Closing the gaps in Australian maternity care together – Dr Wendy Burton

What if we decided to sit down and talk to each other? To identify the gaps and work together to close them?

Where do I begin? There are so many opinions and so much angst around the roles and responsibilities of the various members of the maternity team – principally this involves midwives, GPs, GP obstetricians and obstetricians, but it is wider than that. Anaesthetists, including GP anaesthetists, neonatologists, radiologists, pathologists, physiotherapists, dietitians, pharmacists, psychologists, psychiatrists, maternofetal medicine specialists, geneticists and genetic counsellors, early childhood nurses, family, friends, peers and others all play valuable parts in the care of women in the preconception, antenatal, intrapartum, postnatal, neonatal and early childhood period—the first 1000 days concept.

Somewhere along the way it seems we stopped talking to each other. Poor communication between clinicians and in particular between the hospital and community sector clinicians is a constant and recurrent theme. Somewhere along the way it seems we stopped respecting each other. Doctors dismissive of the skills of midwives, obstetricians dismissive of the skills of GP obstetricians and GPs, and midwives dismissive of the skills of doctors. Some midwives and some internationally trained obstetricians are not aware of the skill set within those GPs who hold a RANZCOG diploma and especially the Advanced RANZCOG diploma.

The cost

This lack of respect and hostility flows over to the interactions we have with women and with each other, harming clinicians of all types and putting women and their families at risk. GPs sit in the middle, fully aware of our interdependence and the importance of team work and clinical handover.  Women benefit from the skills of GPs, midwives, obstetricians and other specialists and I find myself wondering how on earth things got this bad!

Somewhere along the way it seems we stopped funding the private sector in any way that could be considered reasonable with most antenatal visits with GPs, GP obstetricians or obstetricians attracting a rebate of only $40, regardless of the amount of time spent with the woman. This results in either large out-of-pocket expenses for women or short appointments. The fee charged, be it with a gap or bulk billed and hence $40, has to cover everything. Rent, insurance, electricity, internet, computers, receptionists, nurses, vaccine fridge, disposables, holiday pay, superannuation, sick leave, indemnity insurance (more than $100 000/year for a busy obstetrician) and so on, leaving well under half the total that total as taxable income for the clinician.

For this reason, women without Medicare or private insurance have to pay my local public hospital $371 per visit, as well as a deposit of $15 000 to cover the birth itself.  But financial considerations are often cited by hospital staff when talking to women referred to hospital by GPs. Because, under our split funding system, women in public care pay no out-of-pocket expenses for the much more expensive public care versus short appointments or out-of-pocket expenses for women in private care. Private midwives also have appallingly low Medicare rebates and rules mandating long appointments.

Somewhere along the way it seems we decided that hospital-based specialist care, be that midwifery or obstetric, was better than care with a community-based generalist. Despite research showing that societies with a well-informed, appropriated-funded primary health care system outperform societies with hospital and specialist focused systems.

Somewhere along the way we decided that the answer to gaps in the knowledge of generalists was to remove women from their care, that way guaranteeing that the gaps would never be closed. Women referred to antenatal clinic for shared antenatal care who returned postpartum, if at all, with little or no communication about their journey. Opportunities lost to establish or build upon relationships which will help women and their families navigate the physically, emotionally and psychologically complicated journey they are undertaking.

It doesn’t have to be this way

What if we decided to sit down and talk to each other? To identify the gaps and work together to close them? Develop local solutions which respect the importance of the role we each play and that seeks to use our complimentary skills in ways that safety net women and families.

This means that care will most likely look different in Roma to how it looks in Brisbane, that GPs in Hobart may play a different role to a GP in Broome or Wodonga, but welcome to Australia! Our geography, our variable population density and our funding models create challenges that the UK and NZ simply don’t face, so I believe that looking to those healthcare systems for our solutions is unhelpful.

Why does this matter? Because, in the best of GP care, continuity is measured in decades and generations and, for GP obstetricians, can include intrapartum care. Because long after the birth of a child there is a family getting to grips with the next part of their journey and while having a positive pregnancy and birth experience is important, so is the care they receive before the pregnancy and well afterwards. Because if we innovate, integrate and communicate well surely women can have better experiences throughout. Because working together and communicating effectively and efficiently has been demonstrated time and again to improve outcomes.

Because having a well-trained, highly skilled, community-based GP workforce is safer than a deskilled, isolated one. Because of the ripple effect, where what happens in the cities affects the skill base available in the regions and beyond to our rural and remote centres. If we want to have functional, safe, local birthing around the nation (and everything that I hear says that we do) then we need to get on with getting along a whole lot better than we are. If GP obstetricians and GP anaesthetists can’t keep their skill set honed by regular sessions in the busier birthing units, we will have avoidable adverse events which will then be used as evidence for why we need to close smaller birthing units.

This isn’t rocket science. But it isn’t being done consistently around the nation and this has to change. The health outcomes of our nation depend upon it.

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