Overall, AMAQ maternity submission is inflammatory and unhelpful. In a situation that
requires improved integration and collaboration between care providers, AMAQ submission
is a transparent bid for tribal supremacy. In the context of tightening financial constraints,
they propose a service model that would greatly increase cost, without evidence of being
able to improve outcomes. We know we need to improve access to care for marginalised,
rural as well as indigenous women, but the proposed AMAQ model can only be delivered in
large urban hospitals. Its reference to the evidence is cherry-picked at best, and ignores the
great body of papers and systematic reviews that support the safety of primary care models
of maternity care in the context of access to medical care when required.
Private Obstetric Care
The AMAQ paper makes repeated and unhelpful comparisons between Australia's public
and private maternity services, and the recent NZ paper comparing midwifery and obstetricled
maternity care. In both cases the broader population of women is being compared with a
group that has the affluence and social status to enable employment of a specialist doctor
for their primary maternity care. The evidence on the social determinants of health predicts
that this group of women can expect better outcomes in any measure of health,
independent of model of care, so it is not possible to find causation of outcomes such as
mortality from specialist medical care. It is pretty shameless for AMAQ to criticise public
hospitals, which care for the poorest, sickest women who may have received minimal health
care and who suffer the worst outcomes. The paper overlooks the huge excess cost of
private care, the indefensible rates of medical and surgical intervention in private maternity
care, and the consequences for women and families of excess interventions, both
emotionally and physically.
New Zealand's maternity care system is built on community-based primary midwifery care,
with well-developed access to public hospitals and collaboration with hospital medical staff.
According to WHO, New Zealand's perinatal mortality rate has been the same as Australia's
for a long period, while having a significantly lower rate of caesarean section. The facts
about New Zealand do not support the AMAQ claims.
Key claims unsupported by evidence
The main claims in the AMAQ paper stand as opinion, unsupported by a broad
consideration of the evidence. Some examples:
"public hospital maternity services are led by midwives"
Public maternity services employ a range of models of care, with a range of balances of
professional responsibilities. Some are medically dominant, others give midwives increased
clinical responsibility. If the AMA/NASOG propositions had merit, the differences in
outcomes would be evident in current models. Public hospital models, which increase the
clinical responsibility of midwives, have been shown to deliver improved outcomes, not
worse. This does not suggest it is better to have less obstetric input to care, it shows that it
is better to have greater continuity of carer and a stronger primary care base, while having
access to medical input and acute care when indicated rather than routinely.
"it is possible for a labouring mother to have no obstetrician review unless a midwife requests
obstetrician review (which is not mandatory)"
The ACM National Midwifery Guidelines for Consultation and Referral are supported by
RANZCOG and provide professional guidance to midwives on when women require medical
care. The AMAQ paper's claims that midwife referral to obstetricians is "suboptimal" and
"ad hoc" indicate ignorance of regulated midwifery practice.
"decreasing direct involvement of the highly trained obstetrician is a significant cause of the
inferior outcomes endured by mothers and their babies in public hospital maternity services"
This statement infers that public maternity services have increasing rates of poor outcomes,
due to model of care, over time. There is no evidence of increasing rates of poor outcomes
in public hospitals over time, and there is high quality evidence of improved outcomes in
midwife-led primary care models.
"compelling data that the morbidity and mortality rate for mothers and neonates is
significantly lower in the private system"
This is raw, or at best slightly filtered data, which does not meet the standard for evidence.
The evidence supporting midwifery continuity models depends on difficult, expensive, time
consuming, randomised control trials. There are no similarly robust research trials showing
that providing women with private specialist care improves maternity outcomes relative to
other models. It is also difficult to collect strong evidence on rare events, which are so often
determined by socio-economic or other uncontrollable factors, such as perinatal or maternal
mortality. When the most complex obstetric and neonatal cases tend to end up in the public
system, it becomes even more difficult to accumulate strong evidence.
It would be irresponsible not to consider the question of cost. Under the AMAQ proposal,
the historically increasing professionalization and clinical skill level of midwives would be
reversed, and obstetric staffing would be greatly increased. Small maternity units would
close (at great cost to communities, if not the hospital authorities), and services would be
concentrated in larger hospitals. Without a major increase in health service funding, this
would result in significant loss of current services, presumably low-cost primary services, in
order to concentrate funding on high-cost acute services. This proposed direction is in
opposition to the international recognition of the efficiency and effectiveness of building a
strong foundation of primary health care, and towards the American model that delivers
relatively poor population health at exceptionally high cost.
The problems in Rockhampton need a much more systematic analysis than the AMAQ paper
offers. The views of maternity consumer representative are there are systemic problems in
Rockhampton, evident for several years. There had been long-term difficulties maintaining
obstetric staffing, and persistent stories of problems with midwifery staffing and morale.
These things point to problems in leadership and culture, not a lack of supremacy of any
particular professional tribe. The engagement of the AMA in the situation is further evidence
of failure of local relationships and culture: in our experience of maternity care politics, when
the AMA becomes engaged in a public hospital issue, it is evidence of serious failure of local
leadership and culture.
The AMAQ paper represents the prejudices and aspirations of an elite group of private
practice specialists. It does not address the evidence in a systematic way, and its proposals
are divisive, ineffective and unaffordable.