SUBMISSION ON THE MINISTRY OF HEALTH’S “MATERNITY ACTION PLAN”
The "Maternity Action Plan" can be accessed at the Ministry of Health website - http://www.moh.govt.nz/moh.nsf/indexmh/draft-maternity-action-plan-2008-2012-oct08
The Auckland Women’s Health Council (AWHC) is an umbrella organisation for individual women and women’s groups in the Auckland region who have a commitment to women’s health issues. The focus of the Council is broad and spans many issues that are of interest to women, particularly those that impact on their health and the health of their families. The Council has a special interest in consumer rights, informed consent, advocacy, ethics committees, medical ethics and other issues that arose out of the Cartwright Inquiry into the treatment of cervical cancer at National Women’s Hospital.
Introduction
The AWHC welcomes the opportunity to provide feedback on the Maternity Action Plan released by the Ministry of Health in October 2008. The AWHC took part in the meeting organised by Women’s Health Action and the Maternity Services Consumer Council that was held on 13 July 2009. The AWHC’s submission has been informed by the discussion that occurred at this meeting.
Before commenting specifically on the Maternity Action Plan the AWHC offers some general observations about the document and the consultation process.
The AWHC believes that the final Maternity Action Plan document should be a comprehensive document that clearly states and references the facts about maternity services in New Zealand, contains specific goals and details how they will be achieved and have reasonable timeframes attached to them. As it stands many of the principles, goals and actions listed in the document are vague and far too general.
The document should also contain all that is needed to produce a submission. It is unacceptable to produce a consultation document that requires those wanting to make a submission to obtain copies of other documents – in this case, the “Review of the Quality, Safety and Management of Maternity Services in the Wellington Area” and “Perinatal and Maternal Mortality in New Zealand 2006” reports – in order to make an informed response.
The AWHC notes that membership of the Maternity Services Strategic Advisory Group included only one consumer representative, ie someone who is not a health professional, or a researcher or employed by the health system. The lack of an adequate level of consumer representation on the Maternity Services Strategic Advisory Group is reflected in the consultation document produced by the group.
One of the outcomes of the Cartwright Inquiry was the radical change in the way consumer representation and consultation occurred. Advisory groups, working parties, and various committees such as ethics committees were required to include several consumer representatives. In fact, ethics committees were required to have half of their members as lay people. The inclusion of one token consumer representative picked by the committee was and still is unacceptable. Since 1988 it has been standard practice to appoint several consumer representatives, as appointing only one person places too heavy a burden on the sole consumer and increases the risk of that person being co-opted. The AWHC recommends that two more consumer representatives be appointed to the Maternity Services Strategic Advisory Group.
The AWHC’s submission on the Maternity Action Plan is based on our support of the system of a Lead Maternity Carer chosen by the woman to provide her maternity care. The Council also acknowledges the importance of a maternity service that offers continuity of carer as it represents the gold standard of maternity care. A team of health providers who provide fragmented care during pregnancy, birth and the postnatal period are not providing good maternity care that meets the needs of women. All women should be entitled to continuity of midwifery care.
The Vision
The AWHC welcomes the emphasis on pregnancy and birth as normal life events and on the importance of women being given information to enable them to make informed choices about their maternity care.
However the vision for maternity services must encompass the whole of the childbearing cycle and include breastfeeding and early parenthood. The AWHC believes that this needs to be reflected in the vision statement. Women must be encouraged and supported to have confidence in their ability to give birth, to breastfeed and to begin mothering their infant. We suggest the statement be amended to read:
Women will experience pregnancy, birth and motherhood as normal life events with confidence in their ability to give birth and mother their infants.
Principles
The principles are worded in such a way as to allow an unacceptably wide range of interpretations.
For example the AWHC would argue that acknowledging pregnancy and childbirth as a normal life stage (Goal 2) precludes encouraging or insisting upon women submitting to the increasing number of screening and monitoring tests and procedures that have become the norm. The increasing medicalisation of pregnancy and birth has undermined women’s confidence in the process.
A clear and concise definition of “woman-centred care” is needed.
The AWHC wants to see a principle added that acknowledges the right of women to be provided with information in the language of their choice and to be empowered to give informed consent to or refuse:
· the screening procedures and tests during pregnancy
· the usual cascade of interventions during birth
· the various screening tests and procedures during the postnatal period.
Women are entitled to evidence-based information on which to make such informed decisions about all aspects of their maternity care.
There is also a need for a principle that supports the vision – maternity services will aim to reduce unnecessary medical intervention in the pregnancy, labour, birth and early parenting experiences of healthy women and their babies.
There should also be a principle that refers to the requirement for hospitals and other birthing facilities as well as all maternity care providers to provide statistical information to women on their birth outcomes, including their rates of intervention.
Another key principle that needs to be included is the need for regular monitoring and evaluation of maternity services, and for the results of such monitoring and evaluations to be published and made readily available.
Principle 1
The issue of continuity of carer has been fudged and the sentence should read:
“All women should have continuity of care throughout the pregnancy, labour and birth and the postnatal period provided by a Lead Maternity Carer.”
Principle 3
The AWHC is opposed to the targeting of maternity services. All women are entitled to responsive and appropriate maternity care that meets their needs.
Principle 7
The principle that maternity service providers will work together in partnership with women must not detract from the right of women to have continuity of care meaning continuity of carer.
Current Issues in Maternity Services
The lack of adequate consumer representation on the advisory group is reflected in the issues listed in the Maternity Action Plan. The issues also do not align well with the vision.
There is evidence that the increasing number of screening tests and procedures are making women more anxious during pregnancy. The increasing rates of intervention in the birth process are also creating a fear of birth and a lack of confidence in women in their own ability to give birth, breastfeed and parent their baby. The medicalisation of pregnancy and birth is having an increasingly negative impact on women and their babies.
The issues surrounding the medicalisation of birth need to be addressed in the Maternity Action Plan and must include references to the psychological, emotional and social harms to women.
The list of issues also needs to include encouraging healthy women to give birth at home or in primary birthing units. Maternity services should promote and protect physiological childbirth and breastfeeding.
The inadequate level of postnatal care and support also needs to be addressed in the current issues. The recent announcement by the Minister of Health of funding for extra in-patient postnatal care has been misleading as it did not make it clear that it is not available to all new mothers and that there are criteria that need to be met before women can have an extra day or so in hospital.
Leadership
There has been a lack of national leadership in the maternity sector since the departure of Barbara Browne in 2002. The maternity sector has suffered as a result. The MOH must appoint a leader who is able to lead the maternity sector out of the wilderness and work towards achieving the vision described in the Maternity Action Plan. This person will also need to address the negative, sensationalist, and unbalanced reporting of maternity service issues.
Integration of maternity care
The AWHC does not support the provision of maternity services being integrated into Primary Health Organisations as this would be a retrograde step for the midwifery profession and would not be in the best interests of women. The majority of PHOs are still doctor-run and doctor-dominated organisations that have failed to achieve the objectives of working in partnership with both other health workers and their patients and including a wide range of other health professional and community health workers to provide primary health care in their communities.
Maternity Information systems and data collection
There should be a requirement for an annual national maternity report that is published in a timely fashion. All DHBs must also be required to publish accurate reports on the intervention rates and outcomes of the maternity services provided in their own region, so that each woman can make an informed choice and is aware of the level of support that exists for normal physiological pregnancy, birth and breastfeeding in the facility she has chosen to give birth in.
Workforce
The government and the Ministry of Health need to deal with the growing crisis in the maternity workforce by increasing the number of places in midwifery training school annual intakes, and implementing a range of other initiatives to encourage midwives to return to or remain in the profession.
The AWHC believes that there are substantial obstacles that need to be overcome before GPs can begin providing an adequate standard of maternity care that is in alignment with the Maternity Action Plan. The Royal NZ College of General Practitioners produced a Position Statement and a Background Paper on Maternity in 2006. These two documents are not in agreement with the vision statement, principles and goals described in the Maternity Action Plan. This is an issue that needs to be addressed by a National Maternity Manager.
The letters and documents recently produced by the Royal Australia and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) also do not support the aims and objectives contained in the Maternity Action Plan. For example, RANZCOG’s attitude towards normal birth, midwifery care, and their statement on Home Birth and their preferred Models of Maternity care are not only in complete contradiction to the philosophy and goals of the Maternity Action Plan, they do not include as models of care those provided in New Zealand. This is another issue that needs to be addressed by a National Maternity Manager.
Priorities, Goals and Actions
The vision statement’s emphasis on birth as a normal life event must also be reflected in the priorities, goals and actions. As we have already noted the goals and actions are too vague. The timeframes given for some of the long-term goals are also too long.
The AWHC would point out again that an adequate level of consumer representation must be included in all the processes outlined in this section.
Goal 1 Leadership
The maternity sector needs a National Maternity Manager. This has been obvious to women’s health groups for some years.
It is completely unacceptable for RANZCOG to be involved in providing leadership or providing advice to the Ministry of Health when their stance on maternity service issues is so incredibly at variance with that being promoted in the Maternity Action Plan.
There must be an adequate level of consumer representation on the Steering Group that oversees both the implementation and reviews and updates of the Maternity Action Plan. One consumer representative is totally unacceptable.
Goal 2 Integration of maternity services
This goal should be amended to read: “To enhance and monitor maternity services to provide:
· An LMC for women and their babies who provides continuity of carer….”
All women should be entitled to continuity of midwifery care. Women who have health problems that complicate pregnancy and birth have an even greater need for continuity of midwifery care.
Goal 3 Integration of maternity services
This goal needs to be reworded to include women having access to home birth and primary maternity facilities, as well as an adequate level of postnatal care and support. The practice of encouraging well women to give birth in a tertiary hospital needs to change, as it results in increasing rates of unnecessary interventions in the birth process.
Goal 4 Integration of maternity services
There is absolutely no need for innovative approaches to protect, promote and support normal birth. We already know what they are. They include:
· getting healthy pregnant women out of secondary and tertiary hospitals and into primary maternity units or giving birth at home
· the training of all doctors and obstetricians to include attending births in primary units, learning how to support water births, and attending home births
· educating health professionals and women about the risks involved in interventions that are not evidence-based or medically necessary.
The long-term actions need to include the Ministry of Health promoting and publishing annual reports on normal birth outcomes.
This goal is essentially a leadership issue and one that the Ministry of Health can and must act on immediately.
Goal 5 Integration of maternity services
Goal 5 undermines goal 4 and is confused about health promotion and preventative public health measures. For example, much of antenatal screening is not preventative public health interventions. An increasing number are in fact medical interventions that along with other side effects often result in making pregnant women more anxious and fearful of pregnancy and birth.
Preventative public health means include preconception care and information, good nutrition, and an appropriate amount of exercise, giving up smoking, abstaining from alcohol, and reducing stress.
The increasing intervention rates also serve to undermine breastfeeding and the efforts of LMCs and others to implement the Breastfeeding Action Plan.
Goal 6 Quality and Safety
This goal needs to be reworded:
“To develop a nationally consistent framework for maternity services that adheres to the Section 88 Maternity Notice and is aligned to the Vision statement in the Maternity Action Plan.”
The Section 88 Maternity Notice is the document that sets the standard for what services the maternity care system must provide in New Zealand.
The last bullet point refers to key performance and clinical indicators – the focus should be on reducing the rates of intervention and increasing the percentage of normal births.
The current system of monitoring maternity services is fragmented as it occurs across a number of committees, departments and health authorities that work in relative isolation. There needs to be a national multidisciplinary body that works across the Ministry of Health, DHBs, health professionals, and consumers that oversees the monitoring of consumer satisfaction, DHB adherence to service specifications and other maternity service standards, the annual reports from DHBs on their intervention rates and maternity outcomes, health professionals adherence to standards, referral guidelines, etc, the timely production by the MOH of national annual maternity reports, as well as the reports on maternal and perinatal mortality.
There have been repeated calls from coroners, the HDC and those involved in Wellington Inquiry report for robust data on maternity service outcomes, but to no avail. It is unacceptable that the last National Maternity Report was for 2004.
All the short, medium and long-term actions listed must involve an adequate level of consumer representation.
Goal 7 Quality and Safety
This should be Goal 1.
In order to increase access to normal birthing options women need midwives and doctors who promote and through their maternity practice support normal birth. This must include promoting the option of giving birth at home or in primary maternity units.
Short-term actions – the pregnancy, birth and parenting education specifications need to be reviewed as soon as possible. Early pregnancy education classes are needed so that women are able to access the information they need to give them confidence in their ability to have a normal labor and birth.
Medium-term actions – the inclusion of childbirth and parenting information into the Health and Physical Activity curriculum must ensure that this information is provided by childbirth educators, Family Planning Educators, midwives, but not PE teachers or teachers who know little about fertility and maternity issues. Educators must also have an appropriate adult education qualification.
Goal 8 Maternity information systems and data collection
There needs to be regular audits of maternity services and research on the most effective ways to improve the system.
The MNIS advisory group needs to be re-established immediately and it must include several consumer representatives. The fact that there has been only one national maternity report since the MNIS advisory group was disbanded speaks volumes about the Ministry of Health’s failure to support the process of improving the production of accurate data on maternity services in New Zealand.
Goal 9 Inequalities
The goals of the Maternity Action Plan must focus on the provision of maternity services that promote normal birthing and meet the needs of women of all ethnicities. As described in the vision statement the most important outcome measure for a healthy pregnant woman is a normal birth and a healthy baby. Fewer interventions during pregnancy and birth are not necessarily inequalities.
All references to inequalities throughout the document need to include details of exactly what inequalities are being referred to.
Goal 10 Maternity workforce
Refer to the previous comments on workforce issues on page 5.
There is a need for a comprehensive education/orientation programme for all immigrant health professionals on:
· how the New Zealand health system works
· the legal necessity of adhering to the Code of Consumers’ Rights
· the need to work in a manner that acknowledges the rights of women within New Zealand society
The AWHC strongly supports the short-term actions:
· MOH funding for the Midwifery First Year of Practice programme that include independent/community-based midwives
· MOH funding for postgraduate education for the midwifery workforce through the Central Training Agency
· The importance of maintaining the current LMC concept of continuity of carer with responsive acute obstetric service backup. This needs to be the first point in the list of short-term action points.
Goal 11 Relationships and multidisciplinary co-operation
The efforts to develop more effective multidisciplinary relationships must include consumers representatives. Likewise all national multidisciplinary forums must include consumers.
It is difficult to envisage GPs, obstetricians, anaesthetists and paediatricians working together with midwives and consumers to realise the vision, principles and goals set out in the Maternity Action Plan – and working towards achieving a reduction in interventions during pregnancy and birth and an increase in normal births. The new National Maternity Manager is going to have to organise a number of meetings to work on this.
Conclusion
The Maternity Action Plan needs further work to develop into an effective and inspirational document that promotes and supports pregnancy and birth as a normal life event.
A National Maternity Manager must be appointed immediately to lead the maternity sector out of the wilderness and among other things deal with the negative and unbalanced media reporting on maternity services that are undermining public confidence in the maternity system.
Vital committees and working parties that have been disbanded must be re-established and adequately resourced to resume work on addressing the need for regular annual reports on maternity service data, for undertaking regular reviews of facility specifications and referral guidelines, and working on restoring relationships between health professional bodies and women’s health groups involved in the maternity sector.
31 July 2009
