How far would you travel to give birth? Half an hour? An hour? How about six hours?

This is a reality for many Australian women in rural and remote communities in Australia, who have been forgotten when it comes to planning maternity care.

Poor access to services is one reason why women and babies in remote Australia have worse health outcomes than their urban counterparts. So what can we do to fix it?

https://soundcloud.com/thinkhealth/29-how-do-we-improve-maternity-services-in-rural-australia

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Many midwives are calling for the creation of freestanding midwifery units (FMUs) (also known as primary midwifery units) that are local and can offer care to low-risk women.

Producer/Presenter: Ellen Leabeater

Image: Sarah and Cordelia at Ryde MGP. Image: Emily Mccluskey

 

Speakers:

Anne Keely – Midwife, Ryde Midwifery Group Practice
Sarah – Mother
Amy Monk – Lecturer, Faculty of Health, University of Technology Sydney & researcher, EMU study (Australia)
Celia Grigg – Researchers, EMU study (New Zealand)
Sue Kildea – Professor of Midwifery, University of Queensland
Caroline Homer – Professor of Midwifery, University of Technology Sydney
Lesley Barclay – Emeritus Professor, University of Sydney
Jenny Gamble – Head of Midwifery, Griffith University
Michael Permezel – President of Royal Australia and NZ College of Obstetricians and Gynaecologists

Links:

• Babies born before arrival to hospital and maternity unit closures in Queensland and Australia
• National Maternity Services Plan 2010
• Evaluating Midwifery Units (EMU): a prospective cohort study of freestanding midwifery units in New South Wales, Australia
• Primary Maternity Units in rural and remote Australia: Results of a national survey
• Reconceptualising risk: Perceptions of risk in rural and remote maternity service planning

START OF TRANSCRIPT

[Conversation in birthing suite at a maternity clinic in Ryde, Sydney]

Ellen Leabeater: And then you’ve got the bed as well?

Anne Keely: Yeah, but we normally don’t use the bed until after the birth really (laughs)!

Ellen Leabeater: Active labour!

Anne Keely: Yep, that’s exactly right…

(conversation fades down)

Ellen Leabeater: We’re in one of the birthing suites at a maternity clinic in Ryde, located thirty minutes north of the Sydney CBD.

(conversation fades in)

Ellen Leabeater (To Keely): ‘Keep calm and breathe’ is on the wall…

Ann Keely: Yeah! That’s right (laughs)!

(conversation fades down)

Ellen Leabeater (VO): I’m being shown around by a midwife named Anne.

Anne Keely: My name’s Anne Keely, I’m a midwife here at the Ryde Midwifery Group Practice and I’ve been working in the Group Practice since it started in 2004.

Ellen Leabeater (VO): Midwifery Group Practice is increasingly common in Australia. It’s where the same midwife will care for a woman during her pregnancy, labour and in the weeks following birth.

Anne Keely: On Friday night I had a first time Mum having her baby, and you know, she was in that almost-transition, before you get to that pushing stage, and she was like, “Oh, I can’t do this! I can’t do this! I want my epidural!” you know, which you can’t have at Ryde. Anyhow, we got her back on track and in the zone and then she progressed really quickly and had her baby naturally in the shower, not in the pool. And then she said, after the baby is out and the baby is on her chest, “Wow! I could do that again!” (laughs)…

Ellen Leabeater (VO): You might have picked up there that the woman couldn’t have an epidural. That’s because Ryde is not just a Midwifery Group Practice, but what’s called a freestanding midwifery unit.

Ellen Leabeater (to Keely): I remember there was a bit of controversy when this first opened. Has that died down a bit?

Ellen Leabeater: Yeah, it has. “I wouldn’t let my cat give birth in that place!” was one of the comments in the newspaper. But, yes…

(conversation fades down)

Ellen Leabeater (VO): Why the controversy? A freestanding midwifery unit, which are also known as primary midwifery units, is geographically separate from a hospital. They are maternity clinics run by midwives alone, which means there are no caesareans or forceps or any form of obstetrics, and definitely no epidurals.

[Music plays]

Ellen Leabeater (VO): It also means no safety net when something goes wrong, which make a lot of people worried.

[Music plays]

Ellen Leabeater: Hi, Welcome to Think:Health. I’m Ellen Leabeater. Today, we are taking a look at freestanding midwifery units, or FMUs. FMUs have had a chequered history here in Australia, but now local and international research is emerging to support their use. Over the next half hour, we will explore how FMUs work, why so few remain and whether they could be used to boost maternal and child health standards in rural and remote Australia.

[Music plays]

Ellen Leabeater: Back at Ryde, we meet Sarah and her daughter Cordy. Sarah is pregnant with her second child and is here visiting her midwife.

Sarah: Hi, I’m Sarah, and this is my daughter Cordy. And I’m pregnant with my second child and we’re having her at Ryde as well. Cordy was born at Ryde too.

Ellen Leabeater (to Sarah): How many months pregnant are you now?

Sarah: I’m nine months pregnant, so I’m due in about 2 weeks.

Ellen Leabeater: Really! You probably get that reaction a lot!

Sarah: (laughs) I haven’t talked to that many people, so I’m OK.

Ellen Leabeater: I don’t know that much about pregnancy, but you definitely don’t look 9 months pregnant!

Sarah: Thank you! I feel like it, but that’s OK!

Ellen Leabeater (VO): Ryde has a close relationship with Royal North Shore Hospital, which is 13km away in Northern Sydney. Royal North Shore is what’s known as a tertiary hospital – a hospital that has specialised staff that can care for life-threatening conditions. This is the hospital that Sarah originally booked into with Cordy, but they ended up at Ryde for an appointment.

Sarah: When we came to Ryde to do the booking and appointment, we just fell in love with the whole atmosphere of the hospital, the relaxed feeling, how it seemed a lot more natural. So, we were lucky enough that there was an opening for us to join the Midwifery Group Practice. We were very happy.

Ellen Leabeater (to Sarah): And at the time were you planning on having a natural birth?

Sarah: I was scared to death… I was open to C-section, I was open to drugs, I was open to whatever I needed…

Ellen Leabeater: But, you get none of those things here, right?

Sarah: Correct. So, I was actually OK with it. Your midwife is so experienced, and if she thinks that you need to get some extra help, she will tell you that and you’ll get transferred to North Shore, so I was very comfortable with the idea that I could try to get through it naturally, and if things didn’t work out, there was another option.

Ellen Leabeater (VO): Sarah did end up having a natural birth at Ryde. When she found out she was pregnant for a second time, she called up immediately to book in.

Sarah: As soon as I found out, I was like, “I want to get my referral in, to make sure I can get into the program again.”

Ellen Leabeater (VO): When women like Sarah book into the Ryde clinic, the midwives go through their medical history to make sure they are healthy. This sort of service is only set up for low risk women to give birth. If there are any potential complications, women need to go to Royal North Shore Hospital. Here’s midwife Anne again:

Anne Keely: So, we go through their medical history, their family history, if they have any underlying medical conditions, say, if they were already diabetic, they would be excluded from our care, or if they had any heart… like cardiomyopathy of something like that, that would be automatic exclusion. Or if they’d had previous surgery on their uterus for whatever reason, they would be automatically excluded.

Ellen Leabeater: These complications are outlined in the National Midwifery Guidelines for Consultation and Referral. The guidelines also tell midwives when women should be move to hospital – what’s known as a transfer. If it’s discovered they have gestational diabetes for example, they will need to birth at Royal North Shore. Women can also be transferred during labour.

Anne Keely: During labour, the most common reason for transfer is a delay in the labour, or babies in an awkward position, which means the labour is not progressing. So, that’s usually the most common reason to transfer in labour.

Ellen Leabeater: In the case of Ryde, which is located in suburban Sydney, women can be at Royal North Shore Hospital within 20 minutes.

Anne Keely: So, if it’s lights and sirens in the ambulance, we can be there in less than 20 minutes. And the gold standard for decision for caesarean to caesarean is 30 minutes, even in the tertiary hospitals. So if we say “here, this is what’s happening”, when we leave, we’ve even transferred from ambulance to theatre, and it’s been OK, so, we have that smooth transfer.

Ellen Leabeater: And it’s like this for all freestanding midwifery units. They will have the unit itself as well as the tertiary referral hospital that at-risk women can go to.

So, why do women choose to birth in a freestanding unit?

Anne Keely: The main motivation for women to choose to give birth in a freestanding unit is proximity to home. The big thing is that women want to give birth close to home and they want to access a Midwifery Group Practice model of care, and you know, they usually have a philosophy of childbirth that it’s a natural event that is unlikely to require intervention.

Ellen Leabeater: Convenience is one thing, but research is now emerging that women who give birth in FMUs have better outcomes than those who birth in tertiary hospitals. Amy Monk is a lecturer in the Faculty of Health at the University of Technology Sydney. Amy has looked at the outcomes for women who birth in freestanding units, in what’s called the evaluating midwifery units, or EMU study.

Amy Monk: Women who plan to give birth in freestanding midwifery units were significantly more likely to have a spontaneous vaginal birth. They were significantly also likely to have a spontaneous onset of labour, so they didn’t need Syntocinon to have their waters broken or anything to get them into labour. They were also more likely to have a normal amount of blood loss, and they were also more likely to have what’s called a physiological management of third-stage of labour, which is where an injection is not given to a woman to help her placenta come out.

Ellen Leabeater: The outcomes are positive for babies too.

Amy Monk: The babies of women in the freestanding midwifery unit group were significantly more likely to be breastfed at birth, to be exclusively breastfed on hospital discharge, to be of normal birth weight, which is between 2.5 and 4.5 kilos, and they was significantly less likely to be admitted to special care or neonatal intensive care, and there was no significant difference between the freestanding unit babies and the tertiary unit babies with their ATGAR score, which is a measure of how well they are at birth.

Ellen Leabeater: The EMU study followed 500 women who planned to give birth at a freestanding unit, although only half ended up doing so. The majority of those women transferred to a tertiary hospital during their pregnancy, and only 13% during labour. This shows that the need to transfer during labour is low, because the women who are cleared to birth in this unit are low risk. Amy says there is no conclusive reason why their outcomes are as good as they are, but she has a good idea.

Amy Monk: We don’t know what it is… and this has come up in other studies as well – that often, freestanding unit women do better. We don’t know what it is about these women, but certainly we know that midwifery lead models of care have positive outcomes for women with low-risk pregnancies and actually for women with higher risk pregnancies as well. But also, I think there has to be an element of women being allowed to labour.

Ellen Leabeater: The EMU study also had a New Zealand arm to it, however the study was cut short by the 2010 Christchurch earthquake. The results from that study are too small to be statistically significant, but they are comparable to the Australian Research and other international research. While here in Australia, you can almost count the number of FMUs on each hand, New Zealand has between 54 and 57 depending on what definition is used to describe the units. For example, some units only offer antenatal and postnatal care, not assistance at birth. Many of these units are in remote locations, and are hours away from a hospital by car, and given New Zealand’s mountains and cold weather, can be difficult to access should a transfer need to occur. But Celia Grigg says despite these distances, the transfers required were not urgent. Celia is the author of the New Zealand arm of the EMU study.

Ellen Leabeater: So what happens in the case where you need to be transferred and the nearest hospital is a few hours away.

Celia Grigg: Then you transfer as available. Geographic conditions and weather conditions sometimes slow that transfer down. I mean, most transfers are not obstetric emergencies or neonatal emergencies. The majority of transfers are due to slow progress in labour. Nearly two-thirds of the transfers in the EMU study were non-emergency.

Ellen Leabeater: The research coming out of the EMU study backs up previous research from the United Kingdom and Canada about the effectiveness of these units. Canada especially is comparable to Australia because of the vast distances between FMUs and hospitals. Sue Kildea is a Professor of Midwifery at the University of Queensland. She has been looking at the potential application of FMUs in rural and remote Australia.

Sue Kildea: Well, if you’re talking about our remote communities, we need to look at Canada to see the most similar sort of comparison. They’ve got places that are four hours flight from the tertiary centre where they run primary units, and one of them has been going since 1985, and it’s got amazing outcomes. Incredible outcomes.

[Music plays]

Ellen Leabeater: And this brings us to our second question. Could these units be used in rural and remote Australia? If Canada and New Zealand can have freestanding units so far away from a hospital, could it be possible here? Having a freestanding unit is all well and good for women in a metropolitan city, who are spoilt for choice as it is, between public and private, midwife or obstetrician, hospital or birth centre or freestanding midwifery unit. But for women in rural and remote areas, there is only one choice. Head to the nearest hospital, which could be hours away. Sue Kildea again:

Sue Kildea: OK, well, if you’re in Tennant Creek, you have to go to Alice Springs. And there’s a problem with transport between Alice Springs and Tennant Creek, so women might have a newborn baby, they might get discharged from Alice Springs Hospital the second day after they’ve had their baby. They have to then get on a bus and they have to hold their little baby for about six hours or so as they travel up the highway, until they get dropped off at Tennant Creek at about 3am in the morning, and you have to hope that someone’s there to pick them up.

Ellen Leabeater: Currently in Australia, maternal and perinatal mortality is higher among rural and remote families, partially due to poor access to services. Women can be subsidised for having to travel to have their baby, for example, to help cover hotel costs. But it often means women have to give birth alone. Caroline Homer is a Professor of Midwifery at the University of Technology Sydney. She says even though moving women is perceived to be in their best interest, it often opens up another can of worms when they arrive in the next big town.

Caroline Homer: Women have been put on aeroplanes and shipped out to the next big town to sit down and wait until they give birth. And that has big ramifications, not only on your life, but it also increases interventions like induction of labour or elective caesarean section, because women don’t want to sit in the next town for weeks on end, and so the kind of enthusiasm to get the pregnancy over and done with goes up. So women…. “forced” is a strong word, but they’re almost given no option but to have an induction of labour, move the labour along, try and get their baby out so they can go home again.

Ellen Leabeater: We said that there was one choice when you are pregnant in rural Australia. Well, there is actually another choice. Because women don’t want to leave their homes and their families, many end up hiding their pregnancy from health practitioners and choose to give birth at home unassisted.

Caroline Homer: Towards the end of pregnancy when they know, the nurse in town or the midwife in town or the GP in town is going to say, “It’s time to move.” Then they won’t go back. So, essentially, in those last few weeks of pregnancy, they don’t receive any care, because they know they’ll be scolded or roused upon if they make it clear that they’re not moving. And that must be very scary for those women as well towards the end of pregnancy, because they’re making a decision that’s going against the system, and then they’re choosing to have a baby without skilled caregivers, and no one needs to be put in that position.

Ellen Leabeater: Lesley Barclay is an Emeritus Professor from the University of Sydney. She says women not presenting antenatally is causing deaths.

Lesley Barclay: That’s what’s happening in some of our rural areas now. Because women are avoiding antenatal care – it’s too expensive, it’s too difficult to get to – they don’t want to identify to the health system that they’re pregnant, we’re missing antenatal care, and one of the reports in the paper we’ve just presented and had published, is of a woman who is finally examined when she came in with her husband to see the doctor. She was 41-42 weeks, and her baby was stillborn.

[Music plays]

Lesley Barclay: She had had no antenatal care. She was looking after a sick husband, she had other children at home… she was not in a position to travel to a regional centre hundreds of kilometres away to wait for the birth.

[Music plays]

Ellen Leabeater: You’re listening to Think:Health on 2ser 107.3. Online at 2ser.com or on your favourite podcast app.

[Music plays]

Ellen Leabeater: Today, we are discussing whether midwife only maternity units are a viable option to improve maternal and infant outcomes across Australia. The lack of choice for women in rural and remote Australia has only become an issue in the last two decades, as governments failed to recognise the need for local maternity services. But it wasn’t always this way.

Jenny Gamble: Hi, I’m Jenny Gamble. I’m Professor of Midwifery and Head of Midwifery at Griffith University.

Ellen Leabeater: Prior to the 1990s, Australia had many small rural maternity units. These were staffed by midwives and assisted by the town GP who had obstetric experience. However, in the late 90s and early 2000s, many maternity services started shutting their doors. This was due to a combination of factors, such as funding, a desire to centralise and workforce shortages. Health departments wanted these units to run as 24 hour obstetric services, but couldn’t recruit obstetricians, or more commonly GPs with obstetric experience. When this happened, the unit usually shut. Mareeba was one such maternity unit which came within a whisker of experiencing this fate in 2005. Mareeba is a town about 100km from Cairns.

Jenny Gamble: Mareeba is about an hour west of Cairns in the tablelands, and they had been running a sort of mixed service/hospital service with GP obstetric support and they were running out of GPs. And despite having highly-skilled midwives, they were going to close the service and they did actually close the service.

Ellen Leabeater: Jenny Gamble was the Queensland President of the Australian College of Midwives at the time Mareeba was closed in 2005. Queensland Health said that they were closing the unit for six months because they couldn’t find a doctor to provide obstetric care. Jenny said this was common practice at the time in Queensland.

Jenny Gamble: So, I think everybody knew… I mean Queensland Health just say six months because they don’t want to say, “We’re going to close it permanently,” because that’s even more unpalatable, and they think they can get away with saying, “We’re just going to close it for six months.” But, if the Mareeba Maternity Unit closed for six months, then that would be the death knell of it, because you’re not going to have the midwives stick around for six months. What are they going to do over that six month period?

Ellen Leabeater: If the Mareeba Unit closed, women would’ve had to travel up to an hour to Cairns Hospital to give birth. The midwives working at the Unit had come up with and solution to keep it open, by offering midwifery lead care for low-risk women. Importantly, the Mareeba community lobbied to keep the Unit open under this model.

Jenny Gamble: Their activity – they rallied in the streets, they held a meeting in the town hall, they wrote letters to everybody, they hit the press, they really engaged heavily in lobbying to keep their maternity service open, and then they described what and how the maternity service could stay operation and still cover off on providing a high quality service with good attention to women and their babies.

Ellen Leabeater: The Mareeba Unit ended up only closing for six weeks before it was reopened under a midwifery-led model. Obstetrics have since returned to the maternity clinic, meaning it is no longer a freestanding midwifery unit.

Jenny Gamble: Women want to have birth that is safe and feels safe. They want it to be local and feel local. They want to have services that leave them with choice and control, and they want some continuity, so, they saw no reason why they couldn’t have their baby locally, and of course, there is no good reason why they couldn’t.

[Music plays]

Ellen Leabeater: Unfortunately, many regional and remote units in Australia were not as lucky as Mareeba. Between 1995 and 2005, 130 of Australia’s small rural maternity units closed. Statistics about how many remain are hard to gather. If a large mine closes in a town, the maternity services usually close too, meaning the number of units is constantly in flux. A study from this year has found 36 small maternity units remain. 17 of these are freestanding midwifery units. Of the remaining 18, nice offer post and antenatal care only, and the other nine offer obstetrics. The reduction of services has also had an impact on the amount of babies born before arrival. Babies born before arrival is exactly as it sounds – babies born on the side of the road before they reach hospital. Sue Kildea was the author of that study.

Sue Kildea: Well, we found that the rate per thousand… the sheer number has gone up definitely, but the rate has gone up too. And we then looked at it in relation to the number of units that were available, and we saw that not only had the rate gone up, but it was directly correlated with the closure of units. So as units closed, the number of babies born before arrival went up.

Ellen Leabeater: Although Sue’s study says it cannot determine whether babies born before arrival are by choice or accident. In 2010, the national maternity services plan recognised the importance of women being able to birth locally, and recommended State and Federal government help to increase access to midwifery lead models of care, including in remote locations. But Michael Permezel isn’t convinced freestanding midwifery units are the silver bullet. Michael is the President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. He says that complications arise even in what otherwise looks like the healthiest of pregnancies.

Michael Permezel: The problem is however that even in women without any risk factors identified who have an apparently uncomplicated normal pregnancy – a very small number of those will go on and develop sudden and severe complications in labour, either for themselves or their baby, totally unexpectedly. And it’s those women that we’re most concerned about, with respect to freestanding maternity units. The number is low – how low? Difficult to say. It depends on how quickly the resources are available, because obviously if it’s a less sever complication, there may be time to transfer by ambulance. But you’re talking one in several hundred where the complication may be such that the life of the mother or the baby is endangered by birthing in a remote or rural location, without any access to emergency obstetric facilities.

Ellen Leabeater: Michael is critical of the use of FMUs in urban areas, however he recognises they may be of value in remote communities, so long as women recognise the risks involved.

Michael Permezel: In an urban or metropolitan setting, there seems little point in women delivering in a centre that doesn’t have timely access to urgent care, because there are other alternatives available. In remote and rural centres, that situation does change, where this very low incidence of needing urgent care has to be balanced by the woman against all the issues of having to travel or perhaps live or reside for a time in an urban centre, or the nearest available centre where such care can be given.

Ellen Leabeater: However, all the midwives that Think:Health spoke to agree that regardless of whether these units are in rural or urban Australia, they are of great benefit to women. Caroline Homer again.

Caroline Homer: I think freestanding midwifery units in many rural towns in Australia would make an enormous difference. There would probably still be women who should move – women who have risk factors, women who may need obstetric intervention or medical intervention during their labour and birth should be in a town where those things are available. But for women who have had a straightforward normal pregnancy, I think particularly women having their second or subsequent baby… we know there’s really good evidence around freestanding midwifery units, particularly for women having their second and third babies. Those women should have the option to stay in their town, to give birth in their community with the midwives who are in that town.

Ellen Leabeater: Sue Kildea says that for rural and urban women, these units promote normal birth.

Sue Kildea: There’s a paper from Canada that’s really interesting, and it looks at maternity services and shows that when you don’t have enough maternity services, you get poor outcomes, and that’s pretty clear. You can go across the developing world and go out to our remote areas and our very remote areas and you’ll see that there are just not enough services there to get the outcomes that we would want. But it also shows that when you’ve got too many services, it leads to over-servicing. And I think that’s pretty much what we’ve got in Australia. We’ve got caesarean section rates that are more than twice what they should be, according to the World Health Organisation and according to many other countries that have got much lower caesarean section rates than us. Yeah, I think we need to go back to the basics a bit. We need to go back to normal birth, we need to go back to having these primary units that really promote normal birth.

Ellen Leabeater: She also thinks it will save money.

Sue Kildea: I’m absolutely certain this is going to save money. If we had primary maternity units across the country, our normal birth rate would go up. It would skyrocket and bring our caesarean section rate down. Caesarean sections cost between two and three times more – depending on what happens – than a normal birth, so it’s absolutely not about money. I think it goes back to that fear of birth, that fear of birthing a long way away from a tertiary service. I get that. I really get that, but the international evidence is suggesting that we should really try it.

Ellen Leabeater: Michael Permezel says he would like to see more obstetricians, anaesthetists and paediatricians in rural Australia.

Michael Permezel: I think that there’s a lot of work that needs to be done on attracting to services to rural centres. One of the issues that hasn’t been adequately addressed is looking at strategies to improve the rural workforce in terms of anaesthetists, paediatricians and obstetricians. I think this is something that people talk about, but there hasn’t been a huge amount done to improve that rural workforce. It is just such an important thing that our medical schools and our training programs develop a much greater focus on getting doctors into rural locations, so that these appropriate facilities, properly staffed by midwives, obstetricians, anaesthetists and paediatricians can be placed at locations where women don’t have to travel far to have a safe birth of their baby.

Ellen Leabeater: Caroline Homer says that at the end of the day, these units will go where women are pushing for change, although she’s not convinced the right people are listening just yet.

Caroline Homer: The only incentive to open them up again, I see, is women’s push, you know, the communities saying this is not good enough anymore. We also now have a lot of research, and the EMU study is one good example and then there are other studies from around the world. So there’s now the evidence, and there is the consumer movement push. Women around the country are saying to their local health districts, their local health ministers, their federal ministers, we want a better deal.

[Music plays]

Caroline Homer: But sadly they have been saying that now for a long time and I’m not convinced they have a better deal.

[Music plays]

END OF TRANSCRIPT