The proposed closure of a thriving maternity service in Geelong — which follows a crisis in maternity care in other parts of Australia — should raise alarm bells for those who value the health of women and their babes.
The maternity unit at Epworth Geelong supports around 600 women and their babies every year. A decision on its proposed closure is expected within days, after Epworth HealthCare announced back in November its plans to close the unit by March 2023.
Obstetrician Dr Kara Thompson shares just what is at stake and why such service closures highlight a crisis in how we value this care.
A decision on the proposed closure of Epworth Geelong’s maternity unit is expected within days
We live in an era of intense focus on healthcare economics, where every aspect of medicine is put under a financial microscope. As clinicians, we must always demonstrate that our care is beneficial and safe.
Increasingly, we must also ensure that the care we offer is economically attractive, at least in the short term.
In addition, the overall ‘value’ ascribed to certain healthcare outcomes depends on entrenched social norms and is subject to bias, leading to inequality in health outcomes for women.
Indeed, if you happen to be pregnant and in need of hospital care, this poses a problem.
Pregnancy and birth do not conform neatly with hospital metrics where time is money and predictability is paramount. Where most clinical work and surgery can be scheduled into neat office hours to maximise staff utilisation, these rules are meaningless to babies. Newborns defy scheduling and arrive in their own time, often in the quiet hours between midnight and dawn.
Birth is usually safe for both mother and baby. Occasionally, and often without warning, it isn’t. Highly trained midwifery, obstetric, anaesthetic and paediatric staff must be on hand 24 hours a day, 7 days a week for an emergency that may or may not arise.
Like many aspects of women’s healthcare, birth can be messy, complicated and unpredictable. Get it wrong, and the stakes could not be higher. Clearly, there are easier ways for hospitals to make money.
Recently the Epworth Hospital announced a proposal to close its thriving maternity service in Geelong. This comes off the back of a crisis in hospital maternity care in rural Queensland, and the closure of several smaller regional maternity services.
Epworth’s announcement should raise alarm bells not just for those who use the private health care system in Australia, but for everyone who values womens health more broadly.
Maternity care and birth are unique. Viewing maternity care exclusively through the lens of immediate health budgets fails to recognise the unique health care needs of women and jeopardises the mental and physical health of women and babies in both the short and long term.
We expect all of our health care to be safe and of high quality. Yet few people are passionate about their care options when needing their appendix removed or a colonoscopy performed. Even fewer can recount, many years and often decades down the track, who cared for them, exactly what was said to them, and how their experience continues to affect them on a daily basis.
Pregnancy and birth are different.
Firstly, pregnancy is not a state of disease to be fixed and forgotten. It is a unique life event, with many celebrations and challenges. It evolves over many months, with repercussions that last a lifetime. Relationships and trust are formed in the early days of a pregnancy or fertility journey, and families return again and again to their chosen caregivers at different points in their reproductive lives.
Secondly, for the growing baby, the months in the womb will shape not only their lifetime health trajectory, but also impact directly on the health of future generations through genetic and hormonal signalling. There is simply no more important lifetime preventative health opportunity than the benefits available from supporting a healthy pregnancy and birth.
Thirdly, for women and birthing people themselves, the value of safe and supportive pregnancy care are immeasurable.
Despite everyone’s best efforts however, as midwives and doctors working in an over-stretched system, we don’t always get this right. Both physical and mental pregnancy and birth trauma are increasingly being recognised, with implications that can reverberate through a family for a lifetime.
Research tells us that one of the biggest protective factors against birth trauma is having a supportive and known caregiver. This is precisely the reason why so many women and birthing people choose private maternity care.
Public continuity-of-care midwifery teams or group practices are popular, but are not available to everyone. Australian-wide midwifery shortages mean public continuity of care will remain selective for the foreseeable future, and access to one of these programs usually comes down to luck.
Private obstetric care is one way for women to guarantee in advance that they will have access to the same person or team throughout their entire fertility journey. This journey might include preconception care, fertility treatment, management of early pregnancy loss or miscarriage, pregnancy and birth care including the option of induction of labour or caesarean birth, as well as postnatal care into the fourth trimester.
This choice is important. For many, it is the difference between an empowering and supportive pregnancy experience, and getting lost in a system that works incredibly hard, but can’t currently always deliver the level of personalised care or continuity that women need and deserve.
There is also no doubt that private hospital care is the safest place for women to give birth. Australian research consistently demonstrates that serious morbidity and mortality is lowest in private hospitals, even when adjusted for differences between populations.
The question is, should we care about supporting the option of private maternity care in Australia? Or should our focus be on improving public maternity services that are accessible to all? The answer to this is yes, and. Yes we should significantly bolster public maternity services across Australia. We should urgently improve access to public maternity care in rural areas, fund Birthing on Country initiatives and expand continuity programs. And we should fight for the option for women to access private maternity care.
There is no doubt that access to private maternity care is a privilege. However our focus can and should be on improving women’s health and maternity care in all settings, not limiting choice to either public or private, to the detriment of all.
Put simply, the private and public maternity systems in Australia are symbiotic. We cannot have a flourishing public maternity health care system without a functional private system.
Currently around a third of birthing people utilise private care. If private maternity hospitals close, the public system, already stretched, would reach breaking point.
Resources in the public hospital system would be diluted, limiting the quality of care for all birthing people. Access to birth suite beds would be reduced, choices around timing and mode of birth would be restricted, postnatal midwifery and breastfeeding support would be diminshed and women will be sent home even sooner after birth. In this scenario, no one wins. The safety and quality of care would be jeopardised for all.
To value and support the option of private maternity care is to support high quality pregnancy and birth care for all women.
To understand what is at stake, we only have to look to the UK. In recent years the tragic outcomes that can result when maternity care is systemically undervalued and under-resourced have been revealed. In 2022 an investigation into a single trust in the UK revealed that over 200 babies and nine mothers died in just under two decades. It was determined that all of them could or would have survived if they had been provided with better care. And these avoidable tragedies are just the tip of the iceberg. Underneath these figures are hundreds of babies with brain damage or birth injuries, and thousands of women suffering from pain, prolapse, incontinence, sexual dysfunction, post-partum depression, and post-traumatic stress disorder.
In any conversation around prioritising funding for pregnancy and birth, we must remember that our entire medical system is founded on entrenched patriarchal values. This results in stark differences in health outcomes for women and girls compared to men, whom the system was designed for. In particular, the reproductive health needs of women have long been ignored, misunderstood, shamed, and devalued.
Tackling this systemic ‘medical misogyny’ facing women has been recognised as a health priority by the Federal government. In December 2022 the formation of a new National Women’s Health Advisory Council was announced to specifically target gender inequity in healthcare.
This philosophy is also reflected in the Victorian Goverment’s recently announced Women’s Sexual and Reproductive Health Plan for 2022 – 2030, which emphasises the importance of having a wide range of services to suit the unique health needs of women and gender diverse people in our community.
The Epworth is a major maternity hospital offering world-class reproductive care to women in a regional area. Experience tells us that once maternity services are lost, they are almost never reopened. To allow this service to close is a backwards step that flies in the face of the government’s vision for improving women’s reproductive health.
Importantly, if this can happen in Geelong, one of the fastest growing regional areas in the country with a huge influx of young families and rising demand for maternity services, then this can happen anywhere.
The question is, do we truly value the health of women and their babies?
If the answer is yes, then we must actively fight to correct the inherent inequity in women’s healthcare that continues to this day. We must accept that birth is messy, joyous, unpredictable, and unable to be scheduled between 9 and 5. We must embrace the short term economic challenges of this. And we must recognise that a strong maternity system overall is dependent on the survival of private maternity care options.
We must do all of this if our modern society truly values the mental and physical health of women.
As a community, we must do everything we can to protect access to quality care and choice during pregnancy and birth.