My submission for the Maternity Services Review

Submission to the National Maternity Services Review
October 2008
Submitted by: Carolyn Hastie RM, RN, Grad Dip Primary Health Care, IBCLC, Master of Philosophy

Introduction
The current system of maternity service provision in Australia disempowers women in both birth and motherhood (1). Modern maternity care is also plagued with communication failures and turf wars, none of which advantages women and their babies(2, 3). The history of maternity care in Australia is replete with stories of medical domination, midwifery subordination and women being left out or caught in the middle of the warring factions(4, 5). Adverse outcomes in health and maternity care are linked to poor communication (6, 7) and while efforts have been made to improve relationships through workshops and policies promoting teamwork between doctors and midwives, these strategies are insufficient on their own to change the culture (8). The way that the maternity care system is organised must be changed if there is to be any real benefit to childbearing women and their babies. That is because organisational factors are more important than the personalities of the individuals involved in providing maternity care. Organisational factors frame, direct and limit what discourses and therefore behaviours are possible(8). The problem is the underlying structure of health service delivery which gives preference and privilege to one group over another and the enormous power imbalance this system of preferential treatment creates. As the history of maternity services demonstrates, the enormous power imbalance inherent in modern maternity care creates tensions, underhanded practices, over inflated personalities and unsatisfied women. It also produces avoidable adverse outcomes for women and babies(8).

When there is a women centred approach to service delivery, then team work, collaboration, good interprofessional relationships and optimal outcomes for mother and baby are more likely to occur (8). A woman centred approach in maternity care means the care is individualised. The woman is regarded as an autonomous being who is the expert on herself and the best person suited to care for her baby. The woman has the right to be self determining and have control over what happens to her. She has the right to be fully involved in decision making about her care (9). When a woman feels in control, her stress hormones are reduced, enabling her physiology to work in optimal ways, keeping mothers and babies safer (10, 11). In this model, the midwife and doctor establish a partnership with the woman to meet her needs within the context of her childbearing experience. Australia needs a primary health care, woman and family-focused approach to maternity services, which addresses this empowerment issue while providing safe and effective maternity services. (1) A major challenge is that the concept of collaboration for doctors tends to mean midwifery cooperation and submission to medical authority (8). Midwives, however, view collaboration as meaning equal relationships based on professional recognition and respect with a common goal (8). For midwifery, that goal is women centred care. Any organisational effort designed to improve collaboration and outcomes of maternity care will fail unless or until we have a woman centred approach to care provision (8). For a true women centred approach to be made a reality, it must be coupled with successful interventions that move towards disbanding professional silos, instituting genuine dialogic relationships between midwives and doctors as well as addressing social and emotional intelligence and competence in both professional groups (8).

Barriers to equitable, effective and sustainable maternity care

Commonwealth policies and processes are contributing to the lack of women’s access to choice and quality in maternity care and reduced economic effectiveness in the following ways:
• The current organisation of maternity services is geared to the needs of the health professional, particularly medical, rather than the woman’s needs.
• Funding arrangements which perpetuate medical dominance in maternity services and subjugates other professional bodies, such as midwives
• Exclusion of midwives from access to Medicare provider numbers creates an inappropriate monopoly by GP and specialist Obstetricians in private maternity care and disadvantages health services which provide midwifery led options for care in public maternity care.
• The provision of Medicare rebates for medical intervention in birth creates financial incentives to intervene inappropriately in the private arena of maternity service provision.
• The health insurance rebate for private maternity care services provides large subsidies for a sector of maternity care providers who are unaccountable for their outcomes, and who are usually over-servicing clients (e.g. high rates of caesarean section in private hospitals) (12, 13).
• Allowing state expenditure of Commonwealth health funding on inadequate and expensive models of maternity care in public hospitals that deprive women of relationship based care which has been shown to be safer and more satisfying for women.
• State/Commonwealth cost shifting diverts resources and focus from the needs of women and their families.

Although these are only some of the elements obstructing women centered and therefore, equitable, effective and sustainable maternity services in Australia, it is clear that funding is the key element to solving the current crises in maternity care.

Recommendations


Promotion of a woman centered approach to maternity service provision

The Federal government should lead the way in promoting a woman centered approach to maternity service provision. Any and every policy document, guideline or announcement should articulate a women centered focus and approach to maternity service provision.


Access to continuity of midwifery care for all childbearing women in the public health system

Make available to all women the choice of having a community midwife provide continuous maternity care through their childbearing experience in the publicly funded health system. Access to continuity of midwifery care will ensure savings in health dollars and bring Australia into line with international best practice in addition to meeting community demands for a range of readily accessible and appropriate maternity services (10). Whatever the medical risk status of a childbearing woman, the provision of continuity of midwifery care is vital for her emotional and social wellbeing which translates into better physical wellbeing for the woman and her baby.

Remove Medicare item 16400.

Remove the payment for nurses to provide antenatal care. Antenatal care is outside the educational background and scope of practice of all nurses. They have neither the qualifications nor the experience of providing antenatal care to pregnant women. It is dangerous for women to receive antenatal care from a nurse who is being pressured to provide care outside the nurse’s scope of practice. Regulatory bodies for nurses and midwives have developed national competency standards and the provision of antenatal care is not one of the competencies of nursing. GP’s are often ill equipped to provide antenatal care as they do not have the necessary knowledge to do so and it is poor organisation to have them responsible for another health practitioner’s care when they themselves are not competent in that aspect of caring for a pregnant woman.

Medicare provider numbers for midwives

Medicare provider numbers for midwives will enable health services which provide midwifery led models of care to bulk bill Medicare for maternity services provided by midwives and pathology and ultrasonography services ordered by midwives in these models. It will also enable midwives to engage in private practice on a level playing field with medical doctors.

Medicare rebates for birth

Provide the highest rebate rate for normal birth and reduce the payment rate for every intervention performed, as the more women pay for maternity care, the more intervention they receive (12-14).

Accountability

All services receiving direct or indirect taxpayer funding be required to provide timely and publicly accessible data on outcomes. Currently in many states no outcome information is available to the public from facilities providing maternity services. This secrecy is inconsistent with goals of safety, accountability or the control of costs.

References

1. Maternity Coalition, Australian Society of Independent Midwives, Community Midwifery WA Inc. National Maternity Action Plan: Maternity Coalition; 2002 September.
2. Reiger K, Lane K, Possami-Inesedy A. Childbirth and the culture of risk. Health Sociology Review 2006(Special Issue).
3. Reime B, Klein M, C, Kelly A, Duxbury N, Saxell L, Liston R, et al. Do maternity care provider groups have different attitudes towards birth? British Journal of Obstetrics and Gynaecology 2004;111:1388-1393.
4. Fahy K. An Australian history of the subordination of midwifery. Women and Birth 2007;20(1):25-29.
5. Reiger K. Domination or mutual recognition?:Professional subjectivity in midwifery and obstetrics. Social Theory and Health 2007;in press.
6. Hart E, Hazelgrove J. Understanding the organisational context for adverse events in the health services: the role of cultural censorship. Quality and Safety in Health Care 2001;10:257-262.
7. Douglas N, Fahy K, Robinson J. Final Report of the Inquiry into Obstetric and Gynaecological Services at King Edward Memorial Hospital 1990-2000”, (Five volumes), Western Australian Government.Inquiry into Obstetric and Gynaecological Services at King Edward Memorial Hospital Western Australia State Law Publishing. ; 2001.
8. Hastie C. Putting women first: Interprofessional Integrative Power. Newcastle: The University of Newcastle; 2008.
9. Powell Kennedy H. A model of exemplary midwifery practice: results of a Delphi study. Journal of Midwifery and Women's Health 2000;45(1):4-19.
10. Hatern M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4.; 2008.
11. Power ML, Schulkin J, editors. Birth, Distress and Disease. First ed. Cambridge: Cambridge University Press; 2005.
12. Fisher J, Smith A, Astbury J. Private health insurance and a healthy personality: new risk factors for obstetric intervention. Journal of Psychosomatic Obstetrics and Gynecology 1995;16(1).
13. Roberts C, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: population based descriptive study. British Medical Journal 2000;321:137-141.
14. Tracy S, Tracy M. Costing the cascade: estimating the costs of increased intervention in childbirth using population data. British Journal of Obstetrics andGynaecology 2003;110:717-224.

Stop using talcum powder!

The use of talcum powder in the genital area and ovarian cancer have been linked for decades. Talcum powder is still being used and it seems many women do not know the association with ovarian cancer. Here is yet another study which warns women against using talcum powder!

CME Talc Use in Genital Area Linked to Increased Risk for Ovarian Cancer
Women should avoid using talc in the genital area, say researchers reporting further evidence supporting an association between such use and an increase in the risk for ovarian cancer.
(Cancer Epidemiol Biomarkers Prev. 2008;17:2436-2444.) Medscape Medical News
http://mp.medscape.com/cgi-bin1/DM/y/eBxTx0NkcAk0F6A0Jk7L0Gy

Australian Maternity Services Review

It's exciting times. The Federal government is conducting a review of maternity services. I know we have had 41 reviews around Australia all saying the same thing. This is different. Nicola Roxon is fully committed to primary health care and committed to ensuring Australians have health services that really are about health, not just illness, sickness or for the aggrandisement of one professional body.

There is a huge groundswell of change, with midwifery models of care being shown to be safer than other models for healthy pregnant women.

See this latest Cochrane Review of Midwife-led versus other models of care for childbearing women.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004667/frame.html

Conclusion: All women should be offered midwife-led models of care and women should be encouraged to ask for this option.

It would be fantastic if people got together and wrote joint submissions, or wrote their opinions of what is needed for optimal care for women and their babies.

The link for the review terms of reference is:

http://www.health.gov.au/maternityservicesreview

Exciting times indeed.

Carolyn

Mind Movie for Pregnant Women

A mind movie is a visualisation tool that enables a person to provide multisensory input and provide positive suggestions to the subconscious mind about a particular and desired outcome. Quantum physics informs us that we are forever in a field of possibilities. Neuroscience has discovered that the human brain is a quantum processor, making our tomorrows out of our todays.

If we want to create something wonderful in our life, we have to imagine it, in full technicolour, with surround sound and 'be' completely at one with whatever we wish to create.

The experts tell us that imagining/visualising our ideals first thing in the morning and last thing at night is what powerfully impacts our subconscious minds, providing a template for our inner intelligence to express itself through.

Many women do not have experience with birth, other than what they see on that master of suggestion, the television. Unfortunately, what is presented on television is invariably sensationalist, negative, alarming and often, inaccurate or only partially accurate and ultimately distressing. That is particularly true of the birthing process. The birth of our precious babies has been corrupted by false advertising through mainstream media and the ensuing horror stories. That corruption of birth has lead to unbelievable levels of fear and trauma in our society for both mothers and babies. Unmitigated fear is toxic to body and mental function and the reason that is so is explained by our physiology.

Mediated by the nervous system and our 'perceptions', our physiology has two primary modes of 'being'. One, the parasympathetic mode is 'on' when we are calm, relaxed and happy, in love and optimistic. In this mode, the whole body is well perfused with oxygen rich blood, the immune system functions well as do all the other growth and repair functions of the body. In this state, the brain functions optimally, thinking is clear, we are creative and our emotions consist of the positive hormones, such as oxytocin, endorphins and relaxins.

The other mode is switched on when we perceive a threat in our environment, this is the fight, flight or freeze response, the sympathetic branch of our nervous system. When this system is activated, blood is diverted from those parts of us that are not considered essential for immediate survival when attack appears imminent and our life threatened. The parts of us that are deprived of the normal blood flow at these times include our gut and digestion, our reproductive systems and its components, including, for pregnant women, the uterus and baby, plus other maintenance and repair systems. The blood is sent to our arms and legs for fighting and fleeing. The hormones associated with this biobehavioural state are adrenalins, noradrenalins and cortisol. Cortisol is great for helping a person lift a car off someone trapped underneath, we've all heard those kind of heroic stories of unbelievable strength in dire circumstances. However, in day to day life, activation of the sympathetic aspect of our nervous system disrupts cellular and immune system function and shuts down our rational thinking, leading to road rage, neuronal death and illness. It also leads to a self defeating, self reinforcing cycle of negative experiences.

Pregnant women are well advised to avoid horror stories, television dramas and any negative representation of birth, parenting and babies. Pregnant women benefit by being immersed in positive stories, images and surrounding themselves with loving, supportive and encouraging people. Pregnant women also benefit by having someone, preferably a midwife, with whom they can talk though their fears and apprehensions, so that they approach the birth of their precious babies in a loving, confident and calm manner. In this way, women's physiology works optimally and prenates grow well.

A mind movie is designed to provide and develop a positive view and orientation to pregnancy, labour, birth and breastfeeding for pregnant women, their partners and their families.

A woman can make her own mind movie. She can make it in her imagination, or by making a real life video. Either way, collect in your mind or physically, lovely photos of birth, babies and other images that remind you of your body and mind in harmony, working well. Add your favourite music to the mix and every morning and night, soak your mind in the ideas of birth to come, remembering to think about the birth occurring at the perfect time in the perfect way with the perfect people in the perfect place when the baby is fully grown, ready for birth. Imagine the whole process, including the birth of the placenta, your feelings on seeing your baby for the first time, being skin to skin with and breastfeeding your baby. Imagine yourself joyful after the event.

You will be amazed at how effective this process is for helping create a wonderful birth experience for you and your baby.