Campaigning in Australia

AIMS Journal, 2009, Vol 21 No 2

Debbie Slater looks at improving maternity services for women in her new home

I don't think that people wake up one morning and decide that they are going suddenly to give a lot of their spare time to a cause - be it child poverty, climate change or whatever fires their spirit. It certainly wasn't in my case: more a slow realisation that there was an issue that meant a lot to me and was worth fighting for. In my case it was fighting for childbearing women of Australia to have equitable access to choices in how and where to give birth to their babies.

This is my story so far and it is not yet over, but now is a suitable time to reflect on the journey that brought me to where I am now.

In 2000 my family and I moved to Perth, Western Australia from the UK. In the UK, I had worked as an antenatal teacher for the National Childbirth Trust (NCT).

What I found out when I moved here is that the healthcare system in Australia is vastly different from the UK, and there are a number of significant issues which impact on how maternity services are delivered.

The funding of healthcare is complex, with a mixture of funding from state governments (Australia is a federation of states and territories, each with its own government) and from the Commonwealth of Australia.

There is a thriving private health system and private health insurance is encouraged by tax incentives.

Midwives are not autonomous practitioners and so, to all intents and purposes, most women cannot access maternity care with a midwife as their primary carer, although there are a small number of state-funded community midwifery programmes that do enable women to access care with a midwife as a de facto primary carer. Most of these programmes provide home birth services - home births accounting for less than 1% of all Australian births.

Maternity service provision for women living in rural and remote regions is particularly problematic, with some areas having no maternity services at all. In some cases, women are required to travel many thousands of miles to give birth.

Australian maternity services are dominated by the medical model. It should be pointed out that maternal and perinatal mortality rates are low, with the perinatal mortality rate in 2006 being 10.3 per 1,000 birth. The caesarean section rate is also higher than many other comparable OECD (Organisation for Economic Cooperation and Development) countries - nearly 31% in 2006.

It was clear to me that women were not able to access equitable choices in childbirth in Australia. Choice mainly centred on which obstetrician to choose (for women with access to private health insurance) or which hospital to choose. The choice of a home birth in many cases was not available, and access to a VBAC was difficult. Even birth centres based on a low-risk model seemed to exclude many women on the basis that they did not match the quite restrictive low-risk criteria.

What was also surprising to me was that many pregnant women did not appear to be aware of the fact that there were other models for birthing. They didn't seem to want to inform themselves of their options: preferring instead to delegate responsibility to their doctor : seen by many as the 'expert' who knew better than they did.

Perth is lucky to have community midwifery programme (CMP) providing home births. The CMP as it is referred to locally, was formed in 1996 by a group of midwives. A not-for-profit organisation called Community Midwifery Western Australia (CMWA) was set up to run the CMP.

When I arrived in Perth, I looked around for ways to engage with the local birthing community and in 2001 I came across an organisation called Maternity Coalition Inc. - an umbrella organisation of individuals and consumer and midwifery groups committed to improving access to choice in maternity services and, in particular, to lobby for one-to-one midwifery care as an option for birthing women. I also met with a fellow NCT antenatal teacher Melanie.

A group of women within Maternity Coalition were in the process of drafting a document called the National Maternity Action Plan (NMAP). The NMAP document set out a blueprint for maternity services and was based on the CMP model run by CMWA in Perth.

Melanie and I volunteered our services and it became our job to collate all the endorsements of the NMAP document. The two of us would sit there at our computers sorting out emails from all over the world from women and men who shared our vision.

The Plan was launched around Australia on 24 September 2002. In Perth, at the CMWA offices, a group of us sat and put the NMAP document to a small group of journalists. We later moved on to the local Parliament Building where a group of us rallied outside calling for change. Supportive parliamentarians helped us meet with and lobby individual MPs and so began my journey as a consumer activist.

Over the next few years I continued with my lobbying: writing letters to politicians, making statements to newspapers, networking and sometimes appearing on the TV. Of course, I wasn't the only one. All over Australia, similar groups of women and men were doing the same things and trying to get the message across to the policy makers and those in positions of power who are able to make the decision that change was needed.

In Western Australia, a number of reviews of maternity services were carried out over a number of years, the most significant to date being in 2007. Our persistence must have paid off and groups of us were invited to take part in the consultations to develop a new Maternity Services Framework, which was released that year. It enshrined the notion that maternity services should be women-focussed and that midwifery-led models of care should be implemented.

However, making an impact at a Federal government level was proving more difficult.

Meanwhile Australia was growing tired of the incumbent conservative government and looking for change. This was recognised and so began active lobbying of the opposing Labor party about the issue.

In September of 2007 a small but vocal group of midwives and consumers rallied outside the Australian Parliament House and received a commitment from Labor party representatives to looking at change. Just a few months later, the Labor Party was elected into government.

The Labor party certainly appeared to be a party committed to changing the status quo of the previous government which had been in power for 11 years: making an unequivocal apology to the stolen generations of indigenous peoples of Australia and signing the Kyoto Protocol.

Then, late in 2008, the Federal Government announced a review of maternity services. The process included receiving and considering submissions from all over Australia and inviting people (including consumers) to round-table discussions.

In February 2009, the report of the review was released to mixed reviews. There was no commitment to federal funding of home births - that being left to individual states to do. However, commitments to improving maternity care for indigenous women and women in rural remote Australia, to providing fur ther access to information and recommendations that midwives get Medicare provider numbers and access to prescribing rights and that the current inability of privately-practicing midwives to professional indemnity (PI) insurance were to be welcomed.

And, then, early this month (May 2009) the Federal Government announced in its budget that midwives would be given that Holy Grail: a commitment to providing the legislative framework (so-called Medicare Provider numbers, and prescribing rights) as well as PI cover (for midwives working in collaborative arrangements in hospitals and healthcare settings).

This has been an enormous achievement but there is still a way to go. We still don't know how this will work in practice. Home birth is not - at this stage - apparently covered, but it will allow midwives to work autonomously and provide care in a variety of settings and models: this is an enormous step forward.

There is still work to be done: we need to make sure that the opportunities provided by this initiative are seized upon. There is still the thorny issue of prospective legislation which will require all midwives from 2010 to have PI insurance to be registered. It is still unclear how the budget provisions will impact on privately practising midwives who provide home birth services.

The part I have played in all this has been very small: there are hundreds of women and men out there doing what they can. They sit on committees, write letters, meet with politicians, talk at conferences, rally and write submissions. They all do this while holding down jobs, parenting and all the other things that make up our lives. The point is that consumers can (and do) make a difference. Sometimes the journey can be very exhausting and it is very easy to become despondent: but all I can say to the rest of you out there doing the same sort of thing - keep your chin up and keep going.