My wife and I arrived in a small town (population 1250) in rural South Australia, 22 years ago, fresh from upskilling in the UK. I had done 18 months of obstetrics in a busy unit on the English/Welsh border, which had a catchment population of 4500 deliveries per year.
My wife had completed her 18-month midwifery training and then had worked in the system for another 18 months, while I did further anaesthetic training. In that system, I received training in complicated obstetrics and never considered attending normal deliveries. There was an associated midwife unit attached to the specialist unit with agreed protocols for who delivered where and who should be transferred.
The caesarean section rate was 11 per cent and on return to that unit three years ago it was still in the mid teens, while other areas in the UK had followed the trends experienced in Australia towards more intervention. The perinatal mortality rate was the same as the rest of the UK.
When we came to Crystal Brook, I was asked about what set-up I would like for my deliveries. I replied that I thought I would only need to be around for the complicated deliveries, but the midwives said that they had not done a normal delivery for years as the doctors did them. They were deskilled and frightened. I had to ask my wife about what would be needed for a normal delivery! Thus began a program that has matured over the last 22 years, which provides safe care with maximum choice for women in a small rural setting. It is this I will describe, as one of the models that can work.
Our model of care evolves
In starting to upskill the midwives 22 years ago, we invited them into our clinic to see the women with us. The women loved it and it was soon decided that we would run a clinic on a Tuesday morning where the women would see the midwife first and then us at the end. They loved being able to have time with the midwife, but at the same time seeing their usual GP for any medical needs, and in their eyes, the reassurance of ‘seeing a doctor’ (their words, not mine). We found over the next two years that more and more women were travelling from other towns for this care and numbers increased from the traditional 20 per year to between 80 and 100 per year.
Over the years, the model evolved to more midwife involvement with less doctor involvement. Why was the doctor still involved at each antenatal visit? Because that is how he or she was paid. It is a reality that in a fee-for-service (FFS) model, we needed to raise revenue this way, as the fee for the delivery was inadequate. However, it was not just this. From a personal point of view, I looked forward to seeing happy, healthy women as patients as opposed to the pathology we see in other aspects of busy rural practice.
During this period, I was heavily involved in the rewriting of the Diploma in Obstetrics syllabus and a member of the Joint Consultative Committee on Obstetrics (JCCO). This was a time of declining obstetric training for GPs as the need for this for metropolitan GPs was diminishing. However, in the days prior to the formation of an Australian College of Rural and Remote Medicine, the Royal Australian College of General Practitioners ‘represented’ all GP views. There was a lack of realisation that in rural areas, there would still be opportunities and the necessity to practise obstetrics. The Diploma in Obstetrics was really disintegrating into a Diploma in Shared Care. I was part of a working group that rewrote the syllabus and there was great effort invested in ensuring that training positions for rural GPs were available in hospitals to gain experience in basic and advanced obstetrics.
Three other influences threatened the provision of our service. Firstly, at various times, the South Australian Government would conduct a review of obstetric services in rural areas and would inevitably come up with the notion that numbers of deliveries weren’t safe and thus units should be closed. This was done without actually demonstrating that perinatal mortality and maternal morbidity figures were actually poorer, but rather was a ‘knee jerk reaction’ to ‘a case’ that had a poor outcome and had received bad press. They were risk averse, not realising that increased travel would significantly increase risk if smaller units were closed (this is never factored into risk analysis in any document I have seen, therefore, what is the risk per kilometre travelled by the woman, her partner, her family and any other health workers such as ambulance officers and nurses accompanying her).
Secondly, the crisis in medical indemnity hit hard. This was going to wipe out all rural obstetricians who were FFS-funded and at the same time tied to fixed fees in the hospitals for public patients. I was involved in the Commonwealth Tito Review into medical indemnity that predicted this crisis some years before, but was subsequently shelved. I therefore had an intimate understanding regarding the concepts of unfunded liability and run-off cover, which are particularly damaging to the continuation of obstetrics. Thus, when South Australia faced an acute abandonment of rural obstetrics, we were able to communicate the real issues and concerns to State officials. At the time they were very supportive, solution-based officials and thus, with the contribution of the Commonwealth subsidies, we were able to ensure that all rural proceduralists did not pay more for medical indemnity than the equivalent non-proceduralist. They also guaranteed run-off cover if doctors chose to stop obstetrics in the future.
Thirdly, after getting the doctors’ issues sorted out, we got to the stage three years ago of not being able to find midwives. In a small rural hospital, the model was one of having Registered Nurse/Registered Midwife (RN/RM) staff to cover all eventualities. However, as an RN/RM left, it was increasingly difficult to find a replacement and the Director of Nursing was reluctant to employ a RN, as this would mean that she did not have room to employ another RN/RM who might turn up. At the same time, some of the RN/RMs were doing the midwifery out of duty rather than want. The onus on them to keep up with all aspects of nursing and midwifery was becoming too much, and with the increased administrative burden being hoisted on nursing staff, they were finding their time was limited to provide optimal care.
Our model now
Thus, we moved to a model of team care. Now we have a group of midwives who just practise midwifery and have no other general nursing duties. They organise their own roster of both rostered hours and on-call hours.
One of the issues put to us by the midwives in setting this up was that for them to work in this model, they would like to have more autonomy and in the future this might aid in attracting direct entry midwives. Thus we have developed a three-streamed approach.
Stream A consists of what I have done for 22 years. The women are seen by me and the midwife at each visit. At delivery, I turn up and sit in the corner and help out as needed (I may give oxytocic, may resuscitate the baby, may suture or may do a medical procedure, as required).
Stream B is with my medical partner and midwife, where women alternate visits, but are not seen by both carers at the one visit.
Stream C is the midwife-led model, where the midwives see the woman for each visit, and they see a doctor for two of the visits. The women have an allocated midwife who, as much as possible, will attend to all their needs. Initially, we would only be notified when they were in labour and attend if needed, but now we have been asked to attend the hospital around delivery time.
The women are given a brochure at the initial visit and they can choose any of the Streams, provided they meet the agreed guidelines as far as risk factors go.We still run a Tuesday morning clinic where women in Stream A and B are seen and the rostered midwife may invite her women in Stream C to attend. However, most of the women in Stream C are seen outside this time, either at the hospital or at their home.
As with any change, we have all had to adapt to different roles and circumstances, but with open dialogue and tolerance of each other’s roles, we have been able to make it work. From a doctor’s point of view, I see the following issues (but I recognise that it is a one-sided view).
Women are still choosing to see the doctors. They are usually my longstanding patients from a GP point of view and want to have the continuity of care. On starting this model, the argument was put that patients wanted continuity of care. The data presented was all to do with specialist obstetricians versus midwives. Nobody acknowledged that the rural GP has the greatest continuity of care and, if they can practise obstetrics, this can continue through.
Occasionally, women who have chosen to see me have seen the midwives at the first visit and have been ‘persuaded’ to change to Stream C. This really annoys me and we have had robust discussions about it. We have now agreed that I will give out the agreed information (pamphlet) initially and then we will both respect the woman’s decision without further ‘lobbying’.
Initially, I was going to lose out on FFS for the normal deliveries of Stream C women. The hospital has agreed to pay FFS for any delivery where I am the nominated doctor. As mentioned earlier, the initial plan was to not have the doctors come for Stream C women. However, there was a delivery where there was a very flat baby. I happened to be in the hospital at the time and could help out. This prompted the midwife involved to persuade the others that it would be beneficial to have us around – just in case.
Our numbers would not have been enough to enable a full roster of midwives, so the team operates over two services, the other being a larger centre with about 200 deliveries per year. That town has a specialist obstetrician, no GP obstetricians and has a very high intervention rate in the form of caesarean sections. It would be fair to say that the doctor there is not as supportive of the midwife model. The midwives from there who feel more confident and maybe a bit fed up with the high intervention rate, have found this model is easier to work in, so we can have some of the 200 deliveries participate in our model. Thus we have enough work for the team to operate.
Initially, the midwives wanted to run caseload as well as an on-call roster, which extended the nominated care by the midwife into labour, but trying to operate this as well as the on-call roster was not feasible. Therefore, when a woman comes into labour it is the midwife on-call who comes in. This is essential to managing workload when labours may go beyond a 12-hour duration and require a change of midwives. The other necessity is that we have five midwives fulfilling a 2.4FTE roster. If we did not have the part-timers, we would not be able to sustain the model.
The model was opposed by the Australian Nursing Federation initially. I believe now the midwives have a 30 per cent pay loading to recognise the on-call component. For each pay period, they are paid a fixed salary, but keep a record of their hours. Every ten weeks the calculations are done about overtime or undertime and pay adjustments are made – I don’t believe there has ever been undertime.
Over the 22 years, our maternity service has adapted and developed in response to a constantly changing environment. At each stage, the providers have sat down and worked out appropriate solutions to keep the service running. At times, various ideologies have threatened the service, but out of mutual respect for each other and the trust of a long-term relationship between the team members, we have been able to continue to provide high-quality services for the women in our area and beyond.
I am constantly surprised about the number of people who come to look at our ‘model’, or ask us to present our ‘model’ at a conference, as if it is something new and wonderful. I don’t see that we have done anything beyond focusing on the needs of the women and developing a mutually respectful relationship between care providers. People have come and looked at our model over the years but I do not know that any have implemented it, because it is usually either the midwives or the doctors who have looked. Without the trusted relationship, nothing will change. I have observed from afar the constant slinging match on the big stage that seems to occur between the radicals on both sides, which alienates everybody.
I believe nothing will change without both doctors (specialists and GPs) and midwives getting together and jointly developing strategies to chart our way forward for the continued provision of maternity services across both metropolitan and rural Australia. Once this has been done, then the role of government must be to adequately resource this so that the potshot nature of closing down of services by State bureaucrats is halted. While the purse strings rule, there will be disjointed and diminished services to Australian women.