caroline homer - who collaborating centre for nursing, midwifery & health development university...

The challenge is ours …

Improving safety and quality by making maternity care better for all women

Caroline Homer 6th Obstetric Malpractice Conference 26 – 27 June 2014

What is a ‘good’ maternity system?

• What is ‘good’ for you may not be good for someone else

• What feels ‘safe’ to you might not be safe to someone else

• Our willingness to accept ‘risk’ differs • Our own experiences shape our views

My own story ….

How did we get to this?

Choosing outside the ‘system’?

• Lack of choices • Lack of options • Lack of respect

“Some women were abused because they did or didn’t want a particular kind of pain relief during labour. Women were made fun of, or talked sternly to, like a naughty child, by midwives or obstetricians, when

they were at their most vulnerable, naked and prone on a table. Women had their babies taken from them

and placed in nurseries as a matter of course, the babies fed formula against the woman's wishes.”

Source: Mary-Rose McColl, Birth Wars, 2009.

Strengths

“Australia is one of the safest places to give birth or to be born” (Roxon, 2008) •  Well educated workforce •  Well informed consumers

•  High quality facilities •  Modern technology

•  Accessible (mostly)

•  Innovators and researchers Source: Maternity Services Review, Commonwealth of Australia, 2008

Weaknesses

“… current arrangements for the delivery of maternity services in Australia are not serving all Australian women as well as they should” (Roxon 2008)

• Limited models of care options • High rates of intervention - fear • Lack of respect for choice - fear • Funding issues – rural women, women who choose

homebirth • Access issues – Aboriginal and Torres Strait Islander

women, rural women, young women • Professional turf wars

Source: Maternity Services Review, Commonwealth of Australia, 2008

Opportunities

• Well informed consumers • Well educated workforce • Research showing the benefits of different

models of care ▫ Clinical outcomes ▫ Cost benefits

• Positive policy environment – Towards Normal Birth (NSW)

• New collaborative opportunities …..

Threats

• Lack of focus on maternal and newborn health ▫ More focus on acute care, emergency departments,

ageing • Lack of indemnity insurance solutions • Imploding turf wars ▫ Midwife vs obstetrician ▫ Midwife vs GP ▫ Clinicians vs lawyers ▫ Private midwife vs hospital midwife ▫ XXX vs XXX???

Dreaming of better maternity care

AAAQ (triple AQ) framework • Care must be: ▫ Accessible ▫ Available ▫ Acceptable

and of ….

▫ Quality

Source: State of the World’s Midwifery 2014. UNFPA, ICM, WHO

Quality maternal and newborn care

Renfrew et al (2014). The Lancet, 383: doi:10.1016/S0140-6736(14)60789-3

What does this mean in Australia? • Elements of practice ▫  Support for normality – higher level care when needed

• Organisation of care ▫  AAAQ – continuity – community-based care ▫  Learn from errors

• Values ▫  Respect – communication – care tailored to needs

• Philosophy ▫  Using interventions only when necessary

• Care providers ▫  Educated, supported, respected for unique skills ▫  Real collaboration

What can you do?

• Ensure the entire maternity system: ▫  includes respect, communication, community

knowledge and understanding, and care tailored to a woman’s circumstances and needs ▫ will optimise the normal biological, psychological,

social, and cultural processes of childbirth, reducing the use of interventions to a minimum

The Lancet Series on Midwifery 2014

All women need continuity

Midwife-led care should the norm for all women as part of a functional consultation and referral network and effective collaboration

Enable spontaneous labour

Promote mobility during labour

Be with pain in labour

Have water immersion as a real option

Re-think the environment

Ensure one to one care in labour

Be flexible about supporters

Facilitate vaginal breech birth

Have options for place of birth

Enable women to choose homebirth

Promote and facilitate VBAC

Keep mothers and babies together

Have respectful collaboration

Recognise the role of the midwife

Explore why women and midwives choose other options

•  Listen to women o  Ask before telling

•  Be brave enough to hear why we failed – what we did or did not do

o  Don’t put your head in the sand – it won’t all go away

• We have the power to change the system

• Don’t wait for someone else – it is up to us ▫ Midwives ▫ Obstetricians ▫ Policy makers ▫ Lawyers ▫ Managers and many others …..

• We need to work with women to make maternity care better for all women