Senator GIBBS (4:00 PM) —I rise to speak on the report Rocking the cradle: a report into childbirth procedures . On listening to Senator Knowles's speech, I would like to remind her that the terms of reference for this committee were approved by the Senate. The Community Affairs References Committee held six days of public hearings in Canberra, Melbourne, Sydney, Adelaide, Brisbane and Perth. We received almost 200 submissions, which came from a wide range of organisations and individuals, including hospitals, health services, practitioners, independent and hospital based midwives, welfare and peak organisations, and individual mothers.

Over the past 10 years there have been inquiries and reports about childbirth services in New South Wales, Victoria, Western Australia and one from the National Health and Medical Research Council. Obviously, childbirth is an important issue in this country. Unfortunately, despite there being so many inquiries, few of the recommendations the various reports have made have been acted upon. With more than a quarter of a million babies born in Australia every year, childbirth is a very important part of the health of this nation. Childbirth is the major reason for hospitalisation in Australia, and it accounts for the highest number of occupied bed days. It is important that we make childbirth as safe as possible for both mother and child.

The committee found that childbirth in Australia is very safe, although maternal and infant mortality rates are significantly higher than average in indigenous communities. Across Australia there are about 5.3 maternal deaths per 100,000 births and approximately 5.9 infant deaths per 1,000 live births. In indigenous communities, the death rate for mothers is double and the death rate for infants is triple that of the non-indigenous community. Some of the reasons for those problems were best summed up in evidence given to the committee in Adelaide by a number of Aboriginal community health care workers.

Those health care workers told the committee that past policies had created a fear in indigenous women about going to hospital. There was also a feeling of isolation because Aboriginal women were amongst people they did not know, thus creating a sense of shame. The committee heard that many indigenous women have to travel long distances to receive medical attention, further exacerbating the problem. They will visit a doctor or hospital once and usually not return because they see the hospital as a place to go when you are sick, and they do not consider that being pregnant is being sick; they view pregnancy as a natural part of life. One of the specific recommendations that the committee made to combat this problem was that the Office of Aboriginal and Torres Strait Islander Health provide recurrent funding to ensure continuity for existing antenatal programs for Aboriginal and Torres Strait Islander women and to establish new programs in areas of need.

The committee received evidence that Australian women value safety during birth for their babies and themselves above all other considerations. For that reason, the large majority of expectant mothers choose to birth in hospitals. While most women acknowledge the contribution of the medical profession to the low mortality rates, they are concerned about increasing levels of medicalisation of childbirth. Mortality rates are relatively uniform across the country, with the exception of the indigenous population.

The rates of intervention, however, vary. Intervention rates are highest among women who have private health insurance, women who give birth in major tertiary hospitals and women attended by specialist obstetricians. The rates vary by state, with South Australia recording the highest rate of caesarean section. The committee was especially concerned by the high rate of elective caesarean section in Australia for which, the evidence suggests, there is little or no medical justification. The committee received no evidence that justified the significant variation in caesarean section rates between states, between hospitals and between public and private and patients.

The committee did receive some evidence that caesareans were on the increase because of a rise in defensive medicine—a practice whereby doctors provide a service that is not needed because of a concern about possible litigation should a problem with the birth occur. The committee is of the strong view that there is a need for national leadership to reduce caesarean section rates. The committee supports the development of best practice guidelines on interventions and other aspects of maternal and infant care. Such guidelines would improve the quality of care, reduce the use of unnecessary, ineffective services and ensure that care is cost effective.

There is also concern among the committee members about the polarisation of views that emerged during the course of the inquiry. Some witnesses indicated that caesarean sections and other interventions should be available to women on demand, regardless of any medical indication of need. Other witnesses felt that all forms of medical intervention were overused. Many people recognised that an intermediate position was likely to prove most beneficial to women. The committee heard that, where cooperation between midwives and specialists is common, women's satisfaction with the birth experience was enhanced without sacrificing safe and successful outcomes.

We found that the best examples of this middle ground occurred in birth centres. In birth centres, women considered to be at low risk gave birth in home-like surroundings, attended by midwives but with specialist support available should problems arise during birth. Everywhere the committee went, we discovered birth centres that were oversubscribed. They were full to overflowing because of the desire by women for a less medical approach to childbirth, without sacrificing the benefits of medical advances as they became available. Unfortunately, it seems, there is not much effort being made to move resources from expensive interventions, including caesarean sections, to birth centres.

The committee found that the current arrangements for antenatal, birth and postnatal care increased the fragmentation of services. The existing funding arrangements break that care into episodes centred on various care providers. The evidence we received indicated that women would receive much better outcomes if they had continuity of carers throughout the process.

There was also disturbing evidence that a significant and increasing proportion of funding is spent on ultrasound scanning. The committee found that the most recent figures from the Health Insurance Commission, which excludes services provided by hospital doctors to public patients in public hospitals, show that in the period July 1998 to June 1999 expenditure was $38.6 million on ultrasound, almost all of it routine scanning; $27.6 million on labour and delivery, including complex births, caesarean sections and immediate postnatal care; and $30 million on antenatal visits.

Quite a few witnesses voiced the same concerns as the Royal North Shore Hospital, which told the committee:

Of particular concern is the cost of numerous ultrasound examinations. It is our current experience that it is not unusual for women to have undergone three ultrasound examinations before their pregnancy reaches 20 weeks of gestation.

The committee believes the use of ultrasound screening needs to be evaluated as soon as possible. The women of Australia need to know that this procedure is being used properly within clear best practice guidelines. Lowering the use, and therefore the cost, of ultrasound screening may provide a source for funding in other antenatal, birth and postnatal support areas, but I stress that the first step is a full and proper evaluation of ultrasound screening. The committee was also concerned about the increasing trend to discharge new mothers and infants from hospital early. Evidence provided to the committee suggested that, rather than reducing health care costs, early discharge may actually increase them in the longer term.

In summary, let me say that the 35 recommendations made in this report will not provide all the answers. The government, the community and expectant mothers in particular need to maintain interest in the area and to continue to debate, discuss and discover what practices are the best for mother and child.

Question resolved in the affirmative.