Maternity funding and workforce reform: strategies for better design, better value, better health and equity
Donnellan-Fernandez, Roslyn Elizabeth
Newman, Lareen Ann
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The purpose of this paper is to make transparent the connections between funding, workforce issues, and clinical outcomes in Australian maternity services, including their relationship to Casemix. It will also examine how these factors intersect and impact existing service models, emerging service models and, most importantly, contemporary consumer demand, community expectations of health care, and health outcomes for women and babies in the short and long term. Central to this purpose, the paper offers a dual critique: a) that the principles, foundation and model for funding maternity service provision in Australia within acute hospital services is seriously flawed and a significant driver for increased expenditure as well as unnecessary clinical interventions in healthy women and babies, and short term adverse health outcomes for mothers, babies and families; it also results in a larger, hitherto unacknowledged systems legacy with significant implications for long term health and economic outcomes of the population, including future health system management of the burden of chronic disease; b) that there is a current mismatch between policy and funding structure whereby biomedical/acute care models of service delivery for healthy pregnant women and babies are broadly privileged as the dominant paradigm for maternity services. This constitutes incoherent health policy and is inconsistent with both medical research and evidence- based ‘best practice,’ including a population health approach to delivery of maternity services and the view that good maternity service provision can act as a population level preventative health strategy. The paper uses Ulrich’s Systematic Boundary Critique (1) as a framework to make transparent the limitations and dysfunction of the current system and to propose an alternative design which has the capacity to improve equity, access, clinical outcomes, and reconfiguration and utilization of the skilled midwifery workforce. The new design can contribute reduced health care costs, labour force efficiency, staff retention, and economically sustainable services. The paper concludes that a national approach to policy and structural funding reform that relocates mainstream maternity services for healthy women and babies within a primary health care paradigm is urgently required in Australia, and is aligned with widespread consumer lobbying for such reform.