I am here to talk to you about Rural Maternity care, to pose some questions, outline some of the challenges and look at some of the gains we have made.
I would like to take you on a trip and have invited some friends to aid me in this. On the screen you will see a young attractive woman, now she’s a midwife of course.
Next to her is a medical administrator, notice the lack of heart and the axe.
One the far left is a dried up, old GP with some would say no brain and stuck in the past.
They’re going to help us find the courage to ask the hard questions we need to ask to move forward on our journey towards sustainable birthing.
First of all I would invite you all to think deeply about the Questions that you need answers to today.
I have three that I would like to propose to add direction to our deliberations.
Most importantly what is our purpose here, what are we trying to achieve through these Rural Birthing Summits?
I believe that we are seeking a clarity of focus on the delivery of safe sustainable team based care for women as they travel their journey to motherhood.
Who is the client we are serving?
For a long time now we have had models of care that are often hospital based with strict structures and protocols. The focus has been more about Doctors, Midwives and money than mothers, their families or communities.
A women centered approach that understands the needs and desires of mothers, that provides quality and unbiased information about options, and assists mothers and their carers through the continuum of the Pregnancy is the key.
This person centered model must communicate risk to mothers, and seamlessly manage the impacts of changing risk levels in a professional, supportive and caring way.
My final question is who pays for this?
The reality is that any out comes we want have to be cost effective and produce quality outcomes. There is an expectation that Queensland Health should pony up the cash for any Rolls Royce Model that we decide upon.
The challenge for those in the Public sector is moving outside their comfort zones, creating partnerships with Private Doctors, Private Midwives and other care givers.
Rural infrastructure is expensive but there needs to be a rediscovery of community obligation.
We need to accept that the establishment of theaters and birthing facilities is a strategic consideration in a cost prohibitive environment.
Communities need to develop understanding around their own capacity to decide on birthing options for their mothers and babies.
Low risk birthing models are not a cost saving exercise, they must be underpinned by robust secondary care and retrieval services.
Like most journeys there are little bumps in the roads, little detours through unpleasant landscape and the potential to lose our way. There are two roadblocks that I believe we need to navigate here today.
The first is tribalism: a set of behaviors and attitudes that stem from strong loyalty to one’s own tribe or social group. The creation of narratives that favor the tribe and paint another as in conflict with your own has long been a threat to doctor, nurses and others working together.
We need to be aware how our own language can cause rifts and chasms between people that are working together for a common purpose.
Turf wars over who the primary carer is in low risk obstetric care are obsolete, we are here to talk about collaborative care centered of supporting a women’s choice.
Silosim is another where several departments or groups do not want to share information or knowledge with other individuals in the same Organization.
I believe that everyone here should use this opportunity to open lines of communication between the Hospital Board, the Executive, our Tertiary centers, the Rural hospitals and the communities they serve. Ensuring we are all on the same page assists Mothers in their journey.
Case management is a responsibility of everyone in the health team. High risk women need to be assisted to birth as close to home as possible, but where that isn’t possible their care should be facilitated by quality communication and support.
Regional and metropolitan birthing units need to be a part of what happens in rural communities. In fact I would challenge them by saying they need to own it.
But there is a light on the horizon. Exciting and positive things are happening. I am pleased to talk about the Caseload midwifery model of care developed in Emerald.
A strong client focus has seen the development of a model of care that allows women to have a known midwife throughout their pregnancy.
The outcomes have been exceptional, and client satisfaction very high.
The Caseload model does have some challenges moving forward.
I believe that we need to look at how to extend the model from low risk to all risk birthing. We must recognize that often the greatest gains in health care are made by delivering it to those with greatest need – the indigenous and the disadvantaged.
There are still many mothers being dislocated from their homes, as risk mitigation has been replaced by risk avoidance, careful conversations replaced by sums of numbers on a sheet of paper.
There is a reliance on Fly In Fly Out Locum Obstetricians to provide case conferencing and secondary care. The challenge is to integrate the caseload model into community care, to re-engage with GP Obstetricians, GPs and other care providers so that the birthing becomes embedded once more within primary care.
Another innovation is the evolution of the Rural Generalist. Queensland Health has nurtured a whole cohort of enthusiastic medical students, shepherded them through their training and ensured that they are given the key skills that Rural Practice needs including Anesthetics, Obstetrics and Surgery.
And to challenge the stereotype over 50% of these Generalists are women.
We have been given a golden opportunity to grown our service capabilities, improve our ability to keep women in their own towns, and to manage more complex issues with less reliance on Transfer of the mother.
However these enthusiastic young doctors need our support, they also need caseload. The greatest risk to the Rural Generalist program is that the Doctors cannot practice what they trained for and they are moving on.
Any future role for rural birthing needs to embrace the generalist as a team player and partner in care for rural women, not as a person of last resort.
Risk mitigation and how we think about care needs to be redefined by the capabilities that these doctors bring.
Remember too that these young Doctors need support from their senior colleagues if they are going to survive the rigors of rural life.
In summation, then I have posed three questions. Why are we here, who are we here for and how do we create a cost effective system wide solution.
I have looked at some road blocks on the way; tribalism and negative narratives, siloism and the its damaging effect on communication.
I have discussed a couple of really exciting initiatives that have great promise, but like all children need nurturing, mentorship and leadership to grow. So lets continue the journey….
Thank you for the opportunity to give this presentation I wish you well in your own travels
Dr Ewen McPhee
1/. Kornelsen J, Mackie C; The role of risk theory in maternal services planning; Aust. J. Rural and Remote Health (e13), 2206
2/. McKenzie A et al. advanced rural skills training: are recently qualified GPs using their procedural skills? Aust. J. Rural and Remote Health (13), 2159