Office of Colleen Hartland, Greens MP for the Western Suburbs and Victorian Greens spokesperson on health
April 2014
AUTHORED BY ERIN NUNAN RMIT SOCIAL WORK RESEARCH AND POLICY PLACEMENT STUDENT
Maternity Care Matters 2014
Table of Contents
EXECUTIVE SUMMARY 3
GLOSSARY OF TERMS 7
WHY A SUPPORTED, POSITIVE BIRTHING EXPERIENCE IS IMPORTANT 8
LACK OF BIRTH SERVICES AND CHOICES – AUSTRALIAN CONTEXT 10
NATIONAL MATERNITY SERVICES PLAN 11
MATERNITY SERVICES IN VICTORIA 12
VICTORIA’S STRATEGIC POLICY DIRECTION 12
MATERNITY SERVICES IN RURAL AND REGIONAL VICTORIA 12
THE GROWING NEED FOR MATERNITY SERVICES IN METRO MELBOURNE 13 GRAPH 1. BIRTHS IN VICTORIA 2002-2012 14 GRAPH 2. BIRTHS BY MELBOURNE METROPOLITAN REGION. 14
MELBOURNE’S MATERNITY BEDS 16 MAP 1. MATERNITY HOSPITALS ACROSS MELBOURNE METROPOLITAN AREA 16 TABLE 1. NUMBER OF MATERNITY BEDS ACROSS MELBOURNE BASED ON SUBURBS LOCALITY. 17
MATERNITY SERVICES IN MELBOURNE'S WEST 19 THE SUNSHINE HOSPITAL 19 THE WERRIBEE MERCY HOSPITAL 21 THE ROYAL WOMEN’S HOSPITAL CATCHMENT 22
THE CAPACITY OF MATERNITY SERVICES IN VICTORIA: AUDITOR GENERAL’S REPORT 2011 23
IMPACTS OF MATERNITY SERVICE SHORTFALLS 26
THE NEED FOR STRATEGIC PLANNING AND INVESTMENT IN MATERNITY SERVICES 27
MATERNITY CARE CHOICES IN VICTORIA 29 TABLE 2. MATERNITY MODELS OF CARE AVAILABILITY BASED ON MAJOR METROPOLITAN PUBLIC HOSPITALS ACROSS MELBOURNE 32
RESULTS OF OUR SURVEY 33
CONCLUSION AND RECOMMENDATIONS 37
ENDNOTES 40
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Executive summary
Having a baby is one of the most significant events in a women's life. Getting high quality care that meets women's needs is critically important for the wellbeing of women and their baby. Unfortunately, maternity services in Victoria are currently not meeting the needs of many women. There is a shortage of services in urban growth areas, and limited access to midwife-led care and continuity of carer.
Service shortfalls Victorian Auditor General, Des Pearson in 2011 found that access to maternity services in Victoria for antenatal, labour/birth and postnatal care is not equitable. In particular, women living in Melbourne’s growth areas were found to have fewer publically available services, resulting in increased costs for antenatal care and delays in accessing services. He also found shortcomings in the department’s planning approach, stating it cannot demonstrate that maternity services are provided when and where needed.
Since then, there has been little demonstrative progress in this area as shortfalls in service continue to arise.
With our growing population, birth numbers are rising and maternity services in urban growth areas are struggling to keep up with demand. The biggest shortfalls in services are in Melbourne’s western suburbs. Melbourne’s western suburbs have overtaken the Gold Coast as the fastest growing region in Australia, at around 8% a year. Between 2001 and 2012 there was a 70% increase in the number births in the western suburbs (increase of 5,448 births per year). With no private hospitals offering maternity services in the western suburbs, all this pressure falls on just two hospitals, the Werribee Mercy and Sunshine Hospital.
This huge growth in demand has led to significant service shortfalls and difficult conditions for women. Over 200 babies were delivered in emergency at Sunshine hospital between 2006 -20111 due to a lack of birthing suites available. This shortage
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of maternity services in the western suburbs causes significant pressure and stress on hospital staff and resources, and can lead less time spent with midwives and doctors and thus to poorer care for some women. In recent years a number of women were turned away from Werribee Mercy Hospital as it was fully booked, leading to long travel distances and more expense. All these shortfalls can cause unnecessary stress, anxiety and cost for mothers.
Currently the government operates in crisis mode, only responding with band-aid measures when there is public outcry about service shortfalls. Meanwhile, women and their children are getting a raw deal. This is simply not good enough. To meet current and future maternity needs we need strategic forward planning, with matched financial investment.
Immediate action is required to address known shortfalls in service. Much of the demand created by the 70% increase in births in the western suburbs over the past decade has been met by the Sunshine Hospital. This hospital has done its best to fit new maternity beds in the existing infrastructure, but it has led to maternity wards being dispersed within the hospital. This is very challenging for staff and patients.
In 2012/13, Sunshine Hospital had the second-highest number of births of any single hospital in the state, with 5,284 births2. Maternity services at Sunshine are not provided in a dedicated Women’s hospital, unlike other maternity services of that size, such as the Royal Women’s hospital or the Mercy Hospital for Women. Sunshine is also not a tertiary hospital, meaning that newborn babies needing intensive care or women with high risk pregnancies must be moved to the Royal Women’s hospital, as there are no such services in the West.
Having a dedicated, purpose built tertiary hospital in Melbourne’s West with sufficient capacity to meet current need and future growth is essential.
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Lack of choice in care While in theory there are a range of birthing options in Victoria, the level of choice and control over the birth varies depending on how well informed a women is, where she lives and her financial means.
Across Australia, less than 5% of women have the option of midwifery led care3, with less than 1% having access to one-on-one continuity of care from a midwife4. Research suggests that midwife-led care can lead to better outcomes for mothers and their babies5.
Under the 2010 National Maternity Services Plan, Victoria committed to providing women-centred care that is responsive to women's needs and preference, to supporting informed choices, and improved access to a range of models of care. The Victorian Government has taken some steps towards realising this agenda; however as this report indicates there is still a way to go.
Increasingly many women are seeking midwife-led care and continuity of carer, yet some hospitals, including Werribee Mercy Hospital, Northern Hospital and Monash Hospital, do not offer this type of care. Hospitals that do offer this care often have very limited places.
Many women want to give birth in a birth centre or through a public homebirth program, yet with only one birth centre and two public homebirth programs in Victoria, many miss out. We can have women-centred maternity services that provide proper information and continuity of care, provide women with their choice of model of care, and provide more services where they are most needed. With the appropriate support and investment, a safe and fulfilling birth can be achieved for all women.
Recommendations To improve maternity services in Victoria:
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1. Better monitor and respond to demand for maternity services, including developing a strategic plan to meet projected growth in birth numbers. 2. Fund construction of a tertiary Women’s Hospital in the western suburbs to address the growing shortfall in maternity services and capacity restraints at Sunshine Hospital. 3. Establish guidelines for better provision of information about maternity care and choices for women, to support women to make informed choices. 4. Support provision of increased continuity of care in all maternity services. 5. Make midwife-led care more accessible by funding the introduction of caseload or team midwifery models of care at every metropolitan and major regional hospital, and expand places at hospitals where it is currently offered and often booked out. 6. Support expansion of public homebirth programs to more hospitals. 7. Investigate the feasibility of establishing more birth centres in Victoria.
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Glossary of Terms
Antenatal: The period between conception and the onset of labour. Caseload midwifery care: Care provided by the same public hospital midwife for the majority of antenatal, labour, birth and postnatal care. Continuity of care: Ensuring a woman receives care from the same, known provider, or small group of providers, during the pre-natal, birthing and post-natal period. Birth Centre: Midwifery care within a separate section of a hospital where midwives provide antenatal, intrapartum and postpartum care in a home-like environment. Medicare Benefits Schedule (MBS) fee: The fee reimbursed by Medicare when paying for a healthcare service. Medicare will reimburse 100% of the MBS fee for a general practitioner and 85% of the MBS fee for a specialist. Midwifery-led care: Maternity care that is led by a midwife or team of midwives in a variety of settings. Midwifery Group Practice: term used to describe the caseload midwifery model of care, see ‘Caseload Midwifery Care’ Postnatal : The period beginning immediately after the birth of a child and extending for about six weeks. Private maternity care: Private maternity care provided in the home, private rooms or in hospital by a private midwife, obstetrician or GP obstetrician. This includes antenatal, labour and post-natal care. Shared maternity care: Formal arrangements between a local practitioner (GP, or obstetrician or midwife at community health centre) and a public hospital, in which visits to the hospital take place at the beginning and latter stages of pregnancy, but the majority of care is provided by the local practitioner. Standard care: Standard models of maternity care in hospitals are obstetrician led with midwifery support. If it is a low risk pregnancy, often a midwife will provide a majority of the care. Team midwifery care: Small teams of public hospital midwives that provide care during pregnancy, labour, birth and the hospital stay.
Glossary adapted from the Department of Health and Ageing 6 7
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Why a supported, positive birthing experience is important
Childbirth has been described as one of the most important events in a woman’s life.8 Around this time, a woman is coping with the wide-ranging physical, physiological and emotional changes that come with being pregnant whilst planning for this significant event in her life.
A mother’s health status during this time has the potential to impact on the birthing experience and the health of her baby. Research has shown that emotional, tangible and informational support during pregnancy is related to improved physical and mental health of the woman at the time of childbirth and post birth.9
The effects of the childbirth experience have the potential to be life changing,10 11 12 which is why a supported, positive birthing experience is important to provide the best outcome for a mother and her baby.13
“Women’s experience of maternity care has a large impact not only upon the health and wellbeing of their infant, but on that of the whole family”. 14
Having adequate birth knowledge means women are able to exercise power and control over their birthing environments and birth experience.15 Research shows that feeling in control of the birth is important to promote a positive birth experience.16 17 Level of preparedness for labour and delivery has also been found to be strongly associated with positive reactions to the birth and baby.18 Having a choice on such things as proximity of birthing service to their home, cultural responsiveness, necessary medical input, and different models of care would ease the anxiety associated with planning and going through the birth process. Research19 suggests that although the birth may change in the case of medical emergency, the importance of feeling in control of the birth process, including over changes to the
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birth plan and the birthing process, leads to women describing either positive or negative birthing experiences.
Enhancing a woman’s ability to choose the type of birth she will experience by providing her and her family with different birthing options whilst equipping her with the information needed to make informed choices gives women more control over the labour and birthing process.20 Having access to different models of care in the pregnancy and after birth, (i.e. pre- and post-natal support in hospital, in community health setting, shared care with GP or public/private midwife care at home), is also important to promote mother-friendly care and support women’s autonomy.21
The attitudes and practices of a caregiver during birth is shown to also be a major influence on the health of a mother and her baby, highlighting the importance of being able to ‘shop around’ for a caregiver (or model of care) that suits the mother’s needs.22
“Every woman should have the opportunity to have access to the full range of options for pregnancy, birth and nurturing her baby, and to accurate information on all available birthing sites, caregivers and practices” 23
There are a number of maternity care options available to women in Victoira. These options include different places of birth (e.g. hospital, birth centres, home birth with public or private care givers) and different models of care (caseload midwifery, team midwifery, obstetrician led standard care, shared care, private midwife, or private obstetrician). Women can also be assisted through medical interventions (such as caesarean sections, induction of labour and pain relief).24
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Lack of birth services and choices – Australian context
Deciding on a model of care should be based on the personal preferences of the mother. However, increasing birth rates without an increase in the number and type of birthing services increases waiting lists and reduces women’s choice. Although women have been led to believe they have a wide range of choices, in fact access to birth choices has been found to be limited25. Almost all births in Australia (96.9%) take place in conventional labour-ward settings within a hospital.26 Such a high rate of hospital births was found to be due to a lack of access to alternatives 27 and could be further compounded by a lack of understanding about other care options that are available.
Approximately 30% of rural and remote women in Australia have no choice on their maternity care because they live in an area with only one provider or no services at all.
Across Australia, less than 5% of women have the option of midwifery led care within birth centres or of midwifery group practice,28 with less than 1% having access to one-on-one continuity of care from a midwife.29 Research consistently demonstrates that women prefer continuity of care with their maternity care provider.30 This lack of options is due to a lack of access, not to a lack of demand.31
New research suggests that midwife-led care leads to better outcomes for 32 mothers and their babies. In their meta-analysis, Sandall et. al (2013), found that midwife-led continuity of care leads to a reduction in preterm births and use of epidurals, with an increased chance of spontaneous vaginal birth and a greater likelihood of being cared for by a known midwife during labour. The researchers concluded that women should be offered midwife-led continuity models of care.33
Women should be able to access a range of birthing options in their local community or within a reasonable proximity. However, the ability of women to have birthing choices depends on having adequately resourced maternity services offering
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choices as to the type of care, the place of birth and the pre and post-natal support. Adequately resourced maternity services are important to ensure the safe delivery of a newborn baby and to achieve optimal health outcomes during the labour process and after birth.34
A shortage of maternity beds in hospitals can cause unnecessary stress and anxiety to expectant mothers and their families at a time when they need the most support35. If women are unable to access their preferred hospital or model of care due to a shortage of maternity beds, this could mean increased travel times or increased costs to mothers and their families.
A shortage of maternity beds also has repercussions for mothers at postnatal stage, as the demand for beds results in shorter hospital stays and less time for women to receive adequate support with the transition to parenting. 36 Less postnatal support has been found to mean higher levels of post-natal depression in mothers and lower rates of breastfeeding.37
National Maternity Services Plan
In recognition of the limitations in maternity services nationwide, in 2010 the National Maternity Services Plan38 (NMSP) was introduced and agreed to by all state and territory governments, including Victoria. The NMSP provides a national framework to guide policy with the aim of improving and increasing access to maternity care across Australia. It has a five-year vision that maternity service planning and provision should be delivered in a manner that is responsive to women’s needs and preferences, supporting informed choices by enabling women to access information that is objective and evidence based.
The leading priority of the plan is improved access to a range of models of care for all Australian women, as well as greater access to information and support. The Victorian Government has taken some steps towards realising the National agenda, however, as this report will indicate there is still a long way to go.
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Maternity services in Victoria
Victoria’s strategic policy direction
Maternity services are a core part of healthcare delivery, representing 5 per cent of all public hospital admissions and 17 per cent of state-funded hospital outpatient appointments39.
In 2004, the Victorian Government released the ‘Future directions for Victoria’s maternity services’ report40. This report outlines that the Victorian Government’s vision for maternity services, was developed according to the following principles: • ensuring safety and quality • providing women with informed choice and greater control of their birthing experience • achieving the right balance between primary level care and having access to appropriate levels of medical expertise when it is needed • making the best use of the complementary skills of midwives, general practitioners and obstetricians • enhancing a maternity team approach. This vision still appears to guide the Government today, even as it approaches the far end of the 5-10 year intended lifetime.
Maternity services in rural and regional Victoria
The National Consensus Framework for Rural Maternity Services released in 2008 41 was developed to guide policy and planning for rural maternity services across Australia. The Framework outlines that rural women have the right to choice and should have access to safe maternity care. Some of the principles outlined in the Framework include; the promotion of continuity of care, improving accessibility of services as close as possible to where the mother lives, enhancement of the maternity care workforce and targeted recruitment strategies, and incentive funding to support rural models of maternity care. 42
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Whilst demand for maternity services in Melbourne’s growth areas is expected to increase, demand for services in rural areas of Victoria is likely to decline. Across Victoria, rural maternity units continue to close down, meaning women in rural areas are increasingly having less choice on their maternity care.43 Staff shortages means women living in these areas have fewer maternity care options44 and difficulties recruiting staff has led to maternity services in rural areas being closed, requiring pregnant women to travel to receive maternity care.45 Distances of 100-200kms are not a rarity, and numerous car or en-route deliveries have been occurring.46 Such a lack in services poses a threat to the health of mother and child, and it important that steps are taken to restore supply of rural midwives and doctors.
The closing of maternity care services in rural areas is said to be due to workforce issues.47 There is a need for more generalist practitioners trained in obstetrics in rural hospitals, as there is insufficient demand for full time specialists. In 2012-13 the Victorian Government committed $2.4 million across four years to establish a General Practitioner – Rural Generalist (GP-RG) program to enhance retention and recruitment of rural GPs48. The benefits of this program should be realized in coming years, but are not likely to fully address problems. Removing discrepancies in pay between generalists and specialist doctors in rural areas also needs consideration.
The creation of Bachelor of Nursing and Midwifery programs may also serve to provide a more generalist approach where midwives have flexibility to provide nursing care when maternity bookings are low.
The growing need for maternity services in Metro Melbourne
Population growth in Victoria is being matched by a significant increase in birth rates (See graph 1). The number of births in Victoria has increased from 61,478 in 2002, to 77,405 in 2012. Over the ten year period there has been slow but steady
13 Maternity Care Matters 2014 growth, with a jump from 64,245 to 70,325 births from 2006 to 2007, and a jump from 71,444 in 2011 to 77,405 in 201249.
90,000 80,000 70,000 60,000 50,000 40,000 30,000
Number Births of 20,000 10,000 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year
Graph 1. Births in Victoria 2002-2012. Graph adapted from ABS data50.
This growth in demand for maternity services is primarily concentrated in Melbourne’s growth corridors. Major growth corridors are in the south-east, north and west of Melbourne (Graph 2)51.
16,000 15,000 14,000 Western 13,000 suburbs 12,000 Northern 11,000 suburbs 10,000 Eastern 9,000 suburbs 8,000 South - eastern suburbs 7,000 6,000
Graph 2. Births by Melbourne Metropolitan region. Graph adapted from ABS data52.
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In Graph 2, you can see that from 2001 to 2012 there was an increase of just 1,310 births in the eastern suburbs (11.5% increase), compared to 4,048 in the South-East (37% increase) and 3,988 in the Northern suburbs (46% increase). But the biggest growth is in the western suburbs, with an increase 5,448 births (70% increase).
This growth in demand is not projected to abate. Melbourne’s western suburbs have overtaken the Gold Coast as the fastest growing region in Australia, growing, on average, around 8% a year.53 This figure is expected to increase with the expansion of the urban growth boundary and with increasing birth and population rates.
The rapidly growing population will continue to increase the demand for maternity beds in this area. There was a 25% increase in demand in just the three years from 2009 to 2012.54 In just one year, between 2011 and 2012, there was increase of 1,315 births. Figures from the Department of Planning and Community Development (DPCD) predict a surge of more than 40% in births between 2008-2018 in the western suburbs of Melbourne, with a 10-40% increase in births for the Northern, South-Eastern and Outer-Eastern suburbs over the same time period.55
In Wyndham alone, births have increased by 44% in the last 20 years, with an average of 53 babies born per week.56 One in every 26 babies born in Victoria is born in Wyndham.57
Despite having the second highest number of births from the Melbourne metro region (as indicated in Graph 2), there are only two maternity hospitals in the western suburbs. A third hospital, The Royal Women’s Hospital, also accepts bookings from women in the inner western suburbs in acknowledgement of the increasing demand for maternity services in the West.
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Along with Melbourne’s west, the Northern suburbs of Melbourne are also amongst Victoria’s fastest growing postcodes.58 With birth rates increasingly higher than other areas of Melbourne,59 the maternity bed shortage is also a trend in Melbourne’s North. In 2011, 74 mothers gave birth in three days at the Heidelberg Mercy Hospital, 30 more births than would be expected over a three-day period.60
Melbourne’s maternity beds
There are 12 public hospitals providing maternity services across metropolitan Melbourne. There are also 12 private hospitals, located in inner Melbourne, the north, east and south-east. Map 1 shows locations of these hospitals.
Map 1. Maternity hospitals across Melbourne metropolitan area
As can be seen in Table 1 (page 16), the western suburbs have a total capacity of 32 birthing suites (plus 5 recently announced) and 72 postnatal beds, making a total of
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Suburb Public Hospital Number of maternity beds Total Staffing levels Total Locality bed staffing capacity capacity Inner The Royal 18 birthing suites, 1 assessment 75 Staffed for 16 birthing suites, 68 Melbourne Women’s rooms, 56 postnatal 52 postnatal Hospital Total inner 18 birthing suites, 1 75 Staffed for 16 birthing suites, 68 Melbourne assessment rooms, 56 52 postnatal postnatal Northern Mercy Hospital 17 birthing suites, 75 Postnatal 92 Staffed for 13 birthing suites, 78 Suburbs for Women beds and 65 postnatal beds The Northern 9 birthing suites, 28 postnatal 37 Staffed for 8 birthing suites. 34? Hospital beds Staffing for postnatal not known (26 estimate) Total 26 birthing suites, 103 129 Staffed for 21 birth suites and 112 Northern: postnatal 91(estimate) postnatal Eastern Angliss Hospital 8 birthing suites, 24 postnatal 32 Staffed for 6 birthing suites, 22 Suburbs 16 postnatal beds Box Hill Hospital 6 birthing suites, 24 postnatal 30 Staffed for 6 birthing suites 26 beds and 20 postnatal beds Total 14 birthing suites and 48 62 Staffed for 12 birthing suites 48 Eastern: postnatal beds and 36 postnatal South- Monash Birth 10 (birthing rooms) 2 induction 56 Staffed 10 birthing suites and 54 Eastern Centre rooms, 44 postnatal beds 44 postnatal beds Suburbs Dandenong 9 (birthing rooms), 25 postnatal 34 Staffed for 9 birthing rooms, 34 Hospital beds 25 postnatal beds Casey Hospital 10 multipurpose birthing suites, 26 Staffed for 6 birthing suites 22 16 postnatal beds, and a and 16 postnatal beds homebirth program Sandringham 4 birthing suites, 20 postnatal 24 Staffed for 3 birthing suites, 19 Hospital beds 16 postnatal Frankston 9 birthing suites, 24 postnatal 33 Staffed for 6 birthing suites, 28? Hospital staffing for postnatal not known (22 estimate) Total 42 birthing suites, 2 induction 173 Staffed for 34 birthing, 139 157? South- and 129 postnatal. postnatal (estimate) eastern: Western Sunshine 10 birthing suites, 6 early 72 +5 Staffed for 9 birthing suites, 4 57 Suburbs Hospital labour, 6 assessment, 2 HDU, early labour, 4 assessment, 40 48 postnatal, & homebirth postnatal program. Announcement of funding of 5 new birthing suites Werribee Mercy 8 birthing suites, 24 postnatal 32 Staffed for 8 birthing suites, 24 Hospital beds 16 postnatal beds Total 32 birthing suites + 5 newly 104 + 5 81 Western: announced, 72 postnatal beds
Table 1. Number of maternity beds across Melbourne based on suburbs locality. Sourced from primary research. *Note: Royal Women’s hospital services in inner city, which includes parts of the inner west, and inner east. Monash hospital also services parts of eastern suburbs.
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109 maternity beds servicing the western region. This compares with 129 in northern suburbs, 62 in eastern suburbs and 173 in the south-eastern suburbs. Please note that Monash birth centre is actually located on the border of the east and south-eastern suburbs and would also services many women in the eastern suburbs. There is also the Royal Women’s Hospital, which services the inner suburbs of Melbourne, including the inner west, east and north.
The number of beds in the West has improved in recent years with some new funding announced. Still, given that it has the second highest birth rate for a region, and that Sunshine Hospital has the second highest number of births after the Royal Women’s hospital, it does very well in managing the high demand. It has comparatively less beds for the number of births. In Table 1 you can see that one of the ways they manage the demand is by having a higher number of birthing suites and lower number of postnatal beds. This is possible thanks to short stays after birth (in some cases 4-6 hours), offering homebirth services, and perhaps less very complicated births as it is not a tertiary hospital.
Another factor that is masked in Table 1, but revealed in Map 1 is the fact that there are no private maternity hospital services in the western suburbs, however there are 12 private hospitals with approximately 131 private maternity beds across the inner, eastern, south-eastern and northern suburbs. The availability of private hospital maternity beds serves to free-up the public system in these areas.
Table 1 also reveals another consideration in managing demand in hospitals. It shows the difference between bed capacity and staffing capacity. Due to significant funding pressures on hospitals, hospitals roster on staff to lower levels than capacity. Then if there is a spike in demand, they call in further staff. This idea works in theory, but in reality, there can be problems. Staff may not always be available when required, there can be gaps in time between a spike in demand and when staff actually arrive. This serves to place stretched staff under further stress and can affect the time spent with patients.
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The shortage of maternity services in the West is compounded by the distance between Sunshine Hospital and the Werribee Mercy Hospital. Being the only two hospitals geographically within the boundaries of the western suburbs, mothers who cannot access one hospital may be forced to travel to the other. As compared to the density of hospitals in other Melbourne suburbs, women in the West could be forced to travel 40 minutes or more to reach a hospital that will accept them.61
There are no tertiary maternity services, meaning neo-natal intensive care units and no care for high risk pregnancies in the western suburbs.62 This forces women to travel or be transferred to a hospital with these services when required. A women living in Werribee could be stuck travelling for well over an hour to visit their baby receiving neo-natal intensive care at the Royal Women’s Hospital.
The most transparent indication of current maternity bed supply and demand would be an examination of bed to delivery ratio. This would show were hospital capacity is pushed to the limit. Unfortunately, information about birth rates and beds numbers is not available.
Maternity services in Melbourne's west
For the purpose of this report, western suburbs includes: the Brimbank City Council, Hobson’s Bay City Council, Maribyrnong City Council, Melton City Council Monee Valley City Council and Wyndham City Council areas.
The Sunshine Hospital
The maternity ward at Sunshine Hospital has 10 birthing suites, 6 early labour, 6 assessment, 2 HDU, and 48 postnatal beds. This makes a total of 72 beds, 48 of which are post-natal. However on a week to week basis it only staffs for 57 rooms, 40 of which are post-natal. During 2012/13, Sunshine Hospital had the second- highest number of births of any single hospital in the state, with 5,284
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births63. This is a 15.4% growth in births in 12/13 compared with the previous 12 month period.
As can be seen in Table 2 (page 18), the Sunshine Hospital supports four models of care; midwife led (caseload) care, standard care (obstetrician led), shared care and hospital-supported homebirth. Hospital supported homebirths is an innovative new model of care providing another option for women, which is being trialled at Sunshine & Casey Hospitals.64 This model of care provides a low cost homebirth option to women whilst easing pressure on the hospital labour ward.
The Sunshine Hospital has struggled to keep up with demand for maternity beds evidenced by a high level of emergency department births. 65 In 2011, the Victorian Auditor General revealed that Sunshine had delivered 219 babies in the Emergency Department from 2006 - 2011.66 Births in the Emergency Department present risks to both mother and maternity staff, leaving mothers without adequate privacy and comfort and increasing risks of staff burnout with midwives having to attend to women in emergency in addition to their full load in the labour ward.67
The Sunshine Hospital had informed the Department of Health in 2010 of expected birth increases in the West. Whilst the introduction of a four-bed assessment centre in 2010 saw a reduction in the number of births in the Emergency Department, the hospital is still in need of more services. 68 According to the Sunshine Hospital, another five birth suites is required to meet demand on the basis of averages proposed by the Auditor General’s report.69 A recent announcement by the Victorian Health Department made a funding commitment of $15.1 million to deliver those five additional labour delivery rooms.70
This funding announcement is welcome, but yet another is band-aid measure. There is a lack of strategic planning for the growth now and into the future in Melbourne’s West. It is clear that year upon year, the hospital is stretched to the limit to keep up with the birth rate. In years when the birth rate increase is
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particularly high, we see women birthing in the Emergency Department. This is not an acceptable long-term arrangement for mothers (or staff).
The rapid increase in births, without a dedicated women’s hospital, has also led to labour wards being dispersed in the hospital. To best manage this difficult situation birthing suites are separated into groups based on the stage of labour – assessment rooms, early birthing rooms, and birthing suites. This makes the best of a bad situation, but is problematic for staff, who must constantly move from place to place to conduct their job. This is both stressful and time consuming.
Despite having such a high numbers of births, this hospital is not able to provide neo-natal intensive care. So babies in need of such care must be transferred to the Royal Women’s hospital.
The Werribee Mercy Hospital
The Werribee Mercy Hospital caters for over 2000 births per hear71. It is facing similar problems to Sunshine Hospital with an increasing number of births at the hospital each year.72 The maternity ward has 8 birthing suites, 24 postnatal beds in single rooms. The Werribee Mercy Hospital supports the standard model of maternity care and also provides a bath immersion birthing option. For women who are seeking a midwifery-led model of care, this means travelling to Sunshine Hospital, or Bacchus Marsh, which is located outside of the Melbourne metropolitan boundary.
Werribee Mercy is stationed to be hit by a massive rise in births,73 with the Wyndham population estimated to double in the next eighteen years. In 2012, many women and families reported that they had been refused bookings at the Werribee Mercy Hospital, forcing women to travel out of their local area because of a lack of beds.74
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The Maternity Care Matters survey revealed women in the West are facing a lack of options, leading to increased anxiety around having to travel long distances to secure a place to give birth, or at times, being provided with insufficient care as midwives are run off their feet.75
"I was left unchecked for nearly 12 hours in the Werribee Mercy. When asked about it they said they assumed l was coping (with my 3rd baby) and that they were very busy. They then asked if l could go home early as they needed my bed" – Maternity Care Matters Survey respondent.
Multi-million dollar redevelopments at the Werribee Mercy Hospital finished in mid-2012 with a newly constructed maternity ward, Special Care Nursery and an expansion of the Labour Delivery Rooms.76 There is the building space for expansion in maternity bed numbers at this site. What has been missing is funding.
In August, 2013, Mercy Hospital confirmed an increase in funding from the State Government to secure additional staff which would allow for an extra 450 babies, or a 20% increase in births at the hospital per year. 77 This is welcome, but it should not require a crisis in bookings and staff being so overstretched for this funding to be forthcoming. Again improved strategic planning and investment for growth is required to ensure women are not missing out on quality local services.
The Royal Women’s Hospital catchment
Women in the inner West can also turn to the Royal Women’s hospital. The primary catchment for the Royal Women’s Hospital includes inner Melbourne suburbs, including the central business district, inner Northern and inner western suburbs. The Women’s tertiary level catchment area includes the whole of Victoria and some areas interstate.78 The Royal Women’s Hospital has 18 birth suite rooms and has the capacity for 5,000 births per year. However, this hospital is also
22 Maternity Care Matters 2014 struggling to keep up with demand, with booking requests sometimes exceeding the hospitals capacity.79
In 2012/13 the Royal Women’s Hospital recorded 7,120 births80. In late 2012 there were reports that the hospital was turning away women, forcing pregnant mothers to pay for expensive private care or travel to a public hospital willing to take them. 81 82
The Royal Women’s Hospital supports the standard model of care, mid-wife led care (caseload) and the shared care model (see page 18, Table 2). For women that prefer a midwifery led model of care, places are very limited – so limited that they warn women on the website that there is usually a waiting list for this model of care83. In the past, the Royal Women’s Hospital had a birth centre. Sadly, this is no longer the case.
The capacity of maternity services in Victoria: Auditor General’s report 2011
In October 2011, Auditor General (AG) Des Pearson produced a report on the capacity of maternity services in Victoria 84 and explored the ability of the Department of Health to collaboratively and effectively plan with health services to meet current and future demand for maternity services. The 2011 report also examined the accessibility of maternity services for Victorian woman.
“Women attending hospitals we audited in metropolitan growth areas do not have equitable access to maternity services as there is a demand and supply mismatch. This is projected to increase with population growth.” - Auditor General Des Pearson, 2011.
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The AG highlighted that demand for maternity services had increased since 2001 with an increasing number of complex pregnancies with risk factors such as age and obesity further adding to the demand for maternity services.
An important finding by the AG was that women in Melbourne’s growth areas, particularly the western and northern suburbs, experience the poorest access to maternity services compared to mothers living elsewhere in Victoria. In particular, the AG noted that Melbourne’s growth areas have fewer publicly available maternity services resulting in women having to pay increased costs and experiencing delays in accessing antenatal care. Due to demand on birthing facilities in metropolitan growth areas, the AG reported that an inability to access labour ward beds means women risk giving birth in non-admitted settings, such as a hospitals’ emergency department, without a legitimate clinical reason.
The AG reported that the Department of Health had a limited understanding of maternity services in Victoria, leading to ineffective planning and that access to maternity services was not equitable due to this lack of planning.
The AG made a number of recommendations to the Department to assist in addressing these issues. These recommendations included:
1. That the Department of Health works to improve its understanding of planning for maternity services. 2. That the Department of Health focuses on improving access to maternity services in growth areas. 3. That the Department of Health prioritise its work with the Commonwealth to improve access to antenatal care. 4. That the Department of Health provides information in languages other than English informing women how to navigate the maternity care system. 5. That the Department of Health requires health services to monitor and report their progress on improving continuity of care.
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6. That health services in Victoria systematically evaluate programs for vulnerable women to assess whether they are meeting objectives. 85
In July 2013, Colleen Hartland wrote a letter to the Department asking what actions have been put in place to address the recommendations made by the AG in his 2011 report. In September 2013, a response from the Minister for Health Hon David Davis outlined the following changes to maternity care:
1. A portion of funding from the 2013 – 2014 State budget to assist the funding of five additional neonatal intensive care cots. 2. An additional eight cots in the new special care nursery at Sunshine Hospital. 3. The opening of a $14 million expansion and redevelopment of the maternity and neonatal services at the Werribee Mercy Hospital. 4. The establishment of the Ministerial Perinatal Services Advisory Committee.
Whilst these changes are welcome, the additional eight cots at Sunshine Hospital and the $14 million expansion at the Werribee Mercy Hospital were funding commitments made by the Labor Government and work began in 2010, before the Auditor General’s report. 86 87 The additional neonatal services are welcome, but do not really go to the AG recommendations. Work is underway on the Commonwealth level to produce National Antenatal Care Guidelines.88 These are expected to be completed mid-2014. It is unclear whether the Government has taken steps to provide information in relevant languages, to increase the availability of continuity of care.
In the first two years following the AG 2011 report, the main area that seems to be underway is the national antenatal care. In correspondence, the Government failed to identify what has been done to address the other recommendations.
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Impacts of maternity service shortfalls
The shortfall in maternity services is having a number of negative impacts on women and their families. These include stress and anxiety from being placed on a waiting list, feelings of uncertainty around having a secure place of birth, increased travel times to a hospital that will accept them, short hospital stays and even paying higher fees for private care.
Without being able to access a preferred (public) hospital, women report having to pay money they cannot afford, having a significant financial impact on expectant mothers and their families. The AG report has highlighted that the shortage of maternity beds in the public system has forced many women to pay thousands of dollars in costs for procedures such as scans, particularly in Melbourne’s growth areas.89 With Melbourne’s western suburbs being amongst the most socioeconomically disadvantaged communities in Melbourne, this trend in funding arrangements is particularly problematic as many women cannot afford private care.
The shortage of maternity beds also means that women are forced to leave the hospital earlier than would be expected in order to provide the best care and the best health outcome for a woman and her baby. Since 1985, the length of hospital stay post birth has reduced state-wide from 3-4 days to less than two days.90 A number of hospitals will discharge women as early as six hours after birth if a woman has had a routine birth and wants to leave. The Royal Women’s hospital has a 48- hour minimum stay policy, however there has been reports of a woman who was asked to leave 15 hours after delivery because staff needed her bed.91 One woman was discharged from Sunshine Hospital just four hours after giving birth. 92 Another woman who was discharged early from the Mercy Hospital ended up in the emergency department the next day:
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“A nurse popped in and said ‘there’s people waiting for the bed so you have to go’. It was a terrible experience. I ended up in emergency the next day because I was still unwell with high blood pressure and an ear infection” 93 94
A shorter hospital stay post birth means women may not be receiving adequate post-natal support, increasing the likelihood of post-natal depression or problems with breastfeeding.95 96 97 This shortfall is recognised by the Werribee Mercy Hospital and Sunshine Hospital, offering home visits by a midwife to compensate for a short hospital stay.98 Some women prefer a shorter stay and will benefit from home visits while others want longer hospital stays, but do not have that choice.
The short hospital stay can be particularly detrimental for women who are considered vulnerable, such as women from culturally and linguistically diverse backgrounds or who are considered low socio-economic status, a significant proportion of which makes up the population in the western suburbs.99 Short stays and quick turn-around times may mean women from these backgrounds are not given the chance to access all the information they need or to establish rapport with hospital staff.
The need for strategic planning and investment in maternity services
It is evident that hospitals in the western suburbs and other growth areas are struggling to cope with the ever-increasing demand for maternity beds. The population is increasing, with birth rates expected to continue to increase in years to come. In recent years, supply has not been meeting demand in the West, with Sunshine bursting at the seams, and Werribee experiencing insufficient funding to increase bed numbers and staff to required levels. Emergency Department births and women being sent away due to overbookings are the worst symptoms of this,
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but many more women also have experienced insufficient time and attention from overloaded staff, increased out-of-pocket costs, or insufficient antenatal care or postnatal care.
In the past few months the government has taken some steps to address some shortfalls in maternity services in the western metropolitan area, which is most welcome. Subsequent to our correspondence, in October 2013, the Health Minister David Davis announced a $15.1 million development for Sunshine Hospital, including five additional labour delivery rooms, and a pregnancy day stay unit, all to be completed by November 2014. 100 In August 2013 the Mercy Hospital in Werribee confirmed that maternity services funding was being boosted by 20 per cent as it received growth funding from the State Government for the 2013-14 financial year.101
While these incremental improvements are very welcome, they are only just keeping on top of demand. What is needed is a detailed state-wide strategic plan of maternity services. This plan should include an examination of maternity service demand and capacity now. It should include an assessment of where demand will grow in the near future, and how and where services will need to expand to meet that demand. Such a plan also needs to be matched with investment and funding.
In 2011 the Auditor General indicated the government was taking some steps to improve planning such as creating a framework for health services to assess their maternity capacity and capability and report the results to the department. This is useful, but such information needs to be coupled with future growth, to have an understanding of capacity going into the future. Whether or not the department has improved its understanding and planning for maternity services capacity is unclear from the outside, but what is clear is that shortfalls in service continue to surface.
Without significant investment and vision the system will continue to be in this crisis mode, with the government only responding to increased demand when it sees a peak in women birthing in emergency services due to lack of birthing suites,
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or being turned away from their local hospital due to it being fully booked. This is simply not good enough. As changes in capacity do not happen overnight, the government needs to prepare for and anticipate changes, rather than just act in damage control.
Further, when investment in new services is made, it should be based on evidence and an equitable and safe distribution of maternity services across the Victoria. Far too often this has not been the case when it comes to health spending in Victoria.
Over recent years, the significant increase in births and demand for maternity services has been felt most heavily in the West and particularly by Sunshine hospital. The Hospital has done its best to work within existing infrastructure to increase bed numbers. However, maternity wards are dispersed and there are limited options for future growth.
With 5,284 births in 2012/13, Sunshine hospital is one the largest provider of maternity services in Victoria. Despite the huge number of births, it is neither a tertiary hospital, nor does it have a dedicated Women’s or children’s hospital, unlike other maternity services of similar size, such as the Royal Women’s Hospital or the Mercy Hospital for Women. Having a dedicated, purpose built space with sufficient capacity to meet current need and future growth in the western suburbs is essential. It would also help relieve pressure from the Royal Women’s Hospital as it could offer specialist and intensive care services for women in the western suburbs.
Maternity care choices in Victoria
While in theory there are a range of birthing options in Victoria, the level of choice and control over the birth varies depending on how well informed women is, where a woman lives and her financial means.
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Across Victoria, hospitals accept admissions from their local area for most births. In the case of high risk or complex pregnancies woman will be referred to a specialist tertiary hospital.
The 2011 Auditor General’s report found that the maternity ‘system' is not well understood by women and some general practitioners.
Continuity of care is a key principle of the Government’s ‘Future Directions for Victoria’s Maternity Services’. Continuity of care refers to women having the same caregiver or a small group of caregivers during their pregnancy, labour and birth, and postnatally. In the standard model of care at most hospitals, women will receive care from which ever midwife or obstetrician that is rostered on at that time. This means, that details around the women’s particular circumstance and wishes in relation to her care, particularly when they vary from standard procedure, are not often known by her care giver.
The Auditor General found that to improve continuity, some hospitals offer caseload midwifery, often badged Midwifery Group Practice, where a primary midwife provides maternity care during pregnancy, birth and postnatally. However, women have limited access to this model because demand outweighs available places. The Auditor General also found that health services do not routinely monitor or report on their progress in improving continuity of care. This situation is largely the same today as it was in 2011.
There are a number of ways continuity of care can be provided. Continuity of midwife-led care can be provided through the caseload model, as previously mentioned, or through team midwifery care. Team Midwifery care involves a small team of midwives being assigned to a pregnant woman. That woman has the opportunity to meet all women from her team who might be present at her birth. These two different approaches have different benefits and both provide improved continuity of care. The caseload approach has been favoured by some as they
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consider it provides the most continuity, however some health workers find it more difficult as they must be on-call up to five days a week.
Continuity of care can be provided not only via midwife led care, but in standard care. Some hospitals, such as those under Monash Health, have just recently moved to a team care approach under their standard care model. This means that women will be allocated to a team, increasing her chance of having met the midwife or obstetrician attending her birth.
As can be seen in Table 2, across metropolitan Melbourne models of maternity care are dependent upon each hospital. This means women living in some areas may not have access to their preferred model of care. Whilst all hospitals support the standard model of care, the Northern Hospital, Monash Hospital and Werribee Mercy Hospital do not provide midwife led care options. Of those Melbourne hospitals that do provide midwife led models of care, often the numbers are highly restricted. For example, the Royal Women’s caseload program is in hot demand and the website clearly warns women that there is usually a waiting list for this model of care102.
Another model of care preferred by some women are birth centres. In recent years, a number of birth centres have closed in Victoria, leaving just one - the Family Birth Centre at the Heidelberg Mercy Hospital. This hospital has recently decided to take local admissions only (rather than taking admissions state-wide), removing the access to birth centres for many women in Victoria.103
Only two hospitals provide hospital supported homebirth program as part of a trial initiative. Evaluation of this trial found it to be successful and recommended expansion to other health services. Until this happens, public homebirths remains accessible to women in just two localities in Victoria.
31 Table 2. Maternity models of care availability based on major metropolitan public hospitals across Melbourne
Suburbs Midwife Led Standard Care Hospital Shared Care Birth Bath - Locality (caseload) (obstetrician led/ Supported (GP/Community Centre water Hospital midwifery support) Homebirth health centres) immersion / birth Northern Heidelberg Mercy Hospital for ✔ ✔ ✔ ✔ ✔ 104 (team care) Suburbs Women The Northern Hospital105 ✔ ✔ (moving to team care) The Royal Women’s Hospital106 ✔ ✔ ✔ (team care) Eastern Eastern Health (Angliss Hospital)107 ✔ ✔ ✔ ✔ Suburbs Eastern Health (Box Hill Hospital)108 ✔ ✔ ✔ ✔
South-Eastern Frankston Hospital109 ✔ ✔ ✔ ✔ (team midwifery) Suburbs Casey Hospital110 ✔ ✔ ✔ ✔ ✔ (team care)
Dandenong Hospital ✔ ✔ (team care)
Monash Medical Centre ✔ ✔ (team care) Western Werribee Mercy Hospital111 ✔ ✔ (team care) Suburbs The Sunshine Hospital112 ✔ ✔ ✔ ✔ ✔ Of course, women can choose a private midwife led homebirth, however there are a number of barriers, both financially and practically to this choice. Some of these barriers are being addresses through reforms initiated by the National Maternity Service Plan. Other problems remain, but are beyond the scope of this paper to discuss at length as this paper primarily focuses on public services.
For women who prefer mid-wife led, public homebirth and birth centre models of care, but do not live within the catchment area of that particular hospital or have missed out on one of the small number of places, they would need to travel out of their local area (presuming they are accepted within the region of the hospital that does offer these services), go without their preferred model of care, or make a private arrangement at some financial cost.
Having access to a preferred model of care, especially woman-centred care, is important to promote the health and wellbeing of a mother and her baby. However, access to woman-centred care is variable, with less than half Victorian women accessing continuity of care. 113
Results of our survey
As part of our research into maternity care, a survey was conducted to explore women’s experience of maternity services. The survey ran for three weeks, had 8,329 views, 1,100 shares on Facebook and a total of 895 Victorian responses (n=895). The overwhelming response and interest in this survey highlights first and foremost the importance of maternity care issues for members of the Victorian community.
This survey was open to be completed by any women (or partners) who have had a baby in the past 10 years or who are pregnant. Participants were not randomly selected, they self-selected. Individuals with a particular interest in maternity care may have been more likely to take part in this survey, as well as supporters of Colleen Hartland’s work, given it was promoted through her networks. Therefore, Maternity Care Matters 2014
the data collected should be viewed as an indication of the values and opinions of our particular sample (n=895) and should not be generalised to the wider Victorian population. While it is not a random sample, the size of the sample is significant and can offer insight.
For 98% of women, having access to a variety of birthing options was important. When choosing a birth plan, 78% of women said the most important thing was to have minimal medical intervention. Having calm and quiet surroundings was most important for 66% of women and having access to facilities for partner/family to attend was most important for 65% of survey respondents.
Only 27% of women would prefer a hospital birth, with 55% preferring a Birth Centre setting. There is only one birth centre in Victoria and it is only available to women in the Northern metro region. While this is not a random sample, it does demonstrate an appetite for birth centres in the community, which may not be being met.
Of women who preferred a hospital birth, 11% were not able to book into their preferred hospital. Women were unable to access their preferred birth setting due to a number of reasons. Some themes that arose were the costs involved, pregnancy complications, limited bookings at their preferred birth setting and, the most prominent theme, a lack of service availability in their local area. Many women indicated that they could not access their preferred birth setting because they ‘didn’t live in the right catchment’, because it was ‘not available in my area’, and due to the ‘distance from home’. This finding is similar to findings by the Auditor General, with women in growth areas experiencing poorer access to services and having to travel to another health service provider to access maternity care. 114
The importance placed on midwifery care in the birthing process was a dominant theme throughout survey findings, with 86% of respondents saying they would prefer midwives to lead their maternity care, with only 6% preferring obstetrician led care.
34“The most important person in the room while I was in labour was my midwife” – survey respondent. Maternity Care Matters 2014
Only 64% of survey respondents could access their preferred model of care, 16% could not and 20% could only partially. Whilst pregnancy complications made up a proportion of the reasons why women could not access their preferred model of care, other themes found in survey responses included the cost involved in their preferred model, limited booking availability, lack of services within a particular region and a shortage of information on the options available to women.
"When I fell pregnant with my son I saw a GP who simply asked if I had private health insurance, to which I replied no and then she gave me a referral to my local public hospital. I booked in at around 7 weeks and apparently I was lucky as people I've known haven't been able to get in at 4/5 weeks!! It disappoints me that this was my "only option" and that I now know that I could have utilised a service such as MAMA or Sunshine Hospital Homebirth program to have avoid unnecessary medical intervention..." – Survey respondent.
Of all survey respondents, 39% had all birth choices met, 40% stated most of their birth choices were met and 21% said either a few or none of their birth choices were met. The implications of not being able to access preferred birth choices are of most concern, with 27% saying the lack of choices caused unnecessary stress or worry. 10% of women were forced into extra financial cost and for 6% of women, the shortage of choice meant extra travel times. Some women even noted that they used a false address to access their preferred birth setting or model of care.
87% of survey respondents think maternity services are in need of improvement.
Of survey respondents who stated maternity services are in need of improvement (87%), having more Family Birth Centres was at the top of the list (83%) with an increase in midwife-led maternity care coming in at close second (81%). More
35 Maternity Care Matters 2014 support for homebirth was the third most important change (61%). 31% of respondents wanted a longer length of stay at hospitals post birth. Having more hospital maternity beds was a concern for 23%. This lower figure is to be expected, as the majority of women can book into services, and thus it is not a problem. It is only the few who miss out, for whom this is a problem
Results of this survey indicate that maternity care is a deeply important issue for many individuals, both women and men. Whilst a number of women reported experiencing a positive birth, many negative birthing experiences were also shared. The inaccessibility of maternity care services has implications for women and families physically, emotionally and financially, highlighting the urgent need of reform for maternity care in Victoria.
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Conclusion and recommendations
Reform is needed to ensure that there is an adequate and equitable distribution of maternity care services for women across Victoria, particularly in Melbourne’s growth corridors such as the western suburbs of Melbourne. Improvements are also required to ensure maternity services are women-centred, provide continuity of care and choices in models of care.
Address capacity constraints Insufficient planning and funding has led to service shortfalls. This has forced women into difficult situations of women birthing in emergency, women being turned away from fully booked hospitals, and women receiving insufficient care as staff are so far stretched. We need proper planning and investment to meet demand for services now and into the future.
The area most in need is Melbourne’s western suburbs, which have the fastest growing number of births, the second highest number of births of any region in Victoria, yet they have: • Less maternity beds than other regions in Melbourne relative to the number of births • no private maternity hospital services to take the pressure off the two public hospitals with maternity services • no specialist services for complicated pregnancies or intensive care support for very sick newborn babies • no dedicated women’s hospital (such as the Women’s Hospital or Mercy Hospital for Women), despite sunshine having the second highest birth rate of any hospital in Victoria.
It’s not fair that it is the women in the west who face crisis upon crisis, year upon year, in maternity service capacity and then only receive a band-aid response from the government. We need better planning and investment to meet current demand and address future demand, before it becomes another crisis.
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More Choice in Maternity Care According to the Government’s own Maternity Plan, a key to the Victorian Government’s vision for maternity services is providing women with informed choice, greater control of their birthing experience and enhancing a maternity team approach. The National Maternity Services Plan also creates a national commitment to women-centred care that is responsive to women's needs and preferences. It seeks to support informed choices by enabling women to access information and improved access to a range of models of care for all Australian women. The Victorian Government has taken some steps towards realising this agenda, however, as this report indicates there is still a way to go.
Increasingly women want access to different models of care, such as hospital supported homebirths, birth centres, and midwife led models that provide continuity of care. Currently these care options that are in limited supply. There are a number of hospitals that do not offer midwife-led care, or have very limited places.
Every woman should be supported to make informed choices about her maternity care. Every women should have access to a range of safe maternity care choices. We can do so much more to ensure childbirth is an empowering, woman- centred experience.
Recommendations To improve maternity services in Victoria: 1. Better monitor and respond to demand for maternity services, including developing a strategic plan to meet projected growth in birth numbers. 2. Fund construction of a tertiary Women’s Hospital in the western suburbs to address the growing shortfall in maternity services and capacity restraints at Sunshine Hospital. 3. Establish guidelines for better provision of information about maternity care and choices for women, to support women to make informed choices. 4. Support provision of increased continuity of care in all maternity services.
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5. Make midwife-led care more accessible by funding the introduction of caseload or team midwifery models of care at every metropolitan and major regional hospital, and expand places at hospitals where it is currently offered and often booked out. 6. Support expansion of public homebirth programs to more hospitals. 7. Investigate feasibility of establishing more birth centres in Victoria.
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Endnotes
1 Victorian Auditor-General’s Office (2011). Maternity Services: Capacity.
2 Western Health, Annual Report 2012/13, http://www.westernhealth.org.au/AboutUs/CorporatePublications/Documents/AnnualReport/WH_Ann ual_Report_2013_Web.pdf
3 Australian College of Midwives. (2008). Submission to the NHRC: Achieving safe, satisfying and sustainable maternity services in Australia. Retrieved from http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/027-acw/$FILE/027%20- %20SUBMISSION%20-%20Australian%20College%20of%20Midwives.pdf
4 Vernon, B. (n.d). A new national consumer voice pushes for reform of maternity services: The Maternity Coalition. Retrieved from https://www.chf.org.au/pdfs/ahc/ahc-2002-3-maternity- coalition.pdf
5 Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2013). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Summaries: The Cochraine Collaboration. Retrieved from http://summaries.cochrane.org/CD004667/midwife-led-continuity- models-versus-other-models-of-care-for-childbearing-women
6 Department of Health and Ageing. (2012). National Maternity Services Plan: Glossary and References. Australian Government. Retrieved from http://www.health.gov.au/internet/publications/publishing.nsf/Content/pacd-maternityservicesplan- toc~pacd-maternityservicesplan-chapter15
7 Department of Health and Ageing. (2009). Improving maternity services in Australia: The report of the Maternity Services Review. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/64A5ED5A5432C985CA25756000172 578/$File/Improving%20Maternity%20Services%20in%20Australia%20- %20The%20Report%20of%20the%20Maternity%20Services%20Review.pdf
8 Birth Choice UK. (n.d). Normal Birth. Retrieved from http://www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.co m/Professionals/NormalResearch.htm
9 Gjerdingen, D.K., Froberg, D.G., & Fontaine, P. (1991). The effects of social support on women’s health during pregnancy, labor and delivery, and the postpartum period. Family Medicine, 23(5). 370- 375. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1884933
10 Humenick, S.S. (2006). The life-changing significance of normal birth. Journal of Perinatal Education. 15(4),1-3. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804308/
11 Moorhead, J. (2010, December 10). Torn apart by childbirth. The Guardian. Retrieved from http://www.theguardian.com/
12 Geyer, J. & Steiner, V. (2007). Short-run and long-term effects of childbirth on mothers’ employment and working hours across institutional regimes: An empirical analysis based on European Community Household Panel. IZA Discussion Paper. Retrieved from http://www.econstor.eu/handle/10419/34265
13 Gjerdingen, D.K., Froberg, D.G., & Fontaine, P. (1991) op. cit.
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14 Australian College of Midwives. (2008). Op.cit.
15 Moore, S.B. (2011). Reclaiming the body, birthing at home: Knowledge, power and control in childbirth. Humanity & Society, 35, 376-389.
16 Waldenstrom, U. (1999). The experience of labor and birth in 1111 women, Journal of Psychosomatic Research. 47(5), 471-482.
17 Cook, K. & Loomis, C. (2012). The impact of choice and control on women’s childbirth experiences. The Journal of Perinatal Education, 21(3), 158-168. & Willmuth, L.R., (1975). Prepared childbirth and the concept of control, Journal of Obstetric, Gynecologic & Neonatal Nursing, 4(5), 38-41.
18 Doering, S.G. & Entwisle, D.R. (1975) Preparation during pregnancy and ability to cope with labor and delivery. American Journal of Orthopsychiatry, 45(5). 825-837.
19 Cook, K & Loomis, C. (2012), op. cit.
20 Moore, S.B. (2011), op. cit.
21 Coalition for Improving Maternity Services. (1996). The mother-friendly childbirth initiative. Retrieved from http://www.motherfriendly.org/Resources/Documents/MFCI_english.pdf
22 Birth Ready. (2007). Articles: Choosing your caregiver. Retrieved from http://www.birthready.com.au/articles/choosing-your-caregiver/
23 Coalition for Improving Maternity Services. (1996), op. cit.
24 Birth Ready. (2007), op. cit.
25 Australian College of Midwives (2008), op. cit.
26 Australian Government (2010). Australian Institute of Health and Welfare: Australia’s mothers and babies. Retrieved from http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129542372
27 Commonwealth of Australia. (2009), op. cit.
28 Australian College of Midwives. (2008), op. cit.
29 Vernon, B. (n.d). A new national consumer voice pushes for reform of maternity services: The Maternity Coalition. Retrieved from https://www.chf.org.au/pdfs/ahc/ahc-2002-3-maternity- coalition.pdf
30 Victorian Auditor-General’s Office (2011), op. cit.
31 Australian College of Midwives. (2008), op. cit.
32 Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2013), op. cit.
33 Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2013), op. cit.
34 Victorian Auditor-General’s Office (2011), op. cit.
35 ABC News. (2012, October 23). Maternity bed shortage in Western suburbs. Retrieved from http://www.abc.net.au/
36 Australian College of Midwives. (2008), op. cit.
37 Australian College of Midwives. (2008), op. cit.
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38 National Maternity Services Plan (2010). Australian Health Ministers’ Conference. Commonwealth of Australia.
39 Victorian Auditor-General’s Office (2011), op. cit.
40 Department of Health, http://docs.health.vic.gov.au/docs/doc/Future-directions-for-Victorias- Maternity-Service
41 National Consensus Framework for Rural Maternity Services (2008).
42 National Consensus Framework for Rural Maternity Services (2008).
43 Submission to the Maternity Services Review Rural Doctors Association of Victoria (2008). Rural Doctors Association of Victoria.
44 Victorian Auditor-General’s Office (2011), op. cit.
45 Victorian Auditor-General’s Office (2011), op. cit.
46 Submission to the Maternity Services Review Rural Doctors Association of Victoria (2008), op. cit.
47 Miller, N. (2009). Rural maternity services ‘face crisis’. The Age.
48 Victoria’s health workforce, Department of Health, http://health.vic.gov.au/workforce/learning/rural.htm
49 Australian Bureau of Statistics, Births, Australian 2012.
50 Australian Bureau of Statistics, Births, Australian 2012.
51 Australian Bureau of Statistics, Births by local council, 2013.
52 Australian Bureau of Statistics, Births by local council, 2013.
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