It takes a team to deliver quality rural maternity services

Ayman Shenouda

9/01/2019 2:22:29 PM

Dr Ayman Shenouda outlines a possible solution to a growing issue.

Dr Shenouda believes a solution to quality rural maternity services lies in the National Rural Generalist Pathway.
Dr Shenouda believes a solution to quality rural maternity services lies in the National Rural Generalist Pathway.

Timing, as they say, is everything.
This is particularly true in healthcare and, in birthing services right now, it’s actually getting quite critical for GP obstetricians.
For the rural GP obstetrician, the discussion is no longer about a rebirth of obstetric services for rural areas. It has moved rapidly to the preservation of this critical role.
Two key discussions are occurring in obstetric care in Australia at the moment, and they both lack one vital component: valuing the key role of the GP obstetrician in providing this care.
The first discussion on setting national directions for maternity services prioritises access yet omits GPs almost entirely, despite their importance in rural and remote areas.
The other discussion involves a state-led shift in Western Australia towards a new model of care that seems to lock GP obstetricians out completely.
We are seeing spot fires right around the country, but on a slightly different front in midwifery units’ resistance to GP involvement.
In combination, these are worrying developments and it is clear 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 be central to 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 that offers a single solution by factoring together all of the required enablers in one. The vital work done over the last 20 years has shown us solutions 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 necessary skills that 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 and on keeping it sustainable, and so much is connected to a town’s capacity to preserve procedural services like birthing.

Without GP obstetricians, women in rural and remote towns will have to travel considerable distances – often at major expense – to access maternity services. 

State of play
Round two of the National Strategic Approach to Maternity Services Consultation closed late last year (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.
The RACGP has advocated strongly for the Federal Government to acknowledge the role of GPs when this strategy is released this year, having previously outlined concerns about the marginalisation of GPs in obstetric care.
Meanwhile, the debate in Western Australia continues to heat up on hospital-led changes to the obstetric care model in that state, which is seeing GP obstetricians increasingly locked out.

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 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 is at odds with what the Federal Government is trying to achieve nationally through the National Rural Generalist Pathway in building a resilient rural GP workforce.
Choice for women
But perhaps the most important point is that with a new maternity model that favours salaried medical staff over GP obstetricians it is the patient who loses most of all.
With GP obstetricians unable to care for public obstetrics patients, the choice for women is limited as a result.
Carving off GP obstetricians’ continuity-of-care role piece by piece to a fly-in, fly-out service model will come at a significant cost. Women and their families often 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 GP obstetricians, who deliver more babies 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 rural towns.
That is, what it actually takes to sustain a rural maternity service and those inter-connective factors that matter 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 compromising 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.
We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop.
Vital skills
GP obstetricians skilled in childbirth require support, not barriers, in retaining such an essential 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 rural areas is closely tied to the GP obstetric model and it is a skill set we need to nurture and preserve through the National Rural Generalist Framework.
It is about getting a skilled workforce in place, and supporting a collaborative team structure to secure and sustain birthing services across rural Australia.
The rural generalist model offers a way forward that will make a difference for rural patients, ensuring safe, affordable and accessible healthcare.
A version of this column article was first published on Dr Shenouda’s blog.

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Jack Sloss   11/01/2019 2:58:13 PM

Excellent article. Hits the Mark in saying that it is a collaborative team that is the key to caring for women and babies.