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05 May 2017

The following is largely taken from the AMA’s submission to the draft National Maternity Services Framework. The full submission can be viewed at:

The AMA is appalled that an opportunity for Australian governments to articulate a national vision to guide the future of public sector maternity services is being wasted.

The Queensland Government is leading a project to develop a national public maternity services policy, but the AMA has deep concerns about the conduct of the project and its outcome.

The draft National Maternity Services Framework is so lacking in substance, so general and generic, that it ends up providing no ‘framework’ at all. State and Territory health services could provide any kind of maternity services of any standard and still meet the Framework ‘requirements’.

Australia should be striving to have the best maternity services in the world – we are certainly capable of achieving this. Instead it appears that governments are ignoring the elephant in the room – the increase in recent years of infant mortality in some areas of Australia.

It is clear that the views of medical practitioners – the leaders of the provision of high quality maternity services in Australia – have been ignored. The AMA has already complained to the Queensland and Federal Health Ministers about the inadequate process for ensuring that the development of the Framework was informed by the full range of health care professionals involved in the provision of maternity services.

Medical practitioners involved in 21st century best practice maternity care include specialist Obstetricians, General Practitioners, Anaesthetists,  Psychiatrists, Obstetric Physicians, Pathologists and Haematologists. Not even the two key medical practitioners, obstetricians and general practitioners, were genuinely consulted.

The draft Framework does not explain how we will measure the success, or indeed failure, of maternity services in Australia. No quantifiable benchmarks have been provided for what constitutes success – no goals or standards are set. The key and obvious quantifiable measures – maternal and perinatal illness and death – are ignored in the proposed list of National Core Maternity Indicators.

The health of mothers and babies should be paramount, and yet this seems to be a secondary consideration in this Framework. Of course it is important that services are women-centred, recognise cultural differences and are equally accessible by all women. However, we should also recognise and be guided by the evidence and a much greater requirement to focus on the safety and needs of the other half of the equation in this care – the baby.

The fact is that obstetrician-led maternity services provide the best outcomes for mothers and babies. The practice of obstetrician-led care ensures risk is managed appropriately and any co-morbidity or extra precautions to improve patient safety are properly considered.

It is devastating for our obstetrician members to see mothers and babies suffer needlessly. All too often an obstetrician is only made aware of a labour problem once it has become acute or serious, sometimes many hours after it began to develop. The obstetrician is then expected to assume all responsibility for the care and outcome of the mother and baby.

The popular public hospital maternity services model tends to be midwife-led with obstetrician rescue. But sometimes it is too late for rescue.

An obstetrician has broad medical education in addition to their speciality training spanning 15 years, giving them the clinical and surgical skills to assist mothers and babies in all scenarios. Midwifery training is narrower in scope and much shorter, however midwives are often put in the position of managing a patient’s entire pregnancy and labour.

The Framework does not discuss appropriate models of care, let alone the available evidence supporting (or not supporting) different models of care. It does not provide any guidance to governments about the appropriate mix of health practitioners making up a high quality maternity service. It is not acceptable to dodge this issue by saying that Australian environments and conditions are too diverse for this to be prescribed. Access to maternity services cannot be ‘equitable’ if some women – particularly those in rural and remote areas – are only offered substandard models of care.

Related to this is the lack of acknowledgement or discussion about the workforce issues which exist in several states and territories, and are especially in crisis in rural and remote areas. There is little point in proclaiming a ‘vision, values and principles’ if there are insufficient positions for health practitioners, a lack of training opportunities, and adequate infrastructure, to support maternity services in rural and remote Australia.

Women put their trust in the health practitioner managing their care. Not only must this health practitioner be able to fully assess, monitor and address problems as they arise, but they should fully inform women of the risks to themselves and their babies of the choices they make regarding their maternity care plan, whether this concerns the risks of smoking through pregnancy or the risks associated with home births. The AMA fully supports women making their own decisions based on their values and preferences – as long as they are fully informed of the risks and benefits.

Finally, in relation to the Phase 1 Consultation Report for the National Maternity Services Framework that was released at the same time as the consultation draft Framework, the AMA notes that stakeholders were not provided with the opportunity to verify its accuracy.

The AMA understood that this report would be published in order to increase transparency about the consultation process undertaken to inform the draft Framework.

Instead, the report makes no mention of the late one-on-one meeting that was required with the AMA after it had not been included in the stakeholders identified for consultation. The AMA is listed as one of the stakeholder groups attending stakeholder workshops – which is not true. The AMA was not invited to participate in any workshops until it was too late to attend, and nor did it receive an on-line survey to complete. The views of the AMA provided at its one meeting with consultants are not reported.

The report also does not list which stakeholders were contacted, why they were chosen, or what lead time was provided to those stakeholders who were contacted to attend workshops. This is hardly an accurate report of the ‘consultation’ undertaken.

The AMA cannot support the draft National Maternity Services Framework in its current form. Our primary concerns are articulated above, and some specific comments on the draft Framework text are provided in an attachment.

The AMA instead supports the alternative framework being developed by the Royal Australian College of Obstetricians and Gynaecologists – Maternity Care in Australia. This document is evidence-based and provides considered, realistic, meaningful and systematic guidance for public sector maternity services aimed at improving outcomes for mothers and babies.

Chris Johnson

Published: 05 May 2017