by Sally Tracy
In this update on our progress towards a National Maternity Action Plan, the new midwifery services are described – the battles, the strategies and the results so far. Together we can reverse the trends of over-medicalised birth in this country. The first part of my presentation will be based on the results of research that will be extremely important for midwives and women in Australia to argue the safety of small maternity units.
I begin by providing a brief review of the research in this area and the results will be presented on the day. The full research paper is currently in press. In the second half of the presentation I will outline the trials and tribulations of keeping a small maternity hospital open, and transforming it into a free standing birth centre.
The closing of small maternity hospitals all over Australia has gathered pace in the last five years. The Taskforce set to rationalise maternity services in Sydney for instance, claimed that women and babies are not safe in hospitals when there are not enough births each year to maintain high standards of practice1. The technical jargon for this is the “volume threshold”. This is the catch all phrase that describes the availability of technology – there is the belief that if babies are born in bigger hospitals where technology is on hand all the time (24 hours a day) the outcome will be better for everyone! This is particularly the case when epidural anaesthetics are discussed. There is a really strong belief that if epidurals are not available ‘on tap’ 24 hours a day – then women shouldn’t be encouraged to give birth in these places. So closures are taking place based on the following argument. “Due to the volume threshold theory, birth is safest in large tertiary referral hospitals because in public maternity hospitals across Australia with more than 2000 births per annum there are resident obstetric, anaesthetic, and neonatal services as well as facilities for obstetric operations. This allows for a faster response to fetal distress and more rapid delivery and resuscitation of the neonate. In many smaller units both rural and urban, with less than 500 births per annum, this level of medical expertise is not available 24 hours a day”. (However, we also know that in private maternity hospitals across Australia regardless of size, there is not 24 hour ‘on site’ obstetric, anaesthetic, paediatric or laboratory facilities.)
So what is the evidence for this volume threshold theory? We do have some evidence around this issue. From the literature on neonatal mortality in relation to all sizes and gestations of babies (ie regardless of prematurity or low birth weight), it is well established that babies born in hospitals with a high volume of births per annum have a reasonably good outcome in terms of neonatal mortality. This is common sense in many ways. It is also widely accepted that when you look at the outcome of really ‘high-risk’ newborns, if they are born at hospitals providing centralised sophisticated intensive care support will have improved outcomes.2;3 Recently a study was published on the factors predisposing to perinatal death associated with uterine rupture. This study from the UK found that uterine rupture was three times more likely to result in death of the infant if the delivery took place in a hospital with less than 3000 births a year.4 (Note the study didn’t talk about preventing uterine rupture in the fist instance, it merely stated that if a rupture happened there was a better outcome if the baby was born in a big hospital with more emergency facilities.) Several studies have reported the safety of smaller units where proper referral systems are in place5 and there are both sensitive and sophisticated screening processes for recognising a need to transfer.6;7
If we have really good antenatal referral systems and women who have potential problems are referred into tertiary level maternity hospitals with ‘on site’ medical support, it would leave those women perceived to be not at risk to give birth to their babies in small hospitals. In Australia the NH&MRC clinical practice guidelines around preterm birth advise women with complicated pregnancies that perinatal interventions offered in large tertiary perinatal centres will benefit their baby at birth.8 There are highly developed neonatal referral and transport services in each state. They are well supported and funded to retrieve pregnant women or premature babies and admit them to tertiary perinatal centres. A recent study from NSW looking at the trends in preterm births found that there is steady increase in preterm births occurring in perinatal centres.9
In fact we know in NSW that amongst all the in utero transfers of rural women to perinatal centres, about 60% of transfers are for management of possible premature birth and of these women 96% are from rural areas10 with increasing remoteness associated with increased rates of antenatal transfer.11 Other countries report a similar identification of high risk pregnancies and transfer to perinatal centres before birth.12
Regardless of all these findings however, we still haven’t any solid evidence on the safest place for women to give birth when they have healthy pregnancies and have no reason to believe that there is anything that would put them or their baby at risk during the birth process. That is to say, there is ambivalence about, and certainly no consensus on the optimal or safest place for women to give birth following a normal uneventful pregnancy.5-7;13-21
Recently there have been three really big studies, two from Norway22;23 published by Moster et al in 1999 and 2001, and the other from the ‘state’ of Hesse in Germany12 published by Heller et al in 2002. These three studies report that ‘normal’ birth weight babies have a much higher risk of dying in the first seven days after birth if they are born anywhere other than larger maternity hospitals. The German study showed that there was a “persistent pronounced mortality gradient with the size of the delivery unit in low-risk births, despite a well accepted intensive antenatal screening programme” 12(Heller et al, 2002). And the studies from Norway showed that there was a “small but significantly decreased neonatal mortality in areas where the great majority of births occurred in large hospitals” 22;23(Moster et al 1999 & 2001).
Everyone has some idea of the issues and problems faced by women who live in remote areas. We know that remoteness has a lot of disadvantages when it comes to community and health infrastructure and the availability of midwives and doctors. In maternity these are well documented. 10;11;21;24;25
A study published by Roberts et al in 2000 found that the adjusted odds for stillbirth for rural women in one state in Australia compared with metropolitan women ranged from OR 1.16 for large rural centres to OR 1.28 for small rural centres and OR 1.31 for other rural and OR 2.05 for remote areas even after adjusting for age, Indigenous status, medical and obstetric complications, smoking and SGA.11
The closing of small units is a really important issue. The evidence for the regionalisation of maternity care is of critical importance to women who access maternity care and is also of critical importance to those who manage the health care resources and workforce. Small communities who suffer most from the loss of medical services in their areas will be the most affected by policies implemented without a demonstrated evidence base. While many of the studies I’ve mentioned suggest lives could be saved by concentrating all births in large tertiary centres, caution is needed before implementing such a policy. The social and financial stress experienced by parents with babies in hospitals a long way from home is well documented. 26 Maternity services are a component of the socio-economic capital of small rural communities. They not only guarantee that women can give birth close to their homes in a familiar community environment, they are an integral part of the infrastructure of many communities. The Cochrane review on Continuous support for women during childbirth, states,” During labour women may be uniquely vulnerable to environmental influences; modern obstetric care frequently subjects women to institutional routines, high rates of intervention, unfamiliar personnel, lack of privacy, and other conditions that may be experienced as harsh. These conditions may have an adverse effect on the progress of labour and on the development of feelings of competence and confidence; this may in turn impair adjustment to parenthood and establishment of breastfeeding, and increase the risk of depression. This process may to some extent be buffered by the provision of support and companionship during labour.”27
A paper by Mary Newburn , who is part of the National Childbirth Trust (a consumer organisation in the UK), challenges the risk approach to childbirth, and suggest women’s needs are not being adequately met in many hospital settings. There are not adequate opportunities for women to feel both comfort and in control of what’s happening to them in many conventional hospital settings.28 In large centralised hospitals women often feel a loss of power and intimidated by the emphasis on medicalisation and technology. Studies have shown that in everyday practice, handing out leaflets with evidence based information is not very effective in helping women to make informed choices about their care.29 In fact a qualitative study that looked at why this was the case found that inequalities in power and status in the maternity services have a greater influence on what happens to women giving birth than either their hopes and dreams or the choices they feel informed to make.30 These studies are a powerful reminder that the physiological birth process without some degree of technological interference and tampering is rare. When women can form a trusting relationship with a midwife they are more likely to ask questions and feel that they can make choices about their care, rather than simply being compliant.
So, the challenge facing maternity services today is how to balance the need for safety with the need to avoid unnecessary intervention in pregnancy and labour.31;32
The National Maternity Action Plan and other policy reviews have consistently called for maternity service reforms in Australia, advocating new models of care for women with a primary health focus and having access to adequate medical care when required.33-37 Despite these calls for change the health system in Australia has been slow to relinquish decision making to women and their families.
In our study we aimed to see whether women were more likely to have a worse birth outcome if they gave birth in small hospitals.
We gathered data from a national database, the National Perinatal Data Collection (NPDC). This is a collection of cross sectional data on all births in Australia collated by the Australian Institute of Health and Welfare from Midwives Data Collections (MDCs) in each state and territory. The midwives data collections rely on midwives to record information on every birth.
We had a study population of all the women in Australia (750491 women) who gave birth between 1999–2001.
Maternity hospitals were stratified into five categories according to the number of births per annum. The categories were <100; 100-500; 501-1000; 1001-2000; 2001+ births per annum. We included both private and public hospitals. The geographic distribution of hospitals varies within the states of Australia, but the smallest units of less than 100 and less than 500 births per annum are predominantly classified as rural or remote to the main centres. The units that are 501-1000 and 1001-2000 are more likely to be either the large rural centres – the main base hospital for a large rural region; or other metropolitan areas – within the same area health service as the large central tertiary unit but separated geographically by 30 minutes or more.
The rates of intervention and neonatal outcomes were described in relation to the size of hospital defined by the volume of births per annum.
Where women were transferred for birth, the birth was registered at the institution where the infant was born, and excluded if the infant was born before arrival. All home births and birth centre births were excluded. The adverse outcome or neonatal death by definition included babies who were born alive but died within the first 28 days of life. Neonatal mortality rates were babies born live but died within 28 days per 1000 live births.
An overall description of the number and proportion of each obstetric intervention, birth outcome, and neonatal outcome for the whole population was described according to the size of maternity unit measured by volume of births per annum for the three year period 1999-2001. Then the number and proportion of each obstetric intervention, birth outcome and neonatal outcome was described for low risk primiparous women and separately for low risk multiparous women according to the size of the maternity unit. This analysis included the measures of stillbirth as well as neonatal mortality. Next a comparison of the neonatal mortality rates (live born but died within 28 days) per 1000 live births for low risk primiparous women and low risk multiparous women was made using the largest hospitals (greater than 2000 births per annum) as a reference point. Associations between unit size and obstetric and neonatal outcomes for low risk women were then examined.
The results will be presented on tour.
1. NSW Health. Greater Metropolitan Transition Taskforce. GMTT Metropolitan Hospitals Report. 2002. NSW Health, Sydney.
2. Chien LY, Whyte R, Aziz K, Thiessen P, Matthew D, Lee SK. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet.Gynecol. 2001;98:247-52.
3. Parnanum J, Field D, Rennie J, Steer P. National census of availability of neonatal intensive care. British Association for Perinatal Medicine. BMJ 2000;321:727-9.
4. Smith GCS, Pell JP, Pasupathy D, Dobbie R. Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study. BMJ 2004;329:375-80.
5. Viisainen K, Gissler M, Hemminki E. Birth outcomes by level of obstetric care in Finland: a catchment area based analysis. J.Epidemiol.Community Health 1994;48:400-5.
6. Rosenblatt RA, Reinken J, Shoemack P. Is obstetrics safe in small hospitals? Evidence from New Zealand’s regionalised perinatal system. Lancet 1985;2:429-32.
7. Paneth N, Kiely JL, Wallenstein S, Susser M. The choice of place of delivery. Effect of hospital level on mortality in all singleton births in New York City. Am J Dis Child 1987;141:60-8. National Health and Medical Resarch Council. Clinical Practice Guidelines. Care around preterm birth. 1997. AGPS .
9. Roberts CL, Algert CS, Peat B, Henderson-Smart DJ. Trends in place of birth for preterm infants in New South Wales, 1992-2001. J.Paediatr.Child Health 2004;40:139-43.
10. Roberts CL, Henderson-Smart D, Ellwood DA. Antenatal transfer of rural women to perinatal centres. High Risk Obstetric and Perinatal Advisory Working Group. Aust.N.Z.J.Obstet.Gynaecol. 2000;40:377-84.
11. Roberts CL,.Algert CS. The urban and rural divide for women giving birth in NSW, 1990-1997. Aust.N.Z.J.Public Health 2000;24:291-7.
12. Heller G, Richardson DK, Schnell R, Misselwitz B, Künzel W, Schmidt S. Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990-1999. International Journal of Epidemiology 2002;31:1061-8.
13. Viisainen K, Gissler M, Hartikainen AL, Hemminki E. Accidental out-of-hospital births in Finland: incidence and geographical distribution 1963-1995. Acta Obstet.Gynecol.Scand. 1999;78:372-8.
14. Schmidt N, Abelsen B, Oian P. Deliveries in maternity homes in Norway: results from a 2-year prospective study. Acta Obstet.Gynecol.Scand. 2002;81:731-7.
15. Paneth N, Wallenstein S, Kiely JL, Snook CP, Susser M. Medical care and preterm infants of normal birth weight. Pediatrics 1986;77:158-66.
16. Mayfield JA, Rosenblatt RA, Baldwin LM, Chu J, Logerfo JP. The relation of obstetrical volume and nursery level to perinatal mortality. Am.J.Public Health 1990;80:819-23.
17. Lumley J. The safety of small maternity hospitals in Victoria 1982-84. Community Health Stud 1988;12:386-93.
18. LeFevre M, Sanner L, Anderson S, Tsutakawa R. The relationship between neonatal mortality and hospital level. J.Fam.Pract. 1992;35:259-64.
19. Hemminki E. Perinatal mortality distributed by type of hospital in the central district of Helsinki, Finland. Scand Med 1985;13:113-8.
20. Cole SK,.Macfarlane A. Safety and place of birth in Scotland. J Public Health Med 1995;17:17-24.
21. Albers LL,.Savitz DA. Hospital setting and fetal death during labor among women at low risk. 1991; 164:868-73. Am J Obstet Gynecol 1991;164:868-73.
22. Moster D, Lie RT, Markestad T. Relation between size of delivery unit and neonatal death in low risk deliveries: population based study. Arch.Dis.Child Fetal Neonatal Ed 1999;80:F221-F225.
23. Moster D, Lie RT, Markestad T. Neonatal mortality rates in communities with small maternity units compared with those having larger maternity units. BJOG. 2001;108:904-9.
24. Roder D, Nguyen AM, Chan A. Trends in perinatal characteristics in South Australia, 1981 to 1994, by place of residence of mother. Aust.N.Z.J.Public Health 1997;21:483-8.
25. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA. Access to obstetric care in rural areas: effect on birth outcomes. Am.J.Public Health 1990;80:814-8.
26. Fry MJ, Cartwright DW, Huang RC, Davies MW. Preterm birth a long distance from home and its significant social and financial stress. Aust.N.Z.J.Obstet.Gynaecol. 2003;43:317-21.
27. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2004.
28. Newburn M. Culture, control and the birth environment. Pract.Midwife. 2003;6:20-5.
29. O’Cathain A, Walters SJ, Nicholl JP, Thomas KJ, Kirkham M. Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice. BMJ 2002;324:643-6.
30. Stapleton H, Kirkham M, Thomas G. Qualitative study of evidence based leaflets in maternity care. BMJ 2002;324:639-44.
31. Johanson R, Newburn M, Macfarlane AJ. Has the medicalisation of childbirth gone too far? BMJ 2002;324:892-5.
32. Grant J. Editorial . Br J Obstet Gynaecol 2001;108.
33. National Maternity Action Plan 2002. 2002.
34. Barclay L, Brodie P, Lane K, Leap N, Reiger K, and Tracy S. The Final Report of The Australian Midwifery Action Project, AMAP. 2003. Centre for Family Health and Midwifery, UTS, Sydney.
35. Nesbitt TS. Rural Maternity Care: New Models of Access. Birth 1996;23:161-5.
36. NSW Health. NSW Framework for Maternity Services: providing structure and direction for the future development of maternity services. 2000. NSW Health.
37. Victorian Government Department of Human Services. Future Directions for Victorian Maternity Services. 2004. Victorian Government Department of Human Services.
© Birth International 2005
This paper was prepared for the Future Birth: With woman, with child lecture tour Australia, March 2005.