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Midwifery by the sea- riding the waves of change: speech by Julia Gillard to the Annual Conference of the NSW Midwives Association. \n\n

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Thank you very much for your invitation to join you here today at your annual state conference by the sea.

While fair skinned women from Wales don’t really make great surfie chicks, I am definitely a beach person. One of my favourite places is Glenelg Beach in my home state of South Australia, and when I am home (all too rarely) I look forward to my early morning walks along Altona Beach.

Beach walks are great for clearing the mind and thinking about issues. In health care there are always plenty of issues to think about.

Here are some of the things that have been on my mind lately:

• What should the health care system of the 21PstP century look like?

• What do we need to put in place to ensure that all Australians have access to the health care services they need?

• How can we address disadvantage and inequalities in health?

• How can we ensure the long-term investments in preventive health care and the health care workforce?

• And how do we put in place better partnerships between the Commonwealth and the States and Territories and across bureaucracies to stop the cost and blame shifting and provide savings that can be reinvested back into needed services?

Of course, along with these weighty issues go a whole variety of other thoughts and problems:

• My anger at the unwillingness of the Howard Government, and Health Minister Tony Abbott in particular, to actively engage in the hard work that is needed for health care reform.

• What are the costs - in growing health care expenses, in lives cut short or damaged, and to the economy - if we fail to make these essential changes and investments?

• How do we begin this process of change?

Children’s Health - the Modernity Paradox

During my beach walks I have found myself regularly returning to one particular issue - an issue that Professor Fiona Stanley and other experts in child health have been propounding now for some time.

We are used to comfortably believing that ongoing economic progress and medical miracles will ensure that our children will live long and healthy lives. But the evidence is that even in a country as rich as Australia is, this is not longer a truism.

Health outcomes for our children and youth are now impacted by an array of ‘modern’ health conditions with marked increases in a variety of complex diseases and disorders and with the potential to reduce quality of life, participation in the workforce and the community, and life expectancy.

We are seeing rising numbers of low birthweight babies, more children with a range of developmental disorders and conditions, dramatic increases in childhood asthma and other allergies, juvenile diabetes, and mental health problems (depression, anxiety, behavioural problems, autism, schizophrenia and suicide). There is an increasing proportion of children classified as obese, and at the other extreme, there is an epidemic of eating disorders. Child abuse and neglect are far too common, and there is an increase in learning disabilities, aggressive behaviour and violence.

This is what is called the Modernity Paradox. And it is shocking news to parents, health care professionals and policy makers.

This black cloud hanging over our children’s future is highlighted in a report released just this month from Research Australia. The report finds clear evidence that the quality and length of children’s lives is at risk from these emerging health problems that threaten to undo many of the health gains of the past decades. The risk is particularly high for children living in rural and remote areas and from the lowest socio-economic groups.

We cannot hide from the fact that too many children and young people are dying from causes which are potentially preventable. Over 50% of early deaths are due to accidents, poisonings, violence and suicides. Every such death is a family tragedy and a loss to the future of the nation.

And at the same time we are struggling to know how best to improve the appallingly bad health of our Indigenous children, who in some communities face diseases such as rheumatic fever and trachoma that are now unknown outside of developing countries.

Children’s health is affected by a complex mix of risk and protective factors, including genetics, low birthweight, socio-economic status, nutrition and exercise, and parents’ education.

Australia’s economic progress has changed the social context in which children develop. Australian families now have fewer children, smaller households, older mothers, more single parents and higher rates of divorce.



There are no national data to show how all of these factors influence child health, development and wellbeing, but we know that there are impacts into adulthood.

While we need to know more, we do know that if we are to address these problem issues, then early intervention is usually more successful, and in some cases is essential.

The best start in life

It will not surprise this audience - I’m sure you will all agree - if I now say that I see the pregnant woman as the best focus for early intervention.

Between us we could draw up an impressive list of perinatal programs that would boost the health of the mother and her baby, and improve outcomes, and give all our kids the best start in life.

These include:

• Educating all women of childbearing age about eating well and exercising sensibly, nutrition awareness and the importance of supplements such as folate and iodine;

• Alerting women, especially when pregnant, to the dangers of smoking and alcohol and substance abuse, and providing ready access to quit programs;

• Education and support programs for new parents, with a special focus on infants and families at risk;

• Interventions for peri-natal depression;

• Support for breast-feeding, especially in the first 6 months; and

• Ensuring that all newborns are screened for metabolic conditions, foetal alcohol syndrome, and hearing problems.


Obstetric services and workforce shortages

In the middle of this is the big event - the birth.

I know that midwives - as a group and individually - have strong ideas about what should be provided in terms of birthing services.

But shockingly, it is increasingly the case that for some women the idea of having a choice of birthing services and having continuity of care throughout their pregnancy, the birth and in the post-natal period is an impossible luxury - not just unaffordable, but unobtainable in their local area.

This is primarily due to the failure of the Howard Government to invest in the health care workforce. We are now reaping the outcomes of nine long years of arrogance and inaction.

There are serious shortages of obstetricians, procedural GPs and midwives in rural and regional areas, and now outer suburban women are also encountering problems getting obstetric care.

We hear stories of women in labour forced to travel hundreds of miles to give birth - and the cases of women forced to give birth on the roadside when time runs out. Women with risky pregnancies who live in remote areas must leave home, often for months, to get the care they need. Particularly for Indigenous women, this removal from their culture and their family can be extremely isolating.

Some might say the situation is already at crisis point. Certainly it is going to reach crisis point very quickly as practicing professionals reach retiring age.

The average age of obstetricians is 51, and a quarter of Australia’s obstetricians are over 60. A recent study published in the Australian and New Zealand Journal of Obstetrics and Gynaecology found that half of obstetricians (public and private) in country towns expect to quit or retire within five years. Around Australia some 130 rural hospitals are already delivering babies without cover from a specialist obstetrician.

The story is similar for procedural GPs who are getting older and are increasingly less likely to take on obstetric services.

The shortage of midwives is also a problem. The Australian Health Workforce Advisory Committee estimates a current national shortage of 1850 midwives, and this is expected to increase over the remainder of the decade.

All these health professionals are facing the same problems - few new trainees coming through the system, little time to mentor such new trainees, increasing workloads, no ability to take time out for family reasons or for study purposes, and professional indemnity issues.

Midwives face additional concerns about the lack of professional recognition as well as limited opportunities to practise as primary carers and provide continuity of care to women.

The need for a concerted approach

Clearly this is no time for turf warfare between doctors and midwives, but it is time for all health care professionals involved in delivering obstetrics care to mount a combined attack on the Howard Government to force them into action to address this situation.

Unless and until the Government is shocked and shamed into realising that Australian women are now scrambling to find the birthing centre of their choice, and in some



cases scrambling to find any professional who will deliver their child, the situation will not improve.

It seems to me that we need a variety of solutions to fit all the circumstances that arise. There is no ‘one size fits all’ way to solve the problems that present so differently in metropolitan Sydney, the isolated community of Wilcannia, the growing town of Byron Bay and the multicultural suburbs of Western Sydney. The one common factor is the pregnant woman and her child - they must be at the centre of the solution.

There are some obvious places to start:

• More university and training places for doctors, nurses and midwives;

• Smart ways to get people to work where they are most needed;

• New team approaches to looking after the pregnant woman, managing the birth and providing care and support for new parents;

• Addressing current barriers such as professional indemnity and Medicare reimbursement requirements.

I believe that Government must show real leadership and a willingness to invest in the long term issues. That’s what a Beazley Labor Government will do.

But I also believe that the real changes will not come from those imposed from on high by government, but from those worked out in partnerships at the local level, by people like you and your colleagues and peers who work at the coalface, using innovative approaches to address the local needs.


To revert to our surfing analogy:

My message for you today is that this is not a time for playing on the boogie board in the small waves - the ankle busters. No, this is a time for getting out the long board and heading out for the big surf.

I believe that midwives - whatever their surfing abilities - are key heath care professionals whose role in the care of women and their babies has yet to be fully realised in the Australian health care system.

We need to realise that potential so that mothers have real choice in their birthing experience, and their babies have the best start in life.

This is one of the best investments we can make in the future of our nation.