Homebirth Services (27.11.2013)
Written on the 28 November 2013Ms HARTLAND (Western Metropolitan) -- I move:
That this house calls on the Minister for Health, Mr David Davis, MLC, to, as soon as feasible, take the necessary steps to expand public hospital homebirth services including --
(1) committing to fund start-up costs of homebirth programs to hospitals providing maternity services in the next state budget;
(2) developing statewide guidelines and information for health services implementing homebirth services;(3) developing systems to prospectively collect costing data; and
(4) supporting further research into the safety of homebirth programs and research to compare clinical outcome data associated with low-risk births in different birth settings.
I will speak only very briefly on this motion because it is about a fairly straightforward matter. I am bringing this motion before the house because I am concerned that the government is dragging its feet on expanding birth choices for women. Sixteen months ago, in June 2012, the final report on the independent evaluation of the homebirth pilot programs at the Casey and Sunshine hospitals was submitted to the Department of Health. It took nine months, until March, for the Department of Health's summary report to be released publicly.
The summary report is not a complex document; it simply provides a summary of the findings of the evaluation. The summary indicates that the Minister for Health had sought advice from the perinatal services advisory committee on the implementation and expansion of publicly funded homebirthing options in Victoria. Exactly when the minister asked for advice is unclear, but what I can say for sure is that it is eight months or more since it was requested.
In the last sitting week, in response to a question without notice I posed about a different matter, the minister said that he has now received that advice on the homebirth program and that it was supportive of the rollout. It seems to me that each step in this process has been protracted: nine months to produce a summary of a report and eight months to receive advice. It is time the government got on with it and took the necessary steps to expand homebirth services to other leading hospitals in a safe, well-supported and well-monitored way.
Lately I have been talking about maternity services to a lot of women, especially women in the outer suburbs. Mr Finn apparently believes that I never go there, but I actually live in Footscray. He seems to forget that many Greens, including myself, live in the western suburbs. It is time the government got on with the job and took the necessary steps to expand homebirth services to other hospitals.As I said, lately I have been talking about maternity services to a lot of women. I have conducted a survey of 1385 women. What I heard strongly is that women want more choice in publicly funded birthing options.
A public hospital homebirth program is one of the very important options that women want. Currently public hospital homebirth programs are available to only a limited number of women who live in the catchments of the Sunshine and Casey hospitals. There is demand for these services in other areas because, amongst other problems that discriminate against private midwives, many women cannot afford the cost of a private midwife-supported homebirth.While the sample size was not large, the homebirth pilot evaluation found very promising statistics, with 88 per cent of the homebirth group having a vaginal birth, compared to 70 per cent of the hospital group -- that is, there were 18 per cent more natural vaginal births, which is a great outcome.
With regard to neonatal outcomes, women in the hospital group were more likely to have intervention during labour and birth. The perinatal mortality rate was identical for both groups.The homebirth pilot evaluation found that a public hospital supported homebirth program provides this choice to women who otherwise could not afford it. Mothers expressed very high levels of satisfaction with the care and there was very strong support for the program amongst midwives. The lower intervention rates, the higher number of natural births and the high level of mother satisfaction provide a strong case for expanding homebirth services to other hospitals, particularly leading maternity hospitals as a starting point.
While there was a start-up cost associated with establishing these programs, the evaluation found that there were significant savings once programs were operating, with reduced bed day costs and staffing of postnatal wards in homebirth programs. Given that there are growing issues with the demand for maternity services outstripping the physical capacity of hospitals, especially in growth areas, a homebirth program seems to provide an important low-cost means of increasing the capacity of hospitals without compromising on quality or safety. A well-supported, well-monitored and safe expansion of the homebirth program will benefit women who desire this birth choice, and I believe it will benefit the Victorian hospital system.I wish to finish by outlining the elements of the motion. The first point recognises that to get homebirth programs off the ground in additional hospitals some extra funds will be required in the short term. Paragraphs (2), (3) and (4) mirror recommendations outlined in the homebirth program pilot summary report and are elements that will facilitate the expansion of the program and help to ensure that it is well researched and monitored and delivers safe and cost-effective as well as women-centred services. I call on the government to stop dragging its feet on this matter and get on with the expansion of the public hospital homebirth program.
Ms CROZIER (Southern Metropolitan) -- I am very pleased to rise this afternoon to speak on Ms Hartland's motion:That this house calls on the Minister for Health, Mr David Davis, MLC, to, as soon as feasible, take the necessary steps to expand public hospital homebirth services, including --
(1) committing to fund start-up costs of homebirth programs to hospitals providing maternity services in the next state budget;(2) developing statewide guidelines and information for health services implementing homebirth services;
(3) developing systems to prospectively collect costing data; and(4) supporting further research into the safety of homebirth programs and research to compare clinical outcome data associated with low-risk births in different birth settings.
I have listened to most of Ms Hartland's contribution. In her concluding remarks she spoke about the additional resources required and said that additional funds would not be needed in the short term.
I would have thought the four areas outlined in Ms Hartland's motion would require ongoing funding. Continually collecting data and supporting further research requires recurrent funding. I do not know how long she expects them to operate, but these are significant areas for consideration, and I do not believe something as important as the statewide community health system she calls for can be regarded lightly. There are implications for the services she describes, and the government is taking a very considered approach to the issue.
Ms Hartland says there is not enough funding for this area of health care, but I remind her that in the 2013-14 state budget the coalition government committed $14.3 billion to fund health services right across the state, and that included the growing demand for maternity and neonatal services. I practised as a midwife for 10 years. I worked in one of the state's leading hospitals, the Royal Women's Hospital, and I have a very high regard for the day-to-day services it provides.I commend all the nurses, midwives, obstetricians and gynaecologists, as well as the numerous allied health professionals associated with that organisation. They do an extraordinary job every single day. We have a growing population in this state, and there are greater demands on those services. As technology advances we are seeing more demand on neonatal services. There are improved outcomes after premature deliveries, and we are treating a lot more patients with complex health disorders.
In my time I managed one of the high-risk areas in maternity services: diabetes patients, particularly those with gestational diabetes but also women who had type 1 or type 2 diabetes. Patients in this high-risk category need intensive and thorough monitoring. Our health services do a tremendous job in caring for women right across the spectrum, whatever their health condition.
I would like to commend the government for putting in the significant amount of money needed to support a growing population and the more complex needs that our health system is facing year in, year out, specifically in relation to maternity care. In the 2013-14 budget there was a boost of around $24.7 million, which went to providing more neonatal intensive care units (NICUs). A further $22.4 million went towards funding the growth in maternity care and, as I said, treating more patients across the state.
The data tells us that there is a growing demand for maternity services in the northern and western regions, that latter which Ms Hartland represents, and that in our public hospital system overall births have been increasing, year in, year out. I have some statistics from the public hospital system: in 2010-11 there were 52 064 births, in 2011-12 there were 54 362 and in 2012-13 there were 56 097. You can see that there has been a gradual and steady increase.Our hospital services need to meet these demands, and that is exactly what this government is planning for and undertaking. In saying that, there is particular demand for neonatal services such as NICUs, and because of the increase in the number of homebirths, there is obviously going to be an increasing demand for those important neonatal services. I congratulate the minister on his investing in five additional NICU beds to meet the ongoing demand. We now have 95 NICU beds across the state, and as somebody who has worked in the area I understand their importance and the very big job that midwives and health workers do in looking after babies in the NICU.
Turning to the main point of Ms Hartland's motion in relation to homebirths, it is true that in 2009 a homebirth pilot program was commenced at Sunshine Hospital and Casey Hospital, and the Perinatal Services Advisory Committee (PSAC) reviewed the evaluation of the pilot. It is important to explain what the committee does. It is a ministerial advisory committee which was established in May 2012 to provide advice and make recommendations to the Minister for Health and the Department of Health on maternity and neonatal services in Victoria.Its website states:
In particular the PSAC provides advice on:Effective service system design and management strategies to improve the quality and outcomes of care for women and newborns.
Approaches to improve the measurement and understanding of maternity and neonatal services and to evaluate the quality and outcomes of care.Monitoring maternity and neonatal performance to improve planning and management of service capacity across the state.
Policies and strategies to improve the performance of hospitals with maternity and neonatal services and strengthen the interface between service providers and the community.Specific matters referred to the committee by the Minister for Health and the department for recommendations as required.
It has very broad-reaching responsibilities, in particular for the very necessary and important areas of maternity and neonatal services.
I know Ms Hartland has a particular interest in homebirthing services.But from my experience I would suggest that it is not as simple and clean cut as one might think. There are certain things that need to be undertaken, and there need to be certain regulations to ensure the welfare of mother and baby in the situation of a homebirth. As I said, the Perinatal Services Advisory Committee has undertaken a review of the pilot that commenced in 2009, and on the website a summary of what it has said about it is fairly well spelt out. The committee expresses support for the expansion of the publicly funded homebirth models of care in Victoria but at the discretion of the individual health services, and that is the really important point.
Ms Hartland has suggested that homebirths need to be further supported within various health services. It is really up to those individual health services as to whether they want to undertake such a service. The health services should be able to decide, because they look at resourcing issues in relation to homebirths and to their day-to-day operation of maternity and neonatal services.
The situation has to be fluid. You cannot have set bed days or bed times in relation to maternity and neonatal services. It can be complex and very challenging at times. As is highlighted on the committee's website, it is up to individual health services whether or not they want to undertake homebirth programs.
I know many privately practising midwives who have done an extraordinary job for many years, and I support their endeavours. There are eligible midwives who can seek admitting rights and provide maternity services in a public hospital, whether during the antenatal or postnatal periods or during labour. Those privately practising midwives have significant powers because of their experience and ability to provide maternity care for a woman. This is done in the health service and in an environment where there is significant backup, the service can be monitored and medical treatment is available if required.
Unfortunately homebirths, or any birth, can go terribly wrong. I myself have been in situations where I have thought everything was going very well, but there could still have been tragic outcomes. That is the nature of birth and of women going into labour; all sorts of different scenarios might arise from particular situations. Things happen extremely quickly during labour, and circumstances can change very quickly, so it is only right and proper that private midwives should feel safe in practising what they do -- and they do it extremely well -- within the confines of a health service that can provide backup and support if something untoward should occur during the antenatal period, labour or, for that matter, the postnatal period. Privately practising midwives can have authorisation and access to the Medicare benefits schedule (MBS) and the pharmaceutical benefits scheme (PBS), but they are applicable only to health services; they do not apply to the homebirth situation.
Getting back to the pilot homebirth program at Sunshine Hospital and Casey Hospital, an independent evaluation commissioned by the department was positive in that it supported the continuation of the programs offered at the pilot sites.I understand that the department is now commencing work to develop more guidance for public health services on the relevant clinical, administrative, workforce and other service issues to be considered prior to establishing a homebirth model of care. That goes back to the point I made at the start of my contribution to the debate, that Ms Hartland said the cost of bed stays and other neonatal costs would be reduced and there would generally be a low impact on costs. I have to dispute that. We have to be very careful about what we are looking at here. The work required by the department is prudent and should be done. There may be unintended consequences of rolling out homebirth models without certain protections being put in place and guidance being given.
Such a rollout should not be undertaken without that input.The Casey and Sunshine hospitals are continuing their programs. The programs are being monitored for those eligible women. I would like to say again that the Perinatal Services Advisory Committee, which is providing advice to the minister, is doing a very good job. I would like to commend the work it has done as well as the work of all the midwives and others who are involved in the delivery of maternity and neonatal services across Victoria.
Mr JENNINGS (South Eastern Metropolitan) -- On behalf of the Labor Party I am very pleased to support Ms Hartland's motion. The intention of the motion is to improve the range of services and birthing options available to women in Victoria and to improve the availability of homebirthing services, backed up by a safety net of clinical and hospital-based services to try to guarantee safe, appropriate outcomes for mothers and their children.The motion also calls on the government to implement the findings of the evaluation that has been undertaken of a pilot homebirthing program established by the then Labor government in 2009 at the Casey and Sunshine hospitals.
We believe it is appropriate to call on the government to act in accordance with the findings of that evaluation of the pilot program and to act in a way which is consistent with the framework that has operated in Victoria since as far back as 2004, when it was established by the then Labor government, in relation to the way maternity services are designed, implemented and provided to families, and to women and children in particular. We in the Labor Party are very supportive of the intention to increase the range of services and options available to Victorian women and their children.That is the overview of the Labor Party's position.
This is one of those occasions when I am very pleased to wholeheartedly, unequivocally support Ms Hartland. Sometimes there are motions moved by the opposition parties in this place that are full of good principle and good intent but which fall short of getting full support in the chamber, but I think this is a motion that should be supported by all parties. I cannot see any reason the government should not be fulsome in its support for this.The government may have some budgetary constraints and challenges in providing these services, but the cost to be borne by the government on a system-wide scale would be relatively modest given the cost pressures hospital systems are generally under. The rollout of homebirthing options for women would be a modest, incremental cost within the overall running of the health system rather than something of a daunting scale in the health budget.
Quite often the health minister goes on the public record to crow about the value of the health budget and quite often he does not distinguish between the different portfolio matters that he takes credit for, many of which are far beyond the scope of the programs rolled out in hospitals. Given that he pretends to the Parliament that he has access to $14 billion worth of investment, even though only about $8 billion goes into hospital systems, maybe the Minister for Health can call upon that other $6 billion he always takes credit for and allocate some funds for this area.The Labor government had a proud track record of policy development and configuration of maternity services during the life of its administration from 1999 to 2010, including having established back in 2004 a 10-year agenda for strengthening maternity services across Victoria. Indeed that model of care provided for a range of configurations of services to be provided to Victorian families. It allowed for the active participation and increasing role of midwives in the provision of maternity services, including in homebirth situations, and it had to take into account professional indemnity issues, clinical governance issues and supervision issues to provide for the appropriate indemnities and insurance arrangements for people who work in this important service area to give greater confidence to them and clearly for the patients in their care.
Labor for that decade was very committed to the growth of these services. A relatively modest number of Victorian women have chosen to exercise this option for their birthing arrangements. On average somewhere in the order of 340 women each year exercise their discretion in making this their birthing preference.
Of those 340 women, the majority have a safe birth at home, but around 13 per cent end up requiring hospitalisation, clinical intervention and support to keep mother and baby safe and to provide for their health.
In terms of market forces, demand for this service is relatively modest under current configurations of maternity services. While you would anticipate that if the service was universally supplied and made available to more Victorian women, it would lead inevitably to an increase in demand, given the fairly consistent numbers it would not seem likely to be an increase so rapid that it would either embarrass the provision of state services or embarrass the health services in question in terms of being able to provide that level of support.Honourable members interjecting.
Mr JENNINGS -- I am certain the Acting President is aware of the volume of the personal conversation the Minister for Health is undertaking whilst I am making my contribution to the debate. If the minister wants to have that conversation, he may be well advised to take it outside. I am sure the Acting President is on the cusp of assisting me by ensuring that my contribution is protected by the Chair, and I thank him for that wholehearted assistance. As the volume increases exponentially in the chamber, I am certain that Hansard will either want my volume increased or perhaps the volume of other contributions decreased. Alternatively, I could be shut down.I am not sure what is the preference of the chamber, but clearly there is no interest by the Minister for Health in this matter. The minister continues to equivocate, despite receiving very clear advice and receiving fulsome recommendations in the report of the review of the pilot program that ran from 2009 until 2012.
The report included recommendations for rolling out the program, for quality assurance, transparency and guidelines, which Ms Hartland has called for in her motion, which is consistent with questions and propositions that Ms Hartland has put to the minister on a number of occasions in the house.Up until the last 30 seconds of my contribution the minister was not the slightest bit interested in the view of the opposition on this matter, nor has he shown a great interest in adopting the recommendations. In fact, after a three-year pilot and the recommendations, instead of then taking those recommendations and implementing them, he has referred the recommendations to yet another body, asking it to provide him with an implementation plan, without a time frame by which we can have confidence that these services will be provided.
Clearly, the Labor government left a $400 000 pilot program which was to be implemented in those two hospital locations so as to provide a network of support to homebirthing options in the community. The evaluation has indicated that this program is worthy of support. We have seen that 85 per cent of women who have taken up this option have been extremely satisfied, and it has delivered a safe and appropriate outcome for their birthing arrangements. Not only has the minister received the various elements of technical and clinical guidance and governance arrangements that are embedded in this report, but he then, despite all that overwhelming evidence -- the success of the pilot, the popularity of the program and the safe homebirthing delivery outcomes for families in Victoria -- has said he is not in a position to analyse and consider it.Now three years into this government's term in office the minister has said he needs more time and more space to consider the pilot, and he will do that in his own good time, including considering the program and what has been built in the last few years to provide for those services. The minister is continually running away from Ms Hartland's question or, more importantly, the consumers of which she is mindful, including the nurses and midwives that she is obviously well connected to and mindful of what they seek to do in providing better care options for mothers and babies. Despite it being obvious that those programs should be rolled out, the minister always wants more time.
It is not beyond his capability, if he chooses to make a contribution to this debate, to find some way to blame somebody else for not implementing those outcomes,
His track record is to obfuscate his responsibilities and not respond to obvious outcomes within his portfolio. Rather he lays the blame for the floundering health system in Victoria at the foot of other people. Maybe today will be the day when the minister turns his track record on its head and delivers an outcome for Victorian patients, a better outcome for women in Victoria, a better outcome for the midwifery profession in Victoria, better clinical outcomes, better supervision and better integration of services. Maybe today he will step up and indicate that he sees the value of that program, and he will actually endorse the recommendations.That is the challenge Ms Hartland has thrown out to the minister and the government today. It is something that the Labor Party is very happy to support. We wait to see how the minister responds to this opportunity to provide better health care for women in Victoria and better options in terms of the safe delivery of their children in the future.
We look forward to the government stepping up and responding accordingly.
Mrs COOTE (Southern Metropolitan) -- I am particularly interested in Ms Hartland's motion, which deals with the expansion of public hospital homebirth services, and I am pleased to make a contribution to this debate. At the outset of my contribution I will speak about what the excellent Minister for Health, David Davis, who happens to be in the chamber at the moment, has done for midwifery and children in this state. I remind the chamber that the Victorian coalition government has committed $14.3 billion to treat more patients across Victoria in the 2013-14 budget; that is an enormous commitment to health in this state. There is a recognition that maternity services have increased and that there is a need for additional funding in this area.
It is interesting to note that there was a 3.2 per cent increase in births at public hospitals in 2012-13 compared with the previous year, and from 2010-11 to 2011-12 there was a 4 per cent growth in the number of public hospital births across Victoria.It is also important to reflect on the investment in neonatal intensive care unit (NICU) cots and critical care beds. In the 2013-14 budget a $2.2 million investment is being made for five additional NICU cots and critical care beds, which is a recognition of this difficult and sensitive health-care area. These additional respiratory support beds will provide sophisticated technology and medical management to care for premature babies with complex illnesses. The beds will be at Monash Medical Centre, Royal Women's Hospital and Mercy Hospital for Women, and two beds at the Royal Children's Hospital will open in January next year. This investment will increase the NICU cot capacity to 95.
In her contribution Ms Crozier spoke about some of the other initiatives put in place by this minister. She talked about the homebirth pilot program at the Sunshine and Casey hospitals and the Perinatal Services Advisory Committee, which has reviewed the evaluation of the pilot and future options for homebirth models of care in Victoria. The committee has expressed support for the expansion of the publicly funded homebirth models of care in Victoria. A summary of the homebirth pilot program can be seen on the Department of Health website, and I suggest members who are interested have a look at that. Sunshine Hospital and Casey Hospital are continuing to provide publicly funded homebirthing to eligible women as part of their maternity services. The guidance material will be developed in partnership with maternity service providers, and there will be community and stakeholder consultations.Another initiative is admitting privately practising midwives.
The Department of Health has developed and published an implementation framework called Eligible Midwives and Collaborative Arrangements -- an Implementation Framework for Victorian Public Health Services. The framework was developed in partnership with the Mercy Hospital for Women, Monash Medical Centre and the Royal Women's Hospital, in consultation with stakeholders and with the advice of an expert reference group. A number of approaches have been made by eligible private midwives in relation to establishing collaborative arrangements. It is important to understand that these are some of the initiatives that have been implemented by Minister Davis.I now come to the motion at hand. I believe Ms Hartland has put up her motion in good faith. While her sentiments are to be applauded, I believe her motion is ill conceived and some parts of the motion should be changed. I ask to circulate an amendment to Ms Hartland's motion. My amendment will tighten up her motion and make sure that it is more relevant to what Ms Hartland is trying to get at.
I will talk about some of the issues in relation to the amendment, and maybe in her summary Ms Hartland would like to look at them too.I think the amendment to Ms Hartland's motion will be well received in this chamber, and I will read the amendment in a moment. However, I have been in this place for long enough to know that we have a longstanding commitment to not amending motions put up by opposition parties. It is a longstanding convention in this place. We will not actually put this amendment to a vote, but I put this amendment before the chamber because I believe it enhances the motion Ms Hartland has put forward. It is a great opportunity for members of this chamber and for the public who read the debate to understand that this could have been a much better motion with a lot more impact. I ask that it be distributed to members.
In comparing Ms Hartland's motion and my amendment, members will see the difference and that a number of aspects have been tightened and tidied up. As I said, I am not critical of the sentiments that lie behind Ms Hartland's motion. I believe her sentiments are honourable. However, she has misconstrued the situation. Were we to force the issue and debate this amendment and vote on it, we would be out of line and out of step with the traditions of this place. I see Mr Lenders in the chamber. He is counting down to his time of departure. He will also understand some of the subtle rules in this place.Ms Hartland will be pleased to know that I am not going to push the issue of this amendment, which says:
That all the words after 'That' be omitted with the view of inserting in their place -- this house --
(1) congratulates the Minister for Health, Mr David Davis, MP, for taking necessary steps to strengthen the provision of hospital homebirth services, including the expansion of public services, noting the Perinatal Services Advisory Committee has provided advice on the expansion of hospital homebirth programs;
(2) notes the budget provided additional funding for birthing services including homebirth programs;(3) notes the government has released statewide guidelines and information for health services implementing homebirth services;
(4) notes the government has developed systems to prospectively collect costing data; and(5) notes the government has supported research into homebirth programs.--
This amendment enlarges precisely the sentiments expressed by Ms Hartland.Mr Jennings interjected.
Mrs COOTE -- Mr Jennings looks as if he is about to leave. That would be a great pity because all he needed were the lights, the music and the soft tones and he would have been in his theatrical element. He was into reminiscence, by his own words, on the regime of the ALP. It sounds like something from Communist Russia. He talked about his time as a minister, and it was like, 'Lights, camera, action, and I am on stage in the reminiscence'. He was going back to the seriously olden days of the ALP. It was his big moment on his reflections. He did not add anything to the debate.As I said to Ms Hartland, I will not push the amendment. I want it put forward merely as a comparison to her motion, to show that some of the issues that were misconstrued have been tightened up and examined. In keeping with the conventions of this place I will not push my amendment any further, but I would like her to understand that it would have been a much better approach.
I commend my amendment, without developing it further, and I also place on record once more my praise for the work that the minister, David Davis, is doing in this very important field.
Ms HARTLAND (Western Metropolitan) -- I thank everybody who has contributed to the debate on this very important motion. I would have to say to Mrs Coote that her amendment is a government motion and entirely reverses the intent of my motion, so as much as I appreciate her doing this, I do not think I can accept it. The motion I put forward today is very straightforward and talks about a very specific area. One of the reasons I find the hospital-based homebirthing services so attractive is, as Ms Crozier said, things can go wrong during childbirth. You need the backup of a hospital. Many women can very successfully have home births, but there will be the one who needs a quick transfer, and that is what I find attractive about the hospital-based homebirth service.
There are quite small costs around the start up. The evaluation clearly found that it was economical to do it this way because it was supporting women who could safely give birth at home. One of the ways the government can support hospitals to implement this program is by providing the guidelines. Also, the evaluation shows quite clearly that there was a very high satisfaction rate from women. There were less interventions, with up to 18 per cent more women able to deliver vaginally rather than having interventions in hospital, and I think that says a lot for this program. I believe the government is dragging its feet on this matter, and it needs to consider the fact that the Casey and Sunshine hospitals were two pilots in two separate areas. There has not been a statewide rollout.Casey and Sunshine have proved to be highly successful, and it is time that the minister and the government looked at how they can roll it out into other areas, especially in the growth areas where maternity services are quite limited.
This would be a way for women who are going to have straightforward, safe births to do so at home, with support. The government has not indicated whether it is supporting the motion or voting against it, and I urge that it supports the motion.
Motion agreed to.