Video-call the midwife: The future of woman-centered antenatal care

Antenatal care has been in the news again. In recent months, the findings of Queensland Maternal and Perinatal Quality Council’s review into perinatal and neonatal deaths, proposed changes to insurance for Victorian midwives in private practice and the impact this may have on home births, the closure of numerous private maternity departments and the burden this has placed upon the public sector, have all made headlines.

In the first of our new series on the future of women’s health, we ask how the Commonwealth and state and territory governments can ensure high quality, woman-centred care in a sector experiencing changing patient expectations, increased workforce pressures, and geographical and other continuity of care issues.

It is a truth universally acknowledged – and backed up by a robust evidence base – that midwifery-led models of antenatal care, backed by complementary medical interventions and holistic care, reduce birth interventions and improve maternal outcomes. While it is obviously necessary to have medical intervention on hand in case of emergencies, midwifery-led models emphasise continuity of care, as well as continuity of relationships, in a way that provides pregnant women with consistent information from a trusted source and generally lead to improved maternal satisfaction.

But Australia is facing a midwife shortage, compounded by an aging workforce and increasing demand for midwifery services, which means this model is increasingly inaccessible to many women who would otherwise access it. In addition to many midwifes aging out of the sector, or opting out of on-call work, it has also been suggested that there are not enough low-intervention births in Australia to justify a focus on flexibility or the range of women’s preferences. Professional politics and the increasing medicalisation of birth may have something to answer for here.

It is important to remember that this is a shortage within a shortage. The wider maternity workforce, too, is similarly struggling to meet demand. Workforce shortages are especially acute in rural and remote regions, limiting access to specialist antenatal care and rendering continuity of care difficult to maintain. Certain populations, including Aboriginal and Torres Strait Islander women, face further barriers to accessing culturally safe woman-centred care. These same patients are similarly affected by inconsistent screening for perinatal mental health issues, such as anxiety, depression, and PTSD, and access to mental health supports, too, is very often limited. These workforce shortages, cultural barriers, and geographical limitations have alike led to higher rates of maternal transfer and intervention.

But these issues are not limited to those in rural, regional, and remote areas. The workforce shortage is increasingly being felt in metropolitan areas, too, with pressures on the public sector compounded by a decline in the use of private obstetric services. This decline is in large part due to rising out-of-pocket costs, with limited subsidies from private insurers rendering private care out of reach for many families. Concerns over high intervention rates in private settings – Australia has some of the highest caesarean section rates in the world – have only accelerated the trend, with many wary of the long-term health consequences for mothers and infants alike.

Since the height of the COVID-19 pandemic, Australian governments at both the federal and state levels have invested heavily in tele- and digital health capabilities. In some instances, this also included telehealth in the antenatal space.

It is important to set realistic expectations here. No one is talking about delivering babies remotely. But there are countless other adjunct services that advanced and emerging technologies might help to deliver or facilitate, particularly in the case of those who face geographical barriers to access. (The World Health Organisation’s Digital Adaptation Kit for Antenatal Care was released in 2021 and there is emerging evidence that digital health solutions targeted at pregnant women can improve antenatal care services.)

Similarly, while you may not yet be able to teach AI to be compassionate or to deliver someone bad news, clinicians and staff are currently using AI to write letters and find vital information for busy clinicians, especially isolated ones who may not have the resources that their peers in larger services have. Such developments may allow the maternity workforce to focus more fully on the human dimensions of its mission, artificial intelligence ultimately freeing up space for its emotional equivalent.

This goes some way towards addressing the access aspects of the challenges we’re facing. The supply and demand aspects, however, will require other approaches. We must work towards a more integrated system, with neither the midwifery-led nor medical models operating in isolation, siloed from the other. It is not, and should not be, an either/or situation. A change in mindset is required here, a realisation that addressing Australia’s midwife shortage would simultaneously address the wider maternity workforce one, as would building a broader suite of options – think doulas, for example – that reflect the diverse cultural needs of a multicultural society. That midwifery-led and other such models represent a cost-effective alternative to obstetric-led care, especially for low-risk pregnancies, and can help alleviate pressure on overstretched services, is an added extra and should make this course of action more attractive than it has arguably been in the past.

It is also a course of action that puts women back at the centre of their own healthcare experience. Person-centred, patient-centred, and woman-centred care are not new terms. But the history of women’s healthcare has rarely been one that has lived up to such ideals.

The roles of midwives, obstetricians, policymakers, health service leaders, and technology might seem obvious on the surface, even when there is seeming contradiction, even competition, between the moving parts. But it’s the role of women, pregnant or otherwise, in helping to decide what antenatal care looks like – what options are available to them and how they might best and safely access them – that should take precedence and lead future thinking. Understanding and supporting women’s choices, given them a sense of control and autonomy while reducing or avoiding maternal and infant risk, should be central to policy and framework development as governments and health providers work to address the issues the system is moving forward.

Get in touch to discuss antenatal care and the future of women’s health.

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Prepared with input from Paul Eleftheriou, Ian Thompson and Lauren Ware.

This is the first article in our series on the future of women’s health. Read the second part here.