Does Australia's Health Policy Environment Create Unintended Outcomes for Birthing Women?

Abstract

Several health policy reforms in Australia over the past 20 years have directly and indirectly affected the use of maternity care services. Specifically, recent reforms have increased access to obstetric and complementary medicine services—defined here as a range of health services not commonly included in conventional medicine practice—irrespective of health status or need. Additionally, a number of recent policy changes purported to increase access to midwifery services have had the opposite effect of restricting access to these services. Existing Australian maternity and health policies may be directing pregnant women toward engaging with care providers and services that are not necessarily supported by contemporary evidence. In this commentary, we explore recent changes in the health policy and legislative environment in Australia, and their influence on changing trends in maternity care. Since the early 1970s, Australia has adopted a universal health care system providing government-funded health services free to the public under “Medicare,” the national health insurances scheme. Private services are also available to those who are prepared to pay out-of-pocket expenses, and the majority of Australians who access private health services also subscribe to private health insurance as a way to mitigate costs 1. In Australia, legislative changes associated with private health insurance have been ongoing since 1997 when the federal government initiated several stages of policy reform. In an attempt to reduce perceived pressure on public health services caused by long-term declines in private health insurance enrollment, the government introduced strong tax incentives to encourage the uptake of private health insurance. The first stage was the introduction of a Medicare Levy Surcharge of 1 percent of taxable income to higher income earners who did not take out private health insurance. This was accompanied by a 30 percent rebate on private health insurance premiums paid by insurance holders followed by the introduction of a tax penalty for those who do not maintain private health insurance from early adulthood 2. Since 2005 there has been a consistent growth in both the number of privately insured Australians, and the use of health services with substantial out-of-pocket expenses beyond those covered by Medicare where the patient relies on funding through private health insurance rebates to cover the gap in fees. In June 2010, 51.6 percent of Australians were covered by general private health insurance, and 44.6 percent also had specific private health insurance for hospital inpatient services 1. For women using private health insurance for maternity care, the insurer covers 88 percent of their obstetric costs leaving 12 percent of costs as out-of-pocket expenses 3. Recent legislative changes have attempted to increase the choice in models of care and maternity care providers available to women and these changes have had major implications for the maternity care workforce. The introduction of the Health Practitioner Regulation National Law Acts across all states and territories of Australia in 2009–10 4 was in response to a move to national registration (replacing state-based systems) for health professionals including doctors and midwives. The Act created national boards, which replaced the state-based boards who had previously overseen the regulation of the relevant professions. Concurrent with national registration, the federal government also undertook a national review of maternity services. One outcome of the review was the introduction of legislation to expand the role of midwives with the aim to increase access and choice for women. The amendment to the National Health Act 1953 and the Health Insurance Act 1973 along with the introduction of the National Health (Collaborative arrangements for midwives) Determination 2010 enabled authorized midwives to access the pharmaceutical benefits scheme and obtain a Medicare provider number. On the surface, the legislation appeared to provide an opportunity to re-orientate the midwifery workforce to provide midwifery-led services similar to the legislative policy that drove transition to the current lead maternity care model in New Zealand 5. However, the requirement for a “collaborative relationship” between midwives and obstetricians as outlined in this Determination may have impeded women's access to midwife-led maternity care services. More specifically, midwives faced difficulties accessing a collaborative agreement and as such the Determination restricted rather than supported midwives' capacity to provide services to women 6. Reasons for these difficulties included lack of clarity around professional indemnity insurance and a lack of access to specialist obstetricians in rural areas 6. As a result of sustained lobbying from consumer organizations and the midwifery profession the Determination was amended in 2013, enabling midwives in private practice to develop agreements with institutions (such as hospitals) rather than only with specific obstetricians 7. Despite this change, uptake by institutions remains low. Queensland was the first state in Australia to develop collaborative agreements between midwives in private practice and public hospitals through a credentialing structure enabling women to exercise their right to access midwifery care and gain benefit from the changes introduced through legislation. Despite ongoing national lobbying from professional and consumer organizations and individual midwives, other states across Australia have been slow to respond, adopting a “watch and see” approach. The introduction of visiting access agreements for midwives in private practice in other states in Australia did not occur until 2015—5 years after the enabling legislation—and the number of public hospitals across Australia with agreements in place remains very low. The introduction of the legislation promoting private health insurance has been associated with a 51 percent increase in women giving birth in the private sector 8. The trend toward higher proportion of births in the private system may have had an influence on birth outcomes for women and neonates with strong evidence suggesting that the level of interventionist birth is considerably higher in the private health sector. For example, a recent study found a 30 percent higher cesarean delivery rate among women in the private sector compared with women being cared for in the public maternity system 9. Another study found an increase in cesarean births in Australia after implementation of private health insurance policy reforms 8. While the findings of these studies represent significant associations between factors rather than causality, the potential implications are worthy of close consideration by policy makers. By increasing demand for obstetric consultations over other maternity care services, current private health insurance policy may be developing entrenched inefficiencies. The Australian government attempts to reduce individual out-of-pocket health care costs (e.g., the “Medicare Safety Net” which reimburses individual out-of-pocket medical expenses beyond a designated limit 10), with obstetric costs contributing significantly to this expenditure. Given the current trend in increasing cesarean delivery rates in most industrialized countries 11 and the poor cost effectiveness of cesarean delivery for low-risk women 12, the cost of more intervention will likely increase as women are encouraged to access obstetric services using their private health funds. With this in mind, the relationship between private health insurance cover and increased consultations with an obstetrician may have wide-ranging maternal, neonatal, policy, and economic implications, which require careful consideration. Whilst the governmental health insurance policy initiatives are intended to capture young, healthy individuals, they may also be unintentionally deterring healthy women with low-risk pregnancies from choosing a midwife-led model of care. A comparatively higher rate of midwife consultations by women without private health insurance suggest that women accessing public maternity care have better access to the benefits of midwifery care. Midwifery-led care in Australia is associated with fewer interventions (at all levels of risk), better birth outcomes, and cost-savings of over $500 per birth to the public system 13. However, without addressing the barriers to midwifery-led care it is unlikely that these benefits will be readily accessible through privately funded maternity care models. This outcome appears to be counter-productive to the intention of the policy, which was to relieve the public system by providing incentives for private care 2. Government policies encouraging private insurance enrollment may be supporting a higher use of complementary medicine by pregnant women. Australian research has established a link between private health insurance coverage and the use of complementary medicine treatments and providers for maternity care 14, 15. Although the use of complementary medicine in many cases is innocuous and could be beneficial, concerns include a lack of evidence demonstrating safety and efficacy of many procedures during pregnancy, low levels of disclosure to conventional maternity care professionals, and poor information sources used to inform decisions about complementary medicine use 16. Increasing use of complementary medicine during pregnancy also creates a possible conflict between two potentially contrasting philosophical approaches to maternity care: medical obstetric care and the more holistic view of complementary medicine. As a result, women may be forced to navigate conflicting information and ultimately undertake autonomous decision-making, often without disclosing their decisions to their care providers. In contrast, the association between complementary medicine use and private health insurance cover could also be indicative of patient preference, and signal an unmet need for complementary medicine provision within conventional public maternity care pathways 14, 15. On a macro level, it appears that the Australian maternity care sector offers a range of care models to women including (but not limited to) obstetrician-led care, midwifery-led care, and general practice shared care. However, on closer examination, access to some of these models is highly dependent on where a woman lives, her income level, and, increasingly, her personal health status. Women who experience complex pregnancies or have prior health problems have restricted access to midwifery-led care for a range of reasons. One such reason is the introduction of professionally endorsed guidelines and state-wide frameworks 17, 18, which have resulted in an increasing number of women being deemed “high risk” and subsequently directed to obstetrician-led care. Such a diagnostic categorization is occurring alongside growing evidence for midwife-led care models which have been proven to be as safe and clinically effective as obstetric care, not only for low-risk women 19 but also for pregnant women and babies across all risk categories 13. The professionally endorsed guidelines, which aim to support collaboration and consultation between maternity health professionals often underpin hospital and maternity care provider policies. These guidelines are also used to develop the criteria set by insurers indemnifying maternity care practice. Despite the contrary research evidence, “appropriate care” is often interpreted exclusively as obstetric care 18. As such, women's choices regarding the use of maternity services are in many cases defined by their personal health status. In the case of women living in rural and remote regions of Australia, choice is often even further restricted by the lack of midwife-led services or, in some cases, any maternity services in their locale 20. Health insurance policy and legislative changes in recent years may be influencing health service utilization by pregnant women in Australia, and the result may not be to the benefit of women and their babies. Compared with women receiving public hospital care, maternity care provided by privately practicing obstetricians has been linked to higher rates of a range of obstetric interventions. There is increasing recognition of the connection between unnecessary intervention and both decreased maternal well-being and increased economic burden to society. Ensuring unimpeded access to midwifery care for all interested women may assist in offsetting recent increases in obstetric intervention rates, while improving maternity care choices for birthing women. Finally, it is essential to examine the practical impacts of health policies, as there are often unintended outcomes.