Dignity is to maternity care, what justice is to law

A little about us.  Maternal Health Matters Inc. (MHM) is a non-for-profit incorporated organisation and registered charity that is working to improve maternal health by promoting and advocating Respectful Maternity Care (RMC) for all women during maternity care – pregnancy, childbirth, and in the time after birth. During this vulnerable and important time in a woman’s life, pregnant women are due respectful care; that is care that protects their fundamental rights to dignity, autonomy, privacy, equity and to be free from abuse and disrespect. RMC is not just a vision for the future—it is the bare minimum that should and can be provided to everyone, everywhere, now.

There is a once-in-a generation opportunity to show that women’s and girls’ health matters and requires that our leaders to be bold, brave and determined.  We ask that this focus includes a focus on maternity care and perinatal wellbeing; that is antenatal care, labour and birth and postnatal care as women transition to motherhood.

There are three main reasons to invest in respectful maternity care: public health, human rights and socioeconomic development.  There is ever increasing evidence that health promotion and prevention can be cost–effective. Promotion and prevention strategies work by identifying the individual, social and structural determinants of maternal health, and then intervening to reduce risks, build resilience and establish supportive environments for maternal health.

We believe that respectful maternity care is quality care and that the concept of “safe maternity” isn’t just about ensuring a woman’s physical safety or preventing her death or disability. It is respect for a woman’s basic human rights, including her autonomy, dignity, feelings, choices, and preferences.  Unfortunately, as we are certain you are aware, there is still a huge gap between the maternal care a pregnant woman should receive and what she experiences.

Pregnancy and the transition to motherhood is a critical “tipping point” on the road to gender equality and therefore a crucial focus for policy makers at different levels to address the well-being of mothers. Maternal health also ties into issues of economic inequality between genders, since a mother who is unwell, may be unable to participate in economic and social life.

Maternal health is an indicator of global health. Preventing post-natal depression, pelvic floor damage, iatrogenic harm to the mother and infant, and later life poor health for both the mother and infant due to birth harm, prematurity and lack of breastfeeding.

The World Health Organization and numerous studies have shown that respectful maternity care and midwifery continuity of care provide excellent outcomes for women and their infants.  Aligning evidenced based health policy with economic policy & human rights based social policy is a way to create healthy, robust and productive societies.  In the absence of financial incentives and political will, however, the status quo in Australian Maternity Services will continue despite good evidence that it is failing women.

We draw attention to the deep-seated resistance to addressing systemic disrespect for pregnant women in our health system that is thwarting progress towards improving the health and wellbeing of all Australians. A culture of mistreatment endangers both mother and baby, physically and psychologically, directly or indirectly.  This mistreatment of parents and newborns around the time of birth is often ‘normalised’ in the hospital culture and exacerbated by the lack of awareness of human rights, gender discrimination and deficiency in clinical empathy skills and compassionate viewpoint.

Reducing mistreatment and improving women’s experience of maternity care requires a focus on achieving a positive pregnancy experience, in a culture of respect.  There are many instances of physical and verbal abuse, humiliation, neglect and abandonment of care for women receiving maternity care.  At the individual and community level, there is tacit acceptance of mistreatment as customary and even expected.

Current maternity spending by government is about $7 billion per year.  Yet, with all the costly technology, pharmaceuticals and surgery we are not improving maternity outcomes.  In Australia we are seeing more prematurity, more infant mortality, more perinatal mortality and poorer outcomes from maternity care.  For example:

  • 1/3 women have birth trauma. 2/3 of this is due to disrespectful treatment.
  • 1/3 of women who experience birth trauma develop post-traumatic stress disorder.
  • Only 10% of women can access continuity of midwifery carer- the best evidence maternity care.
  • Caesarean rates at 36% are more nearly three times the recommended rate by the World Health Organization (WHO) – with significantly higher rates in city births and hospital births.
  • 43% of low-risk women having their labour induced. Many are reporting not having informed consent.
  • 11-fold variance in 3rd/4th degree tears.
  • Preterm birth rate of aboriginal babies is between 2 and 7 times that of non-indigenous babies.

The Australian Government Department of Health has developed Woman-centred care: Strategic directions for Australian maternity services – with the vision for all women to receive RMC however, it is yet to be implemented.  Our disappointment with the Strategic directions is that it does not reflect the 2009 NMSP and it doesn’t include a clear strategy for implementation with specific targets or accountability mechanisms.  We welcome the Labor Government’s review of the strategy.

We draw attention the 2019, Australian Clinical Practice Guidelines Pregnancy Care.  Once again there is no accountability mechanisms or sanctions for those who do not comply with The Guidelines.  Just as important, there is no corresponding consumer tool based on the Guidelines.  In the interim we have developed The Pregnancy Care Checklist— Australia. For the first time, women in Australia have a tool, based on the Australian Clinical Practice Guidelines Pregnancy Care to assist them to receive appropriate and respectful maternity care.  Feedback from women is that the tool assisted them to make an informed decision – for example the doctor ordered a diabetes test at 20 weeks when the guidelines recommend 26 weeks.  The woman felt confident declining the test at 20 weeks.  Doing the teat at 20 weeks may lead to an incorrect diagnosis with consequent over servicing and unwarranted interventions.

There has been funding to enhance maternity services for example:

What is absent from the initiatives above, is

  • a clear policy direction grounded in primary health, service integration, focussed on prevention not treatment and the mother baby dyad.
  • A focus on respectful maternity care; and
  • Midwife Led Continuity of Care – care that is cost effective and has better outcomes in the five key areas identified above for both mothers and babies.

Primary health care addresses most a person’s health needs throughout their lifetime.  This includes physical social and mental well-being and is people centred rather than disease centred. WHO states all people everywhere deserve the right care, in their community.

The Productivity Commission 2017 – Inquiry Report – Shifting the Dial: 5-year Productivity Review states on page 48 that international and Australian experiences with integrated care indicates that, if properly implemented, it leads to gains in health outcomes for patients, improvements in the patient experience of care, reductions in costs, and improved job satisfaction for clinicians. Therefore, any health strategy needs to focus on integrated care in a primary health model.

Recommendations:

To address the above concerns, we suggest Australia needs a rights-based maternity-care system.  The rights of pregnant women, including her entitlement to care and support based on her needs and preferences, should be enshrined in care standards and practices.  Our recommendations to achieve RMC include:

  1. Protecting human rights. To ensure all women receive maternity care that protects their human rights, engendering an ethos of dignity and respect requires:
    • that health professional curricula includes education on human rights, gender equity, respectful maternity care and working in partnership with pregnant women;
    • assessing the provision of Respectful Maternity Care in health service accreditation; and
    • the Commission for Safety and Quality in Health Care to develop and implement a Pregnancy Care Standard.
  1. Embedding Respectful Maternity Care in Policy. RMC is a legitimate and essential aspect of quality maternal care which needs to be incorporated into health policies nationally. Zero tolerance for any kind of abuse with robust accountability and redressal mechanisms should inform policy.
  2. Enhancing Governance and Accountability. Mistreatment of women represents a breakdown in the accountability of the system. Ineffective governance and weak regulation of maternity services must end to achieve respectful, quality maternity care.  Data holds the key to reform and good governance. Measurement of progress must incorporate respect, protection and fulfilment of human rights in the maternity care setting as well as reporting Women Reported Experience Measures and Women Reported Outcome Measures.
  3. Evidenced Informed Care – Midwifery led continuity of care. With the overwhelming evidence that midwifery continuity of care by a known midwife results in optimal outcomes for a woman and baby, and results in clinical, financial and consumer satisfaction outcomes that benefit families and the community, there needs to be a target of 50% of women of women receiving this care by 2025 and 100% of women receiving this care by 2030.
  4. Financing mechanisms and bundled payments. Focusing expenditure on evidence-based initiatives can reduce incidence and prevalence of harm and chronic disease for women and their infants. The return on investment for a wellness, primary health approach is consistently greater than costly remedial/intervention responses of chronic illness. Extending Medicare funding to midwives as primary maternity care providers is crucial to improving access to evidence-based maternal health care.  Despite midwifery continuity of care models costing less and having better outcomes for both mothers and their babies, the current financing mechanisms actively restrict access to this option and contribute access to affordable maternity care. We reference the MBS Taskforce recommendations.
  5. Addressing the needs of disadvantaged and vulnerable women. There is currently an unequal distribution of maternal health care resources among population groups; with those who are financially, ethnically and geographically marginalised experiencing the greatest disadvantages. First Nations women benefit from ‘Birthing in our Country’ Indigenous-led birthing programs, while those from CALD backgrounds benefit from culturally appropriate care.
  6. Providing reliable information on maternity care options. Women tell us that they frequently had little knowledge about care options. They also tell as they do not know what care to expect, what is appropriate.
    • Make available information about birthing options and the outcomes of each choice, as well as providing service level data on outcomes of care.
    • Women want unbiased information on what is appropriate maternity care. This can be achieved by providing a consumer tool/app based on the Australian Clinical Practice Guidelines Pregnancy Care.
    • The Clinical Practice Guidelines Pregnancy Care only cover the antenatal period. Additional guidelines are also required for labour and birth, and postnatal care.
  1. Equal indemnity for equal work. Remedy the unequal access to professional indemnity insurance for midwives.
  2. Consumer voice. Most importantly, a maternity service should be run in the interests of the public. Unfortunately, any worthwhile reforms of our maternity care sector to benefit women are usually vetoed by lobby groups and unions with their special interests and/or managing their personal risk – for example the ongoing pressure for women to have inductions at 39 weeks, the overuse of caesarean section.

Many of the recommendations above could be implemented within a very short timeframe and will address the demands of women calling for respect, quality and justice in the maternity care system.

The recommendations above will support achieving high quality, woman-centred maternity care, in a safe respectful environment.

  • Firstly, in providing maternity services that honour the childbearing woman’s human right to respect, autonomy, dignity and the attainment of the highest level of health.
  • Secondly, achieving maternity care that does no harm.
  • Thirdly, in achieving effective, efficient and appropriate use of the funds available, while maximising the health outcomes for society.
  • Finally reducing the productivity implications of lost work performance due to ongoing ill health following maternity care.

As a society until we value childbearing, acknowledging that a woman having and raising a child provides a community good at significant personal cost, nothing will change.