Former treasurer Peter Costello may or may not have been responsible for the current baby boom, but a failure by governments and health planners to foresee the dramatic increase that now has the birth rate at a 30-year high has had serious consequences for public hospitals and birthing services.
The impact of the baby boom has been felt more severely because of shortages in the maternity workforce. A workforce survey by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, conducted in 2003 before the onset of the baby boom, predicted serious shortages of experienced practising obstetricians before long owing to retirements, feminisation of the workforce (women tend to work fewer hours) and an increase in doctors giving up obstetrics due to the cost of medical indemnity and the impact of practice hours on their lifestyle.
There are also shortages of midwives right across Australia and their practice is currently restricted by the cost of indemnity insurance and the fact that they cannot access the Medical Benefits Scheme unless they work under medical supervision.
Steady increases in the average maternal age, higher rates of multiple births and growth in the number of pregnancies resulting from assisted reproduction technologies have made maternity care in Australia increasingly complex.
Because of these factors and others, pregnancy and birth have increasingly involved sophisticated medical interventions, as reflected in the dramatic increase in caesarean rates over time.
Improving Maternity Services in Australia, the report from the review of maternity services commissioned by Health Minister Nicola Roxon, was issued last weekend. It finds that achieving the agreed goal of maternity care safe, high-quality and accessible care based on informed choice for all women, regardless of where they live will be difficult and complex because there is a lack of unanimity within and between some groups of the medical and midwifery professions on the issue of how to deal with risk and consumer preferences.
Long time frames are inherent in the development, funding and implementation of the proposed National Maternity Services Plan. But risk management and better integration of care during pregnancy and birth are two critical issues amenable to change in the short term. These can both be tackled, along with necessary improvements in service quality and efficiency, by developing a framework for service provision based on three clinical pathways for maternity care one each for low, moderate and high-risk mothers and babies.
Such a framework needs to be modified to suit conditions in each state and territory, and in the regions within them. It will also need to be modified over time as existing problems, such as workforce shortages and the lack of maternity units in many rural areas, are gradually resolved.
To implement the framework, it will be necessary to develop clear, consistent, mandatory protocols for consultation and referral between health professionals, and to introduce integrated clinical networks for maternity care in each state and territory.
This is not a new idea. In 1989 a major review of maternity services in NSW, chaired by Professor Rodney Shearman, made it clear that to ensure equitable access to quality care in future, an integrated network of community and hospital-based antenatal care would be needed.
The Northern Territory has begun to implement an integrated maternity services framework and some states have shared care guidelines and referral policies.
The key to making this happen is mandatory protocols and the formal communications between health professionals that protocols will require. In an environment where there is a lack of trust, and sometimes even hostility, between professionals, relying on the existing voluntary guidelines for referral and consultation between them is inadequate.
To ensure the highest quality of maternity care in Australia, procedures for risk assessment and management must be clear, accepted and recognised nationally, and mandatory for all health professionals working in obstetrics.
It is critically important for patient safety that these protracted demarcation disputes over health professionals' roles are shifted from the world of clinical silos to integrated services focusing on the pregnant woman's needs and the best outcomes for her and her baby.
Dr Russell is the Menzies Foundation Fellow, and Dr Boxall a former research assistant, at the Menzies Centre for Health Policy, University of Sydney/ANU.
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