Birth centres and the national maternity services review: Response to consumer demand or compromise?

doi:10.1016/j.wombi.2010.11.001

Women and Birth

Volume 24, Issue 4, December 2011, Pages 165-172

https://doi.org/10.1016/j.wombi.2010.11.001 Get rights and content

Abstract

Background

In February 2009 the Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR) was released and recommended improving women's access to and availability of birth centres. It was unclear if this was in response to an overwhelming request for birth centres in the submissions received by the commonwealth or a compromise for excluding homebirth from the maternity service reforms.

Aim

The aim of this paper was to examine what was said in the submissions to the MSR about birth centres.

Methods

Data for this study comprised 832 submissions to the MSR that are publicly available on the Commonwealth of Australia Department of Health and Ageing website. All 832 submissions were downloaded, and read for any mention of the words ‘birth centre’, ‘birth center’. Content analysis was used to categorise and report the data.

Results

Of the 832 submissions to the MSR 197 (24%) mentioned birth centres while 470 (60%) of the submissions mentioned homebirth. Only 31 (4%) of the submissions to the Maternity Review mentioned birth centres without mentioning home birth also. Most of the submissions emphasised that ‘everything should be on the menu’ when it came to place of birth and care provider. Reasons for choosing a birth centre were identified as: ‘the best compromise available, ‘the right and natural way’ and ‘the birth centre as safe’. Women had certain requirements of a birth centre that included: ‘continuity of carer’, ‘midwife led’, ‘a sanctum from medicalised care’, ‘resources to cope with demand’, ‘close to home’, and ‘flexible guidelines and admission criteria’. Women weighed up a series of requirements when deciding whether to give birth in a birth centre.

Discussion

The recommendation by the MSR to expand birth centres and ignore home birth is at odds with the strong view expressed that ‘everything should be on the menu’. The requirements women described of birth centre care are also at odds with current trends.

Conclusion

If there is to be an expansion of birth centres, service providers need to make sure that women's views are central to the design. Women will not cease having homebirths due to expanded birth centre options.

Introduction

‘Women desire homebirth, they desire birth centres and they desire hospital birth. More importantly though, we deserve them (Consumer)’.

In September 2008 the Commonwealth called for public submissions in response to a Discussion Paper aimed at improving maternity services and expanding the range of birthing options available.¹ Over 900 submissions were received by the Department of Health and Ageing – the majority (54%) were from consumers. The Department of Health and Ageing also conducted a series of ‘invitation only’ roundtable forums with a range of organisations and individuals. On the 21st February 2009, Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR)² was released.

One of the recommendations in the MSR was that when the National Maternity Services Plan is developed ‘consideration be given to the demand for, and availability of, a range of models of care including birthing centres’² p. 57. It was unclear if this was in response to an overwhelming request for access to birth centres in the submissions received by the Commonwealth or whether it was a compromise for the decision not to include homebirth in the maternity service reforms being proposed.

This paper set out to examine what was said in the submissions to the MSR about birth centres. It occurred to us in examining the responses to the MSR that there was far less support for birth centres than homebirth. A previous paper examined what was said about homebirth in 60% of the submissions to the MSR.³

Section snippets

Background

In Australia in 2007 around 6400 women were reported as giving birth in a birth centre, which represents 2.2% of all women giving birth.⁴ The proportion of women giving birth in a birth centre has changed little in 10 years (1.9% in 1997).⁵ This could be due to a decline in the number of birth centres in the past ten years with five less birth centres operating in 2007 compared to 1997.⁶ There is also some evidence that birth centres are becoming more conservative in their admission criteria.

Method

This is a qualitative descriptive study that examined the 832 submissions made to the MSR that are publicly available on the Department of Health and Ageing website. The submissions were downloaded from the Department of Health and Ageing website and analysed using content analysis. While over 900 submissions were received some contained confidential or sensitive information that meant they could not be made public.

After multiple readings of transcripts for mentions of birth centre, a coding

Discussion

The MSR recommended improving women's access to and availability of birth centres; and States and Territories were asked to expand this option for women. It would seem from this data however, that once again the choice for women to give birth in a familiar place such as home, has been denied by authorities that feel they know best in terms of safety and recommend birth centre as compromise. The recommendation does not appear to reflect the views expressed in the submissions to the MSR. Only 24%

Conclusion

Birth centres appear to be a compromise position in the MSR between the strong demand for homebirth and requests for more midwife led, non-medicalised options for birth. On the whole women also saw birth centres as a compromise between the medicalised hospital based system and unfunded, unsupported homebirth. However it appears women felt this was not an acceptable position to be put in and that ‘everything should be on the menu’ when it came to birth choices. The MSR appear to see expanding

Ethical statement

Ethics approval was sought but not deemed necessary, as these are now publicly accessible documents. Extracts/quotes from the submissions are included, however names are not used and if a hospital or individual is referred to this has been removed. If the quote came from a consumer, or professional etc. this noted at the end of the quote.

Acknowledgement

To the University of Western Sydney for providing funding for the study through the Internal Research Grant Scheme 2009.

References (23)

M. Foureur et al.
The relationship between birth unit design and safe satisfying birth: developing a hypothetical model
Midwifery
(2010)
Commonwealth of Australia. Improving maternity services in Australia: a discussion paper from the Australian...
Commonwealth of Australia
Improving maternity services in Australia. The report of the maternity services review
(2009)
H. Dahlen et al.
Home birth and the National Australian Maternity Services Review: too hot to handle?
Women and Birth
(2010)
P. Laws et al.
Characteristics and practices of birth centres in Australia
Australian and New Zealand Journal of Obstetrics and Gynaecology
(2009)
P. Laws et al.
Australian mothers and babies 2006
(2009)
P. Laws et al.
Changes to booking, transfer criteria and procedures in birth centres in Australia from 1997 to 2007: a national survey PSANZ
Journal of Paediatrics and Child Health
(2010)
Senate Community Affairs References Committee
Rocking the cradle: a report into childbirth procedures
(1999)
J.P. Byrne et al.
A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia
Australian and New Zealand Journal of Obstetrics and Gynaecology
(2000)
Waldenström U, Lawson J. Birth centre practices in Australia, Unpublished report. Melbourne: Royal Women's Hospital;...

M. Stewart et al.

Report of a structured review of birth centre outcomes 2004

(2005)

Cited by (23)

A comparison of the Woman-centred care: strategic directions for Australian maternity services (2019) national strategy with other international maternity plans
2023, Women and Birth
In 2019 the Australian government released a guiding document for maternity care: Woman-centred care strategic directions for Australian maternity services (WCC Strategy), with mixed responses from providers and consumers. The aims of this paper were to: examine reasons behind reported dissatisfaction, and compare the WCC Strategy against similar international strategies/plans. The four guiding values in the WCC strategy: safety, respect, choice, and access were used to facilitate comparisons and provide recommendations to governments/health services enacting the plan.
Maternity plans published in English from comparable high-income countries were reviewed.
Eight maternity strategies/plans from 2011 to 2021 were included. There is an admirable focus in the WCC Strategy on respectful care, postnatal care, and culturally appropriate maternity models. Significant gaps in support for continuity of midwifery care and place of birth options were notable, despite robust evidence supporting both. In addition, clarity around women’s right to make decisions about their care was lacking or contradictory in the majority of the strategies/plans. Addressing hierarchical, structure-based obstacles to regulation, policy, planning, service delivery models and funding mechanisms may be necessary to overcome concerns and barriers to implementation. We observed that countries where midwifery is more strongly embedded and autonomous, have guidelines recommending greater contributions from midwives.
Maternity strategy/plans should be based on the best available evidence, with consistent and complementary recommendations. Within this framework, priority should be given to women’s preferences and choices, rather than the interests of organisations and individuals.
Two decades of Birth Centre and midwifery-led care in South Australia, 1998–2016
2021, Women and Birth
Citation Excerpt :
The physical environment of a BC is highly desirable as it represents a home-like environment with a known midwife where in today’s fear-based medicalisation of birth, a woman may feel reassured being within a hospital while having the greatest opportunity for a normal physiological birth [22]. Women’s birth preferences in SA mirror those found in other studies; that women (and men) prefer maternity care that allows for mutually respectful relationships predominately with one carer from pregnancy to post-birth [20,23]. The cohort of women who choose BC care have been reported as having a demographic profile similar to those who choose private obstetric care in Australia; higher socio-economic status, older, and more likely to be born in Australia [24].
Birth Centres (BC) are underpinned by a philosophy of woman- centred care and were pivotal in growing models of midwifery-led care in South Australia (SA).
To describe BC utilisation and the growth of midwifery-led care in SA over the past two decades.
The SA Perinatal Statistics Collection was used to describe women birthing from 1998 to 2016. Number of births through midwifery-led services from 2004 to 2016 were obtained from unit managers. Analyses are descriptive.
Women who birthed in BC in SA from 1998 to 2016 comprised approximately 6% of all births per year, and numbers have remained static. Three BC models operate in SA, all with different capacity. Proportionally, women not born in Australia are as likely to birth in BC as labour wards. The proportion of women who received midwifery-led care (whether affiliated with a BC or not), increased from 8.3% in 1998 to 19.2% of all births in 2016. Of the women who received midwifery-led care in 2016, 15.3% went on to birth in a midwifery-led model of care.
Whilst the overall number of BC births has not increased, women seeking midwifery-led care has more than doubled over the past two decades. BC encompass the midwifery philosophy, quality of care, and a physical home-like environment. The BC models in SA are managed through the three tertiary maternity units enabling women to access publicly funded midwifery care and should be more widely available.
Birth models of care and intervention rates: The impact of birth centres
2020, Health Policy
Birth centres offer a midwifery-led model of care which supports a non-medicalised approach to childbirth. They are often reported as having low rates of birth intervention, however the precise impact is obscured because less disadvantaged mothers with less complex pregnancies, and who prefer and often select little intervention, are more likely to choose a birth centre. In this paper, we use a methodology that purges the impact of these selection effects and provides a causal interpretation of the impact of birth centres on intervention outcomes. Using administrative birth data on over 364,000 births in Australia’s most populous state between 2001 and 2012, we implement an instrumental variables framework to address confounding factors influencing choice of birth setting. We find that giving birth in a birth centre results in significantly lower probabilities of intervention, and that critically, this impact has been increasing over time. Our estimates are larger than those in existing studies, reflecting our newer data, diverging intervention rates across birth settings, and our accounting for important selection effects. The results emphasise the greater role of birth centres in delivering on policy priorities which include greater maternal autonomy, lower intervention rates, and lower health system costs.
The development of midwifery unit standards for Europe
2020, Midwifery
The cost of vaginal birth at home, in a birth centre or in a hospital setting in New South Wales: A micro-costing study
2020, Women and Birth
Women want greater choice of place of birth in New South Wales, Australia. It is perceived to be more costly to health services for women with a healthy pregnancy to give birth at home or in a birth centre. It is not known how much it costs the health service to provide care for women planning to give birth in these settings.
The aim of this study was to determine the direct cost of giving birth vaginally at home, in a birth centre or in a hospital for women at low risk of complications, in New South Wales.
A micro-costing design was used. Observational (time and motion) and resource use data collection was undertaken to identify the staff time and resources required to provide care in a public hospital, birth centre or at home for women with a healthy pregnancy.
The median cost of providing care for women who plan to give birth at home, in a birth centre and in a hospital were similar (AUD $2150.07, $2100.59 and $2097.30 respectively). Midwifery time was the largest contributor to the cost of birth at home, and overhead costs accounted for over half of the total cost of BC and hospital birth. The cost of consumables was low in all three settings.
In this study, we have found there is little difference in the cost to the health service when a woman has an uncomplicated vaginal birth at home, in a birth centre or in a hospital setting.
Regulation of unregistered birth workers in Australia: Homebirth and public safety
2018, Women and Birth
Australian midwives are regulated under the National Registration and Accreditation Scheme. Unregistered birth workers may provide midwifery services at homebirths without any regulatory oversight. To address this issue, several states have passed legislation enabling prohibition orders to be made (negative licensing) against unregistered health practitioners who fail to comply with a statutory code of conduct developed for those not covered by the National Scheme.
To explore the consequences for the availability of birth choices for women that arise from the introduction of negative licensing.
An analysis of the regulatory framework and recent cases of unregistered birth workers attending homebirths reveals problems with equitable access to homebirth support, arising from issues with professional indemnity insurance, geography, and poor integration with hospitals and the wider healthcare system. These problems contribute to women choosing to employ the services of unregistered birth workers.
Negative licensing provides a useful additional tool for improving the safety of homebirths for mothers and babies, but it does not address the issues leading expectant parents to choose an unregistered birth worker to attend their births, and may contribute to an increase in high-risk behaviours, such as freebirthing.

View all citing articles on Scopus

View full text

Birth centres and the national maternity services review: Response to consumer demand or compromise?

Abstract

Background

Aim

Methods

Results

Discussion

Conclusion

Introduction

Section snippets

Background

Method

Discussion

Conclusion

Ethical statement

Acknowledgement

Midwifery

Improving maternity services in Australia. The report of the maternity services review

Home birth and the National Australian Maternity Services Review: too hot to handle?

Women and Birth

Characteristics and practices of birth centres in Australia

Australian and New Zealand Journal of Obstetrics and Gynaecology

Australian mothers and babies 2006

Changes to booking, transfer criteria and procedures in birth centres in Australia from 1997 to 2007: a national survey PSANZ

Journal of Paediatrics and Child Health

Rocking the cradle: a report into childbirth procedures

A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia

Australian and New Zealand Journal of Obstetrics and Gynaecology

Report of a structured review of birth centre outcomes 2004