Transcript
Tegan Taylor: As we’ve heard, the kind of care you might get if you’re pregnant varies wildly across Australia, and even within the same city, despite the fact that we know what best practice looks like; continuity of care. A national strategy around improving maternity care was launched in 2019, just in time to get overshadowed by the pandemic. I spoke to midwifery academic Zoe Bradfield from Curtin University about this earlier.
Zoe Bradfield: It’s indefensible to continue to ignore the evidence that we have that is almost shouting from the rooftops to us now, that the systems of care that we have that are designed to provide care to the humans making the next generations of humans in Australia is broken. And what we need is a humanised approach to the care of humans.
The good news is…because often what happens when we say that to people is they imagine in their mind this system that is, you know, bringing people into gold gilded halls where everyone gets their favourite herbal tea and, you know, just something that’s really deluxe and over the top, but the reality is what we’re talking about is continuity of care. The evidence says to us that continuity of care with a known midwife results in improved outcomes for women and for their babies, it results in reduced unnecessary healthcare costs, it results in improved maternal engagement, and when mothers want to engage with the systems that are designed to care for them, then their outcomes are necessarily better because we can assess and screen and pick up any problems earlier.
So it’s improved outcomes and improved engagement and satisfaction by the humans that are accessing that care. It also results in improved workforce retention. And of course we’re in the middle of workforce crisis, we know that we have a global shortage. So what we know about midwives staying in the profession is that providing continuity of care is the most philosophically aligned version of care that midwives want to stay in the profession.
Continuity of care with a known midwife is actually 20% cheaper than standard public fragmented care, just dollar-for-dollar direct health provision of those services is 20% cheaper. That’s not taking into account improved health outcomes, reduced neonatal admissions, reduced unnecessary complications and unnecessary intervention, workforce attrition. Really the question for us now is why wouldn’t we provide that model of care.
Tegan Taylor: But you can’t just turn a tap on and be, like, ‘midwives for everyone’. What does actually resourcing this look like?
Zoe Bradfield: It does…particularly because the health system that we have effectively hasn’t changed much in 100 years, maybe a bit more. You know, way back when, before hospitals were broadly accessible to people, they were seen as a luxury, then enter the postmodern era where birth, instead of being seen as a community event was brought into the hospital and under the auspices of medical models. Largely in the last 10 to 20 years we have had exponential increases in health expenditure, and what we’ve not seen is an exponential improvement in maternal mortality or morbidity, or neonatal mortality and morbidity. So what that probably tells us is that we’ve reached the tipping point, we’ve reached the point where the increased amounts of intervention that we have are possibly not making a difference or maybe doing harm.
Tegan Taylor: So I know that in lots of big public hospitals, there is fantastic midwifery-led models of care. I went through one, twice. But they were really reserved for low-risk women. So how do you see that continuity of care with a known midwife working for people who don’t fit into that low-risk category?
Zoe Bradfield: Yeah, look, the reality is every single human that is pregnant should know their midwife, it should not be risk dependent. We absolutely can build these models, and we should and we must, and they’re actually not that difficult to expand. So we have group practice midwifery. Broadly, we know around Australia fewer than 20% of people receive their care through this model, this publicly funded midwifery group practice model.
There are other kinds of hybrid models. So I’m based in the west, we also have a community midwifery program where we have one of the nation’s longest publicly funded home birth programs. So there are various ways for you to achieve continuity of midwifery care, and the midwifery group practice model that you mentioned is one of the natural models to begin to expand on, and it should not be risk dependent.
Some would argue that those women who have higher risk factors may actually need continuity more. I’d suggest that we shouldn’t be having an argument about who needs it more because every human needs it. And so whether I am completely healthy in my pregnancy, or whether I have a pre-existing condition, or whether I’ve had a previous complication, that means that I may potentially in the future have complication during birth, but I also might not. Every human that is pregnant needs humanised care, and evidence tells us that the best way for that to happen is through continuity of care with a known midwife.
Tegan Taylor: What does it cost to implement the strategy that you’re talking about?
Zoe Bradfield: So there hasn’t been an economic evaluation that would estimate this for the nation. But what we do have is really good modelling around a comparison of real-world Australian-based data to do this cost comparison between standard public fragmented care, where I see a random midwife or a random doctor, depending on which day I turn up. Yeah, it is not individualised care, it is systems orientated care. So no one has the modelling in terms of what it would cost for that at a national level, but we have, using series sets of data, that modelling has occurred. And you could say that our current health spend could potentially be reduced by 20% if we were to implement this as the default model.
Now, there are some women and people who come to pregnancy who have complications that will absolutely need the inclusion of obstetric colleagues, and this is a multidisciplinary gig that we do in maternity. And particularly for those who have pre-existing conditions, those with cardiac conditions, those with complex diabetes, and so on and so forth, we absolutely will be providing care in collaboration with obstetric colleagues, and also with maternal physicians as well who get involved in supporting hypertensive disorders and the like. But that doesn’t dispute the fact that midwives are experts in primary maternity care, and that every human needs midwifery continuity of care.
Tegan Taylor: So there was a national strategy that came out just before the pandemic, bad timing. Where to from here now coming into 2023?
Zoe Bradfield: So what we need is a national reporting framework. But ideally what would really help this to move along is to ensure that there is jurisdictional buy-in from each of the recommendations for reporting. The reality is the challenge of this dual system that we have where we have a commonwealth strategy, and we have jurisdictions effectively rolling out most of the strategy, is that there needs to be this unilateral agreement between each of the jurisdictions that they will actually commit to the recommendations of the national strategy. And that the initial reporting, when it comes, if we do a reporting season, that we’re able to use that as a time…that would be the ideal time, to be honest, to re-evaluate the utility of the current plan that we have, given that it was made before we knew this pandemic was coming, and to really appraise the data that we have from the pandemic. And our team have been involved in leading one of the largest national studies around the impacts of maternity care as a result of the COVID-19 pandemic, and what it showed us was that some of the things that we did were really, really difficult for women, their families, communities and societies. But what we found from each of the five cohorts that we engaged with (which was women, their partners, midwives, doctors and midwifery students) is that every single cohort gave us a silver lining too, and it’s there that we need to look first.
Tegan Taylor: Zoe, thank you so much.
Zoe Bradfield: Pleasure, Tegan.
Tegan Taylor: Dr Zoe Bradfield is a midwifery academic at Curtin University.
And that’s all we’ve got time for on the Health Report tonight. If you want to contribute to The Birth Project or read the stories, you can go to abc.net.au/birthproject, and we’ll catch you next week.
