the very real risk of losing these
services completely.[164]
* * *
There were two major reasons why general practitioners drop
obstetrics, and they are not what you might think. The first one concerned personal
family and lifestyles issues. Obstetric practice is very intrusive; it is
intrusive on your personal life, your family life and the rest of your medical
practice. So when it is not the core business of your medical practice...you tend
to look at things you can get rid of, and obstetrics is one of them. People do
obstetrics for the love of it.
The second reason people are looking at ceasing obstetric
practice...is the rising insurance premiums. A third reason is the perceived
threat of litigation. There was, in fact, another major issue that we looked
at: being able to get back-up in an emergency. This fear of being alone with an
emergency is something that is very high in the minds of general practitioners.
It is not the litigation; it is the fear of not being able to cope with an
emergency in an isolated place.[165]
4.82
The impact of litigation on the
obstetrical work force in country areas is discussed in chapter 10.
4.83
The number of midwives in
country areas is also declining. In the period 1993-1996 the percentage of
midwives in capital cities increased from 65.8% to 69.2%. In all other
geographical locations it declined during this period.[166]
There are significant problems facing rural and remote Australia
in the growing shortage of midwives which places pressure on the continued
provision of rural obstetric services.[167]
4.84
Commonwealth and State
governments have a number of initiatives in place to address this problem and
the related problem of ensuring that rural midwives maintain their skills. They
include the Commonwealth funded Midwives Upskilling Program, begun earlier this
year, through which the Commonwealth will pay State and Northern Territory
governments $3,000 per rural/remote midwife so that they can undertake
retraining for two weeks every two years. Joint programs with the West
Australian and Queensland governments also focus on retraining for rural and
remote midwives.[168]
4.85
In addition, the Committee was
advised of a number of State funded programs designed to develop the skills of
rural midwives. The Royal North Shore Hospital, for example, advised of a
midwifery exchange program through which midwives from the Far West Area Health
Service of New South Wales have worked for three weeks in the North Sydney Area
Health Service.[169] Midwives from the
Royal North Shore and Manly hospitals have replaced them at Bourke, Walgett,
Wilcannia and Broken Hill hospitals.
4.86
The decline in the rural
obstetrical work force and the threatened closure of small hospitals
jeopardises the opportunity for healthy women in rural areas to give birth
close to home. They may be forced to choose between home birth and transfer to
major centres. Neither option is desirable. Home birth in rural areas, even for
healthy women, carries an inherent risk because of the difficulty of obtaining
rapid assistance in an emergency. Transfer to a metropolitan centre is
disruptive to the woman and her family. It is costly and may result in a less
satisfactory birth experience, given that she will be in an unfamiliar setting
and attended by people unknown to her.
Birth in rural and remote areas for Aboriginal and Torres Strait Islander
women
4.87
Many of the issues identified
above as applying to women in rural and remote locations apply also to
Aboriginal and Torres Strait Islander women. For this group however the
position is particularly difficult because they live in the remotest areas
where the problems discussed above are most acute. Their own health and diet is
generally less satisfactory than that of the rural population as a whole. As
noted, they tend to be younger, poorer and have more babies more closely spaced
than does the non indigenous population. In addition they face language and
cultural barriers in accessing services. All these factors contribute to their
poorer outcomes in terms of perinatal and maternal morbidity and mortality.
4.88
Because a greater proportion of
Aboriginal women are deemed to be at risk than is the case for the general
population, more of them are transferred to urban centres for their births. In
the Northern Territory in 1994, for example, nearly 30% of Aboriginal women had
to travel away from their homes to give birth. While such a practice may be
justified on purely medical terms, its costs are significant in financial and
emotional terms.
Transferring women from remote locations to hospital to give
birth is certainly the safest option from a medical perspective, especially
with high-risk pregnancies. Nevertheless this causes significant disruption and
anxiety for women and their families, as many women living in remote locations have
to travel long distances to the nearest town with birthing services, then wait
(sometimes for weeks) for confinement. While birthing in remote locations may
not be feasible or safe, provision of more accessible services may be.[170]
* * *
Let us take the example of Halls Creek in Western Australia,
where Aboriginal mothers are shipped out to Derby, which is hundreds of miles
away. They go by plane and then the poor things are dumped on a bus with their
babies to bring them back to Halls Creek. It is really tragic.[171]
4.89
Some attempts have been made to
assist women who are awaiting the birth of their babies far from their homes
and families. Each State and the Northern Territory has a ‘patient’ assistance
travel scheme, but this does not usually include travel costs for an
accompanying family member. In Cairns, the Commonwealth is funding a special
residence for those women, where they can stay with their immediate family,
receive culturally appropriate antenatal care and be close to medical attention
should they require it. Such an approach is especially helpful for young
Aboriginal women, who are particularly vulnerable in large unfamiliar cities.
4.90
For indigenous women at low
risk who remain in rural areas to give birth, some innovative approaches to
culturally appropriate services were developed under the auspices of the
Alternative Birthing Services Program. These include the Alukura Birthing
Centre at Alice Springs, referred to earlier, which allows traditional
practices within a medically safe environment and the Koori Birthing Support
Service at Ballarat, operated by the Ballarat Community Health Centre and the
Ballarat and District Aboriginal Cooperative.
4.91
For most healthy Aboriginal
women however there are few culturally appropriate services in country areas,
or indeed in metropolitan areas. Where there are no qualified general
practitioners they are obliged, like women at high risk, to transfer to urban
centres.
4.92
One response to the lack of
culturally appropriate birthing services is the movement for birth on the
homelands. But few Aboriginal women choose this option because no back up
health support is currently available for those who do so. In 1996 only 2% of
recorded Aboriginal births took place in locations other than hospitals and these
were mainly in designated birth centres or in bush clinics in the Northern
Territory.[172]
Recommendation
The Committee RECOMMENDS that the Commonwealth Government work
with State governments to assist Aboriginal and Torres Strait Islander women
who have to give birth outside their communities by funding an accompanying
family member, with funding provided through their patient transfer assistance
schemes.
Recommendation
The Committee RECOMMENDS that the Commonwealth Government,
through the Office of Aboriginal and Torres Strait Islander Health, fund
culturally appropriate birthing services, either in hospitals or stand alone,
in centres with large Aboriginal and Torres Strait Islander populations.
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