Rural maternity services: It takes a team to make it work
Dr Ayman Shenouda
Timing is everything - this is particularly true in healthcare - and in birthing services right now, it’s actually getting quite critical for GP obstetrics.
For the rural GP obstetrician, the discussion is no longer about a rebirth of rural obstetric services for rural areas but in has moved rapidly to the preservation of this critical role.
Two key discussions are occurring in obstetric care in Australia at the moment both lacking one vital component and that is valuing the key role of the GP obstetrician in providing this care.
The first, occurring at the national level, in setting national directions for maternity services prioritises access yet omits GPs almost entirely despite their reliance in rural and remote areas.
The other discussion involves a state-led shift in WA towards a new model of care which seems to locks GP obstetricians out completely.
We are seeing spot fires right around the country including in northern NSW but on a slightly different front in resistance of midwifery units to GP involvement.
Combined these are worrying developments and it is clear that major change looms unless we can work to reframe the discussion.
We have the solution
The vital role of the GP obstetrician has to now dominate the national discussion and the National Rural Generalist Pathway is the connecting policy thread here.
We are now at a critical point in building a future rural workforce which offers a single solution by factoring together all the required enablers in one.
The vital work done over the last twenty years has shown us solutions which brought together in one pathway will offer a sustainable way to address rural health needs.
It’s a model that will work – one that prioritises the skills needed – which are reflective of local health needs with the required training supports embedded.
This is a model that brings flexible models of care bridging the primary care and hospital care continuum – it’s based on community need.
And it provides a way to keep it sustainable by enabling a highly skilled GP workforce integrating primary, secondary and tertiary care skills.
But it is reliant on enabling infrastructure too and in keeping it sustainable and so much is connected to a town’s capacity to preserve procedural services like birthing.
State of play
Here’s a brief outline of the current state of play.
Round 2 of the National Strategic Approach to Maternity Services Consultation has just closed (20 November).
The Australian Health Ministers’ Advisory Council’s consultation draft Strategic Directions for Australian Maternity Services is structured around four values — respect, access, choice, and safety. Enabling access to services for rural and remote women is emphasised.
Our College has advocated strongly for the federal government to acknowledge the role of GPs when this strategy is finally released next year having previously outlined concerns about the marginalisation of general practitioners out of obstetric care.
Meanwhile, in Western Australia, the debate continues to heat up on hospital led changes to the obstetric care model in that State which is seeing GP obstetricians increasingly locked out.
The WA shifts
In WA we are hearing that this shift has been occurring gradually over a five-year period.
The move to a hospital system with very little GP involvement and reliant on the fly in fly out specialist with onsite junior staff is becoming more prevalent.
Local reports state that GP obstetricians are being excluded from being involved in intrapartum care with the new model using a salaried medical workforce and shift to midwifery-led care.
This model has resulted in a significant disconnect between the hospital staff and the local primary care workforce.
This being at odds with what the federal government is trying to achieve nationally through the NRGP in building a resilient rural GP workforce.
Choice for women
But perhaps the most important point is that with a new maternity model which favours salaried medical staff over GP obstetricians it is the patient that loses most of all.
With GP obstetricians unable to care for public obstetric patients’ the choice for women is now much limited as a result.
In these towns, the continuity of care role sits with GP obstetricians and carving this off piece by piece to a fly in fly out service model will come at a significant cost.
In other towns we are seeing services close - women and their families have to travel significant distances to access care for pregnancy and birth.
We know the risks that come with increased distance as well as the associated financial burden on already struggling rural families.
Delivering care close to the patient is what works. Rural communities depend on their GP obstetrician with more babies delivered by GP-obstetricians than specialists in rural areas.
A collaborative model
What is missing in these discussions is a real understanding of team care and what it takes to address patient need in small rural towns.
That is, what it actually takes to sustain a rural maternity service and those interconnective factors for why it matters so much for other services.
We know that it takes a collaborative approach and advanced clinical skills encompassing medicine, midwifery, nursing, Aboriginal health and allied health.
What’s important is understanding the role of the team and scope of practice enabling all to work together without comprising quality.
It takes the whole team to make this work. A sustainable model involves a coordinated team involving the obstetrician, GP obstetrician and midwives and a roster divided among all of them.
This is how the service is maintained and we only have to look at the success of places like Albury Wodonga to see how this model sustains their service – sharing on call and the prenatal and antenatal.
We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop.
A vital skill set
GP obstetricians skilled in childbirth require support, not barriers, in retaining such a vital skill set.
At a national level, procedural training grants ensure they can maintain their skills yet on a state-level, at least in parts, this is not sustainable when access is denied.
These latest developments not only risk the provision of obstetric services in rural areas becoming even more of a rarity but there will be some very real flow-on effects for our discipline.
The attraction and retention of GPs to the region is closely tied to the GPO model and it is a skill set we need to nurture to preserve through the National Rural Generalist Framework.
It is about getting the right skilled workforce in place, supporting a collaborative team structure to secure and sustain birthing services across rural Australia.
The rural generalist model offers a way forward which will make a difference for rural patients - ensuring safe, affordable and accessible healthcare.
Dr Ayman Shenouda