My big idea
This weekend there are 1000 or so people meeting in Canberra for the 20-20 Summit. All the delegates have been sorted into 10 groups, and each group is supposed to come up with "one big idea and three concrete policy suggestions - one of which must be cost free." (The Sunday Age, page 1, today)
I am one of the thousands of ordinary Australians who was not invited to participate, and who could not have afforded to go anyway. But I did send my comments to the summit website a week or so ago.

My big idea is: PROMOTE HEALTH IN BIRTH

The three concrete policy suggestions are:

1. reform funding structures to enable mothers to choose their leading professional care provider, a midwife or a GP doctor, who becomes their known and trusted carer ('case manager') and seeks to be with the woman in labour and provides guidance through the episode of care. Restrict access to specialist obstetricians, so that only women who have complications are referred to obstetricians. This reform would not result in increased costs to the health system, and would possibly reduce costs.
   
2. remove restrictions to midwifery practice that prevent us from working to the full scope of our qualification. This is also cost neutral.
   
3. educate the public and the midwifery and medical professions in health promotion through protecting and promoting healthy natural processes in pregnancy, birth and early parenting. This would cost money, but the savings in terms of health expenditure would quickly make it worth while.
   

This is my submission to the 2020 summit. It could not be submitted until I reduced what I wanted to say to less than 500 words!

I propose reform of basic maternity services, thereby improving the health of mothers and babies, while at the same time addressing workforce issues, use of medical facilities, supporting communities and families, and addressing health promotion for all Australian mothers and families, including those in poorer socio-economic groups and indigenous peoples.

The key to reform of maternity is to understand that birth is not an illness (WHO 1996. Care in normal birth). Australia's mainstream maternity services in both public and private hospitals, which cater for over 99% of births, address the care of mothers and their new babies as though they are ill. The medical/hospital system is reasonable and functions well for those who are ill, but poorly for those who are well. In this brief submission I want to offer a solution rather than giving detail of what I think is wrong.

The main change that I propose in reform of maternity funding is to focus on the woman/pregnancy/birth as the unit, in stead of the current fragmented system of 'items' that can be used by doctors in providing out-of-hospital services, and the funding mix for acute care in hospital. New Zealand's maternity services have been reformed in this way since the early 1990s.

A pregnant woman has a definite and agreed need for 'basic' maternity care, which covers her pregnancy, labour and birth, and postnatal services for mother and baby. Pregnancy does not become chronic - there is a beginning and an end to every pregnancy. When this episode of care is without illness or complication, the care is 'basic', and may be provided in primary care settings without immediate access to operative facilities. When a woman or baby require special medical services for an illness, a complication, or other event which is outside the 'basic' services, the additional expert services can be provided by hospitals and specialists as they are at present. The additional specialist services do not require reform; the basic maternity services do.

The appropriate workforce in basic maternity care is midwives and general practitioner doctors with obstetrics education. Referral to specialist obstetricians and paediatricians is an essential part of basic maternity care. Reform of basic maternity services has been described in the Victorian government's 'Future Directions' (2004) policy for maternity services.

Australia's health system does not use the midwifery workforce appropriately. Midwives are predominantly employed as nurses who assist obstetricians in hospitals, and are restricted from practising to the full extent of their qualification. Appropriate care for women requiring basic maternity services is primary care through the pregnancy-birth-postnatal continuum from a known midwife who acts to protect and support wellness, and who refers and supports linkages to specialist services when required. This woman-centred collaboration is based on evidence for best outcomes, not only at the time of birth, but with ongoing social benefits.

Australia's caesarean rates are around 30%, and will continue to increase unless reform of basic maternity care is undertaken.