But Ron Batagol, a pharmacy and drug information consultant, says this will require us to examine some of our somewhat hypocritical attitudes towards breasts.

He writes:

“A meeting of Health Ministers on 13th. November has endorsed the Australian National Breastfeeding Strategy 2010-2015.

The Strategy recognises the biological, health, social, cultural, environmental and economic importance of breastfeeding and provides a framework for priorities and action for Australian governments at all levels to protect, promote, support and monitor breastfeeding throughout Australia.

Australia’s dietary guidelines recommend exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months – and beyond if both mother and infant wish.

It is concerning that a longitudinal study of Australian children conducted in 2004 found that while 92 per cent of new borns were initially breastfed, by one week, only 80 per cent were fully breastfed. The study also indicated a steady decline each month with only 56 per cent fully breastfed at three months and 14 per cent at six months.

The new federal strategy would include increasing community acceptance of breastfeeding as a cultural and social norm, establishing breastfeeding support networks for pregnant women and improved breastfeeding training for health professionals.

But, since it has been estimated that over a quarter of Australians still think that breastfeeding in public is unacceptable, obviously there is still a long way to go!

And  I have to say that it’s quite paradoxical. In the post-modern world of the 21st century, when the fairer sex “frocks up”, as they call it these days, no one gives a second thought about exposed cleavage.  In fact, the dress designers have lead the charge to make the breasts the focal point of society’s attention when women’s attire is “out there” being critically scrutinised by all and sundry.

On the other hand, as we’ve seen in recent times, with unfortunate regular monotony, the sight of women, anywhere outside the confines of their own homes, trying to nourish their infants with the most natural of all beverages, mother’s milk, provokes an outcry of pompous indignation.

Oh, yes, excuse me, I forgot!  On a plane, with all those complete strangers sitting in close proximity? In the sacrosanct and hallowed corridoors of Parliament of all places!  And for God’s sake, worst of all, in a 5-star restaurant – a place where other people pay good money to sit down, quaff a fine wine or three and gourmandise their way through their mouth-watering degustation.

Suddenly, the notion of these mammary glands doing what they were actually created to do in a “public place” is deemed to be titillating, and breastfeeding is transmogrified into something wicked and evil.

Yet, 28 years ago, a worldwide Marketing Code was established for synthetic milk formulas, because millions of infants died in developing countries where well meaning mothers tried to copy their emancipated, more affluent counterparts by preparing formulas despite lack of clean water, refrigeration or education about how to make up the feeds.

So now, breast-milk  is “in” again- transported in  unbreakable packages, and satisfying consumer demand- all in all, the perfect 21st century product, with breast-fed babies having better immunity, and better long-term medical benefits than their bottle-fed buddies.

One can only live in hope that, as a society we may become a little less hypocritical and to try to remember why these mammary appendages were given to women in the first place.

Surely that’s not too much to ask, is it?”

Professor Lesley Barclay, director of the Northern Rivers University Department of Rural Health in NSW, is a leading proponent of the need to reorient maternity care around the needs of women and babies, and has plenty of first-hand experience of why this is particularly necessary for women living outside the major cities, especially Indigenous women from remote communities.

This coming Saturday, she will be speaking at the Australasian Medical Writers Association conference in Sydney.

Here is a sneak preview of her presentation:

“When women talk about what matters to them when it comes to childbirth, the issue they repeatedly mention is safety.

But their understanding of safety around childbirth is often quite different to how health systems and many professionals define it.

For women, a safe childbirth is not only about what occurs at the time of the birth. It also refers to longer-term issues, such as their social and emotional wellbeing in the weeks and month after the birth.

When women talk about safety, they are also thinking about the increased rates of depression and anxiety that manifest after operative birth or the consequences of wound infection on general health.

The Australian health system often makes it difficult for women to make wise choices around birth. Consider, for example, how the system defines childbearing as “obstetrics” and locates it physically and psychologically in acute care hospital services.

It is far more appropriate to speak of “maternity care”, which can be safely located in many locations.

For example, evidence shows for most women most of the time birth does not need to take place in hospital. Some women will only feel safe however, whether this is evidence-based or not, with specialist medical services and technology.

The term “maternity care” describes the range of services women need to enable them to safely and confidently ‘mother’. This incorporates their social and emotional needs. It puts them – rather than the professional or the service – at the core of the system.

Evidence shows maternity care can be provided by both midwives and obstetricians in public and private sector hospitals and can be safely provided at home.

Paradoxically, evidence also shows that safety from morbidity is less likely for Australia’s healthiest and wealthiest women cared for by private obstetricians in private hospitals. More recent epidemiological evidence shows as volumes of operative birth increases, deaths of mothers and infants are also increased by overuse of the very operation that was developed to save lives.

So where does choice fit in this repertoire of terms, locations, professionals, services and outcomes?

Safe birth should be the goal of choices offered to women and decisions taken by those who provide care for them.

Unfortunately, the choices some professionals offer or accept are self or income centered and ignore evidence. As a consequence of gender-located power historically, and a rapid increase in the numbers of more technically oriented professionals in recent decades, health services and costs do not reflect women’s needs or evidence.

The most important example of this is allowing caesarean birth to be a choice rather than only using this as the lifesaving emergency procedure it is.

Today, in many places around the world, including Australia, caesarean birth is rapidly becoming a life threatening procedure itself because of excessive use.

Epidemiological evidence from a number of countries, maternal death reviews and coroner’s reports now show the risks attached to using a major surgical procedure as a routine mode of birth.

Maternal mortality is between two and seven times higher for surgical than vaginal birth. One study of over one million women between 2001 and 2003 in Brazil found, compared to having a vaginal birth, women with CS were 3 times more likely to die in childbirth.

A large US study of 5 million births between 1998 and 2001 demonstrated that neonatal mortality for CS deliveries is nearly 3 times greater than for vaginal birth in women with no medical risk factors.

The physical, social and emotional morbidity attached to women who experience this mode of birth is not recognised therefore ignored within acute care hospitals but is evident in their homes and the community.

Research has identified that physical morbidity associated with CS is five to ten times higher than for women birthing vaginally. No less importantly there are also psychosocial consequences of surgical birth with women less satisfied, more concerned about the baby’s condition and fearful. Women delivering by CS report feeling less in control than women who have birthed vaginally.

Research also shows rates of post natal depression significantly different between women who birthed vaginally and the group of women who delivered either by planned or unplanned CS. There are also differences in parenting perceptions and behaviour between women delivering by CS and vaginally. Women who birth by CS evaluate their babies less favourably, are less likely to breastfeed and/or feed for a shorter duration.

Paradoxically, the choice to have a normal, safe, confidence affirming birth that is low cost and relieves pressure on hospitals is only available to a small minority of women.

This is not possible for Australia’s most vulnerable women and families, who, the evidence suggests, would benefit most. How many rural or remote living Aboriginal women can opt for a home birth attended by a skilful midwife?

Research associated with our NHMRC funded work in the Top End of the NT has shown that 1 in 10 remote living Aboriginal women in one large community avoid hospital services or skilled professionals because of the unacceptable risks to them of being evacuated from their community. One of the reasons they avoid large hospital birth is this takes them from families and other children for weeks at a time.

Other Australian women with more options are also taking this route, fed up with what they see as biased, self-interested advice and unacceptable risks of our current system.

To have real choices, one needs options and good information on which to base decisions. Better resourced women, with access to Internet searching, can chase evidence themselves, or question doctors, hospitals and midwives. They can try to weigh up the range of opinion they are likely to receive. It is hard to know at times where fact lies in the opinions you will generate through asking questions. H

However there are some ultimate arbiters beyond opinion. One of these is the impartial review of evidence provided by such as the Cochrane data base.

I saw to my great delight a writer (male and medically qualified) who also a Member of Parliament, recently quoting this source in a newspaper. His message, while aimed at indemnifying home birth midwives, was that home birth is safe.

He had gone to the Cochrane and reported back in his article that home birth is indeed safer at times than hospital birth when planned and supported by good hospital care for rare emergencies.

I wish the current president of the AMA, an erstwhile obstetrician, would be similarly correct with his claims that certainly are not recognisable as fact to those familiar with the evidence.

Choices for women are difficult when all they receive is highly partial and ill-informed opinion. Choices around birth are important or women will opt out of a system that does not meet their needs.

The Australian maternity system has been associated with increasing risks over recent years and is certainly much more expensive than it need be.

The Commonwealth aims to change this. Recent budget moves to allow midwives to claim for midwifery services and to increase choices for women will, evidence shows, reduce risks of physical and social morbidity. Location for birth similarly is a choice that women make that with good support systems will reduce cost, reduce morbidity and not increase deaths.

Should it be a matter of choice though for women to give birth via major abdominal surgery? Should we permit choice that means their babies avoid the process of vaginal birth that prepares them to live and breathe?  Should it be women’s or obstetrician’s choice that health pays or heavily subsidises the avoidable costs of unnecessary operations that prevent other necessary surgery being performed and add to waiting lists? I think not.

We need to recognise that operative birth is the option to use only when the risks associated with the alternative are unacceptable. This is not a matter of choice.”

Meanwhile, Professor Peter McIntyre, Director, National Centre for Immunisation Research and Surveillance of Vaccine-Preventable Diseases, is concerned that the focus upon swine flu and pregnancy may be distracting attention from the risks of influenza generally for pregnant women. He writes:

“Pregnant women are at risk – not just from swine  influenza, as highlighted in the media in recent days, but from influenza of  any kind.

“Ordinary” seasonal influenza is also still circulating. Both vaccines and antiviral drugs are important.

With respect to vaccines, influenza vaccine has been recommended by  the National Health and Medical Research Council for women in pregnancy for  almost 10 years – but few receive it.

This is  probably related to both lack of familiarity with the whole notion of  vaccines in pregnancy by practitioners caring for pregnant women, as well as reluctance on the part of many, if not most, women to receive any treatment  in pregnancy, either vaccine or drug.

Therefore  it is important to emphasise that there is no theoretical or data-based  reason to expect any adverse effects from vaccines which do not contain  live organisms in pregnancy. In partcular, influenza vaccines are safe in pregnancy. The primary rationale  is to provide protection for the mother but there is accumulating evidence that some protection is probably also afforded to the baby after birth.

Once a swine influenza vaccine is available, pregnant women will be a priority risk group, something which has been emphasised by recent publicity concerning severe cases in pregnant women.

It is important to remember that  vaccines for “ordinary” influenza are available now  and are  recommended for pregnant women, who are especially at risk in the later stages of pregnancy, and that professional and public attitudes to using influenza  vaccines in pregnancy need to change now.

With respect to antiviral drugs, it is important that pregnant women  see their doctor early if influenza is a possibility as anti viral treatment  is most beneficial early. Pregnant women also need to see their doctor if it  is possible that their children have influenza, as this may be an opportunity  for even earlier treatment. Given the potential severity of influenza in  pregnancy, the benefits of treatment clearly exceed the risks.

Regarding risks for Indigenous communities, we know that influenza  rates generally are much higher in Indigenous children and adults, with  hospitalisations for influenza and pneumonia 3.5 times higher than in  non-Indigenous Australians.

The biggest  difference is in 25-49 year olds, where the rates are 8  times higher. This younger adult group is the very group now coming to light  with swine flu but has been evident as an important  risk group in earlier data.  This is  reflected in the recent announcement by the Commonwealth that free influenza vaccine will be provided under the National Immunsation Program for all  Indigenous adults from 15 years of age as well as for all persons from 6  months of age who have conditions placing them at increased of severe  influenza.

This group at increased risk, as mentioned above, includes pregnant women. This is especially so for pregnant Indigenous women, where we know that there are high rates of respiratory and ear disease in babies very early  and that mothers themselves are significantly more likely to have health problems. The  increased risk relates not only to medical conditions, but to general living conditions, and other risk factors such as high rates of  cigarette smoking.

Indigenous people should be a priority  group for access to both antivirals and to vaccine for the swine flu, when it  becomes available. For the whole  community, communication about risks and benefits will be crucial.”

The 18 May edition of the Medical Journal of Australia is devoted to Indigenous health,  and is well worth a read.

One article stands out in particular, both because of the vibrancy with which it is written and the poignancy of its subject – the lack of access to appropriate health services for Indigenous people in jails.

Beverley Spiers is an Aboriginal health worker at the Cessnock Correctional Centre and she writes with a zing and a candour that suggest she is passionate about her work and doesn’t mind ruffling feathers if that will help her patients.

She says Aboriginal prisoners don’t normally access the mainstream Justice Health centres in the jails because Aboriginal staff from many external Aboriginal Medical Services can’t regularly visit the the centres any more due to a lack of staff and funding.

“Despite the Royal Commission into Aboriginal Deaths in Custody 20 years ago, which recommended that culturally appropriate medical care be provided to offenders, with access to Aboriginal Health Workers wherever possible, and despite what you read in annual reports since then, Justince Health 10 years ago adopted an unofficial policy of mainstreamed take-it-or-leave-it medical service to Aboriginal offenders,” she writes.

“It is now slowly moving away from this stance by employing its own Aboriginal Health Workers as part of the health centre staffing profile, beginning with one of the newer facilities at Wellington in midwestern NSW.”

Spiers won the Dr Ross Ingram Memorial Essay Competition for an entertaining and moving description of her efforts to screen prisoners for kidney disease.

Other snippets from the journal include:

• Professor Wendy Hoy, from the University of Qld’s Centre for Chronic Disease, has weighed up the chances of Australia closing the gap in Indigenous life expectancy by 2030, and judged it “probably unattainable”. She argues that it will probably take several generations for Indigenous people’s health to approximate that of non-Indigenous Australians: “Rather than specify an unrealistic time line for aspirational goals, it would be better to focus on shorter-term process measures.”

• A new study showing that Aboriginal people in the NT are far more likely than other Australians to be hospitalised for problems that could have been prevented from reaching hospital with earlier, better treatment. Between 1998-99 and 2005-06, their avoidable hospitalisation rate was 11,090 per 100,000 population, nearly four times higher than the Australian rate of 2,848 per 100,000.

• Andrew Hewett, Executive Director of Oxfam Australia, raises concerns about the slowness of the Federal Government’s response to closing the gap efforts. In March last year, the federal government signed a statement of intent with leading Indigenous health groups, showing its intent to create a national action plan in partnership with peak Indigenous health groups.

“However, after more than a year, we are still waiting for the national plan and the partnership to eventuate,” says Hewett. “Peak Indigenous health groups have created a comprehensive list of targets they would like to achieve in a plan, and are inviting the government to engage with them, as was promised.” Hewett says Indigenous health groups know what to do to be effective. “For instance, the Victorian Aboriginal Health Service in Melbourne has immunisation rates that show an average of 91 per cent of their child patients are fully immunised, compared with rates of less than 50 per cent for Aboriginal children across Victoria.”

• The relative affordability of energy-dense foods (rich in sugars and fats) compared with nutrient-dense foods (such as meat, fruit and vegetables) in remote communities is a major cause of ill health, according to a new study based in one large remote community in northern Australia. The researchers suggest that efforts to improve nutrition should be placed in an economic framework rather than been seen as a matter of individual behavioural change. They conclude “our study highlights the investment that improving nutrition for Indigenous people in remote communities will require.” Meanwhile, other authors note, however, that nutrition issues were not included in the final National Indigenous Reform Agreement of COAG.

• Interventions to tackle smoking by pregnant Aboriginal and Torres Strait Islander women should focus on the social environment and the influences of social networks and partners rather than the traditional predictors of anenatal smoking, a study suggests.

• Lack of local birthing services means pregnant women from Cape York typically have to leave home at 36 weeks to travel to Cairns, meaning weeks away from family and friends “with detrimental social, cultural and financial consequences”. In 2006, 172 women from 14 Cape communities travelled to Cairns to give birth, three-quarters of whom identified as Aboriginal or Torrest Strait Islander.  The researchers say that reopening maternity units at Weipa and Cooktown hospitals would help.

• A new study gives some powerful insights into why so many Aboriginal people find hospitals and other health services daunting, unfriendly and unhelpful.

The news is not all gloomy, however. This article and another one suggest there’s a good news story just waiting to be told about the Inala Indigenous Health Service in Queensland.

The journal also includes pieces from the Australian Indigenous Psychologists Association and Indigenous Dentists’ Association of Australia, as well as organisations representing Indigenous doctors and nurses. That must be a first.

Oh, for some political attention to these issues, rather than worrying so much about health care for the well-heeled.

Take this, from GP Dr Kerri Parnell, the editor of Australian Doctor, a magazine for GPs.

She writes in the latest issue: “Within a month of the Medicare Safety Net being introduced in 2004, I’d heard of several obstetricians who’d automatically jacked up their fees, some to $5,000 per delivery. Presumably they slept at night because the extra costs would come from government coffers, not their own patients’ pockets”.

I expect the sound of pathologists crying poor will attract just as much sympathy from large chunks of the health and medical sector.

But you’ve got to hand it to those pathologists. The Australian Association of Pathology Practices, which represents private providers, has done a very nice job in their press release of framing the cutbacks as an attack on patients.  Mind you, the strategy hasn’t worked too well for the obstetricians so far.

It’s a landmark night for maternity services for Australian women. Finally, after more than 20 years of discussion and debate this Federal government has been brave enough to acknowledge that maternity services are provided by a number of health professional including midwives, GP obstetricians and obstetricians.

Tonight’s announcement goes towards redressing the balance in access and equity in maternity care in this country, enabling midwives to, for the first time, to work as private practitioners, provide services subsidised by the Medical Benefits Schedule and prescribe medications subsidised under the Pharmaceutical Benefits Schedule.

The Improving Maternity Services Package is an initiative for all Australian women. It is an important move forwards and is strong evidence that the recent Review of Maternity Services has been addressed, especially for women in rural and remote areas.

Of course the devil is in the detail. What exactly does “subsidised medical indemnity for eligible midwives working in collaborative arrangements in hospitals and healthcare settings” mean for midwives who provide homebirth services? How will an “advanced midwifery credentialing framework” fit with the existing national peer review process for midwives?

This is not the moment to retreat to professional corners.

This is the moment to take a deep breath and develop new and more constructive ways of working together recognising and respecting our different skills and capacities. We must keep women and babies at the centre of the discussion, not our various professional perspectives.

This is the time to move forwards using the available workforce in the best way, ensuring that midwives, GPs and obstetricians can each work to their full scope and capacity to ensure the best possible maternity service for all Australian women.

***

Justine Caines, Maternity Consumer Advocate – Mother of seven, living in rural NSW, is also calling it a “Landmark Day for Women and Babies”. She writes:

The budget has announced new funding of $120 M over 4 years to introduce Medicare funding for midwives.

This heralds a new age for maternity care.  To date maternity care has catered to the needs of health professionals rather than women and their families.  The all powerful medical lobby has dictated the terms. It would seem that their greed has been a major part of the reform agenda.

In the 4 years since the Medicare safety-net was introduced, Obstetricians have increased their charges by approx 300%. This budget has reeled these obscene costs in with a cap to the safety-net.  By enabling private practice midwifery through Medicare, private health funds will be able to finally offer choice to women. Importantly midwifery care will also have the capacity to reduce unnecessary costs (by reducing interventions, especially caesarean section and associated costs esp when babies are harmed through surgery and spend time in special care nurseries).

With the introduction of Medicare for midwives rural women can breathe a sigh of relief, soon many more women will have the option of primary midwifery care in their local communities.  The social dimension of midwifery is well placed to make in-roads to close the gap for Indigenous Australians, considering the shocking media recently reporting the tragic consequences of foetal alcohol syndrome this is welcome news.

The only down-side is that homebirth is not yet to be funded. It would seem medical groups will ‘die in a ditch’ over funding homebirth services. Perhaps I’m crazy but at the moment it is easier to terminate a pregnancy than to give birth at home.  Men in white coats wrangle to keep control of women’s bodies. Overall thumbs up to Nicola Roxon, I look forward to working through the implementation.

Really?

For another perspective, have a read of this Crikey article in which three academics (with midwifery backgrounds) outline how Federal Government policies, including the Safety Net, have had the unintended side effect of driving up obstetricians’ incomes (at huge cost to the public purse), and promoting a problematic model of care.

For those cynics who might wish to dismiss these concerns on the grounds they were put forward by representatives of a discipline known for contesting the obstetricians’ view of the world, here is an extract from a submission to the Federal Government’s recent maternity services review.

It is by David Ellwood, professor of obstetrics and gynaecology at the ANU. I hope he doesn’t mind but I’m quoting it at length because it is so pertinent to the current debate.

Extract of letter:

1. The current rate of intervention in childbirth

The inexorable rise in the caesarean section rate is something which needs to be addressed as a matter of some urgency.  We don’t know the current rate in 2008, although the last figures published by AIHW (2005) show that the caesarean section rate has risen to above 30%.  I suspect when the latest issue of Australia’s Mothers and Babies for 2006 comes out next month the rate will have climbed again.  I’ve been concerned for a number of years that once we reach a rate of somewhere between 35% – 40% we could reach a tipping point from which the rate will accelerate more rapidly.
Indeed this has been the experience in some overseas countries and there are some  notable examples where the caesarean section rnotable examples where the caesarean section rates have rapidly accelerated to 70% or 80%.

There is now a body of scientific evidence in the literature, much of which has been published over the last few years, to suggest that caesarean section does increase the risks to both mother and baby in the index pregnancy, and also increases significantly the risks in subsequent pregnancies.  Although the absolute risks are still relatively low, the relative risk when compared to vaginal birth is significant for a number of adverse outcomes.

I believe that there are a number of strategies that could be used to reverse this undesirable trend, but there are two which are worth bringing to the attention of the Review.  Firstly, there is a significantly higher rate of caesarean section in the private sector than in the public sector.  Whilst some of this is to do with differences in the population of birthing women who use the private sector there is ample evidence that the rates are inappropriately high, even when corrected for some degree of selection bias.  It does seem to be an odd situation, (as was pointed out during one of the workshops) that a women can choose to have an elective caesarean section in the private sector and be financially supported to make this choice, whilst an indigenous women is unable to choose to birth naturally ‘on country’.  The second area in which I believe there could be a major impact is to increase the midwifery input into natural childbirth.  There is a lot of low risk obstetrics which is practiced in the private sector with minimal midwifery input during the ante-natal period.  A move to midwifery models of care, either in the public sector, or encouraging the use of midwives in the private sector should have a significant impact on reducing the rate of inappropriate caesarean sections.

2. The unexpected impact on the public sector of supporting private obstetrics
About seven or eight years ago it would be fair to say that private obstetrics in this country was under significant threat.  The medico-legal and indemnity insurance crisis at that time was leading to a significant number of obstetricians choosing not to practice
private obstetrics.  Indeed, in 2001 the future looked bleak.  There have been three significant policy initiatives which have gone a long way to reversing this trend.  These  have been, in no particular order, subsidies for medical indemnity insurance premiums, tax benefits for those who take out private health insurance (as well as the 30% rebate), and most recently the use of the Medicare safety net to support private obstetric fees.  Whilst this has lead to a very positive change in the number of obstetricians choosing to work in the private sector, I believe this has had an  unexpected adverse impact on the public sector.  As you would be aware, a lot of high risk obstetrics is practiced in the public sector and this is where there is perhaps the greatest potential for skilled obstetricians to make a significant difference.

The current climate is so favourable that it is now possible for newly graduating obstetricians to choose to work exclusively in the private sector.  The incomes which are possible, as well as the fact that it may be easier to obtain a degree of work / life balance from this choice, has meant that many new graduates choose to work exclusively in the private sector.  It is possible to work effectively part time and limit the number of births to ensure a reasonable income without putting in the long hours which are often required in the public system.  As someone who has worked in the public system for all of his professional life, it now appears that the competition between the two sectors is such that it’s becoming almost non-competitive for the public sector.  It has always been difficult to recruit to full time salaried positions within the public sector but it is now becoming almost impossible.

I have major concerns for my own sub- speciality of maternal/fetal medicine as we are now seeing a significant drift to the private sector, even from those who have chosen to work full time in tertiary high risk obstetrics.  I believe that something has to be done to reverse this trend and to put some balance back into this situation so that full time employment in the public system is much more competitive with the kinds of incomes which are now possible in the private sector.

This trend is also having an impact on academic O & G. The increasingly small pool of full-time salaried specialists, who often have an academic role as well, are becoming the ‘work-horses’ for the public system. Thus, their ability to carve out an academic career is very limited.  If this continues, we can predict the demise of academic O & G in a short time.

You can read the rest of the letter here.

.

The awful irony about maternity care, as an important new report from the US makes clear, is that it is the field that helped launch the evidence-based health care revolution.

The irony arises because is a field which is rife with examples of non evidence-based practice. Interventions which have been proven to be of benefit are not routinely implemented, while other interventions are widely used despite being ineffective or potentially harmful.

The report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, is co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund.

While the report is firmly focused on US practice, many of its arguments are extremely relevant for Australia.  Just substitute “Australia” for “US” in the following excerpts, and see if it rings true…

“A large, growing body of systematic reviews is available to help clarify effects of maternity practices, yet these valuable resources are grossly underutilized in policy, practice, education, and research in the United States.

Practices that are disproved or appropriate for mothers and babies in limited circumstances are in wide use, and beneficial practices are underused.

Rates of use of specific practices vary broadly across facilities, providers, and geographic areas, in large part because of differences in practice style and other extrinsic factors rather than differences in needs of women and newborns.

These gaps between actual practice and lessons from the best evidence reveal tremendous opportunities to improve the structure, process, and outcomes of maternity care for women and babies and to obtain greater value for investments…

Although most childbearing women and newborns in the United States are healthy and at low risk for complications, national surveys reveal that essentially all women who give birth in U.S. hospitals experience high rates of interventions with risks of adverse effects…

Many maternity practices that were originally developed to address specific problems have come to be used liberally and even routinely in healthy women. Examples include labor induction, epidural analgesia, and cesarean section. These interventions are experienced by a large and growing proportion of childbearing women; are often used without consideration of alternatives; involve numerous co-interventions to monitor, prevent, or treat side effects; are associated with risk of maternal and newborn harm; and greatly increase costs.

Mothers, babies, and purchasers would benefit from giving priority to effective, safer care paths and using risky interventions for well-supported indications only or when other measures are inadequate.

The following practices would instead be consistent with the framework of this report: avoiding induction for convenience; using labor support, tubs, and other validated nonpharmacologic pain relief measures and stepping up to epidurals only if needed; and applying the many available measures for promoting labor progress before carrying out cesarean section for “failure to progress.”

Such protocols would require considerable change in many settings, but would lead to a notable reduction in the use of more consequential procedures and an increase in cost savings. Available systematic reviews also do not support the routine use of other common maternity practices, including numerous prenatal tests and treatments, continuous electronic fetal monitoring, rupturing membranes during labor, and episiotomy.

Systematic reviews also clarify that many effective maternity practices with modest or no known adverse effects are underutilized. Greater fidelity in providing these forms of care would lead to improved outcomes for many mothers and babies. In pregnancy, such care includes prenatal vitamins, smoking cessation interventions, measures for preventing preterm birth, and hands-to-belly maneuvers to turn fetuses to a head-first position before birth.

The many beneficial, underused practices around the time of birth include continuous labor support, numerous measures that increase comfort and facilitate labor progress, nonsupine positions for giving birth, delayed cord clamping, and early mother-baby skin-to-skin contact.

Best available evidence also supports providing access to vaginal birth after cesarean (VBAC) for most women with a previous cesarean.

Systematic reviews also identify many strategies for increasing both establishment and duration of breastfeeding and effective ways to treat postpartum depression. However, comparing current maternity care practice and performance in the United States to lessons from the best available research and to performance benchmarks reveals large gaps.

Consistent with common patterns of innovation in medicine (McKinlay 1981), obstetric practices such as episiotomy (Graham 1997) and electronic fetal monitoring (Graham et al. 2004; Hoerst and Fairman 2000) were adopted prior to adequate evaluation. Implementation of best evidence has proven to be extremely difficult following adequate evaluation.

Therefore, many practices that are disproved or appropriate for mothers and babies only in limited circumstances are in wide use. Conversely, numerous beneficial practices are underused because they offer limited scope for economic gain, are less compatible with predominant medical values and practices, have only recently been favorably evaluated, or due to other reasons.

Beyond average overall gaps between evidence and practice, use of specific maternity practices varies broadly across facilities, providers, and geographic areas. This is primarily due to differences in practice style and other extrinsic factors rather than differences in needs of mothers and newborns.

These gaps between where we are and what we could achieve present opportunities to improve the structure, process, and outcomes of care for mothers and babies and to obtain greater value for investments.”

“A lot changes in a week! Yesterday a study of all births in the Netherlands was released.

This paper found home birth was as safe as hospital birth.  The survey size was a whopping 529,688 births.  This figure is close to 2 years of Australian births.

The study found with well trained midwives and good transfer to hospital as necessary, homebirth was a safe option.

This raises issues on what we are doing wrong in Australia.  We have a Health Minister who wants to reform maternity care but is being held back by the powerful medical lobby.

At the same time we have women taking the huge step to birth alone at home rather than face the abuse or trauma previously experienced in the hospital system.

Where are Australia’s homebirth midwives? Oh, they are facing the chopping block.  For 7 years medical practitioners have had their indemnity premiums supported by the taxpayer but privately practicing midwives have been denied any assistance. Private midwives also cannot access Medicare funding and could face de-registration with planned national registration requirements come July 2010.

At the same time the Medicare safety-net has blown out (largely due to a 300% increase in payments to obstetricians).  This issue matters to the hundreds of thousands of women who will give birth each year in Australia.

As the highest volume area of health it should matter to all Australians, because in its current broken state it is negatively impacting many other areas. It’s time for Minister Roxon to put women and their families first.”

Here is the abstract of the new study:

Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
A de Jonge,a BY van der Goes,b ACJ Ravelli,c MP Amelink-Verburg,a,d BW Mol,b JG Nijhuis,e J Bennebroek Gravenhorst,a SE Buitendijka

TNO Quality of Life, Leiden, the Netherlands b Department of Obstetrics and Gynaecology, Amsterdam Medical Centre, Amsterdam, the Netherlands c Department of Medical Informatics, Amsterdam Medical Centre, Amsterdam, the Netherlands d Health Care Inspectorate, Rijswijk, the Netherlands e Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
Correspondence: Dr A de Jonge, TNO Quality of Life, P.O. Box 2215, 2301 CE Leiden, the Netherlands. Email ankdejonge@hotmail.com
Accepted 26 February 2009. Published Online 15 April 2009, An International Journal of Obstetrics and Gynaecology.

Objective: To compare perinatal mortality and severe perinatal
morbidity between planned home and planned hospital births,
among low-risk women who started their labour in primary care.

Design: A nationwide cohort study.

Setting: The entire Netherlands.

Population: A total of 529 688 low-risk women who were in
primary midwife-led care at the onset of labour. Of these, 321 307
(60.7%) intended to give birth at home, 163 261 (30.8%) planned
to give birth in hospital and for 45 120 (8.5%), the intended place
of birth was unknown.

Methods: Analysis of national perinatal and neonatal registration
data, over a period of 7 years. Logistic regression analysis was
used to control for differences in baseline characteristics.

Main outcome measures: Intrapartum death, intrapartum and
neonatal death within 24 hours after birth, intrapartum and
neonatal death within 7 days and neonatal admission to an
intensive care unit.

Results: No significant differences were found between planned
home and planned hospital birth (adjusted relative risks and 95%
confidence intervals: intrapartum death 0.97 (0.69 to 1.37),
intrapartum death and neonatal death during the first 24 hours
1.02 (0.77 to 1.36), intrapartum death and neonatal death up to
7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care
unit 1.00 (0.86 to 1.16).

Conclusions: This study shows that planning a home birth does
not increase the risks of perinatal mortality and severe perinatal
morbidity among low-risk women, provided the maternity care
system facilitates this choice through the availability of well-
trained midwives and through a good transportation and referral
system.

“Feminism is a dirty word, especially if you are a pro-establishment
columnist. Last week many media reports questioned the safety of homebirth.

Doctors were outraged at the death of 4 babies, without revealing any case
facts. Many have regarded women as incubators.

Not one mainstream piece has explored why a number of women feel the need to
give birth without any health professional, nor have they explored simple
tested legal concepts of informed consent and right of refusal.

It would seem far more sensible to herd all women into hospitals where they
can be controlled. Women cannot be trusted, especially those who challenge
the fierce medical domination of childbirth.

As an owner of a female body, I have taken it for a test run seven times.  As a healthy woman, I have chosen to use limited medical technologies, and resisted others. I took
ultimate control of my body and became responsible for the life growing
within me.

As a parent I continue to tread that path of rights and responsibilities.

I paid a price, however.  My decision to give birth at home with a
registered midwife was not respected or funded.  At the same time my taxes
paid for a system controlled by medicine. A system with virtually no
accountability, as illustrated by the case involving Dr Graeme
Reeves.

This case was extreme but lower level violence continues in maternity
wards every day. The prominent columnist Miranda Devine mocked this
violence.  How can this be tolerated?

With this environment how could a woman previously damaged by the system
feel safe?

We have a maternity health system that leaves one in 4 women experiencing
birth as a ‘battlefield’ and suffering debilitating post natal depression or
even post-traumatic stress disorder, usually reserved for soldiers and
victims of crime.

Whilst women cry out for a mainstream midwifery option that puts their needs
first, the medical establishment remains largely unaccountable.

Federal Health Minister, Nicola Roxon put her toe in the water, by
announcing a maternity services review. As expected, there were hundreds of
submissons from the women who have been denied their rights and are funding
services for others.

Yet pro-establishment columnists denounce them as a ‘vocal minority’ and
continue to deny them equity.

As a woman and lawyer, Nicola Roxon is well placed to design a maternity
system with the established principles of informed consent and right of
refusal at the centre.

Medical lobby groups use arguments about women’s “safety and wellbeing” in
order to tightly hold power and control. They have no track record of
respecting women’s rights.  Instead they engage in shroud waving and cripple
women with unnecessary fear.

Neither the church nor the state has the right to control a woman’s body.
Maternity reform must be based on the 3 R’s: rights, responsibilities and
respect.

Consumers have the right to a funded registered health professional in any
setting, and the responsibility to demonstrate they have made informed
decisions. They deserve these decisions be respected.

Health professionals have the right to funding and to give clinical advice
based on evidence. They have a responsibility to be satisfied that
consent/refusal was informed. They deserve the respect of the woman as an
educated professional but ultimately this respect must be reciprocated to
provide healthcare according to woman’s intent.”