Executive Summary and Recommendations
1. The Select Committee into Public Obstetric Services (Committee) was established by the Legislative Council on 24 May 2006 to inquire into the adequacy of the Government’s decision making process (including public consultation and the consideration of relevant evidence) leading to the determination to restrict metropolitan public obstetric services to certain key hospitals outlined in the WA Health Clinical Services Framework 2005-2015.
2. According to the Committee’s Terms of Reference, the models of maternity care being considered by the Government, including the associated decision making process, would also be examined.
3. The Western Australian Statewide Obstetrics Services Review: Report of the Project Working Group (Cohen report) in 2003 was influential in terms of government decision making and its recommendations have been adopted by subsequent reviews of maternity services in Western Australia.
4. A key conclusion of the Cohen report was that in order to ensure safety and quality, secondary obstetric services should meet certain defined service requirements including dedicated specialist staff and a low dependency neonatal unit. While advocating a greater availability of birth centres for low risk births, the Cohen report indicates that such units should also have access to on-site medical and emergency backup.
5. In order for obstetric service requirements to be sustainable, the Cohen report concludes that fewer units would address many of the critical workforce issues impacting on maternity service provision and allow for a more effective and efficient critical mass to develop.
6. A stated aim of the Cohen review was to obtain consensus and support from clinicians and, as a consequence, consultation focused on obtaining clinical, rather than community input. It was intended that the Department of Health (Department) would conduct community consultation following release of the report. Feedback to the Cohen report indicated that consensus was not reached in relation to the report’s conclusions and recommendations and many of the concerns raised by stakeholders at that time remained unresolved to be raised again during the course of this inquiry.
7. In relation to the decision making process following the Cohen report (but preceding the Department’s Future Directions in Maternity Care policy development process in 2006-2007), evidence to this inquiry indicates that many stakeholders are of the opinion that there was inadequate consultation with the community. Evidence also indicates that stakeholders are not satisfied that the Department gave sufficient regard to evidence provided by the community and from the academic literature in its decision making process.
8. In the Committee’s view, a comprehensive examination of models of care, including primary care and its place in the maternity system, is a necessary element for a meaningful review of the maternity system. However, it was not until the Future Directions in Maternity Care process in 2007 that a comprehensive review of local and international evidence was conducted.
9. The Committee notes that the debate about obstetric services can be sidetracked by groups with vested interests in the system or by those with entrenched views about pregnancy and birth. Fear is also influential in any discussion about maternity services - fear of childbirth, fear of pain and fear for the safety of mother and baby. Fear of litigation was also raised in evidence to the Committee. Inevitably, these views impact on the delivery of obstetric services and the range of options provided to women.
10. Most public pregnancy care in Western Australia is provided at hospital clinics or in GP’s private rooms and the majority of babies are born in hospital. There are limited maternity care options available for women, including only one midwifery-led birth centre in the State.
11. Evidence shows that there is a lower uptake of maternity care services among disadvantaged women and the Government’s 2007 draft maternity policy, Improving Maternity Choices, recognises that the needs of some women, particularly minority and Aboriginal groups, are not being adequately met by the current system. There is also evidence to indicate that current after birth programs in general may not provide adequate care and assistance to women. The Committee considers that more work is required to assess the adequacy of pregnancy care and after birth programs and to develop strategies to improve the care provided to disadvantaged women.
12. Maternity services available at metropolitan maternity units vary considerably. In the Committee’s view, access to maternity care options for many women, particularly the disadvantaged, is largely defined by a lack of information and geographic location. In the Committee’s view, development of a maternity services framework will ensure greater consistency of services and better information about care options will assist in adequately informing women about the choices available.
13. Recent developments in Australia and overseas reflect a shift in focus from highly medicalised care toward the provision of community based primary maternity services. In many cases, this change in direction has been in response to problems of workforce sustainability, high rates of medical intervention as well as consumer-focused issues of access and choice.
14. Hospital based obstetrics services that provide specialist backup in case of emergency and the option of an epidural will be the preferred option for a number of women. However, evidence shows that for women assessed to be at low risk of complications, a planned birth either at home or in a midwifery-led birthing centre is also a safe option.
15. Midwifery units (also known as birth centres) provide a home-like setting where the emphasis is on normal birth. Many aspects of care shown to improve satisfaction with care (continuity of care, consideration of individual needs, confidence in the service provider’s clinical skills and involvement in decision making) are characteristic of midwifery-led care. Evidence shows that women are more satisfied with the care received in a birth centre than that provided in a hospital.
16. There is widespread agreement on the benefits of continuity of care by a single provider or a small team throughout the pregnancy, birth and after birth period and the Committee considers that continuity of care should be a fundamental aspect of maternity care.
17. While there is some evidence that midwifery-led units may be a cost-effective alternative to hospital based care, there is insufficient evidence in the academic literature to provide conclusive cost comparisons between birth centre and hospital based care. The Committee considers that a broad range of indicators should be used to evaluate new and existing models of care. These indicators should not be limited to safety, sustainability and cost, but include elements of care such as accessibility, health and well-being and consumer satisfaction.
18. Concern about the effects of centralisation of maternity services was expressed by many stakeholders in evidence to the Committee. The Committee is of the view that the rationalisation of secondary and tertiary obstetrics services should not rule out a third tier of primary maternity units such as birth centres or small community hospitals that can cater for women with low risk pregnancies.
19. The Committee recognises the importance of GP obstetricians to maternity services in Western Australia and to enable this model to continue, the Committee considers that it must be supported within both the metropolitan and non-metropolitan settings. If GP obstetrics becomes an unsustainable model in the metropolitan area (assisted by the closure of small maternity units where GPs deliver babies) there will be a corresponding and more serious impact on services in regional areas.
20. The Committee considers that by ensuring that specialist obstetricians focus on complicated cases, by expanding primary maternity care options and developing hospital and birthing centre access protocols for GP obstetricians and midwives, many of the concerns expressed by stakeholders regarding workforce sustainability, consumer choice and access to services will be addressed.
21. The Future Direction in Maternity Care discussion paper suggests a need to change the focus of maternity care to provide more choices for women with uncomplicated pregnancies outside the secondary and tertiary hospital system. The Committee supports the proposal to extend the range of maternity care options and considers that Area Health Service performance in achieving maternity policy objectives should be publicly accessible.
22. While there have been various reviews and policy documents released since the Cohen report in 2003, the Future Direction in Maternity Care process which commenced in 2006 was the first that sought to incorporate the key elements of community and clinical consultation, a comprehensive review of the evidence and a consideration of local needs and circumstances into the decision making process.
23. Evidence to the Committee indicates that stakeholders are very satisfied to date with the Future Direction in Maternity Care policy development process. In contrast to previous reviews and government processes, the Committee is of the view that Future Direction in Maternity Care has shown a commitment to broad, effective community consultation, the provision of ongoing feedback and procedural information to stakeholders, and flexibility to respond to concerns or deficiencies in established processes as they arise. The Government’s Future Direction in Maternity Care policy development process has succeeded in addressing many of the concerns which prompted this inquiry.
24. The Committee considers that existing community consultation processes should be ongoing and additional formal mechanisms should be established to enable continued community and stakeholder involvement in the development of Western Australia’s maternity system.
25. When this report is debated in the House it is anticipated that the Government will be in a position to respond to the report and its recommendations. Members appointed to the Select Committee look forward to the Government’s response.
Recommendation 1: The Committee recommends that the Government, as a priority, consult with the Aboriginal community and health experts to improve pregnancy care and birth outcomes for Aboriginal women in Western Australia.
Recommendation 2: The Committee recommends that the Government develop a consumer guide to maternity services in WA that informs women about the location and availability of care options and provides detailed information about models of care.
Recommendation 3: The Committee recommends that the Government:
(a) identifies the integration of primary, secondary and tertiary maternity services as a component of its maternity policy; and
(b) develops strategies to improve collaboration between providers of maternity care and to achieve an integrated and responsive maternity system that ensures seamless referral and advice.
Recommendation 4: The Committee recommends that the Government:
(a) assess the extent of inadequate pregnancy care among Aboriginal and disadvantaged women, its underlying causes, and develop strategies to address those issues; and
(b) undertake research to determine whether poor accessibility to free pregnancy care is a factor in the under utilisation of pregnancy care among disadvantaged women in Western Australia.
Recommendation 5: The Committee recommends that the Government develop, with appropriate regard to the experience of other jurisdictions, assessment tools that incorporate a broad range of indicators to evaluate all new and existing models of care.
Recommendation 6: The Committee recommends that the Government assess the adequacy of after birth care in WA and investigate the need for additional after birth services to women.
Recommendation 7: The Committee recommends that the Government’s maternity policy adopt, as a central principle, the provision of continuity of care for women during the pregnancy, birth and after birth period by either a single practitioner or a small team of practitioners.
Recommendation 8: The Committee recommends that the Government in reconfiguring maternity services take into account the flow-on effects to the workforce.
Recommendation 9: The Committee recommends that in order to offset the centralisation of specialist secondary and tertiary services, expanded primary care maternity services (such as home birth, birth centres and community hospitals) that are provided by midwives and GP obstetricians and cater for women with low risk pregnancies should be dispersed throughout the community.
Recommendation 10: The Committee recommends that the Government’s maternity policy and associated workforce strategy take into account the need for registered nurse midwives in rural areas.
Recommendation 11: The Committee recommends that the Government examine options for retaining GP obstetricians as providers of maternity care during pregnancy, birth and after birth.
Recommendation 12: The Committee recommends that the Government conduct a state wide maternity forum every two years.
Recommendation 13: The Committee recommends that there is a Government commitment to:
(a) data gathering and analysis in relation to maternity services and
(b) an ongoing consideration of current evidence in relation to maternity care.
Recommendation 14: The Committee recommends that information about Area Health Service performance and progress toward achieving maternity policy outcomes are made publicly available.
Recommendation 15: The Committee recommends that the Government establish formal mechanisms to ensure ongoing consumer and stakeholder input into the performance and development of maternity services.
Recommendation 16: The Committee recommends that the Government conduct a structured large scale survey on a regular basis to gauge consumer attitude to reforms and assist in the planning and assessment process.