The Secretariat
Maternity Services Review
MDP 94, GPO Box 9848
Canberra ACT 2601
Submission Professor Caroline de Costa and Dr Paul Howat, James Cook
University School of Medicine and Cairns Base Hospital, Cairns, Queensland.
Current service provision in Far North Queensland
The Integrated Women’s Health Unit (IWHU) of Cairns Base Hospital (CBH) provides
antenatal and intrapartum care for all women who are public patients from Cairns and
district, Yarrabah, much of the Tablelands, the Daintree region and the area south to
Tully, and Cape York and the Torres Strait. There are maternity units in which pregnant
women considered to be low-risk can book for antenatal care and birth in Innisfail,
Atherton and Thursday Island and a midwife-lead service in Mareeba. The IWHU acts as
a hub for maternity care in Far North Queensland, which means Cairns obstetricians hold
ultimate responsibility for all complications of pregnancy and childbirth in the entire
region (which is larger than the state of Victoria), being referred cases by general
practitioner obstetricians from smaller communities or consulting by telephone. CBH is
expected to have 2700 births this year with around 300 in the smaller units making CBH
responsible overall for 3000 births. The Special Care Baby Unit cares for babies of 28
weeks gestation and up, due to geographical factors and the inability of southern centres
to accept transfers.
Antenatal care is provided in Cairns by midwives and doctors staffing the IWHU and by
GPs in shared care arrangements. Outside Cairns it is provided by doctors and midwives
resident in communities, by the regular visits of the Royal Flying Doctor Service
(RFDS), by the ‘women doctors’ clinics of the RFDS, and by the Far North Queensland
Regional Obstetric and Gynaecological Service (FROGS) – an outreach service which
every week visits one or more of 15 communities with a team consisting of a specialist
obstetrician, registrar, midwife and other staff. Ultrasound services are provided but are
limited in their scope as a small travelling ultrasound machine is used – fetal nuchal
translucency and fetal morphology scans can only be performed by sending women to
Cairns (or Brisbane if maternal fetal medicine expertise is required.)
Problems
Outreach has been undervalued by hospital administrators and Queensland Health despite
its cost effectiveness. In 2006, 1344 women were seen by the FROGS service; with the
addition of the registrar and midwife in 2007 this increased to 1968 women in 2007. The
cost of running FROGS in 2007 was $84,000 equal to $62 per woman seen; if these
women had been brought to Cairns for these consultations cost would have been
$391,200, equal to approximately $200 per woman.
The past few years have seen the closure of maternity units at Weipa, Cooktown,
Mossman and Tully and the limitation to a midwife-lead service at Mareeba. Women
from Cape York and much of the Tablelands and Daintree regions who have low-risk
pregnancies therefore need to come to Cairns at 36 weeks of pregnancy to await the onset
of labour and the birth of their babies. Women from the entire area served by CBH who
are high risk also need to come to Cairns at or before 36 weeks. All these women face
the social and emotional stress associated with separation from their homes, partners and
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families at what is always an important time in a woman’s life. About 12% of the women
giving birth in CBH are forced by the present arrangements to spend long periods of time
in Cairns prior to the birth of their babies.
Within CBH itself we have midwife-lead antenatal and intrapartum care and have had
team midwifery working well in the unit since 1996. Relationships between midwives
and doctors in this unit are harmonious and mutually respectful. CBH is a teaching
hospital for James Cook University (JCU) School of Medicine and throughout the
academic year undergraduate medical students rotate through the unit. There are four
accredited RANZCOG specialist registrars undergoing training leading to the
FRANZCOG. There are also at any one time four accredited registrars undergoing one
year’s obstetric training leading to the Advanced DRANZCOG. The latter are also
completing advanced rural training in other areas of medicine in order to become general
practitioner obstetricians. Many of these doctors remain in North Queensland and most
are keen to practice obstetrics if they have the opportunity.
Results
We believe the Cairns model works very well for this region and this can be seen in some
of our statistics:
1990 – CBH perinatal mortality rate (PNM) – 30/1000
2008 - CBH PNM – 10/1000 (equal to Australian average)
2008 - Qld indigenous PNM 20/1000
2008 - Cape York indigenous PNM 15/1000
Qld state total indigenous births 5%
CBH total indigenous births 30%
(Source: Qld Perinatal Data Collection Unit)
Therefore despite being the largest population of indigenous women in Queensland, the
most remote, and with the least geographic access to care, Cape York indigenous women
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are doing better than Qld indigenous women as a whole. The gap in PNM is closing.
However there is much room for improvement in statistics – issues such as tobacco and
alcohol abuse (Cape York communities have one of the highest rates of fetal alcohol
syndrome in the world) and diet must be addressed for further improvements.
We also as already noted have good working relationships with midwives both in CBH
and throughout the region. Midwives run a special ‘outreach’ clinic to continue care from
36 weeks when women from the region relocate to Cairns, so that women are cared for
by staff already known to them. We are commencing one-on-one midwifery care within
the hospital. We have seen many of our specialist trainee registrars return to work as
consultants at CBH and many of our GP trainees who have completed their time in CBH
are now in practice throughout North Queensland. We provide a consultant telephone
advice service 24 hours a day for doctors and midwives throughout the region and believe
that this personal contact does much to ensure that the Cairns model works well. The
CBH protocols for antenatal and care and the management of complications of pregnancy
are in place throughout FNQ to ensure the continuation of care when women are
transferred in pregnancy or labour.
Problems
Women have to travel to Cairns for the birth, as already noted. This has
significant physical and psychological impacts on women and their families.
Outreach has been undervalued by hospital administrators and Queensland Health
despite its cost effectiveness. In 2006, 1344 women were seen by the FROGS
service; with the addition of the registrar and midwife in 2007 this increased to
1968 women in 2007. The cost of running FROGS in 2007 was $84,000 equal to
$62 per woman seen; if these women had been brought to Cairns for these
consultations cost would have been $391,200, equal to approximately $200 per
woman.
Antenatal care is still often fragmented with a combination of providers.
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Staff are highly itinerant – recruitment and longterm retention is difficult and
there are not always midwives in remote communities.
Health care workers are important but are not adequate substitutes for midwives
or doctors. Administrators often regard antenatal care as primary care and
therefore within the purview of indigenous health workers. In fact the women
presenting for pregnancy care in rural and remote regions are often high risk and
require the care, direct or supervised, of doctors.
Cairns needs more culturally appropriate accommodation for pregnant women
from remote communities. Funding for an appropriate support person for these
women has ceased. They are often young, alone, and scared. They are parted from
their partners and other family for weeks. Each woman should have the option of
an accompanying support person.
Access to ultrasound is very poor in remote communities and limited to small
portable scanners taken by FROGS and RFDS doctors. Rates of first trimester
nuchal translucency scanning and 18 week anomaly scanning are the lowest in the
state- as demonstrated by the 2007 report by Coory et al (MJA) showing that in
Queensland rural women and those accessing the public system are more likely to
give birth to infants with Down syndrome. A dedicated travelling ultrasound
service with two sonographers is desperately required. There is good evidence to
show that pregnant women reduce intake of alcohol and tobacco when shown
photos of their fetus following ultrasound scanning. Being able to do this in the
first trimester for our population of remote indigenous women is critical if the
rates of fetal alcohol syndrome and of underweight babies are to decrease.
Antenatal education is fragmented, and completely absent from some smaller
centres. Team midwives could provide videoconferenced antenatal classes from
Cairns but videoconferencing equipment is lacking.
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Recommendations
Remote indigenous women need more resources. Improving antenatal care and
perinatal outcomes and reducing the rates of conditions such as fetal alcohol
syndrome will save health costs in the future.
CBH needs to be regarded, and staffed, as a major tertiary maternity centre in its
own right.
Better support for midwives in the region – financial but also educational, plus
accommodation and lifestyle incentives to remain in the region.
Reopening of at least the Weipa and Cooktown maternity units, to be staffed by
GP obstetricians who are well supported financially and educationally, and from
the point of view of lifestyle (e.g.rosters that are not unrealistically demanding,
locum support for holiday and conference leave). The re-institution of GP
obstetricians is absolutely critical to the improvement of maternity services in
rural and remote areas, not just Far North Queensland.
Two travelling sonographers with mobile equipment so that each community can
be visited every two weeks. Again sufficient support is required.
Two additional staff specialist obstetricians to allow the outreach program to
expand – MSOAP should be accessible for these but to date we have not been
permitted to access these funds.
Two extra specialist registrars – this would bring our staffing into line with the
staffing in similar-sized centres.
SCBU needs to be upgraded to NICU.
Better accommodation for women relocating to Cairns for birth.
Currently the provision of services by both Commonwealth and State Health departments
means that much care is fragmented. We believe the best co-ordinator of care for the
women in this region is CBH IWHU and JCU, who have already demonstrated their
continuing commitment to providing the highest standards of care for these women.
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Additional submission to the Maternity Services Review 2008
Professor Caroline de Costa and Dr Paul Howat
James Cook University School of Medicine and
Cairns Base Hospital, Cairns, 4870
We wish to make some comments about reference number 19 in the discussion paper
Improving Maternity Services in Australia. This reference is the 1985 publication from
the World Health Organisation Appropriate Technology for Birth. In this publication it is
speculated that a ‘correct’ rate of caesarean section in a developed country is 15% of all
births.
Having read this publication we would point out firstly that little scientific evidence is
offered for this assertion. Moreover nearly 24 years have passed since this document
appeared. In this time we have seen the Term Breech Trial, a randomised prospective
controlled trail which was reported in The Lancet in 2000 and which established that the
perinatal mortality and morbidity figures for vaginal breech delivery are three times those
of delivery by caesarean section. We have seen enormous advances in the neonatal care
of infants born at 24-28 weeks gestation, with results that were unattainable in 1985.
These very small infants are frequently most safely delivered by caesarean section. We
have seen an increase in the age at which Australian women have their first (and
subsequent) children; we have seen great increases in the incidence of obesity, diabetes
and hypertension among women especially older women in the reproductive age group,
and we have seen an increase in the number of children conceived through IVF. All these
developments have necessarily led to an increase in the number of caesarean births.
We have also seen great increases in the safety of caesarean section, in particular with
regard to the use of regional rather than general anaesthesia. This increased safety means
that the operation has become a legitimate medical alternative to a vaginal birth in many
cases where, for example, a difficult forceps delivery might have been attempted in the
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mid 1980s. (We have noted a decrease in rates of mid-forceps deliveries in Cairns Base
Hospital over the past 15 years concurrent with the rise in caesarean numbers.)
All these factors have contributed to increased caesarean rates in Australia in the past 24
years. We would strongly question the idea that a ‘correct’ caesarean rate exists for any
population (while agreeing that the indications for caesarean in any maternity unit or
private practice should undergo regular review.) We also question the use of such
authoritarian statements by administrators and others to dictate health policy, often for
short term financial gains– we believe that whenever caesarean section is a valid choice
for a pregnant woman she should be assisted by her doctors and other health
professionals into making an informed choice for herself and her baby. We also believe
that while it is essential that maternity care be evidence-based, it is also essential that
recent evidence that is relevant to Australian practice is used.
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