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With growing recognition that the social and emotional needs of women are not being met in their maternity care, it is vital that we understand the needs of the people who use our maternity care systems.
Just over 300 000 women and gender diverse people give birth in Australia each year, and this group is incredibly diverse. Women and gender diverse people receive maternity care in many different models of care. Care is provided by a range of professionals, and can be provided in the public, private or Aboriginal community-controlled sectors. One approach to care is known as continuity of carer, where the majority of a woman’s care is provided by one maternity professional, and this is typically provided in models such as midwifery group practice.
Generally, Australian maternity care services provide competent physical care, evidenced by low mortality and morbidity rates. However, there is growing recognition that the social and emotional needs of women are not being met, with occurrences of birth trauma and psychological distress on the rise. A parliamentary inquiry established in 2023 in New South Wales has been looking into birth trauma in that state, with over 4000 submissions received to date.
Midwives are the largest professional group providing maternity care to Australian women. The Midwifery Futures team has been engaged by the Nursing and Midwifery Board of Australia to undertake a review of the midwifery workforce in Australia to ensure there are enough midwives, in the right places, providing care that meets women’s needs.
Australian women have contributed to much research over the past decade, so rather than going and asking them, we pulled together what is already known about what Australian women need from their maternity care. Recognising that Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse women, women in rural and remote locations, and gender diverse people face specific challenges, we looked for research including these populations.
Understanding the needs of women who use our maternity care systems is incredibly important. With this information, we are in a strong position to continue building maternity care services to meet women’s needs, whoever they are and wherever they are.
Our research
Our scoping review found 59 studies, from all states and territories of Australia, with a range of different research approaches used to answer the question of what women say they need from maternity care. The research was of good quality and, hence, was a good way to use existing findings. More research has been done for some groups of women than for others. Only six studies have looked at the maternity care needs of women in rural and remote areas, two considered younger women, and only one each studied the needs of older women and gender diverse people.
Our research findings were consistent and clear: women want to be treated with respect, feel safe and listened to, be provided with choice and information, be communicated with clearly, and be treated in a culturally sensitive way.
Women wanted to have one care provider from beginning to end, known as continuity of care, in more than half the studies and most wanted that care provider to be a midwife. Women said continuity helped them feel safe, seen, heard and enabled. Continuity was particularly helpful to specific groups, such as women from refugee backgrounds who had aspects of trauma in their past. Continuity meant these women did not need to revisit their trauma story with new care providers at follow-up appointments. Similarly, gender diverse people found continuity meant they did not need to repeatedly explain their gender identity and pronouns to staff members.
Aboriginal and Torres Strait Islander women highly valued Birthing on Country (a continuity of care model with a strong focus on midwifery care and cultural support), being cared for by Aboriginal and Torres Strait Islander staff, and cultural sensitivity. Culturally and linguistically diverse women also valued cultural sensitivity and wanted interpreters to help with communication so they could make decisions about their care. Women in rural and remote parts of Australia highlighted the need for choice, as many of their local services did not offer the sorts of care they preferred, and they wanted care close to home.
Where to from here?
We already have good evidence of the safety and effectiveness of midwifery continuity of care models for women and their babies, with significant benefits and no additional risk compared with standard care. It also benefits midwives, with higher levels of job satisfaction and less burnout, and is cost effective. Our review makes it clear that what Australian women need from maternity care is best provided through continuity of midwifery care. The problem is that only a small percentage of Australian women are currently able to access continuity of care models, and this is particularly a challenge in rural and remote areas.
To better meet women’s needs through midwifery continuity models, we need to reconsider how maternity care systems are funded, designed, regulated and supported. Reform of this nature would mean supporting and funding hospitals and health services to implement, sustain and evaluate local continuity of care models.
It would also involve industrial reform to achieve national consistency in midwifery awards to ensure cost-effective staffing of midwifery continuity of care models. We also argue for the removal of legislative, regulatory and technological barriers that prevent midwives from providing effective care in this way, in both the public and private sectors (such as not being able to enter information into women’s My Health Record).
We also need reform in how continuity is monitored and measured. Currently, there are no available data on the number of women receiving continuity of midwifery care or the number of midwives providing this care.
Women’s maternity care needs are clear and simple. Can the Australian health care system rise to the challenge and deliver care that is both physically and psychologically safe?
A note on language
We use the words women and woman throughout this article, acknowledging that the majority of people who are childbearing are cisgender and recognising the gendered nature of pregnancy and the associated health care. For this article, these terms include women and people whose gender identity does not correspond with their birth sex or who may have a non-binary identity. Most research in maternity care has been conducted with cisgendered women, and generalising all research conclusions to gender diverse individuals may not be appropriate. All those using maternal and reproductive health care and services should receive individualised, respectful care including use of the gender nouns and pronouns they prefer.
Dr Kirsten Small is a Senior Research Fellow at the Burnet Institute, Melbourne.
Dr Lachlan Faktor is a Research Assistant at the Burnet Institute, Melbourne.
Sally Cusack is a member of the consumer organisation Maternity Choices Australia.
Associate Professor Zoe Bradfield is an Associate Professor of Midwifery at Curtin University and King Edward Memorial Hospital in Perth.
Chanelle Warton is a Research Fellow at the Burnet Institute, Melbourne.
Professor Caroline Homer is the Deputy Director (Gender Equity, Diversity and Inclusion) at the Burnet Institute, Melbourne.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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This article completely ignores the only way continuity of care can be achieved in all situations a pregnant person may face!
This of course is with a known obstetrician. Australian data (AIHW Dec 2023) suggests that as many as 50% of women will require either operative vaginal or abdominal delivery, treatment that can only be delivered by a trained obstetrician (specialist or GP).
Care given by a known obstetrician for the entire pregnancy, delivery and postnatal period is now only readily available in the private sector as most public hospitals have moved to a midwifery centric model of care where women only see an obstetrician when things have gone wrong.
This is the net effect of midwifery group practice as it is currently practised in many public hospitals across the nation and is neither satisfying for the woman nor the obstetrician who is frequently involved in the care of the woman far too late.
Private midwifery models fare better with some group practices working closely with obstetricians who will see the woman at varying times during her pregnancy and be available for the delivery in the event the midwife needs specialist assistance. In this model, at least the woman will have met the obstetrician before an emergency develops and has a chance of partial continuity of carer.
A number of government run independent enquiries into adverse maternal and fetal outcomes have recommended greater and earlier involvement of obstetric staff.
A number of studies show that a significant proportion (statistics vary on whether the data was collected on “an intention to treat basis” or not) of women who start out in a midwifery model of care will need the services of an obstetrician to effect safe delivery of the baby and safe care of the mother.
These facts should be known to the authors and the exclusion of the role obstetricians from this article, whether unintentional or deliberate, is a shortcoming. It is not unreasonable to expect that at least a mention of this continuity of carer model be included in the article.
A/Prof Gino Pecoraro OAM FRANZCOG MB BS FAMA
President National Association of Specialist Obstetricians and Gynaecologists
I’m almost lost for words at the naïveté shining through this article. Yes, there is value in documenting the utopian ideals of future mothers. Some ideal, lofty and impossible, has value to keep reminding us to consider the feelings of the woman in labour. But it’s a lower priority than survival of the baby in so many instances. Having attended near 2,500 complicated deliveries in a career of 30 years all in country centres, I almost don’t know where to begin. Contractions in an ambulance rushing miles to the nearest midwife, staying in another town 600k from home so your twins can be managed, arriving too late with a cord prolapse and a dead baby, massive bleeding from abruptio placentae, not to mention staff issues – your midwife hasn’t slept for 24 hours because she was caught up with someone else’s child, or is sick, or her own son has just died in a car accident . . . Glory! And you refer to mothers’ wishes as “simple”?!!
“Our research findings were consistent and clear: women want to be treated with respect, feel safe and listened to, be provided with choice and information, be communicated with clearly, and be treated in a culturally sensitive way.”
So their own health, and the health of their baby, was of lesser subjective importance? When the term ‘birth trauma’ is used to describe psychological distress, rather than a cord prolapse, rectovaginal fistula, brachial plexus palsy or a stillbirth, there appears to be an underappreciation of the benefits of modern obstetric and perinatal care.
When does this continuity of care start? In my experience as a “shared careGP”( sharing care now being non existent due to the primacy of midwifery) I am expected to do all the initial education in relation to choice of method of care and medical assessment is suitability, all reproductive genetic screening and diagnostic options , fill out paperwork without access to the software the rest of maternity uses, and do this in a timely manner to fit in with hospital based protocols . I would really support midwives doing real continuity of care, which means confirming pregnancy and doing all the counseling and bureaucracy.
Whilst continuity of midwifery care is to be aimed at, the authors seem to forget that collaborative care with obstetricians is also essential for wholistic maternity care. The authors risk increasing the divide between doctors and midwives, risking the care of patients and the promotion of siloed practices.